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  1. Plasma Derivative
    • Drug Classes
  3. KEDRION BIOPHARMA, INC.

Generic: antihemophilic factor (human)

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1 Indications And Usage


KOĀTE® is a human plasma-derived antihemophilic factor indicated for the control and prevention of bleeding episodes or in order to perform emergency and elective surgery in patients with hemophilia A (hereditary Factor VIII deficiency).

Limitation of Use

KOĀTE is not indicated for the treatment of von Willebrand disease.


KOĀTE is a human plasma-derived  antihemophilic factor indicated for the control and prevention of bleeding episodes or in order to perform emergency and elective surgery in patients with hemophilia A (hereditary Factor VIII deficiency ). (1)

Limitation of Use KOĀTE is not indicated for the treatment of von Willebrand disease.

2 Dosage And Administration


For intravenous use after reconstitution only.


For  intravenous use after reconstitution only.
  • Each vial of KOĀTE contains the labeled amount of Factor VIII in international units (IU). (2)
  • Required Dose (IU) = Body Weight (kg) x Desired Factor VIII Rise (IU/dL or % of normal ) x 0.5
  • Frequency of KOĀTE administration is determined by the type of bleeding episode and the recommendation of the treating physician.

2.1 Dose

  • Dose and duration of treatment depend on the severity of the Factor VIII deficiency, location and extent of bleeding, and the patient’s clinical condition.
  • Each vial of KOĀTE is labeled with the actual Factor VIII potency in international units (IU). Calculation of the required dose of Factor VIII is based on the empirical finding that one IU of Factor VIII per kg body weight raises the plasma Factor VIII activity by approximately 2% of normal activity or 2 IU/dL.
  • The required dose can be determined using the following formula: Dose (IU) = Body Weight (kg) x Desired Factor VIII Rise (% normal or IU/dL) x 0.5
  • Estimate the expected in vivo peak increase in Factor VIII level, expressed as IU/dL (or % normal), using the following formula:                 Estimated Increment of Factor VIII (% normal or IU/dL) = [Total Dose (IU)/Body Weight (kg)] x 2
  • Patients may vary in their pharmacokinetic (e.g., half-life, in vivo recovery) and clinical responses. Base the dose and frequency on the individual clinical response.

Control and Prevention of Bleeding Episodes

A guide for dosing KOĀTE for the control and prevention of bleeding episodes (1,2) is provided in Table 1. Consideration should be given to maintaining a Factor VIII activity at or above the target range.
Table 1: Dosage Guidelines for Patients with Hemophilia A
Type of Bleeding Factor VIII:C Level Required (% of normal) Doses (IU/kg) Frequency of Doses   (hours) Duration of Therapy (days)
Minor Large bruises Significant cuts or scrapes Uncomplicated joint hemorrhage 30 15 12  (twice daily) Until hemorrhage stops and healing has been achieved (1–2 days).
Moderate Nose, mouth and gum bleeds Dental extractions Hematuria 50 25 12  (twice daily) Until healing has been achieved (2–7 days, on average).
Major Joint hemorrhage Muscle hemorrhage Major trauma Hematuria Intracranial and intraperitoneal bleeding 80-100 Initial: 40-50    Maintenance: 25 12  (twice daily) For at least 3–5 days   Until healing has been achieved for up to 10 days.  Intracranial hemorrhage may require prophylaxis therapy for up to 6 months.
Surgery Prior to surgery: 80-100   After surgery: 60-100 40-50 30-50 Once     12 (twice daily) Prior to surgery     For the next 7–10 days, or until healing has been achieved.

