Source:http://www4.wiwiss.fu-berlin.de/dailymed/resource/drugs/2075
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Vaprisol (Liquid)
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VAPRISOL is for intravenous use only. Administration of VAPRISOL through large veins and change of the infusion site every 24 hours are recommended to minimize the risk of vascular irritation. VAPRISOL therapy should begin with a loading dose of 20 mg IV administered over 30 minutes. The loading dose should be followed by 20 mg of VAPRISOL administered in a continuous intravenous infusion over 24 hours. Following the initial day of treatment, VAPRISOL is to be administered for an additional 1 to 3 days in a continuous infusion of 20 mg/day. If serum sodium is not rising at the desired rate, VAPRISOL may be titrated upward to a dose of 40 mg daily, again administered in a continuous intravenous infusion. The total duration of infusion of VAPRISOL (after the loading dose) should not exceed four days. Patients receiving VAPRISOL must have frequent monitoring of serum sodium and volume status. An overly rapid rise in serum sodium (>12 mEq/L/24 hours) may result in serious sequelae. For patients who develop an undesirably rapid rate of rise of serum sodium, VAPRISOL should be discontinued, and serum sodium and neurologic status should be carefully monitored. If the serum sodium continues to rise, VAPRISOL should not be resumed. If hyponatremia persists or recurs, and the patient has had no evidence of neurologic sequelae of rapid rise in serum sodium, VAPRISOL may be resumed at a reduced dose. For patients who develop hypovolemia or hypotension while receiving VAPRISOL, VAPRISOL should be discontinued, and volume status and vital signs should be frequently monitored. Once the patient is again euvolemic and is no longer hypotensive, VAPRISOL may be resumed at a reduced dose if the patient remains hyponatremic.<br/>Preparation:<br/>Compatibility and Stability: Caution: VAPRISOL should be diluted only with 5% Dextrose Injection. VAPRISOL is compatible with 5% Dextrose Injection and is stable for up to 24 hours after mixing. VAPRISOL should not be mixed or administered with Lactated Ringer's Injection or 0.9% Sodium Chloride Injection. Compatibility with other drugs has not been studied; therefore, VAPRISOL should not be combined with any other product in the same intravenous line or bag.<br/>Loading Dose: Withdraw 4 mL (20 mg) of VAPRISOL (4 mL of conivaptan hydrochloride injection) and add to an infusion bag containing 100 mL of 5% Dextrose Injection, USP. Gently invert the bag several times to ensure complete mixing of the solution. The contents of the IV bag should be administered over 30 minutes.<br/>Continuous Infusion: To prepare a continuous IV infusion containing 20 mg conivaptan hydrochloride, withdraw 4 mL (20 mg) from a single ampule of VAPRISOL and dilute into an IV bag containing 250 mL of 5% Dextrose Injection, USP. Gently invert the bag several times to ensure complete mixing of the solution. The contents of the IV bag should be administered over 24 hours. To prepare a continuous IV infusion containing 40 mg conivaptan hydrochloride, withdraw 4 mL (20 mg) from each of two ampules of VAPRISOL (8 mL [40 mg] of conivaptan hydrochloride injection) and dilute into an IV bag containing 250 mL of 5% Dextrose Injection, USP. Gently invert the bag several times to ensure complete mixing of the solution. The contents of the IV bag should be administered over 24 hours. The VAPRISOL ampule is for single use only. Discard unused contents of the ampule. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. If particulate matter or cloudiness is observed, the drug solution should not be used. The diluted solution of VAPRISOL should be used immediately and administration completed within 24 hours of mixing.
