1. Name Of The Medicinal Product
Forceval Junior Capsules
2. Qualitative And Quantitative Composition
Each capsule contains:
Vitamin A (as β-Carotene) HSE 1,250.0 iu
Vitamin D2 (Ergocalciferol) HSE 200.0 iu
Vitamin B1 (Thiamine) USP 1.5 mg
Vitamin B2 (Riboflavin) BP 1.0 mg
Vitamin B6 (Pyridoxine) BP 1.0 mg
Vitamin B12 (Cyanocobalamin) PhEur 2.0 mcg
Vitamin C (Ascorbic Acid) BP 25.0 mg
Vitamin E (dl-α-Tocopheryl Acetate) USP 5.0 mg
d-Biotin (Vitamin H) FCC 50.0 mcg
Nicotinamide (Vitamin B3) BP 7.5 mg
Pantothenic Acid (Vitamin B5) USP 2.0 mg
Vitamin K1 (Phytomenadione) BP 25.0 mcg
Folic Acid (Vitamin B Complex) BP 100.0 mcg
Iron BP 5.0 mg
Copper HSE 1.0 mg
Magnesium BP 1.0 mg
Zinc HSE 5.0 mg
Iodine BP 75.0 mcg
Manganese HSE 1.25 mg
Selenium BP 25.0 mcg
Chromium HSE 50.0 mcg
Molybdenum HSE 50.0 mcg
3. Pharmaceutical Form
Small, opaque, brown, oval, soft gelatin capsule printed in white with 571.
4. Clinical Particulars
4.1 Therapeutic Indications
1. As a therapeutic nutritional adjunct where the intake of vitamins and minerals is suboptimal, e.g. in the presence of organic disease such as malignancy and immune deficiency syndromes, such as AIDS.
2. As a therapeutic nutritional adjunct in conditions where the absorption of vitamins and minerals is suboptimal, e.g. malabsorption, inflammatory bowel disease and fistulae, short bowel syndrome and Crohn's disease, and where concurrent medication decreases vitamin and mineral absorption.
3. As a therapeutic nutritional adjunct in convalescence from illness, e.g. where anorexia or cachexia exists and following chemo- or radio-therapy.
4. As a therapeutic nutritional adjunct in convalescence from surgery, e.g. where nutritional intake continues to be inadequate.
5. As a therapeutic nutritional adjunct for patients on special or restricted diets, e.g. in renal diets and where several food groups are restricted in therapeutic weight reducing diets.
6. As a therapeutic nutritional adjunct where food intolerance exists, e.g. exclusion diets.
7. As an adjunct in synthetic diets, e.g. in phenylketonuria, galactosaemia and ketogenic diets.
4.2 Posology And Method Of Administration
Children over 5 years of age
2 capsules per day or as recommended by the doctor.
Do not exceed the stated dose.
Adults and the Elderly
Not recommended - use Forceval Capsules.
4.3 Contraindications
Haemochromatosis and other iron storage disorders.
4.4 Special Warnings And Precautions For Use
Forceval Junior Capsules should be used as a vitamin and mineral source in conjunction with an energy-providing diet suitable for individual patient requirements. No other vitamins, minerals or supplements with or without vitamin A should be taken with this preparation except under medical supervision.
Do not exceed the stated dose. Keep out of the reach of children.
The label will state:
Important warning: Contains iron. Keep out of the reach and sight of children, as overdose may be fatal.
This warning will appear on the front of pack, enclosed in a rectangle, in which there is no other information of any kind.
This medicine contains sorbitol. Patients with rare hereditary problems of fructose intolerance should not take this medicine.
Evidence from Randomised Control Trials suggests that high doses (20-30 mg/day) b-carotene intake may increase the risk of lung cancer in current smokers and those previously exposed to asbestos. This high-risk population should consider the potential risks and benefits of Forceval Junior Capsules, which contain 4.5mg per recommended daily dose, before use.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Vitamin K may interact with anticoagulants such as phenindione, warfarin and nicoumalone inhibiting their effect. Folic acid can reduce the plasma concentration of phenytoin. Oral iron and zinc sulphate reduce the absorption of tetracyclines.
4.6 Pregnancy And Lactation
Forceval Junior Capsules can be given to pregnant and lactating women, provided the product is administered with the approval of their clinician.
4.7 Effects On Ability To Drive And Use Machines
None anticipated.
4.8 Undesirable Effects
No undesirable effects due to Forceval Junior therapy have been reported and none can be expected if the dosage schedule is adhered to.
