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Peyvandi F, Mahlangu JN, Pipe SW, Hay CRM, Pierce GF, Kuebler P, Kruse‐Jarres R, Shima M. Application of a hemophilia mortality framework to the Emicizumab Global Safety Database. J Thromb Haemost 2021; 19 Suppl 1:32-41. [PMID: 33331041 PMCID: PMC7756327 DOI: 10.1111/jth.15187] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND As the first non-factor replacement therapy for persons with congenital hemophilia A (PwcHA), emicizumab's safety profile is of particular interest to the community. OBJECTIVES We applied an algorithm for categorization of fatal events contemporaneous to emicizumab using reporter-assessed causality documented in the Roche Emicizumab Global Safety Database. PATIENTS/METHODS All fatalities in PwcHA reported to the database (from clinical trials, pre-market access, and spontaneous post-marketing reports) were categorized into: associated with hemophilia A-hemorrhagic, thrombotic, human immunodeficiency virus (HIV)/hepatitis C virus (HCV), hepatic (non-HCV); associated with general population-trauma/suicide, non-HA-associated conditions; or, unspecified. Reported cause of death was not reassessed. RESULTS As of cut-off May 15, 2020, 31 fatalities in PwcHA taking emicizumab were reported. Median age at death was 58 years; 51% had factor VIII inhibitors. Fifteen fatalities were considered associated with HA; overall, the most frequent category was hemorrhage (11/31). Of these, six had a history of life-threatening bleeds, and four had a history of intracranial hemorrhage. The remaining HA-associated fatalities were related to HIV/HCV (3/31) and other hepatic causes (1/31). No cases were categorized as thrombotic. Of 10 cases considered not associated with HA, two were categorized as cardiovascular (non-thrombotic), five as infection/sepsis, and one each of trauma/suicide, pulmonary, and malignancy. Six cases were unspecified. CONCLUSIONS No unique risk of death was associated with emicizumab prophylaxis in PwcHA. The data reveal that mortality in PwcHA receiving emicizumab was primarily associated with hemorrhage or non-HA-associated conditions, and was not reported by treaters to be related to emicizumab treatment.
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Affiliation(s)
- Flora Peyvandi
- IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterMilanItaly
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | | | - Steven W. Pipe
- Departments of Pediatrics and PathologyUniversity of Michigan Medical SchoolAnn ArborMIUSA
| | | | | | | | - Rebecca Kruse‐Jarres
- University of WashingtonSeattleWAUSA
- Washington Center for Bleeding DisordersSeattleWAUSA
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202
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Lewandowska M, Randall N, Bakeer N, Maahs J, Sagar J, Greist A, Shapiro AD. Management of people with haemophilia A undergoing surgery while receiving emicizumab prophylaxis: Real-world experience from a large comprehensive treatment centre in the US. Haemophilia 2020; 27:90-99. [PMID: 33245841 PMCID: PMC7898816 DOI: 10.1111/hae.14212] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/09/2020] [Accepted: 11/09/2020] [Indexed: 01/24/2023]
Abstract
Introduction Surgery is frequently required in persons with haemophilia A (PwHA). Emicizumab, a bispecific, humanized monoclonal antibody, bridges activated factor (F) IX and FX. Management of patients undergoing surgery while receiving emicizumab is of clinical interest due to paucity of data. Aim Review real‐world experience of PwHA with/without FVIII inhibitors who required surgery while receiving emicizumab prophylaxis. Methods Data regarding peri‐operative management, including type of surgery, haemostatic agent use and bleeding complications, were collected for PwHA receiving emicizumab undergoing surgery between 25/10/18 and 31/12/19 at the Indiana Hemophilia and Thrombosis Center. Analyses were exploratory and descriptive. Results Twenty minor and five major surgeries were performed in 17 and five patients, respectively. Overall, 9/20 minor surgeries were planned to occur with emicizumab as the sole haemostatic agent; of these, four required additional coagulation factor (2 due to haematomas following port removals, 1 due to oozing at port removal site, 1 due to bleeding following squamous cell carcinoma removal). Three of the 11 minor surgeries with planned additional coagulation factor resulted in non‐major bleeds; all were safely managed with additional coagulation factor. All five major surgeries were planned with additional haemostatic agents; there was 1 bleed in a patient undergoing elbow synovectomy with nerve transposition, likely triggered by physical/occupational therapy. There were no major bleeds, thrombotic events or deaths. Conclusions Additional haemostatic agent use is safe in PwHA undergoing surgery while receiving emicizumab. Additional data are needed to determine the optimal dosing/length of treatment of additional haemostatic agents to lower bleeding risk.
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Affiliation(s)
| | - Nicole Randall
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, USA
| | - Nihal Bakeer
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, USA
| | - Jennifer Maahs
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, USA
| | - Jeanne Sagar
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, USA
| | - Anne Greist
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, USA
| | - Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, USA
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203
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Kizilocak H, Marquez-Casas E, Phei Wee C, Malvar J, Carmona R, Young G. Comparison of bypassing agents in patients on emicizumab using global hemostasis assays. Haemophilia 2020; 27:164-172. [PMID: 33245833 DOI: 10.1111/hae.14213] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/23/2020] [Accepted: 11/09/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Emicizumab is a humanized bispecific monoclonal antibody licensed for patients with severe haemophilia A with and without inhibitors. Management of breakthrough bleeding in patients with inhibitors on emicizumab involves episodic treatment with bypassing agents (BPA), activated prothrombin complex concentrate (aPCC) or recombinant activated factor VII (rFVIIa). Thrombotic events and thrombotic microangiopathy were reported when patients on emicizumab received concomitant aPCC at relatively high doses yet such events were not reported with rFVIIa. We studied the effect of spiking various concentrations of BPA on plasma taken from patients on emicizumab. MATERIAL AND METHODS Eleven patients with severe haemophilia A with inhibitors who are on emicizumab were recruited to participate. Blood samples drawn from patients were spiked in vitro with varying concentrations of aPCC and rFVIIa. All samples were tested utilizing global haemostasis assays, thromboelastography and thrombin generation assay. RESULTS Thrombin generation increased with higher concentrations of spiked BPA with a normalized endogenous thrombin potential at a concentration of 0.05 IU/ml and 4 mcg/ml for aPCC and rFVIIa, respectively. Concentrations of aPCC in the range of licensed dosing led to excessive thrombin generation. Thromboelastography was not sufficiently sensitive. CONCLUSION Due to the known thrombotic complications when emicizumab is used in conjunction with aPCC, there has been a large-scale abandonment of the use of aPCC in patients on emicizumab. However, it is possible that aPCC can be used safely with emicizumab albeit with lower doses than are typically prescribed. It would be important to test this hypothesis in a clinical study.
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Affiliation(s)
- Hande Kizilocak
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Choo Phei Wee
- Saban Research Institute, Biostatistics Core, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jemily Malvar
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Roxana Carmona
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Guy Young
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, CA, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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204
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Shima M, Nagao A, Taki M, Matsushita T, Oshida K, Amano K, Nagami S, Okada N, Maisawa S, Nogami K. Long-term safety and efficacy of emicizumab for up to 5.8 years and patients' perceptions of symptoms and daily life: A phase 1/2 study in patients with severe haemophilia A. Haemophilia 2020; 27:81-89. [PMID: 33236410 PMCID: PMC7894561 DOI: 10.1111/hae.14205] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/21/2020] [Accepted: 11/03/2020] [Indexed: 02/06/2023]
Abstract
Introduction Safety and efficacy results of the phase 1 study and phase 1/2 extension study of the bispecific antibody emicizumab in patients with severe haemophilia A with or without factor VIII inhibitors for up to 2.8 years were reported previously. Aim To evaluate further longer‐term data including patients’ perceptions at study completion. Methods Emicizumab was administered subcutaneously once weekly at maintenance doses of 0.3, 1 or 3 mg/kg with potential up‐titration. All patients were later switched to the approved maintenance dose of 1.5 mg/kg. Results Eighteen patients received emicizumab for up to 5.8 years. Most adverse events were mild and unrelated to emicizumab. Annualized bleeding rates (ABRs) for bleeds treated with coagulation factors decreased from pre‐emicizumab rates or remained zero in all patients. The median ABRs were low at 1.25, 0.83 and 0.22 during the 0.3, 1 and 3 mg/kg dosing periods, respectively. Of 8 patients who decreased their doses from 3 to 1.5 mg/kg, ABRs decreased in 4, remained at zero in 2, and increased in 2. Total time spent with symptoms associated with treated bleeds decreased in all patients except 2. All patients answered ‘improved’ for bleeding severity and time until bleeding stops, except 1 answering ‘slightly improved’. Most patients answered ‘improved’ or ‘slightly improved’’ for daily life and feelings; in particular, all patients except 1 answered ‘improved’ or ‘slightly improved’ for anxiety. Conclusions Long‐term emicizumab prophylaxis for up to 5.8 years was safe and efficacious, and may improve patients’ daily lives and feelings, regardless of inhibitor status.
