1
|
Cohen O, Santagata D, Ageno W. Novel horizons in anticoagulation: the emerging role of factor XI inhibitors across different settings. Haematologica 2024; 109:3110-3124. [PMID: 38779744 PMCID: PMC11443408 DOI: 10.3324/haematol.2023.283682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Indexed: 05/25/2024] Open
Abstract
Anticoagulants have long been fundamental in preventing and treating thromboembolic disorders, with a recent shift of focus towards direct oral anticoagulants, thanks to their ease of use, efficacy, and safety. Despite these advancements, bleeding complications remain a major concern with any anticoagulant, highlighting the need for safer drugs. Factor XI (FXI) inhibitors have emerged as promising agents in this regard, offering a novel approach by targeting upstream factors in the coagulation system. Phase II trials have shown encouraging outcomes, indicating a reduced bleeding risk compared to that associated with traditional anticoagulants, particularly in the context of cardiovascular disease management when combined with antiplatelet therapy. However, the variability in findings and limited efficacy data call for a cautious interpretation pending insights from phase III trials. These trials are essential for validating the potential of FXI inhibitors to balance bleeding risk reduction and maintain anticoagulant efficacy. This review explores the pharmacology, potential indications, clinical data, and future directions of FXI inhibitors, providing a perspective on their evolving role in anticoagulant therapy. It also provides a detailed analysis of data from published clinical trials on FXI inhibitors in various indications. Preliminary data from ongoing trials are also outlined. As the field moves forward, a cautiously optimistic outlook can be expected, focusing on comprehensive data from phase III trials to define the role of FXI inhibitors in various clinical scenarios.
Collapse
Affiliation(s)
- Omri Cohen
- Department of Medicine and Surgery, University of Insubria, Varese, Italy; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-Hashomer, Israel; The Amalia Biron Institute of thrombosis research, Aviv University
| | - Davide Santagata
- Department of Medicine and Surgery, University of Insubria, Varese
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese.
| |
Collapse
|
2
|
Goel A, Tathireddy H, Wang SH, Vu HH, Puy C, Hinds MT, Zonies D, McCarty OJ, Shatzel JJ. Targeting the Contact Pathway of Coagulation for the Prevention and Management of Medical Device-Associated Thrombosis. Semin Thromb Hemost 2024; 50:989-997. [PMID: 37044117 PMCID: PMC11069398 DOI: 10.1055/s-0043-57011] [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] [Indexed: 04/14/2023]
Abstract
Hemorrhage remains a major complication of anticoagulants, with bleeding leading to serious and even life-threatening outcomes in rare settings. Currently available anticoagulants target either multiple coagulation factors or specifically coagulation factor (F) Xa or thrombin; however, inhibiting these pathways universally impairs hemostasis. Bleeding complications are especially salient in the medically complex population who benefit from medical devices. Extracorporeal devices-such as extracorporeal membrane oxygenation, hemodialysis, and cardiac bypass-require anticoagulation for optimal use. Nonetheless, bleeding complications are common, and with certain devices, highly morbid. Likewise, pharmacologic prophylaxis to prevent thrombosis is not commonly used with many medical devices like central venous catheters due to high rates of bleeding. The contact pathway members FXI, FXII, and prekallikrein serve as a nexus, connecting biomaterial surface-mediated thrombin generation and inflammation, and may represent safe, druggable targets to improve medical device hemocompatibility and thrombogenicity. Recent in vivo and clinical data suggest that selectively targeting the contact pathway of coagulation through the inhibition of FXI and FXII can reduce the incidence of medical device-associated thrombotic events, and potentially systemic inflammation, without impairing hemostasis. In the following review, we will outline the current in vivo and clinical data encompassing the mechanism of action of drugs targeting the contact pathway. This new class of inhibitors has the potential to herald a new era of effective and low-risk anticoagulation for the management of patients requiring the use of medical devices.
Collapse
Affiliation(s)
- Abhishek Goel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Harsha Tathireddy
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Si-Han Wang
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - Helen H. Vu
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - Cristina Puy
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - Monica T. Hinds
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - David Zonies
- Department of Surgery, Oregon Health and Science University, Portland, Oregon
| | - Owen J.T. McCarty
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| |
Collapse
|
3
|
Clauser S, Calmette L. [How to interpret and pursue a prolonged quick time or APTT]. Rev Med Interne 2024; 45:549-558. [PMID: 38811304 DOI: 10.1016/j.revmed.2024.05.002] [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: 11/15/2023] [Revised: 03/20/2024] [Accepted: 05/02/2024] [Indexed: 05/31/2024]
Abstract
The standard hemostasis workup [quick time (QT), and activated partial thrombin time (APTT)] is very commonly prescribed but its interpretation is often difficult for practitioners who are not specialized in hemostasis. Here, we review the principles of the diagnostic approach to these tests. Only a very basic knowledge of the coagulation cascade is necessary to identify which clotting factor tests to prescribe and to interpret the results. Deficiency in several clotting factors suggests liver dysfunction, disseminated intravascular coagulation (DIC) or vitamin K deficiency. If a single factor is deficient, we review the different causes of acquired deficiencies and briefly discuss the characteristics of the different congenital defects, which generally require specialized management. Lupus anticoagulant is a common and generally benign cause of prolonged APTT to be aware of, which is not related to a hemorrhagic risk. A good knowledge of the diagnostic approach to abnormal QT or APTT generally allows the resolution of the most common situations.
Collapse
Affiliation(s)
- S Clauser
- Service d'hématologie-immunologie-transfusion, hôpital Ambroise-Paré, AP-HP, 9, avenue Charles-de-Gaulle, 92104 Boulogne-Billancourt cedex, France; UFR des sciences de la santé Simone-Veil, université de Versailles Saint-Quentin-en-Yvelines, 2, avenue de la Source-de-la-Bièvre, 78180 Montigny-le-Bretonneux, France.
| | - L Calmette
- Service d'hématologie-immunologie-transfusion, hôpital Ambroise-Paré, AP-HP, 9, avenue Charles-de-Gaulle, 92104 Boulogne-Billancourt cedex, France
| |
Collapse
|
4
|
Ma T, Weng Z, Cao B, Dong Y, Deng C, Huang L, Yang Y, Wang Y, Shen C, Wang L, Shen K, Li J. The first-in-human study to assess the safety, tolerability, pharmacokinetics, and pharmacodynamics of the factor XI monoclonal antibody SHR-2004 in healthy subjects. Expert Opin Investig Drugs 2024:1-8. [PMID: 39166425 DOI: 10.1080/13543784.2024.2391837] [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: 05/12/2024] [Revised: 07/28/2024] [Accepted: 08/09/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Inhibiting the coagulation factor XI (FXI) is a novel strategy for prevention and treatment of thromboembolism without affecting extrinsic coagulation pathways. SHR-2004 is a humanized monoclonal antibody that selectively binds to FXI and factor XIa (FXIa). RESEARCH DESIGN & METHODS This randomized, double-blind, dose-escalation, placebo-controlled study evaluated SHR-2004 administered either intravenously (i.v.; Part A) or subcutaneously (s.c.; Part B). In Part A, 24 subjects received a single i.v. dose of SHR-2004 (0.1, 0.3, or 1.0 mg/kg) or placebo. In Part B, 40 subjects received a single s.c. dose of SHR-2004 (0.5, 1.0, 3.0, or 4.5 mg/kg) or placebo. RESULTS SHR-2004 was well tolerated. Plasma exposure to SHR-2004 increased in a dose-dependent manner. The geometric mean half-time ranged from 11.6 to 13.0 days. FXI activity decreased, and the activated partial thromboplastin time (APTT) was prolonged after i.v. and s.c. administration in a dose- and time-dependent manner. FXI activity was nearly completely abolished immediately after administering the highest i.v. dose, with the average APTT prolonged to nearly three times of baseline. CONCLUSION SHR-2004 is a promising candidate for further development as an anticoagulant drug that exerts effective anticoagulation with minimal risk of bleeding. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov identifier is NCT05369767.
Collapse
Affiliation(s)
- Tingting Ma
- Phase I Clinical Trials Unit, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zuyi Weng
- Phase I Clinical Trials Unit, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Bei Cao
- Phase I Clinical Trials Unit, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yanli Dong
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd., Shanghai, China
| | - Chanjuan Deng
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd., Shanghai, China
| | - Lei Huang
- Phase I Clinical Trials Unit, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yuanxun Yang
- Phase I Clinical Trials Unit, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yuqi Wang
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd., Shanghai, China
| | - Chenxi Shen
- Protein biology department, Beijing TUO JIE Biopharmaceutical Co. Ltd., Beijing, China
| | - Lei Wang
- Protein biology department, Beijing TUO JIE Biopharmaceutical Co. Ltd., Beijing, China
| | - Kai Shen
- Clinical Research & Development, Jiangsu Hengrui Pharmaceuticals Co., Ltd., Shanghai, China
| | - Juan Li
- Phase I Clinical Trials Unit, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| |
Collapse
|
5
|
Moshirfar M, Reynolds JC, Moin KA, Lim MY, Stoakes IM, Hoopes PC. Perioperative Recommendations for Corneal Refractive Surgery Patients With Inherited Bleeding Disorders. Cornea 2024:00003226-990000000-00633. [PMID: 39058250 DOI: 10.1097/ico.0000000000003631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024]
Abstract
PURPOSE To synthesize the current literature regarding patients with inherited bleeding disorders and suggest comprehensive evaluation and preoperative recommendations for these patients before undergoing corneal refractive surgery. METHODS The literature search was conducted through PubMed, Embase, and Google Scholar databases for publications through January 4, 2024 for reports of ocular bleeding manifestations in patients with inherited bleeding disorders and reports of patients without a history of bleeding disorders who had intraoperative or postoperative hemorrhagic complications with corneal refractive surgery. Additional cases from the literature and a retrospective chart review at a corneal practice were obtained describing patients with inherited bleeding disorders who underwent corneal refractive surgery. RESULTS Four articles were found detailing ocular bleeding manifestations in patients with inherited bleeding disorders who underwent ocular surgery other than corneal refractive surgery. Thirty articles were found detailing intraoperative and postoperative bleeding manifestations in patients without a history of inherited bleeding disorders who underwent corneal refractive surgery. Eight cases (3 patients from the literature search and 5 patients from a retrospective chart review) were found regarding patients with inherited bleeding disorders who underwent corneal refractive surgery. CONCLUSIONS For corneal refractive surgery with topical anesthesia, the perioperative risk and need for any hemostasis intervention in individuals with an inherited bleeding disorder depends on the type of disorder, status of preoperative factor level concentrations, or a prior history of bleeding. If required, clotting factor optimization should be tailored to each candidate on a case-by-case basis.
