Mexidol® solution for intravenous and intramuscular administration 50 mg/ml, 5 vials of 5 ml

1. Name of the drug

Mexidol® solution for intravenous and intramuscular administration, 50 mg/ml, 5 ml

2. Qualitative and quantitative composition

Active ingredient: ethylmethylhydroxypyridine succinate. 1 mL of the solution contains 50 mg of ethylmethylhydroxypyridine succinate. 5 mL vial contains 100 mg of ethylmethylhydroxypyridine succinate. Main excipients: sodium metabisulfite – 0.4 mg in 1 mL of the drug (see section 4.4.). A complete list of excipients is given in section 6.1..

3. Dosage form

Solution for intravenous and intramuscular administration.
Transparent colorless or slightly yellowish liquid.

4. Clinical data

4.1. Indications:

• acute cerebral circulation disorders;
• cerebral infarction (ischemic stroke);
• traumatic brain injury, consequences of traumatic brain injury;
• dyscirculatory encephalopathy;
• Chronic cerebral ischemia;
• Vegetative dystonia syndrome;
• Mild (moderate) cognitive disorders;
• Anxiety disorders in neurotic and neurosis-like states;
• acute myocardial infarction (from the first day) as part of complex therapy;
• primary open -angle glaucoma of various stages, as part of complex therapy;
• withdrawal syndrome in alcoholism with predominance of neurosis-like and vegetative-vascular disorders;
• acute intoxication with antipsychotic drugs;
• acute purulent-inflammatory processes of the abdominal cavity (acute necrotizing pancreatitis, peritonitis) as part of complex therapy.

4.2. Dosage and administration:

Dosage regimen
: Adults: The maximum daily dose should not exceed 1200 mg.
For acute cerebrovascular accidents, Mexidol® is administered intravenously (IV) by drip, 200-500 mg 2-4 times daily for the first 10-14 days, then intramuscularly (IM), 200-250 mg 2-3 times daily for 2 weeks, after which a transition to oral dosage forms is recommended.

In case of cerebral infarction (ischemic stroke), Mexidol is administered intravenously by drip at 500 mg (10 ml) 2 times a day for 10 days, after which a transition is made to taking oral dosage forms at a dose of 250 mg 3 times a day for 60 days.

