Aprotinin 10,000 KIU/ml Injection BP

Solution for injection

4.1 Therapeutic indications Aprotinin is indicated for prophylactic use to reduce blood loss and blood transfusion in adult patients who are at high risk of major blood loss undergoing isolated cardiopulmonary bypass graft surgery (i.e. coronary artery bypass graft surgery that is not combined with other cardiovascular surgery). Aprotinin should only be used after careful consideration of the benefits and risks, and the consideration that alternative treatments are available (see section 4.4 and 5.1).4.2 Posology and method of administration An appropriate aprotinin-specific IgG antibody test may be considered if available before administration of aprotinin (see section 4.3). Adult: Owing to the risk of allergic/anaphylactic reactions, a 1ml (10,000 KIU) test dose should be administered to all patients at least 10 minutes prior to the remainder of the dose. After the uneventful administration of the 1ml test dose, the therapeutic dose may be given. A H1 antagonist and a H2 antagonist may be administered 15 minutes prior to the test dose of aprotinin. In any case standard emergency treatments for anaphylactic and allergic reactions should be readily available (see section 4.4). A loading dose of 1 - 2 million KIU is administered as a slow intravenous injection or infusion over 20 - 30 minutes after induction of anaesthesia and prior to sternotomy. A further 1 - 2 million KIU should be added to the pump prime of the heart-lung machine. To avoid physical incompatibility of aprotinin and heparin when adding to the pump prime solution, each agent must be added during recirculation of the pump prime to assure adequate dilution prior to admixture with the other component. The initial bolus infusion is followed by the administration of a continuous infusion of 250,000 - 500,000 KIU per hour until the end of the operation. In general, the total amount of aprotinin administered per treatment course should not exceed 7 million KIU. *Paediatric population* The safety and efficacy in children below 18 years of age have not been established. *Renal impairment* Available clinical experience suggests that patients with decreased renal function do not require special dose adjustment. *Hepatic impairment* No data are available on dosage recommendations for patients with hepatic dysfunction. *Elderly* Reported clinical experience has not identified differences in responses in elderly patients. **Method of administration** Aprotinin should be infused using a central venous catheter. The same lumen should not be used for the administration of any other medicinal product. When using a multi-lumen central catheter a separate catheter is not required. Aprotinin must be given only to patients in the supine position and must be given slowly (maximum 5 - 10ml/min) as an intravenous injection or a short infusion.4.3 Contraindications Hypersensitivity to the active substance or any of the excipients listed in section 6.1. Patients with a positive aprotinin-specific IgG antibody test are at an increased risk of anaphylactic reaction when treated with aprotinin. Therefore, administration of aprotinin is contraindicated in these patients. In case no aprotinin specific IgG antibody test is possible prior to treatment, administration of aprotinin to patients with a suspected previous exposure including in fibrin sealant products during the last 12 months is contraindicated.4.4 Special warnings and precautions for use **Aprotinin should not be used when CABG surgery is combined with another cardiovascular surgery because the benefit risk balance of aprotinin in other cardiovascular procedures has not been established.** *Laboratory monitoring of anticoagulation during cardiopulmonary bypass* Aprotinin is not a heparin-sparing agent and it is important that adequate anticoagulation with heparin be maintained during aprotinin-therapy. The partial thromboplastin time (PTT) and activated partial thromboplastin time (APTT) are similar and become immeasurable with high doses of heparin. Therefore, APTT and PTT should not be used to monitor anticoagulation with heparin in patients undergoing cardiopulmonary bypass graft surgery. In patients undergoing cardiopulmonary bypass graft surgery with aprotinin therapy, one of the following methods is recommended to maintain adequate anticoagulation:

1. Individualized heparin and protamine management should be considered to reduce postoperative coagulation abnormalities and bleeding complications in cardiac surgery with cardiopulmonary bypass (CPB). Individualized heparin management or titration is based on computer-based heparin dosing systems, anti-Xa measurements or blood heparin measurements in addition to the Activated Clotting Time (ACT). Anti-Xa measurement and blood heparin measurements are unaffected by aprotinin and should be carried out following test-manufacturer's notices.
