Folenda

Colorless transparent vial containing white-colored uniform emulsified liquid.
Each mL contains: Propofol 10 mg.

Pharmacology: Pharmacodynamics: Propofol is a short-acting anesthetic given by IV for the induction and maintenance of general anesthesia. It is also used for sedation in adult patients undergoing surgery in conjunction with local or general anesthesia, induction is rapid, as is recovery. Propofol has no analgesic activity and supplementary analgesia may be required.
After intravenous injection of Propofol 10 mg/mL, a hypnotic effect occurs quickly. The induction time is dependent on the injection speed and is normally 30-40 seconds. The duration of effect is short as a result of rapid metabolization and excretion (4-6 minutes). The mechanism of action is not completely known, as with all general anesthetics. However, it is believe that Propofol produces its sedative or anesthetic effect by means of positive modulation of the inhibitory effect of the neurotransmitter GABA through the ligand-gated GABA_A receptors.
Limited studies on the duration of action of anesthesia with Propofol in children indicate that the safety and efficacy remain unchanged up to duration of 4 hours.
Pharmacokinetics: Propofol is up to 98% bound to plasma protein.
After intravenous administration, the initial progression of the blood concentration (alpha base) is characterized by a large decrease due to the rapid distribution in the organism. The half-life for this phase is 1.8-4.1 minutes. The decreased in the blood concentration is slower during the elimination or beta phase. The half-life for this phase was calculated at 34 to 64 minutes. A so-called deep compartment can be identified over a longer period of observation. The half-life for this phase (gamma phase) of the blood concentration is 184-382 minutes. The initial distribution volume V amounts to 22-76l, and the total distribution volume Vdβ is 387-1,587l. Propofol has a large distribution volume and is quickly eliminated from the body (total clearance: 1.5-2 L/min). The elimination occurs through metabolization, primarily in the liver, where inactive conjugates of Propofol and the corresponding hydroquinone are formed depending on the blood flow, which undergo renal excretion. Propofol is predominantly metabolized in the liver, Glucuronides of the Propofol and glucuronides as well as sulphates conjugates 2.6-diisopropyl-1.4-quinol are found as metabolites. 40% of the administered dose is present in the form of glucuronide of Propofol. All metabolites are inactive. Approximately 88% of the applied Propofol is excreted in the urine in the form of metabolites, and approximately 0.3% is unchanged in the stool.
Toxicology: Preclinical safety data: Acute toxicity: The intravenous LD50 in mice is 53, and in rats it is 42 mg Propofol/kg of body weight.
Chronic toxicity: Chronic toxicity trials have been carried out on rats and dogs. Doses of 10-30 mg Propofol/kg of body mass were administered daily or 2-3x per week for up to one month as an infusion. There were no indications of toxic effects or pathological changes.
Mutagenic effect: In-vitro studies in Salmonella thyphimurium (Ames test) and Saccharomyces cerevisiae as well as in-vivo studies in mice and Chinese hamsters did not show any indications of a mutagenic effect.
Reproduction toxicity: Propofol 10 mg/mL crosses the placenta. Embryo toxicity studies in rats and rabbits did not provide any indication of a teratogenic effect.
Published studies in animals (including primates) at doses resulting in light to moderate anesthesia demonstrates that the use of anesthetic agents during the rapid brain growth or synaptogenesis results in cell loss in the developing brain that can be associated with prolonged cognitive deficiencies. The clinical significance of these non-clinical findings is not known.
Propofol 10 mg/mL passes into breast milk. There is no experience in humans with use during pregnancy and the lactation period.
Carcinogenicity: Long-term studies regarding the potential for causing tumors have not been carried out.

Propofol (Folenda) 10 mg/mL is a short acting intravenous anesthetic suitable for induction and maintenance of general anesthesia. It can be also used in ICU (Intensive Care Unit) sedation and sedation for surgical and diagnostic procedures.

