M.V.I. PEDIATRIC- ascorbic acid, retinol, ergocalciferol, thiamine hydrochloride, riboflavin 5-phosphate sodium, pyridoxine hydrochloride, niacinamide, dexpanthenol, .alpha.-tocopherol acetate, dl-, biotin, folic acid, cyanocobalamin, and phytonadione injection, powder, lyophilized, for solution 
Hospira, Inc.

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HIGHLIGHTS OF PRESCRIBING INFORMATION

These highlights do not include all the information needed to use M.V.I. Pediatric® safely and effectively. See full prescribing information for M.V.I. Pediatric.

M.V.I. Pediatric (multiple vitamins for injection), for intravenous use
Initial U.S. Approval: 1983

RECENT MAJOR CHANGES

Dosage And Administration, Dosage Information (2.2)2/2019

INDICATIONS AND USAGE

M.V.I. Pediatric is a combination of vitamins indicated for the prevention of vitamin deficiency in pediatric patients up to 11 years of age receiving parenteral nutrition (1)

DOSAGE AND ADMINISTRATION

  • M.V.I. Pediatric is a combination product that contains the following vitamins: ascorbic acid, vitamin A, vitamin D, thiamine, riboflavin, pyridoxine, niacinamide, dexpanthenol, vitamin E, vitamin K, folic acid, biotin, and vitamin B12 (2.1)
  • Supplied as a single-dose vial of lyophilized powder for reconstitution intended for administration by intravenous infusion after dilution. (2.1)
  • Recommended daily dosage is based on patient's actual weight (2.2)
    • Less than 1 kg: The daily dose is 1.5 mL
    • 1 kg to 3 kg: The daily dose is 3.25 mL
    • 3 kg or more: The daily dose is 5 mL
  • One daily dose of the reconstituted solution (1.5 mL, 3.25 mL or 5 mL) is then added directly to the intravenous fluid (2.2,2.3)
  • See Full Prescribing Information for reconstitution instructions (2.3)
  • Monitor blood vitamin concentrations (2.4)
  • See Full Prescribing Information for drug incompatibilities (2.5)

DOSAGE FORMS AND STRENGTHS

M.V.I. Pediatric for injection is available as a single-dose vial for reconstitution . (3) See Full Prescribing Information for vitamin content (11)

CONTRAINDICATIONS

  • Hypersensitivity to any of the vitamins or excipients (4)
  • Existing hypervitaminosis (4)

WARNINGS AND PRECAUTIONS

  • Risk of Aluminum Toxicity: Aluminum may reach toxic levels with prolonged administration. Monitor aluminum levels in at risk patients (5.1)
  • Allergic Reactions: to thiamine may occur (5.2)
  • Hypervitaminosis A: Patients with renal failure or liver disease may be at higher risk (5.3)
  • Decreased Anticoagulant Effect of Warfarin: Periodically monitor prothrombin time (5.4)
  • Interferes with Megaloblastic Anemia Diagnosis: Avoid use during testing for this disorder (5.5)
  • Risk of Vitamin Deficiencies or Excesses: Monitor blood vitamin concentrations (5.6)
  • False Negative Urine Glucose Tests: May occur due to vitamin C (5.7)
  • Risk of Vitamin E Toxicity: Additional oral and parenteral vitamin E may result in elevated vitamin E blood concentrations in infants (5.8)
  • Low Vitamin A Levels: Monitor vitamin A levels (5.9)
  • Risk of E- Ferol Syndrome: due to polysorbates (5.10)

ADVERSE REACTIONS

Adverse reactions have included anaphylaxis, rash, erythema, pruritus, headache, dizziness, agitation, anxiety, diplopia, urticaria, shortness of breath, wheezing and angioedema (6)


To report SUSPECTED ADVERSE REACTIONS, contact Hospira, Inc. at 1-800-441-4100 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

DRUG INTERACTIONS

Drug Interactions Affecting Co-administered Drugs:

