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  • CLASSES

    Blood Coagulation Factors

    DEA CLASS

    Rx

    DESCRIPTION

    Plasma-derived concentrate of C1 esterase inhibitor
    Used for the prevention or treatment of angioedema attacks in patients with hereditary angioedema
    Not effective for patients with autoantibody-mediated acquired C1 inhibitor deficiency and high titer monoclonal anti-C1 inhibitor antibody concentrations

    COMMON BRAND NAMES

    Berinert, Cinryze, HAEGARDA

    HOW SUPPLIED

    Berinert/Cinryze Intravenous Inj Pwd F/Sol: 500U
    HAEGARDA Subcutaneous Inj Pwd F/Sol: 2000U, 3000U

    DOSAGE & INDICATIONS

    For routine angioedema prophylaxis in patients with hereditary angioedema.
    Intravenous dosage (Cinryze)

    NOTE: One unit of Cinryze corresponds to the mean quantity of C1 inhibitor present in 1 mL of normal human plasma.

    Adults

    1,000 units (10 mL) IV over at least 10 minutes every 3 to 4 days.

    Adolescents

    1,000 units (10 mL) IV over at least 10 minutes every 3 to 4 days.

    Subcutaneous dosage (Haegarda)
    Adults

    60 International Units/kg subcutaneously twice weekly (every 3 or 4 days).

    Adolescents

    60 International Units/kg subcutaneously twice weekly (every 3 or 4 days).

    For the treatment of acute abdominal, facial, or laryngeal attacks of hereditary angioedema (HAE).
    NOTE: Advise patients who may self administer Berinert for acute laryngeal HAE attacks to immediately seek medical attention in an appropriate healthcare facility after Berinert receipt because of the potential for airway obstruction.
    Intravenous dosage (Berinert)
    Adults

    20 International Units/kg IV.

    Children and Adolescents

    20 International Units/kg IV.

    Intravenous dosage (Cinryze)†
    Adults

    1,000 units IV with an additional 1,000 units IV if no improvement 60 minutes after the first dose led to a median time to improvement of 30 minutes; 93.4% of attacks were improved within 4 hours, and a second dose was needed in 160 of the 447 attacks. Attack improvement was similar in all attack locations; 50 of the 447 attacks were laryngeal. In a placebo-controlled, randomized study, the median time to the onset of unequivocal relief of angioedema symptoms was 2 hours with C1 inhibitor as compared with more than 4 hours with placebo. In addition, open-label receipt of C1 inhibitor led to a 100% response rate in 35 attacks including 15 laryngeal attacks.

    MAXIMUM DOSAGE

    Adults

    20 International Units/kg IV for Berinert; 1,000 units IV every 3 days for Cinryze; 60 International Units/kg subcutaneously every 3 days for Haegarda.

    Geriatric

    20 International Units/kg IV for Berinert; 1,000 units IV every 3 days for Cinryze; 60 International Units/kg subcutaneously every 3 days for Haegarda.

    Adolescents

    20 International Units/kg IV for Berinert; 1,000 units IV every 3 days for Cinryze; 60 International Units/kg subcutaneously every 3 days for Haegarda.

    Children

    20 International Units/kg IV for Berinert; safety and efficacy of Cinryze and Haegarda have not been established.

    Infants

    Safety and efficacy have not been established.

    Neonates

    Safety and efficacy have not been established.

    DOSING CONSIDERATIONS

    Hepatic Impairment

    Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.

    Renal Impairment

    Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.

    ADMINISTRATION

    For storage information, see the specific information within the How Supplied section.

    Injectable Administration

    Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
    Reconstitution, product administration, and administration set and needle handling must be done with caution. Place needles in a sharps container, and discard all equipment including any unused product in an appropriate container. C1 inhibitor, human is made from human plasma and may contain infectious agents such as viruses.
    The health care professional should have immediate availability of epinephrine injection and other agents used in the treatment of severe anaphylaxis in the event of a serious allergic reaction. If a prior C1 inhibitor dose has been given, question the patient about any symptoms or signs of an adverse reaction after the previous dose. Depending on the adverse reaction, a subsequent dose may be contraindicated.

