Ondansetron 2mg|Ml Solution For Injection
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Ondansetron 2mg/ml Solution for Injection
2. QUALITATIVE AND QUANTITATIVE COMPOSITION
Each 1mL contains ondansetron hydrochloride dihydrate equivalent to 2mg of ondansetron. Each 2mL polypropylene or glass ampoule contains 4mg of ondansetron.
Each 4mL polypropylene or glass ampoule contains 8mg of ondansetron.
Excipients with known effect: This medicinal product contains 2.3mmol (53.5mg) sodium per maximum daily dose of 32mg.
For the full list of excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Solution for injection.
Clear and colourless aqueous solution.
4.1 Therapeutic indications
Adults:
Ondansetron is indicated for the management of nausea and vomiting induced by cytotoxic chemotherapy and radiotherapy. Ondansetron is indicated for the prevention and treatment of post-operative nausea and vomiting (PONV).
Paediatric Population:
Ondansetron is indicated for the management of chemotherapy-induced nausea and vomiting (CINV) in children aged >6 months, and for the prevention and treatment of PONV in children aged >1 month.
4.2 Posology and method of administration
Chemotherapy and Radiotherapy induced nausea and vomiting:
Adults:
The emetogenic potential of cancer treatment varies according to the doses and combinations of chemotherapy and radiotherapy regimens used. The route of administration and dose of Ondansetron should be flexible in the range of 8 - 32mg a day and selected as shown below. Emetogenic chemotherapy and radiotherapy: Ondansetron can be given either by intravenous or intramuscular administration.
For patients receiving emetogenic chemotherapy or radiotherapy, Ondansetron can be given either by intravenous or other routes of administration. However this product is for injection only.
The recommended dose of Ondansetron is 8mg administered as a slow intravenous or intramuscular injection immediately before treatment or as a short-time infusion over 15 minutes, followed by treatment with dosage forms other than intravenous or intramuscular. Treatment for up to 5 days with dosage forms other than intravenous or intramuscular is recommended to protect against delayed or polonged emesis afther the first 24 hours.
Highly emetogenic chemotherapy: For patients receiving highly emetogenic chemotherapy, e.g. high-dose cisplatin, ondansetron can be given either by intravenous or other routes of administration.
Ondansetron has been shown to be equally effective in the following dose schedules over the first 24 hours of chemotherapy:
- A single dose of 8mg by slow intravenous injection (in not less than 30 seconds) or intramuscular injection immediately before chemotherapy.
- A dose of 8mg by slow intravenous injection (in not less than 30 seconds) or intramuscular injection immediately before chemotherapy, followed by two further intravenous injections ( in not less than 30 seconds) or intramuscular doses of 8mg four hours apart, or by a constant infusion of 1mg/hour for up to 24 hours.
- A maximum initial intravenous dose of 16mg diluted in 50-100ml of saline or other compatible infusion fluid (see section 6.6) and infused over not less than 15 minutes immediately before chemotherapy. The initial dose of Ondansetron may be followed by two additional 8mg intravenous doses (in not less than 30 seconds) or intramuscular doses four hours apart.
A single dose greater than 16 mg must not be given due to dose dependent increase of QT-prolongation risk (see sections 4.4, 4.8 and 5.1).
The selection of dose regimen should be determined by the severity of the emetogenic challenge.
The efficacy of Ondansetron in highly emetogenic chemotherapy may be enhanced by the addition of a single intravenous dose of dexamethasone sodium phosphate, 20mg administered prior to chemotherapy.
To protect against delayed or prolonged emesis after the first 24 hours, oral or rectal treatment with Ondansetron should be continued for up to 5 days after a course of treatment.
Paediatric Population:
CINV in children aged > 6 months and adolescents
The dose for CINV can be calculated based on body surface area (BSA) or weight - see below. In paediatric clinical studies, ondansetron was given by IV infusion diluted in 25 to 50mL of saline or other compatible infusion fluid and infused over not less than 15 minutes. Weight-based dosing results in higher total daily doses compared to BSA-based dosing (sections 4.4 and 5.1).
Ondansetron injection should be diluted in 5% dextrose or 0.9% sodium chloride or other compatible infusion fluid (see section 6.6) and infused intravenously over not less than 15 minutes.
There are no data from controlled clinical trials on the use of Ondansetron in the prevention of delayed or prolonged CINV. There are no data from controlled clinical trials on the use of Ondansetron for
radiotherapy-induced nausea and vomiting in children.