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Affiliation(s)
- Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Azusa Nagao
- Department of Blood Coagulation, Ogikubo Hospital, Tokyo, Japan
| | - Masashi Taki
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Japan
| | | | - Koichi Oshida
- Department of Pediatrics, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | | | | | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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Polack B, Trossaërt M, Cousin M, Baffert S, Pruvot A, Godard C. Cost-effectiveness of emicizumab vs bypassing agents in the prevention of bleeding episodes in haemophilia A patients with anti-FVIII inhibitors in France. Haemophilia 2020; 27:e1-e11. [PMID: 33210412 DOI: 10.1111/hae.14129] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/16/2020] [Accepted: 07/27/2020] [Indexed: 01/19/2023]
Abstract
INTRODUCTION The development of an anti-FVIII inhibitor is the most serious complication of haemophilia A occurring in up to 30% of severe haemophilic patients. The current management of haemophilia A with inhibitor uses bypassing agents (BPA) and represents a significant therapeutic burden together with a limited adherence to prophylactic treatment. Emicizumab is the first monoclonal antibody developed in haemophilia A approved for the prevention of bleeding episodes in patients with anti-FVIII inhibitor. AIM The purpose of this study is to evaluate the incremental cost-effectiveness ratio (ICER) of emicizumab versus BPAs. METHODS A Markov model was developed over a five-year time horizon to estimate the comparative costs and benefits of the different therapeutic approaches in this rare disease. Model inputs were clinical, including annual bleeding rate and quality of life, and economical including mainly costs of prophylaxis, bleeds and adverse events. RESULTS Emicizumab treatment is dominant, ie lest costly and more effective, in the base-case analysis saving 234 191 € for a gain of 0.88 QALY. This is confirmed by both the deterministic and probabilistic sensitivity analyses. The main limit of the study remains the absence of long-term clinical data allowing to relate treatment consumption to clinical benefit, especially in the progression of haemophilic arthropathy. CONCLUSION Our results show that emicizumab is a cost-effective treatment allowing to consider an easy to implement prophylactic treatment for haemophilia A patients with anti-FVIII inhibitors.
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Affiliation(s)
- Benoît Polack
- Département d'Hématologie, Centre Hospitalier Universitaire Grenoble Alpes, Laboratoire TIMC-IMAG, Institut de Biologie et de Pathologie, Université Grenoble Alpes, CNRS UMR 5525, Grenoble, France
| | - Marc Trossaërt
- Haemophilia Treatment Center, University Hospital, Nantes, France
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206
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Chehade H, Cachat F, Beck-Popovic M, Rotman S, Diezi L, Albisetti M, Alberio L, Young G, Rizzi M. Emicizumab-Induced Seronegative Full-House Lupus Nephritis in a Child. Pediatrics 2020; 146:peds.2020-0123. [PMID: 33122347 DOI: 10.1542/peds.2020-0123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2020] [Indexed: 11/24/2022] Open
Abstract
Hemophilia A (HA) is a serious inherited bleeding disorder resulting from a deficiency of coagulation factor VIII (FVIII). Replacement therapy with intravenous infusion of FVIII can be associated with treatment failure in approximately one-third of patients secondary to the development of neutralizing alloantibodies (inhibitor). Emicizumab is a recombinant, humanized, bispecific monoclonal antibody that binds factor IXa and factor X and mimics FVIII. It has been licensed in many countries for the treatment of patients with HA with and without inhibitors with a favorable efficacy and safety profile. A 7-year-old child with severe HA and FVIII inhibitors, refractory to immune tolerance therapy, developed hematuria with nephrotic-range proteinuria after the first dose of emicizumab and subsequently also after a second dose 6 weeks later, which was associated with mild and transient leukopenia. Renal biopsy revealed a pattern of a full-house lupus nephritis. The patient fully and spontaneously recovered between 2 weeks after symptoms onset. In this report, we provide insights on a new and so far unreported renal complication associated to emicizumab treatment. Although emicizumab offers significant benefits for patient with HA, clinicians should be aware of this rare and potential serious renal adverse effect.
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Affiliation(s)
| | | | - Maja Beck-Popovic
- Pediatric Hematology-Oncology Unit, Division of Pediatrics, Department Woman-Mother-Child and
| | | | - Léonore Diezi
- Clinical Pharmacology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Manuela Albisetti
- Department of Pediatrics, University Children's Hospital Zurich and University of Zurich, Zurich, Switzerland; and
| | - Lorenzo Alberio
- Division of Hematology and Central Hematology Laboratory and
| | - Guy Young
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Mattia Rizzi
- Pediatric Hematology-Oncology Unit, Division of Pediatrics, Department Woman-Mother-Child and
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Collins M, Awwad S, Ibeanu N, Khaw PT, Guiliano D, Brocchini S, Khalili H. Dual-acting therapeutic proteins for intraocular use. Drug Discov Today 2020; 26:44-55. [PMID: 33137484 DOI: 10.1016/j.drudis.2020.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/22/2020] [Accepted: 10/26/2020] [Indexed: 12/25/2022]
Abstract
Intravitreally injected antibody-based medicines have revolutionised the treatment of retinal disease. Bispecific and dual-functional antibodies and therapeutic proteins have the potential to further increase the efficacy of intraocular medicines.
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Affiliation(s)
- Matthew Collins
- School of Health, Sport and Bioscience, University of East London, London, E15 4LZ, UK; School of Pharmacy, University College London, London, WC1N 1AX, UK
| | - Sahar Awwad
- School of Pharmacy, University College London, London, WC1N 1AX, UK; National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, EC1V 9EL, UK
| | - Nkiru Ibeanu
- School of Pharmacy, University College London, London, WC1N 1AX, UK; National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, EC1V 9EL, UK
| | - Peng T Khaw
- National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, EC1V 9EL, UK
| | - David Guiliano
- School of Health, Sport and Bioscience, University of East London, London, E15 4LZ, UK
| | - Steve Brocchini
- School of Pharmacy, University College London, London, WC1N 1AX, UK
| | - Hanieh Khalili
- School of Health, Sport and Bioscience, University of East London, London, E15 4LZ, UK; School of Pharmacy, University College London, London, WC1N 1AX, UK.
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208
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Coppola A, Castaman G, Santoro RC, Mancuso ME, Franchini M, Marino R, Rivolta GF, Santoro C, Zanon E, Sciacovelli L, Manca S, Lubrano R, Golato M, Tripodi A, Rocino A. Management of patients with severe haemophilia a without inhibitors on prophylaxis with emicizumab: AICE recommendations with focus on emergency in collaboration with SIBioC, SIMEU, SIMEUP, SIPMeL and SISET. Haemophilia 2020; 26:937-945. [PMID: 33094880 DOI: 10.1111/hae.14172] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/29/2020] [Accepted: 09/21/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The factor VIII (FVIII)-mimetic bispecific monoclonal antibody, emicizumab, previously approved for prophylaxis in haemophilia A with inhibitors, has been recently licensed in several countries also in patients with severe haemophilia A (PWSHA) without inhibitors. The introduction of this innovative agent requires the development of specific pathways at Haemophilia Treatment Centres (HTC), particularly regarding laboratory testing and treatment of breakthrough bleeds and invasive procedures/surgeries, even more critical when patients are managed by non-specialist professionals. Limited literature data and clinical experience in PWSHA without inhibitors on emicizumab are currently available. AIM To promote awareness and overcome these challenges, the Italian Association of Haemophilia Centres (AICE) issued a guidance on the management of PWSHA without inhibitors on emicizumab prophylaxis, focused on emergency and shared with other National Scientific Societies in the field. METHODS The document, drafted by an AICE expert panel and approved through online consultation, was further revised by a multidisciplinary working group, including members of 5 haemostasis, laboratory and emergency scientific societies. The final version was approved by the Council of each society. RESULTS General recommendations about use of FVIII concentrates for the treatment of bleeding or haemostatic coverage of invasive procedures/surgeries and laboratory monitoring in PWSHA without inhibitors on emicizumab are provided. Specific issues of the management in the emergency room are focused, highlighting the need for direct involvement or formalized supervision by specialist HTC physicians. CONCLUSIONS This guidance provides a reference pathway to be implemented in the different healthcare organizations, especially for the challenging emergency management in this setting.
