Spiramycin (Systemic)



JAN:

Spiramycin—Acetylspiramycin {01}

VA CLASSIFICATION
Primary: AM200
Secondary: AP900{01}

Commonly used brand name(s): Provamicina; Rovamicina; Rovamycine; Rovamycine 250; Rovamycine 500; Rovamycine-250; Rovamycine-500; Spiramycine Coquelusédal.

Note: For a listing of dosage forms and brand names by country availability, see Dosage Forms section(s).

*Not commercially available in the U.S.



Category:


Antibacterial (systemic)—

antiprotozoal—

Indications

General considerations
Spiramycin is a macrolide antimicrobial agent with activity against gram-positive organisms, including Streptococcus pyogenes (group A beta-hemolytic streptococci) {02} {06}, S. viridans {02}, Corynebacterium diphtheriae {02} {06}, and methicillin-sensitive Staphylococcus aureus {06}. Increasing resistance has left spiramycin with inconsistent activity against S. pneumoniae and enterococcus. {06} Spiramycin also has activity against some gram-negative bacteria {02} {06} {30}, such as Neisseria meningitidis , Bordetella pertussis , and Campylobacter . {02} {06} {30} Neisseria gonorrhoeae is inconsistently sensitive {06}, and approximately 50% of Haemophilus influenzae strains are sensitive to spiramycin {02}. Clostridium species are sensitive {02} {06}; however, Enterobacteraceae, Pseudomonas species, as well as Bacteroides fragilis {06}, and most other gram-negative bacteria are resistant {06}. Spiramycin also has activity against other organisms, including Mycoplasma pneumoniae {06} {30}, Chlamydia trachomatis {06} {30}, Toxoplasma gondii {06} {30}, Legionella pneumophila {06}, and spirochetes {06}.

Cross-resistance between spiramycin and erythromycin has been reported. {02} {07}

Accepted

Toxoplasmosis (treatment)1—Spiramycin is used as an alternative agent in the treatment of toxoplasmosis during pregnancy. {10} Pyrimethamine and sulfadiazine combination is considered to be more effective than spiramycin. {08} {26} {28} {29} However, because spiramycin has not been found to be teratogenic {03} {28} and has been found to be safe in the pregnant woman, fetus, and newborn {10} {28}, it is often used to treat toxoplasmosis during pregnancy and congenital toxoplasmosis {03} {10} {28} {29}. Spiramycin reduces the transmission of toxoplasmosis from the pregnant woman to the fetus {03} {06} {08} {10} {26} {27} {28} {29} {34} {36}; however, it will not affect the severity of disease in an already infected fetus. {03} {12} {26} {28} {36}

—Although spiramycin is effective in the treatment of some bacterial infections, spiramycin is considered to be a secondary agent and other medications are generally used in place of spiramycin. {54}

Acceptance not established
Spiramycin has not been shown to be clearly effective in the treatment of cryptosporidiosis in immunocompromised patients. {54} Data are mixed {10} {12} {17} {18} {32} {53} and relapse often occurs after spiramycin is discontinued {10}. Cryptosporidiosis is usually self-limiting in non-immunocompromised patients. {17} {32}

Unaccepted
Because spiramycin does not reach adequate concentrations in the cerebrospinal fluid {02} {03} {04} {12}, spiramycin is not accepted in the treatment of meningitis {02} or in preventing toxoplasma encephalitis. {03} {12}

1 Not included in Canadian product labeling.



Pharmacology/Pharmacokinetics

Physicochemical characteristics:

Chemical group—
    A 16-membered ring macrolide antibiotic {03} {04} {40} {46}
Molecular weight—
    843.1 {04}

pKa—
    7.9 {46}

Mechanism of action/Effect:

The mechanism of action of spiramycin is not clear {02} {23} {44}; however, it is thought to reversibly bind to the 50 S subunit of bacterial ribosomes, resulting in blockage of the transpeptidation or translocation reactions, inhibiting protein synthesis and subsequent cell growth. {04} {23} {44} It is primarily bacteriostatic, but may be bactericidal against more sensitive strains when used in high concentrations. {04} Spiramycin also accumulates in high concentrations in the bacterial cell. {23} Unlike erythromycin, spiramycin does not produce gastrointestinal motility stimulation. {30}

