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Pabinger I, Mamonov V, Windyga J, Engl W, Doralt J, Tangada S, Spotts G, Ewenstein B. Results of a randomized phase III/IV trial comparing intermittent bolus versus continuous infusion of antihaemophilic factor (recombinant) in adults with severe or moderately severe haemophilia A undergoing major orthopaedic surgery. Haemophilia 2021; 27:e331-e339. [PMID: 33772963 PMCID: PMC8252548 DOI: 10.1111/hae.14219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 12/01/2022]
Abstract
Introduction In patients with haemophilia A undergoing surgery, factor VIII (FVIII) replacement therapy by continuous infusion (CI) may offer an alternative to bolus infusion (BI). Aim To compare the perioperative haemostatic efficacy and safety of antihaemophilic factor (recombinant) (ADVATE®; Baxalta US Inc., a Takeda company, Lexington, MA, USA) CI or BI administration. Methods In this multicentre, phase III/IV, controlled study (NCT00357656), 60 previously treated adult patients with severe or moderately severe disease undergoing elective unilateral major orthopaedic surgery (knee replacement, n = 48; hip surgery, n = 4; other, n = 8) requiring drain placement were randomized to receive antihaemophilic factor (recombinant) CI (n = 29) or BI (n = 31) through postoperative day 7. Primary outcome measure was cumulative packed red blood cell (PRBC)/blood volume in the drainage fluid within 24 h after surgery, used to establish non‐inferiority of CI to BI. Results CI:BI ratio of cumulative PRBC volume in the 24‐h drainage fluid was 0.92 (p‐value <.001 for non‐inferiority; 95% confidence interval, 0.82–1.05). Total antihaemophilic factor (recombinant) dose per kg body weight received in the combined trans‐ and postoperative periods was similar with CI and BI to maintain targeted FVIII levels during/after surgery. Treatment‐related adverse events (AEs) were reported in five patients treated by CI (eight events) and five treated by BI (six events), including two serious AEs in each arm. Conclusion CI administration of antihaemophilic factor (recombinant) is a viable alternative to BI in patients with haemophilia A undergoing major orthopaedic surgery, providing comparable efficacy and safety.
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Affiliation(s)
| | | | - Jerzy Windyga
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Werner Engl
- Baxalta Innovations GmbH, a Takeda company, Vienna, Austria
| | | | - Srilatha Tangada
- Baxalta US Inc., a Takeda company, Cambridge, Massachusetts, USA
| | - Gerald Spotts
- Baxalta US Inc., a Takeda company, Cambridge, Massachusetts, USA
| | - Bruce Ewenstein
- Baxalta US Inc., a Takeda company, Cambridge, Massachusetts, USA
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2
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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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3
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Batorova A, Galen KV, Mackensen SV, Tsimpanakos I, Grimberg E. Gynaecological issues in women with bleeding disorders: CSL Behring Symposium. ACTA ACUST UNITED AC 2019. [DOI: 10.17225/jhp00142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Abstract
The symposium focused on issues around surgery, ovulation bleeding, health-related quality of life (HRQoL) and pelvic pain in women with bleeding disorders.
Surgery
Young women with congenital bleeding disorders, especially those with severe forms, are more likely to experience gynaecological and obstetric disorders than unaffected women. Surgery may be required to manage heavy menstrual bleeding (HMB), ovulatory bleeding, endometriosis and delivery. Major surgery should be undertaken only in hospitals with a haemophilia centre and 24-hour laboratory capability. Correction of haemostasis, either by desmopressin, coagulation factor or platelet transfusion, is essential for a successful outcome of surgery. Management of pregnancy requires a multidisciplinary approach; the mode of delivery is based on the consensus of gynaecologist and haematologist, and with respect to the patient’s diagnosis.
Ovulation bleeding
Women with bleeding disorders are at risk for excessive gynaecological bleeding associated with menstruation, ovulation, pregnancy and delivery. Ovulation bleeding is associated with the rupture of ovarian cysts and causes abdominal pain; complications include haemoperitoneum, fertility problems and ovarian torsion. Management includes hormonal and haemostatic therapies, in combination if necessary, and surgery as a last resort. Current management is based on experience in a relatively small number of cases and more clinical data are needed.
Health-related quality of life
In addition to experiencing joint and tissue bleeds, women experience psychosocial and medical issues associated with menstruation, pregnancy, labour and delivery. HMB has the greatest impact, and is associated with impaired HRQoL in almost all and dissatisfaction with the burden of treatment. There is a need for focused psychosocial support and a specific tool for the assessment of HRQoL in women with bleeding disorders.
Pelvic pain
Gynaecological causes of pelvic pain in women with bleeding disorders include dysmenorrhoea, mid-cycle pain, bleeding into the corpus luteum and endometriosis. There is no correlation between bleeding tendency and endometriosis severity; however, screening for a bleeding disorder should be considered. Pharmacological management may be hormonal or non-hormonal. Gonadotrophin-releasing hormone agonists offer an alternative to surgery for women with severe bleeding disorders who have endometriosis. Paracetamol is the preferred early analgesic option. Endometrial ablation controls heavy bleeding and pelvic pain but is not recommended for women with large fibroids or a large endometrial cavity. Hysterectomy is an option of last resort. Education for health professionals should include raising awareness about the management of pain in women with bleeding disorders.
