Hydroxyethyl starch, sodium chloride.
1000 ml solution for infusion contain: Poly(O-2-hydroxyethyl)starch (Molar substitution: 0.38-0.45; Mean molecular weight: 130,000 Da) 60.00 g and Sodium chloride 9.00 g.
Electrolytes: Na+ 154 mmol, Cl- 154 mmol.
Theoretical osmolarity 308 mosm/l.
pH 4.0 - 5.5.
Titratable acidity < 1.0 mmol NaOH/l.
Excipients/Inactive Ingredients: Sodium hydroxide, Hydrochloric acid 25%, Water for injections.
Pharmacotherapeutic group: Plasma substitutes and plasma protein fractions. ATC code: B05A A07.
Pharmacology: Pharmacodynamics: Voluven 6% is an artificial colloid for volume replacement whose effect on intravascular volume expansion and haemodilution depends on the molar substitution by hydroxyethyl groups (0.4), the mean molecular weight (130,000 Da), the concentration (6%) as well as the dosage and infusion rate.
Infusion of 500 ml Voluven 6% in 30 minutes in 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.
Isovolaemic exchange of blood with Voluven 6% maintains blood volume for at least 6 hours.
Treatment of pregnant women undergoing caesarean section: There are limited clinical study data available from the use of a single dose of Voluven 6% in pregnant women undergoing caesarean section with spinal anesthesia. The occurrence of hypotension was significantly lower for Voluven 6% compared to crystalloid control (36.6% vs. 55.3%). Overall, efficacy evaluation showed significant benefits for Voluven 6% in the prevention of hypotension and in the occurrence of severe hypotension compared to crystalloid control.
Pharmacokinetics: The pharmacokinetics of hydroxyethyl starch is complex and depends on the molecular weight and mainly on the molar substitution and degree of substitution. When applied intravenously, molecules smaller than the renal threshold (60,000-70,000 Da) are readily excreted in the urine while larger ones are metabolised by plasma α-amylase before the degradation products are renally excreted.
The mean in vivo molecular weight of Voluven 6% in the plasma is 70,000 - 80,000 Da immediately after infusion and remains above the renal threshold throughout the therapeutic period.
The volume of distribution is about 5.9 litres. Within 30 minutes of infusion the plasma level of Voluven 6% is still 75% of the maximum concentration. After 6 hours the plasma level has decreased to 14%. Following a single dose of 500 ml hydroxyethyl starch plasma levels almost return to baseline after 24 hours.
Plasma clearance was 31.4 ml/min when 500 ml of Voluven 6% was administered, with an AUC of 14.3 mg/ml/h, which shows a non-linear pharmacokinetic. Plasma half-lives were t 1/2α = 1.4 h and t 1/2β = 12.1 h when 500 ml were administered on a single occasion.
Using the same dose [500ml] in subjects with stable mild to severe renal impairment, the AUC moderately increased by a factor of 1.7 (95% confidence limits 1.44 and 2.07) in subjects with ClCr < 50 ml/min compared to > 50 ml/min. Terminal half life and peak HES concentration were not affected by renal impairment. At ClCr > 30 ml/min, 59% of the drug could be retrieved in the urine, vs 51 % at ClCr 15 to 30 ml/min.
No significant plasma accumulation occurred even after a daily administration of 500 ml of a 10% solution to volunteers containing HES 130/0.4 over a period of 10 days. In an experimental model in rats using repetitive doses of 0.7g/kg b.w. per day of Voluven 6% over 18 days, 52 days after the last administration tissue storage was 0.6% of the total administered dose.
In a further pharmacokinetic study, eight stable patients with end stage renal disease (ESRD) requiring haemodialysis received a single dose of 250 ml (15g) of HES 130/0.4 (6%.).
