KMG Plus

Magnesium (Magnesium Proteinate):

• Description
• Clinical pharmacology
• Indications and usage
• Contraindications
• Warnings
• Precautions
• Adverse reactions
• Overdosage
• Dosage and administration
• How supplied
• References
• KMG Plus (Magnesium (Magnesium Proteinate)) reviews

KMG Plus (Magnesium (Magnesium Proteinate)) Sulfate

Injection, USP

Ansyr Plastic Syringe

Rx only

Hospira Logo

DESCRIPTION

KMG Plus (Magnesium (Magnesium Proteinate)) Sulfate Injection, USP is a sterile solution of KMG Plus (Magnesium (Magnesium Proteinate)) 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.

KMG Plus (Magnesium (Magnesium Proteinate)) 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

KMG Plus (Magnesium (Magnesium Proteinate)) (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 KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)). While there are large stores of KMG Plus (Magnesium (Magnesium Proteinate)) present intracellularly and in the bones of adults, these stores often are not mobilized sufficiently to maintain plasma levels. Parenteral KMG Plus (Magnesium (Magnesium Proteinate)) therapy repairs the plasma deficit and causes deficiency symptoms and signs to cease.

KMG Plus (Magnesium (Magnesium Proteinate)) prevents or controls convulsions by blocking neuromuscular transmission and decreasing the amount of acetylcholine liberated at the end plate by the motor nerve impulse. KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) levels range from 1.5 to 2.5 mEq/liter.

As plasma KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)). Serum KMG Plus (Magnesium (Magnesium Proteinate)) concentrations in excess of 12 mEq/L may be fatal.

KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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. KMG Plus (Magnesium (Magnesium Proteinate)) is excreted solely by the kidneys at a rate proportional to the plasma concentration and glomerular filtration.

INDICATIONS AND USAGE

KMG Plus (Magnesium (Magnesium Proteinate)) Sulfate Injection, USP is suitable for replacement therapy in KMG Plus (Magnesium (Magnesium Proteinate)) deficiency, especially in acute hypomagnesemia accompanied by signs of tetany similar to those observed in hypocalcemia. In such cases, the serum KMG Plus (Magnesium (Magnesium Proteinate)) (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), KMG Plus (Magnesium (Magnesium Proteinate)) sulfate may be added to the nutrient admixture to correct or prevent hypomagnesemia which can arise during the course of therapy.

KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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. KMG Plus (Magnesium (Magnesium Proteinate)) sulfate should be used during pregnancy only if clearly needed. If KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)), their dosage should be adjusted with caution because of additive CNS depressant effects of KMG Plus (Magnesium (Magnesium Proteinate)).

Because KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) should be given until they return. Serum KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) intoxication in eclampsia.

50% KMG Plus (Magnesium (Magnesium Proteinate)) 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

KMG Plus (Magnesium (Magnesium Proteinate)) sulfate injection should not be given unless hypomagnesemia has been confirmed and the serum concentration of KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)), their dosage should be adjusted with caution because of additive CNS depressant effects of KMG Plus (Magnesium (Magnesium Proteinate)). CNS depression and peripheral transmission defects produced by KMG Plus (Magnesium (Magnesium Proteinate)) may be antagonized by calcium.

Neuromuscular Blocking Agents - Excessive neuromuscular block has occurred in patients receiving parenteral KMG Plus (Magnesium (Magnesium Proteinate)) sulfate and a neuromuscular blocking agent; these drugs should be administered concomitantly with caution.

Cardiac Glycosides - KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) toxicity.

Pregnancy

Teratogenic Effects

Pregnancy Category D (See WARNINGS and PRECAUTIONS )

See WARNINGS and PRECAUTIONS .

KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) sulfate for more than 5 to 7 days.^1-10 KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) toxicity, including neuromuscular or respiratory depression (See OVERDOSAGE ).

