Activase (Page 2 of 6)

2.5 Activase 100 mg Instructions for Use

See the enclosed Instructions for Use for Activase 100 mg enclosed in the carton for reconstitution and administration instructions.

Alternative Dilution Instructions

Activase may be administered as reconstituted at 1 mg/mL or further diluted immediately before administration in an equal volume of 0.9% Sodium Chloride Injection, USP, or 5% Dextrose Injection, USP, to yield a concentration of 0.5 mg/mL, using either polyvinyl chloride bags or glass vials.

3 DOSAGE FORMS AND STRENGTHS

  • 50 mg lyophilized powder in single-dose vial with 50 mL SWFI USP for reconstitution
  • 100 mg lyophilized powder in single-dose vial with 100 mL SWFI USP for reconstitution

4 CONTRAINDICATIONS

4.1 Acute Ischemic Stroke

Do not administer Activase to treat acute ischemic stroke in the following situations in which the risk of bleeding is greater than the potential benefit [see Warnings and Precautions (5.1)]:

  • Current intracranial hemorrhage
  • Subarachnoid hemorrhage
  • Active internal bleeding
  • Recent (within 3 months) intracranial or intraspinal surgery or serious head trauma
  • Presence of intracranial conditions that may increase the risk of bleeding (e.g., some neoplasms, arteriovenous malformations, or aneurysms)
  • Bleeding diathesis
  • Current severe uncontrolled hypertension.

4.2 Acute Myocardial Infarction or Pulmonary Embolism

Do not administer Activase for treatment of AMI or PE in the following situations in which the risk of bleeding is greater than the potential benefit [see Warnings and Precautions (5.1)]:

  • Active internal bleeding
  • History of recent stroke
  • Recent (within 3 months) intracranial or intraspinal surgery or serious head trauma
  • Presence of intracranial conditions that may increase the risk of bleeding (e.g. some neoplasms, arteriovenous malformations, or aneurysms)
  • Bleeding diathesis
  • Current severe uncontrolled hypertension.

5 WARNINGS AND PRECAUTIONS

5.1 Bleeding

Activase can cause significant, sometimes fatal, internal or external bleeding, especially at arterial and venous puncture sites. Avoid intramuscular injections and trauma to the patient while on Activase. Perform venipunctures carefully and only as required. To minimize bleeding from noncompressible sites, avoid internal jugular and subclavian venous punctures. If an arterial puncture is necessary during Activase infusion, use an upper extremity vessel that is accessible to manual compression, apply pressure for at least 30 minutes, and monitor the puncture site closely.

Because of the higher risk of intracranial hemorrhage in patients treated for acute ischemic stroke, limit treatment to facilities that can provide timely access to appropriate evaluation and management of intracranial hemorrhage.

Fatal cases of hemorrhage associated with traumatic intubation in patients administered Activase have been reported.

Aspirin and heparin have been administered concomitantly with and following infusions of Activase in the management of acute myocardial infarction and pulmonary embolism, but the concomitant administration of heparin and aspirin with and following infusions of Activase for the treatment of acute ischemic stroke during the first 24 hours after symptom onset has not been investigated. Because heparin, aspirin, or Activase may cause bleeding complications, carefully monitor for bleeding, especially at arterial puncture sites. Hemorrhage can occur 1 or more days after administration of Activase, while patients are still receiving anticoagulant therapy.

If serious bleeding occurs, terminate the Activase infusion and treat appropriately. In the following conditions, the risks of bleeding with Activase therapy for all approved indications are increased and should be weighed against the anticipated benefits:

  • Recent major surgery or procedure, (e.g., coronary artery bypass graft, obstetrical delivery, organ biopsy, previous puncture of noncompressible vessels)
  • Cerebrovascular disease
  • Recent intracranial hemorrhage
  • Recent gastrointestinal or genitourinary bleeding
  • Recent trauma
  • Hypertension: systolic BP above 175 mm Hg or diastolic BP above 110 mm Hg
  • Acute pericarditis
  • Subacute bacterial endocarditis
  • Hemostatic defects including those secondary to severe hepatic or renal disease
  • Significant hepatic dysfunction
  • Pregnancy
  • Diabetic hemorrhagic retinopathy, or other hemorrhagic ophthalmic conditions
  • Septic thrombophlebitis or occluded AV cannula at seriously infected site
  • Advanced age [see Use in Specific Populations (8.5)]
  • Patients currently receiving anticoagulants (e.g., warfarin sodium)

Any other condition in which bleeding constitutes a significant hazard or would be particularly difficult to manage because of its location.

5.2 Hypersensitivity

Hypersensitivity, including urticarial / anaphylactic reactions, have been reported after administration of Activase (e.g., laryngeal edema, rash and shock). Rare fatal outcome for hypersensitivity was reported. Angioedema has been observed during and up to 2 hours after Activase infusion in patients treated for acute ischemic stroke and acute myocardial infarction. In many cases, patients received concomitant angiotensin-converting enzyme inhibitors [see Drug Interactions (7)].

Monitor patients treated with Activase during and for several hours after infusion for hypersensitivity. If signs of hypersensitivity occur, e.g. anaphylactoid reaction or angioedema develops, discontinue the Activase infusion and promptly institute appropriate therapy (e.g., antihistamines, intravenous corticosteroids, epinephrine).

