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