Dosing by BSA:
Ondansetron should be administered immediately before chemotherapy as a single intravenous dose of 5mg/m2. The single intravenous dose must not exceed 8mg.
Oral dosing can commence twelve hours later and may be continued for up to 5 days (Table 1).
The total dose over 24 hours (given as divided doses) must not exceed adult dose of 32mg.
Table 1: BSA-based dosing for Chemotherapy - Children aged >6 months and adolescents
|
BSA |
Day 1 (a,b) |
Days 2 - 6 (b) |
|
< 0.6 m2 |
5mg/m2 i.v. plus 2mg syrup after 12h |
2mg syrup every 12h |
|
> 0.6 m2 to < 1.2 m2 |
5mg/m2 i.v. plus 4mg syrup or tablet after 12h |
4mg syrup or tablet every 12h |
|
>1.2m2 |
5mg/m2 or 8mg i.v. plus 8mg syrup or tablet after 12 hours |
8mg syrup or tablet every 12 hours |
a The intravenous dose must not exceed 8mg.
b The total dose over 24 hours (given as divided doses) must not exceed adult dose of 32mg.
Dosing by bodyweight:
Weight-based dosing results in higher total daily doses compared to BSA-based dosing (sections 4.4 and 5.1).
Ondansetron should be administered immediately before chemotherapy as a single intravenous dose of 0.15mg/kg. The signle intravenous dose must not exceed 8mg.
Two further intravenous doses may be given in 4-hourly intervals.
Oral dosing can commence twelve hours later and may be continued for up to 5 days (Table 2).
The total dose over 24 hours (given as divided doses) must not exceed adult dose of 32 mg. Table 2: Weight-based dosing for Chemotherapy - Children aged >6 months and adolescents
|
Weight |
Day 1 (a,b) |
Days 2 - 6 (b) |
|
< 10Kg |
Up to 3 doses of 0.15mg/kg IV every 4h |
2mg syrup every 12h |
|
> 10Kg |
Up to 3 doses of 0.15mg/kg IV every 4h |
4mg syrup or tablet every 12h |
a The intravenous dose must not exceed 8mg.
b The total dose over 24 hours (given as divided doses) must not exceed adult dose of 32mg.
Elderly:
In patients 65 to 74 years of age, the dose schedule for adults can be followed. All intravenous doses should be diluted in 50-100 mL of saline or other compatible infusion fluid (see section 6.6) and infused over at least 15 minutes.
In patients 75 years of age or older, the initial intravenous dose of Ondansetron must not exceed 8 mg. All intravenous doses should be diluted in 50-100 mL of saline or other compatible infusion fluid (see section 6.6) and infused over 15 minutes. The initial dose of 8 mg may be followed by two further intravenous doses of 8 mg, infused over 15 minutes and given no less than four hours apart. (see section 5.2)
Patients with Renal Impairment:
No alteration of daily dosage or frequency of dosing, or route of administration are required. Patients with Hepatic Impairment:
Clearance of ondansetron is significantly reduced and serum half-life significantly prolonged in subjects with moderate or severe impairment of hepatic function. In such patients a total daily dose of 8mg should not be exceeded and therefore parenteral or oral administration is recommended.
Patients with Poor Sparteine/Debrisoquine Metabolism:
The elimination half-life of ondansetron is not altered in subjects classified as poor metabolisers of sparteine and debrisoquine. Consequently in such patients repeat dosing will give drug exposure levels no different from those of the general population. No alteration of daily dosage or frequency of dosing is required.
Post-operative nausea and vomiting (PONV):
Adults:
For the prevention of PONV ondansetron can be administered orally or by intravenous or intramuscular injection.
Ondansetron may be administered as a single dose of 4mg given by intramuscular or slow intravenous injection at induction of anaesthesia.
For treatment of established PONV a single dose of 4mg given by intramuscular or slow intravenous injection is recommended.
Paediatric Population:
PONV in children aged > 1 month and adolescents
For prevention of PONV in paediatric patients having surgery performed under general anaesthesia, a single dose of ondansetron may be administered by slow intravenous injection (not less than 30 seconds) at a dose of 0.1mg/kg up to a maximum of 4mg either prior to, at or after induction of anaesthesia.
For the treatment of PONV after surgery in paediatric patients having surgery performed under general anaesthesia, a single dose of ondansetron may be administered by slow intravenous injection (not less than 30 seconds) at a dose of 0.1mg/kg up to a maximum of 4mg.
