Antithrombotic Agent

Reteplase

1 vial contains 10 U* reteplase ** in 0.56 g powder 1 prefilled syringe contains 10 ml water for injections. The reconstituted solution contains 1 U reteplase per ml. * Potency of reteplase is expressed in units (U) by using a reference standard which is specific for reteplase and is not comparable with units used for other thrombolytic agents. ** Recombinant plasminogen activator produced in Escherichia coli by recombinant DNA technology.

Powder and solvent for solution for injection. White powder and clear colourless liquid (water for injections).

Rapilysin is indicated for the thrombolytic treatment of suspected myocardial infarction with persistent ST elevation or recent left Bundle Branch Block within 12 hours after the onset of acute myocardial infarction AMI symptoms.

Treatment with reteplase should be initiated as soon as possible after the onset of AMI symptoms.

Rapilysin should be prescribed by physicians experienced in the use of thrombolytic treatment and with the facilities to monitor its use.

Reteplase is supplied as a freeze-dried substance in vials. The lyophilisate is reconstituted with the contents of the accompanying syringe.

Rapilysin should be injected preferably through an intravenous line whose sole purpose is the injection of Rapilysin. No other medicines should be injected through the line reserved for Rapilysin, neither at the same time, nor prior to, nor following Rapilysin injection. This applies to all products including heparin, and acetylsalicylic acid, which should be administered before and following the administration of reteplase to reduce the risk of re-thrombosis.

In those patients where the same line has to be used, this line (including Y-line) must be flushed thoroughly with 0.9 % sodium chloride or 5 % dextrose solution prior to and following the Rapilysin injection.

Dosage of Rapilysin

Rapilysin is administered as a 10 U bolus dose followed by a second 10 U bolus dose 30 minutes later (double bolus).

Each bolus is administered as a slow intravenous injection within 2 minutes. Ensure that the injection is not mistakenly given paravenously.

Heparin and acetylsalicylic acid should be administered before and following the administration of Rapilysin to reduce the risk of rethrombosis.

Dosage of Heparin

The recommended dose of heparin is 5000 I.U. given as a bolus injection prior to reteplase therapy followed by an infusion of 1000 I.U. per hour starting after the second reteplase bolus. Heparin should be administered for at least 24 hours, preferably for 48 – 72 hours, aiming to keep aPTT values 1.5 to 2 times normal.

Dosage of Acetylsalicylic Acid

The initial dose of acetylsalicylic acid prior to thrombolysis should be at least 250 mg (250 – 350 mg) followed by 75 – 150 mg/day at least until discharge.

Use in children

There is no experience in children

There is no experience in children

Hypersensitivity to reteplase, polysorbate 80 or any of the other ingredients.

Because thrombolytic therapy increases the risk of bleeding, reteplase is contra-indicated in the following situations:

- known haemorrhagic diathesis

- patients with current concomitant therapy with oral anticoagulants (e.g. warfarin sodium)

- intracranial neoplasm, arteriovenous malformation or aneurysm

- neoplasm with increased bleeding risk

- history of cerebrovascular accident

- recent (< 10 days) prolonged and vigorous external heart massage

- severe uncontrolled hypertension

- active peptic ulceration

- portal hypertension (oesophageal varices)

- severe liver or renal dysfunction

- acute pancreatitis, pericarditis, bacterial endocarditis

- within 3 months of severe bleeding, major trauma or major surgery (e.g. coronary artery bypass graft, intracranial or intraspinal surgery or trauma), obstetrical delivery, organ biopsy, previous puncture of non-compressible vessels.

Each patient being considered for therapy with reteplase should be carefully evaluated.

Bleeding

The most common complication encountered during reteplase therapy is bleeding. In the following conditions the risks of reteplase therapy may be increased and should be weighed against the anticipated benefits:

- cerebrovascular disease

- systolic blood pressure at entry > 160 mmHg

- recent gastrointestinal or genitourinary bleeding (within 10 days)

- high likelihood of left heart thrombus, e.g. mitral stenosis with atrial fibrillation

- septic thrombophlebitis or occluded arteriovenous cannula at seriously infected site

- age over 75 years

- any other condition in which bleeding constitutes a significant hazard or would be particularly difficult because of its location

The concomitant use of heparin anticoagulation may contribute to bleeding. As fibrin is lysed during reteplase therapy, bleeding from recent puncture sites may occur. Therefore, thrombolytic therapy requires careful attention to all possible bleeding sites (including catheter insertion sites, arterial and venous puncture sites, cut down sites and needle puncture sites). The use of rigid catheter as well as intramuscular injections and nonessential handling of the patient should be avoided during treatment with reteplase.

Caution should be employed when used with other medicinal products affecting haemostasis such as heparin, low-molecular-weight heparins, heparinoids, oral anticoagulants and antiplatelet agents other than acetylsalicylic acid, such as dipyridamole, ticlopidine, clopidogrel or glycoprotein IIb/IIIa receptor antagonists.