    Intravenous Administration

    If self-administration is deemed appropriate for a patient, ensure that the patient/caregiver receives clear instructions and training on intravenous administration in the home or other appropriate setting and has demonstrated the ability to perform intravenous infusions. For Berinert, ensure that the patient/caregiver understands the importance of not treating any attack if it has progressed to a point that they would be unable to successfully prepare or administer Berinert. Advise patients to get immediate medical attention after Berinert receipt if they treated an acute laryngeal heriditary angioedema (HAE) attack because of the potential for airway obstruction. Also, advise patients who treat a suspected abdominal HAE attack to call their healthcare provider after administering Berinert to help exclude the possibility that another potentially serious medical cause may be responsible for their symptoms. Lastly, instruct patients/caregivers to record the lot number from the drug vial label every time they use the drug.
     
    Berinert Administration Instructions
    Berinert Reconstitution:
    Both the C1 inhibitor vial and the diluent need to be at room temperature before reconstitution. Use either the Mix2Vial transfer set provided with Berinert or a commercially available double-ended needle and vented filter spike to add the supplied 10 mL of Sterile Water for Injection. If the same patient is to receive more than 1 vial of Berinert, the contents of multiple vials may be pooled in a single administration device such as a syringe. Use a new unused Mix2Vial transfer set for each Berinert vial.
    Gently swirl the vial until all powder is dissolved. Do not shake or vigorously agitate the vial. Reconstituted solution should be clear, colorless, and free from visible particles. Do not use if the solution is cloudy, discolored, or contains particulates.
    Storage: Each vial is only for single use; no preservative is present. Reconstituted product must be used within 8 hours of reconstitution and must be stored at a temperature of up to 25 degrees C (77 degrees F). The reconstituted product must only be stored in the vial. Do not freeze or refrigerate the solution. Discard any unused portion.
     
    Berinert IV infusion:
    The solution should be at room temperature before administration to the patient, and the solution must be administered to the patient within 8 hours of reconstitution.
    Do not mix Berinert with other medicinal products or solutions. Administer Berinert by a separate infusion line.
    Use a silicone-free syringe.
    Infuse intravenously at 4 mL/minute.
     
    Cinryze Administration Instructions
    Cinryze Reconstitution:
    Both the C1 inhibitor vial and the diluent need to be at room temperature before reconstitution. Use a Mix2Vial transfer device to add 5 mL of Sterile Water for Injection to the C1 inhibitor vial. The vacuum in the C1 inhibitor vial will draw the diluent into the vial. Do not use the C1 inhibitor vial if a vacuum is absent. Use a new unused Mix2Vial transfer set for each Cinryze vial.
    Gently swirl the vial until all powder is dissolved. Do not shake or vigorously agitate the vial. Reconstituted solution should be colorless to slightly blue and free from visible particles. Do not use if the solution is turbid or discolored. Disconnect the Sterile Water for Injection vial, but do not remove the clear end of the Mix2Vial transfer device from the Cinryze vial.
    Each reconstituted vial has 5 mL of 100 units/mL of C1 inhibitor. Two vials of reconstituted product are combined for a single dose. Using a 10 mL silicone-free syringe, inject 5 mL of air into the clear end of the Mix2Vial transfer device and slowly withdraw the 5 mL of reconstituted solution. Using the same syringe, repeat the steps to obtain the second 5 mL from the other vial.
    Storage: Each vial is only for single use; no preservative is present. Reconstituted product must be used within 3 hours of reconstitution. Do not freeze the solution. Discard any unused portion.
     
    Cinryze IV infusion:
    The solution should be at room temperature before administration to the patient, and the solution must be administered to the patient within 3 hours of reconstitution.
    Do not mix Cinryze with other materials.
    Use a silicone-free syringe.
    Infuse intravenously at 1 mL/minute.

