Consumer medicine information

Paracetamol IV Pfizer

Paracetamol

BRAND INFORMATION

Brand name

Paracetamol IV Pfizer

Active ingredient

Paracetamol

Schedule

What is in this leaflet

This leaflet answers some common questions about Paracetamol IV Pfizer.

It does not contain all the available information. It does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of giving you Paracetamol IV Pfizer against the benefits it is expected to have for you.

If you have any concerns about taking this medicine, ask your doctor or pharmacist.

Keep this leaflet. You may need to read it again.

What PARACETAMOL IV PFIZER is used for

What PARACETAMOL IV PFIZER does

Paracetamol IV Pfizer is used to relieve pain or reduce fever following surgery.

This medicine belongs to a group of medicines called analgesics.

Ask your doctor if you have any concerns about why this medicine has been prescribed for you. Your doctor may have prescribed it for another reason.

This medicine is available only with a doctor's prescription.

Before you are given PARACETAMOL IV PFIZER

When you must not be given PARACETAMOL IV PFIZER

You must not be given Paracetamol IV Pfizer if you have an allergy to paracetamol or to any of the ingredients listed at the end of this leaflet.

Symptoms of an allergic reaction to Paracetamol IV Pfizer may include:

shortness of breath
wheezing or difficulty breathing.
swelling of the face, lips, tongue or other parts of the body
rash, itching or hives on the skin

You must not be given Paracetamol IV Pfizer if you have or have had the following medical conditions:

liver failure
severe liver disease.

If you are not sure whether you should be given Paracetamol IV Pfizer, talk to your doctor.

Before you are given PARACETAMOL IV PFIZER

Tell your doctor if you have allergies to any other medicines, foods, preservatives or dyes.

Tell your doctor if you have or have had any of the following medical conditions:

liver disease (including Gilbert's syndrome)
kidney disease
alcoholism
dehydration
eating disorders (anorexia, bulimia)
a wasting syndrome including unexplained weight loss, fatigue, weakness and loss of appetite (cachexia)
malnutrition (low reserves of glutathione)
a metabolic condition called glucose-6-phosphate dehydrogenase deficiency (G6PD)
hypovolaemia (decreased blood volume).

Tell your doctor if you are pregnant (especially if you are in the third trimester of pregnancy) or plan to become pregnant or are breast-feeding. Your doctor can discuss with you the risks and benefits involved.

If you have not told your doctor about any of the above, tell him/her before you are given Paracetamol IV Pfizer.

Taking other medicines

Tell your doctor or pharmacist if you are taking any other medicines, including:

all prescription medicines
all medicines, vitamins, herbal supplements or natural therapies you buy without a prescription from a pharmacy, supermarket, naturopath or health food shop.

Some medicines may be affected by Paracetamol IV Pfizer or may affect how well it works. You may need different amounts of your medicines, or you may need to take different medicines. Your doctor will advise you.

Tell your doctor or pharmacist if you drink alcohol. Your doctor may advise you to avoid alcohol as it may interfere with Paracetamol IV Pfizer.

Tell your doctor or pharmacist if you are taking any of the following:

Pro-Cid (probenecid) - a medicine used to treat gout, or that is given with antibiotics
Anticonvulsants - medicines used to treat epilepsy or fits - such as Dilantin (phenytoin), Tegretol or Teril (carbamazepine)
Other forms of paracetamol, such as tablets, liquid preparations or capsules
Myleron or Busulfex (busulfan), an anti-cancer drug
Dolobid (diflunisal), an anti-inflammatory drug
Barbiturates (such as amytal sodium or phenobarbitone)
Retrovir (zidovudine) - an anti-HIV drug, or other drugs containing zidovudine
Anti-coagulants, which are used to stop the blood from clotting (including warfarin)
Isoniazid (isoniazid), an anti-tuberculosis drug
Antibiotics containing amoxicillin plus clavulanic acid (such as Clamoxyl or Clavulan) or flucloxacillin.

Your doctor and pharmacist have more information on medicines to be careful with or avoid while receiving Paracetamol IV Pfizer.

How PARACETAMOL IV PFIZER is given

Follow all directions given to you by your doctor or pharmacist carefully. They may differ from the information contained in this leaflet.

How much is given

Your doctor will decide what dose you will be given, and for how long you will be given Paracetamol IV Pfizer. Tell your doctor if you have been taking other forms of paracetamol (eg. tablets, capsules, liquid preparations) and the quantity that you have been taking.

How it is given

Paracetamol IV Pfizer is given as a slow infusion (drip) into a vein.

Paracetamol IV Pfizer must only be given by a doctor or nurse.

