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Nakar C, Shapiro A. Hemophilia A with inhibitor: Immune tolerance induction (ITI) in the mirror of time. Transfus Apher Sci 2019; 58:578-589. [PMID: 31447396 DOI: 10.1016/j.transci.2019.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Inhibitor (neutralizing antibodies) development remains the most significant complication in patients with severe congenital hemophilia A receiving exogenous factor VIII (FVIII). Although our understanding of the pathophysiology of inhibitor development has advanced, the knowledge gained has not yet translated into a robust decline in incidence, with the overall risk remaining at ∼30%. Immune Tolerance Induction (ITI) is the only current method to successfully eradicate an inhibitor and achieve long-term tolerance. Although current practice utilizes a wide variety of ITI regimens, identification of an optimal regimen has not emerged. Over the last decade, the number of replacement products available in hemophilia has greatly expanded. The cumulative evidence with each product for use in ITI is often lacking. Most recently emicizumab, a humanized monoclonal bi-specific antibody that substitutes for the scaffolding effect of FVIIIa was approved; this agent prevents bleeding in both inhibitor and non-inhibitor patients. The use of emicizumab will bring about a new era in care that will require clinicians to challenge current practice paradigms including use and administration of ITI. This review will summarize the main clinical ITI data and practices for patients with severe congenital hemophilia A with inhibitors (CHAwI) over the last four decades and will highlight current studies in the field, with attention to open questions.
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Affiliation(s)
- Charles Nakar
- The Indiana Hemophilia and Thrombosis Center (IHTC), Indianapolis, IN, USA.
| | - Amy Shapiro
- The Indiana Hemophilia and Thrombosis Center (IHTC), Indianapolis, IN, USA
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Batsuli G, Zimowski KL, Tickle K, Meeks SL, Sidonio RF. Immune tolerance induction in paediatric patients with haemophilia A and inhibitors receiving emicizumab prophylaxis. Haemophilia 2019; 25:789-796. [DOI: 10.1111/hae.13819] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/17/2019] [Accepted: 06/17/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Glaivy Batsuli
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, Department of Pediatrics Emory University Atlanta Georgia
| | - Karen L. Zimowski
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, Department of Pediatrics Emory University Atlanta Georgia
| | - Kelly Tickle
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta Atlanta Georgia
| | - Shannon L. Meeks
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, Department of Pediatrics Emory University Atlanta Georgia
| | - Robert F. Sidonio
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, Department of Pediatrics Emory University Atlanta Georgia
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Abstract
INTRODUCTION The development of inhibitors against factors VIII/IX is the most serious complication in hemophilia. The best treatment strategy for inhibitor eradication is immune tolerance induction (ITI). The aim of this study was to evaluate patients treated with low-dose ITI at a single center with limited resources. MATERIALS AND METHODS In total, 29 (8.05%) of 360 hemophilia A patients exhibited inhibitors. The data from hemophilia patients with inhibitors undergoing ITI between 1999 and 2017 were collected and analyzed. RESULTS Seventeen ITIs administered to 15 hemophilia A patients with inhibitors were analyzed, and the data from 13 ITIs conducted in 12 patients were evaluated. The median age at ITI onset was 10 years (range: 1.25 to 52 y). The maximum inhibitor titer before ITI was 30 Bethesda Units (BU) (range: 4.48 to 135), and the median inhibitor titer was 1.25 BU (range: 0 to 5.6) at the onset of ITI. The median time interval between the inhibitor development and ITI onset was 60 months (range: 7 to 264 mo). The median inhibitor titer during ITI was 3.4 BU (range: 0 to 158.7). At the end of the treatment, 4 of the 12 patients (33.3%) exhibited a complete response, 4 (33.3%) had partial responses (with continuing ITI), and 4 (33.3%) exhibited ITI failure. CONCLUSIONS Treatment of hemophilia patients with inhibitors is challenging, and ITI is the best treatment method; however, a high-dose daily ITI regimen cannot be given to every patient in every country due to its high cost. Our results show that low-dose ITI may be a choice for selected patients with inhibitors.
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Trossaert M, Graveleau J, Thiercelin-Legrand MF, Sigaud M, Guerrero F, Neel A, Fouassier M, Sailler L, Chauveau D, Ternisien C, Huart A, Gillet B, Hamidou M, Bene MC, Voisin S. The factor VIII:C/VWF:Ag ratio as a useful tool to predict relapse in patients with acquired haemophilia A: A retrospective cohort study. Haemophilia 2019; 25:527-534. [PMID: 31050100 DOI: 10.1111/hae.13752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Acquired haemophilia A (AHA) is a rare autoimmune bleeding disorder caused by the presence of autoantibodies against coagulation factor VIII (FVIII). The mortality rate remains high. International recommendations define complete remission as undetectable inhibitor (<0.6 Bethesda Units [BU]) and normal FVIII activity (FVIII:C) that persists after immunosuppressive therapy stopped. For patients achieving remission, the risk of relapse reaches 20%. The risk factors for this relapse are not well known. AIM In this study, we examined the accuracy of the FVIII/W ratio (FVIII:C/von Willebrand Factor Antigen (VWF:Ag) ratio) to predict relapse in 64 consecutive patients with AHA. RESULTS In this cohort, all patients had a very low FVIII/W ratio at the time of diagnosis, and this value progressively increased in the first weeks of immunosuppressive treatment. In our study, 9/55 (14%) did not achieve complete remission. Twenty-seven patients were followed long enough (more than a year) to show that in the 22 patients who did not relapse, the FVIII/W ratio remained durably normalized. By contrast, in the five patients who relapsed during follow-up, we noted either no normalization of the FVIII/W ratio, or a secondary decrease to an abnormal value of <0.7 after initial normalization. In all patients who relapsed, the ratio was the first abnormal biological result to be observed, always preceding changes in the activated partial thromboplastin time (aPTT), FVIII:C and anti-FVIII reappearance. CONCLUSION These data suggest that the FVIII/W ratio could be considered a sensitive biological marker to predict recovery and/or relapse in AHA.
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Affiliation(s)
- Marc Trossaert
- Laboratoire d'hémostase, Service d'Hématologie Biologique, CHU de Nantes, France
| | | | | | - Marianne Sigaud
- Laboratoire d'hémostase, Service d'Hématologie Biologique, CHU de Nantes, France
| | | | - Antoine Neel
- Service de Médecine Interne, CHU de Nantes, France
| | - Marc Fouassier
- Laboratoire d'hémostase, Service d'Hématologie Biologique, CHU de Nantes, France
| | | | - Dominique Chauveau
- Département de Néphrologie et Transplantation d'Organes, CHU Rangueil et Université Paul Sabatier, Toulouse, France
| | - Catherine Ternisien
- Laboratoire d'hémostase, Service d'Hématologie Biologique, CHU de Nantes, France
| | - Antoine Huart
- Service de Médecine Interne, CHU de Toulouse, France
| | - Benjamin Gillet
- Laboratoire d'hémostase, Service d'Hématologie Biologique, CHU de Nantes, France
| | | | - Marie C Bene
- Laboratoire d'hémostase, Service d'Hématologie Biologique, CHU de Nantes, France
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Compartment syndrome of the forearm with life-threatening bleeding after fasciotomy as the presenting sign of postpartum acquired hemophilia A: a case report. Blood Coagul Fibrinolysis 2019; 30:120-126. [PMID: 30864964 DOI: 10.1097/mbc.0000000000000799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
: Acquired hemophilia A (AHA) is a rare bleeding disorder caused by the development of autoantibodies against clotting factor VIII. Although the cause of this disorder remains obscure, it is often linked to malignancies, drug administration, autoimmune diseases and pregnancy. In pregnancy-associated AHA, hemorrhagic symptoms usually present 1-4 months peripartum, however they may occur up to 1-year postpartum. Compartment syndrome of the forearm is also very uncommon complication of AHA but can have devastating consequences. We report a rare case of a compartment syndrome of the forearm in a 30-year-old woman 2.5 months postpartum as the presentation of pregnancy-associated AHA.
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Rahman A, Nizarali N, Dougall A, Daly B. U.K. hemophilia treaters' knowledge of risk assessment for prolonged bleeding associated with dental procedures. SPECIAL CARE IN DENTISTRY 2019; 39:173-179. [PMID: 30773677 DOI: 10.1111/scd.12359] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 12/25/2018] [Accepted: 01/18/2019] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Optimal delivery of dental care for adults with congenital bleeding disorders (CBD) requires close collaboration between hemophilia treaters and dentists. AIM To explore U.K. hemophilia treaters' knowledge of dental procedures and associated hemostatic management in adults with CBD. METHOD Staff (N = 180) from N = 60 hemophilia facilities in the United Kingdom were invited to participate in a questionnaire-based study using a web-based tool. The questionnaire assessed participants' knowledge, adherence and appropriateness of application of U.K. guidance on hemostatic management of common dental procedures. RESULTS The response rate was 23% of treaters (n = 41) from 62% (n = 32) hemophilia facilities. Individual participants (87%; n = 34) reported they adhered to guidelines, though knowledge of guidance was poor with only 36% (n = 15) applying guidance appropriately in 3 common dental scenarios. There was a tendency for participants to assign the use of systemic hemostatic measures independent of the agreed bleeding risk associated with the proposed dental procedure. CONCLUSION AND RECOMMENDATIONS While hemophilia treaters were aware of current guidelines, their knowledge of the guidelines and ability to risk assess dental procedures was poor. There was a tendency to overprescribe systemic hemostatic measures for dental procedures. Education initiatives to aid decision making are needed.
