Firming the clot, controlling bleeding...threatening bleeding episodes in congenital fibrinogen disorders. Some years ago, patients received infusions of fresh frozen plasma (FFP)

INDICATION: Treatment and perioperative prophylaxis of bleeding in patients with congenital hypo- or afibrinogenaemia with bleeding tendency.

MONOGRAPH

Powder and solvent for solution for injection/infusion

Firming the clot, controlling bleeding

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SUMMARY

INTRODUCTION ............................................................................................................ 5

FIBRINOGEN AND HAEMOSTASIS ......................................................................... 6 Fibrinogen (or clotting factor I): a large and complex molecule ............................... 6

I. Structure: the 3 chains ........................................................................................................... 6II. Numerous ligands (proteins and cells) ............................................................................... 6

Fibrinogen: a pivotal role in the haemostatic balance .................................................. 6I. Fibrinogen, support for platelet aggregation (primary haemostasis and platelet cross-linking) ............................................................. 7II. Fibrinogen: substrate for fibrin clot formation and plasma coagulation (secondary haemostasis) ...................................................................................................... 7III. Fibrinogen: target of fibrinolysis ......................................................................................... 9

Fibrinogen plasma concentration .......................................................................................... 9I. Physiological level .................................................................................................................. 9II. Physiological and pathological variations .......................................................................... 9

FIBRINOGEN DEFICIENCIES AND COAGULATION DISORDERS ................10 Constitutional fibrinogen defects: two classes ..............................................................10

Clinical heterogeneity ..................................................................................................................11I. Afibrinogenaemia: severe symptoms ..................................................................................11II. Hypofibrinogenaemia: usually asymptomatic ..................................................................11III. Dysfibrinogenaemia: unpredictable clinical phenotype ................................................12

Screening tests for diagnosis of fibrinogen deficiencies ..........................................12I. Routine methods for measuring fibrinogen concentration .............................................12II. Coagulation assays ...............................................................................................................13III. Genotype analysis ...............................................................................................................14IV. Genotype-phenotype correlations ...................................................................................14

Fibrinogen deficiencies and high risk of bleeding conditions ................................15

Treatment of constitutional fibrinogen deficiencies ....................................................15I. Fibrinogen replacement: the standard therapy .................................................................15II. Currently available products ...............................................................................................15

FibCLOT®: HUMAN FIBRINOGEN CONCENTRATE ..........................................17 FibCLOT®: a purified human fibrinogen concentrate ....................................................17

FibCLOT®: a highly secure compound .................................................................................17I. Rigorous donor selection ......................................................................................................18II. Donation screening ..............................................................................................................18III. Three specific steps of inactivation and/or removal of pathogens .............................19

FibCLOT® : formulation of the finished product .............................................................. 20

FibCLOT®: THE CLINICAL DEVELOPMENT PROGRAMME IN CONGENITAL DEFICIENCIES ............................................................................21

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FibCLOT®: CLINICAL PHARMACOLOGY ..............................................................22 Pharmacologic research programme ................................................................................. 22

Pharmacokinetic parameters ................................................................................................. 22

Pharmacodynamic properties ................................................................................................ 24I. Effects on global coagulation tests .....................................................................................24II. Effect on clot strength ..........................................................................................................24

FibCLOT®: CLINICAL EFFICACY .............................................................................26 Clinical studies ............................................................................................................................... 26

I. Evaluation criteria ................................................................................................................. 26II. Treatment .............................................................................................................................. 27

Clinical efficacy .............................................................................................................................. 27I. Overall efficacy ..................................................................................................................... 27II. Efficacy in clinical situations of major and minor bleedings ......................................... 28

FibCLOT®: OVERVIEW OF SAFETY........................................................................29 Evaluation of FibCLOT® Safety ............................................................................................... 29

Tolerance of FibCLOT® ............................................................................................................... 29I. Clinical tolerance .................................................................................................................. 29II. Immunogenicity .................................................................................................................... 30III. Transmissible agents .......................................................................................................... 30

FibCLOT® IN CLINICAL PRACTICE ........................................................................31 Practical advantages of using FibCLOT® ........................................................................... 31

Clinical indications........................................................................................................................ 31

Dosage and method of administration................................................................................ 31I. Treatment and prophylaxis of bleeding ............................................................................ 32II. Preparation and reconstitution .......................................................................................... 33III. Method of administration (injecting FibCLOT®) .............................................................. 34

LFB: A HERITAGE OF QUALITY PLASMA-DERIVED THERAPIES WITH OUTSTANDING RECORDS OF SAFETY AND EFFICACY ....................34

FibCLOT®: GOOD USE ...............................................................................................35 Adequate patient evaluation and monitoring .................................................................. 35

Contraindications .......................................................................................................................... 35

Special warnings and special precautions for use ....................................................... 35

Undesirable effects ..................................................................................................................... 36

Incompatibilities ............................................................................................................................ 37

Storage and stability .................................................................................................................... 37

Shelf life .............................................................................................................................................. 37

REFERENCES ...............................................................................................................38

SmPC ..............................................................................................................................40


INTRODUCTION

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Fibrinogen, also called coagulation factor I, is the primary substrate of the coagulation process. By forming a fibrin clot in response to injury, fibrinogen plays a pivotal role in achieving and maintaining haemostasis [1,2]. Fibrinogen promotes clot formation and stabilisation, and is also as a key ligand between activated platelets [2]. Accordingly, any fibrinogen deficiency may result in defects in these key functions, with an increased risk of bleeding in different clinical settings.

Normal plasma fibrinogen levels are generally considered to range from 1.5 to 4.5 g/L [3,4]. In congenital afibrinogenaemia or hypofibrinogenaemia, plasma fibrinogen is undetectable or reduced respectively [5]. The critical plasma fibrinogen level below which haemorrhages may occur is approximately 0.5 – 1.0 g/L [6].

Fibrinogen replacement therapy is effective to treat potentially life-threatening bleeding episodes in congenital fibrinogen disorders. Some years ago, patients received infusions of fresh frozen plasma (FFP) or cryoprecipitate. These approaches are no longer regarded as optimal on grounds of infectious and immunologic risks. However, these products are still useful when no concentrates are available [5].

An alternative to FFP and cryoprecipitate is high-purity fibrinogen concentrate, now well established as the replacement therapy of choice in these patients.

FibCLOT®, a purified and standardised human fibrinogen, allows for an accurate dosage delivery, with the highest safety standards. Stringent virus-inactivation methods are applied to the manufacturing process. FibCLOT® can be easily reconstituted and administered in a small volume, thus avoiding a risk of fluid overload.

This monograph summarises evidence generated during the clinical development programme and post-marketing experience, including quality, efficacy and safety data for FibCLOT® for the treatment and perioperative prophylaxis of bleeding in patients with congenital hypo-or afibrinogenaemia with bleeding tendency.

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FIBRINOGEN AND HAEMOSTASIS

Fibrinogen (or clotting factor I): a large and complex molecule

I. Structure: the 3 chains

Fibrinogen (clotting factor I) is a 340 kDa glycoprotein mainly synthesised in hepatocytes, that circulates in the plasma and can be converted to fibrin, which is essential for coagulation [5,7]. The structure of fibrinogen is complex. The core structure consists of two identical subunits with two D regions connected to a central E region by a coiled-coil segment [5,7]. Each subunit is composed of three non-identical polypeptide chains: Aa, Bβ and γ, linked with disulfide bridges to form the E region [5,8,9]. Each fibrinogen Aa-chain contains an N-terminal fibrinopeptide A sequence, which is cleaved by thrombin, initiating fibrin assembly [7]. The genes for all three chains are located on the long arm of chromosome 4 [5,8].The molecule is constitutively secreted into the circulation, where it has a half-life of 4 days and a fractional catabolic rate of 25% per day.

II. Numerous ligands (proteins and cells)

Fibrinogen and fibrin play overlapping roles, including binding to thrombin, fibrinolysis, regulation of factor XIII activity, growth factor binding and interactions with cells including platelets, leukocytes, fibroblasts, and endothelial cells. These functions are regulated by the interactive sites on fibrin(ogen), some of which are masked or otherwise not available on fibrinogen, and they commonly evolve as a consequence of fibrin formation or fibrinogen-surface interactions [7].

Fibrinogen: a pivotal role in the haemostatic balance

Fibrinogen is a critical protein for clot formation. The final step of the clotting cascade, fibrinogen leads to the generation of fibrin and provides a matrix and mesh network essential to maintain the clot’s strength in response to injury [11].

The fibrinogen molecule

(a) Schematic representation of the fibrinogen molecule. The three chains of Fg, Aa, Bβ and γ are shown in blue, red and green, respectively. (b) Van der Waals representation of the crystallographic structure (pdb 3GHG) of Fg, color coded as in (a). Carbohydrates are in orange. The aC region and the FpA and FpB peptides were not resolved in the crystal structure.

From Köhler S et al. [10].

FIGURE 1

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I. Fibrinogen, support for platelet aggregation (primary haemostasis and platelet cross-linking)

Fibrinogen is important in primary haemostasis as it acts as the ligand for glycoprotein IIb/IIIa receptors found on the platelet surface, which are responsible for the platelet aggregation. These platelets then become enmeshed within the fibrin strands, further facilitating crosslinking and stabilisation of the growing clot [2,11].

II. Fibrinogen: substrate for fibrin clot formation and plasma coagulation (secondary haemostasis)

1. Activation and amplification pathways of blood coagulation

Fibrinogen is the final step of the clotting cascade.Following tissue injury, a sequence of events leads to fibrin generation:

• Initiation of thrombin generation: this occurs through tissue factor, which is expressed on subendothelial fibroblasts and binds to plasma factor VII, which autoactivates and activates factor X on the fibroblast membranes. This generates small amounts of thrombin and factor IXa.

• Amplification of thrombin generation: the small amount of thrombin upregulates its own production by activating factor XI in the intrinsic pathway (with platelet polyphosphates as a cofactor) as well as the cofactors factor VIII and factor V. This phase occurs on activated platelets (thrombin is a strong platelet agonist), generating a large amount of factor Xa on the platelet surface.

• Propagation of thrombin generation: this occurs through factor Xa on the platelet surface, with the help of factor Va as cofactor, and generates an explosive thrombin burst. This thrombin burst is essential for forming cross-linked fibrin from fibrinogen.

The clotting cascade

Adapted from Hoffman M, Monroe DM. Hematol Oncol Am. 2007 [12].

FibrinogenFibrinogen

FibrinFibrin

Activated plateletActivated platelet

Tissue factor (TF)-bearing fibroblastTissue factor (TF)-bearing fibroblast

CalciumCalcium

damaged endotheliumdamaged endothelium

FIXFIX

FXIFXI

FIXaFIXaFVIIIaFVIIIa

FXIaFXIa

FXaFXa

FXFX

FVaFVa

ThrombinThrombin

TF-FVIIaTF-FVIIacomplexcomplexFXFX

TFTF FXaFXa

AMPLIFICATIONAMPLIFICATION

INITIATIONINITIATION

FIBRIN FORMATIONFIBRIN FORMATION

PROPAGATIONPROPAGATION

Thrombinburst

extracellular matrixextracellular matrix

FVIIaFVIIaFVIIaFVIIa

FIGURE 2

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2. Fibrinogen and conversion to cross-linked fibrin

Fibrin polymerisationFibrin is generated from fibrinogen in three distinct phases by high levels of thrombin [5,11,13]:

• Firstly, there is the formation of soluble f ibrin monomers. The fibrinogen is cleaved at the E region by thrombin to form soluble fibrin. This cleavage releases small peptides from the terminal ends of the a and β chains of fibrinogen, called fibrinopeptide A (from the a chain) and B (from the β chain).

