This information is intended for use by health professionals

1. Name of the medicinal product

Vigam Liquid 5 % w/v, solution for infusion

2. Qualitative and quantitative composition

Human normal immunoglobulin (IVIg)

One ml contains: Human normal immunoglobulin 50 mg (Purity of at least 95% IgG).

Each 2.5 g vial of 50 ml contains: 2.5 g of Human normal immunoglobulin.

Each 5 g vial of 100 ml contains: 5 g of Human normal immunoglobulin.

Each 10 g vial of 200 ml contains: 10 g of Human normal immunoglobulin.

Distribution of the IgG subclasses is similar to plasma (approximate values):

IgG1: 64 %

IgG2: 29 %

IgG3: 6 %

IgG4: 1 %

The maximum IgA content is 14 micrograms/ml.

Produced from the plasma of human donors.

For the full list of excipients, see section 6.1.

3. Pharmaceutical form

Vigam Liquid is a sterile liquid for intravenous administration.

4. Clinical particulars
4.1 Therapeutic indications

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

• Primary immunodeficiency syndromes (PID) with impaired antibody production

• Secondary immunodeficiencies (SID) in patients who suffer from severe or recurrent infections, ineffective antimicrobial treatment and either proven specific antibody failure (PSAF)* or serum IgG level of <4 g/l

* PSAF= failure to mount at least a 2-fold rise in IgG antibody titre to pneumococcal polysaccharide and polypeptide antigen vaccines

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

• Primary immune thrombocytopenia (ITP), in patients at high risk of bleeding or prior to surgery to correct the platelet count

• Guillain Barré Syndrome

• Kawasaki disease (in conjunction with acetylsalicylic acid; see section 4.2)

• Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)

• Multifocal motor neuropathy (MMN)

4.2 Posology and method of administration

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

Posology

The dose and dosage regimen is dependent on the indication.

The dose may need to be individualised for each patient dependent on the clinical response. Dose based on bodyweight may require adjustment in underweight or overweight patients.

The following dosage regimens are given as a guideline.

Replacement therapy in primary immunodeficiency syndromes

The dose regimen should achieve a trough level of IgG (measured before the next infusion) of at least 6 g/l or within the normal reference range for the population age. Three to 6 months are required after the initiation of therapy for equilibration (steady-state IgG levels) to occur. The recommended starting dose is 0.4 - 0.8 g/kg given once, followed by at least 0.2 g/kg given every 3 - 4 weeks.

The dose required to achieve a trough level of IgG of 6 g/l is of the order of 0.2 - 0.8 g/kg/month. The dosage interval when steady state has been reached varies from 3 - 4 weeks.

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

Secondary immunodeficiencies (as defined in 4.1.)

The recommended dose is 0.2-0.4 g/kg every 3 - 4 weeks.

IgG trough levels should be measured and assessed in conjunction with the incidence of infection. Dose should be adjusted as necessary to achieve optimal protection against infections; an increase may be necessary in patients with persisting infection; a dose decrease can be considered when the patient remains infection free.

Primary immune thrombocytopenia

There are two alternative treatment schedules:

• 0.8 - 1 g/kg on day 1; this dose may be repeated once within 3 days.

• 0.4 g/kg given daily for 2 - 5 days.

The treatment can be repeated if relapse occurs.

Guillain Barré Syndrome

0.4 g/kg/day over 5 days (possible repeat of dosing in case of relapse).

Kawasaki Disease

2.0 g/kg should be administered as a single dose. Patients should receive concomitant treatment with acetylsalicylic acid.

Chronic inflammatory demyelinating polyneuropathy (CIDP)

Starting dose: 2 g/kg divided over 2 -5 consecutive days.

Maintenance doses: 1 g/kg over 1-2 consecutive days every 3 weeks.

The treatment effect should be evaluated after each cycle; if no treatment effect is seen after 6 months, the treatment should be discontinued. If the treatment is effective long-term treatment should be subject to the physicians discretion based upon the patient response and maintenance response. The dosing and intervals may have to be adapted according to the individual course of the disease.

Multifocal Motor Neuropathy (MMN)

Starting dose: 2 g/kg given over 2-5 consecutive days.

Maintenance dose: 1 g/kg every 2 to 4 weeks or 2 g/kg every 4 to 8 weeks.

The treatment effect should be evaluated after each cycle; if no treatment effect is seen after 6 months, the treatment should be discontinued. If the treatment is effective long-term treatment should be subject to the physicians' discretion based upon the patient response and maintenance response. The dosing and intervals may have to be adapted according to the individual course of the disease.

