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Munawar Ali R, Abid M, Zafar S, Ali MS, Nadeem R, Ahmed R, Borhany M. Management of Severe Hemophilia A: Low-Dose Prophylaxis vs. On-Demand Treatment. Cureus 2023; 15:e41410. [PMID: 37546069 PMCID: PMC10402932 DOI: 10.7759/cureus.41410] [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] [Accepted: 06/30/2023] [Indexed: 08/08/2023] Open
Abstract
INTRODUCTION Prophylactic clotting factor infusion regimens to prevent bleeding and joint deformity has become the standard of care in severe hemophilia A patients. AIM To assess low-dose factor prophylaxis in our population as an alternative approach to managing severe hemophilia A. METHODS A prospective cohort study that included 68 hemophilia A patients divided into two groups, i.e., Prophylaxis and on-demand. The two groups were compared for annualized bleeding rate (ABR), hospitalization, units of factor VIII (FVIII) infused, or plasma products transfused, i.e., fresh frozen plasma (FFP) and cryoprecipitate (CP), and development of FVIII inhibitors. RESULTS Of the 68 patients recruited in this study, 25 (36.7%) were in the prophylaxis group, and 43(63.3%) were in the on-demand group. The on-demand group presented a higher median-IQR ABR [8(20-3) vs. 5(10-1.5), p-value 0.024], several hospitalizations (39.7% vs. 0, p-value 0.001), and inhibitor development (9.3% vs. 0, p-value 0.289) compared to the prophylaxis group. The prophylaxis approach demonstrated a significant negative correlation of ABR with FVIII prophylaxis (r=-0484, p=value=0.014). Moreover, no hospitalizations or inhibitor development was observed in the prophylaxis group. The estimated annual consumption of FVIII was 328 IU/kg/year in the on-demand group and 1662.6 IU/kg/year in the prophylaxis group. However, a highly significant difference in plasma product utilization was observed between the two groups, i.e., p-value <0.001 and 0.038 for FFP and CP, respectively. CONCLUSION Low-dose factor prophylaxis resulted in improved outcomes compared to on-demand treatment in terms of ABR, joint bleeding, hospitalization, and the development of inhibitors. This treatment approach should be adopted as an economically feasible alternative to high-dose Prophylaxis in resource-constrained countries.
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Affiliation(s)
- Rabeea Munawar Ali
- Hematology, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
| | - Madiha Abid
- Hematology, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
| | - Sidra Zafar
- Research and Development, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
| | - Muhammad Shujat Ali
- Hematology, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
| | - Rukhshanda Nadeem
- Physical Medicine and Rehabilitation, Hemophilia Welfare Society, Karachi, PAK
| | - Raheel Ahmed
- Hematology, Haemophilia Welfare Society, Karachi, PAK
| | - Munira Borhany
- Hematology, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
- Hematology, Haemophilia Welfare Society, Karachi, PAK
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2
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Blatný J, Kardos M, Miljic P, Bilić E, Benedik-Dolničar M, Faganel-Kotnik B, Konstantinov D, Kovalova Z, Ovesná P. Incidence of inhibitor development in PUPs with severe Haemophilia A in the CEE region between 2005 and 2015. Thromb Res 2020; 198:196-203. [PMID: 33360154 DOI: 10.1016/j.thromres.2020.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/05/2020] [Accepted: 12/09/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION This study analyses real-world data on 144 previously untreated patients (PUPs) with severe Haemophilia A, from seven countries in Central and Eastern Europe (CEE: Bulgaria, Croatia, Czech Republic, Hungary, Latvia, Serbia, and Slovenia), over a period of 11 years. It analyses the risk factors associated with development of inhibitors to factor VIII concentrates. METHODS Cox proportional hazard models were used to estimate the hazard risk of factors possibly influencing the development of inhibitors. Patients were followed for up to 100 exposure days (EDs). RESULTS Cumulative inhibitor incidence at the time of 100 EDs was 18.7%, slightly lower than the 25-35% incidence reported in most studies. Of PUPs who developed inhibitors, a majority (56%) developed them within the first 20 EDs and 88% by the 50th ED. FVIII class (recombinant or plasma-derived) did not influence the inhibitors' incidence rate (p = 0.64). We found a significant protective effect of prophylaxis compared to on-demand treatment (p = 0.003). PUPs who had an intensive peak treatment during the first 50 EDs were at significantly higher risk for inhibitor development (HR (95% CI) 5.3 (2.3-12.5), p < 0.001). CONCLUSION Inhibitors are and will continue to be the most significant complication of haemophilia treatment with factor concentrates. This is particularly true for haemophilia A. In our cohort, we were able to show that the treatment regimen used during first 50EDs influenced significantly the inhibitor risk, but the class of the factor concentrate did not play an important role. Real world data will remain one of the important resources for improving our knowledge of haemophilia.
