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Yao W, Ai D, Zhang Q, Li X, Zhou M, Zhang N, Yang S, Chen Z, Zhen Y, Luke KH, Wu R. A long term outcomes analysis of severe haemophilia A boys receiving 4 years prophylaxis on the Chinese Haemophilia Individualized escalating low dose Prophylaxis (CHIPS). Thromb Res 2024; 241:109110. [PMID: 39116483 DOI: 10.1016/j.thromres.2024.109110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 07/28/2024] [Accepted: 07/30/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND The Chinese Haemophilia Individualized Prophylaxis Study (CHIPS), which was launched in 2016, reported a significant reduction in haemarthrosis over a one-year study. However, its long-term efficacy requires verification. This paper summarizes the clinical outcomes of 18 severe haemophilia A (SHA) patients who completed one year on the CHIPS and 3 more years of follow-up. METHODS Clinical follow-up was based on the CHIPS protocol (from July 2018 to July 2021). Escalation was based on index joint bleeding, and serial ultrasound (greyscale and colour Doppler) examinations of the index joints (both sides of the ankles, knees and elbows) were conducted every 6 months via a scoring system. RESULTS A total of 18 SHA patients completed the 3-year study. Fifteen patients dropped out due to the financial crisis during the COVID-19 pandemic in China. The median age was 5.4 (range 4.3-6.9) years. A significant reduction in haemarthrosis was achieved, with mean annual bleeding rates reduced from 18.9 ± 2.8 to 1.7 ± 0.4 (p < 0.001), annual joint bleeding rates from 3.1 ± 0.7 to1.2 ± 0.3 (p < 0.028). 5 out of 8 target joint resolved. Sixteen doses were escalated. At study exit, the heterogeneous treatment outcomes of the SHA boys were 5 at step 4 (20-25 lU/kg, every other day), 10 at step 3 (15-20 IU/kg, 3×/week), 2 at step 2 (10-15 lU/kg, 3×/week) and 1 at step 1 (10-15 lU/kg, 2×/week). The mean FVIII consumption was 2964 IU/kg/year, with savings. The quality of life improved, with Canadian Haemophilia Outcomes-Kids Life Assessment Tool (CHO-KLAT, Chinese Version 2.0) scores ranging from 68.8 to 78.8. There was no change in the ultrasound score. CONCLUSION Our follow-up data on the 18 SHA boys after completing one year on the CHIPS verify the long-term efficacy of the CHIPS for haemarthrosis reduction, joint health preservation, improvement in the quality of life of the boys and cost savings.
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Affiliation(s)
- Wanru Yao
- Hematology Department, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Di Ai
- Hematology Department, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Qing Zhang
- Haemophilia Diagnosis and Treatment Center, Department of Hematology and Oncology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaojing Li
- Haemophilia Treatment Center, Department of Pediatrics, New Century Women's and Children's Hospital, Chengdu, China
| | - Min Zhou
- Haemophilia Diagnosis and Treatment Center, Department of Hematology and Oncology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Ningning Zhang
- Department of Radiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Sheng Yang
- Department of Ultrasound, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Zhenping Chen
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yingzi Zhen
- Hematology Department, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China
| | - Koon-Hung Luke
- Department of Pediatrics, Laboratory Medicine and Pathology, Division of Hematology and Oncology, University of Ottawa, Children Hospital of Eastern Ontario, Ottawa, ON, Canada.
| | - Runhui Wu
- Hematology Department, Beijing Key Laboratory of Pediatric Hematology Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, China.