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Affiliation(s)
- Aza Rahman
- Specialist Dentist in Sedation and Special Care Dentistry, Kurdistan Ministry of Health, General Directorate of health sulaymanaiyah, Iraq
| | - Najla Nizarali
- Consultant in Special Care Dentistry, Guys and St Thomas' NHS Foundation Trust, London
| | - Alison Dougall
- Assistant Professor and Consultant in Special Care Dentistry , Division of Public & Child Dental Health, Dublin Dental University Hospital, University of Dublin, Trinity College Dublin, Lincoln Place, Dublin 2
| | - Blánaid Daly
- Professor and Consultant in Special Care Dentistry , Division of Public & Child Dental Health, Dublin Dental University Hospital, University of Dublin, Trinity College Dublin, Lincoln Place, Dublin 2
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57
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Ljung R, Auerswald G, Benson G, Dolan G, Duffy A, Hermans C, Jiménez-Yuste V, Lambert T, Morfini M, Zupančić-Šalek S, Santagostino E. Inhibitors in haemophilia A and B: Management of bleeds, inhibitor eradication and strategies for difficult-to-treat patients. Eur J Haematol 2018; 102:111-122. [PMID: 30411401 PMCID: PMC6936224 DOI: 10.1111/ejh.13193] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/25/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022]
Abstract
The standard therapy for patients with haemophilia is prophylactic treatment with replacement factor VIII (FVIII) or factor IX (FIX). Patients who develop inhibitors against FVIII/FIX face an increased risk of bleeding, and the likelihood of early development of progressive arthropathy, alongside higher treatment-related costs. Bypassing agents can be used to prevent and control bleeding, as well as the recently licensed prophylaxis, emicizumab, but their efficacy is less predictable than that of factor replacement therapy. Antibody eradication, by way of immune tolerance induction (ITI), is still the preferred management strategy for treating patients with inhibitors. This approach is successful in most patients, but some are difficult to tolerise and/or are unresponsive to ITI, and they represent the most complicated patients to treat. However, there are limited clinical data and guidelines available to help guide physicians in formulating the next treatment steps in these patients. This review summarises currently available treatment options for patients with inhibitors, focussing on ITI regimens and those ITI strategies that may be used in difficult-to-treat patients. Some alternative, non-ITI approaches for inhibitor management, are also proposed.
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Affiliation(s)
- Rolf Ljung
- Department of Clinical Sciences-Paediatrics, Lund University, Lund, Sweden.,Malmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden
| | - Guenter Auerswald
- Klinikum Bremen-Mitte, Professor Hess Children's Hospital, Bremen, Germany
| | - Gary Benson
- Haemophilia and Thrombosis Centre, Belfast City Hospital, Belfast, UK
| | - Gerry Dolan
- Centre for Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - Anne Duffy
- WFH Psychosocial Committee, Irish Haemophilia Society, Dublin, Ireland
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | - Thierry Lambert
- Hemophilia Care Center, Faculté de Médecine Paris XI, Bicêtre AP-HP Hospital, Paris, France
| | | | - Silva Zupančić-Šalek
- University Hospital Centre Zagreb, School of Medicine, University of Osijek and Medical School University of Zagreb, Zagreb, Croatia
| | - Elena Santagostino
- Foundation IRCCS Cà Granda, Maggiore Hospital Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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58
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Oldenburg J, Mahlangu JN, Bujan W, Trask P, Callaghan MU, Young G, Asikanius E, Peyvandi F, Santagostino E, Kruse-Jarres R, Negrier C, Kessler C, Xu J, Windyga J, Shima M, von Mackensen S. The effect of emicizumab prophylaxis on health-related outcomes in persons with haemophilia A with inhibitors: HAVEN 1 Study. Haemophilia 2018; 25:33-44. [PMID: 30427582 DOI: 10.1111/hae.13618] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/14/2018] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Persons with haemophilia A (PwHA) with inhibitors to factor VIII often experience decreased health-related outcomes. In HAVEN 1 (NCT02622321), there was a statistically significant reduction in bleeding with emicizumab prophylaxis versus no prophylaxis. AIM Describe health-related outcomes in PwHA with inhibitors in HAVEN 1. METHODS PwHA with inhibitors aged ≥12 years previously on episodic bypassing agents (BPAs) were randomized to emicizumab prophylaxis (Arm A; n = 35) or no prophylaxis (Arm B; n = 18); participants previously on BPA prophylaxis received emicizumab prophylaxis (Arm C; n = 49). Health-related outcomes assessed at baseline and monthly thereafter: Haemophilia Quality of Life Questionnaire for Adults (Haem-A-QoL), Haemophilia-specific Quality of Life Questionnaire for Children Short Form (Haemo-QoL SF), EuroQol 5-Dimensions 5-Levels (EQ-5D-5L) index utility score (IUS) and visual analogue scale (EQ-VAS) and work/school days. Days hospitalized also recorded. RESULTS At week 25, differences (ANCOVA) in adjusted mean scores (95% confidence interval) favoured Arm A versus B for Haem-A-QoL "Total" score (14.0 [5.6, 22.5]; P = 0.002) and "Physical Health" (21.6 [7.9, 35.2]; P = 0.003); EQ-VAS (-9.7 [-17.6, -1.82]; P = 0.017); and IUS (-0.16 [-0.25, -0.07]; P = 0.001); mean scores are comparable in Arms A and C. Throughout the study, a greater proportion of participants on emicizumab prophylaxis than no prophylaxis exceeded questionnaire-specific responder thresholds. Mean proportion of missed work days and number of days hospitalized were lower with emicizumab prophylaxis than no prophylaxis. CONCLUSIONS In PwHA with inhibitors, emicizumab prophylaxis was associated with substantial and meaningful improvements in health-related outcomes.
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Affiliation(s)
- Johannes Oldenburg
- Department of Experimental Haematology and Transfusion Medicine, Universitätsklinikum University Clinic Bonn, Bonn, Germany
| | - Johnny N Mahlangu
- Haemophilia Comprehensive Care Centre, Faculty of Health Sciences, University of the Witwatersrand and NHLS, Johannesburg, South Africa
| | - Willem Bujan
- Instituto de Costarricense de Investigaciones Científicas, San Jose, Costa Rica
| | - Peter Trask
- Genentech, Inc., South San Francisco, California
| | | | - Guy Young
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | | | - Flora Peyvandi
- IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Santagostino
- IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Rebecca Kruse-Jarres
- Washington Center for Bleeding Disorders at BloodWorks NW, University of Washington, Seattle, Washington
| | | | - Craig Kessler
- Georgetown University Medical Center, N.W., Washington, District of Columbia
| | - Jin Xu
- Genentech, Inc., South San Francisco, California
| | - Jerzy Windyga
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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59
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Mahlangu JN. Bispecific Antibody Emicizumab for Haemophilia A: A Breakthrough for Patients with Inhibitors. BioDrugs 2018; 32:561-570. [DOI: 10.1007/s40259-018-0315-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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60
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Collins PW, Liesner R, Makris M, Talks K, Chowdary P, Chalmers E, Hall G, Riddell A, Percy CL, Hay CR, Hart DP. Treatment of bleeding episodes in haemophilia A complicated by a factor VIII inhibitor in patients receiving Emicizumab. Interim guidance from UKHCDO Inhibitor Working Party and Executive Committee. Haemophilia 2018; 24:344-347. [PMID: 30070072 DOI: 10.1111/hae.13495] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2018] [Indexed: 02/03/2023]
Abstract
Emicizumab is a bispecific antibody that activates FX to FXa in the absence of FVIII. It has been shown to reduce bleeding episodes in people with haemophilia A complicated by a FVIII inhibitor. Despite the protection against bleeds, some breakthrough bleeds are inevitable and these may require additional haemostatic treatment. Emicizumab has been associated with severe adverse events when co-administered with activated prothrombin complex concentrate. To minimize the risk of adverse events, the UK Haemophilia Centre Doctors' Organisation issues the following updated interim guidance to its Inhibitor Guidelines for managing patients receiving Emicizumab based on the limit published information available in February 2018.
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Affiliation(s)
| | - R Liesner
- Great Ormond Street Hospital, London, UK
| | - M Makris
- University of Sheffield, Sheffield, UK
| | - K Talks
- Royal Victoria Infirmary, Newcastle, UK
| | | | - E Chalmers
- Royal Hospital for Children, Glasgow, UK
| | - G Hall
- John Radcliffe Hospital, Oxford, UK
| | | | - C L Percy
- Queen Elizabeth Hospital, Birmingham, UK
| | - C R Hay
- Central Manchester University Hospitals, Manchester, UK
| | - D P Hart
- Barts and The London School of Medicine and Dentistry, Queen Mary University London, Royal London Hospital, London, UK
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61
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[Chinese guidelines on the diagnosis and treatment of coagulation factor Ⅷ/Ⅸ inhibitors (version 2018)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 39:793-799. [PMID: 30369197 PMCID: PMC7348289 DOI: 10.3760/cma.j.issn.0253-2727.2018.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Indexed: 12/15/2022]
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Anti-tissue factor pathway inhibitor (TFPI) therapy: a novel approach to the treatment of haemophilia. Int J Hematol 2018; 111:42-50. [PMID: 30302740 DOI: 10.1007/s12185-018-2548-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 10/04/2018] [Indexed: 02/07/2023]
Abstract
Novel approaches to the treatment of haemophilia are needed due to the limitations of the current standard of care, factor replacement therapy. Aspirations include lessening the treatment burden and effectively preventing joint damage. Treating haemophilia by restoring thrombin generation may be an effective approach. A promising target for restoring thrombin generation is tissue factor pathway inhibitor (TFPI), a multivalent Kunitz-type serine protease inhibitor that regulates tissue factor-induced coagulation via factor Xa-dependent feedback inhibition of the tissue factor-factor VIIa complex. Inhibition of TFPI reverts the coagulation process to a more primitive state evolutionarily, whilst regulation by other natural inhibitors is preserved. An aptamer and three monoclonal antibodies directed against TFPI have been investigated in clinical trials. As well as improving thrombin generation in the range associated with mild haemophilia, anti-TFPI therapies have the advantage of subcutaneous administration. However, the therapeutic window needs to be defined along with the potential for complications due to the novel mechanism of action. This review provides an overview of TFPI, its role in normal coagulation, the rationale for TFPI inhibition, and a summary of anti-TFPI therapies, previously or currently in development.