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Affiliation(s)
- Angelika Batorova
- Director of the National Haemophilia Centre, University Hospital Bratislava , Bratislava Slovakia
| | - Karin van Galen
- Utrecht University Medical Centre , Utrecht , The Netherlands
| | - Sylvia von Mackensen
- Department of Psychology , University Medical Centre , Hamburg -Eppendorf, Germany
| | | | - Evelyn Grimberg
- Women and Bleeding Disorders Committee, European Haemophilia Consortium Utrecht , The Netherlands
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4
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Rajpurkar M, Cooper DL. Continuous infusion of recombinant activated factor VII: a review of data in congenital hemophilia with inhibitors and congenital factor VII deficiency. J Blood Med 2018; 9:227-239. [PMID: 30568523 PMCID: PMC6276614 DOI: 10.2147/jbm.s184040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Introduction Continuous infusion (CI) of clotting factors as a replacement therapy for perioperative hemostatic protection has been performed for many years, including with factors VIII and IX and recombinant activated factor VII (rFVIIa). This approach provides steady factor levels without requiring frequent administration of bolus doses. Aim To review safety, efficacy, and dosing data regarding CI of rFVIIa for hemostatic management of patients with congenital hemophilia with inhibitors (CHwI) or congenital factor VII deficiency (C7D). Materials and methods A literature review identified instances of CI of rFVIIa in patients with CHwI or C7D undergoing surgery or experiencing bleeding episodes. Data regarding safety, efficacy, and dosing were extracted. Results The safety and efficacy of 50 mcg/kg/h CI of rFVIIa following a 90 mcg/kg bolus injection, vs a standard bolus injection regimen, was reported for 24 patients with CHwI undergoing elective surgery in an open-label, randomized, Phase III trial. Efficacy was similar between CI and bolus injection groups at all postoperative time points assessed. Additionally, a postmarketing surveillance study reported effective (80%) and partially effective (20%) CI of rFVIIa in a Japanese cohort of ten patients with CHwI who underwent 15 surgical procedures. Finally, the safety and dosing of rFVIIa CI in 193 and 26 patients with CHwI and C7D, respectively, were reported in 11 prospective studies, 10 retrospective studies, and 30 case reports. No unexpected safety findings were reported. Conclusion rFVIIa CI has been performed safely and effectively in patients with CHwI and C7D undergoing surgery and during bleeding episodes in patients with CHwI.
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Affiliation(s)
- Madhvi Rajpurkar
- Division of Hematology/Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, USA,
| | - David L Cooper
- Clinical, Medical and Regulatory Affairs, Novo Nordisk Inc., Plainsboro, NJ, USA
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5
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Nogami K, Takedani H, Shima M, Yoshioka A, Matsushita T, Takamatsu J, Taki M, Fukutake K, Uchikawa H, Takagi H, Arai M, Engl W, Shirahata A. Perioperative safety and hemostatic efficacy of Advate ® in patients with hemophilia A in a postmarketing surveillance in Japan. Int J Hematol 2018; 108:22-29. [PMID: 29594923 DOI: 10.1007/s12185-018-2434-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 03/12/2018] [Accepted: 03/19/2018] [Indexed: 11/24/2022]
Abstract
Rurioctocog alfa (recombinant factor VIII: Advate®) is available for the control of bleeding among patients with hemophilia A in Japan. To evaluate the perioperative safety and hemostatic efficacy of Advate®, a postmarketing surveillance was conducted in Japanese patients undergoing surgery in a real-world setting. A total of 74 surgical procedures performed in 58 subjects aged 0-75 years, including three females, were studied. A hemostatic efficacy rating of "excellent" or "good" was reported in 73/74 surgical procedures (98.6%). Perioperative bleeding was successfully controlled by Advate® in five subjects with positive FVIII inhibitors (2.4-9.1 BU/mL). Advate® was administered at higher initial bolus doses (114-385 IU/kg) and at higher rates by subsequent initial continuous infusion (8.3-15 IU/kg/hour) in the five subjects with inhibitor than in the subjects without inhibitor (n = 47; mean initial bolus dose: 53.4 IU/kg; subsequent mean initial continuous infusion: 3.8 IU/kg/h). Adverse drug reactions were reported in 7/74 (9.5%) procedures, two of which were the development of de novo FVIII inhibitors. Overall, the perioperative use of Advate® in a real-world setting was found to be safe and effective among Japanese patients with hemophilia A.
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Affiliation(s)
- Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan.
| | - Hideyuki Takedani
- Department of Joint Surgery, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Akira Yoshioka
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Junki Takamatsu
- Japanese Red Cross Tokai-Hokuriku Block Blood Center, Seto, Japan
| | - Masashi Taki
- Department of Pediatrics, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Katsuyuki Fukutake
- Department of Laboratory Medicine, Tokyo Medical University Hospital, Tokyo, Japan
| | - Haruhiko Uchikawa
- Department of Clinical Scientific Writing, Clinical Development Operations, Shire Japan K.K., Tokyo, Japan
| | - Hiroshi Takagi
- Department of Medical Affairs, Shire Japan K.K., Tokyo, Japan
| | - Morio Arai
- Department of Medical Affairs, Shire Japan K.K., Tokyo, Japan
| | - Werner Engl
- Department of Biostatistics, Baxalta Innovations GmbH, Vienna, Austria
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6
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Holme PA, Tjønnfjord GE, Batorova A. Continuous infusion of coagulation factor concentrates during intensive treatment. Haemophilia 2017; 24:24-32. [PMID: 28873263 DOI: 10.1111/hae.13331] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2017] [Indexed: 01/12/2023]
Abstract
In clinical management of bleeds and surgical procedures in patients suffering from bleeding disorders either repetitive bolus injections (BI) or continuous infusion (CI) can be used for coagulation factor replacement. Continuous infusion seems to be an attractive route of administration and may be considered if replacement therapy is required for more than 3 days. The strongest argument favouring continuous infusion is its superiority in providing the patient with a safe and constant level of the deficient coagulation factor by balancing input with clearance. Furthermore, several studies have shown that coagulation factor consumption may be reduced by CI compared to repetitive bolus injections (BI) since unnecessary peaks of factor level are avoided. Concerns have been raised whether continuous infusion of coagulation concentrates is associated with an increased risk of developing inhibitors. However, available data have so far not shown an increased risk for inhibitor development in severe haemophilia patients with more than 50 exposure days of coagulation factor concentrates. Further, previously reported complications when using CI such as phlebitis at the infusion site and pump failure are nowadays very seldom seen when small amounts of heparin are added to the infusion bag, and increased quality of the pumps are available. Over the last decades, numerous reports have confirmed CI to be a safe and effective mode of coagulation factor replacement even in the most challenging surgical procedures, such as total joint arthroplasties.
