1.1 Chronic Immune Thrombocytopenic Purpura (ITP)

Octagam 10% is indicated for the treatment of chronic immune thrombocytopenic purpura to rapidly raise platelet counts to control or prevent bleeding in adults.

1.2 Dermatomyositis (DM)

Octagam 10% is indicated for the treatment of dermatomyositis in adults.

2.1 Dosage

2.2 Preparation and Handling

• Parenteral products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not use if Octagam 10% is turbid and/or if discoloration is observed.
• Do not mix Octagam 10% with other medicinal products or administer simultaneously with other intravenous preparation in the same infusion set. Do not mix Octagam 10% with immune globulin intravenous (IGIV) products from other manufacturers.
• Do not freeze Octagam 10%. Do not use solutions that have been frozen.
• Octagam 10% contains no preservative. Octagam 10% bottle is for single use only. Use promptly any bottle that has been entered or opened, and discard partially used bottles.
• The content of Octagam 10% bottles may be pooled under aseptic conditions into sterile infusion bags and infused within 8 hours after pooling.
• Do not use after expiration date.
• Do not dilute Octagam 10%.
• The infusion line may be flushed before and after administration of Octagam 10% with either normal saline or 5% dextrose in water.

2.3 Administration

• Administer Octagam 10%, which is to be at room temperature, only by the intravenous route.
• Octagam 10% is not supplied with an infusion set. If an in-line filter is used the pore size should be 0.2 – 200 microns.
• Do not use a needle of larger than 16 gauge to prevent the possibility of coring. Insert needle only once, within the stopper area delineated (by the raised ring for penetration). Penetrate the stopper perpendicular to its plane and within the ring.

For rate of administration, see Table 1.

Table 1

*Patients with dermatomyositis are at increased risk for thromboembolic events; monitor carefully and do not exceed an infusion rate of 0.04 ml/kg/min.

• Monitor the patient carefully throughout the infusion. Certain adverse drug reactions may be related to the rate of infusion. Slowing or stopping the infusion usually allows the symptoms to disappear promptly. Once the symptoms subside, the infusion may then be resumed at a lower rate.

• Ensure that patients with pre-existing renal insufficiency are not volume depleted. For patients at risk of renal dysfunction or thromboembolic events, administer Octagam 10% at the minimum infusion rate practicable, not to exceed 3.3 mg/kg/min (0.03 mL/kg/min). Discontinue Octagam 10% if renal function deteriorates.

5.1 Hypersensitivity

Severe hypersensitivity reactions may occur (See Contraindications ( 4 ) ) .[ 1 ] In case of hypersensitivity, discontinue Octagam 10% infusion immediately and institute appropriate treatment. Epinephrine should be immediately available for treatment of severe acute hypersensitivity reactions.

Octagam 10% contains trace amounts of IgA (average 106 µg/mL in a 10% solution). IgA-deficient patients with antibodies against IgA are at greater risk of developing severe hypersensitivity and anaphylactoid reactions when administered Octagam 10% (See Contraindications ( 4 )) .

Octagam 10% may cause hypersensitivity reactions in patients with corn allergy. Octagam 10% contains maltose, a disaccharide sugar which is derived from corn.

5.2 Renal Dysfunction/Failure

Renal dysfunction, acute renal failure, osmotic nephropathy, and death may occur upon use of Octagam 10% in predisposed patients.

Ensure that patients are not volume depleted prior to the initiation of the infusion of Octagam 10%.

For patients at risk of renal dysfunction because of pre-existing renal insufficiency or predisposition to acute renal failure (such as individuals with diabetes mellitus, age greater than 65, volume depletion, sepsis, paraproteinemia, or those receiving known nephrotoxic drugs), administer Octagam 10% at the minimum infusion rate practicable, not to exceed 3.3mg/kg/min (0.03mL/kg/min) (See Boxed Warning, and Dosage and Administration ( 2 )).