  • Antibiotics: Thiamine, riboflavin, pyridoxine, niacinamide and ascorbic acid decrease activities of erythromycin, kanamycin, streptomycin, doxycycline and lincomycin (7.1)
  • Bleomycin: Ascorbic acid and riboflavin may reduce the activity of bleomycin (7.1)
  • Levodopa: Pyridoxine may decrease blood levels of levodopa and levodopa efficacy may decrease (7.1)
  • Phenytoin: Folic acid may decrease phenytoin blood levels and increase risk of seizure (7.1)
  • Methotrexate: Folic acid may decrease response to methotrexate (7.1)

Drug Interactions Affecting Vitamin Levels:

  • Hydralazine, Isoniazid: Concomitant administration of hydralazine or isoniazid may increase pyridoxine requirements (7.2)
  • Phenytoin: May decrease folic acid c conentrations (7.2)

USE IN SPECIFIC POPULATIONS

  • Renal Impairment: Monitor renal function, calcium, phosphorus and vitamin A levels (8.6)
  • Hepatic Impairment: Monitor vitamin A levels (8.7)

See 17 for PATIENT COUNSELING INFORMATION.

Revised: 2/2019

FULL PRESCRIBING INFORMATION: CONTENTS*

1 INDICATIONS AND USAGE

2 DOSAGE AND ADMINISTRATION

2.1 Important Dosage and Administration Instructions

2.2 Dosage Information

2.3 Preparation and Administration Instructions

2.4 Monitoring Vitamin Blood Levels

2.5 Drug Incompatibilities

3 DOSAGE FORMS AND STRENGTHS

4 CONTRAINDICATIONS

5 WARNINGS AND PRECAUTIONS

5.1 Aluminum Toxicity

5.2 Allergic Reactions to Thiamine

5.3 Hypervitaminosis A

5.4 Decreased Anticoagulant Effect of Warfarin

5.5 Interference with Diagnosis of Megaloblastic Anemia

5.6 Potential to Develop Vitamin Deficiencies or Excesses

5.7 Interference with Urine Glucose Testing

5.8 Vitamin E Overdose in Infants Receiving Additional Vitamin E

5.9 Risk of Low Vitamin A Levels

5.10 Risk of E-Ferol syndrome

6 ADVERSE REACTIONS

7 DRUG INTERACTIONS

7.1 Effect of M.V.I. Pediatric on Other Drugs

7.2 Effect of Other Drugs on M.V.I. Pediatric

8 USE IN SPECIFIC POPULATIONS

8.4 Pediatric Use

8.6 Renal Impairment

8.7 Hepatic Impairment

10 OVERDOSAGE

11 DESCRIPTION

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

16 HOW SUPPLIED/STORAGE AND HANDLING

17 PATIENT COUNSELING INFORMATION

*
Sections or subsections omitted from the full prescribing information are not listed.

FULL PRESCRIBING INFORMATION

1 INDICATIONS AND USAGE

M.V.I. Pediatric is a combination of vitamins indicated for the prevention of vitamin deficiency in pediatric patients up to 11 years of age receiving parenteral nutrition.

The physician should not await the development of clinical signs of vitamin deficiency before initiating vitamin therapy.

2 DOSAGE AND ADMINISTRATION

2.1 Important Dosage and Administration Instructions

M.V.I. Pediatric is a combination product that contains the following vitamins: ascorbic acid, vitamin A, vitamin D, thiamine, riboflavin, pyridoxine, niacinamide, dexpanthenol, vitamin E, vitamin K, folic acid, biotin, and vitamin B12 [see Dosage and Administration (2.2)].

M.V.I. Pediatric is supplied as a single-dose vial of lyophilized powder for reconstitution and intended for administration by intravenous infusion after dilution.

Do not administer M.V.I. Pediatric as a direct, undiluted intravenous injection as it may cause dizziness, faintness and tissue irritation.

