1.1 Absorption and Dispersion of Injected Drugs

Hydase™ (hyaluronidase injection) is indicated as an adjuvant to increase the absorption and dispersion of other injected drugs.

1.2 Hypodermoclysis

Hydase™ is indicated as an adjuvant in subcutaneous fluid administration for achieving hydration.

1.3 Subcutaneous Urography

Hydase™ is indicated as an adjuvant in subcutaneous urography for improving resorption of radiopaque.

2.1 Important Administration Instructions

Do not administer Hydase intravenously because hyaluronidase is enzyme is rapidly inactivated with intravenous administration.

Hydase™ may be administered for infiltration use, interstitial use, intramuscular use, intraocular use, retrobulbar use, soft tissue use and subcutaneous use.

Visually inspect parenteral drug products for particulate matter and discoloration prior to administration, whenever the solution and container permit.

Always use aseptic precautions.

2.2 Absorption and Dispersion of Subcutaneously Injected Drugs

Absorption and dispersion of other injected drugs may be enhanced by adding 50 to 300 Units, most typically 150 Units of hyaluronidase, to the injection solution.

It is recommended that appropriate references be consulted regarding physical or chemical incompatibilities before adding Hydase™ to a solution containing another drug.

2.3 Hypodermoclysis

Insert needle with aseptic precautions. With tip lying free and movable between skin and muscle, begin clysis; fluid should start in readily without pain or lump. Then inject Hydase™ (hyaluronidase injection) into rubber tubing close to needle.

An alternate method is to inject Hydase™ under skin prior to clysis. 150 Units will facilitate absorption of 1,000 mL or more of solution. As with all parenteral fluid therapy, observe effect closely, with same precautions for restoring fluid and electrolyte balance as in intravenous injections. The dose, the rate of injection, and the type of solution (saline, glucose, Ringer's, etc.) must be adjusted carefully to the individual patient. When solutions devoid of inorganic electrolytes are given by hypodermoclysis, hypovolemia may occur. This may be prevented by using solutions containing adequate amounts of inorganic electrolytes and/or controlling the volume and speed of administration.

Hydase™ may be added to small volumes of solution (up to 200 mL), such as small clysis for infants or solutions of drugs for subcutaneous injection. For infants and children less than 3 years old, the volume of a single clysis should be limited to 200 mL; and in premature infants or during the neonatal period, the daily dosage should not exceed 25 mL/kg of body weight; the rate of administration should not be greater than 2 mL per minute. For older patients, the rate and volume of administration should not exceed those employed for intravenous infusion.

2.4 Subcutaneous Urography

The subcutaneous route of administration of urographic contrast media is indicated when intravenous administration cannot be successfully accomplished, particularly in infants and small children. With the patient prone, 75 Units of Hydase™ (hyaluronidase injection) is injected subcutaneously over each scapula, followed by injection of the contrast medium at the same sites.

4.1 Hypersensitivity

Hydase™ contraindicated in patients with known hypersensitivity to hyaluronidase or any other ingredient in the formulation. A preliminary skin test for hypersensitivity to Hydase™ can be performed. The skin test is made by an intradermal injection of approximately 0.02 mL (3 Units) of a 150 Unit/mL solution [see Dosage and Administration (2)]. A positive reaction consists of a wheal with pseudopods appearing within five minutes and persisting for 20 to 30 minutes and accompanied by localized itching. Transient vasodilation at the site of the test, i.e., erythema, is not a positive reaction.

Discontinue Hydase™ if sensitization occurs.

5.1 Spread of Localized Injection

Hyaluronidase should not be injected into or around an infected or acutely inflamed area because of the danger of spreading a localized infection.

Hyaluronidase should not be used to reduce the swelling of bites or stings.

5.2 Ocular Damage

Hyaluronidase should not be applied directly to the cornea.

7.1 Incompatibilities

Furosemide, the benzodiazepines and phenytoin have been found to be incompatible with hyaluronidase.

7.2 Drug-Specific Precautions

Hyaluronidase should not be used to enhance the absorption and dispersion of dopamine and/or alpha agonist drugs.

When considering the administration of any other drug with hyaluronidase, it is recommended that appropriate references first be consulted to determine the usual precautions for the use of the other drug.

7.3 Local Anesthetics

When hyaluronidase is added to a local anesthetic agent, it hastens the onset of analgesia and tends to reduce the swelling caused by local infiltration, but the wider spread of the local anesthetic solution increases its absorption; this shortens its duration of action and tends to increase the incidence of systemic reaction.

7.4 Salicylates, Cortisone, ACTH, Estrogens or Antihistamines

Patients receiving large doses of salicylates, cortisone, ACTH, estrogens or antihistamines may require larger amounts of hyaluronidase for equivalent dispersing effect, since these drugs apparently render tissues partly resistant to the action of hyaluronidase.

8.1 Pregnancy

No adequate and well controlled animal studies have been conducted with Hydase™ to determine reproductive effects. Hydase™ should be used during pregnancy only if clearly needed.