5.3 Thromboembolism

The use of thrombolytics can increase the risk of thrombo-embolic events in patients with high likelihood of left heart thrombus, such as patients with mitral stenosis or atrial fibrillation. Activase has not been shown to treat adequately underlying deep vein thrombosis in patients with PE. Consider the possible risk of re-embolization due to the lysis of underlying deep venous thrombi in this setting.

5.4 Cholesterol Embolization

Cholesterol embolism has been reported rarely in patients treated with thrombolytic agents; the true incidence is unknown. Cholesterol embolism may present with livedo reticularis, “purple toe” syndrome, acute renal failure, gangrenous digits, hypertension, pancreatitis, myocardial infarction, cerebral infarction, spinal cord infarction, retinal artery occlusion, bowel infarction, or rhabdomyolysis and can be fatal. It is associated with invasive vascular procedures (e.g., cardiac catheterization, angiography, vascular surgery) and/or anticoagulant therapy.

5.5 Coagulation Tests May Be Unreliable during Activase Therapy

Coagulation tests and measures of fibrinolytic activity may be unreliable during Activase therapy, unless specific precautions are taken to prevent in vitro artifacts. When present in blood at pharmacologic concentrations, Activase remains active under in vitro conditions, which can result in degradation of fibrinogen in blood samples removed for analysis.

6 ADVERSE REACTIONS

The following adverse reactions are discussed in greater detail in the other sections of the label:

6.1 Clinical Trials Experience

Because 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 trials of another drug and may not reflect the rates observed in clinical practice.

The most frequent adverse reaction associated with Activase in all approved indications is bleeding.

Bleeding

Acute Ischemic Stroke (AIS)

In clinical studies in patients with AIS (Studies 1 and 2) the incidence of intracranial hemorrhage, especially symptomatic intracranial hemorrhage, was higher in Activase-treated patients than in placebo patients. A dose-finding study of Activase suggested that doses greater than 0.9 mg/kg may be associated with an increased incidence of intracranial hemorrhage.

The incidence of all-cause 90-day mortality, intracranial hemorrhage, and new ischemic stroke following Activase treatment compared to placebo are presented in Table 3 as a combined safety analysis (n=624) for Studies 1 and 2. These data indicate a significant increase in intracranial hemorrhage following Activase treatment, particularly symptomatic intracranial hemorrhage within 36 hours. There was no increase in the incidences of 90-day mortality or severe disability in Activase-treated patients compared to placebo.

Table 3 Combined Safety Outcomes for Studies 1 and 2
Placebo(n= 312) Activase(n=312) p-Value *
*
Fisher’s Exact Test.
Within trial follow-up period. Symptomatic intracranial hemorrhage was defined as the occurrence of sudden clinical worsening followed by subsequent verification of intracranial hemorrhage on CT scan. Asymptomatic intracranial hemorrhage was defined as intracranial hemorrhage detected on a routine repeat CT scan without preceding clinical worsening.
All-Cause 90-day Mortality 64 (20.5%) 54 (17.3%) 0.36
Total ICH 20 (6.4%) 48 (15.4%) <0.01
Symptomatic 4 (1.3%) 25 (8.0%) <0.01
Asymptomatic 16 (5.1%) 23 (7.4%) 0.32
Symptomatic Intracranial Hemorrhage within 36 hours 2 (0.6%) 20 (6.4%) <0.01
New Ischemic Stroke (3-months) 17 (5.4%) 18 (5.8%) 1.00

Bleeding events other than intracranial hemorrhage were noted in the studies of AIS and were consistent with the general safety profile of Activase. In Studies 1 and 2, the frequency of bleeding requiring red blood cell transfusions was 6.4% for Activase-treated patients compared to 3.8% for placebo (p = 0.19).

Although exploratory analyses of Studies 1 and 2 suggest that severe neurological deficit (National Institutes of Health Stroke Scale [NIHSS > 22]) at presentation was associated with an increased risk of intracranial hemorrhage, efficacy results suggest a reduced but still favorable clinical outcome for these patients.

Acute Myocardial Infarction (AMI)

For the 3-hour infusion regimen in the treatment of AMI, the incidence of significant internal bleeding (estimated as > 250 mL blood loss) has been reported in studies in over 800 patients (Table 4). These data do not include patients treated with the Activase accelerated infusion.

Table 4 Incidence of Bleeding in 3-Hour Infusion in AMI Patients
Total Dose ≤100 mg
Gastrointestinal 5%
Genitourinary 4%
Ecchymosis 1%
Retroperitoneal <1%
Epistaxis <1%
Gingival <1%

The incidence of intracranial hemorrhage in AMI patients treated with Activase is presented in Table 5.

Table 5 Incidence of Intracranial Hemorrhage in AMI Patients
Dose Number of Patients Intracranial Hemorrhage (%)
100 mg, 3-hour 3272 0.4
≤ 100 mg, accelerated 10,396 0.7
150 mg 1779 1.3
1-1.4 mg/kg 237 0.4

A dose of 150 mg or greater should not be used in the treatment of AMI because it has been associated with an increase in intracranial bleeding.

Pulmonary Embolism (PE)

For acute massive pulmonary embolism, bleeding events were consistent with the general safety profile observed with Activase treatment of AMI patients receiving the 3-hour infusion regimen.

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