Coagadex: Package Insert / Prescribing Info

2.1 Dose

• Dose and duration of the treatment depend on the severity of the Factor X deficiency, location and extent of the bleeding, the patient's age (<12 years or >12 years) and the patient's clinical condition.
• Base the dose and frequency on the individual clinical response. Do not administer more than 60 IU/kg daily.
• Each vial of COAGADEX is labeled with the actual Factor X potency/content in International Units (IU).

2.2 Preparation and Reconstitution

• Always work on a clean surface and wash your hands before performing the following procedures.
• To reconstitute, use the diluent (Sterile Water for Injection) and transfer device (Mix2Vial) provided in the COAGADEX carton.
• To administer, you will also need a syringe and suitable needle (not provided in the COAGADEX carton).
• Bring the vials of COAGADEX and the Sterile Water for Injection to room temperature before mixing.
• The reconstitution is performed as follows:

2.3 Administration

For intravenous administration only

• If the dose requires more than one vial of COAGADEX:
  • Reconstitute each vial (steps 1 to 5) using a new Mix2Vial for each vial
  • Draw up all of the solution into a single syringe (steps 6 to 8)
• Visually inspect the final solution for particulate matter and discoloration prior to administration. Do not use if particulate matter or discoloration is observed
• Attach a suitable needle to the syringe
• Administer by intravenous infusion at a rate of 10 mL/min, but no more than 20 mL/min

5.1 Hypersensitivity Reactions

Allergic type hypersensitivity reactions, including anaphylaxis, are possible. Early signs of hypersensitivity reactions including angioedema, infusion site inflammation (e.g. burning, stinging, erythema), chills, cough, dizziness, fever, flushing, generalized urticaria, headache, hives, hypotension, lethargy, musculoskeletal pains, nausea, pruritus, rash, restlessness, tachycardia, tightness of the chest, tingling, vomiting, wheezing. If hypersensitivity symptoms occur, discontinue use of the product immediately and administer appropriate emergency treatment.

COAGADEX contains traces of human proteins other than Factor X.

5.2 Neutralizing Antibodies

The formation of neutralizing antibodies (inhibitors) to Factor X may occur. Monitor all patients treated with COAGADEX for the development of inhibitors by appropriate clinical observations and laboratory tests. If expected Factor X activity levels are not attained, or if bleeding is not controlled with an expected dose, perform an assay that measures Factor X inhibitor concentration.

5.3 Transmissible Infectious Agents

As COAGADEX is made from human blood, it may carry a risk of transmitting infectious agents, e.g. viruses, the variant Creutzfeldt-Jakob disease (vCJD) agent and, theoretically, the Creutzfeldt-Jakob disease (CJD) agent. There is also the possibility that unknown infectious agents may be present in the product. The risk that the product will transmit viruses has been reduced by screening plasma donors for prior exposure to certain viruses, by testing for the presence of certain current virus infections, and by inactivating and removing certain viruses during manufacture. Despite these measures, this product may still potentially transmit diseases.

All infections suspected by a physician possibly to have been transmitted by this product should be reported by the physician or other healthcare providers to Kedrion Biopharma, Inc. at 1-855-3KDRION (1-855-353-7466) or US_Medicalinfo@kedrion.com

5.4 Monitoring and Laboratory Tests

• Monitor plasma Factor X activity by performing a validated test (e.g. one-stage clotting assay), to confirm that adequate Factor X levels have been achieved and maintained [see Dosage and Administration (2)].
• Monitor for the development of Factor X inhibitors. Perform a Nijmegen-Bethesda inhibitor assay if expected Factor X plasma levels are not attained, or if bleeding is not controlled with the expected dose of COAGADEX. Use Nijmegen-Bethesda Units (BU) to report inhibitor levels.

6.1 Clinical Trials Experience

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

During the clinical development of COAGADEX involving three multicenter, open-label, non-randomized clinical studies, 27 individual subjects with hereditary Factor X deficiency received at least one dose of COAGADEX.

Sixteen subjects aged 12 to 58 years with moderate to severe hereditary Factor X deficiency (basal FX:C < 5 IU/dL) received doses of COAGADEX for pharmacokinetic evaluation, on-demand treatment for control of bleeding episodes, and/or perioperative management of minor surgical or dental procedures. A total of 468 infusions were administered, including 242 for on-demand treatment and control of bleeding episodes, 6 for perioperative management and 31 for PK assessments. Spontaneous, traumatic and menorrhagic bleeding episodes were treated with an on-demand dose of 25 IU/kg for up to 2 years.

