In case of overdose (i.e. a patient receives a concentration or amount of dibotermin alfa greater than recommended), treatment should be supportive.
Use of InductOs in patients undergoing cervical spine surgery in amounts lower than or similar to those for lumbar interbody fusion has been associated with reports of localised oedema severe enough to result in airway compromise.
3 years
InductOs is contraindicated for patients with:
-
- Skeletal immaturity
- Any active malignancy or patient undergoing treatment for a malignancy
- An active infection at the operative site
- Persistent compartment syndrome or neurovascular residua of compartment syndrome
- Pathological fractures such as those observed in (but not limited to) Paget's disease or in metastatic bone
Powder:
Sucrose
Glycine
Glutamic acid
Sodium chloride
Polysorbate 80
Sodium hydroxide
Solvent:
Water for injections
Matrix:
Bovine Type I collagen
Powder, solvent and matrix for implantation matrix.
The powder is white. The solvent is a clear colourless liquid. The matrix is white.
Summary of the safety profile
The most common adverse reactions for InductOs in lumbar interbody fusion surgery were radiculopathic events, and in acute tibia fracture surgery it was localised infection. The most severe adverse reaction is localised oedema in cervical spine surgery. The incidence of adverse reactions with InductOs was not affected by gender, age or race.
Tabulated list of adverse reactions
Over 1700 patients have received InductOs in clinical studies. In the long-bone fracture studies, over 500 patients received InductOs. In lumbar interbody fusion studies, over 600 patients received InductOs. The remaining patients participated in studies using InductOs for indications not currently approved in the EU. These data are supplemented with information from use of InductOs in the general population.
The frequency of adverse reactions in patients exposed to treatment with InductOs is presented in the table below. Frequencies are defined as very common (>1/10) or common (>1/100 to <1/10). No reactions are observed with the frequency uncommon (>1/1,000 to <1/100), rare (>1/10,000 to <1/1,000) or very rare (<1/10,000).
The frequencies of adverse reactions identified during post-marketing use of InductOs are not known as these reactions were reported from a population of uncertain size.
| System organ class | Frequencies | ||
| Very common | Common | Unknown | |
| General disorders and administration site conditions | Device dislocation1* Fluid collection2* | ||
| Musculoskeletal and connective tissue disorders | Heterotopic ossification1, 3* | Osteolysis* Resorption bone increased* | |
| Nervous system disorders | Radiculopathic events1, 4 | ||
| Infections and infestations | Localised infection5* | ||
1 Observed during use in lumbar interbody fusion
2 Fluid collection includes localised oedema, pseudocyst and implant site effusion.
3 Heterotopic ossification includes exostosis, extraskeletal ossification, postoperative heterotopic calcification, bone formation increased and implant site calcification.
4 Radiculopathic events includes radiculitis, lumbar radiculopathy, radicular pain, radiculitis lumbosacral, radiculopathy and sciatica.
5 Observed during use in acute tibia fractures
* Additional information provided below
Description of selected adverse reactions
New bone formation and bone remodelling
As part of the pharmacological mechanism of action of dibotermin alfa, bone remodelling occurs. In this process, both bone resorption and formation occur. In some circumstances an exaggeration of these processes can lead to complications such as nerve compression (due to heterotopic ossification) or device dislocation (associated with bone resorption or osteolysis).
During two years follow-up in clinical trials for lumbar interbody fusion using a posterior approach, heterotopic ossification seen on radiographs occurred more often in patients treated with InductOs compared with autograft. This radiographic finding may be asymptomatic or symptomatic.
Fluid collection
Due to the angiogenic activity of InductOs, fluid collection (pseudocyst, localised oedema, implant site effusion) can occur, sometimes encapsulated, sometimes resulting in nerve compression and/or pain.
Localised oedema was common when InductOs was used for cervical spine fusion. The oedema was delayed in onset and, in some cases, severe enough to result in airway compromise.
Localised infection
Localised infection specific to the fractured limb was very common (>1/10) in patients in a clinical study in which the intramedullary canal was reamed to cortical chatter.). For use with unreamed nails, estimated rates of infection were similar between treatment and control groups in a study (21% versus 23%, respectively).