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VAPRISOL (conivaptan hydrochloride injection) is a nonpeptide, dual antagonist of arginine vasopressin (AVP) Vand Vreceptors. Conivaptan hydrochloride is chemically [1,1'-biphenyl]-2-carboxamide, N-[4-[(4,5-dihydro-2-methylimidazo[4,5-d][1]benzazepin-6(1H)-yl)carbonyl]phenyl]-, monohydrochloride having a molecular weight of 535.04 and molecular formula CHNO���HCl . The structural formula of conivaptan hydrochloride is: Conivaptan hydrochloride is a white to off-white or pale orange-white powder that is very slightly soluble in water (0.15 mg/mL at 23��C). Conivaptan hydrochloride injection is supplied as a sterile liquid in an ampule. Each ampule will deliver 20 mg conivaptan hydrochloride, 1.2 g propylene glycol, 0.4 g ethanol and Water for Injection, q.s. Lactic acid is added for pH adjustment to 3.0.
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Pharmacodynamics: Conivaptan hydrochloride is a dual AVP antagonist with nanomolar affinity for human Vand Vreceptors in vitro. The level of AVP in circulating blood is critical for the regulation of water and electrolyte balance and is usually elevated in both euvolemic and hypervolemic hyponatremia. The AVP effect is mediated through Vreceptors, which are functionally coupled to aquaporin channels in the apical membrane of the collecting ducts of the kidney. These receptors help to maintain plasma osmolality within the normal range. The predominant pharmacodynamic effect of conivaptan hydrochloride in the treatment of hyponatremia is through its Vantagonism of AVP in the renal collecting ducts, an effect that results in aquaresis, or excretion of free water. The pharmacodynamic effects of conivaptan hydrochloride include increased free water excretion (i.e., effective water clearance [EWC]) generally accompanied by increased net fluid loss, increased urine output, and decreased urine osmolality. Studies in animal models of hyponatremia showed that conivaptan hydrochloride prevented the occurrence of hyponatremia-related physical signs in rats with the syndrome of inappropriate antidiuretic hormone secretion.<br/>Pharmacokinetics: The pharmacokinetics of conivaptan have been characterized in healthy subjects, special populations and patients following both oral and intravenous dosing regimens. The pharmacokinetics of conivaptan following intravenous infusion (40 mg/day to 80 mg/day) and oral administration are non-linear, and inhibition by conivaptan of its own metabolism seems to be the major factor for the non-linearity. The intersubject variability of conivaptan pharmacokinetics is high (94% CV in CL). The pharmacokinetics of conivaptan and its metabolites were characterized in healthy male subjects administered conivaptan hydrochloride as a 20 mg loading dose (infused over 30 minutes) followed by a continuous infusion of 40 mg/day for 3 days. Mean Cfor conivaptan was 619 ng/mL and occurred at the end of the loading dose. Plasma concentrations reached a minimum at approximately 12 hours after start of the loading dose, then gradually increased over the duration of the infusion to a mean concentration of 188 ng/mL at the end of the infusion. The mean terminal elimination half-life after conivaptan infusion was 5.0 hours, and the mean clearance was 15.2 L/h. In an open-label safety and efficacy study, the pharmacokinetics of conivaptan were characterized in hypervolemic or euvolemic hyponatremia patients (ages 51-89 years) receiving conivaptan hydrochloride as a 20 mg loading dose (infused over 30 minutes) followed by a continuous infusion of 20 or 40 mg/day for 4 days. The median plasma conivaptan concentrations are shown in Figure 1 and pharmacokinetic parameters are summarized in Table 1.<br/>Distribution: Conivaptan is extensively bound to human plasma proteins, being 99% bound over the concentration range of approximately 10 to 1000 ng/mL.