1. Name Of The Medicinal Product
Carnitor 1 g Solution for Injection
2. Qualitative And Quantitative Composition
L-carnitine inner salt 1 g
3. Pharmaceutical Form
A clear, colourless or light straw- coloured solution
4. Clinical Particulars
4.1 Therapeutic Indications
Indicated for the treatment of primary and secondary carnitine deficiency in adults, children, infants and neonates.
Secondary carnitine deficiency in haemodialysis patients.
Secondary carnitine deficiency should be suspected in long-term haemodialysis patients who have the following conditions:
1. Severe and persistent muscle cramps and/or hypotensive episodes during dialysis.
2. Lack of energy causing a significant negative effect on the quality of life.
3. Skeletal muscle weakness and/or myopathy.
4. Cardiomyopathy.
5. Anaemia of uraemia unresponsive to or requiring large doses of erythropoietin.
6. Muscle mass loss caused by malnutrition.
4.2 Posology And Method Of Administration
For slow intravenous administration over 2-3 minutes
Adults, Children, infants and neonates
It is advisable to monitor therapy by measuring free and acyl carnitine levels in both plasma and urine.
The management of inborn errors of metabolism:
The dosage required depends upon the specific inborn error of metabolism concerned and the severity of presentation at the time of treatment. However, the following can be considered as a general guide.
In acute decompensation, dosages of up to 100 mg/kg/day in 3-4 divided doses are recommended. Higher doses have been used although an increase in adverse events, primarily diarrhoea, may occur.
Secondary carnitine deficiency in haemodialysis patients:
It is strongly recommended that, before initiating therapy with Carnitor, plasma carnitine is measured. Secondary carnitine deficiency is suggested by a plasma ratio of acyl to free carnitine of greater than 0.4 and/or when free carnitine concentrations are lower than 20 μmol/litre.
A dose of 20mg per kg should be administered as an intravenous bolus at the end of each dialysis session (assuming three sessions per week). The duration of intravenous treatment should be at least three months, which is the time usually required to restore normal muscle levels of free carnitine. The overall response should be assessed by monitoring plasma acyl to free carnitine levels and by evaluating the patient's symptoms. When carnitine supplementation has been stopped there will be a progressive decline in carnitine levels. The need for a repeat course of therapy can be assessed by plasma carnitine assays at regular intervals and by monitoring the patient's symptoms.
Haemodialysis - maintenance therapy:
If significant clinical benefit has been gained by the first course of intravenous Carnitor then maintenance therapy can be considered using 1 g per day of Carnitor orally. On the day of the dialysis, oral Carnitor has to be administered at the end of the session.
4.3 Contraindications
Hypersensitivity to any of the constituents of the product.
4.4 Special Warnings And Precautions For Use
While improving glucose utilisation, the administration of L-carnitine to diabetic patients receiving either insulin or hypoglycaemic oral treatment may result in hypoglycaemia. Plasma glucose levels in these subjects must be monitored regularly in order to adjust the hypoglycaemic treatment immediately, if required.
The safety and efficacy of oral L-carnitine has not been evaluated in patients with renal insufficiency. Chronic administration of high doses of oral L-carnitine in patients with severely compromised renal function or in end stage renal disease (ESRD) patients on dialysis may result in an accumulation of the potentially toxic metabolites, trimethylamine (TMA) and trimethylamine-N-oxide (TMAO), since these metabolites are usually excreted in the urine. This situation has not been observed following intravenous administration of L-carnitine.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
There are no known interactions.
4.6 Pregnancy And Lactation
Reproductive studies were performed in rats and rabbits. There was no evidence of a teratogenic effect in either species. In the rabbit but not in the rat, there was a statistically insignificant greater number of post implantation losses at the highest dose tested (600 mg/kg daily) as compared with control animals. The significance of these findings for man is unknown. There is no experience of use in pregnant patients with primary systemic carnitine deficiency.
Taking into account the serious consequences to a pregnant woman who has primary systemic carnitine deficiency stopping treatment, the risk to the mother of discontinuing treatment seems greater than the theoretical risk to the foetus if treatment is continued.
