Off-label use of recombinant factor VIIa in patients following bone marrow transplantation

Ineffective off-label use of recombinant activated factor VII in a case of bone-marrow transplantation-related gastrointestinal bleeding

BACKGROUND

For patients with a normal coagulation system, who experience serious bleeding, sound evidence for recombinant activated factor VII (rFVIIa) as an effective haemostatic agent is only scarcely available so far from controlled clinical trials. In systematic reviews on the clinical use of rFVIIa, treatment failures were only rarely reported.

CASE PRESENTATION

We present a 45-year old, Caucasian male with persistent intestinal bleeding due to enterocolitis associated with cytomegalovirus infection and acute graft-versus-host-disease. He had received allogeneic peripheral blood stem cell transplantation from an unrelated HLA-identical donor because of chronic myelogenous leukaemia diagnosed two years earlier. Bleeding started at day 18 after transplantation with bloody diarrhea, which was treated with multiple transfusions of fresh frozen plasma, platelet, and red blood cell concentrates, and continued relentlessly, despite all efforts, including continued transfusions, high-dose prednisolone, broad antibiotic and antiviral coverage, and tranexamic acid. Recombinant FVIIa was started at boluses of 90-120 mug/kg every 4-8 hours. Despite more than 10 doses, recurrent severe bleeding progressed to refractory shock, multiorgan failure and death.

CONCLUSIONS

Little can be concluded from single case reports of clinical improvement, because publication bias in favour of positive effects is likely. Our case suggests that rFVIIa is not a panacea, in particular for severe bleeding after bone-marrow transplantation. As long as rigorous, controlled studies or comprehensive registries are lacking, conventional interventions remain the standard of care in non-haemophilic patients with severe bleeding.

Emerging Off-Label Uses for Recombinant Activated Factor VII: Grading the Evidence

Recombinant activated factor VII (rFVIIa) is currently licensed in the United States for treatment of bleeding episodes in patients with deficiencies of factor VIII (FVIII) or IX (FIX) who are refractory to factor replacement because of circulating inhibitors. A 1999 report of its successful use to stop what was deemed to be lethal hemorrhage after an abdominal gunshot wound in a young soldier without pre-existing coagulopathy has prompted exploration of other uses for rFVIIa. The virtual explosion of proposed uses of rFVIIa raises issues not only regarding our understanding of the coagulation system, but also regarding its efficacy, cost-effectiveness, and safety.

Use of Recombinant Activated Factor VII to Treat the Acquired Coagulopathy of Trauma

Recombinant activated factor VII (rFVIIa) is a drug commonly utilized in the treatment of patients with hemophilia and inhibitors. However, its use in previously normal patients with an acquired coagulopathy after trauma and surgery is increasing. Multiple trauma case reports and several case series are available, lending support for the efficacy of the drug in reversing the coagulopathy of trauma. Data from six large animal studies evaluating the efficacy in trauma models are available for evaluation. A single prospective randomized study in elective surgery has recently been published, documenting reduced blood loss and decreased transfusion after a single preoperative dose. This review describes those studies and reiterates the need for well designed prospective randomized human trauma studies.

Eficacia del factor VII activado en la hemorragia poscirugía cardíaca y oxigenación con membrana extracorpórea

A 4-year-old girl suffered severe postoperative chest tube drainage bleeding after cardiac transplant surgery requiring extracorporeal membrane oxygenation. Transfusions of platelets and fresh frozen plasma failed to decrease the bleeding. At 2.5 hours a dose of 180 mcg/kg of recombinant activated Factor VII was administered. The hemorrhage decreased from 45 ml/kg/h in the first 2.5 hours to 17 ml/kg/h in the next 2.5 hours. The same dose of recombinant activated Factor VII was administered and the hemorrhage suddenly decreased to 1.5 ml/kg/h in the next 2.5 hours, with subsequent disappearance. No adverse events related to activated Factor VII were observed. Recombinant activated Factor VII may be useful in some cases of severe postoperative bleeding in children after cardiac surgery. Randomized controlled studies are needed to confirm its safety and efficacy, and to evaluate the most suitable dose.

