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Summary of Product Characteristics 1. Name Of SUMMARY OF PRODUCT CHARACTERISTICS 1. NAME OF THE MEDICINAL PRODUCT Iloprost Pharmamentum 50 micrograms/0.5 ml concentrate for solution for infusion 2. QUALITATIVE AND QUANTITATIVE COMPOSITION 0.5 ml of aqueous solution contains 67 micrograms of Iloprost trometamol (equivalent to 50 micrograms of iloprost). For a full list of excipients, see section 6.1. 3. PHARMACEUTICAL FORM Concentrate for solution for infusion. Clear, colourless solution with no visible particles. 4. CLINICAL PARTICULARS 4.1 Therapeutic indications Treatment of advanced thromboangiitis obliterans (Buerger’s disease), with severe circulation disturbances, in cases where revasculariation is not indicated. 4.2 Posology and method of administration The treatment with Iloprost Pharmamentum should be performed under strict monitoring in hospitals or clinics that have suitable equipment. Before initiating the treatment in women, pregnancy must be ruled out. Iloprost Pharmamentum is administered after dilution, as described in section 6.6 “Special precautions for disposal”, as an intravenous infusion, for a period of 6 hours/day, through a peripheral vein or a central catheter into a vein. The dose will be adjusted according to the individual tolerability within a dosage range of 0.5 to 2.0 ng iloprost/kg of body weight/min. The solution for infusion should be prepared daily to ensure its sterility. The content of the ampoule and solvent must be completely mixed. Blood pressure and heart rate should be monitored at the beginning of the infusion and after each dose increase. During the first 2 to 3 days the dose tolerated by the patient will be determined. In order to do this, the treatment should start with an infusion rate that supplies a dose of 0.5 ng/kg/min, for 30 minutes. Following, the dose should be gradually increased, in intervals of about 30 minutes, in stages of 0.5 ng/kg/min. to 2.0 ng/ kg/min. The exact infusion rate should be calculated based on the body weight, in order to obtain an infusion between 0.5 and 2.0 ng/kg/min (see tables with the use of an infusion pump or a bypass system). !1 If side effects occur, such as headaches, nausea or blood pressure decrease, the infusion rate should be decreased until a tolerable dose is established. If severe side effects are present, the infusion should be interrupted. Treatment should continue, usually for a period of 4 weeks, with the dose that had been well tolerated in the first 2 to 3 days. Depending on the infusion technique, there are two different dilutions of the ampoule. One of these dilutions is 10 times less concentrated than the other (0.2 "g/ml versus 2 "g/ml) and may only be used with an infusion pump (e.g. Infusomat). On the contrary, the solution with the highest concentration is administered through a bypass system (e.g. Perfusor). For instructions on use and handling, see section 6.6 “Special precautions for disposal”. Infusion rate (ml/hour) for different doses using an infusion pump Generally, the solution ready for infusion is intravenously administered through an infusion pump (e.g. Infusomat). For instructions on dilution and use with an infusion pump, see section 6.6 “Special precautions for disposal”. In case of a concentration of Iloprost Pharmamentum of 0.2 "g/ml, the necessary infusion rate should be calculated according to the scheme described below, in order to obtain a dose between 0.5 and 2.0 ng/Kg/min. The following table can be used to calculate the infusion rate corresponding to the patient’s individual weight and the infusion rate. Please, check the current body weight of the patient and determine the infusion rate for the wanted dose, in ng/ Kg/min. B o d y Dose (ng/kg/min) Weight (Kg) 0.5 1.0 1.5 2.0 Infusion rate (ml/h) 40 6.0 12 18.0 24 50 7.5 15 22.5 30 60 9.0 18 27.0 36 70 10.5 21 31.5 42 80 12.0 24 36.0 48 90 13.5 27 40.5 54 100 15.0 30 45.0 60 !2 110 16.5 33 49.5 66 Infusion rate (ml/hour) for different doses using a bypass system. A bypass system can also be used with a 50 ml injection syringe (e.g. Perfusor). For instructions for dilution on use with a bypass system, see section 6.6 “Special precautions for disposal”. In case of a concentration of Iloprost Pharmamentum of 2 "g/ml, the required infusion rate should be determined according to the following scheme, in order to obtain a dose between 0.5 and 2.0 ng/Kg/min. The following table can be used to calculate the infusion rate corresponding to the patient’s individual weight and the infusion dose. Please, check the current body weight of the patient and determine the infusion rate for the required dose, in ng/ Kg/min. B o d y Dose (ng/kg/min) Weight (Kg) 0.5 1.0 1.5 2.0 Infusion rate (ml/h) 40 0.60 1.2 1.80 2.4 50 0.75 1.5 2.25 3.0 60 