Sodium Valproate for Injection 100mg/ml Taj Pharma

 

  1. Name of the medicinal product

Sodium Valproate for Injection 100mg/ml Taj Pharma

  1. Qualitative and quantitative composition

Each ml of solution contains 100 mg sodium valproate.

Each 4 ml ampoule contains 400 mg sodium valproate.

Each 10 ml ampoule contains 1000 mg sodium valproate.

Excipient with known effect

Sodium

For the full list of excipients, see section 6.1.

  1. Pharmaceutical form

Injection or Infusion.

  1. Clinical particulars

4.1 Therapeutic indications

The treatment of epileptic patients who would normally be maintained on oral sodium valproate, and for whom oral therapy is temporarily not possible.

4.2 Posology and method of administration

Method of administration

Sodium valproate injection may be given by direct slow intravenous injection or by infusion using a separate intravenous line in normal saline, dextrose 5%, or dextrose saline.

Posology

Dosage requirements vary according to age and body weight.

Each vial of sodium valproate injection is for single dose injection only. For instructions on preparation and dilution of sodium valproate injection before administration (see section 6.6).

Sodium valproate injection should not be administered via the same IV line as other IV additives. The intravenous solution is suitable for infusion by PVC, polyethylene or glass containers.

Patients already satisfactorily treated with oral sodium valproate may be continued at their current dosage using continuous or repeated infusion. Other patients may be given a slow intravenous injection over 3-5 minutes, usually 400-800mg depending on body weight (up to 10mg/kg) followed by continuous or repeated infusion up to a maximum of 2500mg/day.

Sodium valproate injection should be replaced by oral valproate therapy as soon as practicable.

Use with children:

Daily requirement for children is usually in the range 20 – 30mg/kg body weight per day and method of administration is as above. Where adequate control is not achieved within this range, the dose may be increased to 40 mg/kg/day but only in patients in whom plasma valproic acid levels can be monitored. Above 40 mg/kg/day clinical chemistry and haematological parameters should be monitored.

Use in elderly:

Although the pharmacokinetics of sodium valproate are modified in the elderly, they have limited clinical significance and dosage should be determined by seizure control. The volume of distribution is increased in the elderly and because of decreased binding to serum albumin, the proportion of free drug is increased. This will affect the clinical interpretation of plasma valproic acid levels.

In patients with renal insufficiency:

It may be necessary to decrease the dosage. Dosage should be adjusted according to clinical monitoring since monitoring of plasma concentrations may be misleading (see section 5.2).

In patients with hepatic insufficiency:

Salicylates should not be used concomitantly with sodium valproate since they employ the same metabolic pathway (see sections 4.4 and 4.8).

Liver dysfunction, including hepatic failure resulting in fatalities, has occurred in patients whose treatment included valproic acid (see sections 4.3 and 4.4).

Salicylates should not be used in children under 16 years (see aspirin/salicylate product information on Reye’s syndrome). In addition in conjunction with sodium valproate, concomitant use in children under 3 years can increase the risk of liver toxicity (see section 4.4).

Female children and women of childbearing potential

Valproate must be initiated and supervised by a specialist experienced in the management of epilepsy. Valproate should not be used in female children and women of childbearing potential unless other treatments are ineffective or not tolerated (see sections 4.3, 4.4 and 4.6).

Valproate is prescribed and dispensed according to the Valproate Pregnancy Prevention Programme (see sections 4.4 and 4.4). The benefits and risks should be carefully reconsidered at regular treatment reviews (see section 4.4).

Valproate should preferably be prescribed as monotherapy and at the lowest effective dose, if possible as a prolonged release formulation. The daily dose should be divided into at least two single doses (see section 4.6).

Combined Therapy:

When starting sodium valproate injection in patients already on other anticonvulsants these should be tapered slowly. Initiation of sodium valproate injection therapy should then be gradual, with target dose reached after about two weeks. In certain cases it may be necessary to raise the dose by 5 to 10mg/kg/day when used in combination with anticonvulsants which induce liver enzyme activity, e.g. phenytoin, phenobarbital and carbamazepine. Once known enzyme inducers have been withdrawn it may be possible to maintain seizure control on a reduced dose of sodium valproate injection.

When barbiturates are being administered concomitantly and particularly if sedation is observed (particularly in children) the dosage of barbiturates should be reduced.

N.B. In children requiring doses higher than 40 mg/kg/day clinical chemistry and haematological parameters should be monitored.

Optimum dosage is mainly determined by seizure control and routine measurement of plasma levels is unnecessary. However, a method for measurement of plasma levels is available and may be helpful where there is poor control or side effects are suspected (see section 5.2).

4.3 Contraindications

Sodium Valproate 100mg/ml Solution for Injection or Infusion is contraindicated in the following situations:

  • In pregnancy unless there is no suitable alternative treatment (see section 4.4 and 4.6).
  • In women of childbearing potential, unless the conditions of the pregnancy prevention programme are fulfilled (see section 4.4 and 4.6).
  • Active liver disease
  • Personal or family history of severe hepatic dysfunction, especially drug related
  • Patients with known urea cycle disorders (see section 4.4)
  • Hypersensitivity to the active substance or to any of the excipients listed in section 6.1
  • Porphyria
  • Valproate is contraindicated in patients known to have mitochondrial disorders caused by mutations in the nuclear gene encoding the mitochondrial enzyme polymerase γ (POLG), e.g. Alpers-Huttenlocher Syndrome and in children under two years of age who are suspected of having a POLG-related disorder (see section 4.4).

4.4 Special warnings and precautions for use

Although there is no specific evidence of sudden recurrence of underlying symptoms following withdrawal of valproate, discontinuation should normally only be done under the supervision of a specialist in a gradual manner. This is due to the possibility of sudden alterations in plasma concentrations giving rise to a recurrence of symptoms. NICE has advised that switching between different manufacturer’s valproate preparations is not normally recommended due to the clinical implications of possible variations in plasma concentrations.

4.4.1 Special warnings

Liver dysfunction:

Conditions of occurrence:

Severe liver damage, including hepatic failure sometimes resulting in fatalities, has been very rarely reported. Experience in epilepsy has indicated that patients most at risk, especially in cases of multiple anti-convulsant therapy, are infants and in particular young children under the age of 3 years and those with severe seizure disorders, organic brain disease, and (or) congenital metabolic or degenerative disease associated with mental retardation.

After the age of 3 years, the incidence of occurrence is significantly reduced and progressively decreases with age.

The concomitant use of salicylates should be avoided in children under 3 years due to the risk of liver toxicity. Additionally, salicylates should not be used in children under 16 years (see aspirin/salicylate product information on Reye’s syndrome).

Monotherapy is recommended in children under the age of 3 years when prescribing sodium valproate injection, but the potential benefit of sodium valproate injection should be weighed against the risk of liver damage or pancreatitis in such patients prior to initiation of therapy

In most cases, such liver damage occurred during the first 6 months of therapy, the period of maximum risk being 2-12 weeks.

Suggestive signs:

Clinical symptoms are essential for early diagnosis. In particular the following conditions, which may precede jaundice, should be taken into consideration, especially in patients at risk (see above: ‘Conditions of occurrence’):

  • non-specific symptoms, usually of sudden onset, such as asthenia, malaise, anorexia, lethargy, oedema and drowsiness, which are sometimes associated with repeated vomiting and abdominal pain.
  • in patients with epilepsy, recurrence of seizure

These are an indication for immediate withdrawal of the drug.

