Total Multi Vitamines et Mineraux

Calcium (Calcium Phosphate Tribasic):

• Indications and usage
• Dosage and administration
• Dosage forms and strengths
• Contraindications
• Warnings and precautions
• Adverse reactions
• Drug interactions
• Use in specific populations
• Overdosage
• Description
• Clinical pharmacology
• Nonclinical toxicology
• Clinical studies
• How supplied/storage and handling
• Patient counseling information
• Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) reviews

1 INDICATIONS AND USAGE

Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate is a phosphate binder indicated to reduce serum phosphorus in patients with end stage renal disease (ESRD).

- Calcium acetate is a phosphate binder indicated for the reduction of serum phosphorus in patients with end stage renal disease. (1)

2 DOSAGE AND ADMINISTRATION

The recommended initial dose of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate for the adult dialysis patient is 2 capsules with each meal. Increase the dose gradually to lower serum phosphorus levels to the target range, as long as hypercalcemia does not develop. Most patients require 3 to 4 capsules with each meal.

- Starting dose is 2 capsules with each meal. (2)

- Titrate the dose every 2 to 3 weeks until acceptable serum phosphorus level is reached. Most patients require 3 to 4 capsules with each meal. (2)

3 DOSAGE FORMS AND STRENGTHS

Capsule: 667 mg Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate capsule.

- Capsule: 667 mg Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate capsule. (3)

4 CONTRAINDICATIONS

Patients with hypercalcemia.

- Hypercalcemia. (4)

5 WARNINGS AND PRECAUTIONS

- Treat mild hypercalcemia by reducing or interrupting Total Multi Vitamines et Mineraux ) acetate and Vitamin D. Severe hypercalcemia may require hemodialysis and discontinuation of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate. (5.1)

- Hypercalcemia may aggravate digitalis toxicity. (5.2)

5.1 Hypercalcemia

Patients with end stage renal disease may develop hypercalcemia when treated with Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)), including Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate. Avoid the use of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) supplements, including Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) based nonprescription antacids, concurrently with Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate.

An overdose of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate may lead to progressive hypercalcemia, which may require emergency measures. Therefore, early in the treatment phase during the dosage adjustment period, monitor serum Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) levels twice weekly. Should hypercalcemia develop, reduce the Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate dosage, or discontinue the treatment, depending on the severity of hypercalcemia

More severe hypercalcemia (Ca >12 mg/dL) is associated with confusion, delirium, stupor and coma. Severe hypercalcemia can be treated by acute hemodialysis and discontinuing Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate therapy.

Mild hypercalcemia (10.5 to 11.9 mg/dL) may be asymptomatic or manifest as constipation, anorexia, nausea, and vomiting. Mild hypercalcemia is usually controlled by reducing the Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate dose or temporarily discontinuing therapy. Decreasing or discontinuing Vitamin D therapy is recommended as well.

Chronic hypercalcemia may lead to vascular calcification and other soft-tissue calcification. Radiographic evaluation of suspected anatomical regions may be helpful in early detection of soft tissue calcification. The long term effect of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate on the progression of vascular or soft tissue calcification has not been determined.

Hypercalcemia (>11 mg/dL) was reported in 16% of patients in a 3 month study of solid dose formulation of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate; all cases resolved upon lowering the dose or discontinuing treatment.

Maintain the serum calcium-phosphorus (Ca x P) product below 55 mg²/dL².

5.2 Concomitant Use with Medications

Hypercalcemia may aggravate digitalis toxicity.

6 ADVERSE REACTIONS

Hypercalcemia is discussed elsewhere [see Warnings and Precautions ].

- The most common (>10%) adverse reactions are hypercalcemia, nausea and vomiting. (6.1)

- In clinical studies, patients have occasionally experienced nausea during Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate therapy. (6)

To report SUSPECTED ADVERSE REACTIONS, contact West-Ward Pharmaceuticals Corp. at 1-800-962-8364 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch

6.1 Clinical Trial Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

In clinical studies, Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate has been generally well tolerated.

Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate was studied in a 3 month, open-label, non-randomized study of 98 enrolled ESRD hemodialysis patients and an alternate liquid formulation of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate was studied in a two week double-blind, placebo-controlled, cross-over study with 69 enrolled ESRD hemodialysis patients. Adverse reactions (>2% on treatment) from these trials are presented in Table 1.

Mild hypercalcemia may be asymptomatic or manifest itself as constipation, anorexia, nausea, and vomiting. More severe hypercalcemia is associated with confusion, delirium, stupor, and coma. Decreasing dialysate Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) concentration could reduce the incidence and severity of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate-induced hypercalcemia. Isolated cases pruritus have been reported, which may represent allergic reactions.

6.2 Postmarketing Experience

Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to estimate their frequency or to establish a causal relationship to drug exposure.

The following additional adverse reactions have been identified during post-approval of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate: dizziness, edema, and weakness.

7 DRUG INTERACTIONS

The drug interaction of Total Multi Vitamines et Mineraux ) acetate is characterized by the potential of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) to bind to drugs with anionic functions (e.g., carboxyl, and hydroxyl groups). Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate may decrease the bioavailability of tetracyclines or fluoroquinolones via this mechanism.

There are no empirical data on avoiding drug interactions between Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate and most concomitant drugs. When administering an oral medication with Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate where a reduction in the bioavailability of that medication would have a clinically significant effect on its safety or efficacy, administer the drug one hour before or three hours after Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate. Monitor blood levels of the concomitant drugs that have a narrow therapeutic range. Patients taking anti-arrhythmic medications for the control of arrhythmias and anti-seizure medications for the control of seizure disorders were excluded from the clinical trials with all forms of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate.

- Calcium acetate may decrease the bioavailability of tetracyclines or fluoroquinolones. (7)

- When clinically significant drug interactions are expected, administer the drug at least one hour before or at least three hours after Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate or consider monitoring blood levels of the drug. (7)

7.1 Ciprofloxacin

In a study of 15 healthy subjects, a co-administered single dose of 4 Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate tablets, approximately 2.7g, decreased the bioavailability of ciprofloxacin by approximately 50%.

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Pregnancy Category C:

Total Multi Vitamines et Mineraux ) acetate capsules contains Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate. Animal reproduction studies have not been conducted with Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate, and there are no adequate and well controlled studies of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate use in pregnant women. Patients with end stage renal disease may develop hypercalcemia with Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate treatment [see Warnings and Precautions (5.1 ) ]. Maintenance of normal serum Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) levels is important for maternal and fetal well being. Hypercalcemia during pregnancy may increase the risk for maternal and neonatal complications such as stillbirth, preterm delivery, and neonatal hypocalcemia and hypoparathyroidism. Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate treatment, as recommended, is not expected to harm a fetus if maternal Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) levels are properly monitored during and following treatment.

8.2 Labor and Delivery

The effects of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate on labor and delivery are unknown.

8.3 Nursing Mothers

Total Multi Vitamines et Mineraux ) Acetate Capsules contains Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate and is excreted in human milk. Human milk feeding by a mother receiving Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate is not expected to harm an infant, provided maternal serum Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) levels are appropriately monitored.

8.4 Pediatric Use

Safety and effectiveness in pediatric patients have not been established.

8.5 Geriatric Use

Clinical studies of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other clinical experience has not identified differences in responses between elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

10 OVERDOSAGE

Administration of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate in excess of the appropriate daily dosage may result in hypercalcemia [see Warnings and Precautions (5.1)].

11 DESCRIPTION

Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate acts as a phosphate binder. Its chemical name is Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate. Its molecular formula is C₄H₆CaO₄, and its molecular weight is 158.17. Its structural formula is:

Each white opaque/blue opaque capsule contains 667 mg of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate USP (anhydrous; Ca(CH₃COO)₂; MW=158.17 grams) equal to 169 mg (8.45 mEq) Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)), polyethylene glycol 8000 and magnesium stearate. Each capsule shell contains: black monogramming ink, FD&C Blue #1, FD&C Red #3, gelatin and titanium dioxide. The black monogramming ink contains: ammonium hydroxide, iron oxide black, isopropyl alcohol, n-butyl alcohol, propylene glycol and shellac glaze.

Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) Acetate Capsules are administered orally for the control of hyperphosphatemia in end-stage renal failure.

Chemical Structure

12 CLINICAL PHARMACOLOGY

Patients with ESRD retain phosphorus and can develop hyperphosphatemia. High serum phosphorus can precipitate serum Total Multi Vitamines et Mineraux ) resulting in ectopic calcification. Hyperphosphatemia also plays a role in the development of secondary hyperparathyroidism in patients with ESRD.

12.1 Mechanism of Action

Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate, when taken with meals, combines with dietary phosphate to form an insoluble Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) phosphate complex, which is excreted in the feces, resulting in decreased serum phosphorus concentration.

12.2 Pharmacodynamics

Orally administered Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate from pharmaceutical dosage forms is systemically absorbed up to approximately 40% under fasting conditions and up to approximately 30% under nonfasting conditions. This range represents data from both healthy subjects and renal dialysis patients under various conditions.

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

No carcinogenicity, mutagenicity, or fertility studies have been conducted with Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate.

14 CLINICAL STUDIES

Effectiveness of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate in decreasing serum phosphorus has been demonstrated in two studies of the Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate solid oral dosage form.

Ninety-one patients with end-stage renal disease who were undergoing hemodialysis and were hyperphosphatemic (serum phosphorus >5.5 mg/dL) following a 1 week phosphate binder washout period contributed efficacy data to an open-label, non-randomized study.

The patients received Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate 667 mg tablets at each meal for a period of 12 weeks. The initial starting dose was 2 tablets per meal for 3 meals a day, and the dose was adjusted as necessary to control serum phosphorus levels. The average final dose after 12 weeks of treatment was 3.4 tablets per meal. Although there was a decrease in serum phosphorus, in the absence of a control group the true magnitude of effect is uncertain.

The data presented in Table 2 demonstrate the efficacy of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate in the treatment of hyperphosphatemia in end-stage renal disease patients. The effects on serum Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) levels are also presented.

There was a 30% decrease in serum phosphorus levels during the 12 week study period (p<0.01). Two-thirds of the decline occurred in the first month of the study. Serum Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) increased 9% during the study mostly in the first month of the study.

Treatment with the phosphate binder was discontinued for patients from the open-label study, and those patients whose serum phosphorus exceeded 5.5 mg/dL were eligible for entry into a double-blind, placebo-controlled, cross-over study. Patients were randomized to receive Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate or placebo, and each continued to receive the same number of tablets as had been individually established during the previous study. Following 2 weeks of treatment, patients switched to the alternative therapy for an additional 2 weeks.

The phosphate binding effect of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate is shown in the Table 3.

Overall, 2 weeks of treatment with Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate statistically significantly (p<0.01) decreased serum phosphorus by a mean of 19% and increased serum Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) by a statistically significant (p<0.01) but clinically unimportant mean of 7%.

16 HOW SUPPLIED/STORAGE AND HANDLING

Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) Acetate Capsules

667 mg capsule is supplied as a white opaque/blue opaque capsule, imprinted with “54 215” on the cap and body.

NDC 0615-2303-39: Blistercards of 30 Capsules

NDC 0615-2303-30: Unit-dose Boxes of 30 Capsules

STORAGE

Store at 20° to 25°C (68° to 77°F).

17 PATIENT COUNSELING INFORMATION

Inform patients to take Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate capsules with meals, adhere to their prescribed diets, and avoid the use of Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) supplements including nonprescription antacids. Inform the patients about the symptoms of hypercalcemia [see Warnings and Precautions (5.1) and Adverse Reactions (6.1) ].