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Affiliation(s)
- Antonio Coppola
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | - Giancarlo Castaman
- Centre for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
| | - Rita C Santoro
- Centre for Haemorrhagic and Thrombotic Disorders, 'Pugliese Ciaccio' Hospital, Catanzaro, Italy
| | - Maria Elisa Mancuso
- Centre for Thrombotic and Haemorrhagic Diseases, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Massimo Franchini
- Department of Haematology and Transfusion Medicine, Carlo Poma Hospital, Mantova, Italy
| | - Renato Marino
- Haemophilia and Thrombosis Centre, University Hospital of Bari, Bari, Italy
| | - Gianna Franca Rivolta
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | | | - Ezio Zanon
- Haemophilia Centre, University Hospital of Padua, Padua, Italy
| | - Laura Sciacovelli
- President of SIBioC; Department of Laboratory Medicine, University Hospital of Padua, Padua, Italy
| | - Salvatore Manca
- President of SIMEU; Department of Emergency Medicine and Intensive Care, S. Martino Hospital, Oristano, Italy
| | - Riccardo Lubrano
- President of SIMEUP; Unit of Paediatric Nephrology, Department of Paediatrics, Sapienza University of Rome, Rome, Italy
| | - Maria Golato
- President of SIPMeL; Unit of Clinical Pathology, 'SS Annunziata' University Hospital, ASL Lanciano-Vasto-Chieti, Chieti, Italy
| | - Armando Tripodi
- President of SISET; IRCCS Cà Granda, Ospedale Maggiore Policlinico Foundation, Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre and 'Luigi Villa' Foundation, Milan, Italy
| | - Angiola Rocino
- President of AICE; Haemophilia and Thrombosis Centre, Haematology, Ospedale del Mare, ASL Napoli 1 Centro, Naples, Italy
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209
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Mackensen S, Catalani O, Asikanius E, Paz‐Priel I, Lehle M, Trask P. Determining meaningful health‐related quality‐of‐life improvement in persons with haemophilia A using the Haemophilia Quality of Life Questionnaire for Adults (Haem‐A‐QoL). Haemophilia 2020; 26:1019-1030. [DOI: 10.1111/hae.14184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/28/2020] [Accepted: 10/01/2020] [Indexed: 12/28/2022]
Affiliation(s)
- Sylvia Mackensen
- Department of Medical Psychology University Medical Centre Hamburg‐Eppendorf Hamburg Germany
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210
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Schmitt C, Adamkewicz JI, Xu J, Petry C, Catalani O, Young G, Negrier C, Callaghan MU, Levy GG. Pharmacokinetics and Pharmacodynamics of Emicizumab in Persons with Hemophilia A with Factor VIII Inhibitors: HAVEN 1 Study. Thromb Haemost 2020; 121:351-360. [PMID: 33086400 PMCID: PMC7895541 DOI: 10.1055/s-0040-1717114] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Emicizumab, a bispecific monoclonal antibody, bridges activated factor IX (FIXa) and FX, replacing the function of missing FVIIIa to restore effective hemostasis in persons with hemophilia A (PwHA). Here we assess pharmacokinetic (PK) and pharmacodynamic (PD) biomarkers in PwHA with FVIII inhibitors in the Phase III HAVEN 1 study (NCT02622321). Blood samples from 112 PwHA receiving 1.5 mg/kg once-weekly subcutaneous emicizumab were analyzed at central laboratories. Emicizumab concentrations for PK analysis were measured via validated immunoassay. PD effects were assessed using FVIII chromogenic activity assay containing human factors (Hyphen Biophen FVIII:C), and by FXIa-triggered thrombin generation (TG). Activated partial thromboplastin time (aPTT), prothrombin time (PT), antigen levels of FIX and FX, fibrinogen, D-dimer, and prothrombin fragment 1.2 (PF1.2) levels were determined. Emicizumab trough concentrations ≥ 50 µg/mL were maintained throughout the study. FVIII-like activity and TG (peak height) correlated with emicizumab concentrations and remained above 20 U/dL and 100 nM, respectively, with a weekly maintenance dose, theoretically converting persons with severe hemophilia A to a mild disease phenotype. aPTT was normalized at subtherapeutic concentrations of emicizumab. Plasma concentrations of target antigens FIX and FX were not significantly affected by emicizumab treatment; nor were fibrinogen, PT (international normalized ratio), D-dimer, or PF1.2. The PK profile of once-weekly emicizumab in HAVEN 1 provides sustained therapeutic plasma levels, consistent with population PK models. Both the PK profile and the PD and safety biomarkers are consistent with the established efficacy of emicizumab prophylaxis in PwHA with FVIII inhibitors.
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Affiliation(s)
- Christophe Schmitt
- Department of Clinical Pharmacology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Joanne I Adamkewicz
- Department of Oncology Biomarker Development, Genentech, Inc., South San Francisco, California, United States
| | - Jin Xu
- Department of Clinical Research, Genentech, Inc., South San Francisco, California, United States
| | - Claire Petry
- Department of Clinical Pharmacology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Olivier Catalani
- Department of Pharma-Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Guy Young
- Hemostasis and Thrombosis Program, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, United States
| | - Claude Negrier
- Hematology Department, Louis Pradel Hospital, University Claude Bernard, Lyon, France
| | - Michael U Callaghan
- Division of Hematology/Oncology, Children's Hospital of Michigan, Detroit, Michigan, United States
| | - Gallia G Levy
- Department of Pharma Development, Genentech, Inc., South San Francisco, California, United States
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Nougier C, Jeanpierre E, Ternisien C, Proulle V, Hezard N, Pouplard C, Lasne D. Emicizumab treatment: Impact on coagulation tests and biological monitoring of haemostasis according to clinical situations (BIMHO group proposals). Eur J Haematol 2020; 105:675-681. [PMID: 32668090 DOI: 10.1111/ejh.13490] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 02/05/2023]
Abstract
Emicizumab, a bispecific humanised monoclonal antibody restoring to some extent the function of activated FVIII deficient in haemophilia A, represents a major therapeutic advance in the management of haemophilia A patients. No dosage adjustment is required, which leads to a major change for patients used to regular biological monitoring which is particularly burdensome in the case of substitution therapy. In some circumstances, such as before an invasive procedure or in case of bleeding, biological monitoring will be necessary and emicizumab's interference with haemostasis tests, particularly those based on an activated partial thromboplastin times (aPTT), must be known to best interpret the tests and to select the most appropriate methods to guide therapy. The normalisation of aPTT in patients treated with emicizumab is not sufficient to consider haemostasis as normalised. In the event of administration of FVIII to a patient receiving emicizumab, the determination of FVIII should use a chromogenic method using non-human reagents. Coagulation global tests have been proposed to evaluate the biological response when using bypassing agents in patients treated with emicizumab, but the usefulness must be confirmed. The French group BIMHO presents proposals for biological monitoring of a patient treated with emicizumab according to clinical situations.
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Affiliation(s)
- Christophe Nougier
- Laboratoire d'hématologie-hémostase, Centre de Biologie et Pathologie Est, Hospices civils de Lyon, Bron, France
| | | | | | - Valérie Proulle
- Service d'Hématologie Biologique, CHU Bicètre, AP-HP, Université Paris Sud Saclay, INSERM U1176, Le Kremlin-Bicêtre, France
| | - Nathalie Hezard
- Laboratoire d'hématologie, Hôpitaux de Marseille, Marseille, France
| | - Claire Pouplard
- Service d'Hématologie Hémostase, Hôpital Trousseau, CHU de Tours, EA 7501 Université François Rabelais, Tours, France
| | - Dominique Lasne
- Laboratoire d'hématologie générale, Hôpital Necker, AP-HP, Paris, France.,Université Paris Sud Paris Saclay, Inserm U1176, Le Kremlin-Bicêtre, France
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Yaoi H, Shida Y, Kitazawa T, Shima M, Nogami K. Emicizumab Augments Thrombus Formation in Whole Blood from Patients with Hemophilia A under High Shear Flow Conditions. Thromb Haemost 2020; 121:279-286. [PMID: 32906155 DOI: 10.1055/s-0040-1716542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Emicizumab is a bispecific antibody to factor (F) IXa and FX that mimics the FVIIIa cofactor function. Emicizumab prophylaxis markedly decreases bleeding episodes in patients with hemophilia A (PwHAs), irrespective of the presence of FVIII inhibitors. However, thrombotic microangiopathy (TMA) was reported when repeated high doses of activated prothrombin complex concentrates (aPCC) were concomitantly used with emicizumab. Although bypassing agents (BPAs) are vital in the hemostatic treatment for PwHAs with inhibitors, the mechanism of emicizumab-related TMA remains unclear. AIM To assess the risk of excessive thrombus formation associated with BPAs and emicizumab under high shear conditions. METHODS Perfusion flow-chamber experiments under high shear conditions were performed using whole blood from PwHAs in the presence of emicizumab without or together with FVIII or BPAs ex vivo. RESULTS Emicizumab (100 μg/mL) added ex vivo to whole blood from PwHAs improved defective thrombus formation in a similar manner to that observed with the addition of recombinant FVIII at the early phase, while FVIII continued to be important at the later stages. aPCC (1.2 U/mL equivalent to 100 U/kg) or recombinant FVIIa (1.1 µg/mL; equivalent to 90 µg/kg) together with emicizumab further promoted platelet interactions and fibrin formation ex vivo but did not induce excessive thrombus formation. CONCLUSION Emicizumab enhanced thrombin generation at local sites and improved defective hemostasis in whole blood from PwHAs under high shear conditions. Simple concomitant use of BPAs with emicizumab did not mediate excessive thrombus formation and remains an option for hemostatic management of emicizumab-treated PwHAs with inhibitors.
