Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K38/00—Medicinal preparations containing peptides
  • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
  • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
  • A61K38/36—Blood coagulation or fibrinolysis factors
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K38/00—Medicinal preparations containing peptides
  • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
  • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
  • A61K38/36—Blood coagulation or fibrinolysis factors
  • A61K38/363—Fibrinogen
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P7/00—Drugs for disorders of the blood or the extracellular fluid
  • A61P7/04—Antihaemorrhagics; Procoagulants; Haemostatic agents; Antifibrinolytic agents

Definitions

• the present invention relates to the field of treatment of severe acute hemorrhages, including but not limited to postpartum haemorrhage, severe post-traumatic and surgical (perioperative) acute hemorrhage
• Severe Acute Hemorrhages are defined as the rapid loss - in a few hours - of at least 20 to 30% of an individual's blood volume.
• the main HAS situations are encountered in particular in obstetrics (mainly postpartum haemorrhage), traumatology and surgery, without limiting themselves to these situations.
• Coagulation disorders are common in HAS and are directly or indirectly related to bleeding.
• the plasma fibrinogen level is chronologically the first to fall to reach critical values (Hippala et al., 1995, Anesth Analg, Vol 81: 360-365, Torrielli et al., 1988, Rev Fr Gynecol Obstet, Vol 83: 7-9).
• These threshold values are conventionally situated between 0.5 and 1 g / l and correspond to the concentrations making it possible to obtain a satisfactory blood coagulation, in a stable non-haemorrhagic situation.
• the mechanisms involved in lowering the level of fibrinogen are: 1 / direct losses, 2 / dilution by vascular filling solutes, and 3 / fibrinogen consumption for clot formation.
• fibrinogen is the first coagulation factor whose blood level falls
• fibrinogen level is a factor of poor clinical prognosis, and this decline is associated with a change in patients' the more severe the fibrinogen concentration is low (Charbit et al., 2006, Journal of Thrombosis and Haemostasis, Vol 5: 266-273, Karlsson et al., 2008, Transfusion, Vol 48 (10): 2152- 2158).
• the conditions of management of an HAS, in emergency, are adapted to each individual case but include common objectives, including the treatment of coagulation disorders when they exist, which is frequent.
• the administration of fibrinogen is recommended when the plasma fibrinogen assay reaches the critical values mentioned above.
• This surrogate approach aims to correct situations of coagulopathies formed, said coagulopathies often being at the stage of disseminated intravascular coagulation (DIC).
• DIC disseminated intravascular coagulation
• fibrinogen is repeated over time as it is conditioned to the results of repeated fibrinogen assays.
• the dose of fibrinogen can be administered in several infusions, each being conditioned by the ratio of the quantized deficit of fibrinogen to the blood fibrinogen threshold value to be reached.
• Fibrinogen is administered at a recommended slow rate of less than 5ml / minute, which is inappropriate for an emergency.
• exogenous fibrinogen When the circulating level of fibrinogen is less than 1 g / L, exogenous fibrinogen is administered to allow the formation of a normal clot.
• the amounts of fibrinogen to be administered successively during the course of treatment are calculated according to the balance sheets of the coagulation parameters that are also successive in time. It should be noted that the precise calculation of the quantity of exogenous fibrinogen to be administered is considered essential, in order to avoid an excess of circulating fibrinogen, for example a circulating fibrinogen level greater than 5 g / L, capable of causing thromboses.
• a platelet concentrate as a means of additional treatment to the treatment means described above, in particular in situations in which the bleeding persists despite the provision of fibrinogen.
• the present invention relates to the use of fibrinogen for the manufacture of a medicament used in the treatment of severe acute bleeding, said drug providing an early and rapid sufficient amount of fibrinogen to restore the coagulant capacity of blood, independently initial fibrinogen level.
• an amount of at least 4.5 g can be administered with a duration of administration of less than 30 minutes.
• severe acute hemorrhages include, but are not limited to, postpartum haemorrhage, perioperative haemorrhage and post-traumatic hemorrhage.
• the fibrinogen that is administered concerns any fibrinogen, regardless of its origin and its nature.
• the invention also relates to pharmaceutical compositions, preventive or curative, comprising fibrinogen, which are specially adapted for the implementation of the uses and methods above.
• Figure 1 illustrates the succession of time steps of the in vivo experimental protocol in pigs.