Should serious bleeding, in particular cerebral haemorrhage, occur any concomitant heparin should be terminated immediately. In addition, the second bolus of reteplase should not be given if the serious bleeding occurs before it is administered. In general, however, it is not necessary to replace the coagulation factors because of the relatively short half-life of reteplase. Most patients who have bleeding can be managed by interruption of thrombolytic and anticoagulant therapy, volume replacement and manual pressure applied to an incompetent vessel. Protamine should be considered if heparin has been administered within 4 hours of the onset of bleeding. In the patients who fail to respond to these conservative measures, judicious use of transfusion products may be indicated. Transfusions of cryoprecipitate, fibrinogen, fresh frozen plasma and platelets should be considered with clinical and laboratory reassessment after each administration. A target fibrinogen level of 1 g/l is desirable with cryoprecipitate or fibrinogen infusion.

At present, insufficient data in patients with a diastolic blood pressure > 100 mmHg prior to thrombolytic therapy are available for reteplase.

Arrhythmias

Coronary thrombolysis may result in arrhythmias associated with reperfusion. It is strongly recommended that antiarrhythmic therapy for bradycardia and/or ventricular tachyarrhythmias (e.g. ventricular tachycardia or fibrillation) be available when reteplase is administered.

Readministration

Since at present there is no experience with readministration of reteplase, the readministration is not recommended. However, no antibody formation to the reteplase molecule has been observed.

If an anaphylactoid reaction occurs, the injection should be discontinued immediately and appropriate therapy should be initiated.

No interaction studies with reteplase and medicinal product commonly administered in patients with AMI have been performed. Retrospective analyses of clinical studies did not reveal any clinically relevant interactions with medicinal product used concomitantly with reteplase in patients with acute myocardial infarction. Heparin, vitamin K antagonists and medicinal product that alter platelet function (such as acetylsalicylic acid, dipyridamole and abciximab) may increase the risk of bleeding if administered prior to, during or after reteplase therapy.

Attention should be paid to this effect especially during periods of low plasma fibrinogen (up to about 2 days after fibrinolytic therapy of AMI).

The most commonly reported adverse drug reaction associated with reteplase treatment is haemorrhage, predominantly at the injection site. Local reactions at injection site can also occur.

As with other thrombolytic agents, recurrent ischaemia / angina, hypotension and heart failure / pulmonary oedema have been reported frequently as sequelae of myocardial infarction and / or thrombolytic administration.

The frequency of the adverse drug reactions is described using the following convention:

Very common 1/10

Common 1/100, < 1/10

Uncommon 1/1,000, < 1/100

Rare 1/10,000, < 1/1,000

Very rare < 1/10,000, (including isolated reports)

Haemorrhage

The most frequent adverse drug reaction associated with reteplase treatment is haemorrhage.

- very common: bleeding at the injection site (e.g. haematoma)

- common: as gastrointestinal (haematemesis, melena), gingival or genitourinary bleeding

- uncommon: haemopericardium, retroperitoneal bleeding, cerebral haemorrhage, epistaxis, haemoptysis, eye haemorrhage and ecchymosis were observed.

Reports of intracranial bleeding, many of which are fatal, are of particular concern.

Systolic blood pressure over 160 mmHg before thrombolysis with reteplase was associated with greater risk for cerebral bleeding. The risk of intracranial bleeding and fatal intracranial bleeding increases with increasing age. Blood transfusions were rarely required. Death and permanent disability are not uncommonly reported in patients who have experienced stroke (including intracranial bleeding) and other serious bleeding episodes.

Cardiovascular disorders

As with other thrombolytic agents, the following events have been reported as sequelae of myocardial infarction and / or thrombolytic administration.

- very common: recurrent ischaemia / angina, hypotension and heart failure / pulmonary oedema

- common: arrhythmias (e.g. AV block, atrial fibrillation / flutter, ventricular tachycardia / fibrillation, electromechanical dissociation (EMD)), cardiac arrest, cardiogenic shock and reinfarction

- uncommon: mitral regurgitation, pulmonary embolism, other systemic embolism / cerebral embolism and ventricular septal defect

These cardiovascular events can be life-threatening and may lead to death.

Nervous system disorders

- uncommon : cerebral haemorrhage was observed.

- very rare : events related to the nervous system (e.g. epileptic seizure, convulsion, aphasia, speech disorder, delirium, acute brain syndrome, agitation, confusion, depression, psychosis)

Ischaemic or haemorrhagic cerebrovascular events may be contributing or underlying conditions.

General disorders and administration site conditions

- very common: haemorrhage at the injection site (e.g. haematoma); a local reaction at injection site for example a burning sensation can occur.

Immune system disorders

- uncommon: hypersensitivity reactions (e.g. allergic reactions)

- very rare : serious anaphylaxis/ anaphylactoid reactions

Available evidence on reteplase does not indicate an antibody-mediated origin of these hypersensitivity reactions.

Actavis UK Ltd

(POM)

13 February 2012