Collapse
Affiliation(s)
- Majid Moshirfar
- Hoopes Vision Research Center, Hoopes Vision, Draper, UT
- John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT
- Utah Lions Eye Bank, Murray, UT
| | | | - Kayvon A Moin
- Hoopes Vision Research Center, Hoopes Vision, Draper, UT
| | - Ming Y Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT; and
| | - Isabella M Stoakes
- Hoopes Vision Research Center, Hoopes Vision, Draper, UT
- Department of Ophthalmology, Kettering Health, Dayton, OH
| | | |
Collapse
|
6
|
Zhang K, Qin L, Xu F, Ye L, Wen M, Pan J, Yang L, Wang M, Xie H. The spectrum of factor XI deficiency in Southeast China: four recurrent variants can explain most of the deficiencies. Orphanet J Rare Dis 2024; 19:224. [PMID: 38835089 DOI: 10.1186/s13023-024-03235-5] [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: 02/13/2024] [Accepted: 05/27/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Factor XI (FXI) deficiency is an autosomal hemorrhagic disorder characterized by reduced plasma FXI levels. Multiple ancestral variants in the F11 gene have been identified in Ashkenazi Jews and other selected European populations. However, there are few reports of predominant variants in Chinese and/or East Asian populations. The aim of this study is to characterize the genotypes and phenotypes of FXI deficiency and identify the predominant variants. RESULTS Of the 41 FXI-deficient patients, 39 exhibited severe FXI defects, considerably more than those with partial defects. The APTT levels showed a negative correlation with FXI activity levels (coefficient=-0.584, P < .001). Only nine patients experienced mild bleeding, including one partially defective patient and eight severely defective patients. The majority of patients were referred for preoperative screenings (n = 22) and checkups (n = 14). Genetic analysis revealed that 90% of the patients had genetic defects, with 2, 16, and 19 cases of heterozygous, homozygous, and compound heterozygous patients, respectively. Seventeen variants were detected in the F11 gene (6 novel), including eleven missense variants, four nonsense variants, and two small deletions scattered throughout the F11. Of the 11 missense variants, six have not yet been studied for in vitro expression. Protein modeling analyses indicated that all of these variants disrupted local structural stability by altering side-chain orientation and hydrogen bonds. Nine variants, consisting of three missense and six null variants, were detected with a frequency of two or more. The highest allele frequency was observed in p.Q281* (21.25%), p.W246* (17.50%), p.Y369* (12.50%), and p.L442Cfs*8 (12.50%). The former two were variants specific to East Asia, while the remaining two were southeast China-specific variants. CONCLUSION Our population-based cohort demonstrated that no correlation between the level of FXI activity and the bleeding severity in FXI deficiency. Additionally, the prevalence of FXI deficiency may have been underestimated. The nonsense p.Q281* was the most common variant in southeast China, suggesting a possible founder effect.
Collapse
Affiliation(s)
- Ke Zhang
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Langyi Qin
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Fei Xu
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Longying Ye
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Mengzhen Wen
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Jingye Pan
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Lihong Yang
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Mingshan Wang
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
| | - Haixiao Xie
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
| |
Collapse
|
7
|
Vlădăreanu AM, Roşca A. Factor XI and coagulation. Factor XI inhibitors - antithrombotic perspectives. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2024; 62:91-100. [PMID: 38153875 DOI: 10.2478/rjim-2023-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Indexed: 12/30/2023]
Abstract
Factor XI is a zymogen with an important role in the coagulation cascade. It is activated by FXII, thrombin and or it can be autoactivated. It has a prothrombotic effect after being activated by thrombin, but also through its antifibrinolytic action, stabilizing the formed clot. Hereditary deficiency of FXI causes haemophilia C - a disease manifested by an usually provoked, small to moderate mucosal bleeding. People with severe FXI deficiency have a low risk of thrombotic events. Conversely, increased FXI values have been found to be associated with increased risk of venous thromboembolism and ischemic stroke. Lowering serum FXI levels has become a treatment target for the prevention of thrombotic events. New pharmacological agents - FXI inhibitors - have been investigated in phase II clinical trials, with promising results in terms of efficacy and safety in the prevention of thrombotic events. FXI inhibitors are emerging as new anticoagulant agents with broad indication prospects beyond direct oral anticoagulants and vitamin K antagonists.
Collapse
Affiliation(s)
- Ana-Maria Vlădăreanu
- 1"Carol Davila" University of Medicine and Pharmacy, Department of Hematology, Emergency University Hospital of Bucharest, Romania
| | - Adrian Roşca
- 2"Carol Davila" University of Medicine and Pharmacy, Department of Functional Sciences, Division of Physiology, Bucharest, Romania
| |
Collapse
|
8
|
Sucker C, Geisen C, Litmathe J, Zawislak B. Two cases of Factor XI deficiency: Use of Thrombin Generation Assays (TGA) to detect a non-bleeding phenotype. Arch Clin Cases 2024; 11:1-4. [PMID: 38655272 PMCID: PMC11034478 DOI: 10.22551/2024.42.1101.10277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Factor XI deficiency is a rare disorder of hemostasis. Previously also known as "hemophilia C", this defect has been regarded as a risk factor for bleeding. However, it has been known for long that bleeding tendency and severity of bleeding are not related to the residual factor XI activity in symptomatic patients. Moreover, a large proportion of patients with even severe factor XI deficiency are clinically unremarkable and do not show any signs of abnormal bleeding. Here, we present two cases of factor XI deficiency with a non-bleeding phenotype. Adequate diagnostic work-up and evaluation of the bleeding risk are reported and discussed with focus on thrombin generation assays (TGA) for the prediction of bleeding in affected patients. This is of high relevance in affected patients, particularly in the context of surgery.
Collapse
Affiliation(s)
- Christoph Sucker
- COAGUMED Coagulation Center, Berlin, Germany
- Medical School Brandenburg, Brandenburg an der Havel, Germany
| | - Christof Geisen
- Institute of Transfusion Medicine and Immunohematology, German Red Cross Blood Transfusion Service Baden Wuerttemberg-Hessen GmbH, Goethe University Hospital Frankfurt/Main, Frankfurt am Main, Germany
| | - Jens Litmathe
- Department of Emergency Medicine, Wesel Protestant Hospital, Wesel, Germany
| | | |
Collapse
|
9
|
Gailani D, Gruber A. Targeting factor XI and factor XIa to prevent thrombosis. Blood 2024; 143:1465-1475. [PMID: 38142404 PMCID: PMC11033593 DOI: 10.1182/blood.2023020722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/22/2023] [Accepted: 12/07/2023] [Indexed: 12/26/2023] Open
Abstract
ABSTRACT Direct oral anticoagulants (DOACs) that inhibit the coagulation proteases thrombin or factor Xa (FXa) have replaced warfarin and other vitamin K antagonists (VKAs) for most indications requiring long-term anticoagulation. In many clinical situations, DOACs are as effective as VKAs, cause less bleeding, and do not require laboratory monitoring. However, because DOACs target proteases that are required for hemostasis, their use increases the risk of serious bleeding. Concerns over therapy-related bleeding undoubtedly contribute to undertreatment of many patients who would benefit from anticoagulation therapy. There is considerable interest in the plasma zymogen factor XI (FXI) and its protease form factor XIa (FXIa) as drug targets for treating and preventing thrombosis. Laboratory and epidemiologic studies support the conclusion that FXI contributes to venous and arterial thrombosis. Based on 70 years of clinical observations of patients lacking FXI, it is anticipated that drugs targeting this protein will cause less severe bleeding than warfarin or DOACs. In phase 2 studies, drugs that inhibit FXI or FXIa prevent venous thromboembolism after total knee arthroplasty as well as, or better than, low molecular weight heparin. Patients with heart disease on FXI or FXIa inhibitors experienced less bleeding than patients taking DOACs. Based on these early results, phase 3 trials have been initiated that compare drugs targeting FXI and FXIa to standard treatments or placebo. Here, we review the contributions of FXI to normal and abnormal coagulation and discuss results from preclinical, nonclinical, and clinical studies of FXI and FXIa inhibitors.
