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Pochopien M, Tytuła A, Toumi M, Falk A, Martone N, Hakimi Z, Eriksson D. Cost-Effectiveness of Recombinant Factor IX Fc Prophylaxis and Recombinant Factor IX On-Demand Treatment in Patients with Haemophilia B Without Inhibitors. Adv Ther 2024; 41:2307-2323. [PMID: 38652439 PMCID: PMC11133064 DOI: 10.1007/s12325-024-02841-w] [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: 12/21/2023] [Accepted: 03/11/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Recombinant factor IX (rFIX) and recombinant FIX Fc fusion protein (rFIXFc) are standard half-life and extended half-life FIX replacement therapies, respectively, and represent established treatment options indicated for adults and children with haemophilia B. These FIX replacement therapies can be administered as prophylaxis (to prevent bleeding) or 'on-demand' (to stop bleeding). This analysis aimed to estimate the cost-effectiveness of once-weekly prophylaxis with rFIXFc versus on-demand treatment with rFIX in patients with haemophilia B without inhibitors in the Italian healthcare setting. METHODS A Markov model was developed to assess a hypothetical cohort of adolescent or adult male patients (≥ 12 years) with haemophilia B (FIX level of ≤ 2 IU/dL) without inhibitors. Model inputs were derived from the pivotal phase 3 clinical studies for rFIXFc and rFIX, published literature and assumptions when published data were unavailable. The model employed a lifelong time horizon with 6-monthly transitions between health states, and it estimated total costs, total quality-adjusted life years (QALYs), number of bleeds, number of surgeries and incremental cost-effectiveness ratio. RESULTS rFIXFc prophylaxis was associated with lower total costs per patient (€5,308,625 versus €6,564,510) and greater total QALYs per patient (15.936 versus 11.943) compared with rFIX on-demand; rFIXFc prophylaxis was therefore the dominant treatment strategy. The model also demonstrated that rFIXFc prophylaxis was associated with fewer incremental bleeds (- 682.29) and surgeries (- 0.39) compared with rFIX on-demand. CONCLUSIONS rFIXFc prophylaxis provides improved health outcomes and lower costs, and represents a cost-effective treatment option compared with rFIX on-demand for adolescent and adult male patients with haemophilia B. This comparative assessment of cost-effectiveness should help to inform both clinicians and healthcare policy makers when making treatment decisions for patients with haemophilia B.
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Affiliation(s)
| | - Anna Tytuła
- Health Economics and Outcomes Research Department, Putnam PHMR, Kraków, Poland
| | - Mondher Toumi
- Department of Public Health, Aix-Marseille University, Marseille, France
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2
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Yu L, Yang D, Chu M, Sun Y. Advances and challenges in the purification of recombinant coagulation factors: A review. J Chromatogr A 2024; 1716:464662. [PMID: 38244305 DOI: 10.1016/j.chroma.2024.464662] [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: 01/02/2024] [Revised: 01/12/2024] [Accepted: 01/14/2024] [Indexed: 01/22/2024]
Abstract
Hemostasis is a complex process for the cessation of bleeding from an injured blood vessel, involving the interplay of 12 coagulation factors in the coagulation cascade with activated blood platelets and the vessel wall. Hence, the coagulation factors are important to control hemorrhage. However, the low abundance of many coagulation factors in human plasma proteins limited their production in therapeutic drugs and their clinical applications. With the development of modern biotechnology, commercially manufactured recombinant coagulation factors became available as hemostatic therapeutics, emerging a huge potential in pharmaceutical manufacturing market. Unlike antibodies, whose standard operation unit or platform purification processes in the industrial-scale downstream processing has been well-established, the complexity in post-translational modification and differences in structures of the coagulation factors posed specific challenges with respect to the downstream processing, which have long been limiting their industrial-scale production. This review presents a comprehensive overview of the technological development of commercially manufactured recombinant coagulation factors, with emphasis on their advances and challenges in the separation and purification processes. Firstly, the licensed products of the plasma derived and recombinant coagulation factors are summarized. Then, typical recombinant coagulation factors, i.e. factors VII, VIII and IX, are introduced with detailed discussion on their preparative separation procedures for both the licensed products of industrial-scale and the experimental cases of laboratory-scale. Finally, perspectives and challenges in the future development of the purification technology of recombinant coagulation factors are highlighted to provide new insight into the design of cost-effective purification processes of recombinant coagulation factors.
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Affiliation(s)
- Linling Yu
- Department of Biochemical Engineering, School of Chemical Engineering and Technology, Key Laboratory of Systems Bioengineering and Frontiers Science Center for Synthetic Biology (Ministry of Education), Tianjin University, Tianjin 300350, China
| | - Dongmei Yang
- Department of Biochemical Engineering, School of Chemical Engineering and Technology, Key Laboratory of Systems Bioengineering and Frontiers Science Center for Synthetic Biology (Ministry of Education), Tianjin University, Tianjin 300350, China
| | - Mengyao Chu
- Department of Biochemical Engineering, School of Chemical Engineering and Technology, Key Laboratory of Systems Bioengineering and Frontiers Science Center for Synthetic Biology (Ministry of Education), Tianjin University, Tianjin 300350, China
| | - Yan Sun
- Department of Biochemical Engineering, School of Chemical Engineering and Technology, Key Laboratory of Systems Bioengineering and Frontiers Science Center for Synthetic Biology (Ministry of Education), Tianjin University, Tianjin 300350, China.