The dosage recommendations are summarised in the following table:

Indication

Dose

Frequency of injections

Replacement therapy

Primary immunodeficiency

Starting dose:

0.4 - 0.8 g/kg

Maintenance dose:

0.2 - 0.8 g/kg

Every 3 - 4 weeks

Secondary immunodeficiency (as defined in 4.1)

0.2 - 0.4 g/kg

Every 3 - 4 weeks

Immunomodulation:

Primary immune thrombocytopenia

0.8 - 1 g/kg

Or

0.4 g/kg/day

On day 1, possibly repeated once within 3 days

For 2 - 5 days

Guillain Barré Syndrome

0.4 g/kg/day

For 5 days

Kawasaki disease

2 g/kg

In one dose in association with acetylsalicylic acid

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)

Starting dose:

2 g/kg

Maintenance dose:

1 g/kg

In divided doses over 2-5 days

Every 3 weeks over 1-2 days

Multifocal Motor Neuropathy (MMN)

Starting dose:

2 g/kg

Maintenance dose:

1 g/kg

Or

2 g/kg

Over 2-5 consecutive days

Every 2-4 weeks

Or

Every 4-8 weeks over 2-5 days

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 of the above mentioned conditions.

Hepatic impairment

No evidence is available to require a dose adjustment.

Renal impairment

No dose adjustment unless clinically warranted, see section 4.4.

Elderly

No dose adjustment unless clinically warranted, see section 4.4.

Method of administration

For intravenous use.

Vigam Liquid should be infused intravenously at an initial rate of 0.60-1.20 ml/kg/hour for 30 minutes. See section 4.4. In case of adverse reaction, either the rate of administration must be reduced, or the infusion stopped. If well tolerated (see section 4.4), the rate of administration may be gradually increased to 2.40 ml/kg/hour up to a maximum of 180 ml/hour.

4.3 Contraindications

Hypersensitivity to the active substance (human immunoglobulins) or to any of the excipients (see section 4.4 and 6.1).

Patients with selective IgA deficiency who developed antibodies to IgA, as administering an IgA-containing product can result in anaphylaxis.

4.4 Special warnings and precautions for use

Traceability

In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded.

Sucrose

This medicinal product contains 2.4 mg of sucrose per ml as an excipient. Reports of renal dysfunction and acute renal failure have been associated with the use of many of the licensed IVIg products, however those containing sucrose as an excipient accounted for a disproportionate share of the total number. For acute renal failure see below.

Precautions for use

Potential complications can often be avoided by ensuring that patients:

• are not sensitive to human normal immunoglobulin by initially injecting the product slowly (0.60 ml/kg/hour)

• are carefully monitored for any symptoms throughout the infusion period. In particular, patients naïve to human normal immunoglobulin, patients switched from an alternative IVIg product or when there has been a long interval since the previous infusion should be monitored at the hospital 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 all patients, IVIg administration requires:

• adequate hydration prior to the initiation of the infusion of IVIg

• monitoring of urine output

• monitoring of serum creatinine levels

• avoidance of concomitant use of loop diuretics (see section 4.5).

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.

Infusion reaction

Certain adverse reactions (e.g. headache, flushing, chills, myalgia, wheezing, tachycardia, lower back pain, nausea, and hypotension) may be related to the rate of infusion. The recommended infusion rate given under section 4.2 must be closely followed. Patients must be closely monitored and carefully observed for any symptoms throughout the infusion period.

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

• in patients with an untreated infection or underlying chronic inflammation

Hypersensitivity

Hypersensitivity reactions are rare.

Anaphylaxis can develop in patients:

• with undetectable IgA who have anti-IgA antibodies

• who had tolerated previous treatment with human normal immunoglobulin

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

Thromboembolism

There is clinical evidence of an association between IVIg administration and thromboembolic events such as myocardial infarction, cerebral vascular accident (including stroke), pulmonary embolism and deep vein thromboses which is assumed to be related to a relative increase in blood viscosity through the high influx of immunoglobulin in at-risk patients. Caution should be exercised in prescribing and infusing IVIg in obese patients and in patients with pre-existing 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 immobilisation, severely hypovolemic patients, patients with diseases which increase blood viscosity).

In patients at risk for thromboembolic adverse reactions, IVIg products should be administered at the minimum rate of infusion and dose practicable.