Propofol (Folenda) 10 mg/mL may only be administered by doctors that have been trained in anesthesiology intensive care. Sedation or anesthesia with Propofol 10 mg/mL and the surgical or diagnostic procedure may not be performed by the same person.
The cardiac, circulatory and respiratory functions should be continuously monitored (e.g. ECG, pulse oxymetry). The customary equipment for possible accidents during anesthesia or sedation must be ready for use at all times.
The dosage should be adjusted individually while taking the premedication and the patient's reaction into consideration.
Normally, the additional administration of analgesics is necessary.
Anesthesia for Adult (including elderly): Induction of anesthesia: For the induction of anesthesia, Propofol (Folenda) 10 mg/mL is administered, titrated at a speed of 20-40 mg Propofol every 10 seconds, until unconsciousness occurs.
Most adults less than 55 years of age would normally require a total dose of 1.5 to 2.5 mg Propofol/kg of body weight.
For patients in risk groups ASA III and IV, especially in the case of prior cardiac damage and elderly patients, it may be necessary to reduce the total dosage of Propofol (Folenda) 10 mg/mL down to 1 mg Propofol/kg body of mass. Whereby Propofol (Folenda) 10 mg/mL is administered at slower infusion speed (approximately 20 mg of Propofol every 10 second).
Maintenance of anesthesia: The anesthesia can be maintained with a long-term infusion or repeated bolus injections of Propofol (Folenda) 10 mg/mL.
Continuous infusion: For maintenance of anesthesia by means of continuous infusion, the dosage and infusion speed must be adjusted for each individual. Normally, the dosage is 4-12 mg Propofol/kg of body mass per hour in order to maintain a satisfactory level of anesthesia.
In the case of elderly patients in a poor general state of health or with hypovolemia and patients in the risk groups ASA III and IV, the dosage of Propofol (Folenda) 10 mg/mL may be reduced down to 4 mg Propofol/kg of body mass per hour.
Repeated bolus injection: For maintenance of anesthesia by means of repeated bolus injection, generally 25-50 mg Propofol (2.5-5 mL Propofol 10 mg/mL) are subsequently injected.
Anesthesia in children from 1 month of age: Induction of anesthesia: For the induction of anesthesia, Propofol (Folenda) 10 mg/mL is titrated slowly until clinical signs can be seen that indicate the start of anesthesia. The dose should be adjusted based on the age and/or body weight. Most children over 8 years of age likely to require approximately 2.5 mg Propofol/kg of body mass for induction of anesthesia. In the case of younger children, especially those in the age range of 1 month to 3 years, the required dose may be higher (2.5-4 mg Propofol/kg of body mass). Lower doses are recommended for patients in the risk groups ASA III and IV.
Maintenance of anesthesia: Maintenance of the required depth of anesthesia can be achieved with the administration of Propofol (Folenda) 10 mg/mL by means of an infusion or repeated bolus administration. The required dosage rates vary considerably among patients, however a satisfactory state of anesthesia is normally achieved at doses in the range of 9-15 mg/kg of body mass per hour. In the case of younger children, especially those in the age range of 1 month to 3 years, the required dose may be higher.
Lower doses are recommended for patients in the risk groups ASA III and IV.
Sedation of patients over 16 years of age during intensive care: For the sedation of ventilated patients during intensive care, Propofol (Folenda) 10 mg/mL should be administered as a continuous infusion. The dosage is based on the required depth of sedation. Normally, the desired depths of sedation can be achieved with doses in the range of 0.3 to 4.0 mg Propofol/kg of body mass per hour.
Propofol (Folenda) 10 mg/mL may not be used for the sedation of children aged 16 years or younger as part of intensive care.
The administration of Propofol (Folenda) 10 mg/mL by means of a TCI system is not recommended for sedation as part of intensive care.
Sedation of adults for surgical and diagnostic procedures: During the administration of Propofol (Folenda) 10 mg/mL, the patient must be continually monitored for signs of a decrease in blood pressure, respiratory tract obstruction and oxygen deficiency and the customary emergency equipment for accidents must be kept ready.
For induction of anesthesia, generally 0.5-1.0 mg Propofol/kg of body mass are administered for 1-5 minutes. For the maintenance of anesthesia, the dosage is determined based on the desired depth of sedation and is generally in the range between 1.5-4.5 mg Propofol/kg of body mass per hour.
In addition to the infusion, 10-20 mg may be injected as a bolus if a quick increase in the depth of sedation is necessary.
