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Wu R, Li X, Yao W, Zhang Q, Zhou M, Zhang N, Yang S, Chen Z, Wang Y, Kuang Y, Tang L, Zhen Y, Abad A, Doria AS, Hilliard P, Ignas DM, Mathew P, Stephens D, Blanchette VS, Luke K. Significant reduction in hemarthrosis in boys with severe hemophilia A: The China hemophilia individualized low-dose secondary prophylaxis study. Res Pract Thromb Haemost 2021; 5:e12552. [PMID: 34568725 PMCID: PMC8449287 DOI: 10.1002/rth2.12552] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/23/2021] [Accepted: 04/29/2021] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION In countries with restricted access to clotting factor concentrates, early implementation of low-dose prophylaxis is recommended over episodic treatment. OBJECTIVE The objective of this 1-year prospective secondary prophylaxis study was to evaluate the efficacy of a dose/frequency escalating protocol in young boys with hemophilia A in China. METHODS Boys were started on a low-dose protocol (minimum 10-15 IU/kg of factor VIII [FVIII] twice weekly). Escalation was based on index joint bleeding, swelling/persistent joint swelling, and serial ultrasound (gray scale and color Doppler) examinations of index joints. RESULTS Thirty-three boys, median age 4.8 years (interquartile range, 3.8-6.1) were enrolled in a 3-month observation period that preceded a 1-year prophylaxis phase. A significant reduction in total bleeding events (43.0%, P = .001), index joint bleeds (53.2%, P = .002), and target index joint bleeds (70.0%, P = 0.02) was observed during the prophylaxis phase. During the prophylaxis period, 40% of target joints resolved. The percentage of boys with zero index joint bleeds increased significantly (P = .004) from 51.5% during the observation phase to 81.8% in last quarter of the prophylaxis phase (months 10-12). There was no progression of arthropathy based on physical examination (Hemophilia Joint Health Score), X-ray, and ultrasound obtained at entry into the prophylaxis phase and at study exit. The median FVIII consumption over the prophylaxis phase was 1786 IU/kg/y. CONCLUSION A low-dose, individualized prophylaxis protocol, guided by individual bleeding profiles and serial assessment of joint status, enables escalation of treatment intensity in boys with severe hemophilia A, leading to a significant reduction in bleeding events and reduction in target joint bleeding.
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Affiliation(s)
- Runhui Wu
- Hemophilia Comprehensive Care CenterHematology DepartmentBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Xiaojing Li
- Hemophilia Diagnosis and Treatment CenterDepartment of Hematology and OncologyChengdu Women’s and Children’s Central HospitalSchool of MedicineUniversity of Electronic Science and Technology of ChinaChengduChina
- Hemophilia Treatment CenterDepartment of PediatricsNew Century Women’s and Children’s HospitalChengduChina
| | - Wanru Yao
- Hemophilia Comprehensive Care CenterHematology DepartmentBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Qing Zhang
- Hemophilia Diagnosis and Treatment CenterDepartment of Hematology and OncologyChengdu Women’s and Children’s Central HospitalSchool of MedicineUniversity of Electronic Science and Technology of ChinaChengduChina
| | - Min Zhou
- Hemophilia Diagnosis and Treatment CenterDepartment of Hematology and OncologyChengdu Women’s and Children’s Central HospitalSchool of MedicineUniversity of Electronic Science and Technology of ChinaChengduChina
| | - Ningning Zhang
- Hemophilia Comprehensive Care Center, Radiology CenterBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Sheng Yang
- Hemophilia and Diagnosis Treatment CenterDepartment of UltrasoundChengdu Women’s and Children’s Central HospitalSchool of MedicineUniversity of Electronic Science and Technology of ChinaChengduChina
| | - Zhenping Chen
- Hemophilia Comprehensive Care CenterHematology DepartmentBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Yan Wang
- Hemophilia Comprehensive Care Center, Rehabilitation DepartmentBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Yangying Kuang
- Hemophilia Diagnosis and Treatment CenterDepartment of RadiologyChengdu Women’s and Children’s Central HospitalSchool of MedicineUniversity of Electronic Science and Technology of ChinaChengduChina
| | - Ling Tang
- Hemophilia Comprehensive Care CenterHematology DepartmentBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Yingzi Zhen
- Hemophilia Comprehensive Care CenterHematology DepartmentBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Audrey Abad
- Child Health Evaluative Sciences, Research InstituteThe Hospital for Sick ChildrenTorontoONCanada
| | - Andrea S. Doria
- Department of Diagnostic ImagingMedical Imaging DepartmentThe Hospital for Sick ChildrenUniversity of TorontoTorontoCanada
- The Hospital for Sick ChildrenResearch InstituteUniversity of TorontoTorontoONCanada
| | - Pamela Hilliard
- Child Health Evaluative Sciences, Research InstituteThe Hospital for Sick ChildrenTorontoONCanada
| | - Danial M. Ignas
- Child Health Evaluative Sciences, Research InstituteThe Hospital for Sick ChildrenTorontoONCanada
| | - Prasad Mathew
- Division of Pediatric Hematology/OncologyPresbyterian Health Services HospitalAlbuquerqueNMUSA
| | - Derek Stephens
- The Hospital for Sick ChildrenResearch InstituteUniversity of TorontoTorontoONCanada
| | - Victor S. Blanchette
- Division of Hematology/OncologyThe Hospital for Sick Children and Department of PediatricsUniversity of TorontoTorontoONCanada
