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Zangi AR, Amiri A, Pazooki P, Soltanmohammadi F, Hamishehkar H, Javadzadeh Y. Non-viral and viral delivery systems for hemophilia A therapy: recent development and prospects. Ann Hematol 2024; 103:1493-1511. [PMID: 37951852 DOI: 10.1007/s00277-023-05459-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/17/2023] [Indexed: 11/14/2023]
Abstract
Recent advancements have focused on enhancing factor VIII half-life and refining its delivery methods, despite the well-established knowledge that factor VIII deficiency is the main clotting protein lacking in hemophilia. Consequently, both viral and non-viral delivery systems play a crucial role in enhancing the quality of life for hemophilia patients. The utilization of viral vectors and the manipulation of non-viral vectors through targeted delivery are significant advancements in the field of cellular and molecular therapies for hemophilia. These developments contribute to the progression of treatment strategies and hold great promise for improving the overall well-being of individuals with hemophilia. This review study comprehensively explores the application of viral and non-viral vectors in cellular (specifically T cell) and molecular therapy approaches, such as RNA, monoclonal antibody (mAb), and CRISPR therapeutics, with the aim of addressing the challenges in hemophilia treatment. By examining these innovative strategies, the study aims to shed light on potential solutions to enhance the efficacy and outcomes of hemophilia therapy.
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Affiliation(s)
- Ali Rajabi Zangi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Pharmaceutics, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, 5166-15731, Iran
| | - Ala Amiri
- Department of Biotechnology, Faculty of Biological Sciences, Alzahra University, Tehran, Iran
| | - Pouya Pazooki
- Cellular and Molecular Biology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Soltanmohammadi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Pharmaceutics, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, 5166-15731, Iran
| | - Hamed Hamishehkar
- Drug Applied Research Center, Tabriz University of Medical Science, Tabriz, 5166-15731, Iran
| | - Yousef Javadzadeh
- Department of Pharmaceutics, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, 5166-15731, Iran.
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Zhao L, Fang S, Ma Y, Ren J, Hao L, Wang L, Yang J, Lu X, Yang L, Wang G. Targeted genome engineering based on CRISPR/Cas9 system to enhance FVIII expression in vitro. Gene 2024; 896:148038. [PMID: 38036077 DOI: 10.1016/j.gene.2023.148038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/13/2023] [Accepted: 11/27/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Hemophilia A is caused by a deficiency of coagulation factor VIII in the body due to a defect in the F8 gene. The emergence of CRISPR/Cas9 gene editing technology will make it possible to alter the expression of the F8 gene in hemophiliacs, while achieving a potential cure for the disease. METHODS Initially, we identified high-activity variants of FVIII and constructed donor plasmids using enzymatic digestion and ligation techniques. Subsequently, the donor plasmids were co-transfected with sgRNA-Cas9 protein into mouse Neuro-2a cells, followed by flow cytometry-based cell sorting and puromycin selection. Finally, BDD-hF8 targeted to knock-in the mROSA26 genomic locus was identified and validated for FVIII expression. RESULTS We identified the p18T-BDD-F8-V3 variant with high FVIII activity and detected the strongest pX458-mROSA26-int1-sgRNA1 targeted cleavage ability and no cleavage events were found at potential off-target sites. Targeted knock-in of BDD-hF8 cDNA at the mROSA26 locus was achieved based on both HDR/NHEJ gene repair approaches, and high level and stable FVIII expression was obtained, successfully realizing gene editing in vitro. CONCLUSIONS Knock-in of exogenous genes based on the CRISPR/Cas9 system targeting genomic loci is promising for the research and treatment of a variety of single-gene diseases.
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Affiliation(s)
- Lidong Zhao
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China; Department of Hematology, Linfen Central Hospital, Linfen, Shanxi, China
| | - Shuai Fang
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China; The Shanxi Provincial Center for Disease Control and Prevention, Taiyuan, Shanxi, China
| | - Yanchun Ma
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Juan Ren
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Lixia Hao
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Lei Wang
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Jia Yang
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Xiaomei Lu
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Linhua Yang
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China.
| | - Gang Wang
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, China.
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Mizumachi K, Nakajima Y, Shimonishi N, Furukawa S, Ogiwara K, Takeyama M, Nogami K. Hybrid human-porcine factor VIII proteins partially escape the inhibitory effects of anti-factor VIII inhibitor alloantibodies having A2 or C2 domain specificity. Haemophilia 2024; 30:140-150. [PMID: 38058226 DOI: 10.1111/hae.14911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/29/2023] [Accepted: 11/28/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Porcine factor (pF)VIII has low cross-reactivity with anti-human (h)FVIII inhibitor alloantibodies. Clinical trials of pFVIII in congenital haemophilia A patients with inhibitor (PwHA-I) are in progress. Most polyclonal anti-hFVIII inhibitors recognize its A2 and/or C2 domain(s), and recombinant human-porcine hybrid (hp)FVIII proteins may escape neutralization by these inhibitors. AIM To evaluate the ability of hpFVIII to limit the anti-FVIII activity of inhibitor alloantibodies. METHODS Three hybrid proteins were created by substituting the hFVIII A2, C2 domain or both with the corresponding domains of pFVIII [termed hp(A2), hp(C2) and hp(A2/C2), respectively]. The reactivity of these hybrids was assessed by one-stage clotting assays (OSA), thrombin generation assays (TGA) and rotational thromboelastometry (ROTEM) by adding them to FVIII-deficient samples. RESULTS OSA demonstrated that the hybrid proteins avoided neutralization by anti-FVIII A2 or C2 monoclonal antibodies (mAb) and polyclonal inhibitor-antibodies (polyAb) from PwHA-I. In TGA, thrombin generation with hp(A2) and hp(A2/C2) was not attenuated in the presence of patient IgG recognizing anti-A2 domain. In contrast, that with hFVIII and hp(C2) was suppressed by this IgG to levels equivalent to those of FVIII-deficient plasma. With anti-A2/C2 polyAb, the activity of hp(A2/C2) was unaffected. ROTEM demonstrated that the addition of hp(A2) or hp(A2/C2) to anti-A2 polyAb shortened clot times/clot formation times, whilst hFVIII or hp(C2) were ineffective. Similarly with anti-A2/C2 polyAb, hp(A2/C2) restored coagulation potential to a greater extent than hp(A2) and hp(C2). CONCLUSION Hybrid FVIII proteins containing porcine FVIII A2 and/or C2 domain(s) could support effective therapy in PwHA-I by avoiding neutralization.
