Following intravenous administration of hematin in non-jaun-diced human patients, an increase in fecal urobilinogen can
be observed which is roughly proportional to the amount of
hematin administered. This suggests an enterohepatic path-
For intravenous infusion only.
way as at least one route of elimination. Bilirubin metabolitesare also excreted in the urine following hematin injections.2
PANHEMATIN® (hemin for injection) should only be used by physi-
PANHEMATIN (hemin for injection) therapy for the acute por-
cians experienced in the management of porphyrias in hospitals
phyrias is not curative. After discontinuation of PANHEMATIN
where the recommended clinical and laboratory diagnostic and
treatment, symptoms generally return although in some cases
monitoring techniques are available.
remission is prolonged. Some neurological symptoms have
PANHEMATIN therapy should be considered after an appropriate
improved weeks to months after therapy although little or no
period of alternate therapy (i.e., 400 g glucose/day for 1 to 2 days).
response was noted at the time of treatment.
(See “WARNINGS”, “PRECAUTIONS” and “DOSAGE AND
Other aspects of human pharmacokinetics have not been defined. INDICATIONS AND USAGE PANHEMATIN (hemin for injection) is indicated for the amelio- DESCRIPTION
ration of recurrent attacks of acute intermittent porphyria tem-
PANHEMATIN (hemin for injection) is an enzyme inhibitor
porally related to the menstrual cycle in susceptible women.
derived from processed red blood cells. Hemin for injection
Manifestations such as pain, hypertension, tachycardia,
was known previously as hematin. The term hematin has been
abnormal mental status and mild to progressive neurologic
used to describe the chemical reaction product of hemin and
signs may be controlled in selected patients with this disorder.
sodium carbonate solution. Hemin is an iron containing metal-loporphyrin. Chemically hemin is represented as chloro [7,12-
Similar findings have been reported in other patients with
acute intermittent porphyria, porphyria variegata and heredi-
ropanoato(2-)-N21,N22,N23,N24] iron. The structural formula for
tary coproporphyria. PANHEMATIN is not indicated in por-
phyria cutanea tarda. CONTRAINDICATIONS
PANHEMATIN is contraindicated in patients with known hyper- sensitivity to this drug. WARNINGS PANHEMATIN is made from human blood. Products made from human blood may contain infectious agents, such as viruses, that can cause disease. The risk that such products will transmit an infectious agent has been reduced by screening blood donors for prior expo- sure to certain viruses, by testing for the presence of certain current virus infections, and by inactivating cer- tain viruses. Despite these measures, such products can still potentially transmit disease. There is also the
PANHEMATIN is a sterile, lyophilized powder suitable for intra-
possibility that unknown infectious agents may be
venous administration after reconstit u t i o n . E a c h d i s p e n s -
present in such products. ALL infections thought by a
i n g v i a l o f PA N H E M AT I N c o n t a i n s t h e e q u i v a l e n t
physician possibly to have been transmitted by this
o f 3 1 3 m g hemin, 215 mg sodium carbonate and 300 mg
product should be reported by the physician or other
of sorbitol. The pH may have been adjusted with hydrochloric
healthcare provider to Ovation Pharmaceuticals, (800-
acid; the product contains no preservatives. When mixed as
455-1141). The physician should discuss the risks and
directed with Sterile Water for Injection, USP, each 43 mL pro-
benefits of this product with the patient.
vides the equivalent of approximately 301 mg hematin (7
Because this product is made from human blood, it may carry
a risk of transmitting infectious agents, e.g., viruses, and the-
oretically, the Creutzfeldt-Jakob disease (CJD) agent.