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63
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Oldenburg J, Young G, Santagostino E, Escuriola Ettingshausen C. The importance of inhibitor eradication in clinically complicated hemophilia A patients. Expert Rev Hematol 2018; 11:857-862. [DOI: 10.1080/17474086.2018.1521718] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Guy Young
- Hemostasis and Thrombosis Center Children’s Hospital, Los Angeles, CA, USA
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Elena Santagostino
- Foundation IRCCS Ca' Granda, Maggiore Hospital Policlinico, Milan, Italy
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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64
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Hart DP, Uzun N, Skelton S, Kakoschke A, Househam J, Moss DS, Shepherd AJ. Factor VIII cross-matches to the human proteome reduce the predicted inhibitor risk in missense mutation hemophilia A. Haematologica 2018; 104:599-608. [PMID: 30266735 PMCID: PMC6395325 DOI: 10.3324/haematol.2018.195669] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 09/27/2018] [Indexed: 12/27/2022] Open
Abstract
Single missense mutations in the F8 gene encoding the coagulation protein factor VIII give rise predominantly to non-severe hemophilia A. Despite only a single amino acid sequence difference between the replacement, therapeutic factor VIII and the patient's endogenous factor VIII, therapeutic factor VIII may still be perceived as foreign by the recipient's immune system and trigger an immune response (inhibitor). Inhibitor formation is a life-long risk for patients with non-severe hemophilia A treated with therapeutic factor VIII, but remains difficult to predict. The aim of this study was to understand whether fortuitous, primary sequence cross-matches between therapeutic factor VIII and proteins in the human proteome are the reason why certain F8 mutations are not associated with inhibitor formation. We predicted which therapeutic factor VIII differences are potentially perceived as foreign by helper T cells - a necessary precursor to inhibitor development - and then scanned potentially immunogenic peptides against more than 100,000 proteins in the proteome. As there are hundreds of disease-causing F8 missense mutations and the human leukocyte antigen gene complex governing peptide presentation to helper T cells is highly polymorphic, these calculations pose a huge combinatorial challenge that we addressed computationally. We found that cross-matches between therapeutic factor VIII and the human proteome are commonplace and have a profound impact on the predicted risk of inhibitor development. Our results emphasize the importance of knowing both the F8 missense mutation and the human leukocyte antigen alleles of a patient with missense mutation hemophilia A if his underlying risk of inhibitor development is to be estimated.
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Affiliation(s)
- Daniel P Hart
- Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, London.,The Royal London Hospital Haemophilia Centre, Barts Health NHS Trust, London
| | - Nazmiye Uzun
- Department of Biological Sciences and Institute of Structural and Molecular Biology, Birkbeck, University of London, UK
| | - Stuart Skelton
- Blizard Institute, Barts and The London School of Medicine and Dentistry, QMUL, London.,Department of Biological Sciences and Institute of Structural and Molecular Biology, Birkbeck, University of London, UK
| | - Alison Kakoschke
- Department of Biological Sciences and Institute of Structural and Molecular Biology, Birkbeck, University of London, UK
| | - Jacob Househam
- Department of Biological Sciences and Institute of Structural and Molecular Biology, Birkbeck, University of London, UK
| | - David S Moss
- Department of Biological Sciences and Institute of Structural and Molecular Biology, Birkbeck, University of London, UK
| | - Adrian J Shepherd
- Department of Biological Sciences and Institute of Structural and Molecular Biology, Birkbeck, University of London, UK
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Batsuli G, Ito J, Mercer R, Baldwin WH, Cox C, Parker ET, Healey JF, Lollar P, Meeks SL. Anti-C1 domain antibodies that accelerate factor VIII clearance contribute to antibody pathogenicity in a murine hemophilia A model. J Thromb Haemost 2018; 16:1779-1788. [PMID: 29981270 PMCID: PMC6123829 DOI: 10.1111/jth.14233] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Indexed: 01/06/2023]
Abstract
Essentials Inhibitor formation remains a challenging complication of hemophilia A care. The Bethesda assay is the primary method used for determining bleeding risk and management. Antibodies that block factor VIII binding to von Willebrand factor can increase FVIII clearance. Antibodies that increase clearance contribute to antibody pathogenicity. SUMMARY Background The development of neutralizing anti-factor VIII (FVIII) antibodies remains a challenging complication of modern hemophilia A care. In vitro assays are the primary method used for quantifying inhibitor titers, predicting bleeding risk, and determining bleeding management. However, other mechanisms of inhibition are not accounted for in these assays, which may result in discrepancies between the inhibitor titer and clinical bleeding symptoms. Objectives To evaluate FVIII clearance in vivo as a potential mechanism for antibody pathogenicity and to determine whether increased FVIII dosing regimens correct the associated bleeding phenotype. Methods FVIII-/- or FVIII-/- /von Willebrand factor (VWF)-/- mice were infused with anti-FVIII mAbs directed against the FVIII C1, C2 or A2 domains, followed by infusion of FVIII. Blood loss via the tail snip bleeding model, FVIII activity and FVIII antigen levels were subsequently measured. Results Pathogenic anti-C1 mAbs that compete with VWF for FVIII binding increased the clearance of FVIII-mAb complexes in FVIII-/- mice but not in FVIII-/- /VWF-/- mice. Additionally, pathogenic anti-C2 mAbs that inhibit FVIII binding to VWF increased FVIII clearance in FVIII-/- mice. Anti-C1, anti-C2 and anti-A2 mAbs that do not inhibit VWF binding did not accelerate FVIII clearance. Infusion of increased doses of FVIII in the presence of anti-C1 mAbs partially corrected blood loss in FVIII-/- mice. Conclusions A subset of antibodies that inhibit VWF binding to FVIII increase the clearance of FVIII-mAb complexes, which contributes to antibody pathogenicity. This may explain differences in the bleeding phenotype observed despite factor replacement in some patients with hemophilia A and low-titer inhibitors.
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MESH Headings
- Animals
- Antibodies, Heterophile/administration & dosage
- Antibodies, Heterophile/immunology
- Antibodies, Heterophile/toxicity
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal/immunology
- Antibodies, Monoclonal/toxicity
- Antibodies, Neutralizing/administration & dosage
- Antibodies, Neutralizing/immunology
- Antibodies, Neutralizing/toxicity
- Epitopes/immunology
- Factor VIII/antagonists & inhibitors
- Factor VIII/immunology
- Factor VIII/pharmacokinetics
- Hemophilia A/drug therapy
- Hemophilia A/immunology
- Hemorrhage/etiology
- Inhibitory Concentration 50
- Mice
- Mice, 129 Strain
- Mice, Inbred C57BL
- Models, Animal
- Phenotype
- Protein Domains
- von Willebrand Diseases
- von Willebrand Factor/metabolism
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Affiliation(s)
- G Batsuli
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - J Ito
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - R Mercer
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - W H Baldwin
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - C Cox
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - E T Parker
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - J F Healey
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - P Lollar
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - S L Meeks
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
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66
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The current and future role of plasma-derived clotting factor concentrate in the treatment of haemophilia A. Transfus Apher Sci 2018; 57:502-506. [DOI: 10.1016/j.transci.2018.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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67
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Mathias MC, Collins PW, Palmer BP, Chalmers E, Alamelu J, Richards M, Will A, Hay CRM. The immunogenicity of ReFacto AF (moroctocog alfa AF-CC) in previously untreated patients with haemophilia A in the United Kingdom. Haemophilia 2018; 24:896-901. [DOI: 10.1111/hae.13551] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2018] [Indexed: 11/29/2022]
Affiliation(s)
- M. C. Mathias
- Great Ormond Street Hospital for Children; NHS Foundation Trust; London UK
| | - P. W. Collins
- Arthur Bloom Haemophilia Centre; School of Medicine; Cardiff University; Cardiff UK
| | - B. P. Palmer
- The UK National Haemophilia Database; Manchester UK
| | | | - J. Alamelu
- The Evelina Children's Hospital; London UK
| | | | - A. Will
- Manchester Children's Hospital; Manchester University NHS Foundation Trust; Manchester UK
| | - C. R. M. Hay
- University Department of Haematology; Manchester University NHS Foundation Trust; Manchester UK
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68
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Iorio A, Edginton AN, Blanchette V, Blatny J, Boban A, Cnossen M, Collins P, Croteau SE, Fischer K, Hart DP, Ito S, Korth‐Bradley J, Lethagen S, Lillicrap D, Makris M, Mathôt R, Morfini M, Neufeld EJ, Spears J. Performing and interpreting individual pharmacokinetic profiles in patients with Hemophilia A or B: Rationale and general considerations. Res Pract Thromb Haemost 2018; 2:535-548. [PMID: 30046759 PMCID: PMC6046594 DOI: 10.1002/rth2.12106] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/09/2018] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES In a separate document, we have provided specific guidance on performing individual pharmacokinetic (PK) studies using limited samples in persons with hemophilia with the goal to optimize prophylaxis with clotting factor concentrates. This paper, intended for clinicians, aims to describe how to interpret and apply PK properties obtained in persons with hemophilia. METHODS The members of the Working Party on population PK (PopPK) of the ISTH SSC Subcommittee on Factor VIII and IX and rare bleeding disorders, together with additional hemophilia and PK experts, completed a survey and ranking exercise whereby key areas of interest in the field were identified. The group had regular web conferences to refine the manuscript's scope and structure, taking into account comments from the external feedback to the earlier document. RESULTS Many clinical decisions in hemophilia are based on some form of explicit or implicit PK assessment. Individual patient PK profiles can be analyzed through traditional or PopPK methods, with the latter providing the advantage of fewer samples needing to be collected on any prophylaxis regimen, and without the need the for a washout period. The most useful presentation of PK results for clinical decision making are a curve of the factor activity level over time, the time to achieve a certain activity level, or related parameters like half-life or exposure (AUC). Software platforms have been developed to deliver this information to clinicians at the point of care. Key characteristics of studies measuring average PK parameters were reviewed, outlining what makes a credible head-to-head comparison among different concentrates. Large data collections of PK and treatment outcomes currently ongoing will advance care in the future. CONCLUSIONS Traditionally used to compare different concentrates, PK can support tailoring of hemophilia treatment by individual profiling, which is greatly simplified by adopting a PopPK/Bayesian method and limited sampling protocol.