Two subjects aged 55 and 59 years with mild hereditary Factor X deficiency (basal FX:C 6 IU/dL and 8 IU/dL) received COAGADEX for perioperative management of four major surgical procedures. There were 40 exposure days to COAGADEX.

Six adverse reactions were reported in 2 of the 18 subjects. These were infusion site erythema (2 reports in 1 subject [5.6%]), fatigue (2 reports in 1 subject [5.6%]), back pain (1 report [5.6%]) and infusion site pain (1 report [5.6%]).

In a separate study, nine children (aged 2 to 11 years), of whom four were less than 6 years of age, received 537 (mean 59.7) doses of COAGADEX as routine prophylaxis of bleeding episodes during a period of at least 6 months. In addition, 22 infusions were given to treat a bleed, equivalent to 2.1 bleeds per subject per year. There were no adverse drug reactions in this study.

6.2 Immunogenicity

Immunogenicity was evaluated in three studies and all subjects (adults and children) underwent Factor X inhibitor testing (inhibitor screen and Nijmegen-Bethesda assay) at baseline, end of study and at 3-monthly intervals in between. For subjects who underwent surgery, inhibitor testing was done pre-surgery and on discharge. All inhibitor tests were negative. Additionally, comparison of pharmacokinetic (PK) parameters at the repeat PK assessment with those at first dose did not suggest development of any inhibitors to Factor X.

The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, it may be misleading to compare the incidence of antibodies to COAGADEX in the studies described above with the incidence of antibodies in other studies or to other products.

8.1 Pregnancy

8.2 Lactation

8.4 Pediatric Use

A prospective, open-label, multicenter study was conducted in nine pediatric patients (0-5 years, n=4; 6-11 years, n=5) with severe (n=8) or moderate (n=1) hereditary factor X deficiency, to assess safety, efficacy, and pharmacokinetics of COAGADEX used prophylactically and on-demand. Patients had baseline FX levels < 5 IU/dL, and were dosed to achieve post-treatment levels of at least 5 IU/dL. After ≥26 weeks and ≥50 exposure days, investigators rated pdFX efficacy for preventing/decreasing bleeds. At end of study, investigators rated pdFX efficacy excellent for all subjects. Ten bleeds occurred (n = 3 subjects; 6 major, 3 minor, 1 unassessed for severity). Trough FX:C levels remained >5 IU/dL for all subjects after achievement of steady state. All AEs were unrelated to treatment; no inhibitor development or clinically significant changes in laboratory parameters were observed.

Six additional pediatric subjects aged 12 to 17 years were included in a prospective, open-label, multicenter study of COAGADEX to treat spontaneous, traumatic and menorrhagic bleeding episodes. Overall efficacy and safety outcomes were comparable to those in the younger age groups. [See Clinical Trial Experience (6.1), Pharmacokinetics (12.3) and Clinical Studies (14)].

8.5 Geriatric Use

Clinical studies of COAGADEX did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

12.1 Mechanism of Action

COAGADEX temporarily replaces the missing Factor X needed for effective hemostasis. Factor X is an inactive zymogen, which can be activated by Factor IXa (via the intrinsic pathway) or by Factor VIIa (via the extrinsic pathway). Factor X is converted from its inactive form to the active form (Factor Xa) by the cleavage of a 52-residue peptide from the heavy chain. Factor Xa associates with Factor Va on a phospholipid surface to form the prothrombinase complex, which activates prothrombin to thrombin in the presence of calcium ions. Thrombin then acts upon soluble fibrinogen and Factor XIII to generate a cross-linked fibrin clot.

12.2 Pharmacodynamics

The administration of COAGADEX increases plasma levels of Factor X and can temporarily correct the coagulation defect in these patients, as reflected by decrease in the aPTT and PT.

12.3 Pharmacokinetics

In a clinical study of COAGADEX in subjects with severe or moderate Factor X deficiency (basal FX:C < 5 IU/dL), the pharmacokinetics of COAGADEX were assessed after intravenous infusion (mean [range] infusion rate 5.9 [1.3-17.1] mL/min) of 25 IU/kg COAGADEX. Pharmacokinetic (PK) parameters were calculated from plasma Factor X:C activity measurements after subtraction of the pre-dose value. The PK assessment was repeated at least 6 months after the first dose. The PK parameters following a single dose are summarized in Table 3. The pharmacokinetics of COAGADEX were similar following the single and repeat dosing.

