Treatment of bleeding and perioperative prophylaxis of bleeding in acquired deficiency of the prothrombin complex coagulation factors, such as deficiency caused by treatment with vitamin K antagonists, or in case of overdose of vitamin K antagonists, when rapid correction of the deficiency is required.

Treatment of bleeding and perioperative prophylaxis in congenital deficiency of the vitamin K dependent coagulation factors II and X when purified specific coagulation factor product is not available.

Posology

Only general dosage guidelines are given below. Treatment should be initiated under the supervision of a physician experienced in the treatment of coagulation disorders. The dosage and duration of the substitution therapy depend on the severity of the disorder, on the location and extent of the bleeding and on the patient's clinical condition.

The amount and the frequency of administration should be calculated on an individual patient basis. Dosage intervals must be adapted to the different circulating half-life of the different coagulation factors in the prothrombin complex (see section 5.2). Individual dosage requirements can only be identified on the basis of regular determinations of the individual plasma levels of the coagulation factors of interest, or on global tests of the prothrombin complex levels (prothrombin time, INR), and continuous monitoring of the clinical condition of the patient.

In case of major surgical interventions precise monitoring of the substitution therapy by means of coagulation assays is essential (specific coagulation factor assays and/or global tests for prothrombin complex levels).

Bleeding and perioperative prophylaxis of bleeding during vitamin K antagonist treatment:

The dose will depend on the INR before treatment and body weight. In the following table approximate doses (units/kg body weight of the reconstituted product) are given.

^† Units refer to International Units.

Dose is based on body weight up to, but not exceeding 100 kg. For patients weighing more than 100 kg, the maximum single dose (IU of factor IX) should therefore not exceed 2500 IU for an INR of 2 - < 4, 3500 IU for an INR of 4 - 6 and 5000 IU for an INR of > 6.

The correction of the vitamin K antagonist induced impairment of haemostasis persists for approximately 6-8 hours. However, the effects of vitamin K, if administered simultaneously, are usually achieved within 4-6 hours. Thus, repeated treatment with human prothrombin complex is not usually required when vitamin K has been administered.

As these recommendations are empirical and recovery and the duration of effect may vary, monitoring of INR during treatment is mandatory.

Bleeding and perioperative prophylaxis in congenital deficiency of the vitamin K dependent coagulation factors II and X when specific coagulation factor product is not available:

The calculated required dosage for treatment is based on the empirical finding that approximately 1 IU of factor II or X per kg body weight raises the plasma factor II or X activity by 0.02 and 0.017 IU/mL, respectively.

The dose of a specific factor administered is expressed in International Units (IU), which are related to the current WHO standard for each factor. The activity in plasma of a specific coagulation factor is expressed either as a percentage (relative to normal plasma) or in International Units (relative to the international standard for the specific coagulation factor).

One International Unit (IU) of a coagulation factor activity is equivalent to the quantity in one mL of normal human plasma.

For example, the calculation of the required dosage of factor X is based on the empirical finding that 1 International Unit (IU) of factor X per kg body weight raises the plasma factor X activity by 0.017 IU/mL. The required dosage is determined using the following formula:

Required units = body weight (kg) x desired factor X rise (IU/mL) x 60

where 60 (mL/kg) is the reciprocal of the estimated recovery.

Required dosage for factor II:

Required units = body weight (kg) x desired factor II rise (IU/mL) x 50

If the individual recovery is known that value should be used for calculation.

Paediatric population

No data are available regarding the use of Octaplex in paediatric population.

Method of administration

Octaplex must be administered intravenously at a rate of 0.12 mL/kg/min (~3 units/kg/min), up to a maximum rate of 8 mL/min (~210 units/min), using an aseptic technique.

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Known allergy to heparin or history of heparin induced thrombocytopenia.

Individuals who have IgA deficiency with known antibodies against IgA.

Traceability

In order to improve traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded.

The advice of a specialist experienced in the management of coagulation disorders should be sought.

In patients with acquired deficiency of the vitamin K dependent coagulation factors (e.g. as induced by treatment with vitamin K antagonists), Octaplex should only be used when rapid correction of prothrombin complex levels is necessary, such as major bleeding or emergency surgery. In other cases, reduction of the dose of the vitamin K antagonist and/or administration of vitamin K is usually sufficient.

Patients receiving a vitamin K antagonist may have an underlying hypercoagulable state and infusion of prothrombin complex concentrate may exacerbate this.

If allergic or anaphylactic-type reactions occur, the infusion should be stopped immediately. In case of shock, standard medical treatment for shock should be implemented.

