Heparin-Akrikhin 1000

For the treatment of thrombo-embolic disorders such as deep vein thrombosis, acute arterial embolism or thrombosis, thrombophlebitis, pulmonary embolism and fat embolism.

For prophylaxis against deep vein thrombosis and thrombo-embolic events in susceptible patients.

For the prevention of clotting in the extracorporeal circuit during haemodialysis.

Posology

For the treatment or prevention of thrombo-embolic disorders:

Treatment Dosage:

Intravenous administration

5,000-10,000 IU every 4 hours or 500 IU/kg bodyweight daily as a continuous infusion in sodium chloride injection or dextrose injection. Doses should be individually adjusted according to coagulation tests.

Subcutaneous administration

The initial dose is 250 IU/kg bodyweight. Further doses should be given every 12 hours and individually adjusted according to coagulation tests.

Dosage adjustment

It is recommended that dosages be adjusted to maintain a thrombin clotting time, whole blood clotting time or activated partial thromboplastin time 1.5 to 2 times that of control on blood withdrawn 4 - 6 hours after the first injection or commencement of infusion and at similar intervals until the patient is stabilised.

Prophylactic Dosage:

Administration is by subcutaneous injection.

Patients undergoing major elective surgery:

5,000 IU should be given 2 hours pre-operatively and then every 8 - 12 hours post-operatively for 10 - 14 days or until the patient is ambulant, whichever is the longer.

Following myocardial infarction:

5,000 IU should be given twice daily for 10 days or until the patient is mobile.

Other patients:

5,000 IU should be given every 8-12 hours.

These standard prophylactic regimens do not require routine control.

Dosage in Children

Treatment Dosage:

Standard treatment dosages should be given initially. Subsequent dosages and/or dosage intervals should be individually adjusted according to changes in thrombin clotting time, whole blood clotting time and/or activated partial thromboplastin time.

Dosage in the Elderly

Treatment Dosage:

Lower treatment dosages may be required. However, standard treatment dosages should be given initially and then subsequent dosages and/or dosage intervals should be individually adjusted according to changes in thrombin clotting time, whole blood clotting time and/or activated partial thromboplastin time.

Prophylactic Dosage:

Dosage alterations are unnecessary for prophylaxis in the elderly.

Pregnancy

This Heparin-Akrikhin 1000 formulation contains the preservative benzyl alcohol. As benzyl alcohol may cross the placenta the use of this formulation should be avoided in pregnancy. If use is considered essential, the dosage recommendations given in this section should be followed.

Treatment Dosage:

Standard treatment dosages should be given initially by continuous intravenous infusion, or every 12 hours by subcutaneous injection. Intermittent intravenous injections are not advised. Subsequent dosages and/or dosage intervals should be individually adjusted according to changes in thrombin clotting time, whole blood clotting time and/or activated partial thromboplastin time.

Prophylactic Dosage:

It is recommended that plasma Heparin-Akrikhin 1000 levels be maintained below 0.4 IU/ml as determined by specific anti-Xa assay. A suggested dosage is 5,000 IU every 12 hours in early pregnancy increasing to 10,000 IU every 12 hours in the last trimester. The dosage should be reduced during labour and the standard prophylactic dosage is suitable in the puerperium.

For the prevention of clotting during haemodialysis:

An initial bolus dose should be given, followed by a continuous intravenous infusion.

Adults:

Initially: 1,000 - 5,000 IU.

Maintenance: 1,000 - 2,000 IU per hour, adjusted to maintain clotting time > 40 minutes.

Method of administration

For intravenous or subcutaneous injection.

Current or history of immune-mediated Heparin-Akrikhin 1000-induced thrombocytopenia. (type II).

Active major haemorrhage and risk factors for major haemorrhage.

Generalised or local haemorrhagic tendency, including uncontrolled severe hypertension, severe liver insufficiency, active peptic ulcer, intracranial haemorrhage or injuries and operations on the central nervous system, eyes and ears, and in women with abortus imminens. This list is not exhaustive.

Septic endocarditis.

