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ropivacaine hydrochloride injection, USP Adverse Reactions

ADVERSE REACTIONS

Reactions to ropivacaine are characteristic of those associated with other amide-type local anesthetics. A major cause of adverse reactions to this group of drugs may be associated with excessive plasma levels, which may be due to overdosage, unintentional intravascular injection or slow metabolic degradation.

The reported adverse events are derived from clinical studies conducted in the U.S. and other countries. The reference drug was usually bupivacaine. The studies used a variety of premedications, sedatives, and surgical procedures of varying length. A total of 3,988 patients have been exposed to ropivacaine at concentrations up to 1% in clinical trials. Each patient was counted once for each type of adverse event.

Incidence ≥5%

For the indications of epidural administration in surgery, cesarean section, postoperative pain management, peripheral nerve block, and local infiltration, the following treatment-emergent adverse events were reported with an incidence of ≥ 5% in all clinical studies (N=3988): hypotension (37%), nausea (24.8%), vomiting (11.6%), bradycardia (9.3%), fever (9.2%), pain (8%), postoperative complications (7.1%), anemia (6.1%), paresthesia (5.6%), headache (5.1%), pruritus (5.1%), and back pain (5%).

Incidence 1 to 5%

Urinary retention, dizziness, rigors, hypertension, tachycardia, anxiety, oliguria, hypoesthesia, chest pain, hypokalemia, dyspnea, cramps, and urinary tract infection.

Incidence in Controlled Clinical Trials

The reported adverse events are derived from controlled clinical studies with ropivacaine (concentrations ranged from 0.125% to 1% for ropivacaine HCl and 0.25% to 0.75% for bupivacaine) in the U.S. and other countries involving 3,094 patients. Table 3A and 3B list adverse events (number and percentage) that occurred in at least 1% of ropivacaine-treated patients in these studies. The majority of patients receiving concentrations higher than 5 mg/mL (0.5%) were treated with ropivacaine HCl.

Table 3A Adverse Events Reported in ≥1% of Adult Patients Receiving Regional or Local Anesthesia (Surgery, Labor, Cesarean Section, Postoperative Pain Management, Peripheral Nerve Block and Local Infiltration)

Adverse Reaction

Ropivacaine

total N=1661

Bupivacaine

total N=1433

N

(%)

N

(%)

Hypotension

536

(32.3)

408

(28.5)

Nausea

283

(17)

207

(14.4)

Vomiting

Bradycardia

117

96

(7)

(5.8)

88

73

(6.1)

(5.1)

Headache

84

(5.1)

68

(4.7)

Paresthesia

82

(4.9)

57

(4)

Back pain

73

(4.4)

75

(5.2)

Pain

71

(4.3)

71

(5)

Pruritus

63

(3.8)

40

(2.8)

Fever

61

(3.7)

37

(2.6)

Dizziness

42

(2.5)

23

(1.6)

Rigors (Chills)

42

(2.5)

24

(1.7)

Postoperative complications

41

(2.5)

44

(3.1)

Hypoesthesia

27

(1.6)

24

(1.7)

Urinary retention

23

(1.4)

20

(1.4)

Progression of labor poor/failed

23

(1.4)

22

(1.5)

Anxiety

21

(1.3)

11

(0.8)

Breast disorder, breast-feeding

21

(1.3)

12

(0.8)

Rhinitis

18

(1.1)

13

(0.9)

 

Table 3B Adverse Events Reported in ≥1% of Fetuses or Neonates of Mothers Who Received Regional Anesthesia (Cesarean Section and Labor Studies)

Adverse Reaction

Ropivacaine

total N=639

Bupivacaine

total N=573

N

(%)

N

(%)

Fetal bradycardia

77

(12.1)

68

(11.9)

Neonatal jaundice

49

(7.7)

47

(8.2)

Neonatal complication-NOS

42

(6.6)

38

(6.6)

Apgar score low

18

(2.8)

14

(2.4)

Neonatal respiratory disorder

17

(2.7)

18

(3.1)

Neonatal tachypnea

14

(2.2)

15

(2.6)

Neonatal fever

13

(2)

14

(2.4)

Fetal tachycardia

13

(2)

12

(2.1)

Fetal distress

11

(1.7)

10

(1.7)

Neonatal infection

10

(1.6)

8

(1.4)

Neonatal hypoglycemia

8

(1.3)

16

(2.8)

Incidence <1%

The following adverse events were reported during the ropivacaine clinical program in more than one patient (N = 3988), occurred at an overall incidence of <1%, and were considered relevant:

