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Shafaati Lambert M, Bruzelius M, Mahmoud Hourani Soutari N, Ranta S, Antovic JP. Laboratory response to paradigm change in hemophilia treatment. Clin Chem Lab Med 2023; 61:e248-e250. [PMID: 37319338 DOI: 10.1515/cclm-2023-0443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/24/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Marjan Shafaati Lambert
- Coagulation & Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Coagulation, Clinical Chemistry, Karolinska University Laboratory, Medical Diagnostics Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Bruzelius
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Nida Mahmoud Hourani Soutari
- Coagulation & Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Coagulation, Clinical Chemistry, Karolinska University Laboratory, Medical Diagnostics Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | - Susanna Ranta
- Astrid Lindgren's Children's Hospital, Karolinska Univeristy Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Jovan P Antovic
- Coagulation & Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Coagulation, Clinical Chemistry, Karolinska University Laboratory, Medical Diagnostics Karolinska, Karolinska University Hospital, Stockholm, Sweden
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Mahlangu J. An update of the current pharmacotherapeutic armamentarium for hemophilia A. Expert Opin Pharmacother 2021; 23:129-138. [PMID: 34404300 DOI: 10.1080/14656566.2021.1961742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION For several decades, we have seen unprecedented advances in novel therapy development for hemophilia A. These advances address the unmet need of replacement therapy, and they include the development of recombinant products with improved pharmacokinetics, subcutaneously administered products, and those with better efficacy and safety profiles in hemophilia A management. AREAS COVERED In this update of hemophilia A treatment, the author summarizes data from completed standard half-life FVIII products, extended half-life FVIII products and FVIII mimetic studies. All products have an acceptable safety profile. The standard half-life products, EHL-FVIII products and emicizumab are efficacious in the prevention and treatment of bleeds and for EHL-FVIII in the perisurgical setting. EXPERT OPINION Advances in pharmacotherapy for hemophilia A have been characterized by changing care goals from supportive care to eliminating infections, preventing inhibitors, and more recently achieving zero bleeds in many patients. While gene therapy has the potential for functional cure in hemophilia A, it has many limitations which need to be addressed. Therefore, pharmacotherapy is likely to remain the mainstay in the management of hemophilia A and promises to get better with currently available therapies. Evolving factor and non-factor replacement therapies may also improve current unmet needs in hemophilia A management.
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Affiliation(s)
- Johnny Mahlangu
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand and NHLS, Parktown, South Africa
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Cadé M, Muñoz-Garcia J, Babuty A, Fouassier M, Heymann MF, Monahan PE, Heymann D. FVIII at the crossroad of coagulation, bone and immune biology: Emerging evidence of biological activities beyond hemostasis. Drug Discov Today 2021; 27:102-116. [PMID: 34311113 DOI: 10.1016/j.drudis.2021.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/27/2021] [Accepted: 07/19/2021] [Indexed: 12/19/2022]
Abstract
Hemophilia A is an X-linked hereditary disorder that results from deficient coagulation factor VIII (FVIII) activity, leading to spontaneous bleeding episodes, particularly in joints and muscles. FVIII deficiency has been associated with altered bone remodeling, dysregulated macrophage polarization, and inflammatory processes that are associated with the neoformation of abnormal blood vessels. Treatment based on FVIII replacement can lead to the development of inhibitors that render FVIII concentrate infusion ineffective. In this context, hemophilia has entered a new therapeutic era with the development of new drugs, such as emicizumab, that seek to restore the hemostatic balance by bypassing pathologically acquired antibodies. We discuss the potential extrahemostatic functions of FVIII that may be crucial for defining future therapies in hemophilia.
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Affiliation(s)
- Marie Cadé
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France
| | - Javier Muñoz-Garcia
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France
| | - Antoine Babuty
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France; Department of Haemostasis, CHU de Nantes, France
| | | | - Marie-Francoise Heymann
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France
| | - Paul E Monahan
- Gene Therapy Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - Dominique Heymann
- Université de Nantes, INSERM, Institut de Cancérologie de l'Ouest, Saint-Herblain 44805, France; University of Sheffield, Department of Oncology and Metabolism, Sheffield, UK.
