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Hassan T, Zakaria M. Emicizumab Prophylaxis in Children and Adolescents with Hemophilia A. Indian J Pediatr 2024:10.1007/s12098-024-05212-z. [PMID: 39023707 DOI: 10.1007/s12098-024-05212-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 07/08/2024] [Indexed: 07/20/2024]
Affiliation(s)
- Tamer Hassan
- Department of Pediatrics, Faculty of Medicine, Zagazig University, Zagazig, 44519, Egypt
| | - Marwa Zakaria
- Department of Pediatrics, Faculty of Medicine, Zagazig University, Zagazig, 44519, Egypt.
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Mancuso ME, McLaughlin P, Forsyth AL, Valentino LA. Joint health and pain in the changing hemophilia treatment landscape. Expert Rev Hematol 2024:1-14. [PMID: 38981851 DOI: 10.1080/17474086.2024.2378936] [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: 03/05/2024] [Accepted: 07/08/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Hemophilia is an inherited bleeding disorder. Bleeding, and in particular joint hemorrhage results in chronic arthropathy and disability. Acute and chronic pain are frequent and limit activity and participation and result in decreased health-related quality of life. Remarkable progress has been made in the diagnosis and treatment of hemophilia but bleeding continues to prove recalcitrant to currently available treatments and joint disease remains problematic. Physiotherapy and pain management are mainstays of current multidisciplinary integrated care of people with hemophilia (PWH). The focus of this review is on preservation of joint health in the era of new and innovative therapies. AREAS COVERED A search of the PubMed Central was conducted on 1 February 2024 using the MeSH Major Topic terms identified as keywords for the manuscript. This review will highlight what is known and unknown about joint bleeding and arthropathy, including insights on pain as a related complication. EXPERT OPINION Recent advances in therapeutic interventions aimed at promoting healthy joints in PWH will be discussed, including both the pharmacological treatment landscape and related strategies to promote joint health.
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Affiliation(s)
- Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, Department of Cardiovascular Medicine, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Humanitas University, Pieve Emanuele, Milan, Italy
| | - Paul McLaughlin
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London, UK
- Research Department of Haematology, University College London, London, UK
| | - Angela L Forsyth
- Physical Therapy Collaborative, Optum Infusion Pharmacy, Eden Praire, MN, USA
| | - Leonard A Valentino
- Hemophilia and Thrombophilia Center, Rush University Medical Center, Chicago, IL, USA
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Josset L, Leuci A, Janbain M, De-Wreede A, Desage S, Lienhart A, Bin V, Lebert D, Delavenne X, Dargaud Y. Multicenter evaluation of the hemostatic activity of emicizumab in patients with severe hemophilia A. J Thromb Haemost 2024; 22:1857-1866. [PMID: 38583717 DOI: 10.1016/j.jtha.2024.03.022] [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: 11/03/2023] [Revised: 02/19/2024] [Accepted: 03/25/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Emicizumab has been approved for the prophylaxis of patients with hemophilia A with or without inhibitors. However, spontaneous and trauma-induced breakthrough bleeds have been reported in patients on emicizumab prophylaxis, and no laboratory assay has been validated to evaluate the hemostatic activity of emicizumab. OBJECTIVES The thrombin generation assay (TGA) could be a surrogate marker of the hemostatic efficacy of emicizumab. The correlation between TGA and the methods used to measure emicizumab blood concentration was evaluated in this study. METHODS TGA was modified by the use of a trigger reagent combining a very low concentration of tissue factor and activated factor (F)XI. Emicizumab quantification was performed by 3 methods: the modified 1-step FVIII assay and 2 methods based on liquid chromatography and mass spectrometry (LC-MS). RESULTS Using tissue factor/activated FXI-triggered TGA and platelet-poor plasma, a relationship was observed between the area under the thrombin generation curve (endogenous thrombin potential [ETP]) and the clinical response of patients to emicizumab. The ultrastructure of fibrin clots was consistent with ETP results and showed that emicizumab had a hemostatic activity equivalent to 20 to 30 IU/dL of FVIII. Finally, pharmacokinetic/pharmacodynamic analyses showed no correlation between ETP and LC-MS nor with modified 1-stage FVIII assay, but a statistically significant correlation between the LC-MS methods and the time-to-peak results of the TGA. CONCLUSION Using a modified TGA, this study showed that patients who experienced breakthrough bleeds while on emicizumab had a lower thrombin-generating capacity compared with others with good clinical response to emicizumab.
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MESH Headings
- Humans
- Hemophilia A/drug therapy
- Hemophilia A/blood
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Bispecific/pharmacology
- Antibodies, Bispecific/pharmacokinetics
- Antibodies, Bispecific/therapeutic use
- Antibodies, Bispecific/blood
- Thrombin/metabolism
- Adult
- Hemostasis/drug effects
- Male
- Young Adult
- Adolescent
- Hemorrhage/blood
- Middle Aged
- Treatment Outcome
- Chromatography, Liquid
- Blood Coagulation Tests
- Hemostatics/therapeutic use
- Hemostatics/pharmacology
- Hemostatics/pharmacokinetics
- Mass Spectrometry
- Blood Coagulation/drug effects
- Child
- Severity of Illness Index
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Affiliation(s)
- Laurie Josset
- UR4609-Hémostase et Thrombose, Université Claude Bernard Lyon I, Lyon, France; Institut national de la santé et de la recherche médicale, unité mixte de recherche 1059, Dysfonction Vasculaire et de l'Hémostase, Université de Lyon, Saint-Etienne, France
| | - Alexandre Leuci
- UR4609-Hémostase et Thrombose, Université Claude Bernard Lyon I, Lyon, France
| | - Maissaa Janbain
- Deming Department of Internal Medicine, Section of Hematology and Medical Oncology, Tulane School of Medicine, New Orleans, Louisiana, USA
| | - Anaëlle De-Wreede
- Laboratoire d'Hémostase, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France
| | - Stephanie Desage
- Unite d'Hémostase Clinique, Hôpital Cardiologique, Hospices Civils de Lyon, Lyon, France
| | - Anne Lienhart
- Unite d'Hémostase Clinique, Hôpital Cardiologique, Hospices Civils de Lyon, Lyon, France
| | - Valérie Bin
- Institut national de la santé et de la recherche médicale, unité mixte de recherche 1059, Dysfonction Vasculaire et de l'Hémostase, Université de Lyon, Saint-Etienne, France
| | | | - Xavier Delavenne
- Institut national de la santé et de la recherche médicale, unité mixte de recherche 1059, Dysfonction Vasculaire et de l'Hémostase, Université de Lyon, Saint-Etienne, France
| | - Yesim Dargaud
- UR4609-Hémostase et Thrombose, Université Claude Bernard Lyon I, Lyon, France; Unite d'Hémostase Clinique, Hôpital Cardiologique, Hospices Civils de Lyon, Lyon, France.
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Lemos F, Petraccia C, Fraga ML, Casuriaga AL, Lutz S, Gómez R, Giachetto G, Boggia B. Prophylaxis with emicizumab in children under 12 years old with haemophilia A without inhibitors in Uruguay: National experience. Haemophilia 2024; 30:1077-1079. [PMID: 38684449 DOI: 10.1111/hae.15024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Felipe Lemos
- Departamento de Medicina Transfusional, Centro de Referencia para la Hemofilia y otros Desórdenes Hemorrágicos Congénitos, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
- Clínica Pediátrica C, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Carlos Petraccia
- Departamento de Medicina Transfusional, Centro de Referencia para la Hemofilia y otros Desórdenes Hemorrágicos Congénitos, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - María Laura Fraga
- Departamento de Medicina Transfusional, Centro de Referencia para la Hemofilia y otros Desórdenes Hemorrágicos Congénitos, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - Ana Laura Casuriaga
- Clínica Pediátrica C, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Stefani Lutz
- Departamento de Medicina Transfusional, Centro de Referencia para la Hemofilia y otros Desórdenes Hemorrágicos Congénitos, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - Rosario Gómez
- Departamento de Medicina Transfusional, Centro de Referencia para la Hemofilia y otros Desórdenes Hemorrágicos Congénitos, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - Gustavo Giachetto
- Clínica Pediátrica C, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Beatriz Boggia
- Departamento de Medicina Transfusional, Centro de Referencia para la Hemofilia y otros Desórdenes Hemorrágicos Congénitos, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
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Xu Y, Wang Y, Wu R, Zheng C, Zhang L, Xu W, Feng X, Wang H, Cao X, He L, Xue T, Jin M, Xie B, Ling J, Sun L, Su R, Cheng H, Fang Y, Poon MC, Liu W, Zhang L, Xue F, Yang R. Reduced doses of emicizumab achieve good efficacy: Results from a national-wide multicentre real-world study in China. Haemophilia 2024; 30:959-969. [PMID: 38853005 DOI: 10.1111/hae.15062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/13/2024] [Accepted: 04/19/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION Reduced doses of emicizumab improve the affordability among patients in developing countries. However, the relationship between variant dose selection and efficacy in the real world of China is still unclear. AIM This study aimed to investigate the efficacy and safety of emicizumab especially in those on reduced dose regimens in a real-world setting. METHODS We carried out a multicentre study from 28 hospitals between June 2019 and June 2023 in China and retrospectively analysed the characteristics including demographics, diagnosis, treatment, bleeding episodes, and surgical procedures. RESULTS In total, 127 patients with haemophilia A, including 42 with inhibitors, were followed for a median duration of 16.0 (IQR: 9.0-30.0) months. Median age at emicizumab initiation was 2.0 (IQR: 1.0-4.0) years. Median (IQR) consumption for loading and maintenance was 12.0 (8.0-12.0) and 4.2 (3.0-6.0) mg/kg/4 weeks, respectively. While on emicizumab, 67 (52.8%) patients had no bleeds, whereas 60 (47.2%) patients had any bleeds, including 26 with treated bleeds. Compared to previous treatments, patients on emicizumab had significantly decreased annualized bleeding rate, annualized joint bleeding rate, target joints and intracerebral haemorrhage. Different dosages had similar efficacy except the proportion of patients with treated spontaneous bleeds and target joints. Adverse events were reported in 12 (9.4%) patients. Postoperative excessive bleeding occurred following two of nine procedures. CONCLUSION This is the largest study describing patients with HA receiving emicizumab prophylaxis on variant dose regimens in China. We confirmed that nonstandard dose is efficacious and can be considered where full-dose emicizumab is ill affordable.
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Affiliation(s)
- Yuan Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Ying Wang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Shenzhen, China
| | - Runhui Wu
- Hematology Oncology Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Changcheng Zheng
- Department of Hematology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Li Zhang
- Department of Hematology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Weiqun Xu
- Division/Center of Pediatric Hematology-Oncology, the Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoqin Feng
- Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hua Wang
- Department of Hematology and Oncology, Xi'an Children's Hospital, Xi'an, China
| | - Xiangshan Cao
- Department of Hematology, Suzhou BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Suzhou, China
| | - Liya He
- Department of Pediatric, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | | | - Mingwei Jin
- Pediatrics, Xuzhou Star Hospital, Xuzhou, China
| | - Bingshou Xie
- Department of Hematology, Wenzhou People's Hospital, Wenzhou, China
| | - Jing Ling
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, China
| | - Lirong Sun
- Department of Pediatrics, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Rui Su
- Department of Hematology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Hongbo Cheng
- Department of Hematology, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, China
| | - Yongjun Fang
- Department of Hematology/Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Man-Chiu Poon
- Departments of Medicine, Paediatrics and Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
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Agarwal S, Hermans C, Miesbach W, Peyvandi F, Sidonio R, Osmond D, Newman V, Henshaw J, Pipe S. Transitioning from emicizumab prophylaxis to valoctocogene roxaparvovec gene therapy: A simulation study for individuals with severe haemophilia A. Haemophilia 2024; 30:905-913. [PMID: 38684460 DOI: 10.1111/hae.15025] [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: 09/26/2023] [Revised: 02/27/2024] [Accepted: 03/19/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION Valoctocogene roxaparvovec, a gene therapy evaluated in the phase 3 GENEr8-1 trial, supports endogenous factor VIII (FVIII) production to prevent bleeding in people with severe haemophilia A. Individuals receiving emicizumab, an antibody mimicking the function of activated FVIII, were excluded from GENEr8-1 enrolment since emicizumab was an investigational therapy at the time of trial initiation. AIM Utilize pharmacokinetic simulations to provide guidance on best practices for maintaining haemostatic control while transitioning from emicizumab prophylaxis to valoctocogene roxaparvovec. METHODS To estimate bleeding risk at weekly intervals following valoctocogene roxaparvovec infusion, a published emicizumab pharmacokinetic model was used to simulate emicizumab concentrations and merged with FVIII activity time-course data for participants in GENEr8-1. The analysis investigated three approved emicizumab dosing regimens for two transition scenarios that varied whether the last dose of emicizumab was administered on the same day or 4 weeks after valoctocogene roxaparvovec infusion. RESULTS Simulations demonstrated administering the last emicizumab dose the day of valoctocogene roxaparvovec infusion and 4 weeks after offered similar levels of haemostatic control, and bleeding risk was similar for all emicizumab dosing regimens. An algorithm was developed to provide guidance for discontinuation of emicizumab. Theoretical cases based on GENEr8-1 participants are presented to illustrate how decisions may vary among individuals. CONCLUSION Pharmacokinetic simulations demonstrated no clinically meaningful difference in bleeding risk caused by decaying emicizumab levels and rising gene therapy-derived endogenous FVIII for all examined emicizumab doses and dosing regimens. Therefore, multiple approaches can safely transition individuals from emicizumab prophylaxis to valoctocogene roxaparvovec.
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Affiliation(s)
| | - Cedric Hermans
- Division of Adult Haematology, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | | | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Robert Sidonio
- Hemostasis and Thrombosis Program, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Dane Osmond
- BioMarin Pharmaceutical Inc., Novato, California, USA
| | | | - Josh Henshaw
- BioMarin Pharmaceutical Inc., Novato, California, USA
| | - Steven Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
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Arcudi S, Gualtierotti R, Scalambrino E, Clerici M, Hassan S, Begnozzi V, Boccalandro EA, Novembrino C, Valsecchi C, Palla R, Peyvandi F. Predictive parameters for spontaneous joint bleeding during emicizumab prophylaxis. Blood Adv 2024; 8:2901-2907. [PMID: 38531053 PMCID: PMC11176939 DOI: 10.1182/bloodadvances.2023012285] [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: 11/28/2023] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 03/28/2024] Open
Abstract
ABSTRACT Emicizumab is approved for prophylaxis of patients with hemophilia A (HA). Despite its efficacy in reducing bleeding, some patients on emicizumab still experience hemarthrosis, but no tool is yet available to identify those at a higher risk of spontaneous joint bleeding. This study aimed to evaluate whether laboratory measurements (global coagulation assays and emicizumab concentration) and/or arthropathy scores can distinguish patients at higher risk of spontaneous joint bleeding while on emicizumab prophylaxis. A thrombin generation assay was performed upon the addition of tissue factor and synthetic phospholipids. Nonactivated thromboelastography was performed on citrated whole blood. Emicizumab concentrations were measured using a modified 1-stage factor VIII assay. The degree of hemophilic arthropathy was assessed using the Hemophilia Joint Health Score and Hemophilia Early Arthropathy Detection with Ultrasound (HEAD-US) score. A Cox proportional hazards model was used to evaluate the association between variables and bleeding. The predictive power of these variables was investigated using receiver operating characteristic (ROC) analysis. Forty patients with severe HA, with or without inhibitors, on emicizumab prophylaxis were enrolled in an observational cohort study. Ten of 40 developed spontaneous joint bleeding. None of the laboratory parameters were able to distinguish patients with a higher risk of spontaneous joint bleeding. ROC analysis showed that during emicizumab prophylaxis, only the presence of synovitis and a higher HEAD-US score were associated with spontaneous joint bleeding (area under the curve, 0.84). A greater degree of arthropathy and the presence of synovitis could help predict the risk of spontaneous joint bleeding in patients with HA on emicizumab prophylaxis.
