4.1. Therapeutic indications

Ropivacaine Altan 7.5 mg/ml is indicated in adults and adolescents older than 12 years in

Surgical anaesthesia:

- Epidural blocks for surgery, including Caesarean section.

- Major nerve blocks.

- Field blocks.

In children older than 1 year of age up to and including 12 years (per- and postoperative):

-Single and continuous peripheral nerve block.

In neonates, infants and children up to and including 12 years (per- and postoperative):

-Caudal epidural block.

-Continuous epidural infusion.

4.2. Posology and method of administration

Ropivacaine Altan should only be used by, or under the supervision of, clinicians experienced in regional anaesthesia.

Posology

Adults and adolescents above 12 years of age:

The following table is a guide to dosage for the more commonly used blocks. The smallest dose required to produce an effective block should be used. The clinician's experience and knowledge of the patient's physical status are of importance when deciding the dose.

Table 1 Adults and adolescents above 12 years of age

Conc.

Volume

Dose

Onset

Duration

mg/ml

ml

mg

minutes

hours

SURGICAL ANAESTHESIA

Lumbar Epidural Administration

Surgery

7.5

15–25

113–188

10–20

3–5

10

15–20

150–200

10–20

4–6

Caesarean section

7.5

15–20

113–150(1)

10–20

3–5

Thoracic Epidural Administration

To establish block for postoperative pain relief

7.5

5–15 (dependent on the level of injection)

38–113

10–20

n/a(2)

Major Nerve Block*

Brachial plexus block

7.5

30–40

225–300(3)

10–25

6–10

Field Block

(e.g. minor nerve blocks and infiltration)

7.5

1–30

7.5–225

1–15

2–6

ACUTE PAIN MANAGEMENT

Lumbar Epidural Administration

Bolus

2.0

10–20

20–40

10–15

0.5–1.5

Intermittent injections (top up) (e.g. labour pain management)

2.0

10–15 (minimum interval 30 minutes)

20–30

Field Block

(e.g. minor nerve blocks and infiltration)

2.0

1–100

2.0–200

1–5

2–6

Peripheral nerve block

(Femoral or interscalene block)

Continuos infusion or intermittent injections

(e.g. postoperative pain management)

2.0

5-10 ml/h

10-20 mg/h

n/a(2)

n/a(2)

The doses in the table are those considered to be necessary to produce a successful block and should be regarded as guidelines for use in adults. Individual variations in onset and duration occur. The figures in the column 'Dose' reflect the expected average dose range needed. Standard textbooks should be consulted for both factors affecting specific block techniques and individual patient requirements.

* With regard to major nerve block, only for brachial plexus block a dose recommendation can be given. For other major nerve blocks lower doses may be required. However, there is presently no experience of specific dose recommendations for other blocks.

(1) Incremental dosing should be applied, the starting dose of about 100 mg (97.5 mg = 13 ml; 105 mg = 14 ml) to be given over 3–5 minutes. Two extra doses, in total an additional 50mg, may be administered as needed.

(2) n/a = not applicable.

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

In general, surgical anaesthesia (e.g. epidural administration) requires the use of the higher concentrations and doses. The 10 mg/ml formulation is recommended for epidural anaesthesia in which a complete motor block is essential for the surgery. For analgesia (e.g. epidural administration for acute pain management) the lower concentrations and doses are recommended.

Renal impairment

Dose modification is not normally required in patients with impaired renal function when single doses or short-term treatments are used (see section 4.4 and 5.2).

Hepatic impairment

Ropivacaine hydrochloride is metabolized in the liver and should be used with caution in patients with severe liver disease. Reduced repeat doses may be required due to delayed elimination (see section 4.4 and 5.2).

Method of administration

Perineural and epidural use.

Careful aspiration before and during injection is recommended to prevent intravascular injection. When a large dose is to be injected, a test dose of 3–5 ml lidocaine (lignocaine) with adrenaline (epinephrine) is recommended. An inadvertent intravascular injection may be recognised by a temporary increase in heart rate and an accidental intrathecal injection by signs of a spinal block.

Aspiration should be performed prior to and during administration of the main dose, which should be injected slowly or in incremental doses, at a rate of 25–50 mg/min, while closely observing the patient's vital functions and maintaining verbal contact. If toxic symptoms occur, the injection should be stopped immediately.

In epidural block for surgery, single doses of up to 250 mg ropivacaine have been used and well tolerated.

In brachial plexus block a single dose of 300 mg has been used in a limited number of patients and was well tolerated.

