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Lévesque H, Guillet B, d'Oiron R, Benhamou Y. [Acquired haemophilia: Update in 2024]. Rev Med Interne 2024:S0248-8663(24)00666-0. [PMID: 39245591 DOI: 10.1016/j.revmed.2024.06.005] [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: 03/07/2024] [Revised: 06/05/2024] [Accepted: 06/13/2024] [Indexed: 09/10/2024]
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune disorder due to autoantibodies against factor VIII, with a high mortality risk. It should be suspected in subjects with abnormal bleedings, especially subcutaneous bleed associated with prolonged activated partial thromboplastin time (aPTT). AHA is often idiopathic but is associated with autoimmune diseases, malignancies, pregnancy and postpartum period or drugs. Treatment is based on haemostatic agents as by-passants agents such as factor VIIa and activated prothrombine concentrate complex or recombinant porcine factor VIII for severe bleeding. Eradication of inhibitor should be established as soon as the diagnosis is confirmed with steroid alone often associated with cytotoxic agents or rituximab, depending on FVIII activity and inhibitor titer. The purpose of this review is to summarize the epidemiology, etiopathogenesis, diagnosis, treatment of AHA and discuss current recommendations.
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Affiliation(s)
- Hervé Lévesque
- Service de médecine interne, CHU de Rouen, Normandie université, UNIROUEN, U 1096, 1, rue de Germont, 76000 Rouen, France.
| | - Benoit Guillet
- Centre de référence de l'hémophilie et des maladies hémorragiques, constitutionnelles, CHU de Rennes, Rennes, France; EHESP, Institut de recherche en santé, environnement et travail (IRSET) - UMR-S 1085, CHU de Rennes, université de Rennes, Inserm, 35000 Rennes, France
| | - Roseline d'Oiron
- Centre de référence de l'hémophilie et des maladies hémorragiques, constitutionnelles, hôpital Bicêtre, AP-HP, HITh, UMR-S1176, Inserm, université Paris Saclay, Le Kremlin-Bicêtre, Paris, France
| | - Ygal Benhamou
- Service de médecine interne, CHU de Rouen, Normandie université, UNIROUEN, U 1096, 1, rue de Germont, 76000 Rouen, France
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Franchini M, Focosi D, Mannucci PM. Tranexamic Acid: An Evergreen Hemostatic Agent. Semin Thromb Hemost 2024; 50:733-738. [PMID: 38335995 DOI: 10.1055/s-0044-1779632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
Tranexamic acid (TXA) is an important antifibrinolytic agent, which inhibits plasminogen activation and fibrinolysis. Several controlled randomized trials have investigated the role of TXA in preventing or decreasing blood loss across different surgical interventions or medical conditions characterized by excessive bleeding, consistently documenting its effectiveness and safety. Although the first clinical use of TXA dates back to more than 60 years ago, TXA remains the focus of intense research. This narrative review summarizes the more recent results and indications on the clinical use of TXA.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantua, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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3
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Ianuà E, Caldarelli M, De Matteis G, Cianci R, Gambassi G. Hematological Complications in a COVID-19 Patient: A Case Report. Diseases 2023; 12:5. [PMID: 38248356 PMCID: PMC10814038 DOI: 10.3390/diseases12010005] [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: 11/24/2023] [Revised: 12/18/2023] [Accepted: 12/22/2023] [Indexed: 01/23/2024] Open
Abstract
Hemophilia A is a hemorrhagic disorder caused by insufficient or inadequate coagulation factor VIII activity. Two different forms are described: congenital, hereditary X-linked, and acquired. Acquired hemophilia A (AHA) is a rare condition and it is defined by the production of autoantibodies neutralizing factor VIII, known as inhibitors. We report the case of a 72-year-old man with a clinical diagnosis of AHA after SARS-CoV-2 infection, which has been described in association with several hematological complications. SARS-CoV-2 infection could represent the immunological trigger for the development of autoantibodies. In our patient, SARS-CoV-2 infection preceded the hemorrhagic complications by 15 days. This lag time is in line with the other cases reported and compatible with the development of an intense immune response with autoantibody production. It is possible that since our patient was affected by type 1 diabetes mellitus, he was more prone to an immune system pathological response against self-antigens. A prompt, appropriate therapeutic intervention with activated recombinant factor VII administration and cyclophosphamide has led to rapid remission of clinical and laboratory findings.
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Affiliation(s)
| | | | | | - Rossella Cianci
- Department of Translational Medicine and Surgery, Catholic University, Fondazione Policlinico Universitario “Agostino Gemelli”, IRCCS, 00168 Rome, Italy; (E.I.); (M.C.); (G.D.M.); (G.G.)