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Affiliation(s)
- Alfonso Iorio
- Department of Health Research, Methods, Evidence and ImpactMcMaster UniversityHamiltonONCanada
- Department of MedicineMcMaster UniversityHamiltonONCanada
| | | | - Victor Blanchette
- Division of Hematology/OncologyHospital for Sick Children and Department of PediatricsUniversity of TorontoTorontoONCanada
| | - Jan Blatny
- Department of Paediatric HaematologyUniversity Hospital BrnoBrnoCzech Republic
| | - Ana Boban
- Department of Internal MedicineUniversity Hospital CenterZagrebCroatia
| | - Marjon Cnossen
- Department of Pediatric HematologyErasmus University Medical CenterSophia Children’s HospitalRotterdamThe Netherlands
| | - Peter Collins
- Arthur Bloom Haemophilia CentreSchool of MedicineUniversity Hospital of WalesCardiff UniversityCardiffUK
| | | | - Katheljin Fischer
- Van CreveldkliniekUniversity Medical CenterUtrecht UniversityUtrechtThe Netherlands
| | - Daniel P. Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and DentistryLondonUK
| | | | | | | | - David Lillicrap
- Department of Pathology & Molecular MedicineQueen’s UniversityKingstonONCanada
| | - Mike Makris
- Department of Infection, Immunity& Cardiovascular DiseaseUniversity of SheffieldSheffieldUK
| | - Ron Mathôt
- Hospital Pharmacy–Clinical PharmacologyAcademic Medical CentreAmsterdamThe Netherlands
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69
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Immune tolerance induction rescue with turoctocog-alfa in a poor risk haemophilia A inhibitor young child. Blood Coagul Fibrinolysis 2018; 29:465-468. [DOI: 10.1097/mbc.0000000000000736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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70
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Carpenter SL, Khair K, Gringeri A, Valentino LA. Prophylactic bypassing agent use before and during immune tolerance induction in patients with haemophilia A and inhibitors toFVIII. Haemophilia 2018; 24:570-577. [DOI: 10.1111/hae.13534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2018] [Indexed: 01/11/2023]
Affiliation(s)
- S. L. Carpenter
- Hematology/OncologyUniversity of Missouri Kansas City School of Medicine Kansas City MO USA
- Kansas City Regional Hemophilia Treatment Center Kansas City MO USA
- Children's Mercy Hospital Kansas City MO USA
| | - K. Khair
- Great Ormond Street Hospital London UK
- London South Bank University London UK
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71
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Abstract
Rapid expansion of therapeutic options have increased the complexity of hemophilia care. Previously, on-demand therapy aimed to reduce morbidity and early mortality; however, now aggressive prophylaxis, particularly in children, encourages an active lifestyle. Accurate diagnosis, recognition of early threats to musculoskeletal health, and optimization of therapy are critical for both males and females affected by hemophilia. The diversity of emerging hemophilia therapies, from modified factor protein concentrates, to gene therapy, to nonfactor hemostatic strategies, provide an exciting opportunity to target unmet needs in the bleeding disorder community.
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72
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Chowdary P. Inhibition of Tissue Factor Pathway Inhibitor (TFPI) as a Treatment for Haemophilia: Rationale with Focus on Concizumab. Drugs 2018; 78:881-890. [PMID: 29845491 PMCID: PMC6013504 DOI: 10.1007/s40265-018-0922-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Replacement therapy with missing factor (F) VIII or IX in haemophilia patients for bleed management and preventative treatment or prophylaxis is standard of care. Restoration of thrombin generation through novel mechanisms has become the focus of innovation to overcome limitations imposed by protein replacement therapy. Tissue factor pathway inhibitor (TFPI) is a multivalent Kunitz-type serine protease inhibitor that regulates tissue factor (TF)-induced coagulation through a FXa-dependent feedback inhibition of the TF.FVIIa complex in plasma and on endothelial surfaces. Concizumab is a monoclonal, humanised antibody, specific for the second Kunitz domain of TFPI that binds and inhibits FXa, abolishing the inhibitory effect of TFPI. Concizumab restored thrombin generation in FVIII and FIX deficient plasmas and decreased blood loss in a rabbit haemophilia model. Phase 1 single and multiple dose escalation studies in haemophilia patients demonstrated a dose dependent decrease in TFPI levels and a pro-coagulant effect with increasing d-dimers and prothrombin fragment 1 + 2. A dose dependent increase in peak thrombin and endogenous thrombin potential was observed with values in the normal range when plasma TFPI levels were nearly undetectable. A few haemophilia patients in the highest dose cohorts with complete inhibition of plasma TFPI showed a decreased fibrinogen concentration with normal levels of anti-thrombin and platelets and no evidence of thrombosis. Pharmacokinetic parameters were influenced by binding to the target (TFPI), demonstrating target mediated drug disposition. A trend towards decreasing bleeding tendency was observed and this preventative effect is being studied in Phase 2 studies with additional data gathered to improve our understanding of the therapeutic window and potential for thrombosis.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, Pond Street, London, NW3 2 QG, UK.
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73
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Batty P, Hart DP, Platton S. Optimization of pre-analytical heat treatment for inhibitor detection in haemophilia A. Int J Lab Hematol 2018; 40:561-568. [PMID: 29777571 DOI: 10.1111/ijlh.12862] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/16/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Factor VIII (FVIII) antibody formation is the greatest clinical and laboratory challenge within the haemophilia centre. The Nijmegen-Bethesda assay (NBA) is the gold standard for inhibitor quantification, but affected by pre-analytical variables including a patient's FVIII activity (FVIII:C). Pre-analytical heat treatment (PHT) provides a methodology for inhibitor testing when measurable FVIII:C is present. METHODS We evaluated the effect of different PHT conditions (time/temperature) on FVIII:C as well as on potency of inhibitory activity in samples containing FVIII:C (endogenous pooled plasma and exogenous recombinant FVIII (rFL-FVIII) concentrate) or FVIII inhibitor. RESULTS PHT of endogenous FVIII at 37°C, 47°C and 52°C resulted in declining measurable FVIII:C at 120 minutes (69%, 57% and 13% of the original FVIII:C, respectively). Incubation at 56°C resulted in FVIII:C ≤ 1IU/dL after 60 minutes for endogenous FVIII and 120 minutes for rFL-FVIII. Incubation at 58°C resulted in FVIII:C < 1IU/dL at 15-30 minutes for endogenous FVIII and at 30-60 minutes for rFL-FVIII. No difference was seen for inhibitor detection following PHT (56°C or 58°C) by NBA or anti-FVIII IgG ELISA. CONCLUSION PHT at 58°C for 30 minutes demonstrated consistent reduction in FVIII:C < 1IU/dL without appearing to affect inhibitor detection. Laboratory awareness of differences in thermostability of different sources of FVIII is important when choosing PHT conditions.
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Affiliation(s)
- P Batty
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK.,The Royal London Hospital Haemophilia Centre, Barts Health, The Royal London Hospital, London, UK
| | - D P Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK.,The Royal London Hospital Haemophilia Centre, Barts Health, The Royal London Hospital, London, UK
| | - S Platton
- The Royal London Hospital Haemophilia Centre, Barts Health, The Royal London Hospital, London, UK
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74
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Bhatnagar N, Hall GW. Major bleeding disorders: diagnosis, classification, management and recent developments in haemophilia. Arch Dis Child 2018; 103:509-513. [PMID: 29175823 DOI: 10.1136/archdischild-2016-311018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 10/13/2017] [Accepted: 10/18/2017] [Indexed: 01/02/2023]
Abstract
In this review, we outline the standard of care for children in the UK with the most common major bleeding disorder, haemophilia, and how exciting new developments in therapy have the potential for further improvements in quality of life and clinical outcome. The combination of comprehensive specialist medical care, safer factor concentrates, earlier introduction of prophylaxis and patient-specific education has allowed the current generation of patients with haemophilia to grow into adulthood with excellent joint function, pursuing full-time employment with a good quality of life. We are entering an exciting new phase in paediatric haemophilia as potentially life-changing products appear on the scene taking a step towards achieving better, easier and personalised prophylaxis.