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Affiliation(s)
- Jan Blatný
- Department of Paediatric Haematology, University Hospital and Masaryk University Brno, Czech Republic.
| | - Mária Kardos
- Department of Paediatrics, Mohács Hospital, Mohács, Hungary
| | - Predrag Miljic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia
| | - Ernest Bilić
- Department of Pediatrics, University Hospital Centre Zagreb, School of Medicine, Zagreb, Croatia
| | - Majda Benedik-Dolničar
- Unit for Haematology and Oncology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Barbara Faganel-Kotnik
- Unit for Haematology and Oncology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Dobrin Konstantinov
- Pediatric Hematology & Oncology Department, University Hospital "Tsaritsa Johanna-ISUL", Sofia, Bulgaria
| | - Zhanna Kovalova
- Department of Hematology and Oncology, Children's Clinical University Hospital, Riga, Latvia
| | - Petra Ovesná
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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3
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Castaman G, Linari S. Prophylactic versus on-demand treatments for hemophilia: advantages and drawbacks. Expert Rev Hematol 2018; 11:567-576. [PMID: 29886751 DOI: 10.1080/17474086.2018.1486704] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Early long-term prophylaxis is the standard of care to prevent joint bleeding and chronic arthropathy in patients with severe hemophilia. Areas covered: Despite the obvious prophylaxis advantages upon the clinical outcomes, there are still several drawbacks to be addressed for the optimal patients' compliance. Frequency of treatment due to short half-life of conventional FVIII and FIX concentrates, difficult venous access, adherence to the prescribed therapy and costs may represent significant critical issues. The development of inhibitors also makes replacement therapy ineffective, preventing patients from receiving long-term prophylaxis. This paper will review these drawbacks and the tools to overcome these limitations, mainly thanks to the use of extended half-life products and the development of novel non-conventional therapeutic approaches. Expert commentary: The use of extended half-life products may help in reducing the burden of the frequent intravenous administration and in better tailoring an individualized prophylaxis. The development of novel therapeutic approaches, like the bi-specific antibody mimicking the coagulation function of FVIII or inhibition of anticoagulant proteins may facilitate prophylaxis treatment not only in patients with inhibitors, but also in severe hemophilia patients without inhibitors. Exciting opportunities are emerging for improving prophylaxis in hemophilia.
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Affiliation(s)
- Giancarlo Castaman
- a Center for Bleeding Disorders and Coagulation, Department of Oncology , Careggi University Hospital , Florence , Italy
| | - Silvia Linari
- a Center for Bleeding Disorders and Coagulation, Department of Oncology , Careggi University Hospital , Florence , Italy
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4
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Modified Primary Prophylaxis in Previously Untreated Patients With Severe Hemophilia A in Iran. J Pediatr Hematol Oncol 2018; 40:188-191. [PMID: 29356759 DOI: 10.1097/mph.0000000000001082] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Recently the low-dose tailoring method of primary prophylaxis has been introduced for previously untreated patients with hemophilia A. OBJECTIVE To evaluate the efficacy and safety of low-dose tailoring method of primary prophylaxis in previously untreated patients with severe hemophilia A. MATERIALS AND METHODS In this pre-post interventional study, 33 patients with severe hemophilia A who were previously untreated and affiliated to universities in the capital city and southern Iran were evaluated during 2014 to 2015. Modified primary continuous prophylaxis was used for patients with age below 3 years old, after first and before the second episodes of obvious clinical bleeding in large joints or large soft tissue hematoma or large amount of bleeding. Prophylaxis was started by 25 IU/kg once per week and increased to twice or 3 times a week according to defined bleeding events. RESULTS The median age at diagnosis and age of starting prophylaxis were: 4 months (at birth, 22 mo) and 12 months (1 to 35 mo), respectively. Mean annual bleeding rate of patients after prophylaxis was 1.08±2.21 episodes per year. None of the patients had inhibitors before therapy. Inhibitor was present in 5 patients (15.1%) after prophylaxis. CONCLUSIONS It seems that modified primary continuous prophylaxis has been successful in reducing bleeding episodes in children with severe hemophilia A and in the texture of lower cost it can improve quality of life of these patients, especially in developing countries where financial resources are limited.