2.2 Preparation and Reconstitution

  • Use aseptic technique (clean and sanitized) and a flat work surface during the reconstitution procedure.
  • Bring the vials of KOĀTE and the diluent (Sterile Water for Injection) to room temperature before use.
  • Remove the shrink band from the KOĀTE vial. Do not use KOĀTE if the shrink band is absent or shows signs of tampering, and notify Grifols Therapeutics LLC immediately.
  • Remove the plastic cap from the KOĀTE vial and clean the top of the stopper with an alcohol swab. Allow the stopper to dry.
  • Repeat this step with the vial of sterile water.
  • Open the sterile Mix2Vial® package by peeling away the lid (Figure 1). Do not remove the device from the package.
  • Place the diluent vial upright on an even surface. Holding the diluent vial securely, push the blue end of the Mix2Vial straight down until the spike penetrates the stopper (Figure 2).
  • Remove the clear outer packaging from the Mix2Vial and discard it (Figure 3).
  • Place the KOĀTE vial upright on a flat surface, and invert the diluent vial with the Mix2Vial still attached.
  • While holding the KOĀTE vial securely on a flat surface, push the clear end of the Mix2Vial straight down until the spike penetrates the stopper (Figure 4). The diluent will automatically transfer into the KOĀTE vial by the vacuum contained within it. Note: If the Mix2Vial is connected at an angle, the vacuum may be released from the product vial and the diluent will not transfer into the product vial. If vacuum is lost, use a sterile syringe and needle to remove the sterile water from the diluent vial and inject it into the KOĀTE vial, directing the stream of fluid against the wall of the vial.
  • With the diluent and KOĀTE vials still attached to the Mix2Vial, agitate vigorously for 10 to 15 seconds, then gently swirl (Figure 5) until the powder is completely dissolved. Avoid excessive foaming. The reconstituted solution should be clear to opalescent. Do not use if particulate matter or discoloration is observed.
  • Remove the diluent vial and the blue end of the Mix2Vial (Figure 6) by holding each side of the vial adapter and twisting counterclockwise.
  • Draw air into an empty, sterile syringe. Connect the syringe to the clear end of the Mix2Vial by pressing and twisting clockwise, and push the air into the KOĀTE vial.
  • Immediately invert the system upside down and then draw the reconstituted KOĀTE into the syringe by pulling the plunger back slowly (Figure 7).
  • Detach the filled syringe from the Mix2Vial by turning counter-clockwise (Figure 8). Use KOĀTE within 3 hours after reconstitution. Do not refrigerate after reconstitution.

2.3 Administration


For intravenous administration only
  • If the dose requires more than one vial of KOĀTE:
    • Reconstitute each vial using a new Mix2Vial.
    • Draw up all the solution into a single syringe.
  • Visually inspect the final solution for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not use if particulate matter or discoloration is observed.
  • Attach the syringe to the connector end of an infusion set.
  • Administer intravenously. The rate of administration should be determined by the patient’s comfort level, and no faster than 10 mL per minute.

3 Dosage Forms And Strengths


KOĀTE is available as a lyophilized powder for reconstitution in single-use vials of 250, 500 and 1,000 IU of Factor VIII activity. The actual Factor VIII potency is labeled on each KOĀTE vial.


KOĀTE is available as a lyophilized powder for reconstitution in single-use vials of 250, 500, and 1,000 international units of Factor VIII activity. (3)

4 Contraindications


KOĀTE is contraindicated in patients who have had hypersensitivity reactions, including anaphylaxis, to KOĀTE or its components. [see Description (11) ]


Do not use in patients who have known hypersensitivity reactions, including anaphylaxis, to KOĀTE or its components. (4)

5 Warnings And Precautions


  • Hypersensitivity reactions, including anaphylaxis, are possible. Should symptoms occur, discontinue KOĀTE and administer appropriate treatment. (5.1)
  • Development of neutralizing antibodies (inhibitors) may occur. If expected plasma Factor VIII activity levels are not attained, or if bleeding is not controlled with an appropriate dose, perform an assay that measures Factor VIII inhibitor concentration. (5.2)
  • Monitor for intravascular hemolysis and decreasing hematocrit values in patients with A, B or AB blood groups who are receiving large or frequent doses. (5.3)
  • KOĀTE is made from human blood and  therefore carries a risk of transmitting infectious agents,  e.g., viruses, the variant Creutzfeldt-Jakob disease (vCJD) agent and, theoretically, the Creutzfeldt-Jakob disease (CJD) agent. (5.4)

5.1 Hypersensitivity Reactions


Hypersensitivity reactions, including anaphylaxis, are possible. Early signs of hypersensitivity reactions, which can progress to anaphylaxis, may include angioedema, chest tightness, hypotension, rash, nausea, vomiting, paresthesia, restlessness, wheezing and dyspnea. If hypersensitivity symptoms occur, discontinue use of the product immediately and administer appropriate emergency treatment.

