Brand Name
FEIBA
Generic Name
Anti-Inhibitor
View Brand Information FDA approval date: January 31, 1986
Form: Kit
What is FEIBA (Anti-Inhibitor)?
FEIBA is an Anti-Inhibitor Coagulant Complex indicated for use in hemophilia A and B patients with inhibitors for: Control and prevention of bleeding episodes Perioperative management Routine prophylaxis to prevent or reduce the frequency of bleeding episodes. FEIBA is not indicated for the treatment of bleeding episodes resulting from coagulation factor deficiencies in the absence of inhibitors to coagulation factor VIII or coagulation factor IX. FEIBA is an Anti-Inhibitor Coagulant Complex indicated for use in hemophilia A and B patients with inhibitors for: Control and prevention of bleeding episodes. Perioperative management. Routine prophylaxis to prevent or reduce the frequency of bleeding episodes. FEIBA is not indicated for the treatment of bleeding episodes resulting from coagulation factor deficiencies in the absence of inhibitors to factor VIII or factor IX.
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Brand Information
FEIBA (anti-inhibitor coagulant complex)
WARNING: EMBOLIC and THROMBOTIC EVENTS
- Thromboembolic events have been reported during postmarketing surveillance following infusion of FEIBA, particularly following the administration of high doses and/or in patients with thrombotic risk factors.
- Monitor patients receiving FEIBA for signs and symptoms of thromboembolic events.
1INDICATIONS AND USAGE
FEIBA is an Anti-Inhibitor Coagulant Complex indicated for use in hemophilia A and B patients with inhibitors for:
- Control and prevention of bleeding episodes
- Perioperative management
- Routine prophylaxis to prevent or reduce the frequency of bleeding episodes.
FEIBA is not indicated for the treatment of bleeding episodes resulting from coagulation factor deficiencies in the absence of inhibitors to coagulation factor VIII or coagulation factor IX.
2DOSAGE AND ADMINISTRATION
For intravenous use after reconstitution only.
2.1Dose
A guide for dosing FEIBA is provided in Table 1.
- Dosage and duration of treatment depend on the location and extent of bleeding, and the patient's clinical condition. Careful monitoring of replacement therapy is necessary in cases of major surgery or life-threatening bleeding episodes.
- Each vial of FEIBA contains the labeled amount of factor VIII inhibitor bypassing activity in units.
- Base the dose and frequency of FEIBA on the individual clinical response. Clinical response to treatment with FEIBA may vary by patient and may not correlate with the patient's inhibitor titer.
- Record the name of the patient and batch number of the product in order to maintain a link between the patient and the batch of the product.
- Do not exceed a single dose of 100 units per kg body weight or a daily dose of 200 units per kg body weight
2.2Preparation and Reconstitution
- Use aseptic technique throughout the entire reconstitution process.
- If the patient uses more than one vial per injection, reconstitute each vial according to the following instructions.
2.3Administration
For intravenous injection or intravenous infusion after reconstitution only.
- Inspect the reconstituted FEIBA solution visually for particulate matter and discoloration prior to administration. The appearance of the solution should be colorless to slightly yellowish. Do not use if particulate matter or discoloration is observed.
- Flush venous access lines with isotonic saline prior to and after infusion of FEIBA. Do not administer in the same tubing or container with other medicinal products.
- Use plastic Luer lock syringes because protein such as FEIBA tends to stick to the surface of all-glass syringes.
3DOSAGE FORMS AND STRENGTHS
FEIBA is available as a lyophilized powder in single-dose glass vials containing nominally 500, 1000, or 2500 units per vial.
4CONTRAINDICATIONS
- Known anaphylactic or severe hypersensitivity reactions to FEIBA or any of its components, including factors of the kinin generating system.
- Disseminated intravascular coagulation (DIC).
- Acute thrombosis or embolism (including myocardial infarction).
5ADVERSE REACTIONS
The most frequently reported adverse reactions observed in >5% of subjects in the prophylaxis trial were anemia, diarrhea, hemarthrosis, hepatitis B surface antibody positive, nausea, and vomiting.
The serious adverse reactions seen with FEIBA are hypersensitivity reactions and thromboembolic events, including stroke, pulmonary embolism and deep vein thrombosis.