Patients (or their family for children) should be instructed to report immediately any such signs to a physician should they occur. Investigations including clinical examination and biological assessment of liver function should be undertaken immediately.

Detection:

Liver function should be measured before therapy and then periodically monitored during the first 6 months of therapy, especially in those who seem most at risk, and those with a prior history of liver disease.

Amongst usual investigations, tests which reflect protein synthesis, particularly prothrombin rate, are most relevant.

Confirmation of an abnormally low prothrombin rate, particularly in association with other biological abnormalities (significant decrease in fibrinogen and coagulation factors; increased bilirubin level and raised transaminases) requires cessation of sodium valproate therapy.

As a matter of precaution and in case they are taken concomitantly salicylates should also be discontinued since they employ the same metabolic pathway.

As with most anti-epileptic drugs, increased liver enzymes are common, particularly at the beginning of therapy; they are also transient.

More extensive biological investigations (including prothrombin rate) are recommended in these patients; a reduction in dosage may be considered when appropriate and tests should be repeated as necessary.

Pancreatitis:

Pancreatitis, which may be severe and result in fatalities, has been very rarely reported. Patients experiencing nausea, vomiting or acute abdominal pain should have a prompt medical evaluation (including measurement of serum amylase).Young children are at particular risk; this risk decreases with increasing age. Severe seizures and severe neurological impairment with combination anticonvulsant therapy may be risk factors. Hepatic failure with pancreatitis increases the risk of fatal outcome. In case of pancreatitis, sodium valproate should be discontinued.

Female children, women of childbearing potential and pregnant women:

Pregnancy Prevention Programme

Valproate has a high teratogenic potential and children exposed in utero to valproate have a high risk for congenital malformations and neurodevelopmental disorders (see section 4.6).

Sodium Valproate 100mg/ml Solution for Injection or Infusion is contraindicated in the following situations:

• in pregnancy unless there is no suitable alternative treatment (see sections 4.3 and 4.6).

• in women of childbearing potential, unless the conditions of the pregnancy prevention programme are fulfilled (see sections 4.3 and 4.6).

Conditions of Pregnancy Prevention Programme:

The prescriber must ensure that

• Individual circumstances should be evaluated in each case, involving the patient in the discussion, to guarantee her engagement, discuss therapeutic options and ensure her understanding of the risks and the measures needed to minimise the risks.

• the potential for pregnancy is assessed for all female patients.

• the patient has understood and acknowledged the risks of congenital malformations and neurodevelopmental disorders including the magnitude of these risks for children exposed to valproate in utero.

• the patient understands the need to undergo pregnancy testing prior to initiation of treatment and during treatment, as needed.

• the patient is counselled regarding contraception, and that the patient is capable of complying with the need to use effective contraception (for further details please refer to subsection contraception of this boxed warning), without interruption during the entire duration of treatment with valproate.

• the patient understands the need for regular (at least annual) review of treatment by a specialist experienced in the management of epilepsy.

• the patient understands the need to consult her physician as soon as she is planning pregnancy to ensure timely discussion and switching to alternative treatment options prior to conception, and before contraception is discontinued.

• the patient understands the need to urgently consult her physician in case of pregnancy.

• the patient has received the patient guide.

• the patient has acknowledged that she has understood the hazards and necessary precautions associated with valproate use (Annual Risk Acknowledgement Form).

These conditions also concern women who are not currently sexually active unless the prescriber considers that there are compelling reasons to indicate that there is no risk of pregnancy.

Female children

• The prescribers must ensure that parents/caregivers of female children understand the need to contact the specialist once the female child using valproate experiences menarche.

The prescriber must ensure that parents/caregivers of female children who have experienced menarche are provided with comprehensive information about the risks of congenital malformations and neurodevelopmental disorders including the magnitude of these risks for children exposed to valproate in uteroIn patients who experienced menarche, the prescribing specialist must reassess the need for valproate therapy annually and consider alternative treatment options. If valproate is the only suitable treatment, the need for using effective contraception and all other conditions of pregnancy prevention programme should be discussed. Every effort should be made by the specialist to switch the female children to alternative treatment before they reach adulthood.

Pregnancy test

Pregnancy must be excluded before start of treatment with valproate. Treatment with valproate must not be initiated in women of child bearing potential without a negative pregnancy test (plasma pregnancy test) result, confirmed by a health care provider, to rule out unintended use in pregnancy.

Contraception

Women of childbearing potential who are prescribed valproate must use effective contraception, without interruption during the entire duration of treatment with valproate. These patients must be provided with comprehensive information on pregnancy prevention and should be referred for contraceptive advice if they are not using effective contraception. At least one effective method of contraception (preferably a user independent form such as an intra-uterine device or implant) or two complementary forms of contraception including a barrier method should be used. Individual circumstances should be evaluated in each case, when choosing the contraception method involving the patient in the discussion, to guarantee her engagement and compliance with the chosen measures. Even if she has amenorrhea she must follow all the advice on effective contraception.

Oestrogen-containing products

Concomitant use with oestrogen-containing products, including oestrogen-containing hormonal contraceptives, may potentially result in decreased valproate efficacy (see section 4.5). Prescribers should monitor clinical response (seizure control) when initiating, or discontinuing oestrogen-containing products.

On the opposite, valproate does not reduce efficacy of hormonal contraceptives.

Annual treatment reviews by a specialist

The specialist should at least annually review whether valproate is the most suitable treatment for the patient. The specialist should discuss the annual risk acknowledgement form, at initiation and during each annual review and ensure that the patient has understood its content.

Pregnancy planning.

If a woman is planning to become pregnant, a specialist experienced in the management of epilepsy, must reassess valproate therapy and consider alternative treatment options. Every effort should be made to switch to appropriate alternative treatment prior to conception, and before contraception is discontinued (see section 4.6). If switching is not possible, the woman should receive further counselling regarding the valproate risks for the unborn child to support her informed decision making regarding family planning.

In case of pregnancy

If a woman using valproate becomes pregnant, she must be immediately referred to a specialist to re-evaluate treatment with valproate and consider alternative options. The patients with a valproate exposed pregnancy and their partners should be referred to a specialist experienced in prenatal medicine for evaluation and counselling regarding the exposed pregnancy (see section 4.6).

Pharmacist must ensure that

• The patient card is provided with every valproate dispensing and that the patients understand its content.

• Patients are advised not to stop valproate medication and to immediately contact a specialist in case of planned or suspected pregnancy.

Educational materials

In order to assist healthcare professionals and patients in avoiding exposure to valproate during pregnancy, the Marketing Authorisation Holder has provided educational materials to reinforce the warnings and provide guidance regarding use of valproate in women of childbearing potential and the details of the pregnancy prevention programme. A patient guide and patient card should be provided to all women of childbearing potential using valproate.

An Annual Risk Acknowledgement Form needs to be used at time of treatment initiation and during each annual review of valproate treatment by the specialist.

Valproate therapy should only be continued after a reassessment of the benefits and risks of the treatment with valproate for the patient by a specialist experienced in the management of epilepsy.

Aggravated convulsions:

As with other anti-epileptic drugs, some patients may experience, instead of an improvement, a reversible worsening of convulsion frequency and severity (including status epilepticus), or the onset of new types of convulsions with valproate. In case of aggravated convulsions, the patients should be advised to consult their physician immediately (see section 4.8).