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Affiliation(s)
- Neha Bhatnagar
- Paediatric Haematology, Children's Hospital, John Radcliffe Hospital, Oxford, UK
| | - Georgina W Hall
- Paediatric Haematology, Children's Hospital, John Radcliffe Hospital, Oxford, UK
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75
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Strandberg K, Astermark J. The role of the laboratory in diagnosis and management of inhibitory antibodies in haemophilia. Haemophilia 2018; 24 Suppl 6:9-14. [DOI: 10.1111/hae.13474] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2018] [Indexed: 01/01/2023]
Affiliation(s)
- K. Strandberg
- Department of Clinical Chemistry; Institution of Laboratory Medicine; Malmö Sweden
| | - J. Astermark
- Department for Hematology Oncology and Radiation Physics; Center for Thrombosis and Hemostasis; Skåne University Hospital; Malmö Sweden
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76
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Soto I, Martínez D, Ávila LF, Bernardo Á. A rare case of late development of inhibitor in haemophilia B with a complex course, and review of the literature. Haemophilia 2018; 24:e125-e128. [PMID: 29488670 DOI: 10.1111/hae.13442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2018] [Indexed: 06/08/2023]
Affiliation(s)
- I Soto
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - D Martínez
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - L F Ávila
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Á Bernardo
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
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77
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Giangrande PLF, Hermans C, O'Mahony B, de Kleijn P, Bedford M, Batorova A, Blatný J, Jansone K. European principles of inhibitor management in patients with haemophilia. Orphanet J Rare Dis 2018; 13:66. [PMID: 29703220 PMCID: PMC5921290 DOI: 10.1186/s13023-018-0800-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 04/06/2018] [Indexed: 12/11/2022] Open
Abstract
Background In spite of recent major advances in the understanding and treatment of inhibitor development in patients with haemophilia, multidisciplinary management of many of these patients remains suboptimal and highly heterogenous across Europe. Methods Following a series of multidisciplinary meetings and a review of the literature, the European haemophilia community of health professionals and patients jointly defined practical optimum standards for ensuring and harmonizing treatment and care for patients with an inhibitor. Results Ten complementary principles for the management of inhibitors in haemophilia have been developed, emphasizing the importance and benefits of a centralized, multidisciplinary, expert and holistic approach. Conclusions This document will serve as a benchmark to improve the multidisciplinary and practical management of patients with inhibitor. Implementation and adherence to each of these principles should have a major positive impact on the management and outcomes of patients developing an inhibitor.
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Affiliation(s)
- P L F Giangrande
- European Haemophilia Consortium, Rue de l'Industrie, B-1000, Brussels, Belgium. .,University of Oxford, Oxford, UK.
| | - C Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - B O'Mahony
- European Haemophilia Consortium, Rue de l'Industrie, B-1000, Brussels, Belgium.,Trinity College, Dublin, Ireland
| | - P de Kleijn
- Department of Rehabilitation, Nursing Science and Sports, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Bedford
- Canterbury Christ Church University, Kent, UK
| | - A Batorova
- National Hemophilia Center, Department of Hematology and Transfusion Medicine, School of Medicine of Comenius University and University Hospital, Bratislava, Slovakia
| | - J Blatný
- Children's University Hospital Brno, Brno, Czech Republic
| | - K Jansone
- European Haemophilia Consortium, Rue de l'Industrie, B-1000, Brussels, Belgium
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78
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Brackmann HH, White G, Berntorp E, Andersen T, Escuriola-Ettingshausen C. Immune tolerance induction: What have we learned over time? Haemophilia 2018. [DOI: 10.1111/hae.13445] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- H.-H. Brackmann
- Institute of Experimental Haematology and Blood Transfusion; University of Bonn; Bonn Germany
| | - G.C. White
- Blood Center of Wisconsin & Medical College of Wisconsin; Milwaukee WI USA
| | - E. Berntorp
- Clinical Coagulation Research Unit; Skåne University Hospital; Lund University; Malmö Sweden
| | - T. Andersen
- Danish Haemophilia Society; Copenhagen Denmark
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79
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Miller CH. Laboratory testing for factor VIII and IX inhibitors in haemophilia: A review. Haemophilia 2018; 24:186-197. [PMID: 29446525 PMCID: PMC6033270 DOI: 10.1111/hae.13424] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2017] [Indexed: 12/13/2022]
Abstract
Inhibitors are antibodies directed against haemophilia treatment products which interfere with their function. Factor VIII (FVIII) inhibitors in haemophilia A and factor IX (FIX) inhibitors in haemophilia B are significant clinically when they require a change in a patient's treatment regimen. Their persistence may increase morbidity and mortality. Multiple laboratory tests are now available for detecting and understanding inhibitors in haemophilia. Inhibitors are traditionally measured by their interference in clotting or chromogenic factor assays. They may also be detected using immunologic assays, such as enzyme-linked immunosorbent assay or fluorescence immunoassay. Anti-FVIII or anti-FIX antibodies of IgG4 subclass best correlate with the presence of functional inhibitors. Improvements in inhibitor measurement have been recently introduced. Preanalytical heat treatment of patient specimens allows testing of patients without delaying treatment. Use of chromogenic and immunologic assays may aid in identification of false-positive results, which are frequent among low-titre inhibitors. Validated reagent substitutions can be used to reduce assay cost. New methods for defining assay positivity and reporting low-titre inhibitors have been suggested. Challenges remain in the areas of quality control, assay standardization, monitoring of patients undergoing immune tolerance induction therapy and testing in the presence of modified and novel treatment products.
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Affiliation(s)
- C H Miller
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
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80
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Ling G, Nathwani AC, Tuddenham EGD. Recent advances in developing specific therapies for haemophilia. Br J Haematol 2018; 181:161-172. [DOI: 10.1111/bjh.15084] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Gavin Ling
- Katherine Dormandy Haemophilia and Thrombosis Centre; Royal Free London NHS Foundation Trust; London UK
| | - Amit C. Nathwani
- Katherine Dormandy Haemophilia and Thrombosis Centre; Royal Free London NHS Foundation Trust; London UK
| | - Edward G. D. Tuddenham
- Katherine Dormandy Haemophilia and Thrombosis Centre; Royal Free London NHS Foundation Trust; London UK
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81
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Santagostino E, Young G, Carcao M, Mannucci PM, Halimeh S, Austin S. A contemporary look at FVIII inhibitor development: still a great influence on the evolution of hemophilia therapies. Expert Rev Hematol 2018; 11:87-97. [PMID: 29258406 DOI: 10.1080/17474086.2018.1419862] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The development of inhibitors against factor VIII (FVIII) replacement therapy remains the most important challenge for clinicians in the treatment of hemophilia patients. This review focusses on risk factors and management of FVIII inhibitors, particularly in light of SIPPET study findings and subsequent analyses. Areas covered: A brief history and evolution of hemophilia therapies is provided, including an overview of conventional and new (including investigational) therapeutic approaches for the treatment of hemophilia. The SIPPET study, the first randomized clinical trial to demonstrate a lower incidence of inhibitors in previously untreated patients treated with plasma-derived FVIII products compared with recombinant FVIII products, has generated much debate. We review the SIPPET trial and reactions, in addition to preliminary observations from a single center's experience, the cost impact of inhibitors, recent findings from SIPPET subanalyses, and inhibitor development in previously-treated patients. Expert commentary: Despite recent advances in potential new treatment options for hemophilia, conventional factor replacement concentrates currently remain the cornerstone of treatment. It is paramount that clinicians familiarize themselves with the findings from the SIPPET trial and substudies, in order to better inform their patients and families on inhibitor risk factors and to aid the treatment decision-making process.
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Affiliation(s)
- Elena Santagostino
- a Angelo Bianchi Bonomi Hemophilia and Thrombosis Center , University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Guy Young
- b Hemostasis and Thrombosis Center, Children's Hospital Los Angeles , University of Southern California Keck School of Medicine , Los Angeles , CA , USA
| | - Manuel Carcao
- c Division of Hematology/Oncology; Department of Pediatrics and Child Health Evaluative Sciences , Research Institute Hospital for Sick Children , Toronto , ON , Canada
| | - Pier Mannuccio Mannucci
- d Scientific Direction , IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan , Milan , Italy
| | - Susan Halimeh
- e Gerinnungszentrum Rhein-Ruhr (GZRR) , Duisburg , Germany
| | - Steve Austin
- f St. George's Healthcare NHS Trust Haemophilia Centre , London , UK
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82
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Ljung RCR. How I manage patients with inherited haemophilia A and B and factor inhibitors. Br J Haematol 2017; 180:501-510. [DOI: 10.1111/bjh.15053] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Rolf C. R. Ljung
- Department of Clinical Sciences - Paediatrics; Lund University; Lund Sweden
- Centre for Thrombosis and Haemostasis; Skåne University Hospital Malmö; Malmo Sweden
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83
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Batty P, Moore G, Platton S, Maloney J, Palmer B, Bowles L, Pasi J, Rangarajan S, Hart D. Diagnostic accuracy study of a factor VIII ELISA for detection of factor VIII antibodies in congenital and acquired haemophilia A. Thromb Haemost 2017; 114:804-11. [DOI: 10.1160/th14-12-1062] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 05/19/2015] [Indexed: 11/05/2022]
Abstract
SummaryAntibody formation to factor VIII (FVIII) remains the greatest clinical and diagnostic challenge to the haemophilia-treating physician. Current guidance for testing for inhibitory FVIII antibodies (inhibitors) recommends the functional Nijmegen-Bethesda assay (NBA). A FVIII ELISA offers a complementary, immunological approach for FVIII antibody testing. It was the aim of this study to retrospectively evaluate the performance of a FVIII ELISA (index) for detection of FVIII antibodies, compared with the NBA (reference). All samples sent for routine FVIII antibody testing at two haemophilia Comprehensive Care Centres, were tested in parallel using the NBA and a solid-phase, indirect FVIII ELISA kit (Immucor). A total of 497 samples from 239 patients (severe haemophilia A=140, non-severe haemophilia A=85, acquired haemophilia A=14) were available for analysis. Sixty-THree samples tested positive by the NBA (prevalence 12.7 %, 95 % confidence interval [CI], 9.9–15.9 %), with a median inhibitor titre of 1.2 BU/ml (range 0.7–978.0). The FVIII ELISA demonstrated a specificity of 94.0 % (95 %CI, 91.3–96.0), sensitivity of 77.8 % (95 %CI, 65.5–87.3), negative predictive value of 96.7 % (95 %CI, 94.5–98.2), positive predictive value 65.3 % (95 %CI, 53.5–76.0), negative likelihood ratio 0.2 (95 %CI, 0.1–0.4), positive likelihood ratio 13.0 (95 %CI, 8.7–19.3) and a diagnostic odds ratio of 54.9 (95 %CI, 27.0–112.0). Strong positive correlation (r=0.77, p< 0.001) was seen between the results of the NBA (log adjusted) and FVIII ELISA optical density. In conclusion, FVIII ELISA offers a simple, specific, surveillance method enabling batch testing of non-urgent samples for the presence of FVIII antibodies.