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Hotea I, Brinza M, Blag C, Zimta AA, Dirzu N, Burzo C, Rus I, Apostu D, Benea H, Marian M, Mester A, Pasca S, Iluta S, Teodorescu P, Jitaru C, Zdrenghea M, Bojan A, Torok-Vistai T, Niculescu R, Tarniceriu C, Dima D, Truica C, Serban M, Tomuleasa C, Coriu D. Current therapeutic approaches in the management of hemophilia-a consensus view by the Romanian Society of Hematology. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1091. [PMID: 34423003 PMCID: PMC8339806 DOI: 10.21037/atm-21-747] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/17/2021] [Indexed: 12/28/2022]
Abstract
Hemophilia A (HA) and hemophilia B (HB) are rare disorders, being caused by the total lack or under-expression of two factors from the coagulation cascade coded by genes of the X chromosome. Thus, in hemophilic patients, the blood does not clot properly. This results in spontaneous bleeding episodes after an injury or surgical intervention. A patient-centered regimen is considered optimal. Age, pharmacokinetics, bleeding phenotype, joint status, adherence, physical activity, personal goals are all factors that should be considered when individualizing therapy. In the past 10 years, many innovations in the diagnostic and treatment options were presented as being either approved or in development, thus helping clinicians to improve the standard-of-care for patients with hemophilia. Recombinant factors still remain the standard of care in hemophilia, however they pose a challenge to treatment adherence because they have short half-life, which where the extended half-life (EHL) factors come with the solution, increasing the half-life to 96 hours. Gene therapies have a promising future with proven beneficial effects in clinical trials. We present and critically analyze in the current manuscript the pros and cons of all the major discoveries in the diagnosis and treatment of HA and HB, as well as identify key areas of hemophilia research where improvements are needed.
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Affiliation(s)
- Ionut Hotea
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania.,Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Melen Brinza
- Department of Hematology, Fundeni Clinical Institute, Bucharest, Romania.,Department of Hematology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Cristina Blag
- Department of Pediatrics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Emergency Clinical Children's Hospital, Cluj Napoca, Romania
| | - Alina-Andreea Zimta
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Noemi Dirzu
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Corina Burzo
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
| | - Ioana Rus
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Dragos Apostu
- Department of Orthopedics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Orthopedics, Emergency Clinical County Hospital, Cluj Napoca, Romania
| | - Horea Benea
- Department of Orthopedics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Orthopedics, Emergency Clinical County Hospital, Cluj Napoca, Romania
| | - Mirela Marian
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
| | - Alexandru Mester
- Department of Oral Health, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Sergiu Pasca
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Sabina Iluta
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Patric Teodorescu
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Ciprian Jitaru
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Mihnea Zdrenghea
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
| | - Anca Bojan
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
| | - Tunde Torok-Vistai
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
| | - Radu Niculescu
- Department of Hematology, Fundeni Clinical Institute, Bucharest, Romania
| | - Cristina Tarniceriu
- Department of Anatomy, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania.,Department of Hematology, St. Spiridon County Clinical Emergency Hospital, Iasi, Romania
| | - Delia Dima
- Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania
| | - Cristina Truica
- Department of Hematology, Constantin Opris Emergency Hospital, Baia Mare, Romania
| | - Margit Serban
- Department of Hematology, Victor Babes University of Medicine and Pharmacy, Timisoara, Romania.,European Haemophilia Treatment Center, Timisoara, Romania
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania.,Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Daniel Coriu
- Department of Hematology, Fundeni Clinical Institute, Bucharest, Romania.,Department of Hematology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Windyga J, Timofeeva M, Stasyshyn O, Mamonov V, Lamas Castellanos JL, Lissitchkov T, Chojnowski K, Chapman M, Pavlova BG, Tangada S. Phase 3 Clinical Trial: Perioperative Use of Nonacog Gamma, a Recombinant Factor IX, in Previously Treated Patients With Moderate/Severe Hemophilia B. Clin Appl Thromb Hemost 2021; 26:1076029620946839. [PMID: 32816519 PMCID: PMC7444148 DOI: 10.1177/1076029620946839] [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] [Indexed: 11/22/2022] Open
Abstract
Hemostatic management is essential for ensuring the safety of patients with hemophilia during surgery. This phase 3, prospective, uncontrolled trial, evaluated hemostatic efficacy, consumption, and safety of a recombinant factor IX concentrate, nonacog gamma (BAX 326, Rixubis® [Baxalta US Inc., a Takeda company, Lexington, MA, USA]), in intraoperative and postoperative settings in previously treated patients (PTPs) with severe or moderately severe hemophilia B undergoing elective surgery (N = 38 surgeries; 21 major, 17 minor). Predefined preoperative hemostatic factor IX levels (80-100% of normal for major and 30-60% for minor surgeries) were maintained for each patient. Intraoperative efficacy was rated as “excellent” or “good” for all surgeries. Postoperative hemostatic efficacy on day of discharge was rated as “excellent,” “good,” and “fair,” respectively, for 29 (76.3%), 7 (18.4%), and 2 (5.3%) surgical procedures. All adverse events were considered unrelated to study drug; most frequently reported was mild procedural pain (9 patients). No thrombotic events, severe allergic reactions, or inhibitor formation were observed. Nonacog gamma was well tolerated and effective for intraoperative and postoperative hemostatic management of PTPs with hemophilia B. NCT01507896, EudraCT: 2011-000413-39