4.9 Overdose
No cases of overdosage due to Forceval Junior therapy have been reported. Any symptoms which may be observed due to ingestion of large quantities of Forceval Junior capsules will be due to the fat soluble vitamin content. If iron overdosage is suspected, symptoms may include nausea, vomiting, diarrhoea, abdominal pain, haematemesis, rectal bleeding, lethargy and circulatory collapse. Hyperglycaemia and metabolic acidosis may also occur. Treatment should be implemented immediately. In severe cases, after a latent phase, relapse may occur after 24 - 48 hours, manifest by hypotension coma and hepatocellular necrosis and renal failure.
Treatment
The following steps are recommended to minimise or prevent further absorption of the medication:
1. Administer an emetic.
2. Gastric lavage may be necessary to remove drug already released into the stomach. This should be undertaken using desferrioxamine solution (2 g/l). Desferrioxamine 5 g in 50-100 ml water should be introduced into the stomach following gastric emptying. Keep the patient under constant surveillance to detect possible aspiration of vomitus; maintain suction apparatus and standby emergency oxygen in case of need.
3. A drink of mannitol or sorbitol should be given to induce small bowel emptying.
4. Severe poisoning: in the presence of shock and/or coma with high serum iron levels >142 μmol/l) immediate supportive measures plus i.v. infusion of desferrioxamine should be instituted. The recommended dose of desferrioxamine is 5 mg/kg/h by slow i.v. infusion up to a maximum of 80 mg/kg/24 hours. Warning: hypotension may occur if the infusion rate is too rapid.
5. Less severe poisoning: i.m. desferrioxamine 50 mg/kg up to a maximum dose of 4 g should be given.
6. Serum iron levels should be monitored throughout.
7. Any fluid or electrolyte imbalance should be corrected.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
The following account summarises the pharmacological effects of the vitamins and minerals in Forceval Junior Capsules and describes the conditions caused by deficiency of these.
Vitamin A
Vitamin A plays an important role in the visual process. It is isomerised to the 11-cis isomer and subsequently bound to the opsin to form the photoreceptor for vision under subdued light. One of the earliest symptoms of deficiency is night blindness which may develop into the more serious condition xerophthalmia. Vitamin A also participates in the formation and maintenance of the integrity of epithelial tissues and mucous membranes. Deficiency may cause skin changes resulting in a dry rough skin with lowered resistance to minor skin infections. Deficiency of Vitamin A, usually accompanied by protein-energy malnutrition, is linked with a frequency of infection and with defective immunological defence mechanisms.
Vitamin D
Vitamin D is required for the absorption of calcium and phosphate from the gastro-intestinal tract and for their transport. Its involvement in the control of calcium metabolism and hence the normal calcification of bones is well documented. Deficiency of Vitamin D in children may result in the development of rickets.
Vitamin B1 (Thiamine)
Thiamine (as the coenzyme, thiamine pyrophosphate) is associated with carbohydrate metabolism. Thiamine pyrophosphate also acts as a co
Vitamin B2 (Riboflavine)
Riboflavine is phosphorylated to flavine mononucleotide and flavine adenine dinucleotide which act as co-enzymes in the respiratory chain and in oxidative phosphorylation. Riboflavine deficiency presents with ocular symptoms, as well as lesions on the lips and at angles of the mouth.
Vitamin B6 (Pyridoxine)
Pyridoxine, once absorbed, is rapidly converted to the co-enzymes pyridoxal phosphate and pyridoxamine phosphate which play an essential role in protein metabolism. Convulsions and hypochromic anaemia have occurred in infants deficient in pyridoxine.
Vitamin B12 (Cyanocobalamin)
Vitamin B12 is present in the body mainly as methylcobalamin and as adenosylcobalamin and hydroxocobalamin. These act as co-enzymes in the trans methylation of homocysteine to methionine; in the isomerisation of methylmalonyl co12 interferes with haemopoiesis and produces megaloblastic anaemia.
Vitamin C (Ascorbic Acid)
Vitamin C cannot be synthesised by man therefore a dietary source is necessary. It acts as a cofactor in numerous biological processes including the hydroxylation of proline to hydroxyproline. In deficiency, the formation of collagen is, therefore, impaired. Ascorbic acid is important in the hydroxylation of dopamine to noradrenaline and in hydroxylations occurring in steroid synthesis in the adrenals. It is a reducing agent in tyrosine metabolism and by acting as an electron donor in the conversion of folic acid to tetrahydrofolic acid is indirectly involved in the synthesis of purine and thymine. Vitamin C is also necessary for the incorporation of iron into ferritin. Vitamin C increases the phagocytic function of leucocytes; it possesses anti-inflammatory activity and it promotes wound healing. Deficiency can produce scurvy. Features include swollen inflamed gums, petechial haemorrhages and subcutaneous bruising. The deficiency of collagen leads to development of thin watery ground substances in which blood vessels are insecurely fixed and readily ruptured. The supportive components of bone and cartilage are also deficient causing bones to fracture easily and teeth to become loose. Anaemia commonly occurs probably due to Vitamin C's role in iron metabolism.