2.2 Dosage Information

  • The recommended daily dosage volume of 1.5 mL, 3.25 mL, or 5 mL of the reconstituted solution is based on the patient's actual weight of less than 1 kg, 1 kg to less than 3 kg, and more than or equal to 3 kg, respectively (see Table 1).
Table 1 – Recommended Weight-Based Dosage of M.V.I. Pediatric
Less than 1 kg1 kg to less than 3 kgMore than or equal to 3 kg
*
0.1 mg vitamin A equals 333.3 USP units = 333.3 IU.
IU = international units.
1 mcg ergocalciferol equals 40 USP units = 40 IU.
§
1 mg vitamin E equals 1 USP units = 1 IU.
Daily Dosage Volume1.5 mL3.25 mL5 mL
Vitamin A* (retinol)690 IU (equals approx. 0.207 mg)1,495 IU (equals approx. 0.449 mg)2,300 IU (equals approx. 0.690 mg)
Vitamin D (ergocalciferol)120 IU (equals 3 mcg)280 IU (equals 7 mcg)400 IU (equals 10 mcg)
Vitamin E§ (dl-alpha-tocopheryl acetate)2.1 IU (equals 2 mg)4.6 IU (equals 5 mg)7 IU (equals 7 mg)
Vitamin K1 (phytonadione)0.1 mg0.1 mg0.2 mg
Vitamin B2 (as riboflavin 5-phosphate sodium)0.4 mg0.9 mg1.4 mg
Vitamin C (ascorbic acid)24 mg52 mg80 mg
Vitamin B6 (pyridoxine hydrochloride)0.3 mg0.7 mg1 mg
Niacinamide5.1 mg11.1 mg17 mg
Dexpanthenol (as d-pantothenyl alcohol)1.5 mg3.3 mg5 mg
Vitamin B1 (thiamine hydrochloride)0.4 mg0.8 mg1.2 mg
Biotin6 mcg13 mcg20 mcg
Folic acid42 mcg91 mcg140 mcg
Vitamin B12 (cyanocobalamin)0.3 mcg0.7 mcg1 mcg
  • One daily dose of the reconstituted solution (1.5 mL, 3.25 mL or 5 mL) is then added directly to the intravenous fluid [see Dosage and Administration (2.3)].
  • Patients with multiple vitamin deficiencies or with increased vitamin requirements may need multiple daily dosages as indicated or additional doses of individual vitamins. However, additional daily dosages in infants are not recommended [see Warnings and Precautions (5.8)]. Supplemental vitamin A may be required for low-birth weight infants.

2.3 Preparation and Administration Instructions

  • M.V.I Pediatric is to be reconstituted and diluted only in a suitable work area such as a laminar flow hood (or an equivalent clean air compounding area).
  • Reconstitue the single-dose vial of M.V.I. Pediatric by adding 5 mL of Sterile Water for Injection USP, or Dextrose Injection USP 5%, or Sodium Chloride Injection USP to the 10 mL vial.
  • Swirl the vial gently after the addition of the diluent to hasten reconstitution. The reconstituted solution is ready within three minutes for use.
  • Visually inspect for particulate matter and discoloration prior to administration.
  • Once reconstituted, immediately withdraw the dose to be added to the appropriate intravenous fluids [see Dosage Information (2.2)] and discard any unused portion. After reconstitution, complete withdrawal of vial contents within 4 hours. The reconstituted solution may be refrigerated and stored for up to 4 hours.
  • After M.V.I. Pediatric is diluted in an intravenous infusion, refrigerate the resulting solution unless it is to be used immediately, and use the solution within 24 hours after dilution.
  • Minimize exposure to light because some of the vitamins in M.V.I.Pediatric, particularly A, D and riboflavin, are light sensitive.

2.4 Monitoring Vitamin Blood Levels

Monitor blood vitamin concentrations to ensure maintenance of adequate levels, particularly in patients receiving parenteral multivitamins as the only source of vitamins for long periods of time.

