nal transport of many organic compounds, including aminohippuric acid, and may affect renal excretion of phenylacetylglutamine and hippurate. there have been reports that valproic acid can induce hyperammonemia through inhibition of the synthesis of n -acetylglutamate, a co-factor for carbamyl phosphate synthetase. therefore, administration of valproic acid to patients with urea cycle disorders may exacerbate their condition and antagonize the efficacy of sodium phenylacetate and sodium benzoate injection 10% / 10%. use of corticosteroids may cause a protein catabolic state and, thereby, potentially increase plasma ammonia levels in patients with impaired ability to form urea.

s, repeat loading doses should not be administered. additionally, neurotoxicity related to phenylacetate has been reported in cancer patients. monitor patients for symptoms of acute neurotoxicity. (5.4) hyperventilation and metabolic acidosis: sodium phenylacetate and sodium benzoate injection 10% / 10% may cause side effects typically associated with salicylate overdose, such as hyperventilation and metabolic acidosis. monitor patient blood chemistry profiles and perform frequent blood ph and pco 2 measurements. (5.5) 5.1 decreased potassium levels because urine potassium loss is enhanced by the excretion of the non-reabsorbable anions, phenylacetylglutamine and hippurate, plasma potassium levels should be carefully monitored and appropriate treatment given when necessary. 5.2 conditions associated with fluid overload sodium phenylacetate and sodium benzoate injection 10% / 10% contains 30.5 mg of sodium per ml of undiluted product. thus, sodium phenylacetate and sodium benzoate injection 10% / 10% should be used with great care, if at all, in patients with congestive heart failure or severe renal insufficiency, and in clinical states in which there is sodium retention with edema. discontinue administration of sodium phenylacetate and sodium benzoate injection 10% / 10%, evaluate the patient, and institute appropriate therapeutic countermeasures if an adverse event occurs. 5.3 extravasation administration must be through a central venous catheter . administration through a peripheral line may cause burns . bolus infusion flow rates are relatively high, especially for infants [ see dosage and administration (2) ]. extravasation of sodium phenylacetate and sodium benzoate injection 10% / 10% into the perivenous tissues may lead to skin necrosis. if extravasation is suspected, discontinue the infusion and resume at a different infusion site, if necessary. the infusion site must be monitored closely for possible infiltration during drug administration. do not administer undiluted product. 5.4 neurotoxicity of phenylacetate because of prolonged plasma levels achieved by phenylacetate in pharmacokinetic studies, repeat loading doses of sodium phenylacetate and sodium benzoate injection 10% / 10% should not be administered. additionally, neurotoxicity was reported in cancer patients receiving intravenous phenylacetate, 250–300 mg/kg/day for 14 days, repeated at 4-week intervals. manifestations were predominantly somnolence, fatigue, and lightheadedness, with less frequent headaches, dysgeusia, hypoacusis, disorientation, impaired memory, and exacerbation of a pre-existing neuropathy. the acute onset of symptoms upon initiation of treatment and reversibility of symptoms when the phenylacetate was discontinued suggest a drug effect. [see animal toxicology and/or pharmacology (13.2) ] 5.5 hyperventilation and metabolic acidosis due to structural similarities between phenylacetate and benzoate to salicylate, sodium phenylacetate and sodium benzoate injection 10% / 10% may cause side effects typically associated with salicylate overdose, such as hyperventilation and metabolic acidosis. monitoring of blood chemistry profiles, blood ph and pco 2 should be performed.