• Secondly, fibrin units self-assemble and laterally associate into long fibrils (fibrin polymer) by covalent associations between terminal (D) ends of each fibrin monomer. Each polymer is also loosely associated with adjacent polymers. An organised soluble fibrin network is formed, in which red blood cells (RBCs) become trapped and a clot begins to form.

• Thirdly, there is a covalent cross-linking of fibrin by activated factor XIII [14]. Fibrin is incorporated into and stabilises the primary platelet plug and is also important for binding the platelet plug to the injured vessel wall, increasing the resistance of the clot to mechanical, chemical and proteolytic insults.

Structure of the clotThe fibrin clot is a branched, three-dimensional network made up of fibers with unique mechanical properties, strong enough to temporary withstand mechanical stress and fibrinolytic dissolution until the vessel wound is healed [14].

A fibrin blood clot

The thrombin cleavage of fibrinogen and polymerisation of fibrin monomers to fibrin. A schematic representation of the thrombin cleavage of fibrinogen, followed by the polymerisation of fibrin monomers to form fibrin strands is illustrated [3].

Fibrinopeptide AFibrinopeptide A

Fibrinopeptide BFibrinopeptide B

α chainα chainβ chainβ chain

γ chainγ chain

PolymerizationPolymerization

D regionE region

THROMBIN

FIGURE 3

FIGURE 4

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III.Fibrinogen: target of fibrinolysis

Fibrinogen contains many binding sites for plasminogen, t-PA (tissue Plasminogen Activator) and PAI-2 (Plasminogen Activator Inhibitor-2) and influences the possible effects of fibrinolysis, the third stage of haemostasis. The importance of the fibrinogen structure for effective fibrinolysis has been well demonstrated through the consequences of certain congenital fibrinogen defects on the risk of thrombosis. The most classic example is the variant called fibrinogen Dusart/Paris V, where activation of plasminogen to plasmin by t-PA under the influence of fibrin is defective because of the fibrin structure generated by this fibrinogen variant [15].

Fibrinogen plasma concentration

I. Physiological level

Plasma fibrinogen concentration is some 1000-fold higher than other coagulation factors [16]. The definition of normal values of plasma fibrinogen concentration varies according to different publications or guidelines. In the scientific literature, normal fibrinogen levels range from 2.0 to 4.5 g/L with a half-life of 3 to 5 days [9,11]. The European guidelines on core SmPC (Summary of Product Characteristics) for human fibrinogen products states that the normal plasma fibrinogen levels range from 1.5 to 4.5 g/L and that the critical plasma fibrinogen level below which haemorrhages may occur is approximately 0.5 – 1.0 g/L [4].

II. Physiological and pathological variations

Plasma fibrinogen concentration increases as an acute-phase reactant during inflammation and in certain clinical settings such as pregnancy [11,13]. In peri-partum women, plasma fibrinogen levels are between 4.4 and 5.8 g/L [17].

• Blood clotting is part of haemostasis, the physiological response that prevents significant blood loss after vascular injury.

• Haemostasis involves a complex set of enzymatic reactions acting as an amplifier, the end-point of which is to convert fibrinogen, a soluble protein, to insoluble strands of fibrin. Together with platelets, the fibrin strands form a stable blood clot.

• Fibrinogen has an influence on all the phases making up the haemostasis process: platelet aggregation (primary haemostasis), clot formation and plasma coagulation (secondary haemostasis), and fibrinolysis.

• Fibrinogen is a critical component and substrate for clot formation, amplification, and clot strength.

• Normal plasma fibrinogen levels range from 1.5 to 4.5 g/L.

HIGHLIGHTS

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FIBRINOGEN DEFICIENCIES AND COAGULATION DISORDERS

Inherited disorders of fibrinogen are rare. In populations where consanguineous marriages are common, the prevalence of afibrinogenaemia as well as other autosomal recessive coagulation disorders is increased [5].

Constitutional fibrinogen defects: two classes

Inherited fibrinogen deficiencies can be subdivided into type I and type II disorders.

• Type I disorders affect the quantity of fibrinogen in circulation. Afibrinogenaemia is the total absence of fibrinogen measured by an antigenic assay. Hypofibrinogenaemia is a decreased level of normal fibrinogen to near or below 1.0 g/L [5,8,18].

• Type II disorders (dysfibrinogenaemia and hypodysfibrinogenaemia) affect the structure the of circulating fibrinogen. These disorders result in normal or reduced antigen levels but with structural abnormalities of the fibrinogen molecule with disproportionately low functional activity [5,8,19].

Type I deficiencies(quantitative abnormalities)

Type II deficiencies(qualitative abnormalities)

Afibrinogenemia Hypofibrinogenemia Dysfibrinogenemia

Prevalence ≈ 1 in 1 million More frequent* More frequent*

Fibrinogen levels Not detectable ≈ 1.0 g/L or less Normal: 1.5–3.5 g/L

Fibrinogen function Not detectable Variably decreased Low activity

SymptomsBleeding (umbilical cord,

cutaneomucous, gastrointestinal, articular, intracranial)Rare thrombosis

In general, asymptomatic (bleeding mainly associated

with trauma or surgery)Asymptomatic, bleeding

and/or thrombosis

Genetic mutation Autosomal recessive Usually autosomal recessive Usually autosomal dominant

Treatment Fibrinogen Occasional fibrinogen Fibrinogen and/or anticoagulants

Congenital fibrinogen (factor I) deficiencies [5,18,19]

* The prevalence of hypofibrinogenemia and dysfibrinogenemia is difficult to establish because of the large number of asymptomatic cases.

TABLE 1

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Clinical heterogeneity

Clinical manifestations vary according to the type of deficiency, and fibrinogen levels are strongly associated with clinical bleeding severity [9].

I. Afibrinogenaemia: severe symptoms

Patients with afibrinogenaemia experience spontaneous bleeds, often severe. Bleeding usually manifests in the neonatal period with 85% of cases presenting with umbilical cord bleeding, although a later age of onset is not unusual. Bleeding may occur in the skin, oral cavity, gastrointestinal tract, genitourinary tract, or the central nervous system with intracranial haemorrhage being the major cause of death [5,18]. Intra-abdominal bleeding related to splenic rupture have been reported. In some patients there have been recurrent events [8]. Afibrinogenaemic women have an increased frequency of gynaecologic and obstetric complications, such as menometrorrhagia, spontaneous recurrent miscarriage, antepartum and postpartum haemorrhage [5,9,20]. Paradoxically for a disorder associated with a significant bleeding tendency, there are reports of thrombotic events in patients with afibrinogenaemia. These complications can occur in the presence of concomitant risk factors such as a co-inherited thrombophilic risk factor or after replacement therapy. However, in many patients, no known risk factors are present [5].

II. Hypofibrinogenaemia: usually asymptomatic

Hypofibrinogenaemic patients are usually asymptomatic with fibrinogen levels around 1.0 g/L. These are levels that are high enough to protect against bleeding and to maintain pregnancy [5]. However, hypofibrinogaemic patients are vulnerable to bleeding when exposed to trauma, and their bleeding risk is increased during surgical procedures [8]. Hypofibrinogenaemic women may also suffer from miscarriage or postpartum haemorrhage [5,9].

Clinical presentation among 110 probands with afibrinogenaemia. Miscellaneous: haematuria, post-surgery, retroperitoneal, and haemoptysis [5]

10%

20%

30%

40%

50%

60%

70%

Umbilical cord

Muscle hematomaSkin

Menorrhagia

Hemarthrosis

Oral cavity

Thrombosis

Central nervous system

Miscellanous

Epistaxis

A�er venous puncture

Gastrointestinal

Prevalence of symptoms at diagnosis of afibrinogenemia (n=110)

FIGURE 5

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III. Dysfibrinogenaemia: unpredictable clinical phenotype

The clinical phenotype of dysfibrinogenaemia is unpredictable [8,19]. Patients with inherited dysfibrinogenaemia are frequently asymptomatic. However, some patients suffer from bleeding, thromboembolic complications (mainly venous) or both [5,19]. Patients with dysfibrinogenemia associated with haemorrhage bleed most often after trauma, surgery, or in the postpartum [5,19].

Screening tests for diagnosis of fibrinogen deficiencies

Establishing a diagnosis of congenital fibrinogen deficiency and distinguishing between the different phenotypes requires a combination of standard coagulation tests and antigenic and functional assays [9,19]. These tests should be supported by genetic analysis (genotype analysis) in order to characterise the molecular defect [5].

I. Routine methods for measuring fibrinogen concentration

The available methods of determining fibrinogen can be classified into two groups: measurement of functional fibrinogen and measurement of antigenic fibrinogen.

1. Functional assays

Most assays used to measure plasma fibrinogen concentrations are functional assays that determine clot formation using either spectroscopic or viscoelastic clot detection [11].

Clauss methodThe most widely used method for the functional fibrinogen assay is the Clauss method, which records the time taken to reach the coagulation end point, (i.e. the formation of a clot) [21]. In the Clauss method, the coagulation time is measured in diluted plasma clotted with a high concentration of thrombin. Under these conditions, the clotting time is inversely proportional to the fibrinogen concentration in the plasma [22].Clauss-based fibrinogen assays may have some variability. However, the assay appears to be the most reliable method for general use in clinical laboratories.

Viscoelastic haemostatic assays Current diagnostic tests are appropriate for establishing the diagnosis but global methods assessing the viscoelastic properties of whole blood may provide an accurate prediction of the clinical phenotype of a patient and consequently the appropriate treatment [5,22].The extent of fibrin polymerisation in whole blood can be estimated by inhibiting platelet-fibrin(ogen) interactions on thromboelastography (TEG) or rotational thromboelastometry (TEM) tests (Fig. 6).The advantage of these techniques is that they have the potential to measure the clotting process, starting with fibrin formation and continue through to clot retraction and fibrinolysis [13,22]. Dependent on fibrinogen concentration, maximal clot firmness (MCF) from TEM or maximal amplitude (MA) from TEG represent the final clot strength and results from firm aggregation of platelets and formation of a stable fibrin network [13,11,24,25].

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2. Immunological assays: fibrinogen antigen (Fg Ag)

The second group of tests, or immunological assays, quantify fibrinogen antigen concentration rather than functional activity. Two commonly used methods are enzyme-linked immunosorbent assays (ELISAs) and immunoturbidimetric (ITB) assays [21,26].These tests are usually employed in the investigation of congenital dysfibrinogenaemias where there is a discrepancy between functional activity and antigen level (i.e. antigen exceeds activity) [26].

II. Coagulation assays

Congenital fibrinogen defects can interfere with all the coagulation tests that are based on the formation of a fibrin clot. Prothrombin time (PT) and activated partial thromboplastin time (aPTT), where there is rapid thrombin generation and fibrin formation, are the most common screening tests [13]. These coagulation times are greatly prolonged in afibrinogenaemia [5].

Laboratory assays in congenital fibrinogen deficiencies adapted from [5,9,18,19]

Type I deficiencies(quantitative abnormalities)

Type II deficiencies(qualitative abnormalities)

Assays Afibrinogenemia Hypofibrinogenemia Dysfibrinogenemia

Fonctional fibrinogen level(e.g. Clauss assay) Undetectable Variably decreased Decreased or normal

Immunoreactive fibrinogen(e.g. ELISA) Decreased Proportionally decreased Normal or increased

Prothrombin Time (PT) Infinitely prolonged Variably prolonged Variably prolonged

Activated Partial Thromboplastin Time (aPTT)

Infinitely prolonged Variably prolonged Variably prolonged

Thromboelastometry Decreased maximum clot firmness

Typical tracings of viscoelastic point-of-care coagulation devices

Upper side: Thrombelastograph (TEG®) tracing:R=reaction time; K=kinetics; a-angle=slope between r and k; MA =maximum amplitude; CL =clot lysis.