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 the national reporting system:
United Kingdom
Yellow Card Scheme
Website: www.mhra.gov.uk/yellowcard
Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, acute and repeated exposure toxicity and genotoxicity.
In reproductive toxicity studies in rats, where dibotermin alfa was administered intravenously to maximize systemic exposure, increased foetal weight and increased foetal ossification was observed and a treatment-related effect could not be ruled out.).
InductOs has been studied in a canine spinal implantation model. InductOs was implanted directly onto the exposed dura following a laminectomy. Although narrowing of the neuroforamen and stenosis was observed, no mineralization of the dura, no spinal cord stenosis, and no neurological deficits subsequent to the application of InductOs were observed.
InductOs is indicated for single-level lumbar interbody spine fusion as a substitute for autogenous bone graft in adults with degenerative disc disease who have had at least 6 months of non-operative treatment for this condition.
InductOs is indicated for the treatment of acute tibia fractures in adults, as an adjunct to standard care using open fracture reduction and intramedullary unreamed nail fixation.
Pharmacotherapeutic group: Drugs for treatment of bone diseases, Bone Morphogenetic Proteins, ATC code: M05BC01
Dibotermin alfa is an osteoinductive protein that results in the induction of new bone tissue at the site of implantation. Dibotermin alfa binds to receptors on the surface of mesenchymal cells and causes cells to differentiate into cartilage- and bone-forming cells. The differentiated cells form trabecular bone as the matrix is degraded, with vascular invasion evident at the same time. The bone formation process develops from the outside of the implant towards the centre, until the entire InductOs implant is replaced by trabecular bone.
Placement of InductOs into trabecular bone resulted in transient resorption of the bone surrounding the implant, followed by replacement with new, more dense bone. Remodeling of the surrounding bone occurs in a manner that is consistent with the biomechanical forces placed on it. The ability of InductOs to support bone remodeling may be responsible for the biological and biomechanical integration of the new bone induced by InductOs with that of the surrounding bone. Radiographic, biomechanical and histologic evaluation of the induced bone indicates that it functions biologically and biomechanically as native bone. Furthermore, non-clinical studies have indicated that the bone induced by InductOs, if fractured, can repair itself in a manner indistinguishable from native bone.
Non-clinical studies have suggested that bone formation initiated by InductOs is a self-limiting process, forming a well-defined volume of bone. This self-limitation is likely due to the loss of dibotermin alfa from the implant site, as well as the presence of BMP inhibitors in the surrounding tissues. In addition, several non-clinical studies indicate that there is a negative feedback mechanism at the molecular level that limits bone induction by BMPs.
Histological evidence from animal studies of lumbar interbody fusion using anterior or posterior surgical approaches showed dibotermin alfa administered with titanium, PEEK or allograft interbody devices was biocompatible and produced consistently high rates of fusion independent of surgical approach or device material with less fibrous tissue evident compared with autograft.
Clinical pharmacology studies demonstrate that the matrix alone is not osteoinductive and is no longer present in biopsies taken as early as 16 weeks post-implantation.
Pharmacodynamic information specific to lumbar interbody fusion studies
The efficacy and safety of InductOs were demonstrated in a randomised, controlled, multicenter, non-inferiority study of 279 patients aged 19-78 years undergoing an open anterior lumbar interbody fusion procedure. Patients had received at least six months of non-operative treatment prior to treatment with InductOs for anterior lumbar spine fusion. Patients were randomised to receive a titanium interbody fusion device filled with either InductOs or autogenous bone graft taken from the iliac crest.
At 24 months post-operation, InductOs was demonstrated to be statistically non-inferior to autogenous bone graft with a success rate for radiologically determined fusion of 94.4% for InductOs versus 88.9% for autogenous bone graft (95% two-sided CI of the difference: -1.53, 12.46). For pain and disability (Oswestry score), the success rate was 72.9% in the group using InductOs versus 72.5% in the group using autogenous bone graft (95% two-sided CI of the difference: -11.2, 12.0).
