Bupivacaine for injection 20mg/4ml in Prefilled Syringe Taj Pharma

1.Name of the medicinal product

Bupivacaine for injection 20mg/4ml in Prefilled Syringe Taj Pharma

2. Qualitative and quantitative composition

Each ml contains bupivacaine hydrochloride 5.28 mg equivalent to anhydrous bupivacaine hydrochloride 5 mg.

Each 4 ml  Prefilled Syringe contains
Bupivacaine hydrochloride 21.1 mg equivalent to anhydrous bupivacaine hydrochloride 20 mg

Excipient with known effect: sodium chloride.

For the full list of excipients, see section 6.1.

3.Pharmaceutical form

Solution for injection in Prefilled Syringe

Clear, colourless or almost colourless solution.

4. Clinical particulars

4.1 Therapeutic indications

Bupivacaine 0.25%w/v and 0.5%w/v solution for injection are used for the production of local anaesthesia by percutaneous infiltration, peripheral nerve block(s) and central neural block (caudal or epidural), that is, for specialist use in situations where prolonged anaesthesia is required. Because sensory nerve block is more marked than motor block, bupivacaine is especially useful in the relief of pain, e.g. during labour.

Bupivacaine is indicated for:

  • Surgical anaesthesia in adults and children above 12 years of age
  • Acute pain management in adults, infants and children above 1 year of age

The suggested dose and strength of solution appropriate for each indication are provided in Section 4.2.

4.2 Posology and method of administration

Adults and children above 12 years of age

The following table is a guide to dosage for the more commonly used techniques in the average adult. The figures reflect the expected average dose range needed. Standard textbooks should be consulted for factors affecting specific block techniques and for individual patient requirements.

N.B. When prolonged blocks are used, either by continuous infusion or by repeated bolus administration, the risks of reaching a toxic plasma concentration or inducing a local neural injury must be considered.

The clinician’s experience and knowledge of the patient’s physical status is important in calculating the required dose. The lowest dose required for adequate anaesthesia should be used. Individual variations in onset and duration occur.

Table 1 Dosage recommendations for adults

Conc

mg/ml

Volume

ml

Dose

mg

Onset

min

Duration of effect

hours7)

SURGICAL ANAESTHESIA
Lumbar Epidural Administration 1)
Surgery5.015-3075-15015-302-3
Lumbar Epidural Administration 1)
Caesarean Section5.015-3075-15015-302-3
Thoracic Epidural Administration 1)
Surgery2.55-1512.5-37.510-151.5-2
5.05-1025-5010-152-3
Caudal Epidural Block 1)
2.520-3050-7520-301-2
5.020-30100-15015-302-3
Major Nerve Block 2)
(e.g. brachial plexus, femoral, sciatic)5.010-3550-17515-304-8
Field block
(e.g. minor nerve blocks and infiltration)2.5<60<1501-33-4
5.0≤30≤1501-103-8
ACUTE PAIN MANAGEMENT
Lumbar Epidural Administration
Intermittent injections 3)

(e.g. post-operative pain relief)

2.56-15;

minimum interval 30 minutes

15-37.5;

minimum interval 30 minutes

2-51-2
Lumbar Epidural Administration
Continuous infusion 4)1.2510-15/h12.5-18.8/h
2.55-7.5/h12.5-18.8/h
Lumbar Epidural Administration
Continuous infusion, labour pain relief 4)1.255-10/h6.25-12.5/h
Thoracic Epidural Administration
Continuous infusion1.255-10/h6.3-12.5/h
2.54-7.5/h10-18.8/h
Intra-Articular Block 6)
(e.g. single injection following knee arthroscopy)2.5≤40≤1005)5-102-4 h after wash out
Field Block
(e.g. minor nerve blocks and infiltration)2.5≤60≤1501-33-4

1) Dose includes test dose

2) The dose for a major nerve block must be adjusted according to site of administration and patient status. Interscalene and supraclavicular brachial plexus blocks may be associated with a higher frequency of serious adverse reactions, regardless of the local anaesthetic used, see also section 4.4.

3) In total ≤400 mg/24 h.

4) This solution is often used for epidural administration in combination with a suitable opioid for pain management. In total ≤400 mg/24 h.

5) If additional bupivacaine is used by any other techniques in the same patient, an overall dose limit of 150 mg should not be exceeded.

6) There have been post-marketing reports of chondrolysis in patients receiving post-operative intra-articular continuous infusion of local anaesthetics. Bupivacaine solution for injection is not approved for this indication (see also section 4.4).

7) Bupivacaine without adrenaline.

In general, surgical anaesthesia (e.g. epidural administration) requires the use of higher concentrations and doses. When a less intense block is required (e.g. in the relief of labour pain), the use of a lower concentration is indicated. The volume of drug used will affect the extent of spread of anaesthesia.