Labor and Delivery

Continuous administration of KMG Plus (Magnesium (Magnesium Proteinate)) sulfate is an unapproved treatment for preterm labor. The safety and efficacy of such use have not been established. The administration of KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) is distributed into milk during parenteral KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) should be monitored in such patients.

ADVERSE REACTIONS

The adverse effects of parenterally administered KMG Plus (Magnesium (Magnesium Proteinate)) usually are the result of KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) sulfate therapy for eclampsia has been reported.

OVERDOSAGE

KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) intoxication. In the event of overdosage, artificial ventilation must be provided until a calcium salt can be injected intravenously to antagonize the effects of KMG Plus (Magnesium (Magnesium Proteinate)).

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 KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) Deficiency

In the treatment of mild KMG Plus (Magnesium (Magnesium Proteinate)) deficiency, the usual adult dose is 1 gram, equivalent to 8.12 mEq of KMG Plus (Magnesium (Magnesium Proteinate)) (2 mL of the 50% solution) injected intramuscularly every six hours for four doses (equivalent to a total of 32.5 mEq of KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) sulfate is 20 grams/48 hours and frequent serum KMG Plus (Magnesium (Magnesium Proteinate)) concentrations must be obtained. Continuous use of KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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, KMG Plus (Magnesium (Magnesium Proteinate)) 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

KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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

KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) sulfate tocolysis. Acta Obstet Gynecol Scan. 2006;85(9):1099-103.
• Malaeb SN, Rassi A, Haddad MC. Bone mineralization in newborns whose mothers received KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) sulfate therapy on neonatal calcium metabolism and bone mineral content. Gynecol Obstet Invest. 1997;43(4):236-41.
• Santi MD, Henry GW, Douglas GL. KMG Plus (Magnesium (Magnesium Proteinate)) 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. KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) sulfate infusion for tocolysis. J Pediatr. 1988; 113(6):1078-82.
• McGuinness GA, Weinstein MM, Cruikshank DP, et al. Effects of KMG Plus (Magnesium (Magnesium Proteinate)) 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 KMG Plus (Magnesium (Magnesium Proteinate)) 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% KMG Plus (Magnesium (Magnesium Proteinate)) Sulfate 5 g/10 mL (500 mg/mL)

Rx only

NDC 0409-1754-10

10 mL Single-dose syringe

50% KMG Plus (Magnesium (Magnesium Proteinate)) 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

Potassium (Potassium Proteinate):

• Description
• Clinical pharmacology
• Indications and usage
• Contraindications
• Warnings
• Precautions
• Adverse reactions
• Overdosage
• Dosage and administration
• How supplied
• KMG Plus (Potassium (Potassium Proteinate)) reviews

KMG Plus (Potassium (Potassium Proteinate)) CHLORIDE EXTENDED RELEASE TABLETS USP 20 mEq K

Rx Only

DESCRIPTION

The KMG Plus (Potassium (Potassium Proteinate)) Chloride Extended Release Tablets USP, 20 mEq product is an immediately dispersing extended release oral dosage form of KMG Plus (Potassium (Potassium Proteinate)) chloride containing 1500 mg of microencapsulated KMG Plus (Potassium (Potassium Proteinate)) chloride, USP equivalent to 20 mEq of KMG Plus (Potassium (Potassium Proteinate)) in a tablet.

These formulations are intended to slow the release of KMG Plus (Potassium (Potassium Proteinate)) so that the likelihood of a high localized concentration of KMG Plus (Potassium (Potassium Proteinate)) chloride within the gastrointestinal tract is reduced.

KMG Plus (Potassium (Potassium Proteinate)) Chloride Extended Release Tablets USP, 20 mEq is an electrolyte replenisher. The chemical name of the active ingredient is KMG Plus (Potassium (Potassium Proteinate)) chloride, and the structural formula is KCl. KMG Plus (Potassium (Potassium Proteinate)) 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.

