51
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Han JP, Kim M, Choi BS, Lee JH, Lee GS, Jeong M, Lee Y, Kim EA, Oh HK, Go N, Lee H, Lee KJ, Kim UG, Lee JY, Kim S, Chang J, Lee H, Song DW, Yeom SC. In vivo delivery of CRISPR-Cas9 using lipid nanoparticles enables antithrombin gene editing for sustainable hemophilia A and B therapy. SCIENCE ADVANCES 2022; 8:eabj6901. [PMID: 35061543 PMCID: PMC8782450 DOI: 10.1126/sciadv.abj6901] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 11/30/2021] [Indexed: 05/24/2023]
Abstract
Hemophilia is a hereditary disease that remains incurable. Although innovative treatments such as gene therapy or bispecific antibody therapy have been introduced, substantial unmet needs still exist with respect to achieving long-lasting therapeutic effects and treatment options for inhibitor patients. Antithrombin (AT), an endogenous negative regulator of thrombin generation, is a potent genome editing target for sustainable treatment of patients with hemophilia A and B. In this study, we developed and optimized lipid nanoparticles (LNPs) to deliver Cas9 mRNA along with single guide RNA that targeted AT in the mouse liver. The LNP-mediated CRISPR-Cas9 delivery resulted in the inhibition of AT that led to improvement in thrombin generation. Bleeding-associated phenotypes were recovered in both hemophilia A and B mice. No active off-targets, liver-induced toxicity, and substantial anti-Cas9 immune responses were detected, indicating that the LNP-mediated CRISPR-Cas9 delivery was a safe and efficient approach for hemophilia therapy.
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Affiliation(s)
- Jeong Pil Han
- Graduate School of International Agricultural Technology and Institute of Green BioScience and Technology, Seoul National University, Pyeongchang, Gangwon 25354, Korea
| | - MinJeong Kim
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Woman’s University, Seodaemun-gu, Seoul 03760, Korea
| | | | - Jeong Hyeon Lee
- Graduate School of International Agricultural Technology and Institute of Green BioScience and Technology, Seoul National University, Pyeongchang, Gangwon 25354, Korea
| | - Geon Seong Lee
- Graduate School of International Agricultural Technology and Institute of Green BioScience and Technology, Seoul National University, Pyeongchang, Gangwon 25354, Korea
| | - Michaela Jeong
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Woman’s University, Seodaemun-gu, Seoul 03760, Korea
| | - Yeji Lee
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Woman’s University, Seodaemun-gu, Seoul 03760, Korea
| | - Eun-Ah Kim
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Woman’s University, Seodaemun-gu, Seoul 03760, Korea
| | | | - Nanyeong Go
- Toolgen Inc., Geumcheon-gu, Seoul 08501, Korea
| | - Hyerim Lee
- Toolgen Inc., Geumcheon-gu, Seoul 08501, Korea
| | - Kyu Jun Lee
- Toolgen Inc., Geumcheon-gu, Seoul 08501, Korea
| | - Un Gi Kim
- Toolgen Inc., Geumcheon-gu, Seoul 08501, Korea
| | | | | | - Jun Chang
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Woman’s University, Seodaemun-gu, Seoul 03760, Korea
| | - Hyukjin Lee
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Woman’s University, Seodaemun-gu, Seoul 03760, Korea
| | | | - Su Cheong Yeom
- Graduate School of International Agricultural Technology and Institute of Green BioScience and Technology, Seoul National University, Pyeongchang, Gangwon 25354, Korea
- WCU Biomodulation Major, Department of Agricultural Biotechnology, Seoul National University, Gwanank-gu, Seoul 08826, Korea
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52
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Páramo JA. [Treatment of haemophilia: From replacement to gene therapy]. Med Clin (Barc) 2021; 157:583-587. [PMID: 34509300 DOI: 10.1016/j.medcli.2021.04.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 01/15/2023]
Abstract
Haemophilia A and B are congenital bleeding disorders characterized by missing or defective factor VIII or factor IX, respectively. Factor replacement therapy has been the gold standard for prophylaxis and treatment of bleeding complications. However, the inconvenience of regular intravenous administration, along with progression of arthropathy and development of inhibitors has driven the need for alternative treatment options, such as extended half-life products, non-factor coagulation products, such as subcutaneous emicizumab, blocking natural anticoagulants (rebalancing haemostatic agents) and gene therapy, which have been useful to control bleeding or are currently under late-phase clinical investigation.
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Affiliation(s)
- José A Páramo
- Servicio de Hematología y Hemoterapia, Clínica Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Navarra, España; CIBERCV.
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53
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Matuk-Villazon O, Roberts JC, Corrales-Medina FF. Hemophilia: The Past, the Present, and the Future. Pediatr Rev 2021; 42:672-683. [PMID: 34850178 DOI: 10.1542/pir.2020-004143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Omar Matuk-Villazon
- Department of Clinical Sciences, University of Houston College of Medicine, Houston, TX
| | - Jonathan C Roberts
- Bleeding & Clotting Disorders Institute, Peoria, IL.,Division of Hematology, Department of Pediatrics, University of Illinois College of Medicine at Peoria, Peoria, IL
| | - Fernando F Corrales-Medina
- Holtz Children's Hospital, Jackson Memorial Medical Center, Miami, FL.,Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL.,University of Miami Hemophilia Treatment Center, Miami, FL
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54
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Kizilocak H, Young G. Emerging drugs for hemophilia A: insights into phase II and III clinical trials. Expert Opin Emerg Drugs 2021; 26:337-350. [PMID: 34601977 DOI: 10.1080/14728214.2021.1988073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Hemophilia is a lifelong, genetic-bleeding disorder, which inadequately treated results in permanent joint damage. It is characterized by spontaneous and trauma-related bleeding episodes. In the last 50 years, treatment has seen dramatic improvements which have improved the quality of life of persons with hemophilia. AREAS COVERED This review will provide a summary of current pharmacological approaches for hemophilia A as well as discuss novel agents which are either approved recently or in phase II-III clinical trials, plasma-derived and recombinant factor VIII (FVIII) products, extended half-life FVIII products, bypassing agents and non-replacement therapies. EXPERT OPINION Novel therapies are already changing the way that hemophilia A is managed, and as more new therapies get approved, there will be a revolution in the management of this serious condition. Clinicians will have both the opportunities as well as the challenges of incorporating such new technologies into clinical practice.
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Affiliation(s)
- Hande Kizilocak
- Children's Hospital Los Angeles, Hemostasis and Thrombosis Center, Cancer and Blood Disease Institute, Los Angeles, CA, USA
| | - Guy Young
- Children's Hospital Los Angeles, Hemostasis and Thrombosis Center, Cancer and Blood Disease Institute, Los Angeles, CA, USA.,Department of Hematology and Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
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55
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Abstract
[Figure: see text].
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Affiliation(s)
- Margaret V Ragni
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Hemophilia Center of Western PA, Pittsburgh, PA, USA
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56
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Okaygoun D, Oliveira DD, Soman S, Williams R. Advances in the management of haemophilia: emerging treatments and their mechanisms. J Biomed Sci 2021; 28:64. [PMID: 34521404 PMCID: PMC8442442 DOI: 10.1186/s12929-021-00760-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/08/2021] [Indexed: 11/10/2022] Open
Abstract
Mainstay haemophilia treatment, namely intravenous factor replacement, poses several clinical challenges including frequent injections due to the short half-life of recombinant factors, intravenous administration (which is particularly challenging in those with difficult venous access), and the risk of inhibitor development. These impact negatively upon quality of life and treatment compliance, highlighting the need for improved therapies. Several novel pharmacological therapies developed for haemophilia aim to rebalance the clotting cascade and potentially circumvent the aforementioned challenges. These therapies utilise a range of different mechanisms, namely: the extension of the circulating half-life of standard recombinant factors; the mimicking of factor VIII cofactor activity; rebalancing of coagulation through targeting of natural anticoagulants such as antithrombin and tissue factor pathway inhibitor; and inducing the production of endogenous factors with gene therapy. These therapies carry the potential of revolutionising haemophilia treatment by alleviating the current challenges presented by mainstay factor replacement. This review will provide an overview of the key trial findings related to novel therapies based on the mechanisms described above.
