Thromb Haemost 2015; 113(04): 759-771
DOI: 10.1160/TH14-06-0514
Coagulation and Fibrinolysis
Schattauer GmbH

Safety of fibrinogen concentrate: analysis of more than 27 years of pharmacovigilance data

Cristina Solomon
1   CSL Behring, Marburg, Germany
2   Department of Anesthesiology, Perioperative Medicine and General Intensive Care, Paracelsus Medical University, Salzburg, Austria
,
Albrecht Gröner
1   CSL Behring, Marburg, Germany
,
Ye Jian
3   CSL Behring, King of Prussia, Pennsylvania, USA
,
Pendrak Inna
3   CSL Behring, King of Prussia, Pennsylvania, USA
› Author Affiliations
Financial Support: The investigation was funded by CSL Behring. Editorial assistance with manuscript preparation was provided by Meridian HealthComms and funded by CSL Behring.
Further Information

Publication History

Received: 13 June 2014

Accepted after major revision: 22 October 2014

Publication Date:
24 November 2017 (online)

Summary

Fibrinogen concentrate use as a haemostatic agent has been increasingly explored. This study evaluates spontaneous reports of potential adverse drug reactions (ADRs) that occurred during postmarketing pharmacovigilance of Haemocomplettan P/RiaSTAP, and reviews published safety data. This descriptive study analysed postmarketing safety reports recorded in the CSL Behring pharmacovigilance database from January 1986 to December 2013. A literature review of clinical studies published during the same period was performed. Commercial data indicated that 2,611,294 g of fibrinogen concentrate were distributed over the pharmacovigilance period, main-contribonding to 652,824 standard doses of 4 g each, across a range of clinical settings and indications. A total of 383 ADRs in 106 cases were reported (approximately 1 per 24,600 g or 6,200 standard doses). Events of special interest included possible hypersensitivity reactions in 20 cases (1 per 130,600 g or 32,600 doses), possible thromboembolic events in 28 cases (1 per 93,300 g or 23,300 doses), and suspected virus transmission in 21 cases (1 per 124,300 g or 31,000 doses). One virus transmission case could not be analysed due to insufficient data; for all other cases, a causal relationship was assessed as unlikely due to negative polymerase chain reaction tests and/or alternative explanations. The published literature revealed a similar safety profile. In conclusion, underreporting of ADRs is a known limitation of pharmacovigilance. However, the present assessment indicates that fibrinogen concentrate is administered across a range of indications, with few ADRs and a low thromboembolic event rate. Overall, fibrinogen concentrate showed a promising safety profile.

Institution to which work should be attributed: CSL Behring, Marburg, Germany.

