Magnesium Chloride, Dextrose Anhydrous, Lactic Acid, Sodium Chloride, Sodium Bicarbonate, and Potassium Chloride

INDICATIONS AND USAGE PRISMASOL and PHOXILLUM solutions are indicated in pediatric and adult patients for use as a replacement solution in Continuous Renal Replacement Therapy (CRRT) to replace plasma volume removed by ultrafiltration and to correct electrolyte and acid-base imbalances. They may also be used in case of drug poisoning when CRRT is used to remove dialyzable substances. PRISMASOL and PHOXILLUM solutions are indicated: As a replacement solution in Continuous Renal Replacement Therapy (CRRT) and in case of drug poisoning when CRRT is used to remove dialyzable substances ( 1 )

DOSAGE AND ADMINISTRATION Therapy must be individualized based on the patient's clinical condition, fluid, electrolyte, acid-base and glucose balance ( 2.2 ) Solution must be mixed prior to use ( 2.2 ) Use only with extracorporeal dialysis equipment appropriate for CRRT ( 2.3 ) 2.1 Administration Instructions Visually inspect PRISMASOL and PHOXILLUM for particulate matter and discoloration prior to administration. Administration should only be under the direction of a physician competent in intensive care treatment including CRRT. Use only with extracorporeal dialysis equipment appropriate for CRRT. The prepared solution is for single patient use only. Aseptic technique should be used throughout administration to the patient. Discard any unused solution. 2.2 Dosing Considerations PRISMASOL replacement solutions contain 4 different combinations of active ingredients (7 different products with varying ingredient amounts). PHOXILLUM replacement solutions contain 2 different combinations of active ingredients (2 different products with varying ingredient amounts). PRISMASOL and PHOXILLUM are supplied in a two-compartment bag that must be mixed immediately prior to use [see Dosage and Administration (2.3) ]: Small compartment A (250 mL) containing an electrolyte solution, and Large compartment B (4750 mL) containing the buffer solution. See Table 1 for the concentrations of the active ingredients (after mixing) in these 9 different replacement solutions (total volume is 5 Liters). Table 1: Concentrations of Active Ingredients in the 7 PRISMASOL and 2 PHOXILLUM Replacement Solutions after Mixing Ca 2+ mEq/L HCO 3 - mEq/L K + mEq/L Mg 2+ mEq/L Na + mEq/L HPO 4 2- mmol/L Cl - mEq/L Lactate mEq/L Dextrose mg/dL Osmolarity mOsm/L Ca 2+ = calcium, HCO 3 - = bicarbonate, K + = potassium, Mg 2+ = magnesium, Na + = sodium, HPO 4 2- = phosphate, Cl- = chloride; osmolarity is estimated PRISMASOL Replacement Solutions BGK0/2.5 2.5 32 0 1.5 140 0 109 3 100 292 BGK4/2.5 2.5 32 4 1.5 140 0 113 3 100 300 BGK2/3.5 3.5 32 2 1 140 0 111.5 3 100 296 BGK2/0 0 32 2 1 140 0 108 3 100 291 B22GK4/0 0 22 4 1.5 140 0 120.5 3 100 296 BGK4/0/1.2 0 32 4 1.2 140 0 110.2 3 100 295 BK0/0/1.2 0 32 0 1.2 140 0 106.2 3 0 282 PHOXILLUM Replacement Solutions BK4/2.5 2.5 32 4 1.5 140 1 114.5 0 0 294 B22K4/0 0 22 4 1.5 140 1 122 0 0 290 The mode of therapy, solute formulation, flow rates, and length of PRISMASOL and PHOXILLUM replacement therapy in CRRT should be established by a physician based on the patient’s clinical condition, blood concentration of phosphate and other electrolytes, acid-base and glucose balance. Administer either PRISMASOL or PHOXILLUM into the extracorporeal circuit: Before (pre-dilution) the hemofilter or hemodiafilter, After (post-dilution) the hemofilter or hemodiafilter, or Before and after the hemofilter or hemodiafilter. 2.3 Preparing the Solution Use only if the overwrap is not damaged, all seals are intact, peel seal is not broken, and the solution is clear. The solution may be warmed to 37°C/98.6°F prior to removing the overwrap to enhance patient comfort. However, only dry heat should be used. Solutions should not be heated in water or in a microwave oven. After heating, verify that the solution remains clear and contains no particulate matter. The solutions are supplied in two different two-compartment bags made of polyolefin with a peel seal separating compartment A and B (see Figure 1 ). Follow the instructions below when connecting the solution bags for correct use of the access ports. Instructions for preparing solutions supplied in a two-compartment, polyolefin bag with a peel seal: Figure 1 Figure 2 Step 1 Immediately before use, remove the overwrap from the bag and mix the solutions in the two different compartments. After removing the overwrap, inspect the bag for leakage by pressing firmly on the bag. Discard the bag if any leakage is detected since sterility cannot be assured. As soon as the overwrap is removed, the reconstitution of compartments A and B should be done and the mixed solution should be used immediately. After removal of the overwrap, the solution is stable for 24 hours including the duration of the treatment. Hold the small compartment with both hands and squeeze it until an opening is created in the peel seal. (See Figure 2 beside) Figure 3 Step 2 Squeeze with both hands on the large compartment until the peel seal between the two compartments is entirely open. Shake gently to mix. (See Figure 3 beside) The solution is now ready to use and the bag can be hung on the equipment. Figure 4a Step 3 The replacement line may be connected to the bag through either of the luer connector or the injection connector (spike connector). Step 3a The luer connector is a needle-less and swabbable connector. Remove the cap with a twist and pull motion, and connect the male luer lock on the replacement line to the female luer receptor on the bag. (See Figure 4 a beside) Ensure that the connection is fully seated and tighten. The connector is now open. Verify that the fluid is flowing freely during use. When the replacement line is disconnected from the luer connector, the connector will close and the flow of the solution will stop. Figure 4b Step 3b If the injection connector (spike connector) is used, first remove the snap-off cap. Then introduce the replacement line spike through the swabbable rubber septum of the bag connector. (See Figure 4 b beside) Ensure that the spike is fully inserted and verify that the fluid is flowing freely during use. Figure 2 Figure 3 Figure 4a Figure 4b 2.4 Adding Drugs to the Solutions After mixing, additional drugs may be added to the bag via injection connector (spike connector) in large compartment B. In general, administer drugs other than phosphate through a different access line. When introducing drugs, use aseptic techniques and mix thoroughly prior to connecting the solution bag to the extracorporeal circuit. Do not use if there is a color change and/or the appearance of precipitates, insoluble complexes or crystals after addition of medication. Phosphate: Up to 1.2 mmol/L of phosphate can be added to the bag as potassium phosphate or sodium phosphate. The total potassium concentration of PRISMASOL solution should not exceed 4 mEq/L. Use sodium phosphate to add phosphate if the total potassium concentration in PRISMASOL solution is 4 mEq/L. PHOXILLUM Solutions: Phosphate: Phosphate up to 0.2 mmol/L may be added to the solution. Use sodium phosphate if adding phosphate to bag. The total phosphate concentration should not exceed 1.2 mmol/L.