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Affiliation(s)
- Sara Arcudi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Roberta Gualtierotti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Erica Scalambrino
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Marigrazia Clerici
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Shermarke Hassan
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Valentina Begnozzi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Elena Anna Boccalandro
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Cristina Novembrino
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Carla Valsecchi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Roberta Palla
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Fager AM, Ellsworth P, Key NS, Monroe DM, Hoffman M. Emicizumab promotes factor Xa generation on endothelial cells. J Thromb Haemost 2024; 22:1605-1615. [PMID: 38460838 DOI: 10.1016/j.jtha.2024.02.017] [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: 06/15/2023] [Revised: 01/31/2024] [Accepted: 02/26/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Until recently, the treatment of hemophilia A relied on factor (F)VIII replacement. However, up to one-third of patients with severe hemophilia A develop neutralizing alloantibodies that render replacement therapies ineffective. The development of emicizumab, a bispecific antibody that partially mimics FVIIIa, has revolutionized the treatment of these patients. However, the use of an activated prothrombin complex concentrate [FEIBA (Takeda)] to treat breakthrough bleeding in patients on emicizumab has been associated with thrombotic complications including a unique microangiopathy. OBJECTIVES We hypothesized that the thrombotic complications observed with the combination of emicizumab and FEIBA might be due to excessive expression of procoagulant activity on the surface of endothelial cells. METHODS We examined the ability of emicizumab to promote FX activation on endothelial cells using 2 cell culture models. RESULTS We found that endothelial cells readily support emicizumab-mediated activation of FX by FIXa. The level of FXa generation depends on the concentration of available FIXa. The addition of FEIBA to emicizumab increased FXa generation in a dose-dependent manner on endothelial cells in both models. The rate of FXa generation was further enhanced by endothelial cell activation. However, unlike emicizumab, we found limited FXa generation in the presence of FVIII(a), which followed a significant lag time and was not dependent on FIXa concentration under these conditions. CONCLUSION Emicizumab promotes FXa generation on the surface of endothelial cells, which is markedly enhanced in the presence of FEIBA. These findings demonstrate a potential mechanism for the thrombotic complications seen with the combined use of emicizumab and FEIBA.
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Affiliation(s)
- Ammon M Fager
- Hematology/Oncology Service, Department of Veterans Affairs Medical Center, Durham, North Carolina, USA; Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Patrick Ellsworth
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nigel S Key
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Laboratory Medicine and Pathology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dougald M Monroe
- Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Maureane Hoffman
- Pathology and Laboratory Medicine Service, Department of Veterans Affairs Medical Center, Durham, North Carolina, USA; Department of Pathology, Duke University School of Medicine, Durham, North Carolina, USA
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Prudente TP, Camelo RM, Guimarães RA, Roberti MDRF. Emicizumab prophylaxis in people with hemophilia A and inhibitors: a systematic review and meta-analysis. SAO PAULO MED J 2024; 142:e2023102. [PMID: 38747872 PMCID: PMC11087007 DOI: 10.1590/1516-3180.2023.0102.r1.20022024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/06/2023] [Accepted: 02/20/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Until recently, the treatment of people with hemophilia A and inhibitors (PwHAi) was based on the use of bypassing agents (BPA). However, the advent of emicizumab as prophylaxis has demonstrated promising results. OBJECTIVES We aimed to compare the bleeding endpoints between PwHAi on BPA and those on emicizumab prophylaxis. DESIGN AND SETTING Systematic review of interventions and meta-analysis conducted at the Universidade Federal de Goiás, Goiânia, Goiás, Brazil. METHODS The CENTRAL, MEDLINE, Scopus, and LILACS databases were searched on February 21, 2023. Two authors conducted the literature search, publication selection, and data extraction. The selected publications evaluated the bleeding endpoints between PwHAi on emicizumab prophylaxis and those on BPA prophylaxis. The risk of bias was evaluated according to the Joanna Briggs Institute criteria. A meta-analysis was performed to determine the annualized bleeding rate (ABR) for treated bleeds. RESULTS Five publications (56 PwHAi) were selected from the 543 retrieved records. Overall, bleeding endpoints were lower during emicizumab prophylaxis than during BPA prophylaxis. All the publications had at least one risk of bias. The only common parameter for the meta-analysis was the ABR for treated bleeds. During emicizumab prophylaxis, the ABR for treated bleeds was lower than during BPA prophylaxis (standard mean difference: -1.58; 95% confidence interval -2.50, -0.66, P = 0.0008; I2 = 68.4%, P = 0.0031). CONCLUSION Emicizumab was superior to BPA in bleeding prophylaxis in PwHAi. However, both the small population size and potential risk of bias should be considered when evaluating these results. SYSTEMATIC REVIEW REGISTRATION CRD42021278726, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278726.
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Affiliation(s)
- Tiago Paiva Prudente
- Medical student, Faculty of Medicine, Universidade Federal de Goiás (UFG), Goiânia (GO), Brazil
| | - Ricardo Mesquita Camelo
- MD, PhD. Physician, Postdoctoral associate, Faculty of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil
| | - Rafael Alves Guimarães
- RN, PhD. Epidemiologist, Professor, Faculty of Nursing, Universidade Federal de Goiás (UFG), Goiânia (GO), Brazil
| | - Maria do Rosário Ferraz Roberti
- MD, PhD. Physician, Professor, Faculty of Medicine, Universidade Federal de Goiás (UFG), Goiânia (GO), Brazil; Physician, Secretaria de Saúde do Estado de Goiás (SES/GERAT), Goiânia (GO), Brazil
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10
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Onishi T, Shimo H, Harada S, Nogami K. The effects of emicizumab on in vitro coagulation and fibrinolysis parameters in patients with disseminated intravascular coagulation with and without addition of anti-FVIII antibody. Haemophilia 2024; 30:836-844. [PMID: 38523253 DOI: 10.1111/hae.14997] [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: 12/07/2023] [Revised: 03/02/2024] [Accepted: 03/09/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Emicizumab (Emi) is used as haemostatic prophylaxis for patients with haemophilia A (PwHA). Disseminated intravascular coagulation (DIC) is a condition characterized by persistent systemic activation of coagulation, but there is yet no information on coagulation and fibrinolysis potentials in Emi-treated PwHA with DIC. AIM To examine the effect of Emi on coagulation and fibrinolysis potentials in HA-model DIC plasmas. METHODS Plasma from a patient with sepsis-DIC (seven patients) was treated with anti-factor (F)VIII monoclonal antibody (HA-model DIC plasma) and incubated with Emi (50 µg/mL). The plasma was then assessed using clot-fibrinolysis waveform analysis (CFWA). Coagulation and fibrinolysis parameters were expressed as ratios relative to normal plasma (|min1|-ratio and |FL-min1|-ratio, respectively). PATIENTS AND RESULTS In case 1, coagulant potential was slightly high and fibrinolytic potential was extremely low, presenting a coagulant-dominant state (|min1|-ratio/|FL-min1|-ratio: 1.1/.38). In cases 2-5, fibrinolytic potential was not suppressed, but there were marked hypercoagulant potentials, indicating relative coagulant-dominant states. In case 6, coagulant and fibrinolytic potentials were increased but well balanced (|min1|-ratio/|FL-min1|-ratio: 1.38/1.28). In case 7, both potentials were severely deteriorated in not only CFWA but also the thrombin/plasmin generation assay. The addition of Emi into the HA-model DIC plasmas increased |min1|-ratio values in all cases, but the coagulant potentials did not exceed the initial ones (DIC plasma before treatment with anti-FVIII antibody). CONCLUSIONS The presence of Emi in the HA-model DIC plasma improved coagulation potentials, but did not increase coagulation potentials beyond those of DIC plasma in non-HA states.
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Affiliation(s)
- Tomoko Onishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Center of Postgraduate Training Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Hanako Shimo
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Suguru Harada
- Chugai Pharmaceutical Co., Ltd, Yokohama, Kanagawa, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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11
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Iarossi M, Hermans C. Emicizumab as first-line therapy in acquired hemophilia A. Res Pract Thromb Haemost 2024; 8:102438. [PMID: 38953052 PMCID: PMC11215093 DOI: 10.1016/j.rpth.2024.102438] [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: 03/13/2024] [Revised: 04/30/2024] [Accepted: 05/01/2024] [Indexed: 07/03/2024] Open
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune disease resulting from the development of autoantibodies directed against endogenous factor (F)VIII, leading to bleeding manifestations that can be life-threatening. The current standard hemostatic treatment involves the use of bypassing agents that circumvent FVIII (recombinant activated FVII, activated prothrombin complex concentrate, and recombinant porcine FVIII) that must be administered intravenously and possess a short half-life. These limitations and the risk of potentially fatal bleeding complications justify the early initiation of immunosuppressive treatment (IST) aimed at promptly eradicating the autoantibodies. IST is not without side effects, sometimes severe and possibly fatal, especially in persons with AHA who are generally older and have multiple comorbidities. Emicizumab, a bispecific antibody that mimics the action of FVIII, has emerged as an effective hemostatic therapy among persons with congenital hemophilia, whether complicated by the presence of anti-FVIII antibodies or not. Numerous arguments from recent clinical experiences suggest positioning emicizumab as a first-line treatment for AHA. This strategy has the potential to reduce bleeding complications and, importantly, the side effects associated with IST, which can be delayed and tailored to each patient.
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Affiliation(s)
- Michael Iarossi
- Division of Hematology, Hemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain, Brussels, Belgium
| | - Cedric Hermans
- Division of Hematology, Hemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain, Brussels, Belgium
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12
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Ramanan R, Evans N, Kaplan Z, McFadyen JD, Tran HA. Mutational landscape, inhibitor development, and health-care burden in non-severe haemophilia A: A single-centre Australian experience. Haemophilia 2024; 30:638-647. [PMID: 38578179 DOI: 10.1111/hae.15007] [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: 11/06/2023] [Revised: 01/16/2024] [Accepted: 03/19/2024] [Indexed: 04/06/2024]
Abstract
AIM To characterise non-severe haemophilia A (HA) patients enrolled on the Australian Bleeding Disorders Registry (ABDR) treated through a state-wide Haemophilia Treatment Centre (HTC) with respect to their mutational profile, inhibitor risk and health-care burden. METHOD We conducted a single-centre observational study of all non-severe HA patients treated at the Alfred Health HTC registered on the ABDR as of the 26th July 2023. Data were extracted from the ABDR and electronic medical record (EMR) regarding demographics, severity, genetic testing, treatment, inhibitors, bleeding events and procedures. Inhibitor risk was calculated as a function of exposure days (EDs) of FVIII replacement. RESULTS There were 289 non-severe HA patients treated at the Alfred HTC registered on the ABDR as of July 2023, all of whom were adult patients aged > 18 years old. Genotyping had been performed in 228/289 (78.9%). Of the inhibitor analysis population, 14/193 (7.3%) had an inhibitor. The cumulative incidence of inhibitor development at 75 EDs was 31% (95% CI 13%-46%). The median cost of bypassing agents per inhibitor patient was $57,087.50/year. CONCLUSION These results demonstrate a relatively high inhibitor prevalence and incidence risk in non-severe HA compared to previously published work, although this may partly reflect a smaller population size. High rates of genotyping have allowed representative mutational characterisation. The burden of care imposed by non-severe HA in terms of bleeding events, procedures and bypassing agent cost is larger than expected, particularly within the inhibitor population.
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Affiliation(s)
- Radha Ramanan
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
- Ronald Sawers Haemophilia Treatment Centre, Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
- Australian Haemophilia Centre Directors' Organisation, Melbourne, Victoria, Australia
| | - Natalie Evans
- Ronald Sawers Haemophilia Treatment Centre, Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
- Australian Haemophilia Centre Directors' Organisation, Melbourne, Victoria, Australia
| | - Zane Kaplan
- Ronald Sawers Haemophilia Treatment Centre, Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Clinical Haematology, Monash Health, Melbourne, Victoria, Australia
| | - James D McFadyen
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
- Ronald Sawers Haemophilia Treatment Centre, Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Huyen A Tran
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
- Ronald Sawers Haemophilia Treatment Centre, Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
- Australian Haemophilia Centre Directors' Organisation, Melbourne, Victoria, Australia
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13
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Pipe SW, Collins P, Dhalluin C, Kenet G, Schmitt C, Buri M, Jiménez-Yuste V, Peyvandi F, Young G, Oldenburg J, Mancuso ME, Kavakli K, Kiialainen A, Deb S, Niggli M, Chang T, Lehle M, Fijnvandraat K. Emicizumab prophylaxis in infants with hemophilia A (HAVEN 7): primary analysis of a phase 3b open-label trial. Blood 2024; 143:1355-1364. [PMID: 38127586 PMCID: PMC11033591 DOI: 10.1182/blood.2023021832] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/27/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
ABSTRACT Subcutaneous emicizumab enables prophylaxis for people with hemophilia A (HA) from birth, potentially reducing risk of bleeding and intracranial hemorrhage (ICH). HAVEN 7 (NCT04431726) is the first clinical trial of emicizumab dedicated to infants, designed to investigate the efficacy, safety, pharmacokinetics, and pharmacodynamics of emicizumab in those aged ≤12 months with severe HA without factor VIII (FVIII) inhibitors. Participants in this phase 3b trial received emicizumab 3 mg/kg maintenance dose every 2 weeks for 52 weeks and are continuing emicizumab during the 7-year long-term follow-up. Efficacy end points included annualized bleed rate (ABR): treated, all, treated spontaneous, and treated joint bleeds. Safety end points included adverse events (AEs), thromboembolic events (TEs), thrombotic microangiopathies (TMAs), and immunogenicity (anti-emicizumab antibodies [ADAs] and FVIII inhibitors). At primary analysis, 55 male participants had received emicizumab (median treatment duration: 100.3; range, 52-118 weeks). Median age at informed consent was 4.0 months (range, 9 days to 11 months 30 days). Model-based ABR for treated bleeds was 0.4 (95% confidence interval, 0.30-0.63), with 54.5% of participants (n = 30) having zero treated bleeds. No ICH occurred. All 42 treated bleeds in 25 participants (45.5%) were traumatic. Nine participants (16.4%) had ≥1 emicizumab-related AE (all grade 1 injection-site reactions). No AE led to treatment changes. No deaths, TEs, or TMAs occurred. No participant tested positive for ADAs. Two participants were confirmed positive for FVIII inhibitors. This primary analysis of HAVEN 7 indicates that emicizumab is efficacious and well tolerated in infants with severe HA without FVIII inhibitors.