• the horizontal line represents time.
• the numbered vertical bars represent the successive steps of the protocol.
• 1 Stage of anesthesia and instrumentation of the animals.
• 2 Perform baseline baseline measurements of HR parameters (Heart Rate), MAP (Average Arterial Pressure), PAP (Pulmonary Pulmonary Pressure) Arterial Pressure "), PCWP (Pulmonary Central Wedge Pressure), CVP (central venous pressure), ROTEM®, standard coagulation tests, hemoglobin, hematocrit, platelets.
• HR parameters Heart Rate
• MAP Average Arterial Pressure
• PAP Pulmonary Pulmonary Pressure
• Arterial Pressure Arterial Pressure
• PCWP Pulmonary Central Wedge Pressure
• CVP central venous pressure
• ROTEM® central venous pressure
• Step 3 Step of carrying out the hemodilution, during which 60% of the blood volume is taken, which is replaced by a composition of HES 130 / 0.4 (Voluven®), with the aim of achieving a MCF value less than 40 mm.
• Step 4 Step of re-transfusion of washed red blood cells, with the objective of achieving a hemoglobin value of 5 to 6 g / dl.
• 5 Realization of the bone wound step.
• 7 Realization of HR, MAP, PAP, PCWP, ROTEM® parameters, standard coagulation tests, hemoglobin, hematocrit, platelets and blood loss at 15 minutes, 1 hour, respectively 2 hours and 4 hours after administration of the drug (fibrinogen at different doses and placebo composition).
• Figure 2 illustrates the results of the INTEM coagulation time (CT) measurement using the ROTEM® method.
• CT INTEM coagulation time
• Figure 2 illustrates the results obtained with the animals that were administered respectively: (i) a placebo composition, represented by solid diamonds, (ii) 37.7 mg / kg of human fibrinogen, represented by filled squares, (iii) 75 mg / kg of human fibrinogen, represented solid black triangles and (iv) 150 mg / kg fibrinogen, represented by gray inverted triangles.
• Figure 3 illustrates the results of the measurement of maximum clot strength (MCF) INTEM using the ROTEM® method.
• MCF maximum clot strength
• PLASMA EXTEM modified FibTEM according to the ROTEM® method.
• the upper part of FIG. 4 shows the results obtained with the animals administered respectively: (i) a placebo composition, represented by solid diamonds, (ii) 37.7 mg / kg of human fibrinogen, represented by solid squares, (iii) 75 mg / kg of human fibrinogen, represented by solid black triangles and (iv) 150 mg / kg of fibrinogen, represented by gray inverted triangles.
• Figure 7 illustrates the measures of blood loss and coagulation capacity. On the ordinate: blood loss value and clot size value, expressed in ml / kg. In Fig. 7, the respective values of clot size ("closed”) and blood loss (“liquid”) are represented by adjacent bars, for each of the increasing concentrations of human fibrinogen administered to the animals and for the placebo composition.
• each pair of adjacent bars represents the respective values for (i) 37.5 mg / kg of fibrinogen, (ii) 75 mg / kg of fibrinogen, (iii) 150 mg / kg fibrinogen, (iv) 300 mg / kg fibrinogen, (v) 450 mg / kg fibrinogen, (vi) 600 mg / kg fibrinogen and (vii) the placebo composition.
• a high dose of exogenous fibrinogen, administered in an early and rapid manner makes it possible to interrupt, in the event of severe acute hemorrhage, the course of a beginning and occult coagulopathy, constituted for the most part by a gradual decrease in the coagulante capacity of the blood, itself caused mainly by the reduction of endogenous fibrinogen, to a coagulopathy that can cause uncontrollable haemorrhage.
• exogenous fibrinogen under the conditions specified in this invention, is in this way both a treatment of severe acute bleeding and prevention of its adverse evolution to uncontrollable hemorrhage.
• a predetermined quantity of exogenous fibrinogen makes it possible to control a severe acute haemorrhage without the need to perform a preliminary measurement of the circulating fibrinogen level.
• the principle of the treatment according to the invention is not to fill a deficit in fibrinogen, that is to say to provide a quantity of fibrinogen from a predetermined blood threshold value as being critical to achieve a presumed effective blood target value, but to restore as quickly as possible the coagulating capacity of the blood.
