1
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Bakhsh E. Impact of Replacement Therapy on Pregnancy Outcomes in Hemophilia Carriers: A Historical Cohort Study in Saudi Arabia. Life (Basel) 2024; 14:623. [PMID: 38792643 PMCID: PMC11122275 DOI: 10.3390/life14050623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
This retrospective cohort study evaluates the safety and efficacy of replacement therapy with regard to pregnancy outcomes in hemophilia carriers. Hemophilia carriers face elevated bleeding risks during pregnancy, necessitating meticulous management, including replacement therapy with clotting factors. This research examines the records of 64 pregnant hemophilia carriers at King Fahad Medical City, Riyadh, from January 2010 to December 2023, analyzing their demographic details, hemophilia type and severity, replacement therapy specifics, and pregnancy outcomes. The study found that 62.5% of the participants had hemophilia A, with 43.8% categorized as severe. Most subjects (87.5%) received recombinant factor VIII at a median dosage of 30 IU/kg weekly. Adverse pregnancy outcomes included gestational hypertension (15.6%), preterm labor (18.8%), and postpartum hemorrhage (12.5%). The cesarean section rate was 28.1%. Neonatal outcomes were generally favorable, with median birth weights at 3100 g and mean Apgar scores of 8.2 and 9.1 at 1 and 5 min, respectively. Logistic regression analysis revealed no significant association between adverse events and therapy type or dosage, though a trend towards significance was noted with once-weekly administration (p = 0.082). The study concludes that replacement therapy is a viable method for managing hemophilia in pregnant carriers, leading to generally favorable maternal and neonatal outcomes. However, it underscores the importance of individualized treatment plans and close monitoring to effectively manage the risks associated with hemophilia during pregnancy.
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Affiliation(s)
- Ebtisam Bakhsh
- Internal Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11564, Saudi Arabia
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2
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Carcao M, Schiavulli M, Kulkarni R, Rendo P, Foster M, Santagostino E, Casiano S, Königs C. A post hoc analysis of previously untreated patients with severe hemophilia A who developed inhibitors in the PUPs A-LONG trial. Blood Adv 2024; 8:1494-1503. [PMID: 38266154 PMCID: PMC10951906 DOI: 10.1182/bloodadvances.2023011475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 01/10/2024] [Accepted: 01/14/2024] [Indexed: 01/26/2024] Open
Abstract
ABSTRACT Inhibitor development is a major therapeutic complication for people with hemophilia. The phase 3 PUPs A-LONG study evaluated the safety and efficacy of efmoroctocog alfa (a recombinant factor VIII Fc fusion protein, herein referred to as rFVIIIFc) in previously untreated patients (PUPs) with severe hemophilia A. Male PUPs <6 years old were enrolled and received rFVIIIFc; inhibitor development was the primary end point. Post hoc analyses, including patient treatment regimen patterns and timing of inhibitor development, descriptive and Kaplan-Meier analyses of time to first inhibitor-positive test by treatment regimen and by titer, and consumption, were performed to describe patients who developed inhibitors during PUPs A-LONG. We investigated patient characteristics (eg, demographics and genotype) and nongenetic risk factors (eg, intense factor exposure and central venous access device [CVAD] placement) that may predict inhibitor development and characteristics of inhibitor development (low-titer vs high-titer inhibitor). Baseline characteristics were similarly distributed for age, race, and ethnicity across both patients who were inhibitor-positive and those who were inhibitor-negative (all P > .05). High-risk F8 variants were associated with development of high-titer inhibitors (P = .028). High-titer inhibitor development was often preceded by the presence of a low-titer inhibitor. Patients whose low-titer inhibitor progressed to a high-titer inhibitor received a higher mean dose per infusion (98.4 IU/kg, n = 5) compared with those whose low-titer inhibitor resolved spontaneously (59.2 IU/kg, n = 7; P = .033) or persisted (45.0 IU/kg, n = 5; P = .047). There was no association between CVAD placement surgery and inhibitor development. Post hoc analyses suggest that F8 genotype and dose of factor are as important as inhibitor risk factors and require further investigation. This study was registered at ClinicalTrials.gov as #NCT02234323.
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Affiliation(s)
- Manuel Carcao
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | | | - Christoph Königs
- University Hospital Frankfurt, Goethe University, Frankfurt, Germany
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3
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[Chinese guidelines on the diagnosis and management of hemophilia with inhibitors (2023)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:881-889. [PMID: 38185516 PMCID: PMC10753256 DOI: 10.3760/cma.j.issn.0253-2727.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Indexed: 01/09/2024]
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4
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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] [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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5
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Sidonio RF, Thompson AA, Peyvandi F, Stasyshyn O, Yeoh SL, Sosothikul D, Antmen AB, Maggiore C, Engl W, Ewenstein B, Tangada S. Immunogenicity, safety, and efficacy of rurioctocog alfa pegol in previously untreated patients with severe hemophilia A: interim results from a phase 3, prospective, multicenter, open-label study. Expert Rev Hematol 2023; 16:793-801. [PMID: 37646148 DOI: 10.1080/17474086.2023.2247160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 07/18/2023] [Accepted: 08/07/2023] [Indexed: 09/01/2023]
Abstract
AIM To determine the immunogenicity, safety, and efficacy of rurioctocog alfa pegol in previously untreated patients (PUPs) with severe hemophilia A (HA). METHODS This prospective, phase 3 study (NCT02615691) was conducted in PUPs, or patients with ≤2 exposure days (EDs) prior to screening, aged <6 years with severe HA. The primary endpoint was incidence of factor VIII (FVIII) inhibitor development. This protocol-specified interim analysis was conducted after 50 patients had completed ≥50 EDs without developing FVIII inhibitors or had developed a confirmed inhibitor at any time. RESULTS Of the enrolled patients, 59/80 (73.8%) received ≥1 dose of rurioctocog alfa pegol; 54 received prophylaxis, and 35 on-demand treatment. Incidence of inhibitor development was 0.19 (10/52). Total annualized bleeding rate (95% CIs) was 3.2 (2.0-5.0) for patients receiving prophylaxis and 3.2 (1.6-6.3) for on-demand treatment. Hemostatic efficacy of most bleedings was rated as 'excellent' or 'good' after 24 hours (122/131 [93.1%]) and at resolution (161/170 [94.7%]). Five patients received ≥1 dose of rurioctocog alfa pegol for immune tolerance induction (ITI) and 1 patient was defined as having ITI success. Thirteen patients experienced 14 treatment-related adverse events, including 10 cases of FVIII inhibitor development. CONCLUSION This is the first prospective study of rurioctocog alfa pegol for the treatment of PUPs with severe HA. TRIAL REGISTRATION This trial is registered at ClinicalTrials.gov (CT.gov identifier: NCT02615691).
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Affiliation(s)
- Robert F Sidonio
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, GA, USA
| | - Alexis A Thompson
- Division of Hematology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Universitàdegli Studi di Milano, Milan, Italy
| | | | - Seoh Leng Yeoh
- Department of Pediatrics, Hospital Pulau Pinang, George Town, Malaysia
| | - Darintr Sosothikul
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Integrative and Innovative Hematology/Oncology Research Unit, Faculty of Medicine, Chulalonkorn University, Bangkok, Thailand
| | - Ali Bulent Antmen
- Department of Pediatric Hematology and Oncology, Acibadem Adana Hospital, Adana, Turkey
| | | | - Werner Engl
- Pharmacometrics & Biostatistics, Baxalta Innovations GmbH, A Takeda Company, Vienna, Austria
| | - Bruce Ewenstein
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
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6
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Belletrutti M, Bhatt M, Samji N. Management of children with hemophilia A on emicizumab who need surgery. Front Pediatr 2023; 11:1155853. [PMID: 37082707 PMCID: PMC10110896 DOI: 10.3389/fped.2023.1155853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/14/2023] [Indexed: 04/22/2023] Open
Abstract
The introduction of emicizumab into the treatment regime of persons with hemophilia A has dramatically reduced frequency of bleeding in patients with and without inhibitors. However, in children with Hemophilia A (CwHA) who require surgical or other invasive procedures, additional treatment with factor replacement or other hemostatic agents may still be needed to prevent intraoperative or postoperative bleeding. This review will look at the reported outcomes in CwHA on emicizumab who have had surgery and propose recommendations for the best perioperative management of major and minor procedures.
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Affiliation(s)
- Mark Belletrutti
- BC Children’s Hospital, Oncology/Hematology/BMT, University of British Columbia, Vancouver, BC, Canada
- Correspondence: Mark Belletrutti
| | - Mihir Bhatt
- McMaster Children’s Hospital, Hematology/Oncology, McMaster University, Hamilton, ON, Canada
| | - Nasrin Samji
- McMaster Children’s Hospital, Hematology/Oncology, McMaster University, Hamilton, ON, Canada
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7
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Ashfaq J, Tariq F, Ahmed R, Thakur W, Abid M, Borhany M. Frequency of Specific and Non-specific Inhibitors in Haemophilia A Patients. Cureus 2022; 14:e26008. [PMID: 35855246 PMCID: PMC9286306 DOI: 10.7759/cureus.26008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 11/24/2022] Open
Abstract
Objective: To determine the frequency of specific and non-specific inhibitors in haemophilia A patients. Study design: This is a cross-sectional study. Patients and methods: A total of 150 male haemophilia A patients were included in this cross-sectional study at the National Institute of Blood Diseases and Bone Marrow Transplant (NIBD), Karachi, Pakistan, from September 2019 to January 2022. Results: Among 150 patients included in this study, 23 (15.3%) had an inhibitor and 127 (84.6%) did not. All patients had specific inhibitors against Factor VIII (FVIII). Non-specific inhibitors were not identified in our population. Among the patients in the inhibitor group, there were 13 (56.5%) in the severe (<1%) category. There were 10 (43.5%) patients in the moderate (1-5%) category. There were no patients in the mild category. The median inhibitor level was 15.4 Bethesda unit (BU). Conclusion: The development of inhibitors has not been identified as a major problem in our population. However, it is noteworthy that only 15.3% of patients with haemophilia A developed inhibitors in this data set. They were essentially treated with plasma and its products.
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8
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Susanah S, Raspati H, Sari NM, Rakhmilla LE, Sribudiani Y, Moestopo O, Sinaga P, Idjradinata P, Maskoen AM. Serum TNF- α Level as a Possible Predictor of Inhibitor Levels in Severe Hemophilia A. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6483490. [PMID: 34778454 PMCID: PMC8589501 DOI: 10.1155/2021/6483490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/06/2021] [Accepted: 10/16/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The development of factor VIII (FVIII) inhibitor in patients with hemophilia A (PWHA) is a great challenge for hemophilia care. Both genetic and environmental factors led to complications in PWHA. The development of inhibitory antibodies is usually induced by the immune response. Tumor necrosis factor α (TNF-α), one of the cytokines, might contribute to its polymorphism. In this study, we investigated the clinical factors, level of serum TNF-α, and polymorphism of c.-308G > A TNF - α gene in inhibitor development in severe PWHA. METHODS A cross-sectional study was conducted among all PWHA in West Java province. The clinical parameters, FVIII, FVIII inhibitor, and serum TNF-α level were assessed. The genotyping of -380G > A TNF-α gene polymorphism was performed using polymerase chain reaction and Sanger sequencing. RESULTS Among the 258 PWHA, 216 (83.7%) were identified as severe PWHA. The FVIII inhibitor was identified in 90/216 (41.6%) of severe PWHA, consisting of 45 high-titer inhibitors (HTI) and 45 low-titer inhibitors (LTI). There was a significant correlation between serum TNF-α level and the development of HTI (p = 0.043). The cutoff point of serum TNF-α level, which can be used to differentiate between HTI and LTI, was 11.45 pg/mL. The frequency of FVIII replacement therapy was significant only in HTI of severe PWHA regarding serum TNF-α level (p = 0.028). There is no correlation between polymorphisms of -380G > A TNF-α gene and inhibitor development (p = 0.645). CONCLUSIONS The prevalence of FVIII inhibitor in severe PWHA in West Java, Indonesia, was 41.6%. The frequency of replacement therapy is a risk factor for inhibitor development. Serum TNF-α level might be used to differentiate between high and low inhibitor levels in severe hemophilia A, and this might support decision making regarding treatment options for inhibitor in severe hemophilia A.
