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Carcao M, Schiavulli M, Kulkarni R, Rendo P, Foster M, Santagostino E, Casiano S, Königs C. A post hoc analysis of previously untreated patients with severe hemophilia A who developed inhibitors in the PUPs A-LONG trial. Blood Adv 2024; 8:1494-1503. [PMID: 38266154 PMCID: PMC10951906 DOI: 10.1182/bloodadvances.2023011475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 01/10/2024] [Accepted: 01/14/2024] [Indexed: 01/26/2024] Open
Abstract
ABSTRACT Inhibitor development is a major therapeutic complication for people with hemophilia. The phase 3 PUPs A-LONG study evaluated the safety and efficacy of efmoroctocog alfa (a recombinant factor VIII Fc fusion protein, herein referred to as rFVIIIFc) in previously untreated patients (PUPs) with severe hemophilia A. Male PUPs <6 years old were enrolled and received rFVIIIFc; inhibitor development was the primary end point. Post hoc analyses, including patient treatment regimen patterns and timing of inhibitor development, descriptive and Kaplan-Meier analyses of time to first inhibitor-positive test by treatment regimen and by titer, and consumption, were performed to describe patients who developed inhibitors during PUPs A-LONG. We investigated patient characteristics (eg, demographics and genotype) and nongenetic risk factors (eg, intense factor exposure and central venous access device [CVAD] placement) that may predict inhibitor development and characteristics of inhibitor development (low-titer vs high-titer inhibitor). Baseline characteristics were similarly distributed for age, race, and ethnicity across both patients who were inhibitor-positive and those who were inhibitor-negative (all P > .05). High-risk F8 variants were associated with development of high-titer inhibitors (P = .028). High-titer inhibitor development was often preceded by the presence of a low-titer inhibitor. Patients whose low-titer inhibitor progressed to a high-titer inhibitor received a higher mean dose per infusion (98.4 IU/kg, n = 5) compared with those whose low-titer inhibitor resolved spontaneously (59.2 IU/kg, n = 7; P = .033) or persisted (45.0 IU/kg, n = 5; P = .047). There was no association between CVAD placement surgery and inhibitor development. Post hoc analyses suggest that F8 genotype and dose of factor are as important as inhibitor risk factors and require further investigation. This study was registered at ClinicalTrials.gov as #NCT02234323.
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Affiliation(s)
- Manuel Carcao
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | | | - Christoph Königs
- University Hospital Frankfurt, Goethe University, Frankfurt, Germany
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Fischer K, Lassila R, Peyvandi F, Gatt A, Hollingsworth R, Lambert T, Kaczmarek R, Bettle A, Samji N, Rivard GÉ, Carcao M, Iorio A, Makris M. Inhibitor development according to concentrate in severe hemophilia: reporting on 1392 Previously Untreated Patients from Europe and Canada. Res Pract Thromb Haemost 2023; 7:102265. [PMID: 38193044 PMCID: PMC10772871 DOI: 10.1016/j.rpth.2023.102265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/01/2023] [Accepted: 10/09/2023] [Indexed: 01/10/2024] Open
Abstract
Background Clotting factor concentrates have been the mainstay of severe hemophilia treatment over the last 50 years. Differences in risk of neutralizing antibody (inhibitor) formation according to concentrate used remain clinically relevant. Objectives To assess inhibitor development according to type of clotting factor concentrate in previously untreated patients (PUPs) with severe hemophilia A and B. Methods The European Haemophilia Safety Surveillance (EUHASS) and Canadian Bleeding Disorders Registry (CBDR) have been monitoring adverse events overall and according to concentrate for 11 and 8 years, respectively. Inhibitors were reported quarterly, and PUPs completed 50 exposure days without inhibitor development annually. Cumulative inhibitor incidences and 95% confidence intervals (CIs) were compared without adjustment for other risk factors. Results Fifty-six European and 23 Canadian centers reported inhibitor development in 312 of 1219 (26%; CI, 23%-28%) PUPs with severe hemophilia A and 14 of 173 (8%; CI, 5%-13%) PUPs with severe hemophilia B. Inhibitor development was lower on plasma-derived factor (F)VIII (pdFVIII, 20%; CI, 14%-26%) than on standard half-life recombinant FVIII (SHL-rFVIII, 27%; CI, 24%-30% and odds ratio, 0.67; CI, 0.45%-0.98%; P = .04). Extended half-life recombinant FVIII (EHL-rFVIII, 22%; CI, 12%-36%) showed an intermediate inhibitor rate, while inhibitor rates for Advate (26%; CI, 22%-31%) and Kogenate/Helixate (30%; CI, 24%-36%) overlapped. For other SHL-rFVIII concentrates, inhibitor rates varied from 3% to 43%. Inhibitor development was similar for pdFIX (11%; CI, 3%-25%), SHL-rFIX (8%; CI, 3%-15%), and EHL-rFIX (7%; CI, 1%-22%). Conclusion While confirming expected rates of inhibitors in PUPs, inhibitor development was lower in pdFVIII than in SHL-rFVIII. Preliminary data suggest variation in inhibitor development among different SHL-rFVIII and EHL-rFVIII concentrates.