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84
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van Velzen AS, Eckhardt CL, Hart DP, Peters M, Rangarajan S, Mancuso ME, Smiers FJ, Khair K, Petrini P, Jimenez-Yuste V, Hay CRM, van der Bom JG, Yee TT, Fijnvandraat K. Inhibitors in nonsevere haemophilia A: outcome and eradication strategies. Thromb Haemost 2017; 114:46-55. [DOI: 10.1160/th14-11-0940] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 02/13/2015] [Indexed: 02/03/2023]
Abstract
SummaryIn nonsevere haemophilia A (HA) patients the presence of an inhibitor may exacerbate the bleeding phenotype dramatically. There are very limited data on the optimal therapeutic approach to eradicate inhibitors in these patients. We aimed to describe inhibitor eradication treatment in a large cohort of unselected nonsevere HA patients with inhibitors. We included 101 inhibitor patients from a source population of 2,709 nonsevere HA patients (factor VIII 2–40 IU/dl), treated in Europe and Australia (median age 37 years, interquartile range (IQR) 15–60; median peak titre 7 BU/ml, IQR 2–30). In the majority of the patients (71 %; 72/101) the inhibitor disappeared; either spontaneously (70 %, 51/73) or after eradication treatment (75 %, 21/28). Eradication treatment strategies varied widely, including both immune tolerance induction and immunosuppression. Sustained success (no inhibitor after rechallenge with factor VIII concentrate after inhibitor disappearance) was achieved in 64 % (30/47) of those patients rechallenged with FVIII concentrate. In high-titre inhibitor patients sustained success was associated with eradication treatment (unadjusted relative risk 2.3, 95 % confidence interval 1.3–4.3), compared to no eradication treatment. In conclusion, in nonsevere HA patients most inhibitors disappear spontaneously. However, in 35 % (25/72) of these patients an anamnestic response still can occur when rechallenged, thus disappearance in these patients does not always equal sustained response. Treatment for those requiring eradication has to be decided case by case, as one single approach is unlikely to be appropriate for all.Study was carried out in: Emma Children’s Hospital, Academic Medical Center, Amsterdam, the Netherlands.
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85
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Sun HL, Chan S, Yenson P, Jackson S. Inhibitor Risk Stratification and Individualized Treatment in Patients With Nonsevere Hemophilia A: A Single-Institution Practice Audit. Clin Appl Thromb Hemost 2017; 24:303-309. [PMID: 29108420 PMCID: PMC6714690 DOI: 10.1177/1076029617737836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Inhibitor risk in nonsevere hemophilia A increases with cumulative factor VIII (FVIII)
exposure days and high-risk mutations. A standardized approach to minimize inhibitor risk
is warranted. Following establishment of a systematic approach to reduce inhibitor risk in
nonsevere hemophilia, we evaluated the uptake of these strategies into clinical practice.
All adult males with nonsevere hemophilia A followed by British Columbia Adult Hemophilia
Program from 2004 to 2016 were included in this retrospective audit. Quality-of-care
indicators on inhibitor prevention were examined. Of 108 patients, 18 patients had
high-risk FVIII mutations for inhibitor development. Rates of FVIII genotyping and
1-deamino-8-d-arginine-vasopressin (DDAVP) testing in mild patients without
contraindications were both over 90%, although DDAVP was used for surgical prophylaxis in
only 70% of procedures. Inhibitor testing and clinic visits occurred at a median interval
of 22 months. Over 80% of patients with high-risk mutations had documentation and
education on their inhibitor risk. Our practice audit demonstrated a high level of
recognition and patient education of individual inhibitor risk. Impact of our standardized
approach on the incidence of inhibitor development is yet to be determined.
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Affiliation(s)
- Haowei Linda Sun
- 1 Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Stella Chan
- 2 Simon Fraser University, Vancouver, British Columbia, Canada
| | - Paul Yenson
- 3 Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shannon Jackson
- 3 Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,4 British Columbia Provincial Bleeding Disorders Program-Adult Division, Vancouver, British Columbia, Canada
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86
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Chai‐Adisaksopha C, Nevitt SJ, Simpson ML, Janbain M, Konkle BA. Bypassing agent prophylaxis in people with hemophilia A or B with inhibitors. Cochrane Database Syst Rev 2017; 9:CD011441. [PMID: 28944952 PMCID: PMC6483761 DOI: 10.1002/14651858.cd011441.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND People with hemophilia A or B with inhibitors are at high risk of bleeding complications. Infusion of bypassing agents, such as recombinant activated FVII (rFVIIa) and plasma-derived activated prothrombin complex concentrate, are suggested as alternative therapies to factor VIII (haemophilia A) or IX (haemophilia B) for individuals who no longer respond to these treatments because they develop inhibitory antibodies. The ultimate goal of treatment is to preserve the individual's joints, otherwise destroyed by recurrent bleeds. OBJECTIVES To assess the effects of bypassing agent prophylaxis to prevent bleeding in people with hemophilia A or B and inhibitors. SEARCH METHODS We searched for relevant studies from the Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched trial registries (16 February 2017) and bibliographic references of retrieved studies were reviewed for potential articles to be included in the review.Date of the last search of the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register: 12 December 2016. SELECTION CRITERIA We included randomized and quasi-randomized controlled studies (cross-over or parallel design) evaluating the effect of prophylaxis treatment with bypassing agents compared with on-demand treatment, or studies evaluating the effects of high-dose compared with low-dose prophylaxis in males of any age with hemophilia with inhibitors. DATA COLLECTION AND ANALYSIS Two authors independently selected studies and extracted data and assessed the risk of bias according to standard Cochrane criteria. They assessed the quality of the evidence using the GRADE criteria. MAIN RESULTS We included four randomized studies (duration 7 to 15 months) involving 116 males. Risk of bias was judged to be high in two studies due to the open-label study design and in one study due to attrition bias.Two studies compared on-demand treatment to prophylaxis with bypassing agents. In one study (34 males) prophylaxis significantly reduced mean overall bleeding rates, MD - 7.27 (95% CI -9.92 to -4.62) (low quality evidence), mean number of overall bleeding events per month, MD -1.10 (95% CI -1.54 to -0.66), mean number of hemarthrosis, MD -6.60 (95% CI -9.32 to -3.88) (low quality evidence) and mean number of joints that had hemarthrosis, MD -0.90 (95% CI -1.36 to -0.44). The meta-analysis did not conclusively demonstrate significant benefit of prophylaxis on health-related quality of life as measured by Haem-A-QoL score, EQ-5D total score and utility score, EQ-5D VAS and SF-36 physical summary and mental summary score (low quality evidence for all health-related quality of life analyses).The remaining two studies compared dose regimens. The results from one study (22 males) did not conclusively demonstrate benefit or harm of high-dose versus low-dose recombinant activated factor VIIa (rFVIIa) as a prophylaxis for overall bleeding rate, MD -0.82 (95% CI -2.27 to 0.63) (moderate quality evidence), target joint bleeding rate, MD -3.20 (95% CI -7.23 to 0.83) (moderate quality evidence) and serious adverse events, RR 9.00 (95% CI, 0.54 to 149.50) (moderate quality evidence).The overall quality of evidence was moderate to low due to imprecision from limited information provided by studies with small sample sizes and incomplete outcome data in one study. AUTHORS' CONCLUSIONS The evidence suggests that prophylaxis with bypassing agents may be effective in reducing bleeding in males with hemophilia with inhibitors. However, there is a lack of evidence for the superiority of one agent over the other or for the optimum dosage regimen. Further studies are needed to evaluate the benefits and harms of prophylaxis treatment on health-related quality of life, as well as the effects of dose of bypassing agents on the outcomes.