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Affiliation(s)
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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[Chinese guidelines on the diagnosis and management of hemophilia with inhibitors (2023)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:881-889. [PMID: 38185516 PMCID: PMC10753256 DOI: 10.3760/cma.j.issn.0253-2727.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Indexed: 01/09/2024]
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Valke LLFG, Verhagen MJA, Mulders BTPM, Polenewen R, Blijlevens NMA, Jansen JH, Mansouritorghabeh H, Elsheikh E, Reipert BM, Turecek PL, O'Donnell JS, Rijpma SR, Schols SEM, van Heerde WL, Meijer D. The Nijmegen ultra-sensitive Bethesda Assay detects very low-titer factor VIII inhibitors in patients with congenital and acquired hemophilia A. Thromb Res 2023; 231:112-120. [PMID: 37844518 DOI: 10.1016/j.thromres.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/23/2023] [Accepted: 10/04/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND An inhibitor can develop in congenital hemophilia A (HA) patients against exogenous infused factor (F)VIII, whereas in acquired HA (AHA) inhibitors initially develop against endogenous FVIII. Inhibitors can be detected with the Nijmegen Bethesda Assay (NBA), which has an international cut-off level of 0.60 Nijmegen Bethesda Units/mL (NBU/mL). Thereby, very low-titer inhibitors may remain undetected. AIM To describe the design and validation of the Nijmegen ultra-sensitive Bethesda Assay (NusBA) for the detection of very low-titer inhibitors. METHODS The NusBA is a modification of the NBA in which the ratio of patient plasma to normal pooled plasma is changed from 1:1 to 9:1. Analytical validation was performed according to the CLSI EP10 guideline in order to determine trueness and reproducibility. Clinical validation was performed in two cohorts of congenital HA patients (82 adults) with pharmacokinetic data and four AHA patients. The limit of quantitation (LOQ) was determined by measuring plasma samples spiked with inhibitor levels in the low range (0.05-0.80 NBU/mL). RESULTS The LOQ for the NusBA was 0.10 NusBU/mL, with a coefficient of variation of 24.2 %. Seven (8.5 %) congenital HA patients had a positive NusBA result, of which only one was detected with the NBA. There was no correlation between NusBA and FVIII half-life. In three of the AHA patients the NusBA remained positive, when the NBA became negative. DISCUSSION The NusBA is able to detect very low-titer FVIII inhibitors of ≥0.10 NBU/mL. Thereby, it may have added value in early inhibitor detection and therapy adjustments in patients with congenital HA and AHA.
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Affiliation(s)
- Lars L F G Valke
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - Marieke J A Verhagen
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands; Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bart T P M Mulders
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Robert Polenewen
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joop H Jansen
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hassan Mansouritorghabeh
- Central Diagnostic Laboratories, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Einas Elsheikh
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Ireland
| | | | - Peter L Turecek
- Baxalta Innovations GmbH, A Member of the Takeda Group of Companies, Vienna, Austria
| | - James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Ireland; National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Sanna R Rijpma
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - Waander L van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands; Enzyre BV, Novio Tech Campus, Nijmegen, the Netherlands.
| | - Danielle Meijer
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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Sun Z, Xi Y, Liu W, Yang L, Wang X, Jin C, Jia H, Zhang L. Efficacy and safety of the B-domain-deleted TQG202 for on-demand treatment in moderate and severe haemophilia A patients: A multicentre, single-arm trial. Haemophilia 2023. [PMID: 36913439 DOI: 10.1111/hae.14777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 02/15/2023] [Accepted: 02/27/2023] [Indexed: 03/14/2023]
Abstract
INTRODUCTION On-demand treatment is the most common treatment strategy for haemophilia A in China. AIM This study aims to evaluate the efficacy and safety of a human-derived B-domain-deleted recombinant factor VIII (TQG202) in the on-demand treatment of bleeding episodes in moderate/severe haemophilia A patients. METHODS This multicentre, single-arm clinical trial enrolled moderate/severe haemophilia patients previously treated with FVIII concentrates for ≥50 exposure days (EDs) from May 2017 to October 2019. TQG202 was injected intravenously on-demand for bleeding episode management. The primary endpoints were the infusion efficiency at 15 and 60 min after the first administration and haemostatic efficacy of the first bleeding episode. Safety was also monitored. RESULTS Fifty-six participants were enrolled with a median age of 24.5 (range: 12-64) years old. The median total dose of TQG202 was 29,250 IU per participant (range: 1750-2,02,500), and the median number of administrations was 24.5 (2-116). The median infusion efficiency at 15 and 60 min after the first administration was 155.4% and 145.2%, respectively. Among the 48 first bleeding episodes evaluated, 47 (83.9%, 95% CI: 71.7%-92.4%) had a haemostatic efficacy rating of excellent or good. Eleven (19.6%) participants had treatment-related adverse events (TRAEs), but no ≥grade 3 TRAE was observed. Inhibitor development (0.6BU) was observed in one participant (1.8%) after 22 EDs, but was undetectable after 43 EDs. CONCLUSION TQG202 for on-demand treatment in moderate/severe haemophilia A shows effective control of the bleeding symptoms, with a low incidence of adverse events and inhibitors development.
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Affiliation(s)
- Zimin Sun
- Department of Hematology, The Affiliated Provincial Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yaming Xi
- Department of Hematology, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Linhua Yang
- Department of Hematology, The Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xuefeng Wang
- Ruijin Hospital, Shanghai Jiaotong University Medical School, Shanghai, China
| | - Chenghao Jin
- Hemophilia Information Management Center of Jiangxi Province, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi, China
| | - Haifei Jia
- R&D Institute, Chia Tai Tianqing Pharmaceutical Group Co. Ltd., Nanjing, Jiangsu, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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Wilkins RA, Siddle HJ, Chapman GJ, Horn E, Walwyn R, Redmond AC. Decline in health-related quality of life and foot and ankle patient reported outcomes measures in patients with haemophilia and ankle haemarthropathy. J Foot Ankle Res 2023; 16:12. [PMID: 36899385 PMCID: PMC10007846 DOI: 10.1186/s13047-023-00611-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 03/01/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND Haemophilia is an X-linked recessive genetic disorder characterised by bleeding within soft tissue and joints. The ankle is disproportionally affected by haemarthropathy when compared to the elbows and knees; reported as the most affected joints in patients with haemophilia. Despite advances in treatment, patients still report ongoing pain and disability, however, the impact has not been evaluated, nor has the effect on health-related quality of life (HRQoL) or foot and ankle patient-reported outcome measures (PROMs). The primary aim of this study was to establish the impact of ankle haemarthropathy in patients with severe and moderate haemophilia A and B. Secondly to identify the clinical outcomes associated with a decline in HRQoL and foot and ankle PROMs. METHODS A cross-sectional multi-centre questionnaire study was conducted across 18 haemophilia centres in England, Scotland and Wales with a recruitment target of 245 participants. The HAEMO-QoL-A and Manchester-Oxford Foot Questionnaire (MOXFQ) (foot and ankle) with total and domain scores measured impact on HRQOL and foot and ankle outcomes. Demographics, clinical characteristics, ankle haemophilia joint health scores, multi-joint haemarthropathy and Numerical Pain Rating Scales (NPRS) of "ankle pain over the past six months" were collected as a measure of chronic ankle pain. RESULTS A total of 243 of 250 participants provided complete data. HAEMO-QoL-A and MOXFQ (foot and ankle) total and index scores indicated worse HRQoL with total scores ranging from a mean of 35.3 to 35.8 (100 best-health) and 50.5 to 45.8 (0 best-health) respectively. NPRS (mean (SD)) ranged from 5.0 (2.6) to 5.5 (2.5), with median (IQR) ankle haemophilia joint health score of 4.5 (1 to 12.5) to 6.0 (3.0 to 10.0) indicating moderate to severe levels of ankle haemarthropathy. Ankle NPRS over six months and inhibitor status were associated with decline in outcome. CONCLUSIONS HRQoL and foot and ankle PROMs were poor in participants with moderate to severe levels of ankle haemarthropathy. Pain was a major driver for decline in HRQoL and foot and ankle PROMs and use of NPRS has the potential to predict worsening HRQoL and PROMs at the ankle and other affected joints.