    Subcutaneous Administration

    If self-administration is deemed appropriate for a patient, ensure that the patient/caregiver receives clear instructions and training on subcutaneous administration in the home or other appropriate setting and has demonstrated the ability to perform subcutaneous injections.
    Haegarda Administration Instructions
    Haegarda Reconstitution:
    Both the C1 inhibitor vial and the diluent need to be at room temperature before reconstitution. Use either the Mix2Vial transfer set provided with Haegarda or a commercially available double-ended needle and vented filter spike. If the same patient is to receive more than 1 vial of Haegarda, the contents of multiple vials may be pooled in a single silicone-free syringe. Use a new unused Mix2Vial transfer set for each Haegarda vial.
    After removing the flip caps and wiping the stoppers with an alcohol swab, peel away the lid to open the Mix2Vial transfer set package.
    Place diluent vial on a flat surface and hold the vial tightly. Grip the Mix2Vial transfer set together with the clear package, and push the plastic spike at the blue end of the Mix2Vial transfer set firmly through the center of the stopper of the diluent vial. Carefully remove the clear package without removing the Mix2Vial transfer set or touching the exposed end of the device.
    With the C1 inhibitor vial on a flat surface, invert the diluent vial with the Mix2Vial transfer set attached and push the plastic spike of the transparent adapter firmly through the center of the stopper of the C1 inhibitor vial. The diluent will automatically transfer into the C1 inhibitor vial.
    Gently swirl the vial until all powder is dissolved. Do not shake. Reconstituted solution should be colorless, clear, and free from visible particles. Do not use if the solution is turbid or discolored.
    With 1 hand, grasp the C1 inhibitor side of the Mix2Vial transfer set, and with the other hand grasp the blue diluent side of the Mix2Vial transfer set. Unscrew the set into 2 pieces.
    Draw air into an empty, sterile silicone-free syringe. While the C1 inhibitor vial is upright, screw the syringe to the Mix2Vial transfer set and inject air into the C1 inhibitor vial.
    While keeping the syringe plunger pressed, invert the system upside down and draw the concentrate into the syringe by pulling the plunger back slowly.
    Disconnect the filled syringe by unscrewing it from the Mix2Vial transfer set.
    Storage: Each vial is only for single use; no preservative is present. Reconstituted product must be used immediately or within 8 hours of reconstitution and must be stored at room temperature. Do not freeze or refrigerate the solution. Discard any unused portion.
    Haegarda Subcutaneous Injection:
    The solution should be at room temperature before administration to the patient, and the solution must be administered to the patient within 8 hours of reconstitution.
    Do not mix Haegarda with other medicinal products.
    Use a silicone-free syringe.
    Attach the syringe containing the reconstituted Haegarda solution to a hypodermic needle or subcutaneous infusion set.
    Inject in the abdominal area or other subcutaneous injection sites; rotate injection sites.
    Administer by subcutaneous injection. Adapt the administration rate to the comfort level of the patient.

    STORAGE

    Berinert:
    - Diluted product must be used within 8 hours
    - Discard unused portion. Do not store for later use.
    - Do not freeze
    - Do not freeze reconstituted product
    - Protect from light
    - Store between 36 to 77 degrees F
    - Store in original package until time of use
    Cinryze :
    - Do not freeze
    - Protect from light
    - Reconstituted product should be used within 3 hours
    - Store between 36 to 77 degrees F
    - Store in original container
    HAEGARDA:
    - Diluted product must be used within 8 hours
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Discard unused portion. Do not store for later use.
    - Do not freeze
    - Protect from light
    - Store below 86 degrees F
    - Store in original package until time of use

    CONTRAINDICATIONS / PRECAUTIONS

    General Information

    C1 inhibitor, human is contraindicated for use by patients who have manifested life-threatening immediate hypersensitivity reactions such as anaphylaxis to the product. Have epinephrine immediately available to treat any acute severe hypersensitivity reactions. Signs and symptoms of hypersensitivity reactions may include urticaria, chest tightness, wheezing, hypotension, and anaphylaxis during or after C1 inhibitor receipt. Symptoms of hypersensitivity reactions may be similar to symptoms of hereditary angioedema attacks, so carefully consider treatment methods. Discontinue the C1 inhibitor infusion if a hypersensitivity reaction occurs.