• the treatment of severe acute hemorrhage can be achieved by early and rapid administration of a single large dose of fibrinogen, an amount of at least 4.5 g , that is to say without requiring the realization of multiple sequential administrations of exogenous fibrinogen during the entire period of treatment and / or monitoring of the patient, related to the adaptation of the amount of fibrinogen as a function of fibrinogen levels.
• the examples illustrate a study in animals administered a range of fibrinogen doses ranging from 37.5 mg / kg to 600 mg / kg, according to a model of hemodilution caused by a traumatic shock with a loss of 60 % of the blood volume, which is then replaced by a 6% solution of hydroxyethyl starch (HES).
• HES hydroxyethyl starch
• the results of the examples show that a treatment of the animals having undergone a haemorrhage with a dose of fibrinogen of 50 mg / kg completely restores the maximum values of clot firmness 15 minutes after the end of the infusion of fibrinogen, this effect being maintained until the end of the experiment. With larger doses of fibrinogen, a plateau is reached for the EXTEM MCF values (ROTEM® test). In contrast, with increasing doses of fibrinogen, the values of INTEM MCF (ROTEM® test: platelet independent coagulation) continue to increase, as shown in Figure 6. The results of the examples show that thrombin production in the animals administered fibrinogen did not differ from the thrombin production in the control group of animals.
• the results of the examples show that the concentration of fibrinogen obtained in the animals that received 300 mg / kg of fibrinogen was close to the base value obtained in control animals without hemorrhage. The concentration of fibrinogen in animals treated with 400 mg / kg of fibrinogen was even greater than the same group of control animals.
• the results of the examples confirm that clot firmness is affected by low levels of fibrinogen, low levels of fibrinogen being caused in the experimental model used by dilution coagulopathy.
• the results of the examples confirm the key role of fibrinogen in this type of coagulopathy.
• the role of fibrinogen is further confirmed by the fact that the single administration of fibrinogen has an intrinsic potential to correct the effects of coagulopathy, in a dose-dependent manner.
• results of the examples show that at least the complete restoration of the fibrinogen concentration to normal levels (ROTEM® test, EXTEM MCF) or even to slightly above normal levels (INTEM MCF and weight of clot) is necessary for optimal coagulation to be restored.
• the results of the examples show that the administration of a high single dose of fibrinogen, without assaying the level of circulating fibrinogen prior to administration, makes it possible to prevent the aggravation of haemostasis disorders, and this in all safety for the patient since, quite surprisingly, no potential effect of hypercoagulation is observed, even with high doses of fibrinogen.
• the present invention relates to the use of fibrinogen for the manufacture of a medicament for use in the treatment of severe acute bleeding, said drug for administering an amount of at least 4.5 g fibrinogen in a single dose.
• the invention also relates to fibrinogen for its use in the treatment of severe acute hemorrhage, intended for parenteral administration, preferably intravenously.
• the invention also relates to a method for the prevention or treatment of severe acute hemorrhage, comprising a step of administering fibrinogen in an amount of at least 4.5 g.
• a duration of the fibrinogen administration step of less than 30 minutes includes durations of less than 29, 28, 27, 26, 25, 24, 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, or 6 minutes.
• the step of administering an amount of 6 g of fibrinogen is five minutes, without causing any adverse effect to the patient.
• a duration of the fibrinogen administration step of less than 30 minutes includes a duration of the administration step greater than 1 minute.
• fibrinogen With the use of fibrinogen according to the invention, it is avoided the compulsory use of an assay of the circulating fibrinogen level in the patient prior to the administration of fibrinogen, which constitutes an important technical advantage for the prevention or the treatment of situations clinical urgency of patients, patients for whom a rapid preventive or therapeutic intervention can be decisive regarding the patient's chances of survival.
• fibrinogen according to the invention is further characterized in that the medicament is intended for the administration of an amount of at least 4.5 g of fibrinogen in a single dose, without control or dosage of circulating rate of fibrinogen prior to administration to the patient. Consequently, the method of prevention or treatment of the invention can be further characterized in that it does not include a control step or for assaying the level of circulating fibrinogen, prior to the fibrinogen administration step.
