AMIKACIN
Please note amikacin is not licensed for the treatment of tuberculosis in the UK.
NB: WHO have issued a rapid guidance in August 2018 with substantive changes to all treatment groups in the last 2016 MDR guidance advising that capreomycin and kanamycin should not be used in MDR TB. Amikacin is still within their guidance but this is now downgraded to a group C medication with Bedaquiline now being upgraded to a group A drug. However given that these new guidelines need to be agreed to be implemented locally and nationally, individual cases should still be managed with expert MDR advice and also in conjunction with the BTS MDR Clinical Advice Service review.
DOSAGE
For intramuscular or intravenous administration only. (Intravenous route is preferred, as the volume of doses required would necessitate two IM injections given as a once daily dose.)
Amikacin is usually given once daily (although for pragmatic reasons there is experience giving it 5 days per week) for an initial period (usually at least two months). In clinical practice the frequency is usually then reduced to three times weekly.
Single-Dose Regimen (usually as an intravenous infusion, diluted in 100mL sodium chloride 0.9% or glucose 5% and infused over 30 to 60 minutes):
Adults: 15mg/kg daily (usual maximum 1g daily, but can be increased if necessary in large muscular adults). After initial period (usually at least two months): 15mg/kg three times per week.
Age >59 years: 10mg/kg daily (maximum 750mg daily). After initial period: 10mg/kg three times per week.
Renal failure: 12-15mg/kg TWO to THREE times a week. Please discuss with a pharmacist.
Obesity: It has been suggested that markedly obese patients should have an adjusted dose using ideal body weight plus 40% of the excess weight in markedly obese patients. The adjusted dose is due to the decreased distribution of extracellular fluids in adipose tissues.
Adjust dose and/or frequency according to serum amikacin concentration (see below).
Children: 15-22.5mg/kg daily (usual maximum 1g daily). After initial period: 15-30mg/kg three times per week.
Adjust dose and/or frequency according to serum amikacin concentration (see below).
PREPARATIONS
Parenteral: 100mg/2mL, 500mg/2mL injection.
DRUG LEVEL MONITORING
Indications for monitoring:
25 – 35mg/L (peak)
Timing of sample:
ADVERSE EFFECTS
COMMON:
Nephrotoxicity: Accumulation if renal impairment.
Ototoxicity: Irreversible vestibulo-cochlear nerve damage.
SERIOUS:
Endocrine: Hypocalcaemia, hypomagnesaemia, and hypokalaemia.
Neurological: Neuromuscular blockade and respiratory paralysis (more common in neuromuscular disease; usually dose-related and self-limiting).
Audiological: Ototoxicity - auditory > vestibular (higher with prolonged use and older age)
Renal: Nephrotoxicity (higher with prolonged use).
ADVERSE EFFECTS: MONITORING
Renal, auditory and vestibular monitoring is essential
Renal function: Month 1 = twice weekly.
Month 2 = weekly.
Month 3 to end of treatment = fortnightly.
Consider reducing to monthly after cessation of treatment with aminoglycoside, if renal function remains stable.
Consider increasing frequency of monitoring if evidence of renal impairment.
Loss of hearing usually occurs first and is detected by regular audiometric testing. Vertigo, loss of balance and auditory disturbances including tinnitus are also signs of ototoxicity.
Ototoxicity on audiogram is defined as a 20 dB loss from baseline at any one test frequency or a 10 dB loss at any two adjacent test frequencies. If this occurs, Amikacin should be discontinued or dosing reduced in frequency to avoid further hearing loss, although the hearing loss that has occurred is likely to be permanent. Expert advice should be sought at this point to consider a regimen change. Of the current injectable agents, Capreomycin may be less ototoxic.
We recommend that patients have baseline audiometry and then monthly reviews until treatment with aminoglycoside ceases. A final audiometry review should be offered 2 months after the final dose.
Routine tests as per generic MDR-TB drug monitoring guidelines.