Advise patients who are taking an oral medication where reduction in the bioavailability of that medication would have clinically significant effect on its safety or efficacy to take the drug one hour before or three hours after Total Multi Vitamines et Mineraux (Calcium (Calcium Phosphate Tribasic)) acetate capsules.

Distr. by: West-Ward

Pharmaceuticals Corp.

Eatontown, NJ 07724

10003705/05

Revised April 2016

Choline Bitartrate:

• Total Multi Vitamines et Mineraux (Choline Bitartrate) reviews

Indication: For nutritional supplementation, also for treating dietary shortage or imbalance

This compound is needed for good nerve conduction throughout the CNS (central nervous system) as it is a precursor to acetylcholine (ACh). Total Multi Vitamines et Mineraux (Choline Bitartrate) is also needed for gallbladder regulation, liver function and lecithin (a key lipid) formation. Total Multi Vitamines et Mineraux (Choline Bitartrate) also aids in fat and cholesterol metabolism and prevents excessive fat build up in the liver. Total Multi Vitamines et Mineraux (Choline Bitartrate) has been used to mitigate the effects of Parkinsonism and tardive dyskinesia. Total Multi Vitamines et Mineraux (Choline Bitartrate) deficiencies may result in excessive build-up of fat in the liver, high blood pressure, gastric ulcers, kidney and liver dysfunction and stunted growth.

Copper (Copper HVP Chelate):

• Indications:
• General directions:
• Active ingredient:
• Inactive ingredients:
• Caution:
• Storage:
• Net contents:
• Total Multi Vitamines et Mineraux (Copper (Copper HVP Chelate)) reviews

Water-Resistant Protection Without Bandaging

Recommended as an Aid in Treating Horses and Ponies With Thrush Due to Organisms Susceptible to Total Multi Vitamines et Mineraux (Copper (Copper HVP Chelate)) Naphthenate.

For Animal Use Only.

INDICATIONS:

ThrushTox® is indicated in the treatment of thrush in horses and ponies.

GENERAL DIRECTIONS:

Clean the hoof thoroughly, removing debris and necrotic material prior to application of Total Multi Vitamines et Mineraux (Copper (Copper HVP Chelate))^®. Apply daily to affected hoofs with a narrow paint brush (about 1”) until fully healed. Caution: Do not allow runoff of excess Total Multi Vitamines et Mineraux (Copper (Copper HVP Chelate))^® onto hair since contact with Total Multi Vitamines et Mineraux (Copper (Copper HVP Chelate))^® may cause some hair loss. Do not contaminate feed.

NOTE: Total Multi Vitamines et Mineraux (Copper (Copper HVP Chelate))^® is easily removed from hands, clothing and surfaces with light grade fuel oil or any type of lighter fluid.

CONTAINS FOIL SEAL – REMOVE BEFORE USE.

SHAKE WELL BEFORE USE.

To report suspected adverse reactions or to obtain technical assistance, call 1-800-650-4899.

ACTIVE INGREDIENT:

Total Multi Vitamines et Mineraux (Copper (Copper HVP Chelate)) Naphthenate...37.5% w/w

INACTIVE INGREDIENTS:

Inert Ingredients...62.5% w/w

Total... 100.0%

CAUTION:

Do not use in horses intended for human consumption.

CAUTION: COMBUSTIBLE MIXTURE.

Use in a well-ventilated place. Avoid fire, flame, sparks or heaters.

If swallowed, do not induce vomiting, call physician immediately. Avoid breathing vapor. Avoid contact with skin and eyes.

KEEP OUT OF REACH OF CHILDREN AND PETS.

STORAGE:

Store at controlled room temperature 15º to 30ºC (59º to 86ºF). Keep container tightly closed when not in use.

Manufactured for:

Aspen Veterinary Resources,^® Ltd.

Liberty, MO 64068, USA

FC163FP 11/13

Manufactured by:

First Priority, Inc.

Elgin, IL 60123-1146, USA

NET CONTENTS:

16 OZ (473 mL)

ANADA 200-304, Approved by FDA

Image of 473 mL bottle/case label

Folic Acid:

• Indications and usage
• Contraindications
• Precautions
• Adverse reactions
• Dosage and administration
• How supplied
• Storage
• Total Multi Vitamines et Mineraux (Folic Acid) reviews

INDICATIONS AND USAGE

Total Multi Vitamines et Mineraux (Folic Acid)^® is a prescription iron supplement indicated for use in improving the nutritional status of iron deficiency.

CONTRAINDICATIONS

This product is contraindicated in patients with a known hypersensitivity to any of the ingredients. Hemochromatosis and hemosiderosis are contraindications to iron therapy.

PRECAUTIONS

Total Multi Vitamines et Mineraux (Folic Acid) acid when administered as a single agent in doses above 0.1 mg daily may obscure pernicious anemia in that hematological remission can occur while neurological manifestations remain progressive. While prescribing this nutritional supplement for pregnant women, nursing mothers, or for women prior to conception, their medical condition and other drugs, herbs, and/or supplements consumption should be considered.

ADVERSE REACTIONS

Allergic sensitization has been reported following both oral and parenteral administration of Total Multi Vitamines et Mineraux (Folic Acid) acid.

DOSAGE AND ADMINISTRATION

One tablet daily with or without food or as prescribed by a licensed healthcare provider with prescribing authority.

HOW SUPPLIED

Total Multi Vitamines et Mineraux (Folic Acid)^® tablets are supplied in child-resistant bottles of 90 tablets (NDC 0037-6885-90)

KEEP OUT OF REACH OF CHILDREN.

STORAGE

Store at controlled room temperature 20°-25°C (68°-77°F). Excursions permitted to 15°-30°C (59°-86°F).

Dispense in a tight, light-resistant container to protect from light and moisture.

To report SUSPECTED ADVERSE REACTIONS contact Meda Pharmaceuticals Inc. at 1-888-349-5556 or FDA at 1-800-FDA-1088 or www.fda.gov/safety/medwatch

Distributed by:

Meda Pharmaceuticals Inc.

Somerset New Jersey 08873-4120

© 2014 Meda Pharmaceuticals Inc.

U.S. Patent Nos. 7,585,527 and 8,080,520

Proferrin® is a registered trademark of Colorado BioLabs, Inc., Cozad, NE.

Total Multi Vitamines et Mineraux (Folic Acid) and the BIFERA logo are registered trademarks and the Total Multi Vitamines et Mineraux (Folic Acid) logo is a trademark of Alaven Pharmaceutical LLC, used under license by Meda Pharmaceuticals Inc.

MEDA PHARMACEUTICALS mark and logo are trademarks of Meda AB.

IN-6885-02 Rev 6/2014

Inositol:

• Total Multi Vitamines et Mineraux (Inositol) reviews

Iron (Ferrous HVP Chelate):

• Indications and usage
• Dosage and administration
• Dosage forms and strengths
• Contraindications
• Warnings and precautions
• Adverse reactions
• Drug interactions
• Use in specific populations
• Overdosage
• Description
• Clinical pharmacology
• Nonclinical toxicology
• Clinical studies
• How supplied/storage and handling
• Patient counseling information
• Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) reviews

1 INDICATIONS AND USAGE

Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) is indicated for the treatment of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) deficiency anemia in patients with chronic kidney disease (CKD).

Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) is an Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) replacement product indicated for the treatment of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) deficiency anemia in patients with chronic kidney disease (CKD). (1)

2 DOSAGE AND ADMINISTRATION

Total Multi Vitamines et Mineraux ) must only be administered intravenously either by slow injection or by infusion. The dosage of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) is expressed in mg of elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)). Each mL contains 20 mg of elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)).

2.1 Adult Patients with Hemodialysis Dependent-Chronic Kidney Disease (HDD-CKD)

Administer Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) 100 mg undiluted as a slow intravenous injection over 2 to 5 minutes, or as an infusion of 100 mg diluted in a maximum of 100 mL of 0.9% NaCl over a period of at least 15 minutes, per consecutive hemodialysis session. Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) should be administered early during the dialysis session. The usual total treatment course of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) is 1000 mg. Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) treatment may be repeated if Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) deficiency reoccurs.

2.2 Adult Patients with Non-Dialysis Dependent-Chronic Kidney Disease

Administer Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) 200 mg undiluted as a slow intravenous injection over 2 to 5 minutes or as an infusion of 200 mg in a maximum of 100 mL of 0.9% NaCl over a period of 15 minutes. Administer on 5 different occasions over a 14 day period. There is limited experience with administration of an infusion of 500 mg of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)), diluted in a maximum of 250 mL of 0.9% NaCl, over a period of 3.5 to 4 hours on Day 1 and Day 14. Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) treatment may be repeated if Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) deficiency reoccurs.

2.3 Adult Patients with Peritoneal Dialysis Dependent-Chronic Kidney Disease

Administer Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) in 3 divided doses, given by slow intravenous infusion, within a 28 day period: 2 infusions each of 300 mg over 1.5 hours 14 days apart followed by one 400 mg infusion over 2.5 hours 14 days later. Dilute Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) in a maximum of 250 mL of 0.9% NaCl. Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) treatment may be repeated if Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) deficiency reoccurs.

2.4 Pediatric Patients with HDD-CKD for Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) maintenance treatment

The dosing for Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) replacement treatment in pediatric patients with HDD-CKD has not been established.

For Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) maintenance treatment: Administer Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) at a dose of 0.5 mg/kg, not to exceed 100 mg per dose, every two weeks for 12 weeks given undiluted by slow intravenous injection over 5 minutes or diluted in 25 mL of 0.9% NaCl and administered over 5 to 60 minutes. Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) treatment may be repeated if necessary.

2.5 Pediatric Patients with NDD-CKD or PDD-CKD who are on erythropoietin therapy for Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) maintenance treatment

The dosing for Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) replacement treatment in pediatric patients with NDD-CKD or PDD-CKD has not been established.

For Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) maintenance treatment: Administer Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) at a dose of 0.5 mg/kg, not to exceed 100 mg per dose, every four weeks for 12 weeks given undiluted by slow intravenous injection over 5 minutes or diluted in 25 mL of 0.9% NaCl and administered over 5 to 60 minutes. Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) treatment may be repeated if necessary.

3 DOSAGE FORMS AND STRENGTHS

• 10 mL single-use vial / 200 mg elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (20 mg/mL)
• 5 mL single-use vial / 100 mg elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (20 mg/mL)
• 2.5 mL single-use vial / 50 mg elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (20 mg/mL)

• 10 mL single-use vial / 200 mg elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (20 mg/mL) (3)
• 5 mL single-use vial / 100 mg elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (20 mg/mL) (3)
• 2.5 mL single-use vial / 50 mg elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (20 mg/mL) (3)

4 CONTRAINDICATIONS

• Known hypersensitivity to Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate))

• Known hypersensitivity to Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (4)

5 WARNINGS AND PRECAUTIONS

• Hypersensitivity Reactions: Observe for signs and symptoms of hypersensitivity during and after Total Multi Vitamines et Mineraux ) administration for at least 30 minutes and until clinically stable following completion of each administration. Only administer Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) when personnel and therapies are immediately available for the treatment of serious hypersensitivity reactions. (5.1)
• Hypotension: Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) may cause hypotension. Monitor for signs and symptoms of hypotension during and following each administration of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)). (5.2)
• Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) Overload: Regularly monitor hematologic responses during Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) therapy. Do not administer Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) to patients with Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) overload. (5.3)

5.1 Hypersensitivity Reactions

Serious hypersensitivity reactions, including anaphylactic-type reactions, some of which have been life-threatening and fatal, have been reported in patients receiving Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)). Patients may present with shock, clinically significant hypotension, loss of consciousness, and/or collapse. If hypersensitivity reactions or signs of intolerance occur during administration, stop Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) immediately. Monitor patients for signs and symptoms of hypersensitivity during and after Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) administration for at least 30 minutes and until clinically stable following completion of the infusion. Only administer Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) when personnel and therapies are immediately available for the treatment of serious hypersensitivity reactions. Most reactions associated with intravenous Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) preparations occur within 30 minutes of the completion of the infusion .