8.2 Labor and Delivery

Administration of hyaluronidase during labor was reported to cause no complications: no increase in blood loss or differences in cervical trauma were observed. It is not known whether hyaluronidase has an effect on the later growth, development, and functional maturation of the infant.

8.3 Nursing Mothers

It is not known whether hyaluronidase is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when hyaluronidase is administered to a nursing woman.

8.4 Pediatric Use

Hyaluronidase may be added to small volumes of solution (up to 200 mL), such as small clysis for infants or solutions of drugs for subcutaneous injection. The potential for chemical or physical incompatibilities should be kept in mind [see Dosage and Administration (2)].

For infants and children less than 3 years old, the volume of a single clysis should be limited to 200 mL; and in premature infants or during the neonatal period, the daily dosage should not exceed 25 mL/kg of body weight; the rate of administration should not be greater than 2 mL per minute. For older patients, the rate and volume of administration should not exceed those employed for intravenous infusion.

During hypodermoclysis, special care must be taken in pediatric patients to avoid overhydration by controlling the rate and total volume of the clysis [see Dosage and Administration (2.1)].

8.5 Geriatric Use

No overall differences in safety or effectiveness have been observed between elderly and younger adult patients.

12.1 Mechanism of Action

Hyaluronidase is a spreading or diffusing substance which modifies the permeability of connective tissue through the hydrolysis of hyaluronic acid, a polysaccharide found in the intercellular ground substance of connective tissue, and of certain specialized tissues, such as the umbilical cord and vitreous humor. Hyaluronic acid is also present in the capsules of type A and C hemolytic streptococci. Hyaluronidase hydrolyzes hyaluronic acid by splitting the glucosaminidic bond between C1 of the glucosamine moiety and C4 of glucuronic acid. This temporarily decreases the viscosity of the cellular cement and promotes diffusion of injected fluids or of localized transudates or exudates, thus facilitating their absorption.

Hyaluronidase cleaves glycosidic bonds of hyaluronic acid and, to a variable degree, some other acid mucopolysaccharides of the connective tissue. The activity is measured in vitro by monitoring the decrease in the amount of an insoluble serum albumin-hyaluronic acid complex as the enzyme cleaves the hyaluronic acid component.

12.2 Pharmacodynamics

When no spreading factor is present, material injected subcutaneously spreads very slowly, but hyaluronidase causes rapid spreading, provided local interstitial pressure is adequate to furnish the necessary mechanical impulse. Such an impulse is normally initiated by injected solutions.

The rate of diffusion is proportionate to the amount of enzyme, and the extent is proportionate to the volume of solution.

12.3 Pharmacokinetics

Knowledge of the mechanisms involved in the disappearance of injected hyaluronidase is limited. It is known, however, that the blood of a number of mammalian species brings about the inactivation of hyaluronidase. Studies have demonstrated that hyaluronidase is antigenic; repeated injections of relatively large amounts of this enzyme may result in the formation of neutralizing anti-bodies. The reconstitution of the dermal barrier removed by intradermal injection of hyaluronidase (20, 2, 0.2, 0.02, and 0.002 Units/mL) to adult humans indicated that at 24 hours the restoration of the barrier is incomplete and inversely related to the dosage of enzyme; at 48 hours the barrier is completely restored in all treated areas.

Results from an experimental study, in humans that evaluated the influence of hyaluronidase in bone repair support the conclusion that this enzyme alone does not deter bone healing when given at the usual clinical dosage.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Long-term animal studies have not been performed to assess the carcinogenic or mutagenic potential of hyaluronidase. Hyaluronidase is found in most tissues of the body.

Long-term animal studies have not been performed to assess whether hyaluronidase impaired fertility; however, it has been reported that testicular degeneration may occur with the production of organ-specific antibodies against this enzyme following repeated injections. Human studies on the effect of intravaginal hyaluronidase in sterility due to oligospermia indicated that hyaluronidase may have aided conception.

Storage: Store in a refrigerator at 2° to 8°C (36° to 46°F).

DO NOT FREEZE.

17.1 Important Precautions Regarding Hydase™

Instruct patient that Hydase™ is being used to increase the dispersion and absorption of fluids or other injected drugs, as appropriate to the intended use.

17.2 What Patients Should Know About Adverse Reactions

The most frequently reported adverse reactions have been mild local injection site reactions such as redness, swelling, itching, or pain.

Anaphylactic-like reactions, and allergic reactions, such as hives, have been reported rarely in patients receiving hyaluronidases.

17.3 Patients Should Inform Their Doctors If Taking Other Medications

You may not receive furosemide, the benzodiazepines, phenytoin, dopamine and/or alpha agonists with Hydase™. These medications have been found to be incompatible with hyaluronidase.

If you are taking salicylates (e.g., aspirin), steroids (e.g., cortisone or estrogens) or antihistamines your doctor may need to prescribe larger amounts of hyaluronidase for equivalent dispersing effect.

AKORN
Manufactured by: Akorn, Inc.
Lake Forest, IL 60045
HD00N           Rev. 10/15