<br/>Metabolism and Excretion: CYP3A4 was identified as the sole cytochrome P450 isozyme responsible for the metabolism of conivaptan. Four metabolites have been identified. The pharmacological activity of the metabolites at Vand Vreceptors ranged from approximately 3-50% and 50-100% that of conivaptan, respectively. The combined exposure of the metabolites following intravenous administration of conivaptan is approximately 7% that of conivaptan and hence, their contribution to the clinical effect of conivaptan is minimal. After intravenous (10 mg) or oral (20 mg) administration of conivaptan hydrochloride in a mass balance study, approximately 83% of the dose was excreted in feces as total radioactivity and 12% in urine over several days of collection. Over the first 24 hours after dosing, approximately 1% of the intravenous dose was excreted in urine as intact conivaptan.<br/>Special Populations:<br/>Drug-Drug Interactions:<br/>CYP3A4: Conivaptan is a sensitive substrate of CYP3A4. The effect of ketoconazole, a potent CYP3A4 inhibitor, on the pharmacokinetics of intravenous conivaptan has not been evaluated. Coadministration of oral conivaptan hydrochloride 10 mg with ketoconazole 200 mg resulted in a 4- and 11-fold increase in Cand AUC of conivaptan, respectively. Conivaptan is a potent inhibitor of CYP3A4. The effect of conivaptan on the pharmacokinetics of CYP3A4 substrates has been evaluated with the coadministration of conivaptan with midazolam, simvastatin, and amlodipine. Intravenous conivaptan hydrochloride 40 mg/day increased the mean AUC values by approximately 2- and 3-fold for 1 mg intravenous or 2 mg oral doses of midazolam, respectively. Intravenous conivaptan hydrochloride 30 mg/day resulted in a 3-fold increase in the AUC of simvastatin. Oral conivaptan hydrochloride 40 mg twice daily resulted in a 2-fold increase in the AUC and half-life of amlodipine.<br/>Digoxin: Coadministration of a 0.5 mg dose of digoxin, a P-glycoprotein substrate, with oral conivaptan hydrochloride 40 mg twice daily resulted in a 30% reduction in clearance and a 79% and 43% increase in digoxin Cand AUC values, respectively.<br/>Warfarin: The effect of intravenous conivaptan on warfarin pharmacokinetics or pharmacodynamics has not been evaluated. The potential drug-drug interaction of oral conivaptan with warfarin, which undergoes major metabolism by CYP2C9 and minor metabolism by CYP3A4, was investigated in a clinical study. The effects of oral conivaptan hydrochloride 40 mg twice daily on prothrombin time was assessed in patients receiving stable oral warfarin therapy. After 10 days of oral conivaptan administration, the S- and R-warfarin concentrations were 90% and 98% of those prior to conivaptan administration. The corresponding prothrombin time values after 10 days of oral conivaptan administration were 95% of baseline. No effect of oral conivaptan on the pharmacokinetics or pharmacodynamics of warfarin was observed.<br/>Captopril and Furosemide: The effects of captopril (25 mg) and furosemide (40 mg or 80 mg once daily for 6 days) on the pharmacokinetics of conivaptan hydrochloride (30 mg) were assessed in separate studies. The pharmacokinetics of conivaptan were unchanged with coadministration of either captopril or furosemide.<br/>Electrophysiology: The effect of VAPRISOL 40 mg IV and 80 mg IV on the QT interval was evaluated after the first dose (Day 1) and at the last day during treatment (Day 4) in a randomized, single-blind, parallel group, placebo- and positive-controlled (moxifloxacin 400 mg IV) study in healthy male and female volunteers aged 18 to 45 years. Digital ECGs were obtained at baseline and on Days 1 and 4. The placebo-corrected change from baseline in individualized QT correction (QTcI) in the VAPRISOL 40 mg and 80 mg dose groups on Day 1 was -3.5 msec and -2.9 msec, respectively, on Day 1, and��2.1 msec for both dose groups on Day 4. Similar results were obtained using either the Bazett's or Fridericia's correction methods. Moxifloxacin elicited a placebo-corrected change from baseline in QTcI of +7 to +10 msec on Days 1 and 4, respectively. The results of the central tendency analysis of QTc indicate that VAPRISOL had no effect on cardiac repolarization.