Levocarnitine is a normal component of human milk. Use of levocarnitine supplementation in nursing mothers has not been studied.
4.7 Effects On Ability To Drive And Use Machines
None known.
4.8 Undesirable Effects
Various mild gastro-intestinal complaints have been reported during the long-term administration of oral levocarnitine, these include transient nausea and vomiting, abdominal cramps and diarrhoea.
Decreasing the dosage often diminishes or eliminates drug-related patient body odour or gastro-intestinal symptoms when present. Tolerance should be monitored very closely during the first week of administration and after any dosage increase.
4.9 Overdose
There have been no reports of toxicity from levocarnitine overdosage. Overdosage should be treated with supportive care.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
ATC Code: A16AA01 (Amino acids and derivatives)
L-Carnitine is present as a natural constituent in animal tissues, micro-organisms and plants. In man the physiological metabolic requirements are met both by the consumption of food containing carnitine and the endogenous synthesis in the liver and kidneys from lysine with methionine serving as the methyl donor. Only the L-isomer is biologically active, playing an essential role in lipid metabolism as well as in the metabolism of ketone bodies as branched chain-amino-acids. L-Carnitine as a factor is necessary in the transport of long-chain fatty acids into the mitochondria – facilitating the oxidation of fatty acids rather than their incorporation into triglycerides. By releasing CoA from its thioesters, through the action of CoA; carnitine acetyl transferase, L-carnitine also enhances the metabolic flux in the Kreb's cycle; with the same mechanism it stimulates the activity of pyruvate dehydrogenase and in skeletal muscle, the oxidation of branched chain-amino acids. L-Carnitine is thus involved, directly or indirectly in several pathways so that its availability should be an important factor controlling not only the oxidative utilisation of fatty acids and ketone bodies but also that of glucose and some amino acids.
5.2 Pharmacokinetic Properties
The absorbed L-carnitine is transported to various organ systems via the blood. The presence of membrane-bound proteins in several tissues including red blood cells that bind carnitine, suggest that a transport system in the blood and a cellular system for the collective uptake is present in several tissues. Tissue and serum carnitine concentration depends on several metabolic processes, carnitine biosynthesis and dietary contributions, transport into and out of tissues, degradation and excretion may all affect tissue carnitine concentrations.
Absorption
L-Carnitine is absorbed by the mucosal cells of the small intestine and enters the blood stream relatively slowly; the absorption is probably associated with an active transluminal mechanism.
The apparent systemic availability after oral administration is limited (<10%) and variable.
Distribution
Absorbed L-carnitine is transported to various organ systems via the blood; it is thought that a transport system in the blood and a cellular system for selective uptake is involved.
Excretion
L-Carnitine is excreted mainly in the urine and is variable. The excretion is directly proportional to the blood levels.
Metabolism
L-Carnitine is metabolised to a very limited extent.
5.3 Preclinical Safety Data
L-Carnitine is a naturally occurring body substance in human beings, plants and animals. Carnitor products are used to bring the level of L-carnitine in the body up to those found naturally. Appropriate pre-clinical studies have been undertaken and show no signs of toxicity at normal therapeutic doses.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Hydrochloric acid 10%
Water for injection
6.2 Incompatibilities
None known.
6.3 Shelf Life
5 years.
6.4 Special Precautions For Storage
Store below 25oC.
Store in the original carton in order to protect from light.
6.5 Nature And Contents Of Container
Ph.Eur. Type 1 clear glass ampoules of 5 ml capacity.
The ampoules are packed in cardboard outer cartons containing 5 ampoules.
6.6 Special Precautions For Disposal And Other Handling
None.
7. Marketing Authorisation Holder
Sigma-Tau Industrie Farmaceutiche Riunite SpA,
Viale Shakespeare 47-00144,
Rome, Italy.
8. Marketing Authorisation Number(S)
PL 08381/0003
9. Date Of First Authorisation/Renewal Of The Authorisation
30 November 1999
10. Date Of Revision Of The Text
November 2008
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