In case of traumatic brain injury and consequences of traumatic brain injury, Mexidol® is used for 10-15 days intravenously by drip at 200-500 mg 2-4 times a day, after which it is recommended to switch to oral dosage forms.
In case of discirculatory encephalopathy in the decompensation phase, Mexidol® should be prescribed intravenously by jet or drip at a dose of 200-500 mg 1-2 times a day for 14 days. Then intramuscularly at 100-250 mg per day for the next 2 weeks, after which it is recommended to switch to oral dosage forms.
For a course of prevention of discirculatory encephalopathy , the drug is administered intramuscularly at a dose of 200-250 mg 2 times a day for 10-14 days, after which it is recommended to switch to oral dosage forms.
In chronic cerebral ischemia, Mexidol® should be prescribed at 10 ml (500 mg) once a day intravenously by drip or intravenously by slow jet stream for 14 days, after which it is recommended to switch to oral dosage forms.
In mild (moderate) cognitive disorders, Mexidol® should be prescribed at 10 ml (500 mg) once a day intravenously by drip or intravenously by slow jet stream for 14 days, after which it is recommended to switch to oral dosage forms.
In anxiety disorders, the drug is used intramuscularly at a daily dose of 100-300 mg per day for 14-30 days, after which it is recommended to switch to oral dosage forms.
In acute myocardial infarction, as part of complex therapy, Mexidol® is administered intravenously or intramuscularly for 14 days against the background of traditional therapy for myocardial infarction, including nitrates, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, thrombolytics, anticoagulant and antiplatelet agents, as well as symptomatic agents as indicated.
In the first 5 days, to achieve the maximum effect, it is advisable to administer the drug intravenously, in the following 9 days, Mexidol® can be administered intramuscularly.
Intravenous administration of the drug is performed by drip infusion, slowly (to avoid side effects) in 0.9% sodium chloride solution or 5% dextrose (glucose) solution in a volume of 100-150 ml for 30-90 minutes. If necessary, a slow jet injection of the drug is possible for at least 5 minutes.
The drug is administered (intravenously or intramuscularly) 3 times a day every 8 hours. The daily therapeutic dose is 6-9 mg/kg of body weight per day, a single dose is 2-3 mg/kg of body weight. The maximum daily dose should not exceed 800 mg, a single dose is 250 mg.
For open-angle glaucoma of various stages, as part of complex therapy, Mexidol® is administered intramuscularly at 100-300 mg per day, 1-3 times a day for 14 days.
For alcohol withdrawal syndrome, Mexidol® is administered at a dose of 200-500 mg intravenously by drip or intramuscularly 2-3 times a day for 5-7 days.
In acute intoxication with antipsychotic drugs, the drug is administered intravenously at a dose of 200-500 mg per day for 7-14 days.
In acute purulent-inflammatory processes of the abdominal cavity (acute necrotic pancreatitis, peritonitis), the drug is prescribed on the first day both in the preoperative and postoperative periods. The administered doses depend on the form and severity of the disease, the prevalence of the process, and the variants of the clinical course. The drug should be discontinued gradually only after a stable positive clinical and laboratory effect.
In acute edematous (interstitial) pancreatitis, Mexidol® is prescribed at 200-500 mg 3 times a day, intravenously by drip (in 0.9% sodium chloride solution) and intramuscularly. Mild necrotic pancreatitis - 100-200 mg 3 times a day intravenously by drip (in 0.9% sodium chloride solution) and intramuscularly. Moderate severity - 200 mg 3 times a day, intravenously by drip (in 0.9% sodium chloride solution). Severe course - in a pulse dosage of 800 mg on the first day, with a twice-daily administration regimen; then 200-500 mg 2 times a day with a gradual reduction in the daily dose. Extremely severe course - in an initial dosage of 800 mg per day until persistent relief of pancreatogenic shock manifestations, after stabilization of the condition, 300-500 mg 2 times a day intravenously by drip (in 0.9% sodium chloride solution) with a gradual reduction in the daily dosage.

Mode of administration
IM or IV (by drop or stream infusion).
Stream infusion of Mexidol® is performed slowly for 5-7 minutes, and drop infusion of the drug is performed at a rate of 40-60 drops per minute.
See section 6.6 for instructions on how to prepare the drug before use.

4.3. Contraindications

• hypersensitivity to ethylmethylhydroxypyridine succinate or to any of the excipients listed in section 6.1;
• acute renal failure;
• acute hepatic failure;
• pregnancy, breastfeeding (due to insufficient knowledge of the drug);
• pediatric use (due to insufficient data on the drug action).

4.4. Special instructions and precautions for use:

In individual cases, especially in predisposed patients with bronchial asthma with hypersensitivity to sulfites, development of severe hypersensitivity reactions and bronchospasm is possible.

4.5. Interaction with other drugs and other types of interaction:

The drug enhances the effects of benzodiazepine anxiolytics, anticonvulsants (carbamazepine) and antiparkinsonian agents (levodopa). The drug reduces the toxic effects of ethyl alcohol.

Based on the results of clinical studies and post-marketing surveillance, no signals of drug-drug interactions have been identified.

4.6. Fertility, pregnancy and lactation:

Mexidol® is contraindicated during pregnancy and breastfeeding.

4.7. Effects on ability to drive and use machines

During the drug administration period, caution should be exercised when performing work requiring quick psychophysical reactions (driving vehicles, using machines, etc.).

4.8. Adverse reactions

Safety profile summary
To avoid the occurrence of adverse reactions, it is recommended to follow the dosage regimen and the rate of the drug administration.