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Affiliation(s)
- Dide Okaygoun
- Imperial College London: Faculty of Medicine, Imperial College Road, London, SW7 2DD, UK
| | - Danielle D Oliveira
- Imperial College London: Faculty of Medicine, Imperial College Road, London, SW7 2DD, UK.
| | - Sooriya Soman
- Imperial College London: Faculty of Medicine, Imperial College Road, London, SW7 2DD, UK
| | - Riccardo Williams
- Imperial College London: Faculty of Medicine, Imperial College Road, London, SW7 2DD, UK
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Olasupo OO, Lowe MS, Krishan A, Collins P, Iorio A, Matino D. Clotting factor concentrates for preventing bleeding and bleeding-related complications in previously treated individuals with haemophilia A or B. Cochrane Database Syst Rev 2021; 8:CD014201. [PMID: 34407214 PMCID: PMC8407508 DOI: 10.1002/14651858.cd014201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The hallmark of severe hemophilia (A or B) is recurrent bleeding into joints and soft tissues with progressive joint damage, despite on-demand treatment. Prophylaxis has long been used, but not universally adopted, because of medical, psychosocial, and cost controversies. OBJECTIVES To determine the effectiveness of clotting factor concentrate prophylaxis in managing previously-treated individuals with hemophilia A or B. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. In addition, we searched MEDLINE and Embase and online trial registries. Most recent search of Group's Coagulopathies Trials Register: 24 February 2021. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs evaluating people with hemophilia A or hemophilia B, who were previously treated with clotting factor concentrates to manage their hemophilia. DATA COLLECTION AND ANALYSIS Two authors independently reviewed trials for eligibility, assessed risk of bias and extracted data. The authors used the GRADE criteria to assess the certainty of the evidence. MAIN RESULTS Ten trials (including 608 participants) were eligible for inclusion. Eight of the trials (477 participants) had arms comparing two or more prophylactic regimens to one another and four of the trials (n = 258) compared prophylaxis to on-demand treatment (two trials had multiple arms and were included in both comparisons). Comparison of two or more prophylactic regimens For trials comparing one prophylaxis regimen to another, given the heterogeneity of the data, none of the data were pooled for this comparison. Considering the individual trials, three trials reported the primary outcome of joint bleeding, and none showed a dfference between dosing regimens (low-certainty evidence). For the secondary outcome of total bleeding events, prophylaxis with a twice-weekly regimen of FIX likely results in reduced total bleeds compared to a once-a-week regimen of the same dose, mean difference (MD) 11.2 (5.81 to 16.59) (one trial, 10 participants, low-certainty evidence). Transient low-titer anti-FVIII inhibitors were reported in one of the trials. Blood-transmitted infections were not identified. Other adverse events reported include hypersensitivity, oedema, and weight gain. These were, however, rare and unrelated to study drugs (very low-certainty evidence). Comparison of prophylactic and on-demand regimens Four of the trials (258 participants) had arms that compared prophylaxis to on-demand treatment. Prophylaxis may result in a large decrease in the number of joint bleeds compared to on-demand treatment, MD -30.34 (95% CI -46.95 to -13.73) (two trials, 164 participants, low-certainty evidence). One of these trials (84 participants) also reported the long-term effects of prophylaxis versus on-demand therapy showing improved joint function, quality of life, and pain; but no differences between groups in joint structure when assessed by magnetic resonance imaging (MRI). In one trial (84 participants) validated measures for joint health and pain assessment showed that prophylaxis likely improves joint health compared to an on-demand regimen with an estimated change difference of 0.94 points (95% CI 0.23 to 1.65) and improves total pain scores, MD -17.20 (95% CI -27.48 to -6.92 (moderate-certainty evidence). Two trials (131 participants) reported that prophylaxis likely results in a slight increase in adverse events, risk ratio 1.71 (1.24 to 2.37) (moderate-certainty evidence). No inhibitor development and blood-transmitted infections were identified. Overall, the certainty of the body of evidence was judged to be low because of different types of bias that could have altered the effect. AUTHORS' CONCLUSIONS: There is evidence from RCTs that prophylaxis, as compared to on-demand treatment, may reduce bleeding frequency in previously-treated people with hemophilia. Prophylaxis may also improve joint function, pain and quality of life, even though this does not translate into a detectable improvement of articular damage when assessed by MRI. When comparing two different prophylaxis regimens, no significant differences in terms of protection from bleeding were found. Dose optimization could, however, result in improved efficacy. Given the heterogeneity of the data, pooled estimates were not obtained for most comparisons. Well-designed RCTs and prospective observational controlled studies with standardised definitions and measurements are needed to establish the optimal and most cost-effective treatment regimens.
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Affiliation(s)
- Omotola O Olasupo
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Canada
| | - Megan S Lowe
- Department of Health Sciences, McMaster University, Hamilton, Canada
| | - Ashma Krishan
- School of Health Sciences, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Peter Collins
- Arthur Bloom Haemophilia Centre, Heath Park, School of Medicine, Cardiff University, Cardiff, UK
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Canada
| | - Davide Matino
- Department of Internal Medicine, McMaster University, Hamilton, Canada
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Abstract
Remarkable changes are occurring in the diagnosis and management of individuals with hemophilia A. Genetic testing, including next-generation sequencing, enables family planning, carrier testing, and prenatal diagnosis. Musculoskeletal ultrasound examination facilitates the early detection of acute bleeds and joint disease in clinic, enabling more rapid bleed resolution and treatment planning. Novel therapies offer simpler weekly or monthly administration, some by subcutaneous injection, with better compliance and quality of life, as well as fewer bleeds. Gene therapy provides a 1-time phenotypic "cure" that is cost effective, but may be complicated by waning levels, vector immune responses, and hepatotoxicity.
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59
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Abstract
Haemophilia is an inherited bleeding disorder in which the haemostatic defect results from deficiency of coagulation factor VIII (FVIII) in haemophilia A or factor IX (FIX) in haemophilia B. Traditional treatments for haemophilia have largely worked by directly replacing the missing coagulation factor, but face challenges due to the short half-life of FVIII and FIX, the need for frequent intravenous access and development of neutralising antibodies to coagulation factors (inhibitors). Recent advances in haemophilia therapy have worked to eliminate these challenges. Half-life extension of factor concentrates has lengthened the time needed between infusions, enhancing quality of life. Subcutaneous administration of therapeutics utilising alternative mechanisms to overcome inhibitors have expanded the options to prevent bleeding. Finally, initial successes with gene therapy offer a cautious hope for durable cure. In the present review, we will discuss currently available treatments, as well as highlight therapeutics in various stages of clinical development for the treatment of haemophilia A and B. In this review, we present therapies that are currently clinically available and highlight therapeutics that are in various stages of clinical development for the treatment of haemophilia A and B.
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Affiliation(s)
- Hannah Fassel
- Tufts University School of Medicine, Boston, MA, USA
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60
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Kjalke M, Kjelgaard‐Hansen M, Andersen S, Hilden I. Thrombin generation potential in the presence of concizumab and rFVIIa, APCC, rFVIII, or rFIX: In vitro and ex vivo analyses. J Thromb Haemost 2021; 19:1687-1696. [PMID: 33819375 PMCID: PMC8360123 DOI: 10.1111/jth.15323] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/03/2021] [Accepted: 03/25/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The anti-tissue factor plasma inhibitor monoclonal antibody concizumab is under clinical investigation for subcutaneous prophylaxis of hemophilia A/B (HA/HB) with or without inhibitors. Breakthrough bleeds while on concizumab prophylaxis may be treated with bypassing agents (recombinant activated factor VIIa [rFVIIa] and activated prothrombin complex concentrate [APCC]), or with factor VIII (FVIII) or factor IX (FIX). OBJECTIVES To evaluate the effect of combining concizumab with rFVIIa, APCC, rFVIII, and rFIX on thrombin generation (TG) potential. METHODS Pooled HA plasma was spiked in vitro with concizumab alone or together with rFVIIa, APCC, or rFVIII. rFVIIa, APCC, and rFVIII were added ex vivo to plasma from HA patients receiving concizumab prophylaxis. Pooled HB plasma was spiked with concizumab alone or together with rFIX. TG potential was measured after initiation with tissue factor. RESULTS Concizumab increased thrombin peak in a concentration-dependent manner. Adding rFVIIa, APCC, rFVIII, or rFIX caused a further increase in thrombin peak. The effects of concizumab and rFVIIa, APCC, rFVIII, or rFIX were mainly additive, with no or up to maximally ~25% extra effect caused by drug--drug interaction. No strong synergistic effects were observed upon combining concizumab with rFVIIa, APCC, rFVIII, or rFIX. The thrombin peak obtained with 0.5 IU/ml rFVIII or rFIX in the presence of concizumab was on occasion slightly higher, but mostly comparable to the thrombin peak with 1 IU/ml rFVIII or rFIX in the absence of concizumab. CONCLUSION rFVIIa, APCC, rFVIII, and rFIX enhanced plasma TG potential in the presence of concizumab. Dose levels of concomitant use should be adjusted accordingly to balance potential safety concerns while maintaining the necessary hemostatic effect. Please see the video in the Supplementary Material for an animated summary of the data presented.