Lower side: Rotation Thrombelastography (ROTEM®) tracing: CT =clotting time; CFT=clot formation time; a-angle=slope of tangent at 2 mm amplitude; MCF=maximal clot firmness; LY=Lysis [22].

MAR

K

CFT

CTMCF

CL

LY

TEG AnalysisROTEM Analysis

Time

Clo

t firm

ness

FIGURE 6

TABLE 2

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III. Genotype analysis

Congenital fibrinogen deficiency is caused by a mutation in one of the three genes (FGA, FGB, and FGG, coding for Aa, Bβ, and c chains respectively) clustered in a 50-kb region on chromosome 4 [9,27]. In recent years, many mutations have been identified that are responsible for afibrinogenaemias, hypofibrinogenaemias and some dysfibrinogenaemias (Fig. 7).With regard to the quantitative deficiencies, causal mutations can be classified into 2 broad categories based on their mechanisms [5]:

• The so-called «null» mutations, which lead to a total absence of residual protein production.

• Mutations that produce an abnormal protein retained in the cells. These are usually missense mutations changing a single amino acid on one of the three fibrinogen chains.

IV. Genotype-phenotype correlations

Mutation analysis of the fibrinogen cluster has not revealed any clear genotype/phenotype correlations, nor any major founder effect [5,27]. In afibrinogenaemia, all patients have unmeasurable functional fibrinogen, but the severity of bleeding is highly variable between patients, even among those with the same genotype [5]. However, characterisation of the molecular defect still provides a valuable tool to confirm the diagnosis, to elaborate an efficient diagnostic strategy and to enable prenatal diagnosis [5,27].

Fibrinogen gene mutations accounting for afibrinogenaemia and hypofibrinogenaemia [5]

1(6)

55

64

29

76

35

42

11

18

78

24

3

cen

tel

FGB

FGA

FGG

c.115-600A>Gc.139C>T; c.213T>G; c.248-249delAGinsT; c.264delA

c.605T>A

c.1036G>T; c.1105C>T; c.1148T>G; c.1244+1G>T; c.1245-1G>C

c.1289G>A; c.1298G>A; c.1328A>G; c.1330G>C; c.1331G>C;c.1346delG; c.1391G>A; c.1399T>G; c.1400G>A; c.1409G>A

c.532C>T; c.541C>T; c.563_564insT; c.609_610insTGA; c.635>G;c.711_712insT; c.718C>T; c.743G>A; c.786_789delGAGA; c.885G>A;

c.934delA; c.945delT; c.946G>T; c.1001G>A; c.1025delG; c.1037delA;c.1055delC; c.1646delA

c.385C>T; c.391T>C; c.431_432delAA; c.448C>T; c.502C>T; c.510+1G>Tc.191G>T; c.196_197insT; c.209T>G; c.229_231delGTCins12;

c.285T>A; c.356C>G; c.364+1_+4delGTAAc.94G>T; c.117delT; c.180+1G>C; c.180+2T>C

c.1201C>T

c.535T>Cc.448delC

c.78+5G>Ac.98delA; c.123+1G>A; c.124-3C>G

c.307+5G>A; c.308-2A>Gc.331A>T; c.400C>T

c.667A>T; c.677G>T; c.759G>T; c.769G>T

c.928G>C; c.944C>T; c.997C>T; c.1018C>A;c.1018A>C; c.1077delT; c.1100C>T; c.1112A>G; c.1190C>T

c.1A>T; c.3_4insC; c.54+1G>A; c.54÷3A>G; c.54+3A>C

c.854G>A; c.850A>G; c.887G>A; c.958+1G>A;c.958+13C>T; c.959-10_14delTTTG

Mutations identified in homozygosity or compound heterozygosity in afibrinogenaemia patients are in normal font, and those identified in heterozygosity in hypofibrinogenaemic individuals are in italic font. Large deletions are indicated by arrows. The colour scale reflects the number of distinct mutations in exons or intron-exon junctions: light green: 1–6, medium green: 7–12, and dark green: > 12 mutations. New mutations identified and appearing in literature since 2009 are shown in red.

FIGURE 7

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Fibrinogen deficiencies and high risk of bleeding conditions

Reduced fibrinogen levels appear to be correlated with an increased risk of bleeding in different clinical settings. Bleeding can manifest during conditions such as surgery (e.g. cardiopulmonary bypass surgery) or other invasive intervention, non-surgical trauma or post-partum [28,29,30]. Severe bleeding is associated with massive transfusion requirements and can have a major impact on morbidity and mortality [2,31,32].

Treatment of constitutional fibrinogen deficiencies

I. Fibrinogen replacement: the standard therapy

There is a general consensus in the medical community that for patients with a clotting factor deficiency such as quantitative fibrinogen deficiency (afibrinogenaemia or hypofibrinogenaemia with significant bleeding), the standard therapy is fibrinogen replacement.The conventional treatment (treatment “on demand”) is episodic, where fibrinogen supplementation is administered as soon as possible after onset of bleeding. Prophylactic fibrinogen supplementation could also be considered for patients at risk of bleeding before elective surgery or who have a history of life-threatening bleeding [5,9,20].Guidelines provide recommendations about the best treatment options (dosage, management of bleeding, surgery, and pregnancy as well as prophylaxis). According to these guidelines, in case of bleeding, the dose and frequency of administration should be adjusted to increase the plasma fibrinogen level to 1.0 g/L and maintained above this threshold until haemostasis is secured and above 0.5 g/L until wound healing is complete [6,8].

II. Currently available products

Options for replacement include fresh frozen plasma (FFP), cryoprecipitate and fibrinogen concentrates [9].

1. FFP and cryoprecipitate

FFP and cryoprecipitate, prepared from FFP, have significant safety concerns that should limit their therapeutic use [13]:

• Firstly, there is a potential risk of viral transmission due to varying effectiveness or, for cryoprecipitate, lack of efficient viral inactivation procedures. In response to these safety issues, cryoprecipitate has been withdrawn from many European markets [33].

• Since fibrinogen is not concentrated in FFP, large volumes are often required to raise fibrinogen levels, which can be associated with transfusion-associated circulatory overload and risk of transfusion-related acute lung injury (TRALI) [33].

• In addition, FFP and cryoprecipitate contain other high molecular weight proteins which are not needed in these patients and may lead to immunoallergic reactions.

16

* Despite this, when medical products prepared from human blood or plasma are administered, the possibility of transmitting infective agents cannot be totally excluded.

Moreover, FFP and cryoprecipitate have a number of practical drawbacks:

• There is a need for blood group matching (for FFP and single-donor cryoprecipitate).

• Thawing and warming are needed before administration, meaning that administration times are prolonged, which is a clear disadvantage in the setting of massive haemorrhage [33].

2. Fibrinogen concentrate

Alternatively, human fibrinogen concentrate is available.

• Fibrinogen concentrate offers standardised fibrinogen content and more precise dosing can be accomplished according to the patients’ need [5].

• Fibrinogen concentrate preparation benefits from a rigorous purification process, reducing the risk of pathogen transmission and immune-mediated complications* [33].

• Fibrinogen concentrate is readily available (in particular in emergency situations) at room temperature, without the need for thawing and checking the ABO and rhesus compatibility.

• Fibrinogen concentrate can be quickly reconstituted and administered in a small volume, without resulting in circulatory overload.

• Inherited fibrinogen deficiencies can affect either the quantity or the quality of the circulating fibrinogen.

• Low fibrinogen levels are associated with reduced clot strength and are strongly associated with severe bleeding [9,34].

• For patients with a quantitative fibrinogen deficiency (afibrinogenaemia or hypofibrinogenaemia), the standard care is replacement therapy [5,34].

• FFP and cryoprecipitate has been found to be effective in treating haemostatic complications of fibrinogen deficiencies, but with significant safety concerns limiting their therapeutic benefits [13, 34].

• Fibrinogen concentrate has a number of advantages: it delivers a standardised dose, is available for administration almost immediately, can be administered in very small volumes and has a very good safety profile [34]. Most importantly, as it undergoes a stringent virus inactivation/removal process [34].

HIGHLIGHTS

17


FibCLOT®: HUMAN FIBRINOGEN CONCENTRATE

FibCLOT®: a purified human fibrinogen concentrate

FibCLOT® is a purified, standardised, lyophilised human fibrinogen developed by LFB to supplement patients with fibrinogen deficiencies. The active substance is an ‘antihaemorrhagic’, human fibrinogen - ATC code B02BB01 according to the Anatomic-Therapeutic-Chemical (ATC) classification [35]. FibCLOT® is for intravenous administration.Once reconstituted with water for injection (supplied), a vial of FibCLOT® delivers a 1.5 g dose of human fibrinogen.The development of FibCLOT® was based on the experience gained with fibrinogen concentrate over the last decade by LFB Biomedicaments. FibCLOT® has the same manufacturing process and formulation as a new generation fibrinogen concentrate which was granted a national marketing authorisation by the French Health Authority (ANSM) in 2009, and currently marketed in France and in several countries for patients with congenital fibrinogen deficiency and, as complementary therapy, for patients with uncontrolled severe haemorrhage in situations of acquired fibrinogen deficiency in different clinical settings (e.g. life-threatening bleeding during obstetric complications, surgery or trauma). The difference in plasma origin has no impact on the clinical data generated [35].

Thanks to a large development program, FibCLOT® has been granted a marketing authorization (MA) in many European countries, with a therapeutic indication for treatment and perioperative prophylaxis of bleeding in patients with congenital hypo- or afibrinogenaemia with bleeding tendency.FibCLOT® substitutes not detectable or low fibrinogen in patients with congenital fibrinogen deficiencies for whom fibrinogen supplementation is a priority for the management or perioperative prophylaxis of bleeding. A sufficient fibrinogen concentration is a prerequisite for providing the fibrin matrix and mesh network that are critical for clot strength and haemostasis [11].

FibCLOT®: a highly secure compound

The production of FibCLOT® is carefully managed, from donation at plasma centres right through to the final product (Fig. 8).Standard safety measures include rigorous selection of donors, screening of individual donations and plasma pools and the inclusion of effective manufacturing purification steps for the inactivation and removal of viruses [6], exceeding European regulatory standards, such as nanofiltration, which the aim is to physically removes pathogens.

18

I. Rigorous donor selection

Plasma of human origin, the starting material for FibCLOT®, is collected from whole blood donation (recovered plasma) and mostly through apheresis (source plasma, for fractionation only). Therefore, the primary consideration for safety from pathogens is rigorous selection of healthy donors to identify any existing medical conditions or risk factor for infections that could be transmitted through transfusion [36].

II. Donation screening

All single donations are screened as detailed in the European Pharmacopoeia, to be non-reactive to HBsAg, anti-HIV1 ⁄ 2 antibodies and anti-HCV antibodies. Furthermore, nucleic acid technology (NAT) is used to test donations for HIV1 ⁄ 2-RNA, HCV-RNA and parvovirus B19 DNA. Plasma pools are released for further processing only if they are non-reactive to the serologic markers and nucleic acids of these viruses [36].

The LFB manufacturing process: several safety stages based on three principals

Quality and safety of LFB Biomedicinal products is based on 3 principles:

*NAT: Nucleic Acid amplification Testing.The viral removal/inactivation procedures may be of limited value against certain particularlyresistant viruses such as parvovirus B19. Appropriate vaccination against hepatitis A and B is recommendedfor patients receiving plasma-derived coagulation factor concentrates.Viral elimination and inactivation remain limited for some non-enveloped viruses in particular PV B19.