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Affiliation(s)
- Hiroaki Yaoi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Yasuaki Shida
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Takehisa Kitazawa
- Research Division, Chugai Pharmaceutical Co., Kamakura, Kanagawa, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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214
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Lee H, Cho H, Han JW, Kim AY, Park S, Lee M, Cho S, Baik D, Kang HY. Cost-utility analysis of emicizumab prophylaxis in haemophilia A patients with factor VIII inhibitors in Korea. Haemophilia 2020; 27:e12-e21. [PMID: 32894895 DOI: 10.1111/hae.14143] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 08/05/2020] [Accepted: 08/12/2020] [Indexed: 01/19/2023]
Abstract
AIMS Haemophilia A patients with factor VIII inhibitors (HAPI) experience frequent spontaneous bleeding, approximately once a week, and require expensive bypassing agent (BPA) treatments to control bleeding over their lifetime. According to the HAVEN 1 trial, weekly emicizumab (Hemlibra®) prophylaxis injection reduces annualized bleeding rates (ABR) by 87% compared with BPA on-demand treatment (BPA-OD) administered at the time of bleeding. Our study aimed to assess the cost-effectiveness of emicizumab prophylaxis in HAPI in Korea. METHODS Using a lifetime Markov model with health states of 'alive with bleeds' and 'dead', we simulated the experience of HAPI receiving emicizumab prophylaxis (treatment arm) or BPA-OD (control arm) and estimated expected clinical and economic outcomes under each treatment arm. Model parameters included comparative effectiveness, clinical and epidemiologic characteristics of Korean HAPI, costs of drug treatment and medical events and utility for 'alive with bleeds' state under each treatment. We utilized local data, including National Health Insurance claims data, national statistics, literature and expert surveys with haematologists. RESULTS Base-case analysis results showed that compared with BPA-OD, lifetime emicizumab prophylaxis prevented 807 bleedings, extended 3.04 quality-adjusted life-years and reduced costs by 2.6 million US dollars. Thus, emicizumab prophylaxis is a dominant treatment option with better effectiveness and lower costs than BPA-OD. A series of one-way sensitivity analyses consistently showed dominant results, confirming that lifetime emicizumab prophylaxis is a cost-saving intervention for HAPI. CONCLUSION Emicizumab prophylaxis is an excellent treatment choice reducing ABR, improving quality of life and reducing costs.
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Affiliation(s)
- Hankil Lee
- College of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, South Korea.,CONNECT-AI Research Center, Yonsei University College of Medicine, Seoul, South Korea.,Institute of Health Services Research, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyeonseok Cho
- College of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, South Korea
| | - Jung Woo Han
- Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, South Korea.,Department of Pediatric Hemato-oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, South Korea
| | - Ah-Young Kim
- Department of Pharmaceutical Medicine and Regulatory Sciences, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, South Korea
| | - Seonyoung Park
- Department of Pharmaceutical Medicine and Regulatory Sciences, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, South Korea
| | - Minjun Lee
- Department of Pharmaceutical Medicine and Regulatory Sciences, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, South Korea
| | - Sunghwa Cho
- Department of Pharmaceutical Medicine and Regulatory Sciences, Colleges of Medicine and Pharmacy, Yonsei University, Incheon, South Korea
| | - Deborah Baik
- College of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, South Korea
| | - Hye-Young Kang
- College of Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, South Korea
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215
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Kwak J, Mazzeffi M, Boggio LN, Simpson ML, Tanaka KA. Hemophilia: A Review of Perioperative Management for Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 36:246-257. [DOI: 10.1053/j.jvca.2020.09.118] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 02/08/2023]
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216
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O'Mahony B. Haemophilia care in Europe: Past progress and future promise. Haemophilia 2020; 26:752-758. [DOI: 10.1111/hae.14097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Brian O'Mahony
- Irish Haemophilia Society Ltd. and Trinity College Dublin Ireland
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217
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Ogiwara K, Nogami K, Matsumoto N, Noguchi-Sasaki M, Hirata M, Soeda T, Shima M. A modified thrombin generation assay to evaluate the plasma coagulation potential in the presence of emicizumab, the bispecific antibody to factors IXa/X. Int J Hematol 2020; 112:621-630. [DOI: 10.1007/s12185-020-02959-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/18/2020] [Accepted: 07/21/2020] [Indexed: 11/25/2022]
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218
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Gelbenegger G, Schoergenhofer C, Knoebl P, Jilma B. Bridging the Missing Link with Emicizumab: A Bispecific Antibody for Treatment of Hemophilia A. Thromb Haemost 2020; 120:1357-1370. [PMID: 32717759 PMCID: PMC7649063 DOI: 10.1055/s-0040-1714279] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hemophilia A, characterized by absent or ineffective coagulation factor VIII (FVIII), is a serious bleeding disorder that entails severe and potentially life-threatening bleeding events. Current standard therapy still involves replacement of FVIII, but is often complicated by the occurrence of neutralizing alloantibodies (inhibitors). Management of patients with inhibitors is challenging and necessitates immune tolerance induction for inhibitor eradication and the use of bypassing agents (activated prothrombin complex concentrates or recombinant activated factor VII), which are expensive and not always effective. Emicizumab is the first humanized bispecific monoclonal therapeutic antibody designed to replace the hemostatic function of activated FVIII by bridging activated factor IX and factor X (FX) to activate FX and allow the coagulation cascade to continue. In the majority of hemophilic patients with and without inhibitors, emicizumab reduced the annualized bleeding rate to almost zero in several clinical trials and demonstrated a good safety profile. However, the concurrent use of emicizumab and activated prothrombin complex concentrate imposes a high risk of thrombotic microangiopathy and thromboembolic events on patients and should be avoided. Yet, the management of breakthrough bleeds and surgery remains challenging with only limited evidence-based recommendations being available. This review summarizes published clinical trials and preliminary reports of emicizumab and discusses the clinical implications of emicizumab in treatment of hemophilia A.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Paul Knoebl
- Division of Hematology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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219
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Levy‐Mendelovich S. Emicizumab for infants and children with haemophilia A. Br J Haematol 2020; 191:145-146. [DOI: 10.1111/bjh.16965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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220
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First report of emicizumab use in a female patient with severe hemophilia A. Blood Adv 2020; 4:2950-2952. [DOI: 10.1182/bloodadvances.2020002364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 06/08/2020] [Indexed: 11/20/2022] Open
Abstract
Key Points
This is the first report of successful use of emicizumab in a female patient with severe hemophilia A.
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221
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Barg AA, Livnat T, Budnik I, Avishai E, Brutman‐Barazani T, Tamarin I, Bashari D, Misgav M, Kenet G. Emicizumab treatment and monitoring in a paediatric cohort: real‐world data. Br J Haematol 2020; 191:282-290. [DOI: 10.1111/bjh.16964] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 06/01/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Assaf A. Barg
- National Hemophilia Center Sheba Medical Center Tel Hashomer Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis Sackler School of MedicineTel Aviv University Tel Aviv Israel
| | - Tami Livnat
- National Hemophilia Center Sheba Medical Center Tel Hashomer Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis Sackler School of MedicineTel Aviv University Tel Aviv Israel
| | - Ivan Budnik
- Department of Pathophysiology Sechenov First Moscow State Medical University (Sechenov University) Moscow Russia
| | - Einat Avishai
- National Hemophilia Center Sheba Medical Center Tel Hashomer Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis Sackler School of MedicineTel Aviv University Tel Aviv Israel
| | - Tami Brutman‐Barazani
- National Hemophilia Center Sheba Medical Center Tel Hashomer Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis Sackler School of MedicineTel Aviv University Tel Aviv Israel
| | - Ilia Tamarin
- National Hemophilia Center Sheba Medical Center Tel Hashomer Israel
| | - Dalia Bashari
- National Hemophilia Center Sheba Medical Center Tel Hashomer Israel
| | - Mudi Misgav
- National Hemophilia Center Sheba Medical Center Tel Hashomer Israel
| | - Gili Kenet
- National Hemophilia Center Sheba Medical Center Tel Hashomer Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis Sackler School of MedicineTel Aviv University Tel Aviv Israel
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222
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Miesbach W, Schwäble J, Müller MM, Seifried E. Treatment Options in Hemophilia. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:791-798. [PMID: 31847949 DOI: 10.3238/arztebl.2019.0791] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 04/30/2019] [Accepted: 08/29/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Approximately 4550 persons were under treatment for hemophilia in Germany in 2017. The condition is currently treated with intravenous supplementa- tion of the missing clotting factor, either prophylactically or as needed. Newer treat- ment options rely on novel mechanisms of action. METHODS This review is based on pertinent publications retrieved by a selective search in MEDLINE/PubMed, as well as on expert opinions and the recommenda- tions of specialty societies. RESULTS Randomized controlled trials have shown that, in children aged 30 months to 6 years, prophylactic clotting-factor supplementation yields a markedly lower an- nual rate of hemorrhage than supplementation as needed: 3.27 (standard deviation [SD] 6.24) for the former vs. 17.69 (SD 9.25) for the latter. A similar large effect was seen in patients aged 12 to 50 years, with hemorrhage rates of 1.9 (SD 4.1) vs. 28.7 (SD 18.8). Clotting-factor preparations with longer half-lives make it possible to lessen the frequency of administration and to prevent subtherapeutic factor levels. A number of alternatives to clotting-factor supplementation have recently been approved or are currently being clinically tested. These new drugs are injected sub- cutaneously and have a longer half-life, possibly enabling better protection against bleeding than the current standard treatment. A further advantage of some of these drugs is that they can be given even in the presence of inhibitors to factor VIII. In addition, initial (phase I) clinical trials of gene therapy have been performed suc- cessfully for both hemophilia A and hemophilia B. CONCLUSION Now that new alternatives to classic supplementation therapy are be- coming available, pertinent treatment algorithms for patients with hemophilia will have to be developed. It is still unclear to what extent the new drugs might supplant clotting factor supplementation as the first line of treatment.