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Affiliation(s)
| | - Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Mindy L Simpson
- Rush University Medical CenterSection of Pediatric Hematology/Oncology1653 W Congress ParkwayChicagoUSAIL 60612
| | - Maissaa Janbain
- Tulane University School of MedicineDepartment of Hematology & Medical Oncology1430 Tulane AvenueNew OrleansLouisianaUSALA 70112
| | - Barbara A Konkle
- 921 Terry AvenueBloodworks North WestSeattleWashingtonUSAWA 98104
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87
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Dolan G. Partnering to change the world for people with haemophilia: 7th Haemophilia Global Summit, Madrid, Spain 22-24 September 2016. Eur J Haematol 2017; 99 Suppl 87:3-9. [PMID: 28921738 DOI: 10.1111/ejh.12924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2017] [Indexed: 01/19/2023]
Abstract
The 7th Haemophilia Global Summit was held in Madrid, Spain, in September 2016. With a programme designed, for the 6th consecutive year, by a Scientific Steering Committee of haemophilia experts, the aim of the summit was to share optimal management strategies for haemophilia at all life stages and to provide an opportunity for specialists from across the haemophilia multidisciplinary care team to engage in discussion and debate with leading international experts on current and future areas of research. Topics covered ranged from the optimisation of haemophilia management, emerging issues in clinical care, practical approaches and future perspectives, in addition to patient engagement and empowerment in modern haemophilia care.
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88
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Xue F, Liu W, Cheng YF, Liu XF, Huang YT, Fu RF, Zhang L, Yang RC. [Immune tolerance induction in a case of hemophilia B with inhibitor with prothrombin complex concentrate and rituximab]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 38:749-753. [PMID: 29081190 PMCID: PMC7348358 DOI: 10.3760/cma.j.issn.0253-2727.2017.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Indexed: 01/01/2023]
Abstract
Objective: To explore the immune tolerance induction (ITI) in a case of severe hemophilia B patient with inhibitor. Methods: The F Ⅸ∶C was detected using a one-stage method and FIX inhibitor was assayed using Bethesda method. ITI was performed with prothrombin complex concentrates (PCC) in combination with rituximab. Results: His past exposure days (ED) with PCC were 20 ED and his peak FⅨ inhibitor titer was 56 BU/ml. When his FIX inhibitor titer decreased to 10.4 BU/ml in Nov. 2015 and after receiving the informed consent from his parents, ITI was started. PCC with low dose rituximab successfully eradicated the high titer inhibitor within 17 months. There was no anaphylaxis, thrombotic event and infection. Conclusion: This is the first case report for successful immune tolerance induction therapy in Chinese hemophilia B patient. ITI using PCC combined with rituximab is an effective choice to induce immune tolerance of hemophilia B with inhibitor.
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Affiliation(s)
- F Xue
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Hospital of Blood Diseases, CAMS & PUMC, Tianjin 300020, China
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89
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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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90
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Kruse-Jarres R, Kempton CL, Baudo F, Collins PW, Knoebl P, Leissinger CA, Tiede A, Kessler CM. Acquired hemophilia A: Updated review of evidence and treatment guidance. Am J Hematol 2017; 92:695-705. [PMID: 28470674 DOI: 10.1002/ajh.24777] [Citation(s) in RCA: 234] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 04/24/2017] [Accepted: 04/25/2017] [Indexed: 12/31/2022]
Abstract
Acquired hemophilia A (AHA) is a rare disease resulting from autoantibodies (inhibitors) against endogenous factor VIII (FVIII) that leads to bleeding, which is often spontaneous and severe. AHA tends to occur in elderly patients with comorbidities and is associated with high mortality risk from underlying comorbidities, bleeding, or treatment complications. Treatment, which consists of hemostatic management and eradication of the inhibitors, can be challenging to manage. Few data are available to guide the management of AHA-related bleeding and eradication of the disease-causing antibodies. Endorsed by the Hemostasis and Thrombosis Research Society of North America, an international panel of experts in AHA analyzed key questions, reviewed the literature, weighed the evidence and formed a consensus to update existing guidelines. AHA is likely underdiagnosed and misdiagnosed in real-world clinical practice. Recommendations for the management of AHA are summarized here based on the available data, integrated with the clinical experience of panel participants.
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Affiliation(s)
| | | | - Francesco Baudo
- Thrombosis and Haemostasis Unit; Niguarda Hospital; Milan Italy
| | - Peter W. Collins
- Arthur Bloom Haemophilia Centre, School of Medicine Cardiff University; Cardiff United Kingdom
| | - Paul Knoebl
- Department of Medicine 1, Division of Hematology and Hemostasis; Medical University of Vienna; Vienna Austria
| | | | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation; Hannover Medical School; Hannover Germany
| | - Craig M. Kessler
- Section of Hematology/Oncology; Georgetown University; Washington District of Columbia
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91
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Poon MC, Di Minno G, Zotz R, d’Oiron R. Glanzmann’s thrombasthenia: strategies for identification and management. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1341306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Man-Chiu Poon
- Cumming School of Medicine, University of Calgary, Calgary, Canada
- Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Canada
| | - Giovanni Di Minno
- Department of Clinical Medicine and Surgery, Regional Reference Center for Coagulation Disorders, Federico II University, Naples, Italy
| | - Rainer Zotz
- Institute for Laboratory Medicine, Blood Coagulation and Transfusion Medicine (LBT), Düsseldorf, Germany
- Department of Haemostasis, Haemotherapy and Transfusion Medicine, Heinrich Heine University Medical Centre, D-40225 Düsseldorf, Germany
| | - Roseline d’Oiron
- Centre for Haemophilia and Rare Congenital Bleeding Disorders, University Hospitals Paris-Sud, Le Kremlin-Bicêtre, France
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92
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Kenet G, Oladapo A, Epstein JD, Thompson C, Novack A, Nugent DJ. Estimating the potential cost of a high dose immune tolerance induction (ITI) therapy relative to the cost of a combined therapy of a low dose ITI therapy with bypassing agent prophylaxis. Haemophilia 2017. [PMID: 28641362 DOI: 10.1111/hae.13294] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION The International Immune Tolerance Study (I-ITI) demonstrated comparable success rates between low (FVIII 50 IU/kg/TIW) and high dose (FVIII 200 IU/kg/day) regimens. While costlier, the high dose ITI regimen achieved shorter time-to-treatment success with fewer bleeding episodes compared to the low dose ITI regimen. Adding bypassing agent prophylaxis (BAP) to a low dose ITI regimen may reduce bleeding while still being less costly than high dose ITI. AIM AND METHODS An economic model was developed to compare high dose ITI to low dose ITI with BAP. All model inputs were derived from clinical trials. The I-ITI study indicated a median time to negative inhibitor titre of 4.6 and 9.2 months and average number of bleeds/patient of 4.2 and 9.9 for the high and low dose regimens respectively. Based on the BAP trials, aPCC (85 U/kg/TIW) and rFVIIa (90 μg/kg/day) achieved a 62% and 45% reduction in bleeding frequency respectively. Cost analysis was from a US third party payer perspective and limited to drug costs. One-way, two-way and probabilistic sensitivity analyses were performed. RESULTS Costs of low dose ITI with aPCC prophylaxis until negative inhibitor titre is achieved was 24.0% less compared to high dose ITI. Low dose ITI with rFVIIa prophylaxis cost 46.5% more compared to high dose ITI. Model results were robust in the majority of the sensitivity analyses. CONCLUSION A low dose ITI regimen with aPCC prophylaxis may be cost saving compared to a high dose ITI regimen with the potential to reduce morbidity by lowering the risk for breakthrough bleeds.
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Affiliation(s)
- G Kenet
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel.,Sackler Medical School, Tel Aviv University, Tel Hashomer, Israel
| | | | | | | | | | - D J Nugent
- Center for Inherited Blood Disorders and CHOC Children's Hospital, Orange, CA, USA
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93
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94
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Bertamino M, Riccardi F, Banov L, Svahn J, Molinari AC. Hemophilia Care in the Pediatric Age. J Clin Med 2017; 6:E54. [PMID: 28534860 PMCID: PMC5447945 DOI: 10.3390/jcm6050054] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/12/2017] [Accepted: 05/16/2017] [Indexed: 01/19/2023] Open
Abstract
Hemophilia is the most common of the severe bleeding disorders and if not properly managed since early infancy can lead to chronic disease and lifelong disabilities. However, it enjoys the most efficacious and safe treatment among the most prevalent monogenic disorders. Hemophilia should be considered in the neonatal period in the case of unusual bleeding or in the case of positive family history. Later, hemophilia should be suspected mainly in males because of abnormal bruising/bleeding or unusual bleeding following invasive procedures-for example, tonsillectomy or circumcision. Prophylactic treatment that is started early with clotting-factor concentrates has been shown to prevent hemophilic arthropathy and is, therefore, the gold standard of care for hemophilia A and B in most countries with adequate resources. Central venous access catheters and arterovenous fistulas play an important role in the management of hemophilia children requiring repeated and/or urgent administration of coagulation factor concentrates. During childhood and adolescence, personalized treatment strategies that suit the patient and his lifestyle are essential to ensure optimal outcomes. Physical activity is important and can contribute to better coordination, endurance, flexibility and strength. The present article focuses also on questions frequently posed to pediatric hematologists like vaccinations, day-care/school access and dental care.
