Fibrinogen
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]
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Overview
Fibrinogen is a blood modifier agent that is FDA approved for the treatment of acute bleeding episodes in patients with congenital fibrinogen deficiency, including afibrinogenemia and hypofibrinogenemia. Common adverse reactions include fever, headache, pulmonary embolism, myocardial infarction, deep vein thrombosis, anaphylactic reactions.
Adult Indications and Dosage
FDA-Labeled Indications and Dosage (Adult)
Indications
- Fibrinogen, Fibrinogen Concentrate (Human) is indicated for the treatment of acute bleeding episodes in patients with congenital fibrinogen deficiency, including afibrinogenemia and hypofibrinogenemia.
- The effectiveness of fibrinogen is based on maximum clot firmness, which measures the structural integrity of a clot, reflecting the underlying effectiveness of the fibrinogen present to form a fibrin clot.
- There are no controlled trials demonstrating a direct benefit on treatment of bleeding episodes with fibrinogen.
- Fibrinogen is not indicated for dysfibrinogenemia.
Dosage For Congenital Fibrinogen Deficiency
- Fibrinogen dosing, duration of dosing and frequency of administration should be individualized based on the extent of bleeding, laboratory values, and the clinical condition of the patient.
Fibrinogen dose when baseline fibrinogen level is known
- Dose should be individually calculated for each patient based on the target plasma fibrinogen level based on the type of bleeding, actual measured plasma fibrinogen level and body weight, using the following formula
Fibrinogen dose when baseline fibrinogen level is not known
- If the patient's fibrinogen level is not known, the recommended dose is 70 mg per kg of body weight administered intravenously.
- Monitoring of patient's fibrinogen level is recommended during treatment with fibrinogen. A target fibrinogen level of 100 mg/dL should be maintained until hemostasis is obtained.
DOSAGE FORMS AND STRENGTHS
- Fibrinogen is available as a single-use vial containing 900 mg to 1300 mg lyophilized fibrinogen concentrate powder for reconstitution with 50 mL of Sterile Water for Injection.
- The actual fibrinogen potency for each lot is printed on the vial label and carton.
Off-Label Use and Dosage (Adult)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Fibrinogen in adult patients.
Non–Guideline-Supported Use
There is limited information regarding Off-Label Non–Guideline-Supported Use of Fibrinogen in adult patients.
Pediatric Indications and Dosage
FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding FDA-Labeled Use of Fibrinogen in pediatric patients.
Off-Label Use and Dosage (Pediatric)
Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Fibrinogen in pediatric patients.
Non–Guideline-Supported Use
There is limited information regarding Off-Label Non–Guideline-Supported Use of Fibrinogen in pediatric patients.
Contraindications
- Fibrinogen is contraindicated in individuals who have manifested severe immediate hypersensitivity reactions, including anaphylaxis to fibrinogen or its components.
Warnings
Allergic Reactions
- Allergic reactions may occur. If symptoms of allergic or early signs of hypersensitivity reactions (including hives, generalized urticaria, tightness of the chest, wheezing, hypotension, and anaphylaxis) occur, immediately discontinue administration. The treatment required depends on the nature and severity of the reaction.
Thrombosis
- Thrombosis may occur spontaneously in patients with congenital fibrinogen deficiency with or without the use of fibrinogen replacement therapy.1 Thromboembolic events have been reported in patients treated with fibrinogen. Weigh the benefits of fibrinogen administration versus the risk of thrombosis. Patients receiving fibrinogen should be monitored for signs and symptoms of thrombosis.
Transmissible Infectious Agents
- Fibrinogen is made from human plasma. Products made from human plasma may contain infectious agents (e.g., viruses and theoretically the Creutzfeldt-Jakob disease agent [CJD]) that can cause disease. The risk that such products will transmit an infectious agent has been reduced by screening plasma donors for prior exposure to certain viruses, by testing for the presence of certain current virus infections, and by a process demonstrated to inactivate and/or remove certain viruses during manufacturing.Despite these measures, such products may still potentially transmit disease. There is also the possibility that unknown infectious agents may be present in such products. All infections thought by a physician possibly to have been transmitted by this product should be reported by the physician or other healthcare provider to CSL.