5.2 Neutralizing Antibodies


The formation of neutralizing antibodies (inhibitors) to Factor VIII may occur. Monitor all patients for the development of Factor VIII inhibitors by appropriate clinical observations and laboratory tests. If expected plasma Factor VIII activity levels are not attained, or if bleeding is not controlled with an appropriate dose, perform an assay that measures Factor VIII inhibitor concentration. [see Warnings and Precautions (5.5) ] 

5.3 Intravascular Hemolysis


KOĀTE contains blood group isoagglutinins which are not clinically significant when small doses are used to treat minor bleeding episodes. However, when large and/or frequent doses of KOĀTE are given to patients with blood groups A, B, or AB, acute hemolytic anemia may occur, resulting in increased bleeding tendency or hyperfibrinogenemia. Monitor these patients for signs of  intravascular hemolysis and falling hematocrit. [see Warnings and Precaustions (5.5) ] Should this condition occur, leading to progressive hemolytic anemia, discontinue KOĀTE and consider administering serologically compatible Type O red blood cells and providing alternative therapy.

5.4 Transmissible Infectious Agents


Because KOĀTE is made from human blood, it may carry a risk of transmitting infectious agents, e.g., viruses, the variant Creutzfeldt-Jakob disease (vCJD) agent and, theoretically, the Creutzfeldt-Jakob disease (CJD) agent. There is also the possibility that unknown infectious agents may be present in the product. The risk that the product will transmit viruses has been reduced by screening plasma donors for prior exposure to certain viruses, by testing for the presence of certain current virus infections, and by inactivating and removing certain viruses during manufacture. Despite these measures, this product may still potentially transmit diseases.

Report all infections suspected by a physician possibly to have been transmitted by this product to Grifols Therapeutics LLC at 1-800-520-2807.

5.5 Monitoring: Laboratory Tests

  • Monitor plasma Factor VIII activity levels by performing a validated test (e.g., one-stage clotting assay) to confirm that adequate Factor VIII levels have been achieved and maintained. [see Dosage and Administration (2.1) ]
  • Monitor for the development of Factor VIII inhibitors. Perform a Bethesda inhibitor assay if expected Factor VIII plasma levels are not attained, or if bleeding is not controlled with the expected dose of KOĀTE. Use Bethesda Units (BU) to report inhibitor levels.
  • Monitor for intravascular hemolysis and decreasing hematocrit values in patients with A, B or AB blood groups who are receiving large or frequent doses of KOĀTE.

6 Adverse Reactions


The most common adverse drug reactions (frequency ≥ 5 % of subjects) observed in the clinical trial were nervousness, headache, abdominal pain, nausea, paresthesia and blurred vision.


The most common adverse drug reactions (frequency ≥ 5% of subjects) observed in the clinical trial were nervousness, headache, abdominal pain, nausea, paresthesia and blurred vision. (6)

To report SUSPECTED ADVERSE REACTIONS, contact Grifols Therapeutics LLC at 1-800-520-2807 or FDA at 1-800-FDA-1088 or http://www.fda.gov/medwatch.

6.1 Clinical Trials Experience


Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed cannot be directly compared to rates in other clinical trials and may not reflect the rates observed in practice.

The safety assessment of KOĀTE is based on data from a 2-stage, safety, pharmacokinetic (PK) and efficacy clinical trial in which twenty subjects with severe hemophilia A (<1% endogenous Factor VIII activity) were evaluable for safety. Nineteen subjects were enrolled in Stage I of the trial, including 15 Caucasian, 3 Hispanic, and 1 Black subjects. The mean age was 29 years (range: 13.9 – 46.4 years). Nineteen subjects, including the 18 subjects who completed Stage I, and one new subject were enrolled in Stage II. The mean age was 30 years (range: 13.9 – 46.4). The subjects received a total of 1053 infusions. Ten adverse reactions related to 7 infusions were reported in 4 subjects.  These were: nervousness (2 subjects [10%]), headache (1 subject [5%]), abdominal pain (1 subject [5%]), nausea (1 subject [5%]), paresthesia (1 subject [5%]), and blurred vision (1 subject [5%]).

Immunogenicity

Subjects were monitored for neutralizing antibodies (inhibitors) to Factor VIII by the Bethesda assay at baseline and at 8, 17 and 26 weeks. No evidence of inhibitor formation was observed in the clinical trial.