In order to avoid intravascular injection, aspiration should be repeated prior to and during administration of the main dose, which should be injected slowly or in incremental doses, at a rate of 25-50 mg/min, while closely observing the patient’s vital functions and maintaining verbal contact. An inadvertent intravascular injection may be recognised by a temporary increase in heart rate and an accidental intrathecal injection by signs of a spinal block. If toxic symptoms occur, the injection should be stopped immediately. (See section 4.8.1)

Experience to date indicates that 400 mg administered over 24 hours is well tolerated in the average adult.

Paediatric patients 1 to 12 years of age

Paediatric regional anaesthetic procedures should be performed by qualified clinicians who are familiar with this population and the technique.

The doses in the table should be regarded as guidelines for use in paediatrics. Individual variations occur. In children with a high body weight a gradual reduction of the dosage is often necessary and should be based on the ideal body weight. Standard textbooks should be consulted for factors affecting specific block techniques and for individual patient requirements.

The lowest dose required for adequate analgesia should be used.

Table 2 Dosage recommendations for children 1 to 12 years of age

Conc.

mg/ml

Volume

ml/kg

Dose

mg/kg

Onset

min

Duration of effect

hours

ACUTE PAIN MANAGEMENT (per- and postoperative)
Caudal Epidural Administration2.50.6-0.81.5-220-302-6
Lumbar Epidural Administration2.50.6-0.81.5-220-302-6
Thoracic Epidural Administration a)2.50.6-0.81.5-220-302-6
Field Block

(e.g. minor nerve blocks and infiltration)

2.50.5- 2.0
5.00.5- 2.0
Peripheral Nerve Blocks

(e.g. ilioinguinal- iliohypogastric)

2.50.5- 2.0b)
5.00.5- 2.0b)
  1. a) Thoracic epidural blocks need to be given by incremental dosage until the desired level of anaesthesia is achieved.
  2. b) The onset and duration of peripheral nerve blocks depend on the type of block and the dose administered

In children the dosage should be calculated on a weight basis up to 2 mg/kg.

In order to avoid intravascular injection, aspiration should be repeated prior to and during administration of the main dose. This should be injected slowly in incremental doses, particularly in the lumbar and thoracic epidural routes, constantly and closely observing the patient’s vital functions.

Peritonsillar infiltration has been performed in children above 2 years of age with bupivacaine 2.5 mg/ml at a dose of 7.5- 12.5 mg per tonsil.

Ilioinguinal-iliohypogastric blocks have been performed in children aged 1 year or older with bupivacaine 2.5mg/ml at a dose of 0.1-0.5 ml/kg equivalent to 0.25-1.25 mg/kg. Children aged 5 years or older have received bupivacaine 5mg/ml at a dose of 1.25-2 mg/kg.

For penile blocks bupivacaine 5mg/ml has been used at total doses of 0.2-0.5 ml/kg equivalent to 1-2.5mg/kg.

The safety and efficacy of Bupivacaine solution for injection with and without adrenaline in children < 1 year of age have not been established. Only limited data are available.

Safety and efficacy of intermittent epidural bolus injection or continuous infusion have not been established. Only limited data is available.

4.3 Contraindications

Bupivacaine hydrochloride solutions for injection are contraindicated in patients withhypersensitivity to the bupivacaine hydrochloride or to local anaesthetic agents of the amide type or to any of the excipients listed in section 6.1

Solutions of bupivacaine hydrochloride are contra-indicated for intravenous regional anaesthesia (Bier’s-block)

Epidural anaesthesia, regardless of the local anaesthetic used, has its own contra-indications which include:

Active disease of the central nervous system such as meningitis, poliomyelitis, intracranial haemorrhage, sub-acute combined degeneration of the cord due to pernicious anaemia and cerebral and spinal tumours; tuberculosis of the spine; pyogenic infection of the skin at or adjacent to the site of lumbar puncture; cardiogenic or hypovolaemic shock; coagulation disorders or ongoing anticoagulation treatment.

4.4 Special warnings and precautions for use

There have been reports of cardiac arrest during the use of bupivacaine for epidural anaesthesia or peripheral nerve blockade where resuscitative efforts have been difficult, and were required to be prolonged before the patient responded. However, in some instances resuscitation has proven impossible despite apparently adequate preparation and appropriate management.

Like all local anaesthetic drugs, bupivacaine may cause acute toxicity effects on the central nervous and cardiovascular systems if utilised for local anaesthetic procedures resulting in high blood concentrations of the drug. This is especially the case after unintentional intravascular administration or injection into highly vascular areas. Ventricular arrhythmia, ventricular fibrillation, sudden cardiovascular collapse and death have been reported in connection with high systemic concentrations of bupivacaine.