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Affiliation(s)
- P A Holme
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - G E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - A Batorova
- Faculty of Medicine of Comenius University, Department of Haematology and Transfusion Medicine, National Haemophilia Centre, University Hospital, Bratislava, Slovakia
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7
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Hazendonk H, Fijnvandraat K, Lock J, Driessens M, van der Meer F, Meijer K, Kruip M, Gorkom BLV, Peters M, de Wildt S, Leebeek F, Cnossen M, Mathôt R. A population pharmacokinetic model for perioperative dosing of factor VIII in hemophilia A patients. Haematologica 2016; 101:1159-1169. [PMID: 27390359 DOI: 10.3324/haematol.2015.136275] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 07/01/2016] [Indexed: 12/31/2022] Open
Abstract
The role of pharmacokinetic-guided dosing of factor concentrates in hemophilia is currently a subject of debate and focuses on long-term prophylactic treatment. Few data are available on its impact in the perioperative period. In this study, a population pharmacokinetic model for currently registered factor VIII concentrates was developed for severe and moderate adult and pediatric hemophilia A patients (FVIII levels <0.05 IUmL-1) undergoing elective, minor or major surgery. Retrospective data were collected on FVIII treatment, including timing and dosing, time point of FVIII sampling and all FVIII plasma concentrations achieved (trough, peak and steady state), brand of concentrate, as well as patients' and surgical characteristics. Population pharmacokinetic modeling was performed using non-linear mixed-effects modeling. Population pharmacokinetic parameters were estimated in 75 adults undergoing 140 surgeries (median age: 48 years; median weight: 80 kg) and 44 children undergoing 58 surgeries (median age: 4.3 years; median weight: 18.5 kg). Pharmacokinetic profiles were best described by a two-compartment model. Typical values for clearance, intercompartment clearance, central and peripheral volume were 0.15 L/h/68 kg, 0.16 L/h/68 kg, 2.81 L/68 kg and 1.90 L/68 kg. Interpatient variability in clearance and central volume was 37% and 27%. Clearance decreased with increasing age (P<0.01) and increased in cases with blood group O (26%; P<0.01). In addition, a minor decrease in clearance was observed when a major surgical procedure was performed (7%; P<0.01). The developed population model describes the perioperative pharmacokinetics of various FVIII concentrates, allowing individualization of perioperative FVIII therapy for severe and moderate hemophilia A patients by Bayesian adaptive dosing.
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Affiliation(s)
- Hendrika Hazendonk
- Department of Pediatric Hematology, Erasmus University Medical Center - Sophia Children's Hospital Rotterdam
| | | | - Janske Lock
- Department of Pediatric Hematology, Erasmus University Medical Center - Sophia Children's Hospital Rotterdam
| | | | - Felix van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center
| | - Karina Meijer
- University of Groningen, Department of Hematology, University Medical Center Groningen
| | - Marieke Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam
| | - Britta Laros-van Gorkom
- Department of Hematology, Radboud university medical center, Sophia Children's Hospital Rotterdam
| | - Marjolein Peters
- Department of Pediatric Hematology, Academic Medical Center, Amsterdam
| | - Saskia de Wildt
- Intensive Care and Department of Pediatric Intensive Care, Erasmus University Medical Center - Sophia Children's Hospital Rotterdam Department of Pharmacology, Radboud university medical center, The Netherlands
| | - Frank Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam
| | - Marjon Cnossen
- Department of Pediatric Hematology, Erasmus University Medical Center - Sophia Children's Hospital Rotterdam
| | - Ron Mathôt
- Hospital Pharmacy-Clinical Pharmacology, Academic Medical Center Amsterdam, The Netherlands
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8
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Hazendonk HCAM, van Moort I, Fijnvandraat K, Kruip MJHA, Laros-van Gorkom BAP, van der Meer FJM, Meijer K, Peters M, Schutgens REG, Zwaan CM, Driessens MHE, Polinder S, Leebeek FWG, Mathôt RAA, Cnossen MH. The "OPTI-CLOT" trial. A randomised controlled trial on periOperative PharmacokineTIc-guided dosing of CLOTting factor concentrate in haemophilia A. Thromb Haemost 2015; 114:639-44. [PMID: 26062822 DOI: 10.1160/th14-11-0925] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 03/28/2015] [Indexed: 01/19/2023]
Abstract
Haemophilia A is an X-linked inherited, rare bleeding disorder, caused by a deficiency of coagulation factor VIII (FVIII). Previous studies in prophylactic dosing have demonstrated that FVIII consumption can be significantly reduced by individualising dosing based on combined analysis of individual pharmacokinetic (PK) profiling and population PK data (Bayesian analysis). So far, no studies have been performed that address perioperative concentrate consumption using iterative PK-guided dosing based on a PK population model. The "OPTI-CLOT" trial is an open-label, prospective, multicentre randomised controlled superiority trial (RCT), aiming to detect a 25 % difference in perioperative FVIII concentrate consumption with iterative Bayesian PK-guided dosing in comparison to the standard dosing procedure. Sixty haemophilia A patients ≥ 12 years of age, with FVIII plasma levels ≤ 0.05 IUml(-1) will be included requiring FVIII replacement therapy administered either by continuous or bolus infusion for an elective, low or medium risk surgical procedure. The proposed study aims to investigate a novel perioperative iterative PK-guided dosing strategy, based on a recently constructed perioperative PK population model. This model will potentially decrease underdosing and overdosing of clotting factor concentrate and is expected to overall reduce FVIII consumption by minimally 25 %. Moreover, participating hospitals will gain experience with PK-guided dosing, facilitating future implementation of this intervention which is expected to optimise current care and reduce costs of treatment.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Marjon H Cnossen