Absorption:

The absorption of spiramycin is incomplete {04} {06}, with an oral bioavailability of 33 to 39% (range, 10 to 69%). {40} The rate of absorption is slower than that of erythromycin and is thought to be due to the high pKa (7.9) of spiramycin, suggesting a high degree of ionization in the acidic stomach. {46} Studies have shown that administration with food reduces bioavailability by approximately 50% and delays the time to peak serum concentration. {40}

Distribution:

Spiramycin is highly concentrated in tissues, such as the lungs, bronchi, tonsils, sinuses {07}, and female pelvic tissues. {45} These high tissue concentrations persist long after serum concentrations have fallen to low levels. {04} Peak concentrations in the saliva are 1.3 to 4.8 times greater than those found in the serum. {07} {20} Spiramycin crosses the placenta {03} {14} {28} and is distributed into breast milk {04}; however, fetal blood concentrations are only 50% of the maternal serum concentrations. {03} {28} Concentrations in the placenta are up to 5 times higher than the corresponding serum concentration. {03} {28} High concentrations are also found in the bile {04}, polymorphonuclear leukocytes, and macrophages. {23} {33} {38} Biliary concentrations are 15 to 40 times higher than the serum concentration. {06} {07} Spiramycin does not cross the blood-brain barrier. {03} {04} {09}

Vol D is large and variable (383 to 660 L). {23} {40} {46}

Protein binding:

Low (10 to 25%). {06} {09} {40}

Biotransformation:

Spiramycin metabolism has not been well studied {46}; however, spiramycin is thought to be metabolized in the liver {04} {40} to active metabolites. {04} {06}

Half-life:


Intravenous:

Young persons (18 to 32 years of age): Approximately 4.5 to 6.2 hours. {40}

Elderly persons (73 to 85 years of age): Approximately 9.8 to 13.5 hours. {40}



Oral:

5.5 to 8 hours. {04} {06} {09} {40}



Rectal (in children):

Approximately 8 hours. {06}


Time to peak concentration:

Intravenous—End of infusion. {40}

Oral—3 to 4 hours. {30} {40}

Rectal (in children)—1.5 to 3 hours. {06}

Peak serum concentration:


Intravenous:

2.3 mcg per mL (mcg/mL) after a 500-mg dose. {40}



Oral:

Approximately 1 mcg/mL after a 1-gram dose. {40}

1.6 to 3.1 mcg/mL after a 2-gram dose. {04} {30} {40}



Rectal (in children):

Approximately 1.6 mcg per mL after a 1.3 million IU dose. {06}


Elimination:
    Fecal—Biliary elimination is substantial {04} {06} {07} {23} {46}, with over 80% of an administered dose excreted in the bile {07}; enterohepatic recycling may occur. {46}
    Renal—Urinary excretion accounts for only 4 to 14% of an administered dose. {04} {06} {30} {40}


Precautions to Consider

Cross-sensitivity and/or related problems

Patients with hypersensitivity reactions to other macrolides (e.g., erythromycin, azithromycin, clarithromycin, troleandomycin, dirithromycin, josamycin) may also have hypersensitivity to spiramycin. {41}

Pregnancy/Reproduction

Pregnancy—
Spiramycin crosses the placenta and reaches concentrations in the placenta up to five times higher than that in the corresponding serum. {03} {28} Spiramycin is used in pregnant women to decrease the risk of toxoplasmosis transmission to the fetus. {03} {08} {12} {26} {34} {36} It is reported to decrease the transmission from 25 to 8% in the first trimester, from 54 to 19% in the second trimester, and from 65 to 44% in the third trimester. {03} However, spiramycin will not affect the severity of disease in an already infected fetus. {03} {12} {26} {28} {36} Fetal blood concentrations are only 50% of the maternal serum concentrations. {03} {28} Spiramycin has not been found to be teratogenic {03} {28}, and has been found to be safe in the pregnant woman, fetus, and newborn. {10} {28}

