Amphotericin B Tillomed liposomal 50 mg powder for dispersion for infusion

Amphotericin B Tillomed liposomal is indicated in adults and children aged 1 month to 18 years old for:

• the treatment of severe systemic and/or deep mycoses;

• the treatment of visceral leishmaniasis in immunocompetent patients including both adults and children;

• the empirical treatment of presumed fungal infections in febrile neutropenic patients, where the fever has failed to respond to broad spectrum antibiotics and appropriate investigations have failed to define a bacterial or viral cause.

Infections successfully treated with liposomal amphotericin B include: disseminated candidiasis, aspergillosis, mucormycosis, chronic mycetoma, cryptococcal meningitis and visceral leishmaniasis.

Amphotericin B Tillomed liposomal should not be used to treat the common clinically inapparent forms of fungal disease which show only positive skin or serologic tests.

Non-equivalence of amphotericin products

Different amphotericin products (sodium deoxycholate, liposomal, lipid complex) are not equivalent in terms of pharmacodynamics, pharmacokinetics and dosing and so the products should not be used interchangeably without accounting for these differences. Both the trade name, common name and dose should be verified pre-administration.

There is a risk of under-dose if Amphotericin B Tillomed liposomal is administered at a dose recommended for amphotericin B deoxycholate.

Posology

Administration of a test dose is advisable before a new course of treatment. A small amount of an Amphotericin B Tillomed liposomal infusion (e.g. 1 mg) can be administered for about 10 minutes and then stopped and the patient observed carefully for the next 30 minutes. If there have been no severe allergic or anaphylactic/anaphylactoid reactions the infusion of Amphotericin B Tillomed liposomal dose can be continued.

Treatment of mycoses

Therapy is usually instituted at a daily dose of 1.0 mg/kg of body weight, and increased stepwise to 3.0 mg/kg, as required. Data are presently insufficient to define total dosage requirements and duration of treatment necessary for resolution of mycoses. However, a cumulative dose of 1.0 - 3.0 g of amphotericin B as Amphotericin B Tillomed liposomal over 3 - 4 weeks has been typical. Dosage of amphotericin B as Amphotericin B Tillomed liposomal must be adjusted to the specific requirements of each patient.

Mucormycosis

The recommended starting dose is 5 mg/kg/day. The duration of therapy should be determined on an individual basis. Courses of up to 6 – 8 weeks are commonly used in clinical practice; longer durations of therapy may be required for deep seated infections or in cases of prolonged courses of chemotherapy or neutropenia.

Although doses greater than 5 mg/kg and up to a maximum of 10 mg/kg have been used in clinical trials and clinical practice, data on the safety and efficacy of liposomal amphotericin B for the treatment of mucormycosis at these higher doses are limited. Therefore, a benefit: risk assessment should be made on an individual patient level to determine whether the potential benefits of treatment are considered to outweigh the known increased risk of toxicity at higher Amphotericin B Tillomed liposomal doses (see section 4.4).

Treatment of visceral leishmaniasis

A total dose of 21.0 - 30.0 mg/kg of body weight given over 10-21 days may be used in the treatment of visceral leishmaniasis. Particulars as to the optimal dosage and the eventual development of resistance are as yet incomplete. The product should be administered under strict medical supervision.

Empirical treatment of febrile neutropenia

The recommended daily dose is 3 mg/kg body weight per day. Treatment should be continued until the recorded temperature is normalised for 3 consecutive days. In any event, treatment should be discontinued after a maximum of 42 days.

Paediatric population

Both systemic fungal infections in children and presumed fungal infections in children with febrile neutropenia have been successfully treated with liposomal amphotericin B, without reports of unusual adverse events. Liposomal amphotericin B has been studied in paediatric patients aged one month to 18 years old. Doses used in these clinical studies were the same as those used in adults on a mg/kg body weight basis.

Liposomal amphotericin B is not recommended for use in children below 1 month old due to lack of data on safety and efficacy.

Elderly patients

No alteration in dose or frequency of dosing is required.