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Affiliation(s)
- Jerzy Windyga
- Department of Hemostatic Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, 49564Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Margarita Timofeeva
- Federal State Budgetary Institution of Science "Kirov Scientific and Research Institute of Hematology and Blood Transfusion of Federal Medico-Biological Agency," Kirov, Russia
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Farid S, Sewaralthahab S, Smith HP. Continuous infusion factor replacement in haemophilia B during and after cardiac surgery: the better choice? BMJ Case Rep 2020; 13:13/11/e235859. [PMID: 33257355 DOI: 10.1136/bcr-2020-235859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 57-year-old man with mild haemophilia B was admitted for coronary artery bypass graft surgery. His factor IX (FIX) activity was 15% on admission. Our goal was to maintain his FIX activity at 80%-100% for post-op days (PODs) 0-3, and at 60%-80% for PODs 4-14. Preoperatively, the patient was given recombinant FIX (rFIX) bolus using the formula:Dosage needed=%(desired FIX level-current level of FIX)×weight (kg)×1.3.This increased his activity to 100%. One IU of rFIX increased FIX activity by 0.8%; the half-life of rFIX is 18-24 hours. The rFIX infusion was started intraoperatively and continued after surgery to maintain target FIX activity. He was discharged on POD 9 on rFIX bolus dosing of 5000 IU every 12 hours for an additional 5 days. Using continuous factor infusion, we managed to decrease the amount rFIX used by >60% while maintaining steady state FIX activity level.
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Affiliation(s)
- Saira Farid
- Internal Medicine, MedStar Georgetown Washington Hospital Center, Washington, DC, USA
| | - Sarah Sewaralthahab
- Internal Medicine, MedStar Georgetown Washington Hospital Center, Washington, DC, USA
| | - Hedy Patricia Smith
- Hematology and Oncology, MedStar Washington Hospital Center, Washington, DC, USA
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Escobar MA, Tehranchi R, Karim FA, Caliskan U, Chowdary P, Colberg T, Giangrande P, Giermasz A, Mancuso ME, Serban M, Tsay W, Mahlangu JN. Low-factor consumption for major surgery in haemophilia B with long-acting recombinant glycoPEGylated factor IX. Haemophilia 2016; 23:67-76. [DOI: 10.1111/hae.13041] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 11/27/2022]
Affiliation(s)
- M. A. Escobar
- University of Texas Health Science Center and the Gulf States Hemophilia and Thrombophilia Center; Houston TX USA
| | - R. Tehranchi
- Medical and Science; Haemophilia R&D Portfolio; Novo Nordisk A/S; Søborg Denmark
| | - F. A. Karim
- National Blood Centre; Kuala Lumpur Malaysia
| | - U. Caliskan
- Department of Pediatric Hematology; NEU Meram Faculty of Medicine; Konya Turkey
| | - P. Chowdary
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
| | - T. Colberg
- Medical and Science; Haemophilia R&D Portfolio; Novo Nordisk A/S; Søborg Denmark
| | - P. Giangrande
- Oxford Haemophilia Centre and Thrombosis Unit; Churchill Hospital; Oxford UK
| | - A. Giermasz
- Division of Hematology Oncology; University of California; San Francisco CA USA
| | - M. E. Mancuso
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; Fondazione IRCCS Ca' Granda; Ospedale Maggiore Policlinico; Milan Italy
| | - M. Serban
- Spitalul Clinic de Urgenta pentru Copii Louis Turcanu; IIIrd Paediatric Clinic; Timisoara Romania
| | - W. Tsay
- Department of Hematology; National Taiwan University Hospital; Taipei Taiwan
| | - J. N. Mahlangu
- Department of Molecular Medicine and Haematology; Faculty of Health Sciences; University of the Witwatersrand; NHLS and Haemophilia Comprehensive Care Centre; Charlotte Maxeke Johannesburg Academic Hospital; Johannesburg South Africa
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7
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Suzuki N, Takedani H, Hirakawa A, Ushijima Y, Matsushita T. The features of clearance in recombinant factor IX (BeneFIX(®) ). Haemophilia 2015; 21:702-7. [PMID: 25854709 DOI: 10.1111/hae.12672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Dosage adjustment is very important to perform continuous infusion (CI) of recombinant factor IX (rFIX) concentrates more effectively and economically, and clearance (CL) is strongly related to the infusion rate. However, previous reports have shown that the CL of rFIX concentrates varies widely (4.2-11.4 mL kg(-1) h(-1) ). AIM The goal of this study was to gain a better understanding of the CL of the rFIX concentrate (BeneFIX(®) ) to precisely set the infusion rate of rFIX concentrates. METHODS We estimated CLs by five different calculation approaches: from area under the blood concentration-time curve (AUC), from in vivo recovery (IVR) and half-life, from actual FIX activity value during CI, and from the simulation by one-compartment model in seven patients with haemophilia B. RESULTS The mean CL calculated from AUC was 3.8 ± 0.4 mL kg(-1) h(-1) (range = 3.3-4.3 mL kg(-1) h(-1) ). CONCLUSION The mean CL calculated from IVR and distribution half-life was 4.4 ± 0.4 mL kg(-1) h(-1) (range = 4.0-5.1 mL kg(-1) h(-1) ). The mean CL calculated from IVR and terminal half-life was 2.1 ± 0.5 mL kg(-1) h(-1) (range = 1.7-2.8 mL kg(-1) h(-1) ). The mean CL during CI was 4.9 ± 0.6 mL kg(-1) h(-1) (range = 4.2-5.6 mL kg(-1) h(-1) ). In addition, when we simulated the theoretical CL using a one-compartment model, the adjusted mean CL during CI was 4.8 ± 0.5 mL kg(-1) h(-1) (range = 4.0-5.4 mL kg(-1) h(-1) ). The CL obtained from distribution half-life was comparable to the CL during CI, while the CL calculated from terminal half-life did not reflect actual CL. Further, the rFIX concentrate was characterized by a one-compartment model under certain conditions.