3.6 g (24%) of the HES dose was eliminated during a 2-hour hemodialysis session (500 mL dialysate per minute, Filter HD Highflux FX 50, Fresenius Medical Care, Germany). After 24 hours the mean HES plasma concentration was 0.7 mg/ml. After 96 hours the mean plasma concentration of HES was 0.25 mg/ml. HES 130/0.4 (6%) is contraindicated in patients receiving dialysis treatment (see Contraindications).
Toxicology: Preclinical safety data: Subchronic toxicity: The intravenous infusion of 9 g of the hydroxyethyl starch contained in Voluven 6%/kg b.w./day in rats and dogs for 3 months resulted in no signs of toxicity, except for a toxicity from the increased workload on the kidney and the liver, uptake and metabolism of hydroxyethyl starch in the reticulo-endothelial system, hepatic parenchyma, and other tissues associated with the animals' unphysiological state during the test period.
The lowest toxic dose is above 9 g/kg b.w./day of the hydroxyethyl starch contained in Voluven 6%, which is at least 5 times greater than maximum human therapeutic dose levels.
Reproductive toxicity: The type of hydroxyethyl starch present in Voluven 6% had no teratogenic properties in rats or rabbits. Embryolethal effects were observed in rabbits at 50 ml/kg b.w./day. In rats, bolus injection of this dose during pregnancy and lactation reduced body weight of offspring and induced developmental delays. Signs of fluid overloading were seen in the dams. Fertility studies on directly exposed animals have not been conducted.
Treatment of hypovolaemia due to acute blood loss when crystalloids alone are not considered sufficient (see Dosage & Administration, Contraindications and Precautions).
For intravenous use as infusion.
Use of HES should be restricted to the initial phase of volume resuscitation with a maximum time interval of 24 h.
The first 10-20 ml should be infused slowly and under careful monitoring of the patient so that any anaphylactic/anaphylactoid reaction can be detected as early as possible.
The daily dose and rate of infusion depend on the patient's blood loss, on the maintenance or restoration of haemodynamics and on the haemodilution (dilution effect).
The maximum daily dose is 30ml/kg for Voluven 6%.
The lowest possible effective dose should be applied. Treatment should be guided by continuous haemodynamic monitoring so that the infusion is stopped as soon as appropriate haemodynamic goals have been achieved. The maximum recommended daily dose must not be exceeded.
Paediatric population: Data are limited in children, therefore it is recommended not to use HES products in this population.
As with all volume substitutes, overdose can lead to overloading of the circulatory system (e.g. pulmonary oedema). In this case the infusion should be stopped immediately and if necessary, a diuretic should be administered.
Hypersensitivity to the active substances or to any of the other excipients listed in Description.
Sepsis; Burns; Renal impairment or renal replacement therapy; Intracranial or cerebral haemorrhage; Critically ill patients (typically admitted to the intensive care unit); Hyperhydration; Pulmonary oedema; Dehydration; Severe hypernatraemia or severe hyperchloraemia; Severely impaired hepatic function; Congestive heart failure; Severe coagulopathy; Organ transplant patients.
Because of the risk of allergic (anaphylactic/anaphylactoid) reactions, the patient should be monitored closely and the infusion instituted at a low rate (see Adverse Reactions).
Surgery and trauma: There is a lack of robust long term safety data in patients undergoing surgical procedures and in patients with trauma. The expected benefit of treatment should be carefully weighed against uncertainty with regard to this long term safety. Other available treatment options should be considered.
The indication for volume replacement with HES has to be considered carefully, and haemodynamic monitoring is required for volume and dose control. (See also Dosage & Administration.)
Volume overload due to overdose or too rapid infusion must always be avoided. The dosage must be adjusted carefully, particularly in patients with pulmonary and cardiocirculatory problems. Serum electrolytes, fluid balance and renal function should be monitored closely.
HES products are contraindicated in patients with renal impairment or renal replacement therapy (see Contraindications). The use of HES must be discontinued at the first sign of renal injury.