2. In the absence of individual heparin dosing tools, it is recommended that ACT tests are performed at regular intervals based on institutional protocols, and heparin doses have to be given accordingly. The required target ACT is dependent on the type of activator and equipment used. Elevations of kaolin and celite ACT are expected in aprotinin-treated patients during surgery, and in the hours after surgery. In patients undergoing cardiopulmonary bypass with aprotinin therapy, a minimal celite ACT of 750 seconds or kaolin ACT of 480 seconds is recommended to maintain anticoagulation, independent of the effects of haemodilution and hypothermia. ACT tests using a mixture of activators should be carried out following test-manufacturer's notices. ***Protamine management*** As the protamine test is unaffected by aprotinin in aprotinin treated patients the neutralisation of heparin by protamine after discontinuation of cardiopulmonary bypass should be carried out following test-manufacturer's notices. ***Graft Conservation*** Blood drawn from the aprotinin central infusion line should not be used for graft preservation. ***Re-exposure to aprotinin*** Administration of aprotinin, especially to patients who have received aprotinin (including aprotinin containing fibrin sealants) in the past requires a careful risk/benefit assessment because an allergic reaction may occur (see sections 4.3 and 4.8). Although the majority of cases of anaphylaxis occur upon re-exposure within the first 12 months, there are also single case reports of anaphylaxis occurring upon re- exposure after more than 12 months. Standard emergency treatment for allergic/anaphylactic reactions should be readily available during treatment with aprotinin. ***Assessment of potential for allergic reactions*** All patients treated with aprotinin should first receive a test dose to assess the potential for allergic reactions (see section 4.2). The test dose of aprotinin should only be administered when facilities and equipment for handling acute anaphylactic reactions are available on-site. ***Renal impairment*** Results from prior observational studies indicate that renal dysfunction could be triggered by aprotinin, particularly in patients with pre-existing renal dysfunction. An analysis of all pooled placebo-controlled studies in patients undergoing coronary artery bypass graft (CABG) has found elevations of serum creatinine values >0.5mg/dL above baseline in patients with aprotinin therapy (see section 5.1). An increase in renal failure and mortality compared to age-matched historical controls has been reported for aprotinin-treated patients undergoing cardiopulmonary bypass with deep hypothermic circulatory arrest during operation of the thoracic aorta. Careful consideration of the balance of risks and benefits is therefore advised before administration of aprotinin to patients with pre-existing impaired renal function or those with risk factors (such as concomitant treatment with aminoglycosides). ***Mortality*** Information on mortality from randomised clinical trials is provided in section 5.1. An association between aprotinin use and increased mortality has been reported in some non-randomised observational studies (e.g, Mangano 2007, Schneeweiss 2008, Olenchock 2008, Shaw 2008) while other non-randomised studies have not reported such an association (e.g, Karkouti 2006, Mangano 2006, Coleman 2007, Pagano 2008, Ngaage 2008, Karkouti, 2009). In these studies, aprotinin was usually administered to patients who had more risk factors for increased mortality before surgery than patients in the other treatment groups. Most of the studies did not adequately account for these baseline differences in risk factors and the influence of these risk factors on the results is not known. Therefore interpretation of these observational studies is limited and an association between aprotinin use and increased mortality can neither be established nor refuted. Thus, aprotinin should only be used as authorized in isolated CABG surgery, after careful consideration of the potential risks and benefits. A publication by Fergusson et al. in 2008 analysed data from a randomised controlled trial, Blood Conservation Using Antifibrinolytics in a Randomised Trial (BART), and reported a higher mortality rate in aprotinin-treated patients compared to those treated with tranexamic acid or aminocaproic acid. However, due to several