Suicidal ideation and behaviour:

Suicidal ideation and behaviour have been reported in patients treated with anti-epileptic agents in several indications. A meta-analysis of randomised placebo controlled trials of anti-epileptic drugs has also shown a small increased risk of suicidal ideation and behaviour. The mechanism of this risk is not known and the available data do not exclude the possibility of an increased risk for sodium valproate.

Therefore patients should be monitored for signs of suicidal ideation and behaviours and appropriate treatment should be considered. Patients (and caregivers of patients) should be advised to seek medical advice should signs of suicidal ideation or behaviour emerge.

Carbapenem agents:

The concomitant use of valproate and carbapenem agents is not recommended.

Patients with known or suspected mitochondrial disease

Valproate may trigger or worsen clinical signs of underlying mitochondrial diseases caused by mutations of mitochondrial DNA as well as the nuclear encoded POLG gene. In particular, valproate-induced acute liver failure and liver-related deaths have been reported at a higher rate in patients with hereditary neurometabolic syndromes caused by mutations in the gene for the mitochondrial enzyme polymerase γ (POLG) e.g. Alpers-Huttenlocher Syndrome.

POLG-related disorders should be suspected in patients with a family history or suggestive symptoms of a POLG-related disorder, including but not limited to unexplained encephalopathy, refractory epilepsy (focal, myoclonic), status epilepticus at presentation, developmental delays, psychomotor regression, axonal sensorimotor neuropathy, myopathy, cerebellar ataxia, ophthalmoplegia or complicated migraine with occipital aura. POLG mutation testing should be performed in accordance with current clinical practice for the diagnostic evaluation of such disorders (see section 4.3).

4.4.2 Precautions

Haematological tests:

Blood tests (blood cell count, including platelet count, bleeding time and coagulation tests) are recommended prior to initiation of therapy or before surgery, and in case of spontaneous bruising or bleeding (see section 4.8).

Renal insufficiency:

In patients with renal insufficiency, it may be necessary to decrease dosage. As monitoring of plasma concentrations may be misleading, dosage should be adjusted according to clinical monitoring (see sections 4.2 and 5.2).

Patients with systemic lupus erythematosus:

Although immune disorders have only rarely been noted during the use of sodium valproate injection, the potential benefit of sodium valproate injection should be weighed against its potential risk in patients with systemic lupus erythematosus (see section 4.8).

Urea cycle disorders:

When a urea cycle enzymatic deficiency is suspected, metabolic investigations should be performed prior to treatment because of the risk of hyperammonaemia with sodium valproate injection (see section 4.3).

Weight gain:

Sodium valproate very commonly causes weight gain, which may be marked and progressive. Patients should be warned of the risk of weight gain at the initiation of therapy and appropriate strategies should be adopted to minimise it (see section 4.8).

Diabetic patients:

Sodium valproate is eliminated mainly through the kidneys, partly in the form of ketone bodies; this may give false positives in the urine testing of possible diabetics.

Carnitine palmitoyltransferase (CPT) type II deficiency:

Patients with an underlying carnitine palmitoyltransferase (CPT) type II deficiency should be warned of the greater risk of rhabdomyolysis when taking sodium valproate.

Alcohol:

Alcohol intake is not recommended during treatment with valproate.

4.5 Interaction with other medicinal products and other forms of interaction

4.5.1 Effects of sodium valproate injection on other drugs

Antipsychotics, MAO inhibitors, antidepressants and benzodiazepines:

Sodium valproate may potentiate the effect of other psychotropics such as antipsychotics, monoamine oxidase inhibitors, antidepressants and benzodiazepines; therefore, clinical monitoring is advised and the dosage of the other psychotropics should be adjusted when appropriate.

In particular, a clinical study has suggested that adding olanzapine to valproate or lithium therapy may significantly increase the risk of certain adverse events associated with olanzapine e.g. neutropenia, tremor, dry mouth, increased appetite and weight gain, speech disorder and somnolence.

Lithium:

Sodium valproate has no effect on serum lithium levels.

Olanzapine:

Valproic acid may decrease the olanzapine plasma concentration.

Phenobarbital:

Sodium valproate increases phenobarbital plasma concentrations (due to inhibition of hepatic catabolism) and sedation may occur, particularly in children. Therefore, clinical monitoring is recommended throughout the first 15 days of combined treatment with immediate reduction of phenobarbital doses if sedation occurs and determination of phenobarbital plasma levels when appropriate.

Primidone:

Sodium valproate increases primidone plasma levels with exacerbation of its adverse effects (such as sedation); these signs cease with long term treatment. Clinical monitoring is recommended especially at the beginning of combined therapy with dosage adjustment when appropriate.

Phenytoin:

Sodium valproate decreases phenytoin total plasma concentration. Moreover sodium valproate increases phenytoin free form with possible overdose symptoms (valproic acid displaces phenytoin from its plasma protein binding sites and reduces its hepatic catabolism). Therefore clinical monitoring is recommended; when phenytoin plasma levels are determined, the free form should be evaluated.

Carbamazepine:

Clinical toxicity has been reported when sodium valproate was administered with carbamazepine as sodium valproate may potentiate toxic effects of carbamazepine. Clinical monitoring is recommended especially at the beginning of combined therapy with dosage adjustment when appropriate.

Lamotrigine:

Sodium valproate reduces the metabolism of lamotrigine and increases the lamotrigine mean half-life by nearly two fold. This interaction may lead to increased lamotrigine toxicity, in particular serious skin rashes. Therefore clinical monitoring is recommended and dosages should be adjusted (lamotrigine dosage decreased) when appropriate.

Felbamate:

Valproic acid may decrease the felbamate mean clearance by up to 16%.

Rufinamide:

Valproic acid may lead to an increase in plasma levels of rufinamide. This increase is dependent on concentration of valproic acid. Caution should be exercised, in particular in children, as this effect is larger in this population.

Propofol:

Valproic acid may lead to an increased blood level of propofol. When co-administered with valproate, a reduction of the dose of propofol should be considered.

Zidovudine:

Sodium valproate may raise zidovudine plasma concentration leading to increased zidovudine toxicity.

Nimodipine:

In patients concomitantly treated with sodium valproate and nimodipine the exposure to nimodipine can be increased by 50%. The nimodipine dose should therefore be decreased in case of hypotension.

Temozolomide:

Co-administration of temozolomide and sodium valproate may cause a small decrease in the clearance of temozolomide that is not thought to be clinically relevant.

4.5.2 Effects of other drugs on Sodium valproate injection

Anti-epileptics

Anti-epileptics with enzyme inducing effect (including phenytoin, phenobarbital, carbamazepine) decrease valproic acid plasma concentrations. Dosages should be adjusted according to clinical response and blood levels in case of combined therapy.

Valproic acid metabolite levels may be increased in the case of concomitant use with phenytoin or phenobarbital. Therefore patients treated with those two drugs should be carefully monitored for signs and symptoms of hyperammonaemia.

On the other hand, combination of felbamate and sodium valproate decreases valproic acid clearance by 22% to 50% and consequently increases valproic acid plasma concentrations. Sodium valproate injection dosage should be monitored.

Anti-malarial agents

Mefloquine and chloroquine increase valproic acid metabolism and may lower the seizure threshold; therefore epileptic seizures may occur in cases of combined therapy. Accordingly, the dosage of sodium valproate may need adjustment.

Highly protein bound agents

In case of concomitant use of sodium valproate and highly protein bound agents (e.g. aspirin), free valproic acid plasma levels may be increased.

Vitamin K-dependent factor anticoagulants

The anticoagulant effect of warfarin and other coumarin anticoagulants may be increased following displacement from plasma protein binding sites by valproic acid. The prothrombin time should be closely monitored.