| | - Koon‐Hung Luke
- Department of PediatricsLaboratory Medicine and PathologyDivision of Hematology and OncologyUniversity of OttawaChildren Hospital of Eastern OntarioOttawaONCanada
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Di Minno A, Spadarella G, Esposito S, Mathew P, Di Minno G, Mannucci PM. Perspective - The case for zero bleeds and drug bioequivalence in the treatment of congenital hemophilia A in 2021. Blood Rev 2021; 50:100849. [PMID: 34024681 DOI: 10.1016/j.blre.2021.100849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 01/19/2023]
Abstract
Not all patients with severe hemophilia A (HA) respond optimally to a given dose of a given product. Within-individual variance in cross-over studies makes each patient unique in the response to each standard half-life (SHL) factor VIII (FVIII) product in pharmacokinetic (PK) terms. This hampers the prediction of efficacy when a SHL FVIII product is employed. PK data showing that half-lives of SHL rFVIII are unsatisfactory to achieve zero bleeding in individual HA patients provide the rationale for switching from SHL to extended half-life (EHL) products. However, not all subjects receiving prophylaxis with EHL products achieve zero bleeding, the most cogent objective of personalized prophylaxis. Known determinants of FVIII half-life (age, von Willebrand factor [VWF] levels, blood group) cumulatively account for one third of the total inter-individual variation in FVIII clearance in subjects with severe HA. Investigations into precision, and accuracy of laboratory measurement to be employed; newer pathways for the clearance of both free-FVIII and VWF-bound FVIII, and adequately powered studies on omics and phenotypic heterogeneity, are likely to provide additional information on the remaining two thirds of inter-individual variation in FVIII clearance in HA. Variability in the clinical response has also been documented in patients when FVIII activity is mimicked by fixed subcutaneous doses of the bispecific antibody emicizumab. National registries that collect PK data of available FVIII products and ad hoc information on the individual response to emicizumab should be encouraged, to establish newer standards of care and ease personalized clinical decisions to achieve zero bleeding.
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Affiliation(s)
- Alessandro Di Minno
- Dipartimento di Farmacia, Università degli Studi di Napoli "Federico II", Italy; CEINGE-Biotecnologie Avanzate, Università degli Studi di Napoli "Federico II", Italy.
| | - Gaia Spadarella
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli "Federico II", Italy
| | - Salvatore Esposito
- Dipartimento di Medicina Clinica e Chirurgia and Centro Hub per le Malattie Emorragiche Congenite e le Trombofilie, Università degli Studi di Napoli "Federico II", Italy
| | | | - Giovanni Di Minno
- Dipartimento di Medicina Clinica e Chirurgia and Centro Hub per le Malattie Emorragiche Congenite e le Trombofilie, Università degli Studi di Napoli "Federico II", Italy.
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy..
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Those with hemophilia or von Willebrand disease do not have increased perioperative complications following anterior cruciate ligament reconstruction: Results of a case-control large-database study. Knee 2020; 27:1729-1734. [PMID: 33197811 DOI: 10.1016/j.knee.2020.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 08/10/2020] [Accepted: 09/27/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is a lack of information on anterior cruciate ligament (ACL) reconstruction outcomes and complications for patients with congenital hypocoagulable conditions. The specific aim of this retrospective study was to report operative outcomes and complications for patients with congenital hypocoagulable disorders who underwent ACL reconstruction. METHODS We performed a retrospective review of all patients who underwent an ACL reconstruction within Truven MarketScan Commercial Claims and Encounter Database from 2010 to 2014. Hemophilia A, hemophilia B and patients were identified. Patient demographics, cost of surgery, blood product use, concomitant injuries, repeat ACL injury, complications and various operative variables were collected. Statistical tests were conducted on SAS 9.4 2013. RESULTS Thirty-three hemophilia A, three hemophilia B, 63 von Willebrand factor patients, and 103,478 controls underwent ACL reconstruction. There is a statistically significant difference for hemarthrosis 1 year leading up to injury for hemophilia A compared with control (P = 0.0083). Total healthcare utilization 90 days after surgery was statistically significant for hemophilia A ($30,310 ± 52,745, P < 0.001) and von Willebrand factor ($20,355 ± 23,570, P < 0.001) compared with control ($14,564 ± 9512). Length of hospital stay, postoperative hemorrhage, concomitant injuries to the knee, additional ACL injury, infection rate, deep-vein thrombosis, and pulmonary embolism were not statistically significant. None of the hemophilia A or von Willebrand factor patients received blood products intraoperatively or postoperatively. CONCLUSION Hemophilia A and von Willebrand factor patients had rates of postoperative complications and ACL re-injuries that were not statistically significant. Cost of healthcare utilization was identified as dramatically greater for hemophilia A and von Willebrand factor patients.