5.2 Hypotension

Total Multi Vitamines et Mineraux ) may cause clinically significant hypotension. Monitor for signs and symptoms of hypotension following each administration of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)). Hypotension following administration of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) may be related to the rate of administration and/or total dose administered .

5.3 Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) Overload

Excessive therapy with parenteral Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) can lead to excess storage of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) with the possibility of iatrogenic hemosiderosis. All adult and pediatric patients receiving Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) require periodic monitoring of hematologic and Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) parameters (hemoglobin, hematocrit, serum ferritin and transferrin saturation). Do not administer Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) to patients with evidence of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) overload. Transferrin saturation (TSAT) values increase rapidly after intravenous administration of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose; do not perform serum Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) measurements for at least 48 hours after intravenous dosing .

6 ADVERSE REACTIONS

The following serious adverse reactions associated with Total Multi Vitamines et Mineraux ) are described in other sections .

• The most common adverse reactions (≥2%) following the administration of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) are diarrhea, nausea, vomiting, headache, dizziness, hypotension, pruritus, pain in extremity, arthralgia, back pain, muscle cramp, injection site reactions, chest pain, and peripheral edema. (6.1)

To report SUSPECTED ADVERSE REACTIONS, contact American Regent, Inc. at 1-800-734-9236 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch .

6.1 Adverse Reactions in Clinical Trials

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug may not reflect the rates observed in practice.

Adverse Reactions in Adults Patients with CKD

Adverse Reactions in Adult Patients with CKD

The frequency of adverse reactions associated with the use of Total Multi Vitamines et Mineraux ) has been documented in six clinical trials involving 231 patients with HDD-CKD, 139 patients with NDD-CKD and 75 patients with PDD-CKD. Treatment-emergent adverse reactions reported by ≥ 2% of treated patients in the six clinical trials for which the rate for Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) exceeds the rate for comparator are listed by indication in Table 1. Patients with HDD-CKD received 100 mg doses at 10 consecutive dialysis sessions until a cumulative dose of 1000 mg was administered. Patients with NDD-CKD received either 5 doses of 200 mg over 2 weeks or 2 doses of 500 mg separated by fourteen days, and patients with PDD-CKD received 2 doses of 300 mg followed by a dose of 400 mg over a period of 4 weeks.

One hundred thirty (11%) of the 1,151 patients evaluated in the 4 U.S. trials in HDD-CKD patients (studies A, B and the two post marketing studies) had prior other intravenous Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) therapy and were reported to be intolerant (defined as precluding further use of that Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) product). When these patients were treated with Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) there were no occurrences of adverse reactions that precluded further use of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) .

Adverse Reactions in Pediatric Patients with CKD (ages 2 years and older)

Adverse Reactions in Pediatric Patients with CKD (ages 2 years and older)

In a randomized, open-label, dose-ranging trial for Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) maintenance treatment with Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) in pediatric patients with CKD on stable erythropoietin therapy , at least one treatment-emergent adverse reaction was experienced by 57% (27/47) of the patients receiving Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) 0.5 mg/kg, 53% (25/47) of the patients receiving Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) 1.0 mg/kg, and 55% (26/47) of the patients receiving Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) 2.0 mg/kg.

A total of 5 (11%) subjects in the Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) 0.5 mg/kg group, 10 (21%) patients in the Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) 1.0 mg/kg group, and 10 (21%) patients in the Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) 2.0 mg/kg group experienced at least 1 serious adverse reaction during the study. The most common treatment-emergent adverse reactions (> 2% of patients) in all patients were headache (6%), respiratory tract viral infection (4%), peritonitis (4%), vomiting (4%), pyrexia (4%), dizziness (4%), cough (4%), renal transplant (4%), nausea (3%), arteriovenous fistula thrombosis (2%), hypotension (2%), and hypertension (2.1%).

6.2 Adverse Reactions from Post-Marketing Experience

Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

In the post-marketing safety studies in 1,051 treated patients with HDD-CKD, the adverse reactions reported by > 1% were: cardiac failure congestive, sepsis and dysgeusia.

The following adverse reactions have been identified during post-approval use of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)). Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure: Anaphylactic-type reactions, shock, loss of consciousness, collapse, bronchospasm, dyspnea, convulsions, light-headedness, confusion, angioedema, swelling of the joints, hyperhidrosis, back pain, bradycardia, and chromaturia.

Symptoms associated with Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) total dosage or infusing too rapidly included hypotension, dyspnea, headache, vomiting, nausea, dizziness, joint aches, paresthesia, abdominal and muscle pain, edema, and cardiovascular collapse. These adverse reactions have occurred up to 30 minutes after the administration of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) injection. Reactions have occurred following the first dose or subsequent doses of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)). Symptoms may respond to intravenous fluids, hydrocortisone, and/or antihistamines. Slowing the infusion rate may alleviate symptoms.

Injection site discoloration has been reported following extravasation. Assure stable intravenous access to avoid extravasation.

7 DRUG INTERACTIONS

Drug interactions involving Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) have not been studied. However, Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) may reduce the absorption of concomitantly administered oral Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) preparations.

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Pregnancy Category B

Pregnancy Category B

There are no adequate and well-controlled studies in pregnant women. In animal reproduction studies, Total Multi Vitamines et Mineraux ) sucrose was administered intravenously to rats and rabbits during the period of organogenesis at doses up to 13 mg/kg/day of elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (half or equivalent to the maximum recommended human dose based on body surface area, respectively) and revealed no evidence of harm to the fetus due to Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose. Because animal reproductive studies are not always predictive of human response, Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) should be used during pregnancy only if clearly needed.

8.3 Nursing Mothers

It is not known whether Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose is excreted in human milk. Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose is secreted into the milk of lactating rats. Because many drugs are excreted in human milk, caution should be exercised when Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) is administered to a nursing woman.

8.4 Pediatric Use

Safety and effectiveness of Total Multi Vitamines et Mineraux ) for Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) replacement treatment in pediatric patients with dialysis-dependent or non-dialysis-dependent CKD have not been established.

Safety and effectiveness of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) for Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) maintenance treatment in pediatric patients 2 years of age and older with dialysis-dependent or non-dialysis-dependent CKD receiving erythropoietin therapy were studied. Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) at doses of 0.5 mg/kg, 1.0 mg/kg, and 2.0 mg/kg was administered. All three doses maintained hemoglobin between 10.5 g/dL and 14.0 g/dL in about 50% of subjects over the 12-week treatment period with stable EPO dosing. [See Clinical Studies (14.6)]

Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) has not been studied in patients younger than 2 years of age.

In a country where Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) is available for use in children, at a single site, five premature infants (weight less than 1,250 g) developed necrotizing enterocolitis and two of the five died during or following a period when they received Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)), several other medications and erythropoietin. Necrotizing enterocolitis may be a complication of prematurity in very low birth weight infants. No causal relationship to Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) or any other drugs could be established.

8.5 Geriatric Use

Clinical studies of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) did not include sufficient numbers of subjects aged 65 years and older to determine whether they respond differently from younger subjects. Of the 1,051 patients in two post-marketing safety studies of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)), 40% were 65 years and older. No overall differences in safety were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. In general, dose administration to an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

10 OVERDOSAGE

No data are available regarding overdosage of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) in humans. Excessive dosages of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) may lead to accumulation of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) in storage sites potentially leading to hemosiderosis. Do not administer Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) to patients with Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) overload.

Toxicities in single-dose studies in mice and rats, at intravenous Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose doses up to 8 times the maximum recommended human dose based on body surface area, included sedation, hypoactivity, pale eyes, bleeding in the gastrointestinal tract and lungs, and mortality.

11 DESCRIPTION

Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (iron sucrose injection, USP), an Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) replacement product, is a brown, sterile, aqueous, complex of polynuclear Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (III)-hydroxide in sucrose for intravenous use. Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose injection has a molecular weight of approximately 34,000 to 60,000 daltons and a proposed structural formula:

[Na₂Fe₅O₈(OH) ·3(H₂O)]_n ·m(C₁₂H₂₂O₁₁)

where: n is the degree of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) polymerization and m is the number of sucrose molecules associated with the Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (III)-hydroxide.

Each mL contains 20 mg elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) as Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose in water for injection. Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) is available in 10 mL single-use vials (200 mg elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) per 10 mL), 5 mL single-use vials (100 mg elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) per 5 mL), and 2.5 mL single-use vials (50 mg elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) per 2.5 mL). The drug product contains approximately 30% sucrose w/v (300 mg/mL) and has a pH of 10.5 to 11.1. The product contains no preservatives. The osmolarity of the injection is 1,250 mOsmol/L.

12 CLINICAL PHARMACOLOGY

12.1 Mechanism of Action

Total Multi Vitamines et Mineraux ) is an aqueous complex of poly-nuclear Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (III)-hydroxide in sucrose. Following intravenous administration, Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) is dissociated into Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) and sucrose and the Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) is transported as a complex with transferrin to target cells including erythroid precursor cells. The Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) in the precursor cells is incorporated into hemoglobin as the cells mature into red blood cells.

12.2 Pharmacodynamics

Following intravenous administration, Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) is dissociated into Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) and sucrose. In 22 patients undergoing hemodialysis and receiving erythropoietin (recombinant human erythropoietin) therapy treated with Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose containing 100 mg of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)), three times weekly for three weeks, significant increases in serum Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) and serum ferritin and significant decreases in total Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) binding capacity occurred four weeks from the initiation of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose treatment.

12.3 Pharmacokinetics

In healthy adults administered intravenous doses of Total Multi Vitamines et Mineraux ), its Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) component exhibited first order kinetics with an elimination half-life of 6 h, total clearance of 1.2 L/h, and steady state apparent volume of distribution of 7.9 L. The Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) component appeared to distribute mainly in blood and to some extent in extravascular fluid. A study evaluating Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) containing 100 mg of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) labeled with ⁵²Fe/⁵⁹Fe in patients with Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) deficiency showed that a significant amount of the administered Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) is distributed to the liver, spleen and bone marrow and that the bone marrow is an irreversible Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) trapping compartment.

Following intravenous administration of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)), Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose is dissociated into Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) and sucrose. The sucrose component is eliminated mainly by urinary excretion. In a study evaluating a single intravenous dose of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) containing 1,510 mg of sucrose and 100 mg of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) in 12 healthy adults (9 female, 3 male: age range 32 to 52), 68.3% of the sucrose was eliminated in urine in 4 h and 75.4% in 24 h. Some Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) was also eliminated in the urine. Neither transferrin nor transferrin receptor levels changed immediately after the dose administration. In this study and another study evaluating a single intravenous dose of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose containing 500 to 700 mg of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) in 26 patients with anemia on erythropoietin therapy (23 female, 3 male; age range 16 to 60), approximately 5% of the Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) was eliminated in urine in 24 h at each dose level. The effects of age and gender on the pharmacokinetics of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) have not been studied.

Pharmacokinetics in Pediatric Patients

Pharmacokinetics in Pediatric Patients

In a single-dose PK study of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)), patients with NDD-CDK ages 12 to 16 (N=11) received intravenous bolus doses of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) at 7 mg/kg (maximum 200 mg) administered over 5 minutes. Following single dose Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)), the half-life of total serum Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) was 8 hours. The mean Cmax and AUC values were 8545 μg/dl and 31305 hr-μg/dL, respectively, which were 1.42- and 1.67-fold higher than dose adjusted adult Cmax and AUC values.

Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) is not dialyzable through CA210 (Baxter) High Efficiency or Fresenius F80A High Flux dialysis membranes. In in vitro studies, the amount of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose in the dialysate fluid was below the levels of detection of the assay (less than 2 parts per million).

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenicity studies have not been performed with Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose.

Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose was not mutagenic in vitro in the bacterial reverse mutation assay (Ames test) or the mouse lymphoma assay. Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose was not clastogenic in the in vitro chromosome aberration assay using human lymphocytes or in the in vivo mouse micronucleus assay.

Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) sucrose at intravenous doses up to 15 mg/kg/day of elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (1.2 times the maximum recommended human dose based on body surface area) had no effect on fertility and reproductive function of male and female rats.

14 CLINICAL STUDIES

Five clinical trials involving 647 adult patients and one clinical trial involving 131 pediatric patients were conducted to assess the safety and efficacy of Total Multi Vitamines et Mineraux ).

14.1 Study A: Hemodialysis Dependent-Chronic Kidney Disease (HDD–CKD)

Study A was a multicenter, open-label, historically-controlled study in 101 patients with HDD-CKD (77 patients with Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) treatment and 24 in the historical control group) with Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) deficiency anemia. Eligibility criteria for Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) treatment included patients undergoing chronic hemodialysis, receiving erythropoietin, hemoglobin level between 8.0 and 11.0 g/dL, transferrin saturation < 20%, and serum ferritin < 300 ng/mL. The mean age of the patients was 65 years with the age range of 31 to 85 years. Of the 77 patients, 44 (57%) were male and 33 (43%) were female.

Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) 100 mg was administered at 10 consecutive dialysis sessions either as slow injection or a slow infusion. The historical control population consisted of 24 patients with similar ferritin levels as patients treated with Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)), who were off intravenous Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) for at least 2 weeks and who had received erythropoietin therapy with hematocrit averaging 31 to 36 for at least two months prior to study entry. The mean age of patients in the historical control group was 56 years, with an age range of 29 to 80 years. Patient age and serum ferritin level were similar between treatment and historical control patients.

Patients in the Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) treated population showed a greater increase in hemoglobin and hematocrit than did patients in the historical control population. See Table 2.

Serum ferritin increased at endpoint of study from baseline in the Venofer-treated population (165.3 ± 24.2 ng/mL) compared to the historical control population (-27.6 ± 9.5 ng/mL). Transferrin saturation also increased at endpoint of study from baseline in the Venofer-treated population (8.8 ± 1.6%) compared to this historical control population (-5.1 ± 4.3%).

14.2 Study B: Hemodialysis Dependent-Chronic Kidney Disease

Study B was a multicenter, open label study of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) in 23 patients with Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) deficiency and HDD-CKD who had been discontinued from Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) dextran due to intolerance. Eligibility criteria were otherwise identical to Study A. The mean age of the patients in this study was 53 years, with ages ranging from 21 to 79 years. Of the 23 patients enrolled in the study, 10 (44%) were male and 13 (56%) were female.

All 23 enrolled patients were evaluated for efficacy. Increases in mean hemoglobin (1.1 ± 0.2 g/dL), hematocrit (3.6 ± 0.6%), serum ferritin (266.3 ± 30.3 ng/mL) and transferrin saturation (8.7 ± 2.0%) were observed from baseline to end of treatment.

14.3 Study C: Hemodialysis Dependent-Chronic Kidney Disease

Study C was a multicenter, open-label study in patients with HDD-CKD. This study enrolled patients with a hemoglobin ≤ 10 g/dL, a serum transferrin saturation ≤ 20%, and a serum ferritin ≤ 200 ng/mL, who were undergoing maintenance hemodialysis 2 to 3 times weekly. The mean age of the patients enrolled in this study was 41 years, with ages ranging from 16 to 70 years. Of 130 patients evaluated for efficacy in this study, 68 (52%) were male and 62 (48%) were female. Forty-eight percent of the patients had previously been treated with oral Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)). Exclusion criteria were similar to those in studies A and B. Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) was administered in doses of 100 mg during sequential dialysis sessions until a pre-determined (calculated) total dose of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) was administered. A 50 mg dose (2.5 mL) was given to patients within two weeks of study entry as a test dose. Twenty-seven patients (20%) were receiving erythropoietin treatment at study entry and they continued to receive the same erythropoietin dose for the duration of the study.

The modified intention-to-treat (mITT) population consisted of 131 patients. Increases from baseline in mean hemoglobin (1.7 g/dL), hematocrit (5%), serum ferritin (434.6 ng/mL), and serum transferrin saturation (14%) were observed at week 2 of the observation period and these values remained increased at week 4 of the observation period.

14.4 Study D: Non-Dialysis Dependent-Chronic Kidney Disease

Study D was a randomized, open-label, multicenter, active-controlled study of the safety and efficacy of oral Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) versus Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) in patients with NDD-CKD with or without erythropoietin therapy. Erythropoietin therapy was stable for 8 weeks prior to randomization. In the study 188 patients with NDD-CKD, hemoglobin of ≤ 11.0 g/dL, transferrin saturation ≤ 25%, ferritin ≤ 300 ng/mL were randomized to receive oral Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (325 mg ferrous sulfate three times daily for 56 days); or Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (either 200 mg over 2 to 5 minutes 5 times within 14 days or two 500 mg infusions on Day 1 and Day 14, administered over 3.5 to 4 hours). The mean age of the 91 treated patients in the Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) group was 61.6 years (range 25 to 86 years) and 64 years (range 21 to 86 years) for the 91 patients in the oral Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) group.

A statistically significantly greater proportion of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) subjects (35/79; 44.3%) compared to oral Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) subjects (23/82; 28%) had an increase in hemoglobin ≥ 1 g/dL at anytime during the study (p = 0.03).

14.5 Study E: Peritoneal Dialysis Dependent-Chronic Kidney Disease

Study E was a randomized, open-label, multicenter study comparing patients with PDD-CKD receiving an erythropoietin and intravenous Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) to patients with PDD-CKD receiving an erythropoietin alone without Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) supplementation. Patients with PDD-CKD, stable erythropoietin for 8 weeks, hemoglobin of ≤ 11.5 g/dL, TSAT ≤ 25%, ferritin ≤ 500 ng/mL were randomized to receive either no Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) or Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (300 mg in 250 mL 0.9% NaCl over 1.5 hours on Day 1 and 15 and 400 mg in 250 mL 0.9% NaCl over 2.5 hours on Day 29). The mean age of the 75 treated patients in the Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) / erythropoietin group was 51.9 years (range 21 to 81 years) vs. 52.8 years (range 23 to 77 years) for 46 patients in the erythropoietin alone group.

Patients in the Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) / erythropoietin group had statistically significantly greater mean change from baseline to the highest hemoglobin value (1.3 g/dL), compared to subjects who received erythropoietin alone (0.6 g/dL) (p < 0.01). A greater proportion of subjects treated with Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) / erythropoietin (59.1 %) had an increase in hemoglobin of ≥ 1 g/dL at any time during the study compared to the subjects who received erythropoietin only (33.3%).

14.6 Study F: Total Multi Vitamines et Mineraux ) Maintenance Treatment Dosing in Pediatric Patients Ages 2 years and Older with Chronic Kidney Disease

Study F was a randomized, open-label, dose-ranging study for Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) maintenance treatment in pediatric patients with dialysis-dependent or non-dialysis-dependent CKD on stable erythropoietin therapy. The study randomized patients to one of three doses of Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (0.5 mg/kg, 1.0 mg/kg or 2.0 mg/kg). The mean age was 13 years (range 2 to 20 years). Over 70% of patients were 12 years or older in all three groups. There were 84 males and 61 females. About 60% of patients underwent hemodialysis and 25% underwent peritoneal dialysis in all three dose groups. At baseline, the mean hemoglobin was 12 g/dL, the mean TSAT was 33% and the mean ferritin was 300 ng/mL. Patients with HDD-CKD received Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) once every other week for 6 doses. Patients with PDD-CKD or NDD-CKD received Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) once every 4 weeks for 3 doses. Among 131 evaluable patients with stable erythropoietin dosing, the proportion of patients who maintained hemoglobin between 10.5 g/dL and 14.0 g/dL during the 12-week treatment period was 58.7%, 46.7%, and 45.0% in the Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) 0.5 mg/kg, 1.0 mg/kg, and 2.0 mg/kg groups, respectively. A dose-response relationship was not demonstrated.

16 HOW SUPPLIED/storage and handling

16.1 How Supplied

Total Multi Vitamines et Mineraux ) is supplied sterile in 10 mL, 5 mL, and 2.5 mL single-use vials. Each 10 mL vial contains 200 mg elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)), each 5 mL vial contains 100 mg elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)), and each 2.5 mL vial contains 50 mg elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) (20 mg/mL).

16.2 Stability and Storage

Contains no preservatives. Store in original carton at 20°C to 25°C (68° F to 77° F); excursions permitted to 15° to 30°C (59° to 86°F).. Do not freeze.

Syringe Stability: Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)), when diluted with 0.9% NaCl at concentrations ranging from 2 mg to 10 mg of elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) per mL, or undiluted (20 mg elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) per mL) and stored in a plastic syringe, was found to be physically and chemically stable for 7 days at controlled room temperature (25°C ± 2°C) and under refrigeration (4°C ± 2°C).

Intravenous Admixture Stability: Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)), when added to intravenous infusion bags (PVC or non-PVC) containing 0.9% NaCl at concentrations ranging from 1 mg to 2 mg of elemental Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) per mL, has been found to be physically and chemically stable for 7 days at controlled room temperature (25°C ± 2°C).

Do not dilute to concentrations below 1 mg/mL.

Do not mix Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) with other medications or add to parenteral nutrition solutions for intravenous infusion.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to infusion.

17 PATIENT COUNSELING INFORMATION

Prior to Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) administration:

• Question patients regarding any prior history of reactions to parenteral Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) products
• Advise patients of the risks associated with Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate))
• Advise patients to report any symptoms of hypersensitivity that may develop during and following Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) administration, such as rash, itching, dizziness, light-headedness, swelling, and breathing problems [see Warnings and Precautions (5)]

AMERICAN

REGENT, INC.

SHIRLEY, NY 11967

Total Multi Vitamines et Mineraux (Iron (Ferrous HVP Chelate)) is manufactured under license from Vifor (International) Inc., Switzerland.

PremierProRx^® is a trademark of Premier, Inc., used under license.

PREMIERProRx^®

IN2340

MG #15727

Magnesium (Magnesium HVP Chelate):

• Description
• Clinical pharmacology
• Indications and usage
• Contraindications
• Warnings
• Precautions
• Adverse reactions
• Overdosage
• Dosage and administration
• How supplied
• References
• Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) reviews

Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) Sulfate

Injection, USP

Ansyr Plastic Syringe

Rx only

Hospira Logo

DESCRIPTION

Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) Sulfate Injection, USP is a sterile solution of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate heptahydrate in Water for Injection, USP administered by the intravenous or intramuscular routes as an electrolyte replenisher or anticonvulsant. Must be diluted before intravenous use. May contain sulfuric acid and/or sodium hydroxide for pH adjustment. The pH is 5.5 to 7.0. The 50% concentration has an osmolarity of 4.06 mOsmol/mL (calc.).

The solution contains no bacteriostat, antimicrobial agent or added buffer (except for pH adjustment) and is intended only for use as a single-dose injection. When smaller doses are required the unused portion should be discarded with the entire unit.

Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) Sulfate, USP heptahydrate is chemically designated MgSO₄ - 7H₂O with molecular weight of 246.48 and occurs as colorless crystals or white powder freely soluble in water.