Good hospital

pharmacy practice

EFS (French blood

Establishment) /Collection

Centres

Hospital

Medical selection of donors with exclusion of those at risk

1

Donation2

Preparation, leukodepletion and freezing

4

Biological qualification of the donations:• Immuno-hematological tests• Serological Viral markers• NAT* for HIV, HCV and HBV

3

Quality control at receptionNAT* for HAVand Parvovirus B19

6

Reception of plasma by the LFB

5

Plasma pool control before fractionation- Serological Viral markers- NAT* tests for: • HIV-1 • HCV • HBV • HAV • Parvovirus B19

8

Quarantine before fractionation

7

Prescription / Dispensing / Administration

11

Quality controlof the medicinal product

10

Manufacturing and safety steps- Viral inactivation and elimination - Contribution to prion elimination

9

1

2

4

3

10

5

76

9

11

8

PharmacovigilanceHaemovigilance

d freezing

Receof plasmby the

5Plasma

oodFSS

/

11

11

222

V 333

4

111

7

ption ceptla

55

Quof

10

10

Manu- Viral

Co

999

Quality contntrorol l

66

8

8

Release

P l a s m a q u a l i t y a s s u r a n c e p r o g r a m

Good manu

factur

ing pr

actic

e

G

ood b

lood c

olle

ction practic

e

PatientDonor T R AC E A B I L I T Y

Starting material Quality

Efficacy of the fractionationtechniques Traceability

FIGURE 8

19


III. Three specific steps of inactivation and/or removal of pathogens

Despite the selection of healthy donors and screening of donations, pathogen inactivation and/or removal during the manufacturing process is required to prevent transmission of infectious agents.FibCLOT® is produced using several specific steps that inactivate or remove transmissible pathogens, namely viruses and prions (Fig. 9):

• Three specific viral inactivation and/or removal steps: - Solvent detergent treatment, which has been shown to inactivate enveloped viruses such as

HIV, HBV and HCV - Nanofiltration (35 nanometers) to remove small, heat-resistant, non-enveloped viruse particles

(larger than the filter size) - Dry heat step (72 hours at +80°C) to inactivate enveloped and non-enveloped viruses such

as HAV

• Three steps known for their capacity to remove transmissible spongiform encephalopathy agents (prions):

- Depth filtration - Ion-exchange chromatography - Nanofiltration (35 nm)

Since some steps like heat inactivation may have some limitations in eliminating certain non-enveloped viruses, nanofiltration, a step of virus reduction filtration, increases the safety with regards to these viruses. Viral inactivation steps have been shown to very effectively inactivate enveloped viruses and small non-enveloped viruses [35].

Steps for pathogen inactivation and/or removalSteps contributing to safety in relation to risk

Viral Prion Virus + Prion

3 specific safety stepsDepth filtration

Nanofiltration 35 nm2

Solvent/detergent treatment1

Dry heating 80° - 72 h3

Ion exchange chromatography

Cryosupernatant

Lyophilisation

Dialysis and concentration

Clarifying filtration

Selection of donors

Leukodepletion

Inactivation of lipid-enveloped viruses, if presents (HIV, HBV, HCV…)

Removal of viruses ≥ 35 mm (HIV, HBV, HCV…) and prions, if presents

Removal of envelopped or non-enveloped viruses < 35 mm (HAV, PVB19) if presents

FIGURE 9

20

FibCLOT®: formulation of the finished product

FibCLOT® is available as a purified white or pale yellow lyophylisate in a glass vial, for intravenous administration. It is supplied with a solvent (100 mL water for injections) and a transfer system equipped with a sterile filtering air vent, which enables quick and easy handling.Each vial contains nominally 1.5 g of human fibrinogen. After reconstitution with 100 mL of solvent, FibCLOT® contains nominally 15 mg/mL of human fibrinogen, allowing precise and accurate dosing consistent with the needs of the individual patient. Potency is determined according to the European Pharmacopoeia for human fibrinogen [4]. With regard to excipients with known effects, the product contains a maximum of 69 mg (3 mmol) of sodium/vial. This should be taken into consideration in patients following a strict low sodium diet [6].

• FibCLOT® is a purified, standardised human fibrinogen, delivering a dose of 1.5 g of clotting factor I after reconstitution, to meet the needs of the individual patient.

• The manufacturing process of FibCLOT® includes three specific and validated pathogen (viruses and prions) inactivation and removal steps, thereby reducing to a minimum the risk of transmission of blood-borne agents.

HIGHLIGHTS

21


FibCLOT®: THE CLINICAL DEVELOPMENT PROGRAMME IN CONGENITAL DEFICIENCIES

The clinical pharmacology, efficacy and safety* of FibCLOT® has been specifically investigated in patients with congenital fibrinogen deficiency in:

• Two multicentre, open-label, single arm, prospective interventional studies to evaluate the efficacy (clinical and biological) and safety of FibCLOT®: one in 6 adult patients and one in 20 adult and adolescent patients (body weight ≥ 23 Kg).

• One observational post-approval efficacy and safety study in congenital deficiency in 14 patients** [35].

Of note, these studies are not completely independent of each others. Patients included in the clinical pharmacology part were included in the efficacy and safety study. Patients from pre-authorisation studies could be enrolled in post-marketing investigations. Overall studies, five patients participated in more than one study.

In these three studies, a total of 35 unique patients with congenital fibrinogen deficiency were administered FibCLOT® in different clinical settings including [35]:

• Treatment of non-surgical bleeding (on-demand treatment)• Prevention of excessive bleeding during surgery• Pharmacology study

* The safety data are also based on 2 studies conducted with FibCLOT® in patients with acquired hypofibrinogenaemia.** An observational study where patients were treated in routine medical practice with the LFB fibrinogen concentrate approved in France.

22

FibCLOT®: CLINICAL PHARMACOLOGY

Pharmacologic research programme

The two prospective clinical pharmacology studies were conducted to assess the clinical pharmacology (biological efficacy) of FibCLOT® in patients with afibrinogenaemia.

The two studies were comparable in design:

• Pharmacokinetics of FibCLOT® were characterised using two validated bioassays measuring plasma fibrinogen concentrations: 1) fibrinogen activity by the Clauss method, 2) fibrinogen antigen by immunonephelometry. The aim was to investigate simultaneously the biologically active fibrinogen and the actual circulating protein, and to verify that there was no dissociation between fibrinogen activity and antigen (activity/antigen ratio of about 1) as it is the case with endogenous fibrinogen [35].

• Pharmacodynamics of FibCLOT® were assessed by global coagulation tests: activated partial thromboplastin time (aPTT), prothrombin time (PT) and thrombin time (TT), as well as by the maximum clot firmness (MCF) measured in plasma by thromboelastometry [35].

Pharmacokinetic parameters

In the two clinical pharmacology studies 19 patients (11 male and 8 female patients) were evaluated over 14 days. Their ages varied from 11 to 48 years, and their weights from 44.0 to 93.5 kg [37].

Mean (SD) plasma fibrinogen activity and antigen concentrations by study [35]

10.0

1.0

0.1

Time a�er the end of infusion (hours)

Mea

n (S

D) P

lasm

aC

once

ntra

tion

(g/L

)

10.0

1.0

0.1


Mea

n (S

D) P

lasm

aC

once

ntra

tion

(g/L

)

Activity assay: detection limit of 0.09 g/LAntigen assay: detection limit of 0.0075 g/L

Activity assay: detection limit of 0.3 g/LAntigen assay: detection limit of 0.1 g/L

24 48 72 96 120 144 168 192 216 240 264 288 312 336 3600 24 48 72 96 120 144 168 192 216 240 264 288 312 336 3600

Fibrinogen antigen Fibrinogen antigen (n=14)

Fibrinogen activity Fibrinogen activity (high curve n=14)

Study 1: n=5 Study 2: n=14

FIGURE 10

23


Subjects received a single fixed dose of 0.06 g/kg body weight (b.w.) of FibCLOT®. Blood samples were collected at 0 (prior to infusion), 1, 3, 6, 24, 72, 144, 240 and 336 hours post-infusion for analysis [35].After infusion of the single dose, the mean maximum concentration (about 1.5 g/L) was rapidly achieved, within 1 hour, and was followed by a monoexponential decay over the 14-day period, reaching the critical plasma fibrinogen level of 0.5 g/L in about 3 to 4 days [35].In both studies, the plasma fibrinogen levels remained above 0.5 g/L for at least 3 days in all subjects after FibCLOT® administration [35].

The in vivo recovery of FibCLOT® is almost complete, with a high value of 93.6% [6].The incremental recovery (IR) corresponds to the increase (g/L) in plasma fibrinogen concentrations per g/kg body weight of administered fibrinogen. In each pivotal clinical pharmacology study, the incremental recovery value of FibCLOT® is approximately 23 g/L per g/kg* [35]. This IR of 23 g/L per g/kg is used to calculate the coefficient 1/IR= 0.043 of the dosage calculation formula found in the FibCLOT® SmPC [6].The pharmacokinetic profiles of fibrinogen activity and antigen are almost superimposable with a high correlation coefficient of 0.97 between the two determinations with no dissociation between activity and antigen (slope ≈ 1) showing that the manufacturing process preserves the functional properties of fibrinogen (Fig. 11) [35]. The main pharmacokinetics results are summarised in table 3.In the clinical pharmacological studies the available pharmacokinetic data with FibCLOT® did not show any notable differences when stratified by gender or age [35].

* The IR was also assessed in 16 subjects participating in the efficacy part of the study. IR was reproducible across the various assessments performed for a single subject in both clinical pharmacology and efficacy parts, regardless of the clinical situation.

Individual plasma fibrinogen antigen versus fibrinogen activity [35]

Pharmacokinetic parameters

FibCLOT® single dose IV infusion

Geometric mean (geometric CV %)

Cmax (g/L) 1.4 (24.4)

t1/2 (h) 69.3 (21.8)

AUC0-∞ (g.h/L) 114 (23.4)

MRT (h) 95.6 (20.7)

Cl (mL/h/kg) 0.53 (22.0)

Vss (mL/kg) 50.7 (16.7)

IR ((g/L)/(g/kg)) 23.5 (23.2)

R (%) 93.6 (20.9)

Main pharmacokinetic parameters [6]

Cmax = maximum concentration (activity), t1/2 = terminal elimination half-life, AUC = area under the curveMRT = mean residence time, Cl = clearance, Vss = volume of distribution at steady state, IR = incremental recovery, R = in vivo recovery, CV = coefficient of variation

Plas

ma

Fibr

inog

en A

ntig

en C

once

ntra

tion

(g/L

)

Plasma Fibrinogen Activity Concentration (g/L)

013001013002013003013004013005013010013011013012013013014001019001019003019004019005

Regression

2.5

2

1.5

1

0.5

0.5 1 1.5 2 2.5

FIGURE 11 TABLE 3

24

Pharmacodynamic properties

The pharmacodynamics of FibCLOT® were assessed by routine coagulation tests, that is, activated partial thromboplastin time (APTT), prothrombin time (PT), thrombin time (TT), and by thromboelastometry [35].

I. Effects on global coagulation tests

In one clinical pharmacology study, global coagulation tests (aPTT, PT and TT) showed almost uniformly unclottable results prior to treatment [6,35]. After a single infusion of 0.06 g/kg of FibCLOT®, global coagulation tests normalised within 30 minutes post-infusion in almost all subjects when fibrinogen concentrations were at or above 0.5 g/L, and the normalisation lasted for at least 3 days (Fig. 12) [6,38]. Results were similar for both perioperative prophylaxis and non-surgical bleeding.