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5
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Rayes J, Ing M, Delignat S, Peyron I, Gilardin L, Vogel CW, Fritzinger DC, Frémeaux-Bacchi V, Kaveri SV, Roumenina LT, Lacroix-Desmazes S. Complement C3 is a novel modulator of the anti-factor VIII immune response. Haematologica 2017; 103:351-360. [PMID: 29146705 PMCID: PMC5792280 DOI: 10.3324/haematol.2017.165720] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 11/10/2017] [Indexed: 01/26/2023] Open
Abstract
Development of neutralizing antibodies against therapeutic Factor VIII (FVIII) is the most serious complication of the treatment of hemophilia A. There is growing evidence to show the multifactorial origin of the anti-FVIII immune response, combining both genetic and environmental factors. While a role for the complement system on innate as well as adaptive immunity has been documented, the implication of complement activation on the onset of the anti-FVIII immune response is unknown. Here, using in vitro assays for FVIII endocytosis by human monocyte-derived dendritic cells and presentation to T cells, as well as in vivo complement depletion in FVIII-deficient mice, we show a novel role for complement C3 in enhancing the immune response against therapeutic FVIII. In vitro, complement C3 and its cleavage product C3b enhanced FVIII endocytosis by dendritic cells and presentation to a FVIII-specific CD4+ T-cell hybridoma. The C1 domain of FVIII had previously been shown to play an important role in FVIII endocytosis, and alanine substitutions of the K2092, F2093 and R2090 C1 residues drastically reduce FVIII uptake in vitro. Interestingly, complement activation rescued the endocytosis of the FVIII C1 domain triple mutant. In a mouse model of severe hemophilia A, transient complement C3 depletion by humanized cobra venom factor, which does not generate anaphylatoxin C5a, significantly reduced the primary anti-FVIII immune response, but did not affect anti-FVIII recall immune responses. Taken together, our results suggest an important adjuvant role for the complement cascade in the initiation of the immune response to therapeutic FVIII.
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Affiliation(s)
- Julie Rayes
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Pierre et Marie Curie-Paris6, UMR S 1138, France.,Université Paris Descartes, UMR S 1138, France
| | - Mathieu Ing
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Pierre et Marie Curie-Paris6, UMR S 1138, France.,Université Paris Descartes, UMR S 1138, France
| | - Sandrine Delignat
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Pierre et Marie Curie-Paris6, UMR S 1138, France.,Université Paris Descartes, UMR S 1138, France
| | - Ivan Peyron
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Pierre et Marie Curie-Paris6, UMR S 1138, France.,Université Paris Descartes, UMR S 1138, France
| | - Laurent Gilardin
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Pierre et Marie Curie-Paris6, UMR S 1138, France.,Université Paris Descartes, UMR S 1138, France
| | - Carl-Wilhelm Vogel
- University of Hawaii Cancer Center, University of Hawaii at Manoa, Honolulu, HI, USA.,Department of Pathology, John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
| | - David C Fritzinger
- University of Hawaii Cancer Center, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Véronique Frémeaux-Bacchi
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Pierre et Marie Curie-Paris6, UMR S 1138, France.,Université Paris Descartes, UMR S 1138, France.,Assistance Publique-Hôpitaux de Paris, Service d'Immunologie Biologique, Hôpital Européen Georges-Pompidou, France
| | - Srinivas V Kaveri
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Pierre et Marie Curie-Paris6, UMR S 1138, France.,Université Paris Descartes, UMR S 1138, France
| | - Lubka T Roumenina
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France.,Université Pierre et Marie Curie-Paris6, UMR S 1138, France.,Université Paris Descartes, UMR S 1138, France
| | - Sébastien Lacroix-Desmazes
- INSERM, UMR S 1138, Centre de Recherche des Cordeliers, Paris, France .,Université Pierre et Marie Curie-Paris6, UMR S 1138, France.,Université Paris Descartes, UMR S 1138, France
