Hyper-Tet

Tetanus immune globulin (human).

Hyper-Tet treated with solvent/detergent is a sterile solution of tetanus hyperimmune immune globulin for IM administration; it contains no preservative. Hyper-Tet is prepared by cold ethanol fractionation from the plasma of donors immunized with tetanus toxoid. The immune globulin is isolated from solubilized Cohn Fraction II. The Fraction II solution is adjusted to a final concentration of 0.3% tri-n-butyl phosphate (TNBP) and 0.2% sodium cholate. After the addition of solvent (TNBP) and detergent (sodium cholate), the solution is heated to 30°C and maintained at that temperature for not less than 6 hrs. After the viral inactivation step, the reactants are removed by precipitation, filtration and finally, ultrafiltration and diafiltration. Hyper-Tet is formulated as a 15-18% protein solution at a pH of 6.4-7.2 in 0.21-0.32 M glycine. It is then incubated in the final container for 21-28 days at 20-27°C. Hyper-Tet is standardized against the U.S. Standard Antitoxin and the U.S. Control Tetanus Toxin and contains not less than 250 tetanus antitoxin units per container.
The removal and inactivation of spiked model enveloped and non-enveloped viruses during the manufacturing process for Hyper-Tet has been validated in laboratory studies. Human immunodeficiency virus, type 1 (HIV-1), was chosen as the relevant virus for blood products; bovine viral diarrhea virus (BVDV) was chosen to model hepatitis C virus; pseudorabies virus (PRV) was chosen to model hepatitis B virus and the herpes viruses; and reovirus type 3 (Reo) was chosen to model non-enveloped viruses and for its resistance to physical and chemical inactivation. Significant removal of model enveloped and non-enveloped viruses is achieved at 2 steps in the Cohn fractionation process leading to the collection of Cohn Fraction II: The precipitation and removal of Fraction III in the processing of Fraction II + IIIW suspension to Effluent III and the filtration step in the processing of Effluent III to Filtrate III. Significant inactivation of enveloped viruses is achieved at the time of treatment of solubilized Cohn Fraction II with TNBP/sodium cholate.

Pharmacology: The occurrence of tetanus in the United States has decreased dramatically from 560 reported cases in 1947, when national reporting began, to a record low of 48 reported cases in 1987. The decline has resulted from widespread use of tetanus toxoid and improved wound management, including use of tetanus prophylaxis in emergency rooms.
Hyper-Tet supplies passive immunity to those individuals who have low or no immunity to the toxin produced by the tetanus organism, Clostridium tetani. The antibodies act to neutralize the free form of the powerful exotoxin produced by this bacterium. Historically, such passive protection was provided by antitoxin derived from equine or bovine serum; however, the foreign protein in these heterologous products often produced severe allergic manifestations, even in individuals who demonstrated negative skin and/or conjunctival tests prior to administration. Estimates of the frequency of these foreign protein reactions following antitoxin of equine origin varied from 5-30%. If passive immunization is needed, human tetanus immune globulin (TIG) is the product of choice. It provides protection longer than antitoxin of animal origin and causes few adverse reactions.
Several studies suggest the value of human tetanus antitoxin in the treatment of active tetanus. In 1961 and 1962, Nation et al, using Hyper-Tet treated 20 patients with tetanus using single doses of 3000-6000 antitoxin units in combination with other accepted clinical and nursing procedures. Six patients, all >45 years, died of causes other than tetanus. The authors felt that the mortality rate (30%) compared favorably with their previous experience using equine antitoxin in larger doses and that the results were much better than the 60% national death rate for tetanus reported from 1951-1954. Blake et al, however, found in a data analysis of 545 cases of tetanus reported to the Centers for Disease Control from 1965-1971 that survival was no better with 8000 units of TIG than with 500 units; however, an optimal dose could not be determined.
Serologic tests indicate that naturally acquired immunity to tetanus toxin does not occur in the United States. Thus, universal primary vaccination, with subsequent maintenance of adequate antitoxin levels by means of appropriately timed boosters, is necessary to protect persons among all age groups. Tetanus toxoid is a highly effective antigen; a completed primary series generally induces protective levels of serum antitoxin that persist for ≥10 years.
Passive immunization with Hyper-Tet may be undertaken concomitantly with active immunization using tetanus toxoid in those persons who must receive an immediate injection of tetanus antitoxin and in whom it is desirable to begin the process of active immunization. Based on the work of Rubbo, McComb and Dwyer, and Levine et al, the physician may thus supply immediate passive protection against tetanus, and at the same time begin formation of active immunization in the injured individual which upon completion of a full toxoid series will preclude future need for antitoxin.
Peak blood levels of IgG are obtained approximately 2 days after IM injection. The half-life of IgG in the circulation of individuals with normal IgG levels is approximately 23 days.
In a clinical study in 8 healthy human adults receiving another hyperimmune immune globulin product treated with solvent/detergent, human rabies immune globulin, HyperRab, prepared by the same manufacturing process, detectable passive antibody titers were observed in the serum of all subjects by 24 hrs post-injection and persisted through the 21-day study period. These results suggest that passive immunization with immune globulin products is not affected by the solvent/detergent treatment.