Renal impairment

Liposomal amphotericin B has been administered to a large number of patients with pre-existing renal impairment at starting doses ranging from 1-3 mg/kg/day in clinical trials and no adjustment in dose or frequency of administration was required (See section 4.4).

Hepatic impairment

No data are available on which to make a dose recommendation for patients with hepatic impairment (See section 4.4).

Method of administration

Amphotericin B Tillomed liposomal should be administered by intravenous infusion over a 30 - 60-minute period. For doses greater than 5mg/kg/day, intravenous infusion over a 2-hour period is recommended (see section 4.4). The recommended concentration for intravenous infusion is 0.20 mg/ml to 2.00 mg/ml amphotericin B as Amphotericin B Tillomed liposomal.

For instructions on reconstitution and dilution of the product before administration, see section 6.6.

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1 unless, in the opinion of the physician, the condition requiring treatment is life-threatening and amenable only to Amphotericin B Tillomed liposomal therapy.

Anaphylaxis and anaphylactoid reactions

Anaphylaxis and anaphylactoid reactions have been reported in association with liposomal amphotericin B infusion. Allergic type reactions, including severe infusion-related reactions can occur during administration of amphotericin-containing products, including Amphotericin B Tillomed liposomal (see section 4.8). Therefore, administration of a test dose is still advisable before a new course of treatment (see section 4.2). If a severe allergic or anaphylactic/anaphylactoid reaction occurs, the infusion should be immediately discontinued and the patient should not receive further infusion of Amphotericin B Tillomed liposomal.

Infusion-related reactions

Other severe infusion-related reactions can occur during administration of amphotericin B containing products, including Amphotericin B Tillomed liposomal (see section 4.8). Although infusion-related reactions are not usually serious, consideration of precautionary measures for the prevention or treatment of these reactions should be given to patients who receive Amphotericin B Tillomed liposomal therapy. Slower infusion rates (over 2 hours) or routine doses of diphenhydramine, paracetamol, pethidine and/or hydrocortisone have been reported as successful in their prevention or treatment.

Renal toxicity

Liposomal amphotericin B has been shown to be substantially less toxic than conventional amphotericin B, particularly with respect to nephrotoxicity; however, renal adverse reactions may still occur.

In studies comparing liposomal amphotericin B 3 mg/kg daily with higher doses (5, 6 or 10 mg/kg daily), it was found that the incidence rates of increased serum creatinine, hypokalaemia and hypomagnesaemia were notably higher in the high dose groups. In particular, caution should be exercised when prolonged therapy is required.

Regular laboratory evaluation of serum electrolytes, particularly potassium and magnesium as well as renal, hepatic and haematopoietic function should be performed. Due to the risk of hypokalaemia, appropriate potassium supplementation may be required during the course of Amphotericin B Tillomed liposomal administration. If clinically significant reduction in renal function or worsening of other parameters occurs, consideration should be given to dose reduction, treatment interruption or discontinuation. Cases of hyperkalaemia (some of them leading to cardiac arrhythmias and cardiac arrest) have been reported. Most of them occurred in patients with renal impairment, and some cases after potassium supplementation in patients with previous hypokalaemia. Therefore, renal function and laboratory evaluation of potassium, should be measured before and during treatment. This is particularly important in patients with pre-existing renal disease, who have already experienced renal failure, or in patients receiving concomitant nephrotoxic medications (see section 4.5).

Pulmonary toxicity

Acute pulmonary toxicity has been reported in patients given amphotericin B (as sodium deoxycholate complex) during or shortly after leukocyte transfusions. It is recommended that these infusions are separated by as long a period as possible and pulmonary function should be monitored.

Diabetic patients

Amphotericin B Tillomed liposomal contains approximately 900 mg of sucrose in each vial. This should be taken into account when treating diabetic patients.

Each vial / dose of Amphotericin B Tillomed liposomal contains less than 1 mmol (23 mg) sodium, which is essentially sodium-free.