ts, and adults (table 1). abbreviations: cps - carbamyl phosphate synthetase; otc - ornithine transcarbamylase; ass -argininosuccinate synthetase; asl-argininosuccinate lyase table 1: dosage and administration patient population components of infusion solution sodium phenylacetate and sodium benzoate injection 10% / 10% must be diluted with sterile 10% dextrose injection at ≥ 25 ml/kg before administration . dosage provided sodium phenylacetate and sodium benzoate injection 10% / 10% arginine hcl injection, 10% sodium phenylacetate sodium benzoate arginine hcl cps and otc deficiency patients 0 to 20 kg: dose loading: over 90 to 120 minutes maintenance: over 24 hours 2.5 ml/kg 2 ml/kg 250 mg/kg 250 mg/kg 200 mg/kg ass and asl deficiency dose loading: over 90 to 120 minutes maintenance: over 24 hours 2.5 ml/kg 6 ml/kg 250 mg/kg 250 mg/kg 600 mg/kg cps and otc deficiency patients >20kg: dose loading: over 90 to 120 minutes maintenance: over 24 hours 55 ml/m 2 2 ml/kg 5.5g/m 2 5.5 g/m 2 200 mg/kg ass and asl deficiency dose loading: over 90 to 120 minutes maintenance: over 24 hours 55 ml/m 2 6 ml/kg 5.5 g/m 2 5.5 g/m 2 600 mg/kg 2.2 administration sodium phenylacetate and sodium benzoate injection 10% / 10% is a concentrated solution and must be diluted before intravenous administration via a central venous catheter. administration through a peripheral intravenous catheter may cause burns. sodium phenylacetate and sodium benzoate injection 10% / 10% may not be administered by any other route. sodium phenylacetate and sodium benzoate injection 10% / 10% should be administered as a loading dose infusion over 90 to 120 minutes, followed by the same dose repeated as a maintenance infusion administered over 24 hours. because of prolonged plasma levels achieved by phenylacetate in pharmacokinetic studies, repeat loading doses of sodium phenylacetate and sodium benzoate injection 10% / 10% should not be administered. maintenance infusions may be continued until elevated plasma ammonia levels have been normalized or the patient can tolerate oral nutrition and medications. an antiemetic may be administered during sodium phenylacetate and sodium benzoate injection 10% / 10% infusion to aid control of infusion-associated nausea and vomiting. administration of analogous oral drugs, such as sodium phenylbutyrate, should be terminated prior to sodium phenylacetate and sodium benzoate injection 10% / 10% infusion. sodium phenylacetate and sodium benzoate injection 10% / 10% infusion should be started as soon as the diagnosis of hyperammonemia is made. treatment of hyperammonemia also requires caloric supplementation and restriction of dietary protein. non-protein calories should be supplied principally as glucose (8–10 mg/kg/min) with an intravenous fat emulsion added. attempts should be made to maintain a caloric intake of greater than 80 kcal/kg/day. during and after infusion of sodium phenylacetate and sodium benzoate injection 10% / 10%, ongoing monitoring of the following clinical laboratory values is crucial: plasma ammonia, glutamine, quantitative plasma amino acids, blood glucose, electrolytes, venous or arterial blood gases, ast and alt. on-going monitoring of the following clinical responses is also crucial to assess patient response to treatment: neurological status, glasgow coma scale, tachypnea, ct or mri scan or fundoscopic evidence of cerebral edema, and/or of gray matter and white matter damage. hemodialysis should be considered in patients with severe hyperammonemia or who are not responsive to sodium phenylacetate and sodium benzoate injection 10% / 10% administration [ see warnings and precautions (5) ]. in the non-neonatal study patient population treated with sodium phenylacetate and sodium benzoate injection 10% / 10%, dialysis was required in 13% of hyperammonemic episodes. standard hemodialysis was the most frequently used dialysis method. high levels of ammonia can be reduced quickly when sodium phenylacetate and sodium benzoate injection 10% / 10% is used with hemodialysis, as the ammonia-scavenging of sodium phenylacetate and sodium benzoate injection 10% / 10% suppresses the production of ammonia from catabolism of endogenous protein and hemodialysis eliminates the ammonia and ammonia conjugates. sodium phenylacetate and sodium benzoate injection 10% / 10% solutions are physically and chemically stable for up to 24 hours at room