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Owaidah T, Momen AA, Alzahrani H, Almusa A, Alkasim F, Tarawah A, Nouno RA, Batniji FA, Alothman F, Alomari A, Abu-Herbish S, Abu-Riash M, Siddiqui K, Ahmed M, Mohamed SY, Saleh M. The prevalence of factor VIII and IX inhibitors among Saudi patients with hemophilia: Results from the Saudi national hemophilia screening program. Medicine (Baltimore) 2017; 96:e5456. [PMID: 28079788 PMCID: PMC5266150 DOI: 10.1097/md.0000000000005456] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Hemophilia A and B are X-linked diseases that predominantly affect male patients. Patients can develop coagulation factor inhibitors, which exponentially increases the treatment cost. However, the prevalence of factor VIII and IX inhibitors in Saudi Arabia is unclear.This study aimed to determine the Saudi prevalence of factor VIII and IX inhibitors.This 4-year, 7-center, cross-sectional study evaluated the Saudi prevalences of hemophilia A and B. We collected the patients' clinical data, evaluated their disease, and tested for factor inhibitors.We included 202 patients with hemophilia (median age at diagnosis: 0.13 years, range: birth-34.8 years). The patients included 198 male patients (98%), 148 patients with hemophilia A (73.3%), and 54 patients with hemophilia B (26.7%). The patients exhibited severe factor VIII activity (<1%; 121 patients; 5.2%), moderate activity (1-5%; 7 patients; 4.9%), and mild activity (14 patients; 9.9%). Among the patients with care-related data, most patients were treated for episodic bleeding (76.8%) or received prophylaxis (22.6%); 1 patient received both treatments. Among the patients with source-related data, the factor replacements were derived from plasma (48.4%), recombinant concentrates (22.9%), both sources (14.6%), or fresh frozen plasma (14.1%). Factor VIII inhibitors were observed in 43 (29.3%) of the 147 patients, and only 1 of the 54 patients developed factor IX inhibitors. Most patients who developed inhibitors had severe hemophilia (40/44; 90.9%), and inhibitors were also common among patients who received recombinant products (14/43; 32.6%).The Saudi prevalence of factor inhibitors was similar to those among other ethnic populations.
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Affiliation(s)
- Tarek Owaidah
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center
- Center of Excellence in Thrombosis and Hemostasis, King Saud University
| | | | | | - Abdulrahman Almusa
- Department of Pediatric Hematology, King Faisal Specialist Hospital and Research Center
| | - Fawaz Alkasim
- Department of Pediatric Hematology, Ministry of Health, Riyadh
| | - Ahmed Tarawah
- Department of Pediatric Hematology, Ministry of Health, Medina
| | - Randa Al Nouno
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center
| | | | - Fahad Alothman
- Department of Pediatric Hematology, Security Force Hospital
| | - Ali Alomari
- Department of Pediatric Hematology, National Guard Hospital
| | - Saud Abu-Herbish
- Department of Oncology, Security Forces Hospital, Riyadh, Saudi Arabia
| | | | - Khawar Siddiqui
- Department of Pediatric Hematology, King Faisal Specialist Hospital and Research Center
| | - Mansor Ahmed
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center
| | | | - Mahasen Saleh
- Department of Pediatric Hematology, King Faisal Specialist Hospital and Research Center
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7
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Abstract
Retrospective and prospective studies unambiguously show that prophylactic treatment of severe hemophilia A or B should be started as primary prophylaxis at 1–2 years’ of age and ideally before the first joint bleed. The dose and dose frequency should be individually tailored depending on the goal of treatment, venous access and the bleeding phenotype. The circumstances during the first exposures of factor VIII concentrates in hemophilia A may have an impact on the risk of developing inhibitors. Enhanced half-life products, in particular in hemophilia B, will facilitate treatment in patients with difficult venous access but also in achieving a higher trough level. Evidence accumulate that prophylactic treatment is beneficial also in adults and in patients with inhibitors.