No specific interaction studies have been performed with liposomal amphotericin B. However, the following drugs are known to interact with amphotericin B and may interact with Amphotericin B Tillomed liposomal:

Nephrotoxic medications: Concurrent administration of liposomal amphotericin B with other nephrotoxic agents (for example ciclosporin, aminoglycosides, polymixins, tacrolimus and pentamidine) may enhance the potential for drug-induced renal toxicity in some patients. However, in patients receiving concomitant ciclosporin and/or aminoglycosides, liposomal amphotericin B was associated with significantly less nephrotoxicity compared to amphotericin B. Regular monitoring of renal function is recommended in patients receiving liposomal amphotericin B with any nephrotoxic medications.

Corticosteroids, corticotropin (ACTH) and diuretics: Concurrent use of corticosteroids, ACTH and diuretics (loop and thiazide) may potentiate hypokalaemia.

Digitalis glycosides: Liposomal amphotericin B-induced hypokalaemia may potentiate digitalis toxicity.

Skeletal muscle relaxants: Liposomal amphotericin B-induced hypokalaemia may enhance the curariform effect of skeletal muscle relaxants (e.g. tubocurarine).

Antifungals: No evidence of benefit from the use of flucytosine with liposomal amphotericin B has been observed. Whilst synergy between amphotericin and flucytosine has been reported, concurrent use may increase the toxicity of flucytosine by possibly increasing its cellular uptake and/or impairing its renal excretion.

Antineoplastic agents: Concurrent use of antineoplastic agents may enhance the potential for renal toxicity, bronchospasm and hypotension. Antineoplastic agents should be given concomitantly with caution.

Leukocyte transfusions: Acute pulmonary toxicity has been reported in patients given amphotericin B (as sodium deoxycholate complex) during or shortly after leukocyte transfusions. It is recommended these infusions are separated by as long a period as possible and pulmonary function should be monitored.

Fertility

Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity (see section 5.3).

Pregnancy

The safety of liposomal amphotericin B in pregnant women has not been established.

Systemic fungal infections have been successfully treated in pregnant women with conventional amphotericin B without obvious effect on the fetus, but the number of cases reported is insufficient to draw any conclusions on the safety of liposomal amphotericin B in pregnancy.

Amphotericin B Tillomed liposomal should only be used during pregnancy if the possible benefits to be derived outweigh the potential risks to the mother and fetus.

Breast-feeding

It is unknown whether liposomal amphotericin B is excreted in human breast milk. A decision on whether to breastfeed while receiving this medicine should take into account the potential risk to the child as well as the benefit of breast feeding for the child and the benefit of Amphotericin B Tillomed liposomal therapy for the mother.

No studies on the effects on the ability to drive and use machines have been performed. Some of the undesirable effects of liposomal amphotericin B presented below may impact the ability to drive and use machines.

Summary of adverse reactions

The following adverse reactions have been attributed to liposomal amphotericin B based on clinical trial data and post-marketing experience. The frequency is based on analysis from pooled clinical trials of 688 liposomal amphotericin treated patients; the frequency of adverse reactions identified from post-marketing experience is not known. Adverse reactions are listed below by body system organ class using MedDRA and are sorted by frequency. Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.

Frequencies are defined as:

Description of selected adverse reactions

Infusion-related reactions

Fever and chills/rigors are the most frequent infusion-related reactions expected to occur during liposomal amphotericin B administration. Less frequent infusion-related reactions may consist of one or more of the following symptoms: chest tightness or pain, dyspnoea, bronchospasm, flushing, tachycardia, hypotension and musculoskeletal pain (described as arthralgia, back pain, or bone pain). These resolve rapidly on stopping the infusion and may not occur with every subsequent dose or when slower infusion rates (over 2 hours) are used. In addition, infusion-related reactions may also be prevented by the use of premedication. However, severe infusion-related reactions may necessitate the permanent discontinuation of Amphotericin B Tillomed liposomal (see section 4.4).