- M. H. Cnossen, MD, PhD, Department of Paediatric Haematology, Erasmus University Medical Centre, Sophia Children's Hospital Rotterdam, P. O. Box 2040, 3000 CA Rotterdam, the Netherlands, E-mail:
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9
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Boban A, Lambert C, Hermans C. The use of short-term central venous catheters for optimizing continuous infusion of coagulation factor concentrate in haemophilia patients undergoing major surgical procedures. Haemophilia 2015; 21:e364-8. [DOI: 10.1111/hae.12722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2015] [Indexed: 11/27/2022]
Affiliation(s)
- A. Boban
- Haemostasis and Thrombosis Unit; Division of Haematology; Haemophilia Clinic; Saint-Luc University Hospital; Brussels Belgium
- Division of Haematology; University Hospital Centre Zagreb; Zagreb Croatia
| | - C. Lambert
- Haemostasis and Thrombosis Unit; Division of Haematology; Haemophilia Clinic; Saint-Luc University Hospital; Brussels Belgium
| | - C. Hermans
- Haemostasis and Thrombosis Unit; Division of Haematology; Haemophilia Clinic; Saint-Luc University Hospital; Brussels Belgium
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10
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Abstract
Hemophilia A and hemophilia B are X chromosome-linked congenital bleeding disorders caused by a deficiency or absence of activity of coagulation factor VIII (hemophilia A) or factor IX (hemophilia B), which are graded in different degrees of severity (mild, moderate, severe). Depending on the severity patients may experience spontaneous bleeding episodes or will develop excessive bleeding in the context of injuries or surgery. Hemophilia should not be a contraindication for an invasive procedure; however, a number of conditions are required to provide successful surgery and an uncomplicated and safe postoperative course. This review provides an overview of hemophilia and the key biochemical laboratory and clinical aspects as well as possible specific and non-specific treatment options and addresses the special needs for the perioperative care of these patients.
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Affiliation(s)
- S Lison
- Klinik für Anaesthesiologie, Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland,
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11
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Lambing A, Kuriakose P, Mueller LM. Infection risk and stability of a continuous 8-h 250 mL rFVIII infusion. Haemophilia 2013; 20:212-8. [DOI: 10.1111/hae.12292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2013] [Indexed: 11/26/2022]
Affiliation(s)
- A. Lambing
- Hematology/Oncology; Henry Ford Health System; Detroit MI USA
| | - P. Kuriakose
- Hematology/Oncology; Henry Ford Health System; Detroit MI USA
| | - L. M. Mueller
- Hematology/Oncology; Henry Ford Health System; Detroit MI USA
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12
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Hutchings RL, Singh SM, Cabello-Villegas J, Mallela KMG. Effect of antimicrobial preservatives on partial protein unfolding and aggregation. J Pharm Sci 2012; 102:365-76. [PMID: 23169345 DOI: 10.1002/jps.23362] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 10/03/2012] [Accepted: 10/18/2012] [Indexed: 12/25/2022]
Abstract
One-third of protein formulations are multi-dose. These require antimicrobial preservatives (APs); however, some APs have been shown to cause protein aggregation. Our previous work on a model protein cytochrome c indicated that partial protein unfolding, rather than complete unfolding, triggers aggregation. Here, we examined the relative strength of five commonly used APs on such unfolding and aggregation, and explored whether stabilizing the aggregation 'hot-spot' reduces such aggregation. All APs induced protein aggregation in the order m-cresol > phenol > benzyl alcohol > phenoxyethanol > chlorobutanol. All these enhanced the partial protein unfolding that includes a local region which was predicted to be the aggregation 'hot-spot'. The extent of destabilization correlated with the extent of aggregation. Further, we show that stabilizing the 'hot-spot' reduces aggregation induced by all five APs. These results indicate that m-cresol causes the most protein aggregation, whereas chlorobutanol causes the least protein aggregation. The same protein region acts as the 'hot-spot' for aggregation induced by different APs, implying that developing strategies to prevent protein aggregation induced by one AP will also work for others.
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Affiliation(s)
- Regina L Hutchings
- Department of Pharmaceutical Sciences & Center for Pharmaceutical Biotechnology, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045, USA
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13
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BATOROVA A, HOLME P, GRINGERI A, RICHARDS M, HERMANS C, ALTISENT C, LOPEZ-FERNÁNDEZ M, FIJNVANDRAAT K. Continuous infusion in haemophilia: current practice in Europe. Haemophilia 2012; 18:753-9. [DOI: 10.1111/j.1365-2516.2012.02810.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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14
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Alford JR, Fowler AC, Wuttke DS, Kerwin BA, Latypov RF, Carpenter JF, Randolph TW. Effect of benzyl alcohol on recombinant human interleukin-1 receptor antagonist structure and hydrogen-deuterium exchange. J Pharm Sci 2011; 100:4215-24. [PMID: 21557223 DOI: 10.1002/jps.22601] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 03/22/2011] [Accepted: 04/18/2011] [Indexed: 11/10/2022]
Abstract
Benzyl alcohol, a preservative commonly added to multidose therapeutic protein formulations, can accelerate aggregation of recombinant human interleukin-1 receptor antagonist (rhIL-1ra). To investigate the interactions between benzyl alcohol and rhIL-1ra, we used nuclear magnetic resonance to observe the effect of benzyl alcohol on the chemical shifts of amide resonances of rhIL-1ra and to measure hydrogen-deuterium exchange rates of individual rhIL-1ra residues. Addition of 0.9% benzyl alcohol caused significant chemical shifts of amide resonances for residues 90-97, suggesting that these solvent-exposed residues participate in the binding of benzyl alcohol. In contrast, little perturbation of exchange rates was observed in the presence of either sucrose or benzyl alcohol.
