Supply of amino acids for parenteral nutrition, when oral or enteral nutrition is impossible, insufficient or contraindicated. For adults, adolescents and children over 2 years of age.

Posology

The dosage has to be adjusted according to the individual need of amino acids and fluid, depending on the clinical condition of the patient (nutritional status and/or degree of nitrogen catabolism due to underlying disease).

Adults and adolescents from 14 to 17 years

Paediatric population

Newborn infants, infants and toddlers less than two years of age.

Aminoplasmal 15% is contraindicated in newborn infants, infants and toddlers less than 2 years of age (see section 4.3).

Children and adolescents 2 to 13 years

The dosages for the age group stated below are average values for guidance. The exact dosage should be adjusted individually according to age, developmental stage and prevailing disease.

Daily dose for children 2 to 4 years old:

1.5 g amino acids/kg body weight 10 ml/kg body weight

Daily dose for children 5 to 13 years old:

1.0 g amino acids/kg body weight 6.7 ml/kg body weight

Critically ill children:

For critically ill patients the advisable amino acid intake may be higher (up to 3.0g amino acids/kg body weight per day).

Maximum infusion rate:

0.1 g amino acids/kg body weight/h 0.67 ml/kg body weight /h

In the case of amino acid requirements of 1.0 g/kg body weight/day or more, particular attention should be paid to the limitations of fluid input. To avoid fluid overload, amino acid solutions with higher amino acid content may have to be used in such situations.

Patients with renal/hepatic impairment

The doses should be adjusted individually in patients with hepatic or renal insufficiency (see also section 4.4). Aminoplasmal 15% is contraindicated in severe hepatic insufficiency and severe renal insufficiency in absence of renal replacement therapy (see section 4.3).

Duration of use

This solution can be administered as long as parenteral nutrition is indicated.

Method of administration

Intravenous use.

For central venous infusion only.

● Hypersensitivity to any of the active substances or to any of the excipients listed in section 6.1

● Inborn errors of amino acid metabolism

● Severe circulation disorders with vital risk (e.g. shock)

● Hypoxia

● Metabolic acidosis

● Severe hepatic insufficiency

● Severe renal insufficiency in absence of renal replacement therapy

● Decompensated cardiac insufficiency

● Acute pulmonary oedema

● Hyperhydration

● Disturbances of the electrolyte and fluid balance

The medicinal product must not be administered to newborn infants, infants and toddlers less than two years of, because the amino acid composition does not properly meet the special requirements of this paediatric age group.

The medicinal product should only be administered after careful benefit-risk assessment in the presence of disorders of amino acid metabolism of other origin than stated under section 4.3.

Care should be exercised in the administration of large volume infusion fluids to patients with cardiac insufficiency.

Caution should be exercised in patients with increased serum osmolarity.

Disturbances of fluid and electrolyte balance (e.g. hypotonic dehydration, hyponatraemia, hypokalaemia) should be corrected prior to the administration of parenteral nutrition.

Serum electrolytes, blood glucose, fluid balance, acid-base balance and renal function (BUN, creatinine) should be monitored regularly.

Monitoring should also include serum protein and liver function tests.

Renal impairment

In patients with renal insufficiency, the dose must be carefully adjusted according to individual needs, severity of organ insufficiency and the kind of instituted renal replacement therapy (haemodialysis, haemofiltration etc.).

Hepatic impairment

In patients with hepatic insufficiency, the dose must be carefully adjusted according to individual needs and severity of organ insufficiency.

Amino acid solutions are only one component of parenteral nutrition. For complete parenteral nutrition, substrates for non-protein energy supply, essential fatty acids, electrolytes, vitamins, fluids and trace elements must be administered together with amino acids.

None known

Pregnancy

There are no data from the use of Aminoplasmal 15% in pregnant women. No animal reproductive studies have been performed Aminoplasmal 15% (see section 5.3). The use of Aminoplasmal 15% may be considered during pregnancy, if necessary. Aminoplasmal 15% should only be given to pregnant women after careful consideration.

Breast-feeding

Amino acids/metabolites are excreted in human milk, but at therapeutic doses of Aminoplasmal 15% no effects on the breastfed newborns/infants are anticipated.

Nevertheless, breast-feeding is not recommended for mothers on parenteral nutrition.

Fertility

No data available.

Not relevant

Undesirable effects that, however, are not specifically related to the product but to parenteral nutrition in general may occur, especially at the beginning of parenteral nutrition.

