Epidemiology of hemophilia and of HIV infection in Italy. GICC. Gruppo Italiano Coagulopatie Congenite

Recent Advances in the Treatment of Hemophilia: A Review

Progress in hemophilia therapy has been remarkable in the first 20 years of the third millennium, but the innovation began with the description the fractionation of plasma in 1946. The first concentrates followed the discovery of FVIII in the cryoprecipitate of frozen plasma and FIX in the supernatant in the early 1960s, which led to the initial attempts at replacement therapy. Unfortunately, the lack of screening methods for viral pathogens resulted in people with hemophilia (PWH) receiving concentrates contaminated by hepatitis A virus, hepatitis C virus, and human immunodeficiency virus, as these concentrates were made from large industrial pools of plasma derived from thousands of donors. Fortunately, by 1985, viral screening methods and proper virucidal techniques were developed that made concentrates safe. Increasingly pure products followed the introduction of chromatography steps with monoclonal antibodies in the production process. The problem of immunogenicity of exogenously administered concentrates has not yet had a complete solution. The development of alloantibodies against FVIII in about 25-35% of PWH is the most serious adverse effect of replacement therapy. The next major advance followed the cloning of the F8 gene and later the F9 genes, which paved the way to produce concentrates of factors obtained by the recombinant DNA technology. The injected FVIII and FIX molecules had a relatively short circulating half-life in the plasma of people with hemophilia A and B, approximately 12 and 18 hours, respectively. The ability to prolong the plasma half-life and extend the interval between injections followed the application of methods to conjugate the factor molecule with the fragment crystallizable of IgG1 or albumin or by adding polyethylene glycol, which has led to an increase in the half-life of concentrates, especially for rFIX. The next frontier in hemophilia therapy is the application of durable and potentially curative therapies such as with gene addition therapy. Experiments in hemophilia B have demonstrated durable responses. Unfortunately, the results with gene therapy for hemophilia A have not been as remarkable and the durability must still be demonstrated. Nonetheless, the long-term safety, predictability, durability, and efficacy of gene therapy for hemophilia A and B remain an open question. At present, only healthy adult PWH have been enrolled in gene therapy clinical trials. The application of gene therapy to children and those with pre-existing antibodies against the delivery vector must also be studied before this therapy becomes widespread.

The role of total ankle replacement in patients with haemophilia and end-stage ankle arthropathy: A review

Haemophilia is the most common X-linked bleeding disorder, affecting over 1 million individuals throughout the world. Patients are subclassified into mild, moderate and severe disease based on per cent factor activity level. Nearly, all patients with haemophilia develop haemophilic arthropathy (HA) by age 30 and HA is known to have a negative impact on physical health subscores in Haem-A-QOL, a validated quality of life scoring system for patients with haemophilia. Unfortunately, many patients progress to end-stage HA of the ankle, which is characterized by pain, contractures, decreased range of motion and muscle atrophy. Ankle arthrodesis (AAD) has been the standard of care in the definitive surgical management of end-stage HA of the ankle. While AAD is a safe surgical procedure known to improve HA-related pain, it decreases functional mobility and has been associated with secondary hindfoot arthritis as well as subtalar degeneration. In recent years, total ankle replacement (TAR) has emerged as an alternative surgical procedure that strives to improve functional mobility, pain and quality of life in end-stage HA of the ankle. However, the safety, durability, and efficacy of this procedure in these patients are unknown. In this review, we analyse the clinical studies investigating TAR in patients with end-stage HA of the ankle. We also discuss important considerations in the perioperative management of patients with haemophilia and compare the risks and benefits of AAD and TAR for patients with end-stage HA of the ankle.

The prevalence of HTLV-1 and its Co-Infection with HCV, HBV and HIV in Hemophilic patients

Background and Objective:

Blood-borne infections, such as the HIV virus and hepatitis B and C, are major problems in patients receiving blood products. Here we examined the prevalence of HTLV-1, HCV, HBV, and HIV in hemophilic patients.

Methods:

A cross-sectional study on 108 hemophilic patients (101 males and 7 females) involved detection of HBV, HCV, HIV and HTLV-1 infections using immunoassays for HBsAg, hepatitis B core antibodies (anti-HBc), hepatitis C antibodies (anti-HCV), HIV antibodies (anti-HIV) and Anti-HTLV-1. Real-time PCR was used to measure HCV RNA, and HCV genotyping was performed by direct sequencing of the 5’ noncoding region.