5.1Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.
The safety assessment of FEIBA is based on the review of the data from two prospective clinical trials in which FEIBA was used for the treatment of acute bleeding episodes and a prospective trial that compared the use of FEIBA prophylactically versus on-demand treatment.
The adverse reactions reported from two prospective clinical trials in which FEIBA was used for the treatment of acute bleeding episodes were chills, chest pain, chest discomfort, dizziness, dysgeusia, dyspnea, hypoesthesia, increase of inhibitor titer (anamnestic response), nausea, pyrexia, and somnolence. Specifically, the first trial was a multicenter randomized, double-blind trial in 15 hemophilia A subjects with inhibitors to factors VIII. The second trial was a multicenter FEIBA study conducted in 44 hemophilia A subjects with inhibitors, 3 hemophilia B subjects with inhibitors and 2 acquired factor VIII inhibitor subjects. Of the 489 infusions used to treat acute bleeds during the second trial, 18 (3.7%) caused minor transient reactions of chills, fever, nausea, dizziness and dysgeusia. Out of 49 subjects, 10 (20%) had a rise in their inhibitor titers after treatment with FEIBA. Five of these subjects (50%) had increases that were tenfold or more, and 3 (30%) of these subjects received factor VIII or IX concentrates within 2 weeks prior to treatment with FEIBA. These anamnestic rises were not associated with decreased efficacy of FEIBA.
Table 2 lists the adverse reactions in >5% of subjects reported in the randomized, prospective prophylaxis trial comparing FEIBA prophylaxis with on-demand treatment in 36 hemophilia A and B subjects with inhibitors to factors VIII or IX
Table 3 lists the adverse reactions and infusion related adverse events reported in >5% of subjects in any of the three groups (50% Reduced Volume, Increased Rate 4 U/kg/min; 50% Reduced Volume, Increased Rate 10 U/kg/min; Overall 50% Reduced Volume) of the randomized, prospective crossover trial evaluating the tolerability and safety of infusing reduced volume of FEIBA at the standard infusion rate of 2 U/kg/min, and at increased rates of 4 and 10 U/kg/min in a total of 33 treated subjects with congenital Hemophilia A with inhibitors.
5.2Postmarketing Experience
The following adverse reactions have been identified during post-approval use of FEIBA. 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.
Blood and Lymphatic System Disorders: disseminated intravascular coagulation
Cardiac Disorders: tachycardia, flushing
Respiratory, Thoracic, and Mediastinal Disorders: bronchospasm, wheezing
Gastrointestinal Disorders: abdominal discomfort
Skin and Subcutaneous Tissue Disorders: pruritus
General Disorders and Administration Site Conditions: malaise, feeling hot, injection site pain
Investigations: Fibrin D-dimer increased
6DESCRIPTION
FEIBA (Anti-Inhibitor Coagulant Complex) is a freeze-dried sterile human plasma fraction with factor VIII inhibitor bypassing activity to be reconstituted for intravenous administration. Factor VIII inhibitor bypassing activity is expressed in arbitrary units. One unit of activity is defined as that amount of FEIBA that shortens the aPTT of high titer factor VIII inhibitor reference plasma to 50% of the blank value.
FEIBA contains mainly non-activated factors II, IX, and X and mainly activated factor VII. It contains approximately equal unitages of factor VIII inhibitor bypassing activity and prothrombin complex factors. In addition, the preparation contains 1-6 units of factor VIII coagulant antigen (FVIII C:Ag) per mL. The product contains traces of factors of the kinin generating system. It contains no heparin. Reconstituted FEIBA contains 4 mg of trisodium citrate and 8 mg of sodium chloride per mL.
FEIBA is manufactured from large pools of human plasma. Screening against potentially infectious agents begins with the donor selection process and continues throughout plasma collection and plasma preparation. Each individual plasma donation used in the manufacture of FEIBA is collected at FDA approved blood establishments and is tested by FDA licensed serological tests for Hepatitis B Surface Antigen (HBsAg), and for antibodies to Human Immunodeficiency Virus (HIV-1/HIV-2) and Hepatitis C Virus (HCV) Mini-pools of the plasma are tested and found negative for the presence of HIV-1 and HCV by FDA licensed Nucleic Acid Testing (NAT).
