BABYBIG Powder for solution for injection Ref.[9962] Active ingredients: Botulinum antitoxin

Only administer BabyBIG as an intravenous infusion, since other routes of administration have not been evaluated. Do not use BabyBIG if the reconstituted solution is turbid [see DOSAGE AND ADMINISTRATION (2.1)].

5.1 Patient Monitoring for Administration

• Patients should be well hydrated prior to the initiation of the BabyBIG infusion.
• Assess renal function, including the measurement of blood urea nitrogen (BUN) or serum creatinine prior to the initial infusion of BabyBIG [see DOSAGE AND ADMINISTRATION (2)]. Periodic monitoring of renal function tests and urine output is particularly important in patients judged to have a potential risk for developing acute renal failure^[1-4]. Increases in serum creatinine and BUN have been observed as soon as one to two days following treatment with other IGIV products.
• During administration, monitor the patient’s vital signs continuously and observe the patient carefully for any associated symptoms.
• DO NOT EXCEED THE RECOMMENDED INFUSION RATE of 1 mL/kg/hour (50 mg/kg/h), and follow the infusion schedule closely [see DOSAGE AND ADMINISTRATION (2.3)]. If a patient develops an infusion reaction, slow the rate of infusion immediately or temporarily interrupt the infusion.

5.2 Renal Adverse Reactions

Other IGIV products have been reported to be associated with renal dysfunction, acute renal failure, osmotic nephrosis, and death^[5-6]. While these reports of renal dysfunction and acute renal failure have been associated with the use of many licensed IGIV products, those that contained sucrose as a stabilizer and were administered at daily doses of 400 mg/kg or greater have accounted for a disproportionate share of the total number⁷. BabyBIG contains sucrose as a stabilizer. Patients predisposed to acute renal failure include those patients with any degree of pre-existing renal insufficiency, diabetes mellitus, volume depletion, sepsis, paraproteinemia, or who are receiving known nephrotoxic drugs. Especially in such patients, BabyBIG should be administered at the minimum concentration available and at the minimum rate of infusion practicable¹.

5.3 Transmission of Blood-Borne Infectious Agents

BabyBIG is made from human plasma and, like other plasma products, carries the possibility for transmission of blood-borne viral agents and, theoretically, the Creutzfeldt-Jakob disease agent. The risk of transmission of recognized blood-borne viruses has been reduced by screening plasma donors for prior exposure to certain viruses, for the presence of certain viral infections, and by the viral inactivation and/or removal properties of the precipitation procedures used for the purification of BabyBIG [see DESCRIPTION (11)]. Despite these measures, some as yet unrecognized blood-borne infectious agents may not be inactivated by the manufacturing process; therefore, BabyBIG, like any other blood product, should be given only if a benefit is expected [see PATIENT COUNSELING INFORMATION (17)].

5.4 Anaphylaxis

• Severe reactions, such as angioedema and anaphylactic shock, although not observed during clinical trials with BabyBIG, are a possibility^[8,9]. Clinical anaphylaxis may occur even when the patient is not known to be sensitive to immune globulin products. A reaction may be related to the rate of infusion; therefore, carefully adhere to the infusion rates as outlined under “DOSAGE AND ADMINISTRATION (2.3).” If anaphylaxis or a drop in blood pressure occurs, discontinue the infusion and administer epinephrine^[1-4].
• Although acute systemic allergic reactions were not seen in clinical trials with BabyBIG, epinephrine should be available for treatment of acute allergic symptoms [see ADVERSE REACTIONS (6.1)]. If hypotension or anaphylaxis occurs, discontinue the administration of BabyBIG immediately and give supportive care as needed.

5.5 Aseptic Meningitis Syndrome

An aseptic meningitis syndrome (AMS) has been reported to occur infrequently in association with IGIV administration^[10-13]. The syndrome usually begins within several hours to two days following IGIV treatment. It is characterized by symptoms and signs that include the following: severe headache, nuchal rigidity, drowsiness, fever, photophobia, painful eye movements, and nausea and vomiting. Cerebrospinal fluid studies are frequently positive with pleocytosis up to several thousand cells per cubic millimeter, predominately from the granulocytic series, and with elevated protein levels up to several hundred mg/dL. Conduct a thorough neurological examination in patients exhibiting such symptoms and signs to rule out other causes of meningitis. ^[10-13] AMS may occur more frequently in association with high total doses (2 g/kg) of IGIV treatment. Discontinuation of IGIV treatment has resulted in remission of AMS within several days without sequelae¹. AMS was not observed in clinical trials of BabyBIG.

5.6 Hyperproteinemia, Hyponatremia, and Serum Viscosity

Hyperproteinemia, hyponatremia, and increased serum viscosity have been observed following administration of IGIV products. It is clinically critical to distinguish true hyponatremia from pseudohyponatremia caused by decreased calculated serum osmolality or elevated osmolar gap, because treatment aimed at decreasing serum free water in patients with pseudohyponatremia may lead to volume depletion, a further increase in serum viscosity and a higher risk of thromboembolic events. These adverse events have not been observed with BabyBIG.

