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Mahlangu J. Emicizumab and unmet needs of patients with hemophilia a who are managed with replacement therapies. Expert Rev Hematol 2024; 17:741-748. [PMID: 39252482 DOI: 10.1080/17474086.2024.2402304] [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: 04/05/2024] [Revised: 09/02/2024] [Accepted: 09/05/2024] [Indexed: 09/11/2024]
Abstract
INTRODUCTION Hemophilia A is managed with coagulation clotting factor VIII (FVIII) therapy that poses significant challenges, such as a high treatment burden, immunogenicity, inconsistent hemostatic cover, poor treatment outcomes, and musculoskeletal progression despite adequate prophylactic treatment. Various non-factor therapies, such as several natural anticoagulant inhibitors and factor FVIII mimetics, have been developed to address these unmet needs. However, the role of emicizumab in addressing these unmet needs remains underexplored. AREAS COVERED This review delves into the evolution of hemophilia A replacement clotting therapy from plasma-derived products to recombinant products and, more recently, nonfactor therapies. It underscores the unmet needs of replacement therapy and explores the nonfactor therapies developed to address them. The review then comprehensively summarizes the clinical trial and real-world experience data, demonstrating how emicizumab tackles these unsatisfied demands. EXPERT OPINION Replacement clotting factor therapies as the standard of care has exposed several needs that have yet to be addressed. However, data from numerous emicizumab clinical trials and real-world experience offer a promising outlook, suggesting that it may effectively address many unmet needs. As hemophilia treatment goals continue to evolve, the role of currently developed nonfactor therapies in hemophilia management is yet to be fully defined.
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Affiliation(s)
- Johnny Mahlangu
- Department of Molecular Medicine and Haematology, Faculty of Health Science, School of Pathology, University of the Witwatersrand and NHLS, Johannesburg, South Africa
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Meijon-Ortigueira MDM, Alvarez-Roman MT, De La Corte H, Butta N, Jimenez-Yuste V. Predicting joint involvement through tailored prophylaxis in severe haemophilia A, is it possible? Haemophilia 2024; 30:678-684. [PMID: 38575526 DOI: 10.1111/hae.15014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/12/2024] [Accepted: 03/26/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Tailored prophylaxis is the current treatment regimen for patients with severe haemophilia A. Recently, published guidelines describe two possible approaches, based on clinical characteristics or estimation of pharmacokinetic parameters. However, both have strengths and weaknesses, and their characteristics need to be integrated to optimize treatment appropriately. In this paper, we present a model that considers together the characteristics of prophylaxis and the relevance of each. METHODS The age at initiation of prophylaxis, number of bleeding events, treatment regimen, therapeutic adherence, FVIII trough levels, and joint status were analyzed in 59 patients followed at La Paz University Hospital between January 2000 and December 2019. RESULTS The mean duration of primary prophylaxis of 113.37 ± 57.79 months. Eighty-three percent (n = 49) had no joint status involvement at the end of follow-up (HJHS and HEAD-US = 0). The median ABR was 0.7 (IQR 0.2 -1.0) and 54.2% presented trough levels of FVIII during follow-up >1 IU/dL. 72,9% engaged in some type of physical activity and overall adherence was over 85% in all patients evaluated. The regression analysis performed, considering all these factors, showed that the initiation of prophylaxis before 21 months of age was the most relevant protective factor against the appearance of joint involvement (OR 88.33 p.031 CI 95% 1.49-5224.40) CONCLUSION: Early initiation of prophylaxis was the most relevant factor in the protection of joint status. More comprehensive analysis models adapted to the characteristics of each population, are needed to adequately individualize treatment.
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Affiliation(s)
| | | | - Hortensia De La Corte
- Department of Physical Medicine and Rehabilitation, La Paz University Hospital-IdiPAZ, Madrid, Spain
| | - Nora Butta
- Department of Hematology, La Paz University Hospital-IdiPAZ, Madrid, Spain
| | - Victor Jimenez-Yuste
- Department of Hematology, La Paz University Hospital-IdiPAZ, Autonomous University of Madrid, Madrid, Spain
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Di Minno G, Spadarella G, Maldonato NM, De Lucia N, Castaman G, De Cristofaro R, Santoro C, Peyvandi F, Borrelli A, Lupi A, Follino M, Guerrino G, Morisco F, Di Minno M. Awareness of individual goals, preferences, and priorities of persons with severe congenital haemophilia A for a tailored shared decision-making approach to liver-directed gene therapy. A practical guideline. Blood Rev 2023; 62:101118. [PMID: 37544828 DOI: 10.1016/j.blre.2023.101118] [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: 06/05/2023] [Revised: 07/26/2023] [Accepted: 07/30/2023] [Indexed: 08/08/2023]
Abstract
In clinical medicine, shared decision making (SDM) is a well-recognized strategy to enhance engagement of both patients and clinicians in medical decisions. The success of liver-directed gene therapy (GT) to transform severe congenital haemophilia A (HA) from an incurable to a curable disease has launched a shift beyond current standards of treatment. However, GT acceptance remains low in the community of HA persons. We argue for both persons with haemophilia (PWH) and specialists in HA care including clinicians, as needing SDM-oriented educational programs devoted to GT. Here, we provide an ad hoc outline to implement education to SDM and tailor clinician information on GT to individual PWHs. Based on routine key components of SDM: patient priorities; recommendations based on individual risk reduction; adverse effects; drug-drug interactions; alternatives to GT; and ongoing re-assessment of the objectives as risk factors (and individual priorities) change, this approach is finalized to exploit efficacious communication.