To reduce the risk of viral transmission, the manufacturing process of FEIBA includes two dedicated and independent virus removal/inactivation steps namely 35 nm nanofiltration and a vapor heat treatment process. In addition, the DEAE-Sephadex adsorption contributes to the virus safety profile of FEIBA.
In vitro spiking studies have been used to validate the capability of the manufacturing process to remove and inactivate viruses. Table 4 summarizes the results of the viral clearance studies for FEIBA.
7CLINICAL STUDIES
Control and Prevention of Bleeding Episodes
The efficacy of FEIBA in the treatment of bleeding episodes has been demonstrated by two prospective clinical trials.
The first trial was a multicenter, randomized, double-blind trial comparing the effect of FEIBA and a non-activated prothrombin complex concentrate in 15 subjects with hemophilia A and inhibitors to factor VIII. The inclusion criteria were history of high titer inhibitors, high responder status, more than 1 bleeding episode per month in the prior year and no signs of liver failure. A total of 150 bleeding episodes including 117 joint, 20 musculoskeletal and 4 mucocutaneous bleeds, were treated. A single dose of 88 units per kg of body weight was used uniformly for treatments with FEIBA. A second treatment was allowed for muscle bleeds after 12 hours and 6 hours after mucocutaneous bleeds, if necessary.
Subjects and investigators were asked to rate hemostatic efficacy based on a scale of effective, partially effective, not effective or not sure. The criteria for evaluation of the effectiveness were severity of pain, subjective improvement, circumference of muscle or joint, restriction of joint mobility, cessation of open bleeding, start of rebleeding and quantity and nature of analgesics. FEIBA was effective in 41% and partly effective in 25% of episodes (i.e. combined effectiveness of 66%), while prothrombin complex concentrate was rated effective in 25% and partly effective in 21% of episodes (i.e., combined effectiveness of 46%).
The second trial with FEIBA was a multicenter randomized, prospective trial. This trial was conducted in 44 hemophilia A subjects with inhibitors, 3 hemophilia B subjects with inhibitors and 2 acquired factor VIII inhibitor subjects. It was designed to evaluate the efficacy of FEIBA in the treatment of joint, mucous membrane, musculocutaneous and emergency bleeding episodes such as central nervous system hemorrhages and surgical bleedings. The inclusion criteria used were age >4 years, history of inhibitor titer ≥4 Bethesda Units (BU) and without chronic liver disease. Subjects were excluded if they had a history of thromboembolic events or allergic reactions to FEIBA.
Forty-nine (49) subjects with inhibitor titers of greater than 5 BU were enrolled from nine co-operating hemophilia centers. Subjects were treated with 50 units per kg of body weight, repeated at 12-hour intervals (6-hour intervals in mucous membrane bleedings), if necessary. A total of 489 infusions were given for the treatment of 165 bleeding episodes (102 joint, 33 muscle and soft tissue, 20 mucous membrane, and 10 emergency bleeds, including 3 central nervous system bleeds and 4 surgical procedures). Bleeding was controlled in 153 episodes (93%). In 130 (78%) of the episodes, hemostasis was achieved with one or more infusions within 36 hours. Of these, 36% were controlled with one infusion within 12 hours. An additional 14% of episodes responded after more than 36 hours.
Routine Prophylaxis
In a multicenter, open-label, prospective, randomized clinical trial comparing subjects receiving FEIBA for prophylaxis with subjects receiving FEIBA for on-demand treatment, 36 hemophilia A and B subjects with inhibitors to factor VIII or IX were analyzed in the intent-to-treat analysis. Study population included 29 (80.6%) Caucasian, 3 (8.3%) Asian, 2 (5.6%) Black/African American, and 2 (5.6%) other. Inclusion criteria were subjects with a history of high titer inhibitors or low titer refractory to increased factor VIII or IX dosing, age range between 4 and 65, and subjects receiving bypassing agents with ≥12 bleeds in the 12 months prior to trial entry. Subjects with a history of thromboembolic events, symptomatic liver disease, or a platelet count <100,000 per mL, and those receiving immune tolerance induction or routine prophylaxis were excluded.