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Affiliation(s)
- N Suzuki
- Department of Clinical Laboratory Medicine, Nagoya University Hospital, Nagoya, Japan
| | - H Takedani
- Department of Joint Surgery, Institute of Medical Science, University of Tokyo Research Hospital, Tokyo, Japan
| | - A Hirakawa
- Biostatistics Section, Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Y Ushijima
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - T Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
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Windyga J, Lissitchkov T, Stasyshyn O, Mamonov V, Ghandehari H, Chapman M, Fritsch S, Wong WY, Pavlova BG, Abbuehl BE. Efficacy and safety of a recombinant factor IX (Bax326) in previously treated patients with severe or moderately severe haemophilia B undergoing surgical or other invasive procedures: a prospective, open-label, uncontrolled, multicentre, phase III study. Haemophilia 2014; 20:651-8. [PMID: 24697870 DOI: 10.1111/hae.12419] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2014] [Indexed: 12/25/2022]
Abstract
Haemostatic management of haemophilia B patients undergoing surgery is critical to patient safety. The aim of this ongoing prospective trial was to investigate the haemostatic efficacy and safety of a recombinant factor IX (rFIX) (Bax326) in previously treated subjects (12-65 years, without history of FIX inhibitors) with severe or moderately severe haemophilia B, undergoing surgical, dental or other invasive procedures. Haemostatic efficacy was assessed according to a predefined scale. Blood loss was compared to the average and maximum blood loss predicted preoperatively. Haemostatic FIX levels were achieved peri- and postoperatively in 100% of subjects (n = 14). Haemostasis was 'excellent' intraoperatively in all patients and postoperatively in those without a drain, and 'excellent' or 'good' at the time of drain removal and day of discharge in those with a drain employed. Following the initial dose, the mean FIX activity level rose from 6.55% to 107.58% for major surgeries and from 3.60% to 81.4% for minor surgeries. Actual vs. predicted blood loss matched predicted intraoperative blood loss but was equal to or higher than (but less than 150%) the maximum predicted postoperative blood loss reflecting the severity of procedure and FIX requirements. There were no related adverse events, severe allergic reactions or thrombotic events. There was no evidence that BAX326 increased the risk of inhibitor or binding antibody development to FIX. BAX326 was safe and effective for peri-operative management of 14 subjects with severe and moderately severe haemophilia B.