Cimetidine or erythromycin

Valproic acid plasma levels may be increased (as a result of reduced hepatic metabolism) in case of concomitant use with cimetidine or erythromycin.

Carbapenem antibiotics (such as imipenem, panipenem and meropenem)

Decreases in blood levels of valproic acid have been reported when it is co-administered with carbapenem agents resulting in a 60%-100% decrease in valproic acid levels within two days, sometimes associated with convulsions. Due to the rapid onset and the extent of the decrease, co-administration of carbapenem agents in patients stabilised on valproic acid should be avoided (see section 4.4). If treatment with these antibiotics cannot be avoided, close monitoring of valproic acid blood levels should be performed.

Rifampicin

Rifampicin may decrease the valproic acid blood levels resulting in a lack of therapeutic effect. Therefore, valproate dosage adjustment may be necessary when it is co-administered with rifampicin.

Protease inhibitors

Protease inhibitors such as lopinavir and ritonavir decrease valproate plasma level when co-administered.

Cholestyramine

Cholestyramine may lead to a decrease in plasma level of valproate when co-adminstered.

Oestrogen-containing products, including oestrogen-containing hormonal contraceptives

Oestrogens are inducers of the UDP-glucuronosyl transferase (UGT) isoforms involved in valproate glucuronidation and may increase the clearance of valproate, which would result in decreased serum concentration of valproate and potentially decreased valproate efficacy (see section 4.4). Consider monitoring of valproate serum levels.

On the opposite, valproate has no enzyme inducing effect; as a consequence, valproate does not reduce efficacy of oestroprogestative agents in women receiving hormonal contraception.

4.5.3 Other Interactions

Caution is advised when using sodium valproate injection in combination with newer anti-epileptics whose pharmacodynamics may not be well established.

Concomitant administration of valproate and topiramate or acetazolamide has been associated with encephalopathy and/or hyperammonaemia. In patients taking these two drugs, careful monitoring of signs and symptoms is advised in particularly at-risk patients such as those with pre-existing encephalopathy.

Quetiapine

Co-administration of sodium valproate and quetiapine may increase the risk of neutropenia/leucopenia.

4.6 Fertility, pregnancy and lactation

• Valproate is contraindicated as treatment for epilepsy during pregnancy unless there is no suitable alternative to treat epilepsy.

• Valproate is contraindicated for use in women of childbearing potential unless the conditions of the pregnancy prevention programme are fulfilled (see sections 4.3 and 4.4).

Pregnancy Exposure Risk related to valproate

Both valproate monotherapy and valproate polytherapy are associated with abnormal pregnancy outcomes. Available data suggest that anti-epileptic polytherapy including valproate is associated with a greater risk of congenital malformations than valproate monotherapy.

Teratogenicity and developmental effects

Congenital malformations

Data derived from a meta-analysis (including registries and cohort studies) has shown that 10.73% of children of epileptic women exposed to valproate monotherapy during pregnancy suffer from congenital malformations (95% CI: 8.16 – 13.29). This is a greater risk of major malformations than for the general population, for whom the risk is about 2-3%. The risk is dose dependent but a threshold dose below which no risk exists cannot be established.

Available data show an increased incidence of minor and major malformations. The most common types of malformations include neural tube defects, facial dysmorphism, cleft lip and palate, craniostenosis, cardiac, renal and urogenital defects, limb defects (including bilateral aplasia of the radius), and multiple anomalies involving various body systems.

Developmental disorders

Data have shown that exposure to valproate in utero can have adverse effects on mental and physical development of the exposed children. The risk seems to be dose-dependent but a threshold dose below which no risk exists, cannot be established based on available data. The exact gestational period of risk for these effects is uncertain and the possibility of a risk throughout the entire pregnancy cannot be excluded.

Studies in preschool children exposed in utero to valproate show that up to 30-40% experience delays in their early development such as talking and walking later, lower intellectual abilities, poor language skills (speaking and understanding) and memory problems.

Intelligence quotient (IQ) measured in school aged children (age 6) with a history of valproate exposure in utero was on average 7-10 points lower than those children exposed to other anti-epileptics. Although the role of confounding factors cannot be excluded, there is evidence in children exposed to valproate that the risk of intellectual impairment may be independent from maternal IQ.

There are limited data on the long term outcomes.

Available data show that children exposed to valproate in utero are at increased risk of autistic spectrum disorder (approximately three-fold) and childhood autism (approximately five-fold) compared with the general study population.

Limited data suggests that children exposed to valproate in utero may be more likely to develop symptoms of attention deficit/hyperactivity disorder (ADHD).

Female children and woman of childbearing potential (see above and section 4.4)

Oestrogen-containing products

Oestrogen-containing products, including oestrogen-containing hormonal contraceptives, may increase the clearance of valproate, which would result in decreased serum concentration of valproate and potentially decreased valproate efficacy (see section 4.4 and 4.5).

If a woman plans a pregnancy

If a woman is planning to become pregnant, a specialist experienced in the management of epilepsy, must reassess valproate therapy and consider alternative treatment options. Every effort should be made to switch to appropriate alternative treatment prior to conception, and before contraception is discontinued (see section 4.4). If switching is not possible, the woman should receive further counselling regarding the valproate risks for the unborn child to support her informed decision making regarding family planning.

Pregnant women

Valproate as treatment for epilepsy is contraindicated in pregnancy unless there is no suitable alternative treatment (see sections 4.3 and 4.4).

If a woman using valproate becomes pregnant, she must be immediately referred to a specialist to consider alternative treatment options. During pregnancy, maternal tonic clonic seizures and status epilepticus with hypoxia may carry a particular risk of death for mother and the unborn child.

If in exceptional circumstances, despite the known risks of valproate in pregnancy and after careful consideration of alternative treatment, a pregnant woman must receive valproate for epilepsy, it is recommended to:

  • Use the lowest effective dose and divide the daily dose of valproate into several small doses to be taken throughout the day.
  • The use of a prolonged release formulation may be preferable to other treatment formulations in order to avoid high peak plasma concentrations (see section 4.2).

All patients with a valproate exposed pregnancy and their partners should be referred to a specialist experienced in prenatal medication for evaluation and counselling regarding the exposed pregnancy. Specialized prenatal monitoring should take place to detect the possible occurrence of neural tube defects or other malformations. Folate supplementation before the pregnancy may decrease the risk of neural tube defects which may occur in all pregnancies. However the available evidence does not suggest it prevents the birth defects or malformations due to valproate exposure.

Risk in the neonate

-Cases of haemorrhagic syndrome have been reported very rarely in neonates whose mothers have taken valproate during pregnancy. This haemorrhagic syndrome is related to thrombocytopenia, hypofibrinogenemia and/or to a decrease in other coagulation factors. Afibrinogenemia has also been reported and may be fatal. However, this syndrome must be distinguished from the decrease of the vitamin-K factors induced by phenobarbital and enzymatic inducers. Therefore, platelet count, fibrinogen plasma level, coagulation tests and coagulation factors should therefore be investigated in neonates.

– Cases of hypoglycaemia have been reported in neonates whose mothers have taken valproate during the third trimester of their pregnancy.

– Cases of hypothyroidism have been reported in neonates whose mothers have taken valproate during pregnancy.

– Withdrawal syndrome (such as, in particular, agitation, irritability, hyperexcitability, jitteriness, hyperkinesia, tonicity disorders, tremor, convulsions and feeding disorders) may occur in neonates whose mothers have taken valproate during the last trimester of their pregnancy.