Summary of adverse reactions
The frequency of adverse reactions was determined pursuant to the World Health Organization (WHO) classification: very common (≥10%), common (≥1 and <10%), uncommon (≥0.1 and <1%), rare (≥0.01% and <0.1%), very rare (<0.01%) and unknown (frequency cannot be determined based on available data).
Immune system disorders: very rare – anaphylactic shock, angioedema, urticaria.
Mental disorders:  very rare – drowsiness.
Nervous system disorders: very rare – headache, dizziness (may be associated with an excessively high rate of administration and is short-term).
Vascular disorders: very rare – decreased blood pressure (BP), increased BP (may be associated with an excessively high rate of administration and is short-term).
Respiratory system, chest and mediastinal organs disorders: very rare – dry cough, throat congestion, chest discomfort, difficulty breathing (may be associated with an excessively high rate of administration and is short-term).
Gastrointestinal disorders: very rare – dry mouth, nausea, unpleasant odor, metallic aftertaste.
Skin and subcutaneous tissue disorders: very rare – itching, rash, hyperemia.
General disorders and reactions at the injection site: very rare – warmth sensation.

Reporting suspected adverse reactions
It is important to report suspected adverse reactions after the marketing authorization of a drug in order to ensure continuous monitoring of its benefit-risk ratio. Healthcare professionals are advised to report any suspected adverse reactions of the drug through the national adverse reaction reporting systems of the Eurasian Economic Union member states.

4.9 Overdosage:

Symptoms
Drowsiness, insomnia.

Treatment
Due to low toxicity, overdose is unlikely. Treatment is usually not required, symptoms disappear within a day. In the case of pronounced manifestations, supportive and symptomatic treatment should be administered.

5. Pharmacological properties

5.1. Pharmacology

Pharmacotherapeutic group: Other drugs for the treatment of diseases of the nervous system. Other drugs for the treatment of diseases of the nervous system.
ATX code: N07XX.

The pharmacological action of Mexidol® is due to its antihypoxant, antioxidant and membrane-protective action. It inhibits lipid peroxidation processes, increases superoxide dismutase activity, increases the lipid-protein ratio, reduces membrane viscosity and increases membrane fluidity. The drug modulates the activity of membrane-bound enzymes (calcium-independent phosphodiesterase, adenylate cyclase, acetylcholinesterase), receptor complexes (benzodiazepine, gamma-aminobutyric acid (GABA), acetylcholine), which enhances their ability to bind to ligands, helps to preserve the structural and functional organization of biomembranes, transport neurotransmitters and improve synaptic transmission. Mexidol® increases the content of dopamine in the brain. It causes enhancement of compensatory activity of aerobic glycolysis and reduction of the inhibition rate of oxidative processes in the Krebs cycle under hypoxia with an increased content of adenosine triphosphate (ATP), creatine phosphate and activation of energy-synthesizing functions of mitochondria, as well as promotes stabilization of cell membranes.

Pharmacodynamic effects
It has antihypoxic, membrane-protective, nootropic, anticonvulsant, anxiolytic effects, increases the body's resistance to stress. The drug increases the body's resistance to the effects of major damaging factors, to oxygen-dependent pathological conditions (shock, hypoxia and ischemia, cerebrovascular accident, intoxication with alcohol and antipsychotic drugs (neuroleptics)). Stabilizes the membrane structures of blood cells (erythrocytes and platelets) during hemolysis.
Mexidol® improves cerebral metabolism and blood supply to the brain, improves microcirculation and rheological properties of blood, reduces platelet aggregation. It has a hypolipidemic effect, reduces the level of total cholesterol and low-density lipoproteins (LDL).

