Version May 2024
Hemophilia B, without inhibitors:
Note: Contains only factor IX. Therefore, NOT INDICATED for replacement therapy of other clotting factors besides factor IX, hemophilia A patients with inhibitors to factor VIII, reversal of anticoagulation due to vitamin K antagonists or other anticoagulants, or bleeding due to low levels of liver-dependent clotting factors.
Treatment and control of bleeding episodes or perioperative management:
Intermittent IV bolus dosing: IV: Utilize steps 1 to 4 to determine intermittent bolus dosing strategy. Individualize dosage based on coagulation studies performed prior to treatment and at regular intervals during treatment.
Step 1: Identify product-specific in vivo recovery (IVR) for dosing calculations (Note: IVR indicates the expected increase in factor IX level, which occurs with 1 unit/kg of factor IX product administration):
Alprolix IVR: 1.
Step 2: Determine desired factor IX peak level and anticipated duration of therapy based on the World Federation of Hemophilia (WFH) treatment recommendations; see table. Selection of the lower dose practice pattern requires closer observation with the potential for requiring escalation to higher doses based on clinical response.
|
Type of hemorrhage or surgery |
Lower dose practice pattern |
Higher dose practice pattern | ||
|---|---|---|---|---|
|
Desired peak factor IX level (units/dL) |
Treatment duration (days) |
Desired peak factor IX level (units/dL) |
Treatment duration (days) | |
|
a WFH = World Federation of Hemophilia; (WFH [Srivastava 2020]). b May be longer if response is inadequate. c Sometimes longer as secondary prophylaxis during physical therapy. d A single dose may be sufficient for some joint bleeds; determine need for additional doses based on clinical response. | ||||
|
Joint |
10 to 20 |
1 to 2b,d |
40 to 60 |
1 to 2b,d |
|
Superficial muscle/no neurovascular compromise (except iliopsoas) |
10 to 20 |
2 to 3b |
40 to 60 |
2 to 3b |
|
Iliopsoas or deep muscle with neurovascular injury or substantial blood loss | ||||
|
Initial |
15 to 30 |
1 to 2 |
60 to 80 |
1 to 2 |
|
Maintenance |
10 to 20 |
3 to 5c |
30 to 60 |
3 to 5c |
|
Intracranial | ||||
|
Initial |
50 to 80 |
1 to 3 |
60 to 80 |
1 to 7 |
|
Maintenance |
20 to 40 |
8 to 14 |
30 |
8 to 21 |
|
30 to 50 |
4 to 7 |
- |
- | |
|
Throat and neck | ||||
|
Initial |
30 to 50 |
1 to 3 |
60 to 80 |
1 to 7 |
|
Maintenance |
10 to 20 |
4 to 7 |
30 |
8 to 14 |
|
GI: | ||||
|
Initial |
30 to 50 |
1 to 3 |
60 to 80 |
7 to 14 |
|
Maintenance |
10 to 20 |
4 to 7 |
30 |
- |
|
Renal |
15 to 30 |
3 to 5 |
40 |
3 to 5 |
|
Deep laceration |
15 to 30 |
5 to 7 |
40 |
5 to 7 |
|
Surgery (major) | ||||
|
Pre-op |
50 to 70 |
- |
60 to 80 |
- |
|
Post-op |
30 to 40 |
1 to 3 |
40 to 60 |
1 to 3 |
|
20 to 30 |
4 to 6 |
30 to 50 |
4 to 6 | |
|
10 to 20 |
7 to 14 |
20 to 40 |
7 to 14 | |
|
Surgery (minor) | ||||
|
Pre-op |
40 to 80 |
- |
50 to 80 |
- |
|
Post-op |
20 to 50 |
1 to 5 |
30 to 80 |
1 to 5 |
Step 3: Calculate dose using IVR from step 1, desired peak factor IX level from step 2, and the following equation:
Factor IX units required = ([desired peak factor IX level − patient's baseline factor IX level] × body weight [kg])/IVR
(Note: Factor IX units are in units/dL.)