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Affiliation(s)
- Marta Bertamino
- Thrombosis and Hemostasis Unit, Regional Reference Center for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
| | - Francesca Riccardi
- Hematology Unit, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
| | - Laura Banov
- Thrombosis and Hemostasis Unit, Regional Reference Center for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
| | - Johanna Svahn
- Thrombosis and Hemostasis Unit, Regional Reference Center for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
| | - Angelo Claudio Molinari
- Thrombosis and Hemostasis Unit, Regional Reference Center for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
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95
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Rocino A, Franchini M, Coppola A. Treatment and Prevention of Bleeds in Haemophilia Patients with Inhibitors to Factor VIII/IX. J Clin Med 2017; 6:jcm6040046. [PMID: 28420167 PMCID: PMC5406778 DOI: 10.3390/jcm6040046] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/06/2017] [Accepted: 04/10/2017] [Indexed: 01/02/2023] Open
Abstract
The development of alloantibodies neutralising therapeutically administered factor (F) VIII/IX (inhibitors) is currently the most severe complication of the treatment of haemophilia. When persistent and at a high titre, inhibitors preclude the standard replacement treatment with FVIII/FIX concentrates, making patients’ management challenging. Indeed, the efficacy of bypassing agents, i.e., activated prothrombin complex concentrates (aPCC) and recombinant activated factor VII (rFVIIa), needed to overcome the haemostatic interference of the inhibitor, is not comparable to that of factor concentrates. In addition, the therapeutical response is unpredictable, with a relevant inter-individual and even intra-individual variability, and no laboratory assay is validated to monitor the efficacy and safety of the treatment. As a result, inhibitor patients have a worse joint status and quality of life compared to inhibitor-free subjects and the eradication of the inhibitor by immune tolerance induction is the preeminent therapeutic goal, particularly in children. However, over the last decades, treatment with bypassing agents has been optimised, allowing home treatment and the individualisation of regimens aimed at improving clinical outcomes. In this respect, a growing body of evidence supports the efficacy of prophylaxis with both bypassing agents in reducing bleeding rates and improving the quality of life, although the impact on long-term outcomes (in particular on preventing/reducing joint deterioration) is still unknown. This review offers an update on the current knowledge and practice of the use of bypassing agents in haemophiliacs with inhibitors, as well as on debated issues and unmet needs in this challenging setting.
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Affiliation(s)
- Angiola Rocino
- Haemophilia and Thrombosis Centre, San Giovanni Bosco Hospital, Napoli 80144, Italy.
| | - Massimo Franchini
- Department of Transfusion Medicine and Haematology, Carlo Poma Hospital, Mantova 46100, Italy.
| | - Antonio Coppola
- Regional Reference Centre for Coagulation Disorders, Federico II University Hospital, Napoli 80131, Italy.
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96
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Trickey RC, Percy C, Jenkins PV, Harris R, Loran C, Collins PW. Experience of immune tolerance in a carrier of severe haemophilia A with inhibitor development post-surgery. Haemophilia 2017; 23:e234-e235. [PMID: 28370910 DOI: 10.1111/hae.13216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2017] [Indexed: 01/11/2023]
Affiliation(s)
- R C Trickey
- Arthur Bloom Haemophilia Centre, University Hospital Wales, Cardiff, UK
| | - C Percy
- Haemophilia Centre, Singleton Hospital, Swansea, Swansea, UK
| | - P V Jenkins
- Haemophilia Centre, Singleton Hospital, Swansea, Swansea, UK
| | - R Harris
- Arthur Bloom Haemophilia Centre, University Hospital Wales, Cardiff, UK
| | - C Loran
- Arthur Bloom Haemophilia Centre, University Hospital Wales, Cardiff, UK
| | - P W Collins
- Arthur Bloom Haemophilia Centre, University Hospital Wales, Cardiff, UK.,Cardiff University, Cardiff, UK
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97
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Batty P, Austin SK, Khair K, Millar CM, Palmer B, Rangarajan S, Stümpel JP, Thanigaikumar M, Yee TT, Hart DP. Treatment burden, haemostatic strategies and real world inhibitor screening practice in non-severe haemophilia A. Br J Haematol 2017; 176:796-804. [PMID: 28198996 DOI: 10.1111/bjh.14543] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/03/2016] [Indexed: 12/11/2022]
Abstract
Inhibitor formation in non-severe haemophilia A is a life-long risk and associated with morbidity and mortality. There is a paucity of data to understand real-world inhibitor screening practice. We evaluated the treatment burden, haemostatic strategies, F8 genotyping and inhibitor screening practices in non-severe haemophilia A in seven London haemophilia centres. In the 2-year study period, 44% (377/853) patients received at least one haemostatic treatment. Seventy-nine percent of those treated (296/377) received factor VIII (FVIII) concentrate. F8 genotype was known in 88% (331/377) of individuals. Eighteen per cent (58/331) had 'high-risk' F8 genotypes. In patients with 'standard-risk' F8 genotypes treated on-demand with FVIII concentrate, 51·3% episodes (243/474) were screened within 1 year. However, poor screening compliance was observed after 'high-risk' treatment episodes. In patients with 'standard-risk' F8 genotypes, 12·3% (28/227) of treatment episodes were screened in the subsequent 6 weeks after surgery or a bleed requiring ≥5 exposure days. Similarly, in the context of 'high-risk' F8 genotypes after any FVIII exposure, only 13·6% (12/88) of episodes were screened within 6 weeks. Further study is required to assess optimal practice of inhibitor screening in non-severe haemophilia A to inform subsequent clinical decisions and provide more robust prevalence data to further understand the underlying immunological mechanism.
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Affiliation(s)
- Paul Batty
- The Royal London Hospital Haemophilia Centre, QMUL, Barts and The London School of Medicine and Dentistry, London, UK
| | - Steve K Austin
- St George's Healthcare NHS Trust, Haemophilia Centre, London, UK.,The Centre for Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - Kate Khair
- Great Ormond Street Haemophilia Centre, London, UK
| | | | - Ben Palmer
- The United Kingdom National Haemophilia Database, Manchester, UK
| | - Savita Rangarajan
- The Centre for Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - Jan-Phillip Stümpel
- The Royal London Hospital Haemophilia Centre, QMUL, Barts and The London School of Medicine and Dentistry, London, UK
| | | | - Thynn T Yee
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Daniel P Hart
- The Royal London Hospital Haemophilia Centre, QMUL, Barts and The London School of Medicine and Dentistry, London, UK
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Calmette L, Martin AC, Le Bonniec B, Zlotnik D, Gouin-Thibault I, Bachelot-Loza C, Gaussem P, Godier A. Ticagrelor reversal: in vitro assessment of four haemostatic agents. J Clin Pathol 2017; 70:733-739. [PMID: 28159767 DOI: 10.1136/jclinpath-2016-204117] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 01/11/2017] [Accepted: 01/12/2017] [Indexed: 12/23/2022]
Abstract
AIM Management of ticagrelor-induced bleeding is challenging as platelet transfusion is ineffective. An effective strategy is needed. This study aimed to investigate in vitro the efficacy of four haemostatic drugs (HDs), namely recombinant activated factor VII (rFVIIa), fibrinogen concentrate (Fib), tranexamic acid (TXA) and factor XIII concentrate (FXIII) to improve the haemostatic capacity in the presence of ticagrelor. METHODS Blood was spiked with ticagrelor then supplemented by either HD or control. Several assays were performed: ADP-induced platelet aggregation measured by impedance aggregometry, light transmission and two global assays, thrombolastography with the platelet mapping device (TEG-PM) and a platelet-dependent thrombin generation assay (TGA). RESULTS Ticagrelor inhibited ADP-induced platelet aggregation and decreased the clot strength maximum amplitude (MA) in TEG-PMADP. None of the HDs corrected these parameters. However, rFVIIa shortened the coagulation time R using TEG-PMthrombin and the time to peak prolonged by ticagrelor in TGA. Fib increased MAthrombin and FXIII decreased LY30. TXA had no effects. CONCLUSIONS Whereas none of the HDs corrected ticagrelor-induced platelet inhibition, rFVIIa shortened coagulation times, Fib increased clot firmness and FXIII decreased fibrinolysis. Consequently, they may bypass ticagrelor effects by acting on fibrin formation or fibrinolysis. Further studies are needed to confirm these data in vivo.
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Affiliation(s)
- Leyla Calmette
- Faculté de Pharmacie, Inserm UMR-S1140, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Laboratoire d'Hématologie, AP-HP, Hôpital Cochin, Paris, France
| | - Anne-Céline Martin
- Faculté de Pharmacie, Inserm UMR-S1140, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Service de Cardiologie, Hôpital Val de Grâce, Paris, France
| | - Bernard Le Bonniec
- Faculté de Pharmacie, Inserm UMR-S1140, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Diane Zlotnik
- Faculté de Pharmacie, Inserm UMR-S1140, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Isabelle Gouin-Thibault
- Faculté de Pharmacie, Inserm UMR-S1140, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Laboratoire d'Hématologie, AP-HP, Hôpital Cochin, Paris, France
| | - Christilla Bachelot-Loza
- Faculté de Pharmacie, Inserm UMR-S1140, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Pascale Gaussem
- Faculté de Pharmacie, Inserm UMR-S1140, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Service d'Hématologie Biologique, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Anne Godier
- Faculté de Pharmacie, Inserm UMR-S1140, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Service d'Anesthésie-Réanimation, Fondation Rothschild, Paris, France
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Ustinnikova OB, Runova OB, Novikova EV, Bondarev VP, Lebedinskaya EV. Critical Development Needs for Recombinant Blood-Coagulation Factors. Pharm Chem J 2016. [DOI: 10.1007/s11094-016-1492-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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100
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Current view and outcome of ITI therapy - A change over time? Thromb Res 2016; 148:38-44. [DOI: 10.1016/j.thromres.2016.10.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/28/2016] [Accepted: 10/14/2016] [Indexed: 01/19/2023]
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