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Affiliation(s)
- Susi Susanah
- Department of Child Health, Hematology-Oncology Division, Dr. Hasan Sadikin General Hospital/Faculty of Medicine, Universitas Padjadjaran, Bandung 40161, Indonesia
| | - Harry Raspati
- Department of Child Health, Hematology-Oncology Division, Dr. Hasan Sadikin General Hospital/Faculty of Medicine, Universitas Padjadjaran, Bandung 40161, Indonesia
| | - Nur Melani Sari
- Department of Child Health, Hematology-Oncology Division, Dr. Hasan Sadikin General Hospital/Faculty of Medicine, Universitas Padjadjaran, Bandung 40161, Indonesia
| | - Lulu Eva Rakhmilla
- Department of Public Health, Epidemiology and Biostatistic Division, Faculty of Medicine, Universitas Padjadjaran, Bandung 40161, Indonesia
| | - Yunia Sribudiani
- Department of Biomedical Sciences, Biochemistry and Molecular Biology Division, Faculty of Medicine, Universitas Padjadjaran, Bandung 40161, Indonesia
- Study Center of Medical Genetics, Faculty of Medicine, Universitas Padjadjaran, Bandung 40161, Indonesia
| | | | - Puspasari Sinaga
- Faculty of Medicine, Universitas Padjadjaran, Bandung 40161, Indonesia
| | - Ponpon Idjradinata
- Department of Child Health, Hematology-Oncology Division, Dr. Hasan Sadikin General Hospital/Faculty of Medicine, Universitas Padjadjaran, Bandung 40161, Indonesia
| | - Ani Melani Maskoen
- Study Center of Medical Genetics, Faculty of Medicine, Universitas Padjadjaran, Bandung 40161, Indonesia
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9
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Hermans C, Mancuso ME, Nolan B, Pasi KJ. Recombinant factor VIII Fc for the treatment of haemophilia A. Eur J Haematol 2021; 106:745-761. [PMID: 33650192 PMCID: PMC8252769 DOI: 10.1111/ejh.13610] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/24/2021] [Indexed: 12/13/2022]
Abstract
Prophylaxis with factor VIII (FVIII) is the current therapeutic approach for people with haemophilia A. However, standard half-life (SHL) FVIII products must be injected frequently, imposing a substantial burden on the individual and making it difficult to tailor therapy according to patient need and lifestyle, which could impact adherence. Recombinant FVIII Fc fusion protein (rFVIIIFc; Elocta® , Sobi; Eloctate® , Sanofi) is a recombinant fusion protein that undergoes slower clearance from the body than SHL FVIII products. This pharmacokinetic property of rFVIIIFc allows prophylactic administration every 3-5 days, or once weekly in selected patients, with doses adjusted to patient needs and clinical outcomes. Higher FVIII levels can be achieved maintaining dosing frequency similar to that usually applied with SHL FVIII. This review provides a summary of recent data from the A-LONG, Kids A-LONG, ASPIRE and PUPs A-LONG studies and recently published real-world experience relevant to rFVIIIFc use in individualised regimens. The review also introduces ongoing studies of rFVIIIFc, including its use for induction of immune tolerance, and discusses some aspects to consider when switching patients to rFVIIIFc and managing ongoing treatment. In summary, rFVIIIFc is suitable for individualised prophylaxis regimens that can be tailored according to patient clinical needs and lifestyle.
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Affiliation(s)
- Cedric Hermans
- Haemostasis and Thrombosis UnitDivision of HaematologyCliniques Universitaires Saint‐LucUniversité catholique de Louvain (UCLouvain)BrusselsBelgium
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic DiseasesHumanitas Clinical and Research Center ‐ IRCCSRozzanoItaly
| | | | - K. John Pasi
- Royal London Haemophilia CentreBarts and the London School of Medicine and DentistryLondonUK
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10
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Liesner RJ, Abraham A, Altisent C, Belletrutti MJ, Carcao M, Carvalho M, Chambost H, Chan AKC, Dubey L, Ducore J, Gattens M, Gresele P, Gruel Y, Guillet B, Jimenez-Yuste V, Kitanovski L, Klukowska A, Lohade S, Mancuso ME, Oldenburg J, Pavlova A, Pollio B, Sigaud M, Vdovin V, 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 Results of the NuProtect Study. Thromb Haemost 2021; 121:1400-1408. [PMID: 33581698 PMCID: PMC8570909 DOI: 10.1055/s-0040-1722623] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Introduction
FVIII inhibitor development is the most serious contemporary treatment complication in haemophilia A, particularly in previously untreated patients (PUPs). No inhibitors developed in clinical trials in previously treated patients treated with simoctocog alfa (Nuwiq), a fourth-generation recombinant FVIII produced in a human cell line.
Methods
The NuProtect study investigated the immunogenicity of simoctocog alfa in PUPs. NuProtect was a prospective, multinational, open-label, non-controlled, phase III study. PUPs with severe haemophilia A (FVIII:C <1%) of any age and ethnicity were treated with simoctocog alfa for 100 exposure days or a maximum of 5 years. Patients were true PUPs without prior exposure to FVIII concentrates or blood components. Inhibitor titres were measured with the Nijmegen-modified Bethesda assay; cut-off for positivity was 0.6 BU mL
−1
(≥0.6 to <5 low-titre, ≥5 high titre).
Results
A total of 108 PUPs with a median age at first treatment of 12.0 months (interquartile range: 8.0–23.5) were treated with simoctocog alfa.
F8
mutation type was known for 102 patients (94.4%) of whom 90 (88.2%) had null
F8
mutations and 12 (11.8%) had non-null mutations. Of 105 PUPs evaluable for inhibitor development, 28 (26.7%) developed inhibitors; 17 high titre (16.2%) and 11 low titre (10.5%). No PUPs with non-null
F8
mutations developed inhibitors.
Conclusion
In the NuProtect study, the rate of inhibitor development in PUPs with severe haemophilia A treated with simoctocog alfa was lower than the rate reported for hamster-cell-derived recombinant factor VIII products in other recent clinical trials. No inhibitors were reported in PUPs with non-null
F8
mutations.
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Affiliation(s)
- Ri J Liesner
- Great Ormond Street Hospital for Children NHS Trust Haemophilia Centre, NIHR GOSH BRC, London, United Kingdom
| | - Aby Abraham
- Department of Hematology, Christian Medical College, Vellore, India
| | - Carmen Altisent
- Unitat d'Hemofilia, Hospital Vall D'Hebron, Barcelona, Spain
| | - Mark J Belletrutti
- Pediatric Hematology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Manuel Carcao
- Division of Haematology/Oncology and Child Health Evaluative Sciences, Department of Paediatrics, 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
- Division of Pediatric Hematology/Oncology, McMaster University, Hamilton, Canada
| | - Leonid Dubey
- Department of Pediatrics, Western Ukrainian Specialized Children's Medical Centre, Lviv, Ukraine
| | - Jonathan Ducore
- Department of Pediatrics, University of California Davis Medical Center, Sacramento, United States
| | - Michael Gattens
- Department of Paediatric Haematology and Oncology, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - 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 Jimenez-Yuste
- Servicio de Hematología, Hospital Univeristario La Paz, Autónoma University, Madrid, Spain
| | - Lidija Kitanovski
- Department of Haemato-Oncology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Anna Klukowska
- Department of Pediatrics, Haematology and Oncology, Warsaw Medical University, Warsaw, Poland
| | - Sunil Lohade
- Department of Hematology, Sahyadri Speciality Hospital, Pune, India
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Anna Pavlova
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Berardino Pollio
- Department of Transfusion Medicine, Regina Margherita Children Hospital of Turin, Turin, Italy
| | - Marianne Sigaud
- Centre Régional de Traitement de I'Hémophilie, University Hospital of Nantes, Nantes, France
| | - Vladimir Vdovin
- Department of Hematology, Morozovskaya Children's Hospital, Moscow, Russian Federation
| | - Kateryna Vilchevska
- Department of Hematology, State Institution "Institute of Urgent and Reconstructive Surgery named after V.K. Gusak of National Academy of Medical Sciences of Ukraine," Donetsk, Ukraine
| | - John K M Wu
- British Columbia Children's Hospital, Vancouver, Canada
| | - Martina Jansen
- Octapharma Pharmazeutika Produktionsges.mbH, Vienna, Austria
| | | | | | | | - Ellis J Neufeld
- St. Jude Children's Research Hospital, Memphis, Tennessee, United States
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11
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Keipert C, Drechsel-Bäuerle U, Oberle D, Müller-Olling M, Hilger A. Epidemiological Challenges in Rare Bleeding Disorders: FVIII Inhibitor Incidence in Haemophilia A Patients-A Known Issue of Unknown Origin. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 18:ijerph18010225. [PMID: 33396748 PMCID: PMC7795862 DOI: 10.3390/ijerph18010225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/17/2020] [Accepted: 12/22/2020] [Indexed: 01/10/2023]
Abstract
There is a broad range of factor products approved in Germany for haemophilia A treatment. Since the introduction of recombinant coagulation factor VIII (FVIII) products in the 1990s, there has been substantial debate whether there is a difference in inhibitor incidence between single FVIII products or product classes. Neither haemophilia registries nor clinical studies, including a randomised controlled clinical trial, provided a consistent and definite answer. The reasons were mainly related to methodological challenges in conducting controlled studies in a rare disease. In this analysis, the most relevant epidemiological challenges and main problems were examined, including study bias, potential overlap of individual studies and advanced development of therapy and methods in the course of time. Meta-analyses on two levels showed that therapies using recombinant products resulted in different event rates when compared to plasma-derived products. These results are accompanied by substantial study heterogeneity evidenced by Cochran's Q tests. Only three studies have been identified that meet the standards of current clinical guidance. To finally resolve this ongoing and disputable safety issue of replacement therapy, collaboration among registry owners, academia and regulators must be fostered.
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Affiliation(s)
- Christine Keipert
- German Haemophilia Registry, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany
- Correspondence:
| | - Ursula Drechsel-Bäuerle
- Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (U.D.-B.); (D.O.)
| | - Doris Oberle
- Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (U.D.-B.); (D.O.)
| | - Mirco Müller-Olling
- Hematology and Transfusion Medicine, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (M.M.-O.); (A.H.)
| | - Anneliese Hilger
- Hematology and Transfusion Medicine, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (M.M.-O.); (A.H.)
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Blatný J, Kardos M, Miljic P, Bilić E, Benedik-Dolničar M, Faganel-Kotnik B, Konstantinov D, Kovalova Z, Ovesná P. Incidence of inhibitor development in PUPs with severe Haemophilia A in the CEE region between 2005 and 2015. Thromb Res 2020; 198:196-203. [PMID: 33360154 DOI: 10.1016/j.thromres.2020.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/05/2020] [Accepted: 12/09/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION This study analyses real-world data on 144 previously untreated patients (PUPs) with severe Haemophilia A, from seven countries in Central and Eastern Europe (CEE: Bulgaria, Croatia, Czech Republic, Hungary, Latvia, Serbia, and Slovenia), over a period of 11 years. It analyses the risk factors associated with development of inhibitors to factor VIII concentrates. METHODS Cox proportional hazard models were used to estimate the hazard risk of factors possibly influencing the development of inhibitors. Patients were followed for up to 100 exposure days (EDs). RESULTS Cumulative inhibitor incidence at the time of 100 EDs was 18.7%, slightly lower than the 25-35% incidence reported in most studies. Of PUPs who developed inhibitors, a majority (56%) developed them within the first 20 EDs and 88% by the 50th ED. FVIII class (recombinant or plasma-derived) did not influence the inhibitors' incidence rate (p = 0.64). We found a significant protective effect of prophylaxis compared to on-demand treatment (p = 0.003). PUPs who had an intensive peak treatment during the first 50 EDs were at significantly higher risk for inhibitor development (HR (95% CI) 5.3 (2.3-12.5), p < 0.001). CONCLUSION Inhibitors are and will continue to be the most significant complication of haemophilia treatment with factor concentrates. This is particularly true for haemophilia A. In our cohort, we were able to show that the treatment regimen used during first 50EDs influenced significantly the inhibitor risk, but the class of the factor concentrate did not play an important role. Real world data will remain one of the important resources for improving our knowledge of haemophilia.
