INOmax · 4.6 Fertility, pregnancy and lactation · 1

HOS-093046 · has-adverse-reaction-information · PDF-Seite 19

Summary of safety profile Abrupt discontinuation of the administration of inhaled nitric oxide may cause rebound reaction; decrease in oxygenation and increase in central pressure and subsequent decrease in systemic blood pressure. Rebound reaction is the most commonly adverse reaction in association with the clinical use of INOmax. The rebound may be seen early as well as late during therapy. In one clinical study (NINOS), treatment groups were similar with respect to the incidence and severity of intracranial haemorrhage, Grade IV haemorrhage, periventricular leukomalacia, cerebral infarction, seizures requiring anticonvulsant therapy, pulmonary haemorrhage, or gastrointestinal haemorrhage. Tabulated list of adverse reactions The table below presents adverse reactions (ADRs) that have been reported with the use of INOmax from either the CINRGI trial of 212 neonates or post marketing experience in neonates (<1 months of age). The displayed frequency categories use the following convention: very common (1/10), common (1/100 to <1/10), uncommon (1/1,000 to <1/100), rare (1/10,000 to <1/1,000), very rare (<1/10,000), not known (cannot be estimated from the available data). 19 REG-15307/v.43 Page 19/56  System organ Very Common Uncommon Rare Very Not known class common rare Blood and Thrombo- - Methaemoglobi - - - lymphatic cytopeniaa naemiaa system disorders Cardiac - - - - - Bradycardiab disorders (following abrupt discontinuation of

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HOS-093040 · has-adverse-reaction-information · PDF-Seite 7

Summary of safety profile Abrupt discontinuation of the administration of inhaled nitric oxide may cause rebound reaction; decrease in oxygenation and increase in central pressure and subsequent decrease in systemic blood pressure. Rebound reaction is the most commonly adverse reaction in association with the clinical use of INOmax. The rebound may be seen early as well as late during therapy. In one clinical study (NINOS), treatment groups were similar with respect to the incidence and severity of intracranial haemorrhage, Grade IV haemorrhage, periventricular leukomalacia, cerebral infarction, seizures requiring anticonvulsant therapy, pulmonary haemorrhage, or gastrointestinal haemorrhage. Tabulated list of adverse reactions The table below presents adverse reactions (ADRs) that have been reported with the use of INOmax from either the CINRGI trial of 212 neonates or post marketing experience in neonates (<1 months of age)). The displayed frequency categories use the following convention: very common (1/10), common (1/100 to <1/10), uncommon (1/1,000 to <1/100), rare (1/10,000 to <1/1,000), very rare (<1/10,000), not known (cannot be estimated from the available data). 7 REG-15307/v.43 Page 7/56  System organ Very Common Uncommon Rare Very Not known class common rare Blood and Thrombo- - Methaemoglobi - - - lymphatic cytopeniaa naemiaa system disorders Cardiac - - - - - Bradycardiab disorders (following abrupt discontinuation of

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HOS-093036 · has-contraindication-information · PDF-Seite 5

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1. Neonates known to be dependent on right-to-left, or significant left-to-right, shunting of blood.

HOS-093042 · has-contraindication-information · PDF-Seite 17

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1. Neonates known to be dependent on right-to-left, or significant left-to-right, shunting of blood.

HOS-093041 · has-indication-information · PDF-Seite 14

INOmax, in conjunction with ventilatory support and other appropriate active substances, is indicated: ▪ for the treatment of newborn infants  34 weeks gestation with hypoxic respiratory failure associated with clinical or echocardiographic evidence of pulmonary hypertension, in order to improve oxygenation and to reduce the need for extracorporeal membrane oxygenation. ▪ as part of the treatment of peri- and post-operative pulmonary hypertension in adults and newborn infants, infants and toddlers, children and adolescents, ages 0-17 years in conjunction to heart surgery, in order to selectively decrease pulmonary arterial pressure and improve right ventricular function and oxygenation.