Results:

Hemophilia A was reported in 93 (86%) patients with severe symptoms in 8 cases. The seroprevalence of anti-HCV and anti-HTLV-1 antibodies was 20% and 3% respectively. One patient with severe hemophilia had a HCV/HTLV-1 co-infection. HCV-RNA was detected in 82% of patients. In terms of genotyping prevalence was 56% HCV genotype 3a, 39% HCV genotype 1a, and 6% HCV genotype2. Anti HIV and HBsAg were not detected in any patient. HTLV1 prevalence was higher, HCV lower in South Khorasan than other regions in Iran or elsewhere.

Conclusion:

Management of transfusion of blood and blood products should account for the underlying prevalence of infectious agents.

Mild hemophilia A

Mild hemophilia A (HA), defined by clinical features and factor VIII coagulant activity (FVIII:C) between 0.05 and 0.40 IU mL(-1), is characteristically distinct from severe HA. Indeed, although the molecular characterization of mild HA has permitted the identification of specific underlying mutations, its clinical phenotype is strikingly different from that of patients with a severe FVIII defect, where spontaneous hemorrhages or recurrent joint bleeding are usual manifestations. With aging, mild HA patients may develop complications (i.e. cancers and cardiovascular disorders), the management of which may prove challenging due to the concomitant bleeding tendency. Furthermore, the development of inhibitors provides an additional major complication in these patients, because it increases the severity of the bleeding phenotype and complicates their management. Standard management of mild HA includes the use of desmopressin and antifibrinolytic agents for minor bleeding episodes or surgical procedures, whilst major bleeding or surgery requires replacement therapy with FVIII concentrates. As regards treatment of patients with inhibitors, bypassing agents (i.e. activated prothrombin complex concentrates and recombinant activated FVII) have proven effective in the treatment of bleeding episodes, but as there are insufficient data to determine the optimal approach to immune tolerance induction in this group of patients, their optimal management remains controversial. Rituximab is a newer, promising therapeutic option for inhibitor eradication in such patients. Many aspects concerning mild HA remain to be clarified, including the molecular basis, the natural history and the optimal diagnostic and therapeutic strategies. Only large prospective studies will shed light on this condition.

A study of variations in the reported haemophilia A prevalence around the world

The objectives of this paper were to study the reported haemophilia A prevalence (per 100 000 males) on a country-by-country basis and address the following: Does the reported prevalence of haemophilia A vary by national economies? We collected prevalence data for 106 countries from the World Federation of Hemophilia (WFH) annual global surveys and the literature. We found that the reported haemophilia A prevalence varied considerably among countries, even among the wealthiest of countries. The prevalence (per 100 000 males) for high income countries was 12.8 +/- 6.0 (mean +/- SD) whereas it was 6.6 +/- 4.8 for the rest of the world. Within a country, there was a strong trend of increasing prevalence over time--the prevalence for Canada ranged from 10.2 in 1989 to 14.2 in 2008 (R = 0.94 and P < 0.001) and for the United Kingdom it ranged from 9.3 in 1974 to 21.6 in 2006 (R = 0.94 and P < 0.001). Prevalence data reported from the WFH compared well with prevalence data from the literature. Patient registries generally provided the highest quality of prevalence data. The lack of accurate country-specific prevalence data has constrained planning efforts for the treatment and care of people with haemophilia A. With improved information, healthcare agencies can assess budgetary needs to develop better diagnostic and treatment facilities for affected patients and families and work to ensure adequate supplies of factor VIII concentrates for treatment. In addition, this information can help manufacturers plan the production of concentrates and prevent future shortages.

Population pharmacokinetics of recombinant factor VIII:C (ReFacto) in adult HIV-negative and HIV-positive haemophilia patients

PURPOSE

The aim of this study was to explore possible differences in the pharmacokinetics (PK) of recombinant factor VIII:C (ReFacto - ReFacto ) in HIV+ vs. HIV- patients and also differences in the chromogenic substrate bioassay (CHS) and one-stage clotting (OSC) methods.

METHODS

Twenty-eight haemophilia A adults (20 HIV- and eight HIV+) were assayed with both the CHS and OSC methods. An average of two and six samples were collected per patient for HIV-/+, respectively, after one, and occasionally two more, prophylactic doses (mean 2,003 IU; range 1,000-4,300 IU). The observations were analysed with the mixed-effects (population) compartmental PK modelling package NONMEM (nonlinear mixed-effects modelling) and the FOCE (first-order conditional estimation) method. Base modelling was performed independently for the CHS and OSC bioassays for comparison, and covariate models and simulation tests were done only for the commonly used OSC bioassay. The final covariate model was validated using the bootstrap method. Monte Carlo simulations were used to estimate the expected probability of exceeding 20%, 40% or 60% of normal factor VIII:C in plasma after a single dose, corresponding to required levels for preventing mild, moderate and life-threatening haemorrhages.