Adverse Reactions
Clinical Trials Experience
- The most serious adverse reactions that have been reported in clinical studies or through postmarketing surveillance following RiaSTAP treatment are allergic-anaphylactic reactions and thromboembolic episodes, including myocardial infarction, pulmonary embolism, deep vein thrombosis, and arterial thrombosis.
- The most common adverse reactions that have been reported in clinical studies or through postmarketing surveillance following RiaSTAP treatment are allergic reactions and generalized reactions such as chills, fever, nausea, and vomiting.
Clinical Studies Experience
- Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed cannot be directly compared to rates in other clinical studies and may not reflect the rates observed in practice.
- The most common adverse reactions observed in more than one subject in clinical studies (frequency >1%) were fever and headache.
Postmarketing Experience
- Because postmarketing reporting of adverse reactions is voluntary and from a population of uncertain size, it is not always possible to reliably estimate the frequency of these reactions or establish a causal relationship to product exposure.
- Adverse reactions reported in patients receiving RiaSTAP for treatment of fibrinogen deficiency include allergic-anaphylactic reactions (including rash, dyspnea, etc.), general reactions such as chills, fever, nausea, vomiting and thromboembolic complications such as myocardial infarction, pulmonary embolism, and deep vein thrombosis.
- The following adverse reactions, identified by system organ class, have shown a possible causal relationship with RiaSTAP.
- Allergic-anaphylactic reactions: anaphylaxis, dyspnea, rash
- Cardiovascular: thromboembolism, pulmonary embolism
- General/Body as a Whole: chills, fever, nausea, vomiting
Drug Interactions
There is limited information regarding Fibrinogen Drug Interactions in the drug label.
Use in Specific Populations
Pregnancy
- Pregnancy Category C. Animal reproduction studies have not been conducted with RiaSTAP. It is not known whether RiaSTAP can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Fibrinogen should be used during pregnancy only if clearly needed.
Pregnancy Category (AUS):
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Fibrinogen in women who are pregnant.
Labor and Delivery
- Fibrinogen has not been studied for use during labor and delivery.
Nursing Mothers
- Fibrinogen has not been studied in nursing mothers with congenital fibrinogen deficiency.
Pediatric Use
- Fibrinogen studies have included subjects below the age of 16 years. In the pharmacokinetic study, 2 children (8 and 11 years), 3 adolescents (12, 14 and 16 years), were studied. Subjects less than 16 years of age (n = 4) had shorter half-life (69.9 ± 8.5h) and faster clearance (0.7 ± 0.1 mg/L) compared to adults (half-life: 82.3 ± 20.0h, clearance: 0.53 ± 0.1 mg/L). The number of subjects less than 16 years of age in this study limits statistical interpretation.
Geriatic Use
- The safety and efficacy of fibrinogen in the geriatric population has not been studied. There were an insufficient number of subjects in this age group to determine whether they respond differently from younger subjects.
Gender
There is no FDA guidance on the use of Fibrinogen with respect to specific gender populations.
Race
There is no FDA guidance on the use of Fibrinogen with respect to specific racial populations.
Renal Impairment
There is no FDA guidance on the use of Fibrinogen in patients with renal impairment.
Hepatic Impairment
There is no FDA guidance on the use of Fibrinogen in patients with hepatic impairment.
Females of Reproductive Potential and Males
There is no FDA guidance on the use of Fibrinogen in women of reproductive potentials and males.
Immunocompromised Patients
There is no FDA guidance one the use of Fibrinogen in patients who are immunocompromised.
Administration and Monitoring
Administration
- Intravenous
- Reconstitute prior to use.
- Do not mix fibrinogen with other medicinal products or intravenous solutions, and should be administered through a separate injection site.
- Use aseptic technique when administering fibrinogen.
- Administer fibrinogen at room temperature by slow intravenous injection at a rate not exceeding 5 mL per minute.
Preparation and Reconstitution
- The procedures below are provided as general guidelines for preparation and reconstitution of fibrinogen.
- Do not use fibrinogen beyond the expiration date. Fibrinogen contains no preservative. Use aseptic technique when preparing and reconstituting fibrinogen.
- Reconstitute fibrinogen at room temperature as follows:
- Remove the cap from the product vial to expose the central portion of the rubber stopper.
- Clean the surface of the rubber stopper with an antiseptic solution and allow it to dry.
- Using an appropriate transfer device or syringe, transfer 50 mL of Sterile Water for Injection into the product vial.
- Gently swirl the product vial to ensure the product is fully dissolved. Do not shake the vial.