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Affiliation(s)
- Richard A Wilkins
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK. .,Leeds Haemophilia Comprehensive Care Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - Heidi J Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Graham J Chapman
- School of Sport and Health Sciences, University of Central Lancashire, Preston, UK
| | - Elizabeth Horn
- Leeds Haemophilia Comprehensive Care Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rebecca Walwyn
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Anthony C Redmond
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Liu W, Xue F, Fu R, Ding B, Li M, Sun T, Chen Y, Liu X, Ju M, Dai X, Wu Q, Zhou Z, Yu J, Wang X, Zhu Q, Zhou H, Yang R, Zhang L. Preclinical studies of a factor X activator and a phase 1 trial for hemophilia patients with inhibitors. J Thromb Haemost 2023; 21:1453-1465. [PMID: 36796484 DOI: 10.1016/j.jtha.2023.01.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 01/10/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Bleeding episodes in hemophiliacs with inhibitors are difficult to control. Staidson protein-0601 (STSP-0601), a specific factor (F)X activator purified from the venom of Daboia russelii siamensis, has been developed. OBJECTIVES We aimed to investigate the efficacy and safety of STSP-0601 in preclinical and clinical studies. METHODS In vitro and in vivo preclinical studies were performed. A phase 1, first-in-human, multicenter, and open-label trial was conducted. The clinical study was divided into parts A and B. Hemophiliacs with inhibitors were eligible for this study. Patients received a single intravenous injection of STSP-0601 (0.01 U/kg, 0.04 U/kg, 0.08 U/kg, 0.16 U/kg, 0.32 U/kg, or 0.48 U/kg) in part A or a maximum of 6 4-hourly injections (0.16 U/kg) in part B. The primary endpoint for each part was the number of adverse events (AEs) from baseline to 168 hours after administration. This study was registered at clinicaltrials.gov (NCT-04747964 and NCT-05027230). RESULTS Preclinical studies showed that STSP-0601 could specifically activate FX in a dose-dependent manner. In the clinical study, 16 patients in part A and 7 patients in part B were enrolled. Eight (22.2%) AEs in part A and 18 (75.0%) AEs in part B were reported to be related to STSP-0601. Neither severe AEs nor dose-limiting toxicity events were reported. There were no thromboembolic event. The antidrug antibody of STSP-0601 was not detected. CONCLUSION Preclinical and clinical studies showed that STSP-0601 had a good ability to activate FX and had a good safety profile. STSP-0601 could be used as a hemostatic treatment in hemophiliacs with inhibitors.
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Affiliation(s)
- Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Rongfeng Fu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Bingjie Ding
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, China
| | - Mengjuan Li
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, China
| | - Ting Sun
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Yunfei Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Xiaofan Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Mankai Ju
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Xinyue Dai
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Quanrui Wu
- Staidson (Beijing) Biopharmaceuticals Co, Ltd, Beijing, China
| | - Zan Zhou
- Staidson (Beijing) Biopharmaceuticals Co, Ltd, Beijing, China
| | - Jiaojiao Yu
- Staidson (Beijing) Biopharmaceuticals Co, Ltd, Beijing, China
| | - Xiaomin Wang
- Staidson (Beijing) Biopharmaceuticals Co, Ltd, Beijing, China
| | - Qing Zhu
- Staidson (Beijing) Biopharmaceuticals Co, Ltd, Beijing, China
| | - Hu Zhou
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, China.
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China.
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China.
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Panuwannakorn M, Jiravichitchai T, Lertthammakiat S, Jaovisidha S, Sirachainan N, Chuansumrit A. Iliopsoas haemorrhage complicated by femoral neuropathy in patients with haemophilia: a case series report. Int J Hematol 2023; 117:293-306. [PMID: 36151351 DOI: 10.1007/s12185-022-03456-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The study aimed to determine the incidence of femoral neuropathy in patients with haemophilia exhibiting iliopsoas haemorrhage. METHODS Patients with iliopsoas haemorrhage confirmed by ultrasonography or CT scan were studied retrospectively. RESULTS A total of 44 episodes of iliopsoas haemorrhage occurred in 20 patients with haemophilia (A17, B3). Most episodes in patients without inhibitors (14/16 = 87.5%) were adequately treated followed by prophylaxis. However, 11 of 28 episodes (39.3%) in patients with inhibitors were adequately treated and no prophylaxis was provided. An appropriate rehabilitation programme was arranged during hospitalisation and follow-up. Femoral neuropathy was observed in 28 of 44 episodes, while 16 episodes of persistent femoral neuropathy from previous bleeding were excluded. As a result, 11 of 28 episodes (39.3%) of femoral neuropathy were similarly found amongst patients with and without inhibitors. The mean time of onset and resolution of femoral neuropathy were 3.7 (1.8) and 23.4 (20.5) days after the onset of iliopsoas haemorrhage, respectively. Patients receiving inadequate and delayed replacement had a significantly higher rate of femoral neuropathy than those who received adequate and prompt replacement. CONCLUSION Femoral neuropathy following iliopsoas haemorrhage was common in haemophilia patients with and without inhibitors.
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Affiliation(s)
- Monratta Panuwannakorn
- Department of Rehabilitation Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Tachit Jiravichitchai
- Department of Rehabilitation Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Surapong Lertthammakiat
- Department of Paediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suphaneewan Jaovisidha
- Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Department of Paediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ampaiwan Chuansumrit
- Department of Paediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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10
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Xi Y, Jin C, Liu W, Zhou H, Wang Z, Zhou R, Lou S, Zhao X, Chen F, Cheng P, Sun Z, Jia H, Zhang L. Efficacy, safety and bioequivalence of the human-derived B-domain-deleted recombinant factor VIII TQG202 for prophylaxis in severe haemophilia A patients. Haemophilia 2022; 28:e219-e227. [PMID: 35996199 DOI: 10.1111/hae.14652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/18/2022] [Accepted: 07/26/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Current treatment of severe haemophilia A includes prophylaxis with factor VIII (FVIII) replacement. The supply of plasma-derived FVIII is short in China. PURPOSE To evaluate the efficacy and safety of a new B-domain deleted (BDD) recombinant FVIII (TQG202) produced by human-derived cells for prophylaxis in severe haemophilia A patients and compare the bioequivalence with Xyntha. METHODS This multicentre, clinical trial consisted of an open-label, randomized, two-period cross-over trial assessing single-dose pharmacokinetics (PK), and a single-arm clinical trial evaluating the efficacy and safety of 24 weeks of TQG202 prophylaxis, and repeated PK were assessed after prophylaxis phase. The single-dose was 50 IU/kg in PK assessment, and the initial dose was 30 ± 5 IU/kg for prophylaxis. The primary endpoints of prophylaxis were the annualized bleeding rate (ABR) and the incremental recovery rate of the first administration. Adverse events (AEs) were recorded. RESULTS Twenty-six participants were enrolled in the PK assessment and 81 participants in the prophylaxis phase. Mean age was 25.9 ± 10.8 years and all participants were male. The results of PK assessment showed TQG202 is bioequivalent to Xyntha. The total ABR was 2.0 (95% CI: 1.2-2.9) in prophylaxis phase. The mean incremental recovery rate of the first administration was .027 (95% CI: .026-.028) (IU/ml)/(IU/kg). AEs occurred in 42 participants, with an incidence of 51.9%. One severe AE not related to TQG202 occurred. No participants developed FVIII inhibitors. CONCLUSION TQG202 shows bioequivalence with Xyntha. The promising efficacy and tolerability in the severe haemophilia A prophylaxis support the use of TQG202in clinical practice.