    Central venous catheter placement, obesity, thromboembolic disease

    Thrombotic events have occurred in patients receiving C1 inhibitor, human therapy. Risk factors for the development of thromboembolic disease events include the presence of an indwelling venous catheter (central venous catheter placement), prior history of thrombosis, underlying atherosclerosis, use of oral contraceptives, certain androgens, morbid obesity, and immobility. Weigh the benefits of routine prophylaxis of HAE attacks against the risks of thrombotic events in patients with underlying risk factors. Closely monitor patients with known risk factors for thrombotic events during and after C1 inhibitor administration.

    Viral infection

    C1 inhibitor, human is derived from human plasma and may therefore carry a risk of transmitting viral infection, and theoretically, the Creutzfeldt-Jakob disease agent. Screening plasma donors for prior exposure to certain viruses, testing for the presence of viruses, and inactivating and/or reducing viruses has reduced the risk of transmission of infectious agents; however, none of the processes are completely effective. Health care professionals should discuss the risks and benefits of C1 inhibitor, human therapy prior to administration. All infections thought to have been transmitted by C1 inhibitor, human should be reported to the manufacturer.

    Pregnancy

    C1 inhibitor, human should only be administered during pregnancy if clearly needed. No harmful effects on 34 neonates and no delivery complications were noted among 20 pregnant women who received human C1 inhibitor with repeated doses up to 3,500 International Units per attack. According to a consensus panel, plasma-derived human C1 inhibitor concentrate is preferred for acute treatment, short-term prophylaxis, or long-term prophylaxis during pregnancy. Also, C1 inhibitor should be available during labor and delivery if not administered prophylactically; prophylaxis is advised before forceps or vacuum extraction or cesarean section and may be warranted in other deliveries based on hereditary angioedema symptoms during the pregnancy and/or during previous deliveries. Among 29 pregnancies, the efficacy of C1 inhibitor treatment was consistent before, during, and after pregnancy; all patients received prophylactic C1 inhibitor immediately before delivery. No abortions or drug-related abnormalities were noted.

    Breast-feeding

    It is not known if C1 inhibitor, human is excreted in human milk. However, the large molecular weight (105 kD) reduces the risk of excretion in human milk. Use caution when human C1 inhibitor is given to a breast-feeding woman. According to a consensus panel, human plasma-derived C1 esterase inhibitor is considered to be the therapy of choice for both treatment and prophylaxis of maternal hereditary angioedema during lactation.

    ADVERSE REACTIONS

    Severe

    anaphylactic shock / Rapid / Incidence not known
    pulmonary embolism / Delayed / Incidence not known
    stroke / Early / Incidence not known
    thrombosis / Delayed / Incidence not known
    myocardial infarction / Delayed / Incidence not known

    Moderate

    erythema / Early / 2.0-2.0
    antibody formation / Delayed / Incidence not known

    Mild

    injection site reaction / Rapid / 3.0-31.0
    headache / Early / 7.0-19.0
    nausea / Early / 18.0-18.0
    pharyngitis / Delayed / 3.5-11.0
    rash (unspecified) / Early / 3.5-10.0
    vomiting / Early / 10.0-10.0
    abdominal pain / Early / 7.0-7.0
    fever / Early / 5.0-5.0
    dizziness / Early / 2.0-5.0
    dysgeusia / Early / 4.7-4.7
    influenza / Delayed / 3.5-3.5
    infection / Delayed / 1.8-3.5
    pruritus / Rapid / 2.0-2.0
    chills / Rapid / Incidence not known

    DRUG INTERACTIONS

    There are no drug interactions associated with C1 Inhibitor, Human products.

    PREGNANCY AND LACTATION

    Pregnancy

    C1 inhibitor, human should only be administered during pregnancy if clearly needed. No harmful effects on 34 neonates and no delivery complications were noted among 20 pregnant women who received human C1 inhibitor with repeated doses up to 3,500 International Units per attack. According to a consensus panel, plasma-derived human C1 inhibitor concentrate is preferred for acute treatment, short-term prophylaxis, or long-term prophylaxis during pregnancy. Also, C1 inhibitor should be available during labor and delivery if not administered prophylactically; prophylaxis is advised before forceps or vacuum extraction or cesarean section and may be warranted in other deliveries based on hereditary angioedema symptoms during the pregnancy and/or during previous deliveries. Among 29 pregnancies, the efficacy of C1 inhibitor treatment was consistent before, during, and after pregnancy; all patients received prophylactic C1 inhibitor immediately before delivery. No abortions or drug-related abnormalities were noted.