When prolonged blocks are used, either through continuous infusion or through repeated bolus administration, the risks of reaching a toxic plasma concentration or inducing local neural injury must be considered. Cumulative doses up to 675 mg ropivacaine for surgery and postoperative analgesia administered over 24 hours were well tolerated in adults, as were postoperative continuous epidural infusions at rates up to 28 mg/hour for 72 hours. In a limited number of patients, higher doses of up to 800 mg/day have been administered with relatively few adverse reactions.

For treatment of postoperative pain, the following technique can be recommended: Unless preoperatively instituted, an epidural block with a concentration of 7.5 mg/ml is induced via an epidural catheter. Analgesia is maintained with Ropivacaine Altan 2 mg/ml infusion.

Infusion rates of 6–14 ml (12–28 mg) per hour provide adequate analgesia with only slight and non-progressive motor block in most cases of moderate to severe postoperative pain. The maximum duration of epidural block is 3 days. However, close monitoring of analgesic effect should be performed in order to remove the catheter as soon as the pain condition allows it. With this technique a significant reduction in the need for opioids has been observed.

When prolonged peripheral nerve blocks are applied, either through continous infusion or through repeated injections, the risks of reaching a toxic plasma concentration or inducing local neural injury must be considered. In clinical studies, femoral nerve block was established with 300 mg Ropivacaine 7.5 mg/ml and interscalene block with 225 mg Ropivacaine 7.5 mg/ml, respectively, before surgery. Analgesia was then maintained with Ropivacaine 2 mg/ml. Infusion rates or intermittent injections of 10-20 mg per hour for 48 hours provided adequate analgesia and well tolerated.

Concentrations above 7.5 mg/ml Rropivacaine have not been documented for Caesarean section.

Prior to administration, the solution should be visually inspected, do not use unless the solution is clear and colorless and the container is not damaged.

For single use only.

Pediatric population

Table 2 Epidural Block: Paediatric patients from 0 up to and including 12 years of age

Conc.

Volume

Dose

mg/ml

ml/kg

mg/kg

ACUTE PAIN MANAGEMENT (per- and postoperative)

Single Caudal Epidural Block

Blocks below T12, in children with a body weight up to 25 kg

2.0

1

2

Continuous Epidural Infusion

In children with a body weight up to 25 kg

0 up to 6 months

Bolus dosea

2.0

0.5–1

1–2

6 up to 12 months

Bolus dosea

2.0

0.5–1

1–2

1 to 12 years

Bolus doseb

2.0

1

2

The dose in the table should be regarded as guidelines for use in paediatrics. Individual variations occur. In children with a high body weight, a gradual reduction of the dosage is often necessary and should be based on the ideal body weight. The volume for single caudal epidural block and the volume for epidural bolus doses should not exceed 25 ml in any patient. Standard textbooks should be consulted for factors affecting specific block techniques and for individual patient requirements.

a Doses in the low end of the dose interval are recommended for thoracic epidural blocks while doses in the high end are recommended for lumbar or caudal epidural blocks.

b Recommended for lumbar epidural blocks. It is good practice to reduce the bolus dose for thoracic epidural analgesia.

The use of Ropivacaine 7.5 and 10 mg/ml may be associated with systemic and central toxic events in children. Lower strengths (2 mg/ml) are more appropriate for administration to this population.

Table 3 Peripheral nerve blocks: Infants and children aged 1-12 years

Concentration

mg/ml

Volume

ml/kg

Dose

mg/kg

ACUTE PAIN MANAGEMENT

(per- and postoperative)

Single injections for peripheral nerve block

e.g. ilioinguinal nerve block, brachial plexus block, fascia iliaca compartment block

2.0

0.5-0.75

1.0-1.5

Multiple blocks

2.0

0.5-1.5

1.0-3.0

The dose in the table should be regarded as guidelines for use in paediatrics. Individual variations occur.

In children with a high body weight a gradual reduction of the dosage is often necessary and should be based on the ideal body weight. Standard textbooks should be consulted for factors affecting specific block techniques and for individual patient requirements.

Infants and children aged 1-12 years:

The doses for peripheral block in infants and children provide guidelines for use in children without severe disease. More conservative doses and close monitoring are recommended for children with severe disease.

Single injections for peripheral nerve block (e.g. ilioinguinal nerve block, brachial plexus block, fascia iliaca compartment block) should not exceed 2.5-3.0 mg/kg.

Method of administration

Perineural and epidural use

Careful aspiration before and during injection is recommended to prevent intravascular injection. The patient's vital functions should be observed closely during the injection. If toxic symptoms occur, the injection should be stopped immediately.