Heme acts to limit the hepatic and/or marrow synthesis of
PANHEMATIN therapy is intended to limit the rate of
porphyrin. This action is likely due to the inhibition of δ-
porphyria/heme biosynthesis possibly by inhibiting the enzyme
aminolevulinic acid synthetase, the enzyme which limits the
δ-aminolevulinic acid synthetase. For this reason, drugs such as
rate of the porphyrin/heme biosynthetic pathway. The exact
estrogens, barbituric acid derivatives and steroid metabolites
mechanism by which hematin produces symptomatic
which increase the activity of δ-aminolevulinic acid synthetase
improvement in patients with acute episodes of the hepatic
Panhematin® Patient Information – Page 1 of 3
Also, because hemin for injection has exhibited transient, mild
important to the health and welfare of the patient to outweigh
anticoagulant effects during clinical studies, concurrent anti-
coagulant therapy should be avoided.9 The extent and duration
of the hypocoagulable state induced by PANHEMATIN® has
It is not known whether this drug is excreted in human milk.
Because many drugs are excreted in human milk, caution
should be exercised when PANHEMATIN is administered to a
Clinical benefit from PANHEMATIN depends on prompt admin-
istration. Attacks of porphyria may progress to a point where
Safety and effectiveness in pediatric patients under 16 years
irreversible neuronal damage has occurred. PANHEMATIN
therapy is intended to prevent an attack from reaching the
critical stage of neuronal degeneration. PANHEMATIN is not
Clinical studies in PANHEMATIN did not include sufficient
numbers of subjects aged 65 and over to determine whether
Recommended dosage guidelines should be strictly followed.
they respond differently from younger subjects. Other reported
Reversible renal shutdown has been observed in a case where
clinical experience has not identified differences in response
an excessive hematin dose (12.2 mg/kg) was administered in
between the elderly and younger patients. In general, dose
a single infusion. Oliguria and increased nitrogen retention
selection for an elderly patient should be cautious, usually
occurred although the patient remained asymptomatic.4 No
starting at the low end of the dosing range, reflecting the
worsening of renal function has been seen with administration
greater frequency of decreased hepatic, renal, or cardiac
function, and of concomitant disease or other drug therapy.
A large arm vein or a central venous catheter should be utilized
for the administration of PANHEMATIN to avoid the possibility
Reversible renal shutdown has occurred with administration of
excessive doses (See “PRECAUTIONS” section).
Since reconstituted PANHEMATIN is not transparent, any undis-
Phlebitis with or without leucocytosis and with or without mild
solved particulate matter is difficult to see when inspected visu-
pyrexia has occurred after administration of hematin through
ally. Therefore, terminal filtration through a sterile 0.45 micron
There have been post-marketing and literature reports of
Tests for Diagnosis and Monitoring of Therapy
thrombocytopenia and coagulopathy (including prolonged pro-
Before PANHEMATIN therapy is begun, the presence of acute
thrombin time and prolonged partial thromboplastin time) in
porphyria must be diagnosed using the following criteria:9
patients receiving PANHEMATIN. The initial literature report8
described coagulopathy occurring in a patient receiving
b. Positive Watson-Schwartz or Hoesch test. (A negative Wat-
hematin therapy. This patient exhibited prolonged prothrombin
son-Schwartz or Hoesch test indicates a porphyric attack is
time and partial thromboplastin time, thrombocytopenia, mild
highly unlikely. When in doubt quantitative measures of δ-
hypofibrogenemia, mild elevation of fibrin split products, and
aminolevulinic acid and porphobilinogen in serum or urine
Urinary concentrations of the following compounds may be mon-
Reversible renal shutdown has been observed in a case where
itored during PANHEMATIN therapy. Drug effect will be demon-
an excessive hematin dose (12.2 mg/kg) was administered in
strated by a decrease in one or more of the following
a single infusion. Treatment of this case consisted of
DOSAGE AND ADMINISTRATION
Before administering PANHEMATIN, an appropriate period of
alternate therapy (i.e., 400 g glucose/day for 1 to 2 days) must
be considered. If improvement is unsatisfactory for the treat-
Carcinogenesis, Mutagenesis, Impairment of Fertility
ment of acute attacks of porphyria, an intravenous infusion of
No data are available on potential for carcinogenicity, muta-
PANHEMATIN containing a dose of 1 to 4 mg/kg/day of hematin
genicity or impairment of fertility in animals or humans.