If you take too much (overdose)

Your doctor has information on how to recognise and treat an overdose. Ask your doctor or nurse if you have any concerns.

Adults: keep to the recommended dose. Don't take this medicine for longer than a few days at a time unless advised to by a doctor.

Children and adolescents: keep to the recommended dose. Do not give this medicine for longer than 48 hours at a time unless advised to by a doctor.

If an overdose is taken or suspected, ring the Poisons Information Centre 131 126) or go to a hospital straightaway even if you feel well because of the risk of delayed, serious liver damage and abnormal blood pigment levels.

Do not take with other products containing paracetamol, unless advised to do so by a doctor or pharmacist.

While you are being given PARACETAMOL IV PFIZER

Things you must do

If you are about to be started on any new medicine, remind your doctor and pharmacist that you are being given Paracetamol IV Pfizer.

Tell any other doctors, dentists, and pharmacists who treat you that you are being given Paracetamol IV Pfizer.

Tell your doctor immediately if you develop a rash or other symptom of an allergic reaction.

These symptoms may be:

shortness of breath
wheezing or difficulty breathing
swelling of the face, lips, tongue or other parts of the body
rash, itching or hives on the skin

Side effects

Tell your doctor or pharmacist as soon as possible if you do not feel well while you are being given Paracetamol IV Pfizer.

All medicines can have side effects. Sometimes they are serious, most of the time they are not. You may need medical attention if you get some of the side effects.

It can be difficult to tell whether side effects are the result of being given Paracetamol IV Pfizer, effects of your condition or side effects of other medicines you may be taking. For this reason, it is important to tell your doctor of any change in your condition.

Do not be alarmed by the list of side effects. You may not experience any of them.

Ask your doctor or pharmacist to answer any questions you may have.

Tell your doctor if...

Tell your doctor or pharmacist if you notice any of the following and they worry you:

feeling unwell
dizziness, light-headedness
bleeding or bruising more easily than normal
vomiting, nausea
constipation

The above list includes rare side effects of your medicine. They are usually mild.

Tell your doctor as soon as possible if...

Tell your doctor as soon as possible if you notice any of the following:

allergic reaction - shortness of breath, wheezing or difficulty breathing, swelling of the face, lips, tongue or other parts of the body, rash, itching or hives on the skin.

The above list includes serious side effects that may require medical attention.

Tell your doctor or pharmacist if you notice anything else that is making you feel unwell. Other side effects not listed above may also occur in some people.

After being given PARACETAMOL IV PFIZER

Storage

Keep Paracetamol IV Pfizer stored in the pharmacy or on the ward. The injection should be kept in a cool dry place, protected from light, where the temperature stays below 25°C.

Do not refrigerate.

If diluted in 0.9% Sodium Chloride or 5 % Glucose, the solution should be used immediately. However, if the solution is not used immediately, do not store for more than one hour (infusion time included).

Product description

What it looks like

PARACETAMOL IV PFIZER is a colourless or faintly straw-brown coloured solution. It is supplied in PVC bags containing 50 mL* or 100 mL of paracetamol solution for infusion. Each bag is sealed in a metallised over-pouch and supplied to hospitals in packs of 12s.

*Not currently marketed in Australia

Ingredients

One 50 mL bag of Paracetamol IV Pfizer contains 500 mg paracetamol and one 100 mL bag contains 1 g of paracetamol.

It also contains:

glucose
glacial acetic acid
sodium acetate trihydrate
sodium citrate
sodium hydroxide/hydrochloric acid (for pH adjustment)
water for injections

This medicine does not contain lactose, sucrose, gluten, tartrazine or any other azo dyes.

Supplier

Pfizer Australia Pty Ltd
SYDNEY, NSW
Toll Free number: 1800 675 229
www.pfizer.com.au

Australian registration numbers

500 mg/50 mL: AUST R 193210

1000 mg/100 mL: AUST R 193213

Date of preparation

This leaflet was prepared in February 2020.

® = Registered Trademark

Published by MIMS April 2020

BRAND INFORMATION

Brand name

Paracetamol IV Pfizer

Active ingredient

Paracetamol

Schedule

1 Name of Medicine

Paracetamol.

6.7 Physicochemical Properties

Chemical structure.

Chemical name: 4-acetamidophenol. Molecular weight: 151.2.

CAS number.

103-90-2.

