IDELVION 3500 IU POWDER AND SOLVENT FOR SOLUTION FOR INJECTION/INFUSION - summary of medicine characteristics

1 NAME OF THE MEDICINAL PRODUCT

IDELVION® 3500 IU powder and solvent for solution for injection

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

IDELVION 3500 IU powder and solvent for solution for injection

Each vial contains nominally 3500 IU of recombinant fusion protein linking coagulation factor IX with albumin (rIX-FP), (albutrepenonacog alfa). After reconstitution with 5 ml water for injections the solution contains 700 IU/ml of albutrepenona­cog alfa.

The potency ( IU) is determined using the European Pharmacopeia one stage clotting test The specific activity of IDELVION is approximately 54 – 85 lU/mg protein.

Albutrepenonacog alfa is a purified protein produced by recombinant DNA technology, generated by the genetic fusion of recombinant albumin to recombinant coagulation factor IX. The genetic fusion of the cDNA of human albumin to the cDNA of human coagulation factor IX enables the protein to be produced as a single recombinant protein and assures product homogeneity by avoiding chemical conjugation. The recombinant factor IX portion is identical to the Thr148 allelic form of plasma-derived factor IX. The cleavable linker between the recombinant factor IX and albumin molecules is derived from the endogenous “activation peptide” in native factor IX.

Excipient with known effect

Each reconstituted 250 IU, 500 IU or 1000 IU vial contains 4.3 mg of sodium.

Each reconstituted 2000 IU or 3500 IU vial contains 8.6 mg of sodium (see section 4.4).

For the full list of excipients, see section 6.1.

3 PHARMACEUTICAL FORM

Powder and solvent for solution for injection.

Pale yellow to white powder and clear, colourless solvent for solution for injection. pH: 6.6 – 7.2

Osmolality:

IDELVION 3500 IU powder and solvent for solution for injection

260 – 300 mOsm/kg.

4 CLINICAL PARTICULARS

4.1 Therapeutic indications

Treatment and prophylaxis of bleeding in patients with haemophilia B (congenital factor IX deficiency).

IDELVION can be used for all age groups.

4.2 Posology and method of administration

Treatment should be under the supervision of a physician experienced in the treatment of haemophilia B.

Previously untreated patients (PUPs)

The safety and efficacy of IDELVION in previously untreated patients have not yet been established.

Treatment monitoring

During the course of treatment, appropriate determination of factor IX levels is advised to guide the dose to be administered and the frequency of repeated infusions. Individual patients may vary in their responses to factor IX, demonstrating different half-lives and recoveries. Dose based on bodyweight may require adjustment in underweight or overweight patients. In the case of major surgical interventions in particular, precise monitoring of the substitution therapy by means of coagulation analysis (plasma factor IX activity) is indispensable.

When using an in vitro thromboplastin time (aPTT)-based one stage clotting assay for determining factor IX activity in patients’ blood samples, plasma factor IX activity results can be significantly affected by both the type of aPTT reagent and the reference standard used in the assay. Measurement with a one-stage clotting assay using a kaolin-based aPTT reagent or Actin FS aPTT reagent will likely result in an underestimation of activity level. This is of importance particularly when changing the laboratory and/or reagents used in the assay.

Posology

Dose and duration of the substitution therapy depend on the severity of the factor IX deficiency, on the location and extent of the bleeding and on the patient's clinical condition.

The number of units of factor IX administered is expressed in International Units (IU), which are related to the current WHO standard for factor IX products. Factor IX activity in plasma is expressed either as a percentage (relative to normal human plasma) or in International Units (relative to an International Standard for factor IX in plasma).

One International Unit (IU) of factor IX activity is equivalent to that quantity of factor IX in one ml of normal human plasma.

On demand treatment

The calculation of the required dose of factor IX is based on the empirical finding that 1 IU factor IX per kg body weight raises the plasmafactor IX activity by an average of 1.3 lU/dl (1.3 % of normal activity) in patients > 12 years of age and by 1.0 lU/dl (1.0 % of normal activity) in patients < 12 years of age. The required dose is determined using the following formulae:

Required dose (IU) = body weight (kg) x desired factor IX rise (% of normal or IU/dl) x {reciprocal of observed recovery (IU/kg per IU/dl)}

Expected factor IX rise (IU/dl or % of normal) = Dose (IU) x Recovery (IU/dl per IU/kg)/body weight (kg)

The amount to be administered and the frequency of administration should always be oriented to the clinical effectiveness in the individual case.