5.7 Thrombotic Events

Thrombotic events may occur following IGIV treatment. Patients at risk may include those with a history of atherosclerosis, multiple cardiovascular risk factors, advanced age, impaired cardiac output, coagulation disorders, prolonged periods of immobilization, and/or known or suspected hyperviscosity. Consider baseline assessment of blood viscosity in patients at risk for hyperviscosity, including those with cryoglobulins, fasting chylomicronemia/markedly high triacylglycerols (triglycerides), or monoclonal gammopathies. For patients judged to be at risk of developing thrombotic events, administer BabyBIG at the minimum rate of infusion practicable.

5.8 Hemolytic Anemia

IGIV products may contain blood group antibodies, which can act as hemolysins and induce in vivo coating of red blood cells with immunoglobulin, causing a positive direct antiglobulin reaction and, rarely, hemolysis. Hemolytic anemia may develop subsequent to IGIV therapy due to enhanced red blood cell sequestration.

Monitor patients for clinical signs and symptoms of hemolysis. If these are present after BabyBIG infusion, perform appropriate confirmatory laboratory testing.

5.9 Transfusion-Related Acute Lung Injury (TRALI)

Non-cardiogenic pulmonary edema may occur in patients following IGIV treatment³¹. TRALI is characterized by severe respiratory distress, pulmonary edema, hypoxemia, normal left ventricular function, and fever. Symptoms typically occur within 1 to 6 hours following treatment [See PATIENT COUNSELING INFORMATION (17)].

Monitor patients for pulmonary adverse reactions. If TRALI is suspected, perform appropriate tests for the presence of anti-neutrophil antibodies in both the product and patient serum.

TRALI may be managed using oxygen therapy with adequate ventilatory support.

• Serious adverse reactions were not observed in clinical trials using BabyBIG.
• The most common adverse reaction observed with BabyBIG treatment during clinical trials (>5%) was skin rash.
• Other reactions such as chills, muscle cramps, back pain, fever, nausea, vomiting, and wheezing were the most frequent adverse reactions observed during the clinical trials of similarly-prepared human IGIV products²¹. The incidence of these reactions was less than 5% of all infusions in BabyBIG clinical trials, and these reactions were most often related to infusion rates⁷.

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.

Two clinical studies of BabyBIG were performed: (1) an adequate and well-controlled study to evaluate safety and efficacy of BabyBIG, which used BabyBIG Lot 1, and (2) an open label study to collect additional safety data and confirm efficacy, which used BabyBIG Lot 2 [see Clinical Studies (14)]^[14,15]. Different methodologies were used to collect adverse events in the controlled study and open label study. Minor clinical events that were not recorded as adverse events in the controlled study were recorded as adverse events in the open label study.

The only adverse event considered possibly related to BabyBIG administration was a mild, transient erythematous rash of the face or trunk. The following table summarizes the occurrence of rash by day of study relative to day of treatment for the randomized, controlled clinical trial (RCT) and for the open label study (OLS).

* Both Gammagard 5% and Gammagard S/D 5% were used as placebo in this study.
^† Day 0 is the day of treatment.
^‡ In reference to treatment.

In the controlled study, when only treatment emergent events are considered, 14% of the BabyBIG-treated patients experienced erythematous rash during or after study infusion. Eight percent of placebo-treated patients also experienced erythematous rash in this study. A similar rash is known to occur both in infant botulism patients who have not received any IGIV products¹⁶ and in patients treated with other IGIVs^[2,3], making it difficult to ascertain the causality of the rash.

In the controlled study only, the following adverse events occurred in at least 5% of the patients receiving BabyBIG or placebo:

* Both Gammagard 5% and Gammagard S/D 5% were used as placebo in this study

In the open label study only, the following adverse events occurred in at least 5% of the patients:

Adverse event coding was used in the open label study to distinguish between minor clinical events that required no intervention and more significant events that required intervention. For example, “increased blood pressure” or “decreased blood pressure” was assigned when transient changes in blood pressure were observed, whereas “hypertension” or “hypotension” was assigned when more prolonged or significant changes were observed.

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.

Experience with BabyBIG

No adverse reactions have been identified or reported that are ascribed to the use of BabyBIG during postapproval use. Retrospective publications have shown safety-related information consistent with the safety-related information in the approved product labeling, and no new safety-related information has been presented for BabyBIG. ^{[22. 23]}

Experience with Other IGIV Products

Some classes of adverse reactions that have not been reported in BabyBIG clinical studies or postmarketing experience have been observed with the overall post-approval use of other IGIV products, as shown in the following table.

• Admixtures of BabyBIG with other drugs have not been evaluated. It is recommended that BabyBIG be administered separately from other drugs or medications that the patient may be receiving [see DOSAGE AND ADMINISTRATION (2)].
• Antibodies present in immune globulin preparations may interfere with the immune response to live virus vaccines such as polio, measles, mumps, and rubella; THEREFORE, VACCINATION WITH LIVE VIRUS VACCINES SHOULD BE DEFERRED UNTIL APPROXIMATELY THREE OR MORE MONTHS AFTER ADMINISTRATION OF BabyBIG. If such vaccinations were given shortly before or after BabyBIG administration, revaccination may be necessary.

BabyBIG has been studied for safety and efficacy only in patients below one year of age [see ADVERSE REACTIONS (6) and CLINICAL STUDIES (14)]. It has not been tested in other populations.