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Affiliation(s)
- Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Riitta Lassila
- Department of Hematology, Unit of Coagulation Disorders, Helsinki University Central Hospital, Helsinki, Finland
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | | | | | - Radek Kaczmarek
- Coagulation Products Safety Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada
- Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Nasrin Samji
- Department of Pediatrics, Division of Hematology-Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Georges-Étienne Rivard
- Department of Pediatrics, Division of Hematology-Oncology, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Manuel Carcao
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alfonso Iorio
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Toronto, Ontario, Canada
| | - Mike Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - EUHASS and CHESS participants
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
- Department of Hematology, Unit of Coagulation Disorders, Helsinki University Central Hospital, Helsinki, Finland
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Mater Dei Hospital, Tal-QRoqq, Msida, Malta
- MDSAS, Manchester, United Kingdom
- Hopital Bicetre, Paris, France
- Coagulation Products Safety Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada
- Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
- IWK Health Centre, Halifax, Nova Scotia, Canada
- Department of Pediatrics, Division of Hematology-Oncology, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, Division of Hematology-Oncology, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Toronto, Ontario, Canada
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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3
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Fischer K, Carcao M, Male C, Ranta S, Pergantou H, Kenet G, Kartal-Kaess M, Königs C, Carvalho M, Alvarez MT, Brakenhoff T, Chambost H, van den Berg HM. Different inhibitor incidence for individual factor VIII concentrates in 1076 previously untreated patients with severe hemophilia A: data from the PedNet cohort. J Thromb Haemost 2023; 21:700-703. [PMID: 36696215 DOI: 10.1016/j.jtha.2022.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/04/2022] [Accepted: 11/17/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Kathelijn Fischer
- Center for Benign Hematology Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center, Utrecht University, The Netherlands.
| | - Manuel Carcao
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Canada
| | - Christoph Male
- Department of Paediatrics, Medical University Hospital of Vienna, Vienna, Austria
| | - Susanna Ranta
- Pediatric Coagulation Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Helen Pergantou
- Haemophilia-Haemostasis Unit, St. Sophia Children's Hospital, Athens, Greece
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer & Amalia Biron Research Institute of Thrombosis & Hemostasis, Tel Aviv University, Israel
| | - Mutlu Kartal-Kaess
- Division of Pediatric Hematology & Oncology, Department of Pediatrics, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Königs
- University Hospital Frankfurt, Department of Paediatrics and Adolescent Medicine, Frankfurt, Germany
| | - Manuela Carvalho
- Centro de Referência de Coagulopatias Congénitas do Centro Hospitalar Universitário S. João, EPE, Porto, Portugal
| | | | | | - Hervé Chambost
- Centre de Traitement de l'Hémophilie, AP-HM, Aix Marseille Université, Marseille, France
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First study of extended half-life rFVIIIFc in previously untreated patients with hemophilia A: PUPs A-LONG final results. Blood 2022; 139:3699-3707. [PMID: 35421219 PMCID: PMC9642851 DOI: 10.1182/blood.2021013563] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 03/24/2022] [Indexed: 01/19/2023] Open
Abstract
PUPs A-LONG is the first study of an extended half-life recombinant factor VIII (rFVIIIFc) in PUPs with hemophilia A. Incidence of inhibitors for patients with ≥10 exposure days was 31.1%; incidence of high-titer inhibitors was relatively low at 15.6%.