Patients <12 years of age

For an incremental recovery of 1 IU/dl per 1 IU/kg, the dose is calculated as follows:

Required dose (IU) = body weight (kg) x desired factor IX rise (IU/dl) x 1 dl/kg

Example

1. A peak level of 50 % of normal is required in a 20 kg patient with severe haemophilia B. The appropriate dose would be 20 kg x 50 IU/dl x 1 dl/kg = 1000 IUs.

2. A dose of 1000 IUs of IDELVION, administered to a 25 kg patient, should be expected to result in a peak post-injection factor IX increase of 1000 IUs/25 kg x 1.0 (IU/dl per IU/kg) = 40 IU/dl (40 % of normal).

Patients >12 years of age

For an incremental recovery of 1.3 IU/dl per 1 IU/kg, the dose is calculated as follows:

Required dose (IU) = body weight (kg) x desired factor IX rise (IU/dl) x 0.77 dl/kg

Example

3. A peak level of 50 % of normal is required in a 80 kg patient with severe haemophilia B. The appropriate dose would be 80 kg x 50 IU/dl x 0.77 dl/kg = 3080 IUs.

4. A dose of 2000 IUs of IDELVION, administered to a 80 kg patient, should be expected to result in a peak post-injection factor IX increase of 2000 IUs x 1.3 (IU/dl per IU/kg) /80 kg = 32.5 IU/dl (32.5 % of normal).

In the case of the following haemorrhagic events, the factor IX activity should not fall below the given plasma activity level (in % of normal or in IU/dl) in the corresponding period. The following table can be used to guide dosing in bleeding episodes and surgery:

Prophylaxis

For long-term prophylaxis against bleeding in patients with severe haemophilia B, the usual doses are 35 to 50 IU/kg once weekly.

Some patients who are well-controlled on a once-weekly regimen might be treated with up to 75 IU/kg on an interval of 10 or 14 days. For patients >18 years, further extension of the treatment interval may be considered (see section 5.1)..

In some cases, especially in younger patients, shorter dose intervals or higher doses may be necessary.

After a bleeding episode during prophylaxis, patients should maintain their prophylaxis regimen as closely as possible, with 2 doses of IDELVION being administered at least 24 hours apart but longer if deemed suitable for the patient.

Paediatric population

For long term prophylaxis the recommended dose regimen is 35 to 50 IU/kg once weekly (see sections 5.1 and 5.2). For adolescents of 12 years of age and above, the dose recommendations are the same as for adults (see above).

Method of administration

Intravenous use.

The reconstituted preparation should be injected slowly intravenously at a rate comfortable for the patient up to a maximum of 5 ml/min.

For instructions on reconstitution of the medicinal product before administration, see section 6.6.

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Known allergic reaction to hamster protein.

4.4 Special warnings and precautions for use

Traceability

In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded.

Hypersensitivity

Allergic type hypersensitivity reactions are possible with IDELVION. The product contains traces of hamster proteins. If symptoms of hypersensitivity occur, patients should be advised to discontinue use of the medicinal product immediately and contact their physician. Patients should be informed of the early signs of hypersensitivity reactions including hives, generalised urticaria, tightness of the chest, wheezing, hypotension and anaphylaxis.

In case of shock, standard medical treatment for shock should be implemented.

Inhibitors

After repeated treatment with human coagulation factor IX products, patients should be monitored for the development of neutralising antibodies (inhibitors) that should be quantified in Bethesda Units (BU) using appropriate biological testing. Formation of inhibitor to factor IX has been reported during factor replacement therapy with IDELVION in the treatment of haemophilia B.