• fibrinogen according to the invention is further characterized in that the medicament is intended for the administration of an amount of at least 4.5 g of fibrinogen in a single dose, without control or dosage of circulating rate of fibrinogen after administration to the patient. Consequently, the method of prevention or treatment of the invention can be further characterized in that it does not comprise a step of controlling or assaying the level of circulating fibrinogen, after the step of administration of the fibrinogen. In the alternative, the absence of a circulating fibrinogen level assay also represents an economic advantage over the overall cost of the preventive or curative medical procedure.
• the amount of fibrinogen can be at least 4.5 g, 4.6 g, 4.7 g, 4.8 g, 4.9 g, 5 g, 5.1 g, 5.2 g, 5.3 g. g, 5.4 g, 5.5 g, 5.6 g, 5.7 g, 5.8 g or 5.9 g.
• said preferred amount of fibrinogen is preferably at most 15 g and most preferably at most 12 g.
• the amount of fibrinogen is about 6 g, which includes an amount of fibrinogen ranging from 5.5 g to 6.5 g, including from 5.8 g to 6.2 g.
• fibrinogen according to the invention is suitable both for the prevention and the treatment of certain severe acute hemorrhages.
• fibrinogen according to the invention is suitable for the treatment of postpartum hemorrhages.
• postpartum haemorrhage is defined as bleeding with a volume of more than 500 mL during the 24-hour period following delivery.
• uterine atony There are various risk factors for postpartum hemorrhage, including persistent anemia, congenital hemostasis, and uterine atony (eg multiparity). , uterine over-distention, long or fast work, existence of chorioamnionitis), situations at risk of abnormal retraction of the uterus (eg retention of placental or clot, fibromatous or malformed uterus , placenta accreta), acquired haemostatic disorders, genital lesions including episiotomy, uterine inversion, uterine rupture or caesarean section.
• fibrinogen according to the invention can be carried out as a preventive measure.
• fibrinogen according to the invention is mainly carried out curatively, in patients who have actually already triggered a postpartum haemorrhage.
• the use of fibrinogen according to the invention is suitable for the prevention and treatment of hemorrhages caused during a surgical procedure. Indeed, the surgeon practitioner can determine in advance, from his experience, surgical procedures for which the risk of causing severe acute hemorrhage are significant. This is the reason why the use of fibrinogen according to the invention is also suitable for the prevention or treatment of severe acute haemorrhages caused during a surgical act, that is to say during a surgical procedure. .
• traumatic hemorrhagic shock caused by major physical trauma, which is often associated with a sudden drop in blood volume and acute anemia.
• the patient's vital prognosis is directly related to the volume of blood loss and the speed of treatment.
• This is another situation of acute bleeding for which a primary aspect of the therapeutic strategy is to restore hemostasis.
• fibrinogen according to the invention is suitable for the treatment of severe acute hemorrhages caused by physical trauma, also called traumatic hemorrhagic shocks.
• fibrinogen is human fibrinogen.
• fibrinogen consists of a purified fibrinogen of natural origin.
• fibrinogen is a recombinant fibrinogen.
• a recombinant fibrinogen prepared according to any one of the processes described in the PCT international applications published under the numbers WO-207/103447, WO-2005/010178, WO-1996/07728 or WO-1995 / may be used. 022,249.
• Said recombinant fibrinogen may be in the form of a pharmaceutical composition in which the recombinant fibrinogen molecules are combined with one or more pharmaceutically acceptable excipients.
• fibrinogen consists of purified fibrinogen of natural origin
• said fibrinogen is purified from human plasma and is optionally combined with one or more pharmaceutically acceptable excipients.
• This 1 is a purified fibrinogen of natural origin is in the form of a fibrinogen concentrate obtained by a purification process from a solubilized human plasma fraction which comprises the successive steps of: a) chromatographic purification comprising the steps of i) charging a weak base type anion exchanger in said solubilized fraction, previously equilibrated by a predetermined ionic strength buffer of basic pH, ii) elution of a biological glue by increasing the ionic strength of said buffer, b) separation of Factor XIII from fibrinogen by addition to at least a part of the biological glue eluate at least one Factor XIII precipitating chemical, and recovering the resulting solution of purified fibrinogen supernatant, and c) diafiltering the solutions of fibrinogen, biological glue and remediated FXIII, followed by lyophilization of said solutions. .
• purified natural fibrinogen prepared as described in PCT Application No. WO-2005/004901. It is a purified fibrinogen of natural origin in the form of a fibrinogen concentrate obtained by a purification process comprising a viral inactivation step by heat treatment of a lyophilizate of cryoprecipitable proteins from human plasma. .
