Volulyte: Indications, Dosage, Precautions, Adverse Effects
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Volulyte - Product Information

Manufacture: Fresenius Kabi USA, LLC
Country: Canada
Condition: Anaphylactic Shock (Anaphylaxis), Fainting (Syncope), Hypovolemia, Low Blood Sugar (Hypoglycemia)
Class: Plasma expanders
Form: Liquid solution, Intravenous (IV)
Ingredients: 6% hydroxyethyl starch 130/0.4 in an isotonic electrolyte injection, magnesium chloride hexahydrate, potassium chloride, sodium acetate trihydrate, sodium chloride, water for injections

6% hydroxyethyl starch 130/0.4 in an isotonic electrolyte injection

Summary Product Information

Route of Administration Dosage Form / Strength Non-medicinal Ingredients
Intravenous Solution for infusion / 6% HES
130/0.4 in an isotonic electrolyte
injection
Magnesium chloride hexahydrate,
Potassium chloride,
Sodium acetate trihydrate,
Sodium chloride,
Water for injections
pH adjusted with sodium hydroxide
or hydrochloric acid

Indications and Clinical Use

Volulyte is indicated for the treatment of hypovolemia when plasma volume expansion is required.

It is not a substitute for red blood cells or coagulation factors in plasma.

Contraindications

Volulyte is contraindicated in patients:

  • with fluid overload (hyperhydration), especially in cases of pulmonary edema and congestive cardiac failure.
  • with sepsis.
  • with renal impairment with oliguria or anuria not related to hypovolemia.
  • with severe liver disease.
  • receiving dialysis treatment.
  • with severe hyperkalemia, hypernatremia or severe hyperchloremia.
  • with known hypersensitivity to hydroxyethyl starch.
  • with intracranial bleeding.
  • with pre-existing coagulation or bleeding disorders.

Warnings and Precautions

Serious Warnings and Precautions

The use of hydroxyethyl starch (HES) products, including Volulyte in critically ill adult patients, is associated with increased risk of mortality and renal replacement therapy.

In patients with hypovolemia requiring intensive or emergent care, a careful evaluation of the risk of sustaining renal injury or liver failure should be undertaken before instituting treatment with Volulyte.

The use of crystalloid solutions in preference to Volulyte should be considered in patients deemed at risk of these adverse reactions.

General

Fluid overload caused by overdose should be avoided in general. Particularly, for patients with cardiac insufficiency or severe kidney dysfunctions the increased risk of hyperhydration must be taken into consideration; posology must be adapted.

Fluid status and rate of infusion should be assessed regularly during treatment, especially in patients with cardiac insufficiency or severe kidney dysfunction.

In case of severe dehydration a crystalloid should be given first. Generally, sufficient fluid should be administered in order to avoid dehydration.

Particular care must be taken in patients with electrolyte abnormalities like hyperkalemia, hypernatremia, hypermagnesemia, and hyperchloremia. In metabolic alkalosis and clinical situations where alkalization should be avoided, saline based solutions like a similar product containing HES 130/0.4 in 0.9% sodium chloride solution should be preferred over alkalizing solutions like Volulyte.

Clinical evaluation and periodic laboratory determinations are necessary to monitor fluid balance, serum electrolyte concentrations, kidney function, acid-base balance, and coagulation parameters during prolonged parenteral therapy or whenever the patient’s condition warrants such evaluation.

Carcinogenesis and Mutagenesis

See PART II: SCIENTIFIC INFORMATION – Toxicology – Mutagenicity study.

Hematologic

Monitor the coagulation status in patients undergoing open heart surgery in association with cardiopulmonary bypass as excess bleeding has been reported with other HES solutions in this population. Discontinue the use of Volulyte at the first sign of clinically relevant coagulopathy.

Administration of large volumes of hydroxyethyl starch may transiently alter the coagulation mechanism and decrease hematocrit and plasma proteins due to hemodilution.

Hepatic/Biliary/Pancreatic

Serum amylase can rise during administration of hydroxyethyl starch and can interfere with the diagnosis of pancreatitis. The elevated amylase is due to the formation of an enzyme-substrate complex of amylase and hydroxyethyl starch subject to slow elimination and must not be considered diagnostic of pancreatitis.

Monitor liver function in patients receiving HES products, including Volulyte.

Immune

Anaphylactic/anaphylactoid reactions (hypersensitivity, mild influenza-like symptoms, bradycardia, tachycardia, bronchospasm, non-cardiac pulmonary edema) have been reported with solutions containing hydroxyethyl starch.

If a hypersensitivity reaction occurs, administration of the drug should be discontinued immediately and the appropriate treatment and supportive measures should be undertaken until symptoms have resolved (please refer to section ADVERSE REACTIONS).