Recombinant activated factor VII in patients with cancer and hemorrhagic disseminated intravascular coagulation

Hemorrhagic disseminated intravascular coagulation (DIC) associated with the presence of underlying advanced or metastatic tumors are often difficult to control by conventional methods. We report the use of recombinant activated factor VII (rFVIIa) in patients with cancer and bleeding secondary to DIC. A total of 18 patients with cancer met pre-defined criteria for DIC. All patients had failed to respond to transfusion with blood products and treatment of the underlying malignancy prior to the introduction of rFVIIa. The median laboratory data at the time of treatment with rFVIIa were as follows: hemoglobin, 7.7 g/dl; platelets, 54 x 10(9)/l; prothrombin time, 21 s; activated partial thromboplastin time, 41 s fibrinogen, 83 mg/dl; D-dimer, 17 microg/ml; and antithrombin, 32%. The dose of rFVIIa was 90 microg/kg and the median number of doses administered was 5 (range, 3-10). Serial measurements of coagulation parameters were obtained at frequent intervals during treatment with rFVIIa. Of the 18 patients, 15 responded with cessation of bleeding and improvement in coagulation data. The prothrombin time and activated partial thromboplastin time normalized in all responding patients within 24 h of treatment. The median fibrinogen was 214 mg/dl while the median D-dimer was 6 microg/dl at 48 h following the administration of rFVIIa. No thromboembolic complications were observed following rFVIIa. Our data provide evidence that rFVIIa can be used successfully to control the hemorrhagic episodes associated with DIC. Although this type of treatment appears to be safe, close monitoring of the patients is warranted.

Use of recombinant activated factor VII for bleeding in pancreatitis: a case series

OBJECTIVES

To describe the effects of recombinant activated factor VII (rFVIIa) in the treatment of bleeding in a series of patients with acute or chronic pancreatitis.

METHODS

Twelve patients (age, 2.5-65 years) with pancreatitis and bleeding were treated with 18.5 to 120 microg/kg of rFVIIa. Eight patients also had sepsis/infection and/or disseminated intravascular coagulation (DIC). The effects of rFVIIa on bleeding, coagulation status, and transfusion requirements were noted.

RESULTS

Bleeding stopped in 4 patients, was markedly reduced in 4 patients, was reduced in 3 patients, and was remained unchanged in 1 patient. For most patients with pre- and post-rFVIIa data, coagulation parameters improved and transfusion requirements reduced. No thrombotic adverse events occurred. Seven patients died for reasons considered to be unrelated to rFVIIa treatment.

CONCLUSIONS

This case series indicates that rFVIIa may be an effective hemostatic treatment of patients with pancreatitis suffering from massive bleeding. There were no thromboembolic events in any patient, including those with sepsis or DIC.

Efficacy and safety of recombinant factor VIIa for treatment of severe bleeding: A systematic review

BACKGROUND

Recombinant activated factor VII (factor VIIa) is a prohemostatic agent that can be used for patients with complicated coagulation disorders. Recombinant factor VIIa is, however, increasingly used for several other indications, including patients with a preexistent normal coagulation system but who experience serious bleeding, for example, after major surgery or trauma.

DATA SOURCE

We performed a systematic review of all published and unpublished clinical studies using MEDLINE (1966-2004) and all other sources available to assess the available evidence on the efficacy and safety of recombinant factor VIIa in patients with or without coagulation disorders.

STUDY SELECTION

We found 483 articles related to the pharmacologic use of recombinant factor VIIa, including 28 clinical trials, 124 case series, and 176 case reports, which were all considered for this review.

DATA SYNTHESIS

Recombinant factor VIIa is an effective and relatively potent prohemostatic agent in approximately 90% of patients with hemophilia and inhibiting antibodies and other types of complex coagulation disorders. The application of recombinant factor VIIa in other patients who experience severe bleeding is promising, and although sound evidence from controlled clinical trials is only scarcely available so far, forthcoming trials are likely to provide more substantiation for this use. Recombinant factor VIIa appears to be relatively safe with a 1-2% incidence of thrombotic complications based on published trials.

CONCLUSIONS

More randomized controlled clinical trials are required to assess the efficacy and safety of recombinant factor VIIa for patients without a preexistent coagulation disorder and with severe bleeding. In the meantime, off-label use of recombinant factor VIIa may be considered in patients with life-threatening bleeding.

Recombinant activated factor VII for severe gastrointestinal bleeding after chemotherapy in an infant with acute megakaryoblastic leukemia

Recombinant activated factor VII (rFVIIa) is a major alternative for management of hemophiliac patients with inhibitors. Additionally, it has been used off-label for the treatment of massive life-threatening hemorrhage associated with various bleeding situations. Herein, we describe a 16-month-old boy with acute megakaryoblastic leukemia and severe intractable gastrointestinal bleeding controlled by rFVIIa. rFVIIa should be considered as a novel treatment alternative in severe bleeding conditions including leukemias that may have hemostatic defects and platelet dysfunction.