The use of Mexidol in cerebral infarction (ischemic stroke) reduces the degree of neurological deficit and improves the recovery of neurological functions, as well as improves the functional outcome and reduces disability. Mexidol® normalizes metabolic processes in the ischemic myocardium, reduces the necrosis zone, restores and improves electrical activity and myocardial contractility, and increases coronary blood flow in the ischemic zone, reduces the effects of reperfusion syndrome in acute coronary insufficiency. Increases the antianginal activity of nitro drugs.
Mexidol® helps preserve retinal ganglion cells and optic nerve fibers in progressive neuropathy caused by chronic ischemia and hypoxia. Improves the functional activity of the retina and optic nerve, increasing visual acuity.
Reduces enzymatic toxemia and endogenous intoxication in acute pancreatitis.

Clinical performance and safety
A randomized double-blind placebo-controlled parallel-group study of efficacy and safety of Mexidol® in phase III (EPICA) in long-term sequential therapy in patients with hemispheric ischemic stroke in the acute and early recovery periods involved 150 patients aged 40 to 79. The patients were randomized into 2 groups: the first group was treated with Mexidol® 500 mg daily by IV drop infusion for 10 days followed by 1 tablet (125 mg) 3 times a day for 8 weeks. The Mexidol® group showed a significant reduction of symptoms and functional disorders, as compared with the placebo group. Mexidol® administration led to significantly more pronounced improvement of vital activity in comparison with the placebo: the average score on the Modified Rankin Scale (mRS) at the end of therapy was lower in the Mexidol® group (p = 0,04). Furthermore, this group demonstrated more pronounced dynamics of decrease in the mRS average score (p = 0.023). The proportion of the patients who achieved recovery corresponding to 0-2 points on the mRS at the end of therapy was significantly higher in the Mexidol® group in comparison with the placebo group: 59 (96,7%) and 53 (84,1%), respectively (p = 0.039). The neurological deficit at the end of therapy was significantly lower in the Mexidol® group: the testing according to the National Institute of Health Stroke Scale showed that the mean value at the end of therapy was lower in the Mexidol® group (p = 0.035). The use of Mexidol® contributed to better functional recovery: the proportion of the patients with no spatial mobility issues was significantly higher (p = 0.022). According to the subanalysis results, the efficacy of Mexidol® on all of the scales used was identical in all of the age groups. There were no significant differences in the frequency of adverse reactions in the patients of both groups, and the safety profile of long-term sequential therapy with Mexidol® was comparable to that of the placebo in the patients of different age groups.
An international multicenter randomized double-blind placebo-controlled study to evaluate the efficacy and safety of sequential therapy with Mexidol® and Mexidol® FORTE 250 in phase III (MEMO) in patients with chronic cerebral ischemia involved 318 patients aged from 40 to 90. The patients were randomized into 2 groups: the first group was treated with Mexidol® 10 ml (500 mg) daily by IV drop or stream infusion slowly for 14 days followed by Mexidol® FORTE 250 1 tablet 3 times a day for the next 60 days. According to the results of the study, statistically significant changes in scores on the Montreal Cognitive Assessment Scale (MoCA) were detected at the end of therapy when comparing the progress between the groups of Mexidol®/Mexidol® FORTE 250 and the placebo (p < 0.000001, t-test for independent samples). The lower boundary of the 95% confidence interval for the mean difference of the main efficacy index between the groups of Mexidol®/Mexidol® FORTE 250 and the placebo was 1.51. This boundary is a positive value, indicative of the superior efficacy of Mexidol® and Mexidol® FORTE 250 over the placebo. Moreover, the results of the study revealed statistically significant changes of the MoCa scores at the end of therapy by the patient for the purpose of comparison of the progress between the groups of Mexidol® and Mexidol® FORTE 250 and placebo in the subanalysis for all of the age groups, which indicates equal efficacy of Mexidol® and Mexidol® FORTE 250 in all of the age groups. According to the results of evaluating secondary endpoints of efficacy of Mexidol® and Mexidol® FORTE 250 during the therapy, statistically significant differences between the drug groups and the placebo group were obtained for the following indicators: changes in cognitive impairment severity over time on the MoCA scale; changes in cognitive impairment severity over time according to the digit symbol substitution test; changes in asthenic disorders severity over time according to the Multidimensional Fatigue Inventory MFI-20; vegetative changes over time according to the Vein’s Questionnaire; changes in the anxiety level over time according to the Beck Depression Inventory; motor changes over time according to the Tinetti test; changes in the general clinical impression over time using the Clinical Global Impressions Scale; changes in the patients’ quality of life according to the Short Form (36) Health Survey questionnaire (psychological component of health).
The results of the statistical analysis of the adverse events frequency as well as the results of laboratory tests and physical examination demonstrate the absence of significant differences between the compared groups in terms of the primary safety endpoints, which is indicative of the comparable nature of the safety profiles of Mexidol® and Mexidol® FORTE 250 and the placebo. The subanalysis performed in patients of different age groups confirmed the similar nature of safety profiles of Mexidol®+Mexidol® FORTE 250 (ethylmethylhydroxypyridine succinate) and the placebo.