Breast-feeding

Valproate is excreted in human milk with a concentration ranging from 1% to 10% of maternal serum levels. Haematological disorders have been shown in breastfed newborns/infants of treated women (see section 4.8).

A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from valproate therapy taking into account the benefit of breast-feeding for the child and the benefit of therapy for the woman.

Fertility

Amenorrhoea, polycystic ovaries and increased testosterone levels have been reported in women using valproate (see section 4.8). Valproate administration may also impair fertility in men (see section 4.8). Case reports indicate that fertility dysfunctions are reversible after treatment discontinuation.

4.7 Effects on ability to drive and use machines

Not applicable – use of intravenous formulation restricted to patients unable to take oral therapy. However, note use of sodium valproate injection may provide seizure control such that the patient may again be eligible to hold a driving licence.

Patients should be warned of the risk of transient drowsiness, especially in cases of anticonvulsant polytherapy or association with benzodiazepines (see section 4.5).

4.8 Undesirable effects

The following CIOMS frequency rating is used, when applicable:

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) ; Very rare (<1/10,000), not known (cannot be estimated from available data).

Congenital malformations and developmental disorders (see sections 4.4 and 4.6)

Hepatobiliary disorders:

Common: liver injury (see section 4.4.1)

Severe liver damage, including hepatic failure sometimes resulting in death, has been reported (see sections 4.2, 4.3 and 4.4.1). Increased liver enzymes are common, particularly early in treatment, and may be transient (see section 4.4.1).

Gastrointestinal disorders:

Very common: nausea occurs a few minutes after intravenous injection with spontaneous resolution within a few minutes.

Common: vomiting, gingival disorder (mainly gingival hyperplasia), stomatitis, gastralgia, diarrhoea

The above adverse events frequently occur at the start of treatment, but they usually disappear after a few days without discontinuing treatment. These problems can usually be overcome by taking sodium valproate with or after food.

Uncommon: pancreatitis, sometimes lethal (see section 4.4).

Nervous system disorders:

Very common: tremor

Common: extrapyramidal disorder, stupor*1, somnolence, convulsion*1, memory impairment, headache, nystagmus, dizziness may occur a few minutes after intravenous injection and it usually resolves spontaneously within a few minutes.

Uncommon: coma*1, encephalopathy, lethargy*1 (see below), reversible Parkinsonism, ataxia, paresthesia, aggravated convulsions (see section 4.4).

Rare: reversible dementia associated with reversible cerebral atrophy, cognitive disorder, diplopia.

Sedation has been reported occasionally, usually when in combination with other anti-convulsants. In monotherapy it occurred early in treatment on rare occasions and is usually transient.

*1Rare cases of lethargy occasionally progressing to stupor, sometimes with associated hallucinations or convulsions have been reported. Encephalopathy and coma have very rarely been observed. These cases have often been associated with too high a starting dose or too rapid a dose escalation or concomitant use of other anti-convulsants, notably phenobarbital or topiramate. They have usually been reversible on withdrawal of treatment or reduction of dosage.

An increase in alertness may occur; this is generally beneficial but occasionally aggression, hyperactivity and behavioural deterioration have been reported.

Psychiatric disorders:

Common: confusional state, hallucinations, aggression*2, agitation*2, disturbance in attention*2,

Rare: abnormal behaviour*2, psychomotor hyperactivity*2, learning disorder*2

*2These ADRs are principally observed in the paediatric population.

Metabolism and nutrition disorders:

Common: hyponatraemia, weight increased*

*Weight increase should be carefully monitored since it is a factor for polycystic ovary syndrome (see section 4.4).

Rare: obesity, hyperammonaemia*3 (see section 4.4.2)

*3Cases of isolated and moderate hyperammonaemia without change in liver function tests may occur, are usually transient and should not cause treatment discontinuation. However, they may present clinically as vomiting, ataxia, and increasing clouding of consciousness. Should these symptoms occur sodium valproate injection should be discontinued.

Hyperammonaemia associated with neurological symptoms has also been reported (see section 4.4.2). In such cases further investigations should be considered.

Endocrine disorders:

Uncommon: Syndrome of Inappropriate Secretion of ADH (SIADH), hyperandrogenism (hirsutism, virilism, acne, male pattern alopecia, and/or androgen increased).

Rare: hypothyroidism (see section 4.6)

Blood and lymphatic system disorders:

Common: anaemia, thrombocytopenia (see section 4.4.2).

Uncommon: pancytopenia, leucopenia.

Rare: bone marrow failure, including pure red cell aplasia, agranulocytosis, anaemia macrocytic, macrocytosis.

The blood picture returned to normal when the drug was discontinued.

Isolated findings of a reduction in blood fibrinogen and/or an increase in prothrombin time have been reported, usually without associated clinical signs and particularly with high doses (sodium valproate has an inhibitory effect on the second phase of platelet aggregation). Spontaneous bruising or bleeding is an indication for withdrawal of medication pending investigations (see section 4.6).

Skin and subcutaneous tissue disorders:

Common: nail and nail bed disorders, hypersensitivity, transient and/or dose related alopecia (hair loss). Regrowth normally begins within six months, although the hair may become curlier than previously.

Uncommon: angioedema, rash, hair disorder (such as hair texture abnormal, hair colour changes, abnormal hair growth).

Rare: toxic epidermal necrolysis, Stevens-Johnson syndrome, erythema multiforme,

Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome.

Reproductive system and breast disorders:

Common: dysmenorrhea

Uncommon: amenorrhea

Rare: male infertility, polycystic ovaries

Very rarely gynaecomastia has occurred.

Vascular disorders:

Common: haemorrhage (see sections 4.4.2 and 4.6).

Uncommon: vasculitis

Ear and labyrinth disorders:

Common: Deafness, a cause and effect relationship has not been established.

Renal and urinary disorders:

Common: urinary incontinence

Uncommon: renal failure.

Rare: enuresis, tubulointerstitial nephritis, reversible Fanconi syndrome (a defect in proximal renal tubular function giving rise to glycosuria, amino aciduria, phosphaturia, and uricosuria) associated with sodium valproate therapy, but the mode of action is as yet unclear.

General disorders and administration site conditions:

Uncommon: hypothermia, non-severe peripheral oedema

Musculoskeletal and connective tissue disorders:

Uncommon: bone mineral density decreased, osteopenia, osteoporosis and fractures in patients on long-term therapy with sodium valproate. The mechanism by which sodium valproate affects bone metabolism has not been identified.

Rare: systemic lupus erythematosus, rhabdomyolysis (see section 4.4.2 Precautions)

Respiratory, thoracic and mediastinal disorders:

Uncommon: pleural effusion

Investigations:

Rare: Coagulation factors decreased (at least one), abnormal coagulation tests (such as prothrombin time prolonged, activated partial thromboplastin time prolonged, thrombin time prolonged, INR prolonged) (see sections 4.4 and 4.6).

Neoplasms benign, malignant and unspecified (including cysts and polyps):

Rare: myelodysplastic syndrome

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.

4.9 Overdose

Cases of accidental and deliberate over dosage have been reported. At plasma concentrations of up to 5 to 6 times the maximum therapeutic levels, there are unlikely to be any symptoms other than nausea, vomiting and dizziness.

Signs of acute massive overdose, i.e. plasma concentration 10 to 20 times maximum therapeutic levels, usually include CNS depression or coma with muscular hypotonia, hyporeflexia, miosis, impaired respiratory function, metabolic acidosis, hypotension and circulatory collapse/shock. A favourable outcome is usual, however some deaths have occurred following massive overdose.