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Affiliation(s)
- John R Alford
- Department of Chemical and Biological Engineering, University of Colorado, Boulder, Colorado 80309
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15
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Singh SM, Hutchings RL, Mallela KMG. Mechanisms of m-cresol-induced protein aggregation studied using a model protein cytochrome c. J Pharm Sci 2011; 100:1679-89. [PMID: 21229618 DOI: 10.1002/jps.22426] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2010] [Revised: 10/29/2010] [Accepted: 11/10/2010] [Indexed: 01/22/2023]
Abstract
Multidose protein formulations require an effective antimicrobial preservative (AP) to inhibit microbial growth during long-term storage of unused formulations. m-cresol (CR) is one such AP, but it has been shown to cause protein aggregation. However, the fundamental physical mechanisms underlying such AP-induced protein aggregation are not understood. In this study, we used a model protein cytochrome c to identify the protein unfolding that triggers protein aggregation. CR induced cytochrome c aggregation at preservative concentrations that are commonly used to inhibit microbial growth. Addition of CR decreased the temperature at which the protein aggregated and increased the aggregation rate. However, CR did not perturb the tertiary or secondary structure of cytochrome c. Instead, it populated an "invisible" partially unfolded intermediate where a local protein region around the methionine residue at position 80 was unfolded. Stabilizing the Met80 region drastically decreased the protein aggregation, which conclusively shows that this local protein region acts as an aggregation "hotspot." On the basis of these results, we propose that APs induce protein aggregation by partial rather than global unfolding. Because of the availability of site-specific probes to monitor different levels of protein unfolding, cytochrome c provided a unique advantage in characterizing the partial protein unfolding that triggers protein aggregation.
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Affiliation(s)
- Surinder M Singh
- Department of Pharmaceutical Sciences and Center for Pharmaceutical Biotechnology, School of Pharmacy, University of Colorado Denver, 12700 E 19th Ave., C238-P15, Aurora, Colorado 80045, USA
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TAKEDANI H. Continuous infusion during total joint arthroplasty in Japanese haemophilia A patients: comparison study among two recombinants and one plasma-derived factor VIII. Haemophilia 2010; 16:740-6. [DOI: 10.1111/j.1365-2516.2010.02244.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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WINDYGA J, RUSEN L, GRUPPO R, O’BRIEN AC, KELLY P, ROTH DA, ARKIN S. BDDrFVIII (Moroctocog alfa [AF-CC]) for surgical haemostasis in patients with haemophilia A: results of a pivotal study. Haemophilia 2010; 16:731-9. [DOI: 10.1111/j.1365-2516.2010.02239.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Mild hemophilia A (HA), defined by clinical features and factor VIII coagulant activity (FVIII:C) between 0.05 and 0.40 IU mL(-1), is characteristically distinct from severe HA. Indeed, although the molecular characterization of mild HA has permitted the identification of specific underlying mutations, its clinical phenotype is strikingly different from that of patients with a severe FVIII defect, where spontaneous hemorrhages or recurrent joint bleeding are usual manifestations. With aging, mild HA patients may develop complications (i.e. cancers and cardiovascular disorders), the management of which may prove challenging due to the concomitant bleeding tendency. Furthermore, the development of inhibitors provides an additional major complication in these patients, because it increases the severity of the bleeding phenotype and complicates their management. Standard management of mild HA includes the use of desmopressin and antifibrinolytic agents for minor bleeding episodes or surgical procedures, whilst major bleeding or surgery requires replacement therapy with FVIII concentrates. As regards treatment of patients with inhibitors, bypassing agents (i.e. activated prothrombin complex concentrates and recombinant activated FVII) have proven effective in the treatment of bleeding episodes, but as there are insufficient data to determine the optimal approach to immune tolerance induction in this group of patients, their optimal management remains controversial. Rituximab is a newer, promising therapeutic option for inhibitor eradication in such patients. Many aspects concerning mild HA remain to be clarified, including the molecular basis, the natural history and the optimal diagnostic and therapeutic strategies. Only large prospective studies will shed light on this condition.
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Affiliation(s)
- M Franchini
- Servizio di Immunoematologia e Medicina Trasfusionale, Dipartimento di Patologia e Medicina di Laboratorio, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy.
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Thompson CA, Kyle R, Gertz M, Heit J, Pruthi R, Pardanani A. Systemic AL amyloidosis with acquired factor X deficiency: A study of perioperative bleeding risk and treatment outcomes in 60 patients. Am J Hematol 2010; 85:171-3. [PMID: 20052750 PMCID: PMC2896569 DOI: 10.1002/ajh.21603] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Systemic light-chain (AL) amyloidosis may be associated with acquired factor X (FX) deficiency and optimal management of this coagulopathy is unknown. We reviewed our experience with 60 patients with isolated FX deficiency (< or =50%) due to AL amyloidosis that underwent an invasive procedure between 1975 and 2007. They were classified as having severe (<10%; n = 6), moderate (10-25%; n = 15), or mild (26-50%; n = 39) FX deficiency. The patients underwent a total of 112 procedures, 19 (17%) of which were managed with periprocedural treatment with one or more hemostatic agents. There were complications in 14 (13%) procedures (bleeding = 12, thrombosis = 1, death = 1). Baseline FX level was not predictive of bleeding risk; the only association with postintervention bleeding was central venous catheter placement. However, bleeding complications were relatively infrequent, particularly in patients with mild or moderate FX deficiency undergoing nonvascular procedures. Activated recombinant factor VII might be considered in patients undergoing major surgical procedures, but further experience is needed. Optimal management of AL patients with FX deficiency undergoing invasive procedures remains to be determined.