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Affiliation(s)
- Wolfgang Miesbach
- Department of Hemostaseology and Transfusion Medicine, University Hospital Frankfurt am Main; DRK-Blutspendedienst Baden-Württemberg-Hessen gGmbH, Department of Transfusion Medicine and Immunohematology, University Hospital Frankfurt am Main
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223
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Acquired Haemophilia A: An Intriguing Disease. Mediterr J Hematol Infect Dis 2020; 12:e2020045. [PMID: 32670523 PMCID: PMC7340240 DOI: 10.4084/mjhid.2020.045] [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: 05/11/2020] [Accepted: 06/18/2020] [Indexed: 12/31/2022] Open
Abstract
Abstract. Acquired Haemophilia A is a rare acquired bleeding disorder caused by Factor VIII autoantibodies, which neutralise FVIII activity. These inhibitors differ from alloantibodies against FVIII, which can occur in congenital Haemophilia A after repeated exposures to plasma-derived or recombinant FVIII products. In most cases, the disease occurs suddenly in subjects without a personal or familiar history of bleedings, with symptoms that may be mild, moderate, or severe. However, only laboratory alterations are present in ~ 30% of patients. The incidence varies from 1 to 4 cases per million/year; more than 80% of patients are elderly, males and females are similarly affected. There is a small peak of incidence related to pregnancy in young women aged 20–40 years. The disease may be underdiagnosed in the elderly. The diagnostic algorithm is based on an isolated prolonged activated partial thromboplastin time, normal thrombin time, absence of Lupus Anticoagulant, and a mixing test that reveals the presence of an inhibitor: the finding of reduced FVIII activity and the detection of neutralising autoantibodies against FVIII lead to the diagnosis. The disease is idiopathic in 44%–63% of cases, while in the others etiological factors are present. Bleeding prevention and treatment are based on therapeutic tools as by-passing agents, recombinant porcine FVIII concentrate or, in a limited number of cases, FVIII concentrates and desmopressin. As soon as the diagnosis has been made, immunosuppressive therapy must be started to eradicate the inhibitor. Better knowledge of the disease, optimal management of bleeding and eradication of the inhibitor have significantly reduced morbidity and mortality in most patients.
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224
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Holstein K, Albisetti M, Bidlingmaier C, Halimeh S, Heine S, Klamroth R, Königs C, Kurnik K, Male C, Oldenburg J, Streif W, Wermes C, Escuriola-Ettingshausen C. Practical Guidance of the GTH Haemophilia Board on the Use of Emicizumab in Patients with Haemophilia A. Hamostaseologie 2020; 40:561-571. [PMID: 32588417 DOI: 10.1055/a-1127-6476] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Emicizumab has been approved for bleeding prophylaxis in patients with haemophilia A (PWHAs) with or without inhibitors. Because of substantial differences between factor VIII (FVIII) and Emicizumab, the 'Ständige Kommission Hämophilie' of the German, Austrian, Swiss Society for Thrombosis and Haemostasis Research (GTH) established a practical guidance for the use of Emicizumab in PWHAs. A systematic literature research was conducted in PubMed. Based on this and on personal experience, this practical guidance has been developed. Each single statement has been discussed among members of the 'Ständige Kommission Hämophilie' and revised accordingly. The final set of recommendations has been approved by all authors analogous to the Delphi method. This practical guidance is provided for physicians treating PWHAs with regard to general aspects, patient education, bleeding treatment, surgery, use of Emicizumab in previously untreated patients (PUPs), patients with newly diagnosed inhibitors and elderly patients. Patients should be treated in expert centres and adequate laboratory tests to monitor Emicizumab levels, FVIII replacement and inhibitors should be available. Early experience of immune tolerance induction protocols integrating Emicizumab is reviewed, and the limited experience in PUPs and very young children is described. So far, no thromboembolic complications have been reported with the concomitant use of FVIII or recombinant activated FVII for bleeding treatment or surgery. Activated prothrombin complex concentrate doses of >100 U/kg for >24 hours should be avoided whenever possible because of the high risk of thrombosis and/or thrombotic microangiopathy. In conclusion, this study is designed to support haemophilia physicians using Emicizumab in physicians treating hemophilia and using (PWHAs). With further post-marketing experience and trials, regular updates are necessary.
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Affiliation(s)
- Katharina Holstein
- Haematology and Clinical Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manuela Albisetti
- Division of Hematology, University Children's Hospital, Zurich, Switzerland
| | - Christoph Bidlingmaier
- Centre for Development and Complex Chronic Diseases in Children (iSPZHauner), Department of Paediatrics, Paediatric Haemophilia Centre, LMU Munich, Munich, Germany
| | | | - Sabine Heine
- Department of Paediatric Oncology/Haematology, Saarland University Hospital, Homburg, Germany
| | - Robert Klamroth
- Internal Medicine, Angiology and Haemostaseology, Haemophilia Centre, Vivantes Hospital Friedrichshain, Berlin, Germany
| | - Christoph Königs
- Department of Paediatrics and Adolescent Medicine, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Karin Kurnik
- Paediatric Haemophilia Centre, Department of Paediatrics, LMU Munich, Munich, Germany
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Johannes Oldenburg
- Institute for Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Werner Streif
- Department of Paediatrics 1, Medical University of Innsbruck (MUI), Innsbruck, Austria
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225
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Linari S, Castaman G. Concomitant Use of rFVIIa and Emicizumab in People with Hemophilia A with Inhibitors: Current Perspectives and Emerging Clinical Evidence. Ther Clin Risk Manag 2020; 16:461-469. [PMID: 32547043 PMCID: PMC7251291 DOI: 10.2147/tcrm.s205310] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/23/2020] [Indexed: 01/19/2023] Open
Abstract
Emicizumab, a humanized, bi-specific, monoclonal antibody subcutaneously administered, mimicking the function of FVIIIa, represents a milestone in treatment of patients affected by hemophilia A complicated with inhibitors. The HAVEN 1 and 2 studies have clearly established its superiority compared to bypassing agents for routine prophylaxis in preventing or reducing bleeding episodes in adult and pediatric patients with inhibitors. However, its protection against bleeding is only partial, and concomitant use of a bypassing agent may be required with potential prothrombotic risk. The emicizumab Phase III trials (HAVEN 1, 2 and 4) have shown that the traditional bypassing agents, activated prothrombin complex concentrates or recombinant activated factor VII (rFVIIa), may be necessary for the treatment of breakthrough bleeds or surgery management. A post hoc analysis in particular has shown that the concomitant use of emicizumab and rFVIIa is safe and no thrombotic events have been described. The review describes the state of the art of the concomitant use of emicizumab and rFVIIa for treating acute bleeding and surgeries, its efficacy and safety and the lack of thrombotic events associated with this treatment modality. Data still derive mainly from HAVEN trials; however, the availability of emicizumab in clinical practice is progressively increasing the number of patients treated and no adverse events directly attributed to this agent have occurred. The availability of guidelines for the use and dosing of rFVIIa during emicizumab prophylaxis is useful in clinical practice for managing suspected or ongoing bleeding, emergency situations and elective invasive procedures. In the next years, careful prospective post-licensure surveillance to monitor safety of rFVIIa use during prophylaxis with emicizumab is highly recommended.