A post-hoc meta-analysis of 6 controlled clinical trials with data from patients treated with InductOs or autogenous bone graft administered using CE-marked interbody fusion devices or allograft bone spacers and various surgical approaches showed that, at 24 months post-surgery, InductOs was associated with a higher fusion success rate (95%, 241 out of 255 patients) compared with autogenous bone graft (85 %, 177 out of 209 patients), with an odds ratio of 3.26 (95% CI: 1.172, 9.075; P = 0.024). The estimated absolute difference in fusion success rate between InductOs and autogenous bone graft was 11.7% (95% CI: 0.8%, 22.5%; P = 0.035).
In a pooled safety data analysis of 8 clinical trials at 24 months post-surgery, the frequency of patients with pseudarthrosis was approximately 2-fold lower following treatment with InductOs (4.8%, 22 out of 456 patients) compared with autogenous bone graft (12.7%, 31 out of 244 patients).
Pharmacodynamic information specific to acute tibia fracture studies
The efficacy of InductOs was demonstrated in a multinational, randomized, controlled, single-blind study of 450 patients (age range 18 to 87 years; 81% male) with open tibial shaft fractures requiring surgical management. Patients received (in a 1:1:1 ratio) standard care (control group) consisting of intramedullary (IM) nail fixation and routine soft-tissue management, standard care plus InductOs 0.75 mg/ml, or standard care plus InductOs 1.5 mg/ml. Patients were followed for 12 months after soft-tissue closure.
In the acute tibia fracture pivotal trial, InductOs increased the probability of fracture healing; patients treated with InductOs 1.5 mg/ml had a 44% reduced risk for treatment failure (secondary intervention to promote fracture healing) compared with patients in the standard-care group (RR = 0.56; 95% CI = 0.40 to 0.78). These results were independently corroborated by a radiology panel blinded to treatment. The number of secondary and subsequent interventions was significantly reduced for the InductOs patients, particularly with regard to more invasive interventions, such as bone graft and exchange nailing (P = 0.0326).
The proportion of patients healed after treatment with InductOs 1.5 mg/ml was significantly higher at all visits from 10 weeks to 12 months post-operative, suggesting accelerated fracture healing.
InductOs 1.5 mg/ml was significantly effective (compared to standard care) in patients both with or without a history of smoking.
Severity of fractures: Treatment with InductOs 1.5 mg/ml was significantly effective in all fracture classes, including severe Gustilo IIIB fractures (52% reduced risk of secondary interventions as compared to standard-care patients).
The proportion of patients with healed soft-tissue wounds was significantly higher at the 6-week post-treatment visit in the InductOs 1.5 mg/ml group compared with the standard-care group (83% versus 65%; P= 0.0010). The proportion of patients with hardware failure (locking screws bent or broken) was significantly lower in the InductOs 1.5 mg/ml group as compared to standard-care group (11% versus 22%; P= 0.0174).
InductOs is active at the site of implantation. In two exploratory studies, pre- and post-surgery serum samples were collected from a few long-bone fracture patients. Dibotermin alfa was not detectable in serum.
In animal studies (rats) using InductOs containing radiolabelled dibotermin alfa, the mean residence time at the site of implantation was 4-8 days. Peak levels of circulating dibotermin alfa (0.1% of the implanted dose) were observed within 6 hours following implantation. When injected intravenously, the terminal half-life of dibotermin alfa was 16 minutes in rats and 6.7 minutes in cynomolgus monkeys. It is concluded, therefore, that at the site of implantation, dibotermin alfa is slowly released from the matrix and rapidly cleared when taken up into the systemic circulation.
06/2015
Medtronic BioPharma B.V.
Earl Bakkenstraat 10
6422 PJ Heerlen
The Netherlands
tel +31 (0) 45 566 8000
fax +31 (0) 45 566 8012
Do not store above 30°C. Do not freeze.
Store in the original package in order to protect from light.
InductOs 4 mg pack contains:
- Powder in a vial (10 ml; Type I glass) with a stopper (bromobutyl rubber).
- Solvent in a vial (10 ml; Type I glass) with a stopper (bromobutyl rubber).
- Two matrices (2.5 cm x 5 cm) in a blister package (polyvinyl chloride - PVC).