2 Qualitative and Quantitative Composition

Each mL of Paracetamol IV Pfizer contains paracetamol 10 mg.
Paracetamol is a white crystalline solid or powder. It is soluble in water (1 in 70), soluble in alcohol (1 in 7), acetone (1 in 13), glycerol (1 in 40), propylene glycol (1 in 9) and also soluble in solutions of the alkali hydroxides.
For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Solution for infusion.
Paracetamol IV Pfizer is a colourless or faintly straw-brown coloured solution.
Paracetamol IV Pfizer contains 10 mg/mL of paracetamol (50 mL bag contains 500 mg of paracetamol; 100 mL bag contains 1 g of paracetamol).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of action.

The precise mechanism of the analgesic and antipyretic properties of paracetamol has yet to be established; it may involve central and peripheral actions.
Paracetamol IV Pfizer provides onset of pain relief within 5 to 10 minutes after the start of administration. The peak analgesic effect is obtained in 1 hour and the duration of this effect is usually 4 to 6 hours.
Paracetamol IV Pfizer reduces fever within 30 minutes after the start of administration with a duration of the antipyretic effect of at least 6 hours.

Clinical trials.

Clinical trials were performed with two different formulations of paracetamol, paracetamol solution for infusion and propacetamol. Propacetamol 2 g is equivalent to paracetamol solution for infusion 1 g. See Section 4.2 Dose and Method of Administration for the correct dosing instructions for Paracetamol IV Pfizer.

Analgesia.

Adults.

Two phase III studies were conducted to compare the safety and analgesic efficacy of IV paracetamol and propacetamol in 303 adults. Two accepted acute pain models, i.e. orthopaedic surgery pain and oral surgery pain were used to evaluate analgesic efficacy.
All the studies presented were phase III, randomised, double blind, active and/or placebo controlled. The studies were well conducted according to the GCP guidelines with ethics approval. Treatment compliance was good in all the studies.

Efficacy of IV paracetamol for the treatment of postoperative pain following orthopaedic surgery.

One hundred and fifty one patients were included in this study; 49 patients were administered paracetamol solution for infusion 1 g and 52 patients placebo. The groups of patients were comparable with regard to demographic and baseline characteristics. One hundred and thirty seven (90.7%) of patients received 4 administrations over 24 hours, 2 (1.3%) patients received 3; 2 (1.3%) patients received 2 and 10 (6.6%) patients received only 1 administration.
The primary measured efficacy endpoint parameter of the trial was the evaluation of paracetamol solution for infusion 1 g versus placebo after single dose pain relief scores pain intensity difference (PID), pain relief intensity difference (PRID), maximum pain relief (maxPR), maximum pain intensity difference (maxPID), sum of the pain intensity difference (SPID), total pain relief (TOTPAR), time to peak effects and time to first rescue medication; numbers and proportion of patients requiring rescue medication (patient controlled analgesia (PCA)-morphine); patients global evaluation (PGA).The secondary measured efficacy endpoint parameter was paracetamol solution for infusion 1 g versus placebo after repeated doses.
An overview of the results is shown in Tables 6 and 7.

Efficacy of IV paracetamol for the treatment of postoperative pain following oral (postdental) surgery.

One hundred and fifty two patients were included in this study; 51 patients were administered paracetamol solution for infusion 1 g and 50 patients placebo. The groups of patients were comparable with regard to demographic and baseline characteristics.
The primary measured efficacy endpoint parameter of the trial was the evaluation of paracetamol solution for infusion 1 g versus placebo after single dose pain relief scores (PID, PRID, maxPR, maxPID, SPID, TOTPAR, time to peak effects and time to first rescue medication; numbers and proportion of patients requiring rescue medication (PCA-morphine); patients global evaluation (PGA).The secondary measured efficacy endpoint parameter was paracetamol solution for infusion 1 g versus placebo after repeated doses.
An overview of the results is shown in Table 8.

Analgesia.

Children.

Efficacy of IV paracetamol with postoperative pain (hernia repair).

One hundred and eighty three patients were included in this study, of which 95 patients were administered paracetamol solution for infusion 15 mg/kg. The groups of patients were comparable with regard to demographic and baseline characteristics.
The primary measured efficacy endpoint parameter of the trial was the evaluation of pain intensity difference (PID) on visual analogue scale (VAS) (investigator rated) at 15, 30 minutes, 1, 2, 3, 4, 5 and 6 hours postdose. The secondary measured efficacy endpoint parameter for the trial was PID on the objective pain scale (OPS), pain relief rated by the investigator, SPID-OPS, SPID-VAS, TOTPAR, number of children with VAS score ≤ 15 mm, investigators global evaluation, time to remedication, changes from baseline in heart rate (HR), systolic blood pressure (SBP) and diastolic blood pressure (DBP).
An overview of the results is shown in Tables 9 and 10.