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Recombinant VWF fragments improve bioavailability of subcutaneous factor VIII in hemophilia A mice. Blood 2021; 137:1072-1081. [PMID: 32877516 DOI: 10.1182/blood.2020006468] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/23/2020] [Indexed: 12/27/2022] Open
Abstract
Conventional treatment of hemophilia A (HA) requires repetitive IV injection of coagulation factor VIII (FVIII). Subcutaneous administration of FVIII is inefficient because of binding to the extravascular matrix, in particular to phospholipids (PLs), and subsequent proteolysis. To overcome this, recombinant dimeric fragments of von Willebrand factor (VWF) containing the FVIII-stabilizing D3 domain were engineered. Two fragments, called VWF-12 and VWF-13, demonstrated high binding affinity to recombinant human FVIII (rhFVIII) and suppressed PL binding in a dose-dependent manner. High concentrations of VWF fragments did not interfere with the functional properties of full-length VWF in vitro. The HA mouse model was used to study the effects of VWF-12 or VWF-13 on the in vivo pharmacokinetics of rhFVIII, demonstrating (1) no significant impact on rhFVIII recovery or half-life after a single IV administration; (2) enhanced bioavailability (up to 18.5%) of rhFVIII after subcutaneous administration; and (3) slow absorption (peak concentration, 6 hours) and prolonged half-life (up to 2.5-fold) of rhFVIII after subcutaneous administration. Formation of anti-FVIII antibodies was not increased after administration of rhFVIII/VWF-12 subcutaneously compared with rhFVIII IV. A single subcutaneous dose of rhFVIII/VWF-12 provided protection in the HA tail-bleeding model for up to 24 hours. In summary, recombinant VWF fragments support FVIII delivery through the subcutaneous space into vascular circulation without interfering with VWF or FVIII function. Slow resorption and excretion of FVIII after subcutaneous administration highlight the potential application of VWF fragments for subcutaneous FVIII prophylaxis in HA.
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Di Minno A, Spadarella G, Esposito S, Mathew P, Di Minno G, Mannucci PM. Perspective - The case for zero bleeds and drug bioequivalence in the treatment of congenital hemophilia A in 2021. Blood Rev 2021; 50:100849. [PMID: 34024681 DOI: 10.1016/j.blre.2021.100849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 01/19/2023]
Abstract
Not all patients with severe hemophilia A (HA) respond optimally to a given dose of a given product. Within-individual variance in cross-over studies makes each patient unique in the response to each standard half-life (SHL) factor VIII (FVIII) product in pharmacokinetic (PK) terms. This hampers the prediction of efficacy when a SHL FVIII product is employed. PK data showing that half-lives of SHL rFVIII are unsatisfactory to achieve zero bleeding in individual HA patients provide the rationale for switching from SHL to extended half-life (EHL) products. However, not all subjects receiving prophylaxis with EHL products achieve zero bleeding, the most cogent objective of personalized prophylaxis. Known determinants of FVIII half-life (age, von Willebrand factor [VWF] levels, blood group) cumulatively account for one third of the total inter-individual variation in FVIII clearance in subjects with severe HA. Investigations into precision, and accuracy of laboratory measurement to be employed; newer pathways for the clearance of both free-FVIII and VWF-bound FVIII, and adequately powered studies on omics and phenotypic heterogeneity, are likely to provide additional information on the remaining two thirds of inter-individual variation in FVIII clearance in HA. Variability in the clinical response has also been documented in patients when FVIII activity is mimicked by fixed subcutaneous doses of the bispecific antibody emicizumab. National registries that collect PK data of available FVIII products and ad hoc information on the individual response to emicizumab should be encouraged, to establish newer standards of care and ease personalized clinical decisions to achieve zero bleeding.
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Affiliation(s)
- Alessandro Di Minno
- Dipartimento di Farmacia, Università degli Studi di Napoli "Federico II", Italy; CEINGE-Biotecnologie Avanzate, Università degli Studi di Napoli "Federico II", Italy.
| | - Gaia Spadarella
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli "Federico II", Italy
| | - Salvatore Esposito
- Dipartimento di Medicina Clinica e Chirurgia and Centro Hub per le Malattie Emorragiche Congenite e le Trombofilie, Università degli Studi di Napoli "Federico II", Italy
| | | | - Giovanni Di Minno
- Dipartimento di Medicina Clinica e Chirurgia and Centro Hub per le Malattie Emorragiche Congenite e le Trombofilie, Università degli Studi di Napoli "Federico II", Italy.
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy..