• the method described in PCT Application No. WO-2005/004901 is characterized in particular by the addition, before the cryoprecipitable proteins are put in the form of a lyophilizate, of a stabilizing and solubilizing formulation comprising a mixture of arginine, at least one hydrophobic amino acid and tri-sodium citrate.
• Fibrinogen purified of natural origin obtained in the form of a human plasma fibrinogen concentrate by a method selected from the methods described in European Patent Application No. EP 0 1739093 or in the PCT Application No. WO-2005 / 004901 has the advantage of comprising a high concentration of human fibrinogen, of the order of 15g / l to 20g / l.
• Such a human fibrinogen concentrate which may also be designated "FGT1" in the present description, is particularly well suited to the uses of fibrinogen according to the invention which require the administration of a large amount of fibrinogen at least equal to 4, 5 g, preferably in a single dose, because of a high rate of fibrinogen recovery of this type of concentrate.
• Another advantage of this type of plasma-derived human fibrinogen concentrate is the low content of said concentrate in the other plasma proteins, which considerably reduces the total amount of plasma proteins that are administered to the patient.
• the fibrinogen is in the form of a lyophilizate, optionally in combination with one or more pharmaceutically acceptable excipients.
• the fibrinogen is in the form of a lyophilizate, optionally in combination with one or more pharmaceutically acceptable excipients, contained in a container whose inner atmosphere is maintained at a pressure below the pressure. atmospheric.
• the interior volume of the container is maintained under a partial vacuum vacuum.
• said lyophilized fibrinogen concentrate is contained in a vacuum reconstitution device.
• the fibrinogen solution to be administered to the patient can be prepared extemporaneously by adding to the vacuum vial the appropriate volume of a suitable solvent, for example water or a saline solution, sterile and pyrogen-free.
• a suitable solvent for example water or a saline solution, sterile and pyrogen-free.
• the fibrinogen solution obtained after reconstitution from the freeze-dried fibrinogen concentrate is stored at most for 7 days, preferably at most 24 hours, at 25 ° C. or preferably at most 6 hours, at 25 ° C.
• the purified fibrinogen or recombinant fibrinogen is in the form of a pharmaceutical composition in which said fibrinogen is combined with one or more excipients selected from lysine hydrochloride, trometamol, glycine, sodium citrate and sodium chloride.
• said fibrinogen is combined with all of the following excipients: lysine hydrochloride, trometamol, glycine, sodium citrate and sodium chloride.
• the solvent used consists of water for injection.
• the purified fibrinogen or the recombinant fibrinogen is in the form of a pharmaceutical composition in which said fibrinogen is combined with one or more excipients chosen from hydrochloride. arginine, isoleucine, lysine hydrochloride, glycine, and sodium citrate.
• said fibrinogen is combined with all of the following excipients: arginine hydrochloride, isoleucine, lysine hydrochloride, glycine, and sodium citrate.
• the solvent used consists of water for injection.
• FGT1 fibrinogen concentrate "FGT1" to be reconstituted with 100 ml of PPI water consists of 1.5 g of fibrinogen, 4 g of Arginine, 1 g of Isoleucine, 0.2 g of Lysine hydrochloride, 0, 2 g of Glycine and 0.25 g of sodium citrate
• the purified fibrinogen or recombinant fibrinogen is in the form of a pharmaceutical composition in which said fibrinogen is combined with one or more excipients selected from albumin human, sodium chloride, arginine hydrochloride, sodium citrate, and sodium hydroxide.
• said fibrinogen is combined with all of the following excipients: human albumin, sodium chloride, arginine hydrochloride, sodium citrate, and sodium hydroxide.
• the solvent used consists of water for injections.
• the step of administering fibrinogen in an amount of at least 4.5 g is carried out with a medicament adapted for parenteral injection, of the type of the pharmaceutical compositions described above.
• fibrinogen in the preferred embodiments of the use of fibrinogen according to the invention, it is carried out with a medicament adapted for intravenous administration.
• the step of administering fibrinogen in an amount of at least 4.5 g consists of a step of administration by route. intravenous.