WARNINGS AND PRECAUTIONS Monitor hemodynamic status and fluid inputs and outputs, potassium, phosphorus, other electrolytes and acid-base balance. Abnormalities may be corrected by the use of appropriate formulations and dosage of PRISMASOL and PHOXILLUM solutions ( 5.1 ) Treatment may affect glucose levels. Monitor blood glucose levels. Antidiabetic therapy adjustment or other corrective measures may be required during treatment ( 5.2 ) To report SUSPECTED ADVERSE REACTIONS, contact Vantive US Healthcare LLC at 1855-857-0003 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch 5.1 Electrolyte and Volume Abnormalities PHOXILLUM and PRISMASOL solutions can affect electrolytes and volume and may result in hyperkalemia or hyperphosphatemia. Monitor hemodynamic status and fluid inputs and outputs, potassium, phosphorous, calcium, other electrolytes and acid-base balance throughout the procedure. Abnormalities may be corrected by changing the formulation of replacement solution and/or dialysate, supplementation, or adjusting flow rates appropriately [ see Dosage and Administration (2) ]. PHOXILLUM replacement solutions contain hydrogen phosphate, a weak acid that may increase the risk of metabolic acidosis. 5.2 Blood Glucose Abnormalities The use of PRISMASOL and PHOXILLUM replacement solutions can affect blood glucose levels resulting in hypo- or hyper-glycemia depending upon the dextrose content of the replacement solution. Monitor blood glucose levels regularly. Patients may require initiation of or modification of antidiabetic therapy or other corrective measures during treatment.

CONTRAINDICATIONS PHOXILLUM and PRISMASOL replacement solutions are contraindicated in patients with known hypersensitivities to these products. Known hypersensitivities to PRISMASOL and PHOXILLUM solutions ( 4 )

DRUG INTERACTIONS As with the use of other replacement solutions, blood concentrations of dialyzable drugs may be reduced by CRRT due to their removal by the hemofilter or hemodiafilter. The blood concentrations of certain drugs may need to be monitored and appropriate therapy implemented to correct for removal during treatment. 7.1 Citrate When used as an anticoagulant, citrate contributes to the overall buffer load and can reduce plasma calcium levels. Select the PRISMASOL/PHOXILLUM formulation(s) accordingly.

ADVERSE REACTIONS The following adverse reactions have been identified during postapproval use with these or other similar products and therefore may occur with use of PHOXILLUM or PRISMASOL. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Metabolic acidosis Hypotension Acid-base disorders Electrolyte imbalance including calcium ionized increased (reported in PRISMASOL solutions containing calcium), hyperphosphatemia, and hypophosphatemia Fluid imbalance

Mechanism of Action PRISMASOL and PHOXILLUM solutions are pharmacologically inactive. The electrolyte concentrations in the solutions are chosen to restore plasma levels to clinically desired concentrations or maintain plasma levels at the desired concentrations. PRISMASOL and PHOXILLUM solutions are used as replacement solution to replace water and electrolytes removed during hemofiltration and hemodiafiltration. Bicarbonate (or precursor lactate) in the solution is used as an alkalinizing buffer to restore acid-base balance to a clinically desirable level.