In two double-blind, comparative studies, liposomal amphotericin B treated patients experienced a significantly lower incidence of infusion-related reactions, as compared to patients treated with conventional amphotericin B or amphotericin B lipid complex.

In pooled study data from randomised, controlled clinical trials comparing liposomal amphotericin B with conventional amphotericin B therapy in greater than 1,000 patients, reported adverse reactions were considerably less severe and less frequent in liposomal amphotericin B treated patients as compared with conventional amphotericin B treated patients.

Renal toxicity

Nephrotoxicity occurs to some degree with conventional amphotericin B in most patients receiving the product intravenously. In a double-blind study involving 687 patients, the incidence of nephrotoxicity with liposomal amphotericin B (as measured by serum creatinine increase greater than 2.0 times baseline measurement), was approximately half that for conventional amphotericin B. In another double-blind study involving 244 patients, the incidence of nephrotoxicity with liposomal amphotericin B (as measured by serum creatinine increase greater than 2.0 times baseline measurement) was approximately half that for amphotericin B lipid complex.

Interference with Phosphorus Chemistry Assay

False elevations of serum phosphate may occur when samples from patients receiving liposomal amphotericin B are analyzed using the PHOSm assay (e.g. used in Beckman Coulter analysers including the Synchron LX20). This assay is intended for the quantitative determination of inorganic phosphorus in human serum, plasma or urine samples.

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

The toxicity of liposomal amphotericin B due to acute overdose has not been defined. If overdose should occur, cease administration immediately. Carefully monitor clinical status including renal and hepatic function, serum electrolytes and haematological status. Haemodialysis or peritoneal dialysis does not appear to affect the elimination of liposomal amphotericin B.

Special populations (including paediatric population):

No additional information is available in special populations

ATC classification

Pharmacotherapeutic group: Antimycotics for systemic use, antibiotics; ATC code: J02AA01.

Mechanism of action and pharmacodynamics effects

Amphotericin B is a macrocyclic polyene antifungal antibiotic produced by Streptomyces nodosus. Amphotericin B is fungistatic or fungicidal depending on the concentration attained in body fluids and the susceptibility of the fungus. The molecule is thought to act by binding to sterols in the fungal cell membrane, with a resulting change in membrane permeability, allowing leakage of a variety of small molecules. Mammalian cell membranes also contain sterols, and it has been suggested that the damage to human cells and fungal cells caused by amphotericin B may share common mechanisms. The lipophilic moiety of amphotericin allows the molecule to be integrated into the lipid bilayer of the liposomes. Liposomes are closed, spherical vesicles formed from a variety of amphiphilic substances such as phospholipids. Phospholipids arrange themselves into membrane bilayers when exposed to aqueous solutions.

Clinical efficacy and safety

The efficacy of liposomal amphotericin B has been established in a number of clinical trials for the treatment of systemic mycotic infections, as empirical therapy for fever of unknown origin in neutropenic patients and for the treatment of visceral leishmaniasis. These studies include comparative randomized studies of liposomal amphotericin B versus conventional amphotericin B in confirmed Aspergillus and Candida infections where the efficacy of both medicinal products was equivalent. In both adult and paediatric febrile neutropenic patients presumed to have fungal infection, the results of a randomized, double-blind clinical trial demonstrated that liposomal amphotericin B administered at 3 mg/kg/day is as effective as conventional amphotericin B. The efficacy of liposomal amphotericin B in the treatment of visceral leishmaniasis has been clearly demonstrated in a large population of immunocompetent and immunocompromised patients.

Invasive Filamentous Fungal infections (IFFIs), including Aspergillus spp.

The efficacy of liposomal amphotericin B has been demonstrated in a prospective, randomised, multicentre study as first line treatment in immunocompromised, mainly neutropenic adults and children (> 30 days old) with proven or probable IFFIs (AmBiLoad Study).