There have been reports in the literature showing a correlation between the occurrence of a factor IX inhibitor and allergic reactions. Therefore, patients experiencing allergic reactions should be evaluated for the presence of an inhibitor. It should be noted that patients with factor IX inhibitors may be at an increased risk of anaphylaxis with subsequent challenge with factor IX.

Because of the risk of allergic reactions with factor IX products, the initial administration of factor IX should, according to the treating physician’s jud­gement, be performed under medical observation where proper medical care for allergic reactions could be provided.

Thromboembolism

Because of the potential risk of thrombotic complications, clinical surveillance for early signs of thrombotic and consumptive coagulopathy should be initiated with appropriate biological testing when administering this product to patients with liver disease, to patients post-operatively, to newborn infants, or to patients at risk of thrombotic phenomena or DIC. In each of these situations, the benefit of treatment with IDELVION should be weighed against the risk of these complications.

Cardiovascular events

In patients with existing cardiovascular risk factors, substitution therapy with FIX may increase the cardiovascular ris­k.

Catheter-related complications

If a central venous access device (CVAD) is required, risk of CVAD-related complications including local infections, bacteraemia and catheter site thrombosis should be considered.

Elderly

Clinical studies of IDELVION did not include subjects aged 65 and over. It is not known whether they respond differently from younger subjects.

Immune tolerance induction

The safety and efficacy of using IDELVION for immune tolerance induction has not been established.

Sodium content

This medicinal product contains up to 8.6 mg vial, equivalent to 0.4% of the WHO recommended maximum daily intake of 2 g sodium for an adult.

Paediatric population

The listed warnings and precautions apply both to adults and children.

4.5 Interaction with other medicinal products and other forms of interaction

No interactions of human coagulation factor IX (rDNA) products with other medicinal products have been reported.

4.6 Fertility, pregnancy and lactation

Animal reproduction studies have not been conducted with factor IX. Based on the rare occurrence of haemophilia B in women, experience regarding the use of factor IX during pregnancy and breast-feeding is not available.

Therefore, factor IX should be used during pregnancy and lactation only if clearly indicated.

There is no information on the effects of factor IX on fertility.

4.7 Effects on ability to drive and use machines

IDELVION has no influence on the ability to drive and use machines.

4.8 Undesirable effects

Summary of the safety profile

Hypersensitivity or allergic reactions (which may include angioedema, burning and stinging at the infusion site, chills, flushing, generalised urticaria, headache, hives, hypotension, lethargy, nausea, restlessness, tachycardia, tightness of the chest, tingling, vomiting, wheezing) have been observed rarely and may in some cases progress to severe anaphylaxis (including shock). In some cases, these reactions have progressed to severe anaphylaxis, and they have occurred in close temporal association with development of factor IX inhibitors (see also section 4.4). Nephrotic syndrome has been reported following attempted immune tolerance induction in haemophilia B patients with factor IX inhibitors and a history of allergic reaction.

Very rarely development of antibodies to hamster protein with related hypersensitivity reactions has been observed.

Patients with haemophilia B may develop neutralising antibodies (inhibitors) to factor IX. If such inhibitors occur, the condition will manifest itself as an insufficient clinical response. In such cases, it is recommended that a specialised haemophilia centre be contacted.

There is a potential risk of thromboembolic episodes following the administration of factor IX products, with a higher risk for low purity preparations. The use of low purity factor IX products has been associated with instances of myocardial infarction, disseminated intravascular coagulation, venous thrombosis and pulmonary embolism. The use of high purity factor IX is rarely associated with such adverse reactions.

Tabulated list of adverse reactions

The table presented below is according to the MedDRA system organ classification (SOC and Preferred Term Level). The table lists adverse reactions that were reported in clinical trials and/or were identified in post-marketing use.

Frequencies have been evaluated according to the following convention: very common (>1/10); common (>1/100 to <1/10); uncommon (>1/1,000 to <1/100); rare (>1/10,000 to <1/1,000); very rare (<1/10,000), not known (cannot be estimated from the available data).

Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

Description of selected adverse reactions

One previously untreated patient (PUP) from the ongoing clinical study developed high titre inhibitor against factor IX. There are insufficient data to provide information on inhibitor incidence in PUPs.