Incremental recovery in children <12 years of age was assessed at baseline and 6 months after the first dose. Values are summarized in Table 4.

Studies were not conducted to evaluate the impact of gender or renal/hepatic function on the pharmacokinetics of COAGADEX.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Nonclinical studies evaluating the carcinogenic or mutagenic potential of COAGADEX have not been conducted. No animal studies regarding impairment of fertility following COAGADEX dosing were conducted; however, no macroscopic or microscopic pathologies in reproductive organs were observed in rats dosed every other day with 6 times the maximum recommended clinical dose of 60 IU/kg COAGADEX for 28 days.

Prophylaxis of Bleeding Episodes

In a multicenter, open-label, non-randomized clinical trial, the use of COAGADEX in routine prophylaxis of bleeding episodes was evaluated in nine children aged less than 12 years of age. The mean age was 7.3 (range 2.6 to 11.9) years. Eight subjects had severe FX deficiency and the other had moderate deficiency. Four subjects were between 0 and 5 years of age and five were between 6 and 11 years of age inclusive. The majority of subjects were Asian (7; 77.8%) and the remainder were Caucasian/White (2; 22.2%). After the first dose of COAGADEX 50 IU/kg, given at a rate not exceeding 3 mL/minute, all subjects underwent a 30-minute post-dose incremental recovery assessment. Routine prophylaxis was started on Day 2 or 3 with unit doses of 40-50 IU/kg and during the first 6 weeks trough levels of Factor X were measured to adjust the dosage regimen to maintain a trough level of at least 5 IU/dL. At the end of the study (at least 6 months and at least 50 exposure days) a repeat 30-minute incremental recovery was performed. A total of 537 (mean 59.7 per subject) prophylactic infusions were administered. The median prophylactic dose per infusion per subject was 39.60 IU/kg (mean 38.76 IU/kg), and ranged from 18.0 to 47.3 IU/kg. Median and mean doses per infusion in the four children less than 6 years of age were both 40.1 IU/kg (95% CI 30.70, 49.57) and in the five children 6 to 11 years of age inclusive, median dose was 39.6 IU/kg and mean dose was 37.7 IU/kg (95% CI: 23.42, 51.91). The median dosing interval for all of the nine children was 3 days (range 2 to 8 days). Investigators' assessment following 6 months of routine prophylaxis was rated excellent in all 9 subjects; excellent was defined as 'no minor or major bleeds occurred during the study period' or 'lower frequency of bleeds than expected, given subject's medical/treatment history'. In addition, 22 infusions were given to treat a bleed, equivalent to 2.1 bleeds per subject per year. One subject had three episodes of epistaxis and the other bleeds were due to trauma or menorrhagia. All bleeds were treated with a single infusion; the median and mean doses per subject were both 31.7 IU/kg (range 24.6 to 38.8 IU/kg) and all recorded efficacy ratings were categorized as 'excellent' i.e. Overt bleed: bleeding stopped within 12 hours with a single dose; Menorrhagic bleed: no additional doses required; Covert bleeds: there were none in this study.

On-demand Treatment and Control of Bleeding Episodes

In a multicenter, open-label, non-randomized clinical trial to evaluate the pharmacokinetics, safety and efficacy of COAGADEX, 16 subjects with moderate to severe hereditary Factor X deficiency (FX:C < 5 IU/dL) received a dose of 25 IU/kg COAGADEX to treat spontaneous, traumatic and menorrhagic bleeding episodes. If hemostasis was not achieved with a single dose of COAGADEX, additional doses could be given until the bleed stopped. Subjects could also continue with treatment after the bleed had stopped to reduce the risk of recurrence of a given bleed. Subjects were aged 12 to 58 years, including 6 pediatric subjects aged 12 to 17 years. Six subjects were male, 10 were female, and 12 were Caucasian.