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Affiliation(s)
- Jan Blatný
- Department of Paediatric Haematology, University Hospital and Masaryk University Brno, Czech Republic.
| | - Mária Kardos
- Department of Paediatrics, Mohács Hospital, Mohács, Hungary
| | - Predrag Miljic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia
| | - Ernest Bilić
- Department of Pediatrics, University Hospital Centre Zagreb, School of Medicine, Zagreb, Croatia
| | - Majda Benedik-Dolničar
- Unit for Haematology and Oncology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Barbara Faganel-Kotnik
- Unit for Haematology and Oncology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Dobrin Konstantinov
- Pediatric Hematology & Oncology Department, University Hospital "Tsaritsa Johanna-ISUL", Sofia, Bulgaria
| | - Zhanna Kovalova
- Department of Hematology and Oncology, Children's Clinical University Hospital, Riga, Latvia
| | - Petra Ovesná
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Drillaud N, Babuty A, Rugeri L, Fouassier M, Lienhart A, Béné M, Lefranc C, Ternisien C, Chamouard V, Sigaud M, Pennetier M, Trossaërt M, Meunier S. Management of previously untreated patients with severe haemophilia A preferentially treated with recombinant factor VIII products: Two French centres' real‐life experience. Haemophilia 2020; 26:e349-e352. [DOI: 10.1111/hae.14132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/30/2020] [Accepted: 07/30/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - Antoine Babuty
- Haemophilia Treatment Center University Hospital Nantes France
| | - Lucia Rugeri
- Haemophilia Treatment Center University Hospital Lyon France
| | - Marc Fouassier
- Haemophilia Treatment Center University Hospital Nantes France
| | - Anne Lienhart
- Haemophilia Treatment Center University Hospital Lyon France
| | - Marie‐C Béné
- Haemophilia Treatment Center University Hospital Nantes France
| | - Carole Lefranc
- Haemophilia Treatment Center University Hospital Lyon France
| | | | | | - Marianne Sigaud
- Haemophilia Treatment Center University Hospital Nantes France
| | | | - Marc Trossaërt
- Haemophilia Treatment Center University Hospital Nantes France
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14
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Jiang L, Liu Y, Zhang L, Santoro C, Rodriguez A. Rituximab for treating inhibitors in people with inherited severe hemophilia. Cochrane Database Syst Rev 2020; 8:CD010810. [PMID: 32761818 PMCID: PMC8407108 DOI: 10.1002/14651858.cd010810.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hemophilia A and B are inherited coagulation disorders characterized by a reduced or absent level of factor VIII or factor IX respectively. The severe form is characterized by a factor level less than 0.01 international units (IU) per milliliter. The development of inhibitors in hemophilia is the main complication of treatment, because the presence of these antibodies, reduces or even nullifies the efficacy of replacement therapy, making it very difficult to control the bleeding. People with inhibitors continue to have significantly higher risks of morbidity and mortality, with considerable treatment costs. Given the wide 'off-label' use of rituximab for treating people with hemophilia and inhibitors, its efficacy and safety need to be evaluated. This is an update of a previously published Cochrane Review. OBJECTIVES To assess the efficacy and safety of rituximab for treating inhibitors in people with inherited severe hemophilia A or B. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, complied from electronic database searches and handsearching of journals and conference abstract books. We searched the reference lists of relevant articles and reviews and also searched for ongoing or unpublished studies. We also undertook further searches of other bibliographic databases and trial registries. Date of last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register: 19 March 2020. SELECTION CRITERIA Randomized controlled trials and controlled clinical trials investigating the efficacy and safety of rituximab for treating inhibitors in people with hemophilia. DATA COLLECTION AND ANALYSIS No randomized controlled trials matching the selection criteria were eligible for inclusion. MAIN RESULTS No randomized controlled trials on rituximab for treating inhibitors in people with hemophilia were identified. AUTHORS' CONCLUSIONS We were unable to identify any relevant trials on the efficacy and safety of rituximab for treating inhibitors in people with hemophilia. The research evidence available is from case reports and case series. Randomized controlled trials are needed to evaluate the efficacy and safety of rituximab for this condition. However, prior to the publication of any possible future randomized controlled trials, meta-analysis of case reports and case series may provide some evidence.
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Affiliation(s)
- Lucan Jiang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
- Ethics Committee, The First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Yi Liu
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- West China School of Pharmacy, Sichuan University, Chengdu, China
| | - Lingli Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Cristina Santoro
- Department of Cellular Biotechnology and Hematology, Sapienza University of Rome, Rome, Italy
| | - Armando Rodriguez
- Association for the Promotion of Multimedia Education, Zagreb, Croatia
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Common Genetic Variants in ABO and CLEC4M Modulate the Pharmacokinetics of Recombinant FVIII in Severe Hemophilia A Patients. Thromb Haemost 2020; 120:1395-1406. [PMID: 32726853 DOI: 10.1055/s-0040-1714214] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The pharmacokinetic (PK) response of severe hemophilia A (HA) patients to infused factor VIII (FVIII) shows substantial variability. Several environmental and genetic factors are associated with changes in FVIII plasma levels and infused FVIII PK. Based on the hypothesis that factors influencing endogenous FVIII can affect FVIII PK, the contribution of single-nucleotide variants (SNVs) in candidate genes was investigated in 51 severe HA patients. The effects of blood group, F8 variant type, von Willebrand factor antigen and activity levels, age, and weight were also explored. The myPKFiT device was used to estimate individual PK parameters, and SNVs and clinically reportable F8 variants were simultaneously analyzed in an Illumina MiSeq instrument, using the microfluidics-based Fluidigm Access Array system. The contribution of SNVs to FVIII half-life and clearance was addressed by robust regression modeling, taking into account other modulators. In line with previous studies, we provide robust evidence that age, body weight, and blood group, as well as SNVs in ABO and CLEC4M, participate in the variability of FVIII PK in HA patients. Main results: each copy of the rs7853989 (ABO) allele increases FVIII half-life by 1.4 hours (p = 0.0131) and decreases clearance by 0.5 mL/h/kg (p = 5.57E-03), whereas each additional rs868875 (CLEC4M) allele reduces FVIII half-life by 1.1 hours (p = 2.90E-05) and increases clearance by 0.3 mL/h/kg (p = 1.01E-03). These results contribute to advancing efforts to improve FVIII replacement therapies by adjusting to each patient's PK profile based on pharmacogenomic data. This personalized medicine will decrease the burden of treatment and maximize the benefits obtained.
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16
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Miesbach W, Schwäble J, Müller MM, Seifried E. Treatment Options in Hemophilia. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:791-798. [PMID: 31847949 DOI: 10.3238/arztebl.2019.0791] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 04/30/2019] [Accepted: 08/29/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Approximately 4550 persons were under treatment for hemophilia in Germany in 2017. The condition is currently treated with intravenous supplementa- tion of the missing clotting factor, either prophylactically or as needed. Newer treat- ment options rely on novel mechanisms of action. METHODS This review is based on pertinent publications retrieved by a selective search in MEDLINE/PubMed, as well as on expert opinions and the recommenda- tions of specialty societies. RESULTS Randomized controlled trials have shown that, in children aged 30 months to 6 years, prophylactic clotting-factor supplementation yields a markedly lower an- nual rate of hemorrhage than supplementation as needed: 3.27 (standard deviation [SD] 6.24) for the former vs. 17.69 (SD 9.25) for the latter. A similar large effect was seen in patients aged 12 to 50 years, with hemorrhage rates of 1.9 (SD 4.1) vs. 28.7 (SD 18.8). Clotting-factor preparations with longer half-lives make it possible to lessen the frequency of administration and to prevent subtherapeutic factor levels. A number of alternatives to clotting-factor supplementation have recently been approved or are currently being clinically tested. These new drugs are injected sub- cutaneously and have a longer half-life, possibly enabling better protection against bleeding than the current standard treatment. A further advantage of some of these drugs is that they can be given even in the presence of inhibitors to factor VIII. In addition, initial (phase I) clinical trials of gene therapy have been performed suc- cessfully for both hemophilia A and hemophilia B. CONCLUSION Now that new alternatives to classic supplementation therapy are be- coming available, pertinent treatment algorithms for patients with hemophilia will have to be developed. It is still unclear to what extent the new drugs might supplant clotting factor supplementation as the first line of treatment.
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Affiliation(s)
- Wolfgang Miesbach
- Department of Hemostaseology and Transfusion Medicine, University Hospital Frankfurt am Main; DRK-Blutspendedienst Baden-Württemberg-Hessen gGmbH, Department of Transfusion Medicine and Immunohematology, University Hospital Frankfurt am Main
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17
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Pipe SW. Delivering on the promise of gene therapy for haemophilia. Haemophilia 2020; 27 Suppl 3:114-121. [PMID: 32490590 DOI: 10.1111/hae.14027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 04/20/2020] [Indexed: 01/19/2023]
Abstract
The promise of gene therapy is a single treatment ('one and done') that leads to steady-state expression of endogenous factor VIII or factor IX sufficient to achieve a functional cure (free of recurrent haemophilic bleeding) if not normalized haemostasis. The elimination of the need for continued prophylaxis, or factor replacement following trauma or prior to surgery would lead to annual cost savings. Such optimized health and well-being would be reaching a level of health equity that was unimaginable several decades ago. 'Before anything else, preparation is the key to success'-Alexander Graham Bell. This quote from the famous inventor, scientist and engineer highlights that, although we currently stand on the threshold of this achievement, delivering on this promise will require broad-based multistakeholder preparation (scientists, manufacturers, federal regulators, health technology assessors, persons with haemophilia, national advocacy groups and multidisciplinary healthcare teams) with a focused emphasis on education, approval of safe and effective therapies, removal of barriers to access and excellence in clinical delivery.
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Affiliation(s)
- Steven W Pipe
- Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
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18
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Peptides identified on monocyte-derived dendritic cells: a marker for clinical immunogenicity to FVIII products. Blood Adv 2020; 3:1429-1440. [PMID: 31053570 DOI: 10.1182/bloodadvances.2018030452] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 03/18/2019] [Indexed: 12/14/2022] Open
Abstract
The immunogenicity of protein therapeutics is an important safety and efficacy concern during drug development and regulation. Strategies to identify individuals and subpopulations at risk for an undesirable immune response represent an important unmet need. The major histocompatibility complex (MHC)-associated peptide proteomics (MAPPs) assay directly identifies the presence of peptides derived from a specific protein therapeutic on a donor's MHC class II (MHC-II) proteins. We applied this technique to address several questions related to the use of factor VIII (FVIII) replacement therapy in the treatment of hemophilia A (HA). Although >12 FVIII therapeutics are marketed, most fall into 3 categories: (i) human plasma-derived FVIII (pdFVIII), (ii) full-length (FL)-recombinant FVIII (rFVIII; FL-rFVIII), and (iii) B-domain-deleted rFVIII. Here, we investigated whether there are differences between the FVIII peptides found on the MHC-II proteins of the same individual when incubated with these 3 classes. Based on several observational studies and a prospective, randomized, clinical trial showing that the originally approved rFVIII products may be more immunogenic than the pdFVIII products containing von Willebrand factor (VWF) in molar excess, it has been hypothesized that the pdFVIII molecules yield/present fewer peptides (ie, potential T-cell epitopes). We have experimentally tested this hypothesis and found that dendritic cells from HA patients and healthy donors present fewer FVIII peptides when administered pdFVIII vs FL-rFVIII, despite both containing the same molar VWF excess. Our results support the hypothesis that synthesis of pdFVIII under physiological conditions could result in reduced heterogeneity and/or subtle differences in structure/conformation which, in turn, may result in reduced FVIII proteolytic processing relative to FL-rFVIII.
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Klukowska A, Komrska V, Vdovin V, Zozulya N, Lissitchkov T, Oldenburg J, Ettingshausen CE. octanate ®: over 20 years of clinical experience in overcoming challenges in haemophilia A treatment. Ther Adv Hematol 2020; 11:2040620720914692. [PMID: 32341775 PMCID: PMC7171997 DOI: 10.1177/2040620720914692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/18/2020] [Indexed: 01/01/2023] Open
Abstract
Treatment of haemophilia A with FVIII replacement has evolved over the past decades to adapt to the needs of patients. octanate®, a plasma-derived, double virus-inactivated, von Willebrand factor (VWF)-containing FVIII concentrate, has been used in clinics worldwide for over 20 years. First licensed in 1998 in Germany, octanate® is approved in over 80 countries for the prevention and treatment of bleeding and for surgical prophylaxis in patients with haemophilia A, and in over 40 countries for immune tolerance induction (ITI). The manufacturing process for octanate® was developed to ensure high viral safety and effectively eliminates both enveloped and nonenveloped viruses. Over the past 20 years, the excellent safety and efficacy of octanate® have been demonstrated in pivotal clinical trials in adult and paediatric previously treated patients (PTPs) for on-demand treatment, prophylaxis and as surgical cover. Importantly, octanate® has displayed low immunogenicity in previously untreated patients (PUPs), with only 9.8% of PUPs developing FVIII inhibitors. octanate® has also shown to be highly effective in inhibitor elimination when used as ITI therapy. In a population of patients with high risk of ITI failure, success was achieved in 79.2% of patients (70.8% complete success), even when using exceptionally stringent success criteria. No relapses were observed. Here we present an overview of the clinical data with octanate® that support its use in a range of patient populations and clinical indications.