Pharmacodynamics of FibCLOT® was also supported by the change in coagulation activation markers and FXIII activity after FibCLOT® administration: - A marked decrease in coagulation activation markers (Thrombin-Antithrombin complex and Prothrombin Fragment 1+2) was observed following the infusion of FibCLOT® (as fibrinogen down regulates thrombin generation) and was followed by a slow return to baseline values. - The activation of FXIII, an indirect way to show the functional activity of FibCLOT®, as full activation of FXIII requires binding to fibrinogen/f ibrin, increased immediately af ter the administration of FibCLOT® and decreased in parallel to fibrinogen plasma concentrations [35].

II. Effect on clot strength

The maximum clot firmness (MCF), one of the screened parameters, assesses the clot strength, i.e., the quality of the clot structure. In clinical practice, this thromboelastometric test, which reflect in vivo haemostasis, may

provide a complementary evaluation of an individual’s haemostatic state [5]. It has been used to guide coagulation therapy in case of coagulopathy in orthopaedic surgery, trauma, and cardiovascular surgery [39]. In both the clinical pharmacology studies, FibCLOT® increased the clot firmness - within the normal range, with a linear relationship between MCF and fibrinogen concentrations (Fig. 13) [35].

Correction of global coagulation parameters in study 2 (n=14) [35]

100908070605040302010


PT (%

)

0 12 24 36 48 60 72 84 96 108 120 132 144

3.02.82.62.42.22.01.81.61.41.21.00.8


aPPT

(rat

io)

0 12 24 36 48 60 72 84 96 108 120 132 144

FIGURE 12

25


These pharmacodynamic findings confirmed that the FibCLOT® manufacturing process preserves the functional properties of fibrinogen.

Maximum clot firmness as a function of fibrinogen concentration in the two pharmacological studies [35]

* Fibrinogen data from the high calibration curve (Clauss assay in study A616)Loess: locally-weighted scatter plot smoothing

• Fibrinogen antigen and activity were similar and highly correlated.

• These findings confirm that the FibCLOT® manufacturing process preserves the functional properties of fibrinogen.

• The in vivo recovery of FibCLOT® is almost complete, with a value of 93.6%.

• The overall data support the incremental recovery (IR) of 23 g/L per g/kg used in the dosing algorithm proposed in the FibCLOT® SmPC.

• In patients with afibrinogenaemia, FibCLOT® restored impaired coagulation in most subjects immediately after a single infusion: all coagulation tests normalised within 30 minutes at or above 0.5 g/L, regardless of the clinical situation (similar results for both perioperative prophylaxis and non-surgical bleeding) and the correction persisted at least 3 days post-infusion.

• Maximum clot firmness (MCF) as a surrogate marker of clot stability was measurable when plasma fibrinogen levels were 0.5 g/L and increased with fibrinogen concentrations.

HIGHLIGHTS

MC

F (m

m)

Plasma Fibrinogen Activity Concentration (g/L)

1300113002130031300413005130101301113012130131400119001190031900419005Loess

15

10

5MC

F (m

m)

15

10

5

00.5

Fibrinogen Activity (g/L)0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1 1.5 2 2.5

Pearson coefficient of correlation = 0.955

Study 1: n=5 Study 2: n=14*

FIGURE 13

26

FibCLOT®: CLINICAL EFFICACY

Clinical studies

The efficacy of FibCLOT® in subjects with congenital deficiencies was evaluated in two prospective, open-label, single arm, non-comparative, multicenter studies and in one observational Post Authorisation Safety Study in real life medical practice [35]. The 3 efficacy studies assessed the ability of FibCLOT® to stop non-surgical bleeding or avoid excessive surgical bleeding in patients with congenital deficiencies.In the 3 studies 31 subjects received at least one infusion of FibCLOT® for the treatment of nonsurgical bleeding, prevention of excessive bleeding during surgical procedures. Subjects could be treated for more than one event and for different clinical situations [35]. The median age was 21 years (range 1 to 78 years) with 21 males and 10 females and most subjects were adults (19/31) [35].

I. Evaluation criteria

1. Primary efficacy endpoint

In all 3 studies, the primary efficacy endpoint was the investigator’s overall assessment of haemostasis after administration of FibCLOT® for non-surgical bleeding and surgical procedures. This overall assessment used a subjective four-point scale: “Excellent, Good, Moderate, None” [35]. Although subjective, this scale is consistent with regulatory guidelines for the evaluation of the treatment of other plasma-derived clotting proteins [4].

2. Classification of the disease and bleeding severity

FibCLOT® was assessed in the treatment of both minor and major non-surgical bleeding events and prevention of excessive bleeding in minor and major surgical procedures.Non-surgical bleeding events were categorised as “Major” or “Minor” in all 3 studies, but theirdefinitions differed between studies [35].In order to better compare results, non-surgical bleeding events were categorised post hoc according to the International Society on Thrombosis and Haemostasis (ISTH) classification, which is considered to be more strict in its definition of major bleeding [38].

ISTH criteria for major bleeding in non-surgical patients [40]

• Fatal bleeding, and/or

• Symptomatic bleeding in a critical area or organ, such as intracranial, intraspinal, intraocular, retroperitoneal, intra-articular or pericardial, or intramuscular with compartment syndrome, and/or

• Bleeding causing a fall in hemoglobin level of 20 g/L (1.24 mmol/L) or more, or leading to transfusion of two or more units of whole blood or red blood cells.

27


II. Treatment

To treat non-surgical bleeding and prevent excessive bleeding during surgical procedures, the dosing of FibCLOT® was individualised to achieve pre-specified target fibrinogen level of between 1 and 1.2g/L or 1.5 g/L depending on the study [35,38].

The dosing of FibCLOT® was calculated according to the formula:

Dose (g) = [target Fg level (g/l) – baseline Fg level (g/l)] x 1/IR* x b.w. (kg)

Potential additional infusions were adapted based on the patient’s clinical condition (until haemostasis was controlled) and laboratory results (to maintain plasma levels above 0.5 g/L until wound healing was complete) [38]. The fibrinogen concentrate was administered by intravenous infusion at a maximum rate of 4 mL/min.

Clinical efficacy

Across all studies in congenital fibrinogen deficiency retained for the marketing authorisation, FibCLOT® was administered for:

• 100 non-surgical bleeding episodes in 18 patients (including 17 major episodes in 9 patients)

• 38 surgical procedures in 15 patients (including 10 major procedures in 7 patients) [35].

Most of the non-surgical bleedings were the result of trauma. Of the surgical events, there were 10 major procedures in 7 subjects (1 splenectomy, 2 inguinal hernia repairs, 1 mammoplasty, 1 pilonidal sinus repair and 5 dental procedures) and 28 minor procedures (including 23 dental procedures) in 12 subjects [35,38].

I. Overall efficacy

The overall haemostatic efficacy was rated “Excellent/Good” (Success) for 137 / 138 events (Table 4).The majority (92.8%) of events (128/138) required only a single dose of about 3 g FibCLOT® to achieve an adequate haemostasis, corresponding to a median dose per infusion of 0.050 g/kg [35].A total of 7 non-surgical events (7%) required more than one infusion, 5 events (3 haemarthroses, 1 haematoma and 1 traumatic haematoma) in 4 subjects required 2 infusions of FibCLOT® and 2 events in 2 subjects required 3 infusions (1 haematoma and 1 intraperitoneal haemorrhage following a splenic rupture). In all instances but one, no more than one infusion was administered per day.

Criteria for major bleeding during surgical procedure [38]

Major surgery Major bleeding

Any orthopaedic, abdominal, gynaecological, urological, neurological or thoracic surgery or multiple dental extraction of rooted teeth

Bleeding requiring hospitalization, and/or symptomatic in a critical organ (i.e. central nervous system, haemarthrosis, deep muscle haematoma or other organ haemorrhage) and/or overt external bleeding (i.e., refractory epistaxis, severe menorrhagia, traumatic haemorrhage or drop in haemoglobin ≥ 2 g/dL)

* Where IR is the previously determined mean incremental recovery.

28

Only 3 surgical procedures (8%) required more than one infusion of FibCLOT® (1 excision of pilonidal cyst, 1 splenectomy and 1 minor surgical procedure) [38].

II. Efficacy in clinical situations of major and minor bleedings

For events stratified by severity, there were no major differences between groups in dosing per infusion (g/kg), number of infusions, or number of treatment days. Most events were treated with a single infusion of FibCLOT®.Overall, the mean doses administered for non-surgical bleeding and surgical procedures were comparable [35].The studies showed that FibCLOT® provides adequate hemostasis for the treatment of bleeding episodes in patients with congenital deficiencies. The efficacy was rated as “Excellent” (9) and “Good” (8) in 17 non surgical major bleeding events (Table 5) [35].

• The clinical and biological data showed that haemostasis was rapidly restored in the majority of patients with congenital fibrinogen deficiency after a single infusion of FibCLOT® at the recommended dose, ensuring an adequate perioperative prophylaxis and treatment of bleeding in patients with congenital hypo- or afibrinogenaemia with bleeding tendency.

• Treatment with FibCLOT® was considered a success in 99% of non-surgical bleedings and in 100% of surgical procedures.

• The majority (92.8%) of the events (128/138) were managed with a single dose of about 3 g of FibCLOT®, corresponding to a median dose per infusion of 0.050 g/kg.

HIGHLIGHTS

OverallNon-surgical bleedingNumber of subjects (N) 18Number of events n 100Excellent/Good (success)

n (%) 99 (99.0)95% CI [94.6 - 100]

Moderate/None (failure) n (%) 1 (1.0)95% CI [0.0 - 5.4]

Surgical proceduresNumber of subjects (N) 15Number of events n 38Excellent/Good (success)

n (%) 38 (100.0)95% CI [90.8 - 100]

Overall efficacy assessment for non-surgical bleeding and surgical procedures [35] Overall

Number of subjects N=31Non-surgical bleeding events: 100 in 18 subjectsMajor (n=17)Number of events (subjects) 17 (9)Excellent response, n (%) 9 (52.9)Good response, n (%) 8 (47.1)Minor (n=79)Number of events (subjects) 79 (16)Excellent response, n (%) 55 (69.6)Good response, n (%) 23 (29.1)Moderate response, n (%) 1 (1.3)Events not classified (n=4)Number of events (subjects) 4 (1)Excellent response, n (%) 4 (100.0)

Efficacy in major and minor bleedings [35]

TABLE 4 TABLE 5

29


* In addition, two other studies in subjects with acquired fibrinogen deficiency (indication not claimed for FibCLOT®), provide additional supportive data to document safety profile. Across all studies, a total of 207 unique subjects were included in the safety [41].

FibCLOT®: OVERVIEW OF SAFETY

The safety evaluation plan during the clinical development programme of FibCLOT® was defined in order to assess its safety profile and in particular to address the known potential risks related to the pharmacological class of human fibrinogen product, including thromboembolic events, allergic or anaphylactic-type reactions, immunogenicity and transmissible agents [35].All subjects with congenital deficiency who received FibCLOT® in any of the three studies in congenital deficiencies (two interventional and one observational) were included in the safety analysis*. In these studies, subjects could be treated for different clinical situations and had a follow-up of up 2 years [41].