Periodic monitoring of renal function tests and urine output is particularly important in patients judged to be at risk of developing acute renal failure. Assess renal function, including a measurement of blood urea nitrogen (BUN)/serum creatinine, prior to the initial infusion of Octagam 10% and again at appropriate intervals thereafter. If renal function deteriorates, consider discontinuation of the product.

5.3 Blood Glucose Monitoring

Some glucose monitoring systems give falsely elevated glucose readings because they interpret the maltose in Octagam 10% as glucose.[ 2 ] This occurs in systems that use glucose dehydrogenase pyrroloquinoline quinone (GDH-PQQ) or glucose-dye-oxidoreductase methods for detecting blood glucose. Inaccurate glucose readings can cause inappropriate administration of insulin and resultant potentially life-threatening hypoglycemia. Also, true hypoglycemia may go undetected when masked by a falsely elevated glucose reading.

Monitor glucose levels in diabetic patients with a glucose-specific method only. Review the product information of blood glucose testing systems, including the test strips, to determine if the system is appropriate to use with maltose-containing parenteral products. Contact the manufacturer if there is any uncertainty about the system.

5.4 Hyperproteinemia, Increased Serum Viscosity and Hyponatremia

Hyperproteinemia, increased serum viscosity and hyponatremia may occur in patients receiving Octagam 10% therapy. It is clinically critical to distinguish true hyponatremia from pseudohyponatremia related to hyperproteinemia with concomitant decreased calculated serum osmolality or elevated osmolar gap, because treatment aimed at decreasing serum free water in patients with pseudohyponatremia may lead to volume depletion, a further increase in serum viscosity and a higher risk of thromboembolic events.[ 3 ]

5.5 Thrombosis

Thrombosis may occur following treatment with immune globulin products, including Octagam 10%. Risk factors may include: advanced age, prolonged immobilization, hypercoagulable conditions, history of venous or arterial thrombosis, use of estrogens, indwelling central vascular catheters, hyperviscosity, and cardiovascular risk factors. Thrombosis may occur in the absence of known risk factors.

Consider baseline assessment of blood viscosity in patients at risk for hyperviscosity, including those with cryoglobulins, fasting chylomicronemia / markedly high triacylglycerols (triglycerides), or monoclonal gammopathies. For patients at risk of thrombotic events, administer Octagam 10% at the minimum dose and infusion rate practicable. Ensure adequate hydration in patients before administration. Monitor for signs and symptoms of thrombosis and assess blood viscosity in patients at risk for hyperviscosity. [ 4-6 ] (See BOXED WARNING, DOSAGE and ADMINSTRATION [ 2.3 ], PATIENT COUNSELING INFORMATION [ 17 ])

5.6 Hemolysis

Octagam 10% may contain blood group antibodies that can act as hemolysins and induce in vivo coating of red blood cells (RBCs) with immunoglobulin, causing a positive direct antiglobulin test (DAT) (Coombs’ test) result and hemolysis. Delayed hemolytic anemia can develop subsequent to IGIV therapy due to enhanced RBC sequestration and acute hemolysis, consistent with intravascular hemolysis, has been reported. Cases of severe hemolysis-related renal dysfunction/failure or disseminated intravascular coagulation have occurred following infusion of IGIV.

The following risk factors may be associated with the development of hemolysis following IGIV administration: high doses (e.g. ≥ 2 g/kg), given either as a single administration or divided over several days, and non-O blood group.[ 7 ]. Other individual patient factors, such as an underlying inflammatory state (as may be reflected by, for example, elevated C-reactive protein or erythrocyte sedimentation rate), have been hypothesized to increase the risk of hemolysis following administration of IGIV.[ 8 ], but their role is uncertain. Hemolysis has been reported following administration of IGIV for a variety of indications, including ITP.