2.5 Drug Incompatibilities

  • M.V.I. Pediatric is not physically compatible with alkaline solutions such as a sodium bicarbonate solution and other alkaline drugs such as acetazolamide sodium, aminophylline, ampicillin sodium, tetracycline HCl and chlorothiazide sodium.
  • Folic acid is unstable in the presence of calcium salts such as calcium gluconate.
  • Vitamin A and thiamine in M.V.I. Pediatric may react with bisulfite solutions such as sodium bisulfite or vitamin K bisulfite.
  • Do not add M.V.I. Pediatric directly to intravenous fat emulsions.
  • Consult appropriate references for listings of physical and chemical compatibility of solutions and drugs with M.V.I. Pediatric. In such circumstances, admixture or Y-site administration with M.V.I. Pediatrc should be avoided.

3 DOSAGE FORMS AND STRENGTHS

M.V.I. Pediatric for injection is available as a single-dose vial of yellow to amber colored lyophilized powder for reconstitution.

See Description section for vitamin strengths [see Description (11)].

4 CONTRAINDICATIONS

M.V.I. Pediatric is contraindicated in patients who have:

5 WARNINGS AND PRECAUTIONS

5.1 Aluminum Toxicity

M.V.I. Pediatric contains aluminum, up to 42 mcg/L that may be toxic. Aluminum may reach toxic levels with prolonged parenteral administration in patients with renal impairment. Premature neonates are particularly at risk because their kidneys are immature, and they require large amounts of calcium and phosphate solutions, which contain aluminum.

Patients with impaired kidney function, including premature neonates, who receive parenteral levels of aluminum at greater than 4 to 5 micrograms per kg per day, accumulate aluminum at levels associated with central nervous system and bone toxicity. Tissue loading may occur at even lower rates of administration. To prevent aluminum toxicity, periodically monitor aluminum levels with prolonged parenteral administration of M.V.I. Pediatric.

5.2 Allergic Reactions to Thiamine

Allergic reactions such as urticaria, shortness of breath, wheezing and angioedema have been reported following intravenous administration of thiamine, an ingredient in M.V.I. Pediatric. There have been rare reports of anaphylaxis following intravenous doses of thiamine. No fatal anaphylaxis reactions associated with M.V.I. Pediatric have been reported.

5.3 Hypervitaminosis A

Hypervitaminosis A, manifested by nausea, vomiting, headache, dizziness, and blurred vision, has been reported in patients with renal failure receiving 1.5 mg per day retinol and in patients with liver disease. Therefore, supplementation of patients with renal failure and patients with liver diseases with vitamin A, an ingredient found in M.V.I. Pediatric, should be undertaken with caution [see Use in Specific Populations (8.6, 8.7)]. Blood levels of Vitamin A should be monitored periodically.

5.4 Decreased Anticoagulant Effect of Warfarin

M.V.I. Pediatric contains Vitamin K, which may decrease the anticoagulant effect of warfarin. In patients who are on warfarin anticoagulant therapy receiving M.V.I. Pediatric, prothrombin time/INR should be periodically monitored to determine if the dose of warfarin needs to be adjusted.

5.5 Interference with Diagnosis of Megaloblastic Anemia

M.V.I. Pediatric contains folic acid and cyanocobalamin, which can mask serum deficits of folic acid and cyanocobalamin in patients with megaloblastic anemia. Avoid the use of M.V.I. Pediatric in patients with suspected or diagnosed megaloblastic anemia prior to blood sampling for the detection of the folic acid and cyanocobalamin deficiencies.

5.6 Potential to Develop Vitamin Deficiencies or Excesses

In patients receiving parenteral multivitamins, such as with M.V.I. Pediatric, blood vitamin concentrations should be periodically monitored to determine if vitamin deficiencies or excesses are developing. M.V.I. Pediatric may not correct long-standing specific vitamin deficiencies. The administration of additional doses of specific vitamins may be required [see Dosage and Administration (2.2)].