Projecting future drug expenditures—2005

PURPOSE

Drug expenditure trends in 2003 and 2004 and projected drug expenditures for 2005 are discussed.

SUMMARY

Various factors are likely to affect drug costs, including drug prices, drugs in development, and generic drugs. In 2003 there was a continued moderation of the increase in drug expenditures. Drug expenditures increased by 11.4% from 2002 to 2003. Through the first nine months of 2004, expenditures increased by only 8.7% compared with 2003. This moderation can be attributed to many factors, particularly patent expirations, prescription-to-nonprescription conversions and a continued slowdown in new drug approvals. Higher cost sharing for consumers and continued weaknesses in several sectors of the U.S. economy affecting employment levels and insurance coverage also contributed to this smaller increase in drug utilization. It is expected that 2005 drug expenditure growth will out-pace the growth in overall health care expenditures and growth in the economy.

CONCLUSION

In 2005, there should be a 10-12% increase in drug expenditures in outpatient settings, a 12-15% increase in clinics, and a 6-9% increase in hospitals.

Immediate haemostasis with recombinant factor VIIa for haemorrhage following Hickman line insertion in acute myeloid leukaemia

Bleeding following Hickman line insertion is not uncommon but can be life threatening, especially in the presence of coagulopathy and thrombocytopenia following chemotherapy. Treatment to control the bleeding can be challenging and treatment options are limited. We present our experience of a patient who had persisting haemorrhage immediately following Hickman line insertion for administration of chemotherapy for relapsed acute myeloid leukaemia. Haemostasis could not be achieved after FFP and platelet administration. A single dose of recombinant factor VIIa (rhFVIIa) stopped the bleeding immediately, avoiding the need for surgical intervention or line removal. Our experience indicates rhFVIIa may be an effective option for bleeding related to Hickman line insertion.

Use of recombinant factor VIIa, Novo Seven, in the management of acute haemorrhage

PURPOSE OF REVIEW

The purpose of this paper is to propose the use of factor VIIa in treating severely bleeding patients.

RECENT FINDINGS

Recombinant factor VIIa was developed in 1988 to treat patients with haemophilia A or B and antibodies against factors VIII and IX, or patients with a spontaneous inhibitor against factors VIII and IX. Since then factor VIIa has been shown to be very effective in treating many other bleeding disorders, such as diverse thrombocytopathias, antibodies against other coagulation proteins like factor V, and bleeding as a result of oral anticoagulation.

SUMMARY

Recombinant factor VIIa may be the universal haemostatic agent, but further studies are needed to prove this.

Platelet membrane fragments enhance the procoagulant effect of recombinant factor VIIa in studies with circulating human blood under conditions of experimental thrombocytopenia

The mechanism of action of recombinant factor VIIa (rFVIIa), which is being considered as an alternative treatment for the control of bleeding episodes in patients with thrombocytopenia, has not been fully characterized. This study was undertaken to explore the effects of rFVIIa and platelet microvesicles on hemostasis in an experimental model of thrombocytopenia. Damaged arterial segments were exposed to thrombocytopenic blood (shear rate 600 s(-1)) either with or without the addition of rFVIIa and/or platelet microvesicles. The presence of fibrin and platelets on the subendothelium were morphometrically quantified and immunolocalization techniques and electron microscopy were used for a more detailed analysis. Both rFVIIa and platelet microvesicles consistently improved fibrin formation on the damaged vascular subendothelium, and microvesicles were shown to be localized at different levels of the fibrin lattice. Further, under conditions of moderate thrombocytopenia, addition of platelet microvesicles potentiated the procoagulant action of rFVIIa. This effect may be due to the phospholipid surface provided by the platelet microvesicles. These studies support the concept that, under conditions of thrombocytopenia, both rFVIIa and platelet microvesicles enhance fibrin formation at sites of vascular damage.

