octaplasLG solution for infusion

Solution for infusion. The frozen solution is (slightly) yellow.

4.1 Therapeutic indications • Complex deficiencies of coagulation factors such as coagulopathy due to severe hepatic failure or massive transfusion. • Substitution therapy in coagulation factor deficiencies, when a specific coagulation factor concentrate (e.g. factor V or factor XI) is not available for use or in emergency situations when a precise laboratory diagnosis is not possible. • Rapid reversal of the effects of oral anticoagulants (coumarin or indanedione type) when a prothrombin complex concentrate is not available for use, or administration of vitamin K is insufficient due to impaired liver function or in emergency situations. • Potentially dangerous haemorrhages during fibrinolytic therapy, using e.g. tissue plasminogen activators, in patients who fail to respond to conventional measures. • Therapeutic plasma exchange procedures, including those in thrombotic thrombocytopenic purpura (TTP).4.2 Posology and method of administration **Posology:** The dosage depends upon the clinical situation and underlying disorder, but 12 - 15 ml octaplasLG/kg body weight is a generally accepted starting dose. This should increase the patient's plasma coagulation factor levels by approximately 25%. It is important to monitor the response, both clinically and with measurement of e.g. activated partial thromboplastin time (aPTT), prothrombin time (PT), and/or specific coagulation factor assays. Dosage for coagulation factor deficiencies: An adequate haemostatic effect in minor and moderate haemorrhages or surgery in coagulation factor deficient patients is normally achieved after the infusion of 5 - 20 ml octaplasLG/kg body weight. This should increase the patient's plasma coagulation factor levels by approximately 10 - 33 %. In the event of major haemorrhage or surgery, the expert advice of a haematologist should be sought. Dosage for TTP and haemorrhages in intensive plasma exchange: For therapeutic plasma exchange procedures, the expert advice of a haematologist should be sought. In TTP patients the whole plasma volume exchanged should be replaced with octaplasLG. **Method of administration** Administration of octaplasLG must be based on ABO-blood group specificity. In emergency cases, octaplasLG blood group AB can be regarded as universal plasma since it can be given to all patients regardless of blood group. octaplasLG must be administered by intravenous infusion after thawing, as described in section 6.6, using an infusion set with a filter. An aseptic technique must be used throughout the infusion. After thawing the solution is clear to slightly opalescent and free of solid or gelatinous particles. Citrate toxicity can occur when more than 0.020 - 0.025 mmol citrate per kg per minute is administered. Therefore, the infusion rate should not exceed 1 ml of octaplasLG per kg per minute. Toxic effects of citrate can be minimised by giving calcium gluconate intravenously into another vein. ***Paediatric population*** There is limited data in children and adolescents (0 - 16 years) (see section 4.4, 4.8 and 5.1).4.3 Contraindications

• IgA deficiency with documented antibodies against IgA
• Hypersensitivity to the active substance or to any of the excipients listed in section 6.1 or residues from the manufacturing process, as stated in section 5.3.
• Severe deficiencies of protein S4.4 Special warnings and precautions for use **octaplasLG should not be used:** • As a volume expander. • In cases of bleeding caused by coagulation factor deficiencies where a specific factor concentrate is available for use. • To correct hyperfibrinolysis in liver transplantation or other conditions with complex disturbances of haemostasis caused by a deficiency of plasmin inhibitor, also named α2-antiplasmin. **octaplasLG should be used with caution under the following conditions:** • IgA deficiency. • Plasma protein allergy. • Previous reactions to fresh-frozen plasma (FFP) or octaplasLG. • Manifest or latent cardiac decompensation. • Pulmonary oedema. In order to reduce the risk for venous thromboembolism caused by the reduced protein S activity of octaplasLG compared to normal plasma (see section 5.1), caution should be exercised and appropriate measures should be considered in all patients at risk for thrombotic complications. In intensive plasma exchange procedures, octaplasLG should only be used to correct the coagulation abnormality when abnormal haemorrhage occurs. **Viral safety** Standard measures to prevent infections resulting from the use of medical products prepared from human blood or plasma include selection of donors, screening of individual donations and plasma pool 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 and emerging viruses and other pathogens. The measures taken are considered effective for enveloped viruses such as HIV, HBV, and HCV. The measures taken may be of limited value against non-enveloped virus such as HAV, HEV and Parvovirus B19. Parvovirus B19 infection may be serious for pregnant woman (fetal infection) and for individuals with immunodeficiency or increased erythropoiesis (e.g. haemolytic anaemia). HEV may also seriously affect seronegative pregnant women. Therefore octaplasLG should only be administered to these patients if strongly indicated. Appropriate vaccination (e.g. against HBV and HAV) for patients in regular receipt of medicinal products derived from human blood or plasma should be considered. Additionally, a step to remove prions is incorporated. **Blood group-specific administration** Administration of octaplasLG must be based on ABO-blood group specificity. In emergency cases, octaplasLG blood group AB can be regarded as universal plasma since it can be given to all patients regardless of blood group. Patients should be observed for at least 20 minutes after the administration. **Anaphylactic reactions** In case of anaphylactic reaction or shock, the infusion must be stopped immediately. Treatment should follow the guidelines for shock