- Two syringes (5 ml; polypropylene).
- Two needles (stainless steel).
InductOs 12 mg pack contains:
- Powder in a vial (20 ml; Type I glass) with a stopper (bromobutyl rubber).
- Solvent in a vial (10 ml; Type I glass) with a stopper (bromobutyl rubber).
- One matrix (7.5 cm x 10 cm) in a blister package (polyvinyl chloride - PVC).
- Two syringes (10 ml; polypropylene).
- Two needles (stainless steel).
Not all pack sizes may be marketed.
EU/1/02/226/001
EU/1/02/226/002
Pregnancy
There are no or limited amount of data from the use of dibotermin alfa in pregnant women.
Animal studies have shown reproductive toxicity.
Due to the unknown risks to the foetus associated with the potential development of neutralising antibodies to dibotermin alfa, InductOs is not recommended during pregnancy and in women of childbearing potential not using contraception.
Breast-feeding
There is no information on the excretion of dibotermin alfa/metabolites in human milk. Considering the type of product, systemic exposure of the suckling infant is not expected, however a risk to the newborn/infant cannot be excluded.
A decision must be made whether to discontinue breast-feeding or to abstain from InductOs therapy taking into account the benefit of breast feeding for the child and the benefit of therapy for the woman.
Fertility
No impact on fertility was detected in non-clinical studies. No clinical data are available; potential risk for human is unknown.
One vial contains 4 mg (4 mg pack) or 12 mg (12 mg pack) dibotermin alfa.
2 may compromise the safety and efficacy of InductOs.
Cervical spine surgery
The safety and efficacy of InductOs in cervical spine surgery have not been established, and InductOs should not be used in this condition. Localised oedema associated with the use of InductOs has been reported in patients undergoing cervical spine surgery. The oedema was delayed in onset and usually occurred in the first week post-operation. In some cases, the oedema was severe enough to result in airway compromise.
Malignancy
InductOs should not be used in patients with history or clinical suspicion of malignancy at the site of application.
Heterotopic ossification
Use of InductOs may cause heterotopic ossification at the site of implantation and/or the surrounding tissues, which may result in complications.
Bone resorption increased
InductOs can cause initial resorption of surrounding trabecular bone as evidenced by radiolucency. Therefore, in the absence of clinical data, the product should not be used for direct applications to trabecular bone where transient bone resorption may create a risk of bone fragility.
Fluid collections
Formation of a fluid collection (pseudocyst, localised oedema, implant site effusion), sometimes encapsulated and in some cases resulting in nerve compression and pain, has been reported associated with the use of InductOs. Clinical intervention (aspiration and/or surgical removal) may be required if symptoms persist.
Immune response
Both dibotermin alfa and bovine Type I collagen have been found to elicit immune responses in patients.
Anti-dibotermin alfa antibodies: In spine fusion studies, 1.3% of patients receiving InductOs developed antibodies to dibotermin alfa versus 0.8% of patients receiving autogenous bone graft. In long-bone fracture studies, 6.3% of patients receiving dibotermin alfa with bovine Type I collagen matrix developed antibodies to dibotermin alfa versus 1.3% in the control group. All patients who were tested for neutralizing antibodies to bone morphogenetic protein-2 were negative.
Anti-bovine Type I collagen antibodies: In spine fusion studies, 13.5% of patients receiving InductOs developed antibodies to bovine Type I collagen versus 14.3% of patients receiving autogenous bone graft. In long-bone fracture studies, 13.0% of patients receiving dibotermin alfa with bovine Type I collagen matrix developed antibodies to bovine Type I collagen versus 5.3% of control patients. None of the patients with positive titers to bovine Type I collagen had cross-reacting antibodies to human type I collagen.
Although no association with clinical outcome or undesirable effects could be observed in clinical studies, the possibility of developing neutralising antibodies or hypersensitivity-type reactions cannot be excluded. The possibility of an immune response to the product should be considered in cases where an undesirable effect with immunological background is suspected. Special consideration of risks and benefits should be given for patients who have previously received injectable collagen. In the absence of any experience, the repeat use of InductOs is not recommended.