The plastic syringe is molded from a specially formulated polypropylene. Water permeates from inside the container at an extremely slow rate which will have an insignificant effect on solution concentration over the expected shelf life. Solutions in contact with the plastic container may leach out certain chemical components from the plastic in very small amounts; however, biological testing was supportive of the safety of the syringe material.

CLINICAL PHARMACOLOGY

Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) (Mg⁺⁺) is an important cofactor for enzymatic reactions and plays an important role in neurochemical transmission and muscular excitability.

As a nutritional adjunct in hyperalimentation, the precise mechanism of action for Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) is uncertain. Early symptoms of hypomagnesemia (less than 1.5 mEq/liter) may develop as early as three to four days or within weeks.

Predominant deficiency effects are neurological, e.g., muscle irritability, clonic twitching and tremors. Hypocalcemia and hypokalemia often follow low serum levels of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)). While there are large stores of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) present intracellularly and in the bones of adults, these stores often are not mobilized sufficiently to maintain plasma levels. Parenteral Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) therapy repairs the plasma deficit and causes deficiency symptoms and signs to cease.

Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) prevents or controls convulsions by blocking neuromuscular transmission and decreasing the amount of acetylcholine liberated at the end plate by the motor nerve impulse. Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) is said to have a depressant effect on the central nervous system (CNS), but it does not adversely affect the woman, fetus or neonate when used as directed in eclampsia or pre-eclampsia. Normal plasma Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) levels range from 1.5 to 2.5 mEq/liter.

As plasma Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) rises above 4 mEq/liter, the deep tendon reflexes are first decreased and then disappear as the plasma level approaches 10 mEq/liter. At this level respiratory paralysis may occur. Heart block also may occur at this or lower plasma levels of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)). Serum Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) concentrations in excess of 12 mEq/L may be fatal.

Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) acts peripherally to produce vasodilation. With low doses only flushing and sweating occur, but larger doses cause lowering of blood pressure. The central and peripheral effects of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) poisoning are antagonized to some extent by intravenous administration of calcium.

Pharmacokinetics

With intravenous administration the onset of anticonvulsant action is immediate and lasts about 30 minutes. Following intramuscular administration the onset of action occurs in about one hour and persists for three to four hours. Effective anticonvulsant serum levels range from 2.5 to 7.5 mEq/liter. Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) is excreted solely by the kidneys at a rate proportional to the plasma concentration and glomerular filtration.

INDICATIONS AND USAGE

Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) Sulfate Injection, USP is suitable for replacement therapy in Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) deficiency, especially in acute hypomagnesemia accompanied by signs of tetany similar to those observed in hypocalcemia. In such cases, the serum Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) (Mg⁺⁺) level is usually below the lower limit of normal (1.5 to 2.5 mEq/liter) and the serum calcium (Ca⁺⁺) level is normal (4.3 to 5.3 mEq/liter) or elevated.

In total parenteral nutrition (TPN), Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate may be added to the nutrient admixture to correct or prevent hypomagnesemia which can arise during the course of therapy.

Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) Sulfate Injection, USP is also indicated for the prevention and control of seizures (convulsions) in pre-eclampsia and eclampsia, respectively.

CONTRAINDICATIONS

Parenteral administration of the drug is contraindicated in patients with heart block or myocardial damage.

WARNINGS

FETAL HARM: Continuous administration of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate beyond 5 to 7 days to pregnant women can lead to hypocalcemia and bone abnormalities in the developing fetus. These bone abnormalities include skeletal demineralization and osteopenia. In addition, cases of neonatal fracture have been reported. The shortest duration of treatment that can lead to fetal harm is not known. Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate should be used during pregnancy only if clearly needed. If Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate is given for treatment of preterm labor, the woman should be informed that the efficacy and safety of such use have not been established and that use of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate beyond 5 to 7 days may cause fetal abnormalities.

ALUMINUM TOXICITY: This product contains aluminum that may be toxic. Aluminum may reach toxic levels with prolonged parenteral administration if kidney function is impaired. Premature neonates are particularly at risk because their kidneys are immature, and they require large amounts of calcium and phosphate solutions, which contain aluminum.

Research indicates that patients with impaired kidney function, including premature neonates, who receive parenteral levels of aluminum at greater than 4 to 5 mcg/kg/day accumulate aluminum at levels associated with central nervous system and bone toxicity. Tissue loading may occur at even lower rates of administration.

Parenteral use in the presence of renal insufficiency may lead to Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) intoxication. Intravenous use in the eclampsia should be reserved for immediate control of life-threatening convulsions.

PRECAUTIONS

General

Administer with caution if flushing and sweating occurs. When barbiturates, narcotics or other hypnotics (or systemic anesthetics) are to be given in conjunction with Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)), their dosage should be adjusted with caution because of additive CNS depressant effects of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)).

Because Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) is removed from the body solely by the kidneys, the drug should be used with caution in patients with renal impairment. Urine output should be maintained at a level of 100 mL or more during the four hours preceding each dose. Monitoring serum Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) levels and the patient's clinical status is essential to avoid the consequences of overdosage in toxemia. Clinical indications of a safe dosage regimen include the presence of the patellar reflex (knee jerk) and absence of respiratory depression (approximately 16 breaths or more/minute). When repeated doses of the drug are given parenterally, knee jerk reflexes should be tested before each dose and if they are absent, no additional Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) should be given until they return. Serum Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) levels usually sufficient to control convulsions range from 3 to 6 mg/100 mL (2.5 to 5 mEq/liter). The strength of the deep tendon reflexes begins to diminish when Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) levels exceed 4 mEq/liter. Reflexes may be absent at 10 mEq magnesium/liter, where respiratory paralysis is a potential hazard. An injectable calcium salt should be immediately available to counteract the potential hazards of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) intoxication in eclampsia.

50% Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) Sulfate Injection, USP must be diluted to a concentration of 20% or less prior to intravenous infusion. Rate of administration should be slow and cautious, to avoid producing hypermagnesemia. The 50% solution also should be diluted to 20% or less for intramuscular injection in infants and children.

Laboratory Tests

Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate injection should not be given unless hypomagnesemia has been confirmed and the serum concentration of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) is monitored. The normal serum level is 1.5 to 2.5 mEq/L.

Drug Interactions

CNS Depressants - When barbiturates, narcotics or other hypnotics (or systemic anesthetics), or other CNS depressants are to be given in conjunction with Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)), their dosage should be adjusted with caution because of additive CNS depressant effects of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)). CNS depression and peripheral transmission defects produced by Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) may be antagonized by calcium.

Neuromuscular Blocking Agents - Excessive neuromuscular block has occurred in patients receiving parenteral Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate and a neuromuscular blocking agent; these drugs should be administered concomitantly with caution.

Cardiac Glycosides - Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate should be administered with extreme caution in digitalized patients, because serious changes in cardiac conduction which can result in heart block may occur if administration of calcium is required to treat Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) toxicity.

Pregnancy

Teratogenic Effects

Pregnancy Category D (See WARNINGS and PRECAUTIONS )

See WARNINGS and PRECAUTIONS .

Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate can cause fetal abnormalities when administered beyond 5 to 7 days to pregnant women. There are retrospective epidemiological studies and case reports documenting fetal abnormalities such as hypocalcemia, skeletal demineralization, osteopenia and other skeletal abnormalities with continuous maternal administration of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate for more than 5 to 7 days.^1-10 Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate injection should be used during pregnancy only if clearly needed. If this drug is used during pregnancy, the woman should be apprised of the potential harm to the fetus.

Nonteratogenic Effects

When administered by continuous intravenous infusion (especially for more than 24 hours preceding delivery) to control convulsions in a toxemic woman, the newborn may show signs of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) toxicity, including neuromuscular or respiratory depression (See OVERDOSAGE ).

Labor and Delivery

Continuous administration of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate is an unapproved treatment for preterm labor. The safety and efficacy of such use have not been established. The administration of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate outside of its approved indication in pregnant women should be by trained obstetrical personnel in a hospital setting with appropriate obstetrical care facilities.

Nursing Mothers

Since Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) is distributed into milk during parenteral Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate administration, the drug should be used with caution in nursing women.

Geriatrics

Geriatric patients often require reduced dosage because of impaired renal function. In patients with severe impairment, dosage should not exceed 20 grams in 48 hours. Serum Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) should be monitored in such patients.

ADVERSE REACTIONS

The adverse effects of parenterally administered Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) usually are the result of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) intoxication. These include flushing, sweating, hypotension, depressed reflexes, flaccid paralysis, hypothermia, circulatory collapse, cardiac and central nervous system depression proceeding to respiratory paralysis. Hypocalcemia with signs of tetany secondary to Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate therapy for eclampsia has been reported.

OVERDOSAGE

Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) intoxication is manifested by a sharp drop in blood pressure and respiratory paralysis. Disappearance of the patellar reflex is a useful clinical sign to detect the onset of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) intoxication. In the event of overdosage, artificial ventilation must be provided until a calcium salt can be injected intravenously to antagonize the effects of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)).

For Treatment of Overdose

Artificial respiration is often required. Intravenous calcium, 10 to 20 mL of a 5% solution (diluted if desirable with isotonic sodium chloride for injection) is used to counteract effects of hypermagnesemia. Subcutaneous physostigmine, 0.5 to 1 mg may be helpful.

Hypermagnesemia in the newborn may require resuscitation and assisted ventilation via endotracheal intubation or intermittent positive pressure ventilation as well as intravenous calcium.

DOSAGE AND ADMINISTRATION

Dosage of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate must be carefully adjusted according to individual requirements and response, and administration of the drug should be discontinued as soon as the desired effect is obtained.

Both intravenous and intramuscular administration are appropriate. Intramuscular administration of the undiluted 50% solution results in therapeutic plasma levels in 60 minutes, whereas intravenous doses will provide a therapeutic level almost immediately. The rate of intravenous injection should generally not exceed 150 mg/minute (1.5 mL of a 10% concentration or its equivalent), except in severe eclampsia with seizures. Continuous maternal administration of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate in pregnancy beyond 5 to 7 days can cause fetal abnormalities.

Solutions for intravenous infusion must be diluted to a concentration of 20% or less prior to administration. The diluents commonly used are 5% Dextrose Injection, USP and 0.9% Sodium Chloride Injection, USP. Deep intramuscular injection of the undiluted (50%) solution is appropriate for adults, but the solution should be diluted to a 20% or less concentration prior to such injection in children.

In Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) Deficiency

In the treatment of mild Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) deficiency, the usual adult dose is 1 gram, equivalent to 8.12 mEq of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) (2 mL of the 50% solution) injected intramuscularly every six hours for four doses (equivalent to a total of 32.5 mEq of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) per 24 hours). For severe hypomagnesemia, as much as 250 mg (approximately 2 mEq) per kg of body weight (0.5 mL of the 50% solution) may be given intramuscularly within a period of four hours if necessary. Alternatively, 5 grams, (approximately 40 mEq) can be added to one liter of 5% Dextrose Injection, USP or 0.9% Sodium Chloride Injection, USP for slow intravenous infusion over a three-hour period. In the treatment of deficiency states, caution must be observed to prevent exceeding the renal excretory capacity.

In Hyperalimentation

In total parenteral nutrition, maintenance requirements for Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) are not precisely known. The maintenance dose used in adults ranges from 8 to 24 mEq (1 gram to 3 grams) daily; for infants, the range is 2 to 10 mEq (0.25 gram to 1.25 grams) daily.