PUPs A-LONG evaluated the safety and efficacy of recombinant factor VIII Fc fusion protein (rFVIIIFc) in previously untreated patients (PUPs) with hemophilia A. This open-label, phase 3 study enrolled male PUPs (<6 years) with severe hemophilia A to receive rFVIIIFc. The primary endpoint was the occurrence of inhibitor development. Secondary endpoints included annualized bleed rate (ABR). Of 103 subjects receiving ≥1 dose of rFVIIIFc, 80 (78%) were aged <1 year at the study start, 20 (19%) had a family history of inhibitors, and 82 (80%) had high-risk F8 mutations. Twenty subjects began on prophylaxis, while 81 began an on-demand regimen (69 later switched to prophylaxis). Eighty-seven (81%) subjects completed the study. Inhibitor incidence was 31.1% (95% confidence interval [CI], 21.8% to 41.7%) in subjects with ≥10 exposure days (or inhibitor); high-titer inhibitor incidence was 15.6% (95% CI, 8.8% to 24.7%). The median (range) time to high-titer inhibitor development was 9 (4-14) exposure days. Twenty-eight (27%) subjects experienced 32 rFVIIIFc treatment-related adverse events; most were inhibitor development. There was 1 nontreatment-related death due to intracranial hemorrhage (onset before the first rFVIIIFc dose). The overall median (interquartile range [IQR]) ABR was 1.49 (0.00-4.40) for subjects on variable prophylaxis dosing regimens. In this study of rFVIIIFc in pediatric PUPs with severe hemophilia A, overall inhibitor development was within the expected range, although high-titer inhibitor development was on the low end of the range reported in the literature. rFVIIIFc was well-tolerated and effective for prophylaxis and treatment of bleeds. This trial is registered at www.clinicaltrials.gov (NCT02234323).
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Abdi A, Eckhardt CL, van Velzen AS, Vuong C, Coppens M, Castaman G, Hart DP, Hermans C, Laros‐van Gorkom B, Leebeek FWG, Mancuso ME, Mazzucconi MG, McRae S, Oldenburg J, Male C, van der Bom JG, Fijnvandraat K, Gouw SC. Treatment-related risk factors for inhibitor development in non-severe hemophilia A after 50 cumulative exposure days: A case-control study. J Thromb Haemost 2021; 19:2171-2181. [PMID: 34107158 PMCID: PMC8457239 DOI: 10.1111/jth.15419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/01/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Non-severe hemophilia A patients have a life-long inhibitor risk. Yet, no studies have analyzed risk factors for inhibitor development after 50 factor VIII (FVIII) exposure days (EDs). OBJECTIVES This case-control study investigated treatment-related risk factors for inhibitor development in non-severe hemophilia A and assessed whether these risk factors were different for early versus late inhibitor development. PATIENTS/METHODS Non-severe hemophilia A patients (FVIII:C 2%-40%) were selected from the INSIGHT study. Inhibitor-positive patients were defined as early (<50 EDs) or late (>50EDs) cases and matched to 1-4 inhibitor-negative controls by year of birth, cumulative number of EDs, and center/country. We investigated treatment intensity during the last 10 EDs prior to inhibitor development. Intensive treatment was defined as: surgery, peak treatment (10 consecutive EDs), and high mean FVIII dose (>45 IU/kg/ED). Odds ratios (OR) were calculated by logistic regression. RESULTS Of 2709 patients, we analyzed 63 early and 26 late cases and 195 and 71 respectively matched controls. Peak treatment was associated with early and late inhibitor risk (crude OR 1.8, 95% confidence interval [CI] 1.0-3.4; 4.0, 95%CI 1.1-14.3). This association was slightly less pronounced after adjustment for mean FVIII dose. High mean FVIII dose was also associated with early and late inhibitor risk (crude OR 2.8, 95%CI 1.5-5.1; 4.5, 95%CI 1.2-16.6). Surgery increased inhibitor risk for early cases. This was less pronounced for late cases. CONCLUSIONS Our findings suggest that intensive FVIII treatment remains a risk factor for inhibitor development in non-severe hemophilia A after more than 50 EDs. Therefore, persistent caution is required throughout the life-time treatment course.