Symptoms may however be variable and seizures have been reported in the presence of very high plasma levels (see section 5.2).

Cases of intracranial hypertension related to cerebral oedema have been reported.

The presence of sodium content in the sodium valproate formulations may lead to hypernatraemia when taken in overdose.

Hospital management of overdose should be symptomatic, including cardio-respiratory monitoring. Gastric lavage may be useful up to 10 to 12 hours following ingestion.

Haemodialysis and haemoperfusion have been used successfully.

Naloxone has been successfully used in a few isolated cases, sometimes in association with activated charcoal given orally.

In case of massive overdose haemodialysis and haemoperfusion have been used successfully.

  1. Pharmacological properties

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Anti-epileptics; Fatty acid derivatives.

Sodium valproate is an anticonvulsant.

In certain in-vitro studies it was reported that sodium valproate could stimulate HIV replication but studies on peripheral blood mononuclear cells from HIV-infected subjects show that sodium valproate does not have a mitogen-like effect on inducing HIV replication. Indeed the effect of sodium valproate on HIV replication ex-vivo is highly variable, modest in quantity, appears to be unrelated to the dose and has not been documented in man.

5.2 Pharmacokinetic properties

In patients with severe renal insufficiency it may be necessary to alter dosage in accordance with free plasma valproic acid levels.

The reported effective therapeutic range for plasma valproic acid levels is 40-100mg/litre (278-694 micromol/litre). This reported range may depend on time of sampling and presence of co-medication. The percentage of free (unbound) drug is usually between 6% and 15% of the total plasma levels. An increased incidence of adverse effects may occur with plasma levels above the effective therapeutic range.

The pharmacological (or therapeutic) effects of sodium valproate may not be clearly correlated with the total or free (unbound) plasma valproic acid levels.

Metabolism

The major pathway of valproate biotransformation is glucuronidation (~ 40%), mainly via UGT1A6, UGT1A9 and UGT2B7.

The half-life of sodium valrpoate is usually reported to be within the range 8 – 20 hours. It is usually shorter in children.

Interaction with oestrogen-containing products

Inter-individual variability has been noted. There are insufficient data to establish a robust PK-PD relationship resulting from this PK interaction.

5.3 Preclinical safety data

There are no pre-clinical data of relevance to the prescriber which are additional to that already included in other sections of the SPC.

  1. Pharmaceutical particulars

6.1 List of excipients

Disodium hydrogen phosphate dodecahydrate

Sodium dihydrogen phosphate dihydrate

Phosphoric acid (for pH adjustment)

Sodium hydroxide (for pH adjustment)

Water for injections

6.2 Incompatibilities

Sodium valproate Intravenous should not be administered via the same line as other IV additives.

This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.

6.3 Shelf life

Unopened: 3 years

After dilution according to the directions in section 6.6: Chemical and physical in-use stability has been demonstrated for seven days at 20 – 22°C. From a microbiological point of view, the product should be used immediately after opening. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally be not longer than 24 hours at 2 to 8°C, unless dilution has taken place in controlled and validated aseptic conditions.

6.4 Special precautions for storage

Do not freeze.

6.5 Nature and contents of container

Clear glass 5ml-capacity ampoules (PhEur Type I, One Point Cut with black spot) containing 4ml of solution and clear glass 10ml-capacity ampoules (PhEur Type I, One Point Cut with red spot) containing 10ml of solution.

The ampoules are packed in a PVC tray and cardboard box in packs of 1, 5 or 10 ampoules per pack. Not all pack sizes may be marketed.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling

For infusion the product may be diluted in 0.9% saline or 5% dextrose. Tests with the recommended infusion solutions over seven days at 20 – 22°C show compatibility.

Prior to use sodium valproate solution for injection and the diluted solution should be visually inspected. Only clear solutions without particles should be used.

The contents of the ampoule are for single use only. Any unused product or waste material should be disposed of in accordance with local requirements.

  1. 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

 

Sodium Valproate for Injection 100mg/ml Taj Pharma

Package leaflet: Information for the patient

This medicine is subject to additional monitoring.

This will allow quick identification of new safety information. This will allow quick identification of

new safety information. You can help by reporting any side effects you may get. See the end of section 4 for how to report side effects.

WARNING

Valproate can cause birth defects and problems with early development of the child if it is given during pregnancy. If you are a female of childbearing age you should use an effective method of contraception throughout your treatment.

Your doctor will discuss this with you but you should also follow the advice in section 2 of this leaflet. Tell your doctor at once if you become pregnant or think you might be pregnant.

 

Read all of this leaflet carefully before you are given this medicine, because it contains important information for you.
  • Keep this leaflet. You may need to read it
  • If you have any further questions, ask your doctor or
  • This medicine has been prescribed for you Do not give it 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 This includes any possible side effects not listed in this leaflet. See Section 4.
What is in this leaflet
  1. What Sodium Valproate Injection is and what it is used for
  2. What you need to know before you are given Sodium Valproate Injection
  3. How Sodium Valproate Injection is given
  4. Possible side effects
  5. How to store Sodium Valproate Injection
  6. Contents of the pack and other information

 

1.  What Sodium Valproate Injection is and what it is used for

The name of your medicine is Sodium Valproate 100mg/ml Solution for Injection or Infusion (called Sodium Valproate Injection in the rest of the leaflet). Sodium Valproate Injection contains a medicine called sodium valproate. This belongs to a group of medicines called anti-convulsants or anti-epileptic agents. It works by helping to calm the brain down.

Sodium Valproate Injection is used to treat epilepsy (fits) in adults and children. The injection is given when it is not possible to have your medicine by mouth.

2.  What you need to know before you are given Sodium Valproate Injection 

Do not have Sodium Valproate Injection and tell your doctor or nurse if:

  • you are allergic (hypersensitive) to sodium valproate or any of the other ingredients of Sodium Valproate Injection (listed in see section 6). Signs of an allergic reaction include: a rash, swallowing or breathing problems, swelling of your lips, face, throat or tongue
  • you have liver problems or your family have a history of liver
  • you have a rare illness called porphyria.
  • you have a genetic problem caused by a mitochondrial disorder (e.g. Alpers-Huttenlocher syndrome)

 

Do not have this medicine if any of the above apply to you. If you are not sure, talk to your doctor or pharmacist before having Sodium Valproate Injection.Warnings and Precautions

A small number of people being treated with anti-epileptics such as sodium valproate have had thoughts of harming or killing themselves. If at any time you have these thoughts, immediately contact your doctor.

Check with your doctor or nurse before you are given this medicine if:
  • you have diabetes. This medicine may affect the results of urine
  • you have kidney problems. Your doctor may give you a lower
  • you have fits (epilepsy), brain disease or a metabolic condition affecting your
  • you have a ‘urea cycle disorder’ where too much ammonia builds up in the body
  • you have an illness called ‘systemic lupus erythematosus (SLE)’ a disease of the immune system which affects skin, bones, joints and internal organs
  • you know that there is a genetic problem caused by a mitochondrial disorder in your

If you are not sure if any of the above apply to you, talk to your doctor or pharmacist before having Sodium Valproate Injection.

Weight gain

Having Sodium Valproate Injection may make you put on weight. Talk to your doctor about how this will affect you.

Blood tests

Your doctor may wish to do blood tests before you start having Sodium Valproate Injection and during your treatment.