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Affiliation(s)
- Silvia Linari
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
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226
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Li H, Zhang W, Petry C, Li L, Fernandez E, Kiialainen A, Feng S, Hsu W, Li L, Wei Y, Schmitt C. Evaluation of the Pharmacokinetics, Pharmacodynamics, and Safety of a Single Dose of Emicizumab in Healthy Chinese Subjects. Clin Pharmacol Drug Dev 2020; 10:30-38. [PMID: 32433829 PMCID: PMC7818492 DOI: 10.1002/cpdd.805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/24/2020] [Indexed: 12/16/2022]
Abstract
This phase 1, open‐label, single‐center study evaluated the pharmacokinetics (PK), pharmacodynamics, safety, and tolerability of single‐dose emicizumab in healthy Chinese males. Overall, 16 subjects received a single subcutaneous dose of 1‐mg/kg emicizumab. Blood samples were obtained before dosing on day 1 and at regular intervals over 16 weeks after dosing for PK evaluation. A single 1‐mg/kg subcutaneous dose of emicizumab was safe and well tolerated in healthy Chinese male subjects in the study. Mean (± standard deviation) area under the concentration‐time curve from time 0 to infinity and maximum concentration were 287 ± 74.2 μg⋅d/mL and 7.11 ± 1.77 μg/mL, respectively, with a terminal half‐life of 26.7 (±4.3) days. Emicizumab administration did not show significant impact on pharmacodynamic markers tested, which mostly remained stable throughout the study. One subject tested positive for antidrug antibody, with no impact on his PK or safety profile. Compared with results from healthy Japanese and Caucasian subjects receiving the same dose in previous clinical trials, the current results further indicated the absence of difference of emicizumab PK profile across Chinese, Japanese, and Caucasian subjects, validating the use of similar therapeutic doses in Asian and non‐Asian populations.
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MESH Headings
- Adult
- Antibodies/blood
- Antibodies, Bispecific/adverse effects
- Antibodies, Bispecific/blood
- Antibodies, Bispecific/pharmacokinetics
- Antibodies, Bispecific/pharmacology
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/blood
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- Antibodies, Monoclonal, Humanized/pharmacology
- Asian People
- Factor VIII/analysis
- Healthy Volunteers
- Humans
- Injections, Subcutaneous
- Male
- White People
- Young Adult
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Affiliation(s)
- Haiyan Li
- Drug Clinical Trial Center and the Department of CardiologyPeking UniversityThird HospitalBeijingChina
| | | | | | - Lindong Li
- F. Hoffmann–La Roche LtdRoche Product Development ShanghaiShanghaiChina
| | | | | | - Sheng Feng
- F. Hoffmann–La Roche LtdpRED Roche ShanghaiChina
| | - Wanling Hsu
- F. Hoffmann–La Roche LtdRoche Product Development ShanghaiShanghaiChina
| | - Li Li
- F. Hoffmann–La Roche LtdRoche Product Development ShanghaiShanghaiChina
| | - Yudong Wei
- Drug Clinical Trial CenterPeking UniversityThird HospitalBeijingChina
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227
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Rayment R, Chalmers E, Forsyth K, Gooding R, Kelly AM, Shapiro S, Talks K, Tunstall O, Biss T. Guidelines on the use of prophylactic factor replacement for children and adults with Haemophilia A and B. Br J Haematol 2020; 190:684-695. [PMID: 32390158 DOI: 10.1111/bjh.16704] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/04/2020] [Accepted: 04/08/2020] [Indexed: 01/19/2023]
Affiliation(s)
| | | | | | | | - Anne M Kelly
- Cambridge University Hospitals NHS foundation Trust, Cambridge, UK
| | - Susan Shapiro
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kate Talks
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Oliver Tunstall
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Tina Biss
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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228
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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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229
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Yada K, Nogami K. Novel Insights and New Developments Regarding Coagulation Revealed by Studies of the Anti-Factor IXa (Activated Factor IX)/Factor X Bispecific Antibody, Emicizumab. Arterioscler Thromb Vasc Biol 2020; 40:1148-1154. [PMID: 32237902 DOI: 10.1161/atvbaha.120.312919] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Emicizumab is a humanized anti-FIXa/FX (factor IXa/X) bispecific monoclonal antibody that mimics FVIIIa (activated factor VIII) cofactor function. The hemostatic efficacy of emicizumab has been confirmed in clinical studies of patients with hemophilia A, irrespective of the presence of FVIII inhibitors. Emicizumab differs in some properties from FVIIIa molecule. Emicizumab requires no activation by thrombin and is not inactivated by activated protein C, but emicizumab-mediated coagulation is regulatable and maintains hemostasis. A small amount of FIXa (activated factor IX) is required to initiate emicizumab-mediated hemostasis, whereas tissue factor/FVIIa (activated factor VII)-mediated FXa (activated factor X) and thrombin activation initiates FVIIIa-mediated hemostasis. Fibrin formation, followed by fibrinolysis, appears to be similar between emicizumab- and FVIIIa-mediated hemostasis. These results suggest possible future uses of emicizumab for treating hemorrhagic diseases other than hemophilia A and reveal previously unobservable behaviors of procoagulation and anticoagulation factors in conventional hemostasis. Here, we have reviewed novel insights and new developments regarding coagulation highlighted by emicizumab.
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Affiliation(s)
- Koji Yada
- From the Department of Pediatrics (K.Y., K.N.), Nara Medical University, Kashihara, Japan.,The Course of Hemophilia Education (K.Y.), Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- From the Department of Pediatrics (K.Y., K.N.), Nara Medical University, Kashihara, Japan
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230
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Takeyama M, Nogami K, Matsumoto T, Noguchi-Sasaki M, Kitazawa T, Shima M. An anti-factor IXa/factor X bispecific antibody, emicizumab, improves ex vivo coagulant potentials in plasma from patients with acquired hemophilia A. J Thromb Haemost 2020; 18:825-833. [PMID: 31984625 DOI: 10.1111/jth.14746] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/31/2019] [Accepted: 01/17/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Acquired hemophilia A (AHA) is caused by autoantibodies against factor (F)VIII, and is characterized by severe, spontaneous bleeding, which can be life-threatening. Emicizumab, an anti-FIXa/FX bispecific antibody, significantly reduces bleeding events in congenital hemophilia A (HA) with and without inhibitors. The known pathophysiological mechanisms and current preclinical data in HA suggest that emicizumab could provide effective treatment for AHA, but the coagulation activities of emicizumab in these patients remain unknown. AIM To evaluate the coagulant effects of emicizumab in plasma from AHA patients. METHODS AND RESULTS Tissue factor-triggered thrombin generation assays using normal plasma preincubated with anti-FVIII monoclonal antibodies recognizing different epitopes demonstrated that 20 µg/mL emicizumab recovered the depressed peak levels of thrombin generation to 46% to 72%. Further studies were devised, therefore, to simulate the clinical course in AHA patients, including during the acute phase for severe bleeding requiring FVIII-bypassing therapy, and during the subacute/chronic phase with less bleeding. Various concentrations of emicizumab were used to represent the potential changes in plasma levels based on the half-life of the antibody (~30 days). The ex vivo addition of emicizumab to plasma samples from AHA patients (n = 16) increased peak thrombin in all cases, irrespective of the inhibitor epitope specificity. Thrombin generation at 20 and 100 µg/mL emicizumab was restored to (median) 43.9% and 92.2%, respectively. Differences were evident in some cases, however, and recovery rates appeared likely to be greater in patients with type 2 inhibitor than those with type 1. CONCLUSION Emicizumab improved ex vivo coagulation potential in plasma from AHA patients.