Antipyrexia.

Propacetamol is a different formulation than paracetamol solution for infusion, which delivers 1 g of paracetamol for every 2 g of propacetamol administered.

Antipyretic efficacy and safety of a single administration of 30 mg/kg of intravenous propacetamol in children (age 3 to 12 years) with acute fever of infectious origin.

Forty one children with acute fever (ear temperature between 38.5°C to 41°C) of infectious origin. The groups of patients were comparable with regard to demographic and baseline characteristics.
The primary measured efficacy endpoint parameter of the trial was to evaluate the antipyretic efficacy of a single intravenous dose of 30 mg/kg of propacetamol (equivalent to 15 mg/kg paracetamol solution for infusion) in comparison with placebo in children with acute fever of infectious origin (changes in body temperature (BT) from 0.5 hours to 6 hours postdose).
The secondary measured efficacy endpoint parameter was the evaluation of the percentage of body temperature reduction from baseline at each evaluation time; weighted sum of changes in body temperature over the T0-T4 and T0-T6 periods; weighted sum of percentages of body temperature reduction over the T0-T4 and T0-T6 periods; time to reach body temperature below 38°C over the T0-T6 period; number and percentage of children with a BT below 38°C over the T0-T6 period; maximum value of changes in body temperature and time to occurrence after T0; vital signs (respiratory rate, heart rate, arterial blood pressure): changes over time after dosing; investigator's global evaluation; time to remedication (with calculation of time at which 50% of children require remedication) over the T0-T6 period; number and percentage of children requiring rescue medication over the T0-T6 period; safety: vital signs and adverse events.
An overview of the results is shown in Tables 11 and 12.

5.2 Pharmacokinetic Properties

Adults.

Absorption.

Paracetamol pharmacokinetics are linear after a single administration of up to 2 g and after repeated administration during 24 hours.
The bioavailability of paracetamol following infusion of 1 g of paracetamol solution for infusion 10 mg/mL is similar to that observed following infusion of 2 g propacetamol (containing 1 g paracetamol). For both these products, peak plasma concentration is obtained as and from the end of infusion. The maximum plasma concentration (C_max) of paracetamol observed following intravenous infusion of 1 g paracetamol solution for infusion 10 mg/mL is about 30 microgram/mL. About 15 minutes is required to obtain the maximal plasma concentration (T_max).
The bioavailability of paracetamol following infusion of 500 mg of paracetamol 10 mg/mL solution for infusion is similar to that observed following infusion of 1 g propacetamol (containing 500 mg paracetamol). The maximum plasma concentration (C_max) of paracetamol observed at the end of 15 minutes intravenous infusion of 500 mg of paracetamol10 mg/mL solution for infusion is about 15 microgram/mL.
The pharmacokinetics of oral paracetamol (500 mg) and intravenous propacetamol (1 g) were compared in a randomised, double blind, 2 period crossover study in 12 healthy male subjects. As expected, plasma concentrations of intravenous propacetamol were significantly higher and obtained earlier, compared to oral administration, however after the first hour and up to 24 hours the plasma concentrations remained similar. See Figure 1 and Table 13.

Distribution.

The volume of distribution of paracetamol is approximately 1 L/kg.
Paracetamol is not extensively bound to plasma proteins.
Following infusion of 2 g propacetamol, (equivalent to 1 g of paracetamol) significant concentrations of paracetamol (about 1.5 microgram/mL) were observed in the cerebrospinal fluid 20 minutes after infusion.

Metabolism.

Paracetamol is metabolised mainly in the liver following two major hepatic pathways: glucuronic acid conjugation and sulphuric acid conjugation. The latter route is rapidly saturable at doses that exceed the therapeutic doses. A small fraction (less than 4%) is metabolised by cytochrome P450 to a reactive intermediate (N-acetyl benzoquinone imine) which, under normal conditions of use, is rapidly detoxified by reduced glutathione and eliminated in the urine after conjugation with cysteine and mercapturic acid. However, during massive poisoning, the quantity of this toxic metabolite is increased.
At therapeutic doses, CYP3A4, the major isoform of P450 in human liver, contributes to the production of the cytotoxic metabolite. For very high, supratherapeutic plasma concentrations (1500 mg/L) of paracetamol, the 2E1 and 1A2 isoforms may also be involved.

Excretion.

The metabolites of paracetamol are mainly excreted in the urine. 90% of the dose administered is excreted in 24 hours, mainly as glucuronide (60-80%) and sulphate (20-30%) conjugates. Less than 5% is eliminated unchanged. Plasma half-life is 2.7 hours and total body clearance is 18 L/h.