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Affiliation(s)
| | - Peter Collins
- School of Medicine, Cardiff University, Cardiff, United Kingdom
| | | | - Gili Kenet
- Sheba Medical Center, Ramat Gan, Israel
- Tel Aviv University, Tel Aviv, Israel
| | | | - Muriel Buri
- F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | | | - Flora Peyvandi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Università degli Studi di Milano, Milan, Italy
| | - Guy Young
- Children’s Hospital Los Angeles, Los Angeles, CA
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
| | - Maria Elisa Mancuso
- IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Humanitas University, Pieve Emanuele, Milan, Italy
| | - Kaan Kavakli
- Ege University Children’s Hospital Department of Hematology, Bornova, İzmir, Turkey
| | | | - Sonia Deb
- Genentech, Inc, South San Francisco, CA
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14
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Tran H, Yang R, Fischer K, Makris M, Konkle BA. The importance and evolution of bleeding disorder registries. Haemophilia 2024; 30 Suppl 3:21-28. [PMID: 38571362 DOI: 10.1111/hae.14993] [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: 01/11/2024] [Revised: 02/13/2024] [Accepted: 02/21/2024] [Indexed: 04/05/2024]
Abstract
Registries are excellent sources of data to address questions that are typically not evaluated in randomized clinical trials, including natural history, disease prevalence, treatment approaches and adverse events, and models of care. Global and regional registries can provide data to identify differences in outcomes and in haemophilia care between countries, economic settings, and regions, while facilitating research and data sharing. In this manuscript, we highlight five bleeding disorder registries: Country registries from Australia and China, Paediatric Network on Haemophilia Management (PedNet) data on children who have received emicizumab, data from the European Haemophilia Safety Surveillance (EUHASS) system, and data on women and girls with haemophilia from the World Federation of Haemophilia (WFH) registries. Data from these and other bleeding disorder registries have been and will continue to be used to advance patient care, understand treatment patterns and adverse reactions, and identify areas of increased need and focus.
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Affiliation(s)
- Huyen Tran
- The Alfred Hospital, Melbourne, Victoria, Australia
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Sciences, Tianjin, China
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, Utrecht University, University Medical Center, Utrecht, Netherlands
| | - Michael Makris
- School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Barbara A Konkle
- Washington Center for Bleeding Disorders, University of Washington, Seattle, Washington, USA
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15
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Jiménez-Yuste V, Álvarez-Román MT, Berrueco R, Bonanad S, Calvo-Villas JM, González-González R, Porras JRG, Núñez-Vázquez RJ, Rodríguez-López M. Management of Urgent Bleeding in Patients with Hemophilia A: Focus on the Use of Emicizumab. TH OPEN 2024; 8:e194-e201. [PMID: 38633730 PMCID: PMC11023713 DOI: 10.1055/s-0044-1785525] [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: 12/11/2023] [Accepted: 02/23/2024] [Indexed: 04/19/2024] Open
Abstract
Management of patients with hemophilia A (HA) requires the knowledge and experience of specialized health care professionals. However, these patients may need to be attended in emergencies, outside the referral hospital, where health care professionals do not know about hemophilia and/or new innovative treatments. This study aimed to develop a simple and practical algorithm that could be used in emergency situations by nonspecialized treaters in HA and bleeding with or without factor VIII (FVIII) inhibitors under emicizumab prophylaxis. A group of experts agreed on a simple algorithm, easy to operate, adapted from previous international guidelines, and based on their clinical experience. The proposed algorithm starts with identifying the patient, confirming the diagnosis of HA, prophylaxis with emicizumab, and/or use of other treatments. After stabilizing the patient and stratifying the bleeding risk, the patient is managed according to the presence/absence of FVIII inhibitors. Patients without FVIII inhibitors should receive FVIII concentrate. Dose and follow-up depend on bleeding localization and severity. Patients with FVIII inhibitors should preferably receive recombinant activated factor VII as bypass agent. A basic coagulation assay, FVIII assessment, and FVIII inhibitors detection assays are necessary in an emergency. However, these tests should be interpreted with caution and appropriately chosen, as emicizumab may alter the results. The management of patients with HA is challenging in emergency situations, especially if they are treated with new agents. Nonspecialized in coagulopathies health care professionals have limited understanding of the disease, highlighting the need for an algorithm to assist them in making informed decisions.
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Affiliation(s)
- Víctor Jiménez-Yuste
- Hematology Department, La Paz University Hospital-IdiPaz, Universidad Autónoma, Madrid, Spain
| | - María T. Álvarez-Román
- Hematology Department, La Paz University Hospital-IdiPaz, Universidad Autónoma, Madrid, Spain
| | - Rubén Berrueco
- Pediatric Hematology Unit, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Santiago Bonanad
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | | | | | - Ramiro J. Núñez-Vázquez
- Hematology Department, Hospital Universitario Virgen del Rocío, Instituto deBiomedicina de Sevilla (IBIS), Sevilla, Spain
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16
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Gupta N, Dutta A, Ahmed B, Ross CR, S C, Dolan G, John MJ, Radhakrishnan N, Aggarwal S, Seth T, Kaul V, Shah V. Expert Opinions on the Management of Hemophilia A in India: The Role of Emicizumab. Cureus 2024; 16:e58941. [PMID: 38725780 PMCID: PMC11081140 DOI: 10.7759/cureus.58941] [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: 04/21/2024] [Indexed: 05/12/2024] Open
Abstract
Hemophilia A (HA) is a genetic disorder of hemostasis associated with a deficiency or reduced activity of clotting factor VIII (FVIII). This disorder remains unacceptably underdiagnosed in India. Early diagnosis and appropriate management of HA can substantially prevent morbidity and mortality. Currently, HA is managed with regular replacement therapy using standard or extended half-life FVIII concentrates or non-factor drug products. The challenges associated with FVIII concentrates include plateauing of drug effect, issues with its administration and adherence to treatment, breakthrough bleeds, and the development of inhibiting antibodies against administered clotting factors. Emicizumab is a bispecific antibody, launched in India in April 2019, for managing patients with HA. To investigate the role of emicizumab in Indian patients with HA, opinions were sought from 13 eminent hematologists and experts from India on the effectiveness of emicizumab in preventing all bleeds, spontaneous bleeds, perioperative bleeds, and intracranial hemorrhage; resolving target joints; and reducing the rate of hospitalizations and fatality associated with HA in children and adults, with or without inhibitors. The benefits of emicizumab over traditional FVIII concentrates include the subcutaneous route of delivery, less frequent dosing, and a lack of inhibitor development, in addition to providing sustained hemostasis without in-depth monitoring. It is a safe and effective management option for all HA patients, especially for patients with certain archetypes, such as those with inhibitors, those with high annualized bleed rates, those living far away from hemophilia care centers, pediatric patients and infants with intravenous access challenges, and those with a history of life-threatening bleeding events.
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Affiliation(s)
- Naresh Gupta
- Medicine and Surgery, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
- Haematology & Haemophilia, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, IND
| | - Anupam Dutta
- General Medicine, Assam Medical College and Hospital, Dibrugarh, IND
| | - Bilal Ahmed
- Pathology, Transfusion Medicine & Hemophilia, Government Medical College, Srinagar, IND
| | - Cecil R Ross
- Hematology, St. John's Medical College and Hospital, Bangalore, IND
| | - Chandrakala S
- Clinical Haematology, King Edward Memorial Hospital, Mumbai, IND
| | - Gerard Dolan
- Haematology, St. Thomas' Haemophilia Comprehensive Care Centre, Bournemouth, GBR
| | - M J John
- Clinical Hematology, Hemato-Oncology & Bone Marrow Transplant, Christian Medical College & Hospital, Ludhiana, IND
| | - Nita Radhakrishnan
- Hematology and Oncology, Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida, IND
| | | | - Tulika Seth
- Hematology, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
| | - Varun Kaul
- Pediatrics, Guru Gobind Singh Medical College & Hospital, Faridkot, IND
| | - Vijay Shah
- Pediatrics, Nirmal Hospital Pvt. Ltd., Surat, IND
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17
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Meeks SL, Zimowski KL. Haemophilia in the era of novel therapies: Where do inhibitors feature in the new landscape? Haemophilia 2024; 30 Suppl 3:95-102. [PMID: 38539060 DOI: 10.1111/hae.14982] [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: 01/10/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION The advent of therapeutic recombinant factor VIII (FVIII) and factor IX (FIX) protein infusions revolutionized the care of persons with haemophilia in the 1990s. It kicked off an era with the increasing use of prophylactic factor infusions for patients and transformed conversations around the ideal trough activity levels as well as the ultimate goals in tailored, individualized care. Our knowledge surrounding the immunologic basis of inhibitor development and treatment derives from a time when patients were receiving frequent factor infusions and focused on immune tolerance induction following inhibitor development. DISCUSSION More recently, care was revolutionized again in haemophilia A with the approval of emicizumab, a bispecific antibody mimicking activated FVIII function, to prevent bleeding. The use of emicizumab prophylaxis has resulted in a significantly slower accumulation of factor exposure days and continued effective prophylaxis in the case of inhibitor development. While emicizumab is effective at reducing the frequency of bleeding events in patients with haemophilia A, management of breakthrough bleeds, trauma, and surgeries still requires additional treatment. Ensuring that FVIII is a therapeutic option, particularly for life-threatening bleeding events and major surgeries is critical to optimizing the care of persons with haemophilia A. Other novel non-factor concentrate therapies, including rebalancing agents, will dramatically change the landscape for persons with haemophilia B with inhibitors. CONCLUSION This review discusses the changing landscape regarding the timing of inhibitor development and management strategies after inhibitor development, stressing the importance of education across the community to continue to vigilantly monitor for inhibitors and be prepared to treat persons with inhibitors.
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Affiliation(s)
- Shannon L Meeks
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Karen L Zimowski
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
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18
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Krishnamoorthy Y, Govindan D, Kannan N, Majella MG, Hariharan VS, Valliappan V. Budget impact and cost-utility analysis of prophylactic emicizumab versus on-demand bypassing agents for adolescent severe haemophilia A patients with inhibitors in India. Heliyon 2024; 10:e27089. [PMID: 38468938 PMCID: PMC10926073 DOI: 10.1016/j.heliyon.2024.e27089] [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: 06/07/2023] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 03/13/2024] Open
Abstract
Introduction Severe Haemophilia A patients with inhibitors are currently being treated with bypassing agents like activated prothrombin complex concentrates (aPCC) and recombinant factor VIIa. Emicizumab is a recombinant humanized monoclonal antibody, introduced to reduce the bleeding events, improve treatment adherence, and quality of life. However, cost-effectiveness and long-term sustainability of the intervention is not studied in a low middle income setting like India. Aim The primary objective of this study was to evaluate the cost-utility of Emicizumab compared to traditional bypassing agents in the treatment of severe haemophilia A patients with inhibitors in India. Secondary objective was to analyze the budgetary impact of introducing Emicizumab for this patient population from the perspective of public health system in India. Methods Markov model was created to compare the prophylactic emicizumab therapy against bypassing agents for a hypothetical cohort of 10-year-old adolescents in India. The time horizon was 10 years and model built based on health system perspective. Cost utility was expressed as costs per quality-adjusted life-years (QALYs) gained. All costs were expressed as 2021 US dollars. Probabilistic sensitivity analysis was performed to check the robustness of the estimates. Results Prophylactic emicizumab was a cost saving intervention with negative Incremental Cost Utility Ratio (ICUR) against recombinant factor VIIa of -853,573 USD (INR -63,109,773), and negative ICUR of -211,675 USD (INR -15,650,403) against APCC. The estimated total budget for treating all the severe Haemophilia A patients with inhibitors in India was USD 59,042,000 (INR 4,365,329,312) for 10 years' time horizon (per patient cost of USD 295,210 [INR 21,826,646.56]). Conclusion Prophylactic emicizumab therapy is a cost saving intervention when compared to both the bypassing agents as it is less costly and more effective for severe Haemophilia A patients with inhibitors in India.
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Affiliation(s)
- Yuvaraj Krishnamoorthy
- PROPUL Evidence Synthesis Unit (PROPUL ESU), PROPUL (Partnership for Research Opportunity Planning Upskilling and Leadership) Evidence, Chennai, Tamilnadu, India
| | - Dhanajayan Govindan
- PROPUL Evidence Synthesis Unit (PROPUL ESU), PROPUL (Partnership for Research Opportunity Planning Upskilling and Leadership) Evidence, Chennai, Tamilnadu, India
| | - Narasimhapriyan Kannan
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Marie Gilbert Majella
- PROPUL Evidence Synthesis Unit (PROPUL ESU), PROPUL (Partnership for Research Opportunity Planning Upskilling and Leadership) Evidence, Chennai, Tamilnadu, India
| | | | - Vivek Valliappan
- Department of Pharmacology, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chengalpattu District, 603103, Tamilnadu, India
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19
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Jiménez-Yuste V, Oldenburg J, Tzeng E, Lim E, Sanabria F, Mahlangu J. Emicizumab is efficacious in people with hemophilia A with comorbidities aged ≥50 years: analysis of 4 phase III trials. Res Pract Thromb Haemost 2024; 8:102405. [PMID: 38783987 PMCID: PMC11112372 DOI: 10.1016/j.rpth.2024.102405] [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: 03/18/2024] [Revised: 04/02/2024] [Accepted: 04/04/2024] [Indexed: 05/25/2024] Open
Abstract
Background The treatment of older people with hemophilia A (HA) can be complicated by comorbidities. Objectives This post hoc analysis evaluates the efficacy and safety of emicizumab in people with HA aged ≥50 years with cardiovascular (CV) risk factors or HIV and/or hepatitis C virus (HCV) infection. Methods The HAVEN 1 (NCT02622321), HAVEN 3 (NCT02847637), HAVEN 4 (NCT03020160), and STASEY (NCT03191799) studies enrolled adults/adolescents with severe HA. Participants were categorized as having a comorbidity if they had any CV risk factors (including history of CV disease, hypertension, diabetes, hyperlipidemia, prior stroke, or obesity), HIV, and/or HCV infection. Efficacy and safety outcomes were compared by age (<50 vs ≥50 years). Results Of 504 participants at data cutoff, 408 were aged <50 years and 96 were aged ≥50 years. In people with HA aged <50 years, 26.7% had ≥1 CV risk factor and 29.4% had HIV and/or HCV infection. In people with HA aged ≥50 years, 72.9% had ≥1 CV risk factor and 74.0% had HIV and/or HCV infection. The mean (95% CI) annualized bleed rate for treated bleeds was 1.29 (0.07-6.06) for people with HA aged <50 years and 1.82 (0.19-6.93) for people with HA aged ≥50 years. No significant differences in annualized bleed rates were observed for those with comorbidities compared with those without. Safety outcomes were similar regardless of age. Conclusion This pooled analysis suggests that emicizumab efficacy and safety in people with HA aged ≥50 years with CV and HIV/HCV comorbidities were consistent with those in people with HA aged <50 years enrolled in the HAVEN 1, 3, and 4 and STASEY studies.