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Affiliation(s)
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Tomoko Matsumoto
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
- Tenri School of Medical Technology, Tenri, Japan
| | | | | | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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231
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A multicenter, open-label phase 3 study of emicizumab prophylaxis in children with hemophilia A with inhibitors. Blood 2020; 134:2127-2138. [PMID: 31697801 DOI: 10.1182/blood.2019001869] [Citation(s) in RCA: 237] [Impact Index Per Article: 59.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 09/22/2019] [Indexed: 12/13/2022] Open
Abstract
Emicizumab, a bispecific humanized monoclonal antibody, bridges activated factor IX (FIX) and FX to restore the function of missing activated FVIII in hemophilia A. Emicizumab prophylaxis in children with hemophilia A and FVIII inhibitors was investigated in a phase 3 trial (HAVEN 2). Participants, previously receiving episodic/prophylactic bypassing agents (BPAs), were treated with subcutaneous emicizumab: 1.5 mg/kg weekly (group A), 3 mg/kg every 2 weeks (group B), or 6 mg/kg every 4 weeks (group C). Pharmacokinetics, safety, and efficacy (including an intraindividual comparison of participants from a noninterventional study) were evaluated. Eighty-five participants aged <12 years were enrolled. In group A (n = 65), the annualized rate of treated bleeding events (ABRs) was 0.3 (95% confidence interval [CI], 0.17-0.50), and 77% had no treated bleeding events. Intraindividual comparison of 15 participants who previously took BPA prophylaxis showed that emicizumab prophylaxis reduced the ABR by 99% (95% CI, 97.4-99.4). In groups B (n = 10) and C (n = 10), ABRs were 0.2 (95% CI, 0.03-1.72) and 2.2 (95% CI, 0.69-6.81), respectively. The most frequent adverse events were nasopharyngitis and injection-site reactions; no thrombotic events occurred. Two of 88 participants developed antidrug antibodies (ADAs) with neutralizing potential, that is, associated with decreased emicizumab plasma concentrations: 1 experienced loss of efficacy, and, in the other, ADAs disappeared over time without intervention or breakthrough bleeding. All other participants achieved effective emicizumab plasma concentrations, regardless of the treatment regimen. Emicizumab prophylaxis has been shown to be a highly effective novel medication for children with hemophilia A and inhibitors. This trial was registered at www.clinicaltrials.gov as #NCT02795767.
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232
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Furukawa S, Nogami K, Shimonishi N, Nakajima Y, Matsumoto T, Shima M. Prediction of the haemostatic effects of bypassing therapy using comprehensive coagulation assays in emicizumab prophylaxis-treated haemophilia A patients with inhibitors. Br J Haematol 2020; 190:727-735. [PMID: 32162680 DOI: 10.1111/bjh.16574] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/20/2020] [Indexed: 02/07/2023]
Abstract
In emicizumab prophylaxis, the concomitant therapy using bypassing agents (BPAs) is required for breakthrough bleeding and invasive procedures with attention to thrombotic complications. To predict coagulant effects of BPAs in emicizumab-treated patients with haemophilia A (PwHA) with inhibitor (PwHAwI), blood samples from emicizumab-treated PwHAwI (n = 8) and PwHA without inhibitor (n = 2) in phase 1/2 and HAVEN 1 study, spiked with activated prothrombin complex concentrates (aPCC) or recombinant factor VIIa (rFVIIa) ex vivo, and blood samples from emicizumab-treated PwHAwI-receiving BPAs were analysed by Ca2+ -triggered rotational thromboelastometry (ROTEM) and ellagic acid/tissue factor-triggered clot waveform analysis (CWA). Spiked aPCC, corresponded to 10-100 U/kg, markedly shortened ROTEM parameters beyond the normal range, while spiked rFVIIa, corresponded to 90-270 μg/kg, shortened them within near-normal range. Each of the spiked BPA-improved adjusted maximum coagulation velocity of CWA to within or near the normal range. In blood samples at post-infusion of aPCC (44-73 U/kg) or rFVIIa (79-93 μg/kg), the parameters of both assays improved to approximately the normal range. Taken together, ex vivo results of spiking tests in ROTEM and CWA, except aPCC spiking test in ROTEM, were relatively consistent with in vivo ones, and could usefully predict the coagulant effects of concomitant bypassing therapy for emicizumab-treated PwHAwI.
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Affiliation(s)
- Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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233
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Shimonishi N, Nogami K, Ogiwara K, Matsumoto T, Nakazawa F, Soeda T, Hirata M, Arai N, Shima M. Emicizumab improves the stability and structure of fibrin clot derived from factor VIII-deficient plasma, similar to the addition of factor VIII. Haemophilia 2020; 26:e97-e105. [PMID: 32157756 DOI: 10.1111/hae.13961] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Emicizumab is an antifactor (F)IXa/FX bispecific antibody, mimicking FVIIIa cofactor function. Emi prophylaxis effectively reduces bleeding events in patients with haemophilia A. The physical properties of emicizumab-induced fibrin clots remain to be investigated, however. AIM We have investigated the stability and structure of emicizumab-induced fibrin clots. METHODS Coagulation was initiated by activated partial thromboplastin time (aPTT) trigger and prothrombin time (PT)/aPTT-mixed trigger in FVIII-deficient plasma with various concentrations of emicizumab or recombinant FVIII. The turbidity and stability of fibrin clots were assessed by clot waveform and clot-fibrinolysis waveform analyses, respectively. The resulting fibrin was analysed by scanning electron microscopy (SEM). RESULTS Using an aPTT trigger, the turbidity was decreased and the fibrinolysis times were prolonged in the presence of emicizumab dose-dependently. Scanning electron microscopy imaging demonstrated that emicizumab improved the structure of fibrin network with thinner fibres than in its absence. Although emicizumab shortened the aPTT dramatically, the nature of emicizumab-induced fibrin clots did not reflect the hypercoagulable state. Similarly, using a PT/aPTT-mixed trigger that could evaluate potential emicizumab activity, emicizumab improved the stability and structure of fibrin clot in a series of experiments. In this circumstance, fibrin clot properties with emicizumab at 50 and 100 µg/mL appeared to be comparable to those with FVIII at ~12 and ~24-32 IU/dL, respectively. CONCLUSION Emicizumab effectively improved fibrin clot stability and structure in FVIII-deficient plasma, and the physical properties of emicizumab-induced fibrin clots were similar to those with FVIII.
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Affiliation(s)
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Tomoko Matsumoto
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | | | | | | | | | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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234
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Mannucci PM. Hemophilia therapy: the future has begun. Haematologica 2020; 105:545-553. [PMID: 32060150 PMCID: PMC7049365 DOI: 10.3324/haematol.2019.232132] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 01/20/2020] [Indexed: 02/06/2023] Open
Abstract
The success story of hemophilia care first began in the 1970s, when the availability of plasma-derived concentrates of coagulation factor VIII (FVIII) and factor IX (FIX) provided efficacious treatment of bleeding in patients with hemophilia A and B. This positive scenario was consolidated in terms of greater safety and availability in the 1990s, when the first recombinant coagulation factors were produced. This meant that, instead of only treating episodic bleeding events, prophylaxis regimens could be implemented as a preventive measure. Following the demonstration of its superiority in the frame of two randomized clinical trials, prophylaxis became evidence-based standard of care. In high-income countries, these achievements have led to a patients’ life expectancy being extended to close to that of the general male population. Alongside this, the last decade has witnessed further spectacular therapeutic progress, such as the availability of coagulation factors with a longer plasma half-life that allow for wider intervals between treatment. Moreover, new therapeutic products based on new mechanisms other than the replacement of the deficient factor, have become available (emicizumab) or are at an advanced stage of development. This review celebrates the success story of hemophilia care, while also discussing current limitations, issues and as yet unmet needs. The prospects of cure by means of gene therapy are also outlined.
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Affiliation(s)
- Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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235
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Le Quellec S. Clinical Evidence and Safety Profile of Emicizumab for the Management of Children with Hemophilia A. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:469-481. [PMID: 32099331 PMCID: PMC7007498 DOI: 10.2147/dddt.s167731] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 01/22/2020] [Indexed: 01/03/2023]
Abstract
Emicizumab is a bispecific, humanized, monoclonal antibody mimicking the factor (F) VIII cofactor activity in mediating the generation of FXa by FIXa in patients with hemophilia A (HA). This subcutaneous non-factor agent has been recently extensively approved for the prophylaxis of patients of HA patients with and without FVIII-inhibitors of all ages, although few data are currently available in children. In Phase 3 clinical trials and case series, emicizumab prophylaxis significantly reduced bleeding rates compared to previous treatment in HA adolescents and children with or without FVIII-inhibitors and was generally well tolerated. In addition, subcutaneous administration of emicizumab provided beneficial effects on health-related quality of life, and lessened the burden of the disease in HA patients as well as in their caregivers. However, additional prospective studies are required to evaluate the long-term safety of emicizumab prophylaxis in very young patients, including previously untreated patients. The aim of this paper was to review the limited data available on the use of emicizumab prophylaxis in children and to highlight the need for further studies to address remaining concerns.
