PERFALGAN 10 mg/ml solution for infusion.

One ml contains 10 mg paracetamol

One 50ml vial contains 500mg paracetamol.

One 100ml vial contains 1000mg paracetamol.

Excipients: Sodium 0.04mg/ml

For the full list of excipients, see section 6.1.

Solution for infusion.

The solution is clear and slightly yellowish.

PERFALGAN is indicated for the short-term treatment of moderate pain, especially following surgery, and for the short-term treatment of fever, when administration by intravenous route is clinically justified by an urgent need to treat pain or hyperthermia and/or when other routes of administration are not possible.

Intravenous use.

The 100ml vial is restricted to adults, adolescents and children weighing more than 33 kg (approximately 11 years old).

The 50 ml vial is restricted to term newborn infants, infants, toddlers and children weighing less than 33 kg.

Posology :

Adolescents and adults weighing more than 50 kg :

Paracetamol 1 g per administration, i.e. one 100 ml vial,up to four times a day.

The minimum interval between each administration must be 4 hours.

The maximum daily dose must not exceed 4 g.

Children weighing more than 33 kg (approximately 11 years old), adolescents and adults weighing less than 50 kg :

Paracetamol 15 mg/kg per administration, i.e. 1.5 ml solution per kg up to four times a day.

The minimum interval between each administration must be 4 hours.

The maximum daily dose must not exceed 60 mg/kg (without exceeding 3g).

Children weighing more than 10kg (approximately 1 year old) and weighing less than 33kg:

Paracetamol 15mg/kg per administration, i.e. 1.5ml solution per kg up to four times a day.

The minimum interval between each administration must be 4 hours.

The maximum daily dose must not exceed 60mg/kg (without exceeding 2g)

Term newborn infants, infants, toddlers and children weighing less than 10kg (up to approximately 1 year old):

Paracetamol 7.5mg/kg per administration i.e. 0.75ml solution per kg up to four times a day.

The minimum interval between each administration must be 4 hours.

The maximum daily dose must not exceed 30mg/kg.

No safety and efficacy data are available for premature neonates (see also section 5.2)

Severe renal insufficiency: it is recommended, when giving paracetamol to patients with severe renal impairment (creatinine clearance 30 ml/min), to increase the minimum interval between each administration to 6 hours (See section 5.2 Pharmacokinetic properties).

In adults with hepatocellular insufficiency, chronic alcoholism, chronic malnutrition (low reserves of hepatic glutathione), dehydration: the maximum daily dose must not exceed 3 g (see section 4.4 Special warnings and precautions for use).

Method of administration :

The paracetamol solution is administered as a 15-minute intravenous infusion.

Perfalgan 50ml vial can also be diluted in a 0.9% sodium chloride solution or 5% glucose solution up to one tenth. In this case, use the diluted solution within the hour following its preparation (infusion time included).

As for all solutions for infusion presented in glass vials, it should be remembered that close monitoring is needed notably at the end of the infusion, regardless of administration route. This monitoring at the end of the infusion applies particularly for central route infusions, in order to avoid air embolism.

PERFALGAN is contraindicated :

- in patients with hypersensitivity to paracetamol or to propacetamol hydrochloride (prodrug of paracetamol) or to any of the excipients.

- in cases of severe hepatocellular insufficiency.

Warnings

It is recommended that a suitable analgesic oral treatment be used as soon as this route of administration is possible.

In order to avoid the risk of overdose, check that other medicines administered do not contain either paracetamol or propacetamol.

Doses higher than those recommended entail the risk of very serious liver damage. Clinical signs and symptoms of liver damage (including fulminant hepatitis, hepatic failure, cholestatic hepatitis, cytolytic hepatitis) are usually first seen after two days of drug administration with a peak seen, usually after 4-6 days. Treatment with antidote should be given as soon as possible (See section 4.9 Overdose).

This medicinal product contains less than 1mmol sodium (23mg) per 100ml of Perfalgan i.e. essentially 'sodium free'.

Precautions for use

Paracetamol should be used with caution in cases of :

- hepatocellular insufficiency,

- severe renal insufficiency (creatinine clearance 30 ml/min) (see sections 4.2 Posology and method of administration and 5.2 Pharmacokinetic properties),

- chronic alcoholism,

- chronic malnutrition (low reserves of hepatic glutathione),

- dehydration.