Special populations.

Neonates and infants < 6 months of age.

Clinical trials examining the pharmacokinetics of paracetamol solution for infusion in neonates and infants < 6 months of age are limited. The safety and efficacy of paracetamol solution for infusion in premature neonates has not been established. In a trial of 12 children between 1 and 232 days of age, which included 5 children less than 10 days of age the pharmacokinetic results for paracetamol solution for infusion were as shown in Figure 2 and Table 14.

The infants in the study were aged between 1 and 232 days; mean 88 ± 95 days. In the neonates aged less than 10 days, the gestational age was 37.4 ± 3.9 weeks (32 to 41.3 weeks). The weight of the neonates at the time of the study was 2.578 ± 0.959 kg (1 to 3.8); birth weight was 2.578 ± 1.022 kg (1 to 3.920 kg). The mean administered dose was 15.3 ± 2 mg/kg (13.40 to 20 mg/kg).
In neonates, the plasma half-life is longer than in infants, i.e. around 3.5 hours. Neonates and, infants excrete significantly less glucuronide and more sulphate conjugates than adults. The potential effect of immaturity in metabolic and elimination pathways of paracetamol should be considered when administering paracetamol to neonates and children < 6 months of age.

Infants and children (> 6 months of age).

The pharmacokinetic parameters of paracetamol observed in infants and children are similar to those observed in adults, except for the plasma half-life that is slightly shorter (1.5 to 2 h) than in adults.

Elderly (> 65 years).

There was a significant increase in AUC and reduction in clearance of paracetamol and its metabolites in elderly subjects. However, these statistically significant differences could be considered as not clinically relevant during short-term infusions. Hence, no dose adjustment is required in this population.

Renal impairment.

Paracetamol should be administered with caution to patients with renal impairment. In cases of severe renal impairment (creatinine clearance ≤ 30 mL/min), the elimination of paracetamol is slightly delayed, the elimination half-life ranging from 2 to 5.3 hours. For the glucuronide and sulphate conjugates, the elimination rate is 3 times slower in subjects with severe renal impairment than in healthy subjects. It is recommended that there be an interval of at least 6 hours between administrations in patients with severe renal impairment (creatinine clearance ≤ 30 mL/min) (see Section 4.2 Dose and Method of Administration).

Hepatic impairment.

Paracetamol should be administered with caution to patients with hepatic impairment (see Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use). Hepatic impairment may decrease the clearance of paracetamol or increase the probability of hepatic toxicity.

5.3 Preclinical Safety Data

Genotoxicity.

Paracetamol was not mutagenic in the bacterial mutagenicity assay, but it was clastogenic in mammalian cell assay systems in vitro (mouse TK, human lymphocyte) and in a mouse micronucleus assay in vivo. The clastogenic effect was dose dependent, and the mechanism appears to involve inhibition of replicative DNA synthesis and ribonucleotide reductase at above threshold doses. The clinical significance of clastogenic findings is equivocal as positive findings in vivo only occurred at exposures (approximately 8 times the maximum anticipated clinical exposure, based on C_max) greater than that for hepatotoxicity, and at doses that were associated with significant cytotoxicity.

Carcinogenicity.

No evidence of carcinogenic potential was observed for paracetamol in long-term oral studies in mice (up to 3000 mg/m²/day, similar to human exposure) and male rats (up to 1800 mg/m²/day, 0.7 times human exposure). Equivocal evidence of carcinogenic potential (mononuclear cell leukaemia) was observed only in female rats at 1900 mg/m²/day, or 0.7 times the maximum anticipated clinical exposure on a mg/m² basis.

4 Clinical Particulars

4.1 Therapeutic Indications

Paracetamol IV Pfizer is indicated for the relief of mild to moderate pain and the reduction of fever where an intravenous route of administration is considered clinically necessary.

4.3 Contraindications

Paracetamol IV Pfizer is contraindicated:
in cases of hypersensitivity to paracetamol or to propacetamol hydrochloride (prodrug of paracetamol) or to any of the excipients;
in cases of severe hepatocellular insufficiency;
in patients with hepatic failure or decompensated active liver disease.
It is recommended to use a suitable analgesic oral treatment as soon as this administration route is possible.
In order to avoid the risk of overdose; check that other medicines administered do not contain paracetamol.
Doses higher than the recommended entail a risk of very serious liver damage. Clinical symptoms and signs of liver damage are usually seen first after two days, and reach a maximum usually after 4 to 6 days. Treatment with antidote should be given as soon as possible (see Section 4.2 Dose and Method of Administration).