A single caudal epidural injection of ropivacaine 2 mg/ml produces adequate postoperative analgesia below T12 in the majority of patients when a dose of 2 mg/kg is used in a volume of 1 ml/kg. The volume of the caudal epidural injection may be adjusted to achieve a different distribution of sensory block, as recommended in standard textbooks. In children above 4 years of age, doses up to 3 mg/kg of a concentration of ropivacaine 3 mg/ml have been studied. However, this concentration is associated with a higher incidence of motor block.

Fractionation of the calculated local anaesthetic dose is recommended, whatever route of administration.

The use of ropivacaine in premature children has not been documented.

Prior to administration, the solution should be visually inspected. Do not use unless the solution is clear and colourless and the container is not damaged.

For single use only.

4.3. Contraindications

Hypersensitivity to ropivacaine or to other local anaesthetics of the amide type or to any of the excipients listed in section 6.1.

General contraindications related to epidural anaesthesia, regardless of the local anaesthetic used, should be taken into account.

Intravenous regional anaesthesia.

Obstetric paracervical anaesthesia.

Hypovolaemia.

4.4. Special warnings and precautions for use

Regional anaesthetic procedures should always be performed in a properly equipped and staffed area. Equipment and drugs necessary for monitoring and emergency resuscitation should be immediately available. Patients receiving major blocks should be in an optimal condition and have an intravenous line inserted before the blocking procedure. The clinician responsible should take the necessary precautions to avoid intravascular injection (see section 4.2 Posology and method of administration) and be appropriately trained and familiar with diagnosis and treatment of side effects, systemic toxicity and other complications (see sections 4.8 Undesirable effects and 4.9 Overdose) such as inadvertent subarachnoid injection, which may produce a high spinal block with apnoea and hypotension.

Convulsions have occurred most often after brachial plexus block and epidural block. This is likely to be the result of either accidental intravascular injection or rapid absorption from the injection site.

Caution is required to prevent injections in inflamed areas.

Major peripheral nerve blocks

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

Head and neck blocks

Certain local anaesthetic procedures, such as injections in the head and neck regions, may be associated with a higher frequency of serious adverse reactions, regardless of the local anaesthetic used.

Patients in poor general health

Patients in poor general condition due to ageing or other compromising factors such as partial or complete heart conduction block, advanced liver disease or severe renal dysfunction require special attention, although regional anaesthesia is frequently indicated in these patients.

Cardiovascular effect

Epidural and intrathecal anaesthesia may lead to hypotension and bradycardia. Hypotension should be treated promptly with a vasopressor intravenously, and with adequate vascular filling.

Patients treated with anti-arrhythmic drugs class III (e.g. amiodarone) should be under close surveillance and ECG monitoring considered, since cardiac effects may be additive.

There have been rare reports of cardiac arrest during the use of ropivacaine for epidural anaesthesia or peripheral nerve blockade, especially after unintentional accidental intravascular administration in elderly patients and in patients with concomitant heart disease. In some instances, resuscitation has been difficult. Should cardiac arrest occur, prolonged resuscitative efforts may be required to improve the possibility of a successful outcome.

Patients with hepatic and renal impairment

Ropivacaine is metabolised in the liver and should therefore be used with caution in patients with severe liver disease; repeated doses may need to be reduced due to delayed elimination. Normally there is no need to modify the dose in patients with impaired renal function when used for single dose or short-term treatment. Acidosis and reduced plasma protein concentration, frequently seen in patients with chronic renal failure, may increase the risk of systemic toxicity.

Acute porphyria

Ropivacaine Altan is possibly porphyrinogenic and should only be prescribed to patients with acute porphyria when no safer alternative is available. Appropriate precautions should be taken in the case of vulnerable patients, according to standard textbooks and/or in consultation with disease area experts.

Hypovolaemia

Patients with hypovolaemia due to any cause can develop sudden and severe hypotension during epidural anaesthesia, regardless of the local anaesthetic used.

Prolonged administration

Prolonged administration of ropivacaine should be avoided in patients concomitantly treated with strong CYP1A2 inhibitors, such as fluvoxamine and enoxacin, (see section 4.5).

Hypersensitivity

A possible cross–hypersensitivity with other amide–type local anaesthetics should be taken into account.