A lower dosage and slower administration may be necessary for patients in risk groups ASA III and IV. A lower dosage may also be necessary in patients over 55 years of age.
Note: In the case of elderly patients, smaller doses are required for the induction of anesthesia with Propofol (Folenda) 10 mg/mL. The patient's general state of health and age should be taken into account. The lowered dose should be administered more slowly and titrated according to the reaction.
Even when using Propofol (Folenda) 10 mg/mL for maintenance of anesthesia and for sedation, the infusion rate and the selected Propofol concentration in the blood should be decreased.
An additional lowering of the dosage and the infusion rate is necessary for patients in risk groups ASA III and IV. Elderly patients should not be given any bolus injections (individual or multiple), since circulatory and respiratory depression may result.
Sedation of children from 1 month of age for surgical and diagnostic procedures: The dosage and the periods between doses are selected based on the desired depth of sedation and the clinical response. For the induction of sedation, a dose of 1-2 mg Propofol/kg of body weight is necessary for most pediatric patients. Maintenance of the sedation is achieved with the titration of Propofol (Folenda) 10 mg/mL via an infusion until the desired depth of sedation is reached. For most patients, 1.5-9 mg Propofol/kg of body mass per hour is required. The infusion can be supplemented with bolus administration of up to 1 mg Propofol/kg of body mass, if a rapid increase in the depth of sedation is required.
Lower doses may be necessary for patients in the risk groups ASA III and IV.
Propofol 10 mg/mL may not be used for the sedation of children aged 16 years or younger as part of intensive care.
Method of use: Prior to use, the rubber stopper must be cleaned with alcohol spray or a swab dipped in alcohol. The rubber stopper does not contain latex. Opened containers should be destroyed after use. Propofol (Folenda) 10 mg/mL is administered intravenously, either undiluted from plastic syringes or glass vials or as a mixture with 5% glucose solution in PVC bags or glass vials.
Propofol (Folenda) 10 mg/mL does not contain any antimicrobial preservation media and the growth of microorganisms is facilitated due to its composition.
The emulsion must be drawn into a sterile syringe or a sterile administration device under aseptic conditions immediately after breaking the seal on the vial. The administration must be started immediately.
Strict asepsis must be adhered to both for Propofol 10 mg/mL and for the infusion equipment used during the period of the infusion. The addition of drugs or fluids into the ongoing infusion of Propofol 10 mg/mL must occur in close proximity to the cannula.
When using Propofol (Folenda) 10 mg/mL, no bacteria filters may be used.
The content of a vial and the respective infusion system are only intended for a single use in one patient.
Infusion of undiluted Propofol 10 mg/mL: For an infusion of undiluted Propofol (Folenda) 10 mg/mL, an infusion pump or volumetric pump should be employed.
The duration of an infusion of Propofol (Folenda) 10 mg/mL from one infusion system may not exceed 12 hours, as is customary for fat emulsions. At the end of the infusion, but after 12 hours at the latest, residual quantities of Propofol (Folenda) 10 mg/mL and the infusion system may not be further used; if necessary, the infusion system must be changed out.
Infusion of diluted Propofol 10 mg/mL: The infusion of diluted Propofol 10 mg/mL must occur by means of a controllable infusion system (burette or volumetric pump), in order to prevent the accidental administration of larger quantities of Propofol 10 mg/mL.
The maximum dilution must not exceed 1 part of Propofol with 4 parts of glucose 50 mg/mL (5%) solution for injection, sodium chloride 9 mg/mL (0.9%) solution for injection or sodium chloride 1.8 mg/mL (0.18%) and glucose 40 mg/mL (4%) solution for injection (minimum concentration 2 mg Propofol/mL). The mixture should be prepared aseptically (controlled and validated conditions preserved) immediately prior to administration and must be administered within 12 hours after preparation.
To reduce pain at the injection site Lidocaine may be injected immediately before the use of Propofol 10 mg/mL or Propofol 10 mg/mL may be mixed, immediately before use, with preservative free Lidocaine injection (20 parts of Propofol 10 mg/mL with up to 1 part of Lidocaine 10 mg/mL (1%) solution for injection) under controlled and validated aseptical conditions. The mixture has to be administered within 12 hours after preparation.
The muscle relaxants Atracurium and Mivacurium should not be administered through the same intravenous access as Propofol 10 mg/mL without first rinsing it out.
The vials should be shaken before use.
Duration of use: Propofol (Folenda) 10 mg/mL may only be used in a patient for a maximum of 7 days.