Vitamin E
Vitamin E deficiency has been linked to disorders such as cystic fibrosis where fat absorbtion is impaired. It is essential for the normal function of the muscular system and the blood.
Nicotinamide
The biochemical functions of nicotinamide as NAD and NADP (nicotinamide adenine dinucleotide phosphate) include the degradation and synthesis of fatty acids, carbohydrates and amino acids as well as hydrogen transfer. Deficiency produces pellagra and mental neurological changes.
Pantothenic Acid
Pantothenic acid is incorporated into co-enzyme A and is involved in metabolic pathways involving acetylation which includes detoxification of drug molecules and biosynthesis of cholesterol, steroid hormones, mucopolysaccharides and acetylcholine. CoA has an essential function in lipid metabolism.
Vitamin K1 (Phytomenadione)
Phytomenadione is a provitamin; following activation it exerts Vitamin K effects. Vitamin K is essential for the formation of prothrombin (Factor II) and other clotting factors (Factors VII, IX and X) in the liver. Deficiency of Vitamin K produces hypoprothrombinaemia, in which the clotting time of the blood is prolonged and spontaneous haemorrhage may occur.
Folic Acid
Folic acid is reduced in the body to tetrahydrofolate which is a co-enzyme for various metabolic processes, including the synthesis of purine and pyrimidine nucleotides and hence in the synthesis of DNA. It is also involved in some amino acid conversion and in the formation and utilisation of formate. Deficiency of folic acid leads to megaloblastic anaemia.
Vitamin H (d-Biotin)
Biotin is a co-enzyme for carboxylation during the metabolism of proteins and carbohydrates.
Selenium
Selenium is an essential trace element, deficiency of which has been reported in man. It is thought to be involved in the functioning of membranes and the synthesis of amino acids. Deficiency of selenium in the diet of experimental animals produces fatty liver followed by necrosis.
Iron
Iron, as a constituent of haemoglobin, plays an essential role in oxygen transport. It is also present in the muscle protein myoglobin and in the liver. Deficiency of iron leads to anaemia.
Copper (Copper Sulphate)
Traces of copper are essential to the body as constituents of enzyme systems involved in oxidation reactions.
Magnesium (Magnesium Sulphate)
Magnesium is essential to the body as a constituent of skeletal structures and in maintaining cell integrity and fluid balance. It is utilised in many of the functions in which calcium is concerned but often exerts the opposite effect. Some enzymes require the magnesium ion as a co-factor.
Zinc (Zinc Sulphate)
Zinc is a constituent of many enzymes and is, therefore, essential to the body. It is present with insulin in the pancreas. It plays a role in DNA synthesis and cell division. Reported effects of deficiency include delayed puberty and hypogonadal dwarfism.
Manganese (Manganese Sulphate)
Manganese is a constituent of enzyme systems including those involved in lipid synthesis, the tricarboxylic acid cycle and purine and pyrimidine metabolism. It is bound to arginase of the liver and activates many enzymes.
Iodine (Potassium Iodide)
Iodine is an essential constituent of the thyroid hormones.
Chromium (Chromium Amino Acid Chelate 10%)
Chromium is an essential trace element involved in carbohydrate metabolism.
Molybdenum (Sodium Molybdate)
Molybdenum is an essential trace element although there have been no reports of deficiency states in man. Molybdenum salts have been used to treat copper poisoning in sheep.
5.2 Pharmacokinetic Properties
The following account describes the absorption and fate of each of the active constituents of Forceval Junior Capsules.
Vitamin A
Except when liver function is impaired, Vitamin A is readily absorbed. β
Vitamin D
The metabolism of ergocalciferol is similar to that of cholecalciferol. Cholecalciferol is absorbed from the gastro-intestinal tract into the circulation. In the liver, it is hydroxylated to 25-hydroxycholecalciferol, is subject to entero-hepatic circulation and is further hydroxylated to 1,25
Vitamin B1 (Thiamine)
Thiamine is absorbed from the gastro-intestinal tract and is widely distributed to most body tissues. Amounts in excess of the body's requirements are not stored but excreted in the urine as unchanged thiamine or its metabolites.
Vitamin B2 (Riboflavine)
Riboflavine is absorbed from the gastro-intestinal tract and in the circulation is bound to plasma proteins. It is widely distributed. Little is stored and excess amounts are excreted in the urine. In the body riboflavine is converted to flavine mononucleotide (FMN) and then to flavine adenine dinucleotide (FAD).