 

Other medicines and Sodium Valproate Injection

Tell your doctor or nurse if you are taking or have recently taken any other medicines. This includes medicines you buy without a prescription, including herbal medicines. This is because Sodium Valproate Injection can affect the way some other medicines work. Also some medicines can affect the way Sodium Valproate Injection Works.

 

The following medicines can increase the chance of you getting side effects, when taken with Sodium Valproate Injection:
  • Some medicines used for pain and inflammation (salicylates) such as aspirin
  • Some other medicines used to treat fits (epilepsy) – see Section 3:

“Patients taking other medicines for fits”. This includes medicines such as phenobarbital, primidone, phenytoin, carbamazepine, topiramate, lamotrigine and felbamate.

Sodium Valproate Injection may increase the effect of the following medicines:
  • Medicines used for thinning the blood (such as warfarin)
  • Zidovudine used to treat HIV infection
  • Temozolomide used to treat cancer
  • Medicines for depression
  • Monoamine oxidase inhibitors (MAOI) such as moclobemide, selegiline, linezolid
  • Medicines used to calm emotional and mental conditions such as diazepam and

 

The following medicines can affect the way Sodium Valproate Injection works:
  • Some medicines used for the prevention and treatment of malaria such as mefloquine and chloroquine
  • Cimetidine used for stomach ulcers
  • Carbapenem agents (antibiotics used to treat bacterial infections) such as imipenem, meropenem, rifampicin and The combination of Sodium Valproate Injection and carbapenems should be avoided because it may decrease the effect of your medicine
  • Colestyramine used to lower blood fat (cholesterol) Sodium Valproate Injection with food, drink and alcohol

Alcohol intake is not recommended during treatment.

Pregnancy, breast feeding and fertility Important advice for women

  • Valproate can be harmful to unborn children when given to a woman during
  • Valproate carries a risk if given during The higher the dose, the higher the risks but all doses carry a risk.
  • It can cause serious birth defects and can affect the way in which the child develops as it grows. Birth defects which have been reported include spina bifida (where the bones of the spine are not properly developed); facial and skull malformations; heart, kidney, urinary tract and sexual organ malformations; limb
  • If you are given valproate during pregnancy you have a higher risk than other women of having a child with birth defects that require medical Because valproate has been used for many years we know that in women who are given valproate around 10 babies in every 100 will have birth defects. This compares to 2-3 babies in every 100 born to women who don’t have epilepsy.
  • It is estimated that up to 30-40% of preschool children whose mothers received valproate during pregnancy may have problems with early childhood Children affected can be slow to walk and talk, intellectually less able than other children, and have difficulty with language and memory.
  • Autistic spectrum disorders are more often diagnosed in children exposed to valproate and there is some evidence children may be more likely to develop symptoms of Attention Deficit Hyperactivity Disorder (ADHD).
  • If you are a woman capable of becoming pregnant your doctor should only prescribe valproate for you if nothing else works for
  • Before prescribing this medicine to you, your doctor will have explained what might happen to your baby if you become pregnant whilst having If you decide later you want to have a child you should not stop having your medicine until you have discussed this with your doctor and agreed a plan for switching you onto another product if this is possible.
  • Ask your doctor about taking folic acid when trying for a baby. Folic acid can lower the general risk of spina bifida and early miscarriage that exists with all However, it is unlikely that it will reduce the risk of birth defects associated with valproate use.

 

FIRST PRESCRIPTION

If this is the first time you have been prescribed valproate your doctor will have explained the risks to an unborn child if you become pregnant. Once you are of childbearing age, you will need to make sure you use an effective method of contraception throughout your treatment. Talk to your doctor or family planning clinic if you need advice on contraception.

Key messages:
  • Make sure you are using an effective method of
  • Tell your doctor at once if you are pregnant or think you might be

 

CONTINUING TREATMENT AND NOT TRYING FOR A BABY

If you are continuing treatment with valproate but you don’t plan to have a baby make sure you are using an effective method of contraception. Talk to your doctor or family planning clinic if you need advice on contraception.

 

Key messages:
  • Make sure you are using an effective method of contraception
  • Tell your doctor at once if you are pregnant or think you might be
CONTINUING TREATMENT AND CONSIDERING TRYING FOR A BABY

If you are continuing treatment with valproate and you are now thinking of trying for a baby you must not stop having your valproate or taking your contraceptive medicine until you have discussed this with your prescriber. You should talk to your doctor well before you become pregnant so that you can put several actions in place so that your pregnancy goes as smoothly as possible and any risks to you and your unborn child are reduced as much as possible.

Your doctor may decide to change the dose of valproate or switch you to another medicine before you start trying for a baby.

If you do become pregnant you will be monitored very closely both for the management of your underlying condition and to check how your unborn child is developing.

Ask your doctor about taking folic acid when trying for a baby. Folic acid can lower the general risk of spina bifida and early miscarriage that exists with all pregnancies. However, it is unlikely that it will reduce the risk of birth defects associated with valproate use.

Key messages:
  • Do not stop using your contraception before you have talked to your doctor and worked together on a plan to ensure your epilepsy is controlled and the risks to your baby are
  • Tell your doctor at once when you know or think you might be

 

UNPLANNED PREGNANCY WHILST CONTINUING TREATMENT

Babies born to mothers who have been on valproate are at serious risk of birth defects and problems with development which can be seriously debilitating. If you are having valproate and you think you are pregnant or might be pregnant contact your doctor at once.

Do not stop having your medicine until your doctor tells you to.

Ask your doctor about taking folic acid. Folic acid can lower the general risk of spina bifida and early miscarriage that exists with all pregnancies.

However, it is unlikely that it will reduce the risk of birth defects associated with valproate use.

Key messages:
  • Tell your doctor at once if you know you are pregnant or think you might be
  • Do not stop having valproate unless your doctor tells you
Make sure you read the patient booklet and sign the Acknowledgement of Risk form which should be given to you and discussed with you by your doctor or pharmacist.

Breast-feeding

Very little Sodium Valproate Injection gets into breast milk. However, talk to your doctor about whether you should breast-feed your baby.

Ask your doctor or nurse for advice before taking any medicine.

Driving and using machines

You may feel sleepy after having Sodium Valproate Injection. If this happens to you, do not drive or use any tools or machines. Taking other medicines used to treat fits or calm emotional and mental health problems may increase sleepiness.

3.  How Sodium Valproate Injection is given

 

Sodium Valproate Injection is always given to you by a doctor or nurse. This is because it needs to be given as a slow injection or infusion into the vein. If you are not sure why you are being given Sodium Valproate Injection or have any questions about how much Sodium Valproate Injection is being given to you, speak to your doctor or nurse.

Your doctor will stop giving you Sodium Valproate Injection and change you to oral therapy (by mouth) as soon as possible.

Sodium Valproate Injection treatment must be started and supervised by a doctor specialised in the treatment of epilepsy.

