Status: approved; marketed

Organizations involved:

CSL Bioplasma Inc. – Manuf.; R&D; Tech.; USA mark.

CSL Bioplasma AG – Intl. mark.; Parent co

CSL Ltd. – Parent

Invitron, Inc. – Manuf. other

Scripps Research Institute, The – R&D; Tech.

Cross ref: See also the entries for Factor VIII Products (#715) and other immunoaffinity purified Factor VIII product entries – Hemofil M (#722) and Monarc-M (#721).

Description: Antihemophilic Factor (Human) or Monoclate-P is a lyophilized (freeze-dried) formulation of Factor VIII:von Willebrand’s Factor (Factor VIII:vWF or Factor VIII:C) protein fractionated and purified from pooled human blood plasma, with purification including immunoaffinity chromatography, viral inactivation by heating, and stabilization with Albumin (Human). Monoclate-P is an ultrahigh purity factor VIII product, in terms of removal of extraneous protein and viral contaminants, and its manufacturing process retains the intact native molecular structure of human Factor VIII. Due to the use of von Willebrand’s Factor (vWF) monoclonal antibodies during the immunoaffinity purification step, with some vWF dissociating from the complex and remaining bound to the separation matrix, Monoclate contains reduced amounts of complexed vWF and an increased amount of uncomplexed Factor VIII, compared to other products. Monoclate-P was the first (and in the U.S., the only) ultrahigh-purity Factor VIII concentrate (32,000 IU/mg protein) subjected to pasteurization (heat treatment in solution; wet heat) for viral inactivation. Prior to the addition of Albumin (Human) as a stabilizer, specific activity is greater than 3,000 units/mg of protein. Albumin is actually the most abundant protein in the product. Monoclate (without the ‘P’ designation for pasteurized) was the product trade name preceding Monoclate-P. Monoclate was similarly immunoaffinity chromatography purified but was pasteurized with a terminal dry heat treatment.

Monoclate-P is the only Antihemophilic Factor (Human) product purified using a von Willebrand’s Factor (vWF) monoclonal antibody, while some other products are purified using Factor VIII monoclonal antibody (e.g., see Hemofil M entry #722). A murine monoclonal antibody specific for vWF is used as an affinity ligand in the immunoaffinity chromatography step to bind Factor VIII:vWF complex. Factor VIII and vWF in solution form this noncovalently bound complex, with vWF serving to stabilize Factor VIII against proteolysis. After Factor VIII:vWF binds to matrix-bound vWF murine monoclonal antibody, Factor VIII:vWF is dissociated from the Mab-bound Factor VIII:vWF complex (resulting in release of Factor VIII:vWF and Factor VIII, with some vWF still bound to the matrix), recovered, formulated, including addition of Albumin (Human), and lyophilized. The process results in high purity Factor VIII:vWF protein with reduced amounts of bound vWF with removal of extraneous plasma-derived proteins.

Monoclate-P is supplied in a single dose vial along with diluent (Sterile Water for Injection, USP), a double-ended needle for reconstitution, a vented filter spike for withdrawal, a winged infusion set, and alcohol swabs. Upon reconstitution with Sterile Water for Injection, USP, Monoclate-P provides 50-150 times as much Factor VIII as an equal volume of normal plasma. Each vial is labeled with the amount of Factor VIII (AHF) specific activity expressed in International Units (IU). The reconstituted solution also contains approximately: 300-450 millimoles (mM) of sodium ions/L with 2-3 times the tonicity of physiologic saline; 2.5 mM of calcium ion/L; 1-2% Albumin (Human); 0.8% mannitol; and 1.2 mM histidine. The pH is adjusted with hydrochloric acid and/or sodium hydroxide. Monoclate-P contains trace amounts (250 ng per 100 IU) of murine monoclonal antibody (residual from immunoaffinity purification).

Nomenclature: Factor VIII:vWF Mab purif./CSL [BIO]; Antihemophilic Factor (Human) [FDA]; Antihemophilic Factor [USAN]; Antihemophilic Factor, Human [former USAN]; Antihemophilic Factor USP [USP]; Blood-coagulation factor VIII:C, complex [CAS]; 1131189-02-9 [CAS RN]; Antihemophilic Factor VIII:C [SY]; Factor VIII:C Pasteurized, Monoclonal Antibody Purified [SY]; NDC 0053-7656-01; 0053-7656-02; 0053-7656-04 [NDC]

Companies.: Monoclate-P was developed and formerly manufactured by Centeon Pharma GmbH, FDA CBER est. no. 1202; later Aventis Behring GmbH, est. 1287. With the July 2000 update of FDA CBER’s Establishment and Products publication, the product was listed as manufactured by Aventis Beh-ring LLC, FDA CBER est. no. 1281, now CSL Bioplasma Inc., CBER/FDA est. no. 1639. Monoclate-P is now manufactured at CSL’s Kankakee, IL, facility. It is marketed in the U.S. by CSL Bioplasma, Inc. and internationally by its parent company, CSL Bioplasma AG, both subsidiaries of CSL Ltd. The murine vWF monoclonal antibody used for purification is manufactured by Invi-tron Inc.

