Ceprotine (Human protein C)

Ceprotine (Human protein C) is indicated in purpura fulminans and coumarin induced skin necrosis in patients with severe congenital protein C deficiency. Furthermore Ceprotine (Human protein C) is indicated for short‑term prophylaxis in patients with severe congenital protein C deficiency if one or more of the following conditions are met:

- surgery or invasive therapy is imminent

- while initiating coumarin therapy

- when coumarin therapy alone is not sufficient

- when coumarin therapy is not feasible.

Treatment with Ceprotine (Human protein C) should be initiated under the supervision of a physician experienced in substitution therapy with coagulation factors/inhibitors where monitoring of protein C activity is feasible.

The dose should be adjusted on the basis of laboratory assessment for each individual case.

A protein C activity of 100 % should be achieved initially and the activity should be maintained above 25 % for the duration of the treatment.

An initial dose of 60 to 80 IU/kg for determination of recovery and half‑life is advised.

As the risk of an allergic type hypersensitivity reaction cannot be excluded, patients should be informed of the early signs of hypersensitivity reactions including hives, generalized urticaria, tightness of the chest, wheezing, hypotension, and anaphylaxis. If these symptoms occur, they should inform the physician. Immediate discontinuation of product use is advised. In case of shock, the current medical standards for shock treatment are to be observed.

No experience in the treatment of patients with renal and/or hepatic impairment is available and therefore it is recommended that such patients be monitored more closely.

Standard measures to prevent infections resulting from the use of medicinal products prepared from human blood or plasma include selection of donors, screening of individual donations and plasma pools for specific markers of infection, and the inclusion of effective manufacturing steps for the inactivation/removal of viruses. Despite this, when medicinal products prepared from human blood or plasma are administered, the possibility of transmitting infective agents cannot be totally excluded. This also applies to unknown or emerging viruses and other pathogens.

The measures taken are considered effective for enveloped viruses such as HIV, HBV and HCV and for the non‑enveloped virus HAV. The measures taken may be of limited value against non‑enveloped viruses such as parvovirus B19. Parvovirus B19 infection may be serious for pregnant women (fetal infection) and for individuals with immunodeficiency or increased erythropoiesis (e.g. haemolytic anaemia).

Appropriate vaccination (hepatitis A and B) should be considered for patients in regular / repeated receipt of human plasma‑derived Protein C products.

It is strongly recommended that every time that Ceprotine (Human protein C) is administered to a patient, the name and batch number of the product are recorded in order to maintain a link between the patient and the batch of the product.

Ceprotine (Human protein C) may contain trace amounts of heparin. Heparin induced allergic reactions, which can be associated with a rapid decrease of the number of thrombocytes, may be observed (heparin induced thrombocytopenia [HIT]). In patients with HIT, symptoms such as arterial and venous thrombosis, disseminated intravascular coagulation (DIC), purpura, petechiae and gastrointestinal bleeding (melena), may occur. If HIT is suspected, the number of thrombocytes should be determined immediately and if necessary therapy with Ceprotine (Human protein C) should be stopped. Identifying HIT is complicated by the fact that these symptoms may already be present in acute phase patients with severe congenital protein C deficiency. Patients with HIT should avoid the use of heparin containing drugs in the future.

In the context of clinical experience several bleeding episodes have been observed. Concurrent anticoagulant medication (such as heparin) may have been responsible for these bleeding episodes. However, it cannot be completely ruled out that the administration of Ceprotine (Human protein C) further contributed to these bleeding events.

The quantity of sodium in the maximum daily dose may exceed 200 mg. This should be taken into consideration by patients on a controlled sodium diet.

Ceprotine (Human protein C) has no influence on the ability to drive and use machines.

As with any intravenous product allergic type hypersensitivity reactions are possible. Patients should be informed of the early signs of hypersensitivity reactions, which may include angioedema, burning and stinging at the injection site, chills, flushing, rash, generalised urticaria, headache, hives, hypotension, lethargy, nausea, restlessness, tachycardia, tightness of the chest, tingling, vomiting and wheezing. Patients should be advised to immediately contact their physician if these symptoms occur.

During clinical studies with Ceprotine (Human protein C), a total of 6 non‑serious adverse drug reactions (ADRs) were reported in 3 of 225 patients enrolled. In total 21,988 administrations of Ceprotine (Human protein C) have been given. The distribution of the related ADRs is as follows:

Nervous system disorders

dizziness

Skin and subcutaneous tissue disorders

urticaria, pruritus, rash

General disorders and administration site conditions

pyrexia

Investigations

increased C‑reactive protein

Each of these ADRs occurred once. The reports of pyrexia and increased C‑reactive protein concerned the same subject.