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4
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Acquired Hemophilia A: An Update on the Etiopathogenesis, Diagnosis, and Treatment. Diagnostics (Basel) 2023; 13:diagnostics13030420. [PMID: 36766524 PMCID: PMC9914651 DOI: 10.3390/diagnostics13030420] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/10/2023] [Accepted: 01/20/2023] [Indexed: 01/25/2023] Open
Abstract
Acquired haemophilia A (AHA) is a rare bleeding disorder caused by inhibitory autoantibodies against coagulation factor VIII (FVIII). AHA is a disease that most commonly affects the elderly but has also been observed in children and in the postpartum period. AHA is idiopathic in 50% of cases and is associated with autoimmune diseases, malignancies, and infections in the remaining 50%. Recently, cases of association between AHA, COVID-19 vaccination, and infection have been reported in the literature. For diagnoses, determining FVIII levels is crucial to distinguish the different causes of aPTT prolongation. Treatment of AHA is based on bypassing agents (recombinant factor VIIa, activated prothrombin complex concentrate) and porcine FVIII to control the bleeding and immunosuppressive therapy (corticosteroids, rituximab, cyclophosphamide) to suppress autoantibody production. It is important to start a prophylactic regimen to prevent further bleeding episodes until the inhibitor is negative. Recently, the series of cases reported in the literature suggest that emicizumab may provide effective and safe haemorrhage prophylaxis in the outpatient setting.
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Lindahl R, Nummi V, Lehtinen A, Szanto T, Hiltunen L, Olsson A, Glenthoej A, Chaireti R, Vaide I, Funding E, Zetterberg E. Acquired Haemophilia A in four north European countries: survey of 181 patients. Br J Haematol 2022; 201:326-333. [PMID: 36541135 DOI: 10.1111/bjh.18611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
Acquired haemophilia A (AHA) is a rare bleeding disorder caused by acquired antibodies against coagulation factor VIII. In the Nordic countries, treatment and outcomes have not been studied in recent times. To collect retrospective data on patients diagnosed with AHA in the Nordic countries between 2006 and 2018 and compare demographic data and clinical outcomes with previously published reports, data were collected by six haemophilia centres: three Swedish, one Finnish, one Danish and one Estonian. The study included 181 patients. Median age at diagnosis was 76 (range 5-99) years, with even gender distribution. Type and severity of bleeding was comparable to that in the large European Acquired Haemophilia Registry study (EACH2). Bleedings were primarily treated with activated prothrombin complex concentrate (aPCC) with a high success rate (91%). For immunosuppressive therapy, corticosteroid monotherapy was used most frequently and this may be the cause of the overall lower clinical remission rate compared to the EACH2 study (57% vs. 72%). Survey data on 181 patients collected from four north European countries showed similar demographic and clinical features as in previous studies on AHA. aPCC was used more frequently than in the EACH2 study and the overall remission rate was lower.
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Affiliation(s)
- Rickard Lindahl
- Department of Haematology, Oncology and Radiation Physics, Coagulation Unit Skåne University Hospital Malmö and Lund University Lund Sweden
| | - Vuokko Nummi
- Coagulation Disorders Unit, Department of Haematology Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University Helsinki Finland
| | - Anna‐Elina Lehtinen
- Coagulation Disorders Unit, Department of Haematology Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University Helsinki Finland
| | - Timea Szanto
- Coagulation Disorders Unit, Department of Haematology Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University Helsinki Finland
| | - Leena Hiltunen
- Department of Haemostasis Finnish Red Cross Blood Service Helsinki Finland
| | - Anna Olsson
- Department of Medicine Region Västra Götaland, Sahlgrenska University Hospital Gothenburg Sweden
| | - Andreas Glenthoej
- Department of Haematology Rigshospitalet Copenhagen Denmark
- Department of Clinical Medicine Copenhagen University Copenhagen Denmark
| | - Roza Chaireti
- Department of Haematology Karolinska University Hospital Stockholm Sweden
| | - Ines Vaide
- Department of Haematology and Oncology Institute of Clinical Medicine, University of Tartu Tartu Estonia
| | - Eva Funding
- Department of Haematology Rigshospitalet Copenhagen Denmark
- Department of Clinical Medicine Copenhagen University Copenhagen Denmark
| | - Eva Zetterberg
- Department of Haematology, Oncology and Radiation Physics, Coagulation Unit Skåne University Hospital Malmö and Lund University Lund Sweden