Prophylaxis against tetanus following injury in patients whose immunization is incomplete or uncertain (see table). It is also indicated, although evidence of effectiveness is limited, in the regimen of treatment of active cases of tetanus.
A thorough attempt must be made to determine whether a patient has completed primary vaccination. Patients with unknown or uncertain previous vaccination histories should be considered to have had no previous tetanus toxoid doses. Persons who had military service since 1941 can be considered to have received at least 1 dose, and although most of them may have completed a primary series of tetanus toxoid, this cannot be assumed for each individual. Patients who have not completed a primary series may require tetanus toxoid and passive immunization at the time of wound cleaning and debridement.
The following table is a summary guide to tetanus prophylaxis in wound management: See table.

Click on icon to see table/diagram/image

Routine Prophylactic Dosage Schedule:
Adults and Children ≥7 years: Hyper-Tet should be given by deep IM injection (see Precautions). At the same time, but in a different extremity and with a separate syringe, adsorbed tetanus and diphtheria toxoids (for adult use) (Td) should be administered. Adults with uncertain histories of a complete primary vaccination series should receive a primary series using the combined Td toxoid. To ensure continued protection, booster doses of Td should be given every 10 years.
Children <7 years: In small children, the routine prophylactic dose of Hyper-Tet may be calculated by the body weight (4 units/kg). However, it may be advisable to administer the entire contents of the vial or syringe of Hyper-Tet regardless of the child's size, since theoretically the same amount of toxin will be produced in the child's body by the infecting tetanus organism as it will in an adult's body. At the same time but in a different extremity and with a different syringe, diphtheria and tetanus toxoids and adsorbed pertussis vaccine (DTP) or adsorbed diphtheria and tetanus toxoids (for pediatric use) (DT), if pertussis vaccine is contraindicated, should be administered.
Note: The single injection of tetanus toxoid only initiates the series for producing active immunity in the recipient. The physician must impress upon the patient the need for further toxoid injections in 1 month and 1 year. Without such, the active immunization series is incomplete. If a contraindication to using tetanus toxoid-containing preparations exists for a person who has not completed a primary series of tetanus toxoid immunization and that person has a wound that is neither clean nor minor, only passive immunization should be given using tetanus immune globulin. (See table under Indications.)
Available evidence indicates that complete primary vaccination with tetanus toxoid provides long-lasting protection, ≥10 years for most recipients. Consequently, after complete primary tetanus vaccination, boosters, even for wound management, need be given only every 10 years when wounds are minor and uncontaminated. For other wounds, a booster is appropriate if the patient has not received tetanus toxoid within the preceding 5 years. Persons who have received at least 2 doses of tetanus toxoid rapidly develop antibodies. The prophylactic dosage schedule for these patients and for those with incomplete or uncertain immunity is shown on the table in Indications.
Since tetanus is actually a local infection, proper initial wound care is of paramount importance. The use of antitoxin is adjunctive to this procedure. However, in approximately 10% of recent tetanus cases, no wound or other breach in skin or mucous membrane could be implicated.
Active Cases of Tetanus: Standard therapy for the treatment of active tetanus including the use of Hyper-Tet must be implemented immediately. The dosage should be adjusted according to the severity of the infection.
Directions for Syringe Usage:
Remove the pre-filled syringe from the package. Lift syringe by barrel, not by plunger.
Twist the plunger rod clockwise until the threads are seated.
With the rubber needle shield secured on the syringe tip, push the plunger rod forward a few millimeters to break any friction seal between the rubber stopper and the glass syringe barrel.
Remove the needle shield and expel air bubbles.
Proceed with hypodermic needle puncture.
Aspirate prior to injection to confirm that the needle is not in a vein or artery.
Inject the medication.
Withdraw the needle and dispose or destroy it.