Evaluation of FibCLOT® Safety

Treatment-emergent adverse events (TEAEs) (limited to interventional studies) or adverse drug reactions (ADRs) (in the observational study) were recorded from inclusion until the end-of-study visit, regardless of the time elapsed since the last administration of the study drug. The standard definition for serious adverse events (SAEs) was used [41].Different outcomes were assessed depending on the studies: vital signs (blood pressure, pulse rate, temperature and respiratory rate), haematology (CBC and platelet count) and biochemistry (AST, ALT, creatinine) parameters. A systematic evaluation for new onset hepatitis A, B, or C, HIV or parvovirus was performed after 6 months of follow-up in 5 patients. In one of the studies (n=14) ultrasonography of the lower limbs was systematically required at screening, prior to and 6 days after the pharmacological study, prior to surgery, during the post-treatment follow-up visit. In the same study, coagulation activation markers (TAT and F1+2) and fibrin degradation products (D-dimers) were also measured. Fibrinogen inhibitor was evaluated in the two interventional studies [41].

Tolerance of FibCLOT®

I. Clinical tolerance

The adverse reactions have been reported in 35 patients with congenital fibrinogen deficiency included in two clinical interventional studies and in one non-interventional post-marketing safety study. During these studies, 36 adverse reactions have been reported in 13/35 (37.1%) patients who received a total of 572 infusions of FibCLOT® [35].Most drug-related adverse events were mild to moderate in intensity. The most commonly reported was headache, occurring in 1.2% of infusions [35].Generalised reactions may occur rarely, such as vomiting, dizziness, chills or urticaria. Two subjects with afibrinogenaemia reported three allergic/anaphylactic-type reactions. FibCLOT®

was re-administered in both subjects without reoccurrence of these reactions [35].

30

Thrombotic complications are rarely observed in afibrinogenaemic patients. These complications can occur in the presence of concomitant risk factors such as a co-inherited thrombophilic risk factor or after replacement therapy [5]. Several hypotheses have been put forward to explain this predisposition to thrombosis: one possible explanation is that fibrin acts as an antithrombin and also binds and sequesters thrombin. This antithrombin activity of fibrin is absent in patients with afibrinogenaemia, who exhibit increased prothrombin activation and thrombin generation. Thrombin, which is not trapped by the Clot, remains available for platelet activation and thrombus formation [5]. In the 3 clinical studies, venous thrombosis were reported in 3 subjects with afibrinogenaemia including 2 asymptomatic venous thrombosis diagnosed by systematic ultrasonography [35].For the complete list of indesirable effects, please refer to page 36 or to the SmPC page 40.

II. Immunogenicity

No immunogenic AEs related to fibrinogen supplementation were detected by laboratory testing or lack of efficacy during clinical studies, either at baseline or at 1 month after infusion [35].

III. Transmissible agents

No transmission of blood-borne pathogens was reported during clinical studies and serologic testing for these pathogens was negative [35,41].

• Safety evaluation was based on exposure of 35 subjects to more than 1300 g of FibCLOT® administered in 572 infusions and it was concluded in the good tolerance of FibCLOT®.

• No subjects developed anti-fibrinogen antibodies.

• The benefit/risk ratio of FibCLOT® in patients with congenital fibrinogen deficiency can be considered favourable.

HIGHLIGHTS

31


FibCLOT® IN CLINICAL PRACTICE

Practical advantages of using FibCLOT®

Products that have been used as fibrinogen replacement therapy to treat or prevent bleeding in fibrinogen deficiencies include fresh frozen plasma (FFP), cryoprecipitate, and plasma derived fibrinogen concentrates.FibCLOT®, purified human fibrinogen concentrate, has been proven to be effective in supplementing congenital fibrinogen deficiencies. FibCLOT® also offers many practical advantages over other therapies and is an additional choice for the replacement of fibrinogen [35].

FibCLOT®: key benefits [35]

• Accurate and reliable dosing

• Readily available “on the shelf”, (particularly in emergency situations) at room temperature without the need for thawing

• No need for checking ABO and Rhesus compatibility

• Easily reconstituted (water for injections and transfer system provided)

• Small infusion volume (100 mL): no risk of fluid overload (vs. FFP)

• Uncommon allergic/anaphylactic-type reactions

• Specific viral/prion inactivation and removal steps

Clinical indications

FibCLOT® is indicated for the treatment and perioperative prophylaxis of bleeding in patients with congenital hypo- or afibrinogenaemia with bleeding tendency [6].

Dosage and method of administration

The dosage and duration of the substitution therapy depend on the severity of the disorder, location and extent of the bleeding and the patient’s clinical condition.The functional fibrinogen level should be determined in order to calculate individual dosage. The amount and frequency of administration should be determined on an individual patient basis by regular measurement of plasma fibrinogen level and continuous clinical monitoring of the patient and of other replacement therapies used.In case of major surgical intervention, precise monitoring of replacement therapy by coagulation assays is essential.

Water for injection

Product vial

Transfer system

32

I. Treatment and prophylaxis of bleeding

To treat non-surgical bleeding episodes, it is recommended to raise fibrinogen levels to 1 g/L and maintain fibrinogen at this level until haemostasis is controlled and above 0.5 g/L until healing is complete.To prevent excessive bleeding during surgical procedures, prophylactic treatment is recommended to raise fibrinogen levels to 1 g/L and maintain fibrinogen at this level until haemostasis is controlled and above 0.5 g/L until wound healing is complete.

In case of surgical procedure or treatment of a non-surgical bleeding, the dose should be calculated as follows:

Dose (g) = (target level (g/L) – baseline level (g/L)) x 0.043 x body weight (kg),where 0.043 corresponds to 1/recovery ((g/L)/(g/kg)).

In case of an emergency situation when the baseline fibrinogen level is not known, the recommended initial dose is 0.05 g per kg of body weight administered intravenously [6].

Subsequent doses and frequency of injections should be adapted based on the patient’s clinical status and laboratory results.The biological half-life of fibrinogen is 3-4 days. Thus, in the absence of consumption, repeated treatment with human fibrinogen is not usually required. Given the accumulation that occurs in case of repeated administration for a prophylactic use, the dose and the frequency should be determined according to the therapeutic goals for a given patient.No recommendation on a posology can be made in children.Treatment should be initiated under the supervision of a physician experienced in the treatment of coagulation disorders [6].

33


II. Preparation and reconstitution

Reconstitution instructions for an aseptic procedure [6]

• If necessary, increase the temperature of the two vials (powder and solvent) to ambient temperature.

• Remove the protective cap from the solvent vial and from the powder vial.

• Disinfect the surface of each stopper.

• Remove the translucent protective sheath from the transfer system and completely insert the exposed piercing spike through the centre of the stopper of the solvent vial while simultaneously twisting the piercing spike.

• Remove the second grey protective sheath from the other end of the transfer system.

• Turn the solvent vial and quickly push the free end of the piercing spike into the centre of the stopper of the powder vial to allow the solvent to transfer into the powder.

• Ensure that the spike always remains immersed in the solvent to avoid releasing the vacuum prematurely.

• During transfer, direct the jet of solvent over the entire surface of the powder and along the wall of the vial by a rotational horizontal movement. Ensure that all of the solvent is transferred.

• The vacuum is automatically released at the end of the transfer procedure by sterile air passing through the venting part of the transfer system.

• Remove the empty solvent vial with the transfer system.• Gently swirl for a few minutes with a rotating movement to avoid the

formation of foam until the powder has completely dissolved.

The reconstituted product should be examined visually prior to administration in order to ensure that it does not contain particulate matter. The reconstituted solution should be almost colourless, slightly opalescent. Do not use solutions which are cloudy or contain deposits.

1

2

3

4

5

6

Scan the QR code with your smartphone or tablet and watch the reconstitution video on line

34

* The Plasma Protein Therapeutics Association (PPTA) is a trade association that represents over 450 human plasma collection centres in North America and Europe, as well as the private sector manufacturers of life-saving plasma protein therapies. It administers standards programmes that help ensure the quality and safety of plasma collection and manufacturing and protect both donors and patients.

LFB: A HERITAGE OF QUALITY PLASMA-DERIVED THERAPIES WITH OUTSTANDING RECORDS OF SAFETY AND EFFICACY

LFB Group is a research-based biopharmaceutical group that develops, manufactures and markets medicinal products that extend and enhance the lives of people suffering from chronic and acute, often life-threatening diseases in major therapeutic areas: immunology, haemostasis and intensive care. LFB Group is the leading manufacturer of plasma-derived medicinal products in France and the 6th-ranked player worldwide. It is also among the leading European companies in the development of monoclonal antibodies and new-generation proteins based on biotechnologies (i.e. cell and gene therapies).

LFB group has been isolating and purifying plasma and blood derived proteins for more than 20 years and has years of experience in coagulation.

The first available human fibrinogen by LFB group was supplied in France under compassionate use between 1995 and 2009.

In 2009, LFB launched a new generation of fibrinogen concentrate, currently available in several countries including France for patients with congenital fibrinogen deficiencies and as complementary therapy in the management of uncontrolled severe haemorrhage in situations of acquired hypofibrinogenaemia.

The development of FibCLOT®, which has the same manufacturing process and composition than previous LFB fibrinogen concentrates and was based on the extensive experience gained in fibrinogen supplementation.

The LFB Group owns the EUROPLASMA Group, a chain of plasma collection centres. Following the highest quality standards, EUROPLASMA is a member of the Plasma Protein Therapeutic Association (PPTA)*.

III. Method of administration (injecting FibCLOT®)

FibCLOT® should only be administered intravenously, as a single dose, immediately after reconstitution, at no more than 4 mL/min [6].If the reconstituted solution is not administered immediately, storage shall not exceed 24 hours at room temperature (maximum 25°C) [6].It is recommended to use an infusion set with a non-sterilising 15 µm filter.Any unused product or waste material should be disposed of in accordance with local requirements.

35


FibCLOT®: GOOD USE

Adequate patient evaluation and monitoring

Treatment should be initiated under the supervision of a physician experienced in the treatment of coagulation disorders.

Contraindications

Hypersensitivity to the active substance or to any of the excipients (arginine hydrochloride, isoleucine, lysine hydrochloride, glycine, sodium citrate dehydrate).

Special warnings and special precautions for use

ThromboembolismThere is a risk of thrombosis when patients are treated with human fibrinogen, particularly with high doses or repeated dosing. Patients given human fibrinogen should be observed closely for signs or symptoms of thrombosis.In patients with a history of coronary heart disease or myocardial infarction, in patients with liver disease, in peri- or post-operative patients, in neonates, or in patients at risk of thromboembolic events or disseminated intravascular coagulation, the potential benefit of treatment with human plasma fibrinogen should be weighed against the risk of thromboembolic complications. Caution and close monitoring should also be performed.

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

Transmissible agentsStandard 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 or 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) and for the non-enveloped hepatitis A virus (HAV). The measures taken may be of limited value against

36

non-enveloped viruses such as 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) should be considered for patients in regular/repeated receipt of human plasma-derived fibrinogen.It is strongly recommended that every time that FibCLOT® 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.

ImmunogenicityIn the case of replacement therapy with coagulation factors in other congenital deficiencies, antibody reactions have been observed, but there is currently no data with fibrinogen.

Sodium LevelThe product contains a maximum of 3 mmol (or 69 mg) of sodium per vial. This should be taken into consideration in patients following a strict low sodium diet.

Paediatric populationThe same warnings and precautions apply to the paediatric population.

Undesirable effects

Adverse reactions have been reported in 35 patients with congenital fibrinogen deficiency included in two clinical interventional studies and in one non-interventional post-marketing safety study. During these studies, 36 adverse reactions have been reported in 13/35 (37.1%) patients who received a total of 572 infusions of FibCLOT®.

• Common adverse reactions (≥1/100 to <1/10) [6]: - Nervous system disorders: headache.