Renal

Avoid use in patients with pre-existing renal dysfunction.

Discontinue use of Volulyte at the first sign of clinically relevant renal injury.

Continue to monitor renal function in hospitalized patients for at least 90 days as use of renal replacement therapy has been recorded up to 90 days after administration of HES products.

Skin

Pruritus is a known complication of administration of hydroxyethyl starches, though is typically more common with prolonged use of high doses.

HES-induced pruritus may be delayed in onset, typically one to six weeks after exposure, may be severe and may be of protracted (weeks and months) persistence. It is generally unresponsive to therapy.

Special Populations

Pregnant Women

No clinical data with Volulyte on exposed pregnancies are available. However, animal studies with a similar product containing HES 130/0.4 in 0.9% sodium chloride solution do not indicate harmful effects with respect to embryo/fetal development, pregnancy, parturition or postnatal development. There were no post-marketing reports of harm when HES 130/0.4 in 0.9% sodium chloride solution was used in pregnant women.

Embryotoxic effects were observed in rabbits when 10% HES 130/0.4 in 0.9 sodium chloride solution is given at 50 mL/kg BW/day. No evidence of teratogenicity was observed.

Volulyte should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Information on the use of Volulyte during labour or delivery is unknown. Use if clearly needed.

Nursing Women

It is not known whether HES 130/0.4 is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when Volulyte is administered to a nursing mother.

A decision on whether to continue/discontinue breast-feeding or to discontinue/continue therapy with Volulyte should be made taking into account the benefit of breast-feeding to the child and the benefit of Volulyte therapy to the nursing mother.

Pediatrics

No clinical trials in children have been performed with Volulyte . However, limited clinical data on the use of a similar product containing 6% HES 130/0.4 in 0.9% sodium chloride solution in children is available. In non- cardiac surgery in 41 children including newborns to infants (< 2 years), a mean dose of 16 ± 9 mL/kg was administered safely and was well tolerated for stabilisation of hemodynamics. The tolerability of this product administered perioperatively was comparable to 5% albumin.

Volulyte may be given to premature infants and newborns only after careful risk/benefit evaluation (who independently of the product have a potential to develop lactic acidosis) taking into account the disease state, as well as the hemodynamics, and hydration status.

Geriatrics

Of the total number of patients in clinical trials of a similar product containing 6% HES 130/0.4 in 0.9% sodium chloride solution (N=471), 25% were 65-75 years old, while 7% were 75 and older. No overall differences in safety or effectiveness were observed between these subjects and younger subjects. Other reported experience has not identified specific risks for the application of 6% HES 130/0.4 in this patient group.

Adverse Reactions

Adverse reactions with Volulyte reported spontaneously, from clinical trials and in the literature include:

Immune System Disorders

Rare: Anaphylactic/anaphylactoid reactions (hypersensitivity, mild influenza-like symptoms, bradycardia, tachycardia, bronchospasm, non-cardiac pulmonary edema) have been reported with solutions containing hydroxyethyl starch (see WARNINGS AND PRECAUTIONS).

Abnormal Hematologic and Clinical Chemistry Findings (Investigations)

Common(dosedependent): Increase in serum amylase (see WARNINGS ANDPRECAUTIONS).

Common (dose dependent): At high dosages the dilution effects may result in a corresponding dilution of blood components such as coagulation factors and other plasma proteins and in a decrease of hematocrit.

Skin and subcutaneous tissue disorders

Common (dose dependent): Pruritus, itching (see WARNINGS AND PRECAUTIONS).

Blood and lymphatic system disorders

Rare (in high dose): Blood coagulation disturbances beyond dilution effects can occur depending on the dosage.

Table: Frequency of Occurrence of Adverse Drug Reactions
System Organ Class Adverse Drug Reaction Frequency of Occurrence
Blood and lymphatic system disorders Coagulation disorders beyond dilution effects Rare (in high doses)
(>0.01% – ≤ 0.1%)
Immune system disorders Anaphylactic/ anaphylactoid reactions Rare
(>0.01% – ≤ 0.1%)
Skin and subcutaneous tissue disorders Pruritus Common (dose dependent)
(≥1% – < 10%)
Abnormal hematologic and clinical chemistry findings (Investigations) Increase of serum amylase Common (dose dependent)
(≥1% – < 10%)
Decrease of hematocrit Common (dose dependent)
(≥1% – < 10%)
Decrease of plasma proteins Common (dose dependent)
(≥1% – < 10%)

Drug Interactions

No interactions of Volulyte with other drugs or nutritional products are known or have been reported to date.

Volulyte must not be mixed with other medicinal products.

Consideration should be given to the concomitant administration of medicinal products that can cause potassium or sodium retention.