There are no data on the use of ondansetron in the treatment of PONV in children below 2 years of age.
Elderly:
There is limited experience in the use of ondansetron in the prevention and treatment of PONV in the elderly, however, ondansetron is well tolerated in patients over 65 years receiving chemotherapy.
Patients with renal impairment:
No alteration of daily dosage or frequency of dosing, or route of administration are required. Patients with hepatic impairment:
Clearance of ondansetron is significantly reduced and serum half life significantly prolonged in subjects with moderate or severe impairment of hepatic function. In such patients a total daily dose of 8mg should not be exceeded.
Patients with poor sparteine/debrisoquine metabolism:
The elimination half-life of ondansetron is not altered in subjects classified as poor metabolisers of sparteine and debrisoquine. Consequently in such patients repeat dosing will give drug exposure levels no different from those of the general population. No alteration of daily dosage or frequency of dosing are required.
4.3 Contraindications
Concomitant use with apomorphine (see section 4.5).
Hypersensitivity to ondansetron or to any of the excipients of the preparation.
4.4 Special warnings and precautions for use
Hypersensitivity reactions have been reported in patients who have exhibited hypersensitivity to other selective 5-HT3 receptor antagonists. Respiratory events should be treated symptomatically and clinicians should pay particular attention to them as precursors of hypersensitivity reactions.
Ondansetron prolongs the QT interval in a dose-dependent manner (see section 5.1). In addition, post-marketing cases of Torsade de Pointes have been reported in patients using ondansetron. Avoid ondansetron in patients with congenital long QT syndrome. Ondansetron should be administered with caution to patients who have or may develop prolongation of QTc, including patients with electrolyte abnormalities, congestive heart failure, bradyarrhythmias or patients taking other medicinal products that lead to QT prolongation or electrolyte abnormalities.
Hypokalaemia and hypomagnesaemia should be corrected prior to ondansetron administration.
There have been post-marketing reports describing patients with serotonin syndrome (including altered mental status, autonomic instability and neuromuscular abnormalities) following the concomitant use of ondansetron and other serotonergic drugs (including selective serotonin reuptake inhibitors (SSRI) and serotonin noradrenaline reuptake inhibitors (SNRIs)). If concomitant treatment with ondansetron and other serotonergic drugs is clinically warranted, appropriate observation of the patient is advised.
As ondansetron is known to increase large bowel transit time, patients with signs of sub-acute intestinal obstruction should be monitored following administration.
In patients with adenotonsillar surgery prevention of nausea and vomiting with ondansetron may mask occult bleeding. Therefore, such patients should be followed carefully after ondansetron administration.
This medicinal product contains 2.3mmol (53.5mg) sodium per maximum daily dose of 32mg. To be taken into consideration by patients on a controlled sodium diet.
Paediatric Population:
Paediatric patients receiving ondansetron with hepatotoxic chemotherapeutic agents should be monitored closely for impaired hepatic function.
CINV
When calculating the dose on an mg/kg basis and administering three doses at 4-hour intervals, the total daily dose will be higher than if one single dose of 5mg/m2 followed by an oral dose is given. The comparative efficacy of these two different dosing regimens has not been investigated in clinical trials. Cross-trial comparison indicates similar efficacy for both regimens (section 5.1).
4.5 Interaction with other medicinal products and other forms of interaction
There is no evidence that ondansetron either induces or inhibits the metabolism of other drugs commonly co-administered with it. Specific studies have shown that there are no interactions when ondansetron is administered with alcohol, temazepam, furosemide, alfentanil, tramadol, morphine, lidocaine, propofol or thiopental.
Ondansetron is metabolised by multiple hepatic cytochrome P-450 enzymes: CYP3A4, CYP2D6 and CYP1A2. Due to the multiplicity of metabolic enzymes capable of metabolising ondansetron, enzyme inhibition or reduced activity of one enzyme (e. g. CYP2D6 genetic
deficiency) is normally compensated by other enzymes and should result in little or no significant change in overall ondansetron clearance or dose requirement.
Caution should be exercised when ondansetron is coadministered with drugs that prolong the QT interval and/or cause electrolyte abnormalities. (see section 4.4)
Use of ondansetron with QT prolonging drugs may result in additional QT prolongation. Concomitant use of ondansetron with cardiotoxic drugs (e.g. anthracyclines (such as doxorubicin, daunorubicin) or trastuzumab), antibiotics (such as erythromycin), antifungals (such as ketoconazole), antiarrhythmics (such as amiodarone) and beta blockers (such as atenolol or timolol) may increase the risk of arrhythmias. (See section 4.4).