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Affiliation(s)
- Yaming Xi
- Department of Hematology, The First Hospital of Lanzhou University, Lanzhou, Gansu Province, China
| | - Chenghao Jin
- Hemophilia Information Management Center of Jiangxi Province, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital,Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Hu Zhou
- Department of Hematology, The Cancer Hospital affiliated to Zhengzhou University, Zhengzhou, China
| | - Zhen Wang
- Department of Hematology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Rongfu Zhou
- Department of Hematology, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Shifeng Lou
- Department of Hematology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Xielan Zhao
- Department of Hematology, Xiangya Hemophilia Diagnosis and Treatment Center, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Fangping Chen
- Department of Hematology, Xiangya Hemophilia Diagnosis and Treatment Center, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Peng Cheng
- Department of Hematology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Province, China
| | - Zimin Sun
- Department of Hematology, The Affiliated Provincial Hospital of Anhui Medical University, Hefei, China
| | - Haifei Jia
- R&D Institute, Chia Tai Tianqing Pharmaceutical Group Co. Ltd., Nanjing, Jiangsu Province, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital,Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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11
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Peyvandi F, Kavakli K, El‐Beshlawy A, Rangarajan S. Management of haemophilia A with inhibitors: A regional cross-talk. Haemophilia 2022; 28:950-961. [PMID: 35868021 PMCID: PMC9796719 DOI: 10.1111/hae.14638] [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: 02/25/2022] [Revised: 07/04/2022] [Accepted: 07/09/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The development of inhibitors with factor VIII (FVIII) replacement therapy is one of the most common and challenging complications of haemophilia A (HA) treatment, jeopardising treatment efficacy and predisposing patients to high risks of morbidity and mortality. The management of patients with inhibitors is particularly challenging in countries where resources are limited. AIM To provide a comprehensive summary of the management of HA with inhibitors while focusing on differences in practice between Western and non-Western countries and how resource scarcity can impact HA management, leading to suboptimal outcomes in patients with inhibitors. METHODS Summary of key evidence and regional expert opinion. RESULTS We address, particularly, the diagnosis of and testing for inhibitors, as well as the epidemiology of inhibitors, including incidence, prevalence and disease burden. Secondly, we provide an overview of the current treatment landscape in HA with inhibitors regarding the eradication of inhibitors with immune tolerance induction and the treatment and prevention of bleeding with bypassing agents, non-factor replacement agents and other experimental therapies. This is complemented with insights from the authors around the applicability of, and challenges associated with, such therapies in their settings of practice. CONCLUSIONS We conclude by proposing some key steps towards bridging the gaps in the management of HA with inhibitors in resource-limited countries, including: (1) the collection of quality data that can inform healthcare reforms and policies; (2) improving disease knowledge among healthcare practitioners and patients with the aim of standardising disease management across centres and (3) working towards promoting equal access to HA care and therapies for everyone.
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Affiliation(s)
- Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly,Department of Pathophysiology and TransplantationUniversità degli Studi di MilanooMilanItaly
| | - Kaan Kavakli
- Department of Pediatric HematologyEge University Children's HospitalIzmirTurkey
| | - Amal El‐Beshlawy
- Department of Pediatric Hematology, Faculty of MedicineCairo UniversityCairoEgypt
| | - Savita Rangarajan
- Department of HaematologyUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK,Clinical Trials and Research UnitKJ Somaiya Super Specialty Hospital and Research CentreMumbaiIndia
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12
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Swan D, Mahlangu J, Thachil J. Non‐factor therapies for bleeding disorders: A primer for the general haematologist. EJHAEM 2022; 3:584-595. [PMID: 36051064 PMCID: PMC9422036 DOI: 10.1002/jha2.442] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 11/09/2022]
Abstract
Management of patients with severe bleeding disorders, particularly haemophilia A and B, and to a lesser extent, von Willebrand disease, has come on leaps and bounds over the past decade. Until recently, patients relied upon the administration of factor concentrates to prevent or treat bleeding episodes. Factor administration requires intravenous access and, in up to one‐third of patients, leads to the development of neutralising antibodies, or inhibitors, which are associated with more frequent bleeding episodes and higher morbidity. Novel non‐factor therapies may offer a solution to these unmet needs. In this review, we discuss the factor mimetics, particularly emicizumab, and the rebalancing agents, which inhibit antithrombin, tissue factor pathway inhibitor and activated protein C, and novel treatments to enhance von Willebrand factor levels. We review the available trial data, unanswered questions and challenges associated with these new treatment modalities. Finally, we provide practical management algorithms to aid the general haematologist when faced with a patient receiving emicizumab who requires surgery or may develop bleeding.
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Affiliation(s)
- Dawn Swan
- National University Ireland Galway Republic of Ireland
| | - Johnny Mahlangu
- Department of Molecular Medicine and Haematology School of Pathology Faculty of Health Sciences University of the Witwatersrand and NHLS Johannesburg South Africa
| | - Jecko Thachil
- Department of Haematology Manchester University Hospitals NHS Foundation Trust Manchester UK
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13
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Croteau SE. Hemophilia A/B. Hematol Oncol Clin North Am 2022; 36:797-812. [DOI: 10.1016/j.hoc.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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14
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Li Z, Liu G, Yao W, Chen Z, Li G, Cheng X, Zhen Y, Ai D, Huang K, Sun J, Poon MC, Wu R. Eradication of FIX inhibitor in haemophilia B children using low-dose immune tolerance induction with rituximab-based immunosuppressive agent(s) in China. Haemophilia 2022; 28:625-632. [PMID: 35503087 DOI: 10.1111/hae.14577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/10/2022] [Accepted: 04/13/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Development of haemophilia B inhibitors (HBI) results in the ineffectiveness of FIX replacement therapy. Inhibitor eradication by immune tolerance induction (ITI) is therefore necessary. In HBI, ITI even at high FIX dose is less effective and has a higher risk of severe complications. AIM To characterize clinical features and outcome of ITI on HBI. METHODS This retrospective study was conducted in Haemophilia Paediatric Comprehensive Care Centre of China. We used low-dose ITI (25-50 FIX IU/kg/three-times-weekly to every-other-day) with domestic prothrombin complex concentrate (PCC), combined with two successive immunosuppressive (IS) regimens. RESULTS Sixteen HBI children, representing 5.7% of all and 14.4% of our severe registered HB patients, were enroled. Seven cases reported allergic reactions (ARs) proximal to inhibitor development. The historic peak inhibitor titre was median 54.2 (range 4.7-512) BU, and 15 (93.8%) had high-titre inhibitors. Twelve patients adherent to ITI were analysable. Of the nine ITI patients who received rituximab/prednisone (IS Regimen-1), four achieved tolerization in 1.4-43.3 months. Two subsequently relapsed but re-tolerized after a second course of IS Regimen-1. During ITI, the median treated bleed was .39/month (82.7% reduction from before ITI), and the incidence of AR and nephrotic syndrome (NS) complications was each at 22% (2/9). Three ITI patients received modified 'Beutel' protocol (IS Regimen-2) using multiple-IS-drugs, and two had rapid tolerization (.8 and 1.8 months). CONCLUSIONS Inhibitor eradication could be achieved by low-dose ITI protocol using PCC combined with IS. Larger studies are needed to confirm if ITI with IS Regimen-2 is more effective with less complications.
