There is a risk of liver injury (including fulminant hepatitis, hepatic failure,cholestatic hepatitis, cytolytic hepatitis), particularly in elderly subjects, in young children, in patients with liver disease, in cases of chronic alcoholism, in patients with chronic malnutrition and in patients receiving enzyme inducers. Overdosing may be fatal in these cases.
â–ª Symptoms generally appear within the first 24 hours and comprise: nausea, vomiting, anorexia, pallor, abdominal pain. Overdose, 7.5 g or more of paracetamol in a single administration in adults and 140 mg/kg of body weight in a single administration in children, causes hepatic cytolysis likely to induce complete and irreversible necrosis, resulting in hepatocellular insufficiency, metabolic acidosis and encephalopathy which may lead to coma and death. Simultaneously, increased levels of hepatic transaminases (AST, ALT), lactate dehydrogenase and bilirubin are observed together with decreased prothrombin levels that may appear 12 to 48 hours after administration.
Clinical symptoms of liver damage are usually evident initially after two days, and reach a maximum after 4 to 6 days.
Emergency measures
â–ª Immediate hospitalisation.
â–ª Before beginning treatment, take a tube of blood for plasma paracetamol assay, as soon as possible after the overdose.
â–ª The treatment includes administration of the antidote, N-acetylcysteine (NAC), by the i.v. or oral route, if possible before the 10th hour. NAC can, however, give some degree protection even after 10 hours, but in these cases prolonged treatment is given.
â–ª Symptomatic treatment.
â–ª Hepatic tests must be carried out at the beginning of treatment and repeated every 24 hours. In most cases hepatic transaminases return to normal in one to two weeks with full restitution of liver function. In very severe cases, however, liver transplantation may be necessary.
Инфулган is contraindicated:
â–ª in patients with hypersensitivity to paracetamol or to propacetamol hydrochloride (prodrug of paracetamol) or to one of the excipients.
â–ª in cases of severe hepatocellular insufficiency.
Инфулган should not be mixed with other medicinal products.
As all paracetamol products, adverse drug reactions are rare (>1/10000, <1/1000) or very rare (<1/10000), they are described below:
| Organ system | Rare >1/10000, <1/1000 | Very rare <1/10000 |
| General | Malaise | Hypersensitivity reaction |
| Cardiovascular | Hypotension | |
| Liver | Increased levels of hepatic transaminases | |
| Platelet/blood | Thrombocytopenia, Leucopenia, Neutropenia. |
Frequent adverse reactions at injection site have been reported during clinical trials (pain and burning sensation).
Very rare cases of hypersensitivity reactions ranging from simple skin rash or urticaria to anaphylactic shock have been reported and require discontinuation of treatment.
Cases of erythema, flushing, pruritus and tachycardia have been reported.
Preclinical data reveal no special hazard for humans beyond the information included in other sections of the SmPC.
Studies on local tolerance of Инфулган in rats and rabbits showed good tolerability. Absence of delayed contact hypersensitivity has been tested in guinea pigs.
Pharmacotherapeutic group: OTHER ANALGESICS AND ANTIPYRETICS, ATC code: N02BE01
The precise mechanism of the analgesic and antipyretic properties of paracetamol has yet to be established; it may involve central and peripheral actions.
Инфулган provides onset of pain relief within 5 to 10 minutes after the start of administration. The peak analgesic effect is obtained in 1 hour and the duration of this effect is usually 4 to 6 hours.
Инфулган reduces fever within 30 minutes after the start of administration with a duration of the antipyretic effect of at least 6 hours.
Adults:
Absorption:
Paracetamol pharmacokinetics is linear up to 2 g after single administration and after repeated administration during 24 hours.
The bioavailability of paracetamol following infusion of 500 mg and 1 g of Инфулган is similar to that observed following infusion of 1 g and 2 g propacetamol (corresponding to 500 mg and 1 g paracetamol respectively). The maximal plasma concentration (Cmax) of paracetamol observed at the end of 15-minutes intravenous infusion of 500 mg and 1 g of Инфулган is about 15 μg/mL and 30 μg/mL respectively.