INTERACTIONS
Increased risk of ototoxicity if given with: loop diuretics
Increased risk of hypocalcaemia with bisphosphonates.
Increased risk of nephrotoxicity if given with: capreomycin, cephalosporins, ciclosporin, colistimethate sodium, tacrolimus.
NB: There is no clinical benefit in prescribing amikacin AND capreomycin or kanamycin or streptomycin.
This information is not inclusive of all drug interactions. Please discuss with a pharmacist.
CONTRA-INDICATIONS & CAUTIONS
Contraindications:
Hypersensitivity: To amikacin or other aminoglycosides.
Myasthenia Gravis: As amikacin may impair neuromuscular transmission.
Pregnancy: Risk of vestibular or auditory nerve damage to foetus if used in second or third trimester.
Cautions:
Obese: Use ideal weight for height to calculate dose and monitor serum amikacin levels closely.
Elderly: Nephrotoxicity and ototoxicity common in the elderly; monitor and reduce dose if necessary.
Renal Disease: Use with caution. Reduce the frequency of dosing and monitor serum concentrations.
LABORATORY INFORMATION
Please find up to date information at www.assayfinder.com regarding individual providers of drug level monitoring tests. Click on the provider for contact details. Turnaround time varies depending on the test and whether it is run locally or sent to an external lab. By contacting laboratories in advance, turnaround time can significantly be reduced.
Sample Type: Serum.
Volume Required: 1-2mL (min 0.1mL).
Sample Container: Plain glass or plastic (non SST).
Container Type: Any.
Availability: NS.
Turnaround Time: Telephoned same day if received 9am-3pm Mon-Fri. Written confirmation report will be sent by 1st Class post.
NB: WHO have issued a rapid guidance in August 2018 with substantive changes to all treatment groups in the last 2016 MDR guidance advising that capreomycin and kanamycin should not be used in MDR TB. Amikacin is still within their guidance but this is now downgraded to a group C medication with Bedaquiline now being upgraded to a group A drug. However given that these new guidelines need to be agreed to be implemented locally and nationally, individual cases should still be managed with expert MDR advice and also in conjunction with the BTS MDR Clinical Advice Service review.
DOSAGE
For intramuscular or intravenous administration only. (Intravenous route is preferred, as the volume of doses required would necessitate two IM injections given as a once daily dose.)
Amikacin is usually given once daily (although for pragmatic reasons there is experience giving it 5 days per week) for an initial period (usually at least two months). In clinical practice the frequency is usually then reduced to three times weekly.
Single-Dose Regimen (usually as an intravenous infusion, diluted in 100mL sodium chloride 0.9% or glucose 5% and infused over 30 to 60 minutes):
Adults: 15mg/kg daily (usual maximum 1g daily, but can be increased if necessary in large muscular adults). After initial period (usually at least two months): 15mg/kg three times per week.
Age >59 years: 10mg/kg daily (maximum 750mg daily). After initial period: 10mg/kg three times per week.
Renal failure: 12-15mg/kg TWO to THREE times a week. Please discuss with a pharmacist.
Obesity: It has been suggested that markedly obese patients should have an adjusted dose using ideal body weight plus 40% of the excess weight in markedly obese patients. The adjusted dose is due to the decreased distribution of extracellular fluids in adipose tissues.
- Male ideal body weight (kg) = 50 + (2.3 x height in cm above (152.4/2.54))
- Female ideal body weight (kg) = 45.5 + (2.3 x height in cm above (152.4/2.54))
Adjust dose and/or frequency according to serum amikacin concentration (see below).
Children: 15-22.5mg/kg daily (usual maximum 1g daily). After initial period: 15-30mg/kg three times per week.
Adjust dose and/or frequency according to serum amikacin concentration (see below).
PREPARATIONS
Parenteral: 100mg/2mL, 500mg/2mL injection.
DRUG LEVEL MONITORING
Indications for monitoring:
- Ensure therapeutic dose.
- Ensures that accumulation is not occurring in renal impairment.
25 – 35mg/L (peak)
Timing of sample:
- Pre dose.
