Posology : מינונים

4.2   Posology and method of administration
Treatment should be initiated under the supervision of a physician experienced in the treatment of haemophilia and/or bleeding disorders.

Posology

Treatment (including routine prophylaxis) with bypassing agents (e.g. activated prothrombin complex concentrate [aPCC] and activated recombinant human FVII [rFVIIa]) should be discontinued the day before starting Hemlibra therapy (see section 4.4).

Factor VIII (FVIII) prophylaxis may be continued for the first 7 days of Hemlibra treatment.

The recommended dose is 3 mg/kg once weekly for the first 4 weeks (loading dose), followed by a maintenance dose from week 5, of either 1.5 mg/kg once weekly, 3 mg/kg every two weeks, or 6 mg/kg every four weeks, all doses administered as a subcutaneous injection.

The loading dose regimen is the same, irrespective of the maintenance dose regimen.

The maintenance dose regimen should be selected based on physician and patient/caregiver dosing regimen preference to support adherence.

The patient dose (in mg) and volume (in mL) should be calculated as follows: 
●     Loading dose (3 mg/kg) once weekly for the first 4 weeks:
Patient bodyweight (kg) x dose (3 mg/kg) = total amount (mg) of emicizumab to be administered ●     Followed by a maintenance dose from week 5, of either 1.5 mg/kg once weekly, 3 mg/kg every two weeks or 6 mg/kg every four weeks:
Patient bodyweight (kg) x dose (1.5; 3 or 6 mg/kg) = total amount (mg) of emicizumab to be administered

The total volume of Hemlibra to be injected subcutaneously is calculated as follows: Total amount (mg) of emicizumab to be administered ÷ vial concentration (mg/mL) = total volume of Hemlibra (mL) to be injected.

Different Hemlibra concentrations (30 mg/mL and 150 mg/mL) should not be combined in the same syringe when making up the total volume to be administered.

A volume greater than 2 mL per injection should not be administered.

Examples:
Patient’s bodyweight of 16 kg, under a maintenance dose regimen of 1.5 mg/kg once weekly: ●     Loading dose (first 4 weeks) example: 16 kg x 3 mg/kg = 48 mg of emicizumab needed for the loading dose.
●     To calculate the volume to be administered divide calculated dose 48 mg by 150 mg/mL: 48 mg of emicizumab ÷ 150 mg/mL = 0.32 mL of 150 mg/mL Hemlibra concentration to be injected.
●     Choose appropriate dose and volume from vial strengths available.

●     Maintenance dose (from week 5 on) example: 16 kg x 1.5 mg/kg = 24 mg of emicizumab needed for the maintenance dose.
●     To calculate the volume to be administered divide calculated dose 24 mg by 30 mg/mL: 24 mg of emicizumab ÷ 30 mg/mL = 0.8 mL of 30 mg/mL Hemlibra concentration to be injected once weekly.
●     Choose appropriate dose and volume from vial strengths available.



Patient’s bodyweight of 40 kg, under a maintenance dose regimen of 3 mg/kg every two weeks: ●     Loading dose (first 4 weeks) example: 40 kg x 3 mg/kg = 120 mg of emicizumab needed for the loading dose.
●     To calculate the volume to be administered divide calculated dose 120 mg by 150 mg/mL: 120 mg of emicizumab ÷ 150 mg/mL = 0.8 mL of 150 mg/mL Hemlibra concentration to be injected.
●     Choose appropriate dose and volume from vial strengths available.

●     Maintenance dose (from week 5 on) example: 40 kg x 3 mg/kg = 120 mg of emicizumab needed for the maintenance dose.
●     To calculate the volume to be administered divide calculated dose 120 mg by 150 mg/mL: 120 mg of emicizumab ÷ 150 mg/mL = 0.8 mL of 150 mg/mL Hemlibra concentration to be injected every two weeks.
●       Choose appropriate dose and volume from vial strengths available.

Patient’s bodyweight of 60 kg, under a maintenance dose regimen of 6 mg/kg every four weeks: ●     Loading dose (first 4 weeks) example: 60 kg x 3 mg/kg = 180 mg of emicizumab needed for the loading dose.
●     To calculate the volume to be administered divide calculated dose 180 mg by 150 mg/mL: 180 mg of emicizumab ÷ 150 mg/mL = 1.20 mL of 150 mg/mL Hemlibra concentration to be injected.
●     Choose appropriate dose and volume from vial strengths available.

●     Maintenance dose (from week 5 on) example: 60 kg x 6 mg/kg = 360 mg of emicizumab needed for the maintenance dose.
●     To calculate the volume to be administered divide calculated dose 360 mg by 150 mg/mL: 360 mg of emicizumab ÷ 150 mg/mL = 2.4 mL of 150 mg/mL Hemlibra concentration to be injected every four weeks.
●     Choose appropriate dose and volume from vial strengths available.


Duration of treatment
Hemlibra is intended for long-term prophylactic treatment.

Dose adjustments during treatment

No dose adjustments of Hemlibra are recommended.
Delayed or missed doses

If a patient misses a scheduled subcutaneous injection of Hemlibra, the patient should be instructed to take the missed dose as soon as possible, up to a day before the day of the next scheduled dose. The patient should then administer the next dose on the usual scheduled dosing day. The patient should not take two doses on the same day to make up for a missed dose.

Special populations

Paediatric
No dose adjustments are recommended in paediatric patients (see section 5.2). There are no data in patients less than 1 year of age.

Elderly

No dose adjustments are recommended in patients ≥ 65 years of age (see sections 5.1 and 5.2). There are no data in patients over 77 years old.
Renal and hepatic impairment

No dose adjustments are recommended in patients with mild or moderate, renal or hepatic impairment (see section 5.2). Emicizumab has not been studied in patients with severe renal or hepatic impairment 
Management in the perioperative setting

The safety and efficacy of emicizumab have not been formally evaluated in the surgical setting.
Patients have had surgical procedures without discontinuing emicizumab prophylaxis in clinical studies.

If bypassing agents (e.g. aPCC and rFVIIa) are required in the perioperative period, please refer to the dosing guidance on the use of bypassing agents in section 4.4.

If FVIII is required in the perioperative period, please refer to section 4.5.

When monitoring a patient’s underlying haemostatic activity, please refer to section 4.4 for laboratory tests unaffected by emicizumab.

Immune tolerance induction (ITI)

The safety and efficacy of emicizumab in patients receiving ongoing immune tolerance induction have not yet been established. No data are available.

Method of administration

Hemlibra is for subcutaneous use only, and it should be administered using appropriate aseptic technique (see section 6.6).

The injection should be restricted to the recommended injection sites: the abdomen, the upper outer arms and the thighs (see section 5.2).

Administration of Hemlibra subcutaneous injection in the upper outer arm should be performed by a caregiver or healthcare professional.

Alternating the site of injection may help prevent or reduce injection site reactions (see section 4.8).
Hemlibra subcutaneous injection should not be administered into areas where the skin is red, bruised, tender or hard, or areas where there are moles or scars.

During treatment with Hemlibra, other medicinal products for subcutaneous administration should, preferably, be injected at different anatomical sites.

Administration by the patient and/or caregiver

Hemlibra is intended for use under the guidance of a healthcare professional. After proper training in subcutaneous injection technique, a patient may self-inject Hemlibra, or the patient’s caregiver may administer it, if their physician determines that it is appropriate.

The physician and the caregiver should determine the appropriateness of the child self-injecting Hemlibra. However, self-administration is not recommended for children below 7 years of age.

For comprehensive instructions on the administration of Hemlibra, see section 6.6 and package leaflet.