Closely monitor patients for clinical signs and symptoms of hemolysis, particularly patients with risk factors noted above. Consider appropriate laboratory testing in higher risk patients, including measurement of hemoglobin or hematocrit prior to infusion and within approximately 36 to 96 hours post infusion. If clinical signs and symptoms of hemolysis or a significant drop in hemoglobin or hematocrit have been observed, perform confirmatory laboratory testing. If transfusion is indicated for patients who develop hemolysis with clinically compromising anemia after receiving IGIV, perform adequate cross-matching to avoid exacerbating on-going hemolysis.

5.7 Aseptic Meningitis Syndrome

Aseptic meningitis syndrome (AMS) may occur with Octagam treatment. Discontinuation of treatment has resulted in remission of AMS within several days without sequelae. The syndrome usually begins within several hours to two days following rapid infusion with Octagam treatment. It is characterized by symptoms and signs including severe headache, nuchal rigidity, drowsiness, fever, photophobia, painful eye movements, nausea and vomiting. Cerebrospinal fluid (CSF) studies frequently reveal pleocytosis up to several thousand cells per cubic millimeter, predominantly from the granulocytic series, and elevated protein levels up to several hundred mg/dl, but negative culture results. Conduct a thorough neurological examination in patients exhibiting such symptoms and signs, including CSF studies, to rule out other causes of meningitis. It appears that patients with a history of migraine may be more susceptible.[ 9 ]

AMS may occur more frequently following high doses (≥2 g/kg) and/or rapid infusion of IGIV.

5.8 Transfusion-Related Acute Lung Injury (TRALI)

Noncardiogenic pulmonary edema [Transfusion-Related Acute Lung Injury (TRALI)] may occur in patients administered IGIV.[ 10 ] TRALI is characterized by severe respiratory distress, pulmonary edema, hypoxemia, normal left ventricular function, and fever. Signs and symptoms typically appear within 1 to 6 hours after transfusion. Patients with TRALI may be managed using oxygen therapy with adequate ventilatory support.

Monitor recipients of Octagam 10% for pulmonary adverse reactions. If TRALI is suspected, perform appropriate tests for the presence of anti-HLA and anti-neutrophil antibodies in the product.

5.9 Transmission of Infectious Agents

Because Octagam 10% is made from human blood, it may carry a risk of transmitting infectious agents, e.g., viruses and theoretically, the Creutzfeldt-Jakob disease (CJD) agent. Report all infections thought by a physician or other healthcare provider to have been possibly transmitted by this product to Pfizer Inc. at 1-800-438-1985. Discuss the risks and benefits of Octagam 10% with the patient before prescribing or administering this product.

5.10 Monitoring Laboratory Tests

• After infusion of immunoglobulin, the transitory rise of the various passively transferred antibodies in the patient’s blood may yield positive serological testing results, with the potential for misleading interpretation.
• Passive transmission of antibodies to erythrocyte antigens (e.g. A, B, and D) may cause a positive direct or indirect antiglobulin (Coombs’) test. Clinically assess patients with known renal dysfunction, diabetes mellitus, age greater than 65, volume depletion, sepsis, paraproteinemia, or those receiving nephrotic agents, and monitor as appropriate (BUN; serum creatinine, urine output) during therapy with Octagam 10%.
• Consider baseline assessment of blood viscosity in patients at risk for hyperviscosity, including those with polycythemia, cryoglobulins, fasting chylomicronemia/markedly high triglycerides, or monoclonal gammopathies.
• Consider measuring hemoglobin or hematocrit at baseline and approximately 36 to 96 hours post infusion in patients at higher risk of hemolysis. If signs and/or symptoms of hemolysis are present after an infusion of Octagam 10%, perform appropriate laboratory testing for confirmation.
• If TRALI is suspected, perform appropriate tests for the presence of anti-neutrophil antibodies in both the product and patient’s serum.

6.1 Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a product cannot be directly compared to rates in the clinical trials of another product and may not reflect the rates observed in clinical practice.