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Affiliation(s)
- Víctor Jiménez-Yuste
- Hematology Department, Hospital Universitario La Paz, IdiPAZ, Autónoma University, Madrid, Spain
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, Germany
| | - Eunice Tzeng
- Genentech, Inc., South San Francisco, California, USA
| | - Elise Lim
- Genentech, Inc., South San Francisco, California, USA
| | | | - Johnny Mahlangu
- Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
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20
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Abdelgawad HAH, Foster R, Otto M. Nothing short of a revolution: Novel extended half-life factor VIII replacement products and non-replacement agents reshape the treatment landscape in hemophilia A. Blood Rev 2024; 64:101164. [PMID: 38216442 DOI: 10.1016/j.blre.2023.101164] [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: 08/30/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/14/2024]
Abstract
Hemophilia A, an X-linked genetic disorder, is characterized by a deficiency or dysfunction of clotting Factor VIII. The treatment landscape has substantially changed by introducing novel extended half-life factor VIII (EHL-FVIII) replacement therapies such as efanesoctocog Alfa and non-factor replacement therapy such as emicizumab. These agents signal a shift from treatments requiring multiple weekly infusions to advanced therapies with long half-lives, offering superior protection against bleeding and improving patient adherence and quality of life. While EHL-FVIII treatment might lead to inhibitor development in some patients, non-factor replacement therapy carries thrombotic risks. Therefore, ongoing research and the generation of robust clinical evidence remain vital to guide the selection of optimal and cost-effective first-line therapies for hemophilia A patients.
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Affiliation(s)
- Hussien Ahmed H Abdelgawad
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA; Department of Child Health, University of Arizona College of Medicine, Phoenix, AZ, USA.
| | - Rachel Foster
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Mario Otto
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA; Department of Child Health, University of Arizona College of Medicine, Phoenix, AZ, USA.
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21
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Olasupo OO, Noronha N, Lowe MS, Ansel D, Bhatt M, Matino D. Non-clotting factor therapies for preventing bleeds in people with congenital hemophilia A or B. Cochrane Database Syst Rev 2024; 2:CD014544. [PMID: 38411279 PMCID: PMC10897951 DOI: 10.1002/14651858.cd014544.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Management of congenital hemophilia A and B is by prophylactic or on-demand replacement therapy with clotting factor concentrates. The effects of newer non-clotting factor therapies such as emicizumab, concizumab, marstacimab, and fitusiran compared with existing standards of care are yet to be systematically reviewed. OBJECTIVES To assess the effects (clinical, economic, patient-reported, and adverse outcomes) of non-clotting factor therapies for preventing bleeding and bleeding-related complications in people with congenital hemophilia A or B compared with prophylaxis with clotting factor therapies, bypassing agents, placebo, or no prophylaxis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, electronic databases, conference proceedings, and reference lists of relevant articles and reviews. The date of the last search was 16 August 2023. SELECTION CRITERIA Randomized controlled trials (RCTs) evaluating people with congenital hemophilia A or B with and without inhibitors, who were treated with non-clotting factor therapies to prevent bleeds. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed studies for eligibility, assessed risk of bias, and extracted data for the primary outcomes (bleeding rates, health-related quality of life (HRQoL), adverse events) and secondary outcomes (joint health, pain scores, and economic outcomes). We assessed the mean difference (MD), risk ratio (RR), 95% confidence interval (CI) of effect estimates, and evaluated the certainty of the evidence using GRADE. MAIN RESULTS Six RCTs (including 397 males aged 12 to 75 years) were eligible for inclusion. Prophylaxis versus on-demand therapy in people with inhibitors Four trials (189 participants) compared emicizumab, fitusiran, and concizumab with on-demand therapy in people with inhibitors. Prophylaxis using emicizumab likely reduced annualized bleeding rates (ABR) for all bleeds (MD -22.80, 95% CI -37.39 to -8.21), treated bleeds (MD -20.40, 95% CI -35.19 to -5.61), and annualized spontaneous bleeds (MD -15.50, 95% CI -24.06 to -6.94), but did not significantly reduce annualized joint and target joint bleeding rates (AjBR and AtjBR) (1 trial; 53 participants; moderate-certainty evidence). Fitusiran also likely reduced ABR for all bleeds (MD -28.80, 95% CI -40.07 to -17.53), treated bleeds (MD -16.80, 95% CI -25.80 to -7.80), joint bleeds (MD -12.50, 95% CI -19.91 to -5.09), and spontaneous bleeds (MD -14.80, 95% CI -24.90 to -4.71; 1 trial; 57 participants; moderate-certainty evidence). No evidence was available on the effect of bleed prophylaxis using fitusiran versus on-demand therapy on AtjBR. Concizumab may reduce ABR for all bleeds (MD -12.31, 95% CI -19.17 to -5.45), treated bleeds (MD -10.10, 95% CI -17.74 to -2.46), joint bleeds (MD -9.55, 95% CI -13.55 to -5.55), and spontaneous bleeds (MD -11.96, 95% CI -19.89 to -4.03; 2 trials; 78 participants; very low-certainty evidence), but not target joint bleeds (MD -1.00, 95% CI -3.26 to 1.26). Emicizumab prophylaxis resulted in an 11.31-fold increase, fitusiran in a 12.5-fold increase, and concizumab in a 1.59-fold increase in the proportion of participants with no bleeds. HRQoL measured using the Haemophilia Quality of Life Questionnaire for Adults (Haem-A-QoL) physical and total health scores was improved with emicizumab, fitusiran, and concizumab prophylaxis (low-certainty evidence). Non-serious adverse events were higher with non-clotting factor therapies versus on-demand therapy, with injection site reactions being the most frequently reported adverse events. Transient antidrug antibodies were reported for fitusiran and concizumab. Prophylaxis versus on-demand therapy in people without inhibitors Two trials (208 participants) compared emicizumab and fitusiran with on-demand therapy in people without inhibitors. One trial assessed two doses of emicizumab (1.5 mg/kg weekly and 3.0 mg/kg bi-weekly). Fitusiran 80 mg monthly, emicizumab 1.5 mg/kg/week, and emicizumab 3.0 mg/kg bi-weekly all likely resulted in a large reduction in ABR for all bleeds, all treated bleeds, and joint bleeds. AtjBR was not reduced with either of the emicizumab dosing regimens. The effect of fitusiran prophylaxis on target joint bleeds was not assessed. Spontaneous bleeds were likely reduced with fitusiran (MD -20.21, 95% CI -32.12 to -8.30) and emicizumab 3.0 mg/kg bi-weekly (MD -15.30, 95% CI -30.46 to -0.14), but not with emicizumab 1.5 mg/kg/week (MD -14.60, 95% CI -29.78 to 0.58). The percentage of participants with zero bleeds was higher following emicizumab 1.5 mg/kg/week (50% versus 0%), emicizumab 3.0 mg/kg bi-weekly (40% versus 0%), and fitusiran prophylaxis (40% versus 5%) compared with on-demand therapy. Emicizumab 1.5 mg/kg/week did not improve Haem-A-QoL physical and total health scores, EQ-5D-5L VAS, or utility index scores (low-certainty evidence) when compared with on-demand therapy at 25 weeks. Emicizumab 3.0 mg/kg bi-weekly may improve HRQoL measured by the Haem-A-QoL physical health score (MD -15.97, 95% CI -29.14 to -2.80) and EQ-5D-5L VAS (MD 9.15, 95% CI 2.05 to 16.25; 1 trial; 43 participants; low-certainty evidence). Fitusiran may result in improved HRQoL shown as a reduction in Haem-A-QoL total score (MD -7.06, 95% CI -11.50 to -2.62) and physical health score (MD -19.75, 95% CI -25.76 to -11.94; 1 trial; 103 participants; low-certainty evidence). The risk of serious adverse events in participants without inhibitors also likely did not differ following prophylaxis with either emicizumab or fitusiran versus on-demand therapy (moderate-certainty evidence). Transient antidrug antibodies were reported in 4% (3/80) participants to fitusiran, with no observed effect on antithrombin lowering. A comparison of the different dosing regimens of emicizumab identified no differences in bleeding, safety, or patient-reported outcomes. No case of treatment-related cancer or mortality was reported in any study group. None of the included studies assessed our secondary outcomes of joint health, clinical joint function, and economic outcomes. None of the included studies evaluated marstacimab. AUTHORS' CONCLUSIONS Evidence from RCTs shows that prophylaxis using non-clotting factor therapies compared with on-demand treatment may reduce bleeding events, increase the percentage of individuals with zero bleeds, increase the incidence of non-serious adverse events, and improve HRQoL. Comparative assessments with other prophylaxis regimens, assessment of long-term joint outcomes, and assessment of economic outcomes will improve evidence-based decision-making for the use of these therapies in bleed prevention.
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Affiliation(s)
- Omotola O Olasupo
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Canada
| | - Noella Noronha
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Canada
| | - Megan S Lowe
- Department of Health Sciences, McMaster University, Hamilton, Canada
| | | | - Mihir Bhatt
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Davide Matino
- Department of Internal Medicine, McMaster University, Hamilton, Canada
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22
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Ocaña Gómez MÁ, Ferrer Machín A, Vera Cabrera M, Álvarez Tosco KI, Ríos de Paz M, de Dios García MD. [Efficacy and safety of prophylaxis with emicizumab in hemophilia A: A study of 13 patients]. Med Clin (Barc) 2024; 162:134-137. [PMID: 37599198 DOI: 10.1016/j.medcli.2023.07.024] [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: 04/10/2022] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION Emicizumab is the first non-replacement therapy for prophylaxis in severe hemophilia A. AIMS The principal aim of this study is to describe the results of our patients in prophylaxis with emicizumab, according to the usual clinical practice. MATERIAL AND METHODS Follow-up of 13 patients from the start of prophylaxis, recording of bleeding, surgeries, adverse reactions and the need or not for factor therapy. Plasma levels were measured at follow-up visits, the technique was coagulative in one stage, modified by 1:20 dilution. RESULTS Median plasma levels were 52.2mg [30.7-71.9]. Prophylaxis was safe and effective; only one spontaneous haemorrhage was recorded over time and no treatment was required. There were no thromboembolic events or serious hypersensitivity, anaphylaxis or anaphylactoid reactions. The incidence of injection site reactions was 8%. Perioperative management in minor interventions was carried out without adjuvant factorial therapy, in 2 major surgeries a dose of plasmatic FVIII concentrate was required in the patient with hemophilia A without inhibitor and FVII in the patient with inhibitor, and it was sufficient to stop the bleeding. CONCLUSION This study demonstrated emicizumab pharmacokinetics and its half life ensure optimal levels with prophylaxis treatment at doses established in the technical data sheet.
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Affiliation(s)
- M Ángeles Ocaña Gómez
- Servicio de Farmacia Hospitalaria, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Alejandro Ferrer Machín
- Servicio de Farmacia Hospitalaria, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Martín Vera Cabrera
- Servicio de Farmacia Hospitalaria, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España.
| | - Karen Ilenia Álvarez Tosco
- Servicio de Farmacia Hospitalaria, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Mario Ríos de Paz
- Servicio de Hematología, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - M Dolores de Dios García
- Servicio de Hematología, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
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23
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Yada K, Ogiwara K, Shimonishi N, Nakajima Y, Soeda T, Kitazawa T, Nogami K. Emicizumab-mediated hemostatic function assessed by thrombin generation assay in an in vitro model of factor VIII-depleted thrombophilia plasma. Int J Hematol 2024; 119:109-118. [PMID: 38112996 DOI: 10.1007/s12185-023-03683-y] [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: 06/01/2023] [Revised: 11/09/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023]
Abstract
Patients with hemophilia A (PwHA) may have concurrent deficiency of representative anticoagulant proteins, protein (P)C, PS, and antithrombin (AT), which reduces bleeding frequency. However, emicizumab-driven hemostasis in PwHA with such thrombophilic potential remains unclarified. This study investigated the influence of natural anticoagulants on emicizumab-driven coagulation in HA model plasma. Various concentrations of PS and AT were added to PS-deficient plasma and AT-deficient plasma in the presence of anti-FVIII antibody (FVIIIAb; 10BU/mL). PC-deficient plasma was mixed with normal plasma at various concentrations in the presence of FVIIIAb. Emicizumab (50 µg/mL) was added to these thrombophilic HA model plasmas, prior to tissue factor/ellagic acid-triggered thrombin generation assays. Co-presence of emicizumab increased peak thrombin values (PeakTh) dependent on PS, AT, and PC concentrations. Maximum coagulation potentials in the PS-reduced HA model plasmas remained normal in the presence of emicizumab. PeakTh were close to normal in the presence of 50%AT irrespective of emicizumab, but were higher than normal in the presence of 25%AT. Addition of recombinant FVIIa (corresponding to an administered dose of 90 μg/kg) enhanced coagulation potential to normal levels. Our findings provide novel information on hemostatic regulation in emicizumab-treated PwHA with a possible thrombophilic disposition.
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Affiliation(s)
- Koji Yada
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan.
- Division of Hemophilia, National Hospital Organization Osaka National Hospital, Osaka, Japan.
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Japan
| | - Tetsuhiro Soeda
- Research Division, Chugai Pharmaceutical Co., Ltd, Kamakura, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
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24
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Tory SS, Ghosh S, Nazneen H, Farhad N, Islam S, Hasan MJ, Biswas AR. Effectiveness of emicizumab in preventing bleeding events in severe and moderate hemophilia A: A single-center experience in Bangladesh. EJHAEM 2024; 5:39-46. [PMID: 38406515 PMCID: PMC10887364 DOI: 10.1002/jha2.832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/22/2023] [Indexed: 02/27/2024]
Abstract
Emicizumab is a monoclonal antibody that bridges activated factor IX (FIX) and factor X (FX) to replace the function of missing activated factor VIII (FVIII) in hemophilia A patients irrespective of FVIII inhibitor status. This study assessed the effectiveness of emicizumab in preventing bleeding episodes in patients with hemophilia A. This observational study included patients with moderate to severe hemophilia A who were undergoing episodic FVIII replacement therapy. The primary endpoint was the difference in annualized bleeding rates (ABR) and the secondary endpoint was the difference in Hemophilia Joint Health Score (HJHS) before and after emicizumab prophylaxis. A total of 30 male hemophilia patients were included, the mean age was 16.7 (SD: ±8.1) years, and most of them had moderate hemophilia A [63.3%]. Before prophylaxis, the median ABR was 48 (interquartile range [IQR]: 35-60), and 93.3% of patients had ABR greater than eight, whereas after prophylaxis the median ABR decreased significantly (median [IQR]: 0 [0.0-0.4], p < 0.001), and 56.7% had zero bleeds. ABR was not significantly different in patient with and without FVIII inhibitors. The HJHS scores significantly improved after prophylaxis (10 vs. 2.5, p < 0.001). The bleeding events were reduced significantly (23 vs. 0.0, p < 0.001), and zero new target joints were reported after prophylaxis. Most of the patients [93.3%] did not face any serious adverse events after prophylaxis. Emicizumab prophylaxis was associated with a significantly lower rate of bleeding events among participants with hemophilia A, regardless of inhibitor status.