RESULTS

One-compartment base-model population PK parameters were [mean parameter (interpatient variability %)] for CHS: clearance (CL) = 2.56 dl h(-1) (33.2%); volume of distribution (V) = 34.8 dl (12.8%); and for OSC: CL = 3.83 dl h(-1) (47.8%), V = 53.7 dl (22.4%). The volumes differed significantly between the CHS and OSC methods (p < 0.0001), and variabilities were higher for OSC. Nevertheless, the empirical half-lives (t(1/2) = l n (2) x V/CL) were similar for CHS and OSC, [(mean +/- standard deviation (SD)], 9.5 +/- 3 h and 10.2 +/- 4 h, respectively. In covariate modelling with the OSC-derived model, HIV status (VIR) was a significant categorical predictor (p < 0.005) for V. The final covariate models with OSC were for CL = 3.93 + 0.09 x (WT-75) and for V = 48.6 x (1 + 0.36 x VIR) + 0.55 x (WT-75); therefore, V for the typical HIV+ patient was 36% higher than for the HIV- patient.

CONCLUSIONS

Both HIV- and HIV+ patients showed 100% success with the 20% threshold at doses >20 IU/kg. HIV- patients receiving >50 IU/kg had a 100% expected chance of success for all thresholds. HIV+ patients for moderate or life-threatening haemorrhage treatment need 10 IU/kg more than the HIV- patient equivalent to have the same probability of success.

Comparison of the rates of joint arthroplasty in patients with severe factor VIII and IX deficiency: an index of different clinical severity of the 2 coagulation disorders

Data from the Italian Hemophilia Centres were collected to perform a retrospective survey of joint arthroplasty in patients with severe hemophilia. Twenty-nine of 49 hemophilia centers reported that 328 of the 347 operations were carried out in 253 patients with severe hemophilia A (HA) and 19 in 15 patients with severe hemophilia B (HB). When results were normalized to the whole Italian hemophilia population (1770 severe HA and 319 severe HB), patients with HA had a 3-fold higher risk of undergoing joint arthroplasty (odds ratio [OR], 3.38; 95% confidence interval [CI], 1.97-5.77; P < .001). These results were confirmed after adjustment for age, HIV, hepatitis C virus (HCV), and inhibitor in a Cox regression model (HR, 2.65; 95% CI, 1.62-4.33; P < .001). The survival analysis of time to joint arthroplasty in the subset of patients with severe HA was not affected by the severity of factor VIII (FVIII) gene mutations. A systematic review of literature articles reporting joint arthroplasties in HA and HB showed that the proportion of HA patients who had undergone arthroplasties was higher than that of HB patients, in agreement with the findings in our Italian cohort. These data suggest that the 2 inherited coagulation disorders have a different severity of clinical phenotype.

[Blood-transmitted viral infections among haemophiliacs in Tunisia]

In this work, we proposed to evaluate prevalences of hepatitis B and C viruses and Parvovirus B19 among 70 Tunisian haemophiliacs treated with clotting factors imported from Europe and/or locally produced cryoprecipitate; among them 6 (8.6%) are known HIV positive patients. HBs antigen, anti-HBc antibodies and anti-Parvovirus B19 antibodies were detected in 7.1%, 52.9% and 91.8%, respectively. HCV prevalence, defined as positive ELISA with positive Immunoblot and/or PCR was 50.0%. Prevalences of these viral infections in haemophiliacs are higher than prevalences detected among general population and in the control group of the study. HCV infection is less frequent in haemophiliacs born after 1985, the year of introduction of the inactivation procedures in the production of coagulation factors concentrates; it decreases more considerably after 1994, date of introduction of systematic screening of HCV among blood donors. In contrast, despite the inactivation of the factors concentrates and the systematic screening of the blood donations against HBs antigen, since 1973, the risk of HBV infection contamination remains high in the Tunisian haemophiliacs. The introduction in 1995 of hepatitis B vaccination in the national schedule of new-born vaccination may resolve in the future the problem of HBV infection in haemophiliacs and in the other categories of the Tunisian population.

Cost of care and quality of life for patients with hemophilia complicated by inhibitors: the COCIS Study Group

Inhibitors in patients with hemophilia are a rare complication of a rare disease causing pain and disability in patients and impairment to the quality of their lives. Recent advances in treatment have brought improvements, but they have done so by absorbing larger amounts of financial resources. This study involved 52 Italian patients with hemophilia with high-responding inhibitors who were longitudinally observed for 18 months to evaluate concomitantly cost of care and quality of life. Overall, 0.6 bleeding episodes per patient per month were recorded. This frequency of events was lower than that reported in other cohorts of patients with hemophilia who were not taking inhibitors. The average monthly cost of care was, in euros, 18,000 (18,000 US dollars) per patient, mainly because of treatment products. Recombinant activated factor VII, mostly used for orthopedic surgery, represented 50% of the expenses. Quality of life, measured through validated questionnaires, was similar to that of patients with severe hemophilia without inhibitors. In particular, physical quality of life was similar to that in patients with diabetes and on dialysis, whereas mental quality of life was comparable to that in the general population. This study shows that hemophilia complicated by inhibitors, a prototype of rare disease, requires high amounts of resources for management that provides a satisfactory quality of life.