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VAPRISOL is contraindicated in patients with hypovolemic hyponatremia and in those who have hypersensitivity to any of its components. The coadministration of VAPRISOL with potent CYP3A4 inhibitors, such as ketoconazole, itraconazole, clarithromycin, ritonavir, and indinavir, is contraindicated. (See PRECAUTIONS: Drug Interactions for details and other important considerations)
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VAPRISOL (conivaptan hydrochloride injection) is supplied in 4 mL clear glass, one-point cut ampules. Each ampule contains 20 mg conivaptan hydrochloride. 10 ampules/carton (NDC 0469-1601-04)
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Hyponatremic Patients with Underlying Congestive Heart Failure: The safety of VAPRISOL in hyponatremic patients with underlying congestive heart failure has not been established.<br/>Overly Rapid Correction of Serum Sodium: An overly rapid increase in serum sodium concentration (>12 mEq/L/24 hours) may result in serious sequelae. In controlled clinical trials of VAPRISOL, about 9% of patients who received VAPRISOL in doses of 20-40 mg/day IV met laboratory criteria for overly rapid correction of serum sodium, but none of these patients had permanent neurologic sequelae. Although not observed in the clinical studies with VAPRISOL, osmotic demyelination syndrome has been reported following rapid correction of low serum sodium concentrations. Serum sodium concentration and neurologic status should be monitored appropriately during VAPRISOL administration, and VAPRISOL administration should be discontinued if thepatient develops an undesirably rapid rate of rise of serum sodium. If the serum sodium concentration continues to rise, VAPRISOL should not be resumed. If hyponatremia persists or recurs (after initial discontinuation of VAPRISOL for an undesirably rapid rate of rise of serum sodium concentration), and the patient has had no evidence of neurologic sequelae of rapid rise in serum sodium, VAPRISOL may be resumed at a reduced dose.<br/>Hepatic Impairment: The use of VAPRISOL in patients with hepatic impairment (including ascites, cirrhosis, or portal hypertension) has not been systematically evaluated. Increased systemic exposures after oral administration of conivaptan have been seen in patients with stable cirrhosis and moderate hepatic impairment. Intravenous VAPRISOL resulted in higher conivaptan exposure than did oral conivaptan, in study subjects without hepatic function impairment. Caution should be used when administering VAPRISOL to patients with hepatic impairment.<br/>Renal Impairment: The effect of renal impairment on the elimination of conivaptan after intravenous administration has not been evaluated. However, following oral administration of conivaptan, the AUC for conivaptan was up to 80% higher after a single oral dose and 35% higher with repeated oral dosing in patients with renal impairment (CLcr<60 mL/min/1.73 m) as compared to those with normal renal function. Intravenous VAPRISOL resulted in higher conivaptan exposure than did oral conivaptan, in study subjects without renal function impairment. Caution should be used when administering VAPRISOL to patients with renal impairment.<br/>Injection Site Reactions: Conivaptan may cause significant injection site reactions, even with proper dilution and infusion rates . Conivaptan must only be administered when properly prepared and diluted (see Preparation) via large veins, and the infusion site should be rotated every 24 hours .<br/>Drug Interactions:<br/>CYP3A4: Conivaptan is a substrate of CYP3A4. Coadministration of VAPRISOL with CYP3A4 inhibitors could lead to an increase in conivaptan concentrations. The consequences of increased conivaptan concentrations are unknown. Concomitant use of VAPRISOL with potent CYP3A4 inhibitors such as ketoconazole, itraconazole, clarithromycin, ritonavir, and indinavir is contraindicated. Conivaptan is a potent inhibitor of CYP3A4. VAPRISOL may increase plasma concentrations of coadministered drugs that are primarily metabolized by CYP3A4. In clinical trials of oral conivaptan hydrochloride, two cases of rhabdomyolysis occurred in patients who were also receiving a CYP3A4-metabolized HMG-CoA reductase inhibitor. Concomitant use of VAPRISOL with drugs that are primarily metabolized by CYP3A4 should be closely monitored or the combination should be avoided. If a clinical decision is made to discontinue concomitant medications at recommended doses, allow an appropriate amount of time following the end of VAPRISOL administration before resuming these medications.