Application Site Reactions - injection site pain
Cardiovascular System - vasovagal reaction, syncope, postural hypotension, non-specific ECG abnormalities
Female Reproductive - poor progression of labor, uterine atony
Gastrointestinal System - fecal incontinence, tenesmus, neonatal vomiting
General and Other Disorders - hypothermia, malaise, asthenia, accident and/or injury
Hearing and Vestibular - tinnitus, hearing abnormalities
Heart Rate and Rhythm - extrasystoles, non-specific arrhythmias, atrial fibrillation
Liver and Biliary System - jaundice
Metabolic Disorders - hypomagnesemia
Musculoskeletal System - myalgia
Myo/Endo/Pericardium - ST segment changes, myocardial infarction
Nervous System - tremor, Horner's syndrome, paresis, dyskinesia, neuropathy, vertigo, coma, convulsion, hypokinesia, hypotonia, ptosis, stupor
Psychiatric Disorders - agitation, confusion, somnolence, nervousness, amnesia, hallucination, emotional lability, insomnia, nightmares
Respiratory System - bronchospasm, coughing
Skin Disorders - rash, urticaria
Urinary System Disorders - urinary incontinence, micturition disorder
Vascular - deep vein thrombosis, phlebitis, pulmonary embolism
Vision - vision abnormalities

For the indication epidural anesthesia for surgery, the 15 most common adverse events were compared between different concentrations of ropivacaine and bupivacaine. Table 4 is based on data from trials in the U.S. and other countries where ropivacaine was administered as an epidural anesthetic for surgery.

Table 4 Common Events (Epidural Administration)

Adverse Reaction

Ropivacaine

Bupivacaine

5 mg/mL

total N = 256

7.5 mg/mL

total N = 297

10 mg/mL

total N = 207

5 mg/mL

total N = 236

7.5 mg/mL

total N = 174

N

(%)

N

(%)

N

(%)

N

(%)

N

(%)

Hypotension

99

(38.7)

146

(49.2)

113

(54.6)

91

(38.6)

89

(51.1)

Nausea

34

(13.3)

68

(22.9)

 

 

41

(17.4)

36

(20.7)

Bradycardia

29

(11.3)

58

(19.5)

40

(19.3)

32

(13.6)

25

(14.4)

Back pain

18

(7)

23

(7.7)

34

(16.4)

21

(8.9)

23

(13.2)

Vomiting

18

(7)

33

(11.1)

23

(11.1)

19

(8.1)

14

(8)

Headache

12

(4.7)

20

(6.7)

16

(7.7)

13

(5.5)

9

(5.2)

Fever

8

(3.1)

5

(1.7)

18

(8.7)

11

(4.7)

 

 

Chills

6

(2.3)

7

(2.4)

6

(2.9)

4

(1.7)

3

(1.7)

Urinary retention

5

(2)

8

(2.7)

10

(4.8)

10

(4.2)

 

 

Paresthesia

5

(2)

10

(3.4)

5

(2.4)

7

(3)

 

 

Pruritus

 

 

14

(4.7)

3

(1.4)

 

 

7

(4)

Using data from the same studies, the number (%) of patients experiencing hypotension is displayed by patient age, drug and concentration in Table 5. In Table 6, the adverse events for ropivacaine are broken down by gender.

Table 5 Effects of Age on Hypotension (Epidural Administration) Total N: Ropivacaine = 760, Bupivacaine = 410

Ropivacaine

Bupivacaine

Age

5 mg/mL

7.5 mg/mL

10 mg/mL

5 mg/mL

7.5 mg/mL

<65

≥65

N

68

31

(%)

(32.2)

(68.9)

N

99

47

(%)

(43.2)

(69.1)

N

87

26

(%)

(51.5)

(68.4)

N

64

27

(%)

(33.5)

(60)

N

73

16

(%)

(48.3)

(69.6)

 

Table 6 Most Common Adverse Events by Gender (Epidural Administration) Total N: Females = 405, Males = 355

Adverse Reaction

FEMALE

MALE

N

(%)

N

(%)

Hypotension

Nausea

Bradycardia

Vomiting

Back pain

Headache

Chills

Fever

Pruritus

Pain

Urinary retention

Dizziness

Hypoesthesia

Paresthesia

220

119

65

59

41

33

18

16

16

12

11

9

8

8

(54.3)

(29.4)

(16)

(14.6)

(10.1)

(8.1)

(4.4)

(4)

(4)

(3)

(2.7)

(2.2)

(2)

(2)

138

23

56

8

23

17

5

3

1

4

7

4

2

10

(38.9)