The efficacy of COAGADEX in treating bleeding episodes was assessed by the subject and/or investigator for each new bleeding episode, using a bleed-specific ordinal rating scale of excellent, good, poor and unassessable for each type of bleed (overt, covert or menorrhagic). Overt bleed: 'excellent' if bleeding stopped within 12 hours with a single dose; 'good' if within 24 hours with ≤2 doses. Covert bleed: 'excellent' if bleeding stopped within 48 hours with 1 or 2 doses; 'good' if within 48 hours with ≤3 doses. Menorrhagic bleed: 'excellent' if ≤2 doses within 48 hours; 'good' if 2 doses over >48 hours. Each bleed was reviewed by a Data Review Committee for its suitability for the efficacy evaluation. Of the 208 bleeding episodes treated with COAGADEX, 187 bleeding episodes in 15 subjects were evaluated for efficacy. Of these 187 bleeding episodes, 79 (42%) occurred spontaneously, 47 (25%) were traumatic and 61 (33%) were menorrhagic. Seventy three (39%) were mucosal in origin, 63 (34%) were joint bleeds, 26 (14%) were muscle bleeds, and 25 (13%) were located elsewhere.

Ninety eight (53%) were major bleeding episodes, and 88 (47%) were minor bleeds (one bleed not assessed). COAGADEX was considered to be good (7%) or excellent (91%) in treating 98% of bleeding episodes. Of the 187 bleeding episodes in the efficacy analysis, a total of 155 bleeds (83%) were treated with one infusion, 28 bleeds (15%) with two infusions, 3 bleeds (2%) with three infusions and 1 bleed (0.5%) with four infusions. The mean dose per infusion and total dose of COAGADEX were 25.4 IU/kg and 30.4 IU/kg, respectively. Four bleeding episodes in two subjects were considered treatment failures.

The recommended dose of 25 IU/kg COAGADEX to treat a bleed was maintained during the study for 14 of the 16 subjects. The other two subjects used doses up to 30 IU/kg and 33 IU/kg.

Perioperative Management of Bleeding

In two multicenter, open-label, non-randomized clinical trials, subjects requiring surgery received a pre-surgical COAGADEX dose to raise plasma Factor X levels to 70-90 IU/dL, followed by post-surgical doses as necessary to maintain plasma Factor X levels at a minimum of 50 IU/dL until the subject was no longer at risk of bleeding due to surgery. The safety and efficacy of COAGADEX for perioperative management was evaluated in five subjects aged 14 to 59 years with mild, moderate or severe hereditary Factor X deficiency, who underwent a total of seven surgical procedures.

For all surgical procedures, COAGADEX was assessed as excellent by the investigator for overall hemostatic control of peri-operative blood loss. Assessment of hemostatic efficacy was based on parameters including: blood loss during surgery, blood transfusion requirements, bleeding episodes and hemoglobin levels. An excellent score required the achievement of outcomes in these parameters similar to patients without a bleeding disorder. For major surgeries, a median of 13 infusions (range 2 to 15 infusions) and a median cumulative dose of 181 IU/kg (range 45 to 210 IU/kg) were required to maintain hemostasis. For minor surgeries, a median of 2.5 infusions (range 1 to 4 infusions) and a median cumulative dose of 89 IU/kg (range 51 to 127 IU/kg) were required to maintain hemostasis.

One subject had insertion of a central venous access device (Portacath) and was given 6 infusions of COAGADEX during 5 days, a total of 2,750 IU (27 IU/kg); there were no bleeding complications or safety concerns.

In a post-marketing registry study, 3 subjects (aged 21 to 30 years) with severe hereditary Factor X deficiency received a total of 10 (mean 3.3) doses of COAGADEX for perioperative hemostatic cover. The median initial (pre-surgery) dose was 44.3 IU/kg (mean 40.6; range 28.6 to 48.9). A median of 4 (range 1 to 5) infusions was administered, with median cumulative dose 110.2 IU/kg (range 28.6 to 171.8). All three subjects achieved excellent hemostatic efficacy outcomes.

How Supplied

COAGADEX is supplied in single-dose glass vials containing a nominal (approximate) 250 IU or 500 IU (approximately 100 IU/mL after reconstitution) of Factor X activity, packaged with 2.5 mL or 5 mL of Sterile Water for Injection, respectively, and a Mix2Vial transfer device.

The vials are closed with a synthetic rubber stopper. The stopper is not made with natural rubber latex. The stopper is secured with an aluminum overseal with a flip-off polypropylene cap.

Storage and Handling

• Store COAGADEX in its original package to protect it from light.
• Store the COAGADEX package in a refrigerator or at room temperature at 36°F to 86°F (2°C to 30°C). Do not freeze.
• Do not use COAGADEX or the Sterile Water for Injection after the expiration date printed on the vial and carton labels.
• Use reconstituted COAGADEX within one hour of reconstitution.
• Do not use COAGADEX if the reconstituted solution is cloudy or contains any particles.