• Uncommon adverse reactions (<1/1,000 to <1/100): - Immune system disorders: allergic/anaphylactic-type reactions (including anaphylactic shock,

pallor, vomiting, cough, blood pressure decreased, chills, urticaria). - Nervous system disorders: dizziness. - Ear and labyrinth disorders: tinnitus. - Vascular disorders: thromboembolic episodes (including deep vein thrombosis, superficial

thrombophlebitis). - Respiratory, thoracic and mediastinal disorders: asthma. - Skin and subcutaneous tissue disorders: rash erythematous, erythema, skin irritation, night

sweat. - General disorders and administration site conditions: feeling hot.

37


Incompatibilities

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.

Storage and stability

Do not store above 25°C. Do not freeze. Store in the original outer package in order to protect from light and moisture.

Shelf life

3 years.Chemical and physical in-use stability has been demonstrated for 24 hours at 25°C. From a microbiological point of view the product should be used immediately.

38

REFERENCES

1. Beyerley A, Nolte MW, Solomon C. et al. Analysis of the safety and pharmacodynamics of human fibrinogen concentrate in animals. Toxicology and Applied Pharmacology 2014; 280:70-7.

2. Levy JH, Welsby I, Goodnough LT. Fibrinogen as a therapeutic target for bleeding: a review of critical levels and replacement therapy. Transfusion 2014;54(5):1389-405.

3. Levy JH, Szlam F, Tanaka KA, Sniecienski RM. Fibrinogen and hemostasis: a primary hemostatic target for the management of acquired bleeding. Anesth Analg 2012;114(2):261-74.

4. EMA 2014- Guideline on core SmPC for Human Fibrinogen Products (EMA/CHMP/BPWP/691754/2013).

5. De Moerloose P, Casini A, Neerman-Arbez M. Congenital fibrinogen Disorders: An update. Semin Thromb Hemost 2013;39:585-95.

6. SmPC FibCLOT®.

7. Mosesson MW. Fibrinogen and fibrin structure and functions. J Thromb Haemost 2005;3:1894-1904.

8. Bolton-Maggs PH, Perry DJ, Chalmers EA, et al. The rare coagulation disorders - review with guidelines for management from the United Kingdom Haemophilia Centre Doctors’ Organisation. Haemophilia 2004;10(5):593–628.

9. Peyvandi F. Epidemiology and treatment of congenital fibrinogen deficiency. Thrombosis Research 2012;130S2:S7–S11.

10. Köhler S, Schmid F, Settanni G. The Internal Dynamics of Fibrinogen and Its Implications for Coagulation and Adsorption. 2015; PLoS Comput Biol 11(9): e1004346. doi:10.1371/journal.pcbi.1004346.

11. Levy JH, Goodnough LT. How I use fibrinogen replacement therapy in acquired bleeding. Blood 2015; 125(9):1387-93.

12. Hofmann M, Monroe DM. Coagulation 2006: A Modern View of Hemostasis. Hematol Oncol Clin N Am 2007;21:1-11.

13. Bolliger D, Szlam F, Levy JH et al. Haemodilution-induced profibrinolytic state is mitigated by fresh-frozen plasma: implications for early haemostatic intervention in massive haemorrhage. British Journal of Anaesthesia 2010;104(3):318-25.

14. Weisel JW. Structure of fibrin: impact on clot stability. J Thromb Haemost 2007;5(1):116-24.

15. Koopman J, Haverkate F, Gnmbergen J et al. Molecular Basis for Fibrinogen Dusart (Aa 554 Arg -- Cys) and Its Association with Abnormal Fibrin Polymerization and Thrombophilia. J Clin Invest 1993; 91:1637-43.

16. Fries D, Martini WZ. Role of fibrinogen in trauma-induced coagulopathy. British Journal of Anaesthesia 2010;105(2):116-21.

17. De Lange NM, van Rheenen-Flach LE, Mooyman LL et al. Peri-partum reference ranges for ROTEM thromboelastometry. British Journal of Anaesthesia 2014;112(5): 852-9.

18. Acharya SS, Dimichele DM. Rare inherited disorders of fibrinogen. Haemophilia 2008;14:1151-8.

19. Casini A, Neerman-Arbez M, Ariëns RA, de Moerloose P. Dysfibrinogenemia: from molecular anomalies to clinical manifestations and management. 2015. Accepted article, DOI: 10-1111/jth.12916.

20. Lebreton A, Casini A, Alhayek R. et al. Successful pregnancy under fibrinogen substitution in a woman with congenital afibrinogenaemia complicated by a postpartum venous thrombosis. Haemophilia 2015;21:e70-e121.

21. Kamath S, LIP GYH. Fibrinogen: biochemistry, epidemiology and determinants. Q J Med 2003; 96:711-29.

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22. Ganter MT, Hofer CK. Coagulation monitoring: current techniques and clinical use of viscoelastic point-of-care coagulation devices. Anesth Analg 2008 May;106(5):1366-75.

23. Schöchl H, Nienaber U, Hofer G. et al. Goal- directed coagulation management of major trauma patients using thromboelastometry (ROTEM®)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Critical Care 2010;14:R55.

24. Tanaka KA, Tanaka, Bolliger D, Vadlamudi R, Nimmo A. Rotational Thromboelastometry (ROTEM)-Based Coagulation Management in Cardiac Surgery and Major Trauma. Journal of Cardiothoracic and Vascular Anesthesia 2012;26(6):1083-93.

25. David JS, Godier A, Dargaud Y, Inaba K. Case Scenario: Management of Trauma-induced Coagulopathy in a Severe Blunt Trauma Patient. Anesthesiology 2013;119:191-200.

26. Mackie I, Cooper P, Lawrie A. et al. Guidelines on the laboratory aspects of assays used in haemostasis and thrombosis. Int Jnl Lab Hem.2013;35:1-13.

27. Asselta R, Duga S, Tenchini ML. The molecular basis of quantitative fibrinogen disorders. J Thromb Haemost 2006;4(10):2115-29.

28. Walden K, Jeppsson A, Nasic S et al. Low Preoperative Fibrinogen Plasma Concentration Is Associated With Excessive Bleeding After Cardiac Operations. Ann Thorac Surg 2014;97:1199-206.

29. Cortet M, Deneux-Tharaux C, Dupont C. et al. Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial. Br J Anaesth 2012;108(6):984-9.

30. Collins P.W, Lilley G, Bruynseels D. et al. Fibrin-based clot formation as an early and rapid biomarker for progression of postpartum hemorrhage: a prospective study. Blood 2014; 124(11):1727-36.

31. Karkouti K, Callum J, Crowther MA, et al. The relationship between fibrinogen levels after cardiopulmonary bypass and large volume red cell transfusion in cardiac surgery: an observational study. Anesth Analg 2013;117(1):14-22.

32. Davenport R. Pathogenesis of acute traumatic coagulopathy. Transfusion 2013;53:23S-27S.

33. Sorensen B, Bevan D. A critical evaluation of cryoprecipitate for replacement of fibrinogen. British Journal of Haematology 2010;149:834-43.

34. Bevan DH. Cryoprecipitate: no longer the best therapeutic choice in congenital fibrinogen disorders? Thromb Res 2009;124 Suppl 2:S12-6.

35. LFB. FibCLOT 1,5g/100mL Core Data on file 2015 - Clinical Overview - Parts 1, 3, 4.1, 4.2, 4.5, 5.1, 5.2, 5.4.2.1, 5.5.2, 5.5.4.1, 5.10, 6.

36. Klamroth R, Gröner A, Simon TL. Pathogen inactivation and removal methods for plasma-derived clotting factor concentrates. Transfusion 2014;54(5):1406-17.

37. LFB. FibCLOT® 1,5g/100mL Core Data on file 2015 – Summary of Clinical Pharmacology Studies- Part 2.2.

38. LFB. FibCLOT® 1,5g/100mL Core Data on file 2015 – Clinical efficacy summary- Parts 2.2.1, 2.2.2, 3.2.1.1.2, 4.1.1.

39. Solomon C, Hagl C, Rahe-meyer N. Time course of haemostatic effects of fibrinogen concentrate administration in aortic surgery. British Journal of Anaesthesia 2013;110(6):947–56.

40. Schulman S, Kearon C. S on behalf of the subcommittee on control of anticoagulation of the Scientific and Standardization committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost 2005;3:692-4.

41. LFB. FibCLOT® 1,5g/100mL Core Data on file 2015 – Summary of clinical safety- Parts 1.1.4, 1.2, 1.2.1.2.

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H This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. See SmPC for how to report adverse reactions.

1. NAME OF THE MEDICINAL PRODUCT: FibCLOT 1.5 g. Powder and solvent for solution for injection/infusion. 2. QUALITATIVE AND QUANTITATIVE COMPOSITION: Human Fibrinogen. Each vial of FibCLOT contains nominally 1.5 g of human fibrinogen. After reconstitution with 100 mL of solvent (water for injections), FibCLOT contains nominally 15 mg/mL of human fibrinogen. The potency is determined according to the European Pharmacopoeia monograph for human fibrinogen. Produced from the plasma of human donors. Excipients with known effect: the product contains a maximum of 69 mg of sodium/vial. For the full list of excipients, see section 6.1. 3. PHARMACEUTICAL FORM: Powder and solvent for solution for injection/infusion. White or pale yellow powder in a vial. 4. CLINICAL PARTICULARS: 4.1. Therapeutic indications: Treatment and perioperative prophylaxis of bleeding in patients with congenital hypo- or afibrinogenaemia with bleeding tendency. 4.2. Posology and method of administration: Treatment should be initiated under the supervision of a physician experienced in the treatment of coagulation disorders. Posology: The dosage and duration of the substitution therapy depend on the severity of the disorder, location and extent of bleeding and the patient’s clinical condition. The (functional) fibrinogen level should be determined in order to calculate individual dosage and the amount and frequency of administration should be determined on an individual patient basis by regular measurement of plasma fibrinogen level and continuous monitoring of the clinical condition of the patient and other replacement therapies used. Normal plasma fibrinogen level is in the range of 1.5 - 4.5 g/L. In congenital hypo- or afibrinogenaemia, the critical plasma fibrinogen level below which haemorrhages may occur is approximately 0.5 – 1.0 g/L. In case of major surgical intervention, precise monitoring of replacement therapy by coagulation assays is essential. Treatment of bleeding and prophylaxis in patients with congenital hypo- or afibrinogenaemia and known bleeding tendency. To treat nonsurgical bleeding episodes, it is recommended to raise fibrinogen levels to 1 g/L and maintain fibrinogen at this level until haemostasis is controlled and above 0.5 g/L until healing is complete. To prevent excessive bleeding during surgical procedures, prophylactic treatment is recommended to raise fibrinogen levels to 1 g/L and maintain fibrinogen at this level until haemostasis is controlled and above 0.5 g/L until wound healing is complete. In case of surgical procedure or treatment of a nonsurgical bleeding, the dose should be calculated as follows: Dose (g) = (target level (g/L) – baseline level (g/L)) x 0.043 x body weight (kg), where 0.043 corresponds to 1/recovery ((g/L)/(g/kg)). In case of an emergency situation when the baseline fibrinogen level is not known, the recommended initial dose is 0.05 g per kg of body weight administered intravenously. Subsequent posology (doses and frequency of injections) should be adapted based on the patient’s clinical status and laboratory results. Biological half-life of fibrinogen is 3 - 4 days. Thus, in the absence of consumption, repeated treatment with human fibrinogen is not usually required. Given the accumulation that occurs in case of repeated administration for a prophylactic use, the dose and the frequency should be determined according to the therapeutic goals of the physician for a given patient. Paediatric population: Currently available data are described in section 4.8 and 5.1 but no recommendation on a posology can be made in children. Method of administration: Intravenous infusion or injection. FibCLOT should be administered by slow intravenous infusion. Maximum rate of 4 mL/min. For instructions on reconstitution of the product before administration, see sections 6.2 and 6.6. 4.3. Contra-indications: Hypersensitivity to the active substance or to any of the excipients listed in section 6.1. 4.4. Special warnings and special precautions for use: Thromboembolism: There is a risk of thrombosis when patients are treated with human fibrinogen particularly with high dose or repeated dosing. Patients given human fibrinogen should be observed closely for signs or symptoms of thrombosis. In patients with a history of coronary heart disease or myocardial infarction, in patients with liver disease, in peri- or post-operative patients, in neonates, or in patients at risk of thromboembolic events or disseminated intravascular coagulation, the potential benefit of treatment with human plasma fibrinogen should be weighed against the risk of thromboembolic complications. Caution and close monitoring should also be performed. Allergic or anaphylactic-type reactions: If allergic or anaphylactic-type reactions occur, the injection/infusion should be stopped immediately. In case of anaphylactic shock, standard medical treatment for shock should be implemented. Transmissible agents: 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 or 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) and for the non-enveloped hepatitis A virus (HAV). The measures taken may be of limited value against non-enveloped viruses such as 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) should be considered for patients in regular/repeated receipt