Safety profile of recombinant factor VIIa

Recombinant factor VIIa (rFVIIa; NovoSeven(R), Novo Nordisk, Bagsvaerd, Denmark) has been used for many years in the successful management of bleeding episodes in patients with hemophilia and inhibitors. More recently, rFVIIa has also shown considerable success as a hemostatic agent in trauma and surgery patients without pre-existing coagulopathy. Despite extensive and varied usage of rFVIIa, the incidence of serious adverse events associated with its use is less than 1%; however, there remain concerns regarding the agent's potential to induce thrombosis. This paper will review the safety profile of rFVIIa by examining existing clinical evidence, and will demonstrate that the isolated thrombotic events reported following rFVIIa treatment are due primarily to an improvement in the coagulation mechanism rather than rFVIIa treatment per se. The demonstrated safety of rFVIIa is probably due to its localization to injured areas of the vascular tree by binding to tissue factor (TF) and activated platelets at the bleeding site, thus avoiding systemic activation of coagulation. Finally, those situations in which rFVIIa therapy may not be safe, such as disseminated intravascular coagulation (DIC) and sepsis, will also be discussed.

Recombinant activated factor VII for life-threatening pulmonary hemorrhage after pediatric cardiac surgery

OBJECTIVE

To report intractable life-threatening pulmonary hemorrhage after cardiac surgery in an infant who was treated successfully with recombinant activated factor VII (rFVIIa).

DESIGN

Descriptive case report.

SETTING

An 18-bed pediatric intensive care unit at a tertiary-care children's hospital.

PATIENT

A 10-wk-old child with acute life-threatening pulmonary hemorrhage after cardiac surgery.

INTERVENTIONS

General supportive intensive care.

MEASUREMENTS AND MAIN RESULTS

Care included mechanical ventilatory support, inotropic support, and concurrent treatment with blood products (packed cells, platelet concentrates, and plasma-derived products), as well as aprotinin and desmopressin to improve hemostasis. The addition of rFVIIa resulted in complete resolution of the hemorrhage.

CONCLUSIONS

rFVIIa should be considered as a possible novel therapeutic approach to be used as rescue therapy for patients presenting with massive life-threatening hemorrhage progressing into hemorrhagic shock. Further controlled trials to elucidate the safety of this treatment are warranted.

Increased local procoagulant action: a mechanism contributing to the favorable hemostatic effect of recombinant FVIIa in PLT disorders

BACKGROUND

Recombinant FVIIa (rFVIIa) has been shown to improve hemostasis in patients with thrombocytopenia and to prevent or control bleeding episodes in patients with inherited deficiencies of major PLT glycoproteins, but the mechanism of action is not well understood.

STUDY DESIGN AND METHODS

Effects of rFVIIa on hemostasis were explored with an in vitro perfusion technique. Blood samples, from healthy donors or from patients with congenital defects of PLT glycoprotein IIb-IIIa (GPIIb-IIIa), were anticoagulated with low-molecular-weight heparin. Experimental thrombocytopenia (<6000 PLTs/microL) was induced by a filtration procedure. rFVIIa was added to blood samples at therapeutic concentrations. A severe GPIIb-IIIa impairment was also induced by exposure of normal blood samples to a specific antibody. Perfusion studies were performed through annular chambers containing damaged vascular segments. The presence of fibrin and PLTs on the perfused subendothelium was morphometrically quantified.

RESULTS

Under conditions of experimental thrombocytopenia, addition of rFVIIa enhanced fibrin formation in a dose-dependent manner (p < 0.05). Improvements in local fibrin generation and partial restoration of PLT interactions were also observed after incubation of blood from patients with Glanzmann's thrombasthenia with rFVIIa at 5 microg per mL (180 microg/kg). Similar improvements were observed in blood samples incubated with antibodies to GPIIb-IIIa. rFVIIa in whole normal blood also enhanced fibrin formation but PLT deposition was unaffected. Evaluation of prothrombin fragments 1 and 2 in the perfusates confirmed that rFVIIa increased thrombin generation in all cases.

CONCLUSION

Our data indicate that rFVIIa promotes a procoagulant activity at sites of vascular damage. This mechanism could explain the beneficial hemostatic effect of rFVIIa in patients with thrombocytopenia or with Glanzmann's thrombasthenia.