 
  • References

  • 1 Blome M, Isgro F, Kiessling AH. et al. Relationship between factor XIII activity, fibrinogen, haemostasis screening tests and postoperative bleeding in cardiopulmonary bypass surgery. Thromb Haemost 2005; 93: 1101-1107.
  • 2 Charbit B, Mandelbrot L, Samain E. et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost 2007; 05: 266-273.
  • 3 Karlsson M, Ternstrom L, Hyllner M. et al. Plasma fibrinogen level, bleeding, and transfusion after on-pump coronary artery bypass grafting surgery: a prospective observational study. Transfusion 2008; 48: 2152-2158.
  • 4 Cortet M, Deneux-Tharaux C, Dupont C. et al. Association between fibrinogen level and severity of postpartum haemorrhage: secondary analysis of a prospective trial. Br J Anaesth 2012; 108: 984-989.
  • 5 Gerlach R, Tolle F, Raabe A. et al. Increased risk for postoperative hemorrhage after intracranial surgery in patients with decreased factor XIII activity: implications of a prospective study. Stroke 2002; 33: 1618-1623.
  • 6 Ucar HI, Oc M, Tok M. et al. Preoperative fibrinogen levels as a predictor of postoperative bleeding after open heart surgery. Heart Surg Forum 2007; 10: E392-E396.
  • 7 Levy JH, Welsby I, Goodnough LT. Fibrinogen as a therapeutic target for bleeding: a review of critical levels and replacement therapy. Transfusion 2013; 54: 1389-1405.
  • 8 Solomon C, Collis RE, Collins PW. Haemostatic monitoring during postpartum haemorrhage and implications for management. Br J Anaesth 2012; 109: 851-863.
  • 9 Rourke C, Curry N, Khan S. et al. Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes. J Thromb Haemost 2012; 10: 1342-1351.
  • 10 Hiippala ST, Myllyla GJ, Vahtera EM. Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates. Anesth Analg 1995; 81: 360-365.
  • 11 Erber WN. Massive blood transfusion in the elective surgical setting. Transfus Apher Sci 2002; 27: 83-92.
  • 12 Khan S, Brohi K, Chana M. et al. Hemostatic resuscitation is neither hemostatic nor resuscitative in trauma hemorrhage. J Trauma Acute Care Surg 2014; 76: 561-568.
  • 13 Schochl H, Voelckel W, Maegele M. et al. Trauma-associated hyperfibrinolysis. Hamostaseologie 2012; 32: 22-27.
  • 14 Schochl H, Cadamuro J, Seidl S. et al. Hyperfibrinolysis is common in out-ofhospital cardiac arrest: results from a prospective observational thromboelastometry study. Resuscitation 2013; 84: 454-459.
  • 15 Dirkmann D, Radu-Berlemann J, Gorlinger K. et al. Recombinant tissue-type plasminogen activator-evoked hyperfibrinolysis is enhanced by acidosis and inhibited by hypothermia but still can be blocked by tranexamic acid. J Trauma Acute Care Surg 2013; 74: 482-488.
  • 16 Martini WZ. The effects of hypothermia on fibrinogen metabolism and coagulation function in swine. Metabolism 2007; 56: 214-221.
  • 17 Weinkove R, Rangarajan S. Fibrinogen concentrate for acquired hypofibrinogenaemic states. Transfus Med 2008; 18: 151-157.
  • 18 Hunault-Berger M, Chevallier P, Delain M. et al. Changes in antithrombin and fibrinogen levels during induction chemotherapy with L-asparaginase in adult patients with acute lymphoblastic leukemia or lymphoblastic lymphoma. Use of supportive coagulation therapy and clinical outcome: the CAPELAL study. Haematologica 2008; 93: 1488-1494.
  • 19 CSL Behring. Haemocomplettan P Prescribing Information. 2008
  • 20 Solomon C, Wendt M. The Factor in the License: In Reference to “Use of Prothrombin Complex Concentrates and Fibrinogen Concentrates in the Perioperative Setting: A Systematic Review”. Transfus Med Rev 2013; 28: 31.
  • 21 CSL Behring. RiaSTAP Prescribing Information. 2009
  • 22 Fenger-Eriksen C, Ingerslev J, Sorensen B. Fibrinogen concentrate--a potential universal hemostatic agent. Expert Opin Biol Ther 2009; 09: 1325-1333.
  • 23 Solomon C, Pichlmaier U, Schoechl H. et al. Recovery of fibrinogen after administration of fibrinogen concentrate to patients with severe bleeding after cardiopulmonary bypass surgery. Br J Anaesth 2010; 104: 555-562.
  • 24 Fenger-Eriksen C, Jensen TM, Kristensen BS. et al. Fibrinogen substitution improves whole blood clot firmness after dilution with hydroxyethyl starch in bleeding patients undergoing radical cystectomy: a randomized, placebo-controlled clinical trial. J Thromb Haemost 2009; 07: 795-802.