Manufacture: Frozen plasma units are thawed and the plasma is pooled under controlled conditions, with thawing controlled to optimize redissolution of plasma proteins. The remaining cold-insoluble cryoprecipitate is further separated from plasma proteins by centrifugation at controlled temperature. The cryoprecipitate is dissolved in a water-alcohol mixture and the temperature and pH are controlled in order to precipitate fibrinogen and cold-insoluble globulins. The Factor IX-rich prothrombin complex factors are removed by addition of and adsorption with aluminium hydroxide, with the resulting precipitate removed by centrifugation. The cryosolution is concentrated and further purified by ultrafiltration/diafil-tration to remove alcohol, and the salt concentration is adjusted. Stabilizers are added, including pasteurized Albumin (Human), to prevent denaturation and proteolysis, and the solution is subjected to pasteurization (wet heat) at 60˚C for 10 hours. From 80-90% of procoagulant activity is retained after pasteurization. The diluted pasteurized solution containing Factor VIII non-covalently complexed with von Willebrand’s Factor (VIII:vWF) is diluted with buffer to reduce the concentration of stabilizers and facilitate binding of Factor VIII:vWF complex during the next step, monoclonal antibody immunoaffinity chromatography.

The solution is passed through an immunoaffinity resin column packed with a murine vWF monoclonal antibody (Manufactured by Invitron Inc.) covalently bound to Sepha-rose-Cl-2B. The column is washed extensively to remove nonbinding proteins and viruses. The Factor VIII:vWF complex is detached and separated (eluted) from the column matrix by passing calcium chloride solution (0.25 M) through the column. The Factor VIII:vWF (containing an increased amount of uncom-plexed Factor VIII due to some vWF remaining bound to the matrix via the monoclonal antibody) is concentrated by ultrafiltration and the bulk is frozen for storage. Frozen fractions are subsequently thawed and combined to increase batch/lot size. Factor VIII:vWF fractions from several runs are combined and passed through an ion exchange chromatography column packed with an ion-exchange resin, agarose beads coupled with positively charged amino-hexyl group (AH-Sepharose), with affinity for Factor VIII. The column is washed extensively with buffers and Factor VIII is eluted with buffer solution containing 0.5 M calcium chloride and pasteurized Albumin (Human) as a stabilizer. This AH-Sepharose chromatography step results in removal of murine protein (monoclonal antibody) that may have leached from the earlier immunoaffinity purification step, and further concentrates the Factor VIII:vWF. Excess calcium is removed by dialysis/diafiltration to achieve the final formulation which is sterile filtered to remove any bacteria. The product is then aseptically filled into vials, frozen, lyophilized, and sealed. Unassociated Factor VIII not be bound by the monoclonal antibody affinity purification step may be lost in the purification process (or recycled).

The immunoaffinity chromatography use of vWF antibody to bind the Factor VIII:vWF allows milder conditions than use of Factor VIII-binding antibody (as is used for purification of other monoclonal antibody purified Factor VIII products), with the higher molecular weight vVF stabilizing the Factor VIII:vWF molecule.

Aventis Behring, now CSL Bioplasma, was the first (May 2000) North American manufacturer of plasma products to exclusively use plasma tested by proprietary investigational PCR (polymerase chain reaction; PCR; commonly termed Nucleic Acid Testing or NAT) screening for HIV-1, hepatitis B and hepatitis C. In 2000, Aventis Behring also added PCR screening for parvovirus B19 and hepatitis A viruses, making them the first and only company in the world to screen plasma using proprietary investigational PCR/NAT for five viruses (HIV-1, hepatitis B, hepatitis C, parvovirus B19, and hepatitis A).

FDA class: Biologic PLA BLA

CBER class: Blood And Blood Derivatives

Approvals: Date = 19720918; first approval of a Antihemophilic Factor (Human) product from Armour Pharmaceuticals/Centeon LLC; Indication = treatment of hemophilia A

Date = 19840125; PLA supplement (no. 83-367); addition of a heat treatment step during manufacture

Date = 19860501; first approval of a pasteurized, lyophilized formulation, PLA 83-086; Indication =hemophilia A

Date = 19870102; PLA supplement (no. 86-526); unspecified heat treatment-related approval

Date = 19900530; PLA supplement (no. 89-002); unspecified heat treatment-related approval

Date = 19960730; PLA supplement (no. 96-0972); update of all release specifications and test methods

Date = 19960822; first approval, apparently BLA, for monoclonal antibody purified formulation (current product); orphan designation (granted -on 10/16/1992; expires 8/22/2003)

Date = 19961020; PLA supplement (no. 89-0081); manufacturing changes, including wet heat viral inactivation

Date = 19970205; PLA supplement; changes in specifications, including tightening of specifications for Factor VIII:C content and pH tests to comply with European Phamacopoeia, and various other tests

Date = 19980924; PLA supplement (no. 97-1049); revision to assays for HBsAg and residual moisture

Date = 20000317; approval revoked from Centeon LLC and granted (reissued) to new owner, Aventis Behring LLC

Date = 20000511; BLA supplement; Indication = added statement to product insert/labeling, “The plasma used in the manufacture of this product has been tested and found negative for HBV [hepatitis B virus], HCV [hepatitis C virus], and HIV-1 by an investigational test procedure referred to as Nucleic Acid Testing (NAT) using Polymerase Chain Reaction (PCR) technology. Investigational testing is being performed to determine the effectiveness of NAT to detect low levels of viral material. The significance of a negative result is unknown since the effectiveness of the test has not been established.”