Acute renal failure

Cases of acute renal failure have been reported in patients receiving IVIg therapy. In most cases, risk factors have been identified, such as pre-existing renal insufficiency, diabetes mellitus, hypovolaemia, overweight, concomitant nephrotoxic medicinal products or age over 65.

Renal parameters should be assessed prior to infusion of IVIG, particularly in patients judged to have a potential increased risk for developing acute renal failure, and again at appropriate intervals. In patients at risk for acute renal failure, IVIg products should be administered at the minimum rate of infusion and dose practicable. In case of renal impairment, IVIg discontinuation should be considered.

While reports of renal dysfunction and acute renal failure have been associated with the use of many of the licensed IVIg products containing various excipients such as sucrose, glucose, and maltose, those containing sucrose as a stabiliser accounted for a disproportionate share of the total number. In patients at risk, the use of IVIg products that do not contain these excipients may be considered. Vigam Liquid contains sucrose.

Aseptic meningitis syndrome (AMS)

Aseptic meningitis syndrome has been reported to occur in association with IVIg treatment. The syndrome usually begins within several hours to 2 days following IVIg treatment. Cerebrospinal fluid studies are frequently positive with pleocytosis up to several thousand cells per mm3, predominantly from the granulocytic series and elevated protein levels up to several hundred mg/dl.

AMS may occur more frequently in association with high-dose (2g/kg) IVIg treatment.

Patients exhibiting such signs and symptoms should receive a thorough neurological examination, including CSF studies, to rule out other causes of meningitis.

Discontinuation of IVIg treatment has resulted in remission of AMS within several days without sequelae.

Haemolytic anaemia

IVIg products can contain blood group antibodies which may act as haemolysins and induce in vivo coating of red blood cells with immunoglobulin, causing a positive direct antiglobulin reaction (Coombs' test) and, rarely, haemolysis. Haemolytic anaemia can develop subsequent to IVIg therapy due to enhanced red blood cells (RBC) sequestration. IVIg recipients should be monitored for clinical signs and symptoms of haemolysis (see section 4.8).

Neutropenia/Leukopenia

A transient decrease in neutrophil count and/or episodes of neutropenia, sometimes severe, have been reported after treatment with IVIgs. This typically occurs within hours or days after IVIg administration and resolves spontaneously within 7 to 14 days.

Transfusion related acute lung injury (TRALI)

In patients receiving IVIg, there have been some reports of acute non-cardiogenic pulmonary oedema [Transfusion Related Acute Lung Injury (TRALI)].

TRALI is characterised by severe hypoxia, dyspnoea, tachypnoea, cyanosis, fever and hypotension. Symptoms of TRALI typically develop during or within 6 hours of a transfusion, often within 1-2 hours. Therefore, IVIg recipients must be monitored for and IVIg infusion must be immediately stopped in case of pulmonary adverse reactions. TRALI is a potentially life-threatening condition requiring immediate intensive-care-unit management.

Interference with serological testing

After the administration 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 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. 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 Vigam Liquid 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.

Paediatric population

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

4.5 Interaction with other medicinal products and other forms of interaction

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 medicinal 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.

Loop diuretics

Avoidance of concomitant use of loop diuretics.

Paediatric population

The listed interaction(s) apply to both adults and children.

4.6 Fertility, pregnancy and lactation

Pregnancy

The safety of this medicinal product for use in human pregnancy has not been established in controlled clinical trials and therefore should only be given with caution to pregnant women and breast-feeding mothers. IVIg 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 foetus, and the neonate, are expected.

Breast-feeding

Immunoglobulins are excreted into human milk. No negative effects on the breastfed new-borns/infants are anticipated.

Fertility

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

4.7 Effects on ability to drive and use machines

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

4.8 Undesirable effects

Summary of the safety profile

Adverse reactions caused by human normal immunoglobulins (in decreasing frequency) encompass (see also Section 4.4):

• chills, headache, dizziness, fever, vomiting, allergic reactions, nausea, arthralgia, low blood pressure and moderate low back pain

• reversible haemolytic reactions; especially in those patients with blood groups A, B, and AB and (rarely) haemolytic anaemia requiring transfusion

• (rarely) a sudden fall in blood pressure and, in isolated cases, anaphylactic shock, even when the patient has shown no hypersensitivity to previous administration

• (rarely) transient cutaneous reactions (including cutaneous lupus erythematosus - frequency unknown)

• (very rarely) thromboembolic reactions such as myocardial infarction, stroke, pulmonary embolism, deep vein thromboses

• cases of reversible aseptic meningitis

• cases of increased serum creatinine level and/or occurrence of acute renal failure

• cases of Transfusion Related Acute Lung Injury (TRALI)

Tabulated list of adverse reactions

The table presented below is according to the MedDRA system organ classification (SOC and Preferred Term Level).

