Factor VIIa (Recombinant)
(FAK ter SEV en aye ree KOM be nant)
- Coagulation Factor VIIa
- Eptacog Alfa (Activated)
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Reconstituted, Intravenous [preservative free]:
NovoSeven RT: 1 mg (1 ea); 2 mg (1 ea); 5 mg (1 ea); 8 mg (1 ea) [contains polysorbate 80]
Brand Names: U.S.
- NovoSeven RT
- Antihemophilic Agent
Recombinant factor VIIa, a vitamin K-dependent glycoprotein, promotes hemostasis by activating the extrinsic pathway of the coagulation cascade. It replaces deficient activated coagulation factor VII, which complexes with tissue factor and may activate coagulation factor X to Xa and factor IX to IXa. When complexed with other factors, coagulation factor Xa converts prothrombin to thrombin, a key step in the formation of a fibrin-platelet hemostatic plug.
Hemophilia A or B: Vss: Children 2 to 12 years: 164 mL/kg; Adults: 107 to 128 mL/kg
Factor VII deficiency: Vss: 280 to 290 mL/kg
Hemophilia A or B: Clearance: Children 2 to 12 years: 58 mL/hour/kg; Adults: 31 to 39 mL/hour/kg
Factor VII deficiency: Clearance: 71 to 79 mL/kg/hour
Hemophilia A or B: Half-life, terminal: Children 2 to 12 years: 2.6 hours; Adults: 2.9 to 3.1 hours
Factor VII deficiency: Half-life, terminal: 2.8 to 3.1 hours
Use: Labeled Indications
Bleeding episodes and perioperative management: Treatment of bleeding episodes and perioperative management in adults and children with hemophilia A or B with inhibitors, congenital factor VII (FVII) deficiency, and Glanzmann’s thrombasthenia with refractoriness to platelet transfusions, with or without antibodies to platelets; treatment of bleeding episodes and perioperative management in adults with acquired hemophilia.
Off Label Uses
Intracranial hemorrhage associated with danaparoid
Based on the Neurocritical Care Society and the Society of Critical Care Medicine guideline for reversal of antithrombotics in intracranial hemorrhage, factor VIIa (recombinant) is recommended to reverse the anticoagulant effect following intracranial hemorrhage associated with danaparoid. Of note, in patients receiving LMWH for prophylaxis (ie, not a full therapeutic dose), the NCS/SCCM guidelines suggest against reversal (danaparoid is a heparinoid with a similar action to the LMWHs).
Refractory bleeding after cardiac surgery in nonhemophiliac patients
Data from a limited number of patients (retrospective cohort study) suggests that factor VIIa (recombinant) may be beneficial for the management of patients with this condition [Chapman 2011], [Karkouti 2007]. Additional data may be necessary to further define the role of factor VIIa (recombinant) in the treatment of this condition.
Based on Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Blood Conservation Clinical Practice Guidelines, factor VIIa (recombinant) is effective and recommended for the treatment of refractory bleeding after cardiac surgery in nonhemophiliac patients.
Warfarin-related intracerebral hemorrhage
Although preliminary data from a limited number of patients suggested that factor VIIa (recombinant) may be beneficial for the management of patients with warfarin-related intracerebral hemorrhage, [Freeman 2004], [Ilyas 2008] factor VIIa (recombinant) does not replenish all the vitamin-K dependent clotting factors and does not restore thrombin generation as well as prothrombin complex concentrates (PCCs), and therefore may not be ideal.
There are no contraindications listed in the manufacturer’s labeling.
Canadian labeling: Additional contraindications (not in US labeling): Hypersensitivity to eptacog alfa, any component of the formulation, or mouse, hamster or bovine protein
Congenital hemophilia A or B with inhibitors:
Bleeding episodes: 90 mcg/kg/dose every 2 hours until hemostasis is achieved or until the treatment is judged ineffective. Doses between 35 and 90 mcg/kg/dose have been used successfully in clinical trials. The dose, interval, and duration of therapy may be adjusted based upon the severity of bleeding and the degree of hemostasis achieved. For patients experiencing severe bleeds, dosing should be continued at 3- to 6-hour intervals post-hemostasis. The duration of any post-hemostatic dosing should be minimized.
Perioperative management: 90 mcg/kg/dose immediately before surgery (additional bolus doses may be administered for major surgery if required); repeat at 2-hour intervals for the duration of surgery. For minor surgery, continue 90 mcg/kg/dose postoperatively every 2 hours for 48 hours, then every 2 to 6 hours until healed. For major surgery, continue 90 mcg/kg/dose postoperatively every 2 hours for 5 days, then every 4 hours until healed.
Congenital factor VII deficiency:
Bleeding episodes: 15 to 30 mcg/kg/dose every 4 to 6 hours until hemostasis is achieved. Doses as low as 10 mcg/kg have been effective.
