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Goedhart TM, Bukkems LH, Zwagemaker AF, Coppens M, Fijnvandraat K, Schols SE, Schutgens RE, Eikenboom J, Heubel-Moenen FC, Ypma PF, Nieuwenhuizen L, Meijer K, Leebeek FW, Mathôt RA, Cnossen MH. Predictive performance of pharmacokinetic-guided prophylactic dosing of factor concentrates in hemophilia A and B. Res Pract Thromb Haemost 2024; 8:102397. [PMID: 38689619 PMCID: PMC11058079 DOI: 10.1016/j.rpth.2024.102397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 03/18/2024] [Indexed: 05/02/2024] Open
Abstract
Background Pharmacokinetic (PK)-guided dosing is used to individualize factor (F)VIII and FIX replacement therapy. Objectives This study investigates the reliability and feasibility of PK-guided prophylactic dosing of factor concentrates in hemophilia A and B. Methods In this multicenter, prospective cohort study, people of all ages with hemophilia received prophylactic treatment with factor concentrates based on individual PK parameters. During follow-up, at least 4 measured FVIII/FIX levels per patient were compared with corresponding predicted levels obtained by Bayesian forecasting. Predictive performance was defined as adequate when ≥80% of measured FVIII/FIX levels were within ±25% of prediction (relative error). Additionally, mean absolute error and mean error were calculated. In post hoc analyses, predictive performance was assessed allowing maximum absolute errors of 1 (trough), 5 (mid), and 15 (peak) IU/dL. Five-point scale questionnaires addressed feasibility of PK guidance. Results We included 50 patients (median age, 19 years; range: 2-72 years). Median follow-up was 36 weeks. Seventy-one percent of levels (58% trough, 83% mid, and 80% peak) were within ±25% of prediction. Mean absolute errors were 0.8 (trough), 2.0 (mid), and 8.6 (peak) IU/dL. In post hoc analyses, 81% (trough), 96% (mid), and 82% (peak) of levels were within set limits. Patients reported low burden and high satisfaction. Conclusion PK-guided dosing was reliable according to post hoc analyses, based on low absolute errors that were regarded as clinically irrelevant in most cases. The predefined predictive performance was achieved in mid and peak factor levels but not in trough factor levels due to measurement inaccuracy. PK guidance also seemed feasible.
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Affiliation(s)
- Tine M.H.J. Goedhart
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Laura H. Bukkems
- Department of Clinical Pharmacology—Hospital Pharmacy, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Anne-Fleur Zwagemaker
- Department of Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Emma Children’s Hospital, Amsterdam, the Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Emma Children’s Hospital, Amsterdam, the Netherlands
| | - Saskia E.M. Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - Roger E.G. Schutgens
- Van Creveldkliniek, Center for Benign Haematology, Thrombosis and Haemostasis, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Paula F. Ypma
- Department of Hematology, Haga Hospital, the Hague, the Netherlands
| | | | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, Groningen, the Netherlands
| | - Frank W.G. Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ron A.A. Mathôt
- Department of Clinical Pharmacology—Hospital Pharmacy, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marjon H. Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Goedhart TMHJ, Janssen A, Mathôt RAA, Cnossen MH. The road to implementation of pharmacokinetic-guided dosing of factor replacement therapy in hemophilia and allied bleeding disorders. Identifying knowledge gaps by mapping barriers and facilitators. Blood Rev 2023; 61:101098. [PMID: 37321952 DOI: 10.1016/j.blre.2023.101098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 04/02/2023] [Accepted: 05/07/2023] [Indexed: 06/17/2023]
Abstract
Clinical guidelines and expert groups recommend the use of pharmacokinetic (PK)-guided dosing of factor replacement therapy for the treatment of bleeding disorders, especially for patients with hemophilia. Although PK-guided dosing is increasingly applied, it is generally not considered standard clinical practice. The aim of this scoping review is to map barriers and facilitators for the implementation of PK-guided dosing in clinical practice and to identify knowledge gaps. A literature search was performed and 110 articles were included that describe PK-guided dosing in patients with bleeding disorders, mostly hemophilia A. We defined two overarching themes, efficacy and feasibility, and discuss five topics within each theme. For each topic, barriers, facilitators and knowledge gaps were described. Although consensus was found with regard to some topics, contradicting reports were found for others, especially with respect to the efficacy of PK-guided dosing. These contradictions highlight the need for future research to elucidate current ambiguities.
