Iron overdosage is dangerous and can be life-threatening in young children, requiring immediate attention.
Symptoms of iron overdose
Early signs and symptoms include nausea, vomiting, abdominal pain and diarrhoea. The vomit and stools may be grey or black. In mild cases early features improve but in more serious cases there may be evidence of hypoperfusion (cool peripheries and hypotension), metabolic acidosis and systemic toxicity. In serious cases there can be recurrence of vomiting and gastrointestinal bleeding, 12 hours after ingestion. Shock can result from hypovolaemia or direct cardiotoxicity. Evidence of hepatocellular necrosis appears at this stage with jaundice, bleeding, hypoglycaemia, encephalopathy and positive anion gap metabolic acidosis. Poor tissue perfusion may lead to renal failure. Rarely, gastric scarring causing stricture or pyloric stenosis (alone or in combination) may lead to partial or complete bowel obstruction 2-5 weeks after ingestion.
Ingestion of 20 mg/kg elemental iron is potentially toxic and 200-250 mg/kg is potentially fatal. No single method of assessment is entirely satisfactory - clinical features as well as laboratory analysis must be taken into account. Serum iron levels measured at about 4 hours after ingestion is the best laboratory measure of severity.
Management
Supportive and symptomatic measures reflecting best standard medical care should be implemented. The use of desferroxamine should be considered: for detailed information see product information provided by the manufacturer. Haemodialysis does not remove iron effectively but should be considered on a supportive basis for acute renal failure as this will facilitate removal of the iron-desferroxamine complex.
18 months
Shelf-life after first opening container: 45 days.
-
- Haemochromatosis and other iron overload syndromes.
- Patients receiving repeated blood transfusions.
Not applicable.
Capsule contents:
Lactose monohydrate
Sodium laurilsulfate
Magnesium stearate
Colloidal anhydrous silica
Crospovidone (Type A)
Capsule shell:
Gelatin
Brilliant Blue (E133)
Allura Red AC (E129)
Titanium dioxide (E171)
Sunset Yellow FCF (E110)
Capsules, hard.
Red capsule (19 mm long x 7 mm diameter).
Summary of the safety profile
The most frequently reported adverse reactions were gastrointestinal symptoms (abdominal pain [8%], flatulence [4%], constipation [4%], abdominal discomfort [2%]/distension [2%] and diarrhoea [3%]) and these were mainly mild to moderate in severity. Reported severe adverse reactions were abdominal pain [4%], constipation [0.9%] and diarrhoea [0.9%].
Tabulated list of adverse reactions
Table 1 presents all adverse reactions occurring during the 12 week controlled phase and during the 52 week extension phase in subjects with IBD treated with Feraccru.
Adverse reaction frequencies are defined as: very common (>1/10), common (>1/100, <1/10), uncommon (>1/1,000, <1/100), rare (>1/10,000, <1/1,000) or very rare (<1/10000).
Table 1: Adverse reactions observed during the 12 week controlled phase of study AEGIS 1/2 and the 52 week extension phase in subjects with IBD
|
SYSTEM ORGAN CLASS |
COMMON (> 1/100 to < 1/10) |
UNCOMMON (> 1/1000 to < 1/100) |
|
Nervous system disorders |
Headache | |
|
Gastrointestinal disorders |
Abdominal pain (including upper abdomen) Flatulence Constipation Abdominal discomfort/ distension Diarrhoea Nausea |
Small intestinal bacterial overgrowth Vomiting |
|
Skin and subcutaneous tissue disorders |
Acne Erythema | |
|
Musculoskeletal and connective tissue disorders |
Joint stiffness Pain in extremity | |
|
General disorders and administration site conditions |
Thirst | |
|
Investigations |
Blood alkaline phosphatase increased Blood thyroid stimulating hormone increased Gamma-glutamyltransferase increased |
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 Yellow Card Scheme (Website: www.mhra.gov.uk/yellowcard).