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20
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Eckhardt CL, Menke LA, van Ommen CH, van der Lee JH, Geskus RB, Kamphuisen PW, Peters M, Fijnvandraat K. Intensive peri-operative use of factor VIII and the Arg593-->Cys mutation are risk factors for inhibitor development in mild/moderate hemophilia A. J Thromb Haemost 2009; 7:930-7. [PMID: 19548904 DOI: 10.1111/j.1538-7836.2009.03357.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND A severe and challenging complication in the treatment of hemophilia A is the development of inhibiting antibodies (inhibitors) directed towards factor VIII (FVIII). Inhibitors aggravate bleeding complications, disabilities and costs. The etiology of inhibitor development is incompletely understood. OBJECTIVES In a large cohort study in patients with mild/moderate hemophilia A we evaluated the role of genotype and intensive FVIII exposure in inhibitor development. PATIENTS/METHODS Longitudinal clinical data from 138 mild/moderate hemophilia A patients were retrospectively collected from 1 January 1980 to 1 January 2008 and analyzed by multivariate analysis using Poisson regression. RESULTS Genotyping demonstrated the Arg593Cys missense mutation in 52 (38%) patients; the remaining 86 patients had 26 other missense mutations. Sixty-three (46%) patients received intensive FVIII concentrate administration, 41 of them for surgery. Ten patients (7%) developed inhibitors, eight of them carrying the Arg593Cys mutation. Compared with the other patients, those with the Arg593Cys mutation had a 10-fold increased risk of developing inhibitors (RR 10; 95% CI, 0.9-119).The other two inhibitor patients had the newly detected mutations Pro1761Gln and Glu2228Asp. In both these patients and in five patients with genotype Arg593Cys, inhibitors developed after intensive peri-operative use of FVIII concentrate (RR 186; 95% CI, 25-1403). In five of the 10 inhibitor patients FVIII was administered by continuous infusion during surgery (RR 13; 95% CI, 1.9-86). CONCLUSION The Arg593Cys genotype and intensive peri-operative use of FVIII, especially when administered by continuous infusion, are associated with an increased risk for inhibitor development in mild/moderate hemophilia A.
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Affiliation(s)
- C L Eckhardt
- Department of Pediatric Hematology, Emma Children's Hospital Acadmic Medical Center, Amsterdam, The Netherlands
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21
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Martinowitz U, Luboshitz J, Bashari D, Ravid B, Gorina E, Regan L, Stass H, Lubetsky A. Stability, efficacy, and safety of continuously infused sucrose-formulated recombinant factor VIII (rFVIII-FS) during surgery in patients with severe haemophilia. Haemophilia 2009; 15:676-85. [PMID: 19298381 DOI: 10.1111/j.1365-2516.2008.01978.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- U Martinowitz
- The Israel National Hemophilia Center, Chaim Sheba Medical Center, Tel Hashomer, Israel.
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22
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Jacquemin M, Neyrinck A, Hermanns MI, Lavend'homme R, Rega F, Saint-Remy JM, Peerlinck K, Van Raemdonck D, Kirkpatrick CJ. FVIII production by human lung microvascular endothelial cells. Blood 2006; 108:515-7. [PMID: 16569771 DOI: 10.1182/blood-2005-11-4571] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
While extrahepatic factor VIII (FVIII) synthesis suffices for hemostasis, the extrahepatic production sites are not well defined. We therefore investigated the ability of the human lungs to produce FVIII. Lungs from heart-beating donors who were declined for transplantation were perfused and ventilated in an isolated reperfusion model for 2 hours. A progressive accumulation of FVIII and von Willebrand factor (VWF) was recorded in the perfusion medium in 3 of 4 experiments. By contrast, factor V, fibrinogen, and immunoglobulin G (IgG) levels remained constant during the perfusion period, indicating that the accumulation of FVIII and VWF was not due to diffusion from the intercellular medium into the vascular system. Purified human lung microvascular endothelial cells produced FVIII during at least 2 passages in vitro. Altogether, these data identify the lung endothelial cells as a FVIII production site in humans.
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Affiliation(s)
- Marc Jacquemin
- Center for Molecular and Vascular Biology, University of Leuven, Belgium.
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24
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Fernandez M, Yu T, Bjornson E, Luu H, Spotts G. Stability of ADVATE, Antihemophilic Factor (Recombinant) Plasma/Albumin-Free Method, during simulated continuous infusion. Blood Coagul Fibrinolysis 2006; 17:165-71. [PMID: 16575253 DOI: 10.1097/01.mbc.0000220236.92219.08] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Continuous infusion of factor VIII (FVIII) concentrates during surgical procedures offers the potential for improved hemostatic control and reduced FVIII consumption, but requires stable FVIII concentrates. The stability of ADVATE, Antihemophilic Factor (Recombinant), Plasma/Albumin-Free Method (rAHF-PFM), was examined using various simulated conditions. Experiments performed with a multi-therapy 6060 pump showed FVIII recoveries of 95% or more after 48 h for multiple lots of high-potency and mid-potency rAHF-PFM, with or without heparin. Non-infused controls maintained at the same temperature showed similar FVIII recovery, demonstrating that the infusion system did not cause loss of FVIII activity. Supportive data generated using single lots of mid-potency or high-potency rAHF-PFM infused through a MEDEX or HARVARD syringe pump, or a CADD Pump-1, demonstrated FVIII recoveries of 83% or more at 24 or 48 h under all conditions tested. Additionally, rAHF-PFM was stable immediately after dilution in saline or saline/dextrose solutions, and after a 10-h exposure to ultraviolet and visible light. Taken together, these data demonstrate that rAHF-PFM is stable under conditions typically encountered during continuous infusion, and suggest that rAHF-PFM should be safe and effective when used for FVIII replacement by continuous infusion in patients with hemophilia A.