Although no data are available, clinical experience with other immunoglobulin preparations suggests that the only manifestations would be pain and tenderness at the injection site.

None known.

Hyper-Tet is made from human plasma. Products made from human plasma may contain infectious agents eg, viruses, that can cause disease. The risk that such products will transmit an infectious agent 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/or removing certain viruses. Despite these measures, such products can still potentially transmit disease. There is also the possibility that unknown infectious agents may be present in such products. Individuals who receive infusions of blood or plasma products may develop signs and/or symptoms of some viral infections, particularly hepatitis C.
The physician should discuss the risks and benefits of Hyper-Tet with the patient, before prescribing or administering it to the patient.
Hyper-Tet should be given with caution to patients with history of prior systemic allergic reactions following the administration of human immunoglobulin preparations.
In patients who have severe thrombocytopenia or any coagulation disorder that would contraindicate IM injections, Hyper-Tet should be given only if the expected benefits outweigh the risks.

Hyper-Tet should not be given IV. IV injection of immunoglobulin intended for IM use can, on occasion, cause a precipitous fall in blood pressure, and a picture like anaphylaxis. Injections should only be made IM and care should be taken to draw back on the plunger of the syringe before injection in order to be certain that the needle is not in a blood vessel. IM injections are preferably administered in the anterolateral aspects of the upper thigh and the deltoid muscle of the upper arm. The gluteal region should not be used routinely as an injection site because of the risk of injury to the sciatic nerve. If the gluteal region is used, the central region must be avoided; only the upper, outer quadrant should be used.
Chemoprophylaxis against tetanus is neither practical nor useful in managing wounds. Wound cleaning, debridement when indicated, and proper immunization are important. The need for tetanus toxoid (active immunization), with or without TIG (passive immunization), depends on both the condition of the wound and the patient's vaccination history. Rarely has tetanus occurred among persons with documentation of having received a primary series of toxoid injections. (See table under Indications.)
Skin tests should not be done. The intradermal injection of concentrated IgG solutions often causes a localized area of inflammation which can be misinterpreted as a positive allergic reaction. In actuality, this does not represent an allergy; rather, it is localized tissue irritation. Misinterpretation of the results of such tests can lead the physician to withhold needed human antitoxin from a patient who is not actually allergic to this material. True allergic responses to human IgG given in the prescribed IM manner are rare.
Although systemic reactions to human immunoglobulin preparations are rare, epinephrine should be available for treatment of acute anaphylactic reactions.
Use in pregnancy: Pregnancy Category C: Animal reproduction studies have not been conducted with Hyper-Tet. It is also not known whether Hyper-Tet can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Hyper-Tet should be given to a pregnant woman only if clearly needed.
Use in children: Safety and effectiveness in the pediatric population have not been established.

Use in pregnancy: Pregnancy Category C: Animal reproduction studies have not been conducted with Hyper-Tet. It is also not known whether Hyper-Tet can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. Hyper-Tet should be given to a pregnant woman only if clearly needed.
Use in children: Safety and effectiveness in the pediatric population have not been established.

Slight soreness at the site of injection and slight temperature elevation may be noted at times. Sensitization to repeated injections of human immunoglobulin is extremely rare.
In the course of routine injections of large numbers of persons with immunoglobulin, there have been a few isolated occurrences of angioneurotic edema, nephrotic syndrome and anaphylactic shock after injection.

Antibodies in immunoglobulin preparations may interfere with the response to live viral vaccines eg, measles, mumps, polio and rubella. Therefore, use of such vaccines should be deferred until approximately 3 months after Hyper-Tet administration.
No interactions with other products are known.

Store at 2-8°C (36-46°F). Solution that has been frozen should not be used.

Vaccines, Antisera & Immunologicals

J06BB02 - tetanus immunoglobulin ; Belongs to the class of specific immunoglobulins. Used in passive immunizations.

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