Indications: [full text of "INDICATIONS AND USAGE” section of product insert/labeling; 3/24/2003]:

Monoclate-P is indicated for treatment of classical hemophilia (Hemophilia A). Affected individuals frequently require therapy following minor accidents. Surgery, when required in such individuals, must be preceded by temporary corrections of the clotting abnormality. Presurgical correction of severe AHF deficiency can be accomplished with a small volume of Monoclate-P.

MONOCLATE-P is not effective in controlling the bleeding of patients with von Willebrand’s disease.

Status: Note, this product traces its regulatory history back to Factor VIII manufactured and marketed by Centeon Pharma GmbH and Armour Pharmaceutical Co./Centeon LLC, later Aventis Behring, now CSL Bioplasma AG/Inc. The current monoclonal antibody-purified product as approved in 1996.

Tech. transfer: The product insert/labeling cites U.S. 4,876,241 and Reissue 32,011.

U.S. 4,876,241, “Stabilization of biological and pharmaceutical products during thermal inactivation of viral and bacterial contaminants,” Oct. 24, 1989, assigned to Armour Pharmaceutical Co. (later Aventis Behring, now CSL Bioplasma), describes methods for stabilizing solubilized (liquid-state) proteins (e.g., Factor VIII) during thermal viral inactivation by mixing the product in an aqueous solution with mono-, di-, or tri-saccharides or sugar alcohol stabilizers (e.g., glucose, sucrose, xylose, fructose and mannitol) and neutral salt stabilizers (e.g., sodium acetate, potassium acetate, lithium acetate, magnesium acetate). This wet heat or wet pasteurization method of viral inactivation (in the liquid state) has been shown to substantially inactivate viruses including cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus (HSV), poliovirus, vaccinia virus, hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV. Neoantigens are not formed during liquid-state pasteurization. Examples in the patent describe viral inactivation of ultrafiltered eluate from an anti-Factor VIII:C-Sepharose-Cl-2B column.

U.S. patent reissue 32,011 (Re. 32,011), Zimmerman and Fulcher, assigned to The Scripps Research Institute, exclusively licensed by Armour, later Aventis Pasteur (now Sanofi Pasteur S.A.), describes a two-step method for purification of Factor VIII – immunoaffinity chromatography and ion-exchange chromatography. [Scripps also holds similar patents for immunoaffinity purification of Factor IX]. Factor VIII:C preparations are passed through columns containing agarose beads coupled with murine (mouse) monoclonal antibodies directed to von Wille-brand’s Factor (vWF; Factor VIII:RP). Factor VIII is protected longer from proteolysis by its association with the von Wille-brand’s Factor, an important feature when isolating this sensitive polypeptide from complex source materials. Factor VIII:C is adsorbed onto the matrix while uncomplexed Factor VIII moieties and contaminants are eluted from the column as unbound material. The Factor VIII:vWF is removed from the bound Factor VIII:vWF:antibody complex with a high salt solution containing calcium. The resulting Factor VIII:vWF solution (also containing uncomplexed Factor VIII) is desalted and adsorbed onto an ion-exchange column (agarose beads) coupled with positively charged aminohexyl groups (e.g., AH-Sepha-rose). The Factor VIII is desorbed from the column with a high salt solution. Depending on the source material, as much as 50% of Factor VIII:C can be Factor VIII not associated with vWF.

Market: The 2005 Average Wholesale Price (AWP) is $1.00/IU for all vial sizes (unchanged from 2004) (Red Book, 2005).

Medicare reimbursement is set at $0.90/IU for inpatient and home care and at $0.51/IU for outpatient care. Estimated Acquisition Costs (for hospitals, treatment centers) is $0.62-$0.81/IU [from NHF].

In its April 18, 2005 price list, FFF Enterprises, a major biologics distributor, reported its price as $0.56/IU ($0.73/IU in March 2004).

In June 2003, Aventis Behring (now CSL Bioplasma, Inc.) launched the Choice Assurance Program. At the time (and, perhaps, still), there was no other similar program in the U.S. Enrolled patients earn one Assurance Award Certificate for every three consecutive months they use one of Aventis Behring’s Factor VIII or IX products (or IVIG). Each Certificate can be redeemed for one month’s worth of free product, based on the average monthly usage by the patient, in the event of a lapse in insurance. Patients can earn up to four months of free product after only a year in the Program and up to a full year after three years.