An overdose can lead to circulatory and respiratory depression. Apnea required artificial ventilation. In the case of circulatory depression, the usual measures should be taken of lowering the head position or/and plasma substitution and vasoconstrictors.

Propofol 10 mg/mL is contraindicated in the following: in the case of hypersensitivity to Propofol injection or its components, or when general anesthesia or sedation is contraindicated; for the sedation of patients aged 16 years or younger as part of intensive care (see Precautions).

During the use of Propofol 10 mg/mL for sedation for surgical and diagnostic procedures, the patient must be continually monitored for the first signs of a decrease in blood pressure, respiratory tract obstruction and oxygen deficiency.
As is also the case with other sedatives, spontaneous movements of the patient during surgical procedures may occur with the use of Propofol 10 mg/mL for sedation. For procedures that require an immobile patient, these movements may jeopardize the success of the operation.
Misuse and dependency on Propofol has been reported, primarily among healthcare personnel. As with all medications for general anesthesia, it may not be used without securing an airway; otherwise, there is the risk of deadly respiratory complications.
After the use of Propofol 10 mg/mL, it should be ensured that the patient has fully recovered from the anesthesia prior to discharge.
In individual cases, a postoperative unconsciousness phase can occur with the use of Propofol 10 mg/mL, which may be accompanied by increased muscle tone. The occurrence of this is dependent on whether or not the patient was previously awake. Even though the patient will spontaneously regain consciousness, an unconscious patient should be kept under intensive observation.
The impairments caused by Propofol 10 mg/mL are usually not observed for longer than 12 hours. When explaining the effect of Propofol 10 mg/mL to the patient, and when making the following recommendations, the doctor should take into consideration the type of procedure, the concomitant medication, the age and the condition of the patient.
The patient should only return home when accompanied by another person.
The patient should be made aware of when manual activities or activities requiring dexterity/risky activities (e.g. operating a motor vehicle) can be carried out again.
The patient should be made aware that taking other sedatives (e.g. Benzodiazepine, Opiates, alcohol) may prolong and increase the impairments.
As with other intravenous anesthetics, Propofol 10 mg/mL should be administered in a slower manner than usual and used with particular caution in patients with cardiac, respiratory, renal and hepatic disorders, hypovolemia or who are in a reduced general state of health.
Heart, circulatory and respiratory insufficiency as well as hypovolemia should be compensated prior to administration of the drug, if possible.
In the case of patients with severe cardiac damage, Propofol 10 mg/mL must be administered with corresponding caution and in combination with intensive monitoring.
A pronounced drop in blood pressure may necessitate the administration of plasma substitutes, possibly of vasoconstrictors, and slower administration of Propofol 10 mg/mL. The possibility of a massive drop in blood pressure should be taken into consideration for patients with reduced coronary or cerebral perfusion or with hypovolemia. The Propofol clearance is dependent on the blood flow. Therefore, if drugs are used at the same time that reduce the cardiac output, the Propofol clearance will also be reduced.
Propofol does not have a vagolytic effect. The use has been associated with the occurrence of bradycardia with an occasionally severe outcome (cardiac arrest). Therefore, in situations where there is pre-existing high vagal tone or when Propofol 10 mg/mL is administered with other drugs, which may decrease the heart rate, intravenous administration of an anticholinergic agent should be considered before or during anesthesia with Propofol 10 mg/mL.
When using Propofol 10 mg/mL in people with epilepsy, it is possible for a seizure to be triggered.
Before repeated or longer (>3 hours) use of Propofol in small children (<3 years of age) and pregnant women, the benefits and risks of the planned procedure should be taken into account, since there are reports of neurotoxicity from preclinical studies.
Notes regarding intensive medical care: The use of infusions with Propofol emulsion for sedation as part of intensive care is associated with a series of metabolic disorders and organ failure, which may lead to death.