Patients were monitored for 12 weeks. A standard-dose regimen of 3 mg/kg/day (N=107) was compared to a loading dose regimen of 10 mg/kg/day (N=94) for the first 14 days of treatment. The favourable overall response rates were 50% of subjects in the standard-dose group and 46% of the subjects in the loading-dose group in the modified intent-to-treat analysis set. Differences were not statistically significant. The median time to resolution of fever was similar in the standard-dose and loading-dose groups (6 and 5 days, respectively). Twelve weeks after the first dose of liposomal amphotericin B, survival was 72% in the standard-dose group and 59% in the loading-dose group, a difference that was not statistically significant.

Invasive candidiasis

Liposomal amphotericin B (3 mg/kg/day) was as effective as Micafungin (100 mg/day [Body weight > 40 kg] or 2 mg/kg/day [Body weight ≤ 40 kg]) as first line treatment of candidaemia and invasive candidiasis in a randomised, double-blind, multinational non-inferiority study in adults and children. Liposomal amphotericin B and Micafungin were administered for a median duration of 15 days. The favourable overall response was 89.5% (170/190) in the liposomal amphotericin B group and 89.6% (181/202) in the Micafungin group (per protocol analysis set). The paediatric sub-study, which enrolled 98 patients of whom 57 were <2 years old, (including 19 premature infants), showed favourable overall response rates of: 88.1% (37/42) for liposomal amphotericin B and 85.4% (35/41) for Micafungin (per protocol analysis set).

Invasive mucormycosis (zygomycosis)

There are no large-scale randomised clinical trials in mucormycosis.

The working group in zygomycosis of the European confederation of medical mycology (ECMM) prospectively collected cases of patients with zygomycosis, 130 patients received liposomal amphotericin B (L-AMB) as first-line therapy, either alone (68) or in combination. In patients who received it as the only antifungal medication, the survival rate was 68%. In patients that were cured, the median duration of treatment was 55 days (range 14-169 days) and the median daily dose was 5 mg/kg (range 3-10 mg/kg), (Skiada et al; Clin Microbiol Infect 2011;17 (12):1859- 67).

In a prospective pilot study of high-dose (10 mg/kg/day) liposomal amphotericin B for the initial treatment of mucormycosis, 29 patients receiving 10 mg/kg/day had a median treatment duration of 13.5 days (range 0-28 days). The primary endpoint was treatment success at week 4 or at end of treatment (if earlier) and 12 (36%) out of 33 evaluable patients responded, including 18% with complete response; the response rate increased to 45% at week 12. The survival rate was 62% at week 12 and 47% at week 24 (Lanternier et al; J Antimicrob Chemother 2015; 70(11):3116-23).

Paediatric population

The pharmacodynamic profile of liposomal amphotericin B in paediatric patients is consistent with that described in adult patients.

The pharmacokinetic profile of liposomal amphotericin B, based upon total plasma concentrations of amphotericin B, was determined in cancer patients with febrile neutropenia and bone marrow transplant patients who received 1 hour infusions of 1.0 to 7.5 mg/kg/day liposomal amphotericin B for 3 to 20 days. Liposomal amphotericin B has a significantly different pharmacokinetic profile from that reported in the literature for conventional presentations of amphotericin B, with higher amphotericin B plasma concentrations (C_max) and increased exposure (AUC_0-24) compared to conventional amphotericin B. After the first dose and last dose, the pharmacokinetic parameters of amphotericin B (mean ± standard deviation) ranged from:

Minimum and maximum pharmacokinetic values do not necessarily relate to the lowest and highest doses, respectively. Following administration of liposomal amphotericin B, steady state was reached quickly (generally within 4 days of dosing).

Absorption

Liposomal amphotericin B pharmacokinetics following the first dose of L-AmB appear nonlinear such that amphotericin B concentrations are greater than proportional with increasing dose. This non-proportional dose response is believed to be due to saturation of reticuloendothelial liposomal amphotericin B clearance. There was no significant drug accumulation in the plasma following repeated administration of 1 to 7.5 mg/kg/day.

Distribution

Volume of distribution on day 1 and at steady state suggests that there is extensive tissue distribution of liposomal amphotericin B.