KMG Plus (Potassium (Potassium Proteinate)) Chloride Extended Release Tablets USP, 20 mEq is a tablet formulation (not enteric coated or wax matrix) containing individually microencapsulated KMG Plus (Potassium (Potassium Proteinate)) chloride crystals which disperse upon tablet disintegration. In simulated gastric fluid at 37°C and in the absence of outside agitation, KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) chloride.

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

CLINICAL PHARMACOLOGY

The KMG Plus (Potassium (Potassium Proteinate)) ion is the principal intracellular cation of most body tissues. KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) 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.

KMG Plus (Potassium (Potassium Proteinate)) is a normal dietary constituent and under steady-state conditions the amount of KMG Plus (Potassium (Potassium Proteinate)) absorbed from the gastrointestinal tract is equal to the amount excreted in the urine. The usual dietary intake of KMG Plus (Potassium (Potassium Proteinate)) is 50 to 100 mEq per day.

KMG Plus (Potassium (Potassium Proteinate)) depletion will occur whenever the rate of KMG Plus (Potassium (Potassium Proteinate)) loss through renal excretion and/or loss from the gastrointestinal tract exceeds the rate of KMG Plus (Potassium (Potassium Proteinate)) intake. Such depletion usually develops as a consequence of therapy with diuretics, primary or secondary hyperaldosteronism, diabetic ketoacidosis, or inadequate replacement of KMG Plus (Potassium (Potassium Proteinate)) in patients on prolonged parenteral nutrition. Depletion can develop rapidly with severe diarrhea, especially if associated with vomiting. KMG Plus (Potassium (Potassium Proteinate)) depletion due to these causes is usually accompanied by a concomitant loss of chloride and is manifested by hypokalemia and metabolic alkalosis. KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) in the form of high KMG Plus (Potassium (Potassium Proteinate)) food or KMG Plus (Potassium (Potassium Proteinate)) chloride may be able to restore normal KMG Plus (Potassium (Potassium Proteinate)) levels.

In rare circumstances (eg, patients with renal tubular acidosis) KMG Plus (Potassium (Potassium Proteinate)) depletion may be associated with metabolic acidosis and hyperchloremia. In such patients KMG Plus (Potassium (Potassium Proteinate)) replacement should be accomplished with KMG Plus (Potassium (Potassium Proteinate)) salts other than the chloride, such as KMG Plus (Potassium (Potassium Proteinate)) bicarbonate, KMG Plus (Potassium (Potassium Proteinate)) citrate, KMG Plus (Potassium (Potassium Proteinate)) acetate, or KMG Plus (Potassium (Potassium Proteinate)) gluconate.

INDICATIONS AND USAGE

BECAUSE OF REPORTS OF INTESTINAL AND GASTRIC ULCERATION AND BLEEDING WITH CONTROLLED-RELEASE KMG Plus (Potassium (Potassium Proteinate)) CHLORIDE PREPARATIONS, THESE DRUGS SHOULD BE RESERVED FOR THOSE PATIENTS WHO CANNOT TOLERATE OR REFUSE TO TAKE LIQUID OR EFFERVESCENT KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) salts may be indicated.

CONTRAINDICATIONS

KMG Plus (Potassium (Potassium Proteinate)) supplements are contraindicated in patients with hyperkalemia since a further increase in serum KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) chloride have produced esophageal ulceration in certain cardiac patients with esophageal compression due to enlarged left atrium. KMG Plus (Potassium (Potassium Proteinate)) supplementation, when indicated in such patients, should be given as a liquid preparation or as an aqueous (water) suspension of KMG Plus (Potassium (Potassium Proteinate)) Chloride (see PRECAUTIONS: Information for Patients , and DOSAGE AND ADMINISTRATION sections).