The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, it may be misleading to compare the incidence of antibodies to KOĀTE in the study described above with the incidence of antibodies in other studies or to other products.

6.2 Postmarketing Experience


Because postmarketing reporting of adverse reactions is voluntary and from a population of uncertain size, it is not always possible to reliably estimate the frequency of these reactions or establish a causal relationship to product exposure.
  • Blood and Lymphatic System Disorders: Factor VIII inhibition, hemolytic anemia
  • Immune System Disorders: Hypersensitivity including anaphylaxis, rash, pruritus
  • Injury, Poisoning and Procedural Complications: Post-procedural hemorrhage
  • Nervous System Disorders: Generalized clonic-tonic seizure

8 Use In Specific Populations



Pediatric: clearance of Factor VIII (based on per kilogram body weight) is higher in children.  Higher or more frequent dosing may be needed. (8.4)

8.1 Pregnancy


Risk Summary

There are no data with KOĀTE use in pregnant women to inform on drug-associated risk. Animal reproduction studies have not been conducted using KOĀTE. It is not known whether KOĀTE can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. KOĀTE should be given to a pregnant woman only if clearly needed. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.

8.2 Lactation


Risk Summary

There is no information regarding the presence of KOĀTE in human milk, the effects on the breastfed infant, or the effects on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for KOĀTE and any potential adverse effects on the breast-fed infant from KOĀTE or from the underlying maternal condition.

8.4 Pediatric Use


Safety and efficacy studies have been performed in 20 previously treated pediatric patients aged 2.5 to 16 years. Subjects received 208 infusions of KOĀTE for treatment or control of bleeding episodes, including perioperative management, and routine prophylaxis.  Children have shorter half-life and lower recovery of Factor VIII than adults. Because clearance of Factor VIII (based on per kilogram body weight) is higher in children, higher or more frequent dosing may be needed.

8.5 Geriatric Use


Clinical studies of KOĀTE did not include any subjects aged 65 and over to determine whether they respond differently from younger subjects. Individualize dose selection for geriatric patients.

11 Description


KOĀTE, Antihemophilic Factor (Human), is a sterile, stable, dried concentrate of human antihemophilic factor  in lyophilized powder form for reconstitution for intravenous injection.  The product is supplied in single-use vials containing nominally 250, 500, or 1,000 international units (IU or units). Each vial of KOĀTE is labeled with the actual amount of Factor VIII expressed in IU. One IU is defined by the current World Health Organization International Standard for Factor VIII concentrate, which can be traced to the level of Factor VIII found in 1 mL of fresh pooled human plasma. The final product when reconstituted as directed contains not more than (NMT) 1500 μg/mL polyethylene glycol (PEG), NMT 0.05 M glycine, NMT 25 μg/mL polysorbate 80, NMT 5 μg/g tri-n-butyl phosphate (TNBP), NMT 3 mM calcium, NMT 1 μg/mL aluminum, NMT 0.06 M histidine, and NMT 10 mg/mL human albumin.

KOĀTE is purified from the cold insoluble fraction of pooled human plasma; the manufacturing process includes solvent/detergent (TNBP and polysorbate 80) treatment and heat treatment of the lyophilized final container. A gel permeation chromatography step serves the dual purpose of reducing the amount of TNBP and polysorbate 80 as well as increasing the purity of the Factor VIII in KOĀTE to 300 to 1,000 times over whole plasma. When reconstituted as directed, KOĀTE contains approximately 50 to 150 times as much Factor VIII as an equal volume of fresh plasma. The specific activity after addition of human albumin is in the range of 9 to 22 units/mg protein. KOĀTE also contains naturally occurring von Willebrand factor, which is co-purified as part of the manufacturing process.