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Mingot-Castellano ME, García Candel F, Benítez Hidalgo O, Marco A, Navarro GAM, Pérez-Montes R, Donas GG, Canaro M, Paloma MJ, Asenjo B, Calle-Gordo VM, González NP, González RR, Caparrón Miranda IS, París LQ, Herrero S, Nuñez R. Activated Prothrombin Complex Concentrate to Treat Bleeding Events in Acquired Hemophilia A: Bahas Study. Eur J Haematol 2022; 109:686-695. [PMID: 36029160 DOI: 10.1111/ejh.13853] [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: 06/05/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Activated prothrombin complex concentrate (aPCC) is a bypassing agent indicated to treat bleeds in patients with acquired hemophilia A (AHA). Nevertheless, its efficacy and safety in the real-world setting has not often been addressed. METHODS We report the experience of Spanish reference centers for coagulation disorders and from acquired haemophilia Spanish Registry (AHASR), from August 2012 to February 2021. Follow-up period of 30 days after aPCC withdrawal. RESULTS Thirty patients with a median age of 70 years old, suffering from 51 bleeds treated with aPCC were finally evaluated. As first line treatment, aPCC stopped bleed in 13 of 14 (92.9%) cases. aPCC as second line after recombinant factor VIIa failure, stopped bleeding in the all cases. In 17 patients aPCC was used far from initial bleed control as prophylaxis of rebleeding with 94% effectiveness. No thromboembolic episodes was communicated. One patient developed hypofibrinogenemia, which did not prevent aPCC from halting bleeding. No other serious adverse events possibly or probably associated with aPCC were reported. CONCLUSIONS this data support aPCC as haemostatic treatment in AHA with high effectiveness and excellent safety profile in acute bleeds and as extended use to prevent rebleedings, even in anging people with high cardiovascular risk. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- María Eva Mingot-Castellano
- Hematology Department, Hospital Universitario Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain.,Hematology Department, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | | | - Ana Marco
- Hematology Department, Hospital General de Alicante4, Alicante, Spain
| | | | | | - Gloria García Donas
- Hematology Department, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Mariana Canaro
- Hematology Department, Hospital Son Espases, Palma de Mallorca, Spain
| | - María José Paloma
- Hematology Department, Hospital Universitario Virgen del Camino, Pamplona, Spain
| | - Beatríz Asenjo
- Hematology Department, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | | | | | | | - Laura Quintana París
- Hematology Department, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Sonia Herrero
- Hematology Department, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Ramiro Nuñez
- Hematology Department, Hospital Universitario Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
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Novembrino C, Quaglia I, Molinari AC, Borchiellini A, Coppola A, Santoro RC, Boscolo-Anzoletti M, Galbiati E, Zanon E, Valpreda A. Analytical Performance of Different Laboratory Methods for Measuring Susoctocog-Alfa. Diagnostics (Basel) 2022; 12:diagnostics12081999. [PMID: 36010349 PMCID: PMC9407080 DOI: 10.3390/diagnostics12081999] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/14/2022] [Accepted: 08/16/2022] [Indexed: 11/29/2022] Open
Abstract
Recombinant porcine factor VIII (rpFVIII) is indicated for treating bleeding episodes in acquired haemophilia A, but there are few data regarding laboratory methods to adequately monitor treatment. This study involving three Italian laboratories aimed to evaluate the analytical performance of different assays for measuring rpFVIII. Five spiked rpFVIII samples (0.5–1.5 IU/mL) were analysed on three days, in triplicate, with eleven combinations of reagents (Werfen, Boston, MA, USA: SynthasIL and SynthaFax for one-stage assay, Chromogenix Coamatic FVIII for chromogenic assay), FVIII depleted plasmas (with or without von Willebrand factor—VWF) and calibrators (HemosIL human calibrator plasma, porcine calibrator diluted in FVIII deficient plasma with or without VWF). The assays were performed on ACL TOP analysers (Werfen, Boston, MA, USA). Intra- and inter-assay and inter-laboratory Coefficient of Variation (CV%) were calculated together with percentage of recovery (% recovery) on the expected value. The results showed that the reagent combinations reaching satisfactory analytical performance are: SynthasIL/human calibrator/deficient plasma+VWF (total recovery 99.4%, inter-laboratory CV 4.04%), SynthasIL/porcine calibrator/deficient plasma+VWF (total recovery 111%, inter-laboratory CV 2.75%) and Chromogenic/ porcine calibrator/deficient plasma+VWF (total recovery 96.6%, inter-laboratory CV 8.32%). This study highlights that the use of porcine standard (when available) and FVIII deficient plasma with VWF should be recommended.