Ferric maltol
Non-clinical studies revealed no special hazard for humans based on repeated dose toxicity and local tolerance studies conducted with ferric maltol.
Deposition of iron in the reticulo-endothelial system, liver and spleen was recorded in dogs adminstered 250 mg/kg/day ferric maltol.
No reproductive and developmental toxicity or carcinogenicity studies have been conducted with ferric maltol.
Maltol
Haemosiderin was observed in Kupffer cells of dogs administered 250 mg/kg/day maltol. At doses of 500 mg/kg/day testicular degeneration and toxic signs indicative of iron chelation were recorded. These effects were not observable in a second study in dogs receiving up to 300 mg/kg/day.
A possible potential genotoxic potential for maltol could not be fully ruled out. However, no carcinogenic effects were recorded in studies conducted in mice and rats receiving up to 400 mg/kg/day maltol.
Feraccru is indicated in adults for the treatment of iron deficiency.
Pharmacotherapeutic group: Iron trivalent, oral preparation, ATC code: B03AB10.
Mechanism of action
Feraccru contains iron in a stable ferric state as a complex with a trimaltol ligand. The complex is designed to provide, in a controlled way, utilisable iron for uptake across the intestinal wall and transfer to the iron transport and storage proteins in the body (transferrin and ferritin, respectively). The complex dissociates on uptake from the gastro-intestinal tract and the complex itself does not enter the systemic circulation.
Clinical efficacy
IBD Studies
The safety and efficacy of Feraccru for the treatment of iron deficiency anaemia was studied in 128 patients (age range 18-76 years; 45 males and 83 females) with inactive to mildly active IBD (58 patients with Ulcerative Colitis [UC] and 70 patients with Crohn's disease [CD]) and baseline Hb concentrations between 9.5 g/dL and 12 / 13 g/dL for females / males. Patients were enrolled in one combined randomised, placebo-controlled clinical study (AEGIS 1/2). 69 % of the patients with UC had a SCCAI score ≤2 and 31 % a SCCAI score of 3. 83 % of the patients with CD had a CDAI-score <150 and 17 % a CDAI-score >150-220. All patients had discontinued from prior oral ferrous product (OFP) treatment: more than 60 % of the subjects stopped taking prior OFP due to adverse events. The median time since last dose of OFP was 22 months in the experimental group and 17 months in the placebo arm. 52 % of the patients in AEGIS 1 and 33 % in AEGIS 2 had a disease flare in the previous 6 months. The median (min-max) time since last disease flare was around 7 months (0.0-450 months). Subjects were randomised to receive either 30 mg Feraccru twice daily or a matched placebo control for 12 weeks. The difference between the change from baseline for Feraccru compared to placebo at week 12 was 2.25 g/dL (p<0.0001). Following completion of the 12-week placebo-controlled phase of the studies, all subjects were switched to Feraccru 30 mg twice daily open-label treatment for a further 52 weeks.
The results for the other key efficacy endpoints are shown in Table 2.