 

How much will be given to you
  • Your doctor will decide how much Sodium Valproate Injection to give you depending on your illness. The amount of Sodium Valproate Injection given to you or your child will depend on you or your child’s age or body weight
  • If you have been taking Sodium Valproate by mouth your doctor may decide to give you the same amount of Sodium Valproate Injection by continuous or repeated

If you have not had Sodium Valproate Injection before, the doctor will use the following doses:

Adults (including the elderly)
  • The starting dose is usually between 400mg and 800mg daily (up to 10mg per kilogram of body weight)
  • This is given as a slow intravenous injection over 3-5 minutes
  • This is followed by a continuous or repeated infusion, up to a maximum dose of 2500mg each day.
Children
  • The usual dose is between 20mg and 30mg for each kilogram of body weight each day
  • This may be increased to 40mg for each kilogram of body weight each day depending on your child’s
Patients with kidney problems
  • Your doctor may decide to adjust your or your child’s dose
Patients taking other medicines for ‘fits’ (epilepsy)
  • You or your child may be taking other medicines for epilepsy at the same time as Sodium Valproate If so, your doctor should gradually initiate treatment depending on you or your child’s condition
  • Your doctor may increase the dose of Sodium Valproate Injection by 5 to 10mg for each kilogram of body weight each day depending on which other medicines you are
If have more Sodium Valproate Injection than you should

It is unlikely that your doctor or nurse will give you too much medicine. Your doctor will be checking your progress and checking the medicine that you are given. Always ask if you are not sure why

you are getting a dose of medicine.

Having too much Sodium Valproate Injection can lead to the following symptoms: feeling sick or being sick, pupils of the eye become smaller, dizziness, loss of consciousness, weak muscles and poor reflexes, breathing problems, headaches, fits (seizures), confusion, memory loss and unusual or inappropriate behaviour.

If you forget to have Sodium Valproate Injection

Your doctor or nurse will have instructions on when to give you this medicine. It is unlikely that you will not be given the medicine as it has been prescribed. However, if you think you may have missed a dose, then talk to your doctor or nurse.

If you stop receiving Sodium Valproate Injection

It is important for you to keep having Sodium Valproate Injection until your doctor decides to stop them. If you stop, your fits may come back.

Tests

Make sure you or your child keep your regular appointments for a check-up. They are very important as your or your child’s dose may need to be changed. Sodium Valproate Injection can change the levels of liver enzymes shown up in blood tests. This can mean that your or your child’s liver is not working properly.

If you or your child go into hospital or visit another doctor or a dentist, tell them you are having Sodium Valproate Injection.

If you have any further questions about receiving this product, ask your doctor or pharmacist.

4.  Possible side effects

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

Tell your doctor straight away if you notice any of the following serious side effects – you may need urgent medical treatment:
  • You have an allergic The signs may include: a rash, joint pain, fever (systemic lupus erythematosus), swallowing or breathing problems, swelling of your lips, face, throat or tongue. Hands, feet or genitals may also be affected. More severe allergic reactions can lead to lymph node enlargement and possible impairment of other organs.
  • Liver problems and problems of the pancreas may show as a sudden illness which may happen in the first six months of treatment. This happens in a very small number of people having Sodium Valproate It includes feeling and being sick many times, being very tired, sleepy and weak, stomach pain including very bad upper stomach pain, jaundice (yellowing of the skin or whites of the eyes), loss of appetite, swelling (especially of the legs and feet but may include other parts of the body), worsening of your fits or a general feeling of being unwell.

Your doctor may stop giving you Sodium Valproate Injection immediately if you have these symptoms.

  • You have a skin rash or skin lesions with a pink/red ring and a pale centre which may be itchy, scaly or filled with The rash may appear especially on the palms or soles of your feet. These could be signs of a serious allergy to the medicine called ‘erythema multiforme.’
  • Blistering or bleeding of the skin around the lips, eyes, mouth, nose and Also flu-like symptoms and fever. This may be something called ‘Stevens-Johnson syndrome.’
  • Severe blistering rash where layers of the skin may peel off to leave large areas of raw exposed skin over the Also a feeling of being generally unwell, fever, chills and aching muscles. This may be something called ‘Toxic epidermal necrolysis.’
  • Bruising more easily and getting more infections than This could be a blood problem called ‘thrombocytopenia’. It can also be due to a fall in the number of white blood cells, bone marrow depression or another condition that affects red blood cells, white blood cells and platelets (pancytopenia) or how the blood clots.
  • Blood clotting problems (bleeding for longer than normal), bruising or bleeding for no
  • Changes in mood, loss of memory, lack of concentration and deep loss of consciousness (coma).
  • Underactive thyroid gland, which may cause tiredness or weight gain (hypothyroidism)
  • Breathing difficulty and pain due to inflammation of the lungs (pleural effusion).
Tell your doctor as soon as possible if you have any of the following side effects:
  • Changes in behaviour including being very alert, and sometimes also aggressive, hyperactive
  • and unusual or inappropriate This is more likely if other medicine to treat fits such as phenobarbital and topiramate are taken at the same time or if the Sodium Valproate Injection starting dose is high or has been suddenly increased.
  • Changes in the amount of ammonia in the Symptoms of this condition are being sick, problems with balance and coordination, feeling lethargic or less alert.
  • Feeling shaky (tremor), sleepy or unsteady when walking or jerky muscle movements
  • Feeling tired or confused with loss of consciousness sometimes accompanied by hallucinations or
  • Blisters with the skin flaking
  • Rapid, uncontrollable movement of the

 

Tell your doctor or pharmacist if any of the following side effects gets serious or lasts longer than a few days, or if you notice any side effects not listed in this leaflet:
  • Feeling sick, stomach ache or diarrhoea, especially when starting
  • Fainting
  • Hearing loss
  • Skin problems such as These happen rarely, but more often in people also taking lamotrigine
  • Acne
  • Hair loss which is usually When it grows back it may be more curly than before
  • Hair, including body or facial hair grows more than normal in
  • women
  • Skin rash caused by narrow or blocked blood vessels (vasculitis)
  • Changes in women’s periods and increased hair growth in women
  • Breast enlargement in men
  • Swelling of the feet and legs (oedema)
  • Weight gain – as your appetite may be increased
  • Kidney problems, bedwetting or increased need to pass urine
  • Headache
  • Aggression, agitation, disturbance in attention, abnormal behaviour, restlessness/hyperactivity and learning disorder
  • Tingling or numbness of the hands or feet

 

Bone Disorders

There have been reports of bone disorders including osteopenia and osteoporosis (thinning of the bone) and fractures. Check with your doctor or pharmacist if you are on long-term antiepileptic medication, have a history of osteoporosis, or take steroids.

Blood tests

Sodium Valproate Injection can change levels of liver enzymes, salts or sugars shown up on blood and urine tests.

Male fertility

Sodium Valproate Injection can be a contributing factor in male infertility.

 

Reporting of side effects

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

By reporting side effects you can help provide more information on the safety of this medicine.

 

5.  How to store Sodium Valproate Injection

This medicine will be kept by your doctor or pharmacist in a safe place where children cannot see or reach it.

Do not freeze. Only clear solutions free of particles should be used.

The contents of the ampoule are for single use only. Before infusion this medicine may be diluted in 0.9% saline, 5% dextrose or 0.9% saline + 5% dextrose. The hospital will ensure the medicine is diluted and stored appropriately. Chemical and physical in-use stability has been demonstrated at 2- 8°C for 24 hours only. From a microbiological point of view, unless the method of opening/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.

Do not use this medicine after the expiry date which is stated on the label and carton. The expiry date refers to the last day of that month.

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

 

6.  Contents of the pack and other information
What Sodium Valproate Injection contains
  • The active substance is sodium valproate 100mg per
  • The other ingredients are: Disodium Edetate and Water for

 

What Sodium Valproate Injection look like and contents of the pack

Sodium Valproate Injection is a clear colourless solution. It is available in glass ampoules containing 3ml (300mg sodium valproate) of the solution for injection. Each pack contains 5 or 10 ampoules.

Not all pack sized may be marketed.

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