Dosage and Administration

Volulyte (6% HES 130/0.4 in an isotonic electrolyte injection) is administered by intravenous infusion only.

Total volume and rate of infusion are dependent on the clinical situation and the individual patient. As with any intravenous fluid, Volulyte should be administered in accordance with accepted clinical practices for fluid and electrolyte management.

In clinical trials, infusions up to 33 mL/kg/day were most commonly used. There is limited experience with infusions between 33 mL/kg/day and 50 mL/kg/day.

The initial 10-20 mL is to be infused slowly, keeping the patient under close observation for possible anaphylactic/anaphylactoid reactions.

Volulyte can be administered repetitively over several days according to the patient’s needs. The dosage and duration of treatment depends on the duration and extent of hypovolemia, the hemodynamics and on the hemodilution.

Children

There is limited clinical data on the use of a similar product containing 6% HES 130/0.4 in 0.9% sodium chloride solution in children. In 41 children including newborns to infants (< 2 years), a mean dose of 16 ± 9 mL/kg 6% HES 130/0.4 in 0.9% sodium chloride solution was administered safely and well tolerated for stabilization of hemodynamics.

The dosage in children should be adapted to the individual patient colloid needs, taking into account disease state as well as the hemodynamic and hydration status.

Overdosage

As with all volume substitutes, overdose with Volulyte can lead to overloading the circulatory system (e.g. pulmonary edema). In this case the infusion should be stopped immediately and if necessary, a diuretic should be administered.

For further information on the management of a suspected drug overdose, contact your regional Poison Control Centre

Action and Clinical Pharmacology

Volulyte contains 6% hydroxyethyl starch (HES 130/0.4), a tetrastarch. HES 130/0.4 is an artificial colloid, third generation starch, for volume replacement which is characterized by the molar substitution by hydroxyethyl groups (0.4), the mean molecular weight (130,000 Da), the concentration (6%), and the substitution ratio (C2 /C6 ratio) of approximately 9:1. The effect on intravascular volume expansion and hemodilution depends on these parameters as well as on the dosage and infusion rate.

Hydroxyethyl starch 130/0.4 is a derivative of thin boiling waxy maize starch, which mainly consists of a glucose polymer (amylopectin) predominately consisting of α-1,4- connected glucose units with several α-1,6-branches. The medium molecular weight (130,000 Da), low degree of substitution (0.4) and narrow molecular weight distribution of hydroxyethyl starch (HES 130/0.4) contained in Volulyte contribute to its beneficial effects on pharmacokinetics and intravascular volume effect.

Pharmacodynamics

Infusion of 500 mL of 6% HES 130/0.4 in 0.9% sodium chloride solution over 30 minutes in healthy volunteers results in a plateau- like non-expansive volume increase of approximately 100% of the infused volume which lasts for approximately 4 to 6 hours. Isovolemic exchange of blood with 6% HES 130/0.4 in 0.9% sodium chloride solution maintains blood volume for at least 6 hours.

The electrolyte content of Volulyte has been adapted to the principal ionic constituents of normal plasma. Volulyte contains the electrolytes sodium (Na+), potassium (K+), magnesium (Mg++), chloride (Cl-) and acetate (CH3COO-) in an isotonic composition. Acetate is a metabolizable anion which is oxidized in different organs and has an alkalizing effect.

Pharmacokinetics

The pharmacokinetic profile of HES is complex and largely dependent on its molar substitution as well as its molecular weight. When administered intravenously, molecules smaller than the renal threshold (60,000 – 70,000 Da) are readily and rapidly excreted in the urine, while molecules with higher molecular weights are metabolised by plasma amylase prior to excretion via the renal route.

The mean in vivo molecular weight of 6% HES 130/0.4 in plasma is 70,000 – 80,000 Da immediately following infusion and remains above the renal threshold throughout the treatment period.

The volume of distribution of 6% HES 130/0.4 after intravenous administration of 500 mL to healthy volunteers is about 5.9 L. Plasma levels of 6% HES 130/0.4 remain at 75% of peak concentration at 30 minutes post-infusion and decrease rapidly to 14% at 6 hours post -infusion. Plasma levels of 6% HES 130/0.4 return to baseline levels 24 hours following infusion.

Plasma clearance of 6% HES 130/0.4 following intravenous administration of 500 mL was 31.4 mL/min with an AUC of 14.3 mg/mL h, following non-linear pharmacokinetics. A single dose of 500 mL of 6% HES 130/0.4 solution results in elimination in the urine of approximately 62% within 72 hours. Six percent HES 130/0.4 is eliminated from systemic circulation with a t1/2α of 1.4 h and a terminal half life (t1/2ß) of 12.1 h following administration of a single dose of 500 mL.