<br/>Digoxin: Coadministration of digoxin, a P-glycoprotein substrate, with oral conivaptan resulted in a reduction in clearance and an increase in digoxin Cand AUC values. Therefore, if digoxin is administered with VAPRISOL, the clinician should be alert to the possibility of increases in digoxin levels.<br/>Carcinogenesis, Mutagenesis, Impairment of Fertility: Standard lifetime (104 week) carcinogenicity bioassays were conducted in mice and rats. Mice were given oral doses of 3, 10 or 30 mg/kg/day in males and 1, 3 or 10 mg/kg/day in females by gavage. Rats were given oral doses of 0.3, 1, 3 or 10 mg/kg/day in males and 1, 3, 10 or 30 mg/kg/day in females by gavage. No increased incidence of tumors was observed at doses up to 30mg/kg/day in mice (6 times human systemic exposure of an IV bolus of 20 mg on day 1 followed by IV infusion 40 mg/day for 3 days based on AUC comparison) or rats (2 times human systemic exposure of an IV bolus of 20 mg on day 1 followed by IV infusion 40 mg/day for 3 days based on AUC comparison). Conivaptan was not mutagenic or clastogenic with or without metabolic activation in the Ames test with Salmonella typhimurium and Escherichia coli, in human peripheral blood lymphocytes, or in vivo rat micronucleus assay. In fertility studies after 4 weeks treatment by intravenous bolus at 0.5, 1.25 or 2.5 mg/kg/day, male fertility was unaffected. However, in females given IV bolus conivaptan 15 days before mating through gestation day 7 there was prolonged diestrus, decreased fertility and increased pre- and post-implantation loss at 2.5 mg/kg/day (systemic exposures less than the therapeutic dose).<br/>Pregnancy:<br/>Pregnancy Category C: Conivaptan has been shown to have adverse effects on the fetus when given to animals during pregnancy at systemic exposures less than those achieved at a therapeutic dose based on AUC comparisons. There are no adequate and well-controlled studies in pregnant women. VAPRISOL should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. The patient should be apprised of the potential hazard to the fetus. Conivaptan crosses the placenta and is found in fetal tissue in rats. Fetal tissue levels were<10% of maternal plasma concentrations while placental levels were 2.2-fold higher than maternal plasma concentrations indicating that conivaptan can be transferred to the fetus. Conivaptan that is taken up by fetal tissue is slowly cleared, suggesting that fetal accumulation is possible. Milk levels were up to 3 times higher than maternal plasma levels following an intravenous dose of 1 mg/kg (systemic exposures less than therapeutic based on AUC comparisons). In female rats given an intravenous bolus dose of 0.5, 1.25 or 2.5 mg/kg/day conivaptan hydrochloride before mating and continuing through gestation day 7, prolonged diestrus, decreased fertility and increased pre- and post-natal implantation loss occurred at 2.5 mg/kg/day (systemic exposures less than the therapeutic dose). In pregnant rats given intravenous doses of 0.5, 1.25 or 2.5 mg/kg/day from gestation day 7 through 17 (organogenesis), no significant maternal or fetal effects were observed at systemic exposures less than therapeutic exposure based on AUC comparisons. Pregnant rats were administered intravenous conivaptan hydrochloride at a dose of 2.5 mg/kg/day (systemic exposures less than therapeutic based on AUC) from gestation day 7 through lactation day 20 (weaning), and the pups showed decreased neonatal viability, weaning indices, delayed growth and physical development (including sexual maturation), and delayed reflex development. No discernible changes were seen in pups from dams administered conivaptan hydrochloride at 0.5 or 1.25 mg/kg/day from this same period. No maternal adverse effects were seen with conivaptan hydrochloride administration (0.5, 1.25, or 2.5 mg/kg/day from gestation day 7 through lactation day 20; systemic exposures less than therapeutic dosebased on AUC comparisons). In pregnant rabbits given intravenous doses of 3, 6 or 12 mg/kg/day from gestation day 6 through 18 (organogenesis) there were no fetal findings; however, maternal toxicity was observed in all groups (systemic exposures less than the therapeutic dose). In bolus intravenous postnatal rat studies, decreased neonatal viability, decreased weaning indices, delayed growth/physical development and delayed sexual maturation of offspring were observed at 2.5 mg/kg/day (systemic exposures less than the therapeutic dose).