The KOĀTE manufacturing process includes two dedicated steps with virus inactivation capacity. The solvent/detergent treatment step has the capacity to inactivate enveloped viruses (such as HIV, HCV, HBV, and WNV). Heat treatment at 80ºC for 72 hours has the capacity to inactivate enveloped viruses (such as HIV and HCV) as well as non‑enveloped viruses (such as HAV and B19V). The polyethylene glycol (PEG) precipitation/depth filtration step has the capacity to remove both enveloped and non‑enveloped viruses. The accumulated virus reduction factors for KOĀTE manufacturing process are presented in Table 2.
Table 2: Virus Clearance Capacity (Log10) for the Antihemophilic Factor (Human) Manufacturing Process
* WNV inactivation was evaluated only for the solvent/detergent treatment step
 
Enveloped Viruses

Non-enveloped Viruses

HIV-1

BVDV

PRV

VSV

WNV

Reo3

HAV

PPV

Model for
HIV-1/2
HCV
Large enveloped DNA viruses (e.g., herpes virus)
Enveloped RNA viruses
WNV
Non-enveloped viruses

HAV
B19V

Global Reduction Factor
≥ 12.0
≥ 11.5
≥ 10.8
≥ 10.9
≥ 5.9*

≥ 9.9
≥ 5.5
4.8

Additionally, the KOĀTE manufacturing process was investigated for its capacity to decrease the infectivity of an experimental agent of transmissible spongiform encephalopathy (TSE), considered a model for the variant Creutzfeldt-Jakob disease (vCJD) and Creutzfeldt-Jakob disease (CJD) agents. The manufacturing process has been shown to decrease TSE infectivity of that experimental model agent (a total of 5.1 log10 reduction), providing reasonable assurance that low levels of vCJD/CJD agent infectivity, if present in the starting material, would be removed.

12 Clinical Pharmacology


12.1 Mechanism of Action


KOĀTE temporarily replaces the missing clotting Factor VIII that is needed for effective hemostasis.

12.2 Pharmacodynamics


Hemophilia A is a bleeding disorder characterized by a deficiency of functional coagulation Factor VIII, resulting in a prolonged plasma clotting time as measured by the activated partial thromboplastin time (aPTT) assay. Treatment with KOĀTE normalizes the aPTT over the effective dosing period.

12.3 Pharmacokinetics


The pharmacokinetics (PK) of KOĀTE were evaluated in a prospective, two-stage clinical trial of 20 previously treated patients (PTPs) with severe hemophilia A. In Stage I, the PK parameters for 19 subjects were based on plasma Factor VIII activity after a single intravenous infusion of 50 IU/kg of KOĀTE. Bioequivalence of the dry heat-treated KOĀTE to the unheated KOĀTE was demonstrated by comparison of Cmaxand the area under the curve, AUC0-48  (Table 3). The incremental in vivo recovery ten minutes after infusion of dry heat-treated KOĀTE was 1.90% unit/kg (unheated KOĀTE was 1.82% units/kg). Mean biologic half-life was 16.1 hours.

In Stage II of the study, participants received KOĀTE treatments for six months on home therapy with a median of 52 days (range 23 to 94 days). At the end of 6 months, the mean AUC0-48 was 1471 ± 237 unit*hour/100 mL, the Cmax was 99 ± 13 unit/100 mL, and the t1/2was 16 ± 3.9 hours.
Table 3: PK Parameters of KOĀTE (Stage I of Crossover Trial)
Parameter KOĀTE Dry Heat-treated (mean ± SD) KOĀTE Unheated (mean ± SD)
AUC0-48 (IU hr/mL) 1432 ±288 1477 ± 343
Cmax (IU/mL) 103 ± 19 99 ± 20
Tmax (hr) 0.41 ± 0.26 0.43 ± 0.44
Half life (hr) 16.1 ± 3.2 16.1 ± 5.1

14 Clinical Studies


The efficacy of KOĀTE for the treatment of bleeding episodes was demonstrated in a 2-stage, safety, PK and efficacy clinical trial. Stage I was a randomized, single-blind, single-dose, crossover, and PK study comparing heat-treated KOĀTE with unheated KOĀTE. Nineteen subjects were randomized and received a single dose of 50 IU/kg of either heated KOĀTE or unheated KOĀTE for PK assessment. Stage II was a 6 month open-label safety study conducted at two hemophilia centers. Nineteen subjects received KOĀTE, including for on-demand treatment and control of bleeding episodes. The study populations included 15 Caucasians, 3 Hispanic, and 1 Black subjects. A total of 306 bleeding episodes were treated, of which 82% were treated with a single infusion of Factor VIII.

15 References

  • Srivastava A, Brewer AK, Mauser-Bunschoten EP, et al. Guidelines for the management of hemophilia. Haemophilia 2013;19(1):e1-47.
  • Abildgaard CF. Current concepts in the management of hemophilia. Semin Hematol 1975;12(3):223-32.