- Probenecid causes an almost two-fold reduction in clearance of paracetamol by inhibiting its conjugation with glucuronic acid. A reduction in the paracetamol dose should be considered if it is to be used concomitantly with probenecid.

- Salicylamide may prolong the elimination half-life of paracetamol.

- Caution should be taken with the concomitant intake of enzyme-inducing substances (see section 4.9 Overdose).

- Concomitant use of paracetamol (4 g per day for at least 4 days) with oral anticoagulants may lead to slight variations of INR values. In this case, increased monitoring of INR values should be conducted during the period of concomitant use as well as for 1 week after paracetamol treatment has been discontinued.

Pregnancy :

Clinical experience of the intravenous administration of paracetamol is limited. However, epidemiological data from the use of oral therapeutic doses of paracetamol indicate no undesirable effects in pregnancy or on the health of the foetus / newborn infant.

Prospective data on pregnancies exposed to overdoses did not show any increase in the risk of malformation.

No reproductive studies with the intravenous form of paracetamol have been performed in animals. However, studies with the oral route did not show any malformation or foetotoxic effects.

Nevertheless, PERFALGAN should only be used during pregnancy after a careful benefit-risk assessment. In this case, the recommended posology and duration must be strictly observed.

Lactation :

After oral administration, paracetamol is excreted into breast milk in small quantities. No undesirable effects on nursing infants have been reported. Consequently, PERFALGAN may be used in breast-feeding women.

Not relevant.

As with all paracetamol products, adverse drug reactions are rare (>1/10000, <1/1000) or very rare (1<1/10000). They are described below :

Very rare cases of hypersensitivity reactions ranging from simple skin rash or urticaria to anaphylactic shock have been reported and require discontinuation of treatment.

Cases of erythema, flushing, pruritus and tachycardia have been reported.

There is a risk of liver injury (including fulminant hepatitis, hepatic failure, cholestatic hepatitis, cytolytic hepatitis), particularly in elderly subjects, in young children, in patients with liver disease, in cases of chronic alcoholism, in patients with chronic malnutrition and in patients receiving enzyme inducers. Overdosing may be fatal in these cases.

Symptoms generally appear within the first 24 hours and comprise: nausea, vomiting, anorexia, pallor and abdominal pain.

Overdose, 7.5 g or more of paracetamol in a single administration in adults or 140 mg/kg of body weight in a single administration in children, causes hepatic cytolysis likely to induce complete and irreversible necrosis, resulting in hepatocellular insufficiency, metabolic acidosis and encephalopathy which may lead to coma and death. Simultaneously, increased levels of hepatic transaminases (AST, ALT), lactate dehydrogenase and bilirubin are observed together with decreased prothrombin levels that may appear 12 to 48 hours after administration. Clinical symptoms of liver damage are usually evident initially after two days, and reach a maximum after 4 to 6 days.

Emergency measures

Immediate hospitalisation.

Before beginning treatment, take a blood sample for plasma paracetamol assay, as soon as possible after the overdose.

The treatment includes administration of the antidote, N-acetylcysteine (NAC) by the intravenous or oral route, if possible before the 10th hour. NAC can, however, give some degree of protection even after 10 hours, but in these cases prolonged treatment is given.

Symptomatic treatment.

Hepatic tests must be carried out at the beginning of treatment and repeated every 24 hours. In most cases hepatic transaminases return to normal in one to two weeks with full return of normal liver function. In very severe cases, however, liver transplantation may be necessary.

Pharmacotherapeutic group: OTHER ANALGESICS AND ANTIPYRETICS, ATC Code : N02BE01

The precise mechanism of the analgesic and antipyretic properties of paracetamol has yet to be established; it may involve central and peripheral actions.

PERFALGAN provides onset of pain relief within 5 to 10 minutes after the start of administration. The peak analgesic effect is obtained in 1 hour and the duration of this effect is usually 4 to 6 hours.

PERFALGAN reduces fever within 30 minutes after the start of administration with a duration of the antipyretic effect of at least 6 hours.

Adults

Absorption:

Paracetamol pharmacokinetics is linear up to 2 g after single administration and after repeated administration during 24 hours.