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Affiliation(s)
- J Windyga
- Institute of Hematology and Transfusion Medicine, Warsaw, Poland
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10
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Auerswald G, Bade A, Haubold K, Overberg D, Masurat S, Moorthi C. No inhibitor development after continuous infusion of factor concentrates in subjects with bleeding disorders undergoing surgery: a prospective study. Haemophilia 2012; 19:438-44. [DOI: 10.1111/hae.12075] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2012] [Indexed: 11/29/2022]
Affiliation(s)
- G. Auerswald
- Center for Thrombosis and Hemostasis; Professor-Hess-Kinderklinik; Klinikum Bremen-Mitte; Bremen; Germany
| | - A Bade
- Center for Thrombosis and Hemostasis; Professor-Hess-Kinderklinik; Klinikum Bremen-Mitte; Bremen; Germany
| | - K. Haubold
- Center for Thrombosis and Hemostasis; Professor-Hess-Kinderklinik; Klinikum Bremen-Mitte; Bremen; Germany
| | - D. Overberg
- Center for Thrombosis and Hemostasis; Professor-Hess-Kinderklinik; Klinikum Bremen-Mitte; Bremen; Germany
| | - S. Masurat
- Center for Thrombosis and Hemostasis; Professor-Hess-Kinderklinik; Klinikum Bremen-Mitte; Bremen; Germany
| | - C. Moorthi
- Center for Thrombosis and Hemostasis; Professor-Hess-Kinderklinik; Klinikum Bremen-Mitte; Bremen; Germany
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Sun YL, Chang YS, Lin YS, Yen CH. Pilot production of recombinant human clotting factor IX from transgenic sow milk. J Chromatogr B Analyt Technol Biomed Life Sci 2012; 898:78-89. [PMID: 22578515 DOI: 10.1016/j.jchromb.2012.04.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 03/28/2012] [Accepted: 04/17/2012] [Indexed: 11/27/2022]
Abstract
Valuable pharmaceutical proteins produced from the mammary glands of transgenic livestock have potential use in the biomedical industry. In this study, recombinant human clotting factor IX (rhFIX) produced from transgenic sow milk for preclinical animal studies have been established. The transgenic sow milk was skimmed and treated with sodium phosphate buffer to remove abundant casein protein. Then, the γ-carboxylated rhFIX fraction was segregated through the Q Sepharose chromatography from uncarboxylated one. For safety issue, the process included virus inactivation by solvent/detergent (S/D) treatment. Subsequently, the S/D treated sample was loaded into the Heparin Sepharose column to recover the rhFIX fraction, which was then reapplied to the Heparin Sepharose column to enhance rhFIX purity and lower the ratio of activated form rhFIX (rhFIXa) easily. This was possible due to the higher affinity of the Heparin affinity sorbent for rhFIXa than for the rhFIX zymogen. Furthermore, an IgA removal column was used to eliminate porcine IgA in purified rhFIX. Finally, nanofiltration was performed for viral clearance. Consequently, a high-quality rhFIX product was produced (approximately 700 mg per batch). Other values for final rhFIX preparation were as follows: purity, >99%; average specific activity, 415.6±57.7 IU/mL and total milk impurity, <0.5 ng/mg. This is the first report that described the whole process and stable production of bioactive rhFIX from transgenic sow milk. The overall manufacturing process presented here has the potential for industrial production of rhFIX for treatment of hemophilia B patients.
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Affiliation(s)
- Yu-ling Sun
- Division of Biotechnology, Animal Technology Institute Taiwan, P.O. Box 23, Chunan 350, Miaoli, Taiwan, ROC
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Chang LC, Yang CY, Chua ACN, Lin YJ, Lai SM. Sustained Release of Transgenic Human Factor IX: Preparation, Characterization, and in Vivo Efficacy. Mol Pharm 2011; 8:1767-74. [DOI: 10.1021/mp200133s] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Li-Chien Chang
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, R.O.C
| | - Chi-Yu Yang
- Division of Animal Medicine, Animal Technology Institute Taiwan, Miaoli, Taiwan, R.O.C
| | | | - Yi-Juain Lin
- Division of Animal Medicine, Animal Technology Institute Taiwan, Miaoli, Taiwan, R.O.C
| | - Sun-Mou Lai
- Department of Chemical and Materials Engineering, National Ilan University, Ilan, Taiwan, R.O.C
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UPRICHARD J, ADAMIDOU D, GODDARD NJ, MANN HA, YEE TT. Factor IX replacement to cover total knee replacement surgery in haemophilia B: a single-centre experience, 2000-2010. Haemophilia 2011; 18:46-9. [DOI: 10.1111/j.1365-2516.2011.02552.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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HERMANS C, ALTISENT C, BATOROVA A, CHAMBOST H, DE MOERLOOSE P, KARAFOULIDOU A, KLAMROTH R, RICHARDS M, WHITE B, DOLAN G. Replacement therapy for invasive procedures in patients with haemophilia: literature review, European survey and recommendations. Haemophilia 2009; 15:639-58. [DOI: 10.1111/j.1365-2516.2008.01950.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Secondary prophylaxis with factor IX concentrates: continuous infusion. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2009; 6 Suppl 2:s21-5. [PMID: 19105506 DOI: 10.2450/2008.0033-08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Haemophilia patients may require prolonged treatment during peri-operative period or life-threatening bleedings. Intermittent bolus infusions of factor concentrates have been used successfully for many years. However, pharmacokinetics may vary among products and patients, and the wide fluctuations in factor levels during therapy can make management inaccurate and unsafe. Specific protocols for continuous infusion have been developed, which may decrease factor utilization, facilitate laboratory monitoring of factor levels, and may decrease the overall cost of therapy. Continuous infusion of different clotting factor concentrates (factor VIII, factor IX, porcine factor VIII, rFVIIa, and activated prothrombin complex concentrates) has been associated with excellent haemostasis and safety: indeed, by continuous infusion unsafe low troughs or dangerous high concentrations can be avoided. In this review, the pharmacokinetic aspects of the continuous infusion of plasma-derived and recombinant factor IX concentrates are showed. Finally, the advantages and disadvantages of continuous infusion are discussed.