  • 25 Fenger-Eriksen C, Lindberg-Larsen M, Christensen AQ. et al. Fibrinogen concentrate substitution therapy in patients with massive haemorrhage and low plasma fibrinogen concentrations. Br J Anaesth 2008; 101: 769-773.
  • 26 Karlsson M, Ternstrom L, Hyllner M. et al. Prophylactic fibrinogen infusion reduces bleeding after coronary artery bypass surgery. A prospective randomised pilot study. Thromb Haemost 2009; 102: 137-144.
  • 27 Rahe-Meyer N, Pichlmaier M, Haverich A. et al. Bleeding management with fibrinogen concentrate targeting a high-normal plasma fibrinogen level: a pilot study. Br J Anaesth 2009; 102: 785-792.
  • 28 Rahe-Meyer N, Solomon C, Winterhalter M. et al. Thromboelastometry-guided administration of fibrinogen concentrate for the treatment of excessive intraoperative bleeding in thoracoabdominal aortic aneurysm surgery. J Thorac Cardiovasc Surg 2009; 138: 694-702.
  • 29 Gorlinger K, Dirkmann D, Hanke AA. et al. First-line therapy with coagulation factor concentrates combined with point-of-care coagulation testing is associated with decreased allogeneic blood transfusion in cardiovascular surgery: a retrospective, single-center cohort study. Anesthesiology 2011; 115: 1179-1191.
  • 30 Rahe-Meyer N, Solomon C, Hanke A. et al. Effects of fibrinogen concentrate as first-line therapy during major aortic replacement surgery: a randomized, placebo-controlled trial. Anesthesiology 2013; 118: 40-50.
  • 31 Weber CF, Gorlinger K, Meininger D. et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 2012; 117: 531-547.
  • 32 Schochl H, Nienaber U, Hofer G. et al. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care 2010; 14: R55.
  • 33 Schochl H, Nienaber U, Maegele M. et al. Transfusion in trauma: thromboelastometry-guided coagulation factor concentrate-based therapy versus standard fresh frozen plasma-based therapy. Crit Care 2011; 15: R83.
  • 34 Bell SF, Rayment R, Collins PW. et al. The use of fibrinogen concentrate to correct hypofibrinogenaemia rapidly during obstetric haemorrhage. Int J Obstet Anesth 2010; 19: 218-223.
  • 35 Warmuth M, Mad P, Wild C. Systematic review of the efficacy and safety of fibrinogen concentrate substitution in adults. Acta Anaesthesiol Scand 2012; 56: 539-548.
  • 36 Kozek-Langenecker S, Sorensen B, Hess JR. et al. Clinical effectiveness of fresh frozen plasma compared with fibrinogen concentrate: a systematic review. Crit Care 2011; 15: R239.
  • 37 Aubron C, Reade MC, Fraser JF. et al. Efficacy and safety of fibrinogen concentrate in trauma patients-a systematic review. J Crit Care 2013; 29: 471 e11–e17.
  • 38 Wikkelso A, Lunde J, Johansen M. et al. Fibrinogen concentrate in bleeding patients. Cochrane Database Syst Rev 2013; 08: CD008864.
  • 39 Kozek-Langenecker SA, Afshari A, Albaladejo P. et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2013; 30: 270-382.
  • 40 Solomon C, Hagl C, Rahe-Meyer N. Time course of haemostatic effects of fibrinogen concentrate administration in aortic surgery. Br J Anaesth 2013; 110: 947-956.
  • 41 Dickneite G, Pragst I, Joch C. et al. Animal model and clinical evidence indicating low thrombogenic potential of fibrinogen concentrate (Haemocomplettan P). Blood Coagul Fibrinolysis 2009; 20: 535-540.
  • 42 Martini J, Maisch S, Pilshofer L. et al. Fibrinogen concentrate in dilutional coagulopathy: a dose study in pigs. Transfusion 2014; 54: 149-157.
  • 43 Danes AF, Cuenca LG, Bueno SR. et al. Efficacy and tolerability of human fibrinogen concentrate administration to patients with acquired fibrinogen deficiency and active or in high-risk severe bleeding. Vox Sang 2008; 94: 221-226.
  • 44 Thorarinsdottir HR, Sigurbjornsson FT, Hreinsson K. et al. Effects of fibrinogen concentrate administration during severe hemorrhage. Acta Anaesthesiol Scand 2010; 54: 1077-1082.
  • 45 Ahmed S, Harrity C, Johnson S. et al. The efficacy of fibrinogen concentrate compared with cryoprecipitate in major obstetric haemorrhage--an observational study. Transfus Med 2012; 22: 344-349.
  • 46 Solomon C, Schochl H, Hanke A. et al. Haemostatic therapy in coronary artery bypass graft patients with decreased platelet function: comparison of fibrinogen concentrate with allogeneic blood products. Scand J Clin Lab Invest 2012; 72: 121-128.
  • 47 Bilecen S, Peelen LM, Kalkman CJ. et al. Fibrinogen concentrate therapy in complex cardiac surgery. J Cardiothorac Vasc Anesth 2013; 27: 12-17.
