1 ml solution (1 ampoule) contains 0.625 mg cholecalciferol, equivalent to 25,000 IU vitamin D.
Excipients/Inactive Ingredients: Tocopherol acetate, Polyglyceryl oleate (E475), Olive oil, refined, Sweet orange peel oil.
Pharmacotherapeutic Group: Vitamin D, cholecalciferol. ATC Code: A11CC05.
Pharmacology: Pharmacodynamics: In its biologically active form Vitamin D stimulates intestinal calcium absorption , incorporation of calcium into the osteoid, and release of calcium from bone tissue. In the small intestine it promotes rapid and delayed calcium uptake. The passive and active transport of phosphate is also stimulated. In the kidney, it inhibits the excretion of calcium and phosphate by promoting tubular resorption. The production of parathyroid hormone (PTH) in the parathyroids is inhibited directly by the biologically active form of vitamin D3. PTH secretion is inhibited additionally by the increased calcium uptake in the small intestine under the influence of biologically active vitamin D.
Pharmacokinetics: The pharmacokinetics of vitamin D is well known.
Absorption: Vitamin D is well absorbed from the gastro-intestinal tract in the presence of bile, so the administration with the major meal of the day might therefore facilitate the absorption of Vitamin D.
Distribution and biotransformation: It is hydroxylated in the liver to form 25-hydroxy-cholecalciferol and then undergoes further hydroxylation in the kidney to form the active metabolite 1, 25-dihydroxycholecalciferol (calcitriol).
Elimination: The metabolites circulate in the blood bound to a specific α-globin, vitamin D and its metabolites are excreted mainly in the bile and faeces.
Characteristics in Specific Groups of Subjects or Patients: A 57% lower metabolic clearance rate is reported in subjects with renal impairment as compared with that of healthy volunteers.
Decreased absorption and increased elimination of vitamin D occurs in subjects with malabsorption.
Obese subjects are less able to maintain vitamin D levels with sun exposure, and are likely to require larger oral doses of vitamin D to replace deficits.
Toxicology: Preclinical safety data: Pre-clinical studies conducted in various animal species have demonstrated that toxic effects occur in animals at doses much higher than those required for therapeutic use in humans.
In toxicity studies at repeated doses, the effects most commonly reported were increased calciuria and decreased phosphaturia and proteinuria.
Hypercalcaemia has been reported in high doses. In a state of prolonged hypercalcaemia, histological alterations (calcification) were more frequently borne by the kidneys, heart, aorta, testes, thymus and intestinal mucosa.
Colecalciferol has been shown to be teratogenic at high doses in animals.
At doses equivalent to those used therapeutically, cholecalciferol has no teratogenic activity.
Cholecalciferol has no potential mutagenic or carcinogenic activity.
The prevention and treatment of vitamin D deficiency.
As an adjunct to specific therapy for osteoporosis in patients with vitamin D deficiency or at risk of vitamin D insufficiency.
Take with meal preferably.
Paediatric posology: Prevention of deficiency 0-1 years 25000 IU (1 ampoule) every 8 weeks.
Prevention of deficiency 1-18 years 25000 IU (1 ampoule) every 6 weeks.
Treatment of deficiency 0-18 years 25000 IU (1 ampoule) once every 2 weeks for 6 weeks (followed by maintenance therapy of 400-1000 IU/day)
Pregnancy and breastfeeding: The high strength formulation is not recommended.
Adults: Prevention of vitamin D deficiency 25000 IU/month (1 ampoule), higher doses may be required in certain situations, see as follows.
As an adjunct to specific therapy for osteoporosis: 25000 IU/month (1 ampoule).
Treatment of vitamin D deficiency (<25 ng/ml) 50,000 IU (2 amp)/wk for 6-8 wk, followed by maintenance therapy (1,400-2,000 IU/day may be required); follow-up 25(OH)D measurements should be made approximately three to four months after initiating maintenance therapy to confirm that the target level has been achieved.
Certain populations are at high risk of vitamin D deficiency, and may require higher doses and monitoring of serum 25(OH)D: Institutionalised or hospitalised individuals; Dark skinned individuals; Individuals with limited effective sun exposure due to protective clothing or consistent use of sun screens; Obese individuals; Patients being evaluated for osteoporosis; Use of certain concomitant medications (e.g., anticonvulsant medications, glucocorticoids); Patients with malabsorption, including inflammatory bowel disease and coeliac disease; Those recently treated for vitamin D deficiency, and requiring maintenance therapy.
Symptoms of overdose: Ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3) have a relatively low therapeutic index. The threshold for vitamin D intoxication is between 40,000 and 100,000 IU daily for 1 to 2 months in adults with normal parathyroid function. Infants and small children may react sensitively to far lower concentrations. Therefore, it is warned against intake of vitamin D without medical supervision.
Overdose leads to increased serum and urinary phosphorus levels, as well as hypercalcaemic syndrome and consequently calcium deposits in the tissues and above all in the kidneys (nephrolithiasis, nephrocalcinosis) and the vessels.
Discontinue D-Cure when calcaemia exceeds 10.6 mg/dl (2.65 mmol/l) or if the calciuria exceeds 300 mg/24 hours in adults or 4-6 mg/kg/day in children.
Chronic overdosage may lead to vascular and organ calcification, as a result of hypercalcaemia.
The symptoms of intoxication are little characteristic and manifest as nausea, vomiting, initially also diarrhoea, later constipation, loss of appetite, weariness, headache, muscle pain, joint pain, muscle weakness, persistent sleepiness, azotaemia, polydipsia and polyuria and, in the final stage, dehydration. Typical biochemical findings include hypercalcaemia, hypercalciuria, as well as increased serum 25 hydroxycholecalciferol concentrations.
Treatment of overdose: Symptoms of chronic vitamin D overdosage may require forced diuresis as well as administration of glucocorticoids or calcitonin.
Overdosage requires measures for treating the - often persisting and under certain circumstances life-threatening - hypercalcaemia.
The first measure is to discontinue the vitamin D preparation; it takes several weeks to normalise hypercalcaemia caused by vitamin D intoxication.
Depending on the degree of hypercalcaemia, measures include a diet that is low in calcium or free of calcium, abundant liquid intake, increase of urinary excretion by means of the drug furosemide, as well as the administration of glucocorticoids and calcitonin.
If kidney function is adequate, calcium levels can be reliably lowered by infusions of isotonic sodium chloride solution (3-6 liters in 24 hours) with addition of furosemide and, in some circumstances, also 15 mg/kg body weight/hour sodium edetate accompanied by continuous calcium and ECG monitoring. In oligoanuria, in contrast, haemodialysis (calcium-free dialysate) is necessary.
No special antidote exists.
It is recommended to point out the symptoms of potential overdose to patients under chronic therapy with higher doses of vitamin D (nausea, vomiting, initially also diarrhoea, later constipation, anorexia, weariness, headache, muscle pain, joint pain, muscle weakness, persistent sleepiness, azotaemia, polydipsia and polyuria).
Hypersensitivity to the active substance(s) or to any of the excipients.
Hypercalcaemia and/or hypercalciuria.
Nephrolithiasis and/or nephrocalcinosis.
Serious renal impairment.
Pseudohypoparathyroidism as the vitamin D requirement may be reduced due to phases of normal vitamin D sensitivity, involving the risk of prolonged overdose. Better-regulatable vitamin D derivatives are available for this.
Vitamin D should be used with caution in patients with impairment of renal function and the effect on calcium and phosphate levels should be monitored. The risk of soft tissue calcification should be taken into account.
Caution is required in patients receiving treatment for cardiovascular disease (see Interactions).
D-Cure should be prescribed with caution in patients with sarcoidosis, due to a possible increase in the metabolism of vitamin D in its active form. In these patients the serum and urinary calcium levels should be monitored.
Allowances should be made for the total dose of vitamin D in cases associated with treatments already containing vitamin D, foods enriched with vitamin D, cases using milk enriched with vitamin D, and the patient's level of sun exposure.
There is no clear evidence for causation between vitamin D supplementation and renal stones, but the risk is plausible, especially in the context of concomitant calcium supplementation. The need for additional calcium supplementation should be considered for individual patients. Calcium supplements should be given under close medical supervision.
Oral administration of high-dose vitamin D (500,000 IU by single annual bolus) was reported to result in an increased risk of fractures in elderly subjects, with the greatest increase occurring during the first 3 months after dosing.
Effects on ability to drive and use machines: Not relevant.
In pregnancy and lactation the high strength formulation is not recommended and a low strength formulation should be used.
Pregnancy: There are no or limited amount of data from the use of cholecalciferol in pregnant women. Studies in animals have shown reproductive toxicity (see Toxicology: Preclinical safety data under Actions). The recommended daily intake for pregnant women is 400 IU, however, in women who are considered to be vitamin D deficient a higher dose may be required (up to 2000 IU/day).
During pregnancy women should follow the advice of their medical practitioner as their requirements may vary depending on the severity of their disease and their response to treatment vitamin D and its metabolites are excreted in breast milk.
Breast-feeding: Vitamin D can be prescribed while the patient is breast-feeding if necessary. This supplementation does not replace the administration of vitamin D in the neonate.
Injury, poisoning and procedural complications are the result of an incorrect route of drug administration, accidental overdose or exposure, or underdose.
The following adverse events can be observed (based on the post-marketing data source):
Confusional state, aggression, insomnia.
Nausea, abdominal pain, diarrhoea, vomiting, gastrointestinal disorder, dyspepsia.
Nervous system disorders:
Metabolism and nutrition disorders:
Hypercalcaemia, hypercalciuria, decreased appetite, tetany.
Skin and subcutaneous tissue disorders:
Pruritus, urticaria, rash, hyperhidrosis.
The side effects are the result of overdose.
Depending on the dose and duration of treatment, severe and prolonged hypercalcaemia with its acute (cardiac arrhythmias, nausea, vomiting, psychic symptoms, disturbances of consciousness) and chronic (increased urgency to urinate, increased thirst, loss of appetite, weight loss, kidney stones, kidney calcification, calcification in tissues outside the skeleton) consequences can occur. A fatal outcome has been reported in very rare cases. (See Precautions as well as Interactions. Furthermore, refer also to Overdosage).
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.
Concomitant use of anticonvulsants (such as phenytoin) or barbiturates (and possibly other drugs that induce hepatic enzymes) may reduce the effect of vitamin D3 by metabolic inactivation.
In cases of treatment with thiazide diuretics, which decrease urinary elimination of calcium, monitoring of serum calcium concentration is recommended.
Concomitant use of glucocorticoids can decrease the effect of vitamin D.
In cases of treatment with drugs containing digitalis and other cardiac glycosides, the administration of vitamin D may increases the risk of digitalis toxicity (arrhythmia). Strict medical supervision is needed, together with serum calcium concentration and electrocardiographic monitoring if necessary.
Simultaneous treatment with ion exchange resin such as cholestyramine, colestipol hydrochloride, orlistat or laxative such as paraffin oil may reduce the gastrointestinal absorption of vitamin D.
The cytotoxic agent actinomycin and imidazole antifungal agents interfere with vitamin D activity by inhibiting the conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D by the kidney enzyme, 25-hydroxyvitamin D-1-hydroxylase.
Special precautions for disposal and other handling: No special requirements.
Any unused product or waste material should be disposed of in accordance with local requirements.
Incompatibilities: Not applicable.
Do not store above 30°C. Protect from light.
Shelf-Life: 18 months.
A11CC05 - colecalciferol ; Belongs to the class of vitamin D and analogues. Used as dietary supplements.
Oral soln (amp) 25,000 IU (clear, slightly yellow, oily liquid with an orange odour) x 1 mL x 4's.