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Bullement A, McMordie ST, Hatswell AJ, Li N, Wilson K. Cost-Effectiveness Analysis of Recombinant Factor VIII Fc-Fusion Protein (rFVIIIFc) for the Treatment of Severe Hemophilia A in Italy Incorporating Real-World Dosing and Joint Health Data. PHARMACOECONOMICS - OPEN 2020; 4:133-142. [PMID: 31280415 PMCID: PMC7018914 DOI: 10.1007/s41669-019-0158-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Patients with severe hemophilia A (SHA) in Italy are routinely treated with standard half-life recombinant factor VIII (rFVIII) products. rFVIII Fc-fusion protein (rFVIIIFc) is an extended half-life rFVIII product that enables less frequent administration than rFVIII, which may support improved adherence. Available data indicate low breakthrough bleed rates and potentially improved long-term joint health for patients treated with rFVIIIFc prophylaxis. OBJECTIVE This study assessed the cost effectiveness of rFVIIIFc versus rFVIII from an Italian healthcare perspective. METHODS A Semi-Markov model was constructed to assess the lifetime costs and benefits of rFVIII and rFVIIIFc prophylaxis. rFVIII product acquisition costs from a published Italian database were included for both prophylaxis and the resolution of breakthrough bleeding. Clinical outcomes within the model were determined based on published annualized bleeding rates and literature regarding the development of target joints (TJs) as the incidence of bleeds and TJs is associated with impaired health-related quality of life. Cost effectiveness was assessed using cost per quality-adjusted life-year (QALY) gained. RESULTS Compared with rFVIII, rFVIIIFc was associated with a per-patient cost saving of approximately €1.3 million and QALY gains of 0.39 over a lifetime horizon. Sensitivity analyses considering alternative efficacy, dosing, and structural assumptions each showed that rFVIIIFc dominated rFVIII (i.e., provided more QALYs at a reduced cost). CONCLUSIONS This cost-effectiveness analysis demonstrated that rFVIIIFc may offer a cost-effective treatment option for patients with SHA in Italy.
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Affiliation(s)
| | | | | | - Nanxin Li
- Bioverativ, a Sanofi Company, Waltham, MA, USA
| | - Koo Wilson
- Swedish Orphan Biovitrum AB (publ), 112 76, Stockholm, Sweden.
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Attempting to remedy sub-optimal medication adherence in haemophilia: The rationale for repeated ultrasound visualisations of the patient's joint status. Blood Rev 2018; 33:106-116. [PMID: 30146094 DOI: 10.1016/j.blre.2018.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 07/14/2018] [Accepted: 08/17/2018] [Indexed: 01/01/2023]
Abstract
Haemophilia is marked by joint bleeding (haemarthrosis) leading to cartilage damage (arthropathy). Lifelong prophylaxis-initiated after the first bleeding episode-leads to a dramatic decrease in arthropathy in haemophilia patients. However, adherence to continuous intravenous administrations of factor VIII (FVIII) or FIX products is challenging, and patients potentially suffer from breakthrough bleedings while on prophylaxis. Newer FVIII/FIX products with enhanced convenience attributes and/or easier infusion procedures are intended to improve adherence. However, pharmacokinetic data should be harmonised with information from individual attitudes and treatment needs, to tailor intravenous dosing and scheduling in patients who receive extended half-life products. Nor is there sound evidence as to how subcutaneous non-FVIII/FIX replacement approaches (concizumab; emicizumab; fitusiran) or single intravenous injections of adeno-associated viral vectors (when employing gene therapy) will revolutionize adherence in haemophilia. In rheumatoid arthritis, repeated ultrasound examination of a patient's major joints is a valuable tool to educate patients and parents to understand the disease and provide an objective framework for clinicians to acknowledge patient's adherence. Joint ultrasound examination in haemophilia significantly correlates with cartilage damage, effusion, and synovial hypertrophy evaluated by magnetic resonance imaging. Furthermore, in patients with haemophilia undergoing prophylaxis with an extended half-life product for a ≈ 2.8 year period, a significant continued improvement in joint health is detected at the physical examination. This provides the rationale for studies on repeated ultrasound examinations of joint status to attempt to remedy sub-optimal medication adherence and help identify which approach is most suited on which occasion and for which patient.
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Riva S, Cutica I, Krampe C, Reinecke LF, Russell-Edu W, Santoro C, Rocino A, Santagostino E, Rusconi V, Pravettoni G. A Cohort Pilot Study on HIV-Associated Neuropsychological Impairments in Hemophilia Patients. Front Hum Neurosci 2015; 9:313. [PMID: 26082706 PMCID: PMC4451691 DOI: 10.3389/fnhum.2015.00313] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 05/16/2015] [Indexed: 11/13/2022] Open
Abstract
Despite advances in the management of HIV infection with the introduction of combination antiretroviral therapy, it is well known that HIV can directly infect the central nervous system and, as a result of such infection, neuropsychological impairments can be manifested. In this study, we tried to determine whether seropositivity was associated with a poor neuropsychological performance in patients with hemophilia and HIV. Such a cohort of patients is very often underrepresented and understudied in the HIV literature. To amend such a gap, we carried out an extensive neuropsychological evaluation on these patients, and compared their performance with that of a group of seronegative hemophilia patients. The results revealed that HIV infection in HIV-seropositive (HIV+) hemophilia patients was associated with deficits in attention, short-term memory, abstraction, and visual recognition. Such results are still preliminary and explorative due to the small cohort of patients enrolled. However, the results do seem to have some important implications for day-to-day functioning, as the level of impairment detected may cause difficulties in completing common everyday tasks such as maintaining adherence to complex medication regimens or maintaining social life activities. Continued research into the mechanisms related to HIV and neurocognitive dysfunction may provide targets for interventions that could have meaningful consequences in the real world for HIV hemophilia patients.