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Mahlangu JN. Progress in the Development of Anti-tissue Factor Pathway Inhibitors for Haemophilia Management. Front Med (Lausanne) 2021; 8:670526. [PMID: 34026796 PMCID: PMC8131856 DOI: 10.3389/fmed.2021.670526] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 03/24/2021] [Indexed: 12/28/2022] Open
Abstract
The unprecedented progress in addressing unmet needs in haemophilia care to date includes developing several novel therapies that rebalance haemostasis by restoring thrombin generation in patients with haemophilia A or B with and without inhibitors. These novel therapies are FVIII mimetics, antithrombin interference RNA therapy and several monoclonal antibodies directed against the tissue factor pathway inhibitor (anti-TFPI). In this review, we provide an update on the progress made in developing anti-TFPI therapie. Phase 1 data from the three anti-TFPI studies showed acceptable safety profiles, and currently, available phase 2 data are encouraging. While these data support these molecules' further development progression, there is uncertainty on several aspects of their evolution. Two of the three anti-TFPIs have shown drug-related thrombosis, with one study consequently terminated. None of the thrombotic events is predictable with current monitoring tools, and none correlate with known coagulation parameters. All three anti-TFPIs undergo target mediated drug disposition, which impacts the formulation of dosing regimen fo these therapies. They would require more frequent dosing than some of the extended half-life clotting factor products and antithrombin RNAi therapy. There is no assay to measure the TFPI as the physiological levels are very low, which makes monitoring the impact of the anti-TFPI a challenge. The anti-TFPIs have several advantages, including their bioavailability when administered subcutaneously, their stable pharmacokinetics and their ability to prevent bleeds in haemophilia A or B patients with and without inhibitors. Whether these advantages can be realized will depend on the outcome of the currently ongoing studies.
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Affiliation(s)
- Johnny N. Mahlangu
- Haemophilia Comprehensive Care Centre, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
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Banchev A, Batorova A, Faganel Kotnik B, Kiss C, Puras G, Zapotocka E, Zupancic-Salek S. A Cross-National Survey of People Living with Hemophilia: Impact on Daily Living and Patient Education in Central Europe. Patient Prefer Adherence 2021; 15:871-883. [PMID: 33953547 PMCID: PMC8091596 DOI: 10.2147/ppa.s303822] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/30/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Information about the impact of hemophilia on daily living and information preferences for patients and their caregivers in Central Europe has been limited. METHODS This cross-national survey was conducted between April 1 and October 15, 2020 and utilized a self-administered questionnaire to collect data (Typeform™) from people living with hemophilia in Bulgaria, Croatia, Czech Republic, Hungary, Slovakia and Slovenia. The questionnaire included 22 questions regarding difficulties in daily life and preferences for receiving hemophilia-related information. Respondents were stratified into two main groups, people with hemophilia (PwH) or their caregivers (CPwH). Results were analyzed using descriptive statistics. RESULTS Of the 364 respondents, 232 were PwH (63.7%) and 132 were CPwH (36.3%). In total, 70.3% of hemophilia patients/caregivers responded that they are kept sufficiently informed about life with hemophilia, with 68.0%, 59.1% and 56.3% of respondents obtaining information from their physicians, patient associations and via digital media (internet and social media), respectively. However, 97.8% of respondents expressed an interest in additional information, particularly new hemophilia treatment options (62.1%), which in contrast to other topics was indicated most frequently by both patients and caregivers in all six countries. Most frequent difficulties in everyday life with hemophilia were identified as mobility problems (41.8%), unexpected bleeding (38.5%), pain (35.4%), and uncertainty with what they can or cannot do (25.0%). During the 2020 COVID-19 pandemic, 52.5% of respondents reported that they did not experience any major change in daily living with hemophilia. CONCLUSION Based on our Central European survey, hemophilia mostly affects peoples' lives by causing mobility difficulties, unexpected bleeding, pain and uncertainty in daily activities. Although the majority of respondents reported being educated about hemophilia, most PwH and CPwH respondents sought additional information, highlighting the need for continuous personalized patient education to cope with present challenges.