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Affiliation(s)
- Rolf Ljung
- Department of Clinical Sciences Lund-Paediatrics, Lund University, Lund, Sweden ; Department of Paediatrics and Malmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden
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8
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Vepsäläinen K, Lassila R, Arola M, Huttunen P, Koskinen S, Ljung R, Lähteenmäki P, Möttönen M, Riikonen P. Inhibitor development in previously untreated patients with severe haemophilia A: a nationwide multicentre study in Finland. Haemophilia 2016; 22:721-9. [PMID: 27339837 DOI: 10.1111/hae.12974] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2016] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Currently the most serious treatment complication of haemophilia is the inhibitor development (ID), i.e. neutralizing antibody development. AIM This nationwide multicentre study in Finland evaluated the incidence and risk factors of ID in previously untreated patients (PUPs) with severe haemophilia A (FVIII:C < 0.01 IU mL(-1) ). METHODS We enrolled all PUPs (N = 62) born between June 1994 and May 2013 with at least 75 exposure days (EDs) to screen ID during follow-up extending to September 2013. RESULTS Thirteen ID (21% of 62) occurred; 10 (16% of 62) with high titre. Fifty-one patients (82%) were on primary prophylaxis (regular prophylaxis before the age of 2 and before the first joint bleed) from the median age of 11.4 months, 90% via a central venous access device. The initial product was rFVIII in 63% and pd-FVIII in 37%, moreover in 24% pd-FVIII was switched to rFVIII concentrate during the 75 EDs. Non-transient inhibitors developed in 9/51 (17.6%; 13.7% high titre) children with primary and in 4/11 (36.4%; 27.3% high titre) patients with secondary prophylaxis (P = 0.24). Overall, 74% had a high-risk genotype similarly distributed among the prophylaxis groups. The history of a major bleed enhanced ID (aHR, 4.0; 95% CI, 1.2-13.7), whereas FVIII treatment intensity or source and early implantation of ports did not increase ID risk. CONCLUSION The cumulative incidence of ID was low notwithstanding prevalent high-risk mutations. Despite patient-related risk factors, our management involving early intensive primary prophylaxis via ports helps to prevent bleeds and lower the incidence of inhibitors.
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Affiliation(s)
- K Vepsäläinen
- Department of Paediatrics, Kuopio University Hospital, Kuopio, Finland.
| | - R Lassila
- Coagulation Disorders Unit, Department of Hematology, Comprehensive Cancer Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - M Arola
- Department of Paediatrics, Tampere University Central Hospital, Tampere, Finland
| | - P Huttunen
- Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - S Koskinen
- Finnish Red Cross Blood Transfusion Service, Helsinki, Finland
| | - R Ljung
- Department of Clinical Sciences - Paediatrics and Paediatric Clinic and Malmö Centre for Thrombosis and Haemostasis, Skånes Universitetssjukhus, Lund University, Lund, Sweden
| | - P Lähteenmäki
- Department of Paediatrics and Adolescent Medicine, Turku University Hospital and Turku University, Turku, Finland
| | - M Möttönen
- Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology, University Hospital of Oulu, Oulu, Finland
| | - P Riikonen
- Department of Paediatrics, Kuopio University Hospital, Kuopio, Finland
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Inhibitors incidence rate in Czech previously untreated patients with haemophilia A has not increased since introduction of recombinant factor VIII treatment in 2003. Blood Coagul Fibrinolysis 2015; 26:673-8. [DOI: 10.1097/mbc.0000000000000298] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Keipert C, Hesse J, Haschberger B, Heiden M, Seitz R, van den Berg HM, Hilger A. The growing number of hemophilia registries: Quantity vs. quality. Clin Pharmacol Ther 2015; 97:492-501. [PMID: 25669198 DOI: 10.1002/cpt.83] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/24/2015] [Indexed: 01/08/2023]
Abstract
Registries for rare diseases provide a tool for obtaining an overview of the clinical situation and can be used to discover points of improvement and to monitor long-term safety. Registries could also become a powerful tool to provide supporting information for marketing authorization. There is an urgent need for a pan-European or global strategy that supports consistent data. Therefore, transparency in data collection, harmonization of the database structures, and the convergence of scientific approaches are required.
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Affiliation(s)
- C Keipert
- Paul-Ehrlich-Institute, Federal Institute for Vaccines and Biomedicines, Hematology, Langen, Germany
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11
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Ljung R, Gretenkort Andersson N. The current status of prophylactic replacement therapy in children and adults with haemophilia. Br J Haematol 2015; 169:777-86. [DOI: 10.1111/bjh.13365] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Rolf Ljung
- Department of Clinical Sciences Lund-Paediatrics; Lund University; Lund Sweden
- Department of Paediatrics and Malmö Centre for Thrombosis and Haemostasis; Skåne University Hospital; Malmö Sweden
| | - Nadine Gretenkort Andersson
- Department of Paediatrics and Malmö Centre for Thrombosis and Haemostasis; Skåne University Hospital; Malmö Sweden
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