Distribution:
The volume of distribution of paracetamol is approximately 1 L/kg.
Paracetamol is not extensively bound to plasma proteins.
Following infusion of 1 g paracetamol, significant concentrations of paracetamol (about 1.5 μg/mL) were observed in the Cerebro Spinal Fluid as and from the 20th minute following infusion.
Metabolism:
Paracetamol is metabolised mainly in the liver following two major hepatic pathways: glucuronic acid conjugation and sulphuric acid conjugation. The latter route is rapidly saturable at doses that exceed the therapeutic doses. A small fraction (less than 4%) is metabolised by cytochrome P450 to a reactive intermediate (N-acetyl benzoquinone imine) which, under normal conditions of use, is rapidly detoxified by reduced glutathione and eliminated in the urine after conjugation with cysteine and mercapturic acid. However, during massive overdosing, the quantity of this toxic metabolite is increased.
Elimination:
The metabolites of paracetamol are mainly excreted in the urine. 90% of the dose administered is excreted in 24 hours, mainly as glucuronide (60-80%) and sulphate (20-30%) conjugates. Less than 5% is eliminated unchanged. Plasma half-life is 2.7 hours and total body clearance is 18 L/h.
Neonates, infants and children
The pharmacokinetic parameters of paracetamol observed in infants and children are similar to those observed in adults, except for the plasma half-life that is slightly shorter (1.5 to 2 h) than in adults. In neonates, the plasma half-life is longer than in infants i.e. around 3.5 hours. Neonates, infants and children up to 10 years excrete significantly less glucuronide and more sulphate conjugates than adults.
Table. Age related pharmacokinetic values (standardized clearance,*CLstd/Foral (l.h-1 70 kg-1), are presented below.
| Age | Weight (kg) | CLstd/Foral (l.h-1 70 kg-1) |
| 40 weeks PCA 3 months PNA 6 months PNA 1 year PNA 2 years PNA 5 years PNA 8 years PNA | 3.3 6 7.5 10 12 20 25 | 5.9 8.8 11.1 13.6 15.6 16.3 16.3 |
*CLstd is the population estimate for CL
Special populations:
Renal insufficiency
In cases of severe renal impairment (creatinine clearance 10-30 mL/min), the elimination of paracetamol is slightly delayed, the elimination half-life ranging from 2 to 5.3 hours. Posology and method of administration).
Elderly subjects
The pharmacokinetics and the metabolism of paracetamol are not modified in elderly subjects. No dose adjustment is required in this population.
Warnings
RISK OF MEDICATION ERRORS Take care to avoid dosing errors due to confusion between milligram (mg) and milliliter (mL), which could result in accidental overdose and death. |
It is recommended to use a suitable analgesic oral treatment as soon as this administration route is possible.
In order to avoid the risk of overdose, check that other medicines administered do not contain either paracetamol or propacetamol.
Doses higher than the recommended entails risk for very serious liver damage. Clinical symptoms and signs of liver damage (including fulminant hepatitis, hepatic failure, cholestatic hepatitis, cytolytic hepatitis) are usually first seen after two days of drug administration with a peak seen usually after 4 - 6 days. Treatment with antidote should be given as soon as possible.
This medicinal product contains less than 1 mmol sodium (23mg) per 100ml of Инфулган, i.e. essentially "sodium free".
Text for the 50ml and 100ml vials:
As for all solutions for infusion presented in glass vials, a close monitoring is needed notably at the end of the infusion.
Precautions for use
Paracetamol should be used with caution in cases of:
â–ª hepatocellular insufficiency,
▪ severe renal insufficiency (creatinine clearance ≤ 30 mL/min) ,
â–ª chronic alcoholism,
â–ª chronic malnutrition (low reserves of hepatic gluthatione),
â–ª dehydration.
Not relevant.
Text for the 50ml and 100ml vials:
Use a 0.8 mm needle and vertically perforate the stopper at the spot specifically indicated.
Before administration, the product should be visually inspected for any particulate matter and discoloration. For single use only. Any unused solution should be discarded.
The diluted solution should be visually inspected and should not be used in presence of opalescence, visible particulate matters or precipitate.