- After reconstitution, the fibrinogen solution should be colorless and clear to slightly opalescent. Inspect visually for particulate matter and discoloration prior to administration. Do not use if the solution is cloudy or contains particulates. Do not freeze fibrinogen solution. Discard partially used vials.
- Fibrinogen is stable for 8 hours after reconstitution when stored at 20-25ºC and should be administered within this time period.
Monitoring
There is limited information regarding Monitoring of Fibrinogen in the drug label.
IV Compatibility
There is limited information regarding IV Compatibility of Fibrinogen in the drug label.
Overdosage
There is limited information regarding Chronic Overdose of Fibrinogen in the drug label.
Pharmacology
Mechanism of Action
- Fibrinogen (factor I) is a soluble plasma glycoprotein with a molecular weight of about 340 kDa. The native molecule is a dimer and consists of three pairs of polypeptide chains (Aα, Bβ and γ). Fibrinogen is a physiological substrate of three enzymes: thrombin, factor XIIIa, and plasmin.
- During the coagulation process, thrombin cleaves the Aα and Bβ chains releasing fibrinopeptides A and B (FPA and FPB, respectively).2 FPA is separated rapidly and the remaining molecule is a soluble fibrin monomer (fibrin I). The slower removal of FPB results in formation of fibrin II that is capable of polymerization that occurs by aggregation of fibrin monomers.2 The resulting fibrin is stabilized in the presence of calcium ions and by activated factor XIII, which acts as a transglutaminase. Factor XIIIa-induced cross-linking of fibrin polymers renders the fibrin clot more elastic and more resistant to fibrinolysis.3 Cross-linked fibrin is the end result of the coagulation cascade, and provides tensile strength to a primary hemostatic platelet plug and structure to the vessel wall.
Structure
- Fibrinogen is a heat-treated, lyophilized fibrinogen (coagulation factor I) powder made from pooled human plasma.
- Each vial contains 900 to 1300 mg fibrinogen, 400 to 700 mg human albumin, 375 to 660 mg L-arginine hydrochloride, 200 to 350 mg sodium chloride and 50 to 100 mg sodium citrate. Sodium hydroxide and hydrochloric acid may have been used to adjust the pH.
- All plasma used in the manufacture of fibrinogen is tested using FDA-licensed serological assays for hepatitis B surface antigen and antibodies to HIV-1/2 and HCV. Additionally, the plasma is tested with FDA-licensed Nucleic Acid Testing (NAT) for HCV and HIV-1 and found to be non-reactive (negative). For HBV, an investigational NAT procedure is used; however, the significance of a negative result has not been established. In addition, the plasma has been tested by NAT for HAV and B19V. Only plasma that passed virus screening is used for production, and the limit for B19V in the fractionation pool is set not to exceed 104 IU of B19V DNA per mL.
- Fibrinogen is manufactured from cryoprecipitate into a glycine precipitate, which is then further purified by multiple precipitation/adsorption steps. The manufacturing process has been demonstrated to reduce the risk of virus transmission in an additive manner: cryoprecipitation, Al(OH)3 adsorption/glycine precipitation/Al(OH)3 adsorption, heat treatment (+60ºC for 20 hours in an aqueous solution), and two subsequent glycine precipitation steps (initial and main glycine precipitation steps). These steps have been validated independently in a series of in vitro experiments for their capacity to inactivate and/or remove both enveloped and non-enveloped viruses. Table 1 shows the virus clearance during the manufacturing process for fibrinogen, expressed as the mean log10 reduction factor (LRF).
Pharmacodynamics
- Administration of fibrinogen to patients with congenital fibrinogen deficiency replaces the missing, or low coagulation factor. Normal levels are in the range of 200 to 450 mg/dL.4
Pharmacokinetics
- A prospective, open label, uncontrolled, multicenter pharmacokinetic study was conducted in 5 females and 9 males with congenital fibrinogen deficiency (afibrinogenemia), ranging in age from 8 to 61 years (2 children, 3 adolescents, 9 adults). Each subject received a single intravenous dose of 70 mg/kg fibrinogen. Blood samples were drawn from the patients to determine the fibrinogen activity at baseline and up to 14 days after the infusion. The pharmacokinetic parameters of fibrinogen are summarized in Table 2.
