4.1. Therapeutic indications

Rocuronium bromide is indicated in adult and paediatric patients (from term neonates to adolescents (0 to < 18 years)) as an adjunct to general anaesthesia to facilitate tracheal intubation during routine sequence induction and to provide skeletal muscle relaxation during surgery. In adults Rocuronium bromide is also indicated to facilitate tracheal intubation during rapid sequence induction and as an adjunct in the intensive care unit (ICU) (e.g. to facilitate intubation) for short term use.

See also sections 4.2 and 5.1.

4.2. Posology and method of administration

Posology

As with other neuromuscular blocking agents, the dosage of rocuronium bromide should be individualised in each patient. The method of anaesthesia and the expected duration of surgery, the method of sedation and the expected duration of mechanical ventilation, the possible interaction with other medicinal products that are administered concomitantly and the condition of the patient should be taken into account when determining the dose. The use of an appropriate neuromuscular monitoring technique is recommended for the evaluation of the neuromuscular block and recovery.

Inhalational anaesthetics potentiate the neuromuscular blocking effects of rocuronium bromide. This potentiation becomes clinically relevant during the course of anaesthesia when a certain tissue concentration of the volatile agents is reached. Consequently, adjustments should be made by administering smaller maintenance doses at less frequent intervals or by using lower infusion rates of rocuronium bromide during long lasting procedures (longer than 1 hour) under inhalational anaesthesia.

In adult patients the following dosage recommendations may serve as a general guidance for tracheal intubation and muscle relaxation for short to long lasting surgical procedures and for use in the intensive care unit.

This medicinal product is for single use only.

Surgical Procedures

Tracheal intubation:

The standard intubating dose during routine anaesthesia is 0.6 mg rocuronium bromide per kg body weight, which results in adequate intubation conditions within 60 seconds in nearly all patients. A dose of 1.0 mg rocuronium bromide per kg body weight is recommended for facilitating tracheal intubation conditions during rapid sequence induction of anaesthesia, after which adequate intubation conditions are also established within 60 seconds in nearly all patients If a dose of 0.6 mg rocuronium bromide per kg body weight is used for rapid sequence induction of anaesthesia, it is recommended to intubate the patient 90 seconds after administration of rocuronium bromide.

Maintenance dosage:

The recommended maintenance dose is 0.15 mg rocuronium bromide per kg body weight. In case of long-term inhalational anaesthesia it should be reduced to 0.075 - 0.1 mg of rocuronium bromide per kg body weight.

The maintenance doses should best be given when twitch height has recovered to 25 % of control twitch height, or when 2 to 3 responses to train-of-four stimulation (TOF) are present.

Continuous infusion:

If rocuronium bromide is administered by continuous infusion, it is recommended to give a loading dose of 0.6 mg rocuronium bromide per kg body weight and, when the neuromuscular block starts to recover, to start administration by infusion. The infusion rate should be adjusted to maintain twitch response at 10 % of control twitch height or to maintain 1 to 2 responses to train-of-four stimulation.

In adults under intravenous anaesthesia, the infusion rate required to maintain the neuromuscular block at this level ranges from 0.3 - 0.6 mg/kg/h. Under inhalational anaesthesia the infusion rate ranges from 0.3 - 0.4 mg/kg/h.

Continuous monitoring of the neuromuscular block is essential since infusion rate requirements vary from patient to patient and with the anaesthetic method used.

Dosage in pregnant patients:

In patients undergoing Caesarean section, it is recommended to only use a dose of 0.6 mg rocuronium bromide per kg body weight, since a 1.0 mg/kg dose has not been investigated in this patient group.

Reversal of neuromuscular block induced by neuromuscular blocking agents may be inhibited or unsatisfactory in patients receiving magnesium salts for toxaemia of pregnancy because magnesium salts enhance neuromuscular blockade. Therefore, in these patients the dosage of rocuronium should be reduced and be titrated to twitch response.

Dosage in paediatric patients:

For neonates (0-28 days), infants (28 days to 3 months), toddlers (˃3 months to 2 years), children (2-11 years) and adolescents (12 to 17 years) the recommended intubation dose during routine anaesthesia and maintenance dose are similar to those in adults.

However, the duration of action of the single intubating dose will be longer in neonates and infants than in children (see Section 5.1).