Treatment of Chronic Immune Thrombocytopenic Purpura (ITP) in Adults

In a prospective, open-label, single-arm, multicenter study 116 subjects with newly diagnosed or chronic ITP received Octagam 10% at a dose of 2 g/kg, administered daily as 1 g/kg intravenous infusions on 2 consecutive days. In the initial study phase, the infusion rate allowed for Octagam 10% administration was up to 6 mg/kg/min [0.06 mL/kg/min], which was achieved in 24 of 26 subjects (92%). Subsequently, the maximum infusion rate allowed was 12 mg/kg/min [0.12mL/kg/min], and 54 (60%) of 90 subjects received Octagam 10% at this rate in the second phase of the trial.

Pre-medication to alleviate potential adverse drug reactions was allowed, and was only administered to 1 (0.9%) of the 116 patients.

The investigators judged 129 (54%) of the temporally associated ("infusional") adverse reactions (AR) in 62 patients to be at least possibly related to the infusion of Octagam 10%. The most common causally related ARs observed in > 5% of subjects are shown in Table 2.

Table 2: Drug-related Adverse Reactions Experienced by >5% of Subjects

Table 3: ARs in >5% Subjects During and Within 72 Hours After the End of 2-Days Treatment Cycle, Irrespective of Causality

One subject experienced a serious adverse reaction (headache).

Treatment of Dermatomyositis (DM) in Adults

In a prospective, double-blind, randomized, placebo-controlled, multicenter study with two study periods, 95 adults with DM were enrolled. In the First Period (16 weeks), 47 subjects received 2 g/kg Octagam 10% and 48 subjects received placebo every 4 weeks for 4 infusion cycles. In the following 6-month open-label Extension Period, 91 subjects received 6 infusion cycles of Octagam 10% (one infusion cycle every 4 weeks). One infusion cycle comprised of all infusions administered over 2-5 days.

Table 4 and Table 5 summarize the most frequent adverse reactions (ARs) that occurred in >5% of subjects with DM in the clinical study. Premedication for infusions was given to 21.3% of patients in the Octagam group.

During the study, no subject met the criteria for a hemolytic transfusion reaction (HTR). No deaths were reported during the study.

The following serious adverse reactions were observed in the study: muscle spasms and dyspnea in one subject, loss of consciousness in one subject, and thromboembolic events (TEEs) in five subjects, including deep vein thrombosis and pulmonary embolism in one subject, cerebrovascular accident in one subject, cerebral infarction in one subject, hypoesthesia in one subject and pulmonary embolism in one subject. For risk factors for TEE see also [ 5.5 ]).

Table 4: Drug-related Adverse Reactions Experienced by >5% of Subjects

Table 5: ARs in >5% of Subjects During and Within 72 Hours After End of Infusion Cycle, Irrespective of Causality

6.2 Postmarketing Experience

Because postmarketing reporting of adverse reactions is voluntary and from a population of uncertain size, it is not always possible to reliably estimate the frequency of these reactions or establish a causal relationship to product exposure.

The following adverse reactions have been identified during post-approval use of Octagam.

8.1 Pregnancy

Risk Summary

No human data are available to indicate the presence or absence of drug-associated risk. Animal reproduction studies have not been conducted with Octagam 10%. It is not known whether Octagam 10% can cause foetal harm when administered to a pregnant woman or can affect reproduction capacity. Immune globulins cross the placenta from maternal circulation increasingly after 30 weeks of gestation. Octagam 10% should be given to pregnant women only if clearly needed. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.

8.2 Lactation

Risk Summary

No human data are available to assess the presence or absence of Octagam 10% in human milk, the effects of Octagam 10% on the breastfed child, and the effects of Octagam 10% on milk production/excretion. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Octagam 10% liquid and any potential adverse effects on the breastfed infant from Octagam 10% liquid or from the underlying maternal condition. Immunoglobulins are excreted into the milk and may contribute to the transfer of protective antibodies to the neonate. 