methodological deficiencies no firm conclusion on cardiovascular risks can be made on the BART study results. In a post-authorization safety study (The Nordic Aprotinin Patient Registry (NAPaR, De Hert 2022)), 5448 adult patients were treated with aprotinin: 1,384 patients (25.4%) for an isolated CABG and 4,064 patients (74.6%) for other cardiac procedures. Within the 'other cardiac procedures' group 972 patients (23.9%) underwent valves with/without CABG surgery, 1,530 patients (37.6%) underwent aortic surgery without aortic valve replacement and 606 patients (14.9%) underwent surgery for active endocarditis. In-hospital mortality in iCABG patients was 1.4% vs. 8.3% in non-iCABG patients.4.5 Interaction with other medicinal products and other forms of interaction Aprotinin has a dose-dependent inhibitory effect on the action of thrombolytic agents, e.g. streptokinase, urokinase, alteplase (r-tPA). Special attention to coagulation should be paid in patients receiving active thrombolytic agents known to be aprotinin targets. Renal dysfunction could be triggered by aprotinin, particularly in patients with pre- existing renal dysfunction. Drugs with a potent nephrotoxic profile (such as aminoglycosides and renin-angiotensin-aldosterone system inhibitors) are a risk factor for renal dysfunction. Special attention to kidney protection should be paid when exposing patients to both aprotinin and other drugs that could trigger a kidney dysfunction.4.6 Fertility, pregnancy and lactation **Pregnancy** There are no adequate and well-controlled studies in pregnant women. Animal studies did not provide any evidence of teratogenic or other embryotoxic effects of aprotinin. Aprotinin should be used throughout pregnancy only if the potential benefit justifies the potential risk. In case of severe adverse drug reactions (like anaphylactic reaction, heart arrest, etc.) and their consecutive therapeutic measures, damage to the foetus has to be taken into account for a risk/benefit evaluation. **Breastfeeding** It is unknown whether aprotinin is excreted in human milk. However, since aprotinin is not bioavailable after oral administration, any drug contained in the milk is not expected to have a systemic effect on the breast-feed child. **Fertility** There are no adequate and well-controlled studies addressing fertility in men or women.4.7 Effects on ability to drive and use machines Not relevant.4.8 Undesirable effects *Summary of the safety profile* The safety of aprotinin has been evaluated in more than forty five phase II and phase III studies including more than 3800 patients exposed to aprotinin. In total, about 11% of aprotinin-treated patients experienced adverse reactions. The most serious adverse reaction was myocardial infarction. The safety of aprotinin has been monitored in the NAPaR between February 2016 and November 2020. Of the total 6682 entered patients, the rate of adverse drug reaction 1.1%. The adverse reactions should be interpreted within the surgical setting. *Tabulated summary of adverse reactions* Adverse drug reactions (ADRs) based on all placebo-controlled clinical studies with aprotinin sorted by CIOMS III categories of frequency (aprotinin n=3817 and placebo n=2682; status: April 2005) and based on the NAPaR are listed in the table below: Frequencies are defined as: 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 | | | | | | | --- | --- | --- | --- | --- | | **MedDRA Standard System organ class** | **Common** | **Uncommon** | **Rare** | **Very Rare** | | **Immune system disorders** | | Allergic reaction Anaphylactic / anaphylactoid reaction | | ***Anaphylactic shock (potentially life threatening)*** | | **Blood and lymphatic system disorders** | | | | ***Disseminated intravascular coagulation, Coagulopathy*** | | **Cardiac disorders** | | Myocardial ischaemia, Coronary occlusion / thrombosis, Myocardial infarction, Pericardial effusion | | | | **Vascular disorders** | | Thrombosis, ***Embolic stroke*** | Arterial thrombosis (and its organ specific manifestations that might occur in vital organs such as kidney, lung or brain), ***Pulmonary embolism*** | | | **Renal and urinary disorders** | | Oliguria, acute kidney injury, Renal tubular necrosis | | | | **General disorders or administration site conditions** | | | | Injection and infusion site reactions, Infusion site (thrombo-)phlebitis | | **Investigations** | ***Blood creatinine