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Maneekhiew S, Kovitwanawong N, Raweekul S, Kijkunasathian C, Panuwannakorn M, Uampornvanich P, Chuansumrit A, Wongwerawattanakoon P, Sirachainan N. Comparison between natural rubber knee support and sponge knee support on the protection of knee joint: A crossover randomized controlled study among patients with bleeding disorders. Health Sci Rep 2024; 7:e2003. [PMID: 38567187 PMCID: PMC10985220 DOI: 10.1002/hsr2.2003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/01/2024] [Indexed: 04/04/2024] Open
Abstract
Background and Aims Knee support, frequently made from sponge, is used to reduce injury. Sponge has less elasticity and durability compared with natural rubber. To our knowledge, there was no study that demonstrated the effectiveness of natural rubber and sponge in prevention of injury in children with bleeding disorders. The study aimed to demonstrate the effectiveness and satisfaction of natural rubber knee support compared with sponge knee support among children with bleeding disorders. Methods The study consisted of three phases: (I) measuring reduced compression force, (II) producing size-appropriate knee support prototypes, and (III) conducting a randomized crossover trial, including 8 weeks wearing natural rubber knee support and sponge knee support with a 4-week wash-out period. The number of knee bleeds and user satisfaction were recorded. Results A better compression force reduction in natural rubber (60%) than sponge (12%) was demonstrated. Knee support comprised a body part, made from natural-stretchable cotton and a protection part, made from either natural rubber or sponge. They were produced in four sizes: S, M, L, and XL and appropriately applied to 42 patients (21 hemophilia, 21 platelet disorders) with a mean (SD) age of 7.0 (2.9) years. The results from randomization showed no significant difference in the number of knee bleeds between the two knee support groups (10 vs. 7, p = 0.37). In terms of satisfaction score, the natural rubber knee supports were more durable (45.2% vs. 23.8%, p = 0.04) and easier to use (28.5% vs. 14.3%, p = 0.03). In addition, a higher percentage of parents chose natural rubber knee support when compared with sponge knee supports (71.0% vs. 29.0%, p = 0.006). Conclusion Natural rubber knee support showed comparable effectiveness in the prevention of knee bleeding but was superior to sponge knee support in compression force reduction and satisfaction.
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Affiliation(s)
- Supicha Maneekhiew
- Department of Pediatrics, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Nalinee Kovitwanawong
- Department of Anesthesiology, Faculty of MedicinePrince of Songkla UniversitySongkhlaThailand
| | - Sakrawee Raweekul
- Faculty of Engineering, Rajamangala University of Technology IsanKhon Kaen CampusKhon KaenThailand
| | - Chusak Kijkunasathian
- Department of Orthopedics, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - Monratta Panuwannakorn
- Department of Rehabilitation Medicine, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | | | - Ampaiwan Chuansumrit
- Department of Pediatrics, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | | | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
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Chuansumrit A, Ruchutrakul T, Sirachainan N, Kitpoka P, Panuwannakorn M, Panburana P, Suwannuraks M, Sri-Udomporn N, Kijkunasathian C, Jaovisidha S, Utamakul C, Natesirinilkul R, Pongtanakul B, Traivaree C, Komvilaisak P, Suwantaroj E, Sosothikul D, Angchaisuksiri P, Rojnuckarin P. National strategic advocacy to manage patients with inherited bleeding disorders in low and lower-middle income countries. Expert Rev Hematol 2023; 16:1063-1076. [PMID: 38100503 DOI: 10.1080/17474086.2023.2293092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023]
Abstract
INTRODUCTION Inherited bleeding disorders (IBDs) including hemophilia, von Willebrand disease, platelet disorders, mucocutaneous bleeding disorders and coagulation factor deficiencies are rarely found and under-recognized in low and lower-middle-income countries. Some patients succumbed to serious bleeding without diagnosis and treatment during childhood. AREA COVERED Diagnosis, management, and prevention should be integrated into the existing health care system. Although some countries have not implemented appropriate health care infrastructure, an initiative plan should be set up by cooperation of experienced experts and health care providers. Identification of patients with IBDs should be started in the antenatal setting to search for females at risk of carrier state. The investigations include bleeding assessment, mixing venous clotting time, coagulogram, coagulation factor assay and mutation detection. Genotypic analysis is helpful for confirming the definite diagnosis, carrier detection as well as prenatal diagnosis for females at risk of bearing an offspring with severe bleeding manifestations. Management involves replacement therapy ranging from blood component to virus-inactivated factor concentrate. Appropriate research is an essential backbone for improving patients' care. EXPERT OPINION Effective national strategic advocacy to manage patients with IBDs requires intensive collaboration among policy makers, health care providers, patients, and family members.