Perioperative management: 15 to 30 mcg/kg/dose immediately before surgery; repeat every 4 to 6 hours for the duration of surgery and until hemostasis achieved. Doses as low as 10 mcg/kg have been effective.
Bleeding episodes: 70 to 90 mcg/kg/dose every 2 to 3 hours until hemostasis is achieved.
Perioperative management: 70 to 90 mcg/kg/dose immediately before surgery; repeat every 2 to 3 hours for the duration of surgery and until hemostasis achieved.
Bleeding episodes (severe, refractory to platelet transfusions): 90 mcg/kg/dose every 2 to 6 hours until hemostasis is achieved.
Perioperative management: 90 mcg/kg/dose immediately before surgery; repeat at 2-hour intervals for the duration of surgery. Continue 90 mcg/kg/dose every 2 to 6 hours to prevent postoperative bleeding. Note: Higher average infused doses (median 100 mcg/kg) were noted for surgical patients who had clinical refractoriness with or without platelet-specific antibodies compared to those with neither.
Intracranial hemorrhage associated with danaparoid (off-label use): IV: 90 mcg/kg once (NCS/SCCM [Frontera 2016]).
Refractory bleeding after cardiac surgery in nonhemophiliac patients (off-label use): Dosing not established; doses in the range of 35 to 70 mcg/kg/dose have been recommended based on low-quality evidence (case series, observational studies) (Chapman 2011; Ferraris 2011; Karkouti 2007); in patients with a left ventricular assist device, lower doses (ie, 10 to 20 mcg/kg) may be preferred to reduce thromboembolic events (Bruckner 2009).
Refer to adult dosing.
Congenital factor VII deficiency: Children and Adolescents: Refer to adult dosing.
Glanzmann’s thrombasthenia: Children and Adolescents: Refer to adult dosing.
Congenital hemophilia A or B with inhibitors: Children and Adolescents: Refer to adult dosing.
Dosing: Renal Impairment
There are no dosage adjustments provided the in manufacturer’s labeling.
Dosing: Hepatic Impairment
There are no dosage adjustments provided in the manufacturer’s labeling; use with caution.
Prior to reconstitution, bring vials to a temperature not above 37°C (98.6°F). Add recommended diluent along wall of vial; do not inject directly onto powder. Gently swirl until dissolved. Do not mix with other infusion solutions.
NovoSeven RT: Reconstitute each vial to a final concentration of 1 mg/mL using the provided histidine diluent as follows:
1 mg vial: 1.1 mL histidine diluent vial or 1 mL prefilled histidine diluent syringe
2 mg vial: 2.1 mL histidine diluent vial or 2 mL prefilled histidine diluent syringe
5 mg vial: 5.2 mL histidine diluent vial or 5 mL prefilled histidine diluent syringe
8 mg vial: 8.1 mL histidine diluent vial or 8 mL prefilled histidine diluent syringe
IV: For IV administration only as a bolus over 2 to 5 minutes (depending on the dose administered). Use NS to flush line (if necessary) before and after administration. Administer within 3 hours after reconstitution.
Some products may contain sodium.
NovoSeven RT: Prior to reconstitution, store between 2°C to 25°C (36°F to 77°F); do not freeze. Protect from light. Reconstituted solutions may be stored at room temperature or under refrigeration, but must be infused within 3 hours of reconstitution. Do not freeze reconstituted solutions. Do not store reconstituted solutions in syringes.
Factor XIII A-Subunit (Recombinant): May enhance the thrombogenic effect of Factor VIIa (Recombinant). Monitor therapy
1% to 10%:
Cardiovascular: Thrombosis (4%), hypertension (2%), bradycardia (1%), edema (1%), hypotension (1%)
Central nervous system: Cerebrovascular disease (<2%), headache (1%), pain (1%)
Dermatologic: Pruritus (1%), skin rash (1%)
Endocrine & metabolic: Decreased serum fibrinogen (2%)
Gastrointestinal: Vomiting (1%)
Hematologic & oncologic: Decreased prothrombin time (1%), disseminated intravascular coagulation (1%), increased fibrinolysis (1%), purpura (1%)
Hepatic: Abnormal hepatic function tests (<2%)
Hypersensitivity: Hypersensitivity reaction (1%)
Local: Injection site reaction (1%)
Neuromuscular & skeletal: Osteoarthrosis (1%)
Renal: Renal function abnormality (1%)
Respiratory: Pneumonia (1%)
Miscellaneous: Fever (4%), decreased therapeutic response (<2%)
<1% (Limited to important or life-threatening): Anaphylactic shock, anaphylaxis, angina pectoris, angioedema, antibody development, arterial embolism (retinal), arterial thrombosis, arterial thrombosis (limb, retinal), bowel infarction, cerebral infarction, cerebral ischemia, cerebrovascular accident, deep vein thrombosis, hepatic artery thrombosis, hypersensitivity, immunogenicity, increased fibrin degradation products (including D-dimer elevation), intracardiac thrombus, local phlebitis, myocardial infarction, myocardial ischemia, nausea, occlusion of cerebral arteries, peripheral ischemia, portal vein thrombosis, pulmonary embolism, renal artery thrombosis, thrombophlebitis, venous thrombosis at injection site
Concerns related to adverse effects:
• Antibody formation: In patients with factor VII deficiency, if factor VIIa activity does not reach the expected level, prothrombin time is not corrected, or bleeding is uncontrolled (with recommended doses), suspect antibody formation and perform antibody analysis. Prothrombin time and factor VII coagulant activity should be measured before and after administration in patients with factor VII deficiency.