therapy. **Traceability** In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded. **Paediatric population** Some cases of hypocalcaemia, possibly caused by citrate binding, have been observed during therapeutic plasma exchange in the paediatric population (see section 4.8). Monitoring of ionized calcium is recommended during such use of octaplasLG. **Interference with serological testing** Passive transmission of plasma components from octaplasLG (e.g. β-human chorionic gonadotropin; β-HCG) may result in misleading laboratory results in the recipient. For example, a false-positive pregnancy test result has been reported following passive transmission of β-HCG. This medicinal product contains maximum 920 mg sodium per bag, equivalent to maximum 46% of the WHO recommended maximum daily intake of 2 g sodium for an adult.4.5 Interaction with other medicinal products and other forms of interaction **Interactions:** No interactions with other drugs have been identified. **Incompatibilities:** • octaplasLG product can be mixed with red blood cells and platelets if ABO compatibility of both preparations is respected. • octaplasLG must not be mixed with other medicinal products, as inactivation and precipitation may occur. • To avoid the possibility of clot formation, solutions containing calcium must not be administered by the same intravenous line as octaplasLG.4.6 Fertility, pregnancy and lactation The safety of octaplasLG for use in human pregnancy has not been established in controlled clinical trials. It is not known whether octaplasLG can affect reproduction capacity. The product should be administered to a pregnant or lactating woman only if alternative therapies are regarded inappropriate. For potential risk of Parvovirus B19 and HEV transmission, see section 4.4.4.7 Effects on ability to drive and use machines After ambulant infusion, the patient should rest for one hour. octaplasLG has no or negligible influence on the ability to drive and use machines.4.8 Undesirable effects Hypersensitivity reactions may rarely be observed. These are usually mild allergic type reactions consisting of localised or generalised urticaria, erythema, flushing and pruritus. More severe forms can be complicated by hypotension or angioedema of the face or larynx. If other organ systems – cardiovascular, respiratory or gastrointestinal – are involved, the reaction would be considered anaphylactic or anaphylactoid. Anaphylactic reactions may have a rapid onset and may be serious; the symptom complex may include hypotension, tachycardia, bronchospasm, wheezing, coughing, dyspnoea, nausea, vomiting, diarrhoea, abdominal or back pain. Severe reactions may proceed to shock, syncope, respiratory failure and very rarely even death. High infusion rates may rarely cause cardiovascular effects as a result of citrate toxicity (fall in ionised calcium), especially in patients with liver function disorders. In the course of plasma exchange procedures, symptoms attributable to citrate toxicity such as fatigue, paraesthesia, tremor, and hypocalcaemia may be observed rarely. Transfusion-related acute lung injury (TRALI) has been reported in patients administered octaplasLG. TRALI is mainly characterised by onset within 6 hours of administration of octaplasLG, hypoxemia, and bilateral pulmonary edema not caused by circulatory overload. During clinical trials with octaplasLG's predecessor product, and its post-approval use, the following adverse reactions have been identified: Frequencies have been evaluated 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), not known (cannot be estimated from the available data). **Table 1: Adverse reactions that have been identified for octaplasLG** | | | | | | | | --- | --- | --- | --- | --- | --- | | **System organ class\*** | **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)** | **Not known§** | | Blood and lymphatic system disorders | | | | haemolytic anaemia haemorrhagic diathesis | | | Immune system disorders | | anaphylactoid reaction | hypersensitivity | anaphylactic shock anaphylactic reaction | | | Psychiatric disorders | | | | anxiety agitation restlessness | | | Nervous system disorders | | hypoesthesia | | dizziness paraesthesia | | | Cardiac disorders | | | | cardiac arrest arrhythmia tachycardia | | | Vascular disorders | | | | thromboembolism (LLT) hypotension hypertension circulatory collapse flushing | | | Respiratory, thoracic and mediastinal disorders | | hypoxia | | respiratory failure pulmonary haemorrhage bronchospasm pulmonary oedema dyspnoea respiratory disorder | transfusion-related acute lung injury | | Gastrointestinal disorders | | vomiting nausea | | abdominal pain | | | Skin and subcutaneous tissue disorders | urticaria pruritus | | | rash (erythematous) hyperhidrosis | | | Musculoskeletal and connective tissue disorders | | | | back pain | | | General disorders and administration site conditions | | pyrexia | | chest pain chest discomfort chills localised oedema malaise application site reaction | | | Investigations | | | | antibody test positive oxygen saturation decreased | | | Injury, poisoning and procedural complications | | | | transfusion-related circulatory overload citrate toxicity haemolytic transfusion reaction | | \*This table contains MedDRA Preferred Terms (PTs) unless indicated otherwise. §Spontaneous reporting data LLT, MedDRA Lowest Level Term Paediatric population In the course of plasma exchange procedures hypocalcaemia may be observed in the paediatric population especially in patients with liver function disorders or in case of high infusion rates. Monitoring of ionized calcium (see section 4.4) is recommended during such use of octaplasLG (see section 4.2). 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 the Yellow Card Scheme, Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose • High dosages or infusion rates may induce hypervolaemia, pulmonary oedema and/or cardiac failure. • High infusion rates may cause cardiovascular effects as a result of citrate toxicity (fall in ionised calcium), especially in patients with liver function disorders.