Adequate resuscitation equipment should be available whenever local or general anaesthesia is administered. The clinician responsible should take the necessary precautions to avoid intravascular injection (see 4.2).

Before any nerve block is attempted, intravenous access for resuscitation purposes should be established. Clinicians should have received adequate and appropriate training in the procedure to be performed and should be familiar with the diagnosis and treatment of side effects, systemic toxicity or other complications (see 4.9 & 4.8).

Major peripheral nerve blocks may require the administration of a large volume of local anaesthetic in areas of high vascularity, often close to large vessels where there is an increased risk of intravascular injection and/or systemic absorption. This may lead to high plasma concentrations.

Overdosage or accidental intravenous injection may give rise to toxic reactions.

Injection of repeated doses of bupivacaine hydrochloride may cause significant increases in blood levels with each repeated dose due to slow accumulation of the drug. Tolerance varies with the status of the patient.

Although regional anaesthesia is frequently the optimal anaesthetic technique, some patients require special attention in order to reduce the risk of dangerous side effects:

  • The elderly and patients in poor general condition should be given reduced doses commensurate with their physical status.
  • Patients with partial or complete heart block – due to the fact that local anaesthetics may depress myocardial conduction
  • Patients with advanced liver disease or severe renal dysfunction
  • Patients in the late stages of pregnancy
  • Patients treated with anti-arrhythmic drugs class III (e.g. amiodarone) should be under close surveillance and ECG monitoring, since cardiac effects may be additive.

Patients allergic to ester-type local anaesthetic drugs (procaine, tetracaine, benzocaine, etc.) have not shown cross-sensitivity to agents of the amide type such as bupivacaine.

Certain local anaesthetic procedures may be associated with serious adverse reactions, regardless of the local anaesthetic drug used.

  • Local anaesthetics should be used with caution for epidural anaesthesia in patients with impaired cardiovascular function since they may be less able to compensate for functional changes associated with the prolongation of A-V conduction produced by these drugs.
  • The physiological effects generated by a central neural blockade are more pronounced in the presence of hypotension. Patients with hypovolaemia due to any cause can develop sudden and severe hypotension during epidural anaesthesia. Epidural anaesthesia should therefore be avoided or used with caution in patients with untreated hypovolaemia or significantly impaired venous return.
  • Retrobulbar injections may very rarely reach the cranial subarachnoid space causing temporary blindness, cardiovascular collapse, apnoea, convulsions etc.
  • Retro- and peribulbar injections of local anaesthetics carry a low risk of persistent ocular muscle dysfunction. The primary causes include trauma and/or local toxic effects on muscles and/or nerves. The severity of such tissue reactions is related to the degree of trauma, the concentration of the local anaesthetic and the duration of exposure of the tissue to the local anaesthetic. For this reason, as with all local anaesthetics, the lowest effective concentration and dose of local anaesthetic should be used.
  • Vasoconstrictors may aggravate tissue reactions and should be used only when indicated.
  • Small doses of local anaesthetics injected into the head and neck, including retrobulbar, dental and stellate ganglion blocks, may produce systemic toxicity due to inadvertent intra-arterial injection.
  • Paracervical block may have a greater adverse effect on the foetus than other nerve blocks used in obstetrics. Due to the systemic toxicity of bupivacaine special care should be taken when using bupivacaine for paracervical block.
  • There have been post-marketing reports of chondrolysis in patients receiving post-operative intra-articular continuous infusion of local anaesthetics. The majority of reported cases of chondrolysis have involved the shoulder joint. Due to multiple contributing factors and inconsistency in the scientific literature regarding mechanism of action, causality has not been established. Intra-articular continuous infusion is not an approved indication for Bupivacaine solution for injection.

Epidural anaesthesia with any local anaesthetic can cause hypotension and bradycardia which should be anticipated and appropriate precautions taken. These may include pre-loading the circulation with crystalloid or colloid solution. If hypotension develops it should be treated with a vasopressor such as ephedrine 10-15mg intravenously. Severe hypotension may result from hypovolaemia due to haemorrhage or dehydration, or aorto-caval occlusion in patients with massive ascites, large abdominal tumours or late pregnancy. Marked hypotension should be avoided in patients with cardiac decompensation.

Patients with hypovolaemia due to any cause can develop sudden and severe hypotension during epidural anaesthesia.

Epidural anaesthesia can cause intercostal paralysis and patients with pleural effusions may suffer respiratory embarrassment. Septicaemia can increase the risk of intraspinal abscess formation in the postoperative period.

When bupivacaine is administered as intra-articular injection, caution is advised when recent major intra-articular trauma is suspected or extensive raw surfaces within the joint have been created by the surgical procedure, as that may accelerate absorption and result in higher plasma concentrations.