Example (Alprolix) for 50 kg patient with desired peak factor IX level of 35 units/dL, baseline factor IX level of 5 units/dL, IVR = 1:
Factor IX units required = ([35 units/dL − 5 units/dL] × 50 kg) ⁄ 1 = 1,500 units factor IX
Step 4: Determine need for repeat dosing based on manufacturer’s recommended frequency of repeat dosing. Note : Frequency of administration must also take into consideration subsequent factor IX activity measurements and clinical response.
|
Product |
Bleeding event |
Surgery | |||
|---|---|---|---|---|---|
|
Minor severity |
Moderate severity |
Major severity |
Minor bleeding risk |
Major bleeding risk | |
|
Alprolix |
Every 48 hours |
Every 48 hours |
Consider repeat dose after 6 to 10 hours, then every 24 hours; may extend interval to every 48 hours after several days of treatment |
Every 24 to 48 hours |
Consider repeat dose after 6 to 10 hours, then every 24 hours; may extend interval to every 48 hours after several days of treatment |
Routine prophylaxis to prevent or reduce the frequency of bleeding episodes in patients with moderate/severe hemophilia B without inhibitors:
IV: 50 units/kg once every 7 days, or 100 units/kg once every 10 days. Dosing should be tailored to ensure trough factor IX levels of at least 1% and preferably ≥3% to 5% are achieved, but prophylaxis targets should be tailored to individual level of activity, lifestyle, and pharmacokinetics. Dose escalation should be considered for patients adherent to prescribed prophylaxis but still experiencing breakthrough bleeding events.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling; monitor factor IX levels.
There are no dosage adjustments provided in the manufacturer's labeling; monitor factor IX levels. Use with caution due to the risk of thromboembolic complications.
There are insufficient data to recommend the best dosing weight to use in patients with obesity. Dose adjustments should ultimately be made based on individual patient response to therapy. Due to the paucity of data, refer to institutional protocols. Refer to adult dosing for indication-specific dosing.
Refer to adult dosing.
Note: Contains only factor IX. Therefore, NOT INDICATED for the treatment of other factors deficiencies (eg, factors II, VII, VIII, and X), hemophilia A patients with inhibitors to factor VIII, reversal of coumarin-induced anticoagulation, and bleeding due to low levels of liver-dependent clotting factors.
Control or prevention of bleeding in patients with factor IX deficiency (hemophilia B or Christmas disease): IV: Dosage is expressed in units of factor IX activity; dosing must be individualized based on severity of factor IX deficiency, extent and location of bleeding, clinical status of patient, pharmacokinetic profile, and recovery of factor IX. Refer to product information for specific manufacturer recommended dosing. Alternatively, the World Federation of Hemophilia (WFH) has recommended general dosing for factor IX products.
Formula for units required to raise blood level %: Note: If patient has severe hemophilia (ie, baseline factor IX level is or presumed to be <1%), then may just use "desired factor IX level" instead of "desired factor IX level increase".
Infants, Children, and Adolescents: IV: Number of factor IX units required = patient weight (in kg) x desired factor IX level increase (as % or units/dL) x reciprocal of observed recovery (as units/kg per units/dL)
Alternative recommendations (off label): Infants, Children, and Adolescents:
Prophylaxis: Refer to adult dosing.
Treatment: Refer to adult dosing.
Routine prophylaxis to prevent bleeding episodes in patients with factor IX deficiency (hemophilia B or Christmas disease): IV:
Infants and Children <12 years of age: Initial: 60 units/kg once weekly; adjust dose based on individual response. More frequent or higher doses may be needed, especially in children <6 years of age.
Children ≥12 years of age and Adolescents: Refer to adult dosing.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling; monitor factor IX levels.
There are no dosage adjustments provided in the manufacturer's labeling; monitor factor IX levels. Use with caution due to the risk of thromboembolic complications.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
1% to 10%:
Gastrointestinal: Oral paresthesia (1%)
Genitourinary: Obstructive uropathy (1%)
Hematologic & oncologic: Factor IX inhibitor in hemophilia B (3%)
Hypersensitivity: Hypersensitivity reaction (3%)
Local: Erythema at injection site (3%)
Nervous system: Headache (1%)
<1%:
Cardiovascular: Hypotension, palpitations
Gastrointestinal: Decreased appetite, dysgeusia, halitosis
Genitourinary: Hematuria
Local: Infusion-site pain
Nervous system: Dizziness, fatigue
Renal: Renal colic
Postmarketing:
Cardiovascular: Thromboembolic complications (especially with continuous infusion through a central venous catheter)
Hypersensitivity: Anaphylaxis
Immunologic: Antibody development (neutralizing)
Hypersensitivity (eg, anaphylaxis) to factor IX (recombinant [Fc fusion protein]) or any component of the formulation (ie, sucrose, mannitol, sodium chloride, L-histidine, and polysorbate 20).