Chondrolysis

There have been post-marketing reports of chondrolysis in patients receiving post- operative intra-articular continuous infusion of local anaesthetics, including ropivacaine. The majority of reported cases of chondrolysis have involved the shoulder joint. Intra-articular continuous infusion is not an approved indication for Ropivacaine Altan. Intra-articular continuous infusion with Ropivacaine Altan should be avoided, as the efficacy and safety has not been established.

Excipients with recognised action/effect

Ropivacaine Altan 2 mg/ml solution for injection:

This medicinal product contains 3.34 mg of sodium per ml, equivalent to 0.17% of the WHO recommended maximum daily intake of 2 g of sodium for an adult.

Ropivacaine Altan 7.5 mg/ml solution for injection:

This medicinal product contains 3.15 mg of sodium per ml, equivalent to 0.16% of the WHO recommended maximum daily intake of 2 g of sodium for an adult.

Ropivacaine Altan 10 mg/ml solution for injection:

This medicinal product contains 3.03 mg of sodium per ml, equivalent to 0.15% of the WHO recommended maximum daily intake of 2 g of sodium for an adult.

Paediatric population

Neonates may need special attention due to immaturity of metabolic pathways. The larger variations in plasma concentrations of ropivacaine observed in clinical trials in neonates suggest that there may be an increased risk of systemic toxicity in this age group, especially during continuous epidural infusion. The recommended doses in neonates are based on limited clinical data. When ropivacaine is used in this patient group, regular monitoring of systemic toxicity (e.g. by signs of CNS toxicity, ECG, SpO2) and local neurotoxicity (e.g. prolonged recovery) is required, which should be continued after ending infusion, due to a slow elimination in neonates.

The safety and efficacy of ropivacaine 7.5 mg/ml and 10 mg/ml in children up to and including 12 years has not been established.

The safety and efficacy of ropivacaine 2 mg/ml for field block in children up to and including 12 years has not been established.

The safety and efficacy of ropivacaine 2 mg/ml for peripheral nerve blocks in infants below 1 year has not been established.

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

Ropivacaine Altan should be used with caution in patients receiving other local anaesthetics or agents structurally related to amide-type local anaesthetics, e.g. certain antiarrhythmics, such as lidocaine and mexiletine, since the systemic toxic effects are additive. Simultaneous use of Ropivacaine Altan with general anaesthetics or opioids may potentiate each others' (adverse) effects. Specific interaction studies with ropivacaine and anti- arrhythmic drugs class III (e.g. amiodarone) have not been performed, but caution is advised (see also section 4.4 Special warnings and precautions for use).

Cytochrome P450 (CYP) 1A2 is involved in the formation of 3-hydroxy- ropivacaine, the major metabolite. In vivo, the plasma clearance of ropivacaine was reduced by up to 77% during co-administration of fluvoxamine, a selective and potent CYP1A2 inhibitor. Thus strong inhibitors of CYP1A2, such as fluvoxamine and enoxacin given concomitantly during prolonged administration of Ropivacaine Altan, can interact with Ropivacaine Altan. Prolonged administration of ropivacaine should be avoided in patients concomitantly treated with strong CYP1A2 inhibitors (see also section 4.4).

In vivo, the plasma clearance of ropivacaine was reduced by 15% during co- administration of ketoconazole, a selective and potent inhibitor of CYP3A4. However, the inhibition of this isozyme is not likely to have clinical relevance.

In vitro, ropivacaine is a competitive inhibitor of CYP2D6 but does not seem to inhibit this isozyme at clinically attained plasma concentrations.

4.6. Fertility, pregnancy and lactation

Pregnancy

Apart from epidural administration for obstetrical use, there are no adequate data on the use of ropivacaine in human pregnancy. Experimental animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/fœtal development, parturition or postnatal development (see section 5.3 Preclinical safety data).

Breast-feeding

There are no data available concerning the excretion of ropivacaine into human milk.

Fertility

There are no data available concerning fertility.

4.7. Effects on ability to drive and use machines

No data are available. Depending on the dose, local anaesthetics may have a minor influence on mental function and co-ordination even in the absence of overt CNS toxicity and may temporarily impair locomotion and alertness. When administered this medicine the doctor should assess on each particular case if the reaction capacity is engaged and if the patient can drive or use machinery.

4.8. Undesirable effects

General

The adverse reaction profile for Ropivacaine Altan is similar to those for other long acting local anaesthetics of the amide type. Adverse drug reactions should be distinguished from the physiological effects of the nerve block itself e.g. a decrease in blood pressure and bradycardia during spinal/epidural block.

The frequencies of the undesirable effects listed below are defined using the following convention:

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 the available data).