Collapse
Affiliation(s)
- David Gailani
- The Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | | |
Collapse
|
10
|
Barg AA, Livnat T, Kenet G. Factor XI deficiency: phenotypic age-related considerations and clinical approach towards bleeding risk assessment. Blood 2024; 143:1455-1464. [PMID: 38194679 DOI: 10.1182/blood.2023020721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 12/22/2023] [Accepted: 12/29/2023] [Indexed: 01/11/2024] Open
Abstract
ABSTRACT Factor XI (FXI) deficiency is a rare bleeding disorder that presents complex challenges in patient assessment and bleeding risk management. Despite generally causing mild to moderate bleeding symptoms, clinical manifestations can vary, and bleeding tendency does not always correlate with FXI plasma levels or genotype. Our manuscript delves into the age-related nuances of FXI deficiency across an individual's lifespan. We emphasize issues faced by specific groups, including neonates and females of reproductive age experiencing abnormal uterine bleeding and postpartum hemorrhage. Older patients present unique challenges and concerns related to the management of bleeding as well as thrombotic complications. The current assortment of diagnostic laboratory assays shows limited success in predicting bleeding risk in the perisurgical setting of patients with FXI deficiency. This review explores the intricate interplay between individual bleeding profiles, surgical sites, and FXI activity levels. We also evaluate the accuracy of existing laboratory assays in predicting bleeding and discuss the potential role of investigational global assays in perioperative assessment. Furthermore, we outline our suggested diagnostic approach to refine treatment strategies and decision making. Available treatment options are presented, including antifibrinolytics, replacement products, and recombinant activated FVII. Finally, we discuss promising nonreplacement therapies for the treatment of rare bleeding disorders that can potentially address the challenges faced when managing FXI deficiency-related bleeding complications.
Collapse
Affiliation(s)
- Assaf Arie Barg
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Livnat
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Hemophilia Center, Coagulation Unit and Amalia Biron Research Institution of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
11
|
Gallego-Fabrega C, Temprano-Sagrera G, Cárcel-Márquez J, Muiño E, Cullell N, Lledós M, Llucià-Carol L, Martin-Campos JM, Sobrino T, Castillo J, Millán M, Muñoz-Narbona L, López-Cancio E, Ribó M, Alvarez-Sabin J, Jiménez-Conde J, Roquer J, Tur S, Obach V, Arenillas JF, Segura T, Serrano-Heras G, Marti-Fabregas J, Freijo-Guerrero M, Moniche F, Castellanos MDM, Morrison AC, Smith NL, de Vries PS, Fernández-Cadenas I, Sabater-Lleal M. A multitrait genetic study of hemostatic factors and hemorrhagic transformation after stroke treatment. J Thromb Haemost 2024; 22:936-950. [PMID: 38103737 PMCID: PMC11103592 DOI: 10.1016/j.jtha.2023.11.027] [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: 07/07/2023] [Revised: 11/08/2023] [Accepted: 11/27/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Thrombolytic recombinant tissue plasminogen activator (r-tPA) treatment is the only pharmacologic intervention available in the ischemic stroke acute phase. This treatment is associated with an increased risk of intracerebral hemorrhages, known as hemorrhagic transformations (HTs), which worsen the patient's prognosis. OBJECTIVES To investigate the association between genetically determined natural hemostatic factors' levels and increased risk of HT after r-tPA treatment. METHODS Using data from genome-wide association studies on the risk of HT after r-tPA treatment and data on 7 hemostatic factors (factor [F]VII, FVIII, von Willebrand factor [VWF], FXI, fibrinogen, plasminogen activator inhibitor-1, and tissue plasminogen activator), we performed local and global genetic correlation estimation multitrait analyses and colocalization and 2-sample Mendelian randomization analyses between hemostatic factors and HT. RESULTS Local correlations identified a genomic region on chromosome 16 with shared covariance: fibrinogen-HT, P = 2.45 × 10-11. Multitrait analysis between fibrinogen-HT revealed 3 loci that simultaneously regulate circulating levels of fibrinogen and risk of HT: rs56026866 (PLXND1), P = 8.80 × 10-10; rs1421067 (CHD9), P = 1.81 × 10-14; and rs34780449, near ROBO1 gene, P = 1.64 × 10-8. Multitrait analysis between VWF-HT showed a novel common association regulating VWF and risk of HT after r-tPA at rs10942300 (ZNF366), P = 1.81 × 10-14. Mendelian randomization analysis did not find significant causal associations, although a nominal association was observed for FXI-HT (inverse-variance weighted estimate [SE], 0.07 [-0.29 to 0.00]; odds ratio, 0.87; 95% CI, 0.75-1.00; raw P = .05). CONCLUSION We identified 4 shared loci between hemostatic factors and HT after r-tPA treatment, suggesting common regulatory mechanisms between fibrinogen and VWF levels and HT. Further research to determine a possible mediating effect of fibrinogen on HT risk is needed.
Collapse
Affiliation(s)
- Cristina Gallego-Fabrega
- Stroke Pharmacogenomics and Genetics Group, Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain. https://twitter.com/FabregaGallego
| | - Gerard Temprano-Sagrera
- Genomics of Complex Disease Group, Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
| | - Jara Cárcel-Márquez
- Stroke Pharmacogenomics and Genetics Group, Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
| | - Elena Muiño
- Stroke Pharmacogenomics and Genetics Group, Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
| | - Natalia Cullell
- Stroke Pharmacogenomics and Genetics Group, Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain; Neurology Unit, Hospital Universitari MútuaTerrassa, Terrassa, Spain
| | - Miquel Lledós
- Stroke Pharmacogenomics and Genetics Group, Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
| | - Laia Llucià-Carol
- Stroke Pharmacogenomics and Genetics Group, Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
| | - Jesús M Martin-Campos
- Stroke Pharmacogenomics and Genetics Group, Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
| | - Tomás Sobrino
- Clinical Neurosciences Research Laboratories, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - José Castillo
- Department of Neurology, Hospital Clínico Universitario de Santiago (CHUS), Santiago de Compostela, Spain
| | - Mònica Millán
- Department of Neuroscience, Hospital Universitario Hermanos Trias y Pujol (HUGTP), Badalona, Spain
| | - Lucía Muñoz-Narbona
- Department of Neuroscience, Hospital Universitario Hermanos Trias y Pujol (HUGTP), Badalona, Spain
| | - Elena López-Cancio
- Stroke Unit, Neurology Department, Hospital Universitario Central de Asturias (HUCA), Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Marc Ribó
- Stroke Unit, Hospital Universitario Valle de Hebrón (HUVH), Barcelona, Spain
| | - Jose Alvarez-Sabin
- Department of Neurology, Hospital Universitario Valle de Hebrón (HUVH), Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Jordi Jiménez-Conde
- Department of Neurology, Neurovascular Research Group, Instituto de investigaciones médicas Hospital del Mar (IMIM) Hospital del Mar, Barcelona, Spain
| | - Jaume Roquer
- Department of Neurology, Neurovascular Research Group, Instituto de investigaciones médicas Hospital del Mar (IMIM) Hospital del Mar, Barcelona, Spain
| | - Silvia Tur
- Department of Neurology, Hospital Universitario Son Espases (HUSE), Mallorca, Spain
| | - Victor Obach
- Department of Neurology, Hospital Clínic i Provincial de Barcelona, Barcelona, Spain
| | - Juan F Arenillas
- Department of Neurology, Hospital Clínico Universitario, University of Valladolid, Valladolid, Spain
| | - Tomas Segura
- Department of Neurology, Complejo Hospitalario Universitario de Albacete (CHUA), Universidad de Castilla-La Mancha (UCLM), Albacete, Spain
| | - Gemma Serrano-Heras
- Research Unit, Complejo Hospital Universitario de Albacete (CHUA), Albacete, Spain
| | - Joan Marti-Fabregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
| | | | - Francisco Moniche
- Department of Neurology, Hospital Universitario Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS), Seville, Spain
| | - Maria Del Mar Castellanos
- Department of Neurology, Hospital Universitario de A Coruña (CHUAC), Biomedical Research Institute, A Coruña, Spain
| | - Alanna C Morrison
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Nicholas L Smith
- Department of Epidemiology, University of Washington, Seattle, Washington, USA; Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA; Department of Veterans Affairs Office of Research and Development, Seattle Epidemiologic Research and Information Center, Seattle, Washington, USA
| | - Paul S de Vries
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, the University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Israel Fernández-Cadenas
- Stroke Pharmacogenomics and Genetics Group, Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain.
| | - Maria Sabater-Lleal
- Genomics of Complex Disease Group, Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain; Cardiovascular Medicine Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
| |
Collapse
|
12
|
El Hassouni F, Bentaleb A, Lahbabi S, Tachinante R, Elkhorassani M, Yousfi M. Management of severe factor XI deficiency in pregnancy: A case report. SAGE Open Med Case Rep 2024; 12:2050313X241241196. [PMID: 38505580 PMCID: PMC10949538 DOI: 10.1177/2050313x241241196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/06/2024] [Indexed: 03/21/2024] Open
Abstract
Factor XI (FXI) deficiency is one of the rarest coagulation disorders with a frequency of 1:1,000,000. A 30-year-old woman, diagnosed with FXI deficiency at the age of 4, was admitted to our maternity service at 25 weeks of gestation. The patient had no history of hemorrhage or abnormal bleeding, and the clinical examination was unremarkable. Antenatal care was also normal. The parturient was admitted in early labor at 38 weeks of gestation. Despite the absence of clinical hemorrhagic syndrome, a transfusion of fresh frozen plasma combined with tranexamic acid was initiated once the active stage of labor was started. Management of FXI deficiency in pregnant women is a challenge due to its unpredictable bleeding tendency, and careful planning and knowledge of appropriate hemostatic management is pivotal for their care.