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Affiliation(s)
- Cristina Novembrino
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
- Correspondence:
| | - Ilaria Quaglia
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital Rozzano, 20089 Milan, Italy
| | - Angelo Claudio Molinari
- Regional Reference Center for Inherited Bleeding Disorders, Istituto Giannina Gaslini, 16147 Genova, Italy
| | - Alessandra Borchiellini
- Regional Reference Center of Thrombotic and Hemorrhagic Disorders of the Adults, Department of Oncology and Hematology “Città della Salute e della Scienza”, 10100 Turin, Italy
| | - Antonio Coppola
- Regional Reference Center for Inherited Bleeding Disorders, University Hospital of Parma, 43125 Parma, Italy
| | - Rita Carlotta Santoro
- Hemostasis and Thrombosis Unit, Regional Reference Centre for Hemophilia, and Inherited Bleeding Disorders, AOPC, 88100 Catanzaro, Italy
| | - Massimo Boscolo-Anzoletti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
| | - Eleonora Galbiati
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
| | - Ezio Zanon
- Haemophilia Centre-General Medicine, Padua University Hospital, 35128 Padua, Italy
| | - Alessandra Valpreda
- Regional Reference Center of Thrombotic and Hemorrhagic Disorders of the Adults, Laboratory Department “Città della Salute e della Scienza”, 10100 Turin, Italy
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Zanon E, Pasca S, Spiezia L, Poletto F, Gherardi S, Simioni P. Acquired haemophilia A, concomitant acute myocardial infarction and urgent major surgery: How to successfully treat a critical patient with rpFVIII (Obizur®). Thromb Res 2020; 195:125-127. [PMID: 32683151 DOI: 10.1016/j.thromres.2020.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 07/06/2020] [Indexed: 01/19/2023]
Abstract
Association of acute myocardial infarction (AMI) and acquired haemophilia A (AHA) is extremely rare, and very difficult to treat, if the patient then presents several serious comorbidities and must undergo an urgent major surgery, the correct choice of haemostatic therapy is essential to avoid potentially life-threatening adverse events for the patient. The recombinant porcine FVIII (rpFVIII) is considered, together with the bypassing agents, as first-line therapy for the AHA, but compared to these it presents a reduced thromboembolic risk which makes it safer in patients who already present at the onset of haemorrhagic event an underlying cardiovascular disease. Haemorrhagic and thrombotic events are always to be taken into consideration in the case of surgery, but in the case of patients with concomitant acquired haemophilia the risk of having serious bleeding has further increase. Today there have been no reports of surgeries carried out under Obizur® coverage. We are reporting the successful case of an elderly critical patient with acquired haemophilia A and concomitant myocardial infarction, treated with rpFVIII and in which an urgent major surgery under coverage of this dug was performed for the first time.
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Affiliation(s)
- Ezio Zanon
- Haemophilia Centre, Department of Medicine, University Hospital of Padua, Italy.
| | - Samantha Pasca
- Haemophilia Centre, Department of Medicine, University Hospital of Padua, Italy
| | - Luca Spiezia
- Centre for Haemorrhagic and Thrombotic Diseases, Department of Medicine, University Hospital of Padua, Italy
| | - Francesco Poletto
- Centre for Haemorrhagic and Thrombotic Diseases, Department of Medicine, University Hospital of Padua, Italy
| | - Simone Gherardi
- Centre for Haemorrhagic and Thrombotic Diseases, Department of Medicine, University Hospital of Padua, Italy
| | - Paolo Simioni
- Centre for Haemorrhagic and Thrombotic Diseases, Department of Medicine, University Hospital of Padua, Italy
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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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Susoctocog-alfa (Obizur ®) in the treatment of nine elderly patients with acquired haemophilia A: an Italian multicentre real world experience. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:312-321. [PMID: 32698943 DOI: 10.2450/2020.00006-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 03/19/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND In 2016, a new recombinant B-domain deleted porcine FVIII (rpFVIII) was licensed in Italy for the treatment of acquired haemophilia A (AHA), but only a few cases of patients receiving this have been reported in the literature. Here we report the largest registry of the use of rpFVIII for the treatment of AHA. The objective of this retrospective study was to describe the efficacy and the safety of susoctocog-alfa for AHA. MATERIAL AND METHODS We studied a population of nine patients, recruited in five Italian haemophilia centres presenting AHA, and treated with Obizur® as first- or second-line therapy. RESULTS rpFVIII was used as a first-line therapy in one-third of the patients. The median delay between clinical onset and diagnosis was 16 days. Initial bolus of infused susoctocog-alfa was 100 IU/kg, lower than the recommended dose. The treatment was maintained for a median of four days. Only one patient with serious co-morbidities and recurrent infections was treated for 32 days. All patients reached a complete resolution of AHA, and no recurrences were reported. Two patients developed a low-titre inhibitor against rpFVIII, neither experienced any complications. DISCUSSION In our real world experience, susoctocog-alfa was proven to be an effective and safe therapeutic option for patients with AHA, also at a lower than recommended dosage. In our report, the appearance of low-titre inhibitors against rpFVIII, was not found to be clinically significant.
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