HOS-093035 · has-indication-information · PDF-Seite 2

INOmax, in conjunction with ventilatory support and other appropriate active substances, is indicated: ▪ for the treatment of newborn infants  34 weeks gestation with hypoxic respiratory failure associated with clinical or echocardiographic evidence of pulmonary hypertension, in order to improve oxygenation and to reduce the need for extracorporeal membrane oxygenation. ▪ as part of the treatment of peri- and post-operative pulmonary hypertension in adults and newborn infants, infants and toddlers, children and adolescents, ages 0-17 years in conjunction to heart surgery, in order to selectively decrease pulmonary arterial pressure and improve right ventricular function and oxygenation.

HOS-093044 · has-interaction-information · PDF-Seite 18

No interaction studies have been performed. A clinically significant interaction with other medicinal products used in the treatment of hypoxic respiratory failure cannot be excluded based on the available data. There may be an additive effect with INOmax on the risk of developing methaemoglobinemia with nitric oxide donor substances, including sodium nitroprusside and nitroglycerin. INOmax has been safely administered with tolazoline, dopamine, dobutamine, steroids, surfactant, and high-frequency ventilation. The combined used with other vasodilators (e.g. sildenafil) is not extensively studied. Available data suggest additive effects on central circulation, pulmonary artery pressure and right ventricular performance. Inhaled nitric oxide combination with other vasodilators acting by the cGMP or cAMP systems should be done with caution. There is an increased risk of methaemoglobin formation if substances with a known tendency to increase methaemoglobin concentrations are administered concomitantly with nitric oxide (e.g. alkyl nitrates and sulphonamides). Substances known to cause increased methaemoglobin levels should thus be used with caution during therapy with inhaled nitric oxide. Prilocaine, whether administered as 18 REG-15307/v.43 Page 18/56  oral, parenteral, or topical formulations may cause methaemoglobinaemia. Care must be taken when INOmax is given at the same time as medicinal products containing prilocaine. In the presence of oxygen, nitric oxide is rapidly oxidised to derivatives which are toxic to the bronchial epithelium and alveolo-capillary membrane. Nitrogen dioxide (NO2) is the main substance formed, and may cause airway inflammation and damage. There are also animal data suggesting an increased susceptibility to airway infections upon exposure to low levels of NO2. During treatment with nitric oxide, the NO2 concentration should be < 0.5 ppm in the nitric oxide dose range < 20 ppm. If at any time the NO2 concentration exceeds 1 ppm, the nitric oxide dose should immediately be reduced. See section

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HOS-093038 · has-interaction-information · PDF-Seite 6

No interaction studies have been performed. A clinically significant interaction with other medicinal products used in the treatment of hypoxic respiratory failure cannot be excluded based on the available data. There may be an additive effect with INOmax on the risk of developing methaemoglobinemia with nitric oxide donor substances, including sodium nitroprusside and nitroglycerin. INOmax has been safely administered with tolazoline, dopamine, dobutamine, steroids, surfactant, and high-frequency ventilation. The combined used with other vasodilators (e.g. sildenafil) is not extensively studied. Available data suggest additive effects on central circulation, pulmonary artery pressure and right ventricular performance. Inhaled nitric oxide combination with other vasodilators acting by the cGMP or cAMP systems should be done with caution. There is an increased risk of methaemoglobin formation if substances with a known tendency to increase methaemoglobin concentrations are administered concomitantly with nitric oxide (e.g. alkyl nitrates and sulphonamides). Substances known to cause increased methaemoglobin levels should thus 6 REG-15307/v.43 Page 6/56  be used with caution during therapy with inhaled nitric oxide. Prilocaine, whether administered as oral, parenteral, or topical formulations may cause methaemoglobinaemia. Care must be taken when INOmax is given at the same time as medicinal products containing prilocaine. In the presence of oxygen, nitric oxide is rapidly oxidised to derivatives which are toxic to the bronchial epithelium and alveolo-capillary membrane. Nitrogen dioxide (NO2) is the main substance formed, and may cause airway inflammation and damage. There are also animal data suggesting an increased susceptibility to airway infections upon exposure to low levels of NO2. During treatment with nitric oxide, the NO2 concentration should be < 0.5 ppm in the nitric oxide dose range < 20 ppm. If at any time the NO2 concentration exceeds 1 ppm, the nitric oxide dose should immediately be reduced. See section

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HOS-093045 · has-pregnancy-information · PDF-Seite 19

There are no adequate data from the use of nitric oxide in pregnant women. The potential risk for humans is unknown. It is unknown whether nitric oxide is excreted in human milk. INOmax should not be used during pregnancy or breastfeeding. No fertility studies have been performed.