Collapse
Affiliation(s)
- Fatima El Hassouni
- Department of Obstetrics and Gynaecology, Oncology and High Risk Pregnancies, Maternity Hospital Souissi, Ibn Sina Teaching Hospital, Rabat, Morocco
| | - Asmae Bentaleb
- Department of Obstetrics and Gynaecology, Oncology and High Risk Pregnancies, Maternity Hospital Souissi, Ibn Sina Teaching Hospital, Rabat, Morocco
| | - Sofia Lahbabi
- Department of Intensive Care Unit, Maternity Hospital IBN SINA, Rabat, Morocco
| | - Rajae Tachinante
- Department of Intensive Care Unit, Maternity Hospital IBN SINA, Rabat, Morocco
| | - Mohamed Elkhorassani
- Haemophilia Treatment Centre, Haematology and Oncology Unit, Mohammed V University Hospital, Rabat, Morocco
| | - Mounia Yousfi
- Department of Obstetrics and Gynaecology, Oncology and High Risk Pregnancies, Maternity Hospital Souissi, Ibn Sina Teaching Hospital, Rabat, Morocco
| |
Collapse
|
13
|
Tian Y, Zheng Z, Song N, Wang J. One case of surgical treatment of coagulation factor XI deficiency complicated with esophageal cancer: a case report. J Cardiothorac Surg 2024; 19:40. [PMID: 38303013 PMCID: PMC10835910 DOI: 10.1186/s13019-024-02494-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/14/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Coagulation factor XI deficiency is an autosomal recessive hereditary disease with a low incidence. It usually occurs after surgery or trauma; Esophageal cancer is a common malignant tumor of the digestive tract in China. But so far, surgery-based comprehensive treatment of esophageal cancer still dominates. CASE PRESENTATION We report a case of an Asian patient with XI factor deficiency and lower esophageal squamous cell carcinoma who was admitted to our hospital recently. After active preoperative preparation, the operation was successfully performed, and there was no obvious abnormal bleeding during and after the operation. CONCLUSIONS Coagulation factor XI deficiency is a relatively rare disease, and patients with the disease will face a greater risk of bleeding during the perioperative period. The encouraging perioperative outcome enables us to have a deeper understanding of surgical treatment strategies for patients with Coagulation factor XI deficiency.
Collapse
Affiliation(s)
- Yang Tian
- Department of Cardiothoracic Surgery, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, 310000, China
| | - Zhaowei Zheng
- Department of Cardiothoracic Surgery, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, 310000, China
| | - Nannan Song
- Department of Cardiothoracic Surgery, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, 310000, China
| | - Jun Wang
- Department of Cardiothoracic Surgery, Hangzhou Hospital of Traditional Chinese Medicine, Hangzhou, 310000, China.
| |
Collapse
|
14
|
Prakash S, Mares AC, Porres-Aguilar M, Mukherjee D, Barnes GD. Factor XI/XIa inhibitors for the prevention and treatment of venous and arterial thromboembolism: A narrative review. Vasc Med 2024; 29:85-92. [PMID: 37947131 DOI: 10.1177/1358863x231206778] [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] [Indexed: 11/12/2023]
Abstract
During the past decade, direct oral anticoagulants (DOACs) have advanced and simplified the prevention and treatment of venous thromboembolism (VTE). However, there remains a high incidence of bleeds, which calls for agents that have a reduced risk of bleeding. Factor XI (FXI) deficiency is associated with lower rates of venous thrombosis and stroke compared to the general population with a lower risk of bleeding. In conjunction with this, phase 2 studies have demonstrated safety and the potential for reduced thrombotic events with FXI inhibitors as compared to currently available medications. The aim of this review is to summarize key data on the clinical pharmacology of FXI, the latest developments in clinical trials of FXI inhibitors, and to describe the efficacy and safety profiles of FXI inhibitors for the prevention of venous and arterial thromboembolism.
Collapse
Affiliation(s)
- Swathi Prakash
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Adriana C Mares
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Mateo Porres-Aguilar
- Department of Internal Medicine, Divisions of Hospital and Adult Thrombosis Medicine, Texas Tech University Health Sciences Center and Paul L Foster School of Medicine, El Paso, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center and Paul L Foster School of Medicine, El Paso, TX, USA
| | - Geoffrey D Barnes
- Department of Internal Medicine, Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
15
|
Páramo JA, Marcos-Jubilar M. [Factor XI inhibitors: A new era in antithrombotic therapy]. Med Clin (Barc) 2024; 162:73-76. [PMID: 37863734 DOI: 10.1016/j.medcli.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 10/22/2023]
Affiliation(s)
- José A Páramo
- Servicio de Hematología y Hemoterapia, Clínica Universidad de Navarra, Pamplona, España.
| | - María Marcos-Jubilar
- Servicio de Hematología y Hemoterapia, Clínica Universidad de Navarra, Pamplona, España
| |
Collapse
|
16
|
Tarandovskiy ID, Ovanesov MV. The effect of factor XIa on thrombin and plasmin generation, clot formation, lysis and density in coagulation factors deficiencies. Thromb Res 2024; 233:189-199. [PMID: 38101192 DOI: 10.1016/j.thromres.2023.11.024] [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: 06/07/2023] [Revised: 08/21/2023] [Accepted: 11/22/2023] [Indexed: 12/17/2023]
Abstract
INTRODUCTION Growing evidence supports the importance of factor (F) XI activation for thrombosis and hemostasis as well as inflammation and complement systems. In this study, we evaluated the effect of activated FXI (FXIa) on the detection of factor deficiencies by global hemostasis assays of thrombin generation (TG), plasmin generation (PG), and clot formation and lysis (CFL). MATERIALS AND METHODS An absorbance and fluorescence microplate assay was used to simultaneously observe TG, PG, and CFL in FV-, FVII-, FVIII-, and FIX-deficient plasmas supplemented with purified factors. Coagulation was initiated with tissue factor with or without FXIa in the presence of tissue plasminogen activator. Thrombin and plasmin peak heights (TPH and PPH), maximal clot density (MCD), times to clotting (CT), thrombin and plasmin peaks (TPT and PPT) and clot lysis (LyT) and a new parameter, clot lifetime (LiT), were evaluated. RESULTS TG/CFL were elevated by the FXIa at low FV (below 0.1 IU/mL), and at FVIII and FIX above 0.01 IU/mL. FXIa affected PG only at low FV and FVII. At high factor concentrations, FXIa reduced MCD. Thrombin and plasmin substrates had effect on CT, LyT, LiT and MCD parameters. CONCLUSIONS FXIa reveals new relationships between TG, PG and CFL parameters in factor deficiencies suggesting potential benefits for discrimination of bleeding phenotypes.
Collapse
Affiliation(s)
- Ivan D Tarandovskiy
- Center of Biologics Evaluation and Research, U.S. Food and Drug Administration, United States of America
| | - Mikhail V Ovanesov
- Center of Biologics Evaluation and Research, U.S. Food and Drug Administration, United States of America.
| |
Collapse
|
17
|
Grabowska K, Grzelak M, Zhao LY, Płuciennik E, Pasieka Z, Kciuk M, Gielecińska A, Smakosz AK, Kałuzińska-Kołat Ż, Kołat D. Emicizumab as a Promising Form of Therapy for Type A Hemophilia - A Review of Current Knowledge from Clinical Trials. Curr Protein Pept Sci 2024; 25:719-737. [PMID: 38797909 DOI: 10.2174/0113892037294674240509094418] [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: 01/31/2024] [Revised: 04/05/2024] [Accepted: 04/16/2024] [Indexed: 05/29/2024]
Abstract
Hemophilia is a plasma bleeding disorder characterized by a deficiency of certain blood clotting factors. The most common forms of this disease, i.e., type A and type B, affect approximately 400,000 people worldwide. Without appropriate treatment ensuring the proper coagulation cascade, this disease may lead to serious disability. Minimizing patient discomfort is possible via replacement therapy, consisting of the substitution of a missing coagulation factor via intravenous administration. Frequent medication and the risk related to factor inhibitors are significant disadvantages, necessitating the improvement of current therapies or the development of novel ones. This review examines the humanized bispecific antibody Emicizumab which ensures hemostasis by mimicking the action of the coagulation factor VIII, a deficiency of which causes type A hemophilia. The paper outlines the topic and then summarizes available clinical trials on Emicizumab in type A hemophilia. Several interventional clinical trials have found Emicizumab to be effective in decreasing bleeding episodes and raising patient satisfaction among various hemophilia A populations. Current Emicizumab-related trials are forecast to be completed between 2024 and 2030, and in addition to congenital hemophilia A, the trials cover acquired hemophilia A and patients playing sports. Providing a more comprehensive understanding of Emicizumab may revolutionize the management of hemophilia type A and improve quality of life. Conclusively, Emicizumab is a gentler therapy owing to subcutaneous delivery and fewer injections, which reduces injection-site reactions and makes therapy less burdensome, ultimately decreasing hospital visits and indirect costs.