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Affiliation(s)
| | | | | | - Ida Hilden
- Global Drug DiscoveryNovo Nordisk A/SMåløvDenmark
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61
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Chowdary P. Nonfactor Therapies: New Approaches to Prophylactic Treatment of Haemophilia. Hamostaseologie 2021; 41:247-256. [PMID: 34187062 DOI: 10.1055/a-1424-7900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
For several decades, the treatment of haemophilia has relied on factor replacement therapy, which restores haemostasis by replacing the missing coagulation factor. In recent years, novel alternative therapies for the treatment of haemophilia in patients with and without inhibitors have been developed. These emergent therapies promote haemostasis by mimicking coagulation factors or inhibiting natural anticoagulants. They provide a less invasive route of administration (i.e. subcutaneous) and some offer reduced frequency of dosing (i.e. every 2 weeks, monthly) compared with the majority of factor replacement therapies, and thus have the potential to simplify treatment, increase adherence and subsequently improve outcomes for patients. Their introduction has transformed the care of haemophilia patients with inhibitors to factor VIII, with similar expectation for haemophilia B patients with inhibitors. However, these therapies also come with several new challenges including their limitation to prophylactic treatment, the observed increased incidence of thrombosis, or their impact on the natural history of the disease and potential disruption of existing treatment guidelines like the use of immune tolerance induction. Moreover, questions remain regarding the long-term impact of non-replacement therapies on joint health as well as the optimal strategy to manage breakthrough bleeds in patients with inhibitors.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London, United Kingdom
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62
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Marchesini E, Morfini M, Valentino L. Recent Advances in the Treatment of Hemophilia: A Review. Biologics 2021; 15:221-235. [PMID: 34163136 PMCID: PMC8214539 DOI: 10.2147/btt.s252580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/10/2021] [Indexed: 01/19/2023]
Abstract
Progress in hemophilia therapy has been remarkable in the first 20 years of the third millennium, but the innovation began with the description the fractionation of plasma in 1946. The first concentrates followed the discovery of FVIII in the cryoprecipitate of frozen plasma and FIX in the supernatant in the early 1960s, which led to the initial attempts at replacement therapy. Unfortunately, the lack of screening methods for viral pathogens resulted in people with hemophilia (PWH) receiving concentrates contaminated by hepatitis A virus, hepatitis C virus, and human immunodeficiency virus, as these concentrates were made from large industrial pools of plasma derived from thousands of donors. Fortunately, by 1985, viral screening methods and proper virucidal techniques were developed that made concentrates safe. Increasingly pure products followed the introduction of chromatography steps with monoclonal antibodies in the production process. The problem of immunogenicity of exogenously administered concentrates has not yet had a complete solution. The development of alloantibodies against FVIII in about 25-35% of PWH is the most serious adverse effect of replacement therapy. The next major advance followed the cloning of the F8 gene and later the F9 genes, which paved the way to produce concentrates of factors obtained by the recombinant DNA technology. The injected FVIII and FIX molecules had a relatively short circulating half-life in the plasma of people with hemophilia A and B, approximately 12 and 18 hours, respectively. The ability to prolong the plasma half-life and extend the interval between injections followed the application of methods to conjugate the factor molecule with the fragment crystallizable of IgG1 or albumin or by adding polyethylene glycol, which has led to an increase in the half-life of concentrates, especially for rFIX. The next frontier in hemophilia therapy is the application of durable and potentially curative therapies such as with gene addition therapy. Experiments in hemophilia B have demonstrated durable responses. Unfortunately, the results with gene therapy for hemophilia A have not been as remarkable and the durability must still be demonstrated. Nonetheless, the long-term safety, predictability, durability, and efficacy of gene therapy for hemophilia A and B remain an open question. At present, only healthy adult PWH have been enrolled in gene therapy clinical trials. The application of gene therapy to children and those with pre-existing antibodies against the delivery vector must also be studied before this therapy becomes widespread.
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Affiliation(s)
- Emanuela Marchesini
- Hemophilia Centre, SC Vascular and Emergency Department, University of Perugia, Perugia, Italy
| | - Massimo Morfini
- Italian Association of Haemophilia Centres (AICE), Naples, Italy
| | - Leonard Valentino
- National Hemophilia Foundation, New York, NY, USA
- Rush University, Chicago, IL, USA
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Siebert AE, Maroney SA, Martinez ND, Mast AE. Intrauterine lethality in Tfpi gene disrupted mice is differentially suppressed during mid- and late-gestation by platelet TFPIα overexpression. J Thromb Haemost 2021; 19:1483-1492. [PMID: 33728763 PMCID: PMC8165032 DOI: 10.1111/jth.15299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 02/05/2021] [Accepted: 03/02/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Tissue factor pathway inhibitor (TFPI) is an anticoagulant protein required for murine embryonic development. Intrauterine lethality of Tfpi-/- mice occurs at mid- and late gestation, the latter of which is associated with severe cerebrovascular defects. Megakaryocytes produce only the TFPIα isoform, which is stored within platelets and released upon activation. OBJECTIVES To examine biological activities of platelet TFPIα (pTFPIα) by characterizing effects of pTFPIα overexpression in Tfpi-/- mice. METHODS Transgenic mice overexpressing pTFPIα were generated and crossed onto the Tfpi-/- background. Genetic and histological analyses of embryos were performed to investigate the function of pTFPIα during embryogenesis. RESULTS The transgene (Tg) increased pTFPIα 4- to 5-fold without altering plasma TFPI in adult Tfpi+/+ and Tfpi+/- mice but did not rescue Tfpi-/- mice to wean. Analyses of the impact of pTFPIα overexpression on Tfpi-/- survival, however, were complicated by linkage between the Tg integration site and the endogenous Tfpi locus on chromosome 2. Strain-specific genetic interactions also modulated Tfpi-/- embryonic survival. After accounting for these underlying genetic factors, pTFPIα overexpression completely suppressed mid-gestational lethality of Tfpi-/- embryos but had no effect on development of cerebrovascular defects during late gestation resulting in their lack of survival to wean. CONCLUSIONS pTFPIα overexpression rescued Tfpi-/- embryos from mid-gestational but not late gestational lethality. The prevalence of underlying genetic factors complicating analyses within our study illustrates the importance of meticulously characterizing transgenic mouse models to avoid spurious interpretation of results.
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Affiliation(s)
| | | | | | - Alan E. Mast
- Versiti Blood Research Institute, Milwaukee, WI, USA
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
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64
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Kwak EY, Kim MJ, Park JH, Jung HW, Jung ME. Target-mediated drug disposition modeling of an anti-TFPI antibody (MG1113) in cynomolgus monkeys to predict human pharmacokinetics and pharmacodynamics. J Thromb Haemost 2021; 19:1425-1435. [PMID: 33448093 DOI: 10.1111/jth.15244] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/18/2020] [Accepted: 01/06/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND MG1113 is a human monoclonal antibody of tissue factor pathway inhibitor (TFPI) under development for prophylaxis for hemophilia patients with or without inhibitors against factor VIII products, which have been used for the treatment of hemophilia. Because TFPI is a negative regulator in the extrinsic coagulation pathway, neutralization of TFPI function by MG1113 can potentially increase coagulation activity by bypassing the intrinsic coagulation pathway, which factor VIII activates. OBJECTIVES This study aims to determine the correlation between pharmacokinetics (PK) and pharmacodynamics (PD) after administering MG1113 to monkeys and to predict the PK and PD of MG1113 in humans by the Target-Mediated Drug Disposition (TMDD) model using the results from monkeys. METHODS The PK profile of MG1113 and the PD effect on the free TFPI level were evaluated after intravenous (IV) and subcutaneous (SC) administrations of MG1113 (2.5, 5, and 10 mg/kg) to male cynomolgus monkeys. After setting up the PK/PD model on monkeys, PK parameters on humans were calculated using allometric scaling, and then clinically effective doses were predicted applying the TMDD model. RESULTS AND CONCLUSIONS MG1113 showed nonlinear PK after both IV and SC administrations at the dosing range from 2.5 to10 mg/kg. The concentrations of MG1113 versus TFPI could be characterized a dose-response relationship using a TMDD model. The TMDD modeling and simulation built in this study were used to simulate various dosage regimens of MG1113 to apply to the first-in-human study design, and moreover expected to be referred to establish the dose for further clinical trials.
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Affiliation(s)
- Eun-Young Kwak
- Department of GC Pharma R&D Center, GC Pharma, Gyeonggi-do, Korea
| | - Min Ju Kim
- Department of GC Pharma R&D Center, GC Pharma, Gyeonggi-do, Korea
| | - Jin Hyun Park
- Department of GC Pharma R&D Center, GC Pharma, Gyeonggi-do, Korea
| | - Ha Wook Jung
- Department of GC Pharma R&D Center, GC Pharma, Gyeonggi-do, Korea
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65
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Berntorp E, Hermans C, Solms A, Poulsen L, Mancuso ME. Optimising prophylaxis in haemophilia A: The ups and downs of treatment. Blood Rev 2021; 50:100852. [PMID: 34243987 DOI: 10.1016/j.blre.2021.100852] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 01/19/2023]
Abstract
The classical goals of haemophilia A treatment are to prevent bleeds, minimise the risk of long-term complications associated with joint damage, and improve quality of life by maintaining appropriate factor VIII [FVIII] levels. The dose and frequency of FVIII replacement therapies required to reduce bleeds is now known to vary amongst individuals, and may change for the same individual over time, meaning that a standardised dose and regimen may not provide optimal protection to all patients. Here we review the evolving treatment landscape for haemophilia A, and discuss how an increased understanding of the pharmacology and pharmacokinetics underlying FVIII replacement and non-factor replacement therapies could improve patient outcomes. We also review the strengths and weaknesses of current treatments and explore the benefits of personalised therapy and review how this may best be achieved with current treatment options. The key points of our review are summarised in this accompanying short video.