An increased need for renal replacement therapy has been reported up to 90 days after HES administration. Monitoring of renal function in patients is recommended for at least 90 days.
Particular caution should be exercised when treating patients with impaired hepatic function or in patients with blood coagulation disorders.
Severe haemodilution resulting from high doses of HES solutions must also be avoided in the treatment of hypovolaemic patients.
In the case of repeated administration, blood coagulation parameters should be monitored carefully.
Discontinue the use of HES at the first sign of coagulopathy.
In patients undergoing open heart surgery in association with cardiopulmonary bypass the use of HES products is not recommended due to the risk of excess bleeding.
Effects on ability to drive and use machines: Not relevant.
Use in Children: Data are limited in children therefore it is recommended not to use HES products in this population. (See Dosage & Administration.)
Pregnancy: For Voluven 6% no clinical data on exposed pregnancies are available.
There are limited clinical study data available from the use of a single dose of Voluven 6% in pregnant women undergoing caesarean section with spinal anesthesia. No negative influence of Voluven 6% on patient safety could be detected; a negative influence on the neonate could also not be detected (see Pharmacology: Pharmacodynamics under Actions).
Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryo/foetal development, parturition or postnatal development (see Pharmacology: Toxicology: Preclinical safety data under Actions). No evidence of teratogenicity was seen.
Voluven 6% should be used during pregnancy only if the potential benefit justifies the potential risk to the foetus.
Breast-feeding: It is unknown whether hydroxyethyl starch is excreted in human breast milk. The excretion of hydroxyethyl starch in milk has not been studied in animals. A decision on whether to continue/discontinue breast-feeding or to continue/discontinue therapy with Voluven 6% should be made taking into account the benefit of breast-feeding to the child and the benefit of Voluven 6% therapy to the woman.
There are currently no clinical data available on the use of Voluven 6% in lactating women.
The undesirable effects are divided into: Very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000), very rare (<1/10,000), frequency not known (cannot be estimated from the available data).
Blood and lymphatic system disorders:
Rare (in high doses): With the administration of hydroxyethyl starch disturbances of blood coagulation can occur depending on the dosage.
Immune system disorders:
Rare: Medicinal products containing hydroxyethyl starch may lead to anaphylactic/anaphylactoid reactions (hypersensitivity, mild influenza-like symptoms, bradycardia, tachycardia, bronchospasm, non-cardiac pulmonary oedema). In the event of an intolerance reaction occurring the infusion should be discontinued immediately and the appropriate emergency medical treatment initiated.
Skin and subcutaneous tissue disorders:
Common (dose dependent): Prolonged administration of high dosages of hydroxyethyl starch may cause pruritus (itching) which is a known undesirable effect of hydroxyethyl starches.
Common (dose dependent): The concentration of serum amylase level 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.
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.
Frequency not known (cannot be estimated from the available data): Hepatic injury.
Renal and urinary disorders:
Frequency not known (cannot be estimated from the available data): Renal injury.
Reporting of suspected adverse reactions:
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product.
No interaction studies have been performed.
Please refer to Adverse Reactions concerning the concentration of serum amylase which can rise during administration of hydroxyethyl starch and can interfere with the diagnosis of pancreatitis.
Special precautions for disposal and other handling: For single use only.
To be used immediately after the bottle or bag is opened.
Do not use Voluven 6% after expiry date. Any unused solution should be discarded.
Use only clear, particle-free solutions and undamaged containers.
Remove the overwrap from the Polyolefin (freeflex) bag prior to use.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
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.
Do not freeze.
Shelf life: a) Shelf life of the product as packaged for sale: freeflex bag: 3 years.
b) shelf life after first opening of the container: The product should be used immediately after opening.
B05AA07 - hydroxyethylstarch ; Belongs to the class of blood substitutes and plasma protein fractions. Used as blood substitutes.
Soln for infusion 6% (clear to slightly opalescent, colourless to slightly yellow) x 500 mL.