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Chandrasekaran R, Dávoli M, Muda Z, Pérez-Lozano U, Salhi N, Saxena N, Shen MC, Song HH, Sosothikul D, Soto-Arellano VS, Solev I. Estimating the impact of improved management of haemophilia a on clinical outcomes and healthcare utilisation and costs. BMC Res Notes 2023; 16:327. [PMID: 37950292 PMCID: PMC10638687 DOI: 10.1186/s13104-023-06552-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 10/02/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVE Haemophilia A (HA) is associated with high clinical and healthcare burden. We developed an Excel-based model comparing current practice to improved management in severe HA patients currently managed on demand (OD). Outcomes included short- and long-term bleed events. Expected annual bleeds were estimated based on locally-derived OD annualised bleed rate (ABR), adjusted by relative prophylaxis-related ABRs (published literature). The objective of our study was to explore the impact of improving HA prophylaxis in target countries with limited published data (Algeria, Argentina, Chile, India, Malaysia, Mexico, Taiwan and Thailand). Bleed-related healthcare resource use (HCRU) and costs were estimated as a function of bleed type, with inputs obtained from local expert estimates. Clotting factor concentrates (CFC) consumption related to treatment and prophylaxis was estimated based on locally relevant dosing. CFC costs were not included. RESULTS When 20% of OD patients were switched to prophylaxis, projected reduction in bleeds was estimated between 3% (Taiwan) through 14% (Algeria and India); projected reductions in hospitalisations ranged from 3% (Taiwan) through 15% (India). Projected HCRU-related annual cost savings were estimated at USD 0.45 m (Algeria), 0.77 m (Argentina), 0.28 m (Chile), 0.13 m (India), 0.29 m (Malaysia), 2.79 m (Mexico), 0.15 m (Taiwan) and 0.78 m (Thailand). Net change in annual CFC consumption ranged from a 0.05% reduction (Thailand) to an overall 5.4% increase (Algeria). Our model provides a flexible framework to estimate the clinical and cost offsets of improved prophylaxis. Modest increase in CFC consumption may be an acceptable offset for improvements in health and healthcare capacity in resource constrained economies.
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Affiliation(s)
- Ravichandran Chandrasekaran
- Department of Paediatric Hematology & Oncology, Institute of Child Health and Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| | - Mauro Dávoli
- Rosario Hemophilia Fundación, Rosario-Santa Fé, Argentina
| | - Zulaiha Muda
- Paediatric Department, Hospital Tunku Azizah Women Children Hospital, Kuala Lumpur, Malaysia
| | - Uendy Pérez-Lozano
- Hematology Service, Unidad Médica de Alta Especialidad "Manuel Avila Camacho", Instituto Mexicano del Seguro Social, Puebla, Mexico
| | - Naouel Salhi
- Department of Hematology, University Hospital of Constantine, Constantine, Algeria
| | - Nakul Saxena
- Takeda Pharmaceuticals International AG Singapore Branch, Singapore, Singapore
| | - Ming-Ching Shen
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | | | - Darintr Sosothikul
- Integrative and Innovative Hematology/Oncology Research Unit, Division of Hematology/Oncology, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Igor Solev
- Takeda Pharmaceuticals International AG Singapore Branch, Singapore, Singapore
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102
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Ragni MV, Chan SY. Innovations in RNA therapy for hemophilia. Blood 2023; 142:1613-1621. [PMID: 37478403 PMCID: PMC10862240 DOI: 10.1182/blood.2022018661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/05/2023] [Accepted: 06/27/2023] [Indexed: 07/23/2023] Open
Abstract
Given the shortcomings of current factor-, nonfactor-, and adeno-associated virus gene-based therapies, the recent advent of RNA-based therapeutics for hemophilia is changing the fundamental approach to hemophilia management. From small interfering RNA therapeutics that knockdown clot regulators antithrombin, protein S, and heparin cofactor II, to CRISPR/Cas9 gene editing that may personalize treatment, improved technologies have the potential to reduce bleeds and factor use and avoid inhibitor formation. These novel agents, some in preclinical studies and others in early phase trials, have the potential to simplify treatment and improve hemostasis and quality of life. Furthermore, because these therapies arise from manipulation of the coagulation cascade and thrombin generation and its regulation, they will enhance our understanding of hemostasis and thrombosis and ultimately lead to better therapies for children and adults with inherited bleeding disorders. What does the future hold? With the development of novel preclinical technologies at the bench, there will be fewer joint bleeds, debilitating joint disease, orthopedic surgery, and improved physical and mental health, which were not previously possible. In this review, we identify current limitations of treatment and progress in the development of novel RNA therapeutics, including messenger RNA nanoparticle delivery and gene editing for the treatment of hemophilia.
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Affiliation(s)
- Margaret V. Ragni
- Division of Hematology Oncology, Department of Medicine, University of Pittsburgh, Hemophilia Center of Western Pennsylvania, Pittsburgh, PA
| | - Stephen Y. Chan
- Division of Cardiology, Department of Medicine, Vascular Medicine Institute, Pittsburgh, PA
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103
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Pasca S, Zanon E, Mannucci PM, Peyvandi F. Emicizumab in acquired hemophilia A: pros and cons of a new approach to the prevention and treatment of bleeding. Blood Transfus 2023; 21:549-556. [PMID: 36795341 PMCID: PMC10645354 DOI: 10.2450/2023.0247-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/22/2022] [Indexed: 02/17/2023]
Abstract
Emicizumab, a monoclonal bispecific antibody that mimics the function of activated factor VIII (FVIII), is currently licensed for prophylactic use in patients with congenital hemophilia A with and without inhibitors. Acquired hemophilia A (AHA) is a very rare bleeding disorder caused by the development of autoantibodies that inhibit FVIII activity in plasma; males and females are equally affected. Therapeutic options for patients with AHA currently include eradication of the inhibitor with immunosuppressive treatments and management of acute bleeding with bypassing agents or recombinant porcine FVIII. More recently, several reports described the off-label use of emicizumab in patients with AHA and a phase III study is ongoing in Japan. The aims of this review are to describe the 73 reported cases, and to highlight the advantages and disadvantages of this novel approach to the prevention and treatment of bleeding in AHA.
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Affiliation(s)
- Samantha Pasca
- Biological Sciences Department (DSB), Padua University Hospital, Padua, Italy
| | - Ezio Zanon
- Hemophilia Center - General Medicine, Padua University Hospital, Padua, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
- Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy
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104
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Wilczyński B, Juszczyk D, Zorena K, Mital A. Strength training program for an athlete with hemophilia A and an inhibitor while taking a new prophylactic drug treatment: a case report. Physiother Theory Pract 2023; 39:2470-2478. [PMID: 35473454 DOI: 10.1080/09593985.2022.2070886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Currently, patients with hemophilia and inhibitor are being offered therapy, including a tissue factor pathway inhibitor (TFPI). The new prophylactic drug treatment may allow for new opportunities for other interventions and overall improvement in quality of life. This case report assessed the safety and effects of a strength training program in a patient with an inhibitor on a specific new study drug. DESCRIPTION A 20-year-old patient with severe hemophilia A with an inhibitor participated in a 6-week strength training program. The strengthening program consisted of 7 exercises involving limb and trunk muscles. A qualitative assessment of movement patterns was performed using the Functional Movement Test. Dynamic balance was measured by the Y-Balance Test, whereby the power of lower extremities was measured by Counter Movement Jump. The Quality of Life Index was done by survey to assess the perceived overall quality of the patient's life. The exercise fatigue after each training was measured with the Borg scale. OUTCOMES After the intervention during treatment with the new drug, the patient's quality of life increased, especially in terms of health and function (from 15.6 to 29.1 points), also, the power of the lower limbs increased. There were no bleeding episodes during the intervention and after a 3-month follow-up. CONCLUSION The proposed program during the application of the new prophylactic treatment seems to be effective in improving quality of life and increasing lower limb power in a hemophilic patient with an inhibitor. However, randomized clinical trials are needed to confirm the results.
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Affiliation(s)
- Bartosz Wilczyński
- Department of Immunobiology and Environment Microbiology, Medical University of Gdańsk, Gdańsk, Poland
- Centre of Rehabilitation and Training "Fizjo-World", Gdynia, Poland
| | - Dawid Juszczyk
- Centre of Rehabilitation and Training "Fizjo-World", Gdynia, Poland
| | - Katarzyna Zorena
- Department of Immunobiology and Environment Microbiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Andrzej Mital
- Department of Haematology and Transplantology, Medical University of Gdańsk, Gdańsk, Poland
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105
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Moonla C, Polprasert C, Krittikarux S, Cheerasiri N, Akkawat B, Rojnuckarin P, Uaprasert N. Adjunctive daratumumab can induce rapid remission in acquired haemophilia A with poor prognostic markers. Haemophilia 2023; 29:1649-1652. [PMID: 37665794 DOI: 10.1111/hae.14850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/28/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023]
Affiliation(s)
- Chatphatai Moonla
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Chantana Polprasert
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - San Krittikarux
- Department of Medicine, Sakaeo Crown Prince Hospital, Sakaeo, Thailand
| | - Nuanrat Cheerasiri
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Benjaporn Akkawat
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Ponlapat Rojnuckarin
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Noppacharn Uaprasert
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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106
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Chamouard V, Freyssenge J, Duport G, Volot F, Varin R, Giraud N, Dargaud Y, Fraticelli L. Evaluation of the care pathway in the context of the dispensing of emicizumab (Hemlibra) in community and hospital pharmacies in France: A patient satisfaction survey. Haemophilia 2023; 29:1490-1498. [PMID: 37718591 DOI: 10.1111/hae.14857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION Since June 2021 in France, patients with haemophilia A with anti-factor VIII inhibitors and patients with severe haemophilia A without anti-factor VIII inhibitors, and treated with emicizumab (Hemlibra), have to choose the dispensing circuit community or hospital pharmacy. AIM To evaluate satisfaction of patients whether they choose dispensation from a community pharmacy or retained dispensation from the hospital pharmacy, to understand the main motivation for choosing the community or the hospital pharmacy. METHODS All patients living in France, regardless of age, were eligible to participate. Between September 13, 2022, and January 9, 2023, 175 respondents answered the satisfaction survey, including 123 in community pharmacy and 52 in hospital pharmacy. RESULTS Eighteen months after availability in community pharmacies, treatment accessibility is improved for the benefit of the patient. The door-to-door travel times are significantly reduced to the community pharmacy with an average gain of 16.5 min saved from the place of residence. Patients are mostly satisfied with the new dispensing circuit especially concerning the overall satisfaction (p < .0001), the travel time (p < .0001) and the strong relationship with the pharmacist (p = .0022) compared to hospital pharmacy. CONCLUSION Innovation in care pathways is showing its full potential in improving access to medication, made possible by the implementation of a rigorous organization accompanied by training to enable healthcare professionals involved in primary care to provide appropriate management.