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Affiliation(s)
- Silvia Riva
- Department of Health Sciences, University of Milan , Milan , Italy
| | - Ilaria Cutica
- Department of Health Sciences, University of Milan , Milan , Italy
| | - Caspar Krampe
- Department of Health Sciences, University of Milan , Milan , Italy
| | - Laura F Reinecke
- Department of Health Sciences, University of Milan , Milan , Italy
| | | | - Cristina Santoro
- Haemophilia and Thrombosis Centre, Umberto I Hospital , Rome , Italy
| | - Angiola Rocino
- Haemophilia and Thrombosis Centre, S. Giovanni Bosco Hospital , Naples , Italy
| | | | - Vega Rusconi
- ABB Haemophilia and Thrombosis Centre, IRCCS Ca'Granda , Milan , Italy
| | - Gabriella Pravettoni
- Department of Health Sciences, University of Milan , Milan , Italy ; European Institute of Oncology (IEO) , Milan , Italy
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7
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Abrahamyan L, Willan AR, Beyene J, Mclimont M, Blanchette V, Feldman BM. Using value-of-information methods when the disease is rare and the treatment is expensive--the example of hemophilia A. J Gen Intern Med 2014; 29 Suppl 3:S767-73. [PMID: 25029970 PMCID: PMC4124117 DOI: 10.1007/s11606-014-2880-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Hemophilia A is a rare, sex-linked genetic disorder treated with intravenous administration of factor VIII (FVIII) to prevent bleeding; however, approaches vary across and within countries. Value-of-information (VOI) methods identify situations in which the cost-benefit evidence is sufficient to adopt one treatment strategy over another; when the evidence is insufficient, VOI methods provide the optimal sample size for additional research. OBJECTIVE The objective of the study was to use VOI methods in a cost-benefit decision context to evaluate the current evidence in support of using (1) alternate day prophylaxis (AP), (2) tailored prophylaxis (TP) or (3) on-demand treatment (OD) with FVIII to prevent arthropathy in children with severe hemophilia A. METHODS To apply VOI methods, several parameters such as incidence, time horizon for the decision, costs, and threshold values to avoid MRI-detected joint damage or arthropathy were defined. Two baseline threshold values of willingness to pay for avoiding arthropathy--$200,000 and $400,000--were selected for comparing the treatment strategies. RESULTS For threshold values < $200,000, OD had a higher expected net benefit than either prophylaxis strategy, and the evidence was sufficient for its adoption. For threshold values > $400,000 prophylaxis strategies had higher expected net benefit; however, a new trial with 38 patients per arm was needed to compare AP and TP, yielding an expected net gain of over $17 million. In sensitivity analyses, the results were robust to assumptions regarding discount rate, trial fixed and variable costs, enrollment fraction, and the time horizon. CONCLUSIONS In rare diseases, evidence is often scarce and insufficient for decision making. In considering the funding of new research and patient reimbursement in rare diseases, VOI methodology may provide more relevant determinations of the value and costs of additional research, compared to standard frequentist methods.