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Affiliation(s)
- Ampaiwan Chuansumrit
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Theera Ruchutrakul
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pimpun Kitpoka
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Monratta Panuwannakorn
- Department of Rehabilitation Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Panyu Panburana
- Department of Obstetrics-Gynecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Monthon Suwannuraks
- Dental Division, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nantana Sri-Udomporn
- Dental Division, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chusak Kijkunasathian
- Department of Orthopedics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suphaneewan Jaovisidha
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chirawat Utamakul
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Bunchoo Pongtanakul
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanchai Traivaree
- Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Patcharee Komvilaisak
- Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | | | - Darintr Sosothikul
- Department of Pediatrics and Integrative and Innovative Hematology/Oncology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pantep Angchaisuksiri
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ponlapat Rojnuckarin
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Mathews N, Pluthero FG, Rand ML, Stain AM, Carcao M, Blanchette VS, Kahr WHA. Thromboelastography and thrombin generation assessments for pediatric severe hemophilia A patients are highly variable and not predictive of clinical phenotypes. Res Pract Thromb Haemost 2022; 6:e12800. [PMID: 36186102 PMCID: PMC9511091 DOI: 10.1002/rth2.12800] [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: 02/14/2022] [Revised: 07/02/2022] [Accepted: 07/23/2022] [Indexed: 11/24/2022] Open
Abstract
Background Severe hemophilia A (SHA) patients vary in severity of bleeding, arthropathy, and requirements for replacement factor VIII (FVIII). Baseline hemostatic activity assays using calibrated automated thrombography (CAT) and thromboelastography (TEG) may offer insights into the physiological basis of clinical heterogeneity. Objectives Use CAT and TEG to measure baseline hemostatic activity in a cohort of 30 pediatric SHA patients with available clinical data. Determine effect of contact activation inhibition with corn trypsin inhibitor (CTI). Assess heterogeneity among patients for baseline hemostatic activity and examine correlations between assay results and clinical parameters including FVIII dosing regimen, von Willebrand factor level, and Pettersson arthropathy score. Methods SHA blood after FVIII washout was subjected to TEG, and platelet‐rich (PRP) and platelet‐poor plasma was used for CAT assays. Varying concentrations of tissue factor (TF) were used. Statistical analysis examined relationships between assay results, and clinical parameters. Results CTI treatment was required to obtain TEG and CAT results representative of baseline hemostatic activity. Weak activity was observed in assays with low TF concentrations (0.5–2 pM), and most but not all samples approached normal activity levels at high TF concentrations (10–20 pM). A significant positive correlation was observed between results of TEG and CAT‐PRP assays. Correlations were not detected between hemostatic assay results and clinical parameters. Conclusions In vitro hemostatic assay results of samples containing platelets showed concordance. Assay results were not predictive of FVIII requirements or correlated with other clinical parameters. SHA patient heterogeneity is influenced by factors other than baseline hemostatic activity.
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Affiliation(s)
- Natalie Mathews
- Division of Haematology/Oncology Hospital for Sick Children Toronto Ontario Canada
| | - Fred G Pluthero
- Cell Biology Program Research Institute, Hospital for Sick Children Toronto Ontario Canada
| | - Margaret L Rand
- Division of Haematology/Oncology Hospital for Sick Children Toronto Ontario Canada.,Translational Medicine Program Hospital for Sick Children Toronto Ontario Canada.,Departments of Laboratory Medicine & Pathobiology Biochemistry, and Pediatrics, University of Toronto Toronto Ontario Canada
| | - Ann Marie Stain
- Division of Haematology/Oncology Hospital for Sick Children Toronto Ontario Canada
| | - Manuel Carcao
- Division of Haematology/Oncology Hospital for Sick Children Toronto Ontario Canada.,Department of Pediatrics University of Toronto Toronto Ontario Canada
| | - Victor S Blanchette
- Division of Haematology/Oncology Hospital for Sick Children Toronto Ontario Canada.,Department of Pediatrics University of Toronto Toronto Ontario Canada
| | - Walter H A Kahr
- Division of Haematology/Oncology Hospital for Sick Children Toronto Ontario Canada.,Cell Biology Program Research Institute, Hospital for Sick Children Toronto Ontario Canada.,Departments of Pediatrics and Biochemistry University of Toronto Toronto Ontario Canada