temperature and room lighting conditions. no compatibility information is presently available for sodium phenylacetate and sodium benzoate injection 10% / 10% infusion solutions except for arginine hcl injection, 10%, which may be mixed in the same container as sodium phenylacetate and sodium benzoate injection 10% / 10%. other infusion solutions and drug products should not be administered together with sodium phenylacetate and sodium benzoate injection 10% / 10% infusion solution. sodium phenylacetate and sodium benzoate injection 10% / 10% solutions may be prepared in glass and pvc containers. arginine administration intravenous arginine is an essential component of therapy for patients with carbamyl phosphate synthetase (cps), ornithine transcarbamylase (otc), argininosuccinate synthetase (ass), or argininosuccinate lyase (asl) deficiency. because hyperchloremic acidosis may develop after high-dose arginine hydrochloride administration, chloride and bicarbonate levels should be monitored and appropriate amounts of bicarbonate administered. in hyperammonemic infants with suspected, but unconfirmed urea cycle disorders, intravenous arginine should be given (6 ml/kg of arginine hcl injection 10%, over 90 minutes followed by the same dose given as a maintenance infusion over 24 hours). if deficiencies of ass or asl are excluded as diagnostic possibilities, the intravenous dose of arginine hcl should be reduced to 2 ml/kg/day arginine hcl injection 10%. converting to oral treatment once elevated ammonia levels have been reduced to the normal range, oral therapy, such as sodium phenylbutyrate, dietary management and maintenance protein restrictions should be started or reinitiated.

o had the following diagnoses: otc (46%), ass (22%), cps (12%), asl (2%), arg (< 1%), thn (< 1%), and other (18%). adverse reactions were reported with similar frequency in patients with otc, ass, cps, and diagnoses categorized as "other." nervous system disorders were more frequent in patients with otc and cps, compared with patients with ass and patients with "other" diagnoses. convulsions and mental impairment were reported in patients with otc and cps. these observations are consistent with literature reports that patients with enzyme deficiencies occurring earlier in the urea cycle (i.e., otc and cps) tend to be more severely affected. adverse reactions profiles differed by age group. patients ≤ 30 days of age had more blood and lymphatic system disorders and vascular disorders (specifically hypotension), while patients > 30 days of age had more gastrointestinal disorders (specifically nausea, vomiting and diarrhea). less common adverse reactions (< 3% of patients) that are characterized as severe are listed below by body system. blood and lymphatic system disorders: coagulopathy, pancytopenia, thrombocytopenia cardiac disorders: atrial rupture, bradycardia, cardiac or cardiopulmonary arrest/failure, cardiogenic shock, cardiomyopathy, pericardial effusion eye disorders: blindness gastrointestinal disorders: abdominal distension, gastrointestinal hemorrhage general disorders and administration-site conditions: asthenia, brain death, chest pain, multiorgan failure, edema hepatobiliary disorders: cholestasis, hepatic artery stenosis, hepatic failure/hepatotoxicity, jaundice infections and infestations: sepsis/septic shock injury, poisoning and procedural complications: brain herniation, subdural hematoma, overdose investigations: blood carbon dioxide changes, blood glucose changes, blood ph increased, cardiac output decreased, pco 2 changes, respiratory rate increased metabolism and nutrition disorders: alkalosis, dehydration, fluid overload/retention, hypoglycemia, hyperkalemia, hypernatremia, alkalosis, tetany neoplasms benign, malignant and unspecified: hemangioma acquired nervous system disorders: areflexia, ataxia, brain infarction, brain hemorrhage, cerebral atrophy, clonus, depressed level of consciousness, encephalopathy, nerve paralysis, intracranial pressure increased, subdural hematoma, tremor psychiatric disorders: acute psychosis, aggression, confusional state, hallucinations renal and urinary disorders: anuria, renal failure, urinary retention respiratory, thoracic and mediastinal disorders: acute respiratory distress syndrome, dyspnea, hypercapnia, hyperventilation, kussmaul respiration, pneumonia aspiration, pneumothorax, pulmonary hemorrhage, pulmonary