• Hypersensitivity reactions: Hypersensitivity reactions, including anaphylaxis, have been reported with use. Use with caution in patients with known hypersensitivity to mouse, hamster, or bovine proteins, or factor VIIa, or any components of the product. If hypersensitivity reaction occurs, discontinue use and administer appropriate treatment; carefully consider the benefits versus the risk of continued treatment with factor VIIa.
• Thromboembolic events: [US Boxed Warning]: Serious arterial and venous thrombotic events following administration of Factor VIIa (recombinant) have been reported. Discuss the risks and explain the signs and symptoms of thrombotic and thromboembolic events to patients who will receive factor VIIa (recombinant). Monitor patients for signs and symptoms of activation of the coagulation system and for thrombosis. All patients receiving factor VIIa should be monitored for signs and symptoms of activation of the coagulation system or thrombosis; thrombotic events may be increased due to circulating tissue factor or predisposing coagulopathy in patients with disseminated intravascular coagulation (DIC), advanced atherosclerotic disease, septicemia, crush injury, concomitant treatment with activated or nonactivated prothrombin complex concentrates, or uncontrolled postpartum hemorrhage. Use with caution in patients with an increased risk of thromboembolic complications (eg, coronary heart disease, liver disease, DIC, postoperative immobilization, elderly patients, and neonates). Decreased dosage or discontinuation is warranted with confirmed intravascular coagulation or presence of clinical thrombosis.
Dosage form specific issues:
• Polysorbate 80: Some dosage forms may contain polysorbate 80 (also known as Tweens). Hypersensitivity reactions, usually a delayed reaction, have been reported following exposure to pharmaceutical products containing polysorbate 80 in certain individuals (Isaksson, 2002; Lucente 2000; Shelley, 1995). Thrombocytopenia, ascites, pulmonary deterioration, and renal and hepatic failure have been reported in premature neonates after receiving parenteral products containing polysorbate 80 (Alade, 1986; CDC, 1984). See manufacturer’s labeling.
• Reduced efficacy: A number of factors influence the efficacy of factor VIIa, including hypothermia, thrombocytopenia, acidosis, and the amount of blood products transfused prior to administration (Dunkley, 2008).
Monitor for evidence of hemostasis and thrombosis (including laboratory confirmation of intravascular coagulation, if appropriate). Although the prothrombin time (PT)/INR, aPTT, and factor VII clotting activity have shown no direct correlation with achieving hemostasis, these parameters may be useful as adjunct tests to evaluate efficacy and guide dose or interval adjustments. In factor VII–deficient patients, monitor PT and factor VII clotting activity before and after administration; if the factor VIIa activity fails to reach the expected level, if PT is not corrected, or if bleeding is not controlled after treatment with recommended doses, monitor for factor VII antibodies.
Adverse events have been observed in animal reproduction studies. Factor VII concentrations may vary significantly in pregnant women with coagulation disorders. Pregnant women with hemophilia should have clotting factors monitored, particularly at 28 and 34 weeks gestation and prior to invasive procedures. Recombinant factor VIIa is recommended for the management of bleeding disorders in pregnant women with factor VII deficiency. Prophylaxis at delivery may be needed if factor VII concentrations are <10 to 20 units /dL or in women with a significant bleeding history and treatment should continue for 3 to 5 days postpartum depending on route of delivery. The neonate may also be at an increased risk of bleeding following delivery and should be tested for the coagulation disorder (Kadir 2009; Lee 2006).
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Have patient report immediately to prescriber signs of severe cerebrovascular disease (change in strength on one side is greater than the other, difficulty speaking or thinking, change in balance, or vision changes), signs of blood clots (numbness or weakness on one side of the body; pain, redness, tenderness, warmth, or swelling in the arms or legs; change in color of an arm or leg; angina; shortness of breath; tachycardia; or coughing up blood), severe headache, vision changes, severe dizziness, passing out, abdominal pain, or abdominal edema (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
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Other brands: NovoSeven RT