The kinetics of 6% HES 130/0.4 are similar following single and multiple dose administration. No significant plasma accumulation occurred after daily administration of 500 mL of a 10% solution containing HES 130/0.4 over a period of 10 days. Elimination rates in the urine were approximately 70% within 72 hours.

In an experimental model in rats using repetitive doses of 7 mL/kg BW per day of 10% HES 130/0.4 over 18 days, 52 days after the last administration tissue storage was 0.6% of the total administered dose.

Special Populations and Conditions

Renal Insufficiency

Single intravenous administration of 6% HES 130/0.4 (500 mL) in subjects with mild to severe renal impairment resulted in a moderate increase in AUC by a factor of 1.7 (95% confidence limits 1.44 and 2.07) only in subjects with ClCr < 50 mL/min compared to > 50 mL/min. However, terminal half-life and peak HES concentration were not affected by renal impairment. Plasma levels of 6% HES 130/0.4 return to baseline levels 24 hours following infusion.

Fifty-nine percent of HES 130/0.4 was recovered in the urine of subjects with ClCr > 30 mL/min versus 51% in those with ClCr between 15 to 30 mL/min.

There is no data available on the use of Volulyte in dialysis.

Hepatic Insufficiency

Pharmacokinetic data in patients with hepatic insufficiency are not available.

Age

Pharmacokinetic data in elderly or children are not available.

Storage and Stability

To be used immediately after the bag is opened.

The solution is intended for intravenous administration using sterile equipment.

Use only clear solutions and undamaged containers.

Parenteral drug products should be inspected visually for clarity, particulate matter, precipitate, discoloration and leakage prior to administration. Solutions showing haziness, particulate matter, precipitate, discoloration or leakage should not be used. Discard unused portion.

Do not use Volulyte after expiry date.

freeflexbag storage: at 15 °C – 25 °C for 3 years.

Do not freeze.

Special Handling Instructions

Before administering the product in plastic bags to patient, review these directions: freeflex® IV Solution Container

These instructions are only intended as guidelines for product use. Please refer to your own departmental guidelines.

  1. Check the solution composition, lot number and expiry date, inspect the container for damage or leakage, if damaged do not use.
  2. Use opening aid to remove over-wrap.
  3. Identify the blue infusion (administration) port.
  4. Break off the blue tamper-evident cover from the freeflex® infusion port.
  5. Close roller clamp. Insert the spike until the clear plastic collar of the port meets the shoulder of the spike.
  6. Use a non-vented standard infusion set and close air inlet.
  7. Hang the bag on the infusion stand. Press drip chamber to get fluid level. Prime infusion set. Connect and adjust the flow rate.

Warnings

  1. Do not remove the freeflex IV container from its overwrap until immediately before use.
  2. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.
  3. Do not administer unless the solution is clear, free from particles and the freeflex IV container is undamaged.
  4. Volulyte should be used immediately after insertion of the administration set.
  5. Discontinue the infusion if adverse reaction occurs.
  6. Do not vent.
  7. It is recommended that administration sets are changed at least once every 24 hours.
  8. For single use only. Discard unused portion.

Incompatibilities

The mixing with other drugs should be avoided. If, in exceptional cases, a mixture with other drugs is required, care should be taken with the compatibility (clouding or precipitation), hygienic injection and a good admixture.

Dosage Forms, Composition and Packaging

Volulyte (6% hydroxyethyl starch 130/0.4 in an isotonic electrolyte injection) is supplied sterile and pyrogen free in 250 and 500 mL plastic bags (freeflex) for intravenous infusion.

The composition of each 100 mL is as follows:

Poly (O-2-hydroxyethyl) starch
  (Molar substitution: 0.4)
  (Mean molecular weight: 130,000 Da)
6.00 g
Sodium chloride 602 mg
Sodium acetate trihydrate 463 mg
Potassium chloride 30 mg

Magnesium chloride hexahydrate 30 mg
pH adjusted with sodium hydroxide or
hydrochloric acid 25%
q.s
Water for injection q.s
Approximate concentration of electrolyte (mmol/L):
Sodium (Na+) 137.0
Potassium (K+) 4.0
Magnesium (Mg++) 1.5
Chloride (Cl-) 110.0
Acetate (CH3COO-) 34.0
Theoretical osmolarity (mosmol/L) 286.5
Titratable acidity (mmol NaOH/L) < 2.5
pH 5.7 – 6.5

Volulyte, 6% HES 130/0.4 in an isotonic electrolyte injection, is supplied in the following primary containers of the following package sizes:

Polyolefin bag (freeflex) with overwrap: 10, 20, 30, 35, 40 x 250 mL; 10, 15, 20 x 500 mL