• vacuum containers containing a lyophilized fibrinogen concentrate comprising an amount of 1.5 g of fibrinogen are used, which means that the contents of four containers are used to prepare administering the desired amount of fibrinogen in a single dose of about 6 g.
• the reconstituted liquid composition containing human fibrinogen is administered intravenously at a delivery rate of from 5 mL / minute to 30 mL / minute.
• the reconstituted human fibrinogen liquid composition is administered intravenously at a flow rate of about 20 mL / minute, which ranges from 15 mL / minute to 25 mL / minute.
• a high rate of administration of this type is justified by the urgency to reduce homeostatic disorders in patients with severe acute bleeding.
• the present invention also relates to a pharmaceutical composition
• a pharmaceutical composition comprising, as active ingredient, fibrinogen, said pharmaceutical composition being characterized in that it is adapted for the parenteral administration of a single dose comprising a quantity of fibrinogen at least 4.5 g, preferably about 6 g, of fibrinogen.
• Severe postpartum haemorrhage is characterized by a haemorrhage volume greater than or equal to 1000 ml and resistant to 2 uterotonic lines of treatment.
• Human Plasma Fibrinoaene Concentrate Patients are treated with a single intravenous bolus injection of FGT1 (6 g) immediately after reconstitution.
• Human fibrinogen concentrate contains 1.5g of fibrinogen
• the volume of blood lost after administration of FGT1 is monitored following the administration of 6g FGT1 administered intravenously and the time between FGT1 administration and the end of bleeding. The success of the therapy will be evaluated on the absence of recourse to ultimate resources, massive transfusion and deaths after 12 hours.
• Example 2 The study of Example 2 was to compare the efficacy of different doses (from 37.5 mg / kg to 600 mg / kg) of fibrinogen compositions (human fibrinogen concentrate compositions designated FGTT) in pigs The effect on hemostasis and blood loss was measured in animals after the application of standardized bone and liver injury.
• fibrinogen compositions human fibrinogen concentrate compositions designated FGTT
• This study was performed in forty-two healthy pigs aged 12 to 14 weeks and having a body weight of 25 to 35 kg.
• the animal model was used to determine the clot strength and blood loss dynamics in a situation where fibrinogen is administered after induction of dilution coagulopathy.
• Animal pre-treatment was performed with azaperone (4 mg / kg, intramuscular injection-Stresnil TM, Janssen, Vienna, Austria) and atropine (0.1 mg / kg by intravenous injection). one hour before the start of the experiment.
• Induction and maintenance of anesthesia were performed with propofol (1-2 mg / kg by intravenous injection).
• propofol 1-2 mg / kg by intravenous injection.
• piritramide (30 mg, opioid with a half-life time of about 4-8 hours-dipidolor TM, Janssen, Vienna, Austria) was injected.
• Muscle relaxation was achieved by using 0.6 mg / kg per hour of rocuronium after endotracheal anesthesia.
• the femoral artery, the two femoral veins and the subclavian artery were anatomically prepared.
• the basic requirement for fluid replacement (4 mg / kg body weight) was achieved during the test with crystalloids (Ringer's lactate solution).
• the following invasive catheters were placed in these vessels: - a large-diameter catheter (double lumen venous access with a length of 20 cm),
• the blood was taken from animals, step by step, using wide catheters and the blood was replaced with the colloidal solution in a ratio of 1: 1.
• the animals with a weight of for example 30 kg were infused with 1700 ml of 6% HES solution: 130 / 0.4 (Voluven®, Fresenius co ., Bad Homburg, Germany).
• the collected blood was processed in a "cell saver" type system (Cats®, Fresenius), was concentrated and transfused again, to prevent anemia related to hemodynamics.
• the normovolemic hemodilution was achieved when the resulting coagulopathy reached a peak clot strength (MCF) value of less than 40 mm, as measured by thromboelastometry (time markers # 3 and 4 in Figure 1).
• MCF peak clot strength
• a standardized bone injury was achieved by drilling a 3 mm hole in the tibia head to a depth required to penetrate the bone marrow five minutes prior to administration of the test drug. Five minutes after the bone wound, a fibrinogen measurement was made (time mark # 5 in Figure 1), followed by administration of the test drug (time mark # 6 in Figure 1). Excess blood was removed by sucking the wound surface between bone and muscle and collecting it in a collection vessel. The duration to hemostasis was also determined. In the case where blood loss due to bone injury exceeded 500 ml, the bleeding was stopped by compression using a standard gas bandage, to ensure that the pig was stable from a hemodynamic point of view. for the next four hours of observation.