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Affiliation(s)
| | - Gaia Spadarella
- Dipartimento di Scienze Mediche Traslazionali, Naples, Italy.
| | - Nelson Mauro Maldonato
- Dipartimento di Neuroscienze e di Scienze Riproduttive e Odontostomatologiche, "Federico II" University, Naples, Italy
| | - Natascia De Lucia
- Dipartimento di Neuroscienze e di Scienze Riproduttive e Odontostomatologiche, "Federico II" University, Naples, Italy.
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy.
| | - Raimondo De Cristofaro
- Section of Haemorrhagic and Thrombotic Diseases, Department of Medicine and Translational Surgery, Sacred Heart University, Rome, Italy..
| | - Cristina Santoro
- Ematologia, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Rome, Italy.
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy; Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy.
| | - Anna Borrelli
- Direzione Sanitaria, AOU "Federico II" Napoli, Italy
| | - Angelo Lupi
- Federazione delle Associazioni Emofilici (FedEmo), Milan, Italy.
| | | | | | | | - Matteo Di Minno
- Dipartimento di Medicina Clinica e Chirurgia, Naples, Italy.
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Mihaila RG. From a bispecific monoclonal antibody to gene therapy: A new era in the treatment of hemophilia A. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023; 167:1-8. [PMID: 36413008 DOI: 10.5507/bp.2022.046] [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: 08/19/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022] Open
Abstract
The treatment of hemophilia A has progressed amazingly in recent years. Emicizumab, a bispecific-humanized monoclonal antibody, is able to improve coagulation by bridging activated factor IX and factor X. Emicizumab is administered subcutaneously and much less often compared to factor VIII products. It has low immunogenicity, does not require dose adjustment, and can be administered regardless of the presence of factor VIII inhibitors. Thrombin generation assays but not factor VIII activity are indicated to guide and monitor the treatment. Emicizumab has enabled the conversion of patients with severe forms into patients with milder forms of hemophilia A. It has reduced the number of bleeding episodes compared to both on-demand and prophylactic substitution therapy and has an excellent safety profile. Gene therapy can elevate factor VIII plasma levels for many years after a single treatment course, could offer long-term protection from bleeding episodes, and minimize or eliminate the need for substitutive treatment with factor VIII concentrates. Gene therapy can provoke an immune response, manifested by an increase in common liver enzymes, that require immunotherapy. Long term monitoring is necessary to identify possible adverse effects. Future objectives are: the development of an ideal viral vector, the possibility of its re-administration, the use of gene therapy in hemophiliac children, and determining whether it can be successfully used to induce immune tolerance to factor VIII ceteri paribus. The future will determine the place of each type of treatment and group of patients for which it is indicated.
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Di Minno G, Castaman G, De Cristofaro R, Brunetti-Pierri N, Pastore L, Castaldo G, Trama U, Di Minno M. Progress, and prospects in the therapeutic armamentarium of persons with congenital hemophilia. Defining the place for liver-directed gene therapy. Blood Rev 2023; 58:101011. [PMID: 36031462 DOI: 10.1016/j.blre.2022.101011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 02/07/2023]
Abstract
In persons with congenital severe hemophilia A (HA) living in high-income countries, twice weekly intravenous infusions of extended half-life (EHL) factor VIII (FVIII) products, or weekly/biweekly/monthly subcutaneous injections of emicizumab are the gold standard home treatments to grant days without hurdles and limitations. Once weekly/twice monthly infusions of EHL Factor IX (FIX) products achieve the same target in severe hemophilia B (HB). Gene therapy, which is likely to be licensed for clinical use within 1-2 years, embodies a shift beyond these standards. At an individual patient level, a single functional gene transfer leads to a > 10-yr almost full correction of the hemostatic defect in HB and to a sustained (3-6-yrs) expression of FVIII sufficient to discontinue exogenous clotting factor administrations. At the doses employed, the limited liver toxicity of systemically infused recombinant adeno-associated virus (rAAV) vectors is documented by long-term (12-15 yrs) follow-ups, and pre-existing high-titer neutralizing antibodies to the AAV5 vector are no longer an exclusion criterion for effective transgene expression with this vector. A safe durable treatment that converts a challenging illness to a phenotypically curable disease, allows persons to feel virtually free from the fears and the obligations of hemophilia for years/decades. Along with patient organizations and health care professionals, communicating to government authorities and reimbursement agencies the liberating potential of this substantial innovation, and disseminating across the Centers updated information on benefits and risks of this strategy, will align expectations of different stakeholders and establish the notion of a potentially lifelong cure of hemophilia.