Breast-feeding

Spiramycin is distributed into breast milk. {04} {06}

Pediatrics

Studies performed in infants and children have not demonstrated pediatrics-specific problems that would limit the usefulness of spiramycin in children. {03} {24} {25} {28}


Geriatrics


No information is available on the relationship of age to the effects of spiramycin in geriatric patients. However, one small pharmacokinetic study showed that elderly patients (73 to 85 years of age) had an elimination half-life that was twice as long as that in younger patients. {40}

Drug interactions and/or related problems
The following drug interactions and/or related problems have been selected on the basis of their potential clinical significance (possible mechanism in parentheses where appropriate)—not necessarily inclusive (» = major clinical significance):


Note: Unlike erythromycin, a related macrolide, spiramycin does not bind to hepatic cytochrome P-450 isoenzymes {19} {48} and has not been shown to interact with cyclosporine {15} {21} {47} {48} or theophylline {48}.
Combinations containing either of the following medications, depending on the amount present, may interact with this medication.

Levodopa and carbidopa combination{51}    (concurrent use of spiramycin with levodopa and carbidopa combination has resulted in an increase in the elimination half-life of levodopa; this is thought to be due to the inhibition of carbidopa absorption by spiramycin secondary to modified gastrointestinal motility)



Laboratory value alterations
The following have been selected on the basis of their potential clinical significance (possible effect in parentheses where appropriate)—not necessarily inclusive (» = major clinical significance):

With physiology/laboratory test values
Alanine aminotransferase (ALT [SGPT]) and
Alkaline phosphatase, serum{31}{43}    (values may be increased rarely)


Medical considerations/Contraindications
The medical considerations/contraindications included have been selected on the basis of their potential clinical significance (reasons given in parentheses where appropriate)— not necessarily inclusive (» = major clinical significance).


Risk-benefit should be considered when the following medical problems exist
Biliary obstruction or
Hepatic function impairment{09}{46}    (biliary obstruction or hepatic function impairment may decrease the elimination of spiramycin, which may increase the risk of side effects)


Hypersensitivity to spiramycin or another macrolide{02}{41}

Patient monitoring
The following may be especially important in patient monitoring (other tests may be warranted in some patients, depending on condition; » = major clinical significance):

Hepatic function determinations{09}{31}{43}    (may be required in patients with hepatic function impairment receiving high-dose spiramycin; spiramycin has also been reported to cause cholestatic hepatitis)




Side/Adverse Effects

Note: Severe adverse reactions due to spiramycin are rare. {19} Hypersensitivity reactions and gastrointestinal disturbances occur most frequently. Thrombocytopenia, QT prolongation in an infant, cholestatic hepatitis, acute colitis, and ulcerated esophagitis have each only been reported as single case reports in the literature {13} {19} {42} {43}; there were two case reports of intestinal mucosal injury. {35}
Thrombocytopenia, reported in a patient infected with human immunodeficiency virus (HIV), was thought to be induced by spiramycin-IgG immune complexes adsorbed onto the surface of platelets. {42}
The two cases of intestinal mucosal injury occurred with high doses of spiramycin. Endoscopic examination revealed erosions of the small bowel wall with loss of the small intestinal folds, marked damage to the large and small bowel with flattened epithelial cells, multifocal apoptosis, and regenerative epithelial changes. {35}

The following side/adverse effects have been selected on the basis of their potential clinical significance (possible signs and symptoms in parentheses where appropriate)—not necessarily inclusive:

Those indicating need for medical attention
Incidence less frequent
    
Hypersensitivity reactions, specifically skin rash and itching{02}{06}{31}{32}{41}
    
thrombocytopenia (unusual bleeding or bruising){42}

Incidence rare
    
Cardiac toxicity, specifically QT prolongation (irregular heartbeat; recurrent fainting){13}
    
cholestatic hepatitis (abdominal pain; nausea; vomiting; yellow eyes or skin){43}
    
gastrointestinal toxicity, specifically acute colitis (abdominal pain and tenderness; bloody stools; fever){19}
    
intestinal injury (abdominal pain and tenderness){35}
    
ulcerated esophagitis (chest pain; heartburn){19}
    
pain at site of injection{06}



Those indicating need for medical attention only if they continue or are bothersome
Incidence less frequent
    
Gastrointestinal disturbances (diarrhea; nausea; stomach pain; vomiting){02}{19}{32}{35}{37}





Patient Consultation
As an aid to patient consultation, refer to Advice for the Patient, Spiramycin (Systemic).