Paediatric population

The safety and efficacy of Bupivacaine hydrochloride in children < 1 year of age have not been established. Only limited data are available.

The use of bupivacaine for intra-articular block in children 1 to 12 years of age has not been documented.

The use of bupivacaine for major nerve block in children 1 to 12 years of age has not been documented.

For Epidural anaesthesia children should be given incremental doses commensurate with their age and weight as especially epidural anaesthesia at a thoracic level may result in severe hypotension and respiratory impairment.

Each 2 ml, 4 ml, 5 ml, 10 ml & 20 ml of Bupivacaine 0.5% w/v solution for injection contains approximately 0.28 mmol, 0.56 mmol, 0.70 mmol, 1.40 mmol & 2.80 mmol (6.4mg, 12.9 mg, 16.1 mg, 32.3 mg & 64.6 mg) sodium respectively. To be taken into consideration by patients on a controlled sodium diet.

4.5 Interaction with other medicinal products and other forms of interaction

Bupivacaine should be used with caution in patients receiving other local anaesthetics or agents structurally related to amide-type local anaesthetics, e.g. certain anti-arrhythmics, such as lidocaine and mexiletine, since the systemic toxic effects are additive. Specific interaction studies with bupivacaine and anti-arrhythmic drugs class III (e.g. amiodarone) have not been performed, but caution should be advised. (see also 4.4)

4.6 Fertility, pregnancy and lactation

There is no evidence of untoward effects in human pregnancy. In large doses there is evidence of decreased pup survival in rats and an embryological effect in rabbits if bupivacaine is administered in pregnancy. Bupivacaine should not therefore be given in early pregnancy unless the benefits are considered to outweigh the risks.

Foetal adverse effects due to local anaesthetics, such as foetal bradycardia, seem to be most apparent in paracervical block anaesthesia. Such effects may be due to high concentrations of anaesthetic reaching the foetus. (see also Section 4.4)

Bupivacaine enters the mother’s milk, but in such small quantities that there is no risk of affecting the child at therapeutic dose levels.

4.7 Effects on ability to drive and use machines

Besides the direct anaesthetic effect, local anaesthetics may have a very mild effect on mental function and co-ordination even in the absence of overt CNS toxicity, and may temporarily impair locomotion and alertness.

4.8 Undesirable effects

Accidental sub-arachnoid injection can lead to very high spinal anaesthesia possibly with apnoea and severe hypotension.

The adverse reaction profile for Bupivacaine solution for injection is similar to those for other long acting local anaesthetics. Adverse reactions caused by the drug per se are difficult to distinguish from the physiological effects of the nerve block (e.g. decrease in blood pressure, bradycardia), events caused directly (e.g. nerve trauma) or indirectly (e.g. epidural abscess) by needle puncture.

Neurological damage is a rare but well recognised consequence of regional and particularly epidural and spinal anaesthesia. It may be due to several causes, e.g. direct injury to the spinal cord or spinal nerves, anterior spinal artery syndrome, injection of an irritant substance, or an injection of a non-sterile solution. These may result in localised areas of paraesthesia or anaesthesia, motor weakness, loss of sphincter control and paraplegia. Occasionally these are permanent.

The adverse reactions considered at least possibly related to treatment with Bupivacaine solution for injection from clinical trials with related products and post-marketing experience are listed below by body system organ class and absolute frequency. 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) including isolated reports, or not known (identified through post-marketing safety surveillance and the frequency cannot be estimated from the available data).

Table 3

Table of Adverse Drug Reactions (ADR)

System Organ ClassFrequency ClassificationAdverse Drug Reaction
Immune system disordersRareAllergic reactions, anaphylactic reaction/shock (see section 4.4)
Nervous system disordersCommonparaesthesia, dizziness
UncommonSigns and symptoms of CNS toxicity (convulsions, circumoral paraesthesia, numbness of the tongue, hyperacusis, visual disturbances, loss of consciousness, tremor, light headedness, tinnitus, dysarthria, muscle twiching)
RareNeuropathy, peripheral nerve injury, arachnoiditis, paresis and paraplegia
Eye disordersRareDiplopia
Cardiac disordersCommonBradycardia (see section 4.4)
RareCardiac arrest (see section 4.4), cardiac arrhythmias
Vascular disordersVery CommonHypotension (see section 4.4)
CommonHypertension (see section 4.5)
Respiratory disordersRareRespiratory depression
Gastrointestinal disordersVery CommonNausea
CommonVomiting
Renal and UrinaryCommonUrinary retention

Hepatic dysfunction, with reversible increases of SGOT, SGPT, alkaline phosphates and bilirubin, has been observed following repeated injections or long-term infusions of bupivacaine. If signs of hepatic dysfunction are observed during treatment with bupivacaine, the drug should be discontinued.

