Replacement therapy in adults, children and adolescents (0-18 years) in:

• Primary immunodeficiency syndromes such with impaired antibody production (see section 4.4)

• Hypogammaglobulinaemia and recurrent bacterial infections in patients with chronic lymphocytic leukaemia (CLL), in whom prophylactic antibiotics have failed or are contra-indicated.

• Hypogammaglobulinaemia and recurrent bacterial infections in multiple myeloma (MM) patients

• Hypogammaglobulinaemia in patients pre- and post- allogenic haematopoietic stem cell transplantation (HSCT)

Replacement therapy should be initiated and monitored under the supervision of a physician experienced in the treatment of immunodeficiency.

Posology

The dose and dose regimen are dependent on the indication.

Replacement therapy

The medicinal product should be administered via the subcutaneous route.

In replacement therapy the dose may need to be individualised for each patient dependent on the pharmacokinetic and clinical response. The following dosage regimens are given as a guideline.

The dosage regimen should achieve a trough level of IgG (measured before the next infusion) of at least 5 to 6 g/L and aim to be within the reference interval of serum IgG for age. A loading dose of at least 0.2-0.5 g/kg (1.2 to 3.0 mL/kg) body weight may be required. This may need to be divided over several days, with a maximal daily dose of 0.1 to 0.15 g/kg.

After steady state IgG levels have been attained, maintenance doses are administered at repeated intervals (approximately once per week) to reach a cumulative monthly dose of the order of 0.4-0.8 g/kg. Each single dose may need to be injected at different anatomic sites.

Trough levels should be measured and assessed in conjunction with the incidence of infections. To reduce the rate of infection, it may be necessary to increase the dose and aim for higher trough levels.

Paediatric population

The posology in children and adolescents (0-18 years) is not different to that of adults as the posology for each indication is given by body weight and adjusted to the clinical outcome in replacement therapy indications.

Method of administration

For subcutaneous use.

Subcutaneous infusion for home treatment should be initiated and monitored by a physician experienced in the guidance of patients for home treatment. The patient must be instructed in the use of a syringe driver, the infusion techniques, the keeping of a treatment diary, recognition of and measures to be taken in case of severe adverse reactions.

For subcutaneous infusions using a pump

Gammanorm may be injected into sites such as abdomen, thigh, upper arm, and lateral hip. It is recommended to use an initial administration speed of 15 mL/hour/site. If well tolerated (see section 4.4), for subsequent infusions, the flow rate may be gradually increased at a rate of 1-2 mL/hour/site to 25 mL per hour per site as tolerated. The maximum flow rate administered, if tolerated, can be 100 mL/hour for all sites combined. More than one infusion device can be used simultaneously. In adults doses over 30 mL may be divided according to patient preference. The maximum volume to be infused per injection site should not exceed 25 mL before the 10th infusion. After the 10th infusion, the maximum volume to be infused per injection site can be gradually increased to 35 mL, if tolerated.

The amount of product infused into a particular site varies.

In infants and children, infusion site may be changed every 5-15 mL.

There is no limit to the number of infusion sites.

For subcutaneous infusions using a syringe

Gammanorm can be administered using a syringe at a single infusion site.

The proposed maximum infusion rate is set at approximately 1-2 mL/minute.

The weekly dose could be divided into three administrations given every other day. In adults, the maximum volume to be infused per injection site should not exceed 25 mL. In children, the maximum volume to be infused per injection site should not exceed 5-15 mL.

It might be necessary to administer the daily dose at more than one injection site.

The maximum flow rate administered, if tolerated, can be 120 mL/hour for all sites combined.

Hypersensitivity to the active substance or to any of the excipients listed in 6.1. (see section 4.4)

Gammanorm must not be given intravascularly.

If Gammanorm is accidentally administered into a blood vessel, patients could develop shock.

The recommended infusion rate stated under section 4.2 must be closely followed. Patients must be closely monitored and carefully observed for any symptoms throughout the infusion period.

Certain adverse reactions may occur more frequently in patients who receive human normal immunoglobulin for the first time or, in rare cases, when the human normal immunoglobulin product is switched or when there has been a long interval since the previous infusion.

Potential complications can often be avoided by:

• initially injecting the product slowly (see section 4.2);

• ensuring that patients are carefully monitored for any symptoms throughout the infusion period. In particular, patients naï ve to human normal immunoglobulin, patients switched from an alternative immunoglobulin product or when there has been a long interval since the previous infusion should be monitored during the first infusion and for the first hour after the first infusion, in order to detect potential adverse signs.