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Affiliation(s)
- Zekun Li
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Guoqing Liu
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Wanru Yao
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Zhenping Chen
- Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Gang Li
- Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Cheng
- Pharmacology Department, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yingzi Zhen
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Di Ai
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Kun Huang
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jie Sun
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Man-Chiu Poon
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Oncology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Hospital, Alberta Health Services, Calgary, Alberta, Canada
| | - Runhui Wu
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
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15
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Hart DP, Matino D, Astermark J, Dolan G, d’Oiron R, Hermans C, Jiménez-Yuste V, Linares A, Matsushita T, McRae S, Ozelo MC, Platton S, Stafford D, Sidonio RF, Tiede A. International consensus recommendations on the management of people with haemophilia B. Ther Adv Hematol 2022; 13:20406207221085202. [PMID: 35392437 PMCID: PMC8980430 DOI: 10.1177/20406207221085202] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/17/2022] [Indexed: 01/19/2023] Open
Abstract
Haemophilia B is a rare X-linked genetic deficiency of coagulation factor IX (FIX) that, if untreated, can cause recurrent and disabling bleeding, potentially leading to severe arthropathy and/or life-threatening haemorrhage. Recent decades have brought significant improvements in haemophilia B management, including the advent of recombinant FIX and extended half-life FIX. This therapeutic landscape continues to evolve with several non-factor replacement therapies and gene therapies under investigation. Given the rarity of haemophilia B, the evidence base and clinical experience on which to establish clinical guidelines are relatively sparse and are further challenged by features that are distinct from haemophilia A, precluding extrapolation of existing haemophilia A guidelines. Due to the paucity of formal haemophilia B-specific clinical guidance, an international Author Group was convened to develop a clinical practice framework. The group comprised 15 haematology specialists from Europe, Australia, Japan, Latin America and North America, covering adult and paediatric haematology, laboratory medicine and biomedical science. A hybrid approach combining a systematic review of haemophilia B literature with discussion of clinical experience utilized a modified Delphi format to develop a comprehensive set of clinical recommendations. This approach resulted in 29 recommendations for the clinical management of haemophilia B across five topics, including product treatment choice, therapeutic agent laboratory monitoring, pharmacokinetics considerations, inhibitor management and preparing for gene therapy. It is anticipated that this clinical practice framework will complement existing guidelines in the management of people with haemophilia B in routine clinical practice and could be adapted and applied across different regions and countries.
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Affiliation(s)
- Daniel P. Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Whitechapel Road, London E1 2AD, UK
| | - Davide Matino
- Department of Medicine, McMaster University and The Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Jan Astermark
- Institution of Translational Medicine and Department of Hematology, Oncology and Radiation Physics, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Gerard Dolan
- Centre for Haemostasis and Thrombosis, St Thomas’ Hospital, London, UK
| | - Roseline d’Oiron
- Centre for Haemophilia and Constitutional Bleeding Disorders, Hôpital Bicêtre AP-HP Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Cédric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | | | - Adriana Linares
- Grupo de Oncohematología Pediátrica, Universidad Nacional de Colombia, Bogotá, Colombia
- Programa de Hemofilia, Clínica Infantil Colsubsidio, Bogotá, Colombia
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Simon McRae
- Launceston General Hospital, Launceston, TAS, Australia
| | | | - Sean Platton
- The Royal London Hospital Haemophilia Centre, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Darrel Stafford
- Department of Biology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Robert F. Sidonio
- Aflac Cancer and Blood Disorders, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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16
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Ito J, Baldwin WH, Cox C, Healey JF, Parker ET, Legan ER, Li R, Gill S, Batsuli G. Removal of single-site N-linked glycans on factor VIII alters binding of domain-specific monoclonal antibodies. J Thromb Haemost 2022; 20:574-588. [PMID: 34863021 PMCID: PMC8885965 DOI: 10.1111/jth.15616] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 11/16/2021] [Accepted: 12/01/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND A portion of individuals with hemophilia A develop neutralizing antibodies called inhibitors to glycoprotein factor VIII (FVIII). There are multiple risk factors that contribute to the risk of inhibitor formation. However, knowledge of the role of FVIII asparagine (N)-linked glycosylation in FVIII immunity is limited. OBJECTIVE To evaluate the effect of site-specific N-linked glycan removal on FVIII biochemical properties, endocytosis by murine bone marrow-derived dendritic cells (BMDCs), and antibody responses. METHODS Four recombinant B domain-deleted (BDD) FVIII variants with single-site amino acid substitutions to remove N-linked glycans were produced for experimental assays. RESULTS BDD FVIII-N41G, FVIII-N239A, FVIII-N1810A, and FVIII-N2118A with confirmed removal of N-linked glycans and similar glycosylation profiles to BDD FVIII were produced. There were no differences in thrombin activation or von Willebrand factor binding of FVIII variants compared with BDD FVIII; however, reduced FVIII expression, activity, and specific activity was observed with all variants. BDD FVIII-N41G and FVIII-N1810A had reduced uptake by BMDCs, but there were no differences in antibody development in immunized hemophilia A mice compared with BDD FVIII. Half of a repertoire of 12 domain-specific FVIII MAbs had significantly reduced binding to ≥1 FVIII variant with a 50% decrease in A1 domain MAb 2-116 binding to FVIII-N239A. CONCLUSIONS Modifications of FVIII N-linked glycans reduced FVIII endocytosis by BMDCs and binding of domain-specific FVIII MAbs, but did not alter de novo antibody production in hemophilia A mice, suggesting that N-glycans do not significantly contribute to inhibitor formation.
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Affiliation(s)
- Jasmine Ito
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Wallace Hunter Baldwin
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Courtney Cox
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - John F Healey
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Ernest T Parker
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Emily R Legan
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Renhao Li
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Surinder Gill
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Glaivy Batsuli
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
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17
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Alblaihed L, Dubbs SB, Koyfman A, Long B. High risk and low prevalence diseases: Hemophilia emergencies. Am J Emerg Med 2022; 56:21-27. [DOI: 10.1016/j.ajem.2022.02.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 10/19/2022] Open
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18
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Teixeira Passos D, Abrantes AM, Santos L, Cardoso A, Pais de Lacerda A. Immunosuppression Therapy in Acquired Hemophilia A: Pursuing an Optimal Regimen. Cureus 2021; 13:e20467. [PMID: 35047291 PMCID: PMC8760006 DOI: 10.7759/cureus.20467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 11/16/2022] Open
Abstract
Acquired hemophilia A (AHA) is a rare bleeding disorder occurring mostly in elderly persons, caused by inhibition of factor VIII (FVIII). It is generally detected prior to surgery by an isolated prolonged activated partial thromboplastin time (aPTT) not correcting on mixing studies, with subsequent identification of reduced FVIII levels and presence of FVIII inhibitor. It is treated with hemostatics and immunosuppressants, which may increase the risk for life-threatening opportunistic infections. A 79-year-old woman with idiopathic acquired FVIII inhibition and severe bleeding presented with anemia, isolated and prolonged aPTT, low FVIII activity (<1%), and elevated FVIII inhibitor titer (471 Bethesda units per milliliter [BU/mL]). Initially, she was treated with recombinant activated factor VII and steroids. However, several hematomas appeared, one of which caused airway compression that required orotracheal intubation. Cyclophosphamide, rituximab (RTX), and activated prothrombin complex concentrate were initiated, resulting in clinical and laboratory resolution after five weeks. Cyclophosphamide and RTX were maintained for six and four weeks more, respectively. After 12 weeks of oral immunosuppression, the patient was readmitted due to antibiotic-resistant Pseudomonas aeruginosa sepsis, which resulted in death. Infection secondary to immunosuppression is the leading cause of death of patients with AHA. In AHA, combination therapy was shown to be more effective than monotherapy, but it was also identified to increase the risk of infection. Age, FVIII activity <1%, and FVIII inhibitor titers >20 BU are predictors of adverse events and poor prognosis in AHA patients. Additional studies are needed to clarify the ideal drug regimens and the need for prophylactic antibiotics in this population.