increased*** | | | | • ADRs derived from post-marketing reports are printed in ***bold italic*** *Description of selected adverse reactions* **Allergic/anaphylactic reactions** are rare in patients with no prior exposure to aprotinin. In case of re-exposure the incidence of allergic/anaphylactic reactions may reach the five percent level. A retrospective review showed that the incidence of an allergic/anaphylactic reaction following re-exposure is increased when the re-exposure occurs within 6 months of the initial administration (5.0% for re-exposure within 6 months and 0.9% for re- exposures greater than 6 months). A retrospective review suggests that the incidence of severe anaphylactic reactions to aprotinin may further increase when patients are re-exposed more than twice within 6 months. Even when a second exposure to aprotinin has been tolerated without symptoms, a subsequent administration may result in severe allergic reactions or anaphylactic shock with, in very rare cases, fatal outcome. The symptoms of allergic/anaphylactic reactions may include: | | | | --- | --- | | Respiratory system: | asthma (bronchospasm) | | Cardiovascular system: | hypotension | | Skin and appendages: | pruritus, rash, urticaria | | Digestive system: | nausea | If allergic reactions occur during injection or infusion, administration should be stopped immediately. Standard emergency treatment may be required, i.e. adrenaline/epinephrine, volume substitution and corticosteroids. **Cardiovascular system** In the pooled analysis of all placebo-controlled clinical studies, the incidence of investigator-reported myocardial infarction (MI) in aprotinin treated patients was 5.8% compared to 4.8% in placebo treated patients, with difference of 0.98% between the groups (aprotinin n=3817 and placebo n=2682; status: April 2005). A trend of increased incidence of MI in association with aprotinin was observed in some studies, while other studies showed a lower incidence compared to placebo. **Mortality** For the risk of mortality associated with the use of aprotinin see section 4.4. **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 Yellow Card Scheme in UK. Website: www.mhra.gov.uk/yellowcard4.9 Overdose There is no specific antidote.

5.1 Pharmacodynamic properties Pharmacotherapeutic group: Antihemorrhagics, proteinase inhibitors, ATC code: B02AB01 Aprotinin is a broad spectrum protease inhibitor which has antifibrinolytic properties. By forming reversible stoichiometric enzyme-inhibitor complexes, aprotinin acts as an inhibitor of human trypsin, plasmin, plasma kallikrein and tissue kallikrein, thus inhibiting fibrinolysis. It also inhibits the contact phase activation of coagulation which both initiates coagulation and promotes fibrinolysis. Data from a global pool of placebo-controlled studies in patients undergoing coronary artery bypass graft (CABG) surgery showed that the incidence of serum creatinine elevations >0.5mg/dL above pre-treatment levels was statistically higher at 9.0% (185/2047) in the full-dose aprotinin group compared with 6.6% (129/1957) in the placebo group, with an odds ratio of 1.41 (1.12-1.79). In the majority of instances, post-operative renal dysfunction was not severe and reversible. The incidence of serum creatinine elevations >2.0mg/dL above baseline was similar (1.1% vs 0.8%) in both the full-dose aprotinin and placebo group, with an odds ratio of 1.16 (0.73-1.85) (see section 4.4). The in-hospital mortality in a pool of randomized, clinical trials is summarised in the table below: | | | | | | | | --- | --- | --- | --- | --- | --- | | **In-hospital Mortality in a pool of Randomised Clinical Trials (Population: All Global CABG Patients Valid for Safety)** | | | | | | | **Population** | **Full-Dose Aprotinin** | | **Placebo** | | **Odds Ratio (95% CI)** | | **n/N** | **%** | **n/N** | **%** | | All CABG | 65/2249 | 2.9 | 55/2164 | 2.5 | 1.09 (0.78, 1.52) | | Primary CABG | 36/1819 | 2.0 | 39/1785 | 2.2 | 0.92 (0.62, 1.38) | | Repeat CABG | 22/276 | 8.0 | 13/255 | 5.1 | 1.47 (0.75, 2.87) | The Nordic Aprotinin Patient Registry (NAPaR), a multicenter non-interventional active surveillance post-authorisation study, aimed, among other outcomes, to measure the incidence of safety outcomes. Up to month 56 data extraction point, 5,448 adult patients were treated with aprotinin, including 1,384 patients (25.4%) with an isolated CABG (iCABG) and 4,064 patients (74.6%) with