16 How Supplied/storage And Handling


How Supplied

KOĀTE is supplied in single-use vials containing 250, 500 or 1,000 IU of Factor VIII activity, packaged with 5 mL or 10 mL of Sterile Water for Injection, and a Mix2Vial® transfer device. The actual amount of KOĀTE in IU is stated on each carton and vial label.

Components used in the packaging of KOĀTE are not made with natural rubber latex.
Strength Carton (Kit) NDC Number
250 IU   76125-256-20, 76125-257-25 or 76125-259-02
500 IU   76125-668-30, 76125-663-50 or 76125-665-02
1,000 IU  76125-676-50, 76125-678-10 or 76125-679-12

Storage and Handling
  • Store KOĀTE in its original package to protect it from light.
  • Store the KOĀTE  package at 2 to 8°C (36 to 46°F). Do not freeze.
  • KOĀTE may also be stored at room temperature (up to 25°C or 77°F) for up to 6 months.
  • Do not use after the expiration date.
  • Use reconstituted KOĀTE immediately or within 3 hours of reconstitution.

17 Patient Counseling Information

  • Inform patients to immediately report the following early signs and symptoms of hypersensitivity reactions to their healthcare professional: angioedema, chest tightness, hypotension, rash, nausea, vomiting, paresthesia, restlessness, wheezing and dyspnea. [see Warnings and Precautions (5.1) ]
  • Inform patients that the development of inhibitors to Factor VIII is a possible complication of treatment with KOĀTE. Advise the patients to contact their healthcare provider for further treatment and/or assessment if they experience a lack of clinical response to KOĀTE because this may be a manifestation of an inhibitor. [see Warnings and Precautions (5.2)]
  • Inform patients that KOĀTE is made from human plasma and may carry a risk of transmitting infectious agents. While the risk that KOĀTE can transmit an infection has been reduced by screening plasma donors for prior exposure, testing donated plasma, and inactivating or removing certain viruses during manufacturing, patients should report any symptoms that concern them. [see Warnings and Precautions (5.4)]

Manufactured for: Kedrion Biopharma Inc. 400 Kelby Street, Fort Lee, NJ 07024  Manufactured by: Grifols Therapeutics LLC Research Triangle Park, NC 27709 USAU.S. License No. 1871 Mix2Vial® is a registered trademark of Medimop Medical Projects Ltd. 3058092 

Package Label


NDC 76125-256-20 Koāte® Antihemophilic Factor (Human) 250 IU FVIII Range Solvent/Detergent Treated Heat-Treated at 80°C 5 mL Rx only WARNING: THIS PRODUCT IS PREPARED FROM LARGE POOLS OF HUMAN PLASMA WHICH MAY CARRY THE RISK OF TRANSMITTING INFECTIOUS AGENTS. The patient and physician should discuss the risks and benefits of this product. Dosage and Administration: Read enclosed package insert. Store refrigerated at 2 to 8°C (36 to 46°F) and no more than 6 months at room temperature (up to 25°C; 77°F) at any time prior to the expiration date.Avoid freezing. Reconstitute with 5 mL Sterile Water for Injection, USP. Administer within 3 hours after reconstitution. This product when reconstituted contains not more than (NMT) 1500 μg/mL polyethylene glycol (PEG), NMT 0.05 M glycine, NMT 25 μg/mL polysorbate 80, NMT 5 μg/g tri-n-butyl phosphate (TNBP), NMT 3 mM calcium, NMT 1 μg/mL aluminum, NMT 0.06 M histidine, and NMT 10 mg/mL Albumin (Human). If the shrink band is absent or shows any sign of tampering, do not use the product and notify Grifols Therapeutics LLC immediately. Not Returnable for Credit or Exchange Manufactured for: Kedrion Biopharma Inc. 400 Kelby Street, Fort Lee, NJ 07024 Manufactured by: Grifols Therapeutics LLC Research Triangle Park, NC 27709 USAU.S. License No. 1871 CONTENTS: One bottle of Koāte 5 mL Sterile Water for Injection, USP One sterile Mix2Vial® filter transfer set No Preservative For Intravenous Administration Only Sterile — Nonpyrogenic Date removed from refrigeration_______________________ GTIN XXXXXXXXXXXXXX LOT XXXXXXXXXX EXP DDMMMYYYY SN XXXXXXXXXXXXXXXXIU XXX NDC 76125-256-20 Koāte ® Antihemophilic Factor (Human) Carton: 3046584