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19
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Hammami E, Borgi WE, Hajer EM, Houda B, Achour M, Zahra K, Meddeb B, Gouider E. Is immune tolerance induction conceivable in haemophilia with inhibitors in a low-middle income country? Real-world data from Tunisia. Haemophilia 2021; 28:e32-e35. [PMID: 34820981 DOI: 10.1111/hae.14464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Emna Hammami
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
| | - Wijden El Borgi
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
| | - El Mahmoudi Hajer
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
| | - Bouattour Houda
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
| | - Mariem Achour
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
| | - Kaouther Zahra
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
| | - Balkis Meddeb
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
| | - Emna Gouider
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
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20
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Swan D, Paran S, Nolan B. Port removal in patients receiving emicizumab prophylaxis: A single centre experience and review of the literature. Haemophilia 2021; 28:42-45. [PMID: 34786787 DOI: 10.1111/hae.14459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Treatment of patients with Haemophilia A has improved significantly in recent years since the advent of novel therapeutic agents such as emicizumab. The low annualised bleeding rates associated with emicizumab have liberated many patients from the need for central venous access devices (CVAD). Optimal peri-operative management of CVAD removal is not currently known and there are no specific formal recommendations available. AIM We reviewed outcomes in a paediatric cohort in our centre undergoing CVAD removal without pre-operative factor or bypassing agent and reviewed the literature regarding port removal in patients on Emicizumab. METHODS Ten male patients with severe Haemophilia A underwent CVAD removal without planned administration of factor concentrate or bypassing agent. Patients were monitored in hospital for 24 h with routine laboratory testing pre- and post-operatively. RESULTS No significant bleeding episodes occurred in any patient, no patient required factor concentrate or bypassing agent and no patients were readmitted due to bleeding within 7 days of surgery. CONCLUSION We propose that, in the era of emicizumab, prophylactic factor administration pre-operatively for elective CVAD removal is not required in the majority of cases.
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Affiliation(s)
- Dawn Swan
- Department of Paediatric Haematology, Children Health Ireland at Crumlin, Dublin, Ireland
| | - Sri Paran
- Department of Paediatric Surgery, Children Health Ireland at Crumlin, Dublin, Ireland
| | - Beatrice Nolan
- Department of Paediatric Haematology, Children Health Ireland at Crumlin, Dublin, Ireland
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21
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Kizilocak H, Young G. Emerging drugs for hemophilia A: insights into phase II and III clinical trials. Expert Opin Emerg Drugs 2021; 26:337-350. [PMID: 34601977 DOI: 10.1080/14728214.2021.1988073] [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: 01/19/2023]
Abstract
INTRODUCTION Hemophilia is a lifelong, genetic-bleeding disorder, which inadequately treated results in permanent joint damage. It is characterized by spontaneous and trauma-related bleeding episodes. In the last 50 years, treatment has seen dramatic improvements which have improved the quality of life of persons with hemophilia. AREAS COVERED This review will provide a summary of current pharmacological approaches for hemophilia A as well as discuss novel agents which are either approved recently or in phase II-III clinical trials, plasma-derived and recombinant factor VIII (FVIII) products, extended half-life FVIII products, bypassing agents and non-replacement therapies. EXPERT OPINION Novel therapies are already changing the way that hemophilia A is managed, and as more new therapies get approved, there will be a revolution in the management of this serious condition. Clinicians will have both the opportunities as well as the challenges of incorporating such new technologies into clinical practice.
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Affiliation(s)
- Hande Kizilocak
- Children's Hospital Los Angeles, Hemostasis and Thrombosis Center, Cancer and Blood Disease Institute, Los Angeles, CA, USA
| | - Guy Young
- Children's Hospital Los Angeles, Hemostasis and Thrombosis Center, Cancer and Blood Disease Institute, Los Angeles, CA, USA.,Department of Hematology and Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
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22
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Measurement of coagulation factor antibody levels is useful for diagnosis and determining therapeutic efficacy in hemorrhagic patients with autoantibodies to coagulation factor VIII and factor V: results from a single center in Japan. Int J Hematol 2021; 115:11-20. [PMID: 34476734 DOI: 10.1007/s12185-021-03212-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/26/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Abstract
Coagulation factor inhibitors (CFIs) sometimes cause fatal bleeding conditions. Determination of an inhibitor titer (INH-titer) using the Bethesda method is essential for diagnosing diseases associated with CFIs and examining the effects of immunosuppressive therapy. We reviewed 17 cases with CFIs (acquired hemophilia A, n = 11; FV inhibitor, n = 6) to examine the usefulness of determining quantities of an autoantibody to a coagulation factor (CF-IgG) by ELISA for diagnosis and therapeutic efficacy, as compared with INH-titer. One patient with an INH-titer and no evidence of CF-IgG was lupus anticoagulant (LA)-positive, and thus the positive INH-titer may have been a false positive caused by LA. Although INH-titer alone was insufficient to correctly identify patients with CFI, determination of CF-IgG appeared to be useful. In addition, even after INH-titer disappearance, hemorrhagic conditions recurred when CF-IgG was detected. These findings suggest that the presence of a clearance antibody against the coagulation factor might reduce the activity of that coagulation factor even after disappearance of the corresponding neutralizing antibody. Although the diagnosis and therapeutic efficacy can also be determined by INH-titer disappearance and improvement of corresponding coagulation factor activity, determination of CF-IgG by ELISA can improve the accuracy of these assessments.
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23
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Liu W, Xue F, Poon MC, Chen L, Jin Z, Zhang L, Yang R. Current status of haemophilia inhibitor management in mainland China: a haemophilia treatment centres survey on treatment preferences and real-world clinical practices. Br J Haematol 2021; 194:750-758. [PMID: 34340252 DOI: 10.1111/bjh.17677] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/12/2021] [Indexed: 01/26/2023]
Abstract
To investigate the current experience and expertise for haemophilia inhibitor patient management in haemophilia treatment centres (HTCs) in mainland China. Questionnaires were distributed to 'tertiary tier A' hospital HTCs across China to collect information on treatment preferences for bleeding control, prophylaxis and inhibitor eradication, as well as their regimens in real-world clinical practice. Of 40 questionnaires distributed, 39 were returned. In all, 38 were analysable for treatment preferences and 34 for actual clinical practice. For haemostatic treatment, 76·3% (29/38) HTCs preferred activated recombinant human Factor VII (rFVIIa). In clinical practice, the most widely used by-pass agent was prothrombin complex concentrate (26 HTCs). Although 65·8% (25/38) of HTCs believed prophylaxis treatment was necessary, it was prescribed in only 12. Similarly, 65·8% (25/38) of HTCs believed immune tolerance induction (ITI) therapy was necessary but only 14·8% (92/622) of patients in 19 HTCs received low-dose ITI treatment. HTCs in relatively economically developed cities (with higher-than-average per-capita gross domestic product) had better access to haemostatic treatment, coagulation testing and were more likely to provide prophylaxis and ITI in practice. The present survey showed there were gaps in haemophilia inhibitor care between the HTC physicians' preferences and their actual clinical practice. More specific care guidelines, education and clinical decision support tools are needed to guide clinical practice.