edema, respiratory acidosis or alkalosis, respiratory arrest/failure skin and subcutaneous tissue disorders: alopecia, blister, pruritis generalized, rash, urticaria vascular disorders: flushing, hemorrhage, hypertension, phlebothrombosis/thrombosis table 2: adverse reactions occurring in ≥ 3% of patients treated with sodium phenylacetate and sodium benzoate injection 10% / 10% patients n=316 number of patients with any adverse event 163 (52%) blood and lymphatic system disorders 35 (11%) anemia 12 (4%) disseminated intravascular coagulation 11 (3%) cardiac disorders 28 (9%) gastrointestinal disorders 42 (13%) diarrhea 10 (3%) nausea 9 (3%) vomiting 29 (9%) general disorders and administration-site conditions 45 (14%) injection-site reaction 11 (3%) pyrexia 17 (5%) infections 39 (12%) urinary tract infection 9 (3%) injury, poisoning and procedural complications 12 (4%) investigations 32 (10%) metabolism and nutrition disorders 67 (21%) acidosis 8 (3%) hyperammonemia 17 (5%) hyperglycemia 22 (7%) hypocalcemia 8 (3%) hypokalemia 23 (7%) metabolic acidosis 13 (4%) nervous system disorders 71 (22%) brain edema 17 (5%) coma 10 (3%) convulsions 19 (6%) mental impairment 18 (6%) psychiatric disorders 16 (5%) agitation 8 (3%) renal and urinary disorders 14 (4%) respiratory, thoracic and mediastinal disorders 47 (15%) respiratory distress 9 (3%) skin and subcutaneous tissue disorders 19 (6%) vascular disorders 19 (6%) hypotension 14 (4%)

nal transport of many organic compounds, including aminohippuric acid, and may affect renal excretion of phenylacetylglutamine and hippurate. there have been reports that valproic acid can induce hyperammonemia through inhibition of the synthesis of n -acetylglutamate, a co-factor for carbamyl phosphate synthetase. therefore, administration of valproic acid to patients with urea cycle disorders may exacerbate their condition and antagonize the efficacy of sodium phenylacetate and sodium benzoate injection 10% / 10%. use of corticosteroids may cause a protein catabolic state and, thereby, potentially increase plasma ammonia levels in patients with impaired ability to form urea.

pmental and health benefits of breastfeeding should be considered along with the mother's clinical need for sodium phenylacetate and sodium benzoate injection 10% / 10% and any potential adverse effects on the breastfed infant from sodium phenylacetate and sodium benzoate injection 10% / 10% or from the underlying maternal condition. 8.4 pediatric use sodium phenylacetate and sodium benzoate injection 10% / 10% has been used as a treatment for acute hyperammonemia in pediatric patients including patients in the early neonatal period [ see dosage and administration (2) ]. 8.5 geriatric use clinical studies of sodium phenylacetate and sodium benzoate injection 10% / 10% did not include any patients aged 65 and over to determine whether they respond differently from younger patients. urea cycle disorders are presently diseases of the pediatric and younger adult populations. no pharmacokinetic studies of sodium phenylacetate and sodium benzoate injection 10% / 10% have been performed in geriatric 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 concomitant disease or other drug therapy in this patient population. 8.6 gender pharmacokinetic parameters of sodium phenylacetate and sodium benzoate injection 10% / 10% were compared in healthy males and females. bioavailability of both benzoate and phenylacetate was slightly higher in females than in males. however, conclusions cannot be drawn due to the limited number of subjects in this study. 8.7 hepatic insufficiency limited information is available on the metabolism and excretion of sodium phenylacetate and sodium benzoate in patients with impaired hepatic function. however, metabolic conjugation of sodium phenylacetate and sodium benzoate is known to take place in the liver and kidney. therefore, caution should be used in administering sodium phenylacetate and sodium benzoate injection 10% / 10% to patients with hepatic insufficiency. 8.8 renal impairment the drug metabolites of sodium phenylacetate and sodium benzoate injection 10% / 10% (phenylacetylglutamine and hippurate) and subsequently ammonia are primarily excreted by the kidney. therefore, use caution and closely monitor patients with impaired renal function who receive sodium phenylacetate and sodium benzoate injection 10% / 10%.