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Affiliation(s)
- Erik Berntorp
- Malmö Center for Thrombosis and Haemostasis, Lund University, Sweden.
| | - Cédric Hermans
- Division of Adult Haematology, Haemostasis and Thrombosis Unit, Université Catholique de Louvain (UCLouvai), Brussels, Belgium
| | | | - Lone Poulsen
- Haemophilia Center, Aarhus University Hospital, Denmark
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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66
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Laboratory monitoring of hemophilia A treatments: new challenges. Blood Adv 2021; 4:2111-2118. [PMID: 32396619 DOI: 10.1182/bloodadvances.2019000849] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/04/2020] [Indexed: 12/12/2022] Open
Abstract
Monitoring factor VIII (FVIII) activity has traditionally been complicated by discrepancies between assays for the various sorts of FVIII molecules. The advent of novel nonfactor therapies (emicizumab, fitusiran, and anti-tissue factor pathway inhibitor antibodies) in hemophilia A poses a new level of difficulty on the laboratory monitoring of these patients. To use the correct assays and for a proper interpretation of their results, it is pertinent to understand the mode of action of these nonfactor agents. Furthermore, the biochemical consequences for the different types of activity assays (whether it be specific FVIII activity assays or global coagulation assays) should be taken into account as well. In this review, these aspects will be discussed. In addition, the use of various animal models to estimate FVIII-equivalence of the nonfactor therapies will be presented.
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67
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Mahlangu JN. Progress in the Development of Anti-tissue Factor Pathway Inhibitors for Haemophilia Management. Front Med (Lausanne) 2021; 8:670526. [PMID: 34026796 PMCID: PMC8131856 DOI: 10.3389/fmed.2021.670526] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 03/24/2021] [Indexed: 12/28/2022] Open
Abstract
The unprecedented progress in addressing unmet needs in haemophilia care to date includes developing several novel therapies that rebalance haemostasis by restoring thrombin generation in patients with haemophilia A or B with and without inhibitors. These novel therapies are FVIII mimetics, antithrombin interference RNA therapy and several monoclonal antibodies directed against the tissue factor pathway inhibitor (anti-TFPI). In this review, we provide an update on the progress made in developing anti-TFPI therapie. Phase 1 data from the three anti-TFPI studies showed acceptable safety profiles, and currently, available phase 2 data are encouraging. While these data support these molecules' further development progression, there is uncertainty on several aspects of their evolution. Two of the three anti-TFPIs have shown drug-related thrombosis, with one study consequently terminated. None of the thrombotic events is predictable with current monitoring tools, and none correlate with known coagulation parameters. All three anti-TFPIs undergo target mediated drug disposition, which impacts the formulation of dosing regimen fo these therapies. They would require more frequent dosing than some of the extended half-life clotting factor products and antithrombin RNAi therapy. There is no assay to measure the TFPI as the physiological levels are very low, which makes monitoring the impact of the anti-TFPI a challenge. The anti-TFPIs have several advantages, including their bioavailability when administered subcutaneously, their stable pharmacokinetics and their ability to prevent bleeds in haemophilia A or B patients with and without inhibitors. Whether these advantages can be realized will depend on the outcome of the currently ongoing studies.
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Affiliation(s)
- Johnny N. Mahlangu
- Haemophilia Comprehensive Care Centre, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
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68
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Jiménez-Yuste V, Auerswald G, Benson G, Dolan G, Hermans C, Lambert T, Ljung R, Morfini M, Santagostino E, Zupančić Šalek S. Practical considerations for nonfactor-replacement therapies in the treatment of haemophilia with inhibitors. Haemophilia 2021; 27:340-350. [PMID: 33742707 DOI: 10.1111/hae.14167] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 08/12/2020] [Accepted: 09/11/2020] [Indexed: 12/19/2022]
Abstract
New therapeutic agents for haemophilia with inhibitors that are in development or already licensed are expected to provide transformative treatment options. Many of these new therapies are not based on simply replacing the missing factor; new strategies include bispecific antibody technology that mimics factor VIII coagulation function (emicizumab), and inhibition of anticoagulant proteins such as tissue factor pathway inhibitor (eg PF-06741086) and antithrombin (eg fitusiran). These agents are administered subcutaneously and should significantly reduce treatment burden and increase the ability to deliver prophylaxis for patients. Limited real-world data and validated practical guidance on these recently licensed/upcoming treatments resulted in the authors convening to discuss recommendations on their use. Emicizumab is currently the only licenced nonfactor therapy; thus, our recommendations focus on this product. Target candidates for emicizumab prophylaxis are difficult-to-treat patients with haemophilia A and inhibitors and/or venous access issues, frequent bleeds and target joints. In case of breakthrough bleeding while receiving emicizumab, patients still require treatment with bypassing agents; the adjunct treatment of choice is recombinant activated factor VII. This treatment is also recommended to prevent bleeds in patients with inhibitors undergoing surgery. Our recommendations on suitable laboratory assays and monitoring new products, as well as the benefit of patient-reported outcomes (such as pain and physical activity levels), are included. We also briefly discuss future treatment options for patients with haemophilia B and inhibitors. Although these nonfactor treatments offer great promise, further data and real-world evidence are needed.
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Affiliation(s)
- Victor Jiménez-Yuste
- Hospital Universitario La Paz, Unidad de Coagulopatías, Servicio de Hematología, Autonoma University, Madrid, Spain
| | - Günter 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
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Thierry Lambert
- Hemophilia Care Center, Bicêtre AP-HP Hospital and Faculté de Médecine Paris XI, Paris, France
| | - Rolf Ljung
- Department of Clinical Sciences Lund - Paediatrics, Lund University, Lund, Sweden
| | | | - Elena Santagostino
- Fondazione IRCCS Cá Granda, Maggiore Hospital Policlinico, Angelo Bianchi Bonomi Haemophilia and Thrombosis Center, Milan, Italy
| | - Silva Zupančić Šalek
- Unit for Haemostasis, Thrombosis and Benign Diseases of Haematopoietic System, Division of Haematology, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
- Medical School University of Zagreb, Zagreb, Croatia
- Faculty of Medicine Osijek, J Strossmayer University of Osijek, Osijek, Croatia
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69
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Zhao Y, Weyand AC, Shavit JA. Novel treatments for hemophilia through rebalancing of the coagulation cascade. Pediatr Blood Cancer 2021; 68:e28934. [PMID: 33577709 PMCID: PMC8751759 DOI: 10.1002/pbc.28934] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/19/2020] [Accepted: 01/12/2021] [Indexed: 11/11/2022]
Abstract
Hemophilia A and B are inherited hemorrhagic disorders that result from alterations in the coagulation cascade. Aside from spontaneous bleeding, the main complication of hemophilia is hemarthrosis. Progress over the last three decades, specifically prophylaxis using recombinant factor, has prevented hemarthrosis and lengthened patient life expectancies. However, many treatments require frequent dosing up to three times a week, and alloantibodies (inhibitors) against replacement factor continues to be an issue. These problems call for novel treatments for patients with hemophilia. Although there has been progress in extended half-life factors and mimetics of factor VIII, an alternative treatment methodology is to rebalance the activities of pro- and anticoagulant factors through inhibition of the natural anticoagulants: antithrombin, tissue factor pathway inhibitor, protein C, and protein S. This review will explore the efficacy of targeting these inhibitory pathways from preclinical development through clinical trials, and delve into concerns of thrombotic risk.