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Affiliation(s)
- Lusine Abrahamyan
- />Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Toronto, Ontario Canada
| | - Andrew R. Willan
- />Child Health Evaluative Sciences Program, The SickKids Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8 Canada
- />The Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
| | - Joseph Beyene
- />Child Health Evaluative Sciences Program, The SickKids Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8 Canada
- />The Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
- />Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario Canada
- />Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario Canada
- />Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Marjorie Mclimont
- />Child Health Evaluative Sciences Program, The SickKids Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8 Canada
| | - Victor Blanchette
- />Child Health Evaluative Sciences Program, The SickKids Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8 Canada
- />Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Brian M. Feldman
- />Child Health Evaluative Sciences Program, The SickKids Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8 Canada
- />The Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
- />Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario Canada
- />Departments of Paediatrics, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - for the Canadian Hemophilia Primary Prophylaxis (CHPS) Study Group
- />Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Toronto, Ontario Canada
- />Child Health Evaluative Sciences Program, The SickKids Research Institute, 555 University Avenue, Toronto, Ontario M5G 1X8 Canada
- />The Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario Canada
- />Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario Canada
- />Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario Canada
- />Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario Canada
- />Departments of Paediatrics, Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario Canada
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Kenet G, Bidlingmaier C, Bogdanova N, Ettingshausen CE, Goldenberg N, Gutsche S, Halimeh S, Holzhauer S, Kurnik K, Limperger V, Junker R, Nowak-Göttl U. Influence of factor 5 rs6025 and factor 2 rs1799963 mutation on inhibitor development in patients with hemophilia A - an Israeli-German multicenter database study. Thromb Res 2014; 133:544-9. [DOI: 10.1016/j.thromres.2014.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 01/02/2014] [Accepted: 01/03/2014] [Indexed: 01/15/2023]
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Halimeh S, Bidlingmaier C, Heller C, Gutsche S, Holzhauer S, Kenet G, Kurnik K, Manner D, Iorio A, Nowak-Göttl U. Risk factors for high-titer inhibitor development in children with hemophilia A: results of a cohort study. BIOMED RESEARCH INTERNATIONAL 2013; 2013:901975. [PMID: 24199202 PMCID: PMC3807559 DOI: 10.1155/2013/901975] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 08/30/2013] [Accepted: 08/31/2013] [Indexed: 01/08/2023]
Abstract
Among the discussed risk factors for high-titre inhibitor (HRI) development in patients with hemophilia A (HA) are high dose FVIII replacement therapy and use of recombinant FVIII concentrates (rFVIII). The aim of this study was to evaluate the aforementioned risk factors for HRI development in children with hemophilia A ≤2%. About 288 ascertained PUPs (Israel and Germany) were followed after initial HA diagnosis over 200 exposure days. Inhibitor-free survival, hazard ratios (HR), and 95% confidence intervals (CIs) were calculated. Adjustment was performed for factor VIII concentrates, median single dose over the first three months of treatment, first FVIII administration before the age of three months, presence of risk HA gene mutations, "intensive treatment moments" and "year of birth" (proxy for different treatment periods). HRI occurred in 71/288 children (24.7%). In multivariate analysis adjusted for "year of birth", underlying risk gene mutations (HR/CI: 2.37/1.40-3.99), FVIII dose, measured per one IU increase per kgbw (HR/CI: 1.05/1.04-1.07), and first FVIII administration before the age of three months showed a significant impact on HR development. The risk of HRI development was similar for recombinant or plasmatic FVIII products. Children at risk should be treated with carefully calculated lower dose regimens, adapted to individual bleeding situations.
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Affiliation(s)
- Susan Halimeh
- Gerinnungszentrum Rhein-Ruhr (GZRR), 47051 Duisburg, Germany
| | | | - Christine Heller
- Department of Pediatric Hematology/Oncology, University Hospital of Frankfurt, 60590 Frankfurt, Germany
| | - Sven Gutsche
- Outpatient Hemophilia Treatment Center, 23564 Lubbock, Germany
| | - Susanne Holzhauer
- Department of Pediatric Hematology/Oncology, Charite, 13353 Berlin, Germany
| | - Gili Kenet
- The Israel National Hemophilia Centre, Sheba Medical Centre, Tel-Hashomer and the Sackler Medical School, Tel Aviv, 52621 Tel-Hashomer, Israel
| | - Karin Kurnik
- Department of Pediatrics, University Hospital of Munich, 80337 Munich, Germany
| | - Daniela Manner
- Department of Pediatrics, University Hospital of Münster, 48149 Münster, Germany
| | - Alfonso Iorio
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada L85 4K1
| | - Ulrike Nowak-Göttl
- Department of Pediatrics, University Hospital of Münster, 48149 Münster, Germany
- Thrombosis & Hemophilia Treatment Center, Institute of Clinical Chemistry, University Hospital of Kiel, 24105 Kiel, Germany
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Zaky LA, Hassan WF. Effect of partial weight bearing program on functional ability and quadriceps muscle performance in hemophilic knee arthritis. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2013. [DOI: 10.1016/j.ejmhg.2013.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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11
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Yan YH, Kung CM. Investigated the hospital utilization and medical resource usage of haemophilia A and B in Taiwan: 2001-2010. Health (London) 2013. [DOI: 10.4236/health.2013.510a1001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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Feldman BM, Berger K, Bohn R, Carcao M, Fischer K, Gringeri A, Hoots K, Mantovani L, Willan AR, Schramm W. Haemophilia prophylaxis: how can we justify the costs? Haemophilia 2012; 18:680-4. [PMID: 22507524 DOI: 10.1111/j.1365-2516.2012.02790.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Severe haemophilia results in increased mortality and poorer quality of life. Factor prophylaxis leads to a more normal life, but is very costly; most of the cost is due to the high cost of replacement factor. Despite its high cost, factor prophylaxis has been adopted throughout the developed world--even in different health care systems. We argue that there are at least five possible reasons why societies may value factor prophylaxis despite its cost: (i) it is directed towards an inherited disease, (ii) the treatment is largely directed towards children, (iii) the disease is rare and the overall cost to society is small, (iv) the treatment is preventative, and v) the high cost is largely the result of providing safe products. In an era of rising health care costs, there is a strong research agenda to establish the factors that determine the value of expensive therapies for rare diseases like haemophilia.