Serotonergic Drugs (e.g. SSRIs and SNRIs): There have been post-marketing reports describing patients with serotonin syndrome (including altered mental status, autonomic instability and neuromuscular abnormalities) following the concomitant use of ondansetron and other serotonergic drugs (including SSRIs and SNRIs). (See section 4.4)
Apomorphine: Based on reports of profound hypotension and loss of consciousness when ondansetron was administered with apomorphine hydrochloride, concomitant use with apomorphine is contraindicated.
Phenytoin, carbamazepine and rifampicin:
In patients treated with potent inducers of CYP3A4 (i.e. phenytoin,carbamazepine and rifampicin), the oral clearance of ondansetron was increased and ondansetron blood concentrations were decreased.
Tramadol: Data from small studies indicate that ondansetron may reduce the analgesic effect of tramadol.
4.6 Fertility, pregnancy and lactation
Pregnancy:
The safety of ondansetron for use in human pregnancy has not been established. Evaluation of experimental animal studies does not indicate direct or indirect harmful effects with respect to the development of the embryo, or foetus, the course of gestation and peri- and post-natal development. However as animal studies are not always predictive of human response, the use of ondansetron in pregnancy is not recommended.
Breast-feeding
Tests have shown that ondansetron passes into the milk of lactating animals. It is therefore recommended that mothers receiving ondansetron should not breast-feed their babies.
Fertility
There is no information on the effects of ondansetron on human fertility.
4.7 Effects on ability to drive and use machines
In psychomotor testing ondansetron does not impair performance nor cause sedation.
No detrimental effects on such activities are predicted from the pharmacology of ondansetron.
4.8 Undesirable effects
Adverse events are listed below by system organ class and frequency.
Frequencies are defined as:
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) and very rare: (<1/10,000).
Very common, common and uncommon events were generally determined from clinical trial data. The incidence in placebo was taken into account. Rare and very rare events were generally determined from post-marketing spontaneous data.
The following frequencies are estimated at the standard recommended doses of ondansetron. The adverse event profiles in children and adolescents were comparable to that seen in adults.
|
Immune system t |
isorders |
|
Rare: |
Immediate hypersensitivity reactions sometimes severe, including anaphylaxis. |
|
Nervous system t |
isorders |
|
Very common: |
Headache. |
|
Uncommon: |
Seizures, movement disorders (including extrapyramidal reactions such as dystonic reactic oculogyric crisis and dyskinesia)(1). |
|
Rare: |
Dizziness predominantly during rapid IV administration. |
|
Eye disorders | |
|
Rare: |
Transient visual disturbances (eg. blurred vision) predominantly during IV administration. |
|
Very rare: |
Transient visual disturbances, predominantly during intravenous administration.1-2-1 |
|
Cardiac disorders | |
|
Uncommon: |
Arrhythmias, chest pain with or without ST segment depression, bradycardia. |
|
Rare: |
QTc prolongation (including Torsade de Pointes). |
|
Vascular disorders | |
|
Common: |
Sensation of warmth or flushing. |
|
Uncommon: |
Hypotension. |
|
Respiratory, thoracic and mediastinal disorders | |
|
Uncommon: |
Hiccups. |
|
Gastrointestinal disorders | |
|
Common: |
Constipation. |
|
Hepatobiliary disorders | |
|
Uncommon: |
Asymptomatic increases in liver function tests(3). |
|
General disorders and administration site conditions | |
|
Common: |
Local IV injection site reactions. |
1. Observed without definitive evidence of persistent clinical sequelae.
2. The majority of the blindness cases reported resolved within 20 minutes. Most patients had received chemotherapeutic agents, which included cisplatin. Some cases of transient blindness were reported as cortical in origin.
3. These events were observed commonly in patients receiving chemotherapy with cisplatin. 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. Healthcare professionals are asked to report any suspected adverse reactions via For UK: Yellow Card Scheme, Website: (www.mhra.gov.uk/yellowcard).
For IE: HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2, Tel: +353 1 6764971, Fax: +353 1 6762517, Website: www. hpra.ie, E-mail: medsafety@hpra.ie.
4.9 Overdose
Symptoms and Signs
There is limited experience of ondansetron overdose. In the majority of cases, symptoms were similar to those already reported in patients receiving recommended doses (see section 4.8). Manifestations that have been reported include visual disturbances, severe constipation, hypotension and a vasovagal episode with transient second degree AV block.