A prospective international multicenter randomized double-blind placebo-controlled study to evaluate the efficacy and safety of Mexidol + Mexidol FORTE 250 (MIR, phase III) in their sequential use in patients in the acute and early recovery periods of ischemic stroke was conducted with the participation of 304 patients aged 40 to 75 years. Patients in the study group received therapy with Mexidol 50 mg / ml, 10 ml (500 mg) 2 times a day (1000 mg per day) intravenously by drip for 10 days, followed by Mexidol FORTE 250 1 tablet 3 times a day for the next 60 days. Patients in the control group received Placebo according to a similar scheme. At the end of therapy, the change in the patient's condition assessment results using the mRS scale relative to the baseline was -2.45 points in the Mexidol + Mexidol FORTE 250 group and -2.01 points in the placebo group, and this difference was statistically significant (p = 0.003). At the end of therapy, a statistically significant prevalence of the proportion of disabled patients (3 or more points on the mRS scale) was revealed in the Placebo group (28%) compared to the Mexidol + Mexidol FORTE 250 group (16%) (p = 0.016). At the same time, the proportion of patients with an assessment of 0-1 point on the mRS scale at the end of therapy was statistically significantly (p = 0.002) higher in the Mexidol + Mexidol FORTE 250 group (60%) than in the Placebo group (41%). The obtained results of the study allow us to state the greater efficacy of Mexidol + Mexidol FORTE 250 in improving the functional outcome of the disease and reducing the level of disability compared to Placebo. Also, by the end of therapy, a statistically significant difference was recorded in terms of absolute dynamics, compared with the initial level and on the NIHSS scale: -7.00 [-9.00; -6.00] points in the Mexidol + Mexidol FORTE 250 group and -7.00 [-8.00; -5.00] points in the Placebo group (p < 0.001). Thus, when using Mexidol + Mexidol FORTE 250, a statistically significant, more pronounced recovery of neurological functions was noted compared to Placebo. The median of absolute dynamics according to the Rivermead index in the group of patients receiving Mexidol + Mexidol FORTE 250 at the end of therapy was 10.00 [7.00; 12.00] points compared to the Placebo group – 9.00 [7.00; 11.00] points (statistically significant differences between the groups at p = 0.008). According to the obtained results, the use of Mexidol in the acute and early recovery periods of ischemic stroke improves the patient's activity and mobility, which leads to more successful rehabilitation. An additional analysis in the ITT population including data from early termination visits confirmed the above findings. Statistical analysis of vital signs. SBP, DBP, HR and RR statistically significantly normalized in both groups. Thus, no negative effect of Mexidol on the cardiovascular system was detected. The safety analysis based on the registration of adverse reactions does not contain data on the presence of adverse drug interactions of the study drug Mexidol (parenteral and oral administration) with other drugs (antihypertensive, antithrombotic, lipid-lowering) included in the basic therapy. The results of the statistical analysis of the frequency of adverse events, physical examination data, including an assessment of vital signs, laboratory and instrumental examination methods demonstrated the absence of significant differences between the compared groups in the main safety indicators.