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Affiliation(s)
- Atanas Banchev
- Department of Pediatric Hematology and Oncology, University Hospital ‘Tzaritza Giovanna – ISUL’, Sofia, Bulgaria
| | - Angelika Batorova
- National Hemophilia Center, Department of Hematology and Transfusion Medicine, Faculty of Medicine of Comenius University and University Hospital, Bratislava, Slovakia
| | - Barbara Faganel Kotnik
- Department of Oncology and Hematology, University Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Csongor Kiss
- Department of Pediatric Hematology-Oncology, Institute of Pediatrics, University of Debrecen, Debrecen, Hungary
| | - Gediminas Puras
- Department of Medical Affairs CEER, Swedish Orphan Biovitrum AG, Basel, Switzerland
| | - Ester Zapotocka
- Department of Pediatric Hematology/Oncology, University Hospital Motol, Prague, Czech Republic
| | - Silva Zupancic-Salek
- Department of Medicine, University Hospital Center Zagreb, Zagreb, Croatia
- Correspondence: Silva Zupancic-Salek Department of Medicine, University Hospital Centre Zagreb, Rebro, Kispatic Str 12, Zagreb, 10 000, CroatiaTel +385 1 337 5199Fax +385 1 332 4650 Email
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Kumar SRP, Wang X, Avuthu N, Bertolini TB, Terhorst C, Guda C, Daniell H, Herzog RW. Role of Small Intestine and Gut Microbiome in Plant-Based Oral Tolerance for Hemophilia. Front Immunol 2020; 11:844. [PMID: 32508814 PMCID: PMC7251037 DOI: 10.3389/fimmu.2020.00844] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/14/2020] [Indexed: 01/03/2023] Open
Abstract
Fusion proteins, which consist of factor VIII or factor IX and the transmucosal carrier cholera toxin subunit B, expressed in chloroplasts and bioencapsulated within plant cells, initiate tolerogenic immune responses in the intestine when administered orally. This approach induces regulatory T cells (Treg), which suppress inhibitory antibody formation directed at hemophilia proteins induced by intravenous replacement therapy in hemophilia A and B mice. Further analyses of Treg CD4+ lymphocyte sub-populations in hemophilia B mice reveal a marked increase in the frequency of CD4+CD25-FoxP3-LAP+ T cells (but not of CD4+CD25+FoxP3+ T cells) in the lamina propria of the small but not large intestine. The adoptive transfer of very small numbers of CD4+CD25-LAP+ Treg isolated from the spleen of tolerized mice was superior in suppression of antibodies directed against FIX when compared to CD4+CD25+ T cells. Thus, tolerance induction by oral delivery of antigens bioencapsulated in plant cells occurs via the unique immune system of the small intestine, and suppression of antibody formation is primarily carried out by induced latency-associated peptide (LAP) expressing Treg that likely migrate to the spleen. Tolerogenic antigen presentation in the small intestine requires partial enzymatic degradation of plant cell wall by commensal bacteria in order to release the antigen. Microbiome analysis of hemophilia B mice showed marked differences between small and large intestine. Remarkably, bacterial species known to produce a broad spectrum of enzymes involved in degradation of plant cell wall components were found in the small intestine, in particular in the duodenum. These were highly distinct from populations of cell wall degrading bacteria found in the large intestine. Therefore, FIX antigen presentation and Treg induction by the immune system of the small intestine relies on activity of a distinct microbiome that can potentially be augmented to further enhance this approach.
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Affiliation(s)
- Sandeep R. P. Kumar
- Herman B Wells Center for Pediatric Research, IAPUI, Indianapolis, IN, United States
| | - Xiaomei Wang
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Nagavardhini Avuthu
- Department of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE, United States
| | - Thais B. Bertolini
- Herman B Wells Center for Pediatric Research, IAPUI, Indianapolis, IN, United States
| | - Cox Terhorst
- Division of Immunology, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, MA, United States
| | - Chittibabu Guda
- Department of Genetics, Cell Biology and Anatomy, University of Nebraska Medical Center, Omaha, NE, United States
| | - Henry Daniell
- Department of Basic and Translational Sciences, School of Dental Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Roland W. Herzog
- Herman B Wells Center for Pediatric Research, IAPUI, Indianapolis, IN, United States
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
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Abstract
INTRODUCTION Clinical trials in haemophilia product development are expanding rapidly however, the number of sites and expertise in the clinical trial conduct is limited. Guidance on the requirement for conducting clinical trials is required AIM: The aim of this paper is to outline generic requirements to participate in clinical trials in haemophilia MATERIALS: This paper describes three elements which are the requirements for success conduct of haemophilia clinical trials. These are the study product, study participant, and the global regulatory and ethics framework RESULTS AND CONCLUSION: In haemophilia clinical trials, requirements for participate in studies are many and include considerations of study product, study participant and ethical and regulatory framework. When these elements are in place, it is possible to conduct haemophilia clinical trials anywhere in the world.