Standard measures to prevent infections resulting from the use of medicinal products prepared from human blood or plasma include selection of donors, screening of individual donations and plasma pools for specific markers of infection and the inclusion of effective manufacturing steps for the inactivation/removal of viruses. Despite this, when medicinal products prepared from human blood or plasma are administered, the possibility of transmitting infective agents cannot be totally excluded. This also applies to unknown or emerging viruses and other pathogens.

The measures taken are considered effective for enveloped viruses such as human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV). The measures taken may be of limited value against non-enveloped viruses such as hepatitis A virus (HAV) and parvovirus B19. Parvovirus B19 infection may be serious for pregnant women (foetal infection) and for individuals with immunodeficiency or increased erythropoiesis (e.g. haemolytic anaemia).

Appropriate vaccination (hepatitis A and B) is recommended for patients in regular/repeated receipt of human plasma-derived prothrombin complex products.

It is strongly recommended that every time Octaplex is administered to a patient, the name and batch number of the product are recorded in order to maintain a link between the patient and the batch of the product.

There is a risk of thrombosis or disseminated intravascular coagulation when patients, with either congenital or acquired deficiency are treated with human prothrombin complex particularly with repeated dosing. Patients given human prothrombin complex should be observed closely for signs or symptoms of intravascular coagulation or thrombosis. Because of the risk of thromboembolic complications, close monitoring should be exercised when administering human prothrombin complex to patients with a history of coronary heart disease, to patients with liver disease, to peri- or postoperative patients, to neonates, or to patients at risk of thromboembolic events or disseminated intravascular coagulation. In each of these situations, the potential benefit of treatment should be weighed against the risk of these complications.

No data is available regarding the use of Octaplex in case of perinatal bleeding due to vitamin K deficiency in the newborn.

This medicinal product contains 75 - 125 mg (500 IU vial) or 150 - 250 mg (1000 IU vial) sodium per vial, equivalent to 3.8 - 6.3 % or 7.5 - 12.5% of the WHO recommended maximum daily intake of 2 g sodium for an adult.

In congenital deficiency of any of the vitamin K dependent factors, specific coagulation factor product should be used when available.

Human prothrombin complex products neutralise the effect of vitamin K antagonist treatment, but no interactions with other medicinal products are known.

Interference with biological testing

When performing clotting tests which are sensitive to heparin in patients receiving high doses of human prothrombin complex, the heparin as a constituent of the administered product must be taken into account.

The safety of human prothrombin complex for use in human pregnancy and during lactation has not been established.

Animal studies are not suitable to assess the safety with respect to pregnancy, embryonal/foetal development, parturition, or postnatal development. Therefore, human prothrombin complex should be used during pregnancy and lactation only if clearly indicated.

No studies on the effects on the ability to drive and use machines have been performed.

Summary of Safety Profile

Replacement therapy may lead to the formation of circulating antibodies inhibiting one or more of the human prothrombin complex factors. If such inhibitors occur, the condition will manifest itself as a poor clinical response.

Allergic or anaphylactic-type reactions may rarely occur (≥ 1/10,000 to < 1/1,000) including severe anaphylactic reactions.

Increase in body temperature has been observed very rarely (< 1/10,000).

There is a risk of thromboembolic episodes following the administration of human prothrombin complex (see section 4.4).

Tabulated List of adverse reactions of Octaplex

The table presented below is according to the MedDRA system organ classification (SOC and Preferred Term Level). Frequencies have been based on clinical trial data, according to the following convention: very common (≥ 1/10); common (≥ 1/100 to <1/10); uncommon (≥ 1/1,000 to <1/100); rare (≥ 1/10,000 to <1/1,000); very rare (<1/10,000) or not known (cannot be estimated from the available data).

The following adverse reactions have been reported during post-marketing use of Octaplex. Because post-marketing reporting of adverse reactions is voluntary and from a population of uncertain size, it is not possible to reliably estimate the frequency of these reactions.

Octaplex contains heparin. Therefore, a sudden, allergy induced reduction of the blood platelet count below 100,000/µ l or 50 % of the starting count may be rarely observed (thrombocytopenia type II). In patients not previously hypersensitive to heparin, this decrease in thrombocytes may occur 6 - 14 days after the start of treatment. In patients with previous heparin hypersensitivity this reduction may happen within a few hours.

The treatment with Octaplex must be stopped immediately in patients showing this allergic reaction. These patients must not receive heparin containing medicinal products in the future.

For safety with respect to transmissible agents, see 4.4.

Paediatric population

No data is available regarding the use of Octaplex in paediatric population.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via www.mhra.gov.uk/yellowcard.

The use of high doses of human prothrombin complex products has been associated with instances of myocardial infarction, disseminated intravascular coagulation, venous thrombosis and pulmonary embolism. Therefore, in case of overdose, the risk of development of thromboembolic complications or disseminated intravascular coagulation is enhanced.