Ondansetron prolongs the QT interval in a dose-dependent fashion. ECG monitoring is recommended in cases of overdose.
Treatment
There is no specific antidote for ondansetron, therefore in all cases of suspected overdose, symptomatic and supportive therapy should be given as appropriate.
The use of ipecacuanha to treat overdose with ondansetron is not recommended, as patients are unlikely to respond due to the anti-emetic action of ondansetron itself.
Paediatric population
Paediatric cases consistent with serotonin syndrome have been reported after inadvertent oral overdoses of ondansetron (exceeded estimated ingestion of 4 mg/kg) in infants and children aged 12 months to 2 years.
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Antiemetics and antinauseants, Serotonin (5-HT3) antagonists ATC Code: A04AA01
Mechanism of Action
Ondansetron is a potent, highly selective 5-HT3 receptor-antagonist. Its precise mode of action in the control of nausea and vomiting is not known. Chemotherapeutic agents and radiotherapy may cause release of 5-HT in the small intestine initiating a vomiting reflex by activating vagal afferents via 5-HT3 receptors. Ondansetron blocks the initiation of this reflex. Activation of vagal afferents may also cause a release of 5-HT in the area postrema, located on the floor of the fourth ventricle, and this may also promote emesis through a central mechanism. Thus, the effect of ondansetron in the management of the nausea and vomiting induced by cytotoxic chemotherapy and radiotherapy is probably due to antagonism of 5-HT3 receptors on neurons located both in the peripheral and central nervous system. The mechanisms of action in post-operative nausea and vomiting are not known but there may be common pathways with cytotoxic induced nausea and vomiting.
Ondansetron does not alter plasma prolactin concentrations. The role of ondansetron in opiate-induced emesis is not yet established.
QT Prolongation
The effect of ondansetron on the QTc interval was evaluated in a double blind, randomised, placebo and positive (moxifloxacin) controlled, crossover study in 58 healthy adult men and women. Ondansetron doses included 8 mg and 32 mg infused intravenously over 15 minutes. At the highest tested dose of 32 mg, the maximum mean (upper limit of 90% CI) difference in QTcF from placebo after baseline-correction was 19.6 (21.5) msec. At the lower tested dose of 8 mg, the maximum mean (upper limit of 90% CI) difference in QTcF from placebo after baseline-correction was 5.8 (7.8) msec. In this study, there were no QTcF measurements greater than 480 msec and no QTcF prolongation was greater than 60 msec. No significant changes were seen in the measured electrocardiographic PR or QRS intervals.
Paediatric population
CINV
The efficacy of ondansetron in the control of emesis and nausea induced by cancer chemotherapy was assessed in a double-blind randomised trial in 415 patients aged 1 to 18 years (S3AB3006). On the days of chemotherapy, patients received either ondansetron 5mg/m2 intravenous and ondansetron 4mg orally after 8 to 12 hours or ondansetron 0.45mg/kg intravenous and placebo orally after 8 to 12 hours. Post-chemotherapy both groups received 4mg ondansetron syrup twice daily for 3 days. Complete control of emesis on worst day of chemotherapy was 49% (5mg/m2 intravenous and ondansetron 4mg orally) and 41% (0.45mg/kg intravenous and placebo orally). Post-chemotherapy both groups received 4mg ondansetron syrup twice daily for 3 days. There was no difference in the overall incidence or nature of adverse events between the two treatment groups.
A double-blind randomised placebo-controlled trial (S3AB4003) in 438 patients aged 1 to 17 years demonstrated complete control of emesis on worst day of chemotherapy in:
• 73% of patients when ondansetron was administered intravenously at a dose of 5mg/m2 intravenous together with 2 to 4mg dexamethasone orally
• 71% of patients when ondansetron was administered as syrup at a dose of 8mg together with 2 to 4mg dexamethasone orally on the days of chemotherapy.
Post-chemotherapy both groups received 4mg ondansetron syrup twice daily for 2 days. There was no difference in the overall incidence or nature of adverse events between the two treatment groups.
The efficacy of ondansetron in 75 children aged 6 to 48 months was investigated in an open-label, non-comparative, single-arm study (S3A40320). All children received three 0.15mg/kg doses of intravenous ondansetron, administered 30 minutes before the start of chemotherapy and then at 4 and 8 hours after the first dose. Complete control of emesis was achieved in 56% of patients.