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Affiliation(s)
- Valérie Chamouard
- Haemophilia Treatment Centre and French Reference Centre on Haemophilia, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France
- Pharmaceutical Unit, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France
- PERMEDES group, French Society of Clinical Pharmacy, France
| | - Julie Freyssenge
- Research on Healthcare Performance RESHAPE, INSERM U1290, Claude Bernard University Lyon 1, Lyon, France
| | | | - Fabienne Volot
- Haemophilia Treatment Centre, Dijon Bourgogne University Hospital, Dijon, France
| | - Rémi Varin
- PERMEDES group, French Society of Clinical Pharmacy, France
- Pharmaceutical Unit, UNIROUEN, Inserm U1234, CHU Rouen, Normandie University, Rouen, France
| | | | - Yesim Dargaud
- Haemophilia Treatment Centre and French Reference Centre on Haemophilia, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France
- University Claude Bernard Lyon 1, UR4609 Hémostase et thrombose, Lyon, France
| | - Laurie Fraticelli
- Laboratory P2S (Health Systemic Process), UR 4129, Faculty of Medicine Laennec, University Claude Bernard Lyon 1, University of Lyon, Lyon, France
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107
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Habay C, Auditeau C, Blandinières A, Bentounes NK, Lavenu-Bombled C, Harroche A, Bally C, Frenzel L, Borgel D, Lasne D. Interferences by factor VIII and lupus anticoagulant in the modified one-stage assay for emicizumab. Haemophilia 2023; 29:1661-1664. [PMID: 37751318 DOI: 10.1111/hae.14873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 09/28/2023]
Affiliation(s)
- Capucine Habay
- Laboratoire d'Hématologie Biologique, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Claire Auditeau
- Laboratoire d'Hématologie Biologique, AP-HP, Hôpital Necker Enfants Malades, Paris, France
- Université Paris-Saclay, INSERM, Hémostase inflammation thrombose HITh U1176, Le Kremlin-Bicêtre, France
| | - Adeline Blandinières
- Université Paris-Saclay, INSERM, Hémostase inflammation thrombose HITh U1176, Le Kremlin-Bicêtre, France
- Laboratoire d'Hématologie Biologique, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Nûn K Bentounes
- Laboratoire d'Hématologie Biologique, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Cécile Lavenu-Bombled
- Université Paris-Saclay, INSERM, Hémostase inflammation thrombose HITh U1176, Le Kremlin-Bicêtre, France
- Laboratoire d'Hématologie Biologique, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Annie Harroche
- Centre de Traitement de l'Hémophilie, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Cecile Bally
- Centre de Traitement de l'Hémophilie, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Laurent Frenzel
- Centre de Traitement de l'Hémophilie, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Delphine Borgel
- Laboratoire d'Hématologie Biologique, AP-HP, Hôpital Necker Enfants Malades, Paris, France
- Université Paris-Saclay, INSERM, Hémostase inflammation thrombose HITh U1176, Le Kremlin-Bicêtre, France
| | - Dominique Lasne
- Laboratoire d'Hématologie Biologique, AP-HP, Hôpital Necker Enfants Malades, Paris, France
- Université Paris-Saclay, INSERM, Hémostase inflammation thrombose HITh U1176, Le Kremlin-Bicêtre, France
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108
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Guan T, Ai D, Zhao N, Liu G, Yao W, Chen Z, Li Z, Zhou Y, Wu R. Treatment-related outcome from patient report outcome (PRO) of children with severe and moderate hemophilia A in China: An analysis report of registration data from patient organization "hemophilia home care center". Haemophilia 2023; 29:1467-1474. [PMID: 37718575 DOI: 10.1111/hae.14863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVES To assess current treatment-related outcomes for children with severe and moderate haemophilia A (cHA) in China. METHODS This cross-section Patient Report Outcome (PRO) report collected PRO data of severe and moderate cHAs registered in the 'Hemophilia Home Care Center' database (http://web.bjxueyou.cn) between January 2021 and November 2022. Data included records of bleeding, activities, and concentrates consumption. All patients had a confirmed diagnosis of moderate or severe haemophilia A (FVIII: C ≤ 5%) and were < 18 years old. RESULTS Among 1038 analysable cases, 9.6% of children with inhibitors had a higher rate of intracranial haemorrhage, dropout school rate, and higher FVIII consumption than children without inhibitors. Among 100 children with inhibitors, 36 patients were treated without immune tolerance induction (ITI), 14 patients with irregular treatment and 50 patients received ITI. Children with ITI had a lower ABR (2.4 (0,6.6) vs. 13.4 (9.5, 26.6), p<.001) and AJBR (0 (0, 3.1) vs. 8.9 (1.6, 19.3), p < .001) compared to those without ITI. Among 938 children without inhibitors, 28.5% received on-demand treatment and 71.5% received prophylaxis. Of 528 children with 1343.8 (1050.4, 2922.9)IU/kg/year median FVIII consumption, 43.0% received low-dose, 43.2% received intermediate-dose, and 13.8% received high-dose regimen; these children with prophylaxis had a lower ABR (3.1 (0, 10.7) vs. 12.8 (2.4, 45.5), p < .001), AJBR (0.5 (0, 3.9) vs. 3.0 (0, 12.0), p < .001) and disability rate (9.0% vs.18.5%, p = .032) compared to children who received on-demand treatment. CONCLUSION The high rate of drop-out of school and disability still present a huge gap to meet the needs in China. It is necessary to improve the level of medical accessibility and medicine affordability and strengthen the patient/parent's education in China.
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Affiliation(s)
- Tao Guan
- Beijing Hemophilia Home Care Centre, Beijing, China
| | - Di Ai
- Hematology Centre, Beijing Key Laboratory of Paediatric Haematology Oncology, National Key Discipline of Paediatrics, Capital Medical University; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Childrenationrsity;, Capital Medical University, National Centre for Childrenal Univer, Beijing, China
| | - Nan Zhao
- Beijing Hemophilia Home Care Centre, Beijing, China
| | - Guoqing Liu
- Hematology Centre, Beijing Key Laboratory of Paediatric Haematology Oncology, National Key Discipline of Paediatrics, Capital Medical University; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Childrenationrsity;, Capital Medical University, National Centre for Childrenal Univer, Beijing, China
| | - Wanru Yao
- Hematology Centre, Beijing Key Laboratory of Paediatric Haematology Oncology, National Key Discipline of Paediatrics, Capital Medical University; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Childrenationrsity;, Capital Medical University, National Centre for Childrenal Univer, Beijing, China
| | - Zhenping Chen
- Hematologic Disease Laboratory, Beijing Paediatric Research Institute, Beijing Childrenute Laborat, Capital Medical University, National Centre for Childrenal Univer, Beijing, China
| | - Zhenping Li
- Hematology Centre, Beijing Key Laboratory of Paediatric Haematology Oncology, National Key Discipline of Paediatrics, Capital Medical University; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Childrenationrsity;, Capital Medical University, National Centre for Childrenal Univer, Beijing, China
| | - Yaohan Zhou
- Hematology Centre, Beijing Key Laboratory of Paediatric Haematology Oncology, National Key Discipline of Paediatrics, Capital Medical University; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Childrenationrsity;, Capital Medical University, National Centre for Childrenal Univer, Beijing, China
| | - Runhui Wu
- Hematology Centre, Beijing Key Laboratory of Paediatric Haematology Oncology, National Key Discipline of Paediatrics, Capital Medical University; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Childrenationrsity;, Capital Medical University, National Centre for Childrenal Univer, Beijing, China
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109
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Malec L, Matino D. Targeting higher factor VIII levels for prophylaxis in haemophilia A: a narrative review. Haemophilia 2023; 29:1419-1429. [PMID: 37758651 DOI: 10.1111/hae.14866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 09/07/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION The standard of care in severe haemophilia A is prophylaxis, which has historically aimed for a factor VIII (FVIII) trough level of ≥1%. However, despite prophylactic treatment, people with haemophilia remain at risk of bleeds that have physical and quality of life implications, and that impact everyday life. AIM The aim of this review was to evaluate evidence supporting the relationship between targeting higher FVIII activity levels with prophylaxis and improved outcomes in people with haemophilia A. METHODS We conducted a narrative review that defined the unmet needs and treatment goals in people with haemophilia A, evaluated evidence to support targeting higher FVIII activity levels, and highlighted therapies that may support higher and sustained FVIII activity levels and improved outcomes for people with haemophilia A. RESULTS Despite recent advances in treatment, unmet needs remain, and people with haemophilia continue to experience joint and functional impairment, acute and chronic pain, and poor mental health. All these negatively impact their health-related quality of life. Evidence suggests that FVIII activity levels of up to 50% may be needed to achieve a near-zero joint bleed rate. However, achieving high FVIII activity levels with current standard and extended half-life (EHL) FVIII replacement therapies is associated with a high treatment burden. Innovative treatment options may provide high sustained FVIII activity levels and improved patient outcomes. CONCLUSION Evidence suggests that FVIII activity levels in people with haemophilia A should be sustained at higher levels to improve joint and patient outcomes and enable progression towards health equity.
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Affiliation(s)
- Lynn Malec
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- Division of Hematology & Oncology, Departments of Medicine and Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Davide Matino
- Division of Hematology & Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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110
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Mannucci PM, Agosti P, Lettino M. Guidance for the antithrombotic management of persons with haemophilia and cardiovascular disease. Haemophilia 2023; 29:1390-1393. [PMID: 37729476 DOI: 10.1111/hae.14874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/15/2023] [Accepted: 09/15/2023] [Indexed: 09/22/2023]
Affiliation(s)
- Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pasquale Agosti
- Department of Pathophysiology and Transplantation and Fondazione Luigi Villa, Università degli Studi di Milano, Milan, Italy
| | - Maddalena Lettino
- Department for Cardiac, Thoracic and Vascular Diseases, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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111
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Kessler CM, Corrales-Medina FF, Mannucci PM, Jiménez-Yuste V, Tarantino MD. Clinical efficacy of simoctocog alfa versus extended half-life recombinant FVIII concentrates in hemophilia A patients undergoing personalized prophylaxis using a matching-adjusted indirect comparison method. Eur J Haematol 2023; 111:757-767. [PMID: 37587687 DOI: 10.1111/ejh.14073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES We aimed to indirectly compare the efficacy of personalized prophylaxis with simoctocog alfa (Nuwiq®) versus three extended half-life (EHL) recombinant FVIII (rFVIII) concentrates. METHODS Treatment effects were compared using matching-adjusted indirect comparisons after matching individual patient-level baseline characteristics for simoctocog alfa (pharmacokinetic [PK]-guided personalized prophylaxis) against published aggregate personalized prophylaxis data for efmoroctocog alfa, damoctocog alfa pegol, and rurioctocog alfa pegol. RESULTS A higher percentage (p < .001) of patients with zero bleeds was found with simoctocog alfa compared with efmoroctocog alfa (75% vs. 45%), damoctocog alfa pegol (77% vs. 38%), and rurioctocog alfa pegol (target trough level 1%-3%; 78% vs. 42%). Similar efficacy was found comparing simoctocog alfa against rurioctocog alfa pegol 8%-12% (77% vs. 62%). The mean total annualized bleeding rate was lower (p < .001) with simoctocog alfa than damoctocog alfa pegol (1.5 vs. 4.9). Consistent with approved dosing, the mean FVIII weekly dose was higher (p < .001) for simoctocog alfa than efmoroctocog alfa, damoctocog alfa pegol, or rurioctocog alfa pegol 1%-3%, but lower (p < .001) than rurioctocog alfa pegol 8%-12%. CONCLUSIONS Indirect comparisons demonstrated that PK-guided, personalized prophylaxis with simoctocog alfa can lead to higher zero bleed rates compared with personalized EHL rFVIII concentrate regimens, albeit with higher weekly doses, and a lower percentage of patients treated twice weekly or less.
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Affiliation(s)
- Craig M Kessler
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Fernando F Corrales-Medina
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida, USA
- Hemophilia Treatment Center, University of Miami, Miami, Florida, USA
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Víctor Jiménez-Yuste
- Hospital Universitario La Paz-Hematology Department, Autónoma University, Madrid, Spain
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112
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Tiede A, Hart C, Knöbl P, Greil R, Oldenburg J, Sachs UJ, Miesbach W, Pfrepper C, Trautmann-Grill K, Holstein K, Pilch J, Möhnle P, Schindler C, Weigt C, Schipp D, May M, Dobbelstein C, Pelzer FJ, Werwitzke S, Klamroth R. Emicizumab prophylaxis in patients with acquired haemophilia A (GTH-AHA-EMI): an open-label, single-arm, multicentre, phase 2 study. Lancet Haematol 2023; 10:e913-e921. [PMID: 37858328 DOI: 10.1016/s2352-3026(23)00280-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Acquired haemophilia A is caused by neutralising autoantibodies against coagulation factor VIII, leading to severe bleeding. Standard treatment involves immunosuppressive therapy, which is associated with adverse events and mortality in the frail population of patients with acquired haemophilia A. This study investigated whether emicizumab, a factor VIIIa mimetic antibody, protects patients with acquired haemophilia A from bleeding and allows deferral of immunosuppression during the first 12 weeks after diagnosis. METHODS We report final results of an open-label, single-arm, phase 2 clinical trial. Adult patients with acquired haemophilia A from 16 haemophilia treatment centres in Germany and Austria were eligible if they had not previously received immunosuppression. Patients received emicizumab subcutaneously (6 and 3 mg/kg on days 1 and 2, 1·5 mg/kg weekly until week 12), but no immunosuppression. Follow-up was until week 24. The primary endpoint was the number of clinically relevant bleeds per patient-week until week 12. Emicizumab was considered effective if the mean bleeding rate was significantly below 0·15 bleeds per patient-week, the rate observed in a previous study of patients with acquired haemophilia A treated with bypassing agents and immunosuppression but no emicizumab. The study is registered with clinicaltrials.gov, NCT04188639 and is complete. FINDINGS Of 49 patients screened from March 25, 2021, to June 10, 2022, 47 were enrolled (23 women, 24 men). Median age was 76 years (IQR 66-80), 46 (98%) of 47 patients were White, median factor VIII activity was 1·4 IU/dL (0·3-5·6), and median inhibitor concentration was 11·4 Bethesda units per mL (3·9-42·7). Mean breakthrough bleeding rate was 0·04 bleeds per patient-week (upper 97·5% CI 0·06). 33 (70%) of 47 patients had no bleeding events, seven patients (15%) had one bleed, six patients (13%) had two bleeds, and one patient (2%) had three bleeds. Adverse events of grade 3 or worse included COVID-19 (n=2), acute kidney injury (n=2), and stroke (n=1). Four of 47 patients died, including two deaths related to bleeding, one from COVID-19, and one from cardiac arrest (none were judged as related to emicizumab). INTERPRETATION This study suggests that emicizumab prophylaxis prevents bleeding in patients with acquired haemophilia A and that immunosuppressive therapy can be deferred while patients are receiving this treatment. The low number of thromboembolic events, severe infections, and fatalities observed in this study are promising. FUNDING This study was supported by funding from Hoffman-La Roche.