For continuous infusion in paediatric patients, the infusion rates, with exception of children, are the same as for adults. For children higher infusion rates might be necessary.

Thus, for children the same initial infusion rates as for adults are recommended which should be then adjusted to maintain twitch response at 10% of control twitch height or to maintain 1 or 2 responses to train-of-four stimulation during the procedure.

The experience with rocuronium bromide in rapid sequence induction in paediatric patients is limited. Rocuronium bromide is therefore not recommended for facilitating tracheal intubation conditions during rapid sequence induction in paediatric patients.

Dosage in geriatric patients and patients with hepatic and/or biliary tract disease and/or renal failure:

The standard intubation dose for geriatric patients and patients with hepatic and/or biliary tract disease and/or renal failure during routine anaesthesia is 0.6 mg rocuronium bromide per kg body weight. A dose of 0.6 mg per kg body weight should be considered for rapid sequence induction of anaesthesia in patients in which a prolonged duration of action is expected however adequate conditions for intubation may not be established for 90 seconds after administration of rocuronium bromide. Regardless of the anaesthetic technique used, the recommended maintenance dose for these patients is 0.075 - 0.1 mg rocuronium bromide per kg body weight, and the recommended infusion rate is 0.3 - 0.4 mg/kg/h (see also Continuous infusion).

Dosage in overweight and obese patients:

When used in overweight or obese patients (defined as patients with a body weight of 30 % or more above ideal body weight) doses should be reduced taking into account a lean body mass.

Intensive care procedures

Tracheal intubation

For tracheal intubation, the same doses should be used as described above under surgical procedures.

Method of Administration

Rocuronium bromide is administered intravenously (i.v.) either as a bolus injection or as a continuous infusion (for further information see also section 6.6).

4.3. Contraindications

Rocuronium bromide is contra-indicated in patients with hypersensitivity to rocuronium bromide or to the bromide ion or to any of the excipients listed in section 6.1.

4.4. Special warnings and precautions for use

Rocuronium bromide should be administered only by an experienced staff familiar with the use of neuromuscular blocking agents. Adequate facilities and staff for endotracheal intubation and artificial ventilation have to be available for immediate use.

Since rocuronium bromide causes paralysis of the respiratory muscles, ventilatory support is mandatory for patients treated with this active substance until adequate spontaneous respiration is restored. As with all neuromuscular blocking agents, it is important to anticipate intubation difficulties, particularly when used as part of a rapid sequence induction technique.

As with other neuromuscular blocking agents, residual curarization has been reported for Rocuronium. In order to prevent complications resulting from residual curarization, it is recommended to extubate only after the patient has recovered sufficiently from neuromuscular block. Geriatric patients (65 years or older) may be at increased risk for residual neuromuscular block. Other factors which could cause residual curarization after extubation in the post-operative phase (such as drug interactions or patient condition) should also be considered. If not used as part of standard clinical practice, the use of a reversal agent (such as sugammadex or acetylcholinesterase inhibitors) should be considered, especially in those cases where residual curarization is more likely to occur.

It is essential to ensure that the patient is breathing spontaneously, deeply and regularly before leaving the theatre after anaesthesia.

Anaphylactic reactions (see above) can occur after the administration of neuromuscular blocking agents. Precautions for treating such reactions should always be taken. Particularly in the case of previous anaphylactic reactions to neuromuscular blocking agents, special precautions should be taken since allergic cross-reactivity to neuromuscular blocking agents has been reported.

Dose levels higher than 0.9 mg rocuronium bromide per kg body weight may increase the heart rate; this effect could counteract the bradycardia produced by other anaesthetic agents or by vagal stimulation.

In general, following long term use of muscle relaxants in the ICU, prolonged paralysis and/or skeletal muscle weakness has been noted. In order to help preclude possible prolongation of neuromuscular blockage and/or overdose, it is strongly recommended that neuromuscular transmission is monitored throughout the use of muscle relaxants. In addition, patients should receive adequate analgesia and sedation. Furthermore, muscle relaxants should be titrated to the effect in the individual patient. This should be done by or under the supervision of experienced clinicians who are familiar with the effects and with appropriate neuromuscular monitoring techniques.