Another open-label, non-comparative, single-arm study (S3A239) investigated the efficacy of one intravenous dose of 0.15mg/kg ondansetron followed by two oral ondansetron doses of 4mg for children aged < 12 years and 8mg for children aged > 12 years (total no. of children n= 28). Complete control of emesis was achieved in 42% of patients.
PONV
The efficacy of a single dose of ondansetron in the prevention of post-operative nausea and vomiting was investigated in a randomised, double-blind, placebo-controlled study in 670 children aged 1 to 24 months (post-conceptual age >44 weeks, weight > 3 kg). Included subjects were scheduled to undergo elective surgery under general anaesthesia and had an ASA status < III. A single dose of ondansetron 0.1mg/kg was administered within five minutes following induction of anaesthesia. The proportion of subjects who experienced at least one emetic episode during the 24-hour assessment period (ITT) was greater for patients on placebo than those receiving ondansetron (28% vs. 11%, p <0.0001).
Four double-blind, placebo-controlled studies have been performed in 1469 male and female patients (2 to 12 years of age) undergoing general anaesthesia. Patients were randomised to either single intravenous doses of ondansetron (0.1mg/kg for paediatric patients weighing 40 kg or less, 4mg for paediatric patients weighing more than 40 kg; number of patients= 735) or placebo (number of patients = 734). Study drug was administered over at least 30 seconds, immediately prior to or following anaesthesia induction. Ondansetron was significantly more effective than placebo in preventing nausea and vomiting. The results of these studies are summarised in Table 3.
Table 3: Prevention and treatment of PONV in Paediatric Patients - Treatment response over 24 hours
|
Study |
Endpoint |
Ondansetron % |
Placebo |
p value |
|
S3A380 |
CR |
68 |
39 |
<0.001 |
|
S3GT09 |
CR |
61 |
35 |
<0.001 |
|
S3A381 |
CR |
53 |
17 |
<0.001 |
|
S3GT11 |
no nausea |
64 |
51 |
0.004 |
|
S3GT11 |
no emesis |
60 |
47 |
0.004 |
CR = no emetic episodes, rescue or withdrawal
5.2 Pharmacokinetic properties
Following oral administration, ondansetron is passively and completely absorbed from the gastrointestinal tract and undergoes first pass metabolism. Peak plasma concentrations of about 30ng/mL are attained approximately 1.5 hours after an 8mg dose. For doses above 8mg the increase in ondansetron systemic exposure with dose is greater than proportional; this may reflect some reduction in first pass metabolism at higher oral doses. Mean bioavailability in healthy male subjects, following the oral administration of a single 8 mg tablet, is approximately 55 to 60%. Bioavailability, following oral administration, is slightly enhanced by the presence of food but unaffected by antacids. Studies in healthy elderly volunteers have shown slight, but clinically insignificant, age-related increases in both oral bioavailability (65%) and half-life (5 hours) of ondansetron. The disposition of ondansetron following oral, intramuscular and intravenous dosing in adults is similar with a terminal half life of about 3 hours and steady state volume of distribution of about 140L. Equivalent systemic exposure is achieved after intramuscular and intravenous administration of ondansetron.
A 4mg intravenous infusion of ondansetron given over 5 minutes results in peak plasma concentrations of about 65ng/mL. Following intramuscular administration of ondansetron, peak plasma concentrations of about 25ng/mL are attained within 10 minutes of injection. Following administration of ondansetron suppository, plasma ondansetron concentrations become detectable between 15 and 60 minutes after dosing. Concentrations rise in an essentially linear fashion, until peak concentrations of 20 - 30ng/mL are attained, typically 6 hours after dosing. Plasma concentrations then fall, but at a slower rate than observed following oral dosing due to continued absorption of ondansetron.The absolute bioavailability of ondansetron from the suppository is approximately 60% and is not affected by gender. The half life of the elimination phase following suppository administration is determined by the rate of ondansetron absorption, not systemic clearance and is approximately 6 hours. Females show a small, clinically insignificant, increase in half-life in comparison with males. Ondansetron is not highly protein bound (70 - 76%). Ondansetron is cleared from the systemic circulation predominantly by hepatic metabolism through multiple enzymatic pathways. Less than 5% of the absorbed dose is excreted unchanged in the urine. The absence of the enzyme CYP2D6 (the debrisoquine polymorphism) has no effect on ondansetron's pharmacokinetics. The pharmacokinetic properties of ondansetron are unchanged on repeat dosing.