Modulation of endothelial cell inflammatory integrins and stress markers with rh-factor VIIa in patients with advanced chronic hepatitis C

Individuals with chronic hepatitis C (CHC) progress to cirrhosis and hepatic cancer. Individuals with advanced CHC are coagulopathic and can manifest fibrinolysis. The coagulopathy is a consequence of hepatocytic dysfunction. The fibrinolysis represents a response to local endothelial cell injury, and is of a low-grade. Based upon this hypothesis, the effect of the infusion of recombinant human factor VIIa (rh-FVIIa) on endothelial cell inflammatory integrins and measures of endothelial stress were determined in 17 individuals with advanced CHC. Immediately prior to the infusion of rh-FVIIa, the plasma levels of tissue factor (TF), Thrombomodulin (TM), human soluble ICAM-1 (hs-ICAM-1), human soluble VCAM-1 (hs-VCAM-1), human soluble L-Selectin (hs-L-Selectin), the prothrombin time and the activated partial thromboplastin time were determined. The same parameters were assayed at 5, 10, 30, 120, 240 and 360 min after infusion. TF and TM levels were very high at baseline consistent with a vascular endothelial stress response. Similarly hs-ICAM-1, hs-VCAM-1 as well as L-Selectin levels were increased. Thirty minutes after the infusion, a marked reduction in ICAM-1 and VCAM-1 and to a lesser degree L-Selectin levels was observed. This reduction persisted for 360 min. No change in measures of fibrinolysis [plasminogen activator inhibitor-1 (PAI-1), total tissue factor pathway inhibitor (t-TFPI), activated tissue factor pathway inhibitor (TFPIa), d-dimers (DD), FSP and fibrinogen levels] occurred. In addition, no change in plasma Annexin-V was observed. Based upon these data it can be concluded that: (1) rh-FVIIa corrects the coagulopathy seen in advanced CHC; (2) reduces endothelial cell injury and/or stress as evidenced by the TF, TM, hs-ICAM-1 and hs-VCAM-1 levels in plasma; (3) these changes in coagulation occurred without inducing a propagated vascular thrombosis.

Treatment of diffuse alveolar hemorrhage after allogeneic bone marrow transplant with recombinant factor VIIa

Diffuse alveolar hemorrhage (DAH) is a potentially life-threatening pulmonary toxicity that occurs in 1-21% of patients following bone marrow transplantation. The syndrome is associated with a high mortality rate; and current treatment options are limited. Recombinant factor VIIa (rFVIIa, Novoseven) has recently been approved for the treatment of bleeding in patients with hemophilia A/B with inhibitors. A greater understanding of the mechanism by which rFVIIa restores hemostasis has recently become available; with in vitro evidence supporting that the thrombin burst achieved by rFVIIa is independent of the presence or binding to tissue factor. This insight has suggested a range of other potential clinical uses for the drug; including the setting of pulmonary hemorrhage. We review our experience with using rFVIIa for treatment of DAH in a patient with acute myelogenous leukemia following a matched unrelated donor bone marrow transplant. Boluses of 90 microg/kg rFVIIa were given every 3 h x 4 doses/day, concurrently with high-dose corticosteroids and maintenance of a platelet count >50 000/mm(3). Rapid clinical and radiological improvement was noted within several doses of rFVIIa, with discontinuation of the drug after eight doses. However, the patient's clinical condition began to rapidly deteriorate following cessation of rVIIa, resulting in reinstitution of therapy 24 h later. The patient again exhibited rapid clinical improvement; and rFVIIa was continued for an additional 16 doses with no further evidence of pulmonary hemorrhage noted. No toxicity or adverse events were observed with rFVIIa treatment. Our experience indicates that rFVIIa may be an effective treatment option for DAH post bone marrow transplant; although further clinical studies are needed before recommendations can be made regarding off label use of rFVIIa in this clinical setting.

Factor XIII replacement in stem-cell transplant recipients with severe hemorrhagic cystitis: a report of four cases

BACKGROUND

Hemorrhagic cystitis (HC) is an important cause of morbidity in patients undergoing allogeneic stem-cell transplantation (SCT). Various causes have been identified, such as the use of high-dose cyclophosphamide or busulfan and the occurrence of acute graft-versus-host disease or viral infections (cytomegalovirus, adenovirus, polyomavirus).

METHODS

The clinical course of four patients treated with factor XIII (FXIII) concentrate for severe HC after allogeneic SCT is described.

RESULTS

Four patients were treated with one or two infusions of 50 IU/kg of FXIII concentrate. Only one patient showed a plasmatic FXIII decrease before treatment. Three of the four patients responded to this treatment, and HC completely resolved in two of them. No adverse event was observed.

CONCLUSION

The use of FXIII concentrate can improve the major symptoms of HC in patients with decreased or normal FXIII plasma level after allogeneic SCT.