In patients receiving Heparin-Akrikhin 1000 for treatment rather than prophylaxis, locoregional anaesthesia in elective surgical procedures is contraindicated because the use of Heparin-Akrikhin 1000 may be very rarely associated with epidural or spinal haematoma resulting in prolonged or permanent paralysis. Furthermore, in patients receiving treatment doses of Heparin-Akrikhin 1000, insertion of epidural catheter is contraindicated. Removal or manipulation of an epidural catheter should only be done when the benefit outweighs the risk.

Heparin-Akrikhin 1000 contains 10 mg/ml of the preservative benzyl alcohol. This must not be given to premature babies or neonates due to the risk of gasping syndrome.

Caution is advised when administering Heparin-Akrikhin 1000 to patients at risk of haemorrhage.

Heparin-Akrikhin 1000 should be used with caution in patients with hypersensitivity to low molecular weight Heparin-Akrikhin 1000.

Care should be taken when Heparin-Akrikhin 1000 is administered to patients with increased risk of bleeding complications, hypertension, renal or hepatic insufficiency. This list is not exhaustive.

The combination with medicinal products affecting platelet function or the coagulation system should be avoided or carefully monitored.

In patients undergoing peridural or spinal anaesthesia or spinal puncture, the prophylactic use of Heparin-Akrikhin 1000 may be very rarely associated with epidural or spinal haematoma resulting in prolonged or permanent paralysis. The risk is increased by the use of a peridural or spinal catheter for anaesthesia, by the concomitant use of drugs affecting haemostasis such as non-steroidal anti-inflammatory drugs (NSAIDs), platelet inhibitors or anticoagulants, and by traumatic or repeated puncture.

In decision making on the interval between the last administration of Heparin-Akrikhin 1000 at prophylactic doses (≤15,000 IU/day) and the placement or removal of a peridural or spinal catheter, the product characteristics and the patient profile should be taken into account. Placement or removal of a peridural or spinal catheter should not be allowed until 4-6 hours after the last Heparin-Akrikhin 1000 administration and subsequent dose should not take place before at least 1 hour post procedure. For treatment doses (>15,000 IU/day), placement or removal of a peridural or spinal catheter should not be allowed until 4-6 hours after last intravenous Heparin-Akrikhin 1000 administration or 8-12 hours after last subcutaneous Heparin-Akrikhin 1000 administration. Re-administration should be delayed until the surgical procedure is completed or at least 1 hour post procedure.

Should a physician decide to administer anti-coagulation in the context of peridural or spinal anaesthesia, extreme vigilance and frequent monitoring must be exercised to detect any signs and symptoms of neurologic impairment, such as back pain, sensory and motor deficits and bowel or bladder dysfunction. Patients should be instructed to inform immediately a nurse or a clinician if they experience any of these. If signs or symptoms of epidural or spinal haematoma are suspected, urgent diagnosis and treatment including spinal cord decompression should be initiated.

Heparin-Akrikhin 1000 should not be administered by intramuscular injection due to the risk of haematoma. Due to the risk of haematoma, concomitant intramuscular injections should also be avoided.

Because of the risk of immune-mediated Heparin-Akrikhin 1000-induced thrombocytopenia (type II), platelet count should be measured before the start of treatment and periodically thereafter. Heparin-Akrikhin 1000 must be discontinued in patients who develop immune-mediated Heparin-Akrikhin 1000 induced thrombocytopenia (type II). Platelet counts will usually normalise within 2 to 4 weeks after withdrawal.

Low molecular weight Heparin-Akrikhin 1000 should not be used as an alternative to Heparin-Akrikhin 1000 in case of Heparin-Akrikhin 1000-induced thrombocytopenia (type II). Heparin-Akrikhin 1000 induced thrombocytopenia and Heparin-Akrikhin 1000 induced thrombocytopenia with thrombosis can occur up to several weeks after discontinuation of Heparin-Akrikhin 1000 therapy. Patients presenting with thrombocytopenia or thrombosis after discontinuation of Heparin-Akrikhin 1000 should be evaluated for HIT and HITT.

Heparin-Akrikhin 1000 products can suppress adrenal secretion of aldosterone leading to hyperkalaemia. Risk factors include diabetes mellitus, chronic renal failure, pre-existing metabolic acidosis, raised plasma potassium at pre-treatment, concomitant therapy with drugs that may elevate plasma potassium and long-term use of Heparin-Akrikhin 1000.