Special populations
The safety and efficacy of the use of InductOs in patients with known autoimmune disease have not been established. These autoimmune diseases include rheumatoid arthritis, systemic lupus erythematosus, scleroderma, Sjögren's syndrome and dermatomyositis/polymyositis.
The safety and efficacy of InductOs have not been demonstrated in patients with metabolic bone diseases.
No studies have been performed in patients with hepatic, renal or cardiac impairment.
For these special populations, the physician is advised to give a careful consideration to the benefits and risks for the specific patient before using InductOs. A close monitoring of the patient for any adverse reactions and the success of the treatment is recommended.
Excipients
This medicinal product contains less than 1 mmol (23 mg) sodium per maximum dose (two 12 mg packs), i.e. it is essentially 'sodium-free'.
Special warnings and precautions for use specific to lumbar interbody fusion
The safety and efficacy of InductOs have not been established in the following conditions:
- used with interbody fusion devices made from material other than titanium, PEEK or bone
- implanted at locations other than lumbar spine
- used in surgical techniques other than lumbar interbody fusion
To avoid exaggerated pharmacological effects of InductOs, care and caution should be used to prevent overfilling the lumbar interbody fusion device and/or the anterior portion of the intervertebral disc space.
Heterotopic ossification
Bone formation outside the intervertebral disc space is not desirable as it may have a deleterious impact on local neurovascular structures.
In clinical trials when degenerative disc disease was treated by a posterior lumbar interbody fusion procedure with dibotermin alfa, posterior bone formation was observed in CT scans. In some cases it may lead to nerve compression potentially requiring surgical intervention. As a precaution, a physical barrier between the matrix and any neurological tissue must be re-created.
Device dislocation
Device dislocation can occur after the use of InductOs in spinal fusion surgery that may necessitate surgical revision.
Special warnings and precautions for use specific to acute tibia fractures
InductOs is intended for use in patients with the following:
- adequate fracture reduction and stabilization to ensure mechanical stability
- adequate neurovascular status (e.g. absence of compartment syndrome, low risk of amputation)
- adequate haemostasis (i.e., providing a relatively dry implantation site)
- absence of large segmental defect repair of long bones, in which significant soft tissue compression can occur
The implant may only be administered to the fracture site under adequate vision and with utmost care.
Efficacy information in tibia fracture is available only from controlled clinical trials in which open tibial fractures were treated using intramedullary nail fixation. In a clinical study in which the intramedullary canal was reamed to cortical chatter, an increased rate of infection was observed in the InductOs-treated group versus the standard of care control group. The use of InductOs with reamed nails in open tibial fracture repair is not recommended.
InductOs does not provide mechanical stability and should not be used to fill a void in the presence of compressive forces. Long-bone fracture and soft-tissue management procedures should be based on standard practice, including control of infection.
InductOs has no or negligible influence on the ability to drive and use machines.
InductOs should be used by an appropriately qualified surgeon.
Posology
InductOs must be prepared exactly in accordance with the directions for preparation.
The appropriate dose is determined by the volume of wetted matrix required for the intended indication.
If the surgical setting requires that only a portion of the product is needed, the wetted matrix should be cut to the desired size, and the unused portion must be discarded.
Dosing table for InductOs 4 mg pack
| InductOs wetted matrices (4 mg pack) | Dimensions of wetted matrix | Volume of wetted matrix | Concentration of wetted matrix | Dibotermin alfa dose |
| 1 matrix | 2.5 cm x 5 cm | 1.3 cm3 | 1.5 mg/cm3 | 2 mg |
| 2 matrices | 2 x (2.5 cm x 5 cm) | 2.7 cm3 | 1.5 mg/cm3 | 4 mg |
Dosing table for InductOs 12 mg pack
| Portion of InductOs wetted matrix (12 mg pack) | Dimensions of wetted matrix | Volume of wetted matrix | Concentration of wetted matrix | Dibotermin alfa dose |
| 1/6 of the matrix | 2.5 cm x 5 cm | 1.3 cm3 | 1.5 mg/cm3 | 2 mg |
| 1/3 of the matrix | 2.5 cm x 10 cm | 2.7 cm3 | 1.5 mg/cm3 | 4 mg |
| 2/3 of the matrix | 5 cm x 10 cm | 5.3 cm3 | 1.5 mg/cm3 | 8 mg |
| Entire matrix | 7.5 cm x 10 cm | 8 cm3 | 1.5 mg/cm3 | 12 mg |
Lumbar interbody fusion surgery
The required volume of InductOs is determined by the intervertebral disc space and the size, shape, and internal volume of the lumbar interbody fusion device(s) being used. Care must be taken not to compress the product or overfill the volume intended for new bone formation.