Table 4 Table of adverse drug reactions

System Organ Class

Frequency

Undesirable Effect

Immune system disorders

Rare

Allergic reactions (anaphylactic reactions, anaphylactic shock, angioneurotic oedema and urticaria)

Psychiatric disorders

Uncommon

Anxiety

Nervous System disorders

Common

Paraesthesia, Dizziness, Headache

Uncommon

Symptoms of CNS toxicity (Convulsions, Grand mal convulsions, Seizures, Light headedness, Circumoral paraesthesia, Numbness of the tongue, Hyperacusis, Tinnitus, Visual disturbances, Dysarthria, Muscular twitching, Tremor)*, Hypoaesthesia

Not known

Dyskinesia, Horner´s syndrome

Cardiac disorders

Common

Bradycardia, Tachycardia

Rare

Cardiac arrest, Cardiac arrhythmias

Vascular disorders

Very common

Hypotensiona

Common

Hypertension

Uncommon

Syncope

Respiratory, Thoracic and Mediastinal disorders

Uncommon

Dyspnoea

Gastrointestinal disorders

Very common

Nausea

Common

Vomitingb

Musculoskeletal and connective tissue disorders

Common

Back pain

Renal and Urinary disorders

Common

Urinary retention

General disorders and Administrative site conditions

Common

Temperature elevation, Chills

Uncommon

Hypothermia

a Hypotension is less frequent in children (>1/100).

b Vomiting is more frequent in children (>1/10).

* These symptoms usually occur because of inadvertent intravascular injection, overdose or rapid absorption, see section 4.9.

Class-related adverse drug reactions

Neurological complications

Neuropathy and spinal cord dysfunction (e.g. anterior spinal artery syndrome, arachnoiditis, cauda equina), which may result in rare cases of permanent sequelae, have been associated with regional anaesthesia, regardless of the local anaesthetic used.

Following epidural administration, cranial spread of local anaesthetic especially in pregnant women may occasionally result in Horner's syndrome characterised by miosis, ptosis, and anhidrosis. Spontaneous resolution occurs upon discontinuation of treatment.

Total spinal block

Total spinal block may occur if an epidural dose is inadvertently administered intrathecally.

Acute systemic toxicity

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

Central nervous system toxicity

Central nervous system toxicity is a graded response with symptoms and signs of escalating severity. Initially symptoms such as visual or hearing disturbances, perioral numbness, dizziness, light-headedness, tingling and paraesthesia are seen. Dysarthria, muscular rigidity and muscular twitching are more serious and may precede the onset of generalised convulsions. These signs must not be mistaken for neurotic behaviour. Unconsciousness and grand mal convulsions may follow, which may last from a few seconds to several minutes. Hypoxia and hypercarbia occur rapidly during convulsions due to the increased muscular activity, together with the interference with respiration. In severe cases even apnoea may occur. The respiratory and metabolic acidosis increases and extends the toxic effects of local anaesthetics.

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

Cardiovascular system toxicity

Cardiovascular toxicity indicates a more severe situation. Hypotension, bradycardia, arrhythmia and even cardiac arrest may occur as a result of high systemic concentrations of local anaesthetics. In volunteers the intravenous infusion of ropivacaine resulted in signs of depression of conductivity and contractility.

Cardiovascular toxic effects are generally preceded by signs of toxicity in the central nervous system, unless the patient is receiving a general anaesthetic or is heavily sedated with drugs such as benzodiazepines or barbiturates.

Paediatric population

Frequency, type and severity of adverse reactions in children are expected to be the same as in adults except for hypotension which happens less often in children (< 1 in 10) and vomiting which happens more often in children (> 1 in 10).

In paediatric population, early signs of local anaesthetic toxicity may be difficult to detect since they may not be able to verbally express them. See also section 4.4.

Treatment of acute systemic toxicity

See section 4.9.

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 or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

Symptoms

Accidental intravascular injections of local anaesthetics may cause immediate (within seconds to a few minutes) systemic toxic reactions. In the event of overdose, peak plasma concentrations may not be reached for one to two hours, depending on the site of the injection, and signs of toxicity may thus be delayed. (See section 4.8.)

Treatment

Equipment and necessary drugs for monitoring and emergency resuscitation should be available at any time. If signs of acute systemic toxicity appear, injection of the local anaesthetic should be stopped immediately and CNS symptoms (convulsions, CNS depression) must promptly be treated with appropriate airway/respiratory support and the administration of anticonvulsant drugs.

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

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

Should cardiac arrest occur, a successful outcome may require prolonged resuscitative efforts.