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Affiliation(s)
- Yakun Zhao
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI
| | - Angela C. Weyand
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI
| | - Jordan A. Shavit
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI
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70
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Martin EJ, Nolte ME, Kuhn J, Schmidt N, Pfaff N, Brophy DF. An in vitro pharmacodynamic spiking study of befovacimab, a tissue factor pathway inhibitor monoclonal antibody, in blood samples from patients with severe FVIII deficiency. Haemophilia 2021; 27:690-698. [PMID: 33915599 DOI: 10.1111/hae.14314] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/17/2021] [Accepted: 03/31/2021] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Tissue factor pathway inhibitor (TFPI) is an endogenous protein that inhibits the extrinsic (tissue factor) pathway and negatively regulates thrombin production during coagulation. Inhibiting TFPI may become a useful target for haemophilia drug development to allow greater thrombin generation without use of the intrinsic (contact) pathway. AIMS The in vitro effects of befovacimab, a humanized TFPI neutralizing antibody, were studied in whole blood and plasma samples from patients with severe FVIII deficiency. METHODS Blood and plasma obtained from participants was supplemented in vitro with befovacimab (0.5, 1, 5, 10 and 100 nM) or recombinant factor VIII (rFVIII) 5-, 10- and 40% and analysed using rotational thromboelastometry (ROTEM), thrombin generation assay (TGA) and the dilute prothrombin time (dPT) assay. The in vitro coagulation effects of befovacimab were compared to samples supplemented with rFVIII. RESULTS Befovacimab induced consistent pro-coagulant responses in ROTEM parameters including reduction in clotting times and increases in α-angle; induced reductions in dPT clotting time; and improvements in TGA parameters (reduced lag time and increased thrombin generation parameters). There was a modest concentration-dependent response generally from 0.5- to 10 nM, after which, the pharmacodynamic effect plateaued through the 100 nM concentration. Befovacimab concentrations of 5 to 10 nM showed pro-coagulant activity comparable to blood samples supplemented with rFVIII 10-40%. CONCLUSIONS Befovacimab has modest dose-response effects from 0.5 to 10 nM with minimal improvement with higher concentrations. In vitro befovacimab blood concentrations of 5 to 10 nM had pro-coagulant effects similar to blood supplemented with rFVIII 10- to 40%.
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Affiliation(s)
- Erika J Martin
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Sciences, Virginia Commonwealth University (VCU) School of Pharmacy, Richmond, VA, USA
| | - Melinda E Nolte
- Department of Internal Medicine, Division of Hematology/Oncology, VCU School of Medicine, Richmond, VA, USA
| | - Janice Kuhn
- Department of Internal Medicine, Division of Hematology/Oncology, VCU School of Medicine, Richmond, VA, USA
| | - Nicole Schmidt
- Research & Development, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - Nils Pfaff
- Research & Development, Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Donald F Brophy
- Coagulation Advancement Laboratory, Department of Pharmacotherapy & Outcomes Sciences, Virginia Commonwealth University (VCU) School of Pharmacy, Richmond, VA, USA
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71
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Lin WY, Zhu R, Zhang Z, Lu X, Wang H, He W, Hu Y, Tang L. RNAi targeting heparin cofactor II promotes hemostasis in hemophilia A. MOLECULAR THERAPY-NUCLEIC ACIDS 2021; 24:658-668. [PMID: 33996250 PMCID: PMC8093307 DOI: 10.1016/j.omtn.2021.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/31/2021] [Indexed: 01/15/2023]
Abstract
Hemophilia A is a hemorrhagic disease due to congenital deficiencies of coagulation factor VIII (FVIII). Studies show that hemophilia patients with anticoagulant deficiency present less severe hemorrhagic phenotypes. We aimed to find a new therapeutic option for hemophilia patients by RNA interference (RNAi) targeting heparin cofactor II (HCII), a critical anticoagulant protein inactivating the thrombin. The optimal small interfering RNA (siRNA) was conjugated to an asialoglycoprotein receptor ligand (N-acetylgalactosamine [GalNAc]-HCII), promoting targeted delivery to the liver. After administration, GalNAc-HCII demonstrated effective, dose-dependent, and persistent HCII inhibition. After 7 days, in normal mice, GalNAc-HCII reduced HCII levels to 25.04% ± 2.56%, 11.65% ± 2.41%, and 6.50% ± 1.73% with 2, 5, and 10 mg/kg GalNAc-HCII, respectively. The hemostatic ability of hemophilia mice in the GalNAc-HCII-treated group significantly improved, with low thrombus formation time in the carotid artery thrombosis models and short bleeding time in the tail-clipping assays. After repeated administration, the prolonged activated partial thromboplastin time (APTT) was reduced. A 30 mg/kg dose did not cause pathological thrombosis. Our study confirmed that GalNAc-HCII therapy is effective for treating hemophilia mice and can be considered a new option for treating hemophilia patients.
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Affiliation(s)
- Wen-Yi Lin
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruiqi Zhu
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhen Zhang
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuan Lu
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huafang Wang
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenjuan He
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Hu
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liang Tang
- Institute of Hematology, Union Hospital Affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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72
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Rehill AM, McCluskey S, O'Donnell JS, Dockal M, Preston RJS. Heterogeneity in Bleeding Tendency and Arthropathy Development in Individuals with Hemophilia. Semin Thromb Hemost 2021; 47:183-191. [PMID: 33636749 DOI: 10.1055/s-0041-1723769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
People with hemophilia (PWH) have an increased tendency to bleed, often into their joints, causing debilitating joint disease if left untreated. To reduce the incidence of bleeding events, PWH receive prophylactic replacement therapy with recombinant factor VIII (FVIII) or FIX. Bleeding events in PWH are typically proportional to their plasma FVIII or IX levels; however, in many PWH, bleeding tendency and the likelihood of developing arthropathy often varies independently of endogenous factor levels. Consequently, many PWH suffer repeated bleeding events before correct dosing of replacement factor can be established. Diagnostic approaches to define an individual's bleeding tendency remain limited. Multiple modulators of bleeding phenotype in PWH have been proposed, including the type of disease-causing variant, age of onset of bleeding episodes, plasma modifiers of blood coagulation or clot fibrinolysis pathway activity, interindividual differences in platelet reactivity, and endothelial anticoagulant activity. In this review, we summarize current knowledge of established factors modulating bleeding tendency and discuss emerging concepts of additional biological elements that may contribute to variable bleeding tendency in PWH. Finally, we consider how variance in responses to new gene therapies may also necessitate consideration of patient-specific tailoring of treatment. Cumulatively, these studies highlight the need to reconsider the current "one size fits all" approach to treatment regimens for PWH and consider therapies guided by the bleeding phenotype of each individual PWH at the onset of therapy. Further characterization of the biological bases of bleeding heterogeneity in PWH, combined with the development of novel diagnostic assays to identify those factors that modulate bleeding risk in PWH, will be required to meet these aspirations.
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Affiliation(s)
- Aisling M Rehill
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Seán McCluskey
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - James S O'Donnell
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland.,St James' Hospital, Dublin, Ireland
| | - Michael Dockal
- Baxalta Innovations GmbH, A Member of the Takeda Group of Companies, Vienna, Austria
| | - Roger J S Preston
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
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73
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Mancuso ME, Mahlangu JN, Pipe SW. The changing treatment landscape in haemophilia: from standard half-life clotting factor concentrates to gene editing. Lancet 2021; 397:630-640. [PMID: 33460559 DOI: 10.1016/s0140-6736(20)32722-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 09/15/2020] [Indexed: 12/13/2022]
Abstract
Congenital haemophilia A (factor VIII deficiency) and B (factor IX deficiency) are X-linked bleeding disorders. Replacement therapy has been the cornerstone of the management of haemophilia, aiming to reduce the mortality and morbidity of chronic crippling arthropathy. Frequent intravenous injections are burdensome and costly for patients, consequently with poor adherence and restricted access to therapy for many patients worldwide. Bioengineered clotting factors with enhanced pharmacokinetic profiles can reduce the burden of treatment. However, replacement therapy is associated with a risk for inhibitor development that adversely affects bleeding prevention and outcomes. Novel molecules that are subcutaneously delivered provide effective prophylaxis in the presence or absence of inhibitors, either substituting for the procoagulant function of clotting factors (eg, emicizumab) or targeting the natural inhibitors of coagulation (ie, antithrombin, tissue factor pathway inhibitor, or activated protein C). The ultimate goal of haemophilia treatment would be a phenotypical cure achievable with gene therapy, currently under late phase clinical investigation.
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Affiliation(s)
- Maria Elisa Mancuso
- Centre for Thrombosis and Hemorrhagic Diseases, Humanitas Clinical and Research Centre, Rozzano, Milan, Italy.
| | - Johnny N Mahlangu
- Faculty of Health Sciences, University of the Witwatersrand, National Health Laboratory Service, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Steven W Pipe
- Pediatrics and Pathology, University of Michigan, Ann Arbor, MI, USA
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74
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Mahlangu JN, Blanchette V, Klamroth R. Redefining prophylaxis in the modern era. Haemophilia 2021; 27 Suppl 3:21-27. [PMID: 32469108 DOI: 10.1111/hae.14035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/23/2020] [Accepted: 04/27/2020] [Indexed: 11/29/2022]
Abstract
Prophylaxis is the globally accepted standard of care for persons with haemophilia and presents many advantages over episodic treatment. The prophylaxis benefits include bleed reduction, reduction in musculoskeletal complications and improvement in the quality of life. The currently evolving novel therapies for the management of haemophilia has ushered a new era characterized by improved prophylaxis targets and outcomes. These redefined targets and outcomes have necessitated the need to also redefine prophylaxis. In this state-of-the-art review, we redefine prophylaxis in the modern era by revisiting its definition, presenting data to support higher trough levels to achieve with prophylaxis and introducing steady-state haemostasis as a possible new target for prophylaxis.