4.8.1 Acute systemic toxicity

Systemic toxic reactions primarily involve the central nervous system (CNS) and the cardiovascular system. Such reactions are caused by high blood concentrations of a local anaesthetic, which may appear due to (accidental) intravascular injection, overdose or exceptionally rapid absorption from highly vascularised areas (see section 4.4). CNS reactions are similar for all amide local anaesthetics, while cardiac reactions are more dependent on the drug, both quantitatively and qualitatively.

Central nervous system toxicity is a graded response with symptoms and signs of escalating severity. The first symptoms are usually light-headedness, circumoral paraesthesia, numbness of the tongue, hyperacusis, tinnitus and visual disturbances. Dysarthria, muscular twitching or tremors are more serious and precede the onset of generalised convulsions. These signs must not be mistaken for neurotic behaviour. Unconsciousness and grand mal convulsions may follow, which may last from a few seconds to several minutes. Hypoxia and hypercarbia occur rapidly following convulsions due to the increased muscular activity, together with the interference with respiration and possible loss of functional airways. In severe cases apnoea may occur. Acidosis, hyperkalaemia and hypoxia increase and extend the toxic effects of local anaesthetics.

Recovery is due to redistribution of the local anaesthetic drug from the central nervous system and subsequent metabolism and excretion. Recovery may be rapid unless large amounts of the drug have been injected.

Cardiovascular system toxicity may be seen in severe cases and is generally preceded by signs of toxicity in the central nervous system. In patients under heavy sedation or receiving a general anaesthetic, prodromal CNS symptoms may be absent. Hypotension, bradycardia, arrhythmia and even cardiac arrest may occur as a result of high systemic concentrations of local anaesthetics, but in rare cases cardiac arrest has occurred without prodromal CNS effects.

Paediatric population

Adverse drug reactions in children are similar to those in adults, however in children, early signs of local anaesthetic toxicity may be difficult to detect in cases where the block is given during general anaesthesia.

4.8.2 Treatment of Acute Toxicity

If signs of acute systemic toxicity appear, injection of the local anaesthetic should be immediately stopped.

Treatment of a patient with systemic toxicity consists of arresting convulsions and ensuring adequate ventilation with oxygen, if necessary by assisted or controlled ventilation (respiration).

Once convulsions have been controlled and adequate ventilation of the lungs ensured, no other treatment is generally required

If cardiovascular depression occurs (hypotension, bradycardia) appropriate treatment with intravenous fluids, vasopressor, inotropic agents and/or lipid emulsion should be considered. Children should be given doses commensurate with age andweight.

If circulatory arrest should occur, immediate cardiopulmonary resuscitation should be instituted. Optimal oxygenation and ventilation and circulatory support as well as treatment of acidosis are of vital importance.

Cardiac arrest due to bupivacaine can be resistant to electrical defibrillation and resuscitation must be continued energetically for a prolonged period.

High or total spinal blockade causing respiratory paralysis and hypotension during epidural anaesthesia should be treated by ensuring and maintaining a patent airway and giving oxygen by assisted or controlled ventilation.

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 www.mhra.gov.uk/yellowcard

4.9 Overdose

Accidental intravascular injections of local anaesthetics may cause immediate (within seconds to a few minutes) systemic toxic reactions. In the event of overdose, systemic toxicity appears later (15-60 minutes after injection) due to the slower increase in local anaesthetic blood concentration. (See sections 4.8.1 & 4.8.2)

5. Pharmacological properties

5.1 Pharmacodynamic properties

Phamacotherapeutic group

Bupivacaine hydrochloride is a long acting local anaesthetic of the amide type with both anaesthetic and analgesic effects. At high doses it produces surgical anaesthesia, while at lower doses it produces sensory block (analgesia) with less pronounced motor block.

Onset and duration of the local anaesthetic effect of bupivacaine depends on the dose and site of administration.

Bupivacaine, like other local anaesthetics, causes a reversible blockade of impulse propagation along nerve fibres by preventing the inward movement of sodium ions through the cell membrane of the nerve fibres. The sodium channels of the nerve membrane are considered a receptor for local anaesthetic molecules.

Local anaesthetics may have similar effects on other excitable membranes e.g. in the brain and myocardium. If excessive amounts of drug reach the systemic circulation, symptoms and signs of toxicity may appear, emanating from the central nervous and cardiovascular systems.

Central nervous system toxicity (See section 4.8.1) usually precedes the cardiovascular effects as central nervous system toxicity occurs at lower plasma concentrations. Direct effects of local anaesthetics on the heart include slow conduction, negative inotropism and eventually cardiac arrest.