5.7 Interference with Urine Glucose Testing

M.V.I. Pediatric contains Vitamin C, which is also known as ascorbic acid. Ascorbic acid in the urine may cause false negative urine glucose determinations.

5.8 Vitamin E Overdose in Infants Receiving Additional Vitamin E

Additional vitamin E supplementation of patients receiving M.V.I Pediatric may result in elevated blood concentrations of vitamin E and potential vitamin E toxicity in infants. Avoid additional oral or parenteral doses of vitamin E in infants. A daily dose of M.V.I. Pediatric contains adequate concentrations of vitamin E required to achieve normal blood levels of vitamin E.

5.9 Risk of Low Vitamin A Levels

Vitamin A may adhere to plastic, resulting in lower vitamin A concentrations after administration of M.V.I. Pediatric. Therefore, blood vitamin A concentrations should be periodically monitored and the administration of additional therapeutic doses of Vitamin A may be required, especially in low birth weight infants.

5.10 Risk of E-Ferol syndrome

E-Ferol syndrome, manifested by thrombocytopenia, renal dysfunction, hepatomegaly, cholestasis, ascites, hypotension and metabolic acidosis, has been reported in low-birth weight infants following administration of polysorbates, which are found in M.V.I. Pediatric. No E-Ferol syndrome associated with M.V.I. Pediatric has been reported.

6 ADVERSE REACTIONS

The following adverse reactions are discussed in greater detail in other sections of the label.

The following adverse reactions have been identified during post approval use of M.V.I. Pediatric. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Allergic: anaphylaxis, urticaria, shortness of breath, wheezing, angioedema

CNS: headache, dizziness, agitation, anxiety

Dermatologic: rash, erythema, pruritus

Ophthalmic: diplopia

7 DRUG INTERACTIONS

7.1 Effect of M.V.I. Pediatric on Other Drugs

Warfarin: Vitamin K, a component of M.V.I. Pediatric, antagonizes the anticoagulant action of warfarin. In patients who are co-administered warfarin and M.V.I. Pediatric, monitor blood levels of prothrombin/INR periodically to determine if the dose of warfarin needs to be adjusted.

Phenytoin: Folic acid may increase phenytoin metabolism and lower the serum concentration of phenytoin, resulting in increased seizure frequency.

Methotrexate: Folic acid may decrease a patient's response to methotrexate therapy.

Levodopa: Pyridoxine may increase the metabolism of levodopa (decrease blood level of levodopa) and decrease its efficacy.

Antibiotics: Thiamine, riboflavin, pyridoxine, niacinamide, and ascorbic acid decrease antibiotic activities of erythromycin, kanamycin, streptomycin, doxycycline, and lincomycin.

Bleomycin: Ascorbic acid and riboflavin inactivate bleomycin in vitro, thus the activity of bleomycin may be reduced.

7.2 Effect of Other Drugs on M.V.I. Pediatric

Hydralazine or Isoniazid: Concomitant administration of hydralazine or isoniazid may increase pyridoxine requirements.

Chloramphenicol: In patients with pernicious anemia, the hematologic response to vitamin B12 therapy may be inhibited by concomitant administration of chloramphenicol.

Phenytoin: Phenytoin may decrease serum folic acid concentrations.

8 USE IN SPECIFIC POPULATIONS

8.4 Pediatric Use

The safety and effectiveness of M.V.I. Pediatric for the prevention of vitamin deficiency have been established in pediatric patients up to 11 years of age receiving parenteral nutrition. The safety and effectiveness of M.V.I. Pediatric have not been established in pediatric patients older than 11 years of age.

M.V.I. Pediatric contains aluminum that may be toxic for premature neonates. Aluminum levels should be monitored periodically during administration of M.V.I. Pediatric to premature neonates [see Warnings and Precautions (5.1)].

Additional vitamin E supplementation of infants receiving M.V.I. Pediatric may result in elevated blood concentrations of vitamin E and potential vitamin E toxicity [see Warnings and Precautions (5.8)].