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Affiliation(s)
- Johnny N Mahlangu
- Faculty of Health Sciences, Haemophilia Comprehensive Care, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand and the NHLS, Johannesburg, South Africa
| | - Victor Blanchette
- Department of Pediatrics, Division of Hematology/Oncology Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Robert Klamroth
- Department of Internal Medicine, Hemophilia Treatment Centre, Vivantes Klinikum im Friedrichshain, Berlin, Germany
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75
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Croteau SE, Wang M, Wheeler AP. 2021 clinical trials update: Innovations in hemophilia therapy. Am J Hematol 2021; 96:128-144. [PMID: 33064330 DOI: 10.1002/ajh.26018] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 01/19/2023]
Abstract
Therapies engineered to prolong clotting factor protein circulation time, manipulate the balance of pro-coagulant and anti-coagulant proteins, or introduce new genetic material to enable endogenous factor protein production dominate the clinical trial landscape of hemophilia. The availability of clotting factor concentrates and the establishment of primary prophylaxis have dramatically improved health outcomes for hemophilia patients. But, the burden of hemostatic therapy remains significant, and many barriers to consistent longitudinal use of prophylaxis exist. Several types of emerging therapeutics including engineered factor concentrates, substitutive therapies, rebalancing therapies, and gene transfer/editing all aim to reduce the challenges of current hemophilia treatment. Emerging treatment options may reduce treatment frequency or need for intravenous administration. They may also introduce new challenges in laboratory assessment of hemostasis. These novel therapies must not introduce significant new health risks and continue to support similar or improved outcomes. The potential ramifications of rebalancing the coagulation cascade, particularly in a stress or inflammatory state, or introduction of new genetic material are not trivial. The focus of this review is to provide an overview of active and recently completed clinical trials as well as emerging preclinical data investigating new therapeutic possibilities for hemophilia patients and potentially other rare bleeding disorders.
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Affiliation(s)
| | - Michael Wang
- University of Colorado Hemophilia and Thrombosis Center Aurora Colorado
| | - Allison P. Wheeler
- Department of Pathology, Microbiology & Immunology Vanderbilt University Medical Center Nashville Tennessee
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76
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Light and shadows of the new therapies for haemophilia treatment in the COVID-19 era. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2021; 19:73-76. [PMID: 32955428 PMCID: PMC7850923 DOI: 10.2450/2020.0241-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 08/25/2020] [Indexed: 01/23/2023]
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77
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Pipe SW, Kaczmarek R, Srivastava A, Pierce GF, Makris M, Hermans C. Management of COVID-19-associated coagulopathy in persons with haemophilia. Haemophilia 2020; 27:41-48. [PMID: 33216448 PMCID: PMC7753457 DOI: 10.1111/hae.14191] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022]
Abstract
Introduction The SARS‐CoV‐2 coronavirus‐induced infection (COVID‐19) can be associated with a coagulopathy mainly responsible for pulmonary microvasculature thrombosis and systemic thromboembolic manifestations. The pathophysiology and management of the COVID‐19 coagulopathy are likely more complex in patients with inherited bleeding diseases such as haemophilia. These individuals might indeed present with both bleeding and thrombotic complications and require simultaneous antithrombotic and haemostatic treatments. Objective We propose practical guidance for the diagnosis and management of COVID‐19 coagulopathy in persons with haemophilia. Results Continuation of regular haemostatic treatment is recommended for ambulatory patients. For patients requiring hospital admission and on replacement therapy with factors VIII or IX concentrates, prophylaxis with concentrates should be intensified according to the risk of bleeding complications and associated with prophylactic doses of LMWH. For patients on nonreplacement therapy, emicizumab should be continued and possibly combined with factor VIII and prophylactic doses of LMWH depending on the risk of bleeding and thrombosis. Dose escalation of LMWH tailored to the risk of thrombosis can be employed but not supported by evidence. Conclusions These practical recommendations are based on the current literature on COVID‐19 with its impact on haemostasis, indications and modalities for thromboprophylaxis mainly in nonhaemophilic patients and how that is likely to affect persons with haemophilia in different circumstances. They will need to be tailored to each patient's clinical status and validated in future studies.
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Affiliation(s)
- Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Radoslaw Kaczmarek
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA.,Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | | | - Mike Makris
- Department of Infection, Immunity and Cardiovascular disease, University of Sheffield, UK.,Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Cedric Hermans
- Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
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- Coagulation Products Safety Supply and Access Committee of the World Federation of Hemophilia, Montreal, QC, Canada
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78
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Kwak H, Lee S, Jo S, Kwon YE, Kang H, Choi G, Jung ME, Kwak M, Kim S, Oh B, Kim D, Hwang SH. MG1113, a specific anti-tissue factor pathway inhibitor antibody, rebalances the coagulation system and promotes hemostasis in hemophilia. Res Pract Thromb Haemost 2020; 4:1301-1312. [PMID: 33313469 PMCID: PMC7695563 DOI: 10.1002/rth2.12438] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/27/2020] [Accepted: 09/04/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Replacement therapy is the most common treatment for reduction of bleeding and control of episodic bleeding in individuals with hemophilia. Despite the proven effectiveness of factor replacement therapy, repeated intravenous administration is a heavy burden to individuals with hemophilia. OBJECTIVES To reduce the burden, therapeutic agents that can be subcutaneously administered need to be developed, and an anti-tissue factor pathway inhibitor (TFPI) antibody may be a suitable candidate for this purpose. METHODS MG1113 is an IgG4 monoclonal antibody that binds to Kunitz-2 domain (KD2) of TFPI. To confirm the coagulation potential of MG1113, several tests were conducted using factor VIII (FVIII)- or IX (FIX)-deficient plasma. For the ex vivo spiking test, platelet-poor plasma samples from 14 individuals with hemophilia were spiked with MG1113. The in vivo efficacy was determined using blood loss tests, modified prothrombin time (mPT), and free TFPI quantification after intravenous or subcutaneous administration of MG1113 into hemophilia A (HA)-induced rabbits. RESULTS Radiographic crystallography demonstrated the specific binding site between MG1113 and KD2. In FVIII-deficient plasma and the plasma of individuals with hemophilia, peak thrombin and endogenous thrombin levels were increased by MG1113 in a concentration-dependent manner. Rotational thromboelastometry assay revealed that clotting time, clot formation time, and maximum clot firmness were normalized in MG1113-treated blood of patients. Intravenous or subcutaneous injection of MG1113 into HA-induced rabbits resulted in rebalancing of blood loss, mPT, and free TFPI levels. CONCLUSIONS These results indicate that subcutaneous administration of MG1113 neutralizes the function of TFPI and regulates bleeding in individuals with hemophilia.
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Affiliation(s)
- Heechun Kwak
- Department of Research and Early DevelopmentGC PharmaGyeonggi‐doKorea
| | - Sumin Lee
- Office of Corporate StrategyGC PharmaGyeonggi‐doKorea
| | - Seunghyun Jo
- Department of Research and Early DevelopmentGC PharmaGyeonggi‐doKorea
| | - Young Eun Kwon
- Department of Research and Early DevelopmentGC PharmaGyeonggi‐doKorea
| | - Hyunju Kang
- Department of Research and Early DevelopmentGC PharmaGyeonggi‐doKorea
| | - Gahee Choi
- Department of Research and Early DevelopmentGC PharmaGyeonggi‐doKorea
| | | | - Mi‐Jeong Kwak
- Department of Biological SciencesKAIST Institute for the BioCenturyKorea Advanced Institute of Science and TechnologyDaejeonKorea
| | - Seonghoon Kim
- Department of Biological SciencesKAIST Institute for the BioCenturyKorea Advanced Institute of Science and TechnologyDaejeonKorea
| | - Byung‐Ha Oh
- Department of Biological SciencesKAIST Institute for the BioCenturyKorea Advanced Institute of Science and TechnologyDaejeonKorea
| | - Dong‐Sik Kim
- MOGAM Institute for Biomedical ResearchGyeonggi‐doKorea
| | - Sung Ho Hwang
- Department of Research and Early DevelopmentGC PharmaGyeonggi‐doKorea
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79
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Escuriola-Ettingshausen C, Auerswald G, Königs C, Kurnik K, Scholz U, Klamroth R, Oldenburg J. Optimizing the management of patients with haemophilia A and inhibitors in the era of emicizumab: Recommendations from a German expert panel. Haemophilia 2020; 27:e305-e313. [PMID: 32937002 DOI: 10.1111/hae.14010] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
Standard treatment of haemophilia A is based on replacing the missing coagulation factor VIII (FVIII) to treat and prevent bleeding episodes. The most challenging complication of FVIII therapy is the development of neutralizing antibodies (inhibitors) that can render treatment ineffective. Eradication of the inhibitor through immune tolerance induction (ITI) remains the most effective strategy for managing these patients. Bypassing agents can be used to help restore haemostasis in inhibitor patients. Several novel agents have recently been developed, such as the FVIII mimetic agent emicizumab, which has been effective in reducing the annualized bleeding rate in haemophilia A patients with inhibitors. When coadministered with repetitive high doses of activated prothrombin complex concentrate (ie >100 U/kg/d for ≥24 hours), emicizumab was associated with thrombotic microangiopathy and thrombosis events. As a consequence the United Kingdom Haemophilia Centres Doctors' Organisation (UKHCDO) issued the first guidance on the treatment of bleeding episodes in patients receiving emicizumab. To build on and extend this work, a panel of German haemophilia specialists met to discuss the UK guidance, review current evidence and provide additional guidance for German healthcare professionals on how to optimize the management of patients with haemophilia A receiving emicizumab. Recommendations are provided on the use of bypassing and other agents to manage breakthrough bleeding, ITI in the emicizumab era, haemostatic support during surgery and issues relating to laboratory monitoring.