All other patients should be observed for at least 20 minutes after administration.

In case of adverse reaction, either the rate of administration must be reduced or the infusion stopped. The treatment required depends on the nature and severity of the adverse reaction.

In case of shock, standard medical treatment for shock should be implemented.

Hypersensitivity

True allergic reactions are rare. They can particularly occur in patients with anti-IgA antibodies who should be treated with particular caution. Patients with anti-IgA antibodies, in whom treatment with subcutaneous IgG products remains the only option, should be treated with Gammanorm only under close medical supervision.

Rarely, human normal immunoglobulin can induce a fall in blood pressure with anaphylactic reaction, even in patients who had tolerated previous treatment with human normal immunoglobulin.

Thromboembolism

Arterial and venous thromboembolic events including myocardial infarction, stroke, deep venous thrombosis and pulmonary embolism have been associated with the use of immunoglobulins. Patients should be sufficiently hydrated before use of immunoglobulins.

Caution should be exercised in patients with preexisting risk factors for thrombotic events (such as advanced age, hypertension, diabetes mellitus and a history of vascular disease or thrombotic episodes, patients with acquired or inherited thrombophilic disorders, patients with prolonged periods of immobilization, severely hypovolaemic patients, patients with diseases which increase blood viscosity).

Patients should be informed about first symptoms of thromboembolic events including shortness of breath, pain and swelling of a limb, focal neurological deficits and chest pain and should be advised to contact their physician immediately upon onset of symptoms.

Aseptic Meningitis Syndrome (AMS)

Aseptic meningitis syndrome has been reported to occur in association with subcutaneous immunoglobulin treatment; the symptoms usually begin within several hours to 2 days following treatment. Discontinuation of immunoglobulin treatment may result in remission of AMS within several days without sequelae.

Patients should be informed about first symptoms which encompass severe headache, neck stiffness, drowsiness, fever, photophobia, nausea, and vomiting.

Important information about some of the ingredients of Gammanorm

This medicinal product contains 25 mg (or 1.1 mmol) sodium per vial of 10 mL, and 60 mg (or 2,61 mmol) sodium per vial of 24 mL, equivalent to 1.25%, and 3%, respectively, of the WHO recommended maximum daily intake of 2 g sodium for an adult. This should be taken into consideration in patients on a controlled sodium diet.

Interference with serological testing

After injection of immunoglobulin the transitory rise of the various passively transferred antibodies in the patient´ s blood may result in misleading positive results in serological testing.

Passive transmission of antibodies to erythrocyte antigens, e.g. A, B, D may interfere with some serological tests for red cell antibodies for example the direct antiglobulin test (DAT, direct Coombs` test).

Transmissible agents

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 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 human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV).

The measures taken may be of limited value against non-enveloped viruses such as HAV and parvovirus B19.

There is reassuring clinical experience regarding the lack of hepatitis A or parvovirus B19 transmission with immunoglobulins and it is also assumed that the antibody content makes an important contribution to the viral safety.

It is strongly recommended that every time that Gammanorm 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.

Gammanorm does not protect against hepatitis A.

Paediatric population

The listed warnings and precautions apply both to adults and children.

Live attenuated virus vaccines

Immunoglobulin administration may impair for a period of at least 6 weeks and up to 3 months the efficacy of live attenuated virus vaccines such as measles, rubella, mumps and varicella. After administration of this product, an interval of 3 months should elapse before vaccination with live attenuated virus vaccines. In the case of measles, this impairment may persist for up to 1 year. Therefore patients receiving measles vaccine should have their antibody status checked.

Paediatric population

There were no specific or additional interactions observed for the paediatric population

Pregnancy

The safety of this medicinal product for use in human pregnancy has not been established in controlled clinical trials and Gammanorm should therefore only be given with caution to pregnant women and breast-feeding mothers. Immunoglobulin products have been shown to cross the placenta, increasingly during the third trimester. Clinical experience with immunoglobulins suggests that no harmful effects on the course of pregnancy, or on the fetus and the neonate are to be expected.

Breast-feeding

Immunoglobulins are excreted into the milk and may contribute to protecting the neonate from pathogens which have a mucosal portal of entry.

Fertility

Clinical experience with immunoglobulins suggests that no harmful effects on fertility are to be expected.