- Take a level 90 – 120 minutes and 6 hours after the infusion ends. Then plot on semi-logarithmic paper and extrapolate back to time = 0 and use this as the peak level.
- Alternatively, taking a level 60mins after infusion ends may be appropriate as a measure of the peak level, but may underestimate the true peak level.
- Peak serum level in first week, repeat if poor response.
- Trough serum levels weekly for 4 weeks. This can reduce to fortnightly when stable.
- Trough level: High – extend interval.
- Peak level: High – reduce dose; low – increase dose.
ADVERSE EFFECTS
COMMON:
Nephrotoxicity: Accumulation if renal impairment.
Ototoxicity: Irreversible vestibulo-cochlear nerve damage.
SERIOUS:
Endocrine: Hypocalcaemia, hypomagnesaemia, and hypokalaemia.
Neurological: Neuromuscular blockade and respiratory paralysis (more common in neuromuscular disease; usually dose-related and self-limiting).
Audiological: Ototoxicity - auditory > vestibular (higher with prolonged use and older age)
Renal: Nephrotoxicity (higher with prolonged use).
ADVERSE EFFECTS: MONITORING
Renal, auditory and vestibular monitoring is essential
Renal function: Month 1 = twice weekly.
Month 2 = weekly.
Month 3 to end of treatment = fortnightly.
Consider reducing to monthly after cessation of treatment with aminoglycoside, if renal function remains stable.
Consider increasing frequency of monitoring if evidence of renal impairment.
Loss of hearing usually occurs first and is detected by regular audiometric testing. Vertigo, loss of balance and auditory disturbances including tinnitus are also signs of ototoxicity.
Ototoxicity on audiogram is defined as a 20 dB loss from baseline at any one test frequency or a 10 dB loss at any two adjacent test frequencies. If this occurs, Amikacin should be discontinued or dosing reduced in frequency to avoid further hearing loss, although the hearing loss that has occurred is likely to be permanent. Expert advice should be sought at this point to consider a regimen change. Of the current injectable agents, Capreomycin may be less ototoxic.
We recommend that patients have baseline audiometry and then monthly reviews until treatment with aminoglycoside ceases. A final audiometry review should be offered 2 months after the final dose.
Routine tests as per generic MDR-TB drug monitoring guidelines.
INTERACTIONS
Increased risk of ototoxicity if given with: loop diuretics
Increased risk of hypocalcaemia with bisphosphonates.
Increased risk of nephrotoxicity if given with: capreomycin, cephalosporins, ciclosporin, colistimethate sodium, tacrolimus.
NB: There is no clinical benefit in prescribing amikacin AND capreomycin or kanamycin or streptomycin.
This information is not inclusive of all drug interactions. Please discuss with a pharmacist.
CONTRA-INDICATIONS & CAUTIONS
Contraindications:
Hypersensitivity: To amikacin or other aminoglycosides.
Myasthenia Gravis: As amikacin may impair neuromuscular transmission.
Pregnancy: Risk of vestibular or auditory nerve damage to foetus if used in second or third trimester.
Cautions:
Obese: Use ideal weight for height to calculate dose and monitor serum amikacin levels closely.
Elderly: Nephrotoxicity and ototoxicity common in the elderly; monitor and reduce dose if necessary.
Renal Disease: Use with caution. Reduce the frequency of dosing and monitor serum concentrations.
LABORATORY INFORMATION
Please find up to date information at www.assayfinder.com regarding individual providers of drug level monitoring tests. Click on the provider for contact details. Turnaround time varies depending on the test and whether it is run locally or sent to an external lab. By contacting laboratories in advance, turnaround time can significantly be reduced.
Sample Type: Serum.
Volume Required: 1-2mL (min 0.1mL).
Sample Container: Plain glass or plastic (non SST).
Container Type: Any.
Availability: NS.
Turnaround Time: Telephoned same day if received 9am-3pm Mon-Fri. Written confirmation report will be sent by 1st Class post.