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Affiliation(s)
| | - Günter Auerswald
- Department of Comprehensive Care in Haemostasis and Thrombosis, Professor Hess Children's Hospital, Bremen, Germany
| | - Christoph Königs
- Department of Pediatrics and Adolescent Medicine, Centre for Hemostasis, University Hospital Frankfurt, Frankfurt, Germany
| | - Karin Kurnik
- Department of Paediatric Haemostasis, University Children's Hospital, Munich, Germany
| | | | - Robert Klamroth
- Department for Internal Medicine, Vascular Medicine and Haemostaseology, Vivantes Klinikum, Berlin, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
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80
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Boban A, Hermans C. Safety of relaxing coagulation control by anti-tissue factor pathway inhibitor in hemophilia patients: Impact of tissue distribution of tissue factor. J Thromb Haemost 2020; 18:2412-2414. [PMID: 32558136 DOI: 10.1111/jth.14955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 05/31/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Ana Boban
- Division of Hematology, Department of Internal Medicine, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Cedric Hermans
- Division of Hematology, Hemostasis and Thrombosis Unit, Cliniques Universitaires Saint- Luc, Université Catholique de Louvain, Brussels, Belgium
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81
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Uchida E, Komori K, Kurata T, Taki M, Sakashita K. Prophylaxis Using a Mixture of Plasma-Derived Activated Factor VII and Factor X (pdFVIIa/FX) in a Patient with Hemophilia B Complicated by Inhibitors and Allergy to Factor IX Concentrates: A Case Report. Acta Haematol 2020; 144:293-296. [PMID: 32702700 DOI: 10.1159/000508722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 05/17/2020] [Indexed: 12/31/2022]
Abstract
Treating patients with hemophilia and inhibitors is often problematic. The presence of inhibitors negatively impacts the effectiveness of treatment to achieve hemostasis especially in patients with hemophilia B, owing mainly to allergic reactions to factor IX (FIX) concentrates and the low success rate of immune tolerance therapy. A 9-month-old boy had intracranial hemorrhage and was diagnosed with hemophilia B. After replacement therapy, he developed inhibitors and an allergic reaction to FIX. Prophylactic therapy was initiated with recombinant activated factor VII (rFVIIa) and later switched to pdFVIIa/factor X (FX; 120 μg/kg as the FVII dose, every other day) because of a recurrence of intracranial hemorrhage. Since then, he remained well without life-threatening bleeding for more than 2 years. Our case suggests that pdFVIIa/FX may be useful for prophylactic therapy in hemophilia B complicated by inhibitors and allergic reaction to FIX concentrates.
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Affiliation(s)
- Eriko Uchida
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Kazutoshi Komori
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Takashi Kurata
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan
| | - Masashi Taki
- Department of Pediatrics, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Kazuo Sakashita
- Department of Hematology and Oncology, Nagano Children's Hospital, Azumino, Japan,
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82
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Valentino LA, Khair K. Prophylaxis for hemophilia A without inhibitors: treatment options and considerations. Expert Rev Hematol 2020; 13:731-743. [PMID: 32573295 DOI: 10.1080/17474086.2020.1775576] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Hemophilia A is a bleeding disorder traditionally managed with standard half-life (SHL) factor (F) VIII concentrates. Extended half-life (EHL) FVIII products and emicizumab-kywh, a nonfactor therapy, are newer treatment options. Additional nonfactor agents and gene therapy are expected to reach the market in the near future. AREAS COVERED A PubMed (MEDLINE) search from 1962 to April 2020 related to hemophilia A, its management, and the products currently available for prophylaxis was performed to comprehensively review these topics and analyze the benefits and drawbacks of each therapeutic. EXPERT OPINION Prophylaxis with SHL FVIII concentrates remains the standard of care for patients with severe hemophilia A and may also be considered for selected individuals with moderate disease. Several years of real-world experience with EHL FVIII, emicizumab-kywh, and other agents in development will be necessary to determine their ultimate roles in the prevention of bleeding and its complications. Gene therapy may not provide a permanent cure for hemophilia A.
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Affiliation(s)
- Leonard A Valentino
- Rush University , Chicago, IL, USA.,National Hemophilia Foundation , New York, NY, USA
| | - Kate Khair
- Centre for Outcomes Research and Experience in Children's Health, Illness, and Disability, Great Ormond Street Hospital for Children, NHS Trust , London, UK
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83
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Abstract
INTRODUCTION A number of new FVIII/IX concentrates enriched the portfolio of products available for the treatment of hemophilia A/B patients. Due to the large inter-patient variability, accurate tailoring of the therapy became essential to improve patients' adherence, clinical outcomes, and cost/effectiveness ratio. Recently, non-replacement therapies have taken the limelight and succeeded in decreasing the bleedings of patients. AREAS COVERED The PK characteristics, efficacy, and safety of the new rFVIII and rFIX concentrates and of non-replacement therapy, are reported in detail in the published clinical trials. EXPERT OPINION Outstanding improvements of rFIX concentrates' pharmacokinetics and pharmacodynamics have allowed to reduce the bleedings in hemophilia B patients, in order to increase their adherence to prophylaxis and quality of life. Less significant are the effects of pegylation or Fc fusion on the pharmacokinetics of the new rFVIII concentrates. The new non-replacement therapy is achieving the favor of many treaters and patients, in particular those with Factor VIII inhibitors. Great attention must be paid to the dangerous synergy of APCC and emicizumab, responsible for some fatal events during the clinical trials and compassionate use of this drug. So far, replacement therapy should be the standard of care for hemophilia patients without inhibitors or difficulties in venous access.
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Affiliation(s)
- Massimo Morfini
- Italian Association of Hemophilia Centres (AICE) , Milan, Italy
| | - Emanuela Marchesini
- Hemophilia Centre - SC Vascular and Emergency Department, University of Perugia , Perugia, Italy
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84
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Shima M. Bispecific Antibodies and Advances in Non-Gene Therapy Options in Hemophilia. Res Pract Thromb Haemost 2020; 4:446-454. [PMID: 32548546 PMCID: PMC7292667 DOI: 10.1002/rth2.12337] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/07/2020] [Accepted: 02/17/2020] [Indexed: 12/28/2022] Open
Abstract
Regular prophylaxis has markedly improved the treatment for patients with hemophilia A, especially after the introduction of highly purified factor VIII (FVIII) concentrates. However, frequent intravenous infusions and the development of FVIII inhibitors remain as unsolved difficulties. To overcome these unmet needs, a bispecific antibody mimicking activated FVIII has been developed in Japan. This bispecific antibody, emicizumab, recognizes activated factor IX (FIXa) and activated factor X (FXa), and promotes FIXa-catalyzed activation of FX in the absence of FVIII. Emicizumab initially reacts with FIXa generated by the action of factor VIIa/tissue factor complexes. Subsequently, thrombin generation is enhanced in the presence of higher amounts of FIXa derived from FXIa-dependent mechanisms. Hence, emicizumab-driven FXa and thrombin generation is maintained by a FXI activation loop in the intrinsic coagulation pathway. Reactions downstream of emicizumab are regulated by natural anticoagulants including activated protein C, antithrombin, and tissue factor pathway inhibitor. Phase 3 studies (HAVEN 1-4 and HOHOEMI studies) demonstrated a remarkable reduction in bleeding rates together with a high percentage of patients with zero treated bleeds irrespective of the presence of inhibitors. In general, emicizumab proved to be well tolerated, although isolated thromboembolic and thrombotic microangiopathic complications were observed in the HAVEN 1 studies, and 3 out of a total of 400 patients developed neutralizing antidrug antibodies. In addition, several questions remain to be discussed with respect to open-use clinical practice, including when to start treatment, how to monitor therapy, and optimum dosage for surgical procedures and immune tolerance induction.