Table 2: Summary of Other Key Efficacy Endpoints (AEGIS 1/2)
|
Endpoint |
Hb change (g/dL) from Baseline* at Week 4 Mean (SE) |
Hb change (g/dL) from Baseline* at Week 8 Mean(SE) |
Proportion of subjects that achieved normalised Hb at Week 12 (%) |
Proportion of subjects that achieved >1 g/dL change in Hb at Week 12 (%) |
Proportion of subjects that achieved >2 g/dL change in Hb at Week 12 (%) |
|
Feraccru (N=64) |
1.06 (0.08)*** |
1.79 (0.11)*** |
66 |
78 |
56 |
|
Placebo (N=64) |
0.02 (0.08) |
0.06 (0.11) |
12 |
11 |
0 |
* Hb at Baseline mean (SE): Feraccru 11.0 (1.027) g/dL, Placebo 11.1 (0.851) g/dL; ***p<0.0001 compared to placebo group;
An increase of >1 g/dL change in Hb at Week 12 was achieved in 90 % and 69 % of the ulcerative colitis (N=29) and Crohn's Disease (N=35) subgroups, respectively. An increase of >2 g/dL change in Hb at Week 12 was achieved in 62 % and 51 % of the ulcerative colitis and Crohn's Disease subgroups, respectively. Iron deficiency was also shown to be corrected by increase in ferritin levels in both studies. Mean ferritin (μg/L) levels in subjects taking feraccru improved steadily from baseline (mean 8.6 μg/L [SD 6.77]) to Week 12 (mean 26.0 μg/L [SD 30.57]), a mean overall improvement of 17.4 μg/L. Ferritin continued to rise over long-term treatment with Feraccru (mean 68.9 μg/L [SD 96.24] at 64 weeks, a mean overall improvement of 60.3 μg/L).
).
Absorption and elimination
The pharmacokinetic properties of Feraccru was assessed through measurement of plasma and urine concentrations of maltol and maltol glucuronide, together with serum iron parameters after a single dose and at steady state (after 1 week) in 24 subjects with iron deficiency, randomised to receive 30 mg, 60 mg or 90 mg Feraccru twice daily. Blood and urine samples were assayed for maltol and maltol glucuronide. Serum samples were assayed for iron parameters.
Maltol was transiently measured in plasma with a AUC0-t between 0.022 and 0.205 h.µg/mL across all dosing regimens and both study days. Non-clinical studies have shown that maltol is metabolised through UGT1A6 and by sulphation. It is not known if medical products that inhibit UGT enzymes have the potential to increase maltol concentration. The maltol appeared to be rapidly metabolised to maltol glucuronide (AUC0-t between 9.83 and 30.9 h.µg/mL across all dosage regimens). Maximum maltol and maltol glucuronide concentrations were reached 1 to 1.5 hours after oral administration of Feraccru. Exposure to maltol glucuronide increased dose proportionally over the Feraccru 30 to 90 mg twice daily dosing range and there was no significant accumulation of either after 7 days treatment with Feraccru. Of the total maltol ingested, a mean of between 39.8 % and 60.0 % was excreted as maltol glucuronide. Peak transferrin saturation (TSAT) and total serum iron values were reached 1.5 to 3 hours after oral administration of Feraccru. Total serum iron concentrations and TSAT values were generally higher with increasing Feraccru doses. TSAT and total serum iron profiles were comparable between Day 1 and Day 8.
The pharmacokinetic properties of Feraccru were also investigated at steady state in 15 subjects who were already participating in the AEGIS1/2 study described above and who had been in the open-label treatment phase for at least 7 days (Feraccru 30 mg twice daily). Maltol was again transiently measured in plasma with a half-life of 0.7 hours, with a Cmax of 67.3 + 28.3 ng/mL. The maltol appeared to be rapidly metabolised to maltol glucuronide (Cmax = 4677 + 1613 ng/mL). Maximum maltol and maltol glucuronide concentrations were reached approximately 1 hour after oral administration of Feraccru. Maximum total iron serum concentrations were measured 1-2 hours after administration. The pharmacokinetic profiles of maltol/maltol glucuronide and iron parameters were independent of one another.
03/2018
Feraccru 30 mg hard capsules
Shield TX (UK) Limited
Gateshead Quays
NE8 3DF, UK
Store below 25°C.
HDPE bottles with a child-proof polypropylene push-lock. Each bottle contains 56 capsules.
EU/1/15/1075/001
Pregnancy
There are no data from the use of Feraccru in pregnant women. Ferric maltol is not systemically available.
Definitive animal studies are not available for maltol with respect to reproductive toxicity. As a precautionary measure, it is preferable to avoid the use of Feraccru during pregnancy.