In providing consultation, consider emphasizing the following selected information (» = major clinical significance):

Before using this medication
»   Conditions affecting use, especially:
Hypersensitivity to spiramycin or other macrolides





Breast-feeding—Spiramycin is distributed into breast milk

Proper use of this medication
» Taking on an empty stomach

» Compliance with full course of therapy

» Importance of taking medication on regular schedule and not missing doses

» Proper administration of spiramycin suppositories

» Proper dosing
Missed dose: taking as soon as possible; not taking if almost time for next dose; not doubling dose

» Proper storage

Precautions while using this medication
Checking with physician if no improvement within a few days


Side/adverse effects
Signs of potential side effects, especially hypersensitivity reactions, cardiac toxicity, cholestatic hepatitis, gastrointestinal toxicity, or pain at site of injection


General Dosing Information

For oral dosage form only
Administration of spiramycin with food reduces bioavailability by approximately 50% and delays the time to peak serum concentration. {40} Spiramycin should be taken on an empty stomach.

For rectal dosage form only
Before rectal administration of spiramycin suppositories, the suppository should be dipped in cold water, then introduced quickly and deeply into the rectum. {05}


Oral Dosage Forms

SPIRAMYCIN CAPSULES

Note: Dosing of spiramycin may be expressed as either milligrams (mg) or International Units (IU). One mg of spiramycin is equivalent to approximately 3000 IU. {02} {04}


Usual adult and adolescent dose
Antibacterial
Oral, 1 to 2 grams (3,000,000 to 6,000,000 IU) two times a day {02} {04} {06}; or 500 mg to 1 gram (1,500,000 to 3,000,000 IU) three times a day {06} {09}. For severe infections, the dose may be increased to 2 to 2.5 grams (6,000,000 to 7,500,000 IU) two times a day. {02}


Note: Toxoplasmosis in pregnant women1
First trimester: Oral, 3 grams (9,000,000 IU) per day, divided into three or four doses. {03} {28} {52}
Second and third trimesters: Oral, 25 to 50 mg of pyrimethamine per day in combination with 2 to 3 grams of sulfadiazine per day and folinic acid 5 mg per day for three weeks, alternating with 3 grams (9,000,000 IU) of spiramycin, divided into three or four doses, for three weeks. {03} {16} {26} {28} {52}


Usual pediatric dose
Antibacterial
Children 20 kg of body weight and over: Oral, 25 mg (75,000 IU) per kg of body weight two times a day, or 16.7 mg (50,000 IU) per kg of body weight three times a day. {02} {04} {06} {09}


Note: Toxoplasmosis1
Subclinical congenital infection: Oral, 0.5 to 1 mg per kg of body weight per day of pyrimethamine in combination with 50 to 100 mg per kg of body weight per day of sulfadiazine for four weeks, alternating with 50 to 100 mg (150,000 to 300,000 IU) per kg of body weight of spiramycin for six weeks; these dosing courses are repeated for one year. {03}
Overt congenital infection: Oral, 0.5 to 1 mg per kg of body weight per day of pyrimethamine in combination with 50 to 100 mg per kg of body weight per day of sulfadiazine and folinic acid 5 mg every three days {52} for six months, alternating with 50 to 100 mg (150,000 to 300,000 IU) per kg of body weight of spiramycin in combination with pyrimethamine and sulfadiazine for four weeks; these dosing courses are repeated until 18 months of age. {03}


Strength(s) usually available
U.S.—
Not commercially available. However, physicians who wish to use spiramycin should contact the FDA's Division of Anti-Infective Drug Products (301-443-4310).

Canada—


250 mg (750,000 IU) (Rx) [Rovamycine 250]


500 mg (1,500,000 IU) (Rx) [Rovamycine 500]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer.

Auxiliary labeling:
   • Continue medicine for full time of treatment.
   • Take on an empty stomach.