Concerns related to adverse effects:
• Hypersensitivity reactions: Hypersensitivity and anaphylactic reactions have been reported with use. Risk is highest during the early phases of initial exposure in previously untreated patients, especially those with high-risk gene mutations. Delayed reactions (up to 20 days after infusion) in previously untreated patients may also occur. Due to potential for allergic reactions, the initial ~10 to 20 administrations should be performed under appropriate medical supervision. Hypersensitivity reactions has been associated with the presence of factor IX inhibitors; patients experiencing allergic reactions should be evaluated for factor IX inhibitors. If hypersensitivity reactions occur, discontinue immediately and consider the use of alternative hemostatic measures (WFH [Srivastava 2013]). Patients with factor IX inhibitors may be at an increased risk of anaphylaxis upon subsequent challenge.
• Nephrotic syndrome: Nephrotic syndrome has been reported following immune tolerance induction with factor IX products in hemophilia B patients with factor IX inhibitors and a history of allergic reactions to factor IX.
• Neutralizing antibody formation: The development of factor IX antibodies (or inhibitors) has been reported with factor IX therapy (usually occurs within the first 10 to 20 exposure days); the risk of severe hypersensitivity reactions occurring may be greater in these patients. When clinical response is suboptimal, the patient has reached a specified number of exposure days, or patient is to undergo surgical procedure, screen for inhibitors. Patients with severe hemophilia compared to those with mild or moderate hemophilia are more likely to develop inhibitors (WFH [Srivastava 2013]).
• Thrombotic events: Observe closely for signs or symptoms of intravascular coagulation or thrombosis; risk is generally associated with the use of factor IX complex concentrates (containing therapeutic amounts of additional factors); however, potential risk exists with use of factor IX products (containing only factor IX) especially when administered as a continuous infusion through a central venous catheter, including life-threatening superior vena cava (SVC) syndrome. Use with caution when administering to patients with liver disease, postoperatively, neonates, patients at risk of thromboembolic phenomena or disseminated intravascular coagulation, or patients with signs of fibrinolysis due to the potential risk of thromboembolic complications.
Disease-related concerns:
• Hepatic impairment: Use with extreme caution in patients with hepatic impairment due to the risk of thromboembolic complications.
Other warnings/precautions:
• Clinical response: Response to factor IX administration may vary. If bleeding is not controlled with the recommended dose, determine plasma level of factor IX and follow with a sufficient dose to achieve satisfactory clinical response. If plasma levels of factor IX fail to increase as expected or bleeding continues, suspect the presence of an inhibitor; test as appropriate.
Strengths expressed with approximate values. Consult individual vial labels for exact potency within each vial.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Reconstituted, Intravenous [preservative free]:
Alprolix: 250 units (1 ea); 500 units (1 ea); 1000 units (1 ea); 2000 units (1 ea); 3000 units (1 ea); 4000 units (1 ea)
No
Solution (reconstituted) (Alprolix Intravenous)
250 unit (Price provided is per AHF Unit): $4.49
500 unit (Price provided is per AHF Unit): $4.49
1000 unit (Price provided is per AHF Unit): $4.49
2000 unit (Price provided is per AHF Unit): $4.49
3000 unit (Price provided is per AHF Unit): $4.49
4000 unit (Price provided is per AHF Unit): $4.49
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Reconstituted, Intravenous:
Alprolix: 500 units (1 ea); 1000 units (1 ea); 2000 units (1 ea); 3000 units (1 ea)
IV: Administer by IV bolus infusion; maximum rate of administration: 10 mL/minute.
Solution should be infused at room temperature. Safety and efficacy of continuous infusion administration have not been determined. Do not infuse via the same tubing as other medications.
IV: Administer within 3 hours of reconstitution. Do not infuse via the same tubing as other medications. With patients who have had allergic reactions during factor IX infusion, administration of hydrocortisone prior to infusion may be necessary (WFH [Srivastava 2013]).
IV bolus: Should be infused slowly over several minutes: Rate of administration should be determined by the response and comfort of the patient.
