4.1. Therapeutic indications

• Immunosuppression in solid organ transplantation

- Prevention of graft rejection in renal transplantation

- Treatment of steroid resistant graft rejection in renal transplantation

- Prevention of graft rejection in heart transplantation.

Thymoglobuline is usually used in combination with other immunosuppressive medicinal products.

4.2. Posology and method of administration

Thymoglobuline must always be used under strict medical supervision and prescribed by physicians with experience in using immunosuppressive agents.

Posology

The posology depends on the indication, the administration regimen and the combination with other immunosuppressive agents.

The following dosage may be used as a reference. Treatment can be discontinued without gradual tapering of the dose.

Immunosuppression in solid organ transplantation

Prophylaxis of graft rejection

1 to 1.5 mg/kg/day for 3 to 9 days after transplantation of a kidney, corresponding to a cumulative dose of 3 to 13.5 mg/kg.

1 to 2.5 mg/kg/day for 3 to 5 days after transplantation of a heart, corresponding to a cumulative dose of 3 to 12.5 mg/kg.

Treatment of steroid resistant graft rejection:

1.5 mg/kg/day for 7 to 14 days after transplantation of a kidney, corresponding to a cumulative dose of 10.5 to 21 mg/kg.

Dose modifications

For obese patients dosing should be based on ideal weight rather than actual weight.

Special population

Paediatric Population

Currently available data are described in section 4.8 and 5.1 but no recommendation on a posology can be made. Available information indicates that paediatric patients do not require a different dosage than adult patients.

Elderly patients

The dose recommendations in elderly patients are the same as for adults.

Renal and hepatic impairment

In view of the PK and metabolism no dose adjustment is necessary in patients with hepatic and/or renal impairment.

Method of administration

Thymoglobuline is usually administered in the context of a therapeutic regimen combining multiple immunosuppressive agents.

It is recommended to administer pre-medication with intravenous corticosteroids and antihistamines prior to infusion of rabbit anti-human thymocyte globulin. Anti-pyretic agents (e.g. paracetamol) may also increase the tolerability of the initial infusion.

Rabbit anti-human thymocyte globulin is infused after dilution in isotonic 0.9% sodium chloride or 5% glucose solution. Inspect solution for particulate matter after reconstitution. To avoid inadvertent administration of particulate matter from reconstitution, it is recommended that Thymoglobuline is administered through a 0.22 μm in-line filter.

Infuse slowly into a high-flow vein. Adjust the infusion rate so that the total duration of infusion is not less than 6 hours. See section 4.4 and section 4.8 for advice about the management of any adverse events associated with infusion.

4.3. Contraindications

• Hypersensitivity to rabbit proteins or to any of the excipients listed in section 6.1.

• Active acute or chronic infections, which would contraindicate any additional immunosuppression.

4.4. Special warnings and precautions for use

Thymoglobuline should be used under strict medical supervision in a hospital setting. Thymoglobuline must only be administered according to the instructions of a physician with experience of immunosuppressive therapy in the transplant setting. Patients should be carefully monitored during the infusion. Particular attention must be paid to monitoring the patient for any symptoms of anaphylactic shock. Close monitoring of the patient must continue during the infusion and for a period of time following the end of the infusion until the patient is stable.

Prior to administration of Thymoglobuline it is advisable to determine whether the patient is allergic to rabbit proteins. Medical personnel and equipment, etc. must be readily at hand during the first days of therapy to provide emergency treatment if necessary.

Warnings

Immune-mediated reactions

In rare instances, serious immune-mediated reactions have been reported with the use of Thymoglobuline and consist of anaphylaxis or severe cytokine release syndrome (CRS).

Very rarely, fatal anaphylaxis has been reported (see section 4.8). If an anaphylactic reaction occurs, the infusion should be terminated immediately and appropriate emergency treatment should be initiated. Equipment for emergency therapy for anaphylactic shock must be readily available.

Any further administration of Thymoglobuline to a patient who has a history of anaphylaxis to Thymoglobuline should only be undertaken after serious consideration.

Severe, acute infusion-associated reactions (IARs) are consistent with CRS which is attributed to the release of cytokines by activated monocytes and lymphocytes. In rare instances, these reported reactions are associated with serious cardiorespiratory events and/or death (see below “Precautions” and section 4.8).

Infection

Thymoglobuline is routinely used in combination with other immunosuppressive agents. Infections (bacterial, fungal, viral and protozoal), reactivation of infection (particularly CMV) and sepsis have been reported after Thymoglobuline administration in combination with multiple immunosuppressive agents. In rare cases, these infections have been fatal.

Hepatic diseases

Thymoglobuline has to be administered with special caution in patients with hepatic diseases as pre-existing clotting disorders may aggravate. Careful monitoring of thrombocytes and coagulation parameters is recommended.