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Affiliation(s)
- B M Feldman
- Division of Rheumatology, The Hospital for Sick Children, Department of Pediatrics, Institute of Health Policy Management & Evaluation, and the Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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Acharya SS. Exploration of the pathogenesis of haemophilic joint arthropathy: understanding implications for optimal clinical management. Br J Haematol 2011; 156:13-23. [DOI: 10.1111/j.1365-2141.2011.08919.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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KLAMROTH R, POLLMANN H, HERMANS C, FARADJI A, YARLAS AS, EPSTEIN JD, EWENSTEIN BM. The relative burden of haemophilia A and the impact of target joint development on health-related quality of life: results from the ADVATE Post-Authorization Safety Surveillance (PASS) study. Haemophilia 2011; 17:412-21. [DOI: 10.1111/j.1365-2516.2010.02435.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kong M, Kang JO, Choi J, Park SH. A long term results of external beam radiation therapy in hemophilic arthropathy of the ankle in children. J Korean Med Sci 2010; 25:1742-7. [PMID: 21165288 PMCID: PMC2995227 DOI: 10.3346/jkms.2010.25.12.1742] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Accepted: 07/22/2010] [Indexed: 11/20/2022] Open
Abstract
Bleeding into joint space is critical to develop hemophilic arthropathy. To reduce the frequency of bleeding in the ankle joint of children with hemophilic arthropathy, low dose external beam irradiation was performed for 37 patients. Among them, 35 patients followed-up for longer than 1 yr (median 87 months) were enrolled for analysis. The average number of bleedings per month was 3.6 during one year prior to radiation therapy. After radiation therapy, it was decreased to 2.1 during the first year, after then it was maintained in the range of 1.0 to 1.5 until the tenth year. The bleeding frequency was reduced to 42% at the first year and it was maintained in the range of 58% to 73% from the second to the tenth year. Especially the patients who had 3 or more bleedings per month, and who had MRI score more than 3 showed significant decreases. During the follow-up period, growth disturbances and secondary malignancies were not found. External beam radiotherapy can be considered for the hemophilic patients with surgical or isotope therapies are not amenable.
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Affiliation(s)
- Moonkyoo Kong
- Department of Radiation Oncology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jin Oh Kang
- Department of Radiation Oncology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jinhyun Choi
- Department of Radiation Oncology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seo Hyun Park
- Department of Radiation Oncology, Kyung Hee University School of Medicine, Seoul, Korea
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16
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Riva S, Bullinger M, Amann E, von Mackensen S. Content comparison of haemophilia specific patient-rated outcome measures with the international classification of functioning, disability and health (ICF, ICF-CY). Health Qual Life Outcomes 2010; 8:139. [PMID: 21108796 PMCID: PMC3022566 DOI: 10.1186/1477-7525-8-139] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 11/25/2010] [Indexed: 11/10/2022] Open
Abstract
Background Patient-Reported Outcomes (PROs) are considered important outcomes because they reflect the patient's experience in clinical trials. PROs have been included in the field of haemophilia only recently. Purpose Comparing the contents of PROs measures used in haemophilia, based on the ICF/ICF-CY as frame of reference. Methods Haemophilia-specific PROs for adults and children were selected on the grounds of international accessibility. The content of the selected instruments were examined by linking the concepts within the items of these instruments to the ICF/ICF-CY. Results Within the 5 selected instruments 365 concepts were identified, of which 283 concepts were linked to the ICF/ICF CY and mapped into 70 different categories. The most frequently used categories were "b152: Emotional functions" and "e1101: Drugs". Conclusions The present paper provides an overview on current PROs in haemophilia and facilitates the selection of appropriate instruments for specific purposes in clinical and research settings. This work was made possible by the grant of the European Murinet Project (Multidisciplinary Research Network on Health and Disability in Europe).
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Affiliation(s)
- Silvia Riva
- Institute of Medical Psychology, Centre of Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Germany.
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17
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Affiliation(s)
- V S Blanchette
- Division of Hematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada.
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18
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Effects of a 6-week, individualized, supervised exercise program for people with bleeding disorders and hemophilic arthritis. Phys Ther 2010; 90:509-26. [PMID: 20203091 DOI: 10.2522/ptj.20080202] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND People with bleeding disorders may develop severe arthritis due to joint hemorrhages. Exercise is recommended for people with bleeding disorders, but guidelines are vague and few studies document efficacy. In this study, 65% of people with bleeding disorders surveyed reported participating in minimal exercise, and 50% indicated a fear of exercise-induced bleeding, pain, or physical impairment. OBJECTIVE The purpose of this study was to examine the feasibility, safety, and efficacy of a professionally designed, individualized, supervised exercise program for people with bleeding disorders. DESIGN A single-group, pretest-posttest clinical design was used. METHODS Thirty-three patients (3 female, 30 male; 7-57 years of age) with mild to severe bleeding disorders were enrolled in the study. Twelve patients had co-existing illnesses, including HIV/AIDS, hepatitis, diabetes, fibromyalgia, neurofibromatosis, osteopenia, osteogenesis imperfecta, or cancer. Pre- and post-program measures included upper- and lower-extremity strength (force-generating capacity), joint range of motion, joint and extremity circumference, and distance walked in 6 minutes. Each patient was prescribed a 6-week, twice-weekly, individualized, supervised exercise program. Twenty participants (61%) completed the program. RESULTS Pre- and post-program data were analyzed by paired t tests for all participants who completed the program. No exercise-induced injuries, pain, edema, or bleeding episodes were reported. Significant improvements occurred in joint motion, strength, and distance walked in 6 minutes, with no change in joint circumference. The greatest gains were among the individuals with the most severe joint damage and coexisting illness. LIMITATIONS Limitations included a small sample size with concomitant disease, which is common to the population, and a nonblinded examiner. CONCLUSIONS A professionally designed and supervised, individualized exercise program is feasible, safe, and beneficial for people with bleeding disorders, even in the presence of concomitant disease. A longitudinal study with a larger sample size, a blinded examiner, and a control group is needed to confirm the results.