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Carcao M, Gouider E, Wu R. Low dose prophylaxis and antifibrinolytics: Options to consider with proven benefits for persons with haemophilia. Haemophilia 2022; 28 Suppl 4:26-34. [PMID: 35521737 DOI: 10.1111/hae.14552] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Prophylaxis has become standard of care for persons with severe phenotype haemophilia (PWsH). However, 'standard prophylaxis' with either factor or non-factor therapies (emicizumab) is prohibitively expensive for much of the world. We sought to evaluate whether haemophilia care can be provided at a lower cost yet achieve good results using Lower dose/Lower frequency prophylaxis (LDP) and with increasing use of antifibrinolytics (Tranexamic acid and Epsilon amino caproic acid). METHODS We identified 12 studies that collectively included 335 PWsH using LDP. Additionally, we undertook a literature search regarding the benefits of antifibrinolytics in haemophilia care. RESULTS Identified studies show that LDP is far superior to no prophylaxis (On demand [OD] therapy) resulting in significant patient benefits. Patients on LDP showed (in comparison to patients OD) on average: 72% less total bleeds; 75% less joint bleeds; 91% less days lost from school; 77% less hospital admission days; and improved quality of life measures. These benefits come at similar or only slightly higher (< 2-fold greater) costs than OD therapy. Antifibrinolytics are effective adjunctive agents in managing bleeds (oral, nasal, intracranial, possibly other) and providing haemostasis for surgeries (particularly oral surgeries). Antifibrinolytics can substitute for more expensive factor concentrates or can reduce the use of such concentrates. There is evidence to show that antifibrinolytics may be used in conjunction with factor concentrates/emicizumab for more effective/less costly prophylaxis. CONCLUSIONS The use of LDP along with appropriate and increased use of antifibrinolytics offers less resourced countries good options for managing patients with haemophilia.
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Affiliation(s)
- Manuel Carcao
- Haemophilia Clinic and Haemostasis Program, Division of Haematology/Oncology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Emna Gouider
- Hemophilia Treatment Centre, Aziza Othmana Hospital, University Tunis El Manar, Tunis, Tunisia
| | - Runhui Wu
- Haemophilia Comprehensive Care Centre, Haematology Centre, Beijing Children's Hospital, National Centre for Children's Health, Capital Medical University, Beijing, China
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Shetty S, Bansal S, Kshirsagar S, Rangarajan S, Hajirnis K, Phadke V. Low-dose prophylaxis and its impact on the health of haemophilia patients. Vox Sang 2022; 117:900-912. [PMID: 35437811 DOI: 10.1111/vox.13278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES There is convincing evidence to show that low-dose prophylaxis (LDP) results in reduction in annualized bleeding rate (ABR) and better health-related quality of life (HRQoL) compared with on-demand or episodic treatment (ET) in haemophilia patients. The aim is to review various LDP protocols practised for the treatment of haemophilia, specifically in resource-limited countries. METHODS A literature survey was made of articles published in English language in PubMed and EMBASE without any time limit using keywords 'low dose', 'prophylaxis' and 'haemophilia' in different combinations. RESULTS A total of 19 reports involving LDP in patients with haemophilia were included in this review. Almost all studies reported reduction in ABR, improvement in joint function, pain and HRQoL compared with ET, but this did not fully translate into significant improvement in structural arthropathy already caused by earlier bleeds, suggesting that LDP may be less or ineffective in either stopping or reversing the damage. Individualized dose escalation protocols based on pharmacokinetic (PK) or clinical parameters were found to be superior to fixed LDP protocols and cost-effective compared with standard dose protocols. CONCLUSION The developing countries can initiate LDP as the first step of prophylaxis, but certainly this should not be the final goal of the health care system in any country. Due to the complex pathophysiological mechanisms underlying haemophilic arthropathy, long-term data on LDP in haemophilia patients are warranted.
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Affiliation(s)
- Shrimati Shetty
- K.J. Somaiya Hospital & Research Centre, Somaiya Ayurvihar, Mumbai, India
| | - Shweta Bansal
- K.J. Somaiya Hospital & Research Centre, Somaiya Ayurvihar, Mumbai, India
| | | | - Savita Rangarajan
- K.J. Somaiya Hospital & Research Centre, Somaiya Ayurvihar, Mumbai, India
| | - Kalpana Hajirnis
- K.J. Somaiya Hospital & Research Centre, Somaiya Ayurvihar, Mumbai, India
| | - Varsha Phadke
- K.J. Somaiya Hospital & Research Centre, Somaiya Ayurvihar, Mumbai, India
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