Collapse
Affiliation(s)
- Katarzyna Grabowska
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
| | - Michalina Grzelak
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
| | - Lin-Yong Zhao
- Department of General Surgery & Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy/Collaborative Innovation Center of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Elżbieta Płuciennik
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
| | - Zbigniew Pasieka
- Department of Biomedicine and Experimental Surgery, Medical University of Lodz, Narutowicza 60, 90-136, Lodz, Poland
| | - Mateusz Kciuk
- Department of Molecular Biotechnology and Genetics, University of Lodz, Banacha 12/16, 90-237, Lodz, Poland
| | - Adrianna Gielecińska
- Department of Molecular Biotechnology and Genetics, University of Lodz, Banacha 12/16, 90-237, Lodz, Poland
- Doctoral School of Exact and Natural Sciences, University of Lodz, Banacha 12/16, 90-237, Lodz, Poland
| | - Aleksander K Smakosz
- Department of Pharmaceutical Biology and Biotechnology, Wroclaw Medical University, 50-367, Wroclaw, Poland
| | - Żaneta Kałuzińska-Kołat
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
- Department of Biomedicine and Experimental Surgery, Medical University of Lodz, Narutowicza 60, 90-136, Lodz, Poland
| | - Damian Kołat
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
- Department of Biomedicine and Experimental Surgery, Medical University of Lodz, Narutowicza 60, 90-136, Lodz, Poland
| |
Collapse
|
18
|
James AH. Management of pregnant women who have bleeding disorders. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:229-236. [PMID: 38066866 PMCID: PMC10727034 DOI: 10.1182/hematology.2023000475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Bleeding disorders, including von Willebrand disease (VWD), hemophilia, other coagulation factor deficiencies, platelet disorders, defects of fibrinolysis, and connective tissue disorders, have both maternal and fetal implications. Successful management of bleeding disorders in pregnant women requires not only an understanding of bleeding disorders but also an understanding of when and how bleeding occurs in pregnancy. Bleeding does not occur during a normal pregnancy with a healthy placenta. Bleeding occurs during pregnancy when there is an interruption of the normal utero-placental interface, during miscarriage, during an ectopic pregnancy, or at the time of placental separation at the conclusion of pregnancy. Although mild platelet defects may be more prevalent, the most commonly diagnosed bleeding disorder among women is VWD. Other bleeding disorders are less common, but hemophilia carriers are unique in that they are at risk of bleeding themselves and of giving birth to an affected male infant. General guidance for maternal management of a woman who is moderately or severely affected includes obtaining coagulation factor levels at a minimum in the third trimester; planning for delivery at a center with hemostasis expertise; and anticipating the need for hemostatic agents. General guidance for fetal management includes pre-pregnancy counseling; the option of preimplantation genetic testing for hemophilia; delivery at a tertiary care center with pediatric hematology and newborn intensive care; consideration of cesarean delivery of a potentially severely affected infant; and avoidance of invasive procedures such as scalp electrodes and operative vaginal delivery in any potentially affected infant.
Collapse
Affiliation(s)
- Andra H. James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology; and Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, NC
| |
Collapse
|
19
|
Rousseau F, Guillet B, Mura T, Fournel A, Volot F, Chambost H, Suchon P, Frotscher B, Biron-Andréani C, Marlu R, Hezard N, Clayssens S, Boissier E, Blanc-Jouvan F, Chamouni P, Tieulie N, Rugeri L, Borel-Derlon A, de Raucourt E, Martin-Toutain I, Castet S, Lebreton A, Girault S, Helley-Russick D, D’Oiron R, Schved JF, Giansily-Blaizot M. Surgery in rare bleeding disorders: the prospective MARACHI study. Res Pract Thromb Haemost 2023; 7:102199. [PMID: 37867585 PMCID: PMC10585326 DOI: 10.1016/j.rpth.2023.102199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 10/24/2023] Open
Abstract
Background Despite the wide use of bleeding scores and the reliability of clotting factor level measurement, bleeding risk stratification before surgery remains challenging in patients with rare inherited bleeding disorders. Objectives This multicenter observational prospective study assessed in patients with rare coagulation factor deficiency, the perioperative hemostatic management choices by hemostasis experts and the bleeding outcomes after surgery. Methods One hundred seventy-eight patients with low coagulation activity level (factor [F] II, FV, combined FV-FVIII, FVII, FX, or FXI <50%) underwent 207 surgical procedures. The bleeding outcome, Tosetto's bleeding score, and perioperative hemostatic protocols were collected. Results Among the 81 procedures performed in patients with severe factor deficiency (level ≤10%), 27 were done without factor replacement (including 6 in patients at high bleeding risk), without any bleeding event. Factor replacement therapy was used mainly for orthopedic procedures. In patients with mild deficiency, 100/126 surgical procedures were carried out without perioperative hemostatic treatment. In patients with FVII or FXI deficiency, factor replacement therapy was in function of the procedure, bleeding risk, and to a lesser extent previous bleeding history. Tranexamic acid was used in almost half of the procedures, particularly in case of surgery in tissues with high fibrinolytic activity (76.8%). Conclusions The current perioperative hemostatic management of patients with rare bleeding disorders appears to be adapted. Among the 207 procedures, only 6 were associated with excessive bleeding. Our findings suggest that rather than the bleeding score, factor level and surgery type are the most relevant criteria for perioperative factor replacement therapy.
Collapse
Affiliation(s)
- Florence Rousseau
- Département d’hématologie biologique, CHU Montpellier, France
- CRC-MHC, CHU Montpellier, France
| | - Benoit Guillet
- Haemophilia Treatment Center, University Hospital, Rennes, France and Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000 Rennes, France
| | - Thibault Mura
- Département d’informatique médicale, CHU Montpellier, CHU Nîmes, Université de Montpellier FR 34090, France
| | - Alexandra Fournel
- Haemophilia Treatment Centre, University Hospital of Besançon, Besançon, France
| | | | | | - Pierre Suchon
- Aix Marseille University, Inserm, Inrae, C2VN, Marseille, France
| | - Brigit Frotscher
- Haemophilia Treatment Centre, University Hospital of Nancy, France
| | | | - Raphaël Marlu
- Hemostasis Unit, CHU Grenoble Alpes, Université Grenoble Alpes, France
| | - Nathalie Hezard
- Laboratoire d’hématologie, CHU Reims, France
- Laboratoire d’hématologie AP-HM Marseille, France
| | | | | | | | | | | | - Lucia Rugeri
- Unité Hémostase Clinique, Hospices Civils de Lyon, France
| | | | | | | | | | - Aurélien Lebreton
- Laboratoire d’hématologie, CHU Clermont Ferrand, Unité de Nutrition Humaine UMR1019, INRAE / Université Clermont Auvergne, Clermont-Ferrand, France
| | | | | | - Roseline D’Oiron
- Centre de référence de l’hémophilie et des maladies hémorragiques constitutionnelles, Hôpital Bicêtre, APHP and Hith, UMR_S1176, INSERM, Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Jean-François Schved
- Département d’hématologie biologique, CHU Montpellier, France
- CRC-MHC, CHU Montpellier, France
| | - Muriel Giansily-Blaizot
- Département d’hématologie biologique, CHU Montpellier, France
- Université Montpellier d’excellence, Montpellier, France
| |
Collapse
|
20
|
Spiezia L, Forestan C, Campello E, Simion C, Simioni P. Persistently High Levels of Coagulation Factor XI as a Risk Factor for Venous Thrombosis. J Clin Med 2023; 12:4890. [PMID: 37568292 PMCID: PMC10420025 DOI: 10.3390/jcm12154890] [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: 06/06/2023] [Revised: 07/12/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
Coagulation factor XI (FXI) promotes fibrin formation and inhibits fibrinolysis. Elevated plasma FXI levels, limited to a single measurement, are associated with a higher thrombotic risk. Our case-control study aimed to identify the effect of persistently increased plasma FXI levels on the risk of deep vein thrombosis (DVT). All patients evaluated between January 2016 and January 2018 for a first episode of proximal DVT of the lower extremity were considered for enrolment. Plasma FXI levels were measured at least 1 month after the discontinuation of anticoagulant treatment (T1). The patients with increased plasma FXI levels (>90th percentile of controls) were tested again 3 months later (T2). Among the 200 enrolled patients (M/F 114/86, age range 26-87 years), 47 patients had increased plasma FXI levels at T1 and16 patients had persistently increased plasma FXI levels at T2. The adjusted odds ratio for DVT was 2.4 (95% CI, 1.3 to 5.5, p < 0.001) for patients with increased FXI levels at T1 and 5.2 (95% CI, 2.3 to 13.2, p < 0.001) for patients with persistently high FXI levels at T2. Elevated FXI levels constitute a risk factor for deep vein thrombosis, and this risk nearly doubled in patients with persistently increased plasma FXI levels. Larger prospective studies are needed to confirm our findings.