In Pre-eclampsia or Eclampsia

In severe pre-eclampsia or eclampsia, the total initial dose is 10 grams to 14 grams of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate. Intravenously, a dose of 4 grams to 5 grams in 250 mL of 5% Dextrose Injection, USP or 0.9% Sodium Chloride Injection, USP may be infused. Simultaneously, intramuscular doses of up to 10 grams (5 grams or 10 mL of the undiluted 50% solution in each buttock) are given. Alternatively, the initial intravenous dose of 4 grams may be given by diluting the 50% solution to a 10 or 20% concentration; the diluted fluid (40 mL of a 10% solution or 20 mL of a 20% solution) may then be injected intravenously over a period of three to four minutes. Subsequently, 4 grams to 5 grams (8 to 10 mL of the 50% solution) are injected intramuscularly into alternate buttocks every four hours as needed, depending on the continuing presence of the patellar reflex and adequate respiratory function. Alternatively, after the initial intravenous dose, some clinicians administer 1 gram to 2 grams/hour by constant intravenous infusion. Therapy should continue until paroxysms cease. A serum Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) level of 6 mg/100 mL is considered optimal for control of seizures. A total daily (24 hr) dose of 30 grams to 40 grams should not be exceeded. In the presence of severe renal insufficiency, the maximum dosage of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate is 20 grams/48 hours and frequent serum Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) concentrations must be obtained. Continuous use of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate in pregnancy beyond 5 to 7 days can cause fetal abnormalities.

Other Uses

In counteracting the muscle-stimulating effects of barium poisoning, the usual dose of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate is 1 gram to 2 grams given intravenously.

For controlling seizures associated with epilepsy, glomerulonephritis or hypothyroidism, the usual adult dose is 1 gram administered intramuscularly or intravenously.

In paroxysmal atrial tachycardia, Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) should be used only if simpler measures have failed and there is no evidence of myocardial damage. The usual dose is 3 grams to 4 grams (30 to 40 mL of a 10% solution) administered intravenously over 30 seconds with extreme caution.

For reduction of cerebral edema, 2.5 grams (25 mL of a 10% solution) is given intravenously.

Incompatibilities

Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate in solution may result in a precipitate formation when mixed with solutions containing:

Alcohol (in high Heavy Metals

concentrations) Hydrocortisone sodium

Alkali carbonates and succinate

bicarbonates Phosphates

Alkali hydroxides Polymixin B sulfate

Arsenates Procaine hydrochloride

Barium Salicylates

Calcium Strontium

Clindamycin phosphate Tartrates

The potential incompatibility will often be influenced by the changes in the concentration of reactants and the pH of the solutions.

It has been reported that Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) may reduce the antibiotic activity of streptomycin, tetracycline and tobramycin when given together.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

HOW SUPPLIED

Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) Sulfate Injection, USP is supplied in single-dose containers as follows:

Do not administer unless solution is clear and container is undamaged. Discard unused portion.

Store at 20 to 25°C (68 to 77°F).

REFERENCES

• Yokoyama K, Takahashi N, Yada Y. Prolonged maternal Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) administration and bone metabolism in neonates. Early Hum Dev. 2010;86(3):187-91. Epub 2010 Mar 12.
• Wedig KE, Kogan J, Schorry EK et al. Skeletal demineralization and fractures caused by fetal Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) toxicity. J. Perinatol. 2006; 26(6):371-4.
• Nassar AH, Sakhel K, Maarouf H, et al. Adverse maternal and neonatal outcome of prolonged course of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate tocolysis. Acta Obstet Gynecol Scan. 2006;85(9):1099-103.
• Malaeb SN, Rassi A, Haddad MC. Bone mineralization in newborns whose mothers received Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulphate for tocolysis of premature labor. Pediatr Radiol. 2004;34(5):384-6. Epub 2004 Feb 18.
• Matsuda Y, Maeda Y, Ito M, et al. Effect of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate treatment on neonatal bone abnormalities. Gynecol Obstet Invest. 1997;44(2):82-8.
• Schanler RJ, Smith LG, Burns PA. Effects of long-term maternal intravenous Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate therapy on neonatal calcium metabolism and bone mineral content. Gynecol Obstet Invest. 1997;43(4):236-41.
• Santi MD, Henry GW, Douglas GL. Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate treatment of preterm labor as a cause of abnormal neonatal bone mineralization. J Pediatr Orthrop. 1994;14(2):249-53.
• Holcomb WL, Shackelford GD, Petrie RH. Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) tocolysis and neonatal bone abnormalities; a controlled study. Obstet Gynecol. 1991; 78(4):611-4.
• Cumming WA, Thomas VJ. Hypermagnesemia: a cause of abnormal metaphyses in the neonate. Am J Roentgenol. 1989; 152(5):1071-2.
• Lamm CL, Norton KL, Murphy RJ. Congenital rickets associated with Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate infusion for tocolysis. J Pediatr. 1988; 113(6):1078-82.
• McGuinness GA, Weinstein MM, Cruikshank DP, et al. Effects of Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate treatment on perinatal calcium metabolism. II. Neonatal responses. Obstet Gynecol. 1980; 56(5): 595-600.
• Riaz M, Porat R, Brodsky NL, et al. The effects of maternal Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) sulfate treatment on newborns: a prospective controlled study. J. Perinatol. 1998;18(6 pt 1):449-54.

Hospira, Inc., Lake Forest, IL 60045 USA

LAB-1024-1.0

April 2017

Hospira Logo

50% Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) Sulfate 5 g/10 mL (500 mg/mL)

Rx only

NDC 0409-1754-10

10 mL Single-dose syringe

50% Total Multi Vitamines et Mineraux (Magnesium (Magnesium HVP Chelate)) Sulfate Injection, USP

5 g/10 mL (500 mg/mL) (4 mEq Mg++/mL)

MUST BE DILUTED FOR INTRAVENOUS USE.

For Intravenous or Intramuscular Use. Sterile. 4.06 mOsmol/mL (calc.).

Contains no more than 75 mcg/L of aluminum.

Hospira, Inc., Lake Forest, IL 60045 USA

Hospira

RL-6891

Manganese (Manganese HVP Chelate):

• Indications and usage
• Contraindications
• Warnings
• Precautions
• Adverse reactions
• Drug abuse and dependence
• Overdosage
• Dosage and administration
• How supplied
• Rl-0104
• Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) reviews

INDICATIONS AND USAGE

Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) 0.1 mg/mL (Manganese Chloride Injection, USP) is indicated for use as a supplement to intravenous solutions given for total parenteral nutrition (TPN).

Administration helps to maintain Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) serum levels and to prevent depletion of endogenous stores and subsequent deficiency symptoms.

CONTRAINDICATIONS

None known.

WARNINGS

Direct intramuscular or intravenous injection of Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) 0.1 mg/mL (Manganese Chloride Injection, USP) is contraindicated as the acidic pH of the solution (pH 2.0) may cause considerable tissue irritation.

Liver and/or biliary tract dysfunction may require omission or reduction of copper and Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) doses because these elements are primarily eliminated in the bile.

WARNING: This product contains aluminum that may be toxic. Aluminum may reach toxic levels with prolonged parenteral administration if kidney function is impaired. Premature neonates are particularly at risk because their kidneys are immature, and they require large amounts of calcium and phosphate solutions, which contain aluminum.

Research indicates that patients with impaired kidney function, including premature neonates, who receive parenteral levels of aluminum at greater than 4 to 5 mcg/kg/day accumulate aluminum at levels associated with central nervous system and bone toxicity. Tissue loading may occur at even lower rates of administration.

PRECAUTIONS

General

Do not use unless solution is clear and seal is intact.

Total Multi Vitamines et Mineraux ) 0.1 mg/mL (Manganese Chloride Injection, USP) should only be used in conjunction with a pharmacy directed admixture program using aseptic technique in a laminar flow environment; it should be used promptly and in a single operation without any repeated penetrations. Solution contains no preservatives; discard unused portion immediately after admixture procedure is completed.

Laboratory Tests

Serum Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) levels can be measured periodically at the discretion of the investigator. Because of the low serum concentration normally present, samples will usually be analyzed by a reference laboratory.

Carcinogenesis, Mutagenesis, and Impairment of Fertility

Long-term animal studies to evaluate the carcinogenic potential of Total Multi Vitamines et Mineraux ) 0.1 mg/mL (Manganese Chloride Injection, USP) have not been performed, nor have studies been done to assess mutagenesis or impairment of fertility.

Nursing Mothers

It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) 0.1 mg/mL (Manganese Chloride Injection, USP) additive is administered to a nursing woman.

Pediatric Use

Safety and effectiveness in pediatric patients have not been established.

Pregnancy Category C.

Animal reproduction studies have not been conducted with Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) chloride. It is also not known whether Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) chloride can cause fetal harm when administered to a pregnant woman or can affect reproductive capacity. Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) chloride should be given to a pregnant woman only if clearly indicated.

Geriatric Use

An evaluation of current literature revealed no clinical experience identifying differences in response between elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

ADVERSE REACTIONS

None known.

DRUG ABUSE AND DEPENDENCE

None known.

OVERDOSAGE

Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) toxicity in TPN patients has not been reported.

DOSAGE AND ADMINISTRATION

Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) 0.1 mg/mL (Manganese Chloride Injection, USP) contains 0.1 mg manganese/mL and is administered intravenously only after dilution. The additive should be administered in a volume of fluid not less than 100 mL. For the adult receiving TPN, the suggested additive dosage for Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) is 0.15 to 0.8 mg/day (1.5 to 8 mL/day). For pediatric patients, a dosage of 2 to 10 mcg manganese/kg/day (0.02 to 0.1 mL/kg/day) is recommended.

Periodic monitoring of Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) plasma levels is suggested as a guideline for subsequent administration.

Parenteral products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. (See PRECAUTIONS .)

HOW SUPPLIED

Total Multi Vitamines et Mineraux (Manganese (Manganese HVP Chelate)) 0.1 mg/mL (Manganese Chloride Injection, USP) is supplied in 10 mL Plastic Vials (NDC No. 0409-4091-01).

Store at 20 to 25°C (68 to 77°F)

Revised: November, 2009

Printed in USA EN-2320

Hospira, Inc., Lake Forest, IL 60045 USA

RL-0104

Potassium (Potassium HVP Chelate):

• Description
• Clinical pharmacology
• Indications and usage
• Contraindications
• Warnings
• Precautions
• Adverse reactions
• Overdosage
• Dosage and administration
• How supplied
• Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) reviews

Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) CHLORIDE EXTENDED RELEASE TABLETS USP 20 mEq K

Rx Only

DESCRIPTION

The Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride Extended Release Tablets USP, 20 mEq product is an immediately dispersing extended release oral dosage form of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride containing 1500 mg of microencapsulated Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride, USP equivalent to 20 mEq of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) in a tablet.

These formulations are intended to slow the release of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) so that the likelihood of a high localized concentration of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride within the gastrointestinal tract is reduced.

Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride Extended Release Tablets USP, 20 mEq is an electrolyte replenisher. The chemical name of the active ingredient is Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride, and the structural formula is KCl. Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride, USP occurs as a white, granular powder or as colorless crystals. It is odorless and has a saline taste. Its solutions are neutral to litmus. It is freely soluble in water and insoluble in alcohol.

Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride Extended Release Tablets USP, 20 mEq is a tablet formulation (not enteric coated or wax matrix) containing individually microencapsulated Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride crystals which disperse upon tablet disintegration. In simulated gastric fluid at 37°C and in the absence of outside agitation, Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride Extended Release Tablets USP, 20 mEq begin disintegrating into microencapsulated crystals within seconds and completely disintegrates within 1 minute. The microencapsulated crystals are formulated to provide an extended release of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride.

Inactive Ingredients: Colloidal silicon dioxide, crospovidone, diethyl phthalate, ethyl-cellulose, microcrystalline cellulose.