SPIRAMYCIN TABLETS

Note: Dosing of spiramycin may be expressed as either milligrams (mg) or International Units (IU). One mg of spiramycin is equivalent to approximately 3000 IU. {02} {04}


Usual adult and adolescent dose
See Spiramycin Capsules .

Usual pediatric dose
See Spiramycin Capsules .

Strength(s) usually available
U.S.—
Not commercially available. However, physicians who wish to use spiramycin should contact the FDA's Division of Anti-Infective Drug Products (301-443-4310).

Canada—
Not commercially available.

France—


500 mg (1,500,000 IU) (Rx) [Rovamycine]


1 gram (3,000,000 IU) (Rx) [Rovamycine]

Germany—


250 mg (750,000 IU) (Rx) [Rovamycine-250]


500 mg (1,500,000 IU) (Rx) [Rovamycine-500]

Italy—


1 gram (3,000,000 IU) (Rx) [Rovamicina]

Mexico—


500 mg (1,500,000 IU) (Rx) [Provamicina]

Spain—


500 mg (1,500,000 IU) (Rx) [Rovamycine]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer.

Auxiliary labeling:
   • Continue medicine for full time of treatment.
   • Take on an empty stomach.



Parenteral Dosage Forms

SPIRAMYCIN ADIPATE INJECTION

Note: Dosing of spiramycin may be expressed as either milligrams (mg) or International Units (IU). One mg of spiramycin is equivalent to approximately 3000 IU. {04}
The dosing and strengths of spiramycin adipate injection are expressed in terms of the base (not the adipate salt). {06}


Usual adult and adolescent dose
Antibacterial
Intravenous infusion, 500 mg (1,500,000 IU) (base), by slow intravenous infusion, every eight hours. {04} {06} For severe infections, the dose may be doubled to 1 gram (3,000,000 IU) every eight hours. {04} {06}


Usual pediatric dose
Dosage has not been established.

Strength(s) usually available
U.S.—
Not commercially available.

Canada—
Not commercially available.

France—


500 mg (1,500,000 IU) (base) (Rx) [Rovamycine]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer.

Preparation of dosage form:
For initial dilution, 4 mL of sterile water for injection should be added to each 500-mg (1,500,000 IU) (base) vial. {06}

After initial dilution, the solution may be further diluted in a minimum of 100 mL of 5% dextrose injection solution and administered by slow intravenous infusion. {06}

Stability:
After reconstitution, the solution retains its potency for 12 hours. {06}

Incompatibilities:
It is recommended that spiramycin injection not be mixed with any other medications. {06}



Rectal Dosage Forms

SPIRAMYCIN ADIPATE SUPPOSITORIES

Note: Dosing of spiramycin may be expressed as either milligrams (mg) or International Units (IU). One mg of spiramycin is equivalent to approximately 3000 IU. {02} {04}
The dosing and strengths of spiramycin adipate suppositories are expressed in terms of the adipate salt (not the base). {05}


Usual adult and adolescent dose
Antibacterial
Rectal, two to three 750 mg (1,950,000 IU) suppositories every 24 hours. {05}


Usual pediatric dose
Antibacterial
Newborns: Rectal, one 250 mg (650,000 IU) suppository per 5 kg of body weight every 24 hours. {05}

Children up to 12 years of age: Rectal, two to three 500 mg (1,300,000 IU) suppositories every 24 hours. {05}

Children 12 years of age and over: See Usual adult and adolescent dose . {05}


Strength(s) usually available
U.S.—
Not commercially available.

Canada—
Not commercially available.

France—


250 mg (650,000 IU) (Rx) [Spiramycine Coquelusédal]


500 mg (1,300,000 IU) (Rx) [Spiramycine Coquelusédal]


750 mg (1,950,000 IU) (Rx) [Spiramycine Coquelusédal]

Packaging and storage:
Store below 40 °C (104 °F), preferably between 15 and 30 °C (59 and 86 °F), unless otherwise specified by manufacturer.

Auxiliary labeling:
   • For rectal use only.



Developed: 05/28/1996



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  1. Reviewers' responses to monograph revision of 8/95.
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