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Affiliation(s)
- Andreas Tiede
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.
| | - Christina Hart
- Department of Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Paul Knöbl
- Department of Medicine 1, Division of Hematology and Hemostasis, Medical University of Vienna, Vienna, Austria
| | - Richard Greil
- Medical Department III, Paracelsus Medical University Salzburg, Salzburg, Austria; Salzburg Cancer Research Institute-CCCIT Salzburg, Austria; Cancer Cluster Salzburg, Salzburg, Austria
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Ulrich J Sachs
- Department of Thrombosis and Haemostasis, Giessen University Hospital, Giessen, Germany
| | | | - Christian Pfrepper
- Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
| | | | - Katharina Holstein
- Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Pilch
- Clinical Hemostaseology and Transfusion Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Patrick Möhnle
- Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | | | | | | | - Marcus May
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Christiane Dobbelstein
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Fabius J Pelzer
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Sonja Werwitzke
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Robert Klamroth
- Internal Medicine, Vascular Medicine and Coagulation Disorders, Vivantes Clinic Friedrichshain, Berlin, Germany
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van Bergen EDP, van Leeuwen FHP, Foppen W, Timmer MA, Schutgens REG, Mastbergen SC, Lafeber FPJG, de Jong PA, Fischer K, van Vulpen LFD. Subclinical synovial proliferation in patients with severe haemophilia A: The value of ultrasound screening and biochemical markers. Haemophilia 2023; 29:1580-1588. [PMID: 37694775 DOI: 10.1111/hae.14861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/24/2023] [Accepted: 08/30/2023] [Indexed: 09/12/2023]
Abstract
AIM Subclinical bleeding and inflammation play a role in progression of haemophilic arthropathy. Synovial proliferation is predictive of joint bleeding and its early detection may guide treatment changes and prevent arthropathy progression. This study evaluated the prevalence of active and inactive subclinical synovial proliferation and investigated potential biochemical blood/urine markers to identify patients with active subclinical synovial proliferation. METHODS This cross-sectional study included patients with severe haemophilia A born 1970-2006 who were evaluated during routine clinic visits. Patients with (a history of) inhibitors or recent joint bleeding were excluded. Elbows, knees and ankles were examined for subclinical synovial proliferation by ultrasound and physical examination. Active synovial proliferation was distinguished from inactive synovial proliferation using predefined criteria. Blood/urine biochemical markers (serum osteopontin, sVCAM-1, Coll2-1, COMP, CS846, TIMP, and urinary CTX-II) were compared individually and as combined indexes between patients with and without active synovial proliferation. RESULTS This cohort consisted of 79 patients with a median age of 31 years (range 16.5-50.8 years) with 62/79 (78%) of the patients using continuous prophylaxis. The annualized joint bleeding rate over the last 5 years was .6 (.2-1.1). Active (17/79, 22%) and inactive subclinical synovial proliferation (17/79, 22%) were both prevalent in this cohort. Biochemical markers were not correlated with active subclinical synovial proliferation. CONCLUSION Subclinical synovial proliferation, both active and inactive, was prevalent in patients with severe haemophilia A with access to prophylaxis and would be overlooked without routinely performed ultrasounds. Biochemical markers were unable to identify patients with active subclinical synovial proliferation.
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Affiliation(s)
- Eline D P van Bergen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Flora H P van Leeuwen
- Department of Radiology & Nuclear Imaging, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Wouter Foppen
- Department of Radiology & Nuclear Imaging, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Merel A Timmer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Roger E G Schutgens
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Simon C Mastbergen
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Floris P J G Lafeber
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology & Nuclear Imaging, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Lize F D van Vulpen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
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114
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Onishi T, Harada S, Shimo H, Tashiro Y, Soeda T, Nogami K. The in vitro effect of anticoagulant agents on coagulation and fibrinolysis in the presence of emicizumab in the plasmas from patients with haemophilia A. Haemophilia 2023; 29:1529-1538. [PMID: 37766492 DOI: 10.1111/hae.14877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Emicizumab is used as hemostatic prophylaxis for patients with hemophilia A (PwHA), irrespective of the presence of inhibitors. Although bacterial infection can lead to a procoagulant state, there is limited information on coagulation and fibrinolysis potentials in emicizumab-treated PwHA and on the use of anticoagulants in such cases. AIM We examined whether anticoagulants affect the coagulation and fibrinolysis potentials in plasma from PwHA spiked with emicizumab. METHODS Plasma from PwHA was in vitro supplemented with emicizumab (50 μg/mL; emi-plasma) and anticoagulants (recombinant thrombomodulin (rTM), nafamostat mesylate (NM), unfractionated heparin (UFH), or low-molecular-weight heparin (LMH)). PwHA plasma spiked with rFVIII (1 IU/mL) was used as a reference (ref-plasma). The coagulation and fibrinolysis potentials in plasma was measured by thrombin and plasmin generation assay (T/P-GA) and clot-fibrinolysis waveform analysis (CFWA). RESULTS In T/P-GA and CFWA, coagulation potentials (maximum coagulation velocity; |min1|, and peak thrombin; Th-Peak) in plasma rose with increasing concentrations of emicizumab and rFVIII, but fibrinolytic potentials (peak plasmin; Plm-Peak, and maximum fibrinolytic velocity; |FL-min1|) remained unchanged. Adding rTM, NM, and UFH to emi-plasma suppressed coagulation and fibrinolysis potentials, similar to ref-plasma. Regarding the heparin, UFH and LMH inhibited the improved coagulation in emi-plasma. UFH inhibited fibrinolysis as well, but LMH did not. CONCLUSIONS Anticoagulants could exhibit the inhibitory effects on the coagulation and fibrinolysis potentials in plasma from PwHA spiked with emicizumab, similar to those in normal plasma.
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Affiliation(s)
- Tomoko Onishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Suguru Harada
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | - Hanako Shimo
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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115
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Valentino LA, Ozelo MC, Herzog RW, Key NS, Pishko AM, Ragni MV, Samelson-Jones BJ, Lillicrap D. A review of the rationale for gene therapy for hemophilia A with inhibitors: one-shot tolerance and treatment? J Thromb Haemost 2023; 21:3033-3044. [PMID: 37225021 DOI: 10.1016/j.jtha.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/09/2023] [Accepted: 05/14/2023] [Indexed: 05/26/2023]
Abstract
The therapeutic landscape for people living with hemophilia A (PwHA) has changed dramatically in recent years, but many clinical challenges remain, including the development of inhibitory antibodies directed against factor VIII (FVIII) that occur in approximately 30% of people with severe hemophilia A. Emicizumab, an FVIII mimetic bispecific monoclonal antibody, provides safe and effective bleeding prophylaxis for many PwHA, but clinicians still explore therapeutic strategies that result in immunologic tolerance to FVIII to enable effective treatment with FVIII for problematic bleeding events. This immune tolerance induction (ITI) to FVIII is typically accomplished through repeated long-term exposure to FVIII using a variety of protocols. Meanwhile, gene therapy has recently emerged as a novel ITI option that provides an intrinsic, consistent source of FVIII. As gene therapy and other therapies now expand therapeutic options for PwHA, we review the persistent unmet medical needs with respect to FVIII inhibitors and effective ITI in PwHA, the immunology of FVIII tolerization, the latest research on tolerization strategies, and the role of liver-directed gene therapy to mediate FVIII ITI.
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Affiliation(s)
- Leonard A Valentino
- National Hemophilia Foundation, New York, New York, USA; Rush University, Chicago, Illinois, USA.
| | | | - Roland W Herzog
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nigel S Key
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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116
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Oda A, Furukawa S, Kitabatake M, Ouji-Sageshima N, Sonobe S, Horiuchi K, Nakajima Y, Ogiwara K, Goitsuka R, Shima M, Ito T, Nogami K. The spleen is the major site for the development and expansion of inhibitor producing-cells in hemophilia A mice upon FVIII infusion developing high-titer inhibitor. Thromb Res 2023; 231:144-151. [PMID: 36948993 DOI: 10.1016/j.thromres.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/22/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Hemophilia A (HA) is a hereditary bleeding disorder caused by defects in endogenous factor (F)VIII. Approximately 30 % of patients with severe HA treated with FVIII develop neutralizing antibodies (inhibitors) against FVIII, which render the therapy ineffective. The managements of HA patients with high-titter inhibitors are especially challenging. Therefore, it is important to understand the mechanism(s) of high-titer inhibitor development and dynamics of FVIII-specific plasma cells (FVIII-PCs). AIMS To identify the dynamics of FVIII-PCs and the lymphoid organs in which FVIII-PCs are localized during high-titer inhibitor formation. METHODS AND RESULTS When FVIII-KO mice were intravenously injected with recombinant (r)FVIII in combination with lipopolysaccharide (LPS), a marked enhancement of anti-FVIII antibody induction was observed with increasing FVIII-PCs, especially in the spleen. When splenectomized or congenitally asplenic FVIII-KO mice were treated with LPS + rFVIII, the serum inhibitor levels decreased by approximately 80 %. Furthermore, when splenocytes or bone marrow (BM) cells from inhibitor+ FVIII-KO mice treated with LPS + rFVIII were grafted into immune-deficient mice, anti-FVIII IgG was detected only in the serum of splenocyte-administered mice and FVIII-PCs were detected in the spleen but not in the BM. In addition, when splenocytes from inhibitor+ FVIII-KO mice were grafted into splenectomized immuno-deficient mice, inhibitor levels were significantly reduced in the serum. CONCLUSION The spleen is the major site responsible for the expansion and retention of FVIII-PCs in the presence of high-titer inhibitors.
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Affiliation(s)
- Akihisa Oda
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | | | | | - Shota Sonobe
- Department of Immunology, Nara Medical University, Kashihara, Japan
| | - Kaoru Horiuchi
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan; The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Ryo Goitsuka
- Division of Development and Aging, Research Institute for Biomedical Sciences, Tokyo University of Science, Chiba, Japan
| | - Midori Shima
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Japan
| | - Toshihiro Ito
- Department of Immunology, Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan.
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117
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Fieux M, Rovera R, Coiffier C, Colomb E, Enjolras N, Béquignon E, Monge C, Le Quellec S. In vivo intranasal delivery of coagulation factor IX: a proof-of-concept study. J Thromb Haemost 2023; 21:3117-3123. [PMID: 37633640 DOI: 10.1016/j.jtha.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/30/2023] [Accepted: 08/15/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Hemophilia B (HB) is a bleeding disorder characterized by coagulation factor (F) IX (FIX) deficiency. The current standard-of-care for severe HB is prophylaxis with long-term repetitive intravenous (i.v.) infusions of recombinant FIX (rFIX) with standard half-life or extended half-life. Unmet needs remain regarding the development of non-invasive administration routes for coagulation factors. The aim of this study was to evaluate the effectiveness of intranasal delivery (IND) of rFIX and rFIX fused to Fc fragment (rFIX-Fc) in mice. METHODS Drops of rFIX and rFIX-Fc were deposited in the nostrils of wild-type, FcRn knock-out, FcRn humanized, and FIX knock-out mice. rFIX mucosal uptake was evaluated by measuring plasma FIX antigen and FIX activity (FIX:C) levels, and by performing histologic analysis of the nasal mucosa following IND. RESULTS After IND, both rFIX and rFIX-Fc were equally delivered to the blood compartment, irrespective of the mouse strain studied, mostly through a passive mechanism of transportation across the mucosal barrier, independent of FcRn receptor. Both plasma FIX antigen and FIX:C activity levels increased following IND in FIX knock-out mice. CONCLUSION This proof-of-concept study describes evidence supporting the nasal route as an alternative to FIX i.v. infusion for the treatment of HB.
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Affiliation(s)
- Maxime Fieux
- Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Service d'ORL, d'otoneurochirurgie et de chirurgie cervico-faciale, F-69310, Pierre Bénite, France; Université de Lyon, Université Lyon 1, F-69003, Lyon, France; Univ Paris Est Créteil, INSERM, IMRB, F-94010 Créteil, France; CNRS EMR 7000, F-94010 Créteil, France
| | - Renaud Rovera
- UMR 5305, Laboratoire de Biologie Tissulaire et d'Ingénierie Thérapeutique, Institut de Biologie et Chimie des Protéines, CNRS/Université Claude Bernard Lyon 1, 7 Passage du Vercors, CEDEX 07, 69367 Lyon, France
| | - Céline Coiffier
- UMR 5305, Laboratoire de Biologie Tissulaire et d'Ingénierie Thérapeutique, Institut de Biologie et Chimie des Protéines, CNRS/Université Claude Bernard Lyon 1, 7 Passage du Vercors, CEDEX 07, 69367 Lyon, France
| | - Evelyne Colomb
- UMR 5305, Laboratoire de Biologie Tissulaire et d'Ingénierie Thérapeutique, Institut de Biologie et Chimie des Protéines, CNRS/Université Claude Bernard Lyon 1, 7 Passage du Vercors, CEDEX 07, 69367 Lyon, France
| | - Nathalie Enjolras
- EA 4609 Hémostase et cancer, Université de Lyon, Université Lyon 1, F-69003, Lyon, France
| | - Emilie Béquignon
- Univ Paris Est Créteil, INSERM, IMRB, F-94010 Créteil, France; CNRS EMR 7000, F-94010 Créteil, France; Centre Hospitalier Intercommunal de Créteil, Service d'Oto-Rhino-Laryngologie et de Chirurgie Cervico-Faciale, F-94010 Créteil, France
| | - Claire Monge
- UMR 5305, Laboratoire de Biologie Tissulaire et d'Ingénierie Thérapeutique, Institut de Biologie et Chimie des Protéines, CNRS/Université Claude Bernard Lyon 1, 7 Passage du Vercors, CEDEX 07, 69367 Lyon, France
| | - Sandra Le Quellec
- EA 4609 Hémostase et cancer, Université de Lyon, Université Lyon 1, F-69003, Lyon, France; Unité d'hémostase clinique, Centre National de Référence de l'hémophilie, Hospices Civils de Lyon, France.