5.2. Pharmacokinetics:

Absorption
When administered intramuscularly, the drug is detected in blood plasma within 4 h after administration. The time-to-peak-concentration Tmax is 0.45-0.5 h. Cmax at an administration dose of 400-500 mg is 3.5-4.0 µg/mL

Distribution
The drug rapidly exits the blood stream into organs and tissues and is rapidly eliminated from the body. The mean residence time of the drug (MRT) is 0.7-1.3 h.

Biotransformation
The drug is metabolized in the liver by glucuronic conjugation. 5 metabolites have been identified: 3-oxypyridine phosphate is formed in the liver and decompounds into phosphoric acid and 3-oxypyridine by alkaline phosphatase; the 2nd metabolite is pharmacologically active, is formed in large quantities and detected in the urine 1-2 days after administration; the 3rd metabolite is excreted in large quantities with urine; the 4th and 5th metaolites are glucuronic conjugates.

Elimation
The drug is excreted mainly with urine, typically in the glucuronic conjugated form and in insignificant amounts in the unchanged form.

5.3. Preclinical safety data

No specific harm to humans has been identified in preclinical data obtained from standardized studies of pharmacological safety, repeated dose toxicity, genotoxicity, carcinogenic potential, reproductive and ontogenetic toxicity.

6. Pharmaceutical properties

6.1. List of excipients:

• Sodium metabisulfite;
• Water for injection.

6.2. Incompatibility:

This drug should not be mixed with other drugs except those listed in section 6.6.

6.3. Validity period (shelf life)

3 years.

6.4. Special storage precautions:

Store in a place protected from light at a temperature no higher than 25°C.

6.5. Description and content of the primary packaging

5 ml of the drug is packaged into vials made of colorless glass of the 1st hydrolytic class or neutral glass of NS-3 grade with a snap-off neck and three marking rings (yellow upper ring, white middle ring, red lower ring) or without marking rings.
The vial has a label made of writing paper, or label paper, or self-adhesive paper, or is inscribed with rotogravure ink or ink for inkjet printing for glassware or using enamel printing with subsequent heat treatment.
5 vials are placed into a blister pack made of polyvinyl chloride film type EP-73.2 or 4 blister packs of 5 ml vials are placed into a folding-box carton pack together with the patient information leaflet (package insert).
2 or 4 blister packs of 5 ml vials are placed into a folding-box carton pack together with the patient information leaflet (package insert).

6.6. Special precautions for disposal of the used drug or waste obtained after the drug administration or handling

There are no special requirements for disposal.
When administered by infusion, the drug should be diluted in 100-150 ml of 0.9% sodium chloride solution or 5% dextrose (glucose) solution.

7. Marketing authorization holder

Russia

PHARMASOFT RESEARCH AND PRODUCTION COMPLEX LLC
Bld. 12, floor 1, 41, Sudostroitelnaya Street, 115407 Moscow, Russia
Phone/fax: +7 495 626-47-55 Email: Pharmasoft@pharmasoft.ru

7.1 Representative of the marketing authorization holder:

Please address consumer complaints to:
in the Russian Federation:
"LLC “RESEARCH AND PRODUCTION COMPANY “PHARMASOFT”
Bld. 12, floor 1, 41, Sudostroitelnaya Street, 115407 Moscow, Russia.
Phone/fax: +7 (495) 626-47-55
Email: Pharmasoft@pharmasoft.ru

8. Marketing authorization number

ЛП-No.(000107)-(РГ-RU)

9. Date of the first marketing authorization (authorization confirmation, re-authorization)

Date of the first marketing authorization: December 29, 2020.

10. Text revision date

The summary of product characteristics for Mexidol® is available on the information portal of the Eurasian Economic Union in the Internet information and communication network at http://eec.eaeunion.org/.