Typically, 4 mg (2.7 cm3 of wetted matrix) of InductOs is used in the intervertebral disc space. The maximum dosage is limited to 8 mg (5.3 cm3 of wetted matrix) of InductOs in the intervertebral disc space. InductOs must be placed within the lumbar interbody fusion device(s) or in the anterior portion of the intervertebral disc space.
Acute tibia fracture surgery
The volume of InductOs to be implanted is determined by the fracture anatomy and the ability to close the wound without overly packing or compressing the product. Generally, each fracture site is treated with the contents of one 12 mg pack. The maximum dosage is limited to 24 mg (2 entire 12 mg pack matrices).
Paediatric population
The safety and efficacy of InductOs in children below 18 years of age have not been established.
No data are available.
Method of administration
The medicinal product is administered by implantation.
Failure to follow the method of administration of InductOs may compromise its safety and efficacy.
Forceps should be used to handle InductOs. During handling and implantation, minimize fluid loss from the matrix. Do not squeeze.
Lumbar interbody fusion surgery
InductOs must not be used alone for this indication, but should be used with an approved (CE-marked) lumbar interbody fusion device(s). Compatibility has been demonstrated with titanium, polyetheretherketone (PEEK), and allograft bone.
Care and caution must be used to prevent overfilling the lumbar interbody fusion device and/or the anterior portion of the intervertebral disc space.
Pre-Implantation
4 mg pack:
The matrix is pre-cut in 2 pieces each of 2.5 x 5 cm.
12 mg pack:
The matrix is in 1 piece of 7.5 cm x 10 cm. The wetted matrix should be cut into 6 equal pieces (approximately 2.5 x 5 cm) as an aid for dose selection. The selected pieces can be further cut as required.
The hollow geometry of the lumbar interbody fusion device must be carefully and loosely filled with the volume of InductOs corresponding to the internal volume of the device.
Implantation
As per standard practice, disc material and the cartilaginous portions of the vertebral endplates should be removed, preserving the cortical portions of the endplates, and haemostasis should be achieved.
For instructions to implant the lumbar interbody fusion device, please refer to the manufacturer's instructions for use.
InductOs must not be implanted posterior to the lumbar interbody fusion device where direct access to the spinal canal and/or nerve root(s) is possible. If leakage into the spinal canal and the nerve root is possible, a physical barrier between the matrix and any neurological tissue must be re-created by using, for example, local bone or allograft.
Post-Implantation
Once InductOs and the lumbar interbody fusion device(s) are implanted, the inside of the intervertebral disc space must not be irrigated. Outside the intervertebral disc space, the surgical field should be irrigated as needed, and any fluid loss from the wetted matrix should be washed away.
If a surgical drain is required, the drain should be placed remotely from the implantation site or, preferably, one layer superficial to the implantation site.
Acute tibia fracture surgery
Pre-Implantation
Definitive fracture reduction, fixation, and haemostasis should be achieved prior to InductOs implantation.
InductOs should be folded or cut as needed prior to implantation.
Implantation
InductOs is implanted after the completion of standard fracture and wound management (i.e. at the time of soft-tissue closure).
To the extent possible, the accessible surface area of the fracture (fracture lines and defects) should be covered with InductOs. InductOs should be placed bridging the fracture region and making good contact with the major proximal and distal fragments.
InductOs may be placed into a void (loosely packed), folded, rolled or wrapped, as the geometry of the fracture requires. InductOs does not provide mechanical stability and should not be used to fill a void in the presence of compressive forces.
Post-Implantation
Once InductOs is implanted, do not irrigate the wound.