Because rocuronium bromide is always used with other agents and because of the possibility of the occurrence of malignant hyperthermia during anaesthesia, even in the absence of known triggering agents, clinicians should be familiar with the early signs, confirmatory diagnosis and treatment of malignant hyperthermia prior to the start of any anaesthesia. In animal studies it was shown that rocuronium bromide is not a triggering factor for malignant hyperthermia. Rare cases of malignant hyperthermia with rocuronium have been observed during post-marketing surveillance; however, a causal association has not been proven.

Myopathy has been reported after long-term concurrent use of non-depolarisating neuromuscular blockers and corticosteroids. The co-administration period should be reduced to be as short as possible (see section 4.5).

Rocuronium should only be administered after full recovery from the neuromuscular blockade caused by suxamethonium.

Hypertensive crisis in patients with phaeochromocytoma

Postmarketing data have identified cases of hypertensive crisis temporally related to administration of rocuronium in patients with diagnosed or latent haeochromocytoma. Rocuronium should therefore be used with caution in such patients.

The following conditions may influence the pharmacokinetics and/or pharmacodynamics of rocuronium bromide:

Hepatic and/or biliary tract disease and renal failure

Rocuronium bromide is excreted in urine and bile. Therefore, it should be used with caution in patients with clinically significant hepatic and/or biliary diseases and/or renal failure. In these patient groups prolongation of the effect has been observed with doses of 0.6 mg rocuronium bromide per kg body weight.

Prolonged circulation time

Conditions associated with prolonged circulation time such as cardiovascular diseases, old age and an oedematous state resulting in an increased volume of distribution, may contribute to a slower onset of the effect. The duration of action may also be prolonged due to a reduced plasma clearance.

Neuromuscular disease

Like other neuromuscular blocking agents, rocuronium bromide should be used with extreme caution in patients with a neuromuscular disease or after poliomyelitis since the response to neuromuscular blocking agents may be considerably altered in these cases. The magnitude and direction of this alteration may vary widely. In patients with myasthenia gravis or with the myasthenic (Eaton-Lambert) syndrome, small doses of rocuronium bromide may have profound effects and rocuronium bromide should be titrated to the response.

Hypothermia

In surgery under hypothermic conditions, the neuromuscular blocking effect of rocuronium bromide is increased and the duration prolonged.

Obesity

Like other neuromuscular blocking agents, rocuronium bromide may exhibit a prolonged duration and a prolonged spontaneous recovery in obese patients, when the administered doses are calculated on actual body weight.

Burns

Patients with burns are known to develop resistance to non-depolarizing neuromuscular blocking agents. It is recommended that the dose is titrated to the response.

Conditions which may increase the effects of rocuronium bromide

Hypokalaemia (e.g. after severe vomiting, diarrhoea or diuretic therapy), hypermagnesaemia, hypocalcaemia (after massive transfusions), hypoproteinaemia, dehydration, acidosis, hypercapnia and cachexia.

Severe electrolyte disturbances, altered blood pH or dehydration should therefore be corrected when possible.

Paediatric population

The same warnings and precautions as for adults should be taken into consideration.

This medicinal product contains less than 1 mmol sodium (23 mg) per dose, that is to say essentially 'sodium- free'.

4.5. Interaction with other medicinal products and other forms of interaction

The following medicinal products have been shown to influence the magnitude and/or duration of the effect of non-depolarizing neuromuscular blocking agents:

Increased effect:

▪ Halogenated volatile anaesthetics potentiate the neuromuscular block of rocuronium bromide. The effect only becomes apparent with maintenance dosing (see section 4.2). Reversal of the block with acetylcholinesterase inhibitors could also be inhibited

▪ High doses of: thiopental, methohexital, ketamine, fentanyl, gammahydroxybutyrate, etomidate and propofol

▪ Other non-depolarizing neuromuscular blocking agents.

▪ Prior administration of suxamethonium. (see section 4.4).

Long term concomitant use of corticosteroids and Rocuronium in the ICU may result in prolonged duration of neuromuscular block or myopathy (see sections 4.4 and 4.8).

Other medicinal products:

- antibiotics: aminoglycosides, lincosamides (e.g. lincomycin and clindamycin), polypeptide antibiotics, acylamino-penicillin antibiotics, tetracyclines, high doses of metronidazole.

- diuretics, thiamine, MAO inhibiting agents, quinidine and its isomer quinine, protamine, adrenergic blocking agents, magnesium salts, calcium channel blocking agents and lithium salts and local anaesthetics (lidocaine i.v., bupivacaine epidural) and acute administration of phenytoin or ß-blocking agents.