mole is identical to that of urea (both contain two moles of nitrogen). two moles of nitrogen are removed per mole of phenylacetate when it is conjugated with glutamine. similarly, preceded by acylation, benzoate conjugates with glycine to form hippuric acid, which is rapidly excreted by the kidneys by glomerular filtration and tubular secretion. one mole of hippuric acid contains one mole of waste nitrogen. thus, one mole of nitrogen is removed per mole of benzoate when it is conjugated with glycine figure 2 cps = carbamyl phosphate synthetase; otc = ornithine transcarbamylase; ass = argininosuccinate synthetase; asl = argininosuccinate lyase; arg = arginase; nags = n- acetylglutamate synthetase 12.2 pharmacodynamics in patients with hyperammonemia due to deficiencies in enzymes of the urea cycle, sodium phenylacetate and sodium benzoate injection 10% / 10% has been shown to decrease elevated plasma ammonia levels. these effects are considered to be the result of reduction in nitrogen overload through glutamine and glycine scavenging by sodium phenylacetate and sodium benzoate injection 10% / 10% in combination with appropriate dietary and other supportive measures. 12.3 pharmacokinetics the pharmacokinetics of intravenously administered sodium phenylacetate and sodium benzoate injection 10% / 10% was characterized in healthy adult volunteers. both benzoate and phenylacetate exhibited nonlinear kinetics. following 90-minute intravenous infusion mean auc last for benzoate was 20.3, 114.9, 564.6, 562.8, and 1599.1 mcg/ml following doses of 1, 2, 3.75, 4, and 5.5 g/m 2 , respectively. the total clearance decreased from 5.19 to 3.62 l/h/m 2 at the 3.75 and 5.5 g/m 2 doses, respectively. similarly, phenylacetate exhibited nonlinear kinetics following the priming dose regimens. auc last was 175.6, 713.8, 2040.6, 2181.6, and 3829.2 mcg⋅h/ml following doses of 1, 2, 3.75, 4, and 5.5 g/m 2 , respectively. the total clearance decreased from 1.82 to 0.89 mcg⋅h/mlwith increasing dose (3.75 and 4 g/m 2 , respectively). during the sequence of 90-minute priming infusion followed by a 24-hour maintenance infusion, phenylacetate was detected in the plasma at the end of infusion (t max of 2 hr at 3.75 g/m 2 ) whereas, benzoate concentrations declined rapidly (t max of 1.5 hr at 3.75 g/m 2 ) and were undetectable at 14 and 26 hours following the 3.75 and 4 g/m 2 dose, respectively. a difference in the metabolic rates for phenylacetate and benzoate was noted. the formation of hippurate from benzoate occurred more rapidly than that of phenylacetylglutamine from phenylacetate, and the rate of elimination for hippurate appeared to be more rapid than that for phenylacetylglutamine. pharmacokinetic observations have also been reported from twelve episodes of hyperammonemic encephalopathy in seven children diagnosed (age 3 to 26 months) with urea cycle disorders who had been administered sodium phenylacetate and sodium benzoate injection 10% / 10% intravenously. these data showed peak plasma levels of phenylacetate and benzoate at approximately the same times as were observed in healthy adults. as in healthy adults, the plasma levels of phenylacetate were higher than benzoate and were present for a longer time. the pharmacokinetics of intravenous phenylacetate have been reported following administration to adult patients with advanced solid tumors. the decline in serum phenylacetate concentrations following a loading infusion of 150 mg/kg was consistent with saturable enzyme kinetics. ninety-nine percent of administered phenylacetate was excreted as phenylacetylglutamine. figure-2

a at the end of infusion (t max of 2 hr at 3.75 g/m 2 ) whereas, benzoate concentrations declined rapidly (t max of 1.5 hr at 3.75 g/m 2 ) and were undetectable at 14 and 26 hours following the 3.75 and 4 g/m 2 dose, respectively. a difference in the metabolic rates for phenylacetate and benzoate was noted. the formation of hippurate from benzoate occurred more rapidly than that of phenylacetylglutamine from phenylacetate, and the rate of elimination for hippurate appeared to be more rapid than that for phenylacetylglutamine. pharmacokinetic observations have also been reported from twelve episodes of hyperammonemic encephalopathy in seven children diagnosed (age 3 to 26 months) with urea cycle disorders who had been administered sodium phenylacetate and sodium benzoate injection 10% / 10% intravenously. these data showed peak plasma levels of phenylacetate and benzoate at approximately the same times as were observed in healthy adults. as in healthy adults, the plasma levels of phenylacetate were higher than benzoate and were present for a longer time. the pharmacokinetics of intravenous phenylacetate have been reported following administration to adult patients with advanced solid tumors. the decline in serum phenylacetate concentrations following a loading infusion of 150 mg/kg was consistent with saturable enzyme kinetics. ninety-nine percent of administered phenylacetate was excreted as phenylacetylglutamine.