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16
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KRAKOW EF, WALKER I, LAMY A, ANDERSON JAM. Cardiac surgery in patients with haemophilia B: a case report and review of the literature. Haemophilia 2009; 15:108-13. [DOI: 10.1111/j.1365-2516.2008.01918.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Lisauskas SFC, Cunha NB, Vianna GR, Mendes ÉA, Ramos GL, Maranhão AQ, Brígido MM, Almeida JOSC, Baptista HA, Motta FLT, Pesquero JB, Aragão FJL, Rech EL. Expression of functional recombinant human factor IX in milk of mice. Biotechnol Lett 2008; 30:2063-9. [DOI: 10.1007/s10529-008-9818-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Revised: 07/18/2008] [Accepted: 07/21/2008] [Indexed: 12/22/2022]
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18
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Abstract
PURPOSE OF REVIEW To review the most recent reports on continuous infusion of coagulation factors, focusing on the current issues relating to this mode of therapy. RECENT FINDINGS Continuous infusion has been extensively used as an alternative to intermittent bolus factor replacement since the 1990s. To date, more than 100 reports comprising more than 800 continuous infusion treatments in various clinical situations have been published, with an increase in the current utilization of recombinant coagulation factors. An excellent hemostatic efficacy of continuous infusion has been reported. Continuous infusion protocols, however, still vary widely in terms of the different hemostatic levels targeted, dosage regimens, modes of continuous infusion and duration of therapy, which obviously result in variations in the cost-effectiveness reported by different centers. SUMMARY Continuous infusion has been shown to be a safe and cost-effective mode of replacement for treatment of hemophilia. The lack of evidence-based information on the hemostatic levels to be maintained in specific clinical situations, and recent concerns regarding the development of inhibitors, particularly in patients with mild hemophilia treated with continuous infusion, need to be addressed by prospective, randomized studies that compare traditional intermittent injections and the continuous infusion mode of factor replacement.
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Affiliation(s)
- Angelika Batorova
- National Hemophilia Center, University Hospital, Bratislava, Slovak Republic, Israel
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19
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Shapiro AD, Korth-Bradley J, Poon MC. Use of pharmacokinetics in the coagulation factor treatment of patients with haemophilia. Haemophilia 2005; 11:571-82. [PMID: 16236106 DOI: 10.1111/j.1365-2516.2005.01149.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Dosing decisions for replacement coagulation factors in patients with haemophilia should be made on an individual patient basis, with the required dose dependent on factors including the clinical situation, the severity of the factor deficiency, and the location and extent of bleeding. Moreover, there is considerable variability in the pharmacokinetics of coagulation products that needs to be considered; in particular, with both factor (F) IX and FVIII products, there is considerable inter-patient variability in in vivo recovery and terminal half-life values. In the present report, we provide a practical guide to calculating and applying pharmacokinetic parameters relevant to the optimal dosing of coagulation products. We discuss the conduct of a pharmacokinetic study in an individual patient, how to calculate pharmacokinetic values from raw data and clinical situations where an individual pharmacokinetic study is helpful. We highlight the importance of considering an individual pharmacokinetic study in all patients starting a new coagulation product.
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Affiliation(s)
- A D Shapiro
- Indiana Hemophilia and Thrombosis Center, Inc., Indianapolis, IN 46260, USA.
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20
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Guilcher GMT, Scully MF, Harvey M, Hand JP. Treatment of intracranial and extracranial haemorrhages in a neonate with severe haemophilia B with recombinant factor IX infusion. Haemophilia 2005; 11:411-4. [PMID: 16011597 DOI: 10.1111/j.1365-2516.2005.01102.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intracranial (ICH) and extracranial (ECH) haemorrhages are potentially life-threatening events that may occur comorbidly in neonates with haemophilia. There is little data on the use of recombinant factor IX (rFIX; BeneFIX in the neonate. Children <15 years of age are known to require higher doses of recombinant Factor IX (FIX) than older persons, which raises specific concerns in the neonate due to the increased risk of thrombosis in this age group (Thromb Haemost 2002; 87: 431). This report describes a case in which a high rate of continuous infusion of recombinant FIX was used to treat a newborn with significant intracranial and subgaleal haemorrhages. A high rate of infusion maintained at 30-35 U kg(-1) h(-1) was necessary to maintain adequate FIX levels. Despite the high rate of continuous infusion, no adverse events were noted. Our patient had a rare genetic mutation causing severe haemophilia B. A neonate with severe haemophilia B was treated successfully with recombinant FIX through continuous infusion. A high rate of infusion was required and no complications were noted.
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Affiliation(s)
- G M T Guilcher
- Department of Paediatrics, Janeway Children's Health and Rehabilitation Centre, Memorial University of Newfoundland, St John's, NL, Canada.
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21
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Dunn AL, Abshire TC. Recent advances in the management of the child who has hemophilia. Hematol Oncol Clin North Am 2004; 18:1249-76, viii. [PMID: 15511615 DOI: 10.1016/j.hoc.2004.06.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This article discusses recent advances in the management of the child who has hemophilia.
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Affiliation(s)
- Amy L Dunn
- AFLAC Cancer Center and Blood Disorders Service, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 2040 Ridgewood Drive NE, Suite 100, Atlanta, GA 30322, USA.
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22
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Abstract
This paper focuses on the benefits of prophylaxis, compared with on-demand therapy, in achieving long-term treatment goals in hemophilia patients. While primary treatment goals are to prevent joint damage and improve quality of life, other issues such as treatment costs-balanced against improvements in health status and direct and indirect costs of hemophilic arthropathy-need to be considered. The ESPRIT study (Evaluation Study on Prophylaxis: a Randomized Italian Trial), a 10-year trial comparing on-demand and prophylactic treatment in terms of efficacy, safety, and cost, is discussed. Early results support findings from other studies regarding the benefits of prophylaxis. Prospective pharmacoeconomic evaluations are needed to help define optimal treatment programs for patients with hemophilia A and B.