Alprolix: Administer IV at a rate not exceeding 10 mL/minute
World Federation of Hemophilia (WFH) recommendations (Srivastava 2013): Infuse at a rate determined by age: Young children: 100 units/minute; Adults: 3 mL/minute
Hemophilia B: On-demand treatment and control of bleeding in patients with factor IX deficiency (hemophilia B [Christmas disease]); perioperative management of bleeding in patients with hemophilia B; routine prophylaxis to reduce the frequency of bleeding episodes in patients with hemophilia B.
Limitations of use: Not indicated for induction of immune tolerance in patients with hemophilia B.
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Efgartigimod Alfa: May diminish the therapeutic effect of Fc Receptor-Binding Agents. Risk C: Monitor therapy
Rozanolixizumab: May diminish the therapeutic effect of Fc Receptor-Binding Agents. Risk C: Monitor therapy
Pregnant carriers of hemophilia B may have an increased bleeding risk following invasive procedures, spontaneous miscarriage, termination of pregnancy, and delivery; close surveillance is recommended. Factor IX levels should be monitored at the first antenatal visit, once or twice during the third trimester, prior to surgical or invasive procedures, and at delivery. Although factor IX levels remain stable during pregnancy, factor IX replacement is recommended if concentrations are <50 units/dL and any of the following occur: need for invasive procedures (including delivery), spontaneous miscarriage, insertion and removal of epidural catheters, or active bleeding. Hemostatic factor IX concentrations should be maintained for at least 3 to 5 days following invasive procedures or postpartum. If replacement with a factor IX concentrate is indicated to increase factor IX during pregnancy, a recombinant product is preferred (NHF 2017; RCOG [Pavord 2017]; WFH [Srivastava 2020]).
It is not known if factor IX (recombinant [Fc fusion protein]) is present in breast milk.
According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother.
Monitoring assay selection: For Alprolix, the World Federation of Hemophilia recommends use of a chromogenic FIX assay or aPTT-based, one-stage FIX activity assay with validated reagents, calibrated with a plasma standard traceable to a WHO international standard. One-stage FIX assays with STA-PTT automate or kaolin activator (CK Prest) reagents significantly underestimate true Alprolix factor IX activity and should not be used (WFH [Srivastava 2020]).
Monitoring frequency: During treatment of an acute bleeding event or in the perioperative setting using intermittent bolus administration, factor IX levels should be measured at baseline, and as peaks 15 to 30 minutes after infusion to assess target level achievement. The frequency of peak factor IX activity monitoring during active treatment depends on the indication, clinical response, and treatment day. Measurement of FIX trough levels may aid in calculation of subsequent doses (WFH [Srivastava 2020]).
For long-term bleeding prophylaxis, trough factor IX measurements should be obtained to tailor prophylaxis regimens, with the goal of achieving factor IX troughs >3 to 5 units/dL; prophylaxis targets should be tailored to individual level of activity, lifestyle, and pharmacokinetics.
Additional monitoring considerations: Heart rate and BP before and during IV administration, signs of hypersensitivity reactions (which may be an early sign of inhibitor development), hemoglobin/hematocrit, and signs and symptoms of intravascular hemolysis.
Lower than expected factor IX recovery or reduced half-life are early signs of inhibitor formation.
Classification of hemophilia; normal is defined as 100% factor IX (WFH [Srivastava 2020]).
Severe: Factor level <1% of normal.
Moderate: Factor level 1% to 5% of normal.
Mild: Factor level 5% to <40% of normal.
Replaces deficient clotting factor IX. Hemophilia B, or Christmas disease, is an X-linked inherited disorder of blood coagulation characterized by insufficient or abnormal synthesis of the clotting protein factor IX. Factor IX is a vitamin K-dependent coagulation factor which is synthesized in the liver. Factor IX is activated by factor XIa in the intrinsic coagulation pathway. Activated factor IX (IXa) in combination with factor VII:C activates factor X to Xa, resulting ultimately in the conversion of prothrombin to thrombin and the formation of a fibrin clot. The infusion of exogenous factor IX to replace the deficiency present in hemophilia B temporarily restores hemostasis.
Distribution: Vss: ~0.3 L/kg
Half-life elimination:
Children: 66 to 72 hours
Children ≥12 years and Adolescents ≤17 years: ~84 hours
Adults: ~87 hours
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