Decreased effect:

▪ Neostigmine, edrophonium, pyridostigmine, aminopyridine derivatives

▪ Prior chronic administration of corticosteroids, phenytoin or carbamazepine

▪ Noradrenaline, azathioprine (only transient and limited effect), theophylline, calcium chloride, potassium chloride

▪ protease inhibitors (gabexate, ulinastatin).

Variable effect:

Administration of other non-depolarizing neuromuscular blocking agents in combination with rocuronium bromide may produce attenuation or potentiation of the neuromuscular block, depending on the order of administration and the neuromuscular blocking agent used.

Suxamethonium given after the administration of rocuronium bromide may produce potentiation or attenuation of the neuromuscular blocking effect of rocuronium bromide.

Effect of rocuronium on other drugs:

Combined use with lidocaine could result in a more instant effect of lidocaine. Recurarization has been reported after post-operative administration of: aminoglycoside, lincosamide, polypeptide and acylamino-penicillin antibiotics, quinidine, quinine and magnesium salts (see section 4.4).

Paediatric patients:

No formal interaction studies have been performed. The above mentioned interactions for adults and their special warnings and precautions for use (see section 4.4) should also be taken into account for paediatric patients.

4.6. Fertility, pregnancy and lactation

Pregnancy

For rocuronium bromide, no clinical data on exposed pregnancies are available. Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development. Caution should be exercised when prescribing rocuronium bromide to pregnant women.

Caesarean section

In patients undergoing Caesarean section, rocuronium bromide can be used as part of a rapid sequence induction technique, provided no intubation difficulties are anticipated and a sufficient dose of anaesthetic agent is administered or following suxamethonium facilitated intubation. Rocuronium bromide, administered in doses of 0.6 mg/kg has been shown to be safe in parturients undergoing Caesarean section. Rocuronium bromide does not affect Apgar score, foetal muscle tone or cardiorespiratory adaptation. From umbilical cord blood sampling it is apparent that only limited placental transfer of rocuronium bromide occurs which does not lead to the observation of clinical adverse effects in the newborn.

Note 1: doses of 1.0 mg/kg have been investigated during rapid sequence induction of anaesthesia, but not in Caesarean section patients. Therefore, only a dose of 0.6 mg/kg is recommended in this patient group.

Note 2: Reversal of neuromuscular block induced by neuromuscular blocking agents may be inhibited or unsatisfactory in patients receiving magnesium salts for toxemia of pregnancy because magnesium salts enhance neuromuscular blockade. Therefore, in these patients the dosage of rocuronium bromide should be reduced and be titrated to twitch response.

Breast-feeding

It is unknown whether rocuronium bromide is excreted in human breast milk. Animal studies have shown insignificant levels of rocuronium bromide in breast milk. Rocuronium bromide should be given to lactating women only when the attending physician decides that the benefits outweigh the risks. After the administration of a single dose, it is recommended to abstain from next breastfeeding for five elimination half-lives of rocuronium, i.e. for about 6 hours.

Fertility

There are no data with regard to effects of rocuronium bromide on fertility.

4.7. Effects on ability to drive and use machines

Rocuronium bromide has a major influence on the ability to drive and use machines. . It is not recommended to use potentially dangerous machinery or to drive a car during the first 24 hours after the full recovery from the neuromuscular blocking action of rocuronium bromide.

4.8. Undesirable effects

The most common undesirable effects are pain/reaction around injection site, changes in vital functions and prolonged neuromuscular block. The most frequently reported serious adverse drug reactions during postmarketing surveillance is 'anaphylactic and anaphylactoid reactions' and associated symptoms. See also the explanations below the table.