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Affiliation(s)
- Anna Klukowska
- Department of Paediatric Oncology, Medical University of Warsaw, Haematology, Clinical Transplantology and Paediatrics, Warsaw, Poland
| | - Vladimír Komrska
- Department of Paediatric Hematology and Oncology, University Hospital Motol, Prague, Czech Republic
| | - Vladimír Vdovin
- Morozovskaya Children’s Hospital, Moscow, Russian Federation
| | - Nadezhda Zozulya
- National Research Centre for Hematology, Moscow, Russian Federation
| | - Toshko Lissitchkov
- Department of Disorders of Haemostasis, SBALHZ - EAD, Sofia, Bulgaria
- Department of Clinical Haematology in Haemorrhagic Diathesis and Anaemia, Specialized Hospital for Active Treatment “Joan Pavel”, Sofia, Bulgaria
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
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20
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van Velzen AS, Eckhardt CL, Peters M, Oldenburg J, Cnossen M, Liesner R, Morfini M, Castaman G, McRae S, van der Bom JG, Fijnvandraat K. Product type and the risk of inhibitor development in nonsevere haemophilia A patients: a case-control study. Br J Haematol 2020; 189:1182-1191. [PMID: 32201943 PMCID: PMC7318706 DOI: 10.1111/bjh.16490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 12/24/2019] [Indexed: 11/27/2022]
Abstract
Inhibitor development is a major complication of treatment with factor VIII concentrates in nonsevere haemophilia A. It has been suggested that plasma-derived factor VIII (FVIII) concentrates elicit fewer inhibitors than recombinant FVIII concentrates, but studies in severe haemophilia A patients have shown conflicting results. We designed a case-control study to investigate the clinical and genetic risk factors for inhibitor development in nonsevere haemophilia A patients. We investigated whether the type of FVIII concentrate was associated with inhibitor development in nonsevere haemophilia A patients. This nested case-control study includes 75 inhibitor patients and 223 controls, from a source population of the INSIGHT study, including all nonsevere haemophilia A patients (FVIII:C 2-40%) that were treated with FVIII concentrates in 33 European and one Australian centre. Cases and controls were matched for date of birth and cumulative number of exposure days (CED) to FVIII concentrate. A conditional logistic regression model was used to calculate unadjusted and adjusted odds ratios. No increased risk for inhibitor development was found for any type of FVIII concentrate; either when comparing recombinant FVIII concentrates to plasma-derived FVIII concentrates (adjusted odds ratio 0·96, 95% confidence interval (CI) 0·36-2·52) or for specific types of FVIII concentrates.
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Affiliation(s)
- Alice S van Velzen
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Corien L Eckhardt
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Marjolein Peters
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Marjon Cnossen
- Department of Pediatric Oncology and Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ri Liesner
- Department of Haematology & Oncology and Children's Haemophilia Comprehensive Care Centre, Great Ormond Street Children's Hospital & Institute of Child Health, London, UK
| | - Massimo Morfini
- Italian Association of Haemophilia Centres (AICE), Florence, Italy
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders, Careggi University Hospital, Firenze, Italy
| | - Simon McRae
- Department of Haematology, Royal Adelaide Hospital, Adelaide, Australia
| | - Johanna G van der Bom
- Sanquin Research and Department of Clinical Epidemiology, Center for Clinical Transfusion Research, Leiden University Medical Center, Leiden, the Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
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21
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Diego VP, Luu BW, Hofmann M, Dinh LV, Almeida M, Powell JS, Rajalingam R, Peralta JM, Kumar S, Curran JE, Sauna ZE, Kellerman R, Park Y, Key NS, Escobar MA, Huynh H, Verhagen AM, Williams-Blangero S, Lehmann PV, Maraskovsky E, Blangero J, Howard TE. Quantitative HLA-class-II/factor VIII (FVIII) peptidomic variation in dendritic cells correlates with the immunogenic potential of therapeutic FVIII proteins in hemophilia A. J Thromb Haemost 2020; 18:201-216. [PMID: 31556206 DOI: 10.1111/jth.14647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/23/2019] [Accepted: 09/23/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Plasma-derived (pd) or recombinant (r) therapeutic factor VIII proteins (FVIIIs) are infused to arrest/prevent bleeding in patients with hemophilia A (PWHA). However, FVIIIs are neutralized if anti-FVIII-antibodies (inhibitors) develop. Accumulating evidence suggests that pdFVIIIs with von Willebrand factor (VWF) are less immunogenic than rFVIIIs and that distinct rFVIIIs are differentially immunogenic. Since inhibitor development is T-helper-cell-dependent, human leukocyte antigen (HLA)-class-II (HLAcII) molecules constitute an important early determinant. OBJECTIVES Use dendritic cell (DC)-protein processing/presentation assays with mass-spectrometric and peptide-proteomic analyses to quantify the DP-bound, DQ-bound, and DR-bound FVIII-derived peptides in individual HLAcII repertoires and compare the immunogenic potential of six distinct FVIIIs based on their measured peptide counts. PATIENTS/METHODS Monocyte-derived DCs from normal donors and/or PWHA were cultured with either: Mix-rFVIII, a VWF-free equimolar mixture of a full-length (FL)-rFVIII [Advate® (Takeda)] and four distinct B-domain-deleted (BDD)-rFVIIIs [Xyntha® (Pfizer), NovoEight® (Novo-Nordisk), Nuwiq® (Octapharma), and Afstyla® (CSL Behring GmBH)]; a pdFVIII + pdVWF [Beriate® (CSL Behring GmBH)]; Advate ± pdVWF; Afstyla ± pdVWF; and Xyntha + pdVWF. RESULTS We showed that (i) Beriate had a significantly lower immunogenic potential than Advate ± pdVWF, Afstyla - pdVWF, and Mix-rFVIII; (ii) distinct FVIIIs differed significantly in their immunogenic potential in that, in addition to (i), Afstyla + pdVWF had a significantly lower immunogenic potential than Beriate, while the immunogenic potential of Beriate was not significantly different from that of Xyntha + pdVWF; and (iii) rFVIIIs with pdVWF had significantly lower immunogenic potentials than the same rFVIIIs without pdVWF. CONCLUSIONS Our results provide HLAcII peptidomic level explanations for several important clinical observations/issues including the differential immunogenicity of distinct FVIIIs and the role of HLAcII genetics in inhibitor development.
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Affiliation(s)
- Vincent P Diego
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
| | - Bernadette W Luu
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
- Haplogenics Corporation, Brownsville, Texas
| | | | | | - Marcio Almeida
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
| | | | - Raja Rajalingam
- Immunogenetics and Transplantation Laboratory, Department of Surgery, School of Medicine, University of California at San Francisco, California
| | - Juan M Peralta
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
| | - Satish Kumar
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
| | - Joanne E Curran
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
| | - Zuben E Sauna
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapeutics, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Roberta Kellerman
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, North Carolina
| | - Yara Park
- Department of Laboratory Medicine and Pathology, University of North Carolina at Chapel Hill, North Carolina
| | - Nigel S Key
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, North Carolina
- Department of Laboratory Medicine and Pathology, University of North Carolina at Chapel Hill, North Carolina
| | - Miguel A Escobar
- Division of Hematology, Department of Medicine, McGovern School of Medicine, University of Texas Health Sciences Center at Houston, Texas
| | - Huy Huynh
- CSL Limited Research, Bio21 Institute, Melbourne, Australia
| | | | - Sarah Williams-Blangero
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
| | - Paul V Lehmann
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Cellular Technology Ltd, Shaker Heights, Ohio
| | | | - John Blangero
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
| | - Tom E Howard
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
- Haplogenics Corporation, Brownsville, Texas
- Department of Pathology and Lab Medicine, VA Valley Coastal Bend Healthcare Center, Harlingen, Texas
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22
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Yaish H, Matsushita T, Belhani M, Jiménez-Yuste V, Kavakli K, Korsholm L, Matytsina I, Philipp C, Reichwald K, Wu R. Safety and efficacy of turoctocog alfa in the prevention and treatment of bleeds in previously untreated paediatric patients with severe haemophilia A: Results from the guardian 4 multinational clinical trial. Haemophilia 2019; 26:64-72. [PMID: 31816159 PMCID: PMC7028046 DOI: 10.1111/hae.13883] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 10/27/2019] [Accepted: 10/28/2019] [Indexed: 02/06/2023]
Abstract
Introduction Turoctocog alfa is a recombinant, B domain‐truncated factor VIII (FVIII) approved for patients with haemophilia A. Aim To evaluate the safety and efficacy of turoctocog alfa in previously untreated patients (PUPs) with severe haemophilia A. Methods Guardian 4 was a multicentre, multinational, non‐randomized, open‐label phase 3 trial comprising a main and extension phase. The former concluded once ≥ 50 patients had received treatment for ≥ 50 exposure days (EDs) or developed inhibitors. Patients received turoctocog alfa intravenously for prevention and treatment of bleeds. The primary endpoint was the incidence rate of FVIII inhibitors (≥0.6 Bethesda Units) reported during the first 50 EDs. Results Of the 58 patients who completed the main phase, 25 (43.1%) patients developed inhibitors (detected within 6‐24 [mean: 14.2] EDs from treatment start). High‐risk mutations were identified in 60% of patients who developed inhibitors in the main phase and were a significant predictor of inhibitor development (P = .003). Of the 21 patients who started immune tolerance induction therapy, 85.7% completed treatment with a negative inhibitor test (note that data on the last 3 patients completing ITI are based on information collated from sites prior to the final database lock). Haemostatic response (including missing values as failure) was rated as ‘excellent’ or ‘good’ for 86.1% of bleeds occurring during prophylaxis. The estimated mean annualized bleeding rate for patients on prophylaxis was 4.26 bleeds/patient/year (95% CI: 3.34 − 5.44). Conclusions Turoctocog alfa was effective at preventing and stopping bleeds and was well tolerated. Inhibitor development was within the expected range for this PUP population.
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Affiliation(s)
- Hassan Yaish
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | | | | | | | | | | | - Claire Philipp
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | - Runhui Wu
- Beijing Children's Hospital, Capital Medical University, Beijing, China
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Schiavoni M, Napolitano M, Giuffrida G, Coluccia A, Siragusa S, Calafiore V, Lassandro G, Giordano P. Status of Recombinant Factor VIII Concentrate Treatment for Hemophilia a in Italy: Characteristics and Clinical Benefits. Front Med (Lausanne) 2019; 6:261. [PMID: 31850352 PMCID: PMC6901793 DOI: 10.3389/fmed.2019.00261] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/28/2019] [Indexed: 01/19/2023] Open
Abstract
The current interest in recombinant factor VIII (rFVIII) products stems from the fact that they offer a technological solution to prolonging the half-life of and reducing the risk of formation of alloantibodies (inhibitors) against FVIII in treated patients with hemophilia A (HA). The Italian health care system has authorized the use of a wide range of rFVIII concentrates of the first, second, and third generation, as well as new innovative rFVIII preparates with an extended half-life (EHL) (Kogenate FS®-Bayer, belonging to the second generation and replaced since 2017 by a product consisting of the same modified molecule; because it is only available until the end of the current year, it will not be considered in this review). Some of these products have unique pharmacodynamic and pharmacokinetic (PK) profiles, including an EHL. The first-generation full-length rFVIII (FL-rFVIII), octocog alfa (Recombinate® Baxter/BIOVIIIx), although the oldest rFVIII product, has several desirable features. Third-generation products include two modified octocog alfa molecules (Advate®, Shire; Kovaltry®, Bayer) as well as the B domain-deleted rFVIII (BDD-rFVIII) moroctocog alfa (ReFacto®-Pfizer). The B domain-truncated (BDT-rFVIII) turoctocog alfa (NovoEight®, Novo Nordisk), the BDD-rFVIII simoctocog alfa (Nuwiq®, Kedrion), the single-chain BDT-rVIII lonoctocog alfa (Afstyla®, CSL Behring), and the BDD-rFVIIIFc efmoroctocog alfa (Elocta®, Sobi-Biogen) are new, innovative products. Simoctocog alfa, because its peculiarities, is considered a fourth-generation rFVIII concentrate. Turoctocog alfa, simoctocog alfa, and lonoctocog alfa have a high affinity for von Willebrand factor (vWF) that reduces renal clearance and prolongs the half-life of rFVIII. Efmoroctocog alfa, a first-in-class rFVIII-Fc fusion protein (rFVIIIFc), has a half-life 1.5–1.8 times longer than that of conventional plasma-derived FVIII (pd-rFVIII) and other rFVIII products. Clinical studies have evaluated the efficacy, safety, and inhibitor development of all these innovative concentrates in both previously treated (PTPs) and untreated patients (PUPs). This review considers the rFVIII products that are indicated for the treatment of patients with severe HA, focusing on those that are commercially available in Italy. Their PK characteristics, immunogenicity, and clinical benefits are discussed and compared.