Paediatric population

Frequency, type and severity of adverse reactions in children are expected to be the same as in adults.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via:

UK: Yellow Card Scheme. Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App store.

Ireland: HPRA Pharmacovigilance, Earlsfort Terrace, IRL – Dublin 2; Tel: +353 1 6764971;

Fax: +353 1 6762517; website: www.hpra.ie; Email: medsafe­ty@hpra.ie

Malta: ADR Reporting Website: www.medicinesauthority.gov.mt/adrportal

4.9 Overdose

No symptoms of overdose with IDELVION have been reported.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: antihaemorrhagics- blood coagulation factor IX, ATC code: B02BD04.

Mechanism of action

Factor IX is a single chain glycoprotein with a molecular mass of about 68,000 Dalton. It is a vitamin-K dependent coagulation factor and it is synthesised in the liver. Factor IX is activated by factor XIa in the intrinsic coagulation pathway and by the factor VII/tissue factor complex in the extrinsic pathway. Activated factor IX, in combination with activated factor VIII, activates factor X. Activated factor X converts prothrombin into thrombin. Thrombin then converts fibrinogen into fibrin and a clot is formed. Haemophilia B is a sex-linked hereditary disorder of blood coagulation due to decreased levels of factor IX and results in profuse bleeding into joints, muscles or internal organs, either spontaneously or as a result of accidental or surgical trauma. By replacement therapy the plasma levels of factor IX is increased, thereby enabling a temporary correction of the factor deficiency and correction of the bleeding tendencies.

Of note, ABR (annualized bleeding rate) is not comparable between different factor concentrates and between different clinical studies.

Albutrepenonacog alfa) is a recombinant coagulation factor IX. Prolongation of the half-life of albutrepenonacog alfa and the enhanced systemic exposure (see section 5.2) are achieved by fusion with recombinant albumin. Albumin is a natural, inert carrier protein in plasma with a half-life of approximately 20 days.

Albutrepenonacog alfaremains intact in the circulation until factor IX is activated, whereupon albumin is cleaved, releasing activated factor IX (FIXa) when it is needed for coagulation.

General information on clinical efficacy and safety

A phase 1/2 study evaluated the treatment efficacy and prevention of bleeding episodes of rIX-FP in 17 subjects (ages 13–46 years), 13 subjects in the prophylaxis arm received weekly prophylaxis with IDELVION for approximately 11 months, and 4 subjects in the on-demand arm received IDELVION upon occurrence of bleeding events. All 85 bleeding episodes were successfully treated with 1 or 2 doses of IDELVION.

The efficacy of IDELVION has been evaluated in the open-label, uncontrolled part of a phase 2/3 study, in which a total of 63 male, previously treated patients (PTPs) between 12 and 61 years of age received IDELVION either for prophylaxis once every 7-, 10– and/or 14-day intervals and/or for the treatment of bleeding episodes on an on-demand basis. All subjects had severe (FIX level <1%) or moderately severe (FIX level < 2%) haemophilia B. Forty PTPs received IDELVION for prophylaxis.

Subjects who received prophylactic treatment started with 35–50 IU/kg once weekly. A subgroup of patients switched to extended treatment intervals (every 10 or 14 days) with a recommended dose of 75 IU/kg and individual adjustments. 21 PTPs remained on the extended 14-day prophylaxis interval for additional treatment duration of 98 to 575 (median 386) days. From those subjects, 8 (38%) experienced at least one bleeding during the 14 day-prophylaxis, while they had no bleeding events during once-weekly prophylaxis. Median Annualised Bleeding Rate (ABR) on 7 day prophylaxis with IDELVION for all bleeds was 0.0 (range 0–6) and on 14 dayprophylaxis it was 1.08 (range 0–9.1).

The long-term efficacy and safety of routine prophylaxis treatment was confirmed in an open-label extension study for up to 5 years. In this study, a total of 59 PTPs >12 years (54 adults and 5 adolescents) received IDELVION either for prophylaxis and/or for the treatment of bleeding episodes on an on-demand basis.