CLINICAL PHARMACOLOGY

The Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) ion is the principal intracellular cation of most body tissues. Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) ions participate in a number of essential physiological processes including the maintenance of intracellular tonicity; the transmission of nerve impulses; the contraction of cardiac, skeletal, and smooth muscle; and the maintenance of normal renal function.

The intracellular concentration of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) is approximately 150 to 160 mEq per liter. The normal adult plasma concentration is 3.5 to 5 mEq per liter. An active ion transport system maintains this gradient across the plasma membrane.

Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) is a normal dietary constituent and under steady-state conditions the amount of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) absorbed from the gastrointestinal tract is equal to the amount excreted in the urine. The usual dietary intake of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) is 50 to 100 mEq per day.

Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) depletion will occur whenever the rate of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) loss through renal excretion and/or loss from the gastrointestinal tract exceeds the rate of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) intake. Such depletion usually develops as a consequence of therapy with diuretics, primary or secondary hyperaldosteronism, diabetic ketoacidosis, or inadequate replacement of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) in patients on prolonged parenteral nutrition. Depletion can develop rapidly with severe diarrhea, especially if associated with vomiting. Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) depletion due to these causes is usually accompanied by a concomitant loss of chloride and is manifested by hypokalemia and metabolic alkalosis. Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) depletion may produce weakness, fatigue, disturbances or cardiac rhythm (primarily ectopic beats), prominent U-waves in the electrocardiogram, and in advanced cases, flaccid paralysis and/or impaired ability to concentrate urine.

If Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) depletion associated with metabolic alkalosis cannot be managed by correcting the fundamental cause of the deficiency, eg, where the patient requires long-term diuretic therapy, supplemental Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) in the form of high Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) food or Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride may be able to restore normal Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) levels.

In rare circumstances (eg, patients with renal tubular acidosis) Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) depletion may be associated with metabolic acidosis and hyperchloremia. In such patients Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) replacement should be accomplished with Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) salts other than the chloride, such as Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) bicarbonate, Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) citrate, Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) acetate, or Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) gluconate.

INDICATIONS AND USAGE

BECAUSE OF REPORTS OF INTESTINAL AND GASTRIC ULCERATION AND BLEEDING WITH CONTROLLED-RELEASE Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) CHLORIDE PREPARATIONS, THESE DRUGS SHOULD BE RESERVED FOR THOSE PATIENTS WHO CANNOT TOLERATE OR REFUSE TO TAKE LIQUID OR EFFERVESCENT Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) PREPARATIONS OR FOR PATIENTS IN WHOM THERE IS A PROBLEM OF COMPLIANCE WITH THESE PREPARATIONS.

1. For the treatment of patients with hypokalemia with or without metabolic alkalosis, in digitalis intoxication, and in patients with hypokalemic familial periodic paralysis. If hypokalemia is the result of diuretic therapy, consideration should be given to the use of a lower dose of diuretic, which may be sufficient without leading to hypokalemia.

2. For the prevention of hypokalemia in patients who would be at particular risk if hypokalemia were to develop, eg, digitalized patients or patients with significant cardiac arrhythmias.

The use of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) salts in patients receiving diuretics for uncomplicated essential hypertension is often unnecessary when such patients have a normal dietary pattern and when low doses of the diuretic are used. Serum Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) should be checked periodically, however, and if hypokalemia occurs, dietary supplementation with potassium-containing foods may be adequate to control milder cases. In more severe cases, and if dose adjustment of the diuretic is ineffective or unwarranted, supplementation with Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) salts may be indicated.

CONTRAINDICATIONS

Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) supplements are contraindicated in patients with hyperkalemia since a further increase in serum Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) concentration in such patients can produce cardiac arrest. Hyperkalemia may complicate any of the following conditions: chronic renal failure, systemic acidosis, such as diabetic acidosis, acute dehydration, extensive tissue breakdown as in severe burns, adrenal insufficiency, or the administration of a potassium-sparing diuretic (eg, spironolactone, triamterene, amiloride) (see OVERDOSAGE ).

Controlled-release formulations of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride have produced esophageal ulceration in certain cardiac patients with esophageal compression due to enlarged left atrium. Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) supplementation, when indicated in such patients, should be given as a liquid preparation or as an aqueous (water) suspension of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride (see PRECAUTIONS: Information for Patients , and DOSAGE AND ADMINISTRATION sections).

All solid oral dosage forms of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride are contraindicated in any patient in whom there is structural, pathological (eg, diabetic gastroparesis), or pharmacologic (use of anticholinergic agents or other agents with anticholinergic properties at sufficient doses to exert anticholinergic effects) cause for arrest or delay in tablet passage through the gastrointestinal tract.

WARNINGS

Hyperkalemia (see OVERDOSAGE )

In patients with impaired mechanisms for excreting Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)), the administration of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) salts can produce hyperkalemia and cardiac arrest. This occurs most commonly in patients given Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) by the intravenous route but may also occur in patients given Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) orally. Potentially fatal hyperkalemia can develop rapidly and be asymptomatic. The use of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) salts in patients with chronic renal disease, or any other condition which impairs Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) excretion, requires particularly careful monitoring of the serum Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) concentration and appropriate dosage adjustment.

Interaction with Potassium-Sparing Diuretics

Hypokalemia should not be treated by the concomitant administration of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) salts and a potassium-sparing diuretic (eg, spironolactone, triamterene, or amiloride) since the simultaneous administration of these agents can produce severe hyperkalemia.

Interaction with Angiotensin-Converting Enzyme Inhibitors

Angiotensin-converting enzyme (ACE) inhibitors (eg, captopril, enalapril) will produce some Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) retention by inhibiting aldosterone production. Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) supplements should be given to patients receiving ACE inhibitors only with close monitoring.

Gastrointestinal Lesions

Solid oral dosage forms of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride can produce ulcerative and/or stenotic lesions of the gastrointestinal tract. Based on spontaneous adverse reaction reports, enteric-coated preparations of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride are associated with an increased frequency of small bowel lesions (40-50 per 100,000 patient years) compared to sustained release wax matrix formulations (less than one per 100,000 patient years). Because of the lack of extensive marketing experience with microencapsulated products, a comparison between such products and wax matrix or enteric-coated products is not available. Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride Extended Release Tablets USP, 20 mEq is a tablet formulated to provide a controlled rate of release of microencapsulated Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride and thus to minimize the possibility of a high local concentration of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) near the gastrointestinal wall.

Prospective trials have been conducted in normal human volunteers in which the upper gastrointestinal tract was evaluated by endoscopic inspection before and after 1 week of solid oral Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride therapy. The ability of this model to predict events occurring in usual clinical practice is unknown. Trials which approximated usual clinical practice did not reveal any clear differences between the wax matrix and microencapsulated dosage forms. In contrast, there was a higher incidence of gastric and duodenal lesions in subjects receiving a high dose of a wax matrix controlled-release formulation under conditions which did not resemble usual or recommended clinical practice (ie, 96 mEq per day in divided doses of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride administered to fasted patients, in the presence of an anticholinergic drug to delay gastric emptying). The upper gastrointestinal lesions observed by endoscopy were asymptomatic and were not accompanied by evidence of bleeding (Hemoccult testing). The relevance of these findings to the usual conditions (ie, non-fasting, no anticholinergic agent, smaller doses) under which controlled-release Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride products are used is uncertain; epidemiologic studies have not identified an elevated risk, compared to microencapsulated products, for upper gastrointestinal lesions in patients receiving wax matrix formulations. Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride Extended Release Tablets USP, 20 mEq should be discontinued immediately and the possibility of ulceration, obstruction, or perforation should be considered if severe vomiting, abdominal pain, distention, or gastrointestinal bleeding occurs.

Metabolic Acidosis

Hypokalemia in patients with metabolic acidosis should be treated with an alkalinizing Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) salt such as Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) bicarbonate, Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) citrate, Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) acetate, or Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) gluconate.

PRECAUTIONS

General

The diagnosis of Total Multi Vitamines et Mineraux ) depletion is ordinarily made by demonstrating hypokalemia in a patient with a clinical history suggesting some cause for Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) depletion. In interpreting the serum Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) level, the physician should bear in mind that acute alkalosis per se can produce hypokalemia in the absence of a deficit in total body Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) while acute acidosis per se can increase the serum Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) concentration into the normal range even in the presence of a reduced total body Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)). The treatment of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) depletion, particularly in the presence of cardiac disease, renal disease, or acidosis requires careful attention to acid-base balance and appropriate monitoring of serum electrolytes, the electrocardiogram, and the clinical status of the patient.

Information for Patients

Physicians should consider reminding the patient of the following: To take each dose with meals and with a full glass of water or other liquid. To take each dose without crushing, chewing, or sucking the tablets. If those patients are having difficulty swallowing whole tablets, they may try one of the following alternate methods of administration:

• Break the tablet in half, and take each half separately with a glass of water.
• Prepare an aqueous (water) suspension as follows:
  

  1. Place the whole tablet(s) in approximately 1/2 glass of water (4 fluid ounces).
  

  2. Allow approximately 2 minutes for the tablet(s) to disintegrate.
  

  3. Stir for about half a minute after the tablet(s) has disintegrated.
  

  4. Swirl the suspension and consume the entire contents of the glass immediately by drinking or by the use of a straw.
  

  5. Add another 1 fluid ounce of water, swirl, and consume immediately.
  

  6. Then, add an additional 1 fluid ounce of water, swirl, and consume immediately.

Aqueous suspension of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride that is not taken immediately should be discarded. The use of other liquids for suspending Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride Extended Release Tablets USP, 20 mEq is not recommended.

To take this medicine following the frequency and amount prescribed by the physician. This is especially important if the patient is also taking diuretics and/or digitalis preparations.

To check with the physician at once if tarry stools or other evidence of gastrointestinal bleeding is noticed.

Laboratory Tests

When blood is drawn for analysis of plasma Total Multi Vitamines et Mineraux ) it is important to recognize that artifactual elevations can occur after improper venipuncture technique or as a result of in vitro hemolysis of the sample.

Drug Interactions

Potassium-sparing diuretics, angiotensin-converting enzyme inhibitors (see WARNINGS ).

Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenicity, mutagenicity, and fertility studies in animals have not been performed. Total Multi Vitamines et Mineraux ) is a normal dietary constituent.

Pregnancy Category C

Animal reproduction studies have not been conducted with Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride Extended Release Tablets USP, 20 mEq. It is unlikely that Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) supplementation that does not lead to hyperkalemia would have an adverse effect on the fetus or would affect reproductive capacity.

Nursing Mothers

The normal Total Multi Vitamines et Mineraux ) ion content of human milk is about 13 mEq per liter. Since oral Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) becomes part of the body Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) pool, so long as body Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) is not excessive, the contribution of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride supplementation should have little or no effect on the level in human milk.

Pediatric Use

Safety and effectiveness in pediatric patients have not been established.

Geriatric Use

Clinical studies of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal or cardiac function, and of concomitant disease or other drug therapy.

This drug is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection; and it may be useful to monitor renal function.

ADVERSE REACTIONS

One of the most severe adverse effects is hyperkalemia (see CONTRAINDICATIONS , WARNINGS , and OVERDOSAGE ). There have also been reports of upper and lower gastrointestinal conditions including obstruction, bleeding, ulceration, and perforation (see CONTRAINDICATIONS and WARNINGS ). The most common adverse reactions to oral Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) salts are nausea, vomiting, flatulence, abdominal pain/discomfort, and diarrhea. These symptoms are due to irritation of the gastrointestinal tract and are best managed by diluting the preparation further, taking the dose with meals or reducing the amount taken at one time.