Subjects were randomized to receive 12 months of prophylactic or on-demand treatment with FEIBA. Seventeen subjects randomized to the prophylaxis arm received 85 units per kg of FEIBA every other day. Nineteen subjects randomized to the on-demand arm received FEIBA for the treatment of acute bleeding episodes per the dose and dosing regimen recommended. Target joints were defined as ≥4 bleeding episodes within 6 months. In this trial, ankles, knees, elbows and hips were target joint locations. Preexisting target joints were not considered as new target joints.
Hemostatic efficacy for treatment of acute bleeds was evaluated at 6 and 24 hours according to a pre-specified four-point scale of excellent, good, fair, or none. An evaluation of "none" was considered a treatment failure. The criteria for evaluation of the effectiveness were relief of pain, cessation of bleeding, and number of infusions required to treat a bleed.
A total of 825 bleeding episodes were reported including 196 that occurred during prophylaxis and 629 that occurred during on-demand therapy. A majority (78%) of the 794 bleeding episodes that were rated for efficacy were treated with 1 or 2 infusions. Hemostatic efficacy was rated as excellent or good for 74% of bleeding episodes rated at 6 hours post infusion and for 87% of the bleeding episodes at 24 hour post infusion. A total of 19 (2.4%) bleeds were rated as "none" at 6 hours post infusion; 1 bleed (0.1%) was rated "none" at 24 hours.
Hemostatic efficacy for routine prophylaxis was evaluated against subjects who received on-demand therapy.
The overall median annual bleed rate (ABR) for the on-demand arm was 28.7 compared to 7.9 for the prophylaxis arm, which represents a 72% reduction in median ABR with prophylaxis. When analyzed by site (e.g. joint, non-joint) and cause of bleed (e.g. spontaneous, traumatic), prophylactic treatment with FEIBA resulted in a greater than 50% reduction in ABR. There were fewer subjects in the prophylaxis arm who developed new target joints (7 new target joints in 5 subjects treated with prophylaxis compared to 23 new target joints in 11 subjects in the on-demand arm). Target joints developed in two subjects in the on-demand arm and three in the prophylaxis arm who did not have reported target joints at trial enrollment. A total of 3 of 17 (18%) subjects had no bleeding episodes on prophylaxis. In the on-demand arm, all subjects experienced a bleeding episode.
ABR by age category between on-demand and prophylaxis regimens is provided in Table 5. One adolescent subject on prophylaxis had a higher rate of bleeding possibly due to increased physical activity after study enrollment.
8REFERENCES
- Sjamsoedin LJ, Heijnen L, Mauser-Bunschoten EP, van Geijlswijk JL, van Houwelingen H, van Asten P, Sixma JJ. The effect of Activated Prothrombin-Complex Concentrate (FEIBA) on joint and muscle bleeding in patients with Hemophilia A and antibodies to Factor VIII. N Engl J Med. 1981;305(13): 717-721.
- Hilgartner MW, Knatterud GL. The use of Factor-Eight-Inhibitor-By-Passing-Activity (FEIBA IMMUNO) product for treatment of bleeding episodes in Hemophiliacs with inhibitors. Blood. 1983;61(1): 36-40.
- Antunes SV, Tangada S, Stasyshyn O, Mamonov V, Phillips J, Guzman-Becerra N, Grigorian A, Ewenstein B, Wong WY. Randomized comparison of prophylaxis and on-demand regimens with FEIBA NF in the treatment of haemophilia A and B with inhibitors. Haemophilia. 2013; DOI 10.1111/hae.12246.
- Turecek PL, Varadi K, Gritsch H, Auer W, Pichler L, Eder G, Schwarz HP. Factor Xa and prothrombin: mechanism of action of FEIBA. Vox Sanguinis 1999;77 Suppl 1:72-79.
- Turecek PL, Varadi K, Gritch H, Schwarz HP. FEIBA: Mode of action Haemophilia 2004;10: Suppl. 2:3-9
- Oldenburg et al. Emicizumab Prophylaxis in Hemophilia A with Inhibitors. N Engl J Med 2017:377:809-818.