Elimination

After repeated administration of liposomal amphotericin B, the terminal elimination half-life (t_½ β ) of amphotericin B was approximately 7 hours. The excretion of liposomal amphotericin B has not been studied. The metabolic pathways of amphotericin B and liposomal amphotericin B are not known. Due to the size of the liposomes, there is no glomerular filtration and renal elimination of liposomal amphotericin B, thus avoiding interaction of amphotericin B with the cells of the distal tubuli and reducing the potential for nephrotoxicity seen with conventional amphotericin B presentations.

Special populations

Renal Impairment

The effect of renal impairment on the pharmacokinetics of liposomal amphotericin B has not been formally studied. Data suggest that no dose adjustment is required in patients undergoing haemodialysis or filtration procedures, however, Amphotericin B Tillomed liposomal administration should be avoided during the procedure.

Pharmacokinetic/pharmacodynamics relationship

Mechanism of resistance

Intrinsic resistance, though rare, may be primarily due to decrease in ergosterol or a change in the target lipid, leading to reduced binding of amphotericin B to the cell membrane.

Breakpoints

EUCAST breakpoints for liposomal amphotericin B have not yet been established, however, susceptibility to L-AmB may differ to that of amphotericin B deoxycholate.

Amphotericin B, the antifungal component of L-AmB, is active in vitro against many species of fungi, most strains of Histoplasma capsulatum, Coccidioides immitis, Candida spp, Blastomyces dermatidis, Rhodotorula, Cryptococcus neoformans, Sporothrix schenkii and Aspergillus fumigatus, Penicillium marneffi, and members of the mucormycetes group of moulds including Mucor mucedo, Rhizomucor and Rhizopus oryzae.

The majority of clinically important fungal species seem to be susceptible to amphotericin B, although intrinsic resistance has rarely been reported, for example, for some strains of S. schenckii, C. glabrata, C.krusei, C. tropicalis, C. lusitaniae, C. parapsilosis and Aspergillus terreus.

L-AmB has been shown to be effective in animal models of visceral leishmaniasis (caused by Leishmania infantum and Leishmania donovani).

In subchronic toxicity studies in dogs (1 month), rabbits (1 month) and rats (3 months) at doses equal to or, in some species, less than the clinical therapeutic doses of 1 to 3 mg/kg/day, the target organs for liposomal amphotericin B toxicity were the liver and kidneys with thrombocytopenia also observed. All are known targets for amphotericin B toxicity.

Liposomal amphotericin B was found to be non-mutagenic in bacterial and mammalian systems.

Carcinogenicity studies have not been conducted with liposomal amphotericin B.

No adverse effects on male or female reproductive function were noted in rats.

Hydrogenated soy phosphatidylcholine

Cholesterol

Distearoylphosphatidylglycerol

Alpha tocopherol

Sucrose

Disodium succinate hexahydrate

Sodium hydroxide (for pH adjustment)

Hydrochloric acid (for pH adjustment)

Amphotericin B Tillomed liposomal is incompatible with saline solutions and may not be mixed with other drugs or electrolytes.

This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.

3 years

Shelf – life of Amphotericin B Tillomed liposomal after first opening

Amphotericin B Tillomed liposomal 50 mg powder for dispersion for infusion does not contain any preservative. Therefore, from a microbiological point of view, once reconstituted, the product must be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2-8° C, unless reconstitution and dilution has taken place under controlled and validated aseptic conditions.

However, the following chemical and physical in-use stability data for Amphotericin B Tillomed liposomal has been demonstrated:

Shelf-life after reconstitution:

Glass vials for 24 hours at 25± 2° C exposed to ambient light

Glass vials and polypropylene syringes up to 7 days at 2-8° C

Do not freeze

DO NOT STORE partially used vials for future patient use.

Shelf-life after dilution with Dextrose solution for injection:

PVC infusion bag: 25± 2° C or at 2-8° C. Do not freeze.

See table below for recommendations.