- No statistically relevant difference was observed between males and females for fibrinogen activity. Subjects less than 16 years of age (n=4) had shorter half-life (69.9 ± 8.5) and faster clearance (0.73 ± 0.14) compared to subjects >16 years of age. The number of subjects less than 16 years of age in this study limits statistical interpretations.
- The incremental in vivo recovery (IVR) was determined from levels obtained up to 4 hours post-infusion. The median incremental IVR was 1.7 mg/dL (range 1.30 – 2.73 mg/dL) increase per mg/kg. The median in vivo recovery indicates that a dose of 70 mg/kg will increase patients' fibrinogen plasma concentration by approximately 120 mg/dL.
- The pharmacokinetic analysis using fibrinogen antigen data (ELISA) was concordant with the fibrinogen activity (Clauss assay).
Nonclinical Toxicology
There is limited information regarding Nonclinical Toxicology of Fibrinogen in the drug label.
Clinical Studies
- The pharmacokinetic study evaluated the single-dose PK and maximum clot firmness (MCF) in subjects with afibrinogenemia. MCF was determined by thromboelastometry (ROTEM) testing. MCF was measured to demonstrate functional activity of replacement fibrinogen when a fixed dose of fibrinogen was administered. Clot firmness is a functional parameter that depends on: activation of coagulation, fibrinogen content of the sample and polymerization/crosslinking of the fibrin network. Thromboelastometry has been shown to be a functional marker for the assessment of fibrinogen content and for the effects of fibrinogen supplementation on clinical efficacy.5
- For each subject, the MCF was determined before (baseline) and one hour after the single dose administration of fibrinogen. Fibrinogen was found to be effective in increasing clot firmness in patients with congenital fibrinogen deficiency (afibrinogenemia) as measured by thromboelastometry. The study results demonstrated that the MCF values were significantly higher after administration of fibrinogen than at baseline (see TABLE 3). The mean change from pre-infusion to 1 hour post-infusion was 8.9 mm in the primary analysis (9.9 mm for subjects < 16 years old and 8.5 mm for subjects ≥ 16 to < 65 years old). The mean change in MCF values closely approximated the levels expected from adding known amounts of fibrinogen to plasma in vitro.6 Hemostatic efficacy in acute bleeding episodes, and its correlation with MCF, are being verified in a postmarketing study.
How Supplied
- RiaSTAP is supplied in a single-use vial. Each carton contains one vial of RiaSTAP. The components used in the packaging for RiaSTAP are latex-free.
- The actual potency of fibrinogen concentrate in milligram (mg) is stated on each RiaSTAP vial label and carton.
- The following dosage form is available:
Storage
- When stored at temperatures of 2-25°C (36-77°F), RiaSTAP is stable for the period indicated by the expiration date on the carton and vial label (up to 30 months). Keep RiaSTAP in its original carton until ready to use. Do not freeze. Protect from light.
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Patient Counseling Information
Allergic Reactions
- Inform patients of the early signs of allergic or hypersensitivity reactions to RiaSTAP, including hives, chest tightness, wheezing, hypotension, and anaphylaxis. Advise them to notify their physician immediately if they experience any of these symptoms.
Thrombosis
- Inform patients that thrombosis with or without embolization may be due to the underlying fibrinogen deficiency and has been reported with the use of RiaSTAP. Any symptoms of thrombotic events such as unexplained pleuritic, chest and/or leg pain or edema, hemoptysis, dyspnea, tachypnea or unexplained neurologic symptoms should be reported to their physician immediately.
Transmissible Infectious Agents
- Inform patients that fibrinogen is made from human plasma (part of the blood) and may contain infectious agents that can cause disease (e.g., viruses and, theoretically, the CJD agent). Explain the risk that RiaSTAP may transmit an infectious agent has been reduced by screening the plasma donors, by testing the donated plasma for certain virus infections, and by a process demonstrated to inactivate and/or remove certain viruses during manufacturing. Symptoms of a possible virus infection include headache, fever, nausea, vomiting, weakness, malaise, diarrhea, or, in the case of hepatitis, jaundice.
Precautions with Alcohol
- Alcohol-Fibrinogen interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.
Brand Names
- RIASTAP ®[1]
Look-Alike Drug Names
There is limited information regarding Fibrinogen Look-Alike Drug Names in the drug label.
Drug Shortage Status
Price
References
The contents of this FDA label are provided by the National Library of Medicine.
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