Breastfeeding
Ferric maltol is not available systemically and is therefore unlikely to pass into the mother's milk. No clinical studies are available to date. As a precautionary measure, it is preferable to avoid the use of Feraccru during breast-feeding.
Fertility
There are no data on the effect of ferric maltol on human fertility. Ferric maltol is not systemically available. Fertility was unaffected following maltol treatment in animal studies. However, the conducted reproductive toxicity studies are insufficient to discard any risk in humans.
Each capsule contains 30 mg iron (as ferric maltol).
Excipient(s) with known effect:
Each capsule contains 91.5 mg of lactose, 0.5 mg of Allura Red AC (E129) and 0.3 mg Sunset Yellow FCF (E110).
Feraccru should not be used in patients with inflammatory bowel disease (IBD) flare or in IBD-patients with haemoglobin (Hb) <9.5 g/dl.
Iron preparations in excess may cause toxicity especially among children. Feraccru must not be administrated to children.
Special care should be taken if other dietary and/or iron salt supplementation are used concurrently.
Iron deficiency or iron deficiency anaemia (IDA) diagnosis should be made based on blood tests; it is important to investigate the cause of the iron deficiency and to exclude underlying causes of anaemia other than iron deficiency.
Feraccru has not been studied in patients with impaired renal and/or hepatic function.
This medicinal product contains lactose: patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine.
This medicinal product also contains Allura Red AC (E129) and Sunset Yellow FCF (E110): these may cause allergic reactions.
No effect is expected from an oral iron product.
Posology
The recommended dose is one capsule twice daily, morning and evening, on an empty stomach.
Treatment duration will depend on the severity of iron deficiency but generally at least 12-weeks treatment is required. The treatment should be continued as long as necessary to replenish the body iron stores according to blood tests.
Paediatric population
The safety and efficacy of Feraccru in children (17 years and under) has not yet been established. No data are available.
The elderly and patients with hepatic or renal impairment
No dose adjustment is needed in elderly patients. No clinical data on the need to adjust the dosage in patients with impaired hepatic or renal function are available.
Method of administration
Oral use.
Feraccru capsules should be taken whole on an empty stomach (with half a glass of water), as the absorption of iron is reduced when Feraccru is taken with food.
No special requirements for disposal.
Date of first authorisation: 18 February 2016
No drug interaction studies have been performed with Feraccru. Based on an in vitro study maltol is glucuronised through UGT1A6.
Food has been shown to inhibit uptake of Feraccru: Feraccru should be taken on an empty stomach
Intravenous administration of iron salts
Concomitant administration of Feraccru and intravenous iron should be avoided as the combination may induce hypotension or even collapse due to the fast release of iron resulting from saturation of transferrin caused by intravenous iron.
Impact of Feraccru on absorption of other medicinal products
Oral iron is known to reduce the absorption of penicillamine, bisphosphonates, ciprofloxacin, entacapone, levodopa, levofloxacin, levothyroxine (thyroxine) moxifloxacin, mycophenolate, norfloxacin and ofloxacin. These medicinal products should be given at least 2 hours apart from Feraccru.
Absorption of both iron and antibiotic may be reduced if oral iron is given with tetracycline. Administration of iron preparations and tetracyclines should be separated by 2 to 3 hours.
Medicinal products that may impact absorption and distribution of iron from Feraccru
Absorption of oral iron may be reduced by calcium and magnesium salts (such as magnesium trisilicate). Administration of iron preparations with such compounds should be separated by at least 2 hours.
Pharmacodynamic interactions
Concomitant use of iron with dimercaprol should be avoided as the combination of dimercaprol and iron is nephrotoxic.
Concomitant use of chloramphenicol with iron should be avoided as chloramphenicol delays plasma iron clearance, incorporation of iron into red blood cells and interferes with erythropoiesis.
Concomitant use of iron with methyldopa should be avoided as oral iron may antagonise the hypotensive effect of methyldopa.