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118
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Farrugia A. The World Health Organisation's list of essential medicines and haemophilia treatment products. Haemophilia 2023; 29:1387-1389. [PMID: 37807613 DOI: 10.1111/hae.14879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Albert Farrugia
- School of Surgery, Faculty of Medicine and Medical Sciences, The University of Western Australia, Perth, Australia
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119
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Mitani Y, Honda M, Mizushima Y, Mori M, Fukuoka K, Oshima K, Arakawa Y, Taira K, Tanami Y, Koh K. Development of VIII inhibitors beyond 50 exposure days to rFVIII during prophylactic emicizumab therapy. Haemophilia 2023; 29:1653-1655. [PMID: 37707369 DOI: 10.1111/hae.14854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/03/2023] [Accepted: 08/28/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Yuichi Mitani
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Mamoru Honda
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Yoshitaka Mizushima
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Makiko Mori
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Kohei Fukuoka
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Koichi Oshima
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Yuki Arakawa
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Katsuaki Taira
- Department of Orthopedic Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
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Bhatti MQ, Gonzalez-Fernandez E, Bhatia K, Divani AA, Di Napoli M, Hinduja A, Datta YH. Neurological Complications Associated with Hereditary Bleeding Disorders. Curr Neurol Neurosci Rep 2023; 23:751-767. [PMID: 37864642 DOI: 10.1007/s11910-023-01313-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW Hereditary bleeding disorders may have a wide variety of clinical presentations ranging from mild mucosal and joint bleeding to severe central nervous system (CNS) bleeding, of which intracranial hemorrhage (ICH) is the most dreaded complication. In this review, we will discuss the pathophysiology of specific hereditary bleeding disorders, namely, hemophilia A, hemophilia B, and von Willebrand disease (vWD); their clinical manifestations with a particular emphasis on neurological complications; a brief overview of management strategies pertaining to neurological complications; and a review of literature guiding treatment strategies. RECENT FINDINGS ICH is the most significant cause of morbidity and mortality in patients with hemophilia. Adequate control of bleeding with the administration of specific factors or blood products, identification of risk factors for bleeding, and maintaining optimal coagulant activity are essential for appropriately managing CNS bleeding complications in these patients. The administration of specific recombinant factors is tailored to a patient's pharmacokinetics and steady-state levels. During acute bleeding episodes, initial factor activity should be maintained between 80 and 100%. Availability of monoclonal antibody Emicizumab has revolutionized prophylactic therapies in patients with hemophilia. Management of ICH in patients with vWD involves using plasma-derived factor concentrates, recombinant von Willebrand factor, and supportive antifibrinolytic agents individualized to the type and severity of vWD. Hemophilia and vWD are the most common hereditary bleeding disorders that can predispose patients to life-threatening CNS complications-intracranial bleeds, intraspinal bleeding, and peripheral nerve syndromes. Early care coordination with a hematologist can help develop an effective prophylactic regimen to avoid life-threatening bleeding complications in these patients. Further research is needed to evaluate using emicizumab as an on-demand treatment option for acute bleeding episodes in patients with hemophilia.
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Affiliation(s)
| | | | - Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA.
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, L'Aquila, Italy
| | - Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Yvonne H Datta
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA
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Chou SC, Hsu YC, Lin SW. Gene therapy for hemophilia, a clinical viewpoint. J Formos Med Assoc 2023; 122:1101-1110. [PMID: 37210312 DOI: 10.1016/j.jfma.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 04/07/2023] [Accepted: 05/08/2023] [Indexed: 05/22/2023] Open
Abstract
Gene therapy for hemophilia has been investigated for decades but no breakthroughs were made until Nathwani et al. achieved a significant and sustainable factor IX increase in hemophilia B patients in 2011. About eleven years later, in August 2022, the first hemophilia A gene therapy product was approved by the European Commission and hemophilia treatment entered a new era. This review does not focus on the newest advances but rather the practical aspects of gene therapy aiming to provide an overview for physicians who treat hemophiliacs who did not participate in the clinical trials. The current status of gene therapy, focusing particularly on products likely to be clinically available soon, are reviewed and summarized. Currently, possible limitations of gene therapy are pre-existing neutralizing antibodies toward the vector, liver health, age, and inhibitor status. Possible safety concerns include infusion reactions, liver damage, and adverse effects from immune suppressants or steroids. In summary, generally speaking, gene therapy is effective, at least for several years, but the exact effect may be unpredictable and intensive monitoring for several months is needed. It can also be considered safe with careful practice on selected patients. In its current form, gene therapy will not replace all hemophilia treatments. Advances in non-factor therapy will also improve hemophilia care greatly in the future. We envisage that gene therapy may be included in multiple novel therapies for hemophilia and benefit some hemophilia patients while novel non-factor therapies may benefit others, together fulfilling the unmet needs of all hemophilia patients.
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Affiliation(s)
- Sheng-Chieh Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Chen Hsu
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Liver Disease Prevention and Treatment Research Foundation, Taiwan
| | - Shu-Wha Lin
- Department of Clinical Laboratory Sciences and Medical Biotechnology, National Taiwan University, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Mohammed Ali IM, Hussein AA, Al-Musawi IMS, Hillawi SSH, Kadhim NS, Jasim AA. Epidemiological profile of hemophilia A in Karbala-Iraq. J Med Life 2023; 16:1611-1614. [PMID: 38406788 PMCID: PMC10893571 DOI: 10.25122/jml-2023-0218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/18/2023] [Indexed: 02/27/2024] Open
Abstract
Hemophilia is an X-linked congenital bleeding disorder caused by a deficiency of coagulation factor VIII (FVIII) (in hemophilia A) or factor IX (FIX) (in hemophilia B) and is one of the most important hereditary conditions in Iraq. The current study tried to provide a glimpse into the epidemiological and clinical status, as well as complications and treatment used for patients with hemophilia A in Karbala, Iraq. This retrospective research was carried out by reviewing the medical records of 90 male patients diagnosed with hemophilia A registered at the Hereditary Blood Disease Center in Karbala Teaching Hospital for children in Karbala, Iraq. The data was collected from May 10, 2023, until June 15, 2023, and included age, severity, type of bleeding, therapeutic approach, chronic viral infections including hepatitis B, hepatitis C, and human immunodeficiency virus (HIV). The median age of the patients was 15 years (18.86±14.42). In this study, one-third of patients' presentations started in the first year of life. The most common type was severe hemophilia A (factor VIII activity < 1%). Consequently, more than half of the patients were treated with factor VIII concentrate. Four patients had hepatitis C, while HIV was confirmed in one patient. The epidemiological or clinical parameters of hemophilia A patients in Karbala seem similar to those in other cities in Iraq. By considering this preliminary data, further comprehensive studies for patients with hemophilia and associated complications in other provinces or cities in Iraq are highly suggested to provide a clear perspective about the prevalence and epidemiological burdens.
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Affiliation(s)
| | - Ashwaq Ali Hussein
- Department of Pediatrics, College of Medicine, University of Kerbala, Karbala, Iraq
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Kenet G, Young G, Chuansumrit A, Matsushita T, Yadav V, Zak M, Male C. The immunogenicity, safety, and efficacy of N8-GP in previously untreated patients with severe hemophilia A: pathfinder6 end-of-trial results. J Thromb Haemost 2023; 21:3109-3116. [PMID: 37597724 DOI: 10.1016/j.jtha.2023.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/05/2023] [Accepted: 07/06/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND The pathfinder6 (NCT02137850) international phase 3 trial examined immunogenicity, safety, and efficacy of the extended half-life factor VIII (FVIII) replacement product N8-GP (turoctocog alfa pegol; Esperoct) in previously untreated patients (PUPs) with hemophilia A. OBJECTIVES We present end-of trial results for extended PUP N8-GP treatment for up to a median (range) 2.5 (0.0; 7.4) years. PATIENTS/METHODS Longer-term N8-GP treatment in PUPs with hemophilia A was examined. The prophylaxis regimen was ∼60 IU/kg N8-GP i.v. twice weekly, or every 3 or 7 days. The primary endpoint was the incidence of FVIII inhibitors. RESULTS Overall, 81 patients received N8-GP and were included in this analysis. The inhibitor incidence was 30.0% (15.7% high-titer [>5 BU]) for the extension phase. Patients had a median (range) 2.9 (0.1; 7.2) years of prophylaxis following the pre-prophylaxis period. During prophylaxis, the median annualized bleeding rate (ABR) (interquartile range) was 1.4 (0.6; 3.5), 13% of patients experienced no bleeding episodes, and 55.1% of patients experienced no spontaneous bleeds. The proportion of patients without any spontaneous bleeding episodes increased after the first year of prophylaxis. The hemostatic success rate in the treatment of bleeding episodes was 87.6%. No additional safety concerns were observed in patients with previously reported observation of temporarily decreased incremental recovery (IR). CONCLUSION Long-term end-of-trial PUP N8-GP prophylaxis data indicate that PUPs respond well to long-term N8-GP treatment. The inhibitor incidence was consistent with previous results. Median ABR during prophylaxis was 1.4. There were no lasting clinical impacts or safety concerns for patients with an observation of temporarily decreased IR.
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Affiliation(s)
- Gili Kenet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel; The Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel.
| | - Guy Young
- Children's Hospital Los Angeles/University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Ampaiwan Chuansumrit
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Vandana Yadav
- Novo Nordisk Service Centre India Private Ltd, Bangalore, India
| | | | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Austria
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Ragni MV. Rapidly loading emicizumab without immunosuppression in acquired haemophilia. Lancet Haematol 2023; 10:e870-e871. [PMID: 37858327 DOI: 10.1016/s2352-3026(23)00303-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Margaret V Ragni
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, and Hemophilia Center of Western PA, Pittsburgh, PA, USA.
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125
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Oldenburg J, Benson G, Chowdary P, Halimeh S, Matsushita T, Nørland A, Wahid MN, Nemes L. Cases of less-than-expected FVIII activity in previously treated patients during post-marketing surveillance of N8-GP. Haemophilia 2023; 29:1475-1482. [PMID: 37729439 DOI: 10.1111/hae.14864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 09/22/2023]
Abstract
INTRODUCTION Turoctocog alfa pegol (N8-GP) is a glycoPEGylated, extended half-life (EHL), human recombinant factor VIII (FVIII) approved for the treatment and prevention of bleeding episodes in patients with haemophilia A. Since its launch in August 2019, > 800 patients have been treated worldwide. AIM To present data from identified post-marketing cases of less-than-expected FVIII activity in previously treated patients (PTPs) without inhibitors after switching to N8-GP. METHODS The post-marketing safety database was searched using keywords such as 'coagulation FVIII level decreased'. Identified cases reported prior to 13 October 2021 were included in this report. Cases in which patients had FVIII inhibitors were excluded. RESULTS Here we report 14 cases of less-than-expected FVIII activity. Details varied greatly amongst the cases. At presentation, FVIII activity ranged from 1% (15 min post-dose) to 51% (2 days post-dose). Seven patients experienced bleeding episodes after switching to N8-GP with heterogeneity in bleeding presentations. Six out of seven patients who were tested for anti-PEG IgG and/or IgM antibodies were positive. In all known cases, FVIII activity returned to the expected range when switched to an alternative FVIII replacement product. CONCLUSION In conclusion, the 14 reported cases of less-than-expected FVIII activity, without presence of detectable FVIII inhibitors, presented with heterogenous characteristics, and wide variations in FVIII activity and anti-PEG antibody titre. FVIII activity returned to the expected range after switching to alternative FVIII products. In line with WFH guidelines, monitoring of FVIII activity can ensure FVIII activity in the expected range. The safety surveillance of N8-GP continues.