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Affiliation(s)
- Amal Abdi
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Corien L. Eckhardt
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Alice S. van Velzen
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Caroline Vuong
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Michiel Coppens
- Vascular MedicineAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Giancarlo Castaman
- OncologyCenter for Bleeding Disorders and CoagulationCareggi University HospitalFlorenceItaly
| | - Dan P. Hart
- Barts and The London School of Medicine and DentistryThe Royal London Hospital Haemophilia CentreQMULLondonUK
| | - Cedric Hermans
- Haemostasis and Thrombosis UnitCliniques Universitaires Saint‐LucUniversité Catholique de LouvainBrusselsBelgium
| | | | - Frank W. G. Leebeek
- HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic DiseasesHumanitas Clinical and Research CenterRozzanoItaly
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center MilanFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | | | - Simon McRae
- HematologyLaunceston General HospitalLauncestonTasmaniaAustralia
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine BonnUniversity Clinic BonnBonnGermany
| | | | - Johanna G. van der Bom
- Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Center for Clinical Transfusion ResearchSanquin ResearchLeidenThe Netherlands
| | - Karin Fijnvandraat
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Molecular Cellular HemostasisSanquin Research and Landsteiner LaboratoryAmsterdamThe Netherlands
| | - Samantha C. Gouw
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
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Agboola F, Rind DM, Walton SM, Herron-Smith S, Quach D, Pearson SD. The effectiveness and value of emicizumab and valoctocogene roxaparvovec for the management of hemophilia A without inhibitors. J Manag Care Spec Pharm 2021; 27:667-673. [PMID: 33908280 PMCID: PMC10390946 DOI: 10.18553/jmcp.2021.27.5.667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
DISCLOSURES: Funding for this summary was contributed by Arnold Ventures, California Health Care Foundation, The Donaghue Foundation, Harvard Pilgrim Health Care, and Kaiser Foundation Health Plan to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from AbbVie, Aetna, America's Health Insurance Plans, Anthem, Alnylam, AstraZeneca, Biogen, Blue Shield of CA, Boehringer-Ingelheim, Cambia Health Services, CVS, Editas, Evolve Pharmacy, Express Scripts, Genentech/Roche, GlaxoSmithKline, Harvard Pilgrim, Health Care Service Corporation, HealthFirst, Health Partners, Humana, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Pfizer, Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, uniQure, and United Healthcare. Agboola, Rind, Herron-Smith, and Pearson are employed by ICER. Walton and Quach, through the University of Illinois at Chicago, received funding from ICER for development of the economic model described in this report.
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Affiliation(s)
| | - David M Rind
- Institute for Clinical and Economic Review, Boston, MA
| | - Surrey M Walton
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago
| | | | - Danny Quach
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago
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8
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Role of Regulatory Cells in Immune Tolerance Induction in Hemophilia A. Hemasphere 2021; 5:e557. [PMID: 33898928 PMCID: PMC8061682 DOI: 10.1097/hs9.0000000000000557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/09/2021] [Indexed: 11/26/2022] Open
Abstract
The main complication of hemophilia A treatment is the development of neutralizing antibodies (inhibitors) against factor VIII (FVIII). Immune tolerance induction (ITI) is the prescribed treatment for inhibitor eradication, although its working mechanism remains unresolved. To clarify this mechanism, we compared blood samples of hemophilia A patients with and without inhibitors for presence of immunoregulatory cells and markers, including regulatory B-cells (Bregs), regulatory T-cells (Tregs), myeloid-derived suppressor cells (MDSCs), and expression of regulatory markers on T-cells (programmed cell death protein 1 [PD1], inducable T-cell costimulator, cytotoxic T-lymphocyte-associated protein 4 [CTLA4]), by use of flow cytometry. By cross-sectional analysis inhibitor patients (N = 20) were compared with inhibitor-negative (N = 28) and ex-inhibitor (N = 17) patients. In another longitudinal study, changes in immunoregulatory parameters were evaluated during ITI (N = 12) and compared with inhibitor-negative hemophilia A patients (N = 36). The frequency of Bregs, but not of Tregs nor MDSCs, was significantly reduced in inhibitor patients (3.2%) compared with inhibitor-negative (5.9%) and ex-inhibitor patients (8.9%; P < 0.01). CTLA4 expression on T-cells was also reduced (mean fluorescence intensity 133 in inhibitor versus 537 in inhibitor-negative patients; P < 0.01). Fittingly, in patients followed during ITI, inhibitor eradication associated with increased Bregs, increased Tregs, and increased expression of CTLA4 and PD1 on CD4+ T-cells. In conclusion, inhibitor patients express significantly lower frequency of Bregs and Tregs marker expression, which are restored by successful ITI. Our findings suggest that an existing anti-FVIII immune response is associated with deficits in peripheral tolerance mechanisms and that Bregs and changes in immunoregulatory properties of CD4+ T-cells likely contribute to ITI in hemophilia A patients with inhibitors.