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Affiliation(s)
- Sandra Le Quellec
- Unité d'hémostase Clinique - Hôpital Cardiologique Louis Pradel - Hospices Civils de Lyon, Lyon, France.,Service d'hématologie biologique, Groupement Hospitalier Est - Hospices Civils de Lyon, Lyon, France
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236
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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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237
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Ebbert PT, Xavier F, Seaman CD, Ragni MV. Emicizumab prophylaxis in patients with haemophilia A with and without inhibitors. Haemophilia 2019; 26:41-46. [DOI: 10.1111/hae.13877] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/29/2019] [Accepted: 10/22/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Patrick T. Ebbert
- Department of Medicine and Hemophilia Center of Western PA University of Pittsburgh Pittsburgh PA USA
| | - Frederico Xavier
- Department of Medicine and Hemophilia Center of Western PA University of Pittsburgh Pittsburgh PA USA
- Children’s Hospital of Pittsburgh University of Pittsburgh Pittsburgh PA USA
| | - Craig D. Seaman
- Department of Medicine and Hemophilia Center of Western PA University of Pittsburgh Pittsburgh PA USA
| | - Margaret V. Ragni
- Department of Medicine and Hemophilia Center of Western PA University of Pittsburgh Pittsburgh PA USA
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238
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Doyle AJ, Back DL, Austin S. Characteristics and management of the haemophilia‐associated pseudotumours. Haemophilia 2019; 26:33-40. [DOI: 10.1111/hae.13870] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Andrew J. Doyle
- Department of Haemostasis & Thrombosis Guy's & St Thomas’ NHS Foundation Trust London UK
| | - Diane L. Back
- Department of Trauma & Orthopaedics Guy's & St Thomas’ NHS Foundation Trust London UK
| | - Steve Austin
- Department of Haemostasis & Thrombosis Guy's & St Thomas’ NHS Foundation Trust London UK
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239
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Aledort L, Mannucci PM, Schramm W, Tarantino M. Factor VIII replacement is still the standard of care in haemophilia A. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2019; 17:479-486. [PMID: 31846611 PMCID: PMC6917528 DOI: 10.2450/2019.0211-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/10/2019] [Indexed: 12/13/2022]
Abstract
Prophylactic factor VIII (FVIII) has dramatically improved haemophilia A treatment, preventing joint bleeding and halting the deterioration of joint status. FVIII products with an extended plasma half-life further improve patients' quality of life and increase therapeutic adherence. New licensed classes of non-replacement products include prophylactic emicizumab, which is administered subcutaneously up to every 4 weeks. However, this drug is not suitable for acute bleeding episodes or management of major surgery, and long-term data on the impact of emicizumab on joint health, FVIII inhibitor development and thrombotic risk are awaited. Prophylaxis with FVIII replacement remains the standard of care in haemophilia A, with the aim of achieving a level of haemostasis control that allows patients to meet their lifestyle goals.
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Affiliation(s)
- Louis Aledort
- Division of Hematology/Oncology, Icahn School of Medicine, Mount Sinai, New York, NY, United States of America
| | - Pier Mannuccio Mannucci
- Scientific Direction, IRCCS Foundation Ca’ Granda Maggiore Policlinico Hospital, Milan, Italy
| | - Wolfgang Schramm
- Department of Transfusion Medicine and Haemostasis, University Hospital of Munich, Munich, Germany
| | - Michael Tarantino
- University of Illinois College of Medicine, and the Bleeding and Clotting Disorders Institute, Peoria, IL, United States of America
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240
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Ahnström J. The potential of serpins for future treatment for haemophilia. J Thromb Haemost 2019; 17:1629-1631. [PMID: 31571418 DOI: 10.1111/jth.14609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 08/09/2019] [Indexed: 11/30/2022]
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241
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242
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Shima M, Nogami K, Nagami S, Yoshida S, Yoneyama K, Ishiguro A, Suzuki T, Taki M. A multicentre, open-label study of emicizumab given every 2 or 4 weeks in children with severe haemophilia A without inhibitors. Haemophilia 2019; 25:979-987. [PMID: 31515851 PMCID: PMC6900083 DOI: 10.1111/hae.13848] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/21/2019] [Accepted: 08/23/2019] [Indexed: 01/13/2023]
Abstract
Introduction Emicizumab is a recombinant humanized bispecific monoclonal antibody mimicking the cofactor function of activated factor VIII. Aim In this multicentre, open‐label study (HOHOEMI), we evaluated the efficacy, safety and pharmacokinetics of emicizumab in Japanese paediatric patients aged <12 years with severe haemophilia A without factor VIII (FVIII) inhibitors. Methods Emicizumab was administered subcutaneously, with four loading doses of 3 mg/kg every week followed by maintenance doses of 3 mg/kg every 2 weeks (Q2W) or 6 mg/kg every 4 weeks (Q4W) in 6 and 7 patients, respectively. Results All patients completed at least 24 weeks of treatment. Baseline ages ranged from 4 months to 10 years, and all patients had been treated with FVIII prophylaxis prior to enrolment except a 4‐month‐old patient untreated with FVIII previously. In the respective Q2W and Q4W cohorts, 2/6 and 5/7 patients experienced no treated bleeding events, and annualized bleeding rates for treated bleeding events were 1.3 (95% confidence interval [CI], 0.6‐2.9) and 0.7 (95% CI, 0.2‐2.6). All caregivers preferred emicizumab to the patient's previous treatment. Only one related adverse event (injection site reaction) was observed. There were no thromboembolic events or thrombotic microangiopathy. Individual trough plasma concentrations of emicizumab were within the variability observed in preceding adult/adolescent studies. All patients tested negative for anti‐emicizumab antibodies. Conclusions Emicizumab administered Q2W or Q4W was efficacious and safe in paediatric patients with severe haemophilia A without inhibitors. This study was registered at http://www.clinicaltrials.jp (JapicCTI‐173710).
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Affiliation(s)
- Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | | | | | | | - Akira Ishiguro
- Division of Hematology, National Center for Child Health and Development, Tokyo, Japan
| | - Takashi Suzuki
- Department of Blood Coagulation, Ogikubo Hospital, Tokyo, Japan
| | - Masashi Taki
- Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan
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243
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Makris M, Iorio A, Lenting PJ. Emicizumab and thrombosis: The story so far. J Thromb Haemost 2019; 17:1269-1272. [PMID: 31368220 DOI: 10.1111/jth.14556] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 06/17/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Michael Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Alfonso Iorio
- Department of Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Peter J Lenting
- INSERM, U1176, Universite Paris-Sud, Le Kremlin-Bicetre, France
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244
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Yada K, Nogami K. Spotlight on emicizumab in the management of hemophilia A: patient selection and special considerations. J Blood Med 2019; 10:171-181. [PMID: 31308776 PMCID: PMC6613000 DOI: 10.2147/jbm.s175952] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/17/2019] [Indexed: 11/23/2022] Open
Abstract
Emicizumab is a factor (F)VIIIa-mimicking bispecific antibody recognizing FIXa and FX molecules. In the phase 1/2 clinical studies, once-weekly subcutaneous administration of emicizumab has shown a favorable safety profile with encouraging efficacy in the patients with hemophilia A (PwHA) irrespective of the presence of anti-FVIII inhibitors. Moreover, in the following phase 3 studies, emicizumab treatment by once-weekly, bi-weekly or tetra-weekly administration have been still well-tolerated, but some thromboembolic events or thrombotic microangiopathy were observed associated with the concomitant use of activated prothrombin complex concentrates (aPCC) for breakthrough bleeds. Since approved for routine prophylaxis in PwHA in the US, EU, and Japan, a compass on patient selection for emicizumab treatment and special considerations on the practical situations such as concomitant treatment by bypassing agents (BPAs) or clotting factor concentrates (CFCs) with less thrombotic risk, inhibitor eradication by immune tolerance induction (ITI) should be provided. There is no doubt that emicizumab is an alternate first-line therapy for any existing BPA as hemostatic treatment for PwHA with inhibitor, but we should be more cautious in combination with aPCC on breakthrough bleeds under emicizumab prophylaxis because of thrombotic risk. For severe PwHA without inhibitor, since most patients are under CFCs prophylaxis, switching from CFCs to emicizumab should be considered when the advantage of emicizumab prophylaxis surpasses that of CFCs prophylaxis from the viewpoint of hemostatic effect by treatment, physical activity according to the life stage, health condition of the joints, adherence and complication. There are pros and cons on the timing of introduction of emicizumab for cases scheduled to start ITI or cases of ongoing ITI. Introduction of emicizumab to previously untreated patients and nonsevere PwHA without inhibitor is also required to discuss in consideration of risk of inhibitor development and unforeseen safety issues.
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Affiliation(s)
- Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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245
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Cafuir L, Kruse-Jarres R, Mancuso ME, Kempton CL. Emicizumab for hemophilia A without inhibitors. Expert Rev Hematol 2019; 12:515-524. [DOI: 10.1080/17474086.2019.1624519] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Lorraine Cafuir
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Maria Elisa Mancuso
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Christine L Kempton
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
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246
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Ragni MV. The effect of emicizumab regimen on haemophilia outcomes. LANCET HAEMATOLOGY 2019; 6:e286-e287. [DOI: 10.1016/s2352-3026(19)30070-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 11/25/2022]
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247
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Pilunni D, Montrasio L, Navarra P. When innovation goes fast. The case of hemophilia. Curr Opin Pharmacol 2019; 45:95-101. [DOI: 10.1016/j.coph.2019.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 06/25/2019] [Indexed: 01/19/2023]
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