Psychological aspects and coping in haemophilic patients: a case-control study

Although enormous progress has been made in recent years in the field of haemophilia, some problems still await solution, such as the risk of sudden haemorrhage, the sequelae of haemophilic arthropathy and social activities. We, therefore, carried out a case-control study in which some psychological dimensions (social expectations, tendency to depression, state of anxiety and self-esteem) were evaluated in a group of 60 haemophiliacs. A control group was formed of 78 healthy subjects matched for age, socio-economic class and level of education. The methodology used was the administration of self-assessment questionnaires which investigate and provide a quantitative measure of psychological dimensions. The results can be subjected to statistical analysis. Three self-assessment questionnaires were used: (i) the Marlowe-Crowne scale, (ii) the Beck Inventory version modified by Cusinato and (iii) the S.T.A.I.-form. Our aim was to evaluate: (i) whether there are significant differences in the considered psychological aspects between haemophiliacs and healthy subjects; (ii) whether there is a significant correlation between the psychological dimensions considered in the haemophiliacs and in the healthy subjects. The results showed that the haemophiliacs have a good psychological adaptation to their disease with the exception of their greater tendency to have less self-esteem than do the healthy subjects. As far as concerns the second aim, we found than self-esteem correlated with all the psychological variables investigated. This information could indicate the enormous importance that the psychological variable 'self-esteem' plays in haemophiliacs with respect to whether or not they develop depressive disorders and/or anxiety states.

The French haemophilia cohort: rationale and organization of a long-term national pharmacosurveillance system

Medicinal products of biological origin still carry a specific iatrogenic risk, mainly because of their starting material, mode of preparation and variability. Careful postmarketing surveillance systems are therefore necessary. To assess the long-term safety of haemophilia treatment with plasma-derived and recombinant clotting factor products, a cohort study was set up in France in 1994. Participants were patients with haemophilia A and B, with or without previous clotting factor therapy. Clinical events, treatments, biological data and adverse events were recorded on standard forms. Blood samples were separated into serum, plasma and peripheral blood mononuclear cells, frozen, and banked in a central laboratory. The same data and samples were collected at yearly follow-up visits. As of December 1999, 1234 haemophiliacs were enrolled in 39 haemophilia centres. At enrollment, 50.2% of patients were under 15 years of age, and the cumulative number of days of exposure to the product was below 50 in 35.1% of cases. The median duration of follow-up was 26.9 months, with a total of 2729 patient-years (135,947 days of exposure and 211 million units of factor VIII or IX). To date, only 17 patients were lost to follow-up. The initial results show good compliance with this health-watch policy among patients and clinicians specializing in haemophilia. The regular follow-up data and centralized sample bank will serve to investigate rapidly any suspected outbreaks as soon as reliable biological tests become available in the future.

Occurrence of hemophilia in the United States. The Hemophilia Surveillance System Project Investigators

An active surveillance system was used to identify all residents with hemophilia in six U.S. states (Colorado, Georgia, Louisiana, Massachusetts, New York, and Oklahoma). A hemophilia case was defined as a person with physician-diagnosed hemophilia A or B and/or a measured baseline factor VIII or IX activity (FA) of 30% or less. Case-finding methods included patient reports from physicians, clinical laboratories, hospitals, and hemophilia treatment centers. Once identified, trained data abstractors collected clinical and outcome data retrospectively from medical records. Among cases identified in 1993-1995, 2,743 were residents of the six states in 1994, of whom 2,156 (79%) had hemophilia A. Of those with available FA measurements, 1,140 (43%) had severe (FA < 1%), 684 (26%) had moderate (FA 1%-5%), and 848 (31%) had mild (FA 6%-30%) disease. The mean and median age was 25.4 and 23 years, respectively. The age-adjusted prevalence of hemophilia in all six states in 1994 was 13.4 cases/100,000 males (10.5 for hemophilia A and 2.9 for B). The prevalence by race/ethnicity was 13.2 cases/100,000 among white, 11.0 among African American, and 11.5 among Hispanic males. Application of age-specific prevalence rates from the six surveillance states to the U.S. population resulted in an estimated national population of 13,320 cases of hemophilia A and 3,640 cases of hemophilia B. For the 10-year period 1982-1991, the average incidence of hemophilia A and B in the hemophilia surveillance system (HSS) states was estimated to be 1 in 5,032 live male births.