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Keipert C, Drechsel-Bäuerle U, Oberle D, Müller-Olling M, Hilger A. Epidemiological Challenges in Rare Bleeding Disorders: FVIII Inhibitor Incidence in Haemophilia A Patients-A Known Issue of Unknown Origin. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 18:ijerph18010225. [PMID: 33396748 PMCID: PMC7795862 DOI: 10.3390/ijerph18010225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/17/2020] [Accepted: 12/22/2020] [Indexed: 01/10/2023]
Abstract
There is a broad range of factor products approved in Germany for haemophilia A treatment. Since the introduction of recombinant coagulation factor VIII (FVIII) products in the 1990s, there has been substantial debate whether there is a difference in inhibitor incidence between single FVIII products or product classes. Neither haemophilia registries nor clinical studies, including a randomised controlled clinical trial, provided a consistent and definite answer. The reasons were mainly related to methodological challenges in conducting controlled studies in a rare disease. In this analysis, the most relevant epidemiological challenges and main problems were examined, including study bias, potential overlap of individual studies and advanced development of therapy and methods in the course of time. Meta-analyses on two levels showed that therapies using recombinant products resulted in different event rates when compared to plasma-derived products. These results are accompanied by substantial study heterogeneity evidenced by Cochran's Q tests. Only three studies have been identified that meet the standards of current clinical guidance. To finally resolve this ongoing and disputable safety issue of replacement therapy, collaboration among registry owners, academia and regulators must be fostered.
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Affiliation(s)
- Christine Keipert
- German Haemophilia Registry, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany
- Correspondence:
| | - Ursula Drechsel-Bäuerle
- Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (U.D.-B.); (D.O.)
| | - Doris Oberle
- Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (U.D.-B.); (D.O.)
| | - Mirco Müller-Olling
- Hematology and Transfusion Medicine, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (M.M.-O.); (A.H.)
| | - Anneliese Hilger
- Hematology and Transfusion Medicine, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (M.M.-O.); (A.H.)
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10
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Kim HK, Peral C, Rubio-Rodríguez D, Rubio-Terrés C. Cost of patients with hemophilia A treated with standard half-life or extended half-life FVIII in Spain. Expert Rev Pharmacoecon Outcomes Res 2020; 21:315-320. [PMID: 32597317 DOI: 10.1080/14737167.2020.1789457] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND In a real-world analysis (RWA) conducted in the United States (US), median international units (IUs) of extended half-life (EHL) recombinant coagulation factor VIII (rFVIII) dispensed were 10% to 45% greater than standard half-life (SHL) rFVIII. The mean IUs of each rFVIII dispensed quarterly were obtained from two databases (N = 776). METHODS A probabilistic model in a 1-year time horizon was used in order to analyze the cost comparison of SHL and EHL rFVIII products in Spain. In this analysis, mean IUs were those of the RWA, and frequency of use and prices for each rFVIII were obtained from sales estimates based on Spanish sources (IQVIA; €, 2019). RESULTS Data showed an average annual savings per patient of €11,227 for SHL rFVIII versus EHL rFVIII products, with a savings probability of 75.5%. The results were stable in the sensitivity analyses. Not switching treatment from SHL to EHL rFVIII resulted in greater savings per patient (€53,078), with a savings probability of 99.9%. Considering the frequency of rFVIII dispensation in the US, annual savings per patient would increase to €16,350 in Spain, with a savings probability of 79.9%. CONCLUSIONS According to this model, use of SHL rFVIII versus EHL rFVIII products could lead to savings for the Spanish National Health System.
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Affiliation(s)
| | - Carmen Peral
- Pfizer, S.L.U., Health Economics & Outcomes Research Department, Madrid, Spain
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11
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Pipe SW. Delivering on the promise of gene therapy for haemophilia. Haemophilia 2020; 27 Suppl 3:114-121. [PMID: 32490590 DOI: 10.1111/hae.14027] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 04/20/2020] [Indexed: 01/19/2023]
Abstract
The promise of gene therapy is a single treatment ('one and done') that leads to steady-state expression of endogenous factor VIII or factor IX sufficient to achieve a functional cure (free of recurrent haemophilic bleeding) if not normalized haemostasis. The elimination of the need for continued prophylaxis, or factor replacement following trauma or prior to surgery would lead to annual cost savings. Such optimized health and well-being would be reaching a level of health equity that was unimaginable several decades ago. 'Before anything else, preparation is the key to success'-Alexander Graham Bell. This quote from the famous inventor, scientist and engineer highlights that, although we currently stand on the threshold of this achievement, delivering on this promise will require broad-based multistakeholder preparation (scientists, manufacturers, federal regulators, health technology assessors, persons with haemophilia, national advocacy groups and multidisciplinary healthcare teams) with a focused emphasis on education, approval of safe and effective therapies, removal of barriers to access and excellence in clinical delivery.