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Affiliation(s)
| | - Sujan Ghosh
- Department of HematologyDhaka Medical College HospitalDhakaBangladesh
| | - Humayra Nazneen
- Department of HematologyDhaka Medical College HospitalDhakaBangladesh
| | - Nurul Farhad
- Department of HematologyDhaka Medical College HospitalDhakaBangladesh
| | - Salwa Islam
- Pi Research Development CenterDhakaBangladesh
| | - Mohammad Jahid Hasan
- Department of Health System ResearchTropical Disease and Health Research CenterDhakaBangladesh
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25
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Mahlangu J, Jiménez-Yuste V, Ventriglia G, Niggli M, Barlera S, Hermans C, Lehle M, Chowdary P, Jew L, Windyga J, Frenzel L, Schmitt C, Castaman G, Pipe SW. Long-term outcomes with emicizumab in hemophilia A without inhibitors: results from the HAVEN 3 and 4 studies. Res Pract Thromb Haemost 2024; 8:102364. [PMID: 38559572 PMCID: PMC10978536 DOI: 10.1016/j.rpth.2024.102364] [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: 02/01/2024] [Accepted: 02/14/2024] [Indexed: 04/04/2024] Open
Abstract
Background Emicizumab, a bispecific monoclonal antibody, bridges activated factor (F) IX and FX, mimicking the function of missing or deficient activated FVIII in people with hemophilia A (HA). Objectives To evaluate the long-term efficacy and safety of emicizumab prophylaxis in people with HA without FVIII inhibitors in the HAVEN 3 and 4 studies. Methods HAVEN 3 and 4 were phase 3 open-label studies. Participants received emicizumab maintenance doses of 1.5 mg/kg every week or 3 mg/kg every 2 weeks (HAVEN 3), or 6 mg/kg every 4 weeks (HAVEN 4). Long-term efficacy and safety were assessed. Results A total of 151 and 40 individuals without FVIII inhibitors received emicizumab in HAVEN 3 and 4, respectively. At the last patient, last visit dates (May 12, 2022 [HAVEN 3] and June 29, 2022 [HAVEN 4]), the median (range) duration of emicizumab exposure across the 2 studies was 248.1 (6.1-287.1) weeks. The mean (95% CI) annualized bleed rate for treated bleeds was 2.0 (0.23-7.15) for weeks 1 to 24, decreasing to 0.9 (0.01-5.28) by weeks 217 to 240. Overall, 188 (98.4%) participants experienced ≥1 adverse event (AE), with 185 treatment-related AEs in 71 (37.2%) participants. Forty-four (23.0%) participants reported a serious AE. Two thromboembolic events were reported, which were deemed unrelated to emicizumab by the investigator. No thrombotic microangiopathies were reported. Conclusion With nearly 5 years of emicizumab exposure across the HAVEN 3 and 4 studies in people with HA without inhibitors, these data indicate continued bleed control with no new safety signals observed during long-term follow-up.
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Affiliation(s)
- Johnny Mahlangu
- Faculty of Health Sciences, University of the Witwatersrand, National Health Laboratory Service, Johannesburg, South Africa
| | - Víctor Jiménez-Yuste
- Jefe de Servicio de Hematología, La Paz University Hospital-IdiPaz, Autónoma University, Madrid, Spain
| | - Giuliana Ventriglia
- Oncology and Hematology Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Markus Niggli
- Product Development Data Sciences, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Simona Barlera
- Department of Biometrics, Parexel International, Milan, Italy
| | - Cédric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Catholic University of Louvain, Brussels, Belgium
| | - Michaela Lehle
- Oncology and Hematology Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Unit, Royal Free London, London, United Kingdom
| | - Lyle Jew
- Product Development Safety, Genentech, Inc. South San Francisco, California, USA
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Laurent Frenzel
- Department of Hematology, Necker-Enfants Malades Hospital, Paris, France
| | - Christophe Schmitt
- Department of Clinical Pharmacology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Steven W. Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
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26
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Kiialainen A, Adamkewicz JI, Petry C, Oldenburg J, Pipe SW, Young G, Mahlangu J, Lehle M, Niggli M, Castaman G, Jiménez-Yuste V, Shima M, Négrier C, Schmitt C. Pharmacokinetics and coagulation biomarkers in children and adults with hemophilia A receiving emicizumab prophylaxis every 1, 2, or 4 weeks. Res Pract Thromb Haemost 2024; 8:102306. [PMID: 38282901 PMCID: PMC10818085 DOI: 10.1016/j.rpth.2023.102306] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 10/25/2023] [Accepted: 11/28/2023] [Indexed: 01/30/2024] Open
Abstract
Background Emicizumab is a bispecific antibody that bridges activated factor (F)IX and FX, mimicking the function of missing activated FVIII and thus improving hemostasis in people with hemophilia A. The efficacy and safety of emicizumab were demonstrated in 4 phase III clinical trials (HAVEN 1-4). Objectives Here, we describe pharmacokinetics (PKs), pharmacodynamics (PDs), and exploratory safety biomarkers in HAVEN 1 to 4. Methods Participants received emicizumab at a loading dose of 3 mg/kg weekly for 4 weeks, followed by maintenance doses of 1.5 mg/kg weekly, 3 mg/kg every 2 weeks, or 6 mg/kg every 4 weeks. PKs, PDs, and safety biomarkers were assessed in samples collected at regular intervals during the trials. Results Emicizumab plasma trough concentrations increased during the loading dose period, reaching a mean of 52.9 μg/mL (SD, 13.6 μg/mL) at week 5, and were sustained at 42.1 to 52.3 μg/mL thereafter with maintenance dosing. Activated partial thromboplastin time shortened following the first emicizumab dose. Mean FVIII-like activity and thrombin generation peak height increased to 25.2 IU/dL (SD, 6.9 IU/dL) and 115.2 nM (SD, 42.5 nM) at week 5, with levels sustained at 17 to 23 IU/dL and >116 nM thereafter, respectively. Emicizumab did not notably affect FIX or FX plasma antigen levels, prothrombin time, or concentrations of exploratory safety markers of coagulation activation (D-dimer, prothrombin fragment 1 + 2, and fibrinogen). Conclusion In HAVEN 1 to 4, emicizumab demonstrated sustained PKs and PDs and improved coagulation parameters without affecting safety biomarkers.
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Affiliation(s)
| | | | | | | | | | - Guy Young
- Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Johnny Mahlangu
- University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | | | | | | | - Víctor Jiménez-Yuste
- Department of Hematology, La Paz University Hospital-IdiPAZ, Autónoma University, Madrid, Spain
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27
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Atsou S, Schellenberg C, Lagrange J, Lacolley P, Lenting PJ, Denis CV, Christophe OD, Regnault V. Thrombin generation on vascular cells in the presence of factor VIII and/or emicizumab. J Thromb Haemost 2024; 22:112-125. [PMID: 37776978 DOI: 10.1016/j.jtha.2023.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/18/2023] [Accepted: 09/16/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND The effect of factor VIII (FVIII) or emicizumab on thrombin generation is usually assessed in assays using synthetic phospholipids. Here, we assessed thrombin generation at the surface of human arterial cells (aortic endothelial cells [hAECs] and aortic vascular smooth muscle cells [hVSMCs]). OBJECTIVES To explore the capacity of hAECs (resting or stimulated) and hVSMCs to support thrombin generation by FVIII or emicizumab. METHODS Primary hVSMCs and hAECs were analyzed for tissue factor (TF)-activity and antigen, phosphatidylserine (PS)-exposure, tissue factor pathway inhibitor (TFPI)-content and thrombomodulin expression. Cells were incubated with FVIII-deficient plasma spiked with FVIII, emicizumab, activated prothrombin complex concentrate (APCC) or combinations thereof. RESULTS TF activity and PS-exposure were present on both hVSMCs and hAECs. In contrast, thrombomodulin and TFPI were expressed on hAECs, while virtually lacking on hVSMCs, confirming the procoagulant nature of hVSMCs. Tumor necrosis factor α-mediated stimulation of hAECs increased not only TF antigen, TF activity, and PS-exposure but also TFPI and thrombomodulin expression. As expected, FVIII and emicizumab promoted thrombin generation on nonstimulated hAECs and hVSMCs, with more thrombin being generated on hVSMCs. Unexpectedly, FVIII and emicizumab increased thrombin generation to a lesser extent on stimulated hAECs compared with nonstimulated hAECs. Finally, adding emicizumab to FVIII did not further increase thrombin generation, whereas the addition of emicizumab to APCC resulted in exaggerated thrombin generation. CONCLUSION Tumor necrosis factor stimulation of hAECs increases both pro- and anticoagulant activity. Unexpectedly, the increased anticoagulant activity is sufficient to limit both FVIII- and emicizumab-induced thrombin generation. This protective effect disappears when emicizumab is combined with APCC.
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Affiliation(s)
- Sénadé Atsou
- Université Paris-Saclay, INSERM, Hémostase Inflammation Thrombose HITh U1176, 94276, Le KremLin-Bicêtre, France
| | - Célia Schellenberg
- Université de Lorraine, INSERM, Défaillance Cardiovasculaire Aigüe et Chronique DCAC U1116, 54505 Vandoeuvre-les-Nancy, France
| | - Jeremy Lagrange
- Université de Lorraine, INSERM, Défaillance Cardiovasculaire Aigüe et Chronique DCAC U1116, 54505 Vandoeuvre-les-Nancy, France
| | - Patrick Lacolley
- Université de Lorraine, INSERM, Défaillance Cardiovasculaire Aigüe et Chronique DCAC U1116, 54505 Vandoeuvre-les-Nancy, France
| | - Peter J Lenting
- Université Paris-Saclay, INSERM, Hémostase Inflammation Thrombose HITh U1176, 94276, Le KremLin-Bicêtre, France.
| | - Cécile V Denis
- Université Paris-Saclay, INSERM, Hémostase Inflammation Thrombose HITh U1176, 94276, Le KremLin-Bicêtre, France. https://twitter.com/InsermU1176
| | - Olivier D Christophe
- Université Paris-Saclay, INSERM, Hémostase Inflammation Thrombose HITh U1176, 94276, Le KremLin-Bicêtre, France
| | - Véronique Regnault
- Université de Lorraine, INSERM, Défaillance Cardiovasculaire Aigüe et Chronique DCAC U1116, 54505 Vandoeuvre-les-Nancy, France
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Nogami K, Fujii T, Sawada A, Nagao A, Nagae C, Nojima M, Suzuki N, Nosaka D, Shimura T, Sugao Y, Amano K. Association of physical activity with bleeding events and safety in patients with haemophilia A starting emicizumab prophylaxis: an interim analysis of the TSUBASA study. Int J Hematol 2024; 119:14-23. [PMID: 38100026 PMCID: PMC10769904 DOI: 10.1007/s12185-023-03679-8] [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: 05/30/2023] [Revised: 10/31/2023] [Accepted: 11/12/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Little information exists on the relationship between bleeding outcomes and physical activity in patients with haemophilia A (PwHA). AIM This interim analysis of the TSUBASA study (UMIN-CTR ID: UMIN000037448) evaluated the association of physical activity with bleeding and safety in PwHA starting emicizumab. METHODS PwHA without factor VIII inhibitors were recruited. Physical activity and bleed data were obtained using an electronic patient-reported outcome application and wearable activity tracker. Adverse events (AEs) were documented. RESULTS At data cut-off (31-May-2021), 107 PwHA were enrolled, with a median (range) age of 35 (0-73) years. Physical activity data were obtained for 74 participants. Of these, 47 (63.5%) recorded a total of 396 exercise events. The most common exercise events were walking (32.4%), cycling (14.9%), and football (5.4%). Two (0.5%) exercise events in the same individual were associated with bleeding (running, weight training). The safety analysis population consisted of 106 participants treated with emicizumab (median observation period: 241.5 days). Twenty-one (19.8%) participants experienced a total of 39 AEs. Five (4.7%) experienced a serious AE, none of which was emicizumab-related, and three (2.8%) experienced an adverse drug reaction. CONCLUSIONS PwHA receiving emicizumab in the TSUBASA study experienced minimal bleeding associated with physical activity. TRIAL REGISTRATION Trial registration: UMIN-CTR ID: UMIN000037448.
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Affiliation(s)
- Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Teruhisa Fujii
- Division of Transfusion Medicine/Hemophilia Treatment Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Akihiro Sawada
- Department of Respiratory Medicine and Hematology, Hyogo College of Medicine, Hyogo, Japan
| | - Azusa Nagao
- Department of Blood Coagulation, Ogikubo Hospital, Tokyo, Japan
| | - Chiai Nagae
- Department of Pediatrics, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masanori Nojima
- Center for Translational Research/Division of Advanced Medicine Promotion, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Nobuaki Suzuki
- Department of Transfusion Medicine, Nagoya University Hospital, Aichi, Japan
| | | | | | | | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
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Nakajima Y, Ogiwara K, Inaba K, Kitazawa T, Nogami K. NXT007-mediated hemostatic potential is suppressed by activated protein C-catalyzed inactivation of activated factor V. Res Pract Thromb Haemost 2024; 8:102271. [PMID: 38115953 PMCID: PMC10727940 DOI: 10.1016/j.rpth.2023.102271] [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: 08/03/2023] [Revised: 10/16/2023] [Accepted: 11/09/2023] [Indexed: 12/21/2023] Open
Abstract
Background Activated protein C (APC) inactivates activated factor (F) V (FVa) and FVIIIa. NXT007, an emicizumab-based engineered therapeutic bispecific antibody, enhances the coagulation potential of FVIII-deficient plasma (FVIIIdef-plasma) to near normal levels. However, little is known about the effect of APC-induced inactivation in NXT007-mediated hemostatic function. Objectives To investigate the contribution of APC-mediated reactions to NXT007-driven hemostasis. Methods In pooled normal plasma (PNP) or FVIIIdef-plasma spiked with NXT007 (10 μg/mL), effects of APC (0-16 nM) were measured using a thrombin generation assay (TGA). The direct effects of APC on cofactor activity of NXT007 or FVIIIa in a FXa generation assay were also measured. The FVdef-plasma and FV Leiden plasma (FVLeiden plasma) were preincubated with 2 anti-FVIII monoclonal antibodies (termed FVIII-depleted), and the APC effect in the presence of NXT007 in FVIII-depleted FVdef-plasma with the addition of exogenous FV (7.5-30 nM) or FVIII-depleted FVLeiden plasma was investigated. Results The APC dose-dependent suppression effect in TGA of FVIIIdef-plasma spiked with NXT007 was similar to that of PNP. FXa generation with NXT007 was not impaired by the addition of APC, suggesting that the APC-induced reaction in TGA with NXT007 was attributed to the direct inactivation of FVa. The addition of APC to FVIII-depleted FVdef-plasma, along with NXT007 and various FV concentrations, showed a similar attenuation to PNP. The NXT007-driven thrombin generation in FVIII-depleted FVLeiden plasma was suppressed by APC, similar to the reaction in native FVLeiden plasma. Conclusion NXT007 did not impair APC-mediated downregulation of FVa in FVIIIdef-plasmas, regardless of the presence of FV mutation with APC resistance.