SmPC

41


of human plasma-derived fibrinogen. It is strongly recommended that every time that FibCLOT 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. Immunogenicity: In the case of replacement therapy with coagulation factors in other congenital deficiencies, antibody reactions have been observed, but there is currently no data with fibrinogen. Sodium Level: The product contains a maximum of 3 mmol (or 69 mg) of sodium/vial. This should be taken into consideration in patients following a strict low sodium diet. Paediatric population: Same warnings and precaution apply to the paediatric population. 4.5. Interaction with other medicinal products and other forms of interaction: No interactions of human fibrinogen products with other medicinal products are known. 4.6. Fertility, pregnancy and lactation: The safety of human plasma fibrinogen products for use in human pregnancy and during lactation has not been established in controlled clinical trials. Clinical experience with fibrinogen products in the treatment of obstetric complications suggests that no harmful effects on the course of the pregnancy or health of the foetus or the neonate are to be expected. 4.7. Effects on ability to drive and use machines: FibCLOT has no influence on the ability to drive and use machines. 4.8. Undesirable effects Tabulated list of adverse reactions: The adverse reactions presented in the table below have been reported in 35 patients with congenital fibrinogen deficiency included in two clinical interventional studies and in one non-interventional post-marketing safety study. During these studies, 36 adverse reactions have been reported in 13/35 (37.1%) patients who received a total of 572 infusions of FibCLOT. The most significant reactions are described according to the MedDRA classification (System Organ Class and Preferred Term Level). Frequencies have been estimated on a per-infusion basis according to the following conventions: very common (O 1/10); common (O 1/100 to <1/10); uncommon (O 1/1,000 to < 1/100); rare (O 1/10,000 to < 1/1,000); very rare (< 1/10,000); not known (cannot be estimated from the available data). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

MedDRA Standard System Organ Class Adverse reactions Frequency per infusion (N=572)

Immune system disordersAllergic/anaphylactic-type reactions (including anaphylactic shock, pallor, vomiting, cough, blood pressure decreased, chills, urticaria)

Uncommon

Nervous system disorders Headache Dizziness Common Uncommon

Ear and labyrinth disorders Tinnitus Uncommon

Vascular disorders Thromboembolic episodes (including deep vein thrombosis, superficial thrombophlebitis) (see section 4.4) Uncommon

Respiratory, thoracic and mediastinal disorders Asthma Uncommon

Skin and subcutaneous tissue disorders

Rash erythematous Uncommon

Erythema Uncommon

Skin irritation Uncommon

Night sweat Uncommon

General disorders and administration site conditions Feeling hot Uncommon

For safety with respect to transmissible agents, see 4.4. The overall safety profile does not differ in patients treated with FibCLOT in other clinical situations requiring fibrinogen therapy. Paediatric population: Among the 35 patients included in the congenital fibrinogen deficiency safety analysis, 14 were less than 18 years, including 10 less than 12 years and 3 under the age of 6. The overall safety profile does not differ between adults and paediatric patients. 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 national reporting system listed in Appendix V. 4.9. Overdose: In order to avoid overdosage, regular monitoring of the plasma level of fibrinogen therapy is indicated (see 4.2). In case of overdosage, the risk of development of thromboembolic complications is enhanced. 5. PHARMACOLOGICAL PROPERTIES: 5.1. Pharmacodynamic properties: Pharmacotherapeutic group: antihaemorrhagics, human fibrinogen, ATC code: B02BB01 Human fibrinogen (coagulation factor I), in the presence of thrombin, activated coagulation

42

factor XIII (FXIIIa) and calcium ions, is converted into a stable and elastic three-dimensional fibrin haemostatic clot. The administration of human fibrinogen provides an increase in plasma fibrinogen level and can temporarily correct the coagulation defect of patients with fibrinogen deficiency. In a clinical pharmacology study (dose 0.06 g/kg of FibCLOT), normalisation of global coagulation tests (e.g. activated partial thromboplastin time [aPTT] and prothrombin time [PT]) was achieved at fibrinogen levels at or above 0.5 g/L and lasted for at least 3 days. Across all studies in congenital fibrinogen deficiency, FibCLOT was administered for: 100 nonsurgical bleeding episodes in 18 patients (including 17 major episodes in 9 patients), 38 surgical procedures in 15 patients (including 10 major procedures in 7 patients). The majority (92.8%) of the events (128/138) were managed with a single dose of about 3 g FibCLOT, corresponding to a median dose per infusion of 0.050 g/kg. In a post marketing study, 9 patients have been treated for long term prophylaxis for at least 12 months with a median dose of 0.059 g/kg once a week. Paediatric population: FibCLOT was administered in clinical studies in 14 patients under the age of 18 years. The median dose per infusion was 0.059 g/kg for the treatment of 26 nonsurgical bleeding episodes or prevention of excessive bleeding during 14 surgical procedures. The European Medicines Agency has deferred the obligation to submit the results of study with FibCLOT in patients less than 12 years of age as per Paediatric Investigation Plan (PIP) decision (see section 4.2 for information on paediatric use). 5.2. Pharmacokinetic properties: In plasma, the biological half-life of fibrinogen is 3-4 days. The product is administered intravenously and is immediately available in the plasma at concentration corresponding to the dosage administered. In a clinical pharmacology study, 14 patients were evaluated over 14 days. After infusion of a dose of 0.06 g/kg of FibCLOT, the maximal fibrinogen concentration was reached within 1 hour and was followed by a slow decrease reaching the critical plasma fibrinogen level of 0.5 g/L in about 3 to 4 days.

Pharmacokinetic parameters FibCLOT single dose IV infusion

(Geometric mean (geometric CV%))

Cmax (g/L) 1.4 (24.4)

t1/2 (h) 69.3 (21.8)

AUC0-∞ (g.h/L) 114 (23.4)

MRT (h) 95.6 (20.7)

Cl (mL/h/kg) 0.53 (22.0)

Vss (mL/kg) 50.7 (16.7)

IR ((g/L)/(g/kg)) 23.5 (23.2)

R (%) 93.6 (20.9)

Cmax = maximum concentration (activity) t1/2 = terminal elimination half-life AUC = area under the curve MRT = mean residence time Cl = clearance Vss = volume of distribution at steady state IR = incremental recovery R = in vivo recovery CV = coefficient of variation.

Paediatric population: No pharmacokinetic data are available in paediatric patients <12 years of age. 5.3. Preclinical safety data: Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, single and repeated dose toxicity as well as thrombogenicity. Given the nature of the product carcinogenicity studies were not conducted. Animal reproduction studies have not been performed since fibrinogen is a normal constituent of the human body. 6. PHARMACEUTICAL PARTICULARS: 6.1. List of excipients: Powder: Arginine hydrochloride Isoleucine Lysine hydrochloride Glycine Sodium citrate dihydrate. Solvent: Water for injections. 6.2. Incompatibilities: In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products. A standard infusion set is recommended for intravenous application of the reconstituted solution at room temperature. 6.3. Shelf life: 3 years. Chemical and physical in-use stability has been demonstrated for 24 hours at 25 °C. From a microbiological point of view the product should be used immediately. 6.4. Special precautions for storage: Do not store above 25°C. Do not freeze. Store in the original outer package in order to protect from light and moisture. For storage conditions after reconstitution of the medicinal product, see section 6.3. 6.5. Nature and contents of container: One pack contains: - Powder (1.5 g human fibrinogen) in a colourless type I glass vial sealed with a siliconised bromobutyl stopper, an aluminium cap and a plastic disc. - Solvent (100 mL water for injections) in a type II glass vial sealed with a bromobutyl stopper, an aluminium cap and a plastic disc. - Transfer system equipped with a sterile filtering air vent. 6.6. Special precaution for disposal and other handling: Reconstitution: Use current guidelines for aseptic procedure.

43


If necessary, increase the temperature of the two vials (powder and solvent) to ambient temperature.

Remove the protective cap from the solvent vial and from the powder vial. Disinfect the surface of each stopper.

Remove the translucent protective sheath from the transfer system and completely insert the exposed piercing spike through the centre of the stopper of the solvent vial while simultaneously twisting the piercing spike.

Remove the second grey protective sheath from the other end of the transfer system. Turn the solvent vial and quickly push the free end of the piercing spike into the center of the stopper of the powder vial to allow the solvent to transfer into the powder. Ensure that the spike always remains immersed in the solvent to avoid releasing the vacuum prematurely.

During transfer, direct the jet of solvent over the entire surface of the powder and along the wall of the vial by a rotational horizontal movement. Ensure that all of the solvent is transferred. The vacuum is automatically released at the end of the transfer procedure by sterile air through the venting part of the transfer system.

Remove the empty vial (solvent) with the transfer system. Gently swirl for a few minutes with a rotating movement to avoid the formation of foam until the powder has completely dissolved.

The reconstituted product should be examined visually prior to administration in order to ensure that it does not contain particulate matter. The reconstituted solution should be almost colourless, slightly opalescent. Do not use solutions which are cloudy or contain deposits. Administration: FibCLOT should only be administered intravenously, as a single dose, immediately after reconstitution, at no more than 4 mL/min. If the reconstituted solution is not administered immediately, storage shall not exceed 24 hours at room temperature (maximum 25°C). It is recommended to use an infusion set with a non-sterilising 15 µm filter. Any unused product or waste material should be disposed of in accordance with local requirements. 7. MARKETING AUTHORISATION HOLDER: Laboratoire Français du Fractionnement et des Biotechnologies 3 Avenue des Tropiques ZA de Courtaboeuf 91940 Les Ulis FRANCE Tel: + 33 (0)1 69 82 70 10 Fax: + 33 (0)1 69 82 19 03 8. MARKETING AUTHORISATION NUMBERS: See local Marketing Authorization 9. DATE OF FIRST AUTHORISATION / RENEWAL OF THE AUTHORISATION: Date of first authorisation: Depending on local Marketing Authorization 10. Date OF REVISION OF THE TEXT Dec 2015 (end of European procedure).

LFB BIOMEDICAMENTSS.A. au capital de 150 000 000 Euros - 491 371 167 RCS EVRY

3, avenue des Tropiques - BP 40305 - 91958 Courtaboeuf Cedex - FranceTéléphone : +33 (0)1 69 82 70 10 - Fax : +33 (0)1 69 07 19 03

www.lfb.fr

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Medical Information Contact: [email protected]

Documents

Firming the clot, controlling bleeding...threatening bleeding episodes in congenital fibrinogen disorders. Some years ago, patients received infusions of fresh frozen plasma (FFP)