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Affiliation(s)
- Steven W Pipe
- Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
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12
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Patel AM, Corman SL, Chaplin S, Raimundo K, Sidonio RF. Economic impact model of delayed inhibitor development in patients with hemophilia a receiving emicizumab for the prevention of bleeding events. J Med Econ 2019; 22:1328-1337. [PMID: 31530050 DOI: 10.1080/13696998.2019.1669614] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Aims: Cumulative exogenous factor VIII (FVIII) exposure is an important predictor of developing neutralizing antibodies (inhibitors) to FVIII in patients with persons with hemophilia A (PwHA). The aim of this study was to model the costs of emicizumab versus FVIII prophylaxis and total treatment costs for patients with severe HA.Materials and Methods: An Excel-based decision model was developed to calculate cumulative costs in PwHA over a 20-year time horizon from the US payer perspective. The model considered persons with severe HA beginning at age 12 months with no prior FVIII exposure and initiating prophylaxis with emicizumab or FVIII. PwHA could develop inhibitors on accumulation of 20 FVIII exposure days. PwHA with inhibitors replaced FVIII with bypassing agents until inhibitors resolved spontaneously, following immune tolerance induction (ITI), or at the end of the time horizon. The primary model outcome was the difference in emicizumab versus FVIII treatment costs in 2019 USD. Sensitivity analyses were performed to test the robustness of results.Results: Total incremental cost over 20 years was -$1,945,480 (emicizumab arm, $4,919,058; FVIII arm, $6,864,538). Prophylaxis costs (emicizumab arm, $4,096,105; FVIII arm, $6,290,919) comprised the majority of costs in both groups, followed by breakthrough bleed treatment for the FVIII arm ($342,652) and ITI costs for the emicizumab arm ($733,671). Higher costs in the FVIII group reflected earlier inhibitor development (FVIII, 4 months; emicizumab, 162 months) and switch to bypassing agents.Limitations: The model design reflects a simplified treatment pathway for patients with severe HA who initiate FVIII or emicizumab prophylaxis. In the absence of clinical data, a key conservative assumption of the model is that patients receiving emicizumab and FVIII prophylaxis have the same risk of developing inhibitors.Conclusions: This study suggests that prophylaxis with emicizumab results in cost savings compared to FVIII prophylaxis in HA.
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MESH Headings
- Antibodies, Bispecific/economics
- Antibodies, Bispecific/immunology
- Antibodies, Bispecific/therapeutic use
- Antibodies, Monoclonal, Humanized/economics
- Antibodies, Monoclonal, Humanized/immunology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Coagulants/administration & dosage
- Coagulants/immunology
- Coagulants/therapeutic use
- Factor VIII/administration & dosage
- Factor VIII/immunology
- Factor VIII/therapeutic use
- Hemophilia A/drug therapy
- Hemorrhage/prevention & control
- Humans
- Models, Economic
- Severity of Illness Index
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Affiliation(s)
| | | | | | | | - Robert F Sidonio
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, GA, USA
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13
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Ahnström J. The potential of serpins for future treatment for haemophilia. J Thromb Haemost 2019; 17:1629-1631. [PMID: 31571418 DOI: 10.1111/jth.14609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 08/09/2019] [Indexed: 11/30/2022]
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14
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Carcao M, Escuriola‐Ettingshausen C, Santagostino E, Oldenburg J, Liesner R, Nolan B, Bátorová A, Haya S, Young G. The changing face of immune tolerance induction in haemophilia A with the advent of emicizumab. Haemophilia 2019; 25:676-684. [PMID: 31033112 PMCID: PMC6850066 DOI: 10.1111/hae.13762] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 03/20/2019] [Accepted: 03/28/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION As a result of the new treatment paradigm that the haemophilia community will face with the availability of novel (non-factor) therapies, an updated consensus on ITI recommendations and inhibitor management strategies is needed. AIM The Future of Immunotolerance Treatment (FIT) group was established to contemplate, determine and recommend the best management options for patients with haemophilia A and inhibitors. DISCUSSION AND CONCLUSIONS Despite the considerable success of emicizumab in the management of inhibitor patients, the FIT group still sees the importance of eradicating inhibitors. However, the availability of emicizumab and other non-factor therapies in the future might impact greatly on how ITI is undertaken. Theoretically, concomitant use of emicizumab and FVIII might allow emicizumab to effectively prevent bleeding with lower dose ITI regimens. This might allow for the greater adoption of low-dose/low-frequency FVIII ITI regimens, which may result in a reduced need for central venous access devices while still maintaining a reasonable likelihood of ITI success. The FIT group proposes a new management algorithm for current ITI (without emicizumab) and a hypothetical new approach with the availability of emicizumab. As there are no published data regarding the concomitant use of emicizumab and FVIII for ITI, the FIT Expert group encourages the undertaking of properly conducted prospective studies to explore these approaches further.