9PATIENT COUNSELING INFORMATION
Inform patients:
- of the signs and symptoms of thrombosis, such as chest pain or pressure, shortness of breath, altered consciousness, vision, or speech, limb or abdomen swelling and/or pain. Advise patients to seek immediate medical attention if any of these symptoms occur.
- of the signs and symptoms of hypersensitivity reactions, such as urticaria, angioedema, gastrointestinal manifestations, bronchospasm, and hypotension. Advise patients to discontinue use of the product if these symptoms occur and seek immediate emergency treatment.
- that because FEIBA is made from human blood, it may carry a risk of transmitting infectious agents, e.g., viruses, the variant Creutzfeldt-Jakob disease (vCJD) agent, and theoretically, the Creutzfeldt-Jakob disease (CJD) agent.
- if they are on emicizumab prophylaxis therapy and need FEIBA to treat a breakthrough bleeding episode then they must be monitored by their hemophilia treating physician, preferably at the hemophilia treatment center (HTC).
- to report any adverse reactions or problems following FEIBA administration to their hemophilia treating physician.
To enroll in the confidential, Industry-wide Patient Notification System, call 1-888-873-2838.
10PRINCIPAL DISPLAY PANEL - Kit Carton
20 mL size, dried
Anti-Inhibitor Coagulant Complex
Nanofiltered & Vapor Heated
For Intravenous Use After Reconstitution
Contains no preservative
Contains no preservative
Dosage and Administration: See accompanying package insert.
Storage: 36°F to 77°F (2°C to 25°C). Store in the original package in order to protect from light.
Reconstitution: Use 20 mL sWFI, U.S.P.;Do not refrigerate after reconstitution.; Use within 3 hours of
reconstitution.
reconstitution.
Do Not Freeze
Rx Only
Takeda
Includes
11PRINCIPAL DISPLAY PANEL - 20 mL Vial Label
20 mL size, dried
Anti-Inhibitor Coagulant Complex
For Intravenous Use After Reconstitution
Dosage & Administration: See accompanying package insert.
Storage: 36°F to 77°F (2°C to 25°C).
Reconstitution: Use 20 mL sWFI, U.S.P.; Do not refrigerate
Rx only
12PRINCIPAL DISPLAY PANEL - Kit Carton
Single-dose vial
Anti-Inhibitor Coagulant Complex
Nanofiltered & Vapor Heated
For Intravenous Use After Reconstitution
Contains no preservative
Contains no preservative
Dosage and Administration: See accompanying package insert.
Storage: 36°F to 77°F (2°C to 25°C).
Store in the original package in order to protect from light.
Store in the original package in order to protect from light.
Reconstitution: Use 50 mL sWFI, U.S.P.; Do not refrigerate after reconstitution.; Use within 3 hours of
reconstitution.
reconstitution.
Do Not Freeze
Rx Only
Takeda
Includes
13PRINCIPAL DISPLAY PANEL - 50 mL Vial Label
50 mL size, dried
Anti-Inhibitor Coagulant Complex
For Intravenous Use After Reconstitution
Dosage & Administration: See accompanying package insert.
Storage: 36°F to 77°F (2°C to 25°C).
Reconstitution: Use 50 mL sWFI, U.S.P.; Do not refrigerate
Rx only
14PRINCIPAL DISPLAY PANEL - Kit Carton
Single-dose vial
Anti-Inhibitor
Nanofiltered & Vapor Heated
For Intravenous Use After Reconstitution
Contains no preservative
Contains no preservative
Dosage and Administration: See accompanying package insert.
Storage: 36°F to 77°F (2°C to 25°C). Store in the original package in order to protect
from light.
from light.
Reconstitution: Use 10 mL sWFI, U.S.P.; Do not refrigerate after reconstitution.; Use within
3 hours of reconstitution.
3 hours of reconstitution.
Do Not Freeze
Rx Only
Takeda
Includes
15PRINCIPAL DISPLAY PANEL - 10 mL Vial Label
Single-dose vial
Anti-Inhibitor Coagulant Complex
For Intravenous Use After Reconstitution
Dosage & Administration: See accompanying package insert.
Storage: 36°F to 77°F (2°C to 25°C).
Reconstitution: Use 10 mL sWFI, U.S.P.; Do not refrigerate after
Rx only