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Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keito Inaba
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Poston J, Kruse-Jarres R. The role of emicizumab in acquired hemophilia A. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:24-30. [PMID: 38066880 PMCID: PMC10727101 DOI: 10.1182/hematology.2023000462] [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
Acquired hemophilia is a rare bleeding disorder that predominantly affects older people with potential underlying comorbidities, including cardiovascular and thrombotic risk factors. The current standard therapies with hemostatic agents for acute bleeding and immunosuppression often require inpatient management, are not approved for routine bleeding prophylaxis, and contribute to the high mortality in this population. Emicizumab is a factor VIII (FVIII) mimetic approved for bleeding prophylaxis in congenital hemophilia A with and without FVIII inhibitors. Given subcutaneously, it may allow easier outpatient bleeding prophylaxis and reduce intensity of immunosuppression. This article summarizes the currently available data on the efficacy and safety of emicizumab in acquired hemophilia A.
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Affiliation(s)
- Jacqueline Poston
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Rebecca Kruse-Jarres
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
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López-Jaime FJ, Benítez O, Díaz Jordán BL, Montaño A, Coll J, Quintana París L, Gómez-Del Castillo Solano MDC. Expert opinion paper on the treatment of hemophilia a with emicizumab. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2023; 28:2166334. [PMID: 36636993 DOI: 10.1080/16078454.2023.2166334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Prophylaxis with emicizumab, a bispecific monoclonal antibody that mimics FVIII function, has shown encouraging results in clinical trials in terms of efficacy and safety. However, current experience is limited, and many areas of concern to clinicians have yet to be reviewed. AREAS COVERED This paper reviews the experience of hemophilia A patients treated with emicizumab based on the results of clinical trials and real-life studies. The authors place special emphasis on issues such as the management of these patients in situations of hemorrhage and/or surgical interventions, joint health or laboratory monitoring. EXPERT OPINION Treatment with emicizumab has been shown to improve joint health and reduce bleeding, of particular interest to patients with inhibitors and high bleeding rates. However, there are still concerns about its administration in neonates and previously untreated patients due to limited reported experience. Laboratory monitoring is not strictly necessary due to the stable pharmacokinetics emicizumab has been shown to exhibit, however, tests that globally assess hemostasis may be useful especially in cases of bleeding or surgery. The authors are also of the opinion that prophylaxis before minor surgery is not necessary and that major surgeries can be safely performed with additional prophylactic coagulation factor.Trial registration ClinicalTrials.gov identifier: NCT04431726..
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Affiliation(s)
| | - Olga Benítez
- Departamento de Hematología Experimental, VHIO Vall d'Hebron Instituto de Oncología, Hospital Universitario Vall d'Hebron, Barcelona, Spain.,Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | - Adrián Montaño
- Unidad de Hemostasia y Trombosis, Hospital Universitario Regional de Málaga, IBIMA, Málaga, Spain.,Universidad de Salamanca, Salamanca, Spain
| | - Julia Coll
- Servicio de Hematología, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Laura Quintana París
- Servicio de Hematología, Hospital Universitario de Gran Canaria Dr. Negrín, Gran Canaria, Spain
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Shimonishi N, Sasai K, Ogiwara K, Furukawa S, Nakajima Y, Mizumachi K, Yada K, Takeyama M, Shima M, Mizuno N, Nogami K. Longitudinal dynamic changes in factor VIII inhibitor titers in patients with hemophilia A and inhibitors receiving emicizumab prophylaxis. Int J Hematol 2023; 118:690-698. [PMID: 37803190 DOI: 10.1007/s12185-023-03667-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 10/08/2023]
Abstract
Emicizumab prophylaxis dramatically reduces bleeding events in patients with hemophilia A (PwHA) with or without factor VIII (FVIII) inhibitors. However, long-term dynamic changes in FVIII inhibitor titers during emicizumab prophylaxis remain to be investigated. We conducted a retrospective follow-up study of FVIII inhibitor titers after initiation of emicizumab prophylaxis in 25 PwHA carrying current or historical FVIII inhibitors. Nineteen PwHA had FVIII inhibitors at initiation of emicizumab prophylaxis (age: median 22 [range 4-60] years and inhibitor titer: 30 [1.0-1450] BU/mL). In 17 of the 19 patients, the inhibitor titers markedly decreased to a median of 1.2 (< 0.6-58) BU/mL at a median follow-up of 71 (38-111) months. In two patients, titers were slightly elevated after initiation of emicizumab but decreased in the long term. The remaining six patients had negative inhibitor status (< 0.6 BU/mL) when switched to emicizumab from FVIII prophylaxis. Five patients maintained negative titers. One patient had inhibitor recurrence, with a peak titer of 1.6 BU/mL that decreased to 0.9 BU/mL. In most cases, FVIII inhibitor titers can be expected to decrease spontaneously during emicizumab prophylaxis, but regular follow-up is necessary to manage breakthrough bleeds.
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Affiliation(s)
- Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan.
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan.
| | - Kana Sasai
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Kuniyoshi Mizumachi
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
- Division of Hemophilia, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
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Camelo RM, Barbosa MM, Henriques LCM, Martin AP, Godman B, Guerra Júnior AA, Acurcio FDA, Alvares-Teodoro J. Emicizumab prophylaxis for people with hemophilia A: Waste estimation and the Brazilian perspective. Saudi Pharm J 2023; 31:101867. [PMID: 38028212 PMCID: PMC10661532 DOI: 10.1016/j.jsps.2023.101867] [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: 08/04/2023] [Accepted: 11/05/2023] [Indexed: 12/01/2023] Open
Abstract
Costs of hemophilia A treatment are increasing. Waste of clotting products should be avoided. To estimate the first-year waste of emicizumab prophylaxis for people with hemophilia A and inhibitors (PwHAi) who failed immune tolerance induction (ITI), in Brazil. We evaluated the manufacturer and the Brazilian Ministry of Health (MoH) protocol-recommended regimens in a budget impact model. The loading dose consisted of 3.0 mg/kg/Q1W for 4 weeks, for both recommendations. The manufacturer maintenance regimens comprised 1.5 mg/kg/Q1W, 3.0 mg/kg/Q2W, and 6.0 mg/kg/Q4W. The MoH protocol maintenance regimen encompassed a hybrid Q1W/Q2W administration, depending on the body weight. The Q4W regimen was not recommended by the MoH protocol. Analyses were performed to estimate waste given its expense based on the World Health Organization body weight range (percentiles [P] 15, 50, and 85). The first-year emicizumab waste was estimated individually and for the disclosed PwHAi who failed ITI (n = 114). The highest emicizumab waste was estimated for the lowest body weights and the Q1W regimen. The Q4W regimen resulted in the lowest emicizumab waste, followed by the MoH protocol regimen. The total reconstituted costs estimated for the PwHAi who failed ITI according to the hybrid MoH protocol ranged from US$32,858,777 (P15) to US$47,186,858 (P85), with emicizumab waste ranging from 7.9 % (US$2,594,515) to 3.7 % (US$1,738,750), respectively. Lost resources due to current protocols for emicizumab prophylaxis for PwHAi who failed ITI in Brazil are considerable. Waste was more pronounced due to lower body weight and shorter administration intervals.
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Affiliation(s)
| | | | | | - Antony Paul Martin
- QC Medica, Liverpool, United Kingdom
- Faculty of Health and Life Science, University of Liverpool, Liverpool, United Kindgom
| | - Brian Godman
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
- Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
- Strathclyde Institute of Pharmacy and Biomedical Science, University of Strathclyde, Glasgow, United Kingdom
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Lee MW, Cheong MA, Ng HJ, Tien SL, Lam JCM. Real-world data on the use of emicizumab in patients with haemophilia A with and without inhibitors in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:580-589. [PMID: 38920147 DOI: 10.47102/annals-acadmedsg.2023100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction Emicizumab is a bispecific monoclonal antibody that mimics the function of factor VIII by binding to factor IXa and factor X to achieve haemostasis in haemophilia A. The long half-life and subcutaneous mode of administration makes emicizumab a compelling treatment option for bleeding prophylaxis. There is still limited real-world data on its use and management considerations, especially during surgical procedures. The objective of the study is to describe the real-world experience of emicizumab in a cohort of adult and paediatric haemophilia A patients in Singapore, including its use in the periprocedural setting. Method This was an observational study conducted at the 2 main haemophilia treatment centres in Singapore. All haemophilia A patients who commenced treatment with emicizumab before 1 July 2022 were recruited. Results A total of 18 patients with haemophilia A were included in this study. Ten (55.6%) patients had active inhibitors. The median annual bleeding rate for all patients before emicizumab use was 4.5 events (interquartile range [IQR] 2.8-8.3) compared with 0 events (IQR 0-0) after emicizumab was commenced (P=0). There were no adverse events of venous or arterial thrombosis, thrombotic microangiopathy, or death. A total of 6 procedures in 5 patients were performed during the study period with no major bleeding complications. Conclusion Emicizumab effectively protects against bleeding in haemophilia A patients with and without inhibitors, including in children less than 12 years old. More studies are required to address clinical nuances, such as periprocedural management and the role of immune tolerance in patients with inhibitors on emicizumab.
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Affiliation(s)
- Ming Wei Lee
- Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore
| | - May Anne Cheong
- Department of Haematology, Singapore General Hospital, Singapore
| | - Heng Joo Ng
- Department of Haematology, Singapore General Hospital, Singapore
| | - Sim Leng Tien
- Department of Haematology, Singapore General Hospital, Singapore
| | - Joyce Ching Mei Lam
- Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore
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35
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Shafaati Lambert M, Bruzelius M, Mahmoud Hourani Soutari N, Ranta S, Antovic JP. Laboratory response to paradigm change in hemophilia treatment. Clin Chem Lab Med 2023; 61:e248-e250. [PMID: 37319338 DOI: 10.1515/cclm-2023-0443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/24/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Marjan Shafaati Lambert
- Coagulation & Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Coagulation, Clinical Chemistry, Karolinska University Laboratory, Medical Diagnostics Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Bruzelius
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Nida Mahmoud Hourani Soutari
- Coagulation & Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Coagulation, Clinical Chemistry, Karolinska University Laboratory, Medical Diagnostics Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | - Susanna Ranta
- Astrid Lindgren's Children's Hospital, Karolinska Univeristy Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Jovan P Antovic
- Coagulation & Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Coagulation, Clinical Chemistry, Karolinska University Laboratory, Medical Diagnostics Karolinska, Karolinska University Hospital, Stockholm, Sweden
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Garcia J, Hammer MR, Zia A. Serious bleeds in pediatric persons with hemophilia A on emicizumab prophylaxis. Res Pract Thromb Haemost 2023; 7:102238. [PMID: 38053983 PMCID: PMC10694589 DOI: 10.1016/j.rpth.2023.102238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/01/2023] [Accepted: 09/22/2023] [Indexed: 12/07/2023] Open
Abstract
Background Clinical trials have shown success in bleed prevention with emicizumab, but real-world data on the effectiveness of emicizumab in preventing serious bleeds in the pediatric population are lacking. Objectives To report real-world data on the effectiveness of Emicizumab in pediatric persons with hemophilia A. Methods We completed a retrospective chart review of 37 pediatric male patients aged ≤18 years on emicizumab prophylaxis for a median duration of 30.5 months at Children's Medical Center in Dallas, Texas. Results We identified 4 pediatric persons with severe hemophilia A with and without inhibitors who experienced a provoked or unprovoked serious bleed requiring hospitalization. Conclusion This study highlights that serious bleeds, both provoked and unprovoked, can occur in pediatric persons with severe hemophilia A. These findings are important for clinicians to provide appropriate counseling/education and recommendation of treatment for pediatric persons with severe hemophilia A through shared decision making. Up-titration of emicizumab or factor VIII replacement needs consideration in persons with hemophilia with suboptimal bleeding control or who participate in activities categorized as moderate- to high-risk activities.
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Affiliation(s)
- Jessica Garcia
- Division of Hematology/Oncology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
- Children’s Medical Center, Dallas, Texas, USA
| | - Matthew R. Hammer
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
- Children’s Medical Center, Dallas, Texas, USA
| | - Ayesha Zia
- Division of Hematology/Oncology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
- Children’s Medical Center, Dallas, Texas, USA
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Guan T, Ai D, Zhao N, Liu G, Yao W, Chen Z, Li Z, Zhou Y, Wu R. Treatment-related outcome from patient report outcome (PRO) of children with severe and moderate hemophilia A in China: An analysis report of registration data from patient organization "hemophilia home care center". Haemophilia 2023; 29:1467-1474. [PMID: 37718575 DOI: 10.1111/hae.14863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVES To assess current treatment-related outcomes for children with severe and moderate haemophilia A (cHA) in China. METHODS This cross-section Patient Report Outcome (PRO) report collected PRO data of severe and moderate cHAs registered in the 'Hemophilia Home Care Center' database (http://web.bjxueyou.cn) between January 2021 and November 2022. Data included records of bleeding, activities, and concentrates consumption. All patients had a confirmed diagnosis of moderate or severe haemophilia A (FVIII: C ≤ 5%) and were < 18 years old. RESULTS Among 1038 analysable cases, 9.6% of children with inhibitors had a higher rate of intracranial haemorrhage, dropout school rate, and higher FVIII consumption than children without inhibitors. Among 100 children with inhibitors, 36 patients were treated without immune tolerance induction (ITI), 14 patients with irregular treatment and 50 patients received ITI. Children with ITI had a lower ABR (2.4 (0,6.6) vs. 13.4 (9.5, 26.6), p<.001) and AJBR (0 (0, 3.1) vs. 8.9 (1.6, 19.3), p < .001) compared to those without ITI. Among 938 children without inhibitors, 28.5% received on-demand treatment and 71.5% received prophylaxis. Of 528 children with 1343.8 (1050.4, 2922.9)IU/kg/year median FVIII consumption, 43.0% received low-dose, 43.2% received intermediate-dose, and 13.8% received high-dose regimen; these children with prophylaxis had a lower ABR (3.1 (0, 10.7) vs. 12.8 (2.4, 45.5), p < .001), AJBR (0.5 (0, 3.9) vs. 3.0 (0, 12.0), p < .001) and disability rate (9.0% vs.18.5%, p = .032) compared to children who received on-demand treatment. CONCLUSION The high rate of drop-out of school and disability still present a huge gap to meet the needs in China. It is necessary to improve the level of medical accessibility and medicine affordability and strengthen the patient/parent's education in China.