  • 48 Weiss G, Lison S, Glaser M. et al. Observational study of fibrinogen concentrate in massive hemorrhage: evaluation of a multicenter register. Blood Coagul Fibrinolysis 2011; 22: 727-734.
  • 49 Kreuz W, Meili E, Peter-Salonen K. et al. Efficacy and tolerability of a pasteurised human fibrinogen concentrate in patients with congenital fibrinogen deficiency. Transfus Apher Sci 2005; 32: 247-253.
  • 50 Gollop ND, Chilcott J, Benton A. et al. National audit of the use of fibrinogen concentrate to correct hypofibrinogenaemia. Transfus Med 2012; 22: 350-355.
  • 51 Kreuz W, Meili E, Peter-Salonen K. et al. Pharmacokinetic properties of a pasteurised fibrinogen concentrate. Transfus Apher Sci 2005; 32: 239-246.
  • 52 Manco-Johnson MJ, Dimichele D, Castaman G. et al. Pharmacokinetics and safety of fibrinogen concentrate. J Thromb Haemost 2009; 07: 2064-2069.
  • 53 Tanaka KA, Egan K, Szlam F. et al. Transfusion and hematologic variables after fibrinogen or platelet transfusion in valve replacement surgery: preliminary data of purified lyophilized human fibrinogen concentrate versus conventional transfusion. Transfusion 2014; 54: 109-118.
  • 54 Haas T, Fries D, Velik-Salchner C. et al. Fibrinogen in craniosynostosis surgery. Anesth Analg 2008; 106: 725-731.
  • 55 Wafaisade A, Lefering R, Maegele M. et al. Administration of fibrinogen concentrate in exsanguinating trauma patients is associated with improved survival at 6 hours but not at discharge. J Trauma Acute Care Surg 2013; 74: 387-395.
  • 56 Groner A. Reply. Pereira A. Cryoprecipitate versus commercial fibrinogen concentrate in patients who occasionally require a therapeutic supply of fibrinogen: risk comparison in the case of an emerging transfusion-transmitted infection. Haematologica 2007; 92: 846-849 Haematologica 2008; 93: e24–27.
  • 57 Velthove KJ, Over J, Abbink K. et al. Viral safety of human plasma-derived medicinal products: impact of regulation requirements. Transfus Med Rev 2013; 27: 179-183.
  • 58 Acharya SS, Coughlin A, Dimichele DM. et al. Rare Bleeding Disorder Registry: deficiencies of factors II, V, VII, X, XIII, fibrinogen and dysfibrinogenemias. J Thromb Haemost 2004; 02: 248-256.
  • 59 Mannucci PM, Duga S, Peyvandi F. Recessively inherited coagulation disorders. Blood 2004; 104: 1243-1252.
  • 60 Ni H, Denis CV, Subbarao S. et al. Persistence of platelet thrombus formation in arterioles of mice lacking both von Willebrand factor and fibrinogen. J Clin Invest 2000; 106: 385-392.
  • 61 Remijn JA, Wu YP, Ijsseldijk MJ. et al. Absence of fibrinogen in afibrinogenemia results in large but loosely packed thrombi under flow conditions. Thromb Haemost 2001; 85: 736-742.
  • 62 Drews RE. Critical issues in hematology: anemia, thrombocytopenia, coagulopathy, and blood product transfusions in critically ill patients. Clin Chest Med 2003; 24: 607-622.
  • 63 Narick C, Triulzi DJ, Yazer MH. Transfusion-associated circulatory overload after plasma transfusion. Transfusion 2012; 52: 160-165.
  • 64 O’Shaughnessy DF, Atterbury C, Bolton Maggs P. et al. Guidelines for the use of fresh-frozen plasma, cryoprecipitate and cryosupernatant. Br J Haematol 2004; 126: 11-28.
  • 65 Peyvandi F, Cattaneo M, Inbal A. et al. Rare bleeding disorders. Haemophilia 2008; 14 (Suppl. 03) 202-210.
  • 66 Murad MH, Stubbs JR, Gandhi MJ. et al. The effect of plasma transfusion on morbidity and mortality: a systematic review and meta-analysis. Transfusion 2010; 50: 1370-1383.
  • 67 Murphy GJ, Reeves BC, Rogers CA. et al. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 2007; 116: 2544-2552.
  • 68 Spiess BD. Platelet transfusions: the science behind safety, risks and appropriate applications. Best Pract Res Clin Anaesthesiol 2010; 24: 65-83.
  • 69 Yang L, Stanworth S, Baglin T. Cryoprecipitate: an outmoded treatment?. Transfus Med 2012; 22: 315-320.
  • 70 Gorlinger K, Kozek-Langenecker SA, Spahn DR. Outcome criteria such as massive transfusion are inadequate for matching and result in questionable conclusions. J Trauma Acute Care Surg 2013; 75: 744-745.
  • 71 Jacob D, Marron B, Ehrlich J. et al. Pharmacovigilance as a tool for safety and monitoring: a review of general issues and the specific challenges with end-stage renal failure patients. Drug Healthc Patient Saf 2013; 05: 105-112.