L-arginine intravenous infusion for adults

Who can administer

May be administered by registered competent doctor or nurse/midwife

Important information

• Unlicensed drug
• This monograph has been prepared for guidance on the use of the L-arginine in stroke associated with MELAS syndrome (mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes)
• For other indications- see the BIMDG guideline

Available preparations

L-Arginine Hydrochloride 50%w/v ampoule (5g/10ml) (Amargine)

Reconstitution

Not required- already in solution

Draw up using a 5 micron filter needle

Further dilution required prior to administration

Infusion fluids

Glucose 10% (preferred) or 5% ^{(ref 1)}

Methods of intravenous administration

Intermittent intravenous infusion (administer using an electronically controlled infusion device)

• Add the required dose to infusion fluid - recommended maximum concentration 50mg/ml ^{(ref 1)}
• Administer via central line (preferable), or a large peripheral vein due to high osmolarity ^{(ref 1)}
• Initial dose: administer first stat dose over 30 minutes ^{(ref 2)}, then use continuous infusion
• An in-line 0.2 micron filter must be used, available from Pharmacy ^{(ref 1)} (Braun filter 409 9303)

Dose in adults

Acute stroke associated with MELAS

• Give 10g/m² (max 30g) by intravenous infusion over 30 minutes within 3 hours of symptom onset
• Followed immediately by 10g/m² as a continuous intravenous infusion (but see below re max daily dose)
• Repeat 10g/m² continuous infusion daily for 3 to 5 days
• Maximum dose 30g per day (on day one, the continuous infusion dose may need to be capped to avoid exceeding 30g)
• Example: patient BSA 1.8m²
  • Give 18g over 30 minutes, followed by 12g over 24 hours (so as not to exceed 30g total daily dose)
  • On day 2 onwards, give 18g over 24 hours
• Use MdCalc to work out Body Surface Area in m²
• See under Further information below re oral doses

For other indications- see the BIMDG guideline

Monitoring

• Monitor for allergic reactions and stop treatment if serious ^{(ref 1)}
• Infusion site reactions (high osmolarity)^{(ref 1)}
• Monitor plasma pH and chloride levels^{(ref 1)}
• Monitor blood glucose levels ^{(ref 2)}
• Monitor blood pressure^{(ref 1)}

Further information

• Further information on adverse reactions etc may be found on the attached SPC
• Patients may be transferred to maintenance dose orally (150 to 300mg/kg/day), in three divided doses (max 24grams/day)
• The injection solution may be administered orally , if oral tablets are not available ^{(ref 2)}

Storage

Store ampoules below 25⁰C

Do not refrigerate

References

SPC 6th August 2018

1: Injectable Medicines Guide Version 5 Medusa NHS. Downloaded 30/03/2023

2: British Inherited Metabolic Diseases Group IMDG guidelines2nd Edition 2020

3: Recommendations for the Management of Strokelike Episodes in Patients With Mitochondrial Encephalomyopathy, Lactic Acidosis, and Strokelike Episodes JAMA 2016 Koenig et al