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Affiliation(s)
- Giovanni Di Minno
- Hub Center for Hemorrhagic and Thrombotic Disorders, Dep. of Clinical Medicine and Surgery, School of Medicine, Federico II University, Naples, Italy.
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy.
| | - Raimondo De Cristofaro
- Center for Hemorrhagic and Thrombotic Diseases, Foundation University Hospital A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy.
| | - Nicola Brunetti-Pierri
- Telethon Institute of Genetics and Medicine, Pozzuoli, Italy; Dept of Translational Medicine, School of Medicine, Università degli Studi di Napoli "Federico II", Italy.
| | - Lucio Pastore
- CEINGE-Biotecnologie Avanzate, and Department of Molecular Medicine and Medical Biotechnology, School of Medicine, University of Naples Federico II, 80131 Naples, Italy.
| | - Giuseppe Castaldo
- CEINGE-Biotecnologie Avanzate, and Department of Molecular Medicine and Medical Biotechnology, School of Medicine, University of Naples Federico II, 80131 Naples, Italy.
| | - Ugo Trama
- Coordination of the Regional Health System, General Directorate for Health Protection, Naples, Italy.
| | - Matteo Di Minno
- Hub Center for Hemorrhagic and Thrombotic Disorders, Dep. of Clinical Medicine and Surgery, School of Medicine, Federico II University, Naples, Italy.
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Wu J, Zhang H, Lian T, Ding Y, Song C, Li D, Wu L, Lei T, Liang H. Biological activity of a new recombinant human coagulation factor VIII and its efficacy in a small animal model. Biochem Biophys Res Commun 2023; 640:80-87. [PMID: 36502635 DOI: 10.1016/j.bbrc.2022.12.005] [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: 11/17/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
Deficiency in human coagulation factor VIII (FVIII) causes hemophilia A (HA). Patients with HA may suffer from spontaneous bleeding, which can be life-threatening. Recombinant FVIII (rFVIII) is an established treatment and prevention agent for bleeding in patients with HA. Human plasma-derived FVIII (pdFVIII), commonly used in clinical practice, is relatively difficult to prepare. In this study, we developed a novel B-domain-deleted rFVIII, produced and formulated without the use of animal or human serum-derived components. rFVIII promoted the generation of activated factor X and downstream thrombin, and, similar to that of other available FVIII preparations, its activity was inhibited by FVIII inhibitors. In addition, rFVIII has ideal binding affinity to human von Willebrand factor. Activated FVIII (FVIIIa) could be degraded by activated protein C and lose its procoagulant activity. In vitro, commercially available recombinant FVIII (Xyntha) and pdFVIII were used as controls, and there were no statistical differences between rFVIII and commercial FVIII preparations, which demonstrates the satisfactory efficacy and potency of rFVIII. In vivo, HA mice showed that infusion of rFVIII rapidly corrected activated partial thromboplastin time, similar to Xyntha. Moreover, different batches of rFVIII were comparable. Overall, our results demonstrate the potential of rFVIII as an effective strategy for the treatment of FVIII deficiency.
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Affiliation(s)
- Junzheng Wu
- Chengdu Rongsheng Pharmaceuticals Co. Ltd., 610041, Chengdu, China
| | - Hang Zhang
- Beijing Tiantan Biological Products Co. Ltd., 100024, Beijing, China
| | - Tong Lian
- Chengdu Rongsheng Pharmaceuticals Co. Ltd., 610041, Chengdu, China
| | - Yaling Ding
- Chengdu Rongsheng Pharmaceuticals Co. Ltd., 610041, Chengdu, China
| | - Chunlei Song
- Chengdu Rongsheng Pharmaceuticals Co. Ltd., 610041, Chengdu, China
| | - Dekuan Li
- Chengdu Rongsheng Pharmaceuticals Co. Ltd., 610041, Chengdu, China
| | - Liheng Wu
- Chengdu Rongsheng Pharmaceuticals Co. Ltd., 610041, Chengdu, China
| | - Tao Lei
- Chengdu Rongsheng Pharmaceuticals Co. Ltd., 610041, Chengdu, China.
| | - Hong Liang
- Chengdu Rongsheng Pharmaceuticals Co. Ltd., 610041, Chengdu, China; Beijing Tiantan Biological Products Co. Ltd., 100024, Beijing, China.
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