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Affiliation(s)
- Midori Shima
- Thrombosis and Hemostasis Research CenterNara Medical UniversityKashihara CityNaraJapan
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85
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Butterfield JSS, Hege KM, Herzog RW, Kaczmarek R. A Molecular Revolution in the Treatment of Hemophilia. Mol Ther 2020; 28:997-1015. [PMID: 31843450 PMCID: PMC7132613 DOI: 10.1016/j.ymthe.2019.11.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 10/31/2019] [Accepted: 11/05/2019] [Indexed: 12/15/2022] Open
Abstract
For decades, the monogenetic bleeding disorders hemophilia A and B (coagulation factor VIII and IX deficiency) have been treated with systemic protein replacement therapy. Now, diverse molecular medicines, ranging from antibody to gene to RNA therapy, are transforming treatment. Traditional replacement therapy requires twice to thrice weekly intravenous infusions of factor. While extended half-life products may reduce the frequency of injections, patients continue to face a lifelong burden of the therapy, suboptimal protection from bleeding and joint damage, and potential development of neutralizing anti-drug antibodies (inhibitors) that require less efficacious bypassing agents and further reduce quality of life. Novel non-replacement and gene therapies aim to address these remaining issues. A recently approved factor VIII-mimetic antibody accomplishes hemostatic correction in patients both with and without inhibitors. Antibodies against tissue factor pathway inhibitor (TFPI) and antithrombin-specific small interfering RNA (siRNA) target natural anticoagulant pathways to rebalance hemostasis. Adeno-associated virus (AAV) gene therapy provides lasting clotting factor replacement and can also be used to induce immune tolerance. Multiple gene-editing techniques are under clinical or preclinical investigation. Here, we provide a comprehensive overview of these approaches, explain how they differ from standard therapies, and predict how the hemophilia treatment landscape will be reshaped.
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Affiliation(s)
| | - Kerry M Hege
- Department of Pediatrics, Indiana University School of Medicine, IUPUI-Wells Center for Pediatric Research, Indianapolis, IN, USA
| | - Roland W Herzog
- Department of Pediatrics, University of Florida, Gainesville, FL, USA; Department of Pediatrics, Indiana University School of Medicine, IUPUI-Wells Center for Pediatric Research, Indianapolis, IN, USA.
| | - Radoslaw Kaczmarek
- Department of Pediatrics, Indiana University School of Medicine, IUPUI-Wells Center for Pediatric Research, Indianapolis, IN, USA; Laboratory of Glycobiology, Hirszfeld Institute of Immunology and Experimental Therapy, Wroclaw, Poland.
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86
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MacDonald S, White D, Langdown J, Downes K, Thomas W. Investigation of patients with unclassified bleeding disorder and abnormal thrombin generation for physiological coagulation inhibitors reveals multiple abnormalities and a subset of patients with increased tissue factor pathway inhibitor activity. Int J Lab Hematol 2020; 42:246-255. [PMID: 32003946 DOI: 10.1111/ijlh.13155] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 11/29/2019] [Accepted: 12/29/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION We have routinely used thrombin generation to investigate patients with unclassified bleeding disorder (UBD). AIMS To investigate haemostatic abnormalities in patients with UBD that had abnormal thrombin generation on at least one occasion. METHODS Investigation of 13 known UBD patients with thrombin generation and detailed haemostatic testing was undertaken including TFPI assays but also thrombomodulin and fibrinogen-γ. RESULTS 12 females and 1 male were included. No patient had a platelet function disorder or coagulation factor deficiency that explained the bleeding phenotype, though 2 patients had factor deficiencies; a factor X of 0.41 IU/mL and a factor XI of 0.51 IU/mL. ThromboGenomics revealed variants for these factors but no other abnormalities. Patients were included who previously had either prolonged lag time or decreased endogenous thrombin potential (ETP) via high dose tissue factor (5 pmol/L) or low dose tissue factor (1.5 pmol/L) with corn trypsin inhibitor (CTI). Tissue factor pathway inhibitor (TFPI) activity was significantly increased (P < .001; increased in 8 patients) compared with controls and abnormalities in soluble thrombomodulin (2 patients), fibrinogen-γ (1 patient) and tPA (4 patients for each) were seen. Total and free TFPI levels were not increased. Mixing studies of patient plasma with 50:50 normal plasma for thrombin generation via low dose tissue factor failed to correct the ETP consistent with ongoing inhibition. Addition of an anti-TFPI antibody partially corrected thrombin generation to normal levels. TFPI sequencing was unremarkable. CONCLUSION TFPI activity may be increased in a subset of UBD patients. Further research studies are warranted in UBD patients for coagulation inhibitor abnormalities.
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Affiliation(s)
- Stephen MacDonald
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Danielle White
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jon Langdown
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Kate Downes
- Department of Haematology, University of Cambridge, Cambridge, UK.,NIHR BioResource-Rare Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,East Midlands and East of England Genomic Laboratory Hub, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Will Thomas
- Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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87
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Lacroix-Desmazes S, Voorberg J, Lillicrap D, Scott DW, Pratt KP. Tolerating Factor VIII: Recent Progress. Front Immunol 2020; 10:2991. [PMID: 31998296 PMCID: PMC6965068 DOI: 10.3389/fimmu.2019.02991] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 12/05/2019] [Indexed: 02/02/2023] Open
Abstract
Development of neutralizing antibodies against biotherapeutic agents administered to prevent or treat various clinical conditions is a longstanding and growing problem faced by patients, medical providers and pharmaceutical companies. The hemophilia A community has deep experience with attempting to manage such deleterious immune responses, as the lifesaving protein drug factor VIII (FVIII) has been in use for decades. Hemophilia A is a bleeding disorder caused by genetic mutations that result in absent or dysfunctional FVIII. Prophylactic treatment consists of regular intravenous FVIII infusions. Unfortunately, 1/4 to 1/3 of patients develop neutralizing anti-FVIII antibodies, referred to clinically as “inhibitors,” which result in a serious bleeding diathesis. Until recently, the only therapeutic option for these patients was “Immune Tolerance Induction,” consisting of intensive FVIII administration, which is extraordinarily expensive and fails in ~30% of cases. There has been tremendous recent progress in developing novel potential clinical alternatives for the treatment of hemophilia A, ranging from encouraging results of gene therapy trials, to use of other hemostatic agents (either promoting coagulation or slowing down anti-coagulant or fibrinolytic pathways) to “bypass” the need for FVIII or supplement FVIII replacement therapy. Although these approaches are promising, there is widespread agreement that preventing or reversing inhibitors remains a high priority. Risk profiles of novel therapies are still unknown or incomplete, and FVIII will likely continue to be considered the optimal hemostatic agent to support surgery and manage trauma, or to combine with other therapies. We describe here recent exciting studies, most still pre-clinical, that address FVIII immunogenicity and suggest novel interventions to prevent or reverse inhibitor development. Studies of FVIII uptake, processing and presentation on antigen-presenting cells, epitope mapping, and the roles of complement, heme, von Willebrand factor, glycans, and the microbiome in FVIII immunogenicity are elucidating mechanisms of primary and secondary immune responses and suggesting additional novel targets. Promising tolerogenic therapies include development of FVIII-Fc fusion proteins, nanoparticle-based therapies, oral tolerance, and engineering of regulatory or cytotoxic T cells to render them FVIII-specific. Importantly, these studies are highly applicable to other scenarios where establishing immune tolerance to a defined antigen is a clinical priority.
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Affiliation(s)
| | - Jan Voorberg
- Sanquin Research and Landsteiner Laboratory, Department of Molecular and Cellular Hemostasis, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - David W Scott
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Kathleen P Pratt
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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88
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Shima M. Current progress and future direction in the treatment for hemophilia. Int J Hematol 2019; 111:16-19. [DOI: 10.1007/s12185-019-02786-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 11/19/2019] [Accepted: 11/26/2019] [Indexed: 12/14/2022]
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89
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90
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Lauritzen B, Hilden I. Concizumab promotes haemostasis via a tissue factor-factor VIIa-dependent mechanism supporting prophylactic treatment of haemophilia: Results from a rabbit haemophilia bleeding model. Haemophilia 2019; 25:e379-e382. [PMID: 31609513 DOI: 10.1111/hae.13861] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/16/2019] [Accepted: 09/26/2019] [Indexed: 01/18/2023]
Affiliation(s)
- Brian Lauritzen
- Global Discovery and Development Sciences, Novo Nordisk A/S, Måløv, Denmark
| | - Ida Hilden
- Projects & Alliance Management, Global Drug Discovery, Novo Nordisk A/S, Måløv, Denmark
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