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Affiliation(s)
- Mario Schiavoni
- Associazione per la Lotta alle Malattie Emorragiche e Trombotiche, Maglie, Italy
| | - Mariasanta Napolitano
- Internal Medicine and Medical Specialities, Haematology Unit, Department of Health Promotion, Mother and Child Care, Reference Regional Center for Thrombosis and Haemostasis, University of Palermo, Palermo, Italy
| | - Gaetano Giuffrida
- U.O.C. di Ematologia, A.O.U. Policlinico "Vittorio Emanuele", Catania, Italy
| | - Antonella Coluccia
- U.O.C di Medicina Interna, Centro Emofilia e Coagulopatie Rare-Ospedale "I.Veris delli Ponti", Scorrano-ASL, Lecce, Italy
| | - Sergio Siragusa
- U.O.C. di Ematologia, Università degli Studi, Palermo, Italy
| | - Valeria Calafiore
- U.O.C. di Ematologia, A.O.U. Policlinico "Vittorio Emanuele", Catania, Italy
| | - Giuseppe Lassandro
- Dipartimento di Scienza Biomedica e Oncologia Umana, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Paola Giordano
- Dipartimento di Scienza Biomedica e Oncologia Umana, Università degli Studi di Bari "Aldo Moro", Bari, Italy
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24
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Timing of inhibitor development in more than 1000 previously untreated patients with severe hemophilia A. Blood 2019; 134:317-320. [DOI: 10.1182/blood.2019000658] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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25
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Carcao M, Escuriola‐Ettingshausen C, Santagostino E, Oldenburg J, Liesner R, Nolan B, Bátorová A, Haya S, Young G. The changing face of immune tolerance induction in haemophilia A with the advent of emicizumab. Haemophilia 2019; 25:676-684. [PMID: 31033112 PMCID: PMC6850066 DOI: 10.1111/hae.13762] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 03/20/2019] [Accepted: 03/28/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION As a result of the new treatment paradigm that the haemophilia community will face with the availability of novel (non-factor) therapies, an updated consensus on ITI recommendations and inhibitor management strategies is needed. AIM The Future of Immunotolerance Treatment (FIT) group was established to contemplate, determine and recommend the best management options for patients with haemophilia A and inhibitors. DISCUSSION AND CONCLUSIONS Despite the considerable success of emicizumab in the management of inhibitor patients, the FIT group still sees the importance of eradicating inhibitors. However, the availability of emicizumab and other non-factor therapies in the future might impact greatly on how ITI is undertaken. Theoretically, concomitant use of emicizumab and FVIII might allow emicizumab to effectively prevent bleeding with lower dose ITI regimens. This might allow for the greater adoption of low-dose/low-frequency FVIII ITI regimens, which may result in a reduced need for central venous access devices while still maintaining a reasonable likelihood of ITI success. The FIT group proposes a new management algorithm for current ITI (without emicizumab) and a hypothetical new approach with the availability of emicizumab. As there are no published data regarding the concomitant use of emicizumab and FVIII for ITI, the FIT Expert group encourages the undertaking of properly conducted prospective studies to explore these approaches further.
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Affiliation(s)
- Manuel Carcao
- Division of Haematology/Oncology, Department of Paediatrics and Child Health Evaluative Sciences, Research Institute, The Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | | | - Elena Santagostino
- Maggiore Hospital PoliclinicoAngelo Bianchi Bonomi Hemophilia and Thrombosis CenterMilanItaly
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion MedicineUniversity of BonnBonnGermany
| | - Ri Liesner
- Haemophilia Centre, Great Ormond Street Hospital for ChildrenNHS Trust Haemophilia CentreLondonUK
| | | | - Angelika Bátorová
- Department of Haematology and Transfusion Medicine and National Haemophilia CentreUniversity Hospital, Comenius UniversityBratislavaSlovakia
| | - Saturnino Haya
- Unit for Congenital Bleeding DisordersHospital Universitario y Politécnico La FeValenciaSpain
| | - Guy Young
- Children's Hospital Los AngelesUniversity of Southern California Keck School of MedicineLos AngelesCalifornia
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Lissitchkov T, Klukowska A, Pasi J, Kessler CM, Klamroth R, Liesner RJ, Belyanskaya L, Walter O, Knaub S, Bichler J, Jansen M, Oldenburg J. Efficacy and safety of simoctocog alfa (Nuwiq®) in patients with severe hemophilia A: a review of clinical trial data from the GENA program. Ther Adv Hematol 2019; 10:2040620719858471. [PMID: 31263528 PMCID: PMC6595650 DOI: 10.1177/2040620719858471] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 05/13/2019] [Indexed: 01/19/2023] Open
Abstract
Simoctocog alfa (human-cl rhFVIII, Nuwiq®) is a 4th generation recombinant FVIII (rFVIII), without chemical modification or fusion with any other protein/fragment. Nuwiq® is produced in a human embryonic kidney cell line (HEK293F), which ensures human-specific post-translational protein processing. Nuwiq® was evaluated in seven prospective clinical studies in 201 adult and pediatric previously treated patients (PTPs) with severe hemophilia A. The NuProtect study in 110 previously untreated patients (PUPs) is ongoing. The mean half-life of Nuwiq® was 15.1–17.1 h in PTP studies with adults and adolescents, and 12.5 h in children aged 2–12 years. Clinical trials in PTPs demonstrated the efficacy and safety of Nuwiq® in the prevention and treatment of bleeds and as surgical prophylaxis. In the NuPreviq study of pharmacokinetic (PK)-guided personalized prophylaxis in 66 adult PTPs, 83% of patients had no spontaneous bleeds during 6 months of personalized prophylaxis and 57% were treated ⩽2 per week. No FVIII inhibitors were detected in PTPs after treatment with 43,267 injections and >80 million IU of Nuwiq®. Interim data for 66 PUPs with ⩾20 exposure days to Nuwiq® in NuProtect demonstrated a low cumulative high-titer inhibitor rate of 12.8% [actual incidence 12.1% (8/66)] and convincing efficacy and safety.
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Affiliation(s)
| | - Anna Klukowska
- Department of Pediatrics, Hematology and Oncology, Warsaw Medical University, Poland
| | - John Pasi
- The Royal London Hospital Barts and The London School of Medicine and Dentistry, UK
| | - Craig M Kessler
- Hemophilia and Thrombosis Comprehensive Treatment Center and The Division of Coagulation, Georgetown University Medical Center, Washington DC, USA
| | - Robert Klamroth
- Department for Internal Medicine, Vascular Medicine and Haemostaseology, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Raina J Liesner
- Great Ormond Street Hospital for Children, NHS Trust Haemophilia Centre, London, UK
| | | | | | | | | | - Martina Jansen
- Octapharma Pharmazeutika Produktionsges mbH, Vienna, Austria
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Sigmund-Freud Strasse 25, 53105 Bonn, Germany
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27
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Dunkley S, Curtin JA, Marren AJ, Heavener RP, McRae S, Curnow JL. Updated Australian consensus statement on management of inherited bleeding disorders in pregnancy. Med J Aust 2019; 210:326-332. [PMID: 30924538 PMCID: PMC6850504 DOI: 10.5694/mja2.50123] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION There have been significant advances in the understanding of the management of inherited bleeding disorders in pregnancy since the last Australian Haemophilia Centre Directors' Organisation (AHCDO) consensus statement was published in 2009. This updated consensus statement provides practical information for clinicians managing pregnant women who have, or carry a gene for, inherited bleeding disorders, and their potentially affected infants. It represents the consensus opinion of all AHCDO members; where evidence was lacking, recommendations have been based on clinical experience and consensus opinion. MAIN RECOMMENDATIONS During pregnancy and delivery, women with inherited bleeding disorders may be exposed to haemostatic challenges. Women with inherited bleeding disorders, and their potentially affected infants, need specialised care during pregnancy, delivery, and postpartum, and should be managed by a multidisciplinary team that includes at a minimum an obstetrician, anaesthetist, paediatrician or neonatologist, and haematologist. Recommendations on management of pregnancy, labour, delivery, obstetric anaesthesia and postpartum care, including reducing and treating postpartum haemorrhage, are included. The management of infants known to have or be at risk of an inherited bleeding disorder is also covered. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT Key changes in this update include the addition of a summary of the expected physiological changes in coagulation factors and phenotypic severity of bleeding disorders in pregnancy; a flow chart for the recommended clinical management during pregnancy and delivery; guidance for the use of regional anaesthetic; and prophylactic treatment recommendations including concomitant tranexamic acid.
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Affiliation(s)
- Scott Dunkley
- Institute of HaematologyRoyal Prince Alfred HospitalSydneyNSW
| | - Julie A Curtin
- The Children's Hospital at WestmeadSydneyNSW
- Australian Haemophilia Centres Directors’ OrganisationMelbourneVIC
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28
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Morfini M, Rapisarda CAP. Safety of recombinant coagulation factors in treating hemophilia. Expert Opin Drug Saf 2019; 18:75-85. [PMID: 30681006 DOI: 10.1080/14740338.2019.1574743] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION During the last decade, new FVIII/IX concentrates have been developed for the treatment of patients affected by hemophilia A/B. Significant progress has been achieved regarding their half-life, but the old issue of immunogenicity and new concerns about safety need to be addressed. AREAS COVERED After the implementation of virucidal methods, both plasma-derived and recombinant clotting factor concentrates achieved a very safe profile. The development of anti-FVIII antibodies is the major adverse event of replacement therapy with both FVIII concentrates. Furthermore, the new extended half-life concentrates, protein fused or pegylated, raised some concerns about their side effects. EXPERT OPINION The treatment of hemophilia A with inhibitors by induction of immunotolerance and using by-passing concentrates, improved the quality of life of patients but did not allow them to have a life expectancy like that of patients without inhibitors. The new humanized monoclonal antibody (MAb) ACE910, mimicking FVIII function, seems to be able to reduce the bleedings of hemophilia A patients with inhibitors. The post-marketing surveillance will clarify if the adverse events observed during the phase III clinical trials and compassionate use were due to the association with a Prothrombin activated complex concentrate or to the prothrombotic effect of the drug itself.
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Affiliation(s)
- Massimo Morfini
- a Italian Association of Haemophilia Centres (AICE) Florence , Italy
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29
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Aledort LM. The ongoing imperative for immune tolerance induction in inhibitor management. Haemophilia 2019; 25:183-186. [PMID: 30748063 DOI: 10.1111/hae.13670] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 07/30/2018] [Accepted: 11/26/2018] [Indexed: 01/19/2023]
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30
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Abstract
Regular prophylactic treatment with factor VIII (FVIII) and factor IX (FIX) concentrates in hemophilia A and B, respectively, is introduced in early infancy and has resulted in dramatic improvement of the conditions. Recombinant FVIII and FIX concentrates have been available for > 25 years and have been modified and refined through the years; however, unfortunately frequent intravenous administrations are still necessary. The half-lives of these products have now been extended (EHL) by fusion with albumin, the Fc-portion of IgG, or by being PEGylated. This has been very successful for EHL-FIX, with 3-5 times longer half-life, and to a lesser degree for EHL-FVIII with a half-life extension of only 1.5 times the conventional products. New treatment principles using FVIII mimetics or monoclonal antibodies that rebalance the pro- and anti-coagulation system by interfering with production of anti-thrombin or tissue factor pathway inhibitor have the benefits of long-lasting activity, subcutaneous administration, and being useful in patients both with and without neutralizing antibodies. As the ultimate treatment, recent progress has also been made with gene therapy of both hemophilia A and B.
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Affiliation(s)
- Rolf C R Ljung
- Department of Clinical Sciences-Paediatrics, Lund University, Lund, Sweden.
- Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden.
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Abstract
The unprecedented emergence of novel therapeutics for both hemophilia A and B during the last half decade has been accompanied by the promise of even more extraordinary progress in ameliorative and curative strategies for both disorders. Paradoxically, the speed of innovation has created new dilemmas for persons with hemophilia and their physicians with respect to optimizing individual choices from the expanding menu of standard and novel therapies and approaches to symptom or risk reduction, and ultimately, to normalizing the hemophilia phenotype. Among the most disruptive new approaches, challenges remain in the form of the adverse reactions that have been observed with nonfactor therapies, as well as in the uncertain long-term safety profile of potentially curative gene therapy. Together, these challenges have generated uncertainty as to how to adopt novel therapies and treatment strategies across a diverse patient population, creating speed bumps on the hemophilia innovation highway. It is from this perspective that this article discusses the current state of gene therapy and bleeding prophylaxis for hemophilia A and B, as well as prevention and treatment of the factor VIII inhibitor phenotype in hemophilia A. It further posits that these speed bumps may provide important clues to the mechanistic understanding of both symptom manifestation and resilience within the hemophilia phenotype, as well as opportunities to reconsider and reconfigure the current paradigms for symptom prediction and individualized therapeutic decision making.