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Affiliation(s)
- Tao Guan
- Beijing Hemophilia Home Care Centre, Beijing, China
| | - Di Ai
- Hematology Centre, Beijing Key Laboratory of Paediatric Haematology Oncology, National Key Discipline of Paediatrics, Capital Medical University; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Childrenationrsity;, Capital Medical University, National Centre for Childrenal Univer, Beijing, China
| | - Nan Zhao
- Beijing Hemophilia Home Care Centre, Beijing, China
| | - Guoqing Liu
- Hematology Centre, Beijing Key Laboratory of Paediatric Haematology Oncology, National Key Discipline of Paediatrics, Capital Medical University; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Childrenationrsity;, Capital Medical University, National Centre for Childrenal Univer, Beijing, China
| | - Wanru Yao
- Hematology Centre, Beijing Key Laboratory of Paediatric Haematology Oncology, National Key Discipline of Paediatrics, Capital Medical University; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Childrenationrsity;, Capital Medical University, National Centre for Childrenal Univer, Beijing, China
| | - Zhenping Chen
- Hematologic Disease Laboratory, Beijing Paediatric Research Institute, Beijing Childrenute Laborat, Capital Medical University, National Centre for Childrenal Univer, Beijing, China
| | - Zhenping Li
- Hematology Centre, Beijing Key Laboratory of Paediatric Haematology Oncology, National Key Discipline of Paediatrics, Capital Medical University; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Childrenationrsity;, Capital Medical University, National Centre for Childrenal Univer, Beijing, China
| | - Yaohan Zhou
- Hematology Centre, Beijing Key Laboratory of Paediatric Haematology Oncology, National Key Discipline of Paediatrics, Capital Medical University; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Childrenationrsity;, Capital Medical University, National Centre for Childrenal Univer, Beijing, China
| | - Runhui Wu
- Hematology Centre, Beijing Key Laboratory of Paediatric Haematology Oncology, National Key Discipline of Paediatrics, Capital Medical University; Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Childrenationrsity;, Capital Medical University, National Centre for Childrenal Univer, Beijing, China
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Hermans C, Ventriglia G, Obaji S, Beckermann BM, Lehle M, Catalani O, d’Oiron R, Frenzel L. Emicizumab use in females with moderate or mild hemophilia A without factor VIII inhibitors who warrant prophylaxis. Res Pract Thromb Haemost 2023; 7:102239. [PMID: 38193069 PMCID: PMC10772889 DOI: 10.1016/j.rpth.2023.102239] [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: 04/17/2023] [Revised: 09/14/2023] [Accepted: 10/16/2023] [Indexed: 01/10/2024] Open
Abstract
Background Hemophilia A (HA) is predominantly associated with males due to X-linked inheritance. Males and females with HA have shared unmet medical needs, highlighting the necessity for comprehensive care irrespective of sex. Objectives This analysis investigated the efficacy and safety of emicizumab prophylaxis in 3 females with HA. Methods HAVEN 6 (NCT04158648) is a phase III study of emicizumab in people with non-severe HA without factor (F)VIII inhibitors warranting prophylaxis per investigator assessment, and the study methodology has been reported previously. Female-specific endpoints included menstruation-related quality of life and menstruation heaviness. Results HAVEN 6 enrolled 3 females aged ≥18 years and within reproductive age (n = 2 mild HA; n = 1 moderate HA; n = 2 receiving prior FVIII prophylaxis; n = 1 receiving prior episodic FVIII). Participants presented with diverse bleeding phenotypes at baseline: 2 had no bleeds in the 24 weeks prior to enrollment, while 1 had an annualized bleed rate for all bleeds of 208.6. On-study annualized bleed rates for all bleeds were 0, 2.8, and 11.6, respectively. The 2 evaluable participants indicated improved menstruation-related quality of life vs baseline. Two participants experienced 3 grade 1/2 treatment-related adverse events; no new safety signals were identified. All 3 participants preferred emicizumab over their previous treatment and reported a better score for treatment burden and preoccupation domains of the Comprehensive Assessment Tool of Challenges in Hemophilia questionnaire. Conclusion Overall, results were consistent with those reported in the male population enrolled in the HAVEN 6 study, suggesting efficacy and a favorable safety profile for emicizumab in females with non-severe HA warranting prophylaxis.
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Affiliation(s)
- Cedric Hermans
- Division of Haematology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Giuliana Ventriglia
- Product Development Clinical Science Hematology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Samya Obaji
- Cardiff Haemophilia Centre, University Hospital of Wales, Cardiff, United Kingdom
| | - Benjamin M. Beckermann
- Product Development Clinical Science Oncology & Hematology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Michaela Lehle
- Product Development Clinical Science Oncology & Hematology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | | | - Roseline d’Oiron
- Reference centre for Haemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital AP-HP, University of Paris-Saclay and UMR-S1176 INSERM, Le Kremlin-Bicêtre, France
| | - Laurent Frenzel
- Centre de Traitement de l'Hémophilie, AP-HP, Hôpital Necker Enfants Malades, Paris, France
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Onishi T, Harada S, Shimo H, Tashiro Y, Soeda T, Nogami K. The in vitro effect of anticoagulant agents on coagulation and fibrinolysis in the presence of emicizumab in the plasmas from patients with haemophilia A. Haemophilia 2023; 29:1529-1538. [PMID: 37766492 DOI: 10.1111/hae.14877] [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: 07/05/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Emicizumab is used as hemostatic prophylaxis for patients with hemophilia A (PwHA), irrespective of the presence of inhibitors. Although bacterial infection can lead to a procoagulant state, there is limited information on coagulation and fibrinolysis potentials in emicizumab-treated PwHA and on the use of anticoagulants in such cases. AIM We examined whether anticoagulants affect the coagulation and fibrinolysis potentials in plasma from PwHA spiked with emicizumab. METHODS Plasma from PwHA was in vitro supplemented with emicizumab (50 μg/mL; emi-plasma) and anticoagulants (recombinant thrombomodulin (rTM), nafamostat mesylate (NM), unfractionated heparin (UFH), or low-molecular-weight heparin (LMH)). PwHA plasma spiked with rFVIII (1 IU/mL) was used as a reference (ref-plasma). The coagulation and fibrinolysis potentials in plasma was measured by thrombin and plasmin generation assay (T/P-GA) and clot-fibrinolysis waveform analysis (CFWA). RESULTS In T/P-GA and CFWA, coagulation potentials (maximum coagulation velocity; |min1|, and peak thrombin; Th-Peak) in plasma rose with increasing concentrations of emicizumab and rFVIII, but fibrinolytic potentials (peak plasmin; Plm-Peak, and maximum fibrinolytic velocity; |FL-min1|) remained unchanged. Adding rTM, NM, and UFH to emi-plasma suppressed coagulation and fibrinolysis potentials, similar to ref-plasma. Regarding the heparin, UFH and LMH inhibited the improved coagulation in emi-plasma. UFH inhibited fibrinolysis as well, but LMH did not. CONCLUSIONS Anticoagulants could exhibit the inhibitory effects on the coagulation and fibrinolysis potentials in plasma from PwHA spiked with emicizumab, similar to those in normal plasma.
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Affiliation(s)
- Tomoko Onishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Suguru Harada
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | - Hanako Shimo
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Shen MC, Chou SC, Chiou SS, Lin PC, Chen YC, Lin HY, Lee YC, Huang CE, Weng TF, Huang TH, Chung CY, Chen JS, Chen SH, Cheng SN, Hsiao CC, Huang YM, Chen SH, Yu YB, Lin SC, Lin CY, Peng CT, Wang JD. Efficacy, safety and cost of emicizumab prophylaxis in haemophilia A patients with inhibitors: A nationwide observational study in Taiwan. Haemophilia 2023; 29:1499-1508. [PMID: 37819166 DOI: 10.1111/hae.14880] [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: 06/12/2023] [Revised: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION Emicizumab mimicking the cofactor function of activated factor VIII (FVIII) restores haemostasis. METHODS This nationwide observational study aimed to retrospectively investigate efficacy, safety, and cost in 1 year before and up to 3 years after emicizumab prophylaxis for haemophilia A (HA) patients with FVIII inhibitors. RESULTS AND DISCUSSION A total of 39 severe HA patients with a median age of 23.0 years were enrolled. The median historical peak FVIII inhibitor titre was 174.2 BU/mL with an interquartile range of 56.5-578.8 BU/mL. The median annualized bleeding rate reduced from 24 to 0 events in the first year after emicizumab prophylaxis (p < .01) and sustained in the second and third years. The median annualized joint bleeding rate reduced to 0 and maintained up to 3 years (p < .01). Twenty-seven patients (69.2%) had target joints before emicizumab prophylaxis and only seven patients (17.9%) of them had target joints after prophylaxis. Medical costs, including cost of haemostatic therapy, frequency of outpatient department visits, emergency room visits and hospital admission, were significantly reduced after emicizumab prophylaxis (p < .01). FVIII inhibitor titre decreased after emicizumab prophylaxis. Overall, three (7.7%) patients experienced 202 grade 1 drug-related adverse events after emicizumab prophylaxis. No serious adverse events were reported during emicizumab prophylaxis period. The adherence to emicizumab prophylaxis was 100% up to 3 years. CONCLUSIONS HA patients with FVIII inhibitors treated with emicizumab prophylaxis resulted in a significant reduction in treated bleeds and associated costs. No new safety events were observed.
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Affiliation(s)
- Ming-Ching Shen
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Sheng-Chieh Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shyh-Shin Chiou
- Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Pei-Chin Lin
- Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yeu-Chin Chen
- Hemophilia Care and Research Center, Tri-Service General Hospital, Taipei, Taiwan
- Division of Hematology/Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsuan-Yu Lin
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Yang-Cheng Lee
- Division of Hematology and Oncology, Departments of Internal Medicine, Tainan Municipal Hospital, Tainan, Taiwan
| | - Cih-En Huang
- Division of Hematology and Oncology, Department of Medicine, Chang Gung Memorial Hospital at Chiayi, Chiayi, Taiwan
| | - Te-Fu Weng
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ting-Huan Huang
- Division of Pediatric Hematology/Oncology, Hsinchu Mackay Memorial Hospital, Hsinchu, Taiwan
| | - Chih-Yuan Chung
- Department of Medical Oncology, China Medical University Hsinchu Hospital, Hsinchu, Taiwan
| | - Jiann-Shiuh Chen
- Division of Hematology and Oncology, Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shu-Huey Chen
- Department of Pediatrics, Shuang Ho Hospital, Ministry of Health and Welfare, Taipei Medical University, New Taipei, Taiwan
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shin-Nan Cheng
- Haemophilia Care and Research Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Paediatrics, Tung's Taichung Metrohabor Hospital, Taichung, Taiwan
| | - Chih-Cheng Hsiao
- Division of Pediatric Hematology/Oncology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yen-Min Huang
- Division of Hematology and Oncology, Department of Internal Medicine, Hemophilia and Thrombosis Treatment Center, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shih-Hsiang Chen
- Division of Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yuan-Bin Yu
- Division of Hematology and Oncology, Far-East Memorial Hospital, New Taipei City, Taiwan
| | - Shih-Chiang Lin
- Division of Hematology and Oncology, Far-East Memorial Hospital, New Taipei City, Taiwan
| | - Ching-Yeh Lin
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Ching-Tien Peng
- Division of Pediatric Haematology and Oncology, China Medical University Children's Hospital, China Medical University, Taichung, Taiwan
| | - Jiaan-Der Wang
- Center for Rare Disease and Hemophilia, Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung City, Taiwan
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Novembrino C, Boscolo-Anzoletti M, Galbiati E, Shinohara S, Peyvandi F. Effect of emicizumab-neutralizing antibodies on activated partial thromboplastin time-based clotting time test results in patients treated with emicizumab. Res Pract Thromb Haemost 2023; 7:102260. [PMID: 38193066 PMCID: PMC10772886 DOI: 10.1016/j.rpth.2023.102260] [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: 03/22/2023] [Revised: 10/17/2023] [Accepted: 10/27/2023] [Indexed: 01/10/2024] Open
Abstract
Background Emicizumab is a bispecific humanized monoclonal antibody that shortens the activated partial thromboplastin time (aPTT), making aPTT-based tests unreliable. Objectives To evaluate the efficacy of a mixture of 2 anti-idiotype monoclonal antibodies (anti-emi) in neutralizing emicizumab in samples from persons with hemophilia A treated with emicizumab. Methods Fifty samples from persons with hemophilia A treated with emicizumab were analyzed for aPTT and factor VIII procoagulant activity; FVIII inhibitor titer was measured using Nijmegen-Bethesda assay in 50 plasma samples of additional patients (positive for FVIII inhibitor) treated with emicizumab. FVIII procoagulant activity and inhibitor titer were measured using 1-stage (Actin FS, Siemens) and chromogenic assays with bovine regents (Factor VIII Chromogenic Assay, Siemens). Emicizumab concentration was measured by modified a 1-stage assay calibrated with a drug-specific calibrator (r2 Diagnostics Inc). All the tests were performed on Sysmex CS-2400 (Sysmex) before and after the addition of anti-emi (Chugai Pharmaceutical). Results Emicizumab concentrations measured after neutralization were <1.6 μg/mL in all samples. FVIII levels were >480 IU/dL with an aPTT of <30.8 seconds in all samples before neutralization and were <1 IU/dL with an aPTT of >70 seconds after adding anti-emi. FVIII inhibitor resulted in a false negative result in 44 of 50 samples measured with the 1-stage assay before neutralization. A good correlation (r = 0.98) was found between inhibitor titer measured using the chromogenic (insensitive to emicizumab) and 1-stage assays after neutralization. Conclusion The anti-emi antibodies were shown to completely neutralize emicizumab, making samples pretreated with anti-emi analyzable with the 1-stage assay.