4.4 Special Warnings and Precautions for Use

Paracetamol IV Pfizer should be used with caution in cases of:
hepatic insufficiency (see Use in hepatic impairment);
renal insufficiency (see Use in renal impairment);
Glucose 6 Phosphate Dehydrogenase (G6PD) deficiency (may lead to haemolytic anaemia);
chronic alcoholism, excessive alcohol intake (3 or more alcoholic drinks every day);
anorexia, bulimia or cachexia; chronic malnutrition (low reserves of hepatic glutathione).
dehydration, hypovolemia (see Section 4.2 Dose and Method of Administration; Section 5.2 Pharmacokinetic Properties).
The total dose of paracetamol should not exceed 4 g per day for patients weighing 50 kg or more, 60 mg/kg for patients weighing 50 kg or less and more than 33 kg (without exceeding 3 g), 60 mg/kg for patients weighing 33 kg or less and more than 10 kg (without exceeding 2 g) and 30 mg/kg for patients weighing 10 kg or less. It is important to consider the contribution of all paracetamol containing medications, including nonprescription, oral or PR forms of the drug to this total daily paracetamol dose prior to administering Paracetamol IV Pfizer. If the daily dose of paracetamol from all sources exceeds the maximum, severe hepatic injury may occur (see Section 4.9 Overdose).
Paracetamol can cause serious skin reactions such as acute generalised exanthematous pustulosis (AGEP), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN), which can be fatal. Patients should be informed about the signs of serious skin reactions, and use of the drug should be discontinued at the first appearance of skin rash or any other sign of hypersensitivity.

High anion gap metabolic acidosis.

Caution is advised when paracetamol is administered concomitantly with flucloxacillin due to the increased risk of high anion gap metabolic acidosis (HAGMA). Patients at high risk for HAGMA are in particular those with severe renal impairment, sepsis or malnutrition especially if the maximum daily doses of paracetamol are used.
After co-administration of flucloxacillin and paracetamol, close monitoring is recommended in order to detect the appearance of acid-base disorders, namely HAGMA, including testing of urinary 5-oxoproline.

Use in hepatic impairment.

Patients with hepatic insufficiency, chronic alcoholism, chronic malnutrition or dehydration may be at a higher risk of liver damage following administration of Paracetamol IV Pfizer.
Paracetamol IV Pfizer should be used with caution in cases of hepatocellular insufficiency, including Gilbert's syndrome (familial hyperbilirubinaemia).
See Section 4.3 Contraindications.

Use in renal impairment.

Paracetamol IV Pfizer should be used with caution in cases of severe renal insufficiency (creatinine clearance ≤ 30 mL/min).

Use in the elderly.

See Section 5.2 Pharmacokinetic Properties.

Paediatric use.

The safety and efficacy of paracetamol solution for infusion in premature neonates has not been established. There is limited data on the use of Paracetamol IV Pfizer in neonates and infants < 6 months of age (see Section 4.2 Dose and Method of Administration; Section 5.2 Pharmacokinetic Properties).

Effects on laboratory tests.

No data available.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Probenecid causes an almost 2-fold reduction in clearance of paracetamol by inhibiting its conjugation with glucuronic acid. A reduction of the paracetamol dose should be considered for concomitant treatment with probenecid.
Caution should be paid to the concomitant intake of enzyme inducing agents. These substances include but are not limited to: barbiturates, isoniazid, anticoagulants, zidovudine, amoxicillin + clavulanic acid, carbamazepine and ethanol. Induction of metabolism of paracetamol from enzyme inducers may result in an increased level of hepatotoxic metabolites.
Concomitant use of paracetamol (4 g per day for at least 4 days) with oral coumarin anticoagulants including warfarin may lead to slight variations of INR values. In this case, increased monitoring of INR values should be conducted during the period of concomitant use as well as for one week after paracetamol treatment has been discontinued.
Phenytoin administered concomitantly may result in decreased paracetamol effectiveness and an increased risk of hepatotoxicity. Patients receiving phenytoin therapy should avoid large and/or chronic doses of paracetamol. Patients should be monitored for evidence of hepatotoxicity.

Busulfan.

Busulfan is eliminated from the body via conjugation with glutathione. Concomitant use with paracetamol may result in reduced busulfan clearance.

Diflunisal.