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Affiliation(s)
- Manuel Carcao
- Division of Haematology/Oncology, Department of Paediatrics and Child Health Evaluative Sciences, Research Institute, The Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | | | - Elena Santagostino
- Maggiore Hospital PoliclinicoAngelo Bianchi Bonomi Hemophilia and Thrombosis CenterMilanItaly
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion MedicineUniversity of BonnBonnGermany
| | - Ri Liesner
- Haemophilia Centre, Great Ormond Street Hospital for ChildrenNHS Trust Haemophilia CentreLondonUK
| | | | - Angelika Bátorová
- Department of Haematology and Transfusion Medicine and National Haemophilia CentreUniversity Hospital, Comenius UniversityBratislavaSlovakia
| | - Saturnino Haya
- Unit for Congenital Bleeding DisordersHospital Universitario y Politécnico La FeValenciaSpain
| | - Guy Young
- Children's Hospital Los AngelesUniversity of Southern California Keck School of MedicineLos AngelesCalifornia
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15
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Pipe SW. Bioengineered molecules for the management of haemophilia: Promise and remaining challenges. Haemophilia 2018; 24 Suppl 6:68-75. [PMID: 29878662 DOI: 10.1111/hae.13507] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2018] [Indexed: 12/14/2022]
Abstract
Recombinant DNA technology has led to accelerating introduction of novel therapeutics for the treatment of haemophilia. This technology has driven the development of recombinant clotting factors, extended half-life clotting factors, alternative biologics to promote haemostasis and enabled the launch of the gene therapy era for haemophilia. At the core of this technology is the ability to study the structure and function of the native molecules and to apply rational bioengineering to overcome limitations to the existing therapies. Through the study of haemophilia-causing mutations, site-directed mutagenesis, detailed structural models and a wide repertoire of animal models, new bioengineering strategies are helping overcome some of the remaining limitations and challenges of traditional clotting factor concentrates. Some of these bioengineering strategies are now being partnered with improvements in vectorology leading to the first wave of successful gene therapy approaches. This study will review past and present bioengineered molecules that are advancing care for haemophilia as well as novel approaches that promise to continue to improve care and outcomes for patients with haemophilia.
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Affiliation(s)
- S W Pipe
- University of Michigan, Ann Arbor, MI, USA
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16
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D'Angiolella LS, Cortesi PA, Rocino A, Coppola A, Hassan HJ, Giampaolo A, Solimeno LP, Lafranconi A, Micale M, Mangano S, Crotti G, Pagliarin F, Cesana G, Mantovani LG. The socioeconomic burden of patients affected by hemophilia with inhibitors. Eur J Haematol 2018; 101:435-456. [DOI: 10.1111/ejh.13108] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2018] [Indexed: 01/19/2023]
Affiliation(s)
| | - Paolo A. Cortesi
- Research Centre on Public Health (CESP); University of Milano Bicocca; Monza Italy
| | - Angiola Rocino
- Hemophilia & Thrombosis Centre; San Giovanni Bosco Hospital; Naples Italy
| | - Antonio Coppola
- Regional Reference Center for Inherited Bleeding Disorders; University Hospital of Parma; Parma Italy
| | - Hamisa J. Hassan
- Department of Oncology and Molecular Medicine; Istituto Superiore di Sanità; Rome Italy
| | - Adele Giampaolo
- Department of Oncology and Molecular Medicine; Istituto Superiore di Sanità; Rome Italy
| | - Luigi P. Solimeno
- Division of Orthopaedic Surgery and Traumatology; Fondazione IRCCS Ca’ Granda; Ospedale Maggiore Policlinico; Milan Italy
| | | | - Mariangela Micale
- Research Centre on Public Health (CESP); University of Milano Bicocca; Monza Italy
| | - Sveva Mangano
- Research Centre on Public Health (CESP); University of Milano Bicocca; Monza Italy
| | - Giacomo Crotti
- Research Centre on Public Health (CESP); University of Milano Bicocca; Monza Italy
| | - Federica Pagliarin
- Research Centre on Public Health (CESP); University of Milano Bicocca; Monza Italy
| | - Giancarlo Cesana
- Research Centre on Public Health (CESP); University of Milano Bicocca; Monza Italy
| | - Lorenzo G. Mantovani
- Research Centre on Public Health (CESP); University of Milano Bicocca; Monza Italy
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17