Collapse
Affiliation(s)
- Luca Spiezia
- General Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, University of Padova, 35138 Padova, Italy; (C.F.); (E.C.); (C.S.); (P.S.)
| | | | | | | | | |
Collapse
|
21
|
Sucker C, Geisen C, Litmathe J, Schmitt U. Concomitant hypofibrinogenemia and factor XI deficiency as rare cause of bleeding during urgent dentistry: case report and short review of the literature. Arch Clin Cases 2023; 10:110-113. [PMID: 37405328 PMCID: PMC10315684 DOI: 10.22551/2023.39.1002.10253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
Hypofibrinogenemia and Factor XI deficiency are rare defects of hemostasis, potentially leading to spontaneous bleeding manifestations and increased bleeding risk during surgery, dentistry, and interventions. Due to the different mode of inheritance, the concomitance of both defects is extremely rare and the clinical management of combined hypofibrinogenemia and factor XI deficiency is not standardized. Here, we report a rare case of concomitant genetically determined hypofibrinogenemia and factor XI deficiency as a cause of increased spontaneous bleeding and bleeding complications during dentistry. The diagnostic procedure including screening assays, single clotting factor determinations, genetic analyses, and also use of thrombin generation assays (TGA) are described. Also, we present our considerations regarding the development of an adequate prophylaxis of bleeding with fibrinogen concentrate in this case. The literature regarding the issue is briefly discussed.
Collapse
Affiliation(s)
- Christoph Sucker
- Coagumed Coagulation Center, Berlin, Germany
- Medical School Brandenburg, Brandenburg an der Havel, Germany
| | - Christof Geisen
- Institute of Transfusion Medicine and Immunohaematology, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen gGmbH, Goethe University Hospital Frankfurt/Main, Frankfurt am Main, Germany
| | - Jens Litmathe
- Emergency Department, Wesel Protestant Medical Center, Wesel, Germany
| | | |
Collapse
|
22
|
Livanou ME, Matsas A, Valsami S, Papadimitriou DT, Kontogiannis A, Christopoulos P. Clotting Factor Deficiencies as an Underlying Cause of Abnormal Uterine Bleeding in Women of Reproductive Age: A Literature Review. Life (Basel) 2023; 13:1321. [PMID: 37374104 DOI: 10.3390/life13061321] [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: 04/25/2023] [Revised: 05/27/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023] Open
Abstract
Clotting Factor deficiencies are rare disorders with variations in clinical presentation and severity of symptoms ranging from asymptomatic to mild to life-threatening bleeding. Thus, they pose a diagnostic and therapeutic challenge, mainly for the primary health care providers, general practitioners, and gynecologists who are more likely to first encounter these patients. An additional diagnostic challenge arises from the variable laboratory presentations, as PT, PTT, and BT are not always affected. The morbidity is higher among women of reproductive age since Abnormal Uterine Bleeding-specifically Heavy Menstrual Bleeding-is one of the most prevalent manifestations of these disorders, and in some cases of severe deficiencies has led to life-threatening episodes of bleeding requiring blood transfusions or even immediate surgical intervention. Physician awareness is important as, in the case of some of these disorders-i.e., Factor XIII deficiency-prophylactic treatment is available and recommended. Although uncommon, the potential for rare bleeding disorders and for hemophilia carrier states should be considered in women with HMB, after more prevalent causes have been excluded. Currently, there is no consensus on the management of women in these instances and it is reliant on the physicians' knowledge.
Collapse
Affiliation(s)
- Maria Effrosyni Livanou
- Second Department of Obstetrics and Gynecology, "Aretaieion" Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Alkis Matsas
- Second Department of Obstetrics and Gynecology, "Aretaieion" Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Serena Valsami
- Hematology Laboratory-Blood Bank, Aretaieion Hospital, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Dimitrios T Papadimitriou
- Second Department of Obstetrics and Gynecology, "Aretaieion" Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Athanasios Kontogiannis
- Second Department of Obstetrics and Gynecology, "Aretaieion" Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Panagiotis Christopoulos
- Second Department of Obstetrics and Gynecology, "Aretaieion" Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| |
Collapse
|
23
|
Alito A, Bellone F, Portaro S, Leonardi G, Cannavò V, Coppini F, Leonetti D, Catalano A, Squadrito G, Fenga D. Haemophilia and Fragility Fractures: From Pathogenesis to Multidisciplinary Approach. Int J Mol Sci 2023; 24:ijms24119395. [PMID: 37298347 DOI: 10.3390/ijms24119395] [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: 04/21/2023] [Revised: 05/13/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
Haemophilia A (HA) and haemophilia B (HB) are X-linked inherited bleeding disorders caused by the absence or deficiency of coagulation factors VIII (FVIII) and IX (FIX), respectively. Recent advances in the development of effective treatments for haemophilia have led to a significant increase in life expectancy. As a result, the incidence of some comorbidities, including fragility fractures, has increased in people with haemophilia (PWH). The aim of our research was to perform a review of the literature investigating the pathogenesis and multidisciplinary management of fractures in PWH. The PubMed, Scopus and Cochrane Library databases were searched to identify original research articles, meta-analyses, and scientific reviews on fragility fractures in PWH. The mechanism underlying bone loss in PWH is multifactorial and includes recurrent joint bleeding, reduced physical activity with consequent reduction in mechanical load, nutritional deficiencies (particularly vitamin D), and FVIII and FIX deficiency. Pharmacological treatment of fractures in PWH includes antiresorptive, anabolic and dual action drugs. When conservative management is not possible, surgery is the preferred option, particularly in severe arthropathy, and rehabilitation is a key component in restoring function and maintaining mobility. Appropriate multidisciplinary fracture management and an adapted and tailored rehabilitation pathway are essential to improve the quality of life of PWH and prevent long-term complications. Further clinical trials are needed to improve the management of fractures in PWH.
Collapse
Affiliation(s)
- Angelo Alito
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98100 Messina, Italy
| | - Federica Bellone
- Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 1, 98100 Messina, Italy
| | - Simona Portaro
- Department of Physical and Rehabilitation Medicine, University Hospital "G. Martino", 98100 Messina, Italy
| | - Giulia Leonardi
- Department of Physical and Rehabilitation Medicine, University Hospital "G. Martino", 98100 Messina, Italy
| | - Vittorio Cannavò
- Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 1, 98100 Messina, Italy
| | - Francesca Coppini
- Department of Orthopaedics and Traumatology, University Hospital A.O.U. "G. Martino", 98100 Messina, Italy
| | - Danilo Leonetti
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98100 Messina, Italy
| | - Antonino Catalano
- Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 1, 98100 Messina, Italy
| | - Giovanni Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Via Consolare Valeria, 1, 98100 Messina, Italy
| | - Domenico Fenga
- Department of Orthopaedics and Traumatology, University Hospital A.O.U. "G. Martino", 98100 Messina, Italy
| |
Collapse
|
24
|
Honda S, Shimahara Y, Chikasawa Y, Ogino H. Hemostatic protocol and risk-reduction surgery for treating coronary artery disease with aortic stenosis in a patient with combined coagulation factor VIII and XI deficiency: a case report. Eur Heart J Case Rep 2023; 7:ytad219. [PMID: 37168362 PMCID: PMC10166512 DOI: 10.1093/ehjcr/ytad219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/25/2023] [Accepted: 04/24/2023] [Indexed: 05/13/2023]
Abstract
Background Cardiac surgery remains a significant challenge in patients with coagulation factor VIII (FVIII) deficiency, especially in those with multiple factor deficiencies. Case summary A 79-year-old man with combined FVIII and factor XI (FXI) deficiency was admitted for heart failure treatment. Transthoracic echocardiography revealed aortic stenosis (AS) with decreased left ventricular ejection fraction (LVEF) of 40%, mean aortic pressure gradient of 21 mmHg, and aortic valve area of 0.58 cm2. Coronary angiography revealed significant triple-vessel disease. The patient had multiple comorbidities, including diabetic end-stage renal disease treated with hemodialysis and liver cirrhosis (Child-Pugh score of A). Considering the high surgical risk, a two-stage treatment strategy was developed: the first with off-pump coronary artery bypass grafting (CABG), and the second with transcatheter aortic valve implantation if AS symptoms were significant after CABG. A perioperative hemostatic protocol by the author's heart team was used to appropriately replenish recombinant FVIII concentrates and fresh frozen plasma. The target preoperative and postoperative FVIII coagulation activity values were set at 80-100% and 60-80%, respectively, whereas the target perioperative FXI coagulation activity value was set at 30-45%. Off-pump CABG without aortic manipulation was completed without bleeding events. Transthoracic echocardiography conducted 20 months postoperatively revealed LVEF of 65% and mean aortic pressure gradient of 31 mmHg. The patient leads a normal life 21 months after surgery. Discussion The hemostatic protocol and risk-reduction surgery provided satisfactory surgical results in a patient with significant coronary artery disease and AS, high-surgical-risks, and combined FVIII and FXI deficiency.
Collapse
Affiliation(s)
- Sayaka Honda
- Tokyo Medical University, Department of Cardiovascular Surgery, Tokyo, Japan
| | - Yusuke Shimahara
- Tokyo Medical University, Department of Cardiovascular Surgery, Tokyo, Japan
| | - Yushi Chikasawa
- Tokyo Medical University, Department of Laboratory Medicine, Tokyo, Japan
| | - Hitoshi Ogino
- Tokyo Medical University, Department of Cardiovascular Surgery, Tokyo, Japan
| |
Collapse
|
25
|
Li X, Chen M, Wang Y, Zhou X, Wang M, Zou L. Successful use of peritoneal dialysis after abdominal surgery in a patient with factor XI deficiency: A case report. Semin Dial 2023; 36:178-182. [PMID: 36597266 DOI: 10.1111/sdi.13136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/19/2022] [Indexed: 01/05/2023]
Abstract
Factor XI (FXI) deficiency is a rare bleeding disorder of unpredictable severity that correlates poorly with FXI coagulation activity and that poses great challenges for perioperative hemostatic management and the dialysis methods potentially available to new end-stage renal disease (ESRD) patients. We describe an individual with both ESRD and severe FXI deficiency, who successfully underwent peritoneal dialysis (PD) after emergency abdominal surgery. In the traditional concept, recent abdominal surgery is a contraindication to PD, especially for patients with bleeding risk. However, this case report highlights that PD can still be an possible option for patients with FXI deficiency who have just undergone abdominal surgery; laparoscopic PD catheter placement offers a chance to establish PD access in patients traditionally viewed as noncandidates for this method. Careful perioperative management and fresh frozen plasma transfusion ensure successful surgery. This case should be of help to clinicians and patients considering PD in similar situations.