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25
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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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26
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von Auer C, Oldenburg J, von Depka M, Escuriola-Ettinghausen C, Kurnik K, Lenk H, Scharrer I. Inhibitor Development in Patients with Hemophilia A after Continuous Infusion of FVIII Concentrates. Ann N Y Acad Sci 2005; 1051:498-505. [PMID: 16126990 DOI: 10.1196/annals.1361.094] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Continuous infusion (CI) of coagulation factor concentrates has been used since the early 1990s. Recent reports of the occurrence of an inhibitor after CI have raised concerns about this method of treatment. We conducted a retrospective study to investigate the development of inhibitors after CI of Factor VIII concentrates in Germany. So far, 13 hemophilia centers have been contacted, and data have been collected by a questionnaire. Of the 13 centers, CI had never been performed in three, no inhibitors had been detected in five, and inhibitor development after CI was recorded in 10 patients in the remaining five centers. Of these 10 patients (ages 7 months to 57 years), five were suffering from severe, one from moderate, and four from mild hemophilia. Indications for treatment were major bleeds and surgical procedures. Plasma-derived (6 cases) and recombinant (4 cases) factor concentrates were given in various infusion sets. Data concerning amount infused (4300 to > 100,000 IU), number of days of exposure to factor concentrates (1 to > 100), and inhibitor characteristics (alloantibodies, 3 LR, 7 HR) were collected. Regarding hemophilia genotype, we found missense mutations in four patients, intron-22 inversions in two, and one small deletion in one; the genotype in three was unknown. In conclusion, only 3 out of 10 patients who developed an inhibitor after CI showed the typical risk profile for inhibitor formation, which is severe hemophilia A with a severe gene defect and less than 50 days of exposure to coagulation factor concentrates. Especially striking was the finding that 50% of the patients who developed inhibitors had mild to moderate hemophilia A. Our data point to the existence of a so-far unknown factor, related to CI, that might lead to inhibitor formation.
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Affiliation(s)
- Ch von Auer
- Haemostaseology, Department of Internal Medicine III, Johann Wolfgang Goethe University Hospital, Theodor-Stern-Kai 7, 60590 Frankfurt/Main, Germany.
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28
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Zhang Y, Roy S, Jones LS, Krishnan S, Kerwin BA, Chang BS, Manning MC, Randolph TW, Carpenter JF. Mechanism for benzyl alcohol‐induced aggregation of recombinant human interleukin‐1 receptor antagonist in aqueous solution. J Pharm Sci 2004; 93:3076-89. [PMID: 15514986 DOI: 10.1002/jps.20219] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Benzyl alcohol, an antimicrobial preservative, accelerates aggregation and precipitation of recombinant human interleukin-1 receptor antagonist (rhIL-1ra) in aqueous solution. The loss of native monomer during incubation at 37 degrees C was determined by analysis of sample aliquots with size exclusion high performance liquid chromatography (SE-HPLC). Benzyl alcohol caused minor perturbation of the tertiary structure of the protein without changing its secondary structure, documenting that the preservative caused a minor shift in the protein molecular population toward partially unfolded species. Consistent with this conclusion, in the presence of benzyl alcohol the rate of H-D exchange was accelerated and the fluorescence of 1-anilinonaphthalene-8-sulfonic acid in the presence of rhIL1ra was increased. Benzyl alcohol did not alter the free energy of unfolding based on unfolding experiments in urea or guanidine HCl. With differential scanning calorimetry it was determined that benzyl alcohol reduced the apparent Tm of rhIL-1ra, but this effect occurred because the preservative lowered the temperature at which the protein aggregated during heating. Isothermal calorimetry documented that the interaction of benzyl alcohol with rhIL-1ra is relatively weak and hydrophobically driven. Thus, benzyl alcohol accelerates protein aggregation by binding to the protein and favoring an increase in the level of partially unfolded, aggregation-competent species. Sucrose partially inhibited benzyl alcohol-induced aggregation and tertiary structural change. Sucrose is preferentially excluded from the surface of the protein, favoring most compact native state species over expanded aggregation-prone forms.
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Affiliation(s)
- Ye Zhang
- Department of Pharmaceutical Science, School of Pharmacy, University of Colorado Health Sciences Center, Denver, Colorado 80262, USA
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30
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Sennett MM, de Alarcón PA. Successful use of ReFacto continuous infusion in two paediatric patients with severe haemophilia A undergoing orthopaedic surgery. Haemophilia 2004; 10:655-60. [PMID: 15357792 DOI: 10.1111/j.1365-2516.2004.00905.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In this report we describe the successful use of B-domain-deleted recombinant factor VIII (ReFacto) administered by continuous infusion during orthopaedic procedures in two children with severe haemophilia A. Both patients underwent ankle synovectomy and in patient 2, a medial patello-femoral ligament repair was performed in the same operative session. Patient 2 developed septic arthritis A in his knee joint and arthroscopic joint irrigation and debridement was performed 2 weeks after the initial procedure. Surgical cover was initiated with a bolus dose of ReFacto 50 IU kg(-1) followed by continuous infusion at 3.3-4.8 IU kg(-1) h(-1) which was maintained for up to 9 days postoperatively. Patient 2 received an additional bolus dose of 15 IU kg(-1) during the infusion period. All procedures were performed without haemostatic complications and long-term orthopaedic outcomes were good in both patients.