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Affiliation(s)
- Tine M H J Goedhart
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - A Janssen
- Department of Clinical Pharmacology - Hospital Pharmacy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Ron A A Mathôt
- Department of Clinical Pharmacology - Hospital Pharmacy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Bukkems LH, Jönsson S, Cnossen MH, Karlsson MO, Mathôt RAA. Relationship between factor VIII levels and bleeding for rFVIII-SingleChain in severe hemophilia A: A repeated time-to-event analysis. CPT Pharmacometrics Syst Pharmacol 2023; 12:706-718. [PMID: 36965157 DOI: 10.1002/psp4.12938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/31/2022] [Accepted: 01/31/2023] [Indexed: 03/27/2023] Open
Abstract
Publications on the exposure-effect relationships of factor concentrates for hemophilia treatment are limited, whereas such analyses give insight on treatment efficacy. Our objective was to examine the relationship between the dose, factor VIII (FVIII) levels and bleeding for rFVIII-SingleChain (lonoctocog alfa, Afstyla). Data from persons with severe hemophilia A on rFVIII-SingleChain prophylaxis from three clinical trials were combined. The published rFVIII-SingleChain population pharmacokinetic (PK) model was evaluated and expanded. The probability of bleeding was described with a parametric repeated time-to-event (RTTE) model. Data included 2080 bleeds, 2545 chromogenic stage assay, and 3052 one-stage assay FVIII levels from 241 persons (median age 19 years) followed for median 1090 days. The majority of the bleeds occurred in joints (65%) and the main bleeding reason was trauma (44%). The probability of bleeding decreased during follow-up and a FVIII level of 8.9 IU/dL (95% confidence interval: 6.9-10.9) decreased the bleeding hazard by 50% compared to a situation without FVIII in plasma. Variability in bleeding hazard between persons with similar FVIII levels was large, and the pre-study annual bleeding rate explained part of this variability. When a FVIII trough level of 1 or 3 IU/dL is targeted during prophylaxis, simulations predicted two (90% prediction interval [PI]: 0-17) or one (90% PI: 0-11) bleeds per year, respectively. In conclusion, the developed PK-RTTE model adequately described the relationship between dose, FVIII levels and bleeds for rFVIII-SingleChain. The obtained estimates were in agreement with those published for the FVIII concentrates BAY 81-8973 (octocog alfa) and BAY 94-9027 (damoctocog alfa pegol), indicating similar efficacy to reduce bleeding.
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Affiliation(s)
- Laura H Bukkems
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Siv Jönsson
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus University Medical Center - Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands
| | | | - Ron A A Mathôt
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Zapotocka E, Batorova A, Bilic E, Boban A, Escuriola Ettingshausen C, Faganel Kotnik B, Hrdlickova R, Laguna P, Machal J, Nemes L, Zupan IP, Puras G, Zombori M. First experience of a hemophilia monitoring platform: florio HAEMO. Res Pract Thromb Haemost 2022; 6:e12685. [PMID: 35308098 PMCID: PMC8918679 DOI: 10.1002/rth2.12685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/11/2022] [Accepted: 02/05/2022] [Indexed: 01/19/2023] Open
Abstract
Background florio HAEMO is a new hemophilia treatment monitoring application consisting of a patient smartphone application (app) and a web-based dashboard for healthcare professionals, providing several novel features, including activity tracking, wearable connectivity, kids and caregiver mode, and real-time pharmacokinetic factor level estimation. Objectives To assess intuitiveness, ease-of-use, and patient preference of florio HAEMO in Central Europe using a cross-sectional survey. Methods This survey was conducted in six Central European countries between 9 December 2020 and 24 May 2021. The online questionnaire included 17 questions about overall satisfaction, ease-of-use, intuitiveness, and patient preference. Adults or children with hemophilia on regular prophylaxis and using the florio HAEMO app for a minimum of 1 week were invited to complete the online questionnaire by their treating physician. Results Sixty-six participants took part in the survey. The median duration for all respondents using the florio HAEMO app was 3 to 4 weeks. Overall, 89.4% of users reported being very satisfied or rather satisfied after using florio HAEMO. Of the 23 respondents who had switched from another hemophilia app, 87.0% indicated that they strongly preferred or preferred using florio HAEMO. Most florio HAEMO users reported that the app was very easy or rather easy to use (97.0%) and intuitive (94.0%). florio HAEMO had a positive impact on daily living, with 78.8% of users reporting that the app was very important or rather important to them. Conclusions This survey suggests that florio HAEMO is an easy-to-use and intuitive app to assist self-management of home prophylaxis.