In patients at risk, potassium levels should be measured before starting Heparin-Akrikhin 1000 and monitored regularly thereafter, particularly if treatment is prolonged beyond about 7 days. Heparin-Akrikhin 1000-related hyperkalaemia is usually reversible upon treatment discontinuation, though other approaches may need to be considered if Heparin-Akrikhin 1000 treatment is considered lifesaving (e.g. decreasing potassium intake, discontinuing other drugs that may affect potassium balance).

Heparin-Akrikhin 1000 contains benzyl alcohol, methyl- and propylhydroxybenzoate and sodium as excipients. Methyl- and propylhydroxybenzoate may cause allergic reactions (possibly delayed), and exceptionally, bronchospasm.

Benzyl alcohol may cause toxic reactions and anaphylactoid reactions in infants and children up to 3 years old.

Heparin-Akrikhin 1000 (Mucous) Injection BP 1000 Units/ml: Heparin-Akrikhin 1000 contains 1.2 mmol sodium (or 27 mg) per 10 ml vial and this should be taken into consideration by patients on a controlled sodium diet.

Heparin-Akrikhin 1000 (Mucous) Injection BP 5000 Units/ml: This medicinal product contains less than 1 mmol sodium (23 mg) per 5 ml vial, i.e. essentially 'sodium-free'.

Heparin-Akrikhin 1000 has no or negligible influence on the ability to drive or use machines.

The estimation of the frequency of undesirable effects is based on a pooled analysis: pooling data together from clinical studies and also a review of data from spontaneous reporting.

The most frequently reported adverse reactions are haemorrhage and erythema.

Haemorrhage may present in any organ and have different degrees of severity. Complications may occur particularly when high doses are administered. Although major haemorrhages are uncommon, death or permanent disability have been reported in some cases.

Immune-mediated Heparin-Akrikhin 1000-induced thrombocytopenia (type II) is an uncommon but well-known adverse reaction in connection with Heparin-Akrikhin 1000 therapy. Immune-mediated Heparin-Akrikhin 1000-induced thrombocytopenia (type II) largely manifests within 5 to 14 days of receiving the first dose. Furthermore, a rapid-onset form has been described in patients previously exposed to Heparin-Akrikhin 1000. Immune-mediated Heparin-Akrikhin 1000-induced thrombocytopenia (type II) may be associated with arterial and venous thrombosis. Heparin-Akrikhin 1000 must be discontinued in all cases of immune-mediated Heparin-Akrikhin 1000-induced thrombocytopenia (type II).

In rare cases, Heparin-Akrikhin 1000 may cause hyperkalaemia due to hypoaldosteronism. Patients at risk include those with diabetes mellitus or renal impairment.

Undesirable effects are listed by MedDRA SOC and the individual undesirable effects are listed starting with the most frequently reported. Within each frequency grouping, adverse reactions are presented in the order of decreasing seriousness.

Very common >1/10

Common >1/100 and < 1/10

Uncommon >1/1,000 and <1/100

Rare >1/10,000 and <1/1,000

Very rare <1/10,000

Paediatric population

The observed safety profile is similar in children and adults.

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.

Haemorrhage is the main complication of overdose.

As Heparin-Akrikhin 1000 is eliminated quickly, a discontinuation of treatment is sufficient in case of minor haemorrhages.

Serious bleeding may require the administration of the antidote protamine sulphate. Patients should be carefully monitored.

Pharmacotherapeutic group: Heparin-Akrikhin 1000 group, ATC code: B01AB01

Heparin-Akrikhin 1000 is a naturally occurring anticoagulant which prevents the coagulation of blood in-vivo and in-vitro. It potentiates the inhibition of several activated coagulation factors, including thrombin and factor X.

The increase in clotting time provided by Heparin-Akrikhin 1000 becomes apparent immediately after administration and lasts for four to six hours after intravenous injection and for about eight hours after subcutaneous injection.

There are no preclinical data of relevance to the prescriber which are additional to that already included in other sections of the SPC.

Heparin-Akrikhin 1000 has been reported to be incompatible in aqueous solution with certain substances, e.g. some antibiotics, hydrocortisone, phenothiazines, narcotic analgesics and some antihistamines.

No special requirements for disposal.