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Affiliation(s)
- Alessandro Gringeri
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Maggiore Hospital and University of Milan, Italy.
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23
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Douvas MG, Monahan PE. Life-threatening thrombosis complicating the management of hepatic hemorrhage: anticoagulant treatment in a newborn with hemophilia B. J Pediatr Hematol Oncol 2004; 26:258-63. [PMID: 15087956 DOI: 10.1097/00043426-200404000-00010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The authors report the case of a neonate presenting with a distended abdomen and shock from factor IX (F.IX) deficiency and intrahepatic bleeding. After resuscitation and treatment with recombinant F.IX through a central venous line, he developed superior vena cava, upper extremity, and intracerebral venous thrombosis resulting in superior vena cava syndrome and intrathalamic hemorrhage. He was treated with F.IX to achieve near-normal F.IX activity levels and with low-dose unfractionated heparin with clinical improvement. F.IX replacement on a subsequent admission was again complicated by upper venous system thrombosis and improved with low-dose heparin. The case illustrates an unusual presentation of hemophilia, life-threatening thrombotic complications associated with factor replacement, and a strategy for anticoagulant management in the setting of hemophilic bleeding.
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Affiliation(s)
- Michael Gregory Douvas
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, USA.
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24
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Hoots WK, Leissinger C, Stabler S, Schwartz BA, White G, Dasani H, Massion C, Negrier C, Schindel F, Schulman S. Continuous intravenous infusion of a plasma-derived factor IX concentrate (Mononine) in haemophilia B. Haemophilia 2003; 9:164-72. [PMID: 12614367 DOI: 10.1046/j.1365-2516.2003.00721.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This prospective, multicentre, open-label study evaluated the efficacy and safety of a plasma-derived factor IX concentrate [Mononine, Coagulation Factor IX (Human) Monoclonal Antibody Purified] administered by continuous intravenous (CIV) infusion to patients with haemophilia B. Admission criteria included documented diagnosis of haemophilia B (mild, moderate, or severe). Twenty-eight patients (25 surgery, two trauma, one severe spontaneous haemorrhage) were enrolled to receive a therapeutic bolus dose followed by CIV infusion of factor IX (FIX) to maintain FIX:C plasma levels of 0.4-1.0 IU mL(-1) (i.e. 40-100%). A median intravenous bolus dose of 54.2 IU kg(-1) FIX was administered to a subset of 13 non-emergency patients 7-21 days prior to CIV infusion to determine pharmacokinetic parameters in order to guide the dosing for CIV. For treatment, a bolus injection (median FIX dose; 89.6 IU kg(-1)) (range, 12.4-108.3), followed by a median total CIV infusion dose of 396.4 IU kg(-1) (range, 44.9-785.5) was administered at a median rate of 3.84 IU kg(-1) h(-1) (range, 1.74-7.33) for 107.17 h (range, 31.75-144). Twenty-four patients completed 72-120 h of FIX CIV infusion. Overall, 'excellent' (i.e. achievement of normal haemostasis) efficacy was reported in 23 of 24 (96%) evaluable patients, and 'good' (i.e. slight oozing) efficacy was reported in one (4%) patient. Median FIX:C was 72-86% for all patients receiving FIX by CIV on all days. Nine patients reported 13 adverse events that were possibly related to study medication but were not deemed serious by the investigator and were mainly because of local irritation at the infusion site. FIX CIV infusion therapy is safe and effective in the treatment of haemophilia B patients undergoing surgery, exposed to trauma, or experiencing severe spontaneous haemorrhage.
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Affiliation(s)
- W K Hoots
- University of Texas, Houston Health Science Center, Houston, TX 77030, USA.
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25
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Evans G, Collett M, Came N, Lloyd J, Powell L, Street A. MonoFIX-VF, a new mono-component factor IX concentrate: a single-centre continuous-infusion study. Haemophilia 2002; 8:635-8. [PMID: 12199671 DOI: 10.1046/j.1365-2516.2002.00663.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
MonoFIX-VF, a monocomponent factor IX concentrate, has replaced the use of Prothrombinex-HT as the treatment of choice for patients with factor IX deficiency in Australia. The haemostatic effect of MonoFIX-VF, administered by continuous infusion, was assessed in four subjects being treated for 10 bleeding episodes including five surgical procedures. MonoFIX-VF was found to be a safe and effective treatment for patients with haemophilia B.
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Affiliation(s)
- G Evans
- Haemophilia Centre, Kent and Canterbury Hospital, Canterbury, Kent, UK.