other (off label) cardiac procedures. Within the 'other cardiac procedures' group 972 patients (23.9%) underwent valves with/without CABG surgery, 1,530 patients (37.6%) underwent aortic surgery without aortic valve replacement and 606 patients (14.9%) underwent surgery for active endocarditis. Three hundred and seventeen (317) patients (6.0%, n=5,278, 95% CI 5.37%; 6.65%) experienced at least one thromboembolic event. All thromboembolic events except 33 occurred in patients treated with other procedures, resulting in a higher incidence in this group than in the iCABG group (7.2% versus 2.5%). Of the 5,267 patients for whom data were available, 286 (5.4%, 95% CI 4.82%; 6.04%) were re-operated for bleeding. Re operation for bleeding was less frequently reported in patients treated with iCABG (29/1,342, 2.2%, 95% CI 1.38%; 2.94%) compared to patients treated with other procedures (257/3,925, 6.6%, 95% CI 5.77%; 7.32%). Six hundred and forty (640) patients (12.2%, n=5,234, 95% CI 11.34%; 13.12%) presented renal dysfunction and 441 (8.6%, n=5,159) required post-operative renal dialysis. Incidence of renal dysfunction and dialysis was higher in patients treated with other procedures (15.5% and 10.9%, respectively) than in patients treated with iCABG (2.7% and 1.7%, respectively). The in-hospital mortality data are described under section 4.4. When comparing with published literature, the findings from the NAPaR in iCABG were essentially in accordance with the known safety profile of aprotinin in the approved indication.5.2 Pharmacokinetic properties After intravenous injection, rapid distribution of aprotinin occurs into the total extracellular space, leading to an initial decrease in plasma aprotinin concentration with a half-life of 0.3 - 0.7 h. At later time points, (i.e. beyond 5 hours post-dose) there is a terminal elimination phase with a half-life of about 5 - 10 hours. The placenta is probably not absolutely impermeable to aprotinin, but permeation appears to take a very slow course. *Metabolism, elimination and excretion* The aprotinin molecule is metabolised to shorter peptides or amino acids by lysosomal activity in the kidney. In man, urinary excretion of active aprotinin accounts for less than 5% of the dose. After receiving injections of 131I-aprotinin healthy volunteers excreted within 48 hours 25 - 40% of the labelled substance as metabolites in the urine. These metabolites lacked enzyme-inhibitory activity. No pharmacokinetic studies are available in patients with terminal renal insufficiency. Studies in patients with renal impairment revealed no clinically significant pharmacokinetic alterations or obvious side effects. A special dose adjustment is not warranted.5.3 Preclinical safety data *Acute toxicity* In rats, guinea-pigs, rabbits and dogs, high doses (>150,000 KIU/kg) injected quickly caused a blood pressure reduction of varying magnitude, which rapidly subsided. *Reproduction toxicity* In rat intravenous studies, daily doses of up to 80,000 KIU/kg produced no maternal toxicity, embryotoxicity, or foetotoxicity. Daily doses of up to 100,000 KIU/kg did not interfere with the growth and development of the young and doses of 200,000 KIU/kg/day were not teratogenic. In rabbits, daily intravenous doses of 100,000 KIU/kg produced no evidence of maternal toxicity, embryotoxicity, foetotoxicity or teratogenicity. *Mutagenic potential* Aprotinin gave a negative mutagenic response in the salmonella/microsome and *B. subtilis* DNA damage system.

6.1 List of excipients Sodium chloride, Water for injections6.2 Incompatibilities Aprotinin is incompatible with antibiotics such as tetracyclines which react with proteins, corticosteroids, heparin and nutrient solutions containing amino acids or fat emulsions. The addition of Aprotinin to mixed infusions (particularly with beta-lactam antibiotics) should be avoided. Electrolyte and sugar solutions are compatible with aprotinin.6.3 Shelf life 3 years6.4 Special precautions for storage Store below 25°C. Store in the original package in order to protect from light.6.5 Nature and contents of container Clear glass vials of 50ml.6.6 Special precautions for disposal and other handling Parenteral drug products should be inspected visually for particulate matter and colour change prior to administration. Any residual solution should not be kept for later use. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.