If a surgical drain is required, the drain should be placed remotely from the implantation site or, preferably, one layer superficially to the implantation site.
To achieve maximum potential efficacy, it is important to attain complete soft-tissue coverage of InductOs following its implantation.
InductOs is prepared immediately prior to use. Dibotermin alfa must only be used following reconstitution with the solvent and matrix provided in the InductOs pack.
Once prepared, InductOs contains dibotermin alfa at a concentration of 1.5 mg/ml.
InductOs must not be used in concentrations higher than 1.5 mg/ml.
Product preparation
To prevent overloading the matrix, it is important to reconstitute the dibotermin alfa and to wet the entire matrix as described below.
4 mg pack:
In the non-sterile field
1. Using sterile technique, place one syringe, one needle and the matrix inner package in the sterile field.
2. Disinfect the stoppers of the dibotermin alfa and solvent vials.
3. Using the remaining syringe and needle from the pack, reconstitute the dibotermin alfa vial with 3.2 ml of solvent. Slowly inject the solvent into the vial containing the lyophilised dibotermin alfa. Swirl the vial gently to aid reconstitution. Do not shake. Discard syringe and needle after use.
4. Disinfect the stopper of the reconstituted dibotermin alfa vial.
| In the sterile field | 3.2 ml solvent |
5. Peel open the interior package of the matrices and leave the matrices in their trays.
6. Using aseptic transfer technique and the syringe and needle from step 1, withdraw 2.8 ml of the reconstituted dibotermin alfa solution from the vial in the non-sterile field, holding up the inverted vial to facilitate withdrawal.
7. Leaving the matrix in its tray, UNIFORMLY distribute 1.4 ml of dibotermin alfa solution on each of the two 2.5 x 5 cm matrices, following the pattern in the figure below.
9. Wait a MINIMUM of 15 minutes before using the prepared InductOs product. The product must be used within 2 hours after preparation.
12 mg pack:
In the non-sterile field
1. Using sterile technique, place one syringe, one needle and the matrix inner package in the sterile field.
2. Disinfect the stoppers of the dibotermin alfa and solvent vials.
3. Using the remaining syringe and needle from the pack, reconstitute the dibotermin alfa vial with 8.4 ml of solvent. Slowly inject the solvent into the vial containing the lyophilised dibotermin alfa. Swirl the vial gently to aid reconstitution. Do not shake. Discard syringe and needle after use.
4. Disinfect the stopper of the reconstituted dibotermin alfa vial.
In the sterile field
5. Peel open the interior package of the matrix and leave the matrix in its tray.
6. Using aseptic transfer technique and the syringe and needle from step 1, withdraw 8.0 ml of the reconstituted dibotermin alfa solution from the vial in the non-sterile field, holding up the inverted vial to facilitate withdrawal.
7. Leaving the matrix in its tray, UNIFORMLY distribute the dibotermin alfa solution on the matrix, following the pattern in the figure below.
8. Wait a MINIMUM of 15 minutes before using the prepared InductOs product. The product must be used within 2 hours after preparation.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
Date of first authorisation: 9 September 2002
Date of latest renewal: 20 July 2012
No interaction studies have been performed.
As dibotermin alfa is a protein and has not been identified in the general circulation, it is an unlikely candidate for pharmacokinetic drug-drug interactions.
In acute tibia fracture clinical trials, more InductOs patients receiving concomitant NSAIDs for 14 consecutive days experienced mild or moderate adverse events related to wound healing (e.g., wound drainage) than InductOs patients not taking NSAIDs. Although patient outcome was not affected, an interaction between NSAIDs and InductOs cannot be excluded.
Information from clinical studies in acute tibia fractures indicated that the use of InductOs in patients receiving glucocorticoids was not associated with any apparent adverse reactions. In non-clinical studies, concurrent administration of glucocorticoids depressed bone repair (measured as a % change from control), but the effects of InductOs were not altered.
In an in vitro study, dibotermin alfa was shown to bind to fibrin-based haemostatic agents or sealants. The use of these products in close proximity to InductOs is not recommended as this may lead to bone formation at the site of implant of the fibrin-based haemostatic agent or sealant.