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Affiliation(s)
- Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Man-Chiu Poon
- Departments of Medicine, Pediatrics and Oncology, University of Calgary Cumming School of Medicine, Calgary, Canada.,Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Canada
| | - Lingling Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Zhaona Jin
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
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24
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Li Z, Chen Z, Liu G, Cheng X, Yao W, Huang K, Li G, Zhen Y, Wu X, Cai S, Poon M, Wu R. Low-dose immune tolerance induction alone or with immunosuppressants according to prognostic risk factors in Chinese children with hemophilia A inhibitors. Res Pract Thromb Haemost 2021; 5:e12562. [PMID: 34278191 PMCID: PMC8279128 DOI: 10.1002/rth2.12562] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/28/2021] [Accepted: 05/18/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND In developing countries, children with hemophilia A (HA) with high-titer inhibitor and poor immune tolerance induction (ITI) prognostic risk(s) cannot afford the recommended high- or intermediate-dose ITI. OBJECTIVES To determine the efficacy of low-dose ITI (plasma-derived factor VIII [FVIII]/von Willebrand factor at 50 FVIII IU/kg every other day) by itself (ITI-alone) or combined with immunosuppressants rituximab and prednisone (ITI-IS) in children with HA with high-titer inhibitor. METHODS All enrolled patients had pre-ITI inhibitor ≥10 BU. We used ITI-alone if inhibitor titer was <40 BU pre-ITI and during ITI, and ITI-IS if titer was ≥100 BU (historic) or ≥40 BU (pre- or during ITI) or if the patient was nonresponsive on ITI-alone. RESULTS Fifty-six children were analyzable, with median historic peak inhibitor titer 48.0 BU and followed for median 31.4 months. Overall, 35 (62.5%) achieved phase 2 success with negative inhibitor and normal FVIII recovery. The phase 2 success rate was 95% for the 20 patients receiving ITI-alone. For the 36 patients receiving ITI-IS, the phase 2 success rate was 44.4%, but would increase to 63.6% if the 14 patients with historic peak inhibitor titer ≥100 BU (and having phase 2 success rate of only 14.3%) were excluded. One patient developed repeated infection after IS treatment. Relapse occurred in 11.4% (4/35) patients with phase 2 success associated with rapid ITI dose reduction or irregular post-ITI FVIII prophylaxis. Our strategy reduced the cost from high-dose ITI by 74% to 90%. CONCLUSION The use of low-dose ITI with or without immunosuppressants according to ITI prognostic risk(s) is a clinically and economically feasible strategy for eradicating inhibitors in children with HA, particularly for those with historic peak inhibitor titer <100 BU.
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Affiliation(s)
- Zekun Li
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Zhenping Chen
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Guoqing Liu
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Xiaoling Cheng
- Department of Pharmacy, Beijing Children’s Hospital, National Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Wanru Yao
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Kun Huang
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Gang Li
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Yingzi Zhen
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Xinyi Wu
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Siyu Cai
- Center for Clinical Epidemiology and Evidence‐based MedicineCapital Medical UniversityBeijingChina
| | - Man‐Chiu Poon
- Departments of Medicine, Pediatrics and OncologySouthern Alberta Rare Blood and Bleeding Disorders Comprehensive Care ProgramFoothills HospitalAlberta Health ServicesUniversity of Calgary Cumming School of MedicineCalgaryABCanada
| | - Runhui Wu
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
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25
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Pasi KJ, Lissitchkov T, Mamonov V, Mant T, Timofeeva M, Bagot C, Chowdary P, Georgiev P, Gercheva‐Kyuchukova L, Madigan K, Van Nguyen H, Yu Q, Mei B, Benson CC, Ragni MV. Targeting of antithrombin in hemophilia A or B with investigational siRNA therapeutic fitusiran-Results of the phase 1 inhibitor cohort. J Thromb Haemost 2021; 19:1436-1446. [PMID: 33587824 PMCID: PMC8251589 DOI: 10.1111/jth.15270] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 01/19/2021] [Accepted: 02/09/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Fitusiran, an investigational small interfering RNA therapy, reduces antithrombin production to rebalance hemostasis in people with hemophilia A or B, with or without inhibitors. OBJECTIVES To evaluate the safety and efficacy of fitusiran treatment for people with moderate/severe hemophilia A or B with inhibitors. PATIENTS/METHODS In this open-label phase 1, part D study, 17 males with hemophilia A or B with inhibitors received three once-monthly subcutaneous injections of fitusiran 50 mg (n = 6) or 80 mg (n = 11); followed for up to 112 days. Endpoints included safety (primary), pharmacokinetics/pharmacodynamics (secondary), annualized bleeding rate, and patient-reported outcomes (exploratory). RESULTS The most common adverse event was injection site erythema (n = 8). No thrombotic events were reported. At nadir, mean (standard error of the mean [SEM]) antithrombin activity decreased from baseline by 82.0% (2.2) and 87.4% (0.7) in the 50 mg and 80 mg groups, respectively. Antithrombin reduction was associated with increased thrombin generation. 11/17 (64.7%) participants had no bleeds during the observation period (mean [standard deviation] 69.4 [16.3] days). Mean (SEM) changes from baseline in Haemophilia Quality of Life Questionnaire for Adults total (-9.2 [2.9]) and physical health (-12.3 [3.9]) domain scores suggested clinically meaningful improvement. CONCLUSIONS Monthly fitusiran was generally well tolerated, lowered antithrombin levels from baseline, and resulted in improved thrombin generation. These preliminary results suggest that monthly fitusiran treatment may reduce bleeding episodes and improve quality of life in participants with hemophilia A or B with inhibitors.
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Affiliation(s)
- K. John Pasi
- Royal London Haemophilia CentreBarts and The London School of Medicine and DentistryLondonUK
| | - Toshko Lissitchkov
- Clinic of HaematologyNational Specialized Hospital for Active Treatment of Haematologic DiseasesSofiaBulgaria
| | | | - Tim Mant
- IqviaReadingUK
- Guy's and St Thomas' NHS Foundation Trust and Kings College LondonLondonUK
| | - Margarita Timofeeva
- Federal State Budget Institution of Science “Kirov Scientific Research Institute of Hematology and Blood Transfusion of the Federal Medical‐Biological Agency"KirovRussia
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free London NHS Foundation TrustLondonUK
| | - Pencho Georgiev
- University Multiprofile Hospital for Active Treatment “Sveti Georgi” and Medical University PlovdivPlovdivBulgaria
| | | | | | | | | | | | | | - Margaret V. Ragni
- Department of MedicineUniversity of PittsburghPittsburghPAUSA
- Hemophilia Center of Western PennsylvaniaPittsburghPAUSA
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26
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Khair K, Chalmers E, Flannery T, Griffiths A, Rowley F, Tobaruela G, Chowdary P. Expert opinion on the UK standard of care for haemophilia patients with inhibitors: a modified Delphi consensus study. Ther Adv Hematol 2021; 12:20406207211007058. [PMID: 33995986 PMCID: PMC8111519 DOI: 10.1177/20406207211007058] [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: 02/08/2021] [Accepted: 03/03/2021] [Indexed: 11/22/2022] Open
Abstract
Background and Aims: Despite advances in haemophilia care, inhibitor development remains a significant complication. Although viable treatment options exist, there is some divergence of opinion in the appropriate standard approach to care and goals of treatment. The aim of this study was to assess consensus on United Kingdom (UK) standard of care for child and adult haemophilia patients with inhibitors. Methods: A modified Delphi study was conducted using a two-round online survey. A haemophilia expert steering committee and published literature informed the Round 1 questionnaire. Invited participants included haematologists, haemophilia nurses and physiotherapists who had treated at least one haemophilia patient with inhibitors in the past 5 years. Consensus for 6-point Likert scale questions was pre-defined as ⩾70% participants selecting 1–2 (disagreement) or 5–6 (agreement). Results: In all, 46.7% and 35.9% questions achieved consensus in Rounds 1 (n = 41) and 2 (n = 34), respectively. Consensus was reached on the importance of improving quality of life (QoL) and reaching clinical goals such as bleed prevention, eradication of inhibitors and pain management. There was agreement on criteria constituting adequate/inadequate responses to immune tolerance induction (ITI) and the appropriate factor VIII dose to address suboptimal ITI response. Opinions varied on treatment aims for adults and children/adolescents, when to offer prophylaxis with bypassing agents and expectations of prophylaxis. Consensus was also lacking on appropriate treatment for mild/moderate patients with inhibitors. Conclusion: UK healthcare professionals appear to be aligned on the clinical goals and role of ITI when managing haemophilia patients with inhibitors, although novel treatment developments may require reassessment of these goals. Lack of consensus on prophylaxis with bypassing agents and management of mild/moderate cases identifies a need for further research to establish more comprehensive, evidence-based treatment guidance, particularly for those patients who are unable/prefer not to receive non-factor therapies.