Collapse
Affiliation(s)
- Xueying Li
- School of Clinical Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China.,Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ming Chen
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yong Wang
- The 2nd Department of Foot and Ankle, Sichuan Provincial Orthopedics Hospital, Chengdu, China
| | - Xuelei Zhou
- Department of Gastroenterology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Min Wang
- Department of Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lihua Zou
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| |
Collapse
|
26
|
Zhang X, Lewandowska M, Aldridge M, Iglay K, Wolford E, Shapiro A. Global epidemiology of factor XI deficiency: A targeted review of the literature and foundation reports. Haemophilia 2023; 29:423-434. [PMID: 36367760 DOI: 10.1111/hae.14687] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/03/2022] [Accepted: 10/15/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Hereditary factor XI (FXI) deficiency is a rare coagulation disorder that may result in excessive bleeding requiring intervention to restore haemostasis. AIM The aim of this review was to report the current knowledge of the worldwide incidence and prevalence of FXI deficiency. METHODS A targeted PubMed search using terms related to FXI deficiency was conducted to identify studies published from April 2002 through April 2022. A manual search supplemented the electronic search. Studies were eligible for data abstraction if they reported population-based incidence proportions/rates or prevalence proportions for FXI deficiency. RESULTS The electronic and manual searches returned 253 publications. After applying exclusion criteria, seven publications were included in the analysis, including a global report from the World Federation of Haemophilia (WFH). Six publications provided information on the prevalence of FXI deficiency that included 74 countries and regions. The estimated prevalence of FXI in the WFH report ranged from 0/100,000 in several countries to 55.85/100,000 individuals in the United Kingdom. Prevalence estimates in the PubMed findings ranged from .1 to 246.2/1,000,000 inhabitants with varying methods of case identification and time periods of analysis. One study estimated the incidence of FXI deficiency in Yecla, Spain at 2% of blood donors and .09% of hospital inpatients/outpatients with activated partial thromboplastin time (aPTT) tests. CONCLUSION FXI deficiency is rare across the world, but additional steps could be taken to improve incidence and prevalence estimation, for example, development of a consistent FXI deficiency definition and incorporating genetic testing into a clinical routine to better identify and characterise cases.
Collapse
Affiliation(s)
- Xinruo Zhang
- CERobs Consulting, LLC., Wrightsville Beach, North Carolina, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Molly Aldridge
- CERobs Consulting, LLC., Wrightsville Beach, North Carolina, USA
| | - Kristy Iglay
- CERobs Consulting, LLC., Wrightsville Beach, North Carolina, USA
| | - Eric Wolford
- Bio Products Laboratory, Ltd., Elstree, Hertfordshire, UK
| | - Amy Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| |
Collapse
|
27
|
Von Willebrand Disease, Hemophilia, and Other Inherited Bleeding Disorders in Pregnancy. Obstet Gynecol 2023; 141:493-504. [PMID: 36800851 DOI: 10.1097/aog.0000000000005083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/07/2022] [Indexed: 02/05/2023]
Abstract
Inherited bleeding disorders, which comprise von Willebrand disease (VWD), hemophilia, other congenital clotting factor deficiencies, inherited platelet disorders, defects of fibrinolysis, and connective tissue disorders, have both maternal and fetal implications. Although mild platelet defects may actually be more prevalent, the most common diagnosed bleeding disorder among women is VWD. Other bleeding disorders, including hemophilia carriership, are much less common, but hemophilia carriers are unique in that they are at risk of giving birth to a severely affected male neonate. General guidance for maternal management of inherited bleeding disorders includes obtaining clotting factor levels in the third trimester, planning for delivery at a center with hemostasis expertise if factor levels do not meet the minimum threshold (eg, less than 0.50 international units/1 mL [50%] for von Willebrand factor, factor VIII, or factor IX), and using hemostatic agents such as factor concentrates, desmopressin, or tranexamic acid. General guidance for fetal management includes prepregnancy counseling, the option of preimplantation genetic testing for hemophilia, and consideration of delivery of potentially affected male neonates with hemophilia by cesarean delivery to reduce the risk of neonatal intracranial hemorrhage. In addition, delivery of possibly affected neonates should occur in a facility where there is newborn intensive care and pediatric hemostasis expertise. For patients with other inherited bleeding disorders, unless a severely affected neonate is anticipated, mode of delivery should be dictated by obstetric indications. Nonetheless, invasive procedures such as fetal scalp clip or operative vaginal delivery should be avoided, if possible, in any fetus potentially affected with a bleeding disorder.
Collapse
|
28
|
Koulas I, Spyropoulos AC. A Review of FXIa Inhibition as a Novel Target for Anticoagulation. Hamostaseologie 2023; 43:28-36. [PMID: 36807817 DOI: 10.1055/a-1984-7021] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Limitations of vitamin K antagonists as chronic oral anticoagulant therapy have largely been supplanted by direct factor IIa and factor Xa inhibitor oral anticoagulants with similar efficacy but an overall better safety profile, lack of routine monitoring, and very limited drug-drug interactions compared with agents such as warfarin. However, an increased risk of bleeding remains even with these new-generation oral anticoagulants in fragile patient populations, in patients requiring dual or triple antithrombotic therapy, or high bleed risk surgeries. Epidemiologic data in patients with hereditary factor XI deficiency and preclinical studies support the notion that factor XIa inhibitors have the ability to be an effective but potentially safer alternative to existing anticoagulants, based on their ability to prevent thrombosis directly within the intrinsic pathway without affecting hemostatic mechanisms. As such, various types of factor XIa inhibitors have been studied in early phase clinical studies, including inhibitors of the biosynthesis of factor XIa with antisense oligonucleotides or direct inhibitors of factor XIa using small peptidomimetic molecules, monoclonal antibodies, aptamers, or natural inhibitors. In this review, we discuss how different types of factor XIa inhibitors work and present findings from recently published Phase II clinical trials across multiple indications, including stroke prevention in atrial fibrillation, dual pathway inhibition with concurrent antiplatelets post-myocardial infarction, and thromboprophylaxis of orthopaedic surgery patients. Finally, we refer to ongoing Phase III clinical trials of factor XIa inhibitors and their potential to provide definitive answers regarding their safety and efficacy in preventing thromboembolic events in specific patient groups.
Collapse
Affiliation(s)
- Ioannis Koulas
- The Institute of Health Systems Science at the Feinstein Institutes for Medical Research, Manhasset, New York, United States
| | - Alex C Spyropoulos
- The Institute of Health Systems Science at the Feinstein Institutes for Medical Research, Manhasset, New York, United States.,Northwell Health at Lenox Hill Hospital, New York, New York, United States.,The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| |
Collapse
|
29
|
Al-Ansari RY, Alruwaili AF, Alqahtani KM, Al-Harbi AF, Woodman A. "Familial Multiple Coagulation Factor Deficiencies of FXI and FXII in an Asymptomatic Saudi Woman". J Investig Med High Impact Case Rep 2023; 11:23247096231199413. [PMID: 37705386 PMCID: PMC10503275 DOI: 10.1177/23247096231199413] [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: 07/26/2023] [Revised: 08/09/2023] [Accepted: 08/19/2023] [Indexed: 09/15/2023] Open
Abstract
Factor XI deficiency (FXI) is the third most common coagulation factor deficiency after hemophilia A and B, ie, in the hierarchy after factors VIII and IX, taking into account von Willebrand's factor deficiency, as bleeding disorders are higher than in hemophilia C. Factor XII deficiency (FXII) is a congenital condition, inherited in the vast majority of cases in an autosomal recessive manner, more often associated with thromboembolic complications. A combination of both factor deficiencies has been found very rarely, and it can be familial multiple coagulation factor deficiency (FMCFD). This study reports the case of a 39-year-old woman from Saudi Arabia who had the combination of FXI and FXII deficiencies, known to be on treatment for hypothyroidism and was referred to a hematology clinic with an incidental finding of prolonged activated partial thromboplastin time (aPTT). Although there was no history of bleeding tendency, her siblings had a family history of an unknown type of bleeding disorder. On physical examination, the patient did not show any bruising, petechiae, or ecchymosis. The aPTT was 69 seconds (27-38) with normal use of other hemostatic agents and was corrected after a 50:50 mixing study. Intrinsic coagulation factors were evaluated, and they revealed severe FXI and moderate FXII deficiencies. Due to a strong family history, the patient was diagnosed with FMCFD. In conclusion, familial combined multiple clotting factor deficiency (FCMFD) is a rare condition that requires attention and reporting. The management strategy in such cases has not been well studied, especially in the long-term symptomatic patient with severe but asymptomatic combined FXI and FXII deficiencies, which is an area for review and further study.