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Affiliation(s)
- M M Sennett
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
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31
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Stieltjes N, Altisent C, Auerswald G, Négrier C, Pouzol P, Reynaud J, Roussel-Robert V, Savidge GF, Villar A, Schulman S. Continuous infusion of B-domain deleted recombinant factor VIII (ReFacto) in patients with haemophilia A undergoing surgery: clinical experience. Haemophilia 2004; 10:452-8. [PMID: 15357770 DOI: 10.1111/j.1365-2516.2004.01013.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This retrospective, open-label, non-comparative study evaluated continuous infusion of recombinant factor VIII (ReFacto), B-domain deleted recombinant FVIII (BDDrFVIII), in patients with haemophilia A undergoing surgery and requiring >5 consecutive days of treatment. Sixteen patients from eight centres underwent a total of 20 procedures. Haemostatic outcome was assessed as 'excellent' or 'good' in 75% of procedures, and target FVIII:C levels were maintained throughout the continuous infusion period. The reported volume of blood loss during surgery was also within the normal range for non-haemophilic patients for the type of surgery performed. Red blood cell transfusions were required to balance excessive blood loss during BDDrFVIII continuous infusion in eight (40%) procedures (seven patients), five with bleeding or requiring volume replacement and three to treat anaemia secondary to blood loss. Non-serious adverse events considered by investigators as possibly or probably related to BDDrFVIII continuous infusion were infrequent (n = 5) considering the duration of treatment (n =239 cumulative days of continuous infusion), and all of these were mild-to-moderate in severity. No thromboembolic complications were reported except for one case of thrombophlebitis occurring at the infusion site. Only two patients (four events) experienced serious adverse bleeding; BDDrFVIII was otherwise well-tolerated. These data show that continuous infusion of BDDrFVIII provides reliable haemostasis and is an effective and well-tolerated regimen for patients with haemophilia A undergoing surgery.
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Affiliation(s)
- N Stieltjes
- Centre Régional de Traitement des Hémophiles, Hôpital Cochin, Paris, France.
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Ewenstein B, Collins P, Tarantino M, Negrier C, Blanchette V, Shapiro A, Baker D, Spotts G, Sensel M, Yi S, Gomperts E. Hemophilia therapy innovation: development of an advanced category recombinant factor VIII by a plasma/albumin-free method. Semin Hematol 2004. [DOI: 10.1053/j.seminhematol.2004.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Oldenburg J, Schröder J, Brackmann HH, Müller-Reible C, Schwaab R, Tuddenham E. Environmental and genetic factors influencing inhibitor development. Semin Hematol 2004; 41:82-8. [PMID: 14872427 DOI: 10.1053/j.seminhematol.2003.11.016] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Inhibitor formation occurs at a frequency of 20% to 30% in severe hemophilia A, and 3% in hemophilia B. Today, it represents the major complication in patient care and renders classical substitution therapy ineffective. Genetic factors, such as factor VIII (FVIII) gene mutations and immune response genes, particularly the major histocompatibility complex, have been shown to constitute decisive risk factors for the development of inhibitors. In severe hemophilia A and B, those mutations that result in the absence or severe truncation of the FVIII/factor IX (FIX) proteins are associated with the highest risk for inhibitor formation, indicating that a major driving force in inhibitor development is the presentation of a novel antigen to the patient's immune system. An alternative pathomechanism may underlie inhibitor development in patients with mild hemophilia A. Missense mutations, especially those in the C1/C2 domains, may alter the immunogenicity of the FVIII protein, eliciting an inhibitor response against the mutated epitope. In some patients with hemophilia B, especially those with large deletions to the FIX gene, a severe allergic reaction occurs simultaneously with inhibitor onset. Despite the obviously strong genetic predisposition, discordant inhibitor status in monozygotic hemophilia A twins demonstrates that environmental factors also play a role in the development of inhibitors.
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Affiliation(s)
- Johannes Oldenburg
- Institute of Transfusion Medicine and Immune Haematology of the DRK Blood Donor Service, Baden-Wuerttemberg-Hessen, Frankfurt, Germany
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Powell JS, Ragni MV, White GC, Lusher JM, Hillman-Wiseman C, Moon TE, Cole V, Ramanathan-Girish S, Roehl H, Sajjadi N, Jolly DJ, Hurst D. Phase 1 trial of FVIII gene transfer for severe hemophilia A using a retroviral construct administered by peripheral intravenous infusion. Blood 2003; 102:2038-45. [PMID: 12763932 DOI: 10.1182/blood-2003-01-0167] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
In a phase 1 dose escalation study, 13 subjects with hemophilia A received by peripheral intravenous infusion a retroviral vector carrying a B-domain-deleted human factor VIII (hFVIII) gene. Infusions were well tolerated. Tests for replication competent retrovirus have been negative. Polymerase chain reaction (PCR) analyses demonstrate the persistence of vector gene sequences in peripheral blood mononuclear cells in 3 of 3 subjects tested. Factor VIII was measured in serial samples using both a one-stage clotting assay and a chromogenic assay. While no subject had sustained FVIII increases, 9 subjects had FVIII higher than 1% on at least 2 occasions 5 or more days after infusion of exogenous FVIII, with isolated levels that ranged from 2.3% to 19%. Pharmacokinetic parameters of exogenous FVIII infused into subjects 13 weeks after vector infusion showed an increased half-life (T1/2; P <.02) and area under the curve (AUC, P <.04) compared with prestudy values. Bleeding frequency decreased in 5 subjects compared with historical rates. These results demonstrate that this retroviral vector (hFVIII(V)) is safe and, in some subjects, persists more than a year in peripheral blood mononuclear cells, with measurable factor VIII levels and with increased available FVIII activity (increased T1/2 and AUC) after infusion of exogenous FVIII concentrate.
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Affiliation(s)
- Jerry S Powell
- Division of Hematology and Oncology, Suite 3016, UC-Davis Cancer Center, University of California at Davis, 4501 X St, Sacramento, CA 95817.
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Guidelines on the selection and use of therapeutic products to treat haemophilia and other hereditary bleeding disorders. Haemophilia 2003; 9:1-23. [PMID: 12558775 DOI: 10.1046/j.1365-2516.2003.00711.x] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Evidence based guidelines are presented on the selection and use of therapeutic products to treat haemophilia. These guidelines offer advice based on the best published scientific and medical information. They will be reviewed regularly by UKHCDO Advisory Committee. Included are details of therapeutic products available in the UK to treat patients with haemophilia and other bleeding disorders and the background information on which the recommendations are based are presented.
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