With a calculated adverse experience rate (per number of administrations) of 0,005% the frequency of these ADRs can be classified as very rare.

The following ADRs have been reported in the post‑marketing experience:

Psychiatric disorders

restlessness

Respiratory, thoracic and mediastinal disorders

haemothorax

Skin and subcutaneous tissue disorders

hyperhydrosis

General disorders and administration site conditions

injection site reaction

Investigations

increased body temperature, increased need of catecholamines to support blood pressure (verbatim term: increased need for catecholamines) in the course of the treatment.

The frequency of these ADRs is not known.

If the preparation is used in patients with severe congenital protein C deficiency, antibodies inhibiting protein C may develop.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.

No symptoms of overdose with Ceprotine (Human protein C) have been reported.

Pharmacotherapeutic group: group antithrombotic; ATC Code: B01AD12

Protein C is a vitamin K‑dependent anticoagulant glycoprotein which is synthesised in the liver. It is converted by thrombin/thrombomodulin‑complex on the endothelial surface to activated protein C (APC). APC is a serine protease with potent anticoagulant effects, especially in the presence of its cofactor protein S. APC exerts its effect by the inactivation of the activated forms of factors V and VIII which leads to a decrease in thrombin formation. APC has also been shown to have profibrinolytic effects.

The intravenous administration of Ceprotine (Human protein C) provides for an immediate but temporary increase in plasma levels of protein C. Replacement of protein C in protein C deficient patients is expected to control or ‑ if given prophylactically ‑ prevent thrombotic complications.

Twelve courses of short‑term prophylaxis prior to surgery or invasive therapy and 7 courses of long‑term prophylaxis were included in the efficacy analyses.

No formal clinical study in either paediatric or neonatal population with severe congenital protein C deficiency was ever conducted. However, several small retrospective and prospective studies investigating other clinical application areas have been published in this population. Indication was prevention and treatment of purpura fulminans and thrombotic disease, enrolling overall 14 subjects of 2 days old throughout adolescence.

Other experience with Ceprotine (Human protein C) covers case reports and a clinical study in overall 69 paediatric patients with acquired protein C deficiency. The study is a randomized, double‑blind, placebo‑controlled dose‑finding study, in the indication of acquired protein C deficiency due to meningococcal sepsis (IMAG 112). The reports suggest that Ceprotine (Human protein C) is well tolerated in children and small infants.

Dosages of the above studies, covering 83 patients, indicate that dosing guidelines for adult subjects are also valid for neonatal and paediatric patient population.

In rare and exceptional cases, subcutaneous infusion of 250‑350 IU/kg was able to produce therapeutic protein C plasma levels in patients with no intravenous access.

21asymptomatic subjects with homozygous or double heterozygous protein C deficiency were evaluated for pharmacokinetic data. The protein C plasma activity was measured by chromogenic assay. The individual half‑lives varied from 4.4 to 15.8 hours using a compartmental model and from 4.9 to 14.7 using the non‑compartmental method. The individual incremental recovery ranged from 0.50 to 1.76 [(IU/dL)/(IU/kg)]. The patients differed significantly in age, body weight and plasma volume.

In patients with acute thrombotic disease, both the incremental increase in protein C plasma levels as well as half‑life may be considerably reduced.

Protein C contained in Ceprotine (Human protein C) is a normal constituent of human plasma and acts like endogenous protein C. Therefore experimental studies on tumorigenic or mutagenic effects ‑ particularly in heterologous species ‑ are not considered necessary.

Single dose toxicity testing showed that even doses of several times the recommended human dosage per kilogram body weight (10‑fold) did not result in toxic effects on rodents.

Ceprotine (Human protein C) proved to have no mutagenic potential in the Ames test performed.

Repeated toxicity studies were not conducted because prior experience with coagulation preparations had shown them to be of limited value. Difference between the recipient species and human Protein C will inevitably result in an immune response with antibody formation.

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.

Reconstitute lyophilised Ceprotine (Human protein C) powder for solution for injection, with the supplied solvent (Sterilised Water for Injections) using the sterile transfer needle. Gently rotate the vial until all powder is dissolved. After reconstitution the solution is colourless to slightly yellowish and clear to slightly opalescent and essentially free from visible particles.

The solution is drawn through the sterile filter needle into a sterile disposable syringe. A separate unused filter needle must be used to withdraw each vial of reconstituted Ceprotine (Human protein C). The solution should be discarded if particulate matter is visible.

The reconstituted solution should be administered immediately by intravenous injection.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.