Indirect cardiovascular effects (hypotension, bradycardia) may occur after epidural administration depending on the extent of the concomitant sympathetic block.

5.2 Pharmacokinetic properties

Bupivacaine has a pKa of 8.2 and a partition coefficient of 346 (25°C n-octanol/ phosphate buffer pH 7.4). The metabolites have a pharmacological activity that is less than that of bupivacaine.

The plasma concentration of bupivacaine depends upon the dose, the route of administration and the vascularity of the injection site.

Bupivacaine shows complete and biphasic absorption from the epidural space with half-lives in the order of 7 min and 6 h respectively. The slow absorption is rate-limiting in the elimination of bupivacaine, which explains why the apparent half-life after epidural administration is longer than that after intravenous administration.

Bupivacaine has a total plasma clearance of 0.58 l/min, a volume of distribution at steady state of 73 l, a terminal half-life of 2.7 h and an intermediate hepatic extraction ratio of 0.38 after IV administration. It is mainly bound to alpha-l-acid glycoprotein with plasma binding of 96%. Clearance of bupivacaine is almost entirely due to liver metabolism and more sensitive to changes in intrinsic hepatic enzyme function that to liver perfusion.

In children the pharmacokinetics are similar to that in adults.

An increase in total plasma concentration has been observed during continuous epidural infusion. This is related to a postoperative increase in alpha 1-acid glycoprotein. The unbound, i.e. pharmacologically active, concentration is similar before and after surgery.

Bupivacaine readily crosses the placenta and equilibrium with regard to the unbound concentration is rapidly reached. The degree of plasma protein binding in the foetus is less than in the mother, which results in lower total plasma concentrations in the foetus.

Bupivacaine is extensively metabolised in the liver, predominately by aromatic hydroxylation to 4-hydroxy-bupivacaine and N-dealkylation to PPX, both mediated by cytochrome P4503A4. About 1% of bupivacaine is excreted in the urine as unchanged drug in 24 h and approximately 5% as PPX. The plasma concentrations of PPX and 4-hydroxy-bupivacaine during and after continuous administration of bupivacaine are low as compared to the parent drug.

5.3 Preclinical safety data

Bupivacaine hydrochloride is a well-established active ingredient.

  1. Pharmaceutical particulars

6.1 List of excipients

Sodium chloride

Sodium hydroxide

Water for injections

6.2 Incompatibilities

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.

6.3 Shelf life

3 years.

6.4 Special precautions for storage

Do not refrigerate or freeze.

6.5 Nature and contents of container

Pre-filled Syringe

4 ml -Pre-filled Syringe s containing 21.1 mg, of bupivacaine hydrochloride and supplied in packs of 5 and 10 Pre-filled Syringes.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling

For single use only.

Use immediately after opening.

Discard any unused solution in Pre-filled Syringes

7. Manufactured in India by:
TAJ PHARMACEUTICALS LTD.
Mumbai, India
Unit No. 214.Old Bake House,
Maharashtra chambers of  Commerce Lane,
Fort, Mumbai – 400001
at:Gujarat, INDIA.
Customer Service and Product Inquiries:
1-800-TRY-FIRST (1-800-222-434 & 1-800-222-825)
Monday through Saturday 9:00 a.m. to 7:00 p.m. EST
E-mail: tajgroup@tajpharma.com

Bupivacaine for injection 20mg/4ml in Prefilled Syringe Taj Pharma

Read all of this leaflet carefully before you start using this medicine because it contains

important information for you.

– Keep this leaflet. You may need to read it again.

– If you have further questions, please ask your doctor or pharmacist.

– This medicine has been prescribed for you only. Do not pass it on to others. It may harm

them even if their signs of illness are the same as yours.

– If you get any side effects, talk to your doctor or pharmacist. This includes any possible

side effects not listed in this leaflet. See section 4.

What is in this leaflet:

  1. What Bupivacaine solution for injection is and what it is used for
  2. What you need to know before you use Bupivacaine solution for injection
  3. How to use Bupivacaine solution for injection
  4. Possible side effects
  5. How to store Bupivacaine solution for injection
  6. Contents of the pack and other information

1.What Bupivacaine solution for injection is and what it is used for

Bupivacaine hydrochloride is a local anaesthetic. It belongs to a group of medicines called amide- type local anaesthetics.

Bupivacaine solution for injection is used to numb (anaesthetise) parts of the body. It is used to stop pain happening or to provide pain relief. It can be used to:

 Numb parts of the body during surgery in adults and children above 12 years.

 Relieve pain during childbirth.