Precautions

General

Appropriate dosing for Thymoglobuline is different from dosing for other anti-thymocyte globulin (ATG) products, as protein composition and concentrations vary depending on the source of ATG used. Physicians should therefore exercise care to ensure that the dose prescribed is appropriate for the ATG product being administered.

Thymoglobuline should be used under strict medical supervision in a hospital setting. Patients should be carefully monitored during the infusion and for a period of time following the end of the infusion until the patient is stable. Close compliance with the recommended dosage and infusion time may reduce the incidence and severity of IARs. Additionally, reducing the infusion rate may minimize many of these adverse reactions. Premedication with antipyretics, corticosteroids, and/or antihistamines may decrease both the incidence and severity of these adverse reactions.

Rapid infusion rates have been associated with case reports consistent with cytokine release syndrome (CRS). In rare instances, severe CRS can be fatal.

Haematological Effects

Thrombocytopenia and/or leukopenia (including lymphopenia and neutropenia) have been identified and are reversible following dose adjustments. When thrombocytopenia and/or leukopenia are not part of the underlying disease or associated with the condition for which Thymoglobuline is being administered, the following dose reductions are suggested:

• A reduction in dosage must be considered if the platelet count is between 50,000 and 75,000 cells/mm3 or if the white cell count is between 2,000 and 3,000 cells/mm3;

• Stopping Thymoglobuline treatment should be considered if persistent and severe thrombocytopenia (<50,000 cells/mm3) occurs or leukopenia (<2,000 cells/mm3) develops.

White blood cell and platelet counts should be monitored during and after Thymoglobuline therapy. Patients with severe neutropenic aplastic anaemia require very careful monitoring, appropriate prophylaxis and treatment of fevers and infections as well as adequate platelet transfusion support.

Infection

Infections, reactivation of infection (particularly CMV), and sepsis have been reported after Thymoglobuline administration in combination with multiple immunosuppressive agents. Careful patient monitoring and appropriate anti-infective prophylaxis are recommended.

Malignancy

Use of immunosuppressive agents, including Thymoglobuline, may increase the incidence of malignancies, lymphoma or lymphoproliferative disorders (which may be virally mediated). These events have sometimes been associated with fatal outcomes (see section 4.8).

Risk of Transmission of Infectious Agents

Human blood components (formaldehyde treated red blood cells), as well as thymus cells are used in the manufacturing process for Thymoglobuline. Standard measures to prevent infections resulting from the use of medicinal products prepared using human components include selection of donors, screening of individual donations for specific markers of infection and the inclusion of effective manufacturing steps for inactivation/removal of viruses.

Despite this, when medicinal products prepared using human components 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 for Thymoglobuline are considered effective for enveloped viruses such as HIV, HBV and HCV, and for the non--enveloped viruses such as HAV and parvovirus B19.

It is strongly recommended that every time that Thymoglobuline is administered to a patient, the name and batch number of the medicinal product are recorded in order to maintain a link between the patient and the batch of the medicinal product.

Special Considerations for Thymoglobuline Infusion

As with any infusion, reactions at the injection site can occur and may include pain, swelling, and erythema.

The recommended route of administration for Thymoglobulin is intravenous infusion using a high-flow vein; however, it may be administered through a peripheral vein. When Thymoglobuline is administered through a peripheral vein, concomitant use of heparin and hydrocortisone in an infusion solution of 0.9% sodium chloride may minimize the potential for superficial thrombophlebitis and deep vein thrombosis.

The combination of Thymoglobuline, heparin and hydrocortisone in a dextrose infusion solution has been noted to precipitate and is not recommended (see section 6.2).

Immunisations

The safety of immunisation with attenuated live vaccines following Thymoglobuline therapy has not been studied; therefore, immunisation with attenuated live vaccines is not recommended for patients who have recently received Thymoglobuline.

Thymoglobulin contains sodium.

This medicinal product contains 4 mg sodium per vial, equivalent to 0.2% of the WHO recommended maximum daily intake of 2 g sodium for an adult.

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.

4.5. Interaction with other medicinal products and other forms of interaction

No drug interaction studies have been performed.

Interactions with food and drink are unlikely.

Thymoglobuline has not been shown to interfere with any routine clinical laboratory tests which use immunoglobulins. However, Thymoglobuline can induce production of human anti-rabbit antibodies which may interfere with rabbit antibody-based immunoassays and with cross-match or panel-reactive antibody cytotoxicity assays. Thymoglobuline may interfere with ELISA tests.

See also section 6.2.

4.6. Fertility, pregnancy and lactation

Fertility

Animal reproduction studies have not been conducted with Thymoglobuline. It is not known whether Thymoglobuline can affect reproductive capacity.

Pregnancy

Animal reproduction studies have not been conducted with Thymoglobuline. It is not known whether Thymoglobuline can cause foetal harm. Thymoglobuline should be given to a pregnant woman only if clearly needed. Thymoglobuline has not been studied in labour or delivery.