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Cortesi PA, D'Angiolella LS, Lafranconi A, Micale M, Cesana G, Mantovani LG. Modern Treatments of Haemophilia: Review of Cost-Effectiveness Analyses and Future Directions. PHARMACOECONOMICS 2018; 36:263-284. [PMID: 29170896 DOI: 10.1007/s40273-017-0588-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Cost is currently one of the most important aspects in haemophilia care. Factor concentrates absorb more than 90% of healthcare direct costs of haemophilia care, and the debate regarding the high cost of haemophilia treatments and their different use across different countries is increasing. OBJECTIVE The objective of this study was to review cost-effectiveness analyses conducted on treatment options in haemophilia, focusing on their results and their strengths and limitations; to highlight the possible issues associated with economic evaluations of new treatment options. METHODS Electronic searches in PubMed and EMBASE were performed to retrieve papers published between November 2015 and September 2017 to update the previous review of economic evaluations of haemophilia treatments by Drummond et al. Reference lists of included articles and reviews were examined for relevant studies, which were assessed for their quality and their empirical results. RESULTS Twenty-six relevant economic analyses were identified; 15 (57.7%) were conducted in patients with haemophilia with inhibitors while 11 (42.3%) involved patients without inhibitors. There were methodological variations among the included studies, and differences in the treatment schemes make a comparative assessment of interventions for patients with haemophilia difficult. Only immune tolerance induction showed consistent results in its cost-saving profile compared with the treatment with bypassing agents. CONCLUSIONS Economic evaluations of haemophilia treatments are increasing, but the identification of general cost-effectiveness trends is still difficult in these studies. We are now facing a new era in haemophilia management with a soaring need for high-quality economic evaluations, performed through proactive collaboration between clinical experts, budget holders and health economists.
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Affiliation(s)
- Paolo A Cortesi
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Via G. Pergolesi 33, Monza, 20900, Italy
| | - Lucia S D'Angiolella
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Via G. Pergolesi 33, Monza, 20900, Italy
| | - Alessandra Lafranconi
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Via G. Pergolesi 33, Monza, 20900, Italy
| | - Mariangela Micale
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Via G. Pergolesi 33, Monza, 20900, Italy
| | - Giancarlo Cesana
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Via G. Pergolesi 33, Monza, 20900, Italy
| | - Lorenzo G Mantovani
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Via G. Pergolesi 33, Monza, 20900, Italy.
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18
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Sherman A, Biswas M, Herzog RW. Innovative Approaches for Immune Tolerance to Factor VIII in the Treatment of Hemophilia A. Front Immunol 2017; 8:1604. [PMID: 29225598 PMCID: PMC5705551 DOI: 10.3389/fimmu.2017.01604] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 11/07/2017] [Indexed: 01/19/2023] Open
Abstract
Hemophilia A (coagulation factor VIII deficiency) is a debilitating genetic disorder that is primarily treated with intravenous replacement therapy. Despite a variety of factor VIII protein formulations available, the risk of developing anti-dug antibodies (“inhibitors”) remains. Overall, 20–30% of patients with severe disease develop inhibitors. Current clinical immune tolerance induction protocols to eliminate inhibitors are not effective in all patients, and there are no prophylactic protocols to prevent the immune response. New experimental therapies, such as gene and cell therapies, show promising results in pre-clinical studies in animal models of hemophilia. Examples include hepatic gene transfer with viral vectors, genetically engineered regulatory T cells (Treg), in vivo Treg induction using immune modulatory drugs, and maternal antigen transfer. Furthermore, an oral tolerance protocol is being developed based on transgenic lettuce plants, which suppressed inhibitor formation in hemophilic mice and dogs. Hopefully, some of these innovative approaches will reduce the risk of and/or more effectively eliminate inhibitor formation in future treatment of hemophilia A.
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Affiliation(s)
- Alexandra Sherman
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Moanaro Biswas
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - Roland W Herzog
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
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