NDC 76125-252-21 Koāte® Antihemophilic Factor (Human) Solvent/Detergent Treated Heat-Treated at 80°C Manufactured for: Kedrion Biopharma Inc. 400 Kelby Street, Fort Lee, NJ 07024 Manufactured by: Grifols Therapeutics LLC Research Triangle Park, NC 27709 USAU.S. License No. 1871 The patient and physician should discuss the risks and benefits of this product. No Preservative For Intravenous Administration Only Sterile—Nonpyrogenic Reconstitute with 5 mL Sterile Water for Injection, USP. Store at 2–8°C (36–46°F) and no more than 6 months at room temperature (up to 25°C; 77°F) at any time prior to the expiration date. Dosage and Administration: Read package insert. Rx only Date removed from refrigeration_____________________ Lot Exp. IU 3051798

NDC 76125-668-30 Koāte® Antihemophilic Factor (Human) 500 IU FVIII Range Solvent/Detergent Treated Heat-Treated at 80°C 5 mL Rx only WARNING: THIS PRODUCT IS PREPARED FROM LARGE POOLS OF HUMAN PLASMA WHICH MAY CARRY THE RISK OF TRANSMITTING INFECTIOUS AGENTS. The patient and physician should discuss the risks and benefits of this product. Dosage and Administration: Read enclosed package insert. Store refrigerated at 2 to 8°C (36 to 46°F) and no more than 6 months at room temperature (up to 25°C; 77°F) at any time prior to the expiration date.Avoid freezing. Reconstitute with 5 mL Sterile Water for Injection, USP. Administer within 3 hours after reconstitution. This product when reconstituted contains not more than (NMT) 1500 μg/mL polyethylene glycol (PEG), NMT 0.05 M glycine, NMT 25 μg/mL polysorbate 80, NMT 5 μg/g tri-n-butyl phosphate (TNBP), NMT 3 mM calcium, NMT 1 μg/mL aluminum, NMT 0.06 M histidine, and NMT 10 mg/mL Albumin (Human). If the shrink band is absent or shows any sign of tampering, do not use the product and notify Grifols Therapeutics LLC immediately. Not Returnable for Credit or Exchange Manufactured for: Kedrion Biopharma Inc. 400 Kelby Street, Fort Lee, NJ 07024 Manufactured by: Grifols Therapeutics LLC Research Triangle Park, NC 27709 USAU.S. License No. 1871 CONTENTS: One bottle of Koāte 5 mL Sterile Water for Injection, USP One sterile Mix2Vial® filter transfer set No Preservative For Intravenous Administration Only Sterile — Nonpyrogenic Date removed from refrigeration_______________________ GTIN XXXXXXXXXXXXXX LOT XXXXXXXXXX EXP DDMMMYYYY SN XXXXXXXXXXXXXXXXIU XXX NDC 76125-668-30 Koāte ® Antihemophilic Factor (Human) Carton: 3046595

NDC 76125-669-31 Koāte® Antihemophilic Factor (Human) Solvent/Detergent Treated Heat-Treated at 80°C Manufactured for: Kedrion Biopharma Inc. 400 Kelby Street, Fort Lee, NJ 07024 Manufactured by: Grifols Therapeutics LLC Research Triangle Park, NC 27709 USAU.S. License No. 1871 The patient and physician should discuss the risks and benefits of this product. No Preservative For Intravenous Administration Only Sterile—Nonpyrogenic Reconstitute with 5 mL Sterile Water for Injection, USP. Store at 2–8°C (36–46°F) and no more than 6 months at room temperature (up to 25°C; 77°F) at any time prior to the expiration date. Dosage and Administration: Read package insert. Rx only Date removed from refrigeration_____________________ Lot Exp. IU 3051807