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Affiliation(s)
- Cristina Novembrino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Boscolo-Anzoletti
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Eleonora Galbiati
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sho Shinohara
- Sysmex Corporation, Kobe, Japan
- Hyphen BioMed, Neuville-sur-Oise, France
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Bertaggia Calderara D, Marchi Cappelletti R, Batista Mesquita Sauvage AP, Durual S, Gomez FJ, Zermatten MG, Aliotta A, Casini A, Alberio L. Pharmacodynamics Monitoring of Emicizumab in Patients with Hemophilia A. Thromb Haemost 2023; 123:955-965. [PMID: 37336473 DOI: 10.1055/s-0043-1769788] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Emicizumab is a bispecific antibody mimicking coagulation factor VIII (FVIII) employed to treat patients with hemophilia A (PwHA) regardless of FVIII inhibitor status. The identification of biological markers reflecting the hemostatic competence of patients under emicizumab therapy would have a great clinical value. Unfortunately, emicizumab over-corrects standard coagulation assays, precluding their use for evaluating the hemostatic correction achieved in vivo. Here, we investigated whether global coagulation assays (GCA) would allow monitoring the biological response to non-factor replacement therapy with emicizumab. MATERIALS AND METHODS Six adults PwHA received a weekly dose of emicizumab of 3 mg/kg during weeks (W) 1 4 and 1.5 mg/kg from W5 onwards. Response to treatment was monitored weekly by emicizumab plasma concentration, thrombin generation (TG), and fibrin clot formation (FCF) and structure. TG and FCF results were compared to patient baseline, FVIII replacement, and healthy donors. RESULTS TG and FCF significantly increased in PwHA after the loading period, reaching a plateau that lasted until the end of monitoring. Similarly, fibrin clot network became denser with thinner fibrin fibers. However, TG contrary to FCF remained at the lower limits of reference values. Remarkably, despite having similar plateau concentrations of emicizumab some patients showed markedly different degrees of TG and FCF improvement. CONCLUSION Our study enriches the knowledge on the use of GCA to monitor non-factor replacement therapy, indicating that TG and FCF could act as direct markers of emicizumab biological activity. GCA allow to capture and visualize the individually variable response to emicizumab, leading a step forward to the personalization of patient treatment.
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Affiliation(s)
- Debora Bertaggia Calderara
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Rita Marchi Cappelletti
- Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Ana Patricia Batista Mesquita Sauvage
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Stéphane Durual
- Biomaterials Laboratory, University Clinics of Dental Medicine, University of Geneva, Switzerland
| | - Francisco J Gomez
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Maxime G Zermatten
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alessandro Aliotta
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alessandro Casini
- Department of Medicine, University of Geneva, Geneva, Switzerland
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
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Batsuli G, Wheeler AP, Weyand AC, Sidonio RF, Young G. Severe muscle bleeds in children and young adults with hemophilia A on emicizumab prophylaxis: Real-world retrospective multi-institutional cohort. Am J Hematol 2023; 98:E285-E287. [PMID: 37471655 DOI: 10.1002/ajh.27039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/04/2023] [Accepted: 07/09/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Glaivy Batsuli
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Allison P Wheeler
- Department of Pathology, Microbiology & Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Angela C Weyand
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Robert F Sidonio
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Guy Young
- Cancer and Blood Disorders Institute, Children's Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Takeyama M, Matsumoto N, Abe H, Harada S, Ogiwara K, Furukawa S, Shimonishi N, Nakajima Y, Yada K, Soeda T, Nogami K. Coagulant potentials of emicizumab in the plasmas from infant and toddler patients with hemophilia A. Pediatr Blood Cancer 2023; 70:e30590. [PMID: 37467119 DOI: 10.1002/pbc.30590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Emicizumab significantly reduces bleedings in patients with hemophilia A (PwHA). A clinical study (HAVEN 7; NCT04431726) for PwHA aged less than or equal to 12 months is ongoing, but emicizumab-driven coagulation potential in PwHA in early childhood remains to be clarified. AIM To investigate the in vitro or in vivo coagulation potential of emicizumab in plasmas obtained from infant and toddler PwHA. METHODS Twenty-seven plasma samples from 14 infant/toddler PwHA (aged 0-42 months, median 19 months) who received emicizumab (n = 9), factor (F)VIII products (n = 8), or no treatment (n = 10) were obtained. FVIII activity in FVIII-treated plasmas was cancelled by the addition of anti-FVIII monoclonal antibody (mAb). Emicizumab-treated plasmas (in vivo) and emicizumab-spiked plasmas (in vitro) were analyzed. Emicizumab-untreated plasma or emicizumab-treated plasma supplemented with two anti-emicizumab mAbs were used as references. Adjusted maximum coagulation velocity (Ad|min1|) by clot waveform analysis and peak thrombin (Peak-Th) by thrombin generation assay was assessed. RESULTS Ad|min1| values in 24 samples were improved by the presence of emicizumab. Values did not improve in the three remaining samples (aged 1, 23, and 31 months). Although the presence of emicizumab showed an age-dependent increase in Peak-Th in 20 samples, this increase was not observed in seven samples (aged 0, 1, 1, 2, 8, 19, and 36 months). Emicizumab-dependent increases in both Ad|min1| and Peak-Th were shown in 18 samples, and increases in either parameter were shown in eight samples. One sample (from patient aged 1 month) showed no increase in both, however. CONCLUSION Emicizumab could improve coagulant potential in plasmas from infant/toddler patients with hemophilia A.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | - Hiroto Abe
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | - Suguru Harada
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Division of Hemophilia, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Cohen O, Levy-Mendelovich S, Budnik I, Ludan N, Lyskov SK, Livnat T, Avishai E, Efros O, Lubetsky A, Lalezari S, Misgav M, Brutman-Barazani T, Kenet G, Barg AA. Management of surgery in persons with hemophilia A receiving emicizumab prophylaxis: data from a national hemophilia treatment center. Res Pract Thromb Haemost 2023; 7:102178. [PMID: 37876894 PMCID: PMC10593567 DOI: 10.1016/j.rpth.2023.102178] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 07/06/2023] [Accepted: 07/09/2023] [Indexed: 10/26/2023] Open
Abstract
Background Persons with hemophilia A may require surgical procedures. Real-world data on invasive procedures in persons with hemophilia A receiving emicizumab prophylaxis are limited. Objectives To evaluate the safety of invasive procedures in persons with hemophilia A receiving emicizumab prophylaxis and their outcomes in a longitudinally followed cohort. Methods Data from medical records of persons with hemophilia A with and without factor VIII (FVIII) inhibitors longitudinally followed at our tertiary center, who received emicizumab prophylaxis and underwent all types of invasive procedures, were retrieved. Outcomes of interest were bleeding and thrombotic complications. Results Overall, 35 patients underwent 56 invasive procedures, 18 (32.1%) were major. The median age was 36.3 years (IQR, 8.8-55.9 years); 12 patients (34.3%) were younger than 18 years at the time of procedure; 17 (48.6%) were patients with FVIII inhibitors. Among major procedures, orthopedic surgeries prevailed. All patients who underwent major procedures received factor replacement with either recombinant activated factor VII (patients with inhibitors) or FVIII (patients without inhibitors). Factor concentrates were administered prior to 32 (84.2%) of the minor procedures. Repeated doses were given according to international expert opinion recommendations and patients' condition.There were 7 bleeding events in 6 patients, 5 were major bleeds, including 1 patient who underwent a minor procedure without factor replacement. None of the patients experienced a thrombotic complication. Conclusion Invasive procedures can be performed safely in patients receiving emicizumab prophylaxis with close surveillance after surgery. Factor concentrates may be advised in selected patients undergoing minor procedures.
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Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Sarina Levy-Mendelovich
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sheba Talpiot Medical leadership program, Sheba Medical Center, Tel Hashomer, Israel
| | - Ivan Budnik
- Division of Hematology/Oncology, Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Noa Ludan
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Tami Livnat
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Einat Avishai
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Efros
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aharon Lubetsky
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shadan Lalezari
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mudi Misgav
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Brutman-Barazani
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assaf A. Barg
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Kizilocak H, Guerrera MF, Young G. Neutralizing antidrug antibody to emicizumab in patients with severe hemophilia A: Case report of a first noninhibitor patient and review of the literature. Res Pract Thromb Haemost 2023; 7:102194. [PMID: 37732158 PMCID: PMC10507376 DOI: 10.1016/j.rpth.2023.102194] [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: 03/17/2023] [Revised: 08/07/2023] [Accepted: 08/19/2023] [Indexed: 09/22/2023] Open
Abstract
Background Hemophilia A (HA) is a genetic bleeding disorder characterized by the deficiency of the coagulation protein factor (F) VIII (FVIII). The development of neutralizing antidrug antibodies (ADAs) to factor concentrates (inhibitors) created an unmet need for novel therapies. The first agent to address this need is emicizumab. Key Clinical Question Can emicizumab ADA occur in patients with HA without FVIII inhibitors? Clinical Approach A new case (the first in a noninhibitor patient) presented with unexpected and excessive bleeding and a prolonged activated partial thromboplastin time. The patient was evaluated by assessing FVIII levels, and the previously published modified version of the Bethesda assay was used to determine the level of ADA to emicizumab. Conclusion Although emicizumab is very effective and has minimal immunogenicity, ADAs, albeit rare, can still occur. There have been 4 previously published anti-emicizumab ADA cases with severe HA with inhibitors, and herein, we describe 1 new case with severe HA without inhibitors.
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Affiliation(s)
- Hande Kizilocak
- Children’s Hospital Los Angeles, Hemostasis and Thrombosis Center, Los Angeles, CA, USA
| | | | - Guy Young
- Children’s Hospital Los Angeles, Hemostasis and Thrombosis Center, Los Angeles, CA, USA
- University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
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Castaman G, Coppens M, Pipe SW. Etranacogene dezaparvovec for the treatment of adult patients with severe and moderately severe hemophilia B. Expert Rev Hematol 2023; 16:919-932. [PMID: 37882214 DOI: 10.1080/17474086.2023.2276206] [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: 06/13/2023] [Accepted: 10/24/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Etranacogene dezaparvovec is the first gene therapy approved for treatment of adults with severe and moderately severe hemophilia B. AREAS COVERED This review describes the results of the clinical trial program of AMT-060 and etranacogene dezaparvovec, outlining the pharmacokinetic, clinical efficacy and safety data. With the entry of etranacogene dezaparvovec into the market, this review summarizes the treatment landscape in hemophilia B and discusses the current unknowns in the field. EXPERT OPINION Gene therapy appears to be a feasible option for adults with severe and moderately severe hemophilia B. Etranacogene dezaparvovec enables most patients to reach stable factor IX (FIX) levels after a single intravenous infusion, eliminating the need for regular prophylaxis; thus, drastically reducing treatment burden and avoiding variable bleeding risk owing to fluctuating FIX activity levels. Efficacy of etranacogene dezaparvovec has been demonstrated even in the presence of preexisting neutralizing antibodies (up to a titer of 1:678), with a relative low risk of transaminitis and its associated potential loss of transgene expression. However, long-term data are required to ascertain the durability of FIX levels achieved and safety. The cost-effectiveness and adoption of innovative payment models for reimbursement are key in choosing gene therapy over existing treatments.
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Affiliation(s)
- Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Michiel Coppens
- Vascular Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, The Netherlands
| | - Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan Medical School, Ann Arbor, MI, USA
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Hahn SM, Han JW, Kim JS, Shim YJ, Kim S, Kim HC, Park YS, Lyu CJ. Real-world data for the use of emicizumab in haemophilia A patients with inhibitors - First nationwide report from Korea. Haemophilia 2023; 29:1163-1166. [PMID: 37347590 DOI: 10.1111/hae.14819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/30/2023] [Accepted: 06/06/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Seung Min Hahn
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung Woo Han
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Seok Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Ye Jee Shim
- Department of Pediatrics, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Soyon Kim
- Kim & Lee's Internal Medicine Clinic, Seoul, South Korea
| | - Hugh Chul Kim
- Kim & Lee's Internal Medicine Clinic, Seoul, South Korea
| | - Young Shil Park
- Department of Pediatrics, Kyung Hee University College of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Chuhl Joo Lyu
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Muniz RL, Camelo RM, Araújo MS, Barbosa MM, Guerra AA, Acurcio FDA, Alvares-Teodoro J. Efficacy/effectiveness and safety of emicizumab prophylaxis of people with hemophilia A: a systematic review and meta-analysis. Expert Rev Hematol 2023; 16:1087-1097. [PMID: 38066708 DOI: 10.1080/17474086.2023.2293096] [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: 08/26/2023] [Accepted: 11/27/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Emicizumab is a monoclonal antibody approved for prophylaxis against bleeds for people with hemophilia A (PwHA). A systematic review was conducted evaluating the efficacy/effectiveness and the safety of emicizumab as prophylaxis for PwHA compared to prophylaxis with factor VIII (FVIII) or bypassing agents (BPA), respectively in patients without and with inhibitors. RESEARCH DESIGN AND METHODS Database-directed search strategies were performed in Aug/26/2022 and updated in Mar/16/2023. Studies evaluating the prophylaxis with emicizumab versus prophylaxis with FVIII or BPA in PwHA without or with inhibitors, respectively, were selected by two independent reviewers. Data were extracted by two independent reviewers. Annualized bleeding rates for total treated bleeding events (ABR-all) were evaluated by meta-analysis. The quality of studies and certainty of evidence were assessed. RESULTS A total of 11 studies were included. The standard mean differences for ABR-all were -0.6 (95%CI -1.0 to -0.2, p-value = 0.0002), among PwHA without inhibitors, and -1.7 (95%CI -2.4 to -0.9, p-value <0.00001), among PwHA with inhibitors. However, there was moderate heterogeneity in both meta-analyses. The most frequent adverse event was injection site reaction. CONCLUSIONS Emicizumab prophylaxis was superior in reducing the ABR-all when compared with prophylaxis with FVIII or BPA.
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Affiliation(s)
- Roberto Lúcio Muniz
- Faculty of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Maiara Silva Araújo
- Faculty of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Yoneyama K, Schmitt C, Portron A, Kiialainen A, Kotani N, Jaminion F, Retout S, Adamkewicz JI. Clinical pharmacology of emicizumab for the treatment of hemophilia A. Expert Rev Clin Pharmacol 2023; 16:775-790. [PMID: 37529848 DOI: 10.1080/17512433.2023.2243213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/22/2023] [Accepted: 07/28/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Emicizumab is a humanized bispecific antibody approved for the routine prophylaxis of bleeding episodes in patients with hemophilia A (PwHA) regardless of the presence of factor VIII (FVIII) inhibitors. It mimics the cofactor function of missing activated FVIII by bridging activated factor IX and factor X, thereby restoring hemostasis. AREAS COVERED This review covers the clinical pharmacology of emicizumab and the translation of its pharmacokinetics (PK) and pharmacodynamics (PD) to clinical efficacy and safety. The PK of emicizumab is linear, with an approximately 1-month half-life. Once-weekly to every-4-week subcutaneous (SC) administrations maintain effective trough concentrations throughout the dosing intervals, associated with a coagulation potential analogous to that in patients with mild hemophilia A. In combination with activated prothrombin complex concentrate, and to a lesser extent with recombinant activated factor VII, emicizumab exerts a synergistic effect, whereas combination with FVIII may result in a non-additive coagulation potential at normal FVIII activity. EXPERT OPINION The translation of emicizumab PK/PD into clinical effects was demonstrated in several phase III studies, which showed remarkable bleed control and a favorable safety profile in PwHA. These emicizumab attributes, together with the convenience of use (infrequent SC injections), offer a novel paradigm for the management of PwHA.
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