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Affiliation(s)
- Johnny N Mahlangu
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Parktown, South Africa
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Emicizumab for the treatment of haemophilia A: a narrative review. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2019; 17:223-228. [PMID: 31246563 DOI: 10.2450/2019.0026-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 04/15/2019] [Indexed: 01/09/2023]
Abstract
One of the most serious complications of the treatment of severe haemophilia A is the development of alloantibodies against exogenous factor VIII (FVIII). Inhibitors render factor replacement therapy ineffective, exposing patients to a remarkably high risk of morbidity and mortality. Besides the well-known bypassing agents (i.e. activated prothrombin complex concentrate and recombinant activated factor VII) used to treat or prevent bleeding in haemophilia patients with inhibitors, there is growing interest in newer haemostatic therapies that are not based on the replacement of the deficient FVIII. This review will focus on the most interesting among these innovative therapies, emicizumab, and will provide an update on its current stage of clinical development.
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Gundabolu K, Goldsweig A, Bhatt VR, Koepsell SA, Harper JL. ST‐Segment Elevation Myocardial Infarction (STEMI) and Pulmonary Embolism in a Hemophilia A Patient Receiving Emicizumab and recombinant Activated Factor VII. Haemophilia 2019; 26:e5-e8. [DOI: 10.1111/hae.13871] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 10/08/2019] [Accepted: 10/11/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Krishna Gundabolu
- Department of Hematology‐Oncology University of Nebraska Medical Center Omaha NE USA
| | - Andrew Goldsweig
- Department of Cardiovascular Medicine University of Nebraska Medical Center Omaha NE USA
| | - Vijaya R. Bhatt
- Department of Hematology‐Oncology University of Nebraska Medical Center Omaha NE USA
| | - Scott A. Koepsell
- Department of Pathology/Microbiology University of Nebraska Medical Center Omaha NE USA
| | - James L. Harper
- Department of Pediatrics‐Hematology‐Oncology University of Nebraska Medical Center Omaha NE USA
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Sande CM, Al-Huniti A, Ten Eyck P, Sharathkumar AA. Impact of the Survey of Inhibitors in Plasma-Product Exposed Toddlers (SIPPET) study and its post hoc analyses on clinical practice in the United States: A survey of Haemophilia and Thrombosis Research Society members. Haemophilia 2019; 25:764-772. [PMID: 31264762 DOI: 10.1111/hae.13806] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 05/15/2019] [Accepted: 05/22/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION A recent randomized trial, the Survey of Inhibitors in Plasma-Product Exposed Toddlers (SIPPET), confirmed that exposure to recombinant FVIII (rFVIII) products doubled the risk of inhibitor development compared to plasma-derived FVIII (pdFVIII) in previously untreated (or minimally treated) patients (PUPs) with severe haemophilia A. SIPPET post hoc analyses showed that early exposure to rFVIII was more immunogenic and that rFVIII could harm low-risk PUPs with non-null mutations. Clinical implications of SIPPET findings for the haemophilia community were unclear. AIM Study the impact of the SIPPET study and its post hoc analyses on clinical practice for PUPs with severe haemophilia A in the United States. METHODS Members of the North American Hemophilia and Thrombosis Research Society (HTRS) completed two online questionnaires related to SIPPET publications and PUP management (study period: 12/2016-8/2018). RESULTS Over 50% participated the study. Sixty per cent expressed methodological concerns about the SIPPET study, yet 55% shared the study with new families. During the study period, rFVIII selection fell from 43/61 (70%) to 15/54 (28%) while use of pdFVIII and shared decision-making increased from 5/61 (8%) to 9/54 (17%) and from 4/61 (7%) to 10/54 (19%), respectively. Based on post hoc analyses, 44/54 (82%) would change their clinical practice with 31/44 (70%) using pdFVIII for PUPs. Barriers to translation of SIPPET analyses included study design concerns, non-inclusion of novel therapies, inability to perform genetic testing at diagnosis and risk of plasma-derived infections. CONCLUSION Despite the methodological concerns about the SIPPET study, this Grade I evidence appears to have influenced the clinical practice of haemophilia providers in the United States.
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Affiliation(s)
| | - Ahmad Al-Huniti
- Division of Pediatric Hematology-Oncology, University of Iowa Stead Family Department of Pediatrics, Iowa City, Iowa
| | | | - Anjali A Sharathkumar
- University of Iowa Carver College of Medicine, Iowa City, Iowa.,Division of Pediatric Hematology-Oncology, University of Iowa Stead Family Department of Pediatrics, Iowa City, Iowa
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