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Affiliation(s)
- Johannes Oldenburg
- Institute for Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, Germany
| | - Gary Benson
- Department of Haematology, Belfast City Hospital, Belfast, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | | | - Tadashi Matsushita
- Nagoya University Hospital, Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | | | | | - Laszlo Nemes
- DepartmentMedical Center of the Hungarian Defence Forces, National Hemophilia Center and Hemostasis, Budapest, Hungary
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126
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Bowyer AE, Hickey K, Kitchen S, Ezban M. A next generation FVIII mimetic bispecific antibody, Mim8, the impact on non-factor VIII related haemostasis assays. Haemophilia 2023; 29:1633-1637. [PMID: 37824563 DOI: 10.1111/hae.14884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/19/2023] [Accepted: 09/29/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION AND AIMS Mim8 is a next generation bispecific antibody developed for the treatment of haemophilia A (HA). Mim8 has an increased potency compared to first generation molecules. The impact on Mim8 on non-FVIII measuring haemostasis assays was assessed in plasma containing Mim8. METHODS Congenital severe HA plasma was spiked with increasing concentrations of Mim8 (0-20 μg/mL). 28 routine and specialist haemostasis assays were used to measure activities. These included tests for prothrombin time (PT), fibrinogen, thrombin, D-dimer, anti-Xa, heparin induced thrombocytopenia (HIT), clotting factors II-XII, factor XIII, von Willebrand factor (VWF), thrombophilia and DRVVT. RESULTS AND CONCLUSIONS Less than 10 % difference was calculated between plasma without Mim8 and plasma spiked to 15 μg/mL Mim8 in all assays except thrombin time (-10.5%), APTT-based factor IX, XI and XII, Werfen VWF:RCo (10.6%) and Siemens LA1 (-26.4%) and LA2 (-16.9%). At the expected therapeutic steady state levels of Mim8 (5-8 μg/mL), less than 10% difference was calculated for thrombin time and Werfen VWF:RCo. APTT-based assays of FIX, XI and XII are significantly elevated in the presence of Mim8 and should not be performed. A chromogenic FIX assay could be used to accurately measure FIX activity in the presence of Mim8. There was some interference in the DRVVT method we used so local assessment of other DRVVT methods is advised. Differences in all other tests would not be predicted to affect patient management.
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Affiliation(s)
| | - Kieron Hickey
- Department of Coagulation, Sheffield Teaching Hospitals NHS FT, Sheffield, UK
| | - Steve Kitchen
- Department of Coagulation, Sheffield Teaching Hospitals NHS FT, Sheffield, UK
| | - Mirella Ezban
- Rare Disease Research, Global Drug Discovery, Novo Nordisk, Måløv, Denmark
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Shen MC, Chou SC, Chiou SS, Lin PC, Chen YC, Lin HY, Lee YC, Huang CE, Weng TF, Huang TH, Chung CY, Chen JS, Chen SH, Cheng SN, Hsiao CC, Huang YM, Chen SH, Yu YB, Lin SC, Lin CY, Peng CT, Wang JD. Efficacy, safety and cost of emicizumab prophylaxis in haemophilia A patients with inhibitors: A nationwide observational study in Taiwan. Haemophilia 2023; 29:1499-1508. [PMID: 37819166 DOI: 10.1111/hae.14880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION Emicizumab mimicking the cofactor function of activated factor VIII (FVIII) restores haemostasis. METHODS This nationwide observational study aimed to retrospectively investigate efficacy, safety, and cost in 1 year before and up to 3 years after emicizumab prophylaxis for haemophilia A (HA) patients with FVIII inhibitors. RESULTS AND DISCUSSION A total of 39 severe HA patients with a median age of 23.0 years were enrolled. The median historical peak FVIII inhibitor titre was 174.2 BU/mL with an interquartile range of 56.5-578.8 BU/mL. The median annualized bleeding rate reduced from 24 to 0 events in the first year after emicizumab prophylaxis (p < .01) and sustained in the second and third years. The median annualized joint bleeding rate reduced to 0 and maintained up to 3 years (p < .01). Twenty-seven patients (69.2%) had target joints before emicizumab prophylaxis and only seven patients (17.9%) of them had target joints after prophylaxis. Medical costs, including cost of haemostatic therapy, frequency of outpatient department visits, emergency room visits and hospital admission, were significantly reduced after emicizumab prophylaxis (p < .01). FVIII inhibitor titre decreased after emicizumab prophylaxis. Overall, three (7.7%) patients experienced 202 grade 1 drug-related adverse events after emicizumab prophylaxis. No serious adverse events were reported during emicizumab prophylaxis period. The adherence to emicizumab prophylaxis was 100% up to 3 years. CONCLUSIONS HA patients with FVIII inhibitors treated with emicizumab prophylaxis resulted in a significant reduction in treated bleeds and associated costs. No new safety events were observed.
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Affiliation(s)
- Ming-Ching Shen
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Sheng-Chieh Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shyh-Shin Chiou
- Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Pei-Chin Lin
- Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yeu-Chin Chen
- Hemophilia Care and Research Center, Tri-Service General Hospital, Taipei, Taiwan
- Division of Hematology/Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsuan-Yu Lin
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Yang-Cheng Lee
- Division of Hematology and Oncology, Departments of Internal Medicine, Tainan Municipal Hospital, Tainan, Taiwan
| | - Cih-En Huang
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital at Chiayi, Chiayi, Taiwan
| | - Te-Fu Weng
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ting-Huan Huang
- Division of Pediatric Hematology/Oncology, Hsinchu Mackay Memorial Hospital, Hsinchu, Taiwan
| | - Chih-Yuan Chung
- Department of Medical Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Jiann-Shiuh Chen
- Division of Hematology and Oncology, Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shu-Huey Chen
- Department of Pediatrics, Shuang Ho Hospital, Ministry of Health and Welfare, Taipei Medical University, New Taipei, Taiwan
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shin-Nan Cheng
- Haemophilia Care and Research Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Paediatrics, Tung's Taichung Metrohabor Hospital, Taichung, Taiwan
| | - Chih-Cheng Hsiao
- Division of Pediatric Hematology/Oncology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yen-Min Huang
- Division of Hematology and Oncology, Department of Internal Medicine, Hemophilia and Thrombosis Treatment Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shih-Hsiang Chen
- Division of Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yuan-Bin Yu
- Division of Hematology and Oncology, Far-East Memorial Hospital, New Taipei City, Taiwan
| | - Shih-Chiang Lin
- Division of Hematology and Oncology, Far-East Memorial Hospital, New Taipei City, Taiwan
| | - Ching-Yeh Lin
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Ching-Tien Peng
- Division of Pediatric Haematology and Oncology, China Medical University Children's Hospital, China Medical University, Taichung, Taiwan
| | - Jiaan-Der Wang
- Center for Rare Disease and Hemophilia, Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung City, Taiwan
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De Pablo-Moreno JA, Miguel-Batuecas A, Rodríguez-Merchán EC, Liras A. Treatment of congenital coagulopathies, from biologic to biotechnological drugs: The relevance of gene editing (CRISPR/Cas). Thromb Res 2023; 231:99-111. [PMID: 37839151 DOI: 10.1016/j.thromres.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/09/2023] [Accepted: 10/02/2023] [Indexed: 10/17/2023]
Abstract
Congenital coagulopathies have, throughout the history of medicine, been a focus of scientific study and of great interest as they constitute an alteration of one of the most important and conserved pathways of evolution. The first therapeutic strategies developed to address them were aimed at restoring the blood components lost during hemorrhage by administering whole blood or plasma. Later on, the use of cryoprecipitates was a significant breakthrough as it made it possible to decrease the volumes of blood infused. In the 1970' and 80', clotting factor concentrates became the treatment and, from the 1990's to the present day, recombinant factors -with increasingly longer half-lives- have taken over as the treatment of choice for certain coagulopathies in a seamless yet momentous transition from biological to biotechnological drugs. The beginning of this century, however, saw the emergence of new advanced (gene and cell) treatments, which are currently transforming the therapeutic landscape. The possibility to use cells and viruses as well as specific or bispecific antibodies as medicines is likely to spark a revolution in the world of pharmacology where therapies will be individualized and have long-term effects. Specifically, attention is nowadays focused on the development of gene editing strategies, chiefly those based on CRISPR/Cas technology. Rare coagulopathies such as hemophilia A and B, or even ultra-rare ones such as factor V deficiency, could be among those deriving the greatest benefit from these new developments.
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Affiliation(s)
- Juan A De Pablo-Moreno
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, Spain
| | - Andrea Miguel-Batuecas
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, Spain
| | - E Carlos Rodríguez-Merchán
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Autonomous University of Madrid), Spain
| | - Antonio Liras
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, Spain.
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Callaghan MU, Negrier C, Paz-Priel I, et al. Long-term outcomes with emicizumab prophylaxis for hemophilia A with or without FVIII inhibitors from the HAVEN 1-4 studies. Blood. 2021;137(16):2231-2242. Blood 2023; 142:1329. [PMID: 37824158 DOI: 10.1182/blood.2023022214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023] Open
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130
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Valoctocogene roxaparvovec (Roctavian) - a gene therapy for severe hemophilia A. Med Lett Drugs Ther 2023; 65:157-158. [PMID: 37755692 DOI: 10.58347/tml.2023.1686c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
Valoctocogene roxaparvovec-rvox (Roctavian – Biomarin), an adeno-associated virus (AAV) vector-based gene therapy, has been approved by the FDA for one-time treatment of severe hemophilia A in adults without pre-existing antibodies to AAV serotype 5. It is the first gene therapy to be approved in the US for treatment of hemophilia A.
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Bou-Jaoudeh M, Mimoun A, Delignat S, Peyron I, Capdevila L, Daventure V, Deligne C, Dimitrov JD, Christophe OD, Denis CV, Lenting PJ, Proulle V, Lacroix-Desmazes S. Imlifidase, a new option to optimize the management of patients with hemophilia A on emicizumab. J Thromb Haemost 2023; 21:2776-2783. [PMID: 37473843 DOI: 10.1016/j.jtha.2023.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/07/2023] [Accepted: 06/29/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Emicizumab is a bispecific, chimeric, humanized immunoglobulin G (IgG)4 that mimics the procoagulant activity of factor (F) VIII (FVIII). Its long half-life and subcutaneous route of administration have been life-changing in treating patients with hemophilia A (HA) with or without FVIII inhibitors. However, emicizumab only partially mimics FVIII activity; it prevents but does not treat acute bleeds. Emergency management is particularly complicated in patients with FVIII inhibitors receiving emicizumab prophylaxis in whom exogenous FVIII is inefficient. We have shown recently that Imlifidase (IdeS), a bacterial IgG-degrading enzyme, efficiently eliminates human anti-FVIII IgG in a mouse model of severe HA with inhibitors and opens a therapeutic window for the administration of exogenous FVIII. OBJECTIVES To investigate the impact of IdeS treatment in inhibitor-positive HA mice injected with emicizumab. METHODS IdeS was injected to HA mice reconstituted with human neutralizing anti-FVIII IgG and treated with emicizumab. RESULTS IdeS hydrolyzed emicizumab in vitro and in vivo, albeit, at slower rates than another recombinant human monoclonal IgG4. While F(ab')2 fragments were rapidly cleared from the circulation, thus leading to a rapid loss of emicizumab procoagulant activity, low amounts of single-cleaved intermediate IgG persisted for several days. Moreover, the IdeS-mediated elimination of the neutralizing anti-FVIII IgG and restoration of the hemostatic efficacy of exogenous FVIII were not impaired by the presence of emicizumab and polyclonal human IgG in inhibitor-positive HA mice. CONCLUSION Our results suggest that IdeS could be administered to inhibitor-positive patients with HA receiving emicizumab prophylaxis to improve and ease the management of breakthrough bleeds or programmed major surgeries.
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Affiliation(s)
- Melissa Bou-Jaoudeh
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
| | - Angelina Mimoun
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
| | - Sandrine Delignat
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
| | - Ivan Peyron
- Laboratory for Hemostasis, Inflammation & Thrombosis, Unité Mixte de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, 94276 Le Kremlin-Bicêtre, France
| | - Ladislas Capdevila
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université Paris Cité, Paris, France; Service d'Hématologie Biologique et Unité Fonctionnelle d'Hémostase, Hôpital Cochin, AP-HP Centre, Université Paris Cité, Paris, France
| | - Victoria Daventure
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
| | - Claire Deligne
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
| | - Jordan D Dimitrov
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
| | - Olivier D Christophe
- Laboratory for Hemostasis, Inflammation & Thrombosis, Unité Mixte de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, 94276 Le Kremlin-Bicêtre, France
| | - Cécile V Denis
- Laboratory for Hemostasis, Inflammation & Thrombosis, Unité Mixte de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, 94276 Le Kremlin-Bicêtre, France
| | - Peter J Lenting
- Laboratory for Hemostasis, Inflammation & Thrombosis, Unité Mixte de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, 94276 Le Kremlin-Bicêtre, France
| | - Valérie Proulle
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université Paris Cité, Paris, France; Service d'Hématologie Biologique et Unité Fonctionnelle d'Hémostase, Hôpital Cochin, AP-HP Centre, Université Paris Cité, Paris, France
| | - Sébastien Lacroix-Desmazes
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université Paris Cité, Paris, France.