5.1 Pharmacodynamic properties Pharmacotherapeutic group: Blood substitutes and plasma protein fractions, ATC code: B05A A. The content and distribution of plasma proteins in octaplasLG remain in the final product at comparable levels to those in the raw material FFP, i.e. 45 - 70 mg/ml, and the major plasma proteins are all within the reference ranges for healthy blood donors (see table 2). Out of a mean total protein content of 58 mg/ml, albumin accounts for 50% (29 mg/ml), whereas the immunoglobulin classes G, A, and M are present at levels of 8.1, 1.6, and 0.8 mg/ml, respectively. As a result of the S/D treatment and purification, the content in lipids and lipoproteins is reduced. This is of no relevance within the indications for octaplasLG. The manufacturing process levels out inter-donor variations and maintain the plasma proteins in a functional state. Therefore, octaplasLG possesses the same clinical activity as the average single-donor FFP unit, but is more standardised. The finished product is tested for coagulation factors V, VIII, and XI, and the inhibitors protein C, protein S, and plasmin inhibitor. A minimum of 0.5 IU/ml is obtained for each of the three coagulation factors, whereas the inhibitor levels are guaranteed equal or higher than 0.7, 0.3, and 0.2 IU/ml. The fibrinogen content is between 1.5 and 4.0 mg/ml. In routine production, all clinically important parameters are within the 2.5 - 97.5 percentiles reference range for single-donor FFP, except plasmin inhibitor (also known as α2-antiplasmin) that is just below (see table 2). octaplasLG displays the same von Willebrand factor multimeric pattern as normal plasma. **Table 2: Global coagulation parameters and specific coagulation factors and inhibitors in octaplasLG** | | | | | --- | --- | --- | | **Parameter** | **octaplasLG** **Mean ± standard deviation** **(n = 5)** | **Reference range\** | | Activated partial thromboplastin time [sec] | 30 ± 1 | 28 - 41 | | Prothrombin time [sec] | 11 ± 0 | 10 - 14\\* | | Fibrinogen [mg/ml] | 2.6 ± 0.1 | 1.5 - 4.0\\ | | Coagulation factor II [IU/ml] | 1.01 ± 0.07 | 0.65 - 1.54 | | Coagulation factor V [IU/ml] | 0.76 ± 0.05 | 0.54 - 1.45 | | Coagulation factor VII [IU/ml] | 1.09 ± 0.05 | 0.62 - 1.65 | | Coagulation factor VIII [IU/ml] | 0.80 ± 0.07 | 0.45 - 1.68 | | Coagulation factor IX [IU/ml] | 0.88 ± 0.10 | 0.45 - 1.48 | | Coagulation factor X [IU/ml] | 0.99 ± 0.05 | 0.68 - 1.48 | | Coagulation factor XI [IU/ml] | 0.88 ± 0.04 | 0.42 - 1.44 | | Coagulation factor XII [IU/ml] | 1.04 ± 0.08 | 0.40 - 1.52 | | Coagulation factor XIII [IU/ml] | 1.03 ± 0.06 | 0.65 - 1.65 | | Antithrombin [IU/ml] | 0.86 ± 0.11 | 0.72 - 1.45 | | Heparin cofactor II [IU/ml] | 1.12 ± 0.05 | 0.65 - 1.35 | | Protein C [IU/ml] | 0.86 ± 0.08 | 0.58 - 1.64 | | Protein S [IU/ml] | 0.63 ± 0.08 | 0.56 - 1.68 | | Von Willebrand factor ristocetin cofactor activity [IU/ml] | 0.93 ± 0.08 | 0.45 - 1.75 | | ADAMTS13# activity [IU/ml] | 1.13 ± 0.17 | 0.50 - 1.10\\ | | Plasminogen [IU/ml] | 0.84 ± 0.06 | 0.68 - 1.44 | | Plasmin inhibitor## [IU/ml] | 0.61 ± 0.04 | 0.72 - 1.32 | \According [1,2] based on the testing of 100 healthy blood donors and defined by the 2.5 and 97.5 percentiles; or \\*according package insert of test kit. #A disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13. Also known as von Willebrand factor-cleaving protease (VWFCP). ##Also known as α2-antiplasmin. Clinical studies: An open-label, multicentre, post-marketing study investigated the safety, tolerability, and efficacy of octaplasLG in 37 neonates/infants (0 to 2 years old), and 13 children and adolescents (> 2 to 16 years old). Forty patients had cardiac surgery, 5 an orthotopic liver transplant, and 5 required replacement of multiple coagulation factors (4 of these patients had sepsis). In the 28 patients who had bypass priming (all aged ≤ 2 years), the mean dose was 20.2 ml/kg. In 20 other patients, the mean dose of the first infusion was 16.5 ml/kg in those aged ≤ 2 years and 12.7 ml/kg in those aged > 2 years. There were no