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26
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Abstract
UNLABELLED Continuous infusion (CI) of coagulation factor concentrate is aimed at maintaining a steady haemostatic level of the missing factor in circulation, preventing dangerous troughs below the haemostatic level and unnecessary high peaks, which increase the safety and decrease the consumption of factor concentrate replacement therapy. This can be achieved by the administration of the coagulation factor at a rate corresponding to its elimination. CI has been used in wider extent since the early 1990s, after the resolution of basic questions such as the stability of factor concentrates after reconstitution, the risk of contamination and bacterial overgrowth in these biological materials during either preparation of infusion bags or prolonged administration, the frequent local thrombophlebitis, the knowledge of pharmacokinetics of coagulation factors in the conditions of CI and the development of adequate minipumps. The increasing clinical experience with CI used in haemophilia A and B and von Willebrand disease has proven the advantages of this mode of replacement therapy, providing improved margins of efficacy and safety in various clinical settings requiring the maintenance of haemostatic levels over prolonged periods, as well as reduction in treatment cost compared with the traditional therapy via intermittent injections of coagulation factors. KEYWORDS continuous infusion, factor VIII, factor IX, haemophilia, recombinant FVIIIa, von willebrand disease.
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Affiliation(s)
- A Batorova
- The National Hemophilia Center, Institute of Hematology and Blood Transfusion, University Hospital, Bratislava, Slovakia
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27
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Björkman S, Berntorp E. Pharmacokinetics of coagulation factors: clinical relevance for patients with haemophilia. Clin Pharmacokinet 2002; 40:815-32. [PMID: 11735604 DOI: 10.2165/00003088-200140110-00003] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Haemophilia is a recessively inherited coagulation disorder, in which an X-chromosome mutation causes a deficiency of either coagulation factor VIII (FVIII) in haemophilia A, or factor IX (FIX) in haemophilia B. Intravenous administration of FVIII or FIX can be used to control a bleeding episode, to provide haemostasis during surgery or for long term prophylaxis of bleeding. In special cases, activated factor VII (FVIIa) may be used instead of FVIII or FIX. The aim of this work is to review the pharmacokinetics of FVIII, FIX and FVIIa and to give an outline of the use of pharmacokinetics to optimise the treatment of patients with haemophilia. The pharmacokinetics of FVIII are well characterised. The systemic clearance (CL) of FVIII is largely determined by the plasma level of von Willebrand factor (vWF), which protects FVIII from degradation. Typical average CL in patients with normal vWF levels is 3 ml/h/kg, with an apparent volume of distribution at steady state (Vss) that slightly exceeds the plasma volume of the patient, and the average elimination half-life (t1/2) is around 14 hours. There are still some discrepancies in the literature on the pharmacokinetics of FIX. The average CL of plasma-derived FIX seems to be 4 ml/h/kg, the Vss is 3 to 4 times the plasma volume and the elimination t1/2 often exceeds 30 hours. FVIIa has a much higher CL (average of 33 ml/h/kg), and a short terminal t1/2 (at 2 to 3 hours). The Vss is 2 to 3 times the plasma volume. Since the therapeutic levels of coagulation factors are well defined in most clinical situations, applied pharmacokinetics is an excellent tool to optimise therapy. Individual tailoring of administration in prophylaxis has been shown to considerably increase the cost effectiveness of the treatment. Dosage regimens for the treatment of bleeding episodes or for haemostasis during surgery are also designed using pharmacokinetic data, and the advantages of using a constant infusion instead of repeated bolus doses have been explored. The influence of antibodies (inhibitors) on the pharmacokinetics of FVIII and FIX is in part understood, and the doses of coagulation factor needed to treat a patient can tentatively be calculated from the antibody titre. In conclusion, therapeutic monitoring of coagulation factor levels and the use of clinical pharmacokinetics to aid therapy are well established in the treatment of patients with haemophilia.
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Affiliation(s)
- S Björkman
- Hospital Pharmacy and Department for Coagulation Disorders, Malmö University Hospital, Sweden.
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28
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Ragni MV, Pasi KJ, White GC, Giangrande PL, Courter SG, Tubridy KL. Use of recombinant factor IX in subjects with haemophilia B undergoing surgery. Haemophilia 2002; 8:91-7. [PMID: 11952843 DOI: 10.1046/j.1365-2516.2002.00587.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Recombinant human FIX (rFIX) was evaluated in 28 subjects, including 26 with mild, moderate, or severe haemophilia B and two haemophilia B carriers undergoing 36 surgical procedures. Preoperative rFIX dose was highly correlated with postinfusion FIX activity, r=0.61, P=0.0158. Peri- and post-operative estimated blood loss was similar to that expected in non-haemophilic individuals, and haemostasis was rated as excellent or good in 34 of 35 (97.1%) of the operative procedures. Transfusions were required in five of 36 (13.9%) procedures, including one liver transplantation, and three knee and one hip arthroplasties. Adverse events occurred in 15 of 28 (53.6%) subjects, but there were no perioperative haemorrhages, thromboembolic events, coagulation activation, viral transmission, or inhibitor formation. A transient low-responding FIX inhibitor developed in one subject preoperatively, but required no change in treatment and resolved 15 months later. Thus, rFIX was found to be safe and effective in achieving haemostasis in subjects with FIX deficiency undergoing surgery.
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Affiliation(s)
- M V Ragni
- University of Pittsburgh School of Medicine, General Clinical Research Center, Hemophilia Center of Western Pennsylvania, Pittsburgh 15213, USA.
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