MedDRA SOC

Preferred term1

Uncommon/rare2

(<1/100, >1/10 000)

Very rare

(<1/10 000)

Not known

(cannot be estimated from the available data)

Immune system disorders

Hypersensitivity

Anaphylactic reaction

Anaphylactoid reaction

Anaphylactic shock

Anaphylactoid shock

Nervous system disorders

Flaccid paralysis

Kounis syndrome

Eye disorders

Mydriasis3

Fixed pupils3

Cardiac disorders

Tachycardia

Vascular disorders

Hypotension

Circulatory collapse and shock

Flushing

Respiratory, thoracic and mediastinal disorders

Bronchospasm

Apnoea

Respiratory failure

Skin and subcutaneous tissue disorders

Angioneurotic edema

Urticaria

Rash

Erythematous rash

Musculoskeletal and connective tissue disorders

Muscular weakness4

Steroid myopathy4

General disorders and administration site conditions

Drug ineffective

Drug effect/ therapeutic response decreased

Drug effect/ therapeutic response increased

Injection site pain

Injection site reaction

Injury, poisoning and procedural complications

Prolonged neuromuscular block

Delayed recovery from anesthesia

Airway complication of anaesthesia

[1] Frequencies are estimates derived from post-marketing surveillance reports and data from the general literature.

[2] Post-marketing surveillance data cannot give precise incidence figures. For that reason, the reporting frequency was divided over -three rather than five categories.

[3] in the context of a potential increase of permeability or compromise of the integrity of the Blood-Brain Barrier (BBB)

[4] after long-term use in the ICU

Additional information on adverse reactions:

Anaphylaxis

Although very rare, severe anaphylactic reactions to neuromuscular blocking agents, including rocuronium bromide, have been reported.

Anaphylactic/anaphylactoid reactions are: bronchospasm, cardiovascular changes (e.g. hypotension, tachycardia, circulatory collapse – shock), and cutaneous changes (e.g. angioedema, urticaria). These reactions have, in some cases, been fatal. Due to the possible severity of these reactions, one should always assume they may occur and take the necessary precautions.

In postmarketing reports, hypersensitivity has been observed for rocuronium as well as for rocuronium-sugammadex complex.

Local injection site reactions

During rapid sequence induction of anaesthesia, pain on injection has been reported, especially when the patient has not yet completely lost consciousness and particularly when propofol is used as the induction agent. In clinical studies, pain on injection has been noted in 16% of the patients who underwent rapid sequence induction of anaesthesia with propofol and in less than 0.5% of the patients who underwent rapid sequence induction of anaesthesia with fentanyl and thiopental.

Increased histamine level

Since neuromuscular blocking agents are known to be capable of inducing histamine release both locally and systemically, the possible occurrence of itching and erythematous reaction at the site of injection and/or generalised histaminoid (anaphylactoid) reactions such as bronchospasm and cardiovascular changes e.g. hypotension and tachycardia should always be taken into consideration when administering these drugs. Rash, exanthema, urticaria, bronchospasm and hypotension have been reported very rarely in patients given rocuronium bromide.

In clinical studies only a slight increase in mean plasma histamine level has been observed following rapid bolus administration of 0.3 - 0.9 mg rocuronium bromide per kg body weight.

Prolonged neuromuscular block

The most frequent adverse reaction to non-depolarizing blocking agents as a class consists of an extension of the agent's pharmacological action beyond the time period needed. This may vary from skeletal muscle weakness to profound and prolonged skeletal muscle paralysis resulting in respiratory insufficiency or apnoea.

Myopathy

Myopathy has been reported after the use of various neuromuscular blocking agents in the ICU in combination with corticosteroids (see section 4.4).

Paediatric patients

A meta-analysis of 11 clinical studies in paediatric patients (n=704) with rocuronium bromide (up to 1 mg/kg) showed that tachycardia was identified as an adverse drug reaction with a frequency of 1.4%.

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 the Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

In the event of overdose and prolonged neuromuscular block, the patient should continue to receive ventilatory support and sedation. There are two options for the reversal of neuromuscular block: (1) In adults, sugammadex can be used for reversal of intense (profound) and deep block. The dose of sugammadex to be administered depends on the level of neuromuscular block. (2) An acetylcholinesterase inhibitor (e.g. neostigmine, edrophonium, pyridostigmine) or sugammadex can be used once spontaneous recovery starts and should be administered in adequate doses. When administration of an acetylcholinesterase inhibiting agent fails to reverse the neuromuscular effects of rocuronium bromide, artificial ventilation must be continued until spontaneous breathing is restored. Repeated dosages of an acetylcholinesterase inhibitor can be dangerous.

In animal studies, severe depression of cardiovascular function, ultimately leading to cardiac collapse, did not occur until a cumulative dose of 750 x ED90 (135 mg per kg body weight) was administered.