8.4 Pediatric Use

The safety and effectiveness of Octagam 10% has not been established in pediatric patients with ITP or DM.

8.5 Geriatric Use

Patients > 65 years of age may be at increased risk for developing certain adverse reactions such as thromboembolic events and acute renal failure (See Boxed Warnings and Thrombotic Events ( 5.5 ) and Renal Failure ( 5.2 ) . Do not exceed recommended doses in this population, and the applied infusion rate should be the minimum practicable. Clinical studies of Octagam 10% did not include sufficient numbers of subjects > 65 years to determine whether they respond differently from younger subjects. During the First Period (placebo-controlled) of the DM trial, 11 patients over 65 years were treated with Octagam.

12.1 Mechanism of Action

The mechanism of action of immunoglobulins in the treatment of chronic ITP or in Dermatomyositis has not been fully elucidated.

12.3 Pharmacokinetics

Pharmacokinetic studies with Octagam 10% have not been performed in patients with chronic ITP nor in patients with Dermatomyositis.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

No studies were conducted on carcinogenesis, mutagenesis, or impairment of fertility with Octagam 10%.

Repeated-dose toxicity studies and genotoxic studies gave no evidence of carcinogenic properties of TNBP and Octoxynol.[ 11,12 ].

The results of in vitro and in vivo genotoxicity studies for TNBP and Octoxynol were negative. The results of studies on the embryotoxic and teratogenic properties of TNBP and Octoxynol in rats and rabbits at a wide range of i.v. doses were also negative.

13.2 Animal Toxicology and/or Pharmacology

No studies were conducted on pharmacology and pharmacokinetics with Octagam 10% in animals.

A variety of single-dose toxicity studies were performed for TNBP and Octoxynol alone or in combination: the lowest toxic dose of TNBP + Octoxynol (in a ratio of 1:5) was 10,000 mcg/kg BW in rats after intravenous administration. Studies on 13-week toxicity were performed for intravenous combinations of TNBP + Octoxynol in a broad dose range in dogs and rats: the lowest toxic dose for rats was local 60 mcg TNBP/kg + 300 mcg Octoxynol/kg BW (concentration: 0.0006% and 0.003%, respectively) and systemic 300 mcg TNBP/kg + 1,500 mcg Octoxynol/kg BW (concentration: 0.003% and 0.015%, respectively); the lowest toxic dose for dogs was local 50 mcg TNBP/kg + 250 mcg Octoxynol/kg BW (concentration: 0.005% and 0.025%, respectively) and systemic 500 mcg TNBP/kg + 2,500 mcg Octoxynol/kg BW (concentration: 0.05% and 0.25%, respectively).

A pharmacokinetic study was carried out in rats given 300 mcg of TNBP/kg and 1,500 mcg Octoxynol/kg BW i.v. The plasma half-life for TNBP was approximately 20 minutes. Octoxynol was not detected.

14.1 Treatment of Chronic Immune Thrombocytopenic Purpura

A prospective, open-label, single-arm, multicenter study assessed the efficacy, safety, and tolerability of Octagam 10% in 116 subjects with tentative newly diagnosed or chronic ITP and a platelet count of 20 x 10 9 /L or less. Subjects ranged in age from 17 to 88; 64% were female and 36% were male.

Subjects received a 2 g/kg dose of Octagam 10% administered as two daily 1 g/kg intravenous doses, given on 2 consecutive days. Pre-medication to alleviate potential adverse drug reactions was allowed but only given to 1 (0.9%) of 116 patients. In the initial study phase, the infusion rate allowed for Octagam 10% administration was up to 6 mg/kg/min [0.06 mL/kg/min], which was achieved in 24 of 26 subjects (92%). Subsequently, the maximum infusion rate allowed was 12 mg/kg/min [0.12mL/kg/min], which was achieved in 54 of 90 subjects (60%). Platelet counts were measured on Days 1 to 7, 14, 21, and 63.