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KHAN U, BOGUE C, UNGAR WJ, HILLIARD P, CARCAO M, MOINEDDIN R, DORIA AS. Cost-effectiveness analysis of different imaging strategies for diagnosis of haemophilic arthropathy. Haemophilia 2009; 16:322-32. [DOI: 10.1111/j.1365-2516.2009.02125.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Abshire T. The role of prophylaxis in the management of von Willebrand disease: today and tomorrow. Thromb Res 2009; 124 Suppl 1:S15-9. [DOI: 10.1016/s0049-3848(09)70153-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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21
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Affiliation(s)
- A Llinás
- Department of Orthopedics and Traumatology, Fundación Santa Fe de Bogotá and Fundación Cosme y Damián, Bogotá, Colombia.
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22
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Mejia-Carvajal C, Hakobyan N, Enockson C, Valentino LA. The impact of joint bleeding and synovitis on physical ability and joint function in a murine model of haemophilic synovitis. Haemophilia 2008; 14:119-26. [PMID: 18184259 DOI: 10.1111/j.1365-2516.2007.01527.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Haemophilia is a congenital disorder that commonly results in musculoskeletal bleeding and orthopaedic complications. After an acute joint haemorrhage, an increase in intra-articular pressure and inflammation cause pain, swelling and limited motion. Blood in the joint space provokes a proliferative disorder known as haemophilic synovitis. Overgrowth of the synovial membrane causes mechanical dysfunction. Eventually, there is destruction of the articular surface and underlying bone. The aim of this project was to test the hypothesis that a minimum number of haemarthroses negatively impacts on joint function and that this would be reflected by decreased physical performance of experimental animals. Mice deficient in factor VIII coagulant activity were trained to ambulate on a rotating rod then injured three times at weekly intervals. Their ability to walk was then compared to a group of uninjured mice. Cohorts of mice were killed after 1, 2 or 3 months and the knee joints examined by gross and histological methods. The results supported the following conclusions: (i) haemophilic mice can be trained to ambulate on a rotating rod; (ii) acute hemarthrosis temporarily impairs their ability to ambulate and (iii) following recovery from acute injury, mice developing synovitis demonstrated inferior physical ability compared to mice not developing synovitis. This is the first description of a quantitative assay to monitor joint function in experimental animals and should be useful to evaluate the efficacy of new therapies developed to prevent and treat bleeding and to test strategies to counter the devastating effects of synovitis.
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Affiliation(s)
- C Mejia-Carvajal
- The Division of Pediatric Hematology-Oncology, The University of Chicago Hospitals, Chicago, IL, USA
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23
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Acharya SS. Hemophilic joint disease – current perspective and potential future strategies. Transfus Apher Sci 2008; 38:49-55. [DOI: 10.1016/j.transci.2007.12.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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24
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Ota S, Mclimont M, Carcao MD, Blanchette VS, Graham N, Paradis E, Feldman BM. Definitions for haemophilia prophylaxis and its outcomes: The Canadian Consensus Study. Haemophilia 2007; 13:12-20. [PMID: 17212719 DOI: 10.1111/j.1365-2516.2006.01409.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The creation of acceptable standard definitions for terms used in the care and assessment of haemophilia patients has become increasingly important, as a growing number of international clinical studies have been initiated. The Delphi approach has been used in health research to reach consensus in large groups and can be used to develop definitions by using several iterations of surveys eliciting opinions from specialists in the field. Three consecutive surveys were designed based on the Delphi approach and distributed to specialist physicians, nurses and physiotherapists in order to develop definitions for seven haemophilia terms: 'primary prophylaxis', 'secondary prophylaxis', 'target joint', 'joint bleed', 'significant soft-tissue bleed', 'superficial soft-tissue bleed' and 'mucosal bleed'. Suggestions were solicited, compiled into a subsequent survey and fed back to the group to rank-order the importance of each suggested component of the definition. Final definitions were created using the top-ranked suggestions and sent back to the experts for approval. Five of the seven terms were highly endorsed with greater than 90% agreement. Some differences in agreement were found when analysed by profession. Haemophilia terms were successfully defined using the Delphi approach. Further refinement from members of the international haemophilia community will ensure that comprehensive standard definitions can be used in multicentre studies in the future.