The ability to drive and operate machines may be impaired by some adverse reactions associated with Gammanorm. Patients who experience adverse reactions during treatment should wait for these to resolve before driving or operating machines.

Summary of the safety profile

Adverse reactions such as chills, headache, dizziness, fever, vomiting, allergic reactions, nausea, arthralgia, low blood pressure and moderate low back pain may occur occasionally.

Rarely human normal immunoglobulins may cause a sudden fall in blood pressure and, in isolated cases, anaphylactic shock, even when the patient has shown no hypersensitivity to previous administration.

Local reactions at infusion sites: swelling, soreness, redness, induration, local heat, itching, bruising and rash, may frequently occur.

Tabulated list of adverse reactions

The safety of Gammanorm administered subcutaneously was evaluated in two studies in 60 subjects with primary immunodeficiency syndromes.

The following table shows an overview of adverse reactions observed in clinical studies, post-marketing safety studies, and from other postmarketing sources, categorized according the MedDRA System Organ Class (SOC), Preferred Term Level (PT) and frequency.

Frequencies have been evaluated according to the following convention:

Very common (≥ 1/10); common (≥ 1/100 to <1/10); uncommon (≥ 1/1,000 to <1/100); rare (≥ 1/10,000 to <1/1,000); very rare (<1/10,000), not known (cannot be estimated from the available data).

For spontaneously reported post-marketing adverse reactions the reporting frequency is categorised as not known.

^# See also Section 4.4 * MedDRA low level term (LLT)

For safety information with respect to transmissible agents, see section 4.4

Paediatric population

Frequency, type and severity of adverse reactions in children are the same as in adults.

Reporting of suspected adverse reactions

Reporting of 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 reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.

Consequences of an overdose are not known.

Pharmacotherapeutic group: immune sera and immunoglobulins: immunoglobulins, normal human, for extravascular administration, ATC code: J06BA01

Human normal immunoglobulin contains mainly immunoglobulin G (IgG) with a broad spectrum of antibodies against infectious agents.

Human normal immunoglobulin contains the IgG antibodies present in the normal population. It is usually prepared from pooled plasma from not fewer than 1000 donations. It has a distribution of immunoglobulin G subclasses closely proportional to that in native human plasma. Adequate doses of this medicinal product may restore abnormally low immunoglobulin G levels to the normal range.

Clinical Studies

In two studies, 60 subjects with primary immunodeficiency syndromes, aged 20 to 79 years, were treated with Gammanorm. Each subject was treated for two consecutive periods of three months each according to the sequence assigned based on the cross-over design (syringe and then pump, or pump and then syringe) without any intermediate washout period. The total duration of study treatment was therefore 6 months for each subject.

The mean dose administered per month was 496.9 mg/kg body weight when given via pump and 476.2 mg/kg body weight when given via syringe. Sustained IgG trough levels with mean concentrations of 9.6 g/L were achieved during the pump treatment sequence and when patients received treatment via syringe, mean IgG concentrations were at 9.4 g/L. Subjects received a mean total of 12.8 Gammanorm infusions per 3-month treatment period during the pump sequence and 34.2 infusions per 3-month treatment period when Gammanorm was administered via syringe.

Paediatric population

No specific studies in the paediatric population were performed with Gammanorm.

Following subcutaneous administration of Gammanorm, peak serum levels are achieved after 4-6 days.

Data from clinical studies show that IgG trough levels of ≥ 8.2 g/L (mean) can be maintained by dosing regimens of 100 mg/kg per week.

IgG and IgG-complexes are broken down in the cells of the reticuloendothelial system.

Paediatric population

No specific studies in the paediatric population were performed with Gammanorm.

There are no relevant data.

Glycine, sodium chloride, sodium acetate, polysorbate 80 and water for injections.

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

3 years

After first opening, the product should be used immediately.

Store in a refrigerator (2° C – 8° C). Do not freeze.

Keep the vial in the outer carton.

Within its shelf-life, the product may be stored below 25 ° C for up to 6 months, without being refrigerated again during this period, and must be discarded if not used after this.

6 mL, 10 mL, 12 mL, 20 mL, 24 mL or 48 mL of solution in a vial (Type I glass) with a stopper (bromobutyl rubber) - pack size of 1, 10 or 20.

Not all pack sizes may be marketed.

The medicinal product should be brought to room or body temperature before use.

The solution should be clear or slightly opalescent and colourless or pale yellow or light brown.

Solutions that are cloudy or have deposits should not be used.

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