Vitamin B6 (Pyridoxine)
Pyridoxine is absorbed from the gastro-intestinal tract and converted to the active pyridoxal phosphate which is bound to plasma proteins. It is excreted in the urine as 4
Vitamin B12 (Cyanocobalamin)
Cyanocobalamin is absorbed from the gastro-intestinal tract and is extensively bound to specific plasma proteins. Vitamin B12 is taken up by the intestinal mucosa and held there for 2
Vitamin C (Ascorbic Acid)
Ascorbic acid is readily absorbed from the gastro-intestinal tract and is widely distributed in the body tissues. Ascorbic acid in excess of the body's needs is rapidly eliminated in the urine.
Vitamin E
Vitamin E is absorbed from the gastro-intestinal tract. Most appears in the lymph and is then widely distributed to all tissues. Most of a dose is slowly excreted in the bile and the remainder is eliminated in the urine as glucuronides of tocopheronic acid or other metabolites.
Nicotinamide (Nicotinic Acid Amide)
Nicotinamide is absorbed from the gastro-intestinal tract, is widely distributed in the body tissues and has a short half-life.
Calcium Pantothenate
Pantothenic acid is readily absorbed from the gastro-intestinal tract and is widely distributed in the body tissues. About 70% of pantothenic acid is excreted unchanged in the urine and about 30% in the faeces.
Vitamin K1 (Phytomenadione)
Phytomenadione is absorbed from the gastro-intestinal tract. It is rapidly metabolised and excreted and is not significantly stored in the body.
Folic Acid
Folic acid is absorbed mainly from the proximal part of the small intestine. Folate polyglutamates are considered to be deconjugated to monoglutamates during absorption. Folic acid rapidly appears in the blood where it is extensively bound to plasma proteins. Some folic acid is distributed in body tissues, some is excreted as folate in the urine and some is stored in the liver as folate.
Vitamin H (d-Biotin)
Following absorption, biotin is stored in the liver, kidney and pancreas.
Selenium
Although it has been established that selenium is essential to human life, very little information is available on its function and metabolism.
Ferrous Fumarate (Iron)
Iron is absorbed chiefly in the duodenum and jejunum. Absorption is aided by the acid secretion of the stomach and if the iron is in the ferrous state as in ferrous fumarate. In iron deficiency, absorption is increased and, conversely, it is decreased in iron overload. Iron is stored as ferritin.
Copper Sulphate (Copper)
Copper is absorbed from the gastro-intestinal tract and its major route of excretion is in the bile.
Magnesium Sulphate (Magnesium)
Magnesium salts are poorly absorbed from the gastro-intestinal tract; however, sufficient magnesium will normally be absorbed to replace deficiency states. It is excreted in both the urine and the faeces but excretion in the urine is reduced in deficiency states.
Zinc Sulphate (Zinc)
Zinc is poorly absorbed from the gastro-intestinal tract. It is widely distributed throughout the body. It is excreted in the faeces with traces appearing in the urine.
Manganese Sulphate (Manganese)
Manganese salts are poorly absorbed.
Potassium Iodide (Iodine)
Iodides are absorbed and stored in the thyroid gland as thyroglobulin. Iodides are excreted in the urine with smaller amounts appearing in the faeces, saliva and sweat.
Chromium Amino Acid Chelate 10% (Chromium)
Although it has been established that chromium is essential to human life, little information is available on its function and metabolism.
Sodium Molybdate (Molybdenum)
Although it has been established that molybdenum is essential to human life, little information is available on its function and metabolism.
5.3 Preclinical Safety Data
There are no pre-clinical data of relevance to the prescriber which are additional to that already included in other sections of the SPC.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Soya Bean Oil BP
Soya Lecithin HSE
Fat Mix HSE
Purified Water PhEur
Gelatin BP
Glycerine BP
Black Iron Oxide Pigment (E172) HSE
Red Iron Oxide Pigment (E172) HSE
Sorbitol Solution 70% BP
6.2 Incompatibilities
No major incompatibilities are known.
6.3 Shelf Life
24 months, as packaged for sale.
6.4 Special Precautions For Storage
Store in a cool dry place at a temperature not exceeding 25°C.
Protect from light.
6.5 Nature And Contents Of Container
The product is presented in press-thru blister packs, each blister strip containing 10 Forceval Junior capsules. The blister strip is composed of PVC/PVdC with a printed aluminium foil lidding. The foil is printed (red on gold) with the name and PL number of the product, the number of vitamins and minerals per capsule and the daily dose.
The product is available in packs of 30, 60 or 120 capsules.
6.6 Special Precautions For Disposal And Other Handling
Not applicable.
7. Marketing Authorisation Holder
Alliance Pharmaceuticals Ltd
Avonbridge House
2 Bath Road
Chippenham
Wiltshire
SN15 2BB
United Kingdom
8. Marketing Authorisation Number(S)
PL 16853/0080
9. Date Of First Authorisation/Renewal Of The Authorisation
18th April 2005
10. Date Of Revision Of The Text
April 2005
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