The study was designed to determine the response rate defined as the percentage of subjects with an increase in platelet count to at least 50 x 10 9 /L within 7 days after the first infusion (responders). Additionally, maximum platelet count, the time to reach a platelet count of at least 50 x 10 9 /L within the first 7 days, the duration of that response (i.e. the number of days the platelet count remained in excess of 50 x 10 9 /L), and the regression of hemorrhages in subjects who had bleeding at baseline were observed.

Of the 66 subjects with chronic ITP in the efficacy analysis, 54 (82%) responded to Octagam 10% with a rise in platelet counts to at least 50 x 10 9 /L within 7 days after the first infusion. The lower bound of the overall 95% confidence interval for the response rate (73%) is above the predefined response rate of 70%.

The mean maximum platelet count achieved in the 66 subjects with chronic ITP was 227 x 10 9 /L.

Table 7. Maximum Platelet Count (x10 9 /L)

The median time to reach a platelet response of at least 50 x 10 9 /L was 2 days after the first infusion. The duration of platelet response was analyzed for the 54 subjects with chronic ITP who achieved a response within 7 days after the first infusion: the median duration of platelet response in these subjects was 12 days (range: 1 to 79 days).

Table 8. Time to and Duration of Platelet Response (Responders Only).

In 35 of the 45 subjects with chronic ITP (78%) who had bleeding at baseline, the hemorrhages had completely resolved by Day 7. A decrease in the severity of hemorrhage from baseline to Day 7 was observed in 38 of 45 subjects (84%) with chronic ITP.

Table 9. Assessment of Bleeding at Day 7 in Subjects with Baseline Bleeding

14.2 Treatment of Dermatomyositis

In a prospective, double-blind, randomized, placebo-controlled, multicenter study, 95 adults with dermatomyositis were enrolled and randomized. Forty-seven subjects received Octagam and 48 subjects received placebo in an initial 16week, double-blind First Period, followed by a 6-month, open-label Extension Period, during which all subjects who were eligible to continue, received Octagam 10% every 4 weeks. Forty-five subjects in the initial Octagam group and 46 subjects in the placebo group entered the Extension Period.

Efficacy in this study was based on the proportion of responders at Week 16. A responder was defined as a subject with a minimal improvement of ≥20 points on the Total Improvement Score (TIS). TIS is based on six Core Set Measures (CSM) which include: Manual Muscle Testing MMT-8, Physician Global Disease Activity (GDA) as part of Myositis Disease Activity Assessment Tool (MDAAT) assessed by the Investigator on a Visual Analog Scale (VAS), Extramuscular Activity as part of MDAAT assessed by the Investigator on a VAS, Patient GDA assessed by the Patient on a VAS, Health Assessment Questionnaire (HAQ) assessed by the Patient, and Muscle Enzymes: aldolase, creatine kinase, alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LDH).

Table 10 shows the proportion of responders in the Octagam 10% and the placebo groups, and the difference in responder rate between the two groups at Week 16. The median time to response was 35 days in the Octagam 10% group. In addition, there was a greater proportion of subjects in the Octagam 10% group compared to placebo with at least moderate improvement defined as ≥40 points on the TIS and major improvement defined as ≥60 points on the TIS (Table 10).

Table 10. Total Improvement Score – Proportion of Responders by Improvement Category at Week 16

*Cochran-Mantel-Haenszel Test; CI = Confidence interval

Efficacy was further supported by an improvement in the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) total activity score, with a mean decrease of 9.4 (SD: 10.5) points from baseline to Week 16 in the Octagam 10% group versus 1.2 (SD: 7.0) point in the placebo group.

The Octagam 10% group maintained their improvement in TIS (32/45, 71.1%) during the 6-month Extension Period. Among the 46 subjects who switched from placebo to Octagam 10% in the Extension Period, 69.6% (32/46) were classified as responders at the end of the 6-month Extension Period.