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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: 11] [Impact Index Per Article: 2.8] [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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Boulassel MR, Al-Ghonimi M, Al-Balushi B, Al-Naamani A, Al-Qarni Z, Wali Y, Elshinawy M, Al-Shezawi M, Khan H, Nazir H, Khater D, Pathare A, Al-Kindi S. Regulatory B Cells Are Functionally Impaired in Patients Having Hemophilia A With Inhibitors. Clin Appl Thromb Hemost 2017; 24:618-624. [PMID: 28393618 DOI: 10.1177/1076029617702244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Development of inhibitors remains a major clinical complication in patients with hemophilia A receiving replacement therapy with factor VIII (FVIII). Understanding the immune mechanisms involved in the development of inhibitors can provide valuable information about pathways to human tolerance. Recent evidence indicates that B regulatory (Breg) cells play a pivotal role in controlling the production of antibodies (Abs) while promoting follicular T helper (Tfh) cells and monocytes, expressing the low-density lipoprotein receptor-related protein (LRP/CD91), which is involved in FVIII intake from the circulation. We studied circulating levels of Breg cells along with Tfh cells and the expression of LRP/CD91 on monocytes in patients with hemophilia A using 8-color flow cytometry and cell culture. Compared to healthy controls, patients with hemophilia A with inhibitors showed a severe reduction in levels of Breg cells and produced less interleukin-10 when activated via the CD40 signaling pathway. In addition, patients with hemophilia A with inhibitors exhibited an overexpression of LPR/CD91 on monocytes and normal levels of Tfh cells. Levels of Breg cells were not significantly related to LPR/CD91 although negative associations were evidenced. Collectively, these results provide new insights into the role of Breg cells and LPR/CD91 in the development of inhibitors in patients with hemophilia A.
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Affiliation(s)
- Mohamed-Rachid Boulassel
- 1 Department of Allied Health Sciences, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman.,2 Department of Haematology, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
| | - Maryam Al-Ghonimi
- 1 Department of Allied Health Sciences, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Badriya Al-Balushi
- 2 Department of Haematology, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
| | - Amal Al-Naamani
- 1 Department of Allied Health Sciences, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Zahra Al-Qarni
- 1 Department of Allied Health Sciences, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Yasser Wali
- 3 Department of Child Health, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman.,4 Faculty of Medicine, Pediatric Department, Alexandria University, Alexandria Governorate, Egypt
| | - Mohamed Elshinawy
- 3 Department of Child Health, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman.,4 Faculty of Medicine, Pediatric Department, Alexandria University, Alexandria Governorate, Egypt
| | - Maryam Al-Shezawi
- 3 Department of Child Health, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
| | - Hamad Khan
- 2 Department of Haematology, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
| | - Hanan Nazir
- 3 Department of Child Health, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman.,4 Faculty of Medicine, Pediatric Department, Alexandria University, Alexandria Governorate, Egypt
| | - Doaa Khater
- 3 Department of Child Health, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman.,4 Faculty of Medicine, Pediatric Department, Alexandria University, Alexandria Governorate, Egypt
| | - Anil Pathare
- 2 Department of Haematology, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
| | - Salam Al-Kindi
- 2 Department of Haematology, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Oman
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Groomes CL, Gianferante DM, Crouch GD, Parekh DS, Scott DW, Lieuw K. Reduction of Factor VIII Inhibitor Titers During Immune Tolerance Induction With Recombinant Factor VIII-Fc Fusion Protein. Pediatr Blood Cancer 2016; 63:922-4. [PMID: 26739399 DOI: 10.1002/pbc.25874] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 11/23/2015] [Accepted: 11/25/2015] [Indexed: 11/09/2022]
Abstract
The development of inhibitors toward factor VIII (FVIII) is a common and serious complication of hemophilia A (HA) therapy. Patients with hemophilia who develop inhibitors often undergo time- and resource-intensive immune tolerance induction (ITI) protocols. We report a 15-month-old male with severe HA and a high-titer inhibitor that occurred while receiving prophylactic treatment with recombinant FVIII (rFVIII), in whom significant inhibitor titer reduction was achieved with thrice weekly infusions of a new, prolonged half-life rFVIII-Fc fusion protein product (trade name Eloctate). Further studies are warranted to explore the potential of Eloctate in ITI protocols.
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Affiliation(s)
- Charles L Groomes
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Gary D Crouch
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Dina S Parekh
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Walter Reed National Military Medical Center, Bethesda, Maryland
| | - David W Scott
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Kenneth Lieuw
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Walter Reed National Military Medical Center, Bethesda, Maryland
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Marlu R, Polack B. Gla-domainless factor Xa: molecular bait to bypass a blocked tenase complex. Haematologica 2012; 97:1165-72. [PMID: 22491732 DOI: 10.3324/haematol.2011.055699] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Hemophilia is caused by deficiencies in coagulation factor VIII or IX, resulting in direct blockade of the intrinsic tenase complex and indirect blockade of the extrinsic tenase complex which is rapidly inhibited upon binding of factor Xa to tissue factor pathway inhibitor. We evaluated the ability of Gla-domainless factor Xa, a truncated form of factor Xa devoid of procoagulant properties, to bind to tissue factor pathway inhibitor and to alleviate the physiological inhibition of the extrinsic tenase. DESIGN AND METHODS Using a thrombin generation assay triggered by a low concentration of tissue factor, we evaluated the ability of Gla-domainless factor Xa to restore blood coagulation in plasma from hemophilia A and B patients without and with inhibitors. We then compared its efficacy to generate thrombin to depletion of antithrombin or tissue factor pathway inhibitor by specific antibodies. Finally, we compared the kinetics of neutralization of factor Xa and Gla-domainless factor Xa by antithrombin and tissue factor pathway inhibitor. RESULTS Gla-domainless factor Xa was able to restore thrombin generation in plasma samples from hemophiliacs. This effect was observed for plasma from hemophilia A patients without or with inhibitors and for plasma from hemophilia B patients. Gla-domainless factor Xa had a lower affinity than factor Xa for tissue factor pathway inhibitor whereas the affinities of both proteins for antithrombin were similar. Finally, despite a short half-life in plasma, the effect of Gla-domainless factor Xa on thrombin generation was sustained for at least 1 hour. CONCLUSIONS As Gla-domainless factor Xa was able to restore thrombin generation in plasma from hemophilia patients, our results suggest that it may be an effective alternative to current treatments for hemophilia with or without an inhibitor.
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Affiliation(s)
- Raphaël Marlu
- Therex, TIMC-IMAG, CNRS Université Joseph Fourier, UMR 5525, Grenoble, France
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