Special Patient Populations Gender
Gender differences were shown in the disposition of ondansetron, with females having a greater rate and extent of absorption following an oral dose and reduced systemic clearance and volume of distribution (adjusted for weight).
Children and Adolescents (aged 1 month to 17years)
In paediatric patients aged 1 to 4 months (n=19) undergoing surgery, weight normalised clearance was approximately 30% slower than in patients aged 5 to 24 months (n=22) but comparable to the patients aged 3 to 12 years. The half-life in the patient population aged 1 to 4 month was reported to average 6.7 hours compared to 2.9 hours for patients in the 5 to 24 month and 3 to 12 year age range. The differences in pharmacokinetic parameters in the 1 to 4 month patient population can be explained in part by the higher percentage of total body water in neonates and infants and a higher volume of distribution for water soluble drugs like ondansetron.
In paediatric patients aged 3 to 12 years undergoing elective surgery with general anaesthesia, the absolute values for both the clearance and volume of distribution of ondansetron were reduced in comparison to values with adult patients. Both parameters increased in a linear fashion with weight and by 12 years of age, the values were approaching those of young adults. When clearance and volume of distribution values were normalised by body weight, the values for these parameters were similar between the different age group populations. Use of weight-based dosing compensates for age-related changes and is effective in normalising systemic exposure in paediatric patients.
Population pharmacokinetic analysis was performed on 428 subjects (cancer patients, surgery patients and healthy volunteers) aged 1 month to 44 years following intravenous administration of ondansetron. Based on this analysis, systemic exposure (AUC) of ondansetron following oral or IV dosing in children and adolescents was comparable to adults, with the exception of infants aged 1 to 4 months. Volume was related to age and was lower in adults than in infants and children. Clearance was related to weight but not to age with the exception of infants aged 1 to 4 months. It is difficult to conclude whether there was an additional reduction in clearance related to age in infants 1 to 4 months or simply inherent variability due to the low number of subjects studied in this age group. Since patients less than 6 months of age will only receive a single dose in PONV a decreased clearance is not likely to be clinically relevant.
Elderly
Early Phase I studies in healthy elderly volunteers showed a slight age-related decrease in clearance, and an increase in half-life of ondansetron. However, wide inter-subject variability resulted in considerable overlap in pharmacokinetic parameters between young (< 65 years of age) and elderly subjects (> 65 years of age) and there were no overall differences in safety or efficacy observed between young and elderly cancer patients enrolled in CINV clinical trials to support a different dosing recommendation for the elderly.
Based on more recent ondansetron plasma concentrations and exposure-response modelling, a greater effect on QTcF is predicted in patients >75 years of age compared to young adults. Specific dosing information is provided for patients over 65 years of age and over 75 years of age for IV dosing (see section 4.2).
Renal Impairment
In patients with renal impairment (creatinine clearance 15 - 60mL/min), both systemic clearance and volume of distribution are reduced following IV administration of ondansetron, resulting in a slight, but clinically insignificant, increase in elimination half-life (5.4 hours). A study in patients with severe renal impairment who required regular haemodialysis (studied between dialyses) showed ondansetron's pharmacokinetics to be essentially unchanged following intravenous administration.
Hepatic Impairment
Following oral, intravenous or intramuscular dosing in patients with severe hepatic impairment, ondansetron's systemic clearance is markedly reduced with prolonged elimination half-lives (15 to 32 hours) and an oral bioavailability approaching 100% due to reduced pre-systemic metabolism. The pharmacokinetics of ondansetron following administration as a suppository have not been evaluated in patients with hepatic impairment.
5.3 Preclinical safety data
No additional data of relevance.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Citric acid monohydrate Sodium citrate dihydrate Sodium chloride Water for injections
6.2 Incompatibilities
Ondansetron injection should not be administered in the same syringe or infusion as any other medication. This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.
6.3 Shelf life
Unopened :2 years
After dilution:
Chemical and physical in-use stability has been demonstrated for 24 hours stored at 25°C and 36 hours stored in a refrigerator (2-8°C). Dilutions of Ondansetron injection in compatible intravenous infusion fluids are stable under normal room lighting conditions or daylight for at least 24 hours, thus no protection from light is necessary while infusion takes place.
From a microbiological point of view, unless the method of opening or dilution 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.
6.4 Special precautions for storage
Store below 25°C. Store the product in the original package in order to protect from light
For storage conditions of the diluted medicinal product, see section 6.3.
6.5. Nature and contents of container
2ml or 4ml Polypropylene blow-fill-sealed ampoules with a twist-off top or clear colourless, glass (Ph.Eur., type I) ampoules.