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Affiliation(s)
- Donna M DiMichele
- Division of Blood Diseases and Resources, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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32
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Abolghasemi H, Panahi Y, Ahmadinejad M, Toogeh G, Karimi M, Eghbali A, Mirbehbahani NB, Dehdezi BK, Badiee Z, Hoorfar H, Eshghi P, Maghsoudi N, Sahebkar A, Gholami-Fesharaki M. Comparative evaluation of the safety and efficacy of recombinant FVIII in severe hemophilia A patients. J Pharmacopuncture 2018; 21:76-81. [PMID: 30151307 PMCID: PMC6054092 DOI: 10.3831/kpi.2018.21.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 03/20/2018] [Accepted: 05/17/2018] [Indexed: 11/09/2022] Open
Abstract
Objective This study compared the safety and efficacy of Safacto® versus xyntha® in patients with severe hemophilia A. Methods Thirty-three male patients with severe hemophilia A were randomly divided into two groups. Seventeen patients received Safacto® and 16 patients received Xyntha® for four consecutive times. The dosage of FVIII was 40-50 IU/kg for each injection. Plasma level of FVIII activity was evaluated before every injection, 15 minutes after the injection and one month after the start of the trial. The rate of factor VIII activity, pain and joint motion were also assessed before and after the treatment. Results Plasma level of FVIII clotting activity in Safacto® and Xyntha® were 1.96±0.5 IU/dl and 1.63±0.5 IU/dl and increased to 88.84±25.2 IU/dl and 100.09±17.8 IU/dl, respectively (P<0.001). Pain score and range of motion improvement were 9.3±0.9 and 8.7±0.1 in Safacto® (P=0.17); and 9.4±0.8 and 8.8±0.3 in Xyntha® (P=0.35), respectively. No allergic or other unfavorable reactions was observed with either of the preparations. Conclusion This study showed that Safacto® has a favorable efficacy and safety profile.
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Affiliation(s)
- Hassan Abolghasemi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Yunes Panahi
- Pharmacotherapy Department, Faculty of Pharmacy, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Minoo Ahmadinejad
- High Institute of Research, Iranian Blood Transfusion Organization, Tehran, Iran
| | - Gholamreza Toogeh
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Pharmacotherapy Department, Faculty of Pharmacy, Baqiyatallah University of Medical Sciences, Tehran, Iran.,High Institute of Research, Iranian Blood Transfusion Organization, Tehran, Iran.,Hematology Research Centre, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Pediatric Hematology-Oncology, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Golestan University of Medical Sciences, Gorgan, Iran.,Department of Thalassemia & Hemoglobinopathy Research Center, Ahvaz Jundishapur University of Medical Science, Ahvaz, Iran.,Doctor Sheikh Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.,Isfahan University of Medical Sciences, Isfahan, Iran.,Neuroscience Research Center (NRC), Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.,Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Mehran Karimi
- Hematology Research Centre, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Aziz Eghbali
- Department of Pediatric Hematology-Oncology, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Bighan Keikhaei Dehdezi
- Department of Thalassemia & Hemoglobinopathy Research Center, Ahvaz Jundishapur University of Medical Science, Ahvaz, Iran
| | - Zahra Badiee
- Doctor Sheikh Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamid Hoorfar
- Isfahan University of Medical Sciences, Isfahan, Iran
| | - Peyman Eshghi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nader Maghsoudi
- Neuroscience Research Center (NRC), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran.,Neurogenic Inflammation Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.,School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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Neufeld EJ, Sidonio RF, O'Day K, Runken MC, Meyer K, Spears J. Cost analysis of plasma-derived factor VIII/von Willebrand factor versus recombinant factor VIII for treatment of previously untreated patients with severe hemophilia A in the United States. J Med Econ 2018; 21:762-769. [PMID: 29681200 DOI: 10.1080/13696998.2018.1468335] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Inhibitor development to factor VIII (FVIII) hemophilia therapy results in increased complications and substantial economic costs. The SIPPET study, the first randomized controlled trial to compare the immunogenicity of plasma-derived FVIII (pdFVIII)/von Willebrand factor (VWF) and recombinant-DNA-derived FVIII (rFVIII), demonstrated higher inhibitor rates in previously untreated patients (PUPs) treated with rFVIII than in PUPs treated with pdFVIII/VWF. OBJECTIVE To quantify the economic impact of treating PUPs with pdFVIII/VWF vs rFVIII. METHODS An Excel-based clinical and economic model was developed from a US healthcare payer perspective and run over a 5-year period. The analysis utilized a cohort approach to model patient treatment and outcomes over a monthly cycle to quantify differences in costs of FVIII, bypassing agents, and hospitalizations for serious bleeds. Rates of high-titer inhibitor development were obtained from the SIPPET study. Patients developing high-titer inhibitors were treated with immune tolerance induction (ITI). Patients who developed low-titer inhibitors and those who did not develop inhibitors continued their usual FVIII treatment. Patients who were successfully treated with ITI returned to FVIII treatment, while unsuccessfully treated patients received bypassing agents. Total costs per treated patient were estimated and a one-way sensitivity analysis was conducted to quantify the impact of parameter uncertainty on the model outcomes. RESULTS Total cumulative costs per patient over 5 years were $834,621 for pdFVIII/VWF patients and $1,237,163 for rFVIII patients, representing a total saving of $402,542 per patient over the 5-year period, for an average annual saving of $80,508 per patient. CONCLUSIONS Based on data from the SIPPET study, this analysis found that initiating FVIII treatment in severe hemophilia A PUPs with pdFVIII/VWF has the potential to offer substantial cost savings to healthcare payers, amounting to a one-third reduction in costs.
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Affiliation(s)
| | - Robert F Sidonio
- b Emory University and Aflac Cancer and Blood Disorders , Atlanta , GA , USA
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34
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Meta-analysis on incidence of inhibitors in patients with haemophilia A treated with recombinant factor VIII products. Blood Coagul Fibrinolysis 2018; 28:627-637. [PMID: 28678027 DOI: 10.1097/mbc.0000000000000647] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
: Recent cohort studies showed differences in inhibitor incidence in previously untreated patients (PUPs) with haemophilia A treated with recombinant factor VIII (rFVIII) concentrates. We carried out a systematic literature search and meta-analysis for all randomized clinical trials and observational studies published from 1 January 1988 to 31 August 2015, to assess the incidence of inhibitor development and the relationship with rFVIII product used in PUPs and minimally treated patients (MTPs, ≤5 previous exposure days), with severe haemophilia. The primary outcome measure was development of all inhibitors and high-titre inhibitors. We computed pooled meta-analytic estimates according to the rFVIII product used with the inverse-variance method, assuming a fixed, or a random-effects model if significant between-studies heterogeneity was present. Out of 781 articles, 16 published between 1998 and 2015 were included in the meta-analysis, involving a total of 2094 haemophilia A PUPs or MTPs. The pooled estimate of all inhibitors was 0.27 (95% confidence interval 0.23-0.31). No significant difference in pooled inhibitor incidence across products was found (P = 0.72). Meta-analysis of studies reporting inhibitor hazard ratios with different rFVIII products, adjusted to different risk factors, showed that PUPs/MTPs treated with Advate had a pooled inhibitor hazard ratio estimate of 0.63 (95% confidence interval 0.48-0.83) as compared with Kogenate FS. The overall inhibitor incidence in PUPs/MTPs was 27%. Differences between products were found considering hazard ratios in which potential confounders were taken into account.
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Garagiola I, Palla R, Peyvandi F. Risk factors for inhibitor development in severe hemophilia A. Thromb Res 2018; 168:20-27. [DOI: 10.1016/j.thromres.2018.05.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/11/2018] [Accepted: 05/24/2018] [Indexed: 12/21/2022]
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Klukowska A, Komrska V, Vdovin V, Pavlova A, Jansen M, Lowndes S, Belyanskaya L, Walter O, Laguna P. Low incidence of factor VIII inhibitors in previously untreated patients with severe haemophilia A treated with octanate ® : Final report from a prospective study. Haemophilia 2018; 24:221-228. [PMID: 29314439 DOI: 10.1111/hae.13385] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2017] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Octanate® is a human, plasma-derived, von Willebrand factor-stabilized coagulation factor VIII (FVIII) concentrate with demonstrated haemostatic efficacy in previously treated patients with haemophilia A. AIM This prospective, open-label study aimed to assess the immunogenicity of octanate® in previously untreated patients (PUPs). METHODS The study monitored development of FVIII inhibitors in 51 PUPs. Tolerability, viral safety, FVIII recovery and efficacy of octanate® for the prevention and treatment of bleeds and in surgical procedures were also assessed. RESULTS Five (9.8%) of the 51 patients developed inhibitors during the study, 4 of which (7.8%) were high titre. Three inhibitor cases (5.9%) were considered clinically relevant; 2 were transient inhibitors that disappeared during regular octanate® treatment without a change in dose or treatment frequency. Amongst 45 patients with FVIII:C <1% at baseline and who received ≥20 exposure days (EDs) or had <20 EDs but developed an inhibitor, inhibitor incidence was 11.1% (6.7% clinically relevant). All clinically relevant inhibitors developed within 20 EDs of on-demand treatment. No inhibitors developed in PUPs receiving prophylaxis. All patients who developed inhibitors had either intron 22 inversions or large deletions. Irrespective of the reason for administration, haemostatic efficacy was rated as "excellent" in 99.6% of all infusions (4700 of 4717 infusions), and no complications were reported in 23 surgical procedures. Mean incremental in vivo recovery was 2.0%/IU/kg (±0.7) and 1.9%/IU/kg (±0.5) for the first and second assessments, respectively. Tolerability was rated "very good" in 99.9% of infusions. CONCLUSION In PUPs with severe haemophilia A, octanate® demonstrated haemostatic efficacy with a low rate of inhibitor development.
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Affiliation(s)
- A Klukowska
- Department of Paediatrics, Haematology and Oncology, Medical University of Warsaw, Warsaw, Poland
| | - V Komrska
- Motol University Hospital, Prague, Czech Republic
| | - V Vdovin
- Morozovskaya Children's Hospital, Moscow, Russia
| | - A Pavlova
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic, Bonn, Germany
| | | | | | | | - O Walter
- Octapharma AG, Lachen, Switzerland
| | - P Laguna
- Department of Paediatrics, Haematology and Oncology, Medical University of Warsaw, Warsaw, Poland
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Raso S, Hermans C. Lonoctocog alfa (rVIII-SingleChain) for the treatment of haemophilia A. Expert Opin Biol Ther 2017; 18:87-94. [PMID: 29256333 DOI: 10.1080/14712598.2018.1416088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The administration of factor VIII (FVIII) concentrates on-demand or on long-term prophylaxis is the effective and safe standard of care of patients with hemophilia A (HA). Development of neutralizing antibodies against exogenous FVIII and the short half-life of the current available products remain major challenges. There is currently a great interest towards newer FVIII products with the goal of reducing the inhibitor risk and increasing the half-life. Area covered: In this review, the authors describe the efficacy and safety of rVIII-SingleChain (Lonoctocog alfa), the first and only single chain recombinant FVIII (rFVIII) molecule developed for the prevention and treatment of bleeding episodes in HA patients. The pre-clinical and clinical studies of rVIII-SingleChain as well as the results of the AFFINITY trial program in previously treated patients both adults and pediatric are presented and discussed. Expert opinion: The results from PTP studies document the efficacy and safety profile of the rVIII-SingleChain. However, even if rFVIII-SingleChain presents advantageous pharmacokinetic features compared to conventional rFVIII, it should not be considered as an EHL-FVIII while its immunogenicity is currently being studied in PUPs. The slightly better PK profile of rFVIII-SingleChain could however allow a small number of selected patients to be treated with a less intensive regimen.