• time parameter # 4 Fifteen minutes after administration of the test drug, additional determinations of all measured parameters were made (time parameter # 4). In addition, one hour, two hours and four hours after administration of the test drug, measurements of all parameters were made (time mark No. 7 in FIG. 1).
• standardized liver injury was achieved by making a central incision of the falciform ligament above the central liver lobe, using a template.
• the resulting hepatic incision is about 8 cm long and about 2 cm deep (time mark # 8 in Figure 1). No effect on the catecholamine-mediated circulation occurred. Achievement of a standardized hepatic injury was chosen to demonstrate that impaired coagulation negatively affected mortality.
• mice were randomized (randomized) to groups 1-6 (1: 37.5 mg / kg, 2: 75 mg / kg, 3: 150 mg / kg, 4: 300 mg / kg, 5: 450 mg / kg and 6: 600 mg / kg).
• the experimental protocol is illustrated in particular in FIG. 1 and in the Table below, in which the details of the treatment of the 42 pigs included in the study are described.
• Fibrinogen administration was by infusion for 30 minutes.
• D-dimer measurements For D-dimer measurements, the D-dimer-0020008500® test (Instrumentation Laboratory Company, Lexington, USA) was used. Blood cell counts were performed using the Sysmex Poch-100i® counter (Sysmex, Lake Zurich, Illinois, USA).
• ROTEM® Rotational thromboelastometry
• ROTEM® consists of a modification of the concept of thromboelastography that was originally developed by Hartert in 1948.
• the method consists of a cylindrical sensor that is immersed in a cuvette containing the blood sample. The sensor is rotating at a degree of 4.75 ° along its longitudinal axis. This movement is altered as the fibrin strands begin to form between the bowl and the sensor. This inhibition is detected by a change in the light reflection factor which is detected continuously and converted into a typical typical ROTEM® curve in which the following parameters are determined:
• Maximum Lysis %
• MCF amplitude
• Example 2 Various tests of coagulation activating agents are available, as detailed below.
• the tests used in Example 2 are the INTEM test and the modified FIBTEM test.
• - INTEM when performing an INTEM test, coagulation is activated via the intrinsic pathway.
• the INTEM reagent contains ellagic acid which is a strong activator of the intrinsic coagulation pathway.
• FIBTEM test activates coagulation with tissue factor.
• tissue factor tissue factor
• thrombocyte function is altered by adding cytochalasin D. This results in the formation of a clot that is only induced by fibrinogen.
• the modified FIBTEM test was used because previous experiments showed that porcine thrombocytes can not be completely blocked by cytochalasin D. For this reason, thrombocytes were completely eliminated from this test by performing an EXTEM test. in a plasma sample instead of whole blood (modified FIBTEM).
• A.1 Tissue sampling, preservation, slide preparation and microscopic examination
• Tissue samples from organs lungs, heart, kidneys, intestines and liver
• the samples were immediately immersed in 10% formalin solution. After dehydration with an ascending sequence of steps using alcohol samples, the samples were embedded in paraffin and cut into 7 ⁇ m thick slices.
• the assay slides were stained by the conventional hematoxylin / eosin staining technique and then examined.
• the Shapiro Wilks test was used to verify the normality of the distribution of study variables. The presumption of normality of the distribution was rejected for the following variables: ZVD, WEDGE, SPO2, CT, ALPHA.
• ANOVA was used for repeated measurements to evaluate the differences between the test groups.
• a significance value of 0.05 was used for the effect groups, the measures, and the group x measure.
• the Jonckheere-Terpstra test tests the null hypothesis that the distribution of total blood loss does not differ according to the groups that received separate doses of fibrinogen (respectively control, 37.5 mg / kg, 75 mg / kg, 150 mg / kg, 300 mg / kg, 450 mg / kg and 600 mg / kg).
• the Student's test was used to compare the parameters specific to the baseline control values after hemodilution.