E-Ferol syndrome has been reported in low-birth weight infants following administration of polysorbates, which are found in M.V.I. Pediatric [see Warnings and Precautions (5.10)].

8.6 Renal Impairment

M.V.I. Pediatric has not been studied in patients with renal impairment. Monitor renal function, calcium, phosphorus and vitamin A levels in patients with renal impairment [see Warnings and Precautions (5.1, 5.3)].

8.7 Hepatic Impairment

M.V.I. Pediatric has not been studied in patients with hepatic impairment. Monitor vitamin A level in patients with liver disease [see Warnings and Precautions (5.3)].

10 OVERDOSAGE

Signs and symptoms of acute or chronic overdosage may be those of individual M.V.I. Pediatric component toxicity.

11 DESCRIPTION

M.V.I. Pediatric (multiple vitamins for injection) is a yellow to amber colored lyophilized, sterile powder for reconstitution intended for administration by intravenous infusion after dilution [see Dosage and Administration (2.3)].

Table 2 provides the strengths of the vitamins provided in each 5 mL of reconstituted product:

Table 2: M.V.I. PEDIATRIC FORMULATION
IngredientAmount per Unit Dose
With Butylated Hydroxyanisole – 14 mcg; Butylated Hydroxytoluene – 58 mcg; Mannitol – 375 mg; Polysorbate 20 - 0.8 mg; Polysorbate 80 - 50 mg; Sodium hydroxide for pH adjustment.
*
Fat-soluble vitamins A, D, E and K1 are water-solubilized with polysorbate 80.
0.7 mg vitamin A equals 2,300 USP units = 2,300 IU.
IU = international units.
§
10 mcg ergocalciferol equals 400 USP units = 400 IU.
7 mg vitamin E equals 7 USP units = 7 IU.
Fat Soluble Vitamins*
Vitamin A* (retinol)2,300 IU (equals 0.7 mg)
Vitamin D§* (ergocalciferol)400 IU (equals 10 mcg)
Vitamin E* (dl-alpha-tocopheryl acetate)7 IU (equals 7 mg)
Vitamin K1* (phytonadione)200 mcg
Water Soluble Vitamins
Vitamin B2 (as riboflavin 5-phosphate sodium)1.4 mg
Vitamin C (ascorbic acid)80 mg
Vitamin B6 (pyridoxine hydrochloride)1 mg
Niacinamide17 mg
Dexpanthenol (as d-pantothenyl alcohol)5 mg
Vitamin B1 (thiamine hydrochloride)1.2 mg
Biotin20 mcg
Folic acid140 mcg
Vitamin B12 (cyanocobalamin)1 mcg

M.V.I. Pediatric (multiple vitamins for injection) provides a combination of oil-soluble and water-soluble vitamins, formulated for incorporation into intravenous infusions after reconstitution. The liposoluble vitamins A, D, E and K1 have been solubilized in an aqueous medium with polysorbate 80, permitting intravenous administration of these vitamins.

13 NONCLINICAL TOXICOLOGY

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenicity, mutagenicity, and fertility studies have not been performed with M.V.I. Pediatric.

16 HOW SUPPLIED/STORAGE AND HANDLING

M.V.I. Pediatric for injection is supplied as a single-dose vial of lyophilized powder for reconstitution available as:

See Description section for vitamin strengths [see Description (11)].

Minimize the exposure of M.V.I. Pediatric to light, because vitamins A, D and riboflavin are light sensitive. Store under refrigeration, 2 to 8°C (36 to 46°F).

17 PATIENT COUNSELING INFORMATION

Instruct patients (if age appropriate) and caregivers:

Distributed by:
Hospira, Inc. Lake Forest, IL 60045 USA

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LAB-0992-3.0

Revised: 6/2019
Document Id: 9ae79f9d-7708-42b0-bcc3-74277d6a7715
Set id: 7589f8f3-e82a-43b0-868a-cbb991e2183f
Version: 7
Effective Time: 20190613
 
Hospira, Inc.