Concomitant diflunisal increases paracetamol plasma concentrations and this may increase hepatotoxicity.
Caution should be taken when paracetamol is used concomitantly with flucloxacillin as concurrent intake has been associated with high anion gap metabolic acidosis, especially in patients with risk factors.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

Intravenous paracetamol (administered as propacetamol) had no effect on fertility of rats at systemic exposure levels (based on AUC) greater than twice those anticipated at the maximum clinical dose.
(Category A)
Paracetamol has been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed.
The reproductive toxicity of IV Paracetamol IV Pfizer has not been directly tested in animal studies. IV administration of maternotoxic doses of the prodrug, propacetamol, to pregnant rats and rabbits during organogenesis increased the incidence of extranumerary ribs and sacral vertebrae (normal variations in these species) at 0.7-fold (rabbits; mg/m² basis) and 7-fold (rats; AUC basis) the maximum anticipated clinical exposure to paracetamol. The clinical significance of these findings is not known. No signs of pre/postnatal toxicity were observed in rats treated with IV propacetamol at maternal exposures (based on AUC) greater than 3-fold those anticipated at the maximum clinical dose.
Premature constriction/closure of the fetal ductus arteriosus has been reported following in utero exposure to paracetamol. In most of these reports, exposure to paracetamol occurred during the third trimester of pregnancy.
Nevertheless, Paracetamol IV Pfizer should only be used during pregnancy after a careful benefit risk assessment. In pregnant patients, the recommended posology and duration must be strictly observed.
After oral administration, paracetamol is excreted into breast milk in small quantities. Rash in nursing infants has been reported. No signs of toxicity were observed in rat pups of dams that received IV propacetamol postpartum at maternal exposures (based on AUC) greater than twice those anticipated at the maximum clinical dose. Paracetamol IV Pfizer may be used in breastfeeding women, but caution should be observed.

4.8 Adverse Effects (Undesirable Effects)

The overall incidence of adverse events in paracetamol solution for infusion treated patients compared to placebo within the clinical trial set; can be observed in Table 2 and 3.
As with all paracetamol products, adverse drug reactions are rare (> 1/10000, < 1/1000) or very rare (< 1/10000), they are described in Table 4.

Postmarketing adverse events for propacetamol/paracetamol.

The following adverse events have also been reported during postmarketing surveillance, but incidence rate (frequency) is not known. See Table 5.

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration 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 at www.tga.gov.au/reporting-problems.

4.2 Dose and Method of Administration

Dosage.

Dosing is based on patient weight. Dosing recommendations are presented in Table 1.

The prescribed dose must be based on the patient's weight.
Unintentional overdose can lead to serious liver damage and death (see Section 4.9 Overdose). Healthcare providers are reminded that it is essential to follow both the weight related dose recommendations and to consider individual patient risk factors for hepatotoxicity including hepatocellular insufficiency, chronic alcoholism, chronic malnutrition (low reserves of hepatic glutathione), and dehydration (see Section 4.2 Dose and Method of Administration, Hepatic impairment).
It is recommended that a suitable oral analgesic treatment be substituted for paracetamol as soon as the patient can be treated by oral route (see Section 4.3 Contraindications).

Method of administration.

Intravenous route.

Use of the 100 mL bag is restricted to adults, adolescents and children weighing more than 33 kg.
Paracetamol IV Pfizer should not be mixed with other medicinal products.
Before administration, the product should be visually inspected for any particulate matter and discoloration.
The paracetamol solution is administered as a 15-minute intravenous infusion; it contains no antimicrobial agent, and is for single use in one patient only. The product should be used immediately after opening and any unused solution should be discarded.
Paracetamol IV Pfizer can also be diluted in a 0.9% sodium chloride or 5% glucose solution up to one tenth. In this case, use the diluted solution within the hour following its preparation (infusion time included).
As for all solutions for infusion, it should be remembered that close monitoring is needed notably at the end of the infusion, regardless of the administration route. This monitoring at the end of the perfusion applies particularly for central route infusion, in order to avoid air embolism.
It is recommended that for the administration of Paracetamol IV Pfizer a syringe or giving set with a diameter equal to or below 0.8 mm should be used for solution sampling. In addition, it is recommended that the bung is pierced at the location specifically designed for needle introduction (where the thickness of the bung is the lowest). If these recommendations are not adhered to the likelihood of bung fragmentation or the bung being forced into the vial is increased.

Dosage adjustment.

Hepatic impairment.

In patients with impaired hepatic function, the dose must be reduced or the dosing interval prolonged. The maximum daily dose should not exceed 60 mg/kg/day (not exceeding 2 g/day) in the following situations:
adults weighing less than 50 kg;
chronic or compensated active hepatic disease, especially those with mild to moderate hepatocellular insufficiency;
Gilbert's syndrome (familial hyperbilirubinaemia);
chronic malnutrition (low reserves of hepatic glutathione);
dehydration.

Paediatric patients.