Polyolefin infusion bags: 25 ± 2° C or 2 - 8° C. Do not freeze.

See table below for recommendations:

Amphotericin B Tillomed liposomal: unopened vials.

Do not store above 25° C. Keep the container in the outer carton.

For storage conditions after reconstitution and dilution of the medicinal product, see Section 6.3.

Amphotericin B Tillomed liposomal is presented in 20ml sterile, Type I glass vials. The closure consists of a grey butyl rubber stopper and aluminium ring seal fitted with a removable plastic cap.

Vials are available in cartons with 5-micron filters.

Pack sizes: 1 vial with 1 filter and 10 vials with 10 filters.

Not all pack sizes may be marketed.

READ THIS ENTIRE SECTION AND SECTION 4.4 CAREFULLY BEFORE BEGINNING RECONSTITUTION.

Amphotericin B Tillomed liposomal is NOT equivalent to other amphotericin products (see section 4.2).

Amphotericin B Tillomed liposomal must be reconstituted using Sterile Water for Injection (without a bacteriostatic agent) and diluted in Dextrose solution (5%, 10% or 20%) for infusion only.

The use of any solution other than those recommended, or the presence of a bacteriostatic agent (e.g. benzyl alcohol) in the solution, may cause precipitation of Amphotericin B Tillomed liposomal.

Amphotericin B Tillomed liposomal is NOT compatible with saline and must not be reconstituted or diluted with saline or administered through an intravenous line that has previously been used for saline unless first flushed with dextrose solution (5%, 10% or 20%) for infusion. If this is not feasible, Amphotericin B Tillomed liposomal should be administered through a separate line.

Do NOT mix Amphotericin B Tillomed liposomal with other medicinal products or electrolytes.

Aseptic technique must be strictly observed in all handling, since no preservative or bacteriostatic agent is present in Amphotericin B Tillomed liposomal, or in the materials specified for reconstitution and dilution.

Amphotericin B Tillomed liposomal must be reconstituted by suitably trained staff.

Vials of Amphotericin B Tillomed liposomal containing 50 mg of amphotericin are prepared as follows:

1. Add 12 ml of Sterile Water for Injection to each Amphotericin B Tillomed liposomal vial, to yield a preparation containing 4 mg/ml amphotericin B.

2. IMMEDIATELY after the addition of water, SHAKE THE VIAL VIGOROUSLY for 30 seconds to completely disperse the Amphotericin B Tillomed liposomal. After reconstitution the concentrate is a translucent, yellow dispersion. Visually inspect the vial for particulate matter and continue shaking until complete dispersion is obtained. Do not use if there is any evidence of precipitation of foreign matter.

3. Calculate the amount of reconstituted Amphotericin B Tillomed liposomal (4 mg/ml) to be further diluted (see table below).

4. The infusion solution is obtained by dilution of the reconstituted Amphotericin B Tillomed liposomal with between one (1) and nineteen (19) parts dextrose solution (5%, 10% or 20%) for infusion by volume, to give a final concentration in the recommended range of 2.00 mg/ml to 0.20 mg/ml amphotericin as Amphotericin B Tillomed liposomal (see table below).

5. Withdraw the calculated volume of reconstituted Amphotericin B Tillomed liposomal into a sterile syringe. Using the 5-micron filter provided, instill the Amphotericin B Tillomed liposomal preparation into a sterile container with the correct amount of dextrose solution (5%, 10% or 20%) for infusion.

An in-line membrane filter may be used for intravenous infusion of Amphotericin B Tillomed liposomal. However, the mean pore diameter of the filter should not be less than 1.0 micron.

Example of the preparation of Amphotericin B Tillomed liposomal dispersion for infusion at a dose of 3 mg/kg/day in dextrose 5% solution for infusion.

^* Each vial of Amphotericin B Tillomed liposomal (50mg) is reconstituted with 12ml Water for Injection to provide a concentration of 4mg/ml amphotericin B.

Any unused product or waste material should be disposed of in accordance with local requirements.