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Affiliation(s)
- Simona Raso
- a Haemostasis and Thrombosis Unit, Division of Haematology , Cliniques Universitaires Saint-Luc , Brussels , Belgium.,b Division of Haematology, Biomedical Department of Internal Medicine and Specialties (DiBiMIS) , Paolo Giaccone Hospital, University of Palermo , Palermo , Italy
| | - Cedric Hermans
- a Haemostasis and Thrombosis Unit, Division of Haematology , Cliniques Universitaires Saint-Luc , Brussels , Belgium
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Nemes L, Jimenez-Yuste V, Rusen L, Cid A, Charnigo R, Baumann J, Smith L, Korth-Bradley J, Rendo P, Lopez RP. Prospective surveillance study of haemophilia A patients switching from moroctocog alfa or other factor VIII products to moroctocog alfa albumin-free cell culture (AF-CC) in usual care settings. Thromb Haemost 2017; 114:676-84. [DOI: 10.1160/th14-09-0760] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 04/29/2015] [Indexed: 01/21/2023]
Abstract
SummaryThis prospective, open-label, postauthorisation safety surveillance study assessed clinically significant inhibitor development in patients with severe haemophilia A transitioning from moroctocog alfa or other factor VIII (FVIII) replacement products to reformulated moroctocog alfa (AF-CC). Males aged12 years with severe haemophilia A (FVIII:C) < 1 IU/dl), > 150 exposure days (EDs) to recombinant or plasma-derived FVIII products, and no detectable inhibitor at screening were enrolled. Primary end point was the incidence of clinically significant FVIII inhibitor development. Secondary end points included annualised bleeding rate (ABR), less-than-expected therapeutic effect (LETE), and FVIII recovery. Patients were assigned to one of two cohorts based on whether they were transitioning to moroctocog alfa (AF-CC) from moroctocog alfa (cohort 1; n=146) or from another recombinant or plasma-derived FVIII product (cohort 2; n=62). Mean number of EDs on study was 94 (range, 1–139). Six positive FVIII inhibitor results, as determined by local laboratories, were reported in four patients; none were confirmed by a central laboratory, no inhibitor-related clinical manifestations were reported, and all anti-FVIII antibody assays were negative. Median ABRs were 23.4 and 3.4 in patients categorised at baseline as following on-demand and prophylactic regimens, respectively; 86.5 % of bleeding episodes resolved after one infusion. LETE incidence was 0.06 % and 0.19 % in the on-demand and prophylaxis settings, respectively. FVIII recovery remained constant throughout the study. No new safety concerns were identified. This study found no increased risk of clinically significant FVIII inhibitor development in patients transitioning from moroctocog alfa or other FVIII replacement products to moroctocog alfa (AF-CC).
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Cafuir LA, Kempton CL. Current and emerging factor VIII replacement products for hemophilia A. Ther Adv Hematol 2017; 8:303-313. [PMID: 29051801 DOI: 10.1177/2040620717721458] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/22/2017] [Indexed: 12/31/2022] Open
Abstract
Hemophilia A is a congenital X-linked bleeding disorder caused by coagulation factor VIII (FVIII) deficiency. Routine infusion of factor replacement products is the current standard of care; however, the development of alloantibodies against FVIII remains a challenge. The treatment of hemophilia has undergone major advances over the past century to improve safety, effectiveness, manufacturing, and convenience of factor products. Major recent advances in the treatment of hemophilia A include the emergence of extended half-life products, factor VIII orthologs, and gene therapy products. Extended half-life products were designed to decrease the frequency of infusions, but only modest half-life extension is achieved. Factor VIII orthologs featuring lower cross-reactivity with anti-FVIII antibodies may be less susceptible to inactivation by inhibitors. Meanwhile, gene therapy may potentially provide a cure for hemophilia A, thus abrogating the need for protein-based factor replacement. This review aims to discuss current and emerging FVIII replacement products for hemophilia A.
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Affiliation(s)
- Lorraine A Cafuir
- Department of Hematology and Medical Oncology, Emory University School of Medicine, USA
| | - Christine L Kempton
- Department of Hematology and Medical Oncology, Emory University, School of Medicine, 550 Peachtree Street NE, Medical Office Tower, Suite 1035, Atlanta, GA 30308, USA
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Liesner RJ, Abashidze M, Aleinikova O, Altisent C, Belletrutti MJ, Borel-Derlon A, Carcao M, Chambost H, Chan AKC, Dubey L, Ducore J, Fouzia NA, Gattens M, Gruel Y, Guillet B, Kavardakova N, El Khorassani M, Klukowska A, Lambert T, Lohade S, Sigaud M, Turea V, Wu JKM, Vdovin V, Pavlova A, Jansen M, Belyanskaya L, Walter O, Knaub S, Neufeld EJ. Immunogenicity, efficacy and safety of Nuwiq®
(human-cl rhFVIII) in previously untreated patients with severe haemophilia A-Interim results from the NuProtect Study. Haemophilia 2017; 24:211-220. [PMID: 28815880 DOI: 10.1111/hae.13320] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2017] [Indexed: 01/19/2023]
Affiliation(s)
- R. J. Liesner
- Great Ormond Hospital for Children NHS Trust Haemophilia Centre; London UK
| | - M. Abashidze
- JSC Institute of Haematology and Transfusiology; Tbilisi Georgia
| | - O. Aleinikova
- Republican Scientific and Practical Centre of Children Oncology, Hematology and Immunology; Minsk Belarus
| | - C. Altisent
- Unitat d'Hemofilia; Hospital Vall D'Hebron; Barcelona Spain
| | - M. J. Belletrutti
- Pediatric Hematology; Department of Pediatrics; University of Alberta; Edmonton AB Canada
| | | | - M. Carcao
- Hospital for Sick Children; Toronto ON Canada
| | - H. Chambost
- Department of Pediatric Hematology Oncology; Children Hospital La Timone; APHM and Inserm; UMR 1062; Aix Marseille University; Marseille France
| | - A. K. C. Chan
- Division of Pediatric Hematology/Oncology; McMaster University; Hamilton ON Canada
| | - L. Dubey
- Western Ukrainian Specialized Children's Medical Centre; Lviv Ukraine
| | - J. Ducore
- Department of Pediatrics; UC Davis Medical Center; Sacramento CA USA
| | - N. A. Fouzia
- Christian Medical College Vellore; Vellore India
| | - M. Gattens
- Cambridge University Hospital NHS Foundation Trust; Cambridge UK
| | - Y. Gruel
- Hôpital Trousseau; Centre Régional de Traitement de l'Hémophilie; Tours France
| | - B. Guillet
- Haemophilia Treatment Centre of Rennes-Brittany; University Hospital of Rennes; Rennes France
| | - N. Kavardakova
- National Children's Specialized Clinic “OHMATDET”; Kiev Ukraine
| | - M. El Khorassani
- Centre de traitement de l'hémophilie; University Mohamed V; Rabat Morocco
| | | | - T. Lambert
- CRTH Hôpital Universitaire Bicêtre APHP; Le Kremlin Bicêtre France
| | - S. Lohade
- Sahyadri Speciality Hospital; Pune India
| | - M. Sigaud
- Centre Régional de Traitement de I'Hémophilie; University Hospital of Nantes; Nantes France
| | - V. Turea
- Scientific Research Institute of Mother and Child Health Care; Chişinău Moldova
| | - J. K. M. Wu
- B.C. Children's Hospital; Vancouver BC Canada
| | - V. Vdovin
- Morozovskaya Children's Hospital; Moscow Russia
| | - A. Pavlova
- Institute of Experimental Haematology and Transfusion Medicine; University Clinic Bonn; Bonn Germany
| | - M. Jansen
- Octapharma Pharmazeutika Produktionsges.mbH; Vienna Austria
| | | | | | - S. Knaub
- Octapharma AG; Lachen Switzerland
| | - E. J. Neufeld
- St. Jude Children’s Research Hospital; Memphis TN USA
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Jiang L, Liu Y, Zhang L, Santoro C, Rodriguez A. Rituximab for treating inhibitors in people with inherited severe hemophilia. Cochrane Database Syst Rev 2017; 7:CD010810. [PMID: 28685500 PMCID: PMC6483299 DOI: 10.1002/14651858.cd010810.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hemophilia A and B are inherited coagulation disorders characterized by a reduced or absent level of factor VIII or factor IX respectively. The severe form is characterized by a factor level less than 0.01 international units (IU) per milliliter. The development of inhibitors in hemophilia is the main complication of treatment, because the presence of these antibodies, reduces or even nullifies the efficacy of replacement therapy, making it very difficult to control the bleeding. People with inhibitors continue to have significantly higher risks of morbidity and mortality, with considerable treatment costs. Given the wide 'off-label' use of rituximab for treating people with hemophilia and inhibitors, its efficacy and safety need to be evaluated. This is an update of a previously published Cochrane Review. OBJECTIVES To assess the efficacy and safety of rituximab for treating inhibitors in people with inherited severe hemophilia A or B. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, complied from electronic database searches and handsearching of journals and conference abstract books. We searched the reference lists of relevant articles and reviews and also searched for ongoing or unpublished studies. We also undertook further searches of other bibliographic databases and trial registries.Date of last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register: 16 February 2017. SELECTION CRITERIA Randomized controlled trials and controlled clinical trials investigating the efficacy and safety of rituximab for treating inhibitors in people with hemophilia. DATA COLLECTION AND ANALYSIS No randomized controlled trials matching the selection criteria were eligible for inclusion. MAIN RESULTS No randomized controlled trials on rituximab for treating inhibitors in people with hemophilia were identified. AUTHORS' CONCLUSIONS We were unable to identify any relevant trials on the efficacy and safety of rituximab for treating inhibitors in people with hemophilia. The research evidence available is from case reports and case series. Randomized controlled trials are needed to evaluate the efficacy and safety of rituximab for this condition. However, prior to the publication of any possible future randomized controlled trials, meta-analysis of case reports and case series may provide some evidence.
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Affiliation(s)
- Lucan Jiang
- West China Second University Hospital, Sichuan UniversityDepartment of PharmacyNo. 17, Section Three, Ren Min Nan Lu AvenueRoadChengduSichuanChina610041
- Sichuan University, Ministry of EducationKey Laboratory of Birth Defects and Related Diseases of Women and ChildrenChengduChina
- West China Second University Hospital, Sichuan UniversityEvidence‐Based Pharmacy CenterChengduChina
- Sichuan UniversityWest China School of PharmacyChengduChina
| | - Yi Liu
- West China Second University Hospital, Sichuan UniversityDepartment of PharmacyNo. 17, Section Three, Ren Min Nan Lu AvenueRoadChengduSichuanChina610041
- Sichuan University, Ministry of EducationKey Laboratory of Birth Defects and Related Diseases of Women and ChildrenChengduChina
- West China Second University Hospital, Sichuan UniversityEvidence‐Based Pharmacy CenterChengduChina
- Sichuan UniversityWest China School of PharmacyChengduChina
| | - Lingli Zhang
- West China Second University Hospital, Sichuan UniversityDepartment of PharmacyNo. 17, Section Three, Ren Min Nan Lu AvenueRoadChengduSichuanChina610041
- Sichuan University, Ministry of EducationKey Laboratory of Birth Defects and Related Diseases of Women and ChildrenChengduChina
- West China Second University Hospital, Sichuan UniversityEvidence‐Based Pharmacy CenterChengduChina
| | - Cristina Santoro
- Sapienza University of RomeDepartment of Cellular Biotechnology and HematologyVia Benevento 6RomeItaly00161
| | - Armando Rodriguez
- Association for the Promotion of Multimedia EducationBa?ćanska 6ZagrebCroatia10110
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Hartholt RB, van Velzen AS, Peyron I, Ten Brinke A, Fijnvandraat K, Voorberg J. To serve and protect: The modulatory role of von Willebrand factor on factor VIII immunogenicity. Blood Rev 2017; 31:339-347. [PMID: 28716211 DOI: 10.1016/j.blre.2017.07.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 05/26/2017] [Accepted: 07/03/2017] [Indexed: 12/23/2022]
Abstract
Hemophilia A is a bleeding disorder characterized by the absence or dysfunction of blood coagulation factor VIII (FVIII). Patients are treated with regular infusions of FVIII concentrate. In response to treatment, approximately 30% of patients with severe hemophilia A develop inhibitory antibodies targeting FVIII. Both patient and treatment related risk factors for inhibitor development have been described. Multiple studies comparing the immunogenicity of recombinant and plasma-derived FVIII have yielded conflicting results. The randomized controlled SIPPET (Survey of Inhibitors in Plasma-Product Exposed Toddlers) trial demonstrated an increased risk of inhibitor development of recombinant FVIII when compared to von Willebrand factor (VWF)-containing plasma-derived FVIII. Presently, it is unclear which mechanism underlies the reduced immunogenicity of plasma-derived FVIII. In this review we address the potential role of VWF on FVIII immunogenicity and we discuss how VWF affects the immune recognition, processing and presentation of FVIII. We also briefly discuss the potential impact of glycan-composition on FVIII immunogenicity. It is well established that VWF shields the uptake of FVIII by antigen presenting cells. We have recently shown that VWF binds to the surface of dendritic cells. Here, we present a novel model in which surface bound FVIII-VWF complexes regulate the internalization of FVIII. Binding of FVIII to VWF is critically dependent on sulfation of Tyr1699 (HVGS numbering) in the light chain of FVIII. Incomplete sulfation of Tyr1699 has been suggested to occur in several recombinant FVIII products resulting in a loss of VWF binding. We hypothesize that this results in alternative pathways of FVIII internalization by antigen presenting cells which are not regulated by VWF. This hypothetical mechanism may explain the reduced immunogenicity of VWF containing plasma-derived FVIII concentrates as found in the SIPPET study.