The bioavailability of paracetamol following infusion of 500mg and 1 g of PERFALGAN is similar to that observed following infusion of 1g and 2 g propacetamol (containing 500mg and 1 g paracetamol respectively). The maximal plasma concentration (Cmax) of paracetamol observed at the end of 15-minutes intravenous infusion of 500mg and 1 g of PERFALGAN is about 15μg/ml and 30 μg/ml respectively.

Distribution:

The volume of distribution of paracetamol is approximately 1 L/kg.

Paracetamol is not extensively bound to plasma proteins.

Following infusion of 1 g paracetamol, significant concentrations of paracetamol (about 1.5 µg/ml) were observed in the cerebrospinal fluid at and after the 20th minute following infusion.

Metabolism:

Paracetamol is metabolised mainly in the liver following two major hepatic pathways: glucuronic acid conjugation and sulphuric acid conjugation. The latter route is rapidly saturable at doses that exceed the therapeutic doses. A small fraction (less than 4%) is metabolised by cytochrome P450 to a reactive intermediate (N-acetyl benzoquinone imine) which, under normal conditions of use, is rapidly detoxified by reduced glutathione and eliminated in the urine after conjugation with cysteine and mercapturic acid. However, during massive overdosing, the quantity of this toxic metabolite is increased.

Elimination:

The metabolites of paracetamol are mainly excreted in the urine. 90% of the dose administered is excreted within 24 hours, mainly as glucuronide (60-80%) and sulphate (20-30%) conjugates. Less than 5% is eliminated unchanged. Plasma half-life is 2.7 hours and total body clearance is 18 L/h.

Neonates, infants and children:

The pharmacokinetic parameters of paracetamol observed in infants and children are similar to those observed in adults, except for the plasma half-life that is slightly shorter (1.5 to 2 h) than in adults. In neonates, the plasma half-life is longer than in infants i.e. around 3.5 hours. Neonates, infants and children up to 10 years excrete significantly less glucuronide and more sulphate conjugates than adults.

Table - Age related pharmacokinetic values (standardised clearance, *CL_std/F_oral (L.h^-1 70kg^-1)

*CL_std is the population estimate for CL

Special populations:

Renal insufficiency:

In cases of severe renal impairment (creatinine clearance 10-30 mL/min), the elimination of paracetamol is slightly delayed, the elimination half-life ranging from 2 to 5.3 hours. For the glucuronide and sulphate conjugates, the elimination rate is 3 times slower in subjects with severe renal impairment than in healthy subjects. Therefore when giving paracetamol to patients with severe renal impairment (creatinine clearance 30 ml/min), the minimum interval between each administration should be increased to 6 hours (see section 4.2. Posology and method of administration).

Elderly subjects :

The pharmacokinetics and the metabolism of paracetamol are not modified in elderly subjects. No dose adjustment is required in this population.

Preclinical data reveal no special hazard for humans beyond the information included in other sections of the SmPC.

Studies on local tolerance of PERFALGAN in rats and rabbits showed good tolerability. Absence of delayed contact hypersensitivity has been tested in guinea pigs.

Cysteine hydrochloride monohydrate

Disodium phosphate dihydrate

Hydrochloric acid

Mannitol

Sodium hydroxide

Water for injections

PERFALGAN should not be mixed with other medicinal products.

2 years.

From a microbiological point of view, unless the method of opening precludes the risk of microbial contamination, the product should be used immediately. If not used immediately, in-use storage times and conditions are the responsibility of the user.

If diluted in 0.9% sodium chloride or 5% glucose, the solution should also be used immediately. However, if the solution is not used immediately, do not store for more than 1 hour (infusion time included).

Do not store above 30°C. Do not refrigerate or freeze.

50ml and 100 ml Type II clear glass vial with bromobutyl stopper and an aluminium/plastic flip-off cap.

Pack size : pack of 12 vials.

Before administration, the product should be visually inspected for any particulate matter and discolouration. For single use only. Any unused solution should be discarded.

Bristol-Myers Squibb Pharmaceuticals Ltd

Uxbridge Business Park

Sanderson Road

Uxbridge

Middlesex UB8 1DH

United Kingdom

PL 11184/0094

20 November 2002 / 13 December 2006

July 2009