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Batsuli G, Wheeler AP, Weyand AC, Sidonio RF, Young G. Severe muscle bleeds in children and young adults with hemophilia A on emicizumab prophylaxis: Real-world retrospective multi-institutional cohort. Am J Hematol 2023; 98:E285-E287. [PMID: 37471655 DOI: 10.1002/ajh.27039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/04/2023] [Accepted: 07/09/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Glaivy Batsuli
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Allison P Wheeler
- Department of Pathology, Microbiology & Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Angela C Weyand
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Robert F Sidonio
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Guy Young
- Cancer and Blood Disorders Institute, Children's Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Mathias M, Abraham A, Belletrutti MJ, Carcao M, Carvalho M, Chambost H, Chan AKC, Dubey L, Ducore J, Gattens M, Gresele P, Gruel Y, Guillet B, Jiménez-Yuste V, Kitanovski L, Klukowska A, Lohade S, Mancuso ME, Oldenburg J, Pollio B, Sigaud M, Vilchevska K, Wu JKM, Jansen M, Belyanskaya L, Walter O, Knaub S, Neufeld EJ. Simoctocog alfa (Nuwiq®) in previously untreated patients with severe haemophilia A-Final efficacy and safety results from the NuProtect study. Eur J Haematol 2023; 111:544-552. [PMID: 37439123 DOI: 10.1111/ejh.14040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 07/14/2023]
Abstract
INTRODUCTION Simoctocog alfa (Nuwiq®) is a 4th generation recombinant FVIII with proven efficacy for the prevention and treatment of bleeding episodes (BEs) in previously treated patients with severe haemophilia A. The NuProtect study assessed the immunogenicity, efficacy and safety of simoctocog alfa in 108 previously untreated patients (PUPs). The incidence of high-titre inhibitors was 16.2% and no patients with non-null F8 mutations developed inhibitors. AIM To report the efficacy and safety results from the NuProtect study. METHODS PUPs received simoctocog alfa for prophylaxis, treatment of BEs, or as surgical prophylaxis. The efficacy of prophylaxis (during inhibitor-free periods) was assessed using annualised bleeding rates (ABRs). The efficacy in treating BEs and in surgical prophylaxis was assessed using a 4-point scale. Adverse events were recorded throughout the study. RESULTS Of 108 PUPs treated with simoctocog alfa, 103 received at least one prophylactic dose and 50 received continuous prophylaxis for at least 24 weeks. In patients on continuous prophylaxis, the median ABR was 0 (mean 0.5) for spontaneous BEs and 2.5 (mean 3.6) for all BEs. In 85 patients who had BEs, efficacy of BE treatment was excellent or good for 92.9% (747/804) of rated BEs; 92.3% of BEs were treated with 1 or 2 infusions. The efficacy of surgical prophylaxis was excellent or good for 94.7% (18/19) of rated procedures. There were no safety concerns and no thromboembolic events. CONCLUSION Simoctocog alfa was efficacious and well tolerated as prophylaxis, surgical prophylaxis and for the treatment of BEs in PUPs with severe haemophilia A.
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Affiliation(s)
- Mary Mathias
- Haemophilia Comprehensive Care Centre, Great Ormond Street Hospital for Children NHS Trust Haemophilia Centre, NIHR GOSH BRC, London, UK
| | - Aby Abraham
- Department of Hematology, Christian Medical College, Vellore, India
| | - Mark J Belletrutti
- Department of Pediatrics, Division of Hematology/Oncology/BMT, University of British Columbia and British Columbia Children's Hospital, Vancouver, Canada
| | - Manuel Carcao
- Department of Paediatrics, Division of Haematology/Oncology and Child Health Evaluative Sciences, Research Institute Hospital for Sick Children, Toronto, Canada
| | - Manuela Carvalho
- Congenital Coagulopathies Reference Centre, São João University Hospital Centre, Porto, Portugal
| | - Hervé Chambost
- AP-HM, Department of Pediatric Hematology Oncology, Children Hospital La Timone, Aix Marseille Univ INSERM, INRA, C2VN, Marseille, France
| | - Anthony K C Chan
- Department of Pediatrics, McMaster Centre of Transfusion Research, McMaster University, Hamilton, Canada
| | - Leonid Dubey
- Department of Paediatrics, Western Ukrainian Specialized Children's Medical Centre, Lviv, Ukraine
| | - Jonathan Ducore
- Department of Pediatrics, University of California Davis Medical Center, Sacramento, California, USA
| | - Michael Gattens
- Department of Paediatric Haematology and Oncology, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Paolo Gresele
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Yves Gruel
- Centre Régional de Traitement de l'Hémophilie, Hôpital Trousseau, Tours, France
| | - Benoit Guillet
- Haemophilia Treatment Centre, Univ Rennes, CHU Rennes, INSERM, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France
| | - Victor Jiménez-Yuste
- Servicio de Hematología, Hospital Univeristario La Paz, Autónoma, University of Madrid, Madrid, Spain
| | - Lidija Kitanovski
- Department of Haematooncology, Division of Paediatrics, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Anna Klukowska
- Haemostasis Group of the Polish Society of Haematology and Transfusiology, Warsaw, Poland
| | - Sunil Lohade
- Department of Hematology, Sahyadri Speciality Hospital, Pune, India
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Berardino Pollio
- Regional Reference Centre for Inherited Bleeding and Thrombotic Disorders, Regina Margherita Children Hospital, Turin, Italy
| | - Marianne Sigaud
- Centre Régional de Traitement de I'Hémophilie, University Hospital of Nantes, Nantes, France
| | - Kateryna Vilchevska
- Department of Hematology, OHMATDYT - National Specialized Children's Hospital, Kiev, Ukraine
| | - John K M Wu
- Department of Pediatrics, Division of Hematology/Oncology/BMT, University of British Columbia and British Columbia Children's Hospital, Vancouver, Canada
| | - Martina Jansen
- Octapharma Pharmazeutika Produktionsges m.b.H, Vienna, Austria
| | | | | | | | - Ellis J Neufeld
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Hillarp A, Holme PA, Wåland EP, Le MS, Henriksson CE, Tjønnfjord GE, Måseide RJ. Report on 4 cases with decreased recovery due to neutralizing antibodies specific for PEGylated recombinant factor VIII. J Thromb Haemost 2023; 21:2771-2775. [PMID: 37543216 DOI: 10.1016/j.jtha.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/21/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND The immunogenicity, safety, and efficacy of recombinant factor VIII (rFVIII) have gained increasing interest after the introduction of extended half-life products with various modifications of the rFVIII molecule, such as covalent attachment of polyethylene glycol (PEG). Anti-PEG antibodies may be associated with a temporary reduction of FVIII recovery, but according to previous studies, they usually disappear after continuous dosing. Anti-PEG antibodies with an inhibitory capacity have never been demonstrated in patients treated with PEGylated rFVIII products. OBJECTIVES To routinely switch from standard half-life to PEGylated extended half-life rFVIII products in patients with hemophilia A. METHODS From December 2022 until May 2023, 83 adults with hemophilia A attending Oslo Haemophilia Comprehensive Care Centre received a test dose with a PEGylated rFVIII product to switch treatment. Four patients presented with decreased recovery without the presence of an FVIII inhibitor. Accordingly, we performed a variant inhibitor test utilizing different rFVIII concentrates as a source of FVIII and enzyme-linked immunosorbent assay to search for anti-PEG antibodies. RESULTS We found inhibitory anti-PEG/anti-PEGylated rFVIII antibodies in 4 patients (5%), both persistent and transient, explaining the impaired recovery. The patients had neutralizing anti-PEG antibodies prior to the first dosing of PEGylated rFVIII. We demonstrated neutralizing antibodies (mainly immunoglobuline G) specific for PEG and all 3 commercially available PEGylated rFVIII products. CONCLUSION The number of patients with inhibitory anti-PEG antibodies was significant, and the presence of inhibitors against PEGylated rFVIII emphasizes the importance of individual monitoring when switching FVIII concentrates to ensure safety and efficacy of the treatment.
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Affiliation(s)
- Andreas Hillarp
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway; Department of Translational Medicine, Lund University, Lund, Sweden
| | - Pål A Holme
- Department of Haematology, Oslo University Hospital, Oslo, Norway; Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Erik P Wåland
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Marie S Le
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Carola E Henriksson
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Geir E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Takeyama M, Matsumoto N, Abe H, Harada S, Ogiwara K, Furukawa S, Shimonishi N, Nakajima Y, Yada K, Soeda T, Nogami K. Coagulant potentials of emicizumab in the plasmas from infant and toddler patients with hemophilia A. Pediatr Blood Cancer 2023; 70:e30590. [PMID: 37467119 DOI: 10.1002/pbc.30590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Emicizumab significantly reduces bleedings in patients with hemophilia A (PwHA). A clinical study (HAVEN 7; NCT04431726) for PwHA aged less than or equal to 12 months is ongoing, but emicizumab-driven coagulation potential in PwHA in early childhood remains to be clarified. AIM To investigate the in vitro or in vivo coagulation potential of emicizumab in plasmas obtained from infant and toddler PwHA. METHODS Twenty-seven plasma samples from 14 infant/toddler PwHA (aged 0-42 months, median 19 months) who received emicizumab (n = 9), factor (F)VIII products (n = 8), or no treatment (n = 10) were obtained. FVIII activity in FVIII-treated plasmas was cancelled by the addition of anti-FVIII monoclonal antibody (mAb). Emicizumab-treated plasmas (in vivo) and emicizumab-spiked plasmas (in vitro) were analyzed. Emicizumab-untreated plasma or emicizumab-treated plasma supplemented with two anti-emicizumab mAbs were used as references. Adjusted maximum coagulation velocity (Ad|min1|) by clot waveform analysis and peak thrombin (Peak-Th) by thrombin generation assay was assessed. RESULTS Ad|min1| values in 24 samples were improved by the presence of emicizumab. Values did not improve in the three remaining samples (aged 1, 23, and 31 months). Although the presence of emicizumab showed an age-dependent increase in Peak-Th in 20 samples, this increase was not observed in seven samples (aged 0, 1, 1, 2, 8, 19, and 36 months). Emicizumab-dependent increases in both Ad|min1| and Peak-Th were shown in 18 samples, and increases in either parameter were shown in eight samples. One sample (from patient aged 1 month) showed no increase in both, however. CONCLUSION Emicizumab could improve coagulant potential in plasmas from infant/toddler patients with hemophilia A.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | - Hiroto Abe
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | - Suguru Harada
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Division of Hemophilia, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Marino R. Acquired Hemophilia A: Bleeding Pattern and Hemostatic Therapeutic Strategies. Medicina (Kaunas) 2023; 59:1739. [PMID: 37893457 PMCID: PMC10608116 DOI: 10.3390/medicina59101739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023]
Abstract
Acquired Hemophilia A (AHA) is a rare autoimmune disorder characterized by the onset of a sudden and unexpected bleeding episode in a patient with no personal or family history of bleeding diathesis, and with a typical laboratory feature, i.e., a prolonged activated partial thromboplastin time that is not otherwise explained. This bleeding disorder is caused by autoantibodies directed against the coagulation factor VIII (FVIII). AHA is idiopathic in 50% of cases and is secondary to well-defined diseases in the remaining 50%. AHA affects elderly patients although it has also been observed in the post-partum period. Bleeding manifestations are heterogeneous, ranging from mild to life-threatening bleeds involving limbs and organs. Severe bleeding with a significant decrease in hemoglobin levels must be promptly and adequately treated in order to avoid a worsening of the hemorrhages and their complications. According to international recommendations, the bypass agents (i.e., activated prothrombin complex concentrate and activated recombinant factor VII) and the replacement therapy with recombinant porcine FVIII are considered as the first-line therapy for bleeding control, due to their proven clinical efficacy. Plasma-derived or recombinant FVIII concentrates could be used as second-line treatments. Emicizumab may represent a valid and interesting therapeutic option for prophylaxis of bleeding recurrences.
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Affiliation(s)
- Renato Marino
- Hemophilia and Thrombosis Centre, University Hospital of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
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137
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Preston RJS. New targeted therapy for hemophilia. Blood 2023; 142:1032-1034. [PMID: 37733378 DOI: 10.1182/blood.2023021385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Affiliation(s)
- Roger J S Preston
- Royal College of Surgeons in Ireland University of Medicine and Health Sciences and Children's Health Ireland Crumlin
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138
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Jiang M, Yang F, Jiang Y, Cheng L, Han J, Yi J, Zuo B, Huang L, Ma Z, Li T, Cao LJ, Xia Z, Bai X, Jia C, Yang TTC, Esmon NL, Ruan C, Xia L, Esmon CT, Han Y, Wu D, Xu J. Safety and efficacy of an anti-human APC antibody for prophylaxis of congenital factor deficiencies in preclinical models. Blood 2023; 142:1071-1081. [PMID: 37294924 DOI: 10.1182/blood.2023020005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/04/2023] [Accepted: 05/29/2023] [Indexed: 06/11/2023] Open
Abstract
Rebalance of coagulation and anticoagulation to achieve a hemostatic effect has recently gained attention as an alternative therapeutic strategy for hemophilia. We engineered a humanized chimeric antibody, SR604, based on a previously published murine antibody, HAPC1573, which selectively blocks the anticoagulant activity of human activated protein C (APC). SR604 effectively blocked the anticoagulation activities of APC in human plasma deficient in various coagulation factors in vitro with affinities ∼60 times greater than that of HAPC1573. SR604 exhibited prophylactic and therapeutic efficacy in the tail-bleeding and knee-injury models of hemophilia A and B mice expressing human APC (humanized hemophilic mice). SR604 did not interfere with the cytoprotection and endothelial barrier function of APC, nor were there obvious toxicity effects in humanized hemophilic mice. Pharmacokinetic study showed a high bioavailability (106%) of subcutaneously injected SR604 in cynomolgus monkeys. These results demonstrate that SR604 is expected to be a safe and effective therapeutic and/or prophylactic agent with a prolonged half-life for patients with congenital factor deficiencies including hemophilia A and B.