<br/>Labor and Delivery: The effect of conivaptan on labor and delivery in humans has not been studied. Conivaptan hydrochloride delayed delivery in rats dosed orally at 10 mg/kg/day by oral gavage (systemic exposures equivalent to the therapeutic dose based on AUC comparisons). Administration of conivaptan hydrochloride at 2.5 mg/kg/day intravenously increased peripartum pup mortality (systemic exposures were less than the therapeutic dose based on AUC comparisons). These effects may be associated with conivaptan activity on oxytocin receptors in the rat. The relevance to humans is unclear.<br/>Lactating Women: It is not known whether conivaptan is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when VAPRISOL is administered to a lactating woman. Conivaptan is excreted in milk and detected in neonates when given by intravenous administration to lactating rats. Milk levels of conivaptan in rats reached maximal levels at 1 hour post dose following intravenous administrations and were up to 3 times greater than maternal plasma levels. Administration of conivaptan hydrochloride at 2.5 mg/kg/day intravenously increased peripartum pup mortality; systemic exposures were less than the therapeutic dose based on AUC comparisons.<br/>Pediatric Use: The safety and effectiveness of VAPRISOL in pediatric patients have not been studied.<br/>Geriatric Use: In clinical studies of intravenous VAPRISOL administered as a 20 mg IV loading dose followed by 40 mg/day IV for 2 to 4 days, 52% of participants were greater than or equal to 65 years of age and 34% were greater than or equal to 75 years of age. In general, the adverse event profile in elderly patients was similar to that seen in the general study population.
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Although no data on overdosage in humans are available, VAPRISOL has been administered as a 20 mg loading dose on Day 1 followed by continuous infusion of 80 mg/day for 4 days in hyponatremia patients and up to 120 mg/day for 2 days in CHF patients. No new toxicities were identified at these higher doses, but adverse events related to the pharmacologic activity of VAPRISOL, e.g. hypotension and thirst, occurred more frequently at these higher doses. In case of overdose, based on expected exaggerated pharmacological activity, symptomatic treatment with frequent monitoring of vital signs and close observation of the patient is recommended.
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conivaptan hydrochloride
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Vaprisol (Liquid)
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The most common adverse reactions reported with VAPRISOL administration were infusion site reactions. In studies in patients and healthy volunteers, infusion site reactions occurred in 52.5% of subjects treated with VAPRISOL 40 mg/day compared to 3.3% in the placebo group. The majority of the reactions were mild and did not lead to discontinuation of drug. However, some serious infusion site reactions did occur, and infusion site reactions were the most common type of adverse event leading to discontinuation of VAPRISOL. The adverse reactions presented in Table 5 are derived from 72 healthy volunteers and 111 patients with euvolemic hyponatremia who received VAPRISOL 20 mg IV as a loading dose followed by 40 mg/day IV for 2 to 4 days and from 40 healthy volunteers and 21 patients with euvolemic hyponatremia who received placebo. The adverse reactions occurred in at least 2% of patients treated with VAPRISOL and at a higher incidence for VAPRISOL-treated patients than for placebo-treated patients. The safety of VAPRISOL in hyponatremic patients with underlying congestive heart failure has not been established.
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VAPRISOL is indicated for the treatment of euvolemic hyponatremia (e.g., the syndrome of inappropriate secretion of antidiuretic hormone, or in the setting of hypothyroidism, adrenal insufficiency, pulmonary disorders, etc.) in hospitalized patients. VAPRISOL is not indicated for the treatment of patients with congestive heart failure.
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Vaprisol
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