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Affiliation(s)
- Ester Zapotocka
- Department of Pediatric Hematology/OncologyUniversity Hospital Motol2nd Faculty of MedicineCharles UniversityPragueCzech Republic
| | - Angelika Batorova
- National Hemophilia CenterDepartment of Hematology and Transfusion MedicineFaculty of Medicine of Comenius University and University HospitalBratislavaSlovakia
| | - Ernest Bilic
- Department of PediatricsDivision of Hematology and OncologyUniversity Hospital Center ZagrebZagrebCroatia
| | - Ana Boban
- Division of HematologyDepartment of Internal MedicineUniversity Hospital Center ZagrebSchool of MedicineUniversity of ZagrebZagrebCroatia
| | | | - Barbara Faganel Kotnik
- Department of Hematology and OncologyUniversity Children's HospitalUniversity Medical Center LjubljanaLjubljanaSlovenia
| | | | - Pawel Laguna
- Department of Pediatrics, Hematology, and OncologyWarsaw Medical UniversityWarsawPoland
| | - Jan Machal
- Department of Pediatric Hematology and BiochemistryMasaryk University and University Hospital BrnoBrnoCzech Republic
| | - Laszlo Nemes
- Medical Center of Hungarian Defense ForcesBudapestHungary
| | - Irena Preloznik Zupan
- Department of HematologyUniversity Medical Center LjubljanaFaculty of MedicineUniversity of LjubljanaLjubljanaSlovenia
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5
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Titman AC, Wolfsegger MJ, Jaki TF. Recurrent events modelling of haemophilia bleeding events. J R Stat Soc Ser C Appl Stat 2021. [DOI: 10.1111/rssc.12462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Andrew C. Titman
- Department of Mathematics and Statistics Lancaster University Lancaster UK
| | | | - Thomas F. Jaki
- Department of Mathematics and Statistics Lancaster University Lancaster UK
- MRC Biostatistics Unit University of Cambridge Cambridge UK
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Assessing the Performance of Extended Half-Life Coagulation Factor VIII, FC Fusion Protein by Using Chromogenic and One-Stage Assays in Saudi Hemophilia A Patients. Adv Hematol 2020; 2020:8768074. [PMID: 32963537 PMCID: PMC7499282 DOI: 10.1155/2020/8768074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/25/2020] [Accepted: 07/15/2020] [Indexed: 11/19/2022] Open
Abstract
Background The one-stage assay is the most common method to measure factor VIII activity (FVIII : C) in hemophilia A patients. The chromogenic assay is another two-stage test involving purified coagulation factors followed by factor Xa-specific chromogenic substrate. Aim This study aimed to assess the discrepancy and correlation between the chromogenic and one-stage assays in measuring FVIII : C levels in hemophilia patients receiving Extended Half-Life Elocta® as a recombinant extended half-life coagulation factor. Methods We performed a study comparing the measurements of FVIII : C levels by the chromogenic versus the one-stage assays at different drug levels. Data of FVIII : C levels, dosage, and the time interval from administration to measurement were retrieved from the hospital records. The correlation, mean differences, and discrepancy between the two assays were calculated. The linear regression analysis was used to predict the time interval till reaching 1% FVIII : C. Results Fourteen patients with 56 samples were included in the study. Of them, 13 patients were receiving Elocta® as a prophylactic, while one was receiving Elocta® on demand. One-third of these samples showed a discrepancy between the chromogenic and one-stage assays. The two assays were well correlated. Mean differences were significant at the individual and the time interval level. The time since the last Elocta® injection could significantly predict FVIII : C levels (β = 0.366, P < 0.001). Conclusion Our findings suggested a significant difference between both methods; the FVIII : C levels measured by the one-stage assay were less than those estimated by the chromogenic assay. However, the measurements of FVIII levels by the two assays were well correlated but discrepant in one-third of the samples. The levels of FVIII : C reach 1% after 5.4 days since the last Elocta® administration.