NDC 76125-676-50 Koāte® Antihemophilic Factor (Human) 1000 IU FVIII Range Solvent/Detergent Treated Heat-Treated at 80°C 10 mL Rx only WARNING: THIS PRODUCT IS PREPARED FROM LARGE POOLS OF HUMAN PLASMA WHICH MAY CARRY THE RISK OF TRANSMITTING INFECTIOUS AGENTS. The patient and physician should discuss the risks and benefits of this product. Dosage and Administration: Read enclosed package insert. Store refrigerated at 2 to 8°C (36 to 46°F) and no more than 6 months at room temperature (up to 25°C; 77°F) at any time prior to the expiration date.Avoid freezing. Reconstitute with 10 mL Sterile Water for Injection, USP. Administer within 3 hours after reconstitution. This product when reconstituted contains not more than (NMT) 1500 μg/mL polyethylene glycol (PEG), NMT 0.05 M glycine, NMT 25 μg/mL polysorbate 80, NMT 5 μg/g tri-n-butyl phosphate (TNBP), NMT 3 mM calcium, NMT 1 μg/mL aluminum, NMT 0.06 M histidine, and NMT 10 mg/mL Albumin (Human). If the shrink band is absent or shows any sign of tampering, do not use the product and notify Grifols Therapeutics LLC immediately. Not Returnable for Credit or Exchange Manufactured for: Kedrion Biopharma Inc. 400 Kelby Street, Fort Lee, NJ 07024 Manufactured by: Grifols Therapeutics LLC Research Triangle Park, NC 27709 USAU.S. License No. 1871 CONTENTS: One bottle of Koāte 10 mL Sterile Water for Injection, USP One sterile Mix2Vial® filter transfer set No Preservative For Intravenous Administration Only Sterile — Nonpyrogenic Date removed from refrigeration_______________________ GTIN XXXXXXXXXXXXXX LOT XXXXXXXXXX EXP DDMMMYYYY SN XXXXXXXXXXXXXXXXIU XXXX NDC 76125-676-50 Koāte ® Antihemophilic Factor (Human) Carton: 3046596 

NDC 76125-673-51 Koāte® Antihemophilic Factor (Human) Solvent/Detergent Treated Heat-Treated at 80°C Manufactured for: Kedrion Biopharma Inc. 400 Kelby Street, Fort Lee, NJ 07024 Manufactured by: Grifols Therapeutics LLC Research Triangle Park, NC 27709 USAU.S. License No. 1871 The patient and physician should discuss the risks and benefits of this product. No Preservative For Intravenous Administration Only Sterile—Nonpyrogenic Reconstitute with 10 mL Sterile Water for Injection, USP. Store at 2–8°C (36–46°F) and no more than 6 months at room temperature (up to 25°C; 77°F) at any time prior to the expiration date. Dosage and Administration: Read package insert. Rx only Date removed from refrigeration_____________________ Lot Exp. IU 3051812

NDC 13533-000-04               3053017 Nonpyrogenic               Single-Dose Container               5 mL Sterile Water for Injection, USP for reconstitution of accompanying product Do not use unless clear. No antimicrobial agent or other substance has been added. Do not use for intravascular injection without making approximately isotonic by addition of suitable solute. Discard unused portion. Rx Only. Mfd by:  Baxter Healthcare Corporation               Deerfield, IL 60015 USA Mfd for: Grifols Therapeutics LLC                Research Triangle Park, NC 27709 USA 07-32-00-0008 LotExp

NDC 13533-200-05   Sterile Water for Injection, USP  5 mL  Rx Only For reconstitution of accompanying product Single-Dose Container, NonpyrogenicDo not use unless clear. No antimicrobial agent or other substance has been added. Do not use for intravascular injection without making approximately isotonic by addition of suitable solute. Discard unused portion. Mfd by: Laboratorios Grifols, S. A., Parets del Vallès, Barcelona, 08150 Spain Mfd for: Grifols Therapeutics LLC, Research Triangle Park, NC, 27709 USA 3051804 Lot / Exp.

NDC 76297-002-02  Sterile Water for Injection, USP   5 mL  Rx Only For reconstitution of accompanying product Single-Dose Container, Nonpyrogenic Do not use unless clear. No antimicrobial agent or other substance has been added. Do not use for intravascular injection without making approximately isotonic by addition of suitable solute. Discard unused portion. Mfd by: Laboratorios Grifols, S.A. Parets del Vallès, Barcelona 08150 Spain Lot EXP 3057422

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