Paracetamol IV Pfizer should not be hung as an infusion due to the small volume of the product to be administered in the paediatric population.
To avoid dosing errors in neonates and infants (≤ 10 kg) and confusion between milligrams (mg) and millilitres (mL), it is recommended to specify the intended volume for administration in millilitres (mL). The volume of Paracetamol IV Pfizer (10 mg/mL) administered should never exceed 7.5 mL per dose in this weight group. In neonates and infants (≤ 10 kg), very small volumes will be required. A 5 mL or 10 mL syringe should be used to measure the dose as appropriate for the weight of the child and the desired volume.
For paediatric dosing, the 50 mL bag of Paracetamol IV Pfizer can be diluted using either a 0.9% sodium chloride solution or a 5% glucose solution up to one-tenth dilution (one volume paracetamol injection into nine volumes diluent). The diluted solution must be used within one hour following its preparation (infusion time included).

4.7 Effects on Ability to Drive and Use Machines

The effects of this medicine on a person's ability to drive and use machines were not assessed as part of its registration.

4.9 Overdose

There is a risk of poisoning, particularly in elderly subjects, in young children, in patients with liver disease, in cases of chronic alcoholism, in patients with chronic malnutrition and in patients receiving enzyme inducers. Poisoning may be fatal in these cases. Acute overdose with paracetamol may also lead to acute renal tubular necrosis.
Symptoms generally appear within the first 24 hours and comprise of nausea, vomiting, anorexia, pallor and abdominal pain. Overdose, 7.5 g or more of paracetamol in a single administration in adults or 140 mg/kg of bodyweight in a single administration in children, causes cytolytic hepatitis likely to induce complete and irreversible hepatic necrosis, resulting in acute or fulminant hepatic failure, hepatocellular insufficiency, metabolic acidosis and encephalopathy which may lead to coma and death.
Simultaneously, increased levels of hepatic transaminases (AST, ALT), lactate dehydrogenase and bilirubin are observed together with decreased prothrombin levels that may appear 12 to 48 hours after administration. Clinical symptoms of liver damage are usually evident initially after two days, and reach a maximum after 4 to 6 days.
The Rumack-Matthews nomogram relates plasma levels of paracetamol and the time after oral ingestion to the predicted severity of liver injury. The relation of parental paracetamol levels in overdose to liver toxicity has not been examined. Advice or treatment protocols based on oral paracetamol overdoses may not accurately predict the incidence of liver toxicity or need for antidote therapy in Paracetamol IV Pfizer overdose.
Methaemoglobinaemia has been reported in cases of paracetamol overdose.

Emergency measures.

Immediate hospitalisation.
Before beginning treatment, take blood for plasma paracetamol assay, as soon as possible after the overdose.
Treatment of paracetamol overdose may include the antidote N-acetyl cysteine (NAC) by the IV or oral route. In overdoses of oral paracetamol NAC is administered, if possible, before 8 hours but may give some degree of protection from liver toxicity even after this time. The optimal time for administration of NAC and necessary duration of therapy have not been established for overdoses of paracetamol solution for infusion.
Symptomatic treatment.
Hepatic tests must be carried out at the beginning of treatment and repeated every 24 hours. In most cases hepatic transaminases return to normal in one to two weeks with full restitution of the liver function. In very severe cases, however, liver transplantation may be necessary.

Adults.

Keep to the recommended dose. Do not take this medicine for longer than a few days at a time unless advised by a doctor.

Children and adolescents.

Keep to the recommended dose. Do not give this medicine for longer than 48 hours at a time unless advised to by a doctor.
If an overdose is taken or suspected, go to a hospital straightaway even if you feel well because of the risk of delayed, serious liver damage.
Do not take with other products containing paracetamol, unless advised to do so by a doctor or pharmacist.
For information on the management of overdose, contact the Poisons Information Centre on 13 11 26 (Australia).

7 Medicine Schedule (Poisons Standard)

S4.

6 Pharmaceutical Particulars

6.1 List of Excipients

Glucose, acetic acid, sodium acetate trihydrate, sodium citrate, sodium hydroxide/ hydrochloric acid, water for injections.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store below 25°C. Do not refrigerate. Protect from light.
If diluted in 0.9% Sodium Chloride or 5% Glucose, the solution should be used immediately. However, if the solution is not used immediately, do not store for more than one hour (infusion time included).

6.5 Nature and Contents of Container

Paracetamol IV Pfizer is available in 50 mL and 100 mL (10 mg/mL) hermetically sealed PVC bags, contained within a metallised triple layer, double lamina outer packaging. They are available, in pack sizes of 12s.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of by taking to your local pharmacy.

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