Vedrop is indicated in vitamin E deficiency due to digestive malabsorption in paediatric patients with congenital chronic cholestasis or hereditary chronic cholestasis, from birth (full term newborns) up to 18 years of age.

The treatment with Vedrop should be initiated and supervised by a physician experienced in the management of patients suffering from congenital chronic cholestasis or hereditary chronic cholestasis.

Bioavailability of vitamin E from Vedrop differs from that of other medicinal products. The dose should be prescribed in mg of d-alpha-tocopherol in the form of tocofersolan. Plasma vitamin E level should be monitored monthly for at least the first few months of therapy, thereafter at regular intervals and the dose adjusted accordingly if necessary.

Posology

The recommended total daily dose in paediatric patients suffering from congenital chronic cholestasis or hereditary chronic cholestasis is 0.34 ml/kg/day (17 mg/kg of d-alpha-tocopherol in the form of tocofersolan). The dose should be prescribed in ml.

The dose should be adjusted according to plasma vitamin E level.

To calculate the dose of Vedrop to be administered, divide the prescribed dose of d-alpha-tocopherol (in mg) by 50. The result is the volume of Vedrop in ml:

The following table gives the volume of oral solution in function of patients' weights.

Special populations

Hepatic or renal impairment

Experience with tocofersolan therapy in patients with renal impairment or underlying liver impairment has demonstrated no need to adapt the dose regimen of Vedrop (see section 4.4).

Method of administration

Vedrop is administered orally with or without water. The 1-ml or 2-ml oral syringes included in the container are designed to assist in measuring out the exact dose in accordance with the prescribed posology.

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Vedrop must not be used in preterm newborn infants.

As large doses of vitamin E have been reported to increase bleeding tendency in vitamin-K deficient patients or those taking oral anti-vitamins K treatment, it is therefore recommended to monitor the prothrombin time and international normalised ratio (INR). A possible adjustment of the dose of oral anticoagulant during and after treatment with Vedrop may be necessary.

As data on patients with renal impairment are limited, Vedrop should be administered with caution and under close monitoring of the renal function in patients with renal impairment e.g. dehydrated patients (see section 4.2).

Vedrop should be administered with caution in patients with underlying liver impairment and under close monitoring of the hepatic functions in such patients (see section 4.2).

Vedrop contains sodium methyl parahydroxybenzoate (E219) and sodium ethyl parahydroxybenzoate (E215) which may cause allergic reactions (possibly delayed).

This medicinal product contains sodium. It should be taken into consideration by patients on a controlled sodium diet.

No interaction studies have been performed.

It is recommended to monitor the coagulation function when administered with anti-vitamins K treatment (see section 4.4).

Due to inhibition of P-Glycoprotein transporter, tocofersolan may also enhance intestinal absorption of other concomitant fat-soluble vitamins (A, D, E, K) or that of highly lipophilic medicinal products (such as steroids, antibiotics, antihistamines, cyclosporine, tacrolimus). Therefore, monitoring should be performed and, when necessary, doses should be adjusted.

Pregnancy

For tocofersolan no clinical data on exposed pregnancies are available. Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or post-natal development (see section 5.3). Caution should be exercised when prescribing to pregnant women.

Breast-feeding

It is unknown whether tocofersolan is excreted in human breast milk. The excretion of tocofersolan in milk has not been studied in animals. A decision on whether to continue/discontinue breast-feeding or to continue/discontinue therapy with Vedrop should be made taking into account the benefit of breast-feeding to the child and the benefit of tocofersolan therapy to the woman.

Fertility

No data is available

Vedrop has no or negligible influence on the ability to drive and use machines.

Summary of the safety profile

The most commonly reported adverse reaction during treatment is diarrhoea.

Tabulated list of adverse reactions

Reported adverse reactions are listed below, by system organ class and by frequency.

Frequencies are defined as: 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).

Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

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

Large vitamin E doses may cause diarrhoea, abdominal pain, and other gastrointestinal disturbances.

In case of overdose, a symptomatic treatment should be proposed.