om gestation day 7 through normal delivery. prenatal exposure of rat pups to phenylacetate produced lesions in layer 5 cortical pyramidal cells; dendritic spines were longer and thinner than normal and reduced in number.

0 (10%) > 16 years 31 (10%) otc 146 (46%) ass 71 (22%) cps 38 (12%) enzyme deficiency asl 7 (2%) arg 2 (< 1%) thn 2 (< 1%) other diagnosis unknown or pending (33 episodes), acidemia (14 episodes), hhh syndrome (6 episodes), carnitine translocase deficiency (4 episodes), liver disease (3 episodes), hmg coa lyase deficiency (1 episode), non-ketotic hyperglycinemia (1 episode), suspected fatty acid oxidation deficiency (1 episode), and valproic-acid-induced hyperammonemia (1 episode). 56 (18%) on admission to the hospital, patients with hyperammonemia and a suspected or confirmed urea cycle disorder (ucd) diagnosis were treated with a bolus dose of 0.25 g/kg (or 5.5 g/m 2 ) sodium phenylacetate + 0.25 g/kg (or 5.5 g/m 2 ) sodium benzoate over a period of 90 minutes to 6 hours, depending on the specific ucd. infusions also contained arginine; the dose of arginine depended on the specific ucd. after completion of the bolus dose, maintenance infusions of the same dose over 24 hours were continued until the patient was no longer hyperammonemic or oral therapy could be tolerated. the mean (sd) duration of treatment was 4.6 (6.45) days per episode, and ranged from 1 to 72 days. survival was substantially improved after sodium phenylacetate and sodium benzoate injection 10% / 10% treatment compared with historical values (estimated 14% 1-year survival rate with dietary therapy alone) and with dialysis (estimated 43% survival of acute hyperammonemia). eighty percent of patients (252 of 316) survived their last episode. of the 64 patients who died, 53 (83%) died during their first hyperammonemic episode. of the 104 neonates (< 30d) treated with sodium phenylacetate and sodium benzoate injection 10% / 10%, 34 (33%) died during the first hyperammonemic episode. ammonia levels decreased from very high levels (>4 times the upper limit of normal [uln]) to lower levels in 91% of episodes after treatment. in patients responding to therapy, mean ammonia concentrations decreased from 200.9 µmol/l at hour zero to 101.6 µmol/l within four hours of initiation of sodium phenylacetate and sodium benzoate injection 10% / 10% therapy and were maintained. hemodialysis is recommended for those patients whose plasma ammonia levels fail to fall below 150 µmol/l or by more than 40% within 4 to 8 hours after receiving sodium phenylacetate and sodium benzoate injection 10% / 10%. a shift from high (≤ 4 times uln) to very high (> 4 times uln) levels was observed in only 4% of the episodes. overall, investigators rated neurological status as improved, much improved, or the same in 93% of episodes, and overall status in response to treatment as improved, much improved, or the same in 97% of episodes. recovery from coma was observed in 97% of episodes where coma was present at admission (111 of 114 episodes).