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Affiliation(s)
- Robin B Hartholt
- Department of Plasma Proteins, Sanquin Research, Plesmanlaan 125, 1066 CX Amsterdam, The Netherlands.
| | - Alice S van Velzen
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands.
| | - Ivan Peyron
- Department of Plasma Proteins, Sanquin Research, Plesmanlaan 125, 1066 CX Amsterdam, The Netherlands.
| | - Anja Ten Brinke
- Department of Plasma Proteins, Sanquin Research, Plesmanlaan 125, 1066 CX Amsterdam, The Netherlands.
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands.
| | - Jan Voorberg
- Department of Plasma Proteins, Sanquin Research, Plesmanlaan 125, 1066 CX Amsterdam, The Netherlands.
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van Velzen AS, Eckhardt CL, Peters M, Leebeek FWG, Escuriola-Ettingshausen C, Hermans C, Keenan R, Astermark J, Male C, Peerlinck K, le Cessie S, van der Bom JG, Fijnvandraat K. Intensity of factor VIII treatment and the development of inhibitors in non-severe hemophilia A patients: results of the INSIGHT case-control study. J Thromb Haemost 2017; 15:1422-1429. [PMID: 28440011 DOI: 10.1111/jth.13711] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Indexed: 12/14/2022]
Abstract
Essentials Research suggests that intensive treatment episodes may increase the risk to develop inhibitors. We performed an international nested case-control study with 298 non-severe hemophilia A patients. Surgery and a high dose of factor VIII concentrate were associated with increased inhibitor risk. Physicians need to review arguments for factor VIII dose and elective surgery extra critically. SUMMARY Background Inhibitor development is a major complication of treatment with factor VIII concentrates in hemophilia. Findings from studies among severe hemophilia A patients suggest that intensive treatment episodes increase the risk of developing inhibitors. Objectives We set out to assess whether intensive treatment is also associated with an increased risk of inhibitor development among non-severe hemophilia A patients. Patients/Methods We performed a nested case-control study. A total of 75 inhibitor patients (cases) and 223 control patients were selected from 2709 non-severe hemophilia A patients (FVIII:C, 2-40%) of the INSIGHT cohort study. Cases and controls were matched for date of birth and cumulative number of exposure days (EDs) to FVIII concentrates. Conditional logistic regression was used to calculate both unadjusted and adjusted odds ratios (aOR); the latter were adjusted for a priori specified confounders. Results Peak treatment of 5 or 10 consecutive EDs did not increase inhibitor risk (aOR, 1.0; 95% confidence interval (CI), 0.4-2.5; and aOR, 1.8; CI, 0.6-5.5, respectively). Both surgical intervention (aOR, 4.2; CI, 1.7-10.3) and a high mean dose (> 45 IU kg-1 /ED) of FVIII concentrate (aOR, 7.5; CI, 1.6-35.6) were associated with an increased inhibitor risk. Conclusions Our findings suggest that high-dose FVIII treatment and surgery increase the risk of inhibitor development in non-severe hemophilia A. Together with the notion that non-severe hemophilia A patients are at a lifelong risk of inhibitor development, we suggest that in the future physicians will review the arguments for the FVIII dose and elective surgery extra critically.
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Affiliation(s)
- A S van Velzen
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - C L Eckhardt
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - M Peters
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - F W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - C Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, St-Luc University Hospital, Brussels, Belgium
| | - R Keenan
- Liverpool Paediatric Haemophilia Centre, Haematology Treatment Centre, Alderhey Childrens Hospital, Liverpool, UK
| | - J Astermark
- Centre for Thrombosis and Haemostasis, Lund University, Skåne University Hospital Malmö, Malmo, Sweden
| | - C Male
- Universitätsklinik für Kinder- und Jugendheilkunde, Medical University of Vienna, Vienna, Austria
| | - K Peerlinck
- Department of Vascular Medicine and Haemostasis, University of Leuven, Leuven, Belgium
| | - S le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - J G van der Bom
- Center for Clinical Transfusion Research, Sanquin Research and Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - K Fijnvandraat
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
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Wang SX, Yang RC. [Advances in Hemophilia A inhibitors]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 38:444-448. [PMID: 28565748 PMCID: PMC7354181 DOI: 10.3760/cma.j.issn.0253-2727.2017.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Indexed: 01/19/2023]
Affiliation(s)
| | - R C Yang
- Institute of Hematology & Blood Disease Hospital, CAMS & PUMC, Tianjin 300020, China
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Peyvandi F, Ettingshausen CE, Goudemand J, Jiménez-Yuste V, Santagostino E, Makris M. New findings on inhibitor development: from registries to clinical studies. Haemophilia 2017; 23 Suppl 1:4-13. [PMID: 27990784 DOI: 10.1111/hae.13137] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2016] [Indexed: 02/06/2023]
Abstract
The high incidence of inhibitors against factor VIII (FVIII) concentrates in patients with haemophilia A has encouraged debate as to whether product-type plays a role. There is debate in the literature as to whether rFVIII concentrates are associated with a higher incidence of inhibitors compared to pdFVIII products. The management of haemophilia in patients with inhibitors includes on-demand/prophylaxis treatment with bypassing agents, and/or immune tolerance induction (ITI). However, these options create an economic and emotional burden on patients, their families and healthcare practitioners. Although ITI eliminates inhibitors successfully in 60-80% of cases, it is costly. Despite high costs, preliminary data from a decision analytical model have indicated that ITI is economically advantageous compared with on-demand/prophylactic treatment with bypassing agents. In patients with persistent inhibitors and those who are not candidates for ITI or have failed ITI, bleeding-related mortality and morbidity increase and quality of life decreases, compared with non-inhibitor patients. This article provides an update on the risk of inhibitor development and discusses best management approaches for patients with high-risk factors for inhibitor development.
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Affiliation(s)
- F Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | | | - J Goudemand
- School of Medicine, University of Lille, Lille, France
| | - V Jiménez-Yuste
- Department of Haematology, Autónoma University Madrid and La Paz University Hospital, Madrid, Spain
| | - E Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - M Makris
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, United Kingdom
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Shima M, Lillicrap D, Kruse-Jarres R. Alternative therapies for the management of inhibitors. Haemophilia 2017; 22 Suppl 5:36-41. [PMID: 27405674 DOI: 10.1111/hae.13005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2016] [Indexed: 12/21/2022]
Abstract
The development of inhibitors to factor VIII (FVIII) or factor IX (FIX) remains a major treatment complication encountered in the treatment of haemophilia. Not all patients with even the same severity and genotype develop inhibitors suggesting an underlying mechanism of tolerance against FVIII- or FIX-related immunity. One mechanism may be central tolerance observed in patients in whom the FVIII mutation enables some production of the protein. The other is a peripheral tolerance mechanism which may be evident in patients with null mutation. Recently, recombinant porcine FVIII (rpFVIII, Obixur, OBI-1, BAX801) has been developed for the haemostatic treatment of both congenital haemophilia with inhibitor (CHAWI) and acquired haemophilia A (AHA). In 28 subjects with AHA with life-/limb-threatening bleeding, rpFVIII reduced or stopped bleeding in all patients within 24 h. The cross-reactivity of anti-human FVIII antibodies to rpFVIII remains around 30-50%. Recently, new therapeutics based on the quite novel concepts have been developed and clinical studies are ongoing. These are humanized asymmetric antibody mimicking FVIIIa function by maintaining a suitable interaction between FIXa and FX (Emicizumab, ACE910), and small interfering RNAs (siRNA, ALN-AT3) suppress liver production of AT through post-transcriptional gene silencing and a humanized anti-TFPI monoclonal antibody (Concizumab). Their main advantages are longer half-life, subcutaneous applicability and efficacy irrespective of the presence of inhibitors which will make it easier to initiate more effective treatment especially early childhood.
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Affiliation(s)
- M Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - D Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - R Kruse-Jarres
- Washington Center for Bleeding Disorders at Bloodworks NW, University of Washington, Seattle, WA, USA
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Iorio A, Barbara AM, Makris M, Fischer K, Castaman G, Catarino C, Gilman E, Kavakli K, Lambert T, Lassila R, Lissitchkov T, Mauser-Bunschoten E, Mingot-Castellano ME, Ozdemir N, Pabinger I, Parra R, Pasi J, Peerlinck K, Rauch A, Roussel-Robert V, Serban M, Tagliaferri A, Windyga J, Zanon E. Natural history and clinical characteristics of inhibitors in previously treated haemophilia A patients: a case series. Haemophilia 2017; 23:255-263. [PMID: 28205285 DOI: 10.1111/hae.13167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Development of inhibitors is the most serious complication in haemophilia A treatment. The assessment of risk for inhibitor formation in new or modified factor concentrates is traditionally performed in previously treated patients (PTPs). However, evidence on risk factors for and natural history of inhibitors has been generated mostly in previously untreated patients (PUPs). The purpose of this study was to examine cases of de novo inhibitors in PTPs reported in the scientific literature and to the EUropean HAemophilia Safety Surveillance (EUHASS) programme, and explore determinants and course of inhibitor development. METHODS We used a case series study design and developed a case report form to collect patient level data; including detection, inhibitor course, treatment, factor VIII products used and events that may trigger inhibitor development (surgery, vaccination, immune disorders, malignancy, product switch). RESULTS We identified 19 publications that reported 38 inhibitor cases and 45 cases from 31 EUHASS centres. Individual patient data were collected for 55/83 (66%) inhibitor cases out of 12 330 patients. The median (range) peak inhibitor titre was 4.4 (0.5-135.0), the proportion of transient inhibitors was 33% and only two cases of 12 undergoing immune tolerance induction failed this treatment. In the two months before inhibitor development, surgery was reported in nine (22%) cases, and high intensity treatment periods reported in seven (17%) cases. CONCLUSIONS By studying the largest cohort of inhibitor development in PTPs assembled to date, we showed that inhibitor development in PTPs, is on average, a milder event than in PUPs.
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Affiliation(s)
- A Iorio
- Department of Clinical Epidemiology and Biostastics, McMaster University, Hamilton, ON, Canada
| | - A M Barbara
- Department of Clinical Epidemiology and Biostastics, McMaster University, Hamilton, ON, Canada
| | - M Makris
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - K Fischer
- Van Creveldkliniek University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - C Catarino
- Congenital Coagulopathies Centre, Santa Maria Hospital, Lisbon, Portugal
| | - E Gilman
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - K Kavakli
- Department of Pediatric Hematology, Ege University Children's Hospital, Izmir, Turkey
| | - T Lambert
- Centre de traitement des Hemophiles de Bicetre, Paris, France
| | - R Lassila
- Department of Hematology, Cancer Center, Helsinki University Hospital, Helsinki, Finland
| | | | - E Mauser-Bunschoten
- Van Creveldkliniek University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - N Ozdemir
- Istanbul University Haemophilia Centre, Istanbul, Turkey
| | - I Pabinger
- Department of Medicine I, Haemophilia Centre, Medical University of Vienna, Vienna, Austria
| | - R Parra
- Hospital Vall d'Hebron, Barcelona, Spain
| | - J Pasi
- Barts and the London School of Medicine, London, UK
| | - K Peerlinck
- Haemophilia Center, Universitaire Ziekenhuis Gasthuisberg, Leuven, Belgium
| | - A Rauch
- Département d'Hématologie Transfusion, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - V Roussel-Robert
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | | | - A Tagliaferri
- European Haemophilia Center, Paediatric Clinical Emergency Hospital Louis Turcanu, Timisoara, Romania
| | - J Windyga
- Department of Disorders of Haemostasis and Internal Medicine, Institute of Haematology & Transfusion Medicine, Warsaw, Poland
| | - E Zanon
- Haemophilia Centre, Azienda Universitaria Ospedaliera di Padova, Padova, Italy
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50
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van den Berg HM, Pipe S, Ljung R. Plasma products do not solve the inhibitor problem. Haemophilia 2016; 23:346-347. [DOI: 10.1111/hae.13132] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2016] [Indexed: 11/29/2022]
Affiliation(s)
- H. M. van den Berg
- Julius Centre for Health Sciences and Primary Care; University Hospital Utrecht; Utrecht The Netherlands
| | - S. Pipe
- Pediatrics; Univ. of Michigan; Ann Arbor MI USA
| | - R. Ljung
- Pediatrics; University of Lund; Malmö Sweden
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