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Affiliation(s)
- Kate Khair
- Centre for Outcomes and Experience Research in Children's Health Illness and Disability (ORCHID), NIHR Biomedical Research Centre Great Ormond Street Hospital for Children, London, UK
| | - Elizabeth Chalmers
- Paediatric Haemophilia Comprehensive Care Centre, Royal Hospital for Sick Children, Glasgow, UK
| | - Thuvia Flannery
- Leeds Haemophilia Centre, St James' University Hospital, Leeds, UK
| | | | | | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, Pond Street, London, NW3 2QG, UK
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27
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Dolan G, Benson G, Bowyer A, Eichler H, Hermans C, Jiménez-Yuste V, Ljung R, Pollard D, Santagostino E, Šalek SZ. Principles of care for acquired hemophilia. Eur J Haematol 2021; 106:762-773. [PMID: 33527471 PMCID: PMC8252574 DOI: 10.1111/ejh.13592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 01/26/2021] [Indexed: 12/20/2022]
Abstract
Objective To establish clear priorities for the care of patients with acquired hemophilia A (AHA) by proposing 10 key principles of practical, holistic AHA management. Method These principles were developed by the Zürich Haemophilia Forum, an expert panel of European hemophilia specialists comprising physicians and nursing and laboratory specialists. Results The 10 proposed principles for AHA care are as follows: (a) Improving initial diagnosis of AHA; (b) Differential diagnosis of AHA: laboratory assessment of patients with unusual bleeding; (c) Effective communication between laboratories, physicians, and specialists; (d) Improving clinical care: networking between healthcare professionals in the treating hospital and specialist hemophilia centers; (e) Comprehensive assessment of bleeding; (f) Appropriate use of bypassing agents; (g) Long‐term follow‐up and monitoring for efficacy and safety of immunosuppressive treatment; (h) Inpatient/outpatient settings; (i) Access to innovative and disruptive treatments; (j) Promotion of international collaborative research. Conclusion The proposed principles for holistic AHA care aim to ensure swift diagnosis and optimal patient management. Key to achieving this goal is training for healthcare personnel in non‐specialist hospitals and collaboration between different specialists. We hope these principles will increase awareness of AHA in the wider medical community and catalyze efforts toward improving its practical, multidisciplinary management.
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Affiliation(s)
- Gerry Dolan
- Centre for Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - Gary Benson
- Haemophilia and Thrombosis Centre, Belfast City Hospital, Belfast, Northern Ireland
| | - Annette Bowyer
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, UK
| | - Hermann Eichler
- Institute of Clinical Haemostaseology and Transfusion Medicine, University and University Hospital of the Saarland, Homburg, Germany
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Victor Jiménez-Yuste
- Hospital Universitario La Paz, Unidad de Coagulopatías, Servicio de Hematología, Autonoma University, Madrid, Spain
| | - Rolf Ljung
- Department of Clinical Sciences - Pediatrics, Lund University, Lund, Sweden
| | - Debra Pollard
- Katharine Dormandy Haemophilia & Thrombosis Centre, Royal Free London NHS Foundation Trust, London, UK
| | - Elena Santagostino
- Fondazione IRCCS Cá Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Silva Zupančić Šalek
- University Hospital Centre Zagreb, School of Medicine, University of Osijek and Medical School University of Zagreb, Croatia
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Batty P, Riddell A, Kitchen S, Sardo Infirri S, Walker I, Woods T, Jennings I, Hart DP. Factor VIII/IX inhibitor testing practices in the United Kingdom: Results of a UKHCDO and UKNEQAS national survey. Haemophilia 2021; 27:490-499. [PMID: 33650732 DOI: 10.1111/hae.14158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 08/07/2020] [Accepted: 09/03/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Inhibitor formation is the greatest challenge facing persons with haemophilia treated with factor concentrates. The gold standard testing methodologies are the Nijmegen-Bethesda assay (NBA) for FVIII and Bethesda assay (BA) for FIX inhibitors, which are affected by pre-analytical and inter-laboratory variability. AIMS To evaluate inhibitor testing methodology and assess correlation between self-reported and actual methodology. METHODS Methodology was evaluated using a survey distributed alongside a UK National External Quality Assessment Service Blood Coagulation external quality assurance (EQA) exercise for FVIII and FIX inhibitor testing. RESULTS Seventy four survey and EQA exercise responses were received (response rate 63.2%), with 50 paired survey/EQA results. 47.1% (33/70) reported using the NBA and 42.9% (30/70) the BA for FVIII inhibitor testing. Review of FVIII inhibitor assay methodology demonstrated discrepancy (self-reported to actual) in 64.3% (BA reporting) and 27.6% (NBA reporting). Pre-analytical heat treatment was used by 32.4%, most commonly 56°C for 30 minutes. Assay cut-offs of 0.1-1.0 BU/mL were reported. EQA samples (acquired FVIII and congenital FIX) demonstrated titres and coefficients of variation (CV) of 3.1 BU/mL (0.7-15.4 BU/mL; CV = 43%) and 18.0 BU/mL (0-117 BU/mL; CV = 33%), respectively. No significant assay or laboratory factors were found to explain this variance, which could have resulted in change in management for 6 patients (5 misclassified high-titre FVIII inhibitors and 1 false negative for a FIX inhibitor). CONCLUSIONS Heterogeneity was seen at each stage of assay methodology. No assay-related factors were found to explain variation in inhibitor titres. Further standardization is required to improve inhibitor quantification to guide patient care.
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Affiliation(s)
- Paul Batty
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - Anne Riddell
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, London, UK
| | | | - Sofia Sardo Infirri
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | | | - Tim Woods
- UK NEQAS (Blood Coagulation), Sheffield, UK
| | | | - Daniel P Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
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29
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Sakai T, Azuma Y, Sano A, Sadamoto S, Tochigi N, Nagase D, Iyoda A. Perioperative Bypassing Agent Therapy for Pulmonary Pleomorphic Carcinoma with Acquired Hemophilia. Ann Thorac Cardiovasc Surg 2021; 28:302-306. [PMID: 33473052 PMCID: PMC9433887 DOI: 10.5761/atcs.cr.20-00257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 74-year-old man was admitted with lung cancer, and preoperative blood test showed abnormal activated partial thromboplastin time (APTT). Coagulation factor screening and APTT mixing test achieved a diagnosis of acquired hemophilia A (AHA). Bypassing agent therapy was indicated and lobectomy was successfully performed without bleeding complications. APTT returned to normal after the operation without any additional treatment for AHA. The pathogenesis of AHA is still unknown and there is no evidence for hemostatic strategy for AHA patients requiring surgery. This study supports the importance of hemostatic therapy and