Patients who received prophylactic treatment continued or started with 35–50 IU/kg once weekly. A subgroup of patients switched to extended treatment intervals (every 10, 14 or 21 days) with a recommended dose of 75 IU/kg (10 or 14 days) or 100 IU/kg (21 days). At the end of the study 14 PTPs (24%) were on the 7 day prophylaxis interval, and a total of 11 (19%), 25 (42%) and 9 (15%) PTPs remained on the extended prophylaxis interval of 10, 14 and 21 days, respectively. During the study, 2 PTPs (18%) in the 21-day regimen switched back to a more frequent dosing due to increased bleeding complications. The estimated median Annualised Bleeding Rates (ABRs) on 7-, 14-, and 21-day prophylaxis with IDELVION for all bleeds were 1.3 (range 0–8), 0.9 (range 0–13), and 0.3 (range 0–5), respectively.

Currently available information supports extension of treatment intervals for some patients, although potentially associated with an increased risk for bleeding compared to a once-weekly regimen.

Prophylaxis and control of bleeding in PTPs below 12 years

The efficacy of IDELVION has been evaluated in a phase 3 study, in which a total of 27 male PTPs between 1 and 10 years (median age 6.0 years) with 12 patients < 6 years, received IDELVION for prophylaxis and control of bleeding episodes. All 27 subjects received weekly prophylaxis treatment with IDELVION for a mean time on study of 13.1 months (9, 18 months).

Of the 106 bleeding episodes, the majority (94; 88.7%) was treated with single injection, 103; 97.2% were treated with 1–2 injections. Haemostatic efficacy at resolution of a bleed was rated excellent or good in 96% of all treated bleeding episodes.

The long-term efficacy and safety of routine prophylaxis treatment was confirmed in an open-label extension study for up to 5 years. In the study, a total of 24 PTPs < 12 years received IDELVION either for prophylaxis and/or for the treatment of bleeding episodes on an on-demand basis.

Patients who received prophylactic treatment continued with 35–50 IU/kg once weekly. A subgroup of patients switched to extended treatment intervals (every 10 or 14 days) with a recommended dose of 75 IU/kg. At the end of the study 17 PTPs (71%) were on the 7 day prophylaxis interval, and a total of 3 (12%), and 4 (17%) PTPs remained on the extended prophylaxis interval of 10 and 14 days, respectively. During the study, 4 PTPs (50%) in the 14-day regimen switched back to a more frequent dosing due to increased bleeding complications. The estimated median Annualised Bleeding Rates (ABRs) for 7-, and 14-day prophylaxis with IDELVION for all bleeds were 2.0 (range 0–14), and 5.6 (range 0–8), respectively.

Perioperative management:

The safety and efficacy in the perioperative setting was evaluated in two pivotal Phase 3 studies and a long-term extension study. The per protocol efficacy analysis includes 30 surgeries performed in 21 patients between 5 and 58 years undergoing major or minor surgical, dental or other surgical invasive procedures. Dosing was individualized based on the subject’s PK and clinical response to treatment. A single preoperative bolus ranging from 14 to 163 IU/kg was used in 96.7% (n=29) of surgeries. Haemostatic efficacy was rated as excellent or good in all of the assessed procedures. During the 14-day postoperative period, patients received between 0 and 11 infusions and total doses ranging from 0 to 444 IU/kg.

Paediatric population

The European Medicines Agency has deferred the obligation to submit the results of studies with IDELVION in previously untreated patients in the treatment and prophylaxis of bleeding in haemophilia B (see section 4.2 for information on paediatric use).

5.2 Pharmacokinetic properties

Adult population

The pharmacokinetics (PK) of IDELVION were evaluated following an intravenous injections of a single dose of 25, 50, and 75 IU/kg. The PK parameters following a single injection of 50 IU/kg IDELVION (see table below) were based on plasma factor IX activity measured by the one-stage clotting assay. The mean factor IX activity at day 7, and day14 was 13.76% and 6.10%, respectively, after a single dose of 50 IU/kg IDELVION. Repeat PK assessment for up to 30 weeks demonstrated a stable pharmacokinetic profile and incremental recovery was consistent over time.