• ROTEM® parameters were significantly affected after hemodilution with Voluven®. Coagulation time increased and peak clot strength decreased significantly after Voluven® infusion (p ⁇ 0.0001). In the same way, the angle ⁇ decreased significantly and the duration of clot formation significantly increased (p ⁇ 0.001). Fibrinogen administration did not significantly shorten the prolonged duration of coagulation but significantly increased MCF (p ⁇ 0.001 versus placebo for the corresponding 150 mg / kg to 600 mg / kg groups, 15 minutes after completion of fibrinogen infusion) and angle ⁇ (p ⁇ 0.05 versus placebo for all dosing groups 15 minutes after completion of fibrinogen infusion).
• the aPTT values increased significantly from 10.94 +/- 3.34 s initially up to 21.7 +/- 2.72 sec after hemodilution (p ⁇ 0.001).
• aPTT After administration of fibrinogen, the value of aPTT remained high compared to the initial value. There was no difference between the groups, with the exception of the F group, which showed a significantly increased value of aPTT, compared with the placebo group and the other dosage groups, at all times after the administration of the drug. .
• D-dimer was significantly increased compared to placebo at four hours after fibrinogen administration for groups E and F (p ⁇ 0.01).
• groups A, D, E and F there was a significant increase in the D-dimer value at the end of the experiment (p ⁇ 0.05 for group A and p ⁇ 0.001 for groups D, E and F).
• TAT and thrombin generation values were not different from the placebo group values.
• hemoglobin values dropped significantly to levels between 3-4 g / dl (p ⁇ 0.0001, compared to baseline initial "BL”).
• the hematocrit significantly decreased in parallel to values between 11% and 13% (p ⁇ 0.0001).
• hemoglobin and hematocrit values increased significantly up to 5-6 g / dl and up to 18-20% respectively (p ⁇ 0.0001 versus the initial baseline "BL” for both parameters).
• the total blood loss after bone injury and liver injury was:
• the first main result of the study of Example 2 is that the administration of fibrinogen is capable of reversing the dilution coagulopathy in a dose-dependent manner.
• ROTEM® measurements clearly showed that maximum clot firmness (MCF) was increased and normalized after fibrinogen administration.
• the modified FIBTEM test showed the same trend regarding MCF values; however, for 300, 450 and 600 mg / kg, MCF values increased well above baseline levels.
• Fibrinogen did not affect thrombin production or TAT.
• the results presented in Example 2 are the first to show that doses of fibrinogen as high as 12 times the recommended fibrinogen dosage in humans (according to the Austrian Society of Anesthesiology, Reanimation and Intensive Care Medicine, available on the internet at the following address: http://www.oeagri.at/dateiarchiv/1 16 / Traumaindu becamees o /o20Gerinnungsmanagement.pdf, can be administered in vivo.
• Example 2 also showed a reduction in blood loss after fibrinogen administration and a dose-dependent increase in clot size after hepatic injury.
• Example 2 confirms that the administration of a human fibrinogen concentrate (FGTW) is capable of reversing the dilution coagulopathy in a dose-dependent manner.
• FGTW human fibrinogen concentrate
• Treatment at a dose of 150mg / kg is able to completely restore MCF values to baseline.
• the results of Example 2 also show that the INTEM MCF values plateau at plasma fibrinogen concentrations of 350 mg / dl. Higher concentrations of plasma fibrinogen do not increase the MCF values.
• Administration of fibrinogen significantly reduces blood loss after hepatic injury and increases coagulation capacity in a dose-dependent manner.
• Example 2 when transposed to human fibrinogen administration, indicate that a dose of 6 g of fibrinogen can be administered for a duration of 1 hour. a five-minute administration step, the administration of fibrinogen having the effect of preventing or stopping haemorrhage, without simultaneously causing an undesirable effect for the patient. More specifically, the results of Example 2 show that the expected beneficial effects on the recovery of haemodynamic parameters, without causing any undesirable effect, are obtained by administering to the experimental model of pork which is illustrated an amount of fibrinogen of 600 mg / ml. kg with a duration of the 30-minute administration step, i.e. a fibrinogen dose of 0.02 g / kg / min.
• the fibrinogen concentrate composition which was used in Example 2 has a human fibrinogen concentration of 15 g / l, ie 0.015 g / ml.
• the pigs were administered a dose of the above-mentioned "FGT1" composition of 1.33 ml / kg / min.
• the administration of a dose of composition "FGT1" of 1.33 ml / kg / min consists in administering the composition "FGT1" to said patient according to a speed of administration of 80 ml / min.

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