0.90 1.8 2.70 3.6 70 1.05 2.1 3.15 4.2 80 1.20 2.4 3.60 4.8 90 1.35 2.7 4.05 5.4 100 1.50 3.0 4.50 6.0 110 1.65 3.3 4.95 6.6 The treatment duration is 4 weeks. Due to possible occurrences of tachyphylaxis of the platelet effect and a possible platelet hyperaggregation rebound at the end of the treatment, a continuous infusion for several days is not advised, even though no clinical complications were reported due to these manifestations. - Patients with renal or hepatic failure !3 It should be taken into account that, in patients with renal failure undergoing dialysis, as well as in patients who suffer from hepatic cirrhosis, iloprost elimination is reduced. In these patients, it is required to reduce the dose (e.g., half of the recommended dose). 4.3 Contraindications - Hypersensitivity to iloprost or to any of the excipients - Pregnancy; - Breastfeeding; - Situations in which the effect of Iloprost Pharmamentum on platelets might increase the risk of haemorrhages (e.g. active peptic ulcers, traumas, intracranial haemorrhages); - Severe coronary heart disease or unstable angina pectoris; - Myocardial infarction in the past 6 months; - Chronic or acute cardiac failure (NYHA II-IV); - Severe arrhythmias; - Suspicion of pulmonary congestion; 4.4 Special warnings and precautions for use Special warnings A surgical intervention should not be postponed in patients who need to be submitted to an urgent amputation (e.g. in case of infected gangrene). The patients should be strongly advised to stop smoking. The elimination of iloprost is reduced in patients with hepatic or renal failure who require dialysis (see section 4.2 “Posology and method of administration” and 5.2 “Pharmacokinetic properties”). Caution is advised in hypotensive patients, to avoid a worsening of this situation. Patients with relevant cardiac conditions should be carefully monitored. Attention should be exercised due to the possible occurrence of orthostatic hypotension in patients who switch from lying down to standing straight, at the end of the infusion. For patients with cerebrovascular disorders (transient ischaemic attack, stroke) in the past 3 months, a rigorous risk-benefit assessment should be performed (see also 4.3 “Contraindications: risk of haemorrhage, e.g. intracranial haemorrhage”). Special precautions Currently, there are only sporadic reports available on the use in children and adolescents. !4 Paravascular infusion of undiluted Iloprost Pharmamentum may cause changes in the injection site. Oral ingestion and contact with mucous membranes should be avoided. When in contact with the skin, iloprost can cause persistent but painless erythema. Thus, the appropriate measures to avoid skin contact with iloprost must be taken. If such contact happens, the affected area should be rinsed immediately with plenty of water or saline solution. 4.5 Interaction with other medicinal products and other forms of interaction Iloprost can increase the anti-hypertensive activity of ß-receptor blockers, calcium antagonists, vasodilators and ACE inhibitors. If significant hypotension is seen, the dose of iloprost should be reduced. Given that iloprost inhibits platelet aggregation, its simultaneous use with anticoagulants (such as heparin, coumarin derived anticoagulants) or other platelet aggregation inhibitors (such as acetylsalicylic acid, non-steroidal anti- inflammatory drugs, phosphodiesterase inhibitors and nitrovasodilators, e.g. molsidomine), may increase the risk of haemorrhage. If haemorrhages occur, the administration of iloprost should be interrupted. Oral pre-medication with acetylsalicylic acid up to 300 mg daily for 8 days did not have impact on the pharmacokinetics of iloprost. In an animal study, it was discovered that iloprost may result in a reduction of the steady-state of t-PA (plasminogen activator) plasma concentration. The results of human studies show that iloprost infusions do not affect the pharmacokinetics of multiple oral doses of digoxin in patients and iloprost does not have any impact on the pharmacokinetics of the co-administered t-PA. During animal experiments, it was seen that the vasodilator effect of iloprost is reduced when the animals are previously treated with glucocorticoids, without alteration of its antiplatelet action. The significance of this is still unknown in humans. Although clinical trials were performed, in vitro studies to investigate the inhibitory potential of iloprost in the enzymatic activity of the cytochrome P450 have revealed that a relevant inhibition of the metabolism of drugs by this enzymatic pathway is not expected by iloprost. 4.6 Fertility, pregnancy and lactation Iloprost Pharmamentum should not be administered to pregnant women or during breastfeeding (see section 4.3.
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