Trough levels of 5–10% have been targeted in clinical studies for achieving bleeding control while on prophylaxis. PK simulations suggest the time to reach 5% plasma FIX activity following a single injection of 50 IU/kg IDELVION to be 12.5 days for adults.

Pharmacokinetic parameters for subjects with severe haemophilia (Median (min, max)) following a single injection of IDELVION in adults

a = corrected for baseline levels

IR = incremental recovery; AUC = area under the factor IX activity time curve; CL = body weight adjusted clearance; Elimination t1/2 = Elimination half-life

Paediatric population

Pharmacokinetic parameters of IDELVION were evaluated in adolescents (12 to <18 years of age) and infants and children (1 to <12 years of age) following an intravenous injection of a single dose of 50 IU/kg. PK parameters (presented below) were estimated based on the plasma factor IX activity over time profile measured by the one-stage clotting assay.

Comparison of pharmacokinetic parameters of IDELVION in children (Median (min, max)) following a single injection of 50 IU/kg IDELVION

IR = incremental recovery; AUC = area under the factor IX activity time curve; CL = body weight adjusted clearance; Elimination t1/2 = Elimination half-life

Trough levels of 5–10% have been targeted in clinical studies for achieving bleeding control while on prophylaxis. PK simulations suggest the time to reach 5% plasma FIX activity following a single injection of 50 IU/kg IDELVION to be 7 days for 1-<6years, 9 days for 6-<12 years and 11 days for 12-<18 years of age).

5.3 Preclinical safety data

Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, single and repeat dose toxicity, genotoxicity, thrombogenicity and local tolerability.

No investigations on carcinogenicity and reproductive toxicology have been conducted.

6 PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Powder:

Sodium citrate,

Polysorbate 80,

Mannitol, Sucrose,

Hydrochloric acid (for pH adjustment).

Solvent:

Water for injections

6.2 Incompatibilities

In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.

Only the provided injection sets should be used because treatment failure can occur as a consequence of human coagulation factor IX adsorption to the internal surfaces of some injection equipment.

6.3 Shelf life

IDELVION 3500 IU powder and solvent for solution for injection

30 months

After reconstitution the chemical and physical in-use stability has been demonstrated for 8 hours at 2–25 °C). From a microbiological point of view, the product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are in the responsibility of the user.

6.4 Special precautions for storage

Do not store above 25 °C.

Do not freeze. Keep vials in the outer carton in order to protect from light.

For storage conditions after reconstitution of the medicinal product, see section 6.3.

6.5 Nature and contents of container

IDELVION 3500 IU powder and solvent for solution for injection

Powder (3500 IU) in a 10 ml vial (type I glass), with a stopper (bromobutyl rubber) a disc (plastic) and a cap (aluminium).

5 ml of solvent in a vial (type I glass), with a stopper (bromo- or chlorobutyl rubber) a disc (plastic) and a cap (aluminium).

Presentations

Each pack contains:

IDELVION 3500 IU powder and solvent for solution for injection

1 vial with powder

1 vial with 5 ml water for injections

1 filter transfer device 20/20

One inner box containing:

1 disposable 10 ml syringe

1 venipuncture set

2 alcohol swabs

1 non-sterile plaster

Not all pack sizes may be marketed.

6.6 Special precautions for disposal

General instructions

– The reconstituted solution should be clear or slightly opalescent, yellow to colourless. After filtering/wit­hdrawal (see below) the reconstituted product should be inspected visually for particulate matter and discoloration prior to administration.

– Do not use solutions that are cloudy or have deposits.

– Reconstitution and withdrawal must be carried out under aseptic conditions.

Reconstitution

Bring the solvent to room temperature (below 25 °C). Ensure product and solvent vial flip caps are removed and the stoppers are treated with an antiseptic solution and allowed to dry prior to opening the Mix2Vial package.

Withdrawal and application

Care should be taken that no blood enters the syringe filled with product, as there is a risk that the blood could coagulate in the syringe and fibrin clots could therefore be administered to the patient.

The reconstituted IDELVION solution must not be diluted.

The reconstituted solution should be administered by slow intravenous injection The rate of administration should be determined by the patient’s comfort level, up to a maximum of 5 ml/min.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.