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Affiliation(s)
- Miao Jiang
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Medical Center of Soochow University, Suzhou, China
| | - Fei Yang
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yizhi Jiang
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Hematology, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Lu Cheng
- Shanghai RAAS Blood Products Co, Ltd, Shanghai, China
| | - Jingjing Han
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiawei Yi
- Shanghai RAAS Blood Products Co, Ltd, Shanghai, China
| | - Bin Zuo
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Lulu Huang
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhenni Ma
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Tianyi Li
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Lijuan J Cao
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhisong Xia
- Shanghai RAAS Blood Products Co, Ltd, Shanghai, China
| | - Xia Bai
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
| | - Chenjun Jia
- Shanghai ChemPartner Co, Ltd, Shanghai, China
| | | | - Naomi L Esmon
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Changgeng Ruan
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
| | - Lijun Xia
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Charles T Esmon
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Yue Han
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
| | - Depei Wu
- Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, NHC Key Laboratory of Thrombosis and Hemostasis, The First Affiliated Hospital of Soochow University, Suzhou, China
- Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
- State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
| | - Jun Xu
- Shanghai RAAS Blood Products Co, Ltd, Shanghai, China
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139
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Potnis KC, Viswanathan G, Bona RD, Ito S, Kempton CL, Pandya A, Krumholz HM, Goshua G. Cost-effectiveness of prophylactic emicizumab versus prophylactic recombinant factor VIII in patients with moderate or mild hemophilia A without inhibitors in the United States. Am J Hematol 2023; 98:E247-E250. [PMID: 37401660 DOI: 10.1002/ajh.27014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 07/05/2023]
Abstract
Prophylactic emicizumab is cost-ineffective in adults with moderate or mild hemophilia A without inhibitors at current pricing. The price of prophylactic emicizumab would need to decrease by >35% to become cost-effective in this patient population.
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Affiliation(s)
- Kunal C Potnis
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Robert D Bona
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, Connecticut, USA
| | - Satoko Ito
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, Connecticut, USA
| | - Christine L Kempton
- Department of Hematology and Medical Oncology and Hemophilia of Georgia Center for Bleeding and Clotting Disorders of Emory, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - George Goshua
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine and Yale Cancer Center, New Haven, Connecticut, USA
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Young G, Callaghan MU, Balasa V, Soni A, Ahuja S, Roberts JC, Simpson ML, Kizilocak H, Frick A, Mokdad AG, Xing S, Caicedo J. Effects of PK-guided prophylaxis on clinical outcomes and FVIII consumption for patients with moderate to severe Haemophilia A. Haemophilia 2023; 29:1234-1242. [PMID: 37553998 DOI: 10.1111/hae.14826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 08/10/2023]
Abstract
INTRODUCTION In recent years, there has been increased focus on individualizing treatment for persons with hemophilia including pharmacokinetic-guided (PK) dosing. AIMS In this retrospective study clinical outcomes before and after PK-guided prophylaxis were examined. MATERIALS AND METHODS Eight Haemophilia Treatment Centres from the United States participated in the study and included 132 patients classified into two cohorts: those undergoing a PK-assessment for product switch (switchers) or to optimize treatment (non-switchers). Subset analyses for the two most common products and patients with dosing per prescription label were included for annual bleeding rates (ABR), mean weekly consumption outcomes, and annualized cost of prophylaxis. RESULTS The most common products before and after index date were octocog alfa, rurioctocog alfa pegol, and efmoroctocog alfa. Seventy-four (56%) patients were identified as switchers and 58 (44%) patients were classified as non-switchers. The majority of patients (78.0%) experienced either a decrease in ABR post-index or maintained 0 ABR during pre- and post-index time periods, with similar proportions identified in both switchers (77.0%) and non-switchers (79.3%) populations. Non-switchers were identified as having no significant change in cost of therapy, while switchers experienced increased cost of therapy driven by higher price of extended half-life products. Within subset analyses, patients receiving rurioctocog alfa pegol and efmoroctocog alfa had mean ABR under 1 after index date. CONCLUSION PK-guided prophylaxis has the potential to improve clinical outcomes without increase in cost of therapy for patients maintaining product and can aid in maintaining effective protection against bleeds in those switching product.
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Affiliation(s)
- Guy Young
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | | | - Vinod Balasa
- Hemotology/Oncology, Valley Children's Healthcare, Madera, California, USA
| | - Amit Soni
- Center for Inherited Blood Disorders, Orange, California, USA
| | - Sanjay Ahuja
- UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | | | | | - Hande Kizilocak
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | | | - Ali G Mokdad
- Takeda Pharmaceuticals U.S.A, 95 Hayden Ave, Cambridge, Massachusetts, USA
| | - Shan Xing
- Takeda Pharmaceuticals U.S.A, 95 Hayden Ave, Cambridge, Massachusetts, USA
| | - Jorge Caicedo
- Takeda Pharmaceuticals U.S.A, 95 Hayden Ave, Cambridge, Massachusetts, USA
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141
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Ranta S, Motwani J, Blatny J, Bührlen M, Carcao M, Chambost H, Escuriola C, Fischer K, Kartal-Kaess M, de Kovel M, Kenet G, Male C, Nolan B, d'Oiron R, Olivieri M, Zapotocka E, Andersson NG, Königs C. Dilemmas on emicizumab in children with haemophilia A: A survey of strategies from PedNet centres. Haemophilia 2023; 29:1291-1298. [PMID: 37647211 DOI: 10.1111/hae.14847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/30/2023] [Accepted: 08/03/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Haemophilia A care has changed with the introduction of emicizumab. Experience on the youngest children is still scarce and clinical practice varies between haemophilia treatment centres. AIM We aimed to assess the current clinical practice on emicizumab prophylaxis within PedNet, a collaborative research platform for paediatricians treating children with haemophilia. METHODS An electronic survey was sent to all PedNet members (n = 32) between October 2022 and February 2023. The survey included questions on the availability of emicizumab, on the practice of initiating prophylaxis in previously untreated or minimally treated patients (PUPs or MTPs) and emicizumab use in patients with or without inhibitors. RESULTS All but four centres (28/32; 88%) responded. Emicizumab was available in clinical practice in 25/28 centres (89%), and in 3/28 for selected patients only (e.g. with inhibitors). Emicizumab was the preferred choice for prophylaxis in PUPs or MTPs in 20/25 centres; most (85%) started emicizumab prophylaxis before 1 year of age (30% before 6 months of age) and without concomitant FVIII (16/20; 80%). After the loading dose, 13/28 centres administered the recommended dosing, while the others adjusted the interval of injections to give whole vials. In inhibitor patients, the use of emicizumab during ITI was common, with low-dose ITI being the preferred protocol. CONCLUSION Most centres choose to initiate prophylaxis with emicizumab before 12 months of age and without concomitant FVIII. In inhibitor patients, ITI is mostly given in addition to emicizumab, but there was no common practice on how to proceed after successful ITI.
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Affiliation(s)
- Susanna Ranta
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Sweden and Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | | | - Jan Blatny
- Department of Paediatric Haematology and Biochemistry, University Hospital and Masaryk University, Brno, Czech Republic
| | - Martina Bührlen
- Department of Pediatrics, Klinikum Bremen Mitte, Bremen, Germany
| | - Manuel Carcao
- Haemophilia Clinic and Haemostasis Program, Division of Haematology/Oncology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Hervé Chambost
- AP-HM, Department of Pediatric Hematology Oncology, Children Hospital La Timone & Aix Marseille University, INSERM, INRA, C2VN, Marseille, France
| | - Carmen Escuriola
- Haemophilie-Zentrum Rhein Main, HZRM, Mörfelden-Walldorf, Germany
| | - Kathelijn Fischer
- Center for Benign Hematology Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - Mutlu Kartal-Kaess
- Division of Pediatric Hematology & Oncology, Department of Pediatrics, Inselspital, University Hospital Bern, Bern, Switzerland
| | | | - Gili Kenet
- The National Hemophilia Center& Institute of Thrombosis & Hemostasis, Sheba Medical Center, Tel Hashomer, Israel and The Amalia Biron Research Institute of Thrombosis & Hemostasis, Tel Aviv University, Tel Aviv, Israel
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Beatrice Nolan
- Children's Coagulation Centre, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Roseline d'Oiron
- Centre de Référence de l'Hémophilie et des Maladies Hémorragiques Constitutionnelles rares, Hôpital Bicêtre AP-HP, et INSERM Hémostase inflammation thrombose HITH U1176, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Martin Olivieri
- Pediatric thrombosis and Hemostasis Unit, Pediatric Hemophilia Centre, Dr. von Hauner Children´s Hospital LMU Munich, Munich, Germany
| | - Ester Zapotocka
- Department of Pediatric Hematology and Oncology, University Hospital Motol, Prague and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Nadine G Andersson
- Center for Thrombosis and Hemostasis, Department of Clinical Sciences and Pediatrics, Skåne University Hospital, Malmö, Lund University, Lund, Sweden
| | - Christoph Königs
- Department of Paediatrics and Adolescent Medicine, Goethe University Frankfurt, Frankfurt, Germany
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Pruthi RK, Chen D. The Use of Bypassing Treatment Strategies in Hemophilia and Their Effect on Laboratory Testing. Semin Thromb Hemost 2023; 49:651-660. [PMID: 37146647 DOI: 10.1055/s-0043-1768660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Factor VIII and IX inhibitors in congenital hemophilia A and B, respectively, neutralize the infused coagulation factor concentrate rendering them ineffective. Bypassing agents (BPAs) that circumvent the block imposed by the inhibitors are used for the prevention and management of bleeding. Activated prothrombin complex concentrate was the original BPA, recombinant activated factor VII was then introduced, and more recently nonfactor agents that target the procoagulant and anticoagulant systems have been developed and are in clinical use (e.g., emicizumab, a bispecific antibody for hemophilia A). Other BPAs are in clinical trials (e.g., fitusiran targets antithrombin, concizumab and marstacimab target tissue factor pathway inhibitor, and SerpinPC targets activated protein C). The BPAs have a varied effect on coagulation assays, and as more patients are exposed to these agents, it is important to be aware of the effects. Herein, we present an overview of the effect of BPAs on routine and specialized coagulation assays including thrombin generation and viscoelastic assays.
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Affiliation(s)
- Rajiv K Pruthi
- Division of Hematology, Department of Internal Medicine, Comprehensive Hemophilia Center, Rochester, Minnesota
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Special Coagulation Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Dong Chen
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Special Coagulation Laboratory, Mayo Clinic, Rochester, Minnesota
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143
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Nekkal MS, Mesli N, Grifi F, Cherif N, Ouchenane Z, Bettayeb MS. Haemophilia B in Algeria: Realities and therapeutic perspectives. Haemophilia 2023; 29:1176-1183. [PMID: 37467156 DOI: 10.1111/hae.14827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/19/2023] [Accepted: 07/04/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Haemophilia B is a debilitating hereditary coagulation disorder characterized by prolonged or spontaneous episodes of bleeding caused by a deficiency of endogenous factor IX. In Algeria, even though many studies are being carried out to evaluate the prevalence and management of haemophilia B, there is a paucity of locally published literature that can be used to understand the most recent information on the disease's epidemiology, diagnostic techniques and treatment options. AIMS The aim of this manuscript is to raise awareness among patients and family clinicians about current practices, recent developments and unmet needs related to haemophilia B in Algeria. METHODS A comprehensive literature search was conducted through online scientific databases to review publications regarding haemophilia B in Algeria. Exclusions of the review include case studies, interregional comparisons, abstract-only papers and studies outside the range of 2012-2022. RESULTS The findings discussed relate to the epidemiology of haemophilia B in Algeria, the clinical diagnostic process, disease symptoms, the benefits of molecular and genetic testing, advancements in prophylactic care, as well as unmet needs hindering the progression of optimal haemophilia B management. CONCLUSION These findings are crucial to encourage the maintenance of national registries with updated epidemiological data, facilitate early and timely detection of disease symptoms, improve the provision of diagnostic facilities and enhance the overall treatment landscape for better patient outcomes.