(6.5)

(15.8)

(2.3)

(6.5)

(4.8)

(1.4)

(0.8)

(0.3)

(1.1)

(2)

(1.1)

(0.6)

(2.8)

Systemic Reactions

The most commonly encountered acute adverse experiences that demand immediate countermeasures are related to the central nervous system and the cardiovascular system. These adverse experiences are generally dose-related and due to high plasma levels that may result from overdosage, rapid absorption from the injection site, diminished tolerance or from unintentional intravascular injection of the local anesthetic solution. In addition to systemic dose-related toxicity, unintentional subarachnoid injection of drug during the intended performance of lumbar epidural block or nerve blocks near the vertebral column (especially in the head and neck region) may result in underventilation or apnea ("Total or High Spinal"). Also, hypotension due to loss of sympathetic tone and respiratory paralysis or underventilation due to cephalad extension of the motor level of anesthesia may occur. This may lead to secondary cardiac arrest if untreated. Factors influencing plasma protein binding, such as acidosis, systemic diseases that alter protein production or competition with other drugs for protein binding sites, may diminish individual tolerance.

Epidural administration of ropivacaine has, in some cases, as with other local anesthetics, been associated with transient increases in temperature to > 38.5°C. This occurred more frequently at doses of ropivacaine HCl > 16 mg/h.

Neurologic Reactions

These are characterized by excitation and/or depression. Restlessness, anxiety, dizziness, tinnitus, blurred vision or tremors may occur, possibly proceeding to convulsions. However, excitement may be transient or absent, with depression being the first manifestation of an adverse reaction. This may quickly be followed by drowsiness merging into unconsciousness and respiratory arrest. Other central nervous system effects may be nausea, vomiting, chills, and constriction of the pupils.

The incidence of convulsions associated with the use of local anesthetics varies with the route of administration and the total dose administered. In a survey of studies of epidural anesthesia, overt toxicity progressing to convulsions occurred in approximately 0.1% of local anesthetic administrations.

The incidence of adverse neurological reactions associated with the use of local anesthetics may be related to the total dose and concentration of local anesthetic administered and are also dependent upon the particular drug used, the route of administration, and the physical status of the patient. Many of these observations may be related to local anesthetic techniques, with or without a contribution from the drug. During lumbar epidural block, occasional unintentional penetration of the subarachnoid space by the catheter or needle may occur. Subsequent adverse effects may depend partially on the amount of drug administered intrathecally as well as the physiological and physical effects of a dural puncture. These observations may include spinal block of varying magnitude (including high or total spinal block), hypotension secondary to spinal block, urinary retention, loss of bladder and bowel control (fecal and urinary incontinence), and loss of perineal sensation and sexual function. Signs and symptoms of subarachnoid block typically start within 2 to 3 minutes of injection. Doses of 15 and 22.5 mg of ropivacaine HCl resulted in sensory levels as high as T5 and T4, respectively. Analgesia started in the sacral dermatomes in 2 to 3 minutes and extended to the T10 level in 10 to 13 minutes and lasted for approximately 2 hours. Other neurological effects following unintentional subarachnoid administration during epidural anesthesia may include persistent anesthesia, paresthesia, weakness, paralysis of the lower extremities, and loss of sphincter control; all of which may have slow, incomplete or no recovery. Headache, septic meningitis, meningismus, slowing of labor, increased incidence of forceps delivery, or cranial nerve palsies due to traction on nerves from loss of cerebrospinal fluid have been reported (see DOSAGE AND ADMINISTRATION discussion of Lumbar Epidural Block). A high spinal is characterized by paralysis of the arms, loss of consciousness, respiratory paralysis and bradycardia.

Cardiovascular System Reactions

High doses or unintentional intravascular injection may lead to high plasma levels and related depression of the myocardium, decreased cardiac output, heart block, hypotension, bradycardia, ventricular arrhythmias, including ventricular tachycardia and ventricular fibrillation, and possibly cardiac arrest (see WARNINGS, PRECAUTIONS, and OVERDOSAGE).

Allergic Reactions

Allergic type reactions are rare and may occur as a result of sensitivity to the local anesthetic (see WARNINGS). These reactions are characterized by signs such as urticaria, pruritus, erythema, angioneurotic edema (including laryngeal edema), tachycardia, sneezing, nausea, vomiting, dizziness, syncope, excessive sweating, elevated temperature, and possibly, anaphylactoid symptomatology (including severe hypotension). Cross-sensitivity among members of the amide-type local anesthetic group has been reported. The usefulness of screening for sensitivity has not been definitively established.

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