Icodextrin (Adept, Extraneal) is an iso-osmotic solution used to prevent adhesions in patients undergoing gynecological surgery. It is also used as a colloid osmotic solution for peritoneal dialysis.

Adept, Extraneal (Icodextrin) Uses:

• Adept:
  • It is used as an adjunct to surgery for the reduction of post-surgical adhesions in gynecologic laparoscopic adhesiolysis
• Extraneal:
  • It is used in peritoneal dialysis for the management of peritoneal dialysis (Daily exchange for the long dwell (8- to 16-hour) during CAPD (continuous ambulatory peritoneal dialysis) or APD (automated peritoneal dialysis)
  • For the improvement of long-dwell ultrafiltration and clearance of creatinine and urea nitrogen in patients with high average or greater transport characteristics as measured by peritoneal equilibration test (compared to 4.25% dextrose).

Adept, Extraneal (Icodextrin) Dose in Adults:

Extraneal (Icodextrin) Dose in the CAPD or APD:

• Intraperitoneal:
  • It is given as a single daily exchange in CAPD or APD;
  • A dwell time of 8 -16 hours is suggested

Adept (Icodextrin) Dose in the Laparoscopic gynecologic surgery:

• Intraperitoneal:
  • Irrigation for at least 30 minutes with at least 100 mL is suggested during surgery
  • Aspirate the remaining fluid after the surgery is completed, followed by instillation of 1 L into the cavity.

Use in Children:

Not indicated.

Pregnancy Risk Factor C

• Studies on animal reproduction have not been done.

Icodextrin use during breastfeeding:

• It is unknown if the drug will be excreted into breastmilk.
• It is recommended that you use it with caution if you are lactating.

Use in patients with renal disease:

It is contrainidcated in acute renal failure.

Use in patients with liver disease:

No dosage adjustments mentioned in the manufacturer's labeling.

CAPD or APD (Extraneal®):

Common Side Effects of Extraneal (Icodextrin):

• Cardiovascular:

  • Hypertension

• Respiratory:

  • Upper respiratory infection

• Miscellaneous:

  • Peritonitis

Less Common Side Effects of Extraneal (Icodextrin):

• Cardiovascular:

  • Edema
  • Chest Pain
  • Hypervolemia
  • Hypotension

• Central Nervous System:

  • Headache
  • Dizziness

• Dermatological:

  • Rash
  • Pruritus
  • Skin Disorder

• Endocrine & Metabolic:

  • Hyperglycemia
  • Hyperphosphatemia
  • Hypokalemia
  • Hypoproteinemia

• Gastrointestinal:

  • Abdominal Pain
  • Nausea
  • Dyspepsia
  • Diarrhea
  • Vomiting

• Hematologic:

  • Anemia

• Neuromuscular & Skeletal:

  • Arthralgia
  • Pain
  • Weakness

• Respiratory:

  • Cough Increased
  • Dyspnea

• Miscellaneous:

  • Accidental Injury
  • Flu Syndrome
  • Infection

Laparoscopic surgery (Adept®):

Common Side Effects of Adept (Icodextrin):

• Central nervous system:

  • Headache

• Endocrine & metabolic:

  • Dysmenorrhea

• Gastrointestinal:

  • Nausea
  • Constipation

Less Common Side Effects of Adept (Icodextrin):

• Central Nervous System:

  • Pyrexia
  • Insomnia

• Gastrointestinal:

  • Flatulence
  • Abdominal Pain
  • Abdominal Distention
  • Vomiting
  • Diarrhea

• Genitourinary:

  • Dysuria
  • Urinary Tract Infection; Labial
  • Vulvar
  • Or Vaginal Swelling; Vaginal Bleeding

• Neuromuscular & Skeletal:

  • Arthralgia
  • Back Pain

• Respiratory:

  • Nasopharyngitis
  • Cough

Contraindications to Adept, Extraneal (Icodextrin):

• Allergy to cornstarch, icodextrin or any other component of the formulation
• Glycogen storage disease
• Isomaltose and maltose intolerance
• Severe lactic acidosis (contraindication for Extraneal only)
• Peritoneal infection (peritonitis), performed using a laparotomy, bowel repair, or resection. Appendectomy (Contraindications only for Adept).
• Canadian labeling (Extraneal):
  • Acute renal failure
  • If mechanical defects are not corrected, they can prevent effective peritoneal dialysis or increase the chance of infection.
  • Peritoneal adhesions and documented loss of peritoneal functions that compromise peritoneal function.
  • In the last month, abdominal surgery
  • Abdominal fistulae can be caused by open wounds, tumors or herniae.
  • These conditions may also affect the integrity of the abdominal wall, abdominal surface or intra-abdominal cavity.

Warnings and precautions

• Hypersensitivity reactions

  • There have been reports of severe allergic reactions including anaphylaxis and TEN (toxic epidermal necrolysis), erythema multiforme and serum sickness.
  • Hypersensitivity reactions must be immediately reported and the infusion stopped. The solution must be drained from your peritoneal cavity.
  • It is possible to get a rash that will disappear with treatment. This happens especially in the first few weeks.

• Peritonitis

  • Peritonitis should be closely monitored in patients as both sterile peritonitis and infectious peritonitis have been reported.
  • Incorrect priming or clamping could result in air infusion in the peritoneal cavity, causing abdominal pain or peritonitis.
  • Peritonitis must be treated immediately.

Monitoring parameters:

• Serum electrolytes
• Blood chemistry
• Fluid balance
• Weight

Extraneal:

• Monitor the patients for lactic acidosis during treatment especially those at a higher risk of developing lactic acidosis such as those with severe hypotension or sepsis associated with acute renal failure, patients with inborn errors of metabolism, and those on nucleoside or nucleotide reverse transcriptase inhibitors).

How to administer Adept (Icodextrin)?

It should be administered into the peritoneal cavity only. Intravenous or intra-arterial administration should be avoided.

Adept:

• The solution should be warmed to body temperature before using it.
• Osmolarity is 278 mOsm/L.

Extraneal:

• It should be infused into the peritoneal cavity over 10 to 20 minutes if administered manually.
• The solution may be warmed using dry heat such as a heating pad or a warming plate, to 37°C (98.6°F) before administration.
• The solution should not be heated above 40°C (104°F).
• The solution should not be warmed by immersing it in water or using a microwave oven.
• Osmolarity: 282 to 286 mOsm/L.
• pH: 5.0 to 6.0.

Mechanism of action of Adept (Icodextrin):

• It is used to dialysis and results in transcapillary Ultrafiltration.
• This happens by exerting osmotic tension across small intercellular pores within the dwell.
• The colloidal osmotic effect allows fluid to remain in the peritoneal cavity for up to four days when used for laparoscopic surgery. 
• It temporarily separates the peritoneal surfaces to reduce adhesion formation.

Absorption:

• 40% of the drug is absorbed during the 12-hour dwell (CAPD);
• It is slowly transferred via peritoneal lymphatic drainage into the systemic circulation.

Metabolism:

• It is metabolized primarily by alpha-amylase into maltose (DP2), maltotriose (DP3), maltotetraose (DP4), and higher molecular weight species.

Time to peak plasma concentrations:

• 13 hours

Excretion:

• Renal (proportional to residual renal function);
• diasylate

International Brands of Icodextrin:

• Adept
• Extraneal
• Extraneal Dialysis Solution

Icodextrin Brand Names in Pakistan:

No Brands Available in Pakistan.