hyperfibrinolytic events or thromboembolic events reported that were judged to be related to treatment with octaplasLG. Results of the haemostatic tests performed following infusions of octaplasLG were within the ranges expected by the investigators for patients requiring plasma infusions for bleeding indications. [1] Hellstern P, Sachse H, Schwinn H, Oberfrank K. Manufacture and characterization of a solvent/detergent-treated human plasma. Vox Sang 1992; 63:178-185 [2] Beeck H, Hellstern P. In vitro characterization of solvent/detergent-treated human plasma and of quarantine fresh frozen plasma. Vox Sang 1998; 74 (Suppl. I):219-2235.2 Pharmacokinetic properties octaplasLG has similar pharmacokinetic properties as FFP.5.3 Preclinical safety data Virus inactivation is carried out using Tri (N-Butyl) Phosphate (TNBP) and Octoxynol (Triton X-100). These S/D reagents are removed during the purification process. The maximum amounts of TNBP and Octoxynol in the finished product are < 2 µg/ml and < 5 µg/ml, respectively.

6.1 List of excipients Sodium citrate dihydrate Sodium dihydrogenphosphate dihydrate Glycine6.2 Incompatibilities

• octaplasLG product can be mixed with red blood cells and platelets if ABO compatibility of both preparations is respected.
• octaplasLG must not be mixed with other medicinal products, as inactivation and precipitation may occur.
• To avoid the possibility of clot formation, solutions containing calcium must not be administered by the same intravenous line as octaplasLG.6.3 Shelf life 4 years. After thawing, chemical and physical in-use stability has been demonstrated for 5 days at 2 – 8 ºC or 8 hours at room temperature (20 – 25 ºC). From a microbiological point of view, unless the method of opening 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.6.4 Special precautions for storage Store and transport frozen (at ≤ -18 ºC). Store in the original package in order to protect from light.6.5 Nature and contents of container 200 ml of ABO-blood group specific human plasma proteins in bag (polyvinyl chloride) over-wrapped with a film. Pack size of 1 and 10.6.6 Special precautions for disposal and other handling Do not use after the expiry date given on the label. **There are several options for thawing frozen octaplasLG:**
• Water bath: Thaw in the outer wrapper for not less than 30 minutes in a circulating water bath at +30 ºC to +37 ºC. An overwrap bag may be used to provide further protection of contents if appropriate. Prevent water from contaminating the entry port. The minimum thawing time is 30 minutes at 37 ºC. Temperature in the water bath must never exceed +37 ºC and should not be lower than +30 ºC. The thawing time depends on the number of bags in the water bath. If more plasma bags are thawed in parallel, the thawing time can be prolonged, but should not be longer than 60 minutes.
• Using a dry tempering system such as the SAHARA-III: Place the octaplasLG bags on the agitation plate according to the manufacturer instructions and thaw plasma using the fast tempering function. When a +37 ºC blood component temperature is indicated on the temperature display, terminate the tempering process and remove the bags. During thawing of octaplasLG using a dry tempering system, it is recommended to use the protocol printer to record the course of the blood component temperature and error messages in event of failure.
• Others: Other thawing systems for frozen octaplasLG can be used on the condition that the methods are validated for that purpose. Allow the content of the bag to warm to approximately +37 ºC before infusion. The temperature of octaplasLG must not exceed +37 ºC. Remove the outer wrapper and examine the bag for cracks or leaks. Avoid shaking. After thawing the solution is clear to slightly opalescent and free of solid or gelatinous particles. Do not use solutions which are cloudy or have deposits and/or discoloration. Thawed octaplasLG must not be refrozen. Unused product must be discarded. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.