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Affiliation(s)
- S Ota
- Research program in Child Health Evaluation Sicenses, The Hospital for Sick Children, Toronto, Canada
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25
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Feldman BM, Pai M, Rivard GE, Israels S, Poon MC, Demers C, Robinson S, Luke KH, Wu JKM, Gill K, Lillicrap D, Babyn P, McLimont M, Blanchette VS. Tailored prophylaxis in severe hemophilia A: interim results from the first 5 years of the Canadian Hemophilia Primary Prophylaxis Study. J Thromb Haemost 2006; 4:1228-36. [PMID: 16706965 DOI: 10.1111/j.1538-7836.2006.01953.x] [Citation(s) in RCA: 197] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prophylactic treatment for severe hemophilia A is likely to be more effective than treatment when bleeding occurs, however, prophylaxis is costly. We studied an inception cohort of 25 boys using a tailored prophylaxis approach to see if clotting factor use could be reduced with acceptable outcomes. METHODS Ten Canadian centers enrolled subjects in this 5-year study. Children were followed every 3 months at a comprehensive care hemophilia clinic. They were initially treated with once-weekly clotting factor; the frequency was escalated in a stepwise fashion if unacceptable bleeding occurred. Bleeding frequency, target joint development, physiotherapy and radiographic outcomes, as well as resource utilization, were determined prospectively. RESULTS The median follow-up time was 4.1 years (total 96.9 person-years). The median time to escalate to twice-weekly therapy was 3.42 years (lower 95% confidence limit 2.05 years). Nine subjects developed target joints at a rate of 0.09 per person-year. There was an average of 1.2 joint bleeds per person-year. The cohort consumed on average 3656 IU kg(-1)year(-1) of factor (F) VIII. Ten subjects required central venous catheters (three while on study); no complications of these devices were seen. One subject developed a transient FVIII inhibitor. End-of-study joint examination scores--both clinically and radiographically--were normal or near-normal. CONCLUSIONS Most boys with severe hemophilia A will probably have little bleeding and good joint function with tailored prophylaxis, while infusing less FVIII than usually required for traditional prophylaxis.
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Affiliation(s)
- B M Feldman
- Division of Rheumatology, Hospital for Sick Children, Toronto, ON, Canada.
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Abstract
Haemophilia is a rare, inherited blood disorder in which blood clotting is impaired such that patients suffer from excessive internal and external bleeding. At present there is no cure for haemophilia A and patients require expensive, life-long treatment involving clotting factor replacement therapy. Treatment costs are perceived to be higher for patients who have developed inhibitory antibodies to factor VIII, the standard therapy for haemophilia A. However, initial cost analyses suggest that clotting factor therapy with alternative haemostatic agents, such as recombinant activated factor VII or activated prothrombin complex concentrate, is no more expensive for the majority of haemophilia A patients with inhibitors than for those without inhibitors. With the availability of effective alternative haemostatic agents, orthopaedic surgery for haemophilia A patients with inhibitors is now a clinical option, and initial cost analyses suggest this may be a cost-effective treatment strategy for patients with inhibitors whose quality of life (QoL) is severely impaired by joint arthropathy. In an era of finite healthcare resourcing it is important to determine whether new treatments justify higher unit costs compared with standard therapies and whether such higher costs are justified from an individual perspective in terms of improved QoL, and from a societal perspective in terms of improved productivity and reduced overall healthcare costs. This paper examines current data on the health economics of treating haemophilia A patients with inhibitors, focusing on the overall costs of clotting factor replacement therapy and the cost consequences of joint replacement.
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Affiliation(s)
- C Knight
- RTI Health Solutions, Manchester, UK.
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Abstract
PURPOSE OF REVIEW Degenerative arthropathy resulting from recurrent hemarthrosis remains the largest source of noninfectious morbidity for persons with hemophilia. Optimal treatment to prevent or reduce joint destruction remains controversial. RECENT FINDINGS The most exciting developments in the past year have contributed to our understanding of the pathophysiology behind this destructive process. Particularly interesting is the possible role of protooncogenes and angiogenic factors in the development of hypertrophic synovitis. Arthroscopic synovectomy effectively controls the hypertrophic synovium and resultant bleeding, and can be used safely even in very young patients. Prophylactic factor replacement remains the mainstay to reduce or prevent joint damage. New approaches, chiefly dose escalation strategies, have shown promise instead of standard prophylactic regimens. Additionally aggressive on-demand approaches may be feasible. These techniques allow for fewer indwelling venous access devices in small children, as rates of complications with these devices are shown to be increasingly high. Whether prophylactic therapy can be safely stopped in certain patients is an evolving area of interest. Outcome measures are being validated to assess the impact of interventions on patient quality of life. SUMMARY As hemophilia care evolves, current on-demand and prophylactic regimens will be optimized. Synovectomy will likely play a larger role in the control of synovitis, and validated quality-of-life scores will allow more consistent communication of outcomes. New understanding of the molecular mechanisms of joint destruction will pave the way for new therapeutic options for persons with hemophilia.
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Affiliation(s)
- Amy L Dunn
- AFLAC Cancer Center and Blood Disorders Service, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, GA 30322, USA.
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