Pharmacotherapeutic group: Vitamins, Other plain vitamin preparations; ATC code: A11HA08

Vitamin E is the principal lipo-soluble antioxidant in the organism. It acts as a free radical chain breaking molecule, stopping the peroxidation of polyunsaturated fatty acids and it is involved in maintaining the stability and integrity of cell membranes.

This medicinal product has been authorised under “ exceptional circumstances” . This means that due to the rarity of the disease it has not been possible to obtain complete information on this medicinal product.

The European Medicines Agency will review any new information which may become available every year and this SmPC will be updated as necessary.

Absorption

The active substance d-alpha-tocopherol-polyethylene glycol 1000 succinate (tocofersolan) is a pro-drug; the active metabolite is the d-alpha-tocopherol. At low concentrations, tocofersolan forms micelles which enhance absorption of non-polar lipids such as fat-soluble vitamins. Its critical micellar concentration is low (0.04 to 0.06 mmol/l).

The hydrolysis of tocofersolan occurs in the gut lumen. Taken up by cells, the alpha-tocopherol moiety appears in chylomicrons in the lymph in a manner identical to vitamin E absorbed from the diet. Cellular uptake does not require receptors, binding proteins or metabolic processes and does not occur by pinocytosis. Absorption of deuterated tocofersolan showed a normal pattern in lipoproteins: alpha-tocopherol peaked first in chylomicrons, then in very low- density lipoproteins (VLDL) and finally in low-density lipoproteins (LDL) and high-density lipoproteins (HDL), and the disappearance portions of the curves paralleled those in control subjects.

A study in 12 healthy volunteers compared tocofersolan with a water-miscible reference vitamin E after a single oral loading dose of 1200 IU. The relative bioavailability of tocofersolan tended to be higher (F_rel of 1.01 ± 1.74) with AUC_0-t of 0.383 ± 0.203µ M.h/mg, C_max of 0.013 ± 0.006, t_max of 6.0 h (6.0 – 24.0), and t_1/2 of 29.7 h (16.0 – 59.5).

In a similar study tocofersolan showed a higher bioavailability than a water-miscible reference vitamin E in paediatric patients with chronic cholestasis (n=6), absorption was significantly higher on both plasma concentration maximum increase (p=0.008) and AUC (p=0.0026).

Distribution

Located principally on cell membranes, within mitochondria and microsomes, vitamin E is ubiquitously distributed (red blood cells, brain, muscle, liver, platelets) and fat tissues are its major reservoir.

Elimination

Vitamin E is mainly eliminated in the bile (75%) and stools, either as free tocopherol or as oxidized forms. Urine represents a minor elimination route of vitamin E (as glucuro-conjugate).

Non-clinical data in the literature reveal no special hazard for humans based on conventional studies of repeated dose toxicity, genotoxicity and toxicity to reproduction.

Potassium sorbate

Sodium methyl parahydroxybenzoate (E219)

Sodium ethyl parahydroxybenzoate (E215)

Glycerol

Disodium phosphate dodecahydrate

Concentrated hydrochloric acid

Purified water

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.

2 years.

After first opening the bottle: 1 month.

This medicinal product does not require any special storage conditions.

Type III brown glass bottle with a child-resistant screw cap of HDPE and LDPE seal. Oral syringes with housing of LDPE and piston of polystyrol. Each bottle contains 10 ml, 20 ml or 60 ml of oral solution.

Boxes containing:

▪ one 10 ml bottle and one 1 ml oral syringe

▪ one 20 ml bottle and one 1 ml oral syringe

▪ one 60 ml and one 2 ml oral syringe

Not all pack sizes may be marketed.

Doses for administration should be extracted from the bottle using the oral syringes which are provided in the pack.

The 1 ml oral syringe is graduated from 0.05 to 1 ml in steps of 0.05 ml. One graduation of the 1 ml oral syringe corresponds to 2.5 mg of d-alpha-tocopherol in the form of tocofersolan.

The 2 ml oral syringe is graduated from 0.1 to 2 ml in steps of 0.1 ml. One graduation of the 2-ml oral syringe corresponds to 5 mg of d-alpha-tocopherol in the form of tocofersolan.