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Affiliation(s)
| | - Naima Mesli
- Dr Tidjani Damerdji University Hospital, Tlemcen, Algeria
| | | | | | - Zohra Ouchenane
- Constantine Dr Benbadis University Hospital, Constantine, Algeria
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144
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Tian C, Perija B, Kotb R, Houston BL, Israels SJ, Houston DS, Rimmer E, Zarychanski R. Acquired haemophilia A: A 15-year population-based review of incidence rate, patient demographics and treatment outcomes. Haemophilia 2023; 29:1269-1275. [PMID: 37639377 DOI: 10.1111/hae.14845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/10/2023] [Accepted: 08/06/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Acquired haemophilia A (AHA) is a rare bleeding disorder characterized by autoantibodies against coagulation factor VIII (FVIII). Estimates of AHA incidence are largely based on registry data, which may be prone to referral bias. Population-based studies can enhance our understanding of the epidemiology, presentation and outcomes of AHA. METHODS We conducted a retrospective, population-based cohort study of all AHA diagnosed and treated in Manitoba, Canada over a 15-year period. Using records from the sole provincial reference laboratory, we identified all patients with FVIII inhibitors who did not have congenital haemophilia. Using a piloted case report form, patient data was ascertained from hospital and bleeding disorder clinic records. RESULTS From 2006 to 2021, we identified 34 patients with AHA, corresponding to a population-based incidence rate of AHA of 1.78 cases per million per year. The median age at presentation was 76 years and most cases were idiopathic (79%). Almost all patients (97%) presented with bleeding, of which 58% were considered major bleeds and required haemostatic agents in 67%. Longstanding unexplained bleeding symptoms were commonly reported, suggesting delayed diagnosis. Immunosuppressive therapy (IST) was administered in 88% of patients. Remission was achieved in 79% of patients; median time to remission was 2.1 months. There were two deaths due to bleeding. No deaths due to IST were reported. CONCLUSION The population-based incidence of AHA in Manitoba is 1.78 cases/million/year. Bleeding is common and can be life-threatening. AHA outcomes are encouraging with the use of haemostatic agents and IST. Serious treatment-associated morbidity and mortality is uncommon.
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Affiliation(s)
- Chantal Tian
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, Canada
| | - Brittany Perija
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Rami Kotb
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, Canada
| | - Brett L Houston
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, Canada
| | - Sara J Israels
- Department of Paediatrics and Child Health, University of Manitoba, Winnipeg, Canada
- Department of Paediatric Haematology/Oncology, CancerCare Manitoba, Winnipeg, Canada
| | - Donald S Houston
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, Canada
| | - Emily Rimmer
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Department of Medical Oncology and Haematology, CancerCare Manitoba, Winnipeg, Canada
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145
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Okolo A, Shapiro A, Janson I, Okungade J, Roberson C, Nolte M, Littner L, Kronenberger W. Psychometrics and applications of a novel self-report measure of emicizumab adherence: VERITASNexGen. Haemophilia 2023; 29:1299-1305. [PMID: 37647212 DOI: 10.1111/hae.14851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/03/2023] [Accepted: 08/21/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION Treatment adherence is critical to minimize bleeding episodes in persons with haemophilia. Suboptimal adherence increases risk of adverse medical outcomes and negatively impacts quality of life. Assessment of treatment adherence is therefore an integral component of intervention to mitigate the adverse impacts of haemophilia. AIM To develop and validate a multifactorial, patient (self or caregiver) report adherence measure for emicizumab treatment and report the first patient-report data on adherence to specific components of emicizumab treatment (dosing, timing, injection, planning and bleeds). METHODS An IRB approved multi-site prospective study enrolled 83 participants with factor VIII deficiency being treated with emicizumab. Participants completed the 25-item VERITAS NexGen (self-report from 50 adults age 18+ years; caregiver-report from 33 parents of children aged 6 months to 17 years) as well as a global adherence rating (GAR) scale. Providers of participants also completed a GAR scale. RESULTS Most VERITAS-NexGen subscales had good-to-excellent internal consistency reliability, test-retest reliability, and validity. VERITASNexGen scores revealed globally strong patient-reported adherence; however timing and bleed management were reported as greater challenges to adherence compared to dosing and injections. Adults struggled more with timing and planning of injections than caregivers. CONCLUSION The VERITASNexGen is the first validated multifactorial patient-report measure of adherence designed specifically for emicizumab treatment. Results suggest excellent adherence, with only 4%-13% of participants reporting suboptimal adherence to different components of the treatment regimen. Used in conjunction with other adherence measures, VERITAS-NexGen meets a crucial need for monitoring and understanding patient adherence to emicizumab in clinical and research settings.
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Affiliation(s)
- Amanda Okolo
- Indiana Haemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Amy Shapiro
- Indiana Haemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Isaac Janson
- Indiana Haemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - James Okungade
- Indiana Haemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Chris Roberson
- Indiana Haemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - MacKenzie Nolte
- Cancer and Blood Diseases Institute, Department of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Lisa Littner
- Cancer and Blood Diseases Institute, Department of Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - William Kronenberger
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
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146
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Goedhart TMHJ, Janssen A, Mathôt RAA, Cnossen MH. The road to implementation of pharmacokinetic-guided dosing of factor replacement therapy in hemophilia and allied bleeding disorders. Identifying knowledge gaps by mapping barriers and facilitators. Blood Rev 2023; 61:101098. [PMID: 37321952 DOI: 10.1016/j.blre.2023.101098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 04/02/2023] [Accepted: 05/07/2023] [Indexed: 06/17/2023]
Abstract
Clinical guidelines and expert groups recommend the use of pharmacokinetic (PK)-guided dosing of factor replacement therapy for the treatment of bleeding disorders, especially for patients with hemophilia. Although PK-guided dosing is increasingly applied, it is generally not considered standard clinical practice. The aim of this scoping review is to map barriers and facilitators for the implementation of PK-guided dosing in clinical practice and to identify knowledge gaps. A literature search was performed and 110 articles were included that describe PK-guided dosing in patients with bleeding disorders, mostly hemophilia A. We defined two overarching themes, efficacy and feasibility, and discuss five topics within each theme. For each topic, barriers, facilitators and knowledge gaps were described. Although consensus was found with regard to some topics, contradicting reports were found for others, especially with respect to the efficacy of PK-guided dosing. These contradictions highlight the need for future research to elucidate current ambiguities.
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Affiliation(s)
- Tine M H J Goedhart
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - A Janssen
- Department of Clinical Pharmacology - Hospital Pharmacy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Ron A A Mathôt
- Department of Clinical Pharmacology - Hospital Pharmacy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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147
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Thornburg CD, Simmons DH, von Drygalski A. Evaluating Gene Therapy as a Potential Paradigm Shift in Treating Severe Hemophilia. BioDrugs 2023; 37:595-606. [PMID: 37490225 PMCID: PMC10432364 DOI: 10.1007/s40259-023-00615-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 07/26/2023]
Abstract
Hemophilia is characterized by a deficiency in coagulation factors VIII or IX. The general standard of care for severe hemophilia is frequent intravenous recombinant or plasma-derived factor replacement to prevent bleeding. While this treatment is effective in preventing bleeding, frequent infusions are burdensome for patients. Nonadherence to the therapeutic regimen leaves people with hemophilia at risk for spontaneous and traumatic bleeds into joints as well as life-threatening bleeds such as intracranial hemorrhage. The chronicity of the disorder often leads to the formation of target joints, causing long-term pain and impairing mobility. As a monogenic disorder with well-understood genetics, hemophilia is an ideal disorder for implementing innovations in gene therapies. Indeed, recent approvals of two gene therapy products have the potential to shift the hemophilia treatment paradigm. Valoctocogene roxaparvovec and etranacogene dezaparvovec-drlb are gene therapies for hemophilia A and B, respectively. These therapies, given as a single intravenous infusion, may improve patients' quality of life, decreasing treatment burden and resulting in factor expression that virtually eliminates the need for factor replacement. Since both treatments involve viral vectors targeted to the liver, short- and long-term safety and efficacy monitoring involves monitoring liver enzymes to track liver health. Long-term monitoring of efficacy, durability of gene expression, and safety are ongoing. Gene therapy presents a promising new therapeutic option for patients with hemophilia and warrants continued innovation and investigation.
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Affiliation(s)
- Courtney D Thornburg
- Hemophilia and Thrombosis Treatment Center, Rady Children's Hospital San Diego, San Diego, CA, USA.
- Department of Pediatrics, University of California, San Diego, La Jolla, CA, USA.
| | | | - Annette von Drygalski
- Division of Hematology/Oncology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
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Wang YH, Wu WC, Hsiao LT, Ma SH, Chen CC, Ho YH. Acquired hemophilia A in a Taiwanese patient with bullous pemphigoid. Int J Rheum Dis 2023; 26:1838-1839. [PMID: 37182928 DOI: 10.1111/1756-185x.14690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/13/2023] [Accepted: 03/19/2023] [Indexed: 05/16/2023]
Affiliation(s)
- Ying-Hsiang Wang
- Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Chi Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Liang-Tsai Hsiao
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Sheng-Hsiang Ma
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chih-Chiang Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Hsin Ho
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan
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George C, Parikh S, Carter T, Mccosker J, Carlino S, Tran H. Evaluation of treatment and outcome for patients with haemophilia A and haemophilia B on extended half-life (EHL) factor products: A 12-month data analysis. Haemophilia 2023; 29:1283-1290. [PMID: 37565529 DOI: 10.1111/hae.14842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 07/14/2023] [Accepted: 07/30/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION Extended half-life (EHL) factor VIII and IX concentrates as prophylaxis against bleeds have been available to selected persons with haemophilia (PWH) in Australia since March 2018. Preliminary analysis of switching to EHL demonstrated increased treatment adherence, fewer injections and improved bleeding outcomes. AIMS To characterise clinical practices regarding the use of EHL in Australia, to further evaluate treatment regimens and bleeding outcomes, and to analyse the influence of EHL product pharmacokinetics on clinical decision-making. METHODS A national, retrospective study was conducted using the Australian Bleeding Disorders Registry (ABDR). Patients on EHL products during the entire 2019 calendar year were included for analysis. RESULTS A complete and validated dataset of 174 PWH was analysed, 115 Haemophilia A (HA) and 59 Haemophilia B (HB). Adherence to EHL therapy was 85.7% in HA and 87.2% in HB. About 63.5% of HA and 64.4% of HB PWH reported zero spontaneous bleeds over 12months. Ankles were the most frequent spontaneous bleed site. Approximately one-third patients underwent dose adjustments, with most frequent reasons being pharmacokinetics, body weight change and breakthrough bleeds. About 19.5% of PWH had target joint history, with spontaneous bleeds reported in 58% of that cohort on EHL. Multivariate regression showed significant impact of non-adherence, target joint history and short half-life on spontaneous bleeds in the HA cohort; however only short half-life had significant impact in the HB cohort. CONCLUSION EHL usage in Australia shows excellent treatment adherence and bleeding outcomes. This study affirms the use and value of widely available population-based pharmacokinetics as a clinical tool.
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Affiliation(s)
- Carly George
- Australian Haemophilia Centre Directors' Organisation, Melbourne, Australia
- Perth Children's Hospital, Perth, Australia
| | - Sumit Parikh
- Australian Haemophilia Centre Directors' Organisation, Melbourne, Australia
| | - Tina Carter
- Australian Haemophilia Centre Directors' Organisation, Melbourne, Australia
- Perth Children's Hospital, Perth, Australia
| | | | | | - Huyen Tran
- Australian Haemophilia Centre Directors' Organisation, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
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Okayama Y, Bingo M, Sakatoku K, Okamura H, Nanno S, Nishimoto M, Nakashima Y, Koh H, Hino M, Nakamae H. The safety of the combination therapy of recombinant factor VIIa and plasma-derived factor VIIa and factor X for refractory hemorrhage in acquired hemophilia A. Blood Coagul Fibrinolysis 2023; 34:419-422. [PMID: 37577920 DOI: 10.1097/mbc.0000000000001243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Acquired hemophilia A (AHA) is a rare, life-threatening hemorrhagic disease caused by autoantibodies against factor VIII (FVIII), and bypassing agents (BPA) are used to control bleeding. However, some cases need a change of BPA or BPAs given sequentially or in combination for refractory bleeding. A 71-year-old man was admitted with subcutaneous hemorrhage. Laboratory investigations showed prolongation of activated partial thromboplastin time (APTT) and low-coagulation FVIII activity and FVIII inhibitor; we, therefore, diagnosed AHA. He was treated with recombinant factor VIIa (rFVIIa) BPA and prednisolone. However, his symptoms did not improve sufficiently, thus we switched BPA to activated prothrombin complex concentrate. Unfortunately, this was not effective and he suffered hemorrhagic shock. Therefore, we selected rFVIIa, with plasma-derived FVIIa and factor X (pd-FVIIa/FX) as combination therapy, and hemostasis was achieved without thrombosis. This case suggests that the combination of rFVIIa and pd-FVIIa/FX short-term can be well tolerated for refractory hemorrhage in AHA.
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Affiliation(s)
- Yusuke Okayama
- Department of Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka
| | - Masato Bingo
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Kazuki Sakatoku
- Department of Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka
| | - Hiroshi Okamura
- Department of Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka
| | - Satoru Nanno
- Department of Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka
| | - Mitsutaka Nishimoto
- Department of Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka
| | - Yasuhiro Nakashima
- Department of Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka
| | - Hideo Koh
- Department of Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka
| | - Masayuki Hino
- Department of Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka
| | - Hirohisa Nakamae
- Department of Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka
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