OVERDOSAGE

The administration of oral Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) salts to persons with normal excretory mechanisms for Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) rarely causes serious hyperkalemia. However, if excretory mechanisms are impaired or if Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) is administered too rapidly intravenously, potentially fatal hyperkalemia can result (see CONTRAINDICATIONS and WARNINGS ). It is important to recognize that hyperkalemia is usually asymptomatic and may be manifested only by an increased serum Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) concentration (6.5-8.0 mEq/L) and characteristic electrocardiographic changes (peaking of T-waves, loss of P-waves, depression of S-T segment, and prolongation of the QT-interval). Late manifestations include muscle paralysis and cardiovascular collapse from cardiac arrest (9-12 mEq/L).

Treatment measures for hyperkalemia include the following:

• Patients should be closely monitored for arrhythmias and electrolyte changes.
• Elimination of foods and medications containing Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) and of any agents with potassium-sparing properties such as potassium-sparing diuretics, ARBS, ACE inhibitors, NSAIDS, certain nutritional supplements and many others.
• Intravenous calcium gluconate if the patient is at no risk of developing digitalis toxicity.
• Intravenous administration of 300 to 500 mL/hr of 10% dextrose solution containing 10-20 units of crystalline insulin per 1,000 mL.
• Correction of acidosis, if present, with intravenous sodium bicarbonate.
• Use of exchange resins, hemodialysis, or peritoneal dialysis.

In treating hyperkalemia, it should be recalled that in patients who have been stabilized on digitalis, too rapid a lowering of the serum Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) concentration can produce digitalis toxicity.

The extended release feature means that absorption and toxic effects may be delayed for hours.

Consider standard measures to remove any unabsorbed drug.

DOSAGE AND ADMINISTRATION

The usual dietary intake of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) by the average adult is 50 to 100 mEq per day. Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) depletion sufficient to cause hypokalemia usually requires the loss of 200 or more mEq of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) from the total body store.

Dosage must be adjusted to the individual needs of each patient. The dose for the prevention of hypokalemia is typically in the range of 20 mEq per day. Doses of 40-100 mEq per day or more are used for the treatment of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) depletion. Dosage should be divided if more than 20 mEq per day is given such that no more than 20 mEq is given in a single dose.

Each Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride Extended Release Tablet USP, 20 mEq provides 20 mEq of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride.

Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride Extended Release Tablets USP, 20 mEq should be taken with meals and with a glass of water or other liquid. This product should not be taken on an empty stomach because of its potential for gastric irritation (see WARNINGS ).

Patients having difficulty swallowing whole tablets may try one of the following alternate methods of administration:

• Break the tablet in half, and take each half separately with a glass of water.
• Prepare an aqueous (water) suspension as follows:
  • Place the whole tablet(s) in approximately 1/2 glass of water (4 fluid ounces).
  • Allow approximately 2 minutes for the tablet(s) to disintegrate.
  • Stir for about half a minute after the tablet(s) has disintegrated.
  • Swirl the suspension and consume the entire contents of the glass immediately by drinking or by the use of a straw.
  • Add another 1 fluid ounce of water, swirl, and consume immediately.
  • Then, add an additional 1 fluid ounce of water, swirl, and consume immediately.

Aqueous suspension of Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride that is not taken immediately should be discarded. The use of other liquids for suspending Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride Extended Release Tablets USP, 20 mEq is not recommended.

HOW SUPPLIED

Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) Chloride Extended Release Tablets USP, 20 mEq are available in bottles of 100 (NDC 62037-999-01), bottles of 500 (NDC 62037-999-05), and bottles of 1000 (NDC 62037-999-10). Potassium Chloride Extended Release Tablets USP, 20 mEq are capsule shaped, white to off-white tablets, with “ABRS-123” imprinted on one side and scored on the other side for flexibility of dosing.

Storage Conditions

Keep tightly closed. Store at controlled room temperature, 20°-25°C (68°-77°F).

Manufactured by:

Eurand, Inc.

Vandalia, OH 45377 USA

Distributed by:

Watson Pharma, Inc.

Rev. Date (01/09) 173714

Total Multi Vitamines et Mineraux (Potassium (Potassium HVP Chelate)) chloride 20 Meq

Vitamin A (Retinol):

• Dosage and administration
• Warning
• Clinical pharmacology
• Dietary supplementation
• Warnings
• Precautions
• Adverse reactions
• Dosage and administration
• How supplied
• Total Multi Vitamines et Mineraux (Vitamin A (Retinol)) reviews

DOSAGE AND ADMINISTRATION

One tablet daily or as directed by a physician.

WARNING

KEEP OUT OF THE REACH OF CHILDREN.

In case of accidental overdose, seek professional assistance or contact a Poison Control Center immediately.

Other Ingredients: Artificial cherry flavor, artificial grape flavor, ascorbic acid, cholecalciferol, compressible sugar, D&C Red #7 calcium lake, FD&C Blue #1 aluminum lake, FD&C Yellow #6 aluminum lake, folic acid, magnesium stearate, microcrystalline cellulose, natural and artificial orange flavor, niacinamide, polyethylene glycol, pyridoxine HCl, riboflavin, sodium ascorbate, sodium fluoride, stearic acid, sucralose, thiamine HCl, Total Multi Vitamines et Mineraux (Vitamin A (Retinol)) acetate, vitamin B12 and vitamin E acetate.

Active ingredient for caries prophylaxis: Fluoride as sodium fluoride.

CLINICAL PHARMACOLOGY

Significant decrease in the incidence of dental caries can be linked to the fluoridation of the water supply (1ppm fluoride) during the period of tooth development.

Total Multi Vitamines et Mineraux (Vitamin A (Retinol)) Tablets provide sodium fluoride and ten essential vitamins in a chewable tablet. Because the tablets are chewable, they provide a topical as well as systemic source of fluoride. Hydroxyapatite is the principal crystal for all calcified tissue in the human body. The fluoride ion reacts with the Hydroxyapatite in the tooth as it is formed to produce the more caries-resistant crystal, fluorapatite.

The reaction may be expressed by the equation:

Three stages of fluoride deposition in tooth enamel can be distinguished:

• Small amounts (reflecting the low levels of fluoride in tissue fluids) are incorporated into the enamel crystals while they are being formed.
• After enamel has been laid down, fluoride deposition continues in the surface enamel. Diffusion of fluoride from the surface inward is apparently restricted.
• After eruption, the surface enamel acquires fluoride from the water, food, supplementary fluoride and smaller amounts of saliva.

DIETARY SUPPLEMENTATION

Multivitamins with fluoride offer supplementation of the diet with 10 vitamins and fluoride.

WARNINGS

AS IN THE CASE OF ALL MEDICATIONS, KEEP OUT OF THE REACH OF CHILDREN. This tablet should be chewed. This product, as with all chewable tablets are not recommended for children under the age of 4 due to risk of choking.

PRECAUTIONS

The suggested dose of Total Multi Vitamines et Mineraux (Vitamin A (Retinol)) Tablets should not be exceeded, since dental fluorosis may result from continued ingestion of large amounts of fluoride.

Before recommending Total Multi Vitamines et Mineraux (Vitamin A (Retinol)) Tablets

• Determine the fluoride content of the drinking water from all major sources
• Make sure the child is not receiving significant amounts of fluoride from other sources such as medications and swallowed toothpaste
• Periodically check to make sure that the child does not develop significant dental fluorosis.

ADVERSE REACTIONS

Allergic rash and other idiosyncrasies have been rarely reported.

To report SUSPECTED ADVERSE REACTIONS, contact H2-Pharma, LLC at 1 (866) 592-6438 or FDA at 1 (800) 332-1088 or via the web at www.fda.gov/medwatch/index.html for voluntary reporting of adverse reactions.

DOSAGE AND ADMINISTRATION

One tablet daily or as directed by a physician.

HOW SUPPLIED

Total Multi Vitamines et Mineraux ) Tablets 0.25 mg are available as orange, red and purple chewable tablets imprinted with "151" in 100 tablet bottles.

Total Multi Vitamines et Mineraux (Vitamin A (Retinol)) Tablets 0.5 mg are available as orange, red and purple chewable tablets imprinted with "152" in 100 tablet bottles.

Total Multi Vitamines et Mineraux (Vitamin A (Retinol)) Tablets 1.0 mg are available as orange, red and purple chewable tablets imprinted with "153" in 100 tablet bottles.

STORAGE

Store at controlled room temperature 20ºC-25ºC (68º-77ºF), excursions permitted between 15º-30ºC (59º-86ºF).

Distributed by:

H2-Pharma, LLC

2010 Berry Chase Place

Montgomery, AL 36117

www.h2-pharma.com

1067084

61269-151-01

MultiVitamin

with Fluoride

Chewable Tablets

Rx

0.25 mg

MultiVitamin and Fluoride Supplement

Dietary Supplement

100 Tablets

H²pharma

Vitamin E (D-Alpha Tocopherol Acid Succinate):

• Total Multi Vitamines et Mineraux (Vitamin E (D-Alpha Tocopherol Acid Succinate)) reviews

Indication: Total Multi Vitamines et Mineraux (Vitamin E (D-Alpha Tocopherol Acid Succinate)), known for its antioxidant activities, is protective against cardiovascular disease and some forms of cancer and has also demonstrated immune-enhancing effects. It may be of limited benefit in some with asthma and rheumatoid arthritis. It may be helpful in some neurological diseases including Alzheimer's, some eye disorders including cataracts, and diabetes and premenstrual syndrome. It may also help protect skin from ultraviolet irradiation although claims that it reverses skin aging, enhances male fertility and exercise performance are poorly supported. It may help relieve some muscle cramps.

Total Multi Vitamines et Mineraux (Vitamin E (D-Alpha Tocopherol Acid Succinate)) has antioxidant activity. It may also have anti-atherogenic, antithrombotic, anticoagulant, neuroprotective, antiviral, immunomodulatory, cell membrane-stabilizing and antiproliferative actions. Total Multi Vitamines et Mineraux (Vitamin E (D-Alpha Tocopherol Acid Succinate)) is a collective term used to describe eight separate forms, the best-known form being alpha-tocopherol. Total Multi Vitamines et Mineraux (Vitamin E (D-Alpha Tocopherol Acid Succinate)) is a fat-soluble vitamin and is an important antioxidant. It acts to protect cells against the effects of free radicals, which are potentially damaging by-products of the body's metabolism. Total Multi Vitamines et Mineraux (Vitamin E (D-Alpha Tocopherol Acid Succinate)) is often used in skin creams and lotions because it is believed to play a role in encouraging skin healing and reducing scarring after injuries such as burns. There are three specific situations when a Total Multi Vitamines et Mineraux (Vitamin E (D-Alpha Tocopherol Acid Succinate)) deficiency is likely to occur. It is seen in persons who cannot absorb dietary fat, has been found in premature, very low birth weight infants (birth weights less than 1500 grams, or 3½ pounds), and is seen in individuals with rare disorders of fat metabolism. A Total Multi Vitamines et Mineraux (Vitamin E (D-Alpha Tocopherol Acid Succinate)) deficiency is usually characterized by neurological problems due to poor nerve conduction. Symptoms may include infertility, neuromuscular impairment, menstrual problems, miscarriage and uterine degradation. Preliminary research has led to a widely held belief that Total Multi Vitamines et Mineraux (Vitamin E (D-Alpha Tocopherol Acid Succinate)) may help prevent or delay coronary heart disease. Antioxidants such as Total Multi Vitamines et Mineraux (Vitamin E (D-Alpha Tocopherol Acid Succinate)) help protect against the damaging effects of free radicals, which may contribute to the development of chronic diseases such as cancer. It also protects other fat-soluble vitamins (A and B group vitamins) from destruction by oxygen. Low levels of Total Multi Vitamines et Mineraux (Vitamin E (D-Alpha Tocopherol Acid Succinate)) have been linked to increased incidence of breast and colon cancer.