    It is not known if C1 inhibitor, human is excreted in human milk. However, the large molecular weight (105 kD) reduces the risk of excretion in human milk. Use caution when human C1 inhibitor is given to a breast-feeding woman. According to a consensus panel, human plasma-derived C1 esterase inhibitor is considered to be the therapy of choice for both treatment and prophylaxis of maternal hereditary angioedema during lactation.

    MECHANISM OF ACTION

    C1 inhibitor is a normal constituent of human blood that functions as a serine protease inhibitor. C1 inhibitor regulates the fibrinolytic system, the complement system, and the contact system (intrinsic coagulation pathway). For example, C1 inhibitor binds to and inactivates proteases that activate the complement system such as C1r, C1s, and mannan-binding, lectin-associated proteases. C1 inhibitor also binds to and inactivates proteases that activate the contact system such as factor XIIa and plasma kallikrein. Lastly, C1 inhibitor binds to and inactivates proteases that activate the fibrinolytic system such as tissue plasminogen activator and plasmin. C1 inhibitor is known as a suicide inhibitor: binding of C1 inhibitor and the protease inactivates both and consumes the C1 inhibitor. Patients with hereditary angioedema (HAE) already have a low baseline C1 inhibitor concentration. The average C1 inhibitor concentration is approximately 30% of normal. So, activation of any protease that is inactivated by C1 inhibitor leads to consumption of the C1 inhibitor to the extent that activation of the complement and contact systems becomes completely unregulated.
     
    During HAE attacks, contact system activation leads to bradykinin generation. Bradykinin interacts with the Bk2 receptor on endothelial cells and mediates an increase in vascular permeability. The release of vasoactive mediators during a HAE attack appears to be associated with fibrinolytic system activation. In fact, during an attack, contact system and fibrinolytic system activation are strictly correlated. Specifically, a significant correlation was found between plasma plasmin-alpha2-antiplasmin (PAP) complex concentrations and cleaved high molecular weight kininogen. Contact system activation was demonstrated by cleaved high molecular weight kininogen. During attacks, a significant increase in PAP complexes occurs as compared with baseline concentrations during remission, which implies that attacks are characterized by plasmin generation. As expected, a significant increase in plasmin concentrations occurs during an attack. Plasma tissue plasminogen activator concentrations were normal during both remission and attacks, so fibrinolysis activation during an attack appears to occur independent of the release of tissue plasminogen activator.
     
    Administration of C1 inhibitor suppresses contact system activation by inactivating plasma kallikrein and factor XIIa, which may modulate vascular permeability by preventing bradykinin generation.

    PHARMACOKINETICS

    C1 inhibitor, human is administered via the intravenous or subcutaneous routes. During hereditary angioedema attacks, classical complement activation occurs because of depletion of C1 inhibitor. As a result of unregulated complement activation, C4 and C2 concentrations fall.

    Intravenous Route

    Among asymptomatic patients with hereditary angioedema, the mean baseline C1 inhibitor concentration was 0.31 +/- 0.2 units/mL and reached a maximum of 0.68 +/- 0.08 units/mL 3.9 hours after a 1,000 unit IV dose of Cinryze. Intravenous administration of C1 inhibitor, human increases the plasma concentration of C1 inhibitor within 1 hour. After a 1,000 unit IV dose of Cinryze, the mean half-life of functional C1 inhibitor was 56 +/- 36 hours (range, 11 to 108 hours). Biological activity was demonstrated by a subsequent increase in plasma C4 concentrations from a baseline average of 8.1 mg/mL to 8.6 mg/mL 12 hours after a dose. After a single Berinert dose of 500 to 1,500 International Units IV, the half-life ranged from 7.4 to 22.8 hours.

    Subcutaneous Route

    After twice weekly 60 International Units/kg subcutaneous dosing, the half-life was 69 hours (95% CI, 24 to 251 hours). Additional PK parameters included a mean bioavailability of 42.7%, clearance of 1.03 mL/kg/hour, Vd of 0.05 L/kg, and Tmax of 59 hours.