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Centanni M, Friberg LE. Model-Based Biomarker Selection for Dose Individualization of Tyrosine-Kinase Inhibitors. Front Pharmacol 2020; 11:316. [PMID: 32226388 PMCID: PMC7080977 DOI: 10.3389/fphar.2020.00316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 03/03/2020] [Indexed: 11/17/2022] Open
Abstract
Tyrosine-kinase inhibitors (TKIs) demonstrate high inter-individual variability with respect to safety and efficacy and would therefore benefit from dose or schedule adjustments. This study investigated the efficacy, safety, and economical aspects of alternative dosing options for sunitinib in gastro-intestinal stromal tumors (GIST) and axitinib in metastatic renal cell carcinoma (mRCC). Dose individualization based on drug concentration, adverse effects, and sVEGFR-3 was explored using a modeling framework connecting pharmacokinetic and pharmacodynamic models, as well as overall survival. Model-based simulations were performed to investigate four different scenarios: (I) the predicted value of high-dose pulsatile schedules to improve clinical outcomes as compared to regular daily dosing, (II) the potential of biomarkers for dose individualizations, such as drug concentrations, toxicity measurements, and the biomarker sVEGFR-3, (III) the cost-effectiveness of biomarker-guided dose-individualizations, and (IV) model-based dosing approaches versus standard sample-based methods to guide dose adjustments in clinical practice. Simulations from the axitinib and sunitinib frameworks suggest that weekly or once every two weeks high-dosing result in lower overall survival in patients with mRCC and GIST, compared to continuous daily dosing. Moreover, sVEGFR-3 appears a safe and cost-effective biomarker to guide dose adjustments and improve overall survival (€36 784.- per QALY). Model-based estimations were for biomarkers in general found to correctly predict dose adjustments similar to or more accurately than single clinical measurements and might therefore guide dose adjustments. A simulation framework represents a rapid and resource saving method to explore various propositions for dose and schedule adjustments of TKIs, while accounting for complicating factors such as circulating biomarker dynamics and inter-or intra-individual variability.
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Affiliation(s)
- Maddalena Centanni
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Lena E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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Abrantes JA, Solms A, Garmann D, Nielsen EI, Jönsson S, Karlsson MO. Relationship between factor VIII activity, bleeds and individual characteristics in severe hemophilia A patients. Haematologica 2019; 105:1443-1453. [PMID: 31371418 PMCID: PMC7193498 DOI: 10.3324/haematol.2019.217133] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 07/23/2019] [Indexed: 01/19/2023] Open
Abstract
Pharmacokinetic-based prophylaxis of replacement factor VIII (FVIII) products has been encouraged in recent years, but the relationship between exposure (factor VIII activity) and response (bleeding frequency) remains unclear. The aim of this study was to characterize the relationship between FVIII dose, plasma FVIII activity, and bleeding patterns and individual characteristics in severe hemophilia A patients. Pooled pharmacokinetic and bleeding data during prophylactic treatment with BAY 81-8973 (octocog alfa) were obtained from the three LEOPOLD trials. The population pharmacokinetics of FVIII activity and longitudinal bleeding frequency, as well as bleeding severity, were described using non-linear mixed effects modeling in NONMEM. In total, 183 patients [median age 22 years (range, 1-61); weight 60 kg (11-124)] contributed with 1,535 plasma FVIII activity observations, 633 bleeds and 11 patient/study characteristics [median observation period 12 months (3.1-13.1)]. A parametric repeated time-to-categorical bleed model, guided by plasma FVIII activity from a 2-compartment population pharmacokinetic model, described the time to the occurrence of bleeds and their severity. Bleeding probability decreased with time of study, and a bleed was not found to affect the time of the next bleed. Several covariate effects were identified, including the bleeding history in the 12-month pre-study period increasing the bleeding hazard. However, unexplained inter-patient variability in the phenotypic bleeding pattern remained large (111%CV). Further studies to translate the model into a tool for dose individualization that considers the individual bleeding risk are required. Research was based on a post-hoc analysis of the LEOPOLD studies registered at clinicaltrials.gov identifiers: 01029340, 01233258 and 01311648.
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Affiliation(s)
- João A Abrantes
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | | | | | - Elisabet I Nielsen
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Siv Jönsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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