Undesirable effects are listed according to their frequencies as follows:

Very common (≥ 1/10)

Common (≥ 1/100 to < 1/10)

Uncommon (≥ 1/1000 to < 1/100)

Rare (≥ 1/10,000 to < 1/1000)

Very rare (< 1/10,000)

Not known (cannot be estimated from the available data)

Immune system disorders

Not known: Allergic reactions

Gastrointestinal disorders

Uncommon: Nausea, vomiting

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via Yellow Card Scheme at: www.mhra.gov.uk/yellowcard

Symptoms of fluid overdose

Overdose or too high infusion rates may lead to hyperhydration, electrolyte imbalance and pulmonary oedema.

Symptoms of amino acid overdose

Overdose or too high infusion rates may lead to intolerance reactions manifesting in the form of nausea, vomiting, shivering, headache, metabolic acidosis and renal amino acid losses.

Treatment

If intolerance reactions occur, the amino acid infusion must be interrupted temporarily and resumed later on at a lower infusion rate.

Pharmacotherapeutic group: Blood substitutes and perfusion solutions, i.v. solutions for parenteral nutrition, amino acids

ATC- code: B05B A01

Mechanism of action

The aim of parenteral nutrition is the supply of all nutrients necessary for the growth, maintenance and regeneration of body tissues etc.

Amino acids are of special importance as they partly are essential for protein synthesis. Intravenously administered amino acids are incorporated in the respective intravascular and intracellular amino acid pools. Both endogenous and exogenous amino acids serve as substrate for the synthesis of functional and structural proteins.

To prevent the metabolisation of amino acids for energy production, and also to fuel the other energy-consuming processes in the organism, simultaneous non-protein energy supply (in the form of carbohydrates or fats) is necessary.

Absorption

Because this medicinal product is infused intravenously, the bio-availability of the amino acids contained in the solution is 100%.

Distribution

Amino acids are incorporated in a variety of proteins in different tissues of the body. In addition each amino acid is present as free amino acid in the blood and inside cells.

The composition of the amino acid solution is based upon the results of clinical investigations of the metabolism of intravenously administered amino acids. The quantities of the amino acids contained in the solution have been chosen so that a homogenous increase of the concentrations of all plasma amino acids is achieved. The physiological ratios of plasma amino acids, i.e. the amino acid homeostasis, are thus maintained during infusion of the medicinal product. Normal foetal growth and development depend on a continuous supply of amino acids from the mother to the foetus. The placenta is responsible for the transfer of amino acids between the two circulations.

Biotransformation

Amino acids that do not enter protein synthesis are metabolised as follows: The amino group is separated from the carbon skeleton by transamination. The carbon chain is either oxidised directly to CO2 or utilised as substrate for gluconeogenesis in the liver. The amino group is also metabolised in the liver to urea.

Elimination

Only minor amounts of amino acids are excreted unchanged in the urine.

No non-clinical studies have been performed with Aminoplasmal 15%. The amino acids contained in Aminoplasmal 15% are substances which occur naturally in the organism.

Therefore, no toxic reactions are expected to occur as long as the indications, contraindications and dosage recommendations are duly observed.

Sodium hydroxide

Citric acid monohydrate (for pH-adjustment)

Water for injections

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

Unopened

3 years

After first opening

The medicinal product should be used immediately.

After admixture of additives

From a microbiological point of view, mixtures should be administered immediately after preparation. If not administered immediately, storage times and conditions of mixtures prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2°C – 8°C, unless mixing has taken place under controlled and validated aseptic conditions.

Keep the bottles in the outer carton in order to protect from light.

Do not freeze.

Cool storage of the undiluted solution, below 15°C, may lead to formation of crystals, that can, however, be easily dissolved by gentle warming at 25°C until dissolution is complete. Shake container gently to ensure homogeneity.

Bottles of colourless glass (type II), sealed with halogen butyl rubber stoppers, containing 500ml or 1000ml of solution.

Pack sizes: 1 × 500ml, 10 × 500ml, 1 × 1000ml, 6 × 1000ml

Not all pack sizes may be marketed.

No special requirements for disposal.

Containers are for single use only. Discard container and any unused content after use.

Only to be used if the solution is clear and colourless up to faintly straw-coloured and the bottle and its closure are undamaged.

Use a sterile giving set for administration.

Aminoplasmal 15% should only be mixed with other iv solutions, if compatibility has been proven in advance. Compatibility data for different additives (e.g. glucose, lipids, electrolytes, trace elements, vitamins) and the corresponding shelf-life of such admixtures can be provided on demand by the manufacturer.

It is essential that any admixture be prepared using strict aseptic techniques as this nutrient mixture supports microbial growth.