In addition, combined occurrence of the following undesirable effects has also been reported: metabolic acidosis, rhabdomyolysis, hyperkalemia, hepatomegaly, renal failure, hyperlipidemia, heart arrhythmia, Brugada-type ECG (saddle or tent shaped ST segment elevations in the right precordial leads [V1-V3] and concave T waves) and/or quickly progressing heart failure, which was usually not able to be treated with supportive inotropic therapeutic measures.
The combination of these events is also called "Propofol infusion syndrome".
These events were most frequently observed in patients with severe head injuries and in children with respiratory tract infections, which had received higher doses than is foreseen for adults for the purpose of sedation during intensive care.
The following factors are believed to be significant risk factors for the development of this complication: Low oxygen saturation in tissue, severe neurological damage and/or sepsis; high doses of one or more of the following listed drugs: vasoconstrictors, steroids, inotropic agents and/or Propofol (usually at dosages of >4 mg Propofol/kg of body mass per hour for more than 48 hours).
The prescribing doctor should be aware of these possible undesired effects in patients with the risk factors described previously and immediately discontinue the use of Propofol if signs of the symptoms described previously occur. All sedatives and drugs, which are used during intensive care, should be titrated in such a way that optimal oxygen supply is ensured and the hemodynamic parameters remain optimized. In the case of these changes in therapy, patients with elevated intracranial pressure should receive an appropriate treatment that supports cerebral perfusion. The treating doctor should make sure that the recommended dosage of 4 mg Propofol/kg of body mass per hour is not exceeded, to the greatest extent possible.
Attention must be paid to lipid metabolism disorders or other disorders, as a result of which fat-containing emulsions should be used with caution.
A check of the lipid metabolism parameters is recommended if Propofol 10 mg/mL is used in patients, where there is the suspicion of elevated blood lipid values. The administration of Propofol 10 mg/mL should be adjusted accordingly if the analysis indicates a lipid metabolism disorder. In the case of patients that are simultaneously receiving parenteral nutrition, the quantity of lipids administered as a result of Propofol 10 mg/mL should be taken into account. 1.0 mL Propofol 10 mg/mL contains 0.1 g of fat.
Additional precaution: Patients with mitochondrial disorders should be treated with caution. These patients could experience an exacerbation of their disease if anesthesia is used on them or a surgical procedure or intensive care treatment is administered. It is recommended that a normal body temperature be maintained for these patients, that carbohydrates by administered and that they be provided with sufficient fluids. The early signs of an exacerbation of a mitochondrial disorder and Propofol infusion syndrome may be similar.
Propofol 10 mg/ml does not contain any antimicrobial preservation media, and the growth of microorganisms is facilitated due to its composition.
If Propofol 10 mg/mL is administered in combination with Lidocaine, it should be noted that Lidocaine may not be administered to patients with hereditary acute porphyria.
Propofol 10 mg/mL contains soybean oil, which may trigger severe allergic reactions very rarely.
This medicinal product contains less than 1 mmol sodium (23 mg) per vial, that is to say essentially 'sodium-free'.
Effects on Ability to Drive and Use Machines: After the administration of Propofol 10 mg/mL, the patient should be observed for an appropriate period of time. Patients should be made aware of fact that the ability to participate in traffic and use machinery may be impaired for some time after the administration of Propofol 10 mg/mL. The impairments caused by Propofol 10 mg/mL are usually not observed for longer than 12 hours (see as previously mentioned). The patient may only return home when accompanied by another person and may not drink any alcohol.
Use in Children: The use of Propofol 10 mg/mL in newborns is not recommended, since this patient group has not been sufficiently evaluated. Pharmacokinetic data indicate that the clearance of Propofol is considerably reduced in newborns and varies widely per individual. When using doses that are recommended for older children, an overdose occur and lead to severe circulatory and respiratory depression (see Adverse Reactions).
Propofol may not be used for sedation in patients 16 years of age or younger during intensive care, since the safety and efficacy of Propofol has not been validated for sedation in this age group (see Contraindications).