HOS-093039 · has-pregnancy-information · PDF-Seite 7

There are no adequate data from the use of nitric oxide in pregnant women. The potential risk for humans is unknown. It is unknown whether nitric oxide is excreted in human milk. INOmax should not be used during pregnancy or breastfeeding. No fertility studies have been performed.

HOS-093043 · has-warning-information · PDF-Seite 17

Inadequate response If it is judged that clinical response is inadequate at 4-6 hours after starting INOmax, the following should be considered. For patients who are to be referred to another hospital, to prevent worsening of their condition on acute discontinuation of INOmax, the availability of nitric oxide during transport should be assured. Rescue, such as Extra Corporeal Membrane Oxygenation (ECMO) where available, should be considered based on continued deterioration or failure to improve, defined by criteria based on local circumstances. Special patient populations In clinical trials, no efficacy has been demonstrated with the use of inhaled nitric oxide in patients with congenital diaphragmatic hernia. Treatment with inhaled nitric oxide might aggravate cardiac insufficiency in a situation with left-to- right shunting. This is due to unwanted pulmonary vasodilation caused by inhaled nitric oxide, resulting in a further increase of already existing pulmonary hyperperfusion thus potentially giving raise to forward or backward failure. It, therefore, is recommended that prior to the administration of nitric oxide, pulmonary artery catheterisation or echocardiographic examination of central haemodynamics be performed. Inhaled nitric oxide should be used with caution in patients with complex heart defect, where high pressure in the pulmonary artery is of importance for maintaining circulation. 17 REG-15307/v.43 Page 17/56  Inhaled nitric oxide should also be used with caution in patients with compromised left ventricular function and elevated baseline pulmonary capillary pressure (PCWP) as they may be at an increased risk of developing cardiac failure (e.g. pulmonary oedema). Discontinuation of therapy The INOmax dose should not be discontinued abruptly as it may result in an increase in pulmonary artery pressure (PAP) and/or worsening of blood oxygenation (PaO2). Deterioration in oxygenation and elevation in PAP may also occur in neonates with no apparent respo

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HOS-093037 · has-warning-information · PDF-Seite 5

Inadequate response If it is judged that clinical response is inadequate at 4-6 hours after starting INOmax, the following should be considered. For patients who are to be referred to another hospital, to prevent worsening of their condition on acute discontinuation of INOmax, the availability of nitric oxide during transport should be assured. Rescue, such as Extra Corporeal Membrane Oxygenation (ECMO) where available, should be considered based on continued deterioration or failure to improve, defined by criteria based on local circumstances. Special patient populations In clinical trials, no efficacy has been demonstrated with the use of inhaled nitric oxide in patients with congenital diaphragmatic hernia. Treatment with inhaled nitric oxide might aggravate cardiac insufficiency in a situation with left-to- right shunting. This is due to unwanted pulmonary vasodilation caused by inhaled nitric oxide, resulting in a further increase of already existing pulmonary hyperperfusion thus potentially giving raise to forward or backward failure. It, therefore, is recommended that prior to the administration of nitric oxide, pulmonary artery catheterisation or echocardiographic examination of central haemodynamics be performed. Inhaled nitric oxide should be used with caution in patients with complex heart defect, where high pressure in the pulmonary artery is of importance for maintaining circulation. 5 REG-15307/v.43 Page 5/56  Inhaled nitric oxide should also be used with caution in patients with compromised left ventricular function and elevated baseline pulmonary capillary pressure (PCWP) as they may be at an increased risk of developing cardiac failure (e.g. pulmonary oedema). Discontinuation of therapy The INOmax dose should not be discontinued abruptly as it may result in an increase in pulmonary artery pressure (PAP) and/or worsening of blood oxygenation (PaO2). Deterioration in oxygenation and elevation in PAP may also occur in neonates with no apparent respon

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