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).

Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

Frequency of Adverse Reactions (ADRs) in clinical studies with Vigam Liquid

MedDRA System Organ Class (SOC)

Adverse Reaction

Frequency

Nervous system disorders

Headache

Common

Vascular disorders

Hypertension NOS

Common

Hypotension NOS

Common

Respiratory, thoracic and mediastinal disorders

Pharyngitis

Common

Transfusion related acute lung injuries (TRALI)

Not known

Gastrointestinal disorders

Vomiting

Common

Nausea

Common

Skin and subcutaneous tissue disorders

Dermatitis exfoliative NOS

Common

Rash macular

Common

Urticaria NOS

Common

Cutaneous lupus erythematosus

Unknown

Musculoskeletal and connective tissue disorders

Arthralgia

Common

General disorders and administration site conditions

Pyrexia

Very common

Infusion site pain/inflammation

Common

Lethargy

Common

Fatigue

Common

Description of selected adverse reactions

None of the reported adverse reactions to Vigam Liquid warrant separate description.

Paediatric population

Frequency, type and severity of adverse reactions in children are expected to be the same as in 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 professional are asked to report any suspected adverse reactions via the Yellow Card Scheme. Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9 Overdose

Overdose may lead to fluid overload and hyperviscosity, particularly in patients at risk, including elderly patients or patients with cardiac renal impairment (see section 4.4).

5. Pharmacological properties
5.1 Pharmacodynamic properties

Pharmacotherapeutic group: immune sera and immunoglobulins: immunoglobulins, normal human, for intravascular administration, ATC code: J06BA02.

Human normal immunoglobulin contains mainly immunoglobulins 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.

The mechanism of action in indications other than replacement therapy is not fully elucidated.

Paediatric population

There is no clinical data on the pharmacodynamics of Vigam Liquid in children.

5.2 Pharmacokinetic properties

Human normal immunoglobulin is immediately and completely bioavailable in the recipient's circulation after intravenous administration. It is distributed relatively rapidly between plasma and extravascular fluid, after approximately 3 - 5 days equilibrium is reached between intra- and extravascular compartments. Vigam Liquid has a half-life of about 23 - 25 days. This half-life may vary from patient to patient, particularly in primary immunodeficiency.

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

Paediatric population

There is no clinical data on the pharmacokinetics of Vigam Liquid in children.

5.3 Preclinical safety data

Human proteins include antibodies in heterologous species. Therefore, pre-clinical studies have not been carried out with Vigam Liquid which contains immunoglobulins which are normal constituents of human blood.

6. Pharmaceutical particulars
6.1 List of excipients

Human Albumin Solution 20% added at 2 g/100 ml

Sodium n-octanoate

Sucrose

Sodium acetate

Glycine

6.2 Incompatibilities

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products nor with any other IVIg products.

6.3 Shelf life

36 months if stored unopened between 2°C and 8°C.

6.4 Special precautions for storage

Vigam Liquid should be stored in its carton to protect it from light, between 2°C and 8°C.

Do not freeze.

A short period up to 3 months up to 25°C is possible within the shelf-life period.

Do not use after the expiry date printed on the label. The conditions of expired or incorrectly stored product cannot be guaranteed. Such product may be unsafe and should not be used.

6.5 Nature and contents of container

Vigam Liquid is a sterile colourless to pale amber or pale green liquid immunoglobulin G supplied as 2.5 g, 5 g and 10 g doses. The product is contained in a clear glass bottle and stoppered with a rubber bung. The bung is over-sealed with a tamper-evident cap.

6.6 Special precautions for disposal and other handling

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

The solution should be clear or slightly opalescent and colourless or pale amber or green. Solutions that are cloudy or have deposits should not be used.

Use of Vigam Liquid should begin immediately after piercing the cap.

Vigam Liquid is for single use only.

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

7. Marketing authorisation holder

Bio Products Laboratory Ltd

Elstree

WD6 3BX

United Kingdom

8. Marketing authorisation number(s)

PL 08801/0040

9. Date of first authorisation/renewal of the authorisation

Date of first authorisation: 29 October 1997

Date of latest renewal: 25 April 2003

10. Date of revision of the text

June 2020