 Relieve pain in adults, infants and children above 1 year of age

You must talk to a doctor if you do not feel better or if you feel worse after {number of} days

2. What you need to know before you use Bupivacaine solution for injection

Do not use Bupivacaine solution for injection:

 if you are allergic to bupivacaine hydrochloride or any of the other ingredients of this medicine (listed in section 6)

 if you are allergic to any other local anaesthetics of the same class (such as lidocaine or ropivacaine).

 if you have a skin infection near to where the injection will be given.

 if you have something called cardiogenic shock (a condition where the heart is unable to supply enough blood to the body).

 if you have something called hypovolaemic shock (very low blood pressure leading to collapse).

 if you have problems with clotting of your blood.

 if you have diseases of the brain or spine such as meningitis, polio or spondylitis.

 if you have a severe headache caused by bleeding inside the head (intracranial haemorrhage).

 if you have problems with your spinal cord due to anaemia.

 if you have blood poisoning (septicaemia).

 if you have had a recent trauma, tuberculosis or tumours of the spine

 adrenaline containing bupivacaine for special techniques (e.g. penile block, Oberst block) to numb parts of the body where areas with end arteries are affected.

You must not be given Bupivacaine solution for injection if any of the above apply to you. If you are not sure, talk to your doctor before you are given Bupivacaine solution for injection.

Warnings and Precautions

Talk to your doctor before using Bupivacaine solution for injection.

 if you have heart , kidney or liver problems. This is because your doctor may need to adjust the dose of Bupivacaine solution for injection.

 if you have a swollen stomach due to more fluid than normal.

 if you have a stomach tumour.

 if you have been told that you have decreased volume of blood (hypovolaemia).

 if you have fluid in your lungs.

 In children < 12 years as some injections of Bupivacaine solution for injection in order to numb parts of the body during surgery are not established in younger children. The use of Bupivacaine solution for injection is not established in children < 1 year of age.

If you are not sure if any of the above apply to you, talk to your doctor before you are given Bupivacaine solution for injection.

Other medicines and Bupivacaine solution for injection

Tell your doctor or pharmacist if you are taking, have recently taken, or might take any other medicines. This is because Bupivacaine solution for injection can affect the way some medicines work and some medicines can have an effect on Bupivacaine solution for injection.

In particular, tell your doctor if you are taking any of the following medicines:

 Medicines used to treat an uneven heart beat (arrhythmia) such as lidocaine, mexiletine or amiodarone.

 Medicines used to stop blood clots (anti-coagulants).

Your doctor needs to know about these medicines to be able to work out the correct dose of Bupivacaine solution for injection for you.

Pregnancy and breast-feeding

If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby,

ask your doctor or pharmacist for advice before taking any medicine if you are pregnant or breastfeeding.

Driving and using machines

Bupivacaine solution for injection may make you feel sleepy and affect the speed of your reactions. After you have been given Bupivacaine solution for injection, you should not drive or use tools or machines until the next day.

Bupivacaine solution for injection contains Sodium

Each ml of Bupivacaine 0.25% w/v solution for injection contains 0.15 mmol (3.4 mg) of sodium.Each ml of Bupivacaine 0.5% w/v solution for injection contains 0.14 mmol (3.2 mg) of sodium. To be taken into consideration by patients on a controlled sodium diet.

3. How to use Bupivacaine solution for injection

Always take use this medicine exactly as your doctor or pharmacist has told you. Check with your doctor or pharmacist if you are not sure.

The recommended dose that your doctor gives you will depend on the type of pain relief that you need and the part of your body that the medicine will be injected into. It will also depend on your body size, age, and physical condition. Usually one dose will last long enough but more doses may be given if the surgery takes a long time.

Bupivacaine solution for injection will be given to you as an injection. The part of the body where you are injected will depend on why you are being given Bupivacaine solution for injection. Your doctor will give you Bupivacaine solution for injection in one of the following places:

 Near to the part of the body that needs to be numbed.

 In an area away from the part of the body that needs to be numbed. This is the case if you are given an epidural injection (an injection around the spinal cord).

When Bupivacaine solution for injection is injected into the body in one of these ways, it stops the nerves from being able to pass pain messages to the brain. It will slowly wear off when the medical procedure is over.

If you have been given too much Bupivacaine solution for injection

Serious side effects from getting too much Bupivacaine solution for injection are unlikely. They need special treatment and the doctor treating you is trained to deal with these situations. The first signs of being given too much Bupivacaine solution for injection are usually as follows:

 Feeling dizzy or light-headed

 Numbness of the lips and around the mouth.

 Numbness of the tongue.

 Hearing problems.

 Problems with your sight (vision).

To reduce the risk of serious side effects, your doctor will stop giving you Bupivacaine solution for injection as soon as these signs appear. This means that if any of these happen to you, or you think you have received too much Bupivacaine solution for injection, tell your doctor immediately.