should be given over a period of 10 to 15 minutes for 3 to 14
days based on the clinical signs. In more severe cases this dose
Teratogenic effects-Pregnancy Category C: Animal reproduc-
may be repeated no earlier than every 12 hours. No more than
tion studies have not been conducted with hematin. It is also
6 mg/kg of hematin should be given in any 24 hour period.
not known whether hematin can cause fetal harm when admin-
After reconstitution each mL of PANHEMATIN contains the
istered to a pregnant woman or can affect reproduction capac-
equivalent of approximately 7 mg of hematin. The drug may
ity. For this reason PANHEMATIN should not be given to a
be administered directly from the vial.
pregnant woman unless the expected benefits are sufficiently
Panhematin® Patient Information – Page 2 of 3 Dosage Calculation Table
1 mg hematin equivalent = 0.14 mL PANHEMATIN
2 mg hematin equivalent = 0.28 mL PANHEMATIN3 mg hematin equivalent = 0.42 mL PANHEMATIN
4 mg hematin equivalent = 0.56 mL PANHEMATIN
Since reconstituted PANHEMATIN® is not transparent, any undissolved particulate matter is difficult to see when inspected visually. Therefore, terminal filtration through a ster- ile 0.45 micron or smaller filter is recommended. Preparation of Solution: Reconstitute PANHEMATIN by aseptically adding 43 mL of Sterile Water for Injection, USP, to the dispensing vial.
® Registered Trademark of Ovation Pharmaceuticals, Deerfield, IL 60015, U.S.A.
Immediately after adding diluent, the product should be
shaken well for a period of 2 to 3 minutes to aid dissolution. NOTE: Because PANHEMATIN contains no preservative and because PANHEMATIN undergoes rapid chemical decomposition in solution, it should not be reconstituted until immediately before use. After the first withdrawal from the vial, any solution remaining must be discarded. No drug or chemical agent should be added to a PANHEMATIN fluid admixture unless its effect on the chemical and physical stability has first been determined. HOW SUPPLIED PANHEMATIN is supplied as a sterile, lyophilized black powder in single dose dispensing vials (NDC 67386-701-54). When mixed as directed with Sterile Water for Injection, USP, each 43 mL pro- vides the equivalent of approximately 301 mg hematin (7 mg/mL). Store lyophilized powder in refrigerator (2-8°C) until time of use. Caution: The packaging (vial stopper) of this product contains natural rubber latex which may cause allergic reactions. REFERENCES
1.Bickers, D., Treatment of the Porphyrias: Mechanisms of Action,
J Invest Dermatol 77(1):107-113, 1981.
2.Watson, C. J., Hematin and Porphyria, editorial, N Engl J Med
293(12):605-607, September 18, 1975.
3.Lamon, J. M., Hematin Therapy for Acute Porphyria, Medicine
4. Dhar, G J., et al., Effects of Hematin in Hepatic Porphyria, Ann Intern
5.Watson, C. J., et al., Use of Hematin in the Acute Attack of the
“Inducible” Hepatic Porphyrias, Adv Intern Med 23:265-286,1978.
6.McColl, K. E., et al., Treatment with Haematin in Acute Hepatic
Porphyria, Q J Med, New Series L (198):161-174, Spring,1981.
7. Dhar, G. J., et al., Transitory Renal Failure Following Rapid Admin-
istration of a Relatively Large Amount of Hematin in a Patient withAcute Intermittent Porphyria in Clinical Remission, Acta Med Scand203:437-443, 1978.
8.Morris, D.L., et al., Coagulopathy Associated with Hematin Treat-
ment for Acute Intermittent Prophyria, Ann Intern Med 95:700-701, 1981.
9.Pierach, C. A., Hematin Therapy for the Porphyric Attack, SeminLiver Dis 2(2):125-131, May, 1982. Panhematin® Patient Information – Page 3 of 3
THE JOURNAL OF FINANCE • VOL. LVII, NO. 5 • OCTOBER 2002 Information Production and Capital Allocation: Decentralized versus Hierarchical Firms ABSTRACT This paper asks how well different organizational structures perform in terms ofgenerating information about investment projects and allocating capital to theseprojects. A decentralized approach—with small, single-manager firms—is
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