Pharmacotherapeutic group: antihemorrhagics, blood coagulation factors IX, II, VII, and X in combination, ATC code: B02BD01.

The coagulation factors II, VII, IX and X, which are synthesised in the liver with the help of vitamin K, are commonly called the Prothrombin Complex.

Factor VII is the zymogen of the active serine protease factor VIla by which the extrinsic pathway of blood coagulation is initiated. The tissue factor-factor VIla complex activates coagulation factors X and IX, whereby factor IXa and Xa are formed. With further activation of the coagulation cascade prothrombin (factor II) is activated and transformed to thrombin. By the action of thrombin, fibrinogen is converted to fibrin, which results in clot formation. The normal generation of thrombin is also of vital importance for platelet function as a part of the primary haemostasis.

Isolated severe deficiency of factor VII leads to reduced thrombin formation and a bleeding tendency due to impaired fibrin formation and impaired primary haemostasis. Isolated deficiency of factor IX is one of the classical haemophilias (haemophilia B). Isolated deficiency of factor II or factor X is very rare but in severe form they cause a bleeding tendency similar to that seen in classical haemophilia.

Acquired deficiency of the vitamin K dependent coagulation factors occurs during treatment with vitamin K antagonists. If the deficiency becomes severe, a severe bleeding tendency results, characterised by retroperitoneal or cerebral bleeds rather than muscle and joint haemorrhage.

Severe hepatic insufficiency also results in markedly reduced levels of the vitamin K dependent coagulation factors and a clinical bleeding tendency which, however, is often complex due to a simultaneous ongoing low-grade intravascular coagulation, low platelet levels, deficiency of coagulation inhibitors and disturbed fibrinolysis.

The administration of human prothrombin complex provides an increase in plasma levels of the vitamin K dependent coagulation factors and can temporarily correct the coagulation defect of patients with deficiency of one or several of these factors.

The plasma half-life ranges are:

Octaplex is administered intravenously and therefore immediately available in the organism.

There are no preclinical data considered relevant to clinical safety beyond data included in other sections of the SmPC.

Powder

Heparin: 0.2-0.5 IU/IU FIX

Tri-sodium citrate dihydrate

Solvent

Water for Injections

This medicinal product must not be mixed with other medicinal products.

3 years

Chemical and physical in-use stability has been demonstrated for up to 8 hours at +25° C.

From a microbiological point of view, unless the method of opening/reconstitution precludes the risk of microbial contamination, the product should be used immediately. If not used immediately, in-use storage times and conditions are the responsibility of the user.

Do not store above 25° C.

Do not freeze.

Store in the original package in order to protect from light.

For storage conditions after reconstitution of the medicinal product, see section 6.3.

Package sizes:

Octaplex 500 IU

One package contains:

- Powder in a vial (type I glass) with a stopper (halobutyl rubber) and a flip off cap (aluminium)

- 20 mL of Water for Injections in a vial (type I glass) with a stopper (halobutyl rubber) and a flip off cap (aluminium)

- 1 Nextaro^® transfer device.

Octaplex 1000 IU

One package contains:

- Powder in a vial (type I glass) with a stopper (halobutyl rubber) and a flip off cap (aluminium)

- 40 mL of Water for Injections in a vial (type I glass) with a stopper (halobutyl rubber) and a flip off cap (aluminium)

- 1 Nextaro^® transfer device.

Please read all the instructions and follow them carefully.

During the procedure described below, aseptic technique must be maintained.

The product reconstitutes quickly at room temperature.

The solution should be clear or slightly opalescent. Do not use solutions that are cloudy or have deposits. Reconstituted products should be inspected visually for particulate matter and discoloration prior to administration.

After reconstitution the solution must be used immediately.

Any unused product or waste material should be disposed of in accordance with local requirements.

Instructions for reconstitution

If the powder fails to dissolve completely or an aggregate is formed, do not use the preparation.

Instructions for infusion

As a precautionary measure, the patients pulse rate should be measured before and during the infusion. If a marked increase in the pulse rate occurs, the infusion speed must be reduced, or the administration must be interrupted.

1. Attach a 20 mL (500 IU) or 40 mL (1000 IU) syringe to the luer lock outlet on the white part of the Nextaro^® . Turn the vial upside down and draw the solution into the syringe.

Once the solution has been transferred, firmly hold the plunger of the syringe (keeping it facing down) and remove the syringe from the Nextaro^® . Dispose of the Nextaro^® and the empty vial.

2. Disinfect the intended injection site appropriately.

3. Inject the solution intravenously at a rate of 0.12 mL/kg/min (~3 units/kg/min), up to a maximum rate of 8 mL/min (~210 units/min), using an aseptic technique.

No blood must flow into the syringe due to the risk of formation of fibrin clots. The Nextaro^® is for single use only.