Collapse
|
30
|
Dorgalaleh A, Bahraini M, Shams M, Parhizkari F, Dabbagh A, Naderi T, Fallah A, Fazeli A, Ahmadi SE, Samii A, Daneshi M, Heydari F, Tabibian S, Tavasoli B, Noroozi-Aghideh A, Tabatabaei T, Gholami MS. Molecular basis of rare congenital bleeding disorders. Blood Rev 2022; 59:101029. [PMID: 36369145 DOI: 10.1016/j.blre.2022.101029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/26/2022] [Accepted: 10/23/2022] [Indexed: 11/11/2022]
Abstract
Rare bleeding disorders (RBDs), including factor (F) I, FII, FV, FVII, combined FV and FVIII (CF5F8), FXI, FXIII and vitamin-K dependent coagulation factors (VKCF) deficiencies, are a heterogeneous group of hemorrhagic disorder with a variable bleeding tendency. RBDs are due to mutation in underlying coagulation factors genes, except for CF5F8 and VKCF deficiencies. FVII deficiency is the most common RBD with >330 variants in the F7 gene, while only 63 variants have been identified in the F2 gene. Most detected variants in the affected genes are missense (>50% of all RBDs), while large deletions are the rarest, having been reported in FVII, FX, FXI and FXIII deficiencies. Most were located in the catalytic and activated domains of FXI, FX, FXIII and prothrombin deficiencies. Understanding the proper molecular basis of RBDs not only can help achieve a timely and cost-effective diagnosis, but also can help to phenotype properties of the disorders.
Collapse
|
31
|
Sabnis R. Factor XI Activation Inhibitors for Treating Thromboses, Embolism, Hypercoagulability, or Fibrotic Changes. ACS Med Chem Lett 2022; 13:1548-1549. [PMID: 36267132 PMCID: PMC9578030 DOI: 10.1021/acsmedchemlett.2c00392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Indexed: 11/28/2022] Open
Abstract
Provided herein are novel compounds as Factor XIa inhibitors, pharmaceutical compositions, use of such compounds in treating thromboses, embolism, hypercoagulability, or fibrotic changes, and processes for preparing such compounds.
Collapse
Affiliation(s)
- Ram
W. Sabnis
- Smith, Gambrell & Russell LLP,
1105 W. Peachtree Street NE, Suite 1000, Atlanta, Georgia 30309,
United States
| |
Collapse
|
32
|
Nopp S, Kraemmer D, Ay C. Factor XI Inhibitors for Prevention and Treatment of Venous Thromboembolism: A Review on the Rationale and Update on Current Evidence. Front Cardiovasc Med 2022; 9:903029. [PMID: 35647061 PMCID: PMC9133368 DOI: 10.3389/fcvm.2022.903029] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022] Open
Abstract
Although anticoagulation therapy has evolved from non-specific drugs (i.e., heparins and vitamin K antagonists) to agents that directly target specific coagulation factors (i.e., direct oral anticoagulants, argatroban, fondaparinux), thrombosis remains a leading cause of death worldwide. Direct oral anticoagulants (i.e., factor IIa- and factor Xa-inhibitors) now dominate clinical practice because of their favorable pharmacological profile and ease of use, particularly in venous thromboembolism (VTE) treatment and stroke prevention in atrial fibrillation. However, despite having a better safety profile than vitamin K antagonists, their bleeding risk is not insignificant. This is true for all currently available anticoagulants, and a high bleeding risk is considered a contraindication to anticoagulation. As a result, ongoing research focuses on developing future anticoagulants with an improved safety profile. Several promising approaches to reduce the bleeding risk involve targeting the intrinsic (or contact activation) pathway of coagulation, with the ultimate goal of preventing thrombosis without impairing hemostasis. Based on epidemiological data on hereditary factor deficiencies and preclinical studies factor XI (FXI) emerged as the most promising candidate target. In this review, we highlight unmet clinical needs of anticoagulation therapy, outlay the rationale and evidence for inhibiting FXI, discuss FXI inhibitors in current clinical trials, conduct an exploratory meta-analysis on their efficacy and safety, and provide an outlook on the potential clinical application of these novel anticoagulants.
Collapse
Affiliation(s)
| | | | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
33
|
Poenou G, Dumitru Dumitru T, Lafaie L, Mismetti V, Heestermans M, Bertoletti L. Factor XI Inhibition for the Prevention of Venous Thromboembolism: An Update on Current Evidence and Future perspectives. Vasc Health Risk Manag 2022; 18:359-373. [PMID: 35707632 PMCID: PMC9191224 DOI: 10.2147/vhrm.s331614] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/30/2022] [Indexed: 12/18/2022] Open
Abstract
During the past decade, emergence of direct oral anticoagulants (DOACs) has drastically improved the prevention of thrombosis. However, several unmet needs prevail in the field of thrombosis prevention, even in the DOACs’ era. The use of DOACs is still constrained and the drugs cannot be administered in every clinical scenario, such as an increased anticoagulant-associated bleeding risk, particularly in some specific populations (cancer – notably those with gastrointestinal or genitourinary cancer – and frail patients), the impossibility to be used in certain patients (eg, end-stage kidney failure during hemodialysis, pregnancy and breastfeeding), and their lack of efficacy in certain clinical scenarios (eg, mechanical heart valves, triple-positive antiphospholipid syndrome). Efforts to find a factor that upon antagonization prevents thrombosis but spares haemostasis have resulted in the identification of coagulation factor XI (FXI) as a therapeutic target. After briefly recapitulating the role of factor XI in the balance of haemostasis, we propose a narrative review of the key data published to date with compounds targeting factor XI to prevent thrombosis as well as the main ongoing clinical studies, opening up prospects for improving the care of patients requiring thrombosis prevention.
Collapse
Affiliation(s)
- Geraldine Poenou
- Therapeutic and Vascular Medicine Department, University Hospital of Saint Etienne, Saint Etienne, France
| | - Teona Dumitru Dumitru
- Therapeutic and Vascular Medicine Department, University Hospital of Saint Etienne, Saint Etienne, France
- Internal Medicine Department, University Hospital Santa Lucía, Cartagena, Murcia, Spain
- Catholic University San Antonio, Murcia, Spain
| | - Ludovic Lafaie
- Geriatric Department, University Hospital of Saint Etienne, Saint Etienne, France
- INSERM, UMR1059, Haemostasis and Vascular Dysfunction Team, Jean Monnet University, Saint-Etienne, F-42055, France
| | - Valentine Mismetti
- INSERM, UMR1059, Haemostasis and Vascular Dysfunction Team, Jean Monnet University, Saint-Etienne, F-42055, France
- Pneumology Department, University Hospital of Saint Etienne, Saint Etienne, France
| | - Marco Heestermans
- INSERM, UMR1059, Haemostasis and Vascular Dysfunction Team, Jean Monnet University, Saint-Etienne, F-42055, France
- Auvergne-Rhône-Alpes French Blood Donation Agency, Saint-Etienne, F-42100, France
| | - Laurent Bertoletti
- Therapeutic and Vascular Medicine Department, University Hospital of Saint Etienne, Saint Etienne, France
- INSERM, UMR1059, Haemostasis and Vascular Dysfunction Team, Jean Monnet University, Saint-Etienne, F-42055, France
- INSERM, CIC-1408, University Hospital of Saint Etienne, Saint Etienne, France
- Correspondence: Laurent Bertoletti, Therapeutic and Vascular Medicine Department, University Hospital of Saint Etienne, Saint Etienne, France, Tel +33477827771, Fax +33477820482, Email
| |
Collapse
|
34
|
A Case Report of Severe Factor XI Deficiency during Cardiac Surgery: Less Can Be More. J Cardiovasc Dev Dis 2022; 9:jcdd9040118. [PMID: 35448094 PMCID: PMC9027232 DOI: 10.3390/jcdd9040118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/10/2022] [Accepted: 04/14/2022] [Indexed: 01/27/2023] Open
Abstract
Severe congenital Factor XI (FXI) deficiency (<20% normal activity) can be associated with significant bleeding disorders, and there has been great concern for severe bleeding following cardiac surgery requiring cardiopulmonary bypass (CPB) in this patient population. Over the past four decades remarkably different approaches to this problem have been taken, including the administration of blood volumes of fresh frozen plasma, administration of activated recombinant Factor VII, and diminutive administration of heparin. We describe a case wherein the patient was assessed in the perioperative period with a point-of-care, viscoelastic hemostasis device (ROTEM), with changes in the intrinsic/Factor XII-dependent coagulation pathway determined before, during, and after CPB. Fresh frozen plasma was administered in small amounts (5−7.5 mL/kg) just before surgery began and just before cessation of CPB. Administering fresh frozen plasma to the patient to nearly normalize in vitro ROTEM hemostasis values at times when hemostasis was needed resulted in no important bleeding occurring or need of further transfusion of other blood products. In conclusion, by using small amounts of fresh frozen plasma guided by ROTEM, an evidenced-based, precision medicine approach resulted in optimized patient care and outcome.
Collapse
|
35
|
Gailani D. Factor XI as a target for preventing venous thromboembolism. J Thromb Haemost 2022; 20:550-555. [PMID: 35023278 PMCID: PMC9540353 DOI: 10.1111/jth.15628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 01/10/2023]
Affiliation(s)
- David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
36
|
Juan-Casamayor L, Fuentes-Valenzuela E, Alonso-Martín C, Fernández-Fontecha E, García-Pajares F. XI factor deficiency as cause of recurrent gastrointestinal bleeding. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2022; 114:504-505. [DOI: 10.17235/reed.2022.8669/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|