All solid oral dosage forms of KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)), the administration of KMG Plus (Potassium (Potassium Proteinate)) salts can produce hyperkalemia and cardiac arrest. This occurs most commonly in patients given KMG Plus (Potassium (Potassium Proteinate)) by the intravenous route but may also occur in patients given KMG Plus (Potassium (Potassium Proteinate)) orally. Potentially fatal hyperkalemia can develop rapidly and be asymptomatic. The use of KMG Plus (Potassium (Potassium Proteinate)) salts in patients with chronic renal disease, or any other condition which impairs KMG Plus (Potassium (Potassium Proteinate)) excretion, requires particularly careful monitoring of the serum KMG Plus (Potassium (Potassium Proteinate)) concentration and appropriate dosage adjustment.

Interaction with Potassium-Sparing Diuretics

Hypokalemia should not be treated by the concomitant administration of KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) retention by inhibiting aldosterone production. KMG Plus (Potassium (Potassium Proteinate)) supplements should be given to patients receiving ACE inhibitors only with close monitoring.

Gastrointestinal Lesions

Solid oral dosage forms of KMG Plus (Potassium (Potassium Proteinate)) chloride can produce ulcerative and/or stenotic lesions of the gastrointestinal tract. Based on spontaneous adverse reaction reports, enteric-coated preparations of KMG Plus (Potassium (Potassium Proteinate)) 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. KMG Plus (Potassium (Potassium Proteinate)) Chloride Extended Release Tablets USP, 20 mEq is a tablet formulated to provide a controlled rate of release of microencapsulated KMG Plus (Potassium (Potassium Proteinate)) chloride and thus to minimize the possibility of a high local concentration of KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) 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. KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) salt such as KMG Plus (Potassium (Potassium Proteinate)) bicarbonate, KMG Plus (Potassium (Potassium Proteinate)) citrate, KMG Plus (Potassium (Potassium Proteinate)) acetate, or KMG Plus (Potassium (Potassium Proteinate)) gluconate.

PRECAUTIONS

General

The diagnosis of KMG Plus ) depletion is ordinarily made by demonstrating hypokalemia in a patient with a clinical history suggesting some cause for KMG Plus (Potassium (Potassium Proteinate)) depletion. In interpreting the serum KMG Plus (Potassium (Potassium Proteinate)) level, the physician should bear in mind that acute alkalosis per se can produce hypokalemia in the absence of a deficit in total body KMG Plus (Potassium (Potassium Proteinate)) while acute acidosis per se can increase the serum KMG Plus (Potassium (Potassium Proteinate)) concentration into the normal range even in the presence of a reduced total body KMG Plus (Potassium (Potassium Proteinate)). The treatment of KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) Chloride that is not taken immediately should be discarded. The use of other liquids for suspending KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus ) 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. KMG Plus ) is a normal dietary constituent.

Pregnancy Category C

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

Nursing Mothers

The normal KMG Plus ) ion content of human milk is about 13 mEq per liter. Since oral KMG Plus (Potassium (Potassium Proteinate)) becomes part of the body KMG Plus (Potassium (Potassium Proteinate)) pool, so long as body KMG Plus (Potassium (Potassium Proteinate)) is not excessive, the contribution of KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) salts to persons with normal excretory mechanisms for KMG Plus (Potassium (Potassium Proteinate)) rarely causes serious hyperkalemia. However, if excretory mechanisms are impaired or if KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) by the average adult is 50 to 100 mEq per day. KMG Plus (Potassium (Potassium Proteinate)) depletion sufficient to cause hypokalemia usually requires the loss of 200 or more mEq of KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) Chloride Extended Release Tablet USP, 20 mEq provides 20 mEq of KMG Plus (Potassium (Potassium Proteinate)) chloride.

KMG Plus (Potassium (Potassium Proteinate)) 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 KMG Plus (Potassium (Potassium Proteinate)) Chloride that is not taken immediately should be discarded. The use of other liquids for suspending KMG Plus (Potassium (Potassium Proteinate)) Chloride Extended Release Tablets USP, 20 mEq is not recommended.

HOW SUPPLIED

KMG Plus (Potassium (Potassium Proteinate)) 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

KMG Plus (Potassium (Potassium Proteinate)) chloride 20 Meq