Breastfeeding

Thymoglobuline has not been studied in nursing women. It is not known whether this medicinal product is excreted in human milk. Because other immunoglobulins are excreted in human milk, breast-feeding should be discontinued during Thymoglobuline therapy.

4.7. Effects on ability to drive and use machines

Given the possible adverse events which can occur during the period of Thymoglobuline infusion, in particular cytokine release syndrome, it is recommended that patients should not drive or operate machinery.

4.8. Undesirable effects

Tabulated list of adverse reactions

The adverse reactions observed in clinical studies and reported in post-marketing experience are detailed below.

Adverse reactions frequency is defined using 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).

Adverse events from French Multi-centre Post-marketing Surveillance Study are also included in the table below.

From June 1997 to March 1998, 18 French transplantation centres participated in the French Multicentre Post-marketing Surveillance Study-00PTF0.

A total of 240 patients participated in this prospective, single arm, observational cohort study. All patients received Thymoglobuline as prophylaxis of acute rejection for renal transplant.

Adverse reactions considered to be related to Thymoglobuline reported in clinical trials and post-marketing

Blood and lymphatic system disorders

Very common: lymphopenia, neutropenia, thrombocytopenia, anaemia

Common: febrile neutropenia

Gastrointestinal disorders

Common: diarrhoea, dysphagia, nausea, vomiting

General disorders and administrative site conditions

Very common: fever

Common: shivering

Uncommon: infusion related reactions (infusion associated reactions (IARs))*

Hepatobiliary disorders

Common: transaminases increased*

Uncommon: hepatocellular injury, hepatotoxicity, hepatic failure*

Unknown: hyperbilirubinaemia

Immune system disorders

Uncommon: serum sickness*, cytokine release syndrome (CRS)*, anaphylactic reaction

Infections and infestations

Very common: infection (including reactivation of infection)

Common: sepsis

Musculoskeletal and connective tissue disorders

Common: myalgia

Neoplasms benign, malignant and unspecified (including cysts and polyps)

Common: malignancy, lymphomas (which may be virally mediated), neoplasms malignant (solid tumours)

Uncommon: lymphoproliferative disorder

Respiratory, thoracic and mediastinal disorders

Common: dyspnoea

Skin and subcutaneous tissue disorder

Common: pruritus, rash

Vascular disorder

Common: hypotension

*= see below

Description of selected adverse reactions

Infusion-Associated Reactions and Immune System Disorders

Infusion-associated reactions (IAR) may occur following the administration of Thymoglobuline and may occur as soon as the first or second dose. Clinical manifestations of IARs have included some of the following signs and symptoms: fever, chills/rigors, dyspnoea, nausea/vomiting, diarrhoea, hypotension or hypertension, malaise, rash, urticaria, and/or headache. IARs with Thymoglobuline are usually mild and transient and are managed with reduced infusion rates and/or medications. Serious and in very rare instances, fatal anaphylactic reactions have been reported (see section 4.4). These fatal reactions occurred in patients who did not receive adrenaline during the event.

IARs consistent with Cytokine Release Syndrome (CRS) have been reported. Severe and potentially life-threatening CRS is rarely reported. Post-marketing reports of severe Cytokine Release Syndrome have been associated with cardiorespiratory dysfunction (including hypotension, ARDS, pulmonary oedema, myocardial infarction, tachycardia, and/or death).

Hepatobiliary disorders

Transient reversible elevations in transaminases without any clinical signs or symptoms have also been reported during Thymoglobuline administration.

Cases of hepatic failure have been reported secondary to allergic hepatitis and reactivation of hepatitis in patients with hematologic disease and/or stem cell transplant as confounding factors.

Serum Sickness

During post-marketing surveillance, reactions such as fever, rash, urticaria, arthralgia, and/or myalgia, indicating possible serum sickness, have been reported. Serum sickness tends to occur 5 to 15 days after onset of Thymoglobuline therapy. Symptoms are usually self-limited or resolve rapidly with corticosteroid treatment.

Adverse events due to immunosuppression

Infections, reactivation of infection, febrile neutropenia, and sepsis have been reported after Thymoglobuline administration in combination with multiple immunosuppressive agents. In rare cases, these infections have been fatal. Malignancies including, but not limited to lymphoproliferative disorders (LPD) and other lymphomas (which may be virally mediated) as well as solid tumours have been reported. These events have sometimes been associated with fatal outcome (see section 4.4). These adverse events were always associated with a combination of multiple immunosuppressive agents.

For safety relating to transmissible agents, see section 4.4.

Paediatric Population

Currently available data are limited. Available information indicates that the safety profile of Thymoglobuline in paediatric patients is not fundamentally different to that seen 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 professionals are asked to report any suspected adverse reactions via Yellow Card Scheme at: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store

4.9. Overdose

Inadvertent overdose may induce leucopenia (including lymphopenia and neutropenia) and thrombocytopenia.