More serious side effects from being given too much Bupivacaine solution for injection include twitching of your muscles, fits (seizures), and loss of consciousness.

4. Possible side effects

Like all medicines, this medicine can cause side effects, although not everyone gets them.

Severe allergic reactions (rare, affects less than 1 in 1,000 people)

If you have a severe allergic reaction, tell your doctor immediately. The signs may include sudden

onset of:

 Swelling of your face, lips, tongue or throat. This may make it difficult to swallow.

 Severe or sudden swelling of your hands, feet and ankles.

 Difficulty breathing.

 Severe itching of the skin (with raised lumps).

Other possible side effects:

Very common (affects more than 1 in 10 people)

 Low blood pressure. This might make you feel dizzy or light-headed.

 Feeling sick (nausea).

Common (affects less than 1 in 10 people)

 Being sick (vomiting).

 Feeling dizzy.

 Pins and needles.

 High blood pressure (hypertension).

 Slow heartbeat.

 Problems passing water.

Uncommon (affects less than 1 in 100 people)

 Feeling light-headed.

 Fits (seizures).

 Numbness of the tongue or around the mouth.

 Ringing in the ears or being sensitive to sound.

 Difficulty speaking.

 Blurred sight (vision).

 Loss of consciousness.

 Shaking (tremors).

 Twitching of your muscles. Rare (affects less than 1 in 1,000 people)

 Double vision.

 Nerve damage that may cause changes in sensation or muscle weakness (neuropathy). This may include peripheral nerve damage.

 A condition called arachnoiditis (inflammation of the membrane that surrounds the spinal cord). The signs include a stinging or burning pain in the lower back or legs and tingling, numbness or weakness in the legs.

 Weak or paralysed legs.

 Uneven heart beat (arrhythmias). This could be life-threatening.

 Slowed or stopped breathing or stopped heartbeat. This could be life-threatening.

Possible side effects seen with other local anaesthetics which might also be caused by Bupivacaine solution for injection include:

 Problems with your liver enzymes. This may happen if you have long-term treatment with this medicine.

 Damaged nerves. Rarely this may cause permanent problems.

 Blindness which is not permanent or problems with the muscles of the eyes that are longlasting. This may happen with some injections given around the eyes.

Additional side effects in children and adolescents

 Adverse drug reactions in children are similar to those in adults.

Reporting of side effects

If you get any side effects, talk to your doctor or pharmacist or nurse. This includes any possible side effects not listed in this leaflet. You can also report side effects directly.

5. How to store Bupivacaine solution for injection

Keep this medicine out of the sight and reach of children.

Do not use this medicine after the expiry date, which is stated on the ampoule, vial and carton.

The expiry date refers to the last day of that month.

Do not refrigerate or freeze.

Bupivacaine Injection is for single use only and should be used immediately after opening. Discard any unused solution.

Do not use this medicine if you notice the contents are discoloured in any way or if particles are present.

Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help protect the environment.

6. Contents of the pack and other information

What Bupivacaine solution for injection contains

The active substance is bupivacaine hydrochloride.

Bupivacaine 0.25% w/v solution for injection: Each 1 ml of solution contains 2.5 mg of anhydrous Bupivacaine hydrochloride.

Bupivacaine 0.5% w/v solution for injection: Each 1 ml of solution contains 5 mg of anhydrous Bupivacaine hydrochloride.

The other ingredients are water for injections, sodium chloride and sodium hydroxide.

What Bupivacaine solution for injection looks like and contents of the pack

Bupivacaine solution for injection is a clear, colourless, sterile solution for injection. It is available in two strengths, 0.25% w/v and 0.5% w/v. Both product strengths are available in ampoule and vial.

Bupivacaine 0.25% w/v solution for injection is filled in 5 ml and 10 ml ampoules and also in 20 ml vials.

Bupivacaine 0.5% w/v solution for injection is filled in 2 ml, 4 ml, 5 ml and 10 ml ampoules and also in 20 ml vials. The 2 ml, 4 ml and 5 ml ampoules are supplied in packs of 5 and 10 ampoules. The 10 ml ampoules are supplied in packs of 5, 10, 15 and 20 ampoules. The 20 ml vials are supplied in packs of 1 vial.

Not all pack sizes may be marketed.

7. Manufactured in India by:
TAJ PHARMACEUTICALS LTD.
Mumbai, India
Unit No. 214.Old Bake House,
Maharashtra chambers of  Commerce Lane,
Fort, Mumbai – 400001
at:Gujarat, INDIA.
Customer Service and Product Inquiries:
1-800-TRY-FIRST (1-800-222-434 & 1-800-222-825)
Monday through Saturday 9:00 a.m. to 7:00 p.m. EST
E-mail: tajgroup@tajpharma.com