Pregnancy: The safety of Propofol during pregnancy has not been proven. Therefore, Propofol 10 mg/mL should only be used during pregnancy if absolutely necessary. Propofol 10 mg/ml crosses the placenta and may be associated with the depression of vital functions in newborns. Propofol can be employed as anesthesia in the case of termination of pregnancy.
High dosages (more than 2.5 mg Propofol/kg body mass for induction or 6 mg Propofol/kg of body mass per hour for maintenance of anesthesia) should be avoided.
Studies in animals have shown reproductive toxicity (see Pharmacology: Toxicology: Preclinical safety data under Actions).
Breast-feeding: Studies with breast-feeding women have shown that Propofol passes into breast milk in small quantities. Therefore, mothers should suspend breast-feeding for up to 24 hours after administration of Propofol and discard the corresponding breast milk.

The induction and maintenance of anesthesia and sedation with Propofol is normally gentle with only a few signs of excitation. The most frequently reported undesirable effects are pharmacologically foreseeable effects of anesthetics/sedatives, such as, for example, hypotension and respiratory depression. The type, severity and frequency of these effects, which were observed in patients during the use of Propofol, are dependent on the patient's state of health, type of procedure and the therapeutic measures taken. The frequency of the occurrence of undesirable effects is based on the following categories: Very common (≥1/10); Common (≥1/100 to <1/10); Uncommon (≥1/1,000 to <1/100); Rare (≥1/10,000 to <1/1,000); Very rare (<1/10,000); not known (cannot be estimated from the available data).
The following undesirable effects were particularly observed: See table.

Click on icon to see table/diagram/image

Propofol 10 mg/mL is compatible with other agents for anesthesia (premedication, muscle relaxants, inhaled anesthesia, analgesics, local anesthetics). In the case of regional anesthesia procedures, smaller doses of Propofol 10 mg/mL may be necessary. No indications of severe interactions have been observed. Some of the agents mentioned may decrease the blood pressure or impair respiration, so that there can be cumulative effects with the use of Propofol 10 mg/mL. A pronounced decrease in blood pressure when inducing anesthesia with Propofol has been reported in patients that were treated with Rifampicin.
If opiates are additionally administered prior to the anesthesia, apnea can occur more frequently and for a longer period of time.
In patients that take Valproate, the necessity of lower doses of Propofol has been observed. In the case of simultaneous use, a reduction of in the Propofol dose may be considered.

Store at temperatures not exceeding 30°C.

Anaesthetics - Local & General

N01AX10 - propofol ; Belongs to the class of other general anesthetics.

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