[Recombinant activated factor VII: a new treatment for hemophilia]

Detection and quantification of single chain rFVII impurity in final drug products by SE-UPLC and CE-SDS as an alternative to SDS-PAGE

Recombinant factor VII, produced in recombinant BHK cell line, is secreted as a single chain zymogen form (rFVII, non-activated) in cell culture supernatant and subsequently converts to its active form during anion exchange chromatography step in the downstream purification process, with the aid of calcium ion. Single chain rFVII impurity (non-activated form) in final drug products should not exceed more than 3.0 % of total rFVIIa content. Therefore, one of the most essential quality control tests in pharmaceutical companies is to precisely quantify and report this impurity. SDS-PAGE, as a traditional method in quality control laboratories to quantify single chain rFVII, is a laborious, time-consuming, low output, and semi-quantitative method for quantification of non-activated form impurity which utilizes a densitometer to scan the gel and calculate the non-activated form band density. In this work, we developed two novel instrumental-based techniques (SE-UPLC and CE-SDS) with superior precision, accuracy, sensitivity, and efficiency that overcome SDS-PAGE shortcomings. The results of both methods were comparable to SDS-PAGE and showed an even higher correlation with expected values. Finally, we concluded that these two methods could be used as a high throughput routine method in quality control laboratories as an alternative choice to manual SDS-PAGE.

Successful treatment of hereditary factor VII deficiency presented for the first time with epistaxis in pregnancy: a case report

OBJECTIVE

To present a rare case with factor VII deficiency (FVIID) that first diagnosed during pregnancy, and to disccuss the ante-, peri- and postpartum management.

STUDY DESIGN

A case report and review of the literature.

RESULTS

FVIID was diagnosed for the first time in a 23-year-old pregnant woman at the 24th week of gestation due to complaint of intermittent epistaxis. She was successfully treated by ante-, peripartum and postpartum replacement of recombinant FVII (rFVII). She was uneventfully discharged on the 3rd postoperative day and referred to hematology department for further follow-up.

CONCLUSION

FVIID, a rare cause of ante- and postpartum hemorrhages that may differently present by other hemorrhages (i.e.: epistaxis), can be optimally managed with replacement of rFVII.

A cost evaluation of treatment alternatives for mild-to-moderate bleeding episodes in patients with haemophilia and inhibitors in Brazil

The first-line treatment for mild-to-moderate bleeding episodes in patients with haemophilia and inhibitors in Brazil is currently activated prothrombin complex concentrate (aPCC), with recombinant activated factor VII (rFVIIa) used as second-line therapy or as a last resort. The aim of this study was to determine the cost and effectiveness of these treatments from the perspective of the Brazilian National Health Service. A decision analysis model was constructed to assess total direct medical costs (including drug costs, costs of outpatient or inpatient care, ambulance transportation and cost of concomitant medications) of first-line treatment with aPCC or rFVIIa. Clinical outcome and resource utilization data were obtained both retrospectively and prospectively and validated by the consensus of an expert panel of Brazilian haematologists. A total of 103 bleeds in 25 patients were included in the analysis. rFVIIa resolved bleeds more quickly (4.4 h) than aPCC (62.6 h) and was more effective (100% vs. 56.7% respectively). Mean total direct medical costs (from initiation to cessation of bleed) were estimated to be US$13 500 (aPCC) and US$7590 (rFVIIa). Extensive sensitivity analyses confirmed the cost-effectiveness of rFVIIa. Compared with aPCC, rFVIIa was more effective and less expensive when used as first-line treatment for mild-to-moderate bleeding episodes in patients with haemophilia and inhibitors in Brazil. rFVIIa should be considered a first-line treatment for the management of these patients.

[Diagnosis and management of a haemorrhagic emergency revealing an acquired haemophilia]

We relate the case of a 22-year-old woman, without any particular medical history, apart from a previous full-term pregnancy with no complication, for whom the discovery of prolongated APTT (Activated Partial Thromboplastin Time) postponed an emergency operation in spite of intracystic ovarian haemorrhage. The complementary check-up revealed the existence of an autoantibody antifactor VIII (antithromboplastinogen), showing acquired postpartum haemophilia.

Experience with use of recombinant activated factor VII

Recombinant activated factor VII (rFVIIa) has recently been introduced for improving haemostasis in haemophiliac patients developing alloantibodies (inhibitors) to factor VIII (FVIII) or factor IX (FIX). We describe the successful management of haemorrhagia with rFVIIa in five different situations: an episode of surgical bleeding in a patient with haemophilia A and non-surgical haemorrhages in four patients with haemophilia A, acquired haemophilia, congenital severe FV defect and pseudo-acquired haemophilia, respectively. In each case, rFVIIa was effective and safe. There is no doubt that rFVIIa is useful in the therapeutic management of patients with antibodies to FVIII or FIX. However, the treatment is expensive and a cost-effectiveness analysis would be useful.

[Acquired hemophilia: current diagnostic and therapeutic approaches]

PURPOSE

Acquired haemophilia is a rare disease, occurring most frequently in elderly patients, caused by the development of autoantibodies against factor VIII.

CURRENT KNOWLEDGE AND KEY POINTS

The disease is characterised by spontaneous haemorrhagic complications which can be fatal in 15-20% of the patients. However spontaneous remission is possible and in fact natural evolution and aetiology are still partly unknown. Acquired haemophilia may arise in association with auto-immune diseases, lymphoproliferative malignancy, pregnancy and also as a drug reaction. The aims of the treatment are first to treat the bleeding which is the most common cause of morbidity and mortality, and second to eliminate the inhibitor by immunosuppression. However no consensus exists for these two parts of the treatment. Bleeding may be controlled by prothrombin complex concentrates, recombinant factor VIIa or porcine factor VIII. The inhibitor is abolished in up 70% of patients using prednisone and cyclophosphamide. Other combinations of prednisone with azathioprine or with cyclophosphamide and vincristine or the use of high-dose immunoglobulin or double-filtration plasmapheresis have also proven effective in some patients.

FUTURE AND PROJECTS

The rare occurrence of the disease, the associated with various diseases, and lack of consensus about treatment, require multicentric prospective studies.