The plastic ampoules are overwrapped in aluminium foil blisters and placed in cartons. The glass ampoules are placed in plastic cases inside cartons.
Packs of 5 ampoules.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
Ondansetron should not be autoclaved.
Compatibility with intravenous fluids
Ondansetron injection should only be mixed with those infusion solutions which are recommended:
|
Diluent |
Resulting concentration of ondansetron |
|
Sodium Chloride Intravenous Infusion BP 0.9%w/v |
0.16mg/mL |
|
Glucose Intravenous Infusion BP 5%w/v |
0.16mg/mL |
|
Mannitol Intravenous Infusion BP 10%w/v |
0.16mg/mL |
|
Ringers Intravenous Infusion |
0.16mg/mL |
|
Potassium Chloride 0.3%w/v and Sodium Chloride 0.9%w/v Intravenous Infusion BP |
0.16mg/mL |
|
Potassium Chloride 0.3%w/v and Glucose 5%w/v Intravenous Infusion BP |
0.16mg/mL |
In complying with good pharmaceutical practice, dilutions of ondansetron injection in intravenous fluids should be prepared at the time of infusion. However, it has been demonstrated that dilutions of ondansetron in polyethylene bottles with the following intravenous infusion fluids remain stable for 24 hours at room temperature (25±2°C) or for 36 hours in the refrigerator (2 - 8°C).
Compatibility with other drugs
Ondansetron may be administered by intravenous infusion at lmg/hour, e.g. from an infusion bag or syringe pump. The following drugs may be administered via the Y-site of an infusion set for ondansetron concentrations of 16 to 160 micrograms/mL (e.g. 8mg/500mL and 8mg/50mL respectively):
Cisplatin:
Concentrations up to 0.48mg/mL (e.g. 240mg in 500mL) administered over one to eight hours.
5-Fluorouracil:
Concentrations up to 0.8mg/mL (e.g. 2.4g in 3 litres or 400mg in 500mL) administered at a rate of at least 20mL per hour (500mL per 24 hours). Higher concentrations of 5-fluorouracil may cause precipitation of ondansetron. The 5-fluorouracil infusion may contain up to 0.045%w/v magnesium chloride in addition to other excipients shown to be compatible.
Carboplatin:
Concentrations in the range 0.18mg/mL to 9.9mg/mL (e.g. 90mg in 500mL to 990mg in 100mL), administered over ten minutes to one hour.
Etoposide:
Concentrations in the range 0.14mg/mL to 0.25mg/mL (e.g. 72mg in 500mL to 250mg in 1L), administered over thirty minutes to one hour.
Ceftazidime:
Doses in the range 250mg to 2000mg reconstituted with Water for Injections BP as recommended by the manufacturer (e.g. 2.5mL for 250mg and 10mL for 2g ceftazidime) and given as an intravenous bolus injection over approximately five minutes.
Cyclophosphamide:
Doses in the range 100mg to 1g, reconstituted with Water for Injections BP, 5mL per 100mg cyclophosphamide, as recommended by the manufacturer and given as an intravenous bolus injection over approximately five minutes.
Doxorubicin:
Doses in the range 10 - 100mg reconstituted with Water for Injections BP, 5mL per 10mg doxorubicin, as recommended by the manufacturer and given as an intravenous bolus injection over approximately 5 minutes.
Dexamethasone:
Dexamethasone sodium phosphate 20mg may be administered as a slow intravenous injection over 2 - 5 minutes via the Y-site of an infusion set delivering 8 or 16mg of ondansetron diluted in 50 - 100mL of a compatible infusion fluid over approximately 15 minutes. Compatibility between dexamethasone sodium phosphate and ondansetron has been demonstrated supporting administration of these drugs through the same giving set resulting in concentrations in line of 32 microgram - 2.5 mg/mL for dexamethasone sodium phosphate and 8 microgram - 1mg/mL for ondansetron.
Any unused product or waste material should be disposed of in accordance with local requirements.
7 MARKETING AUTHORISATION HOLDER
Noridem Enterprises Ltd (trading as Fannin)
Evagorou & Makariou Mitsi Building 3 Suit. 115, 1065 Nicosia Cyprus
Tel: +357 22 451 555 Fax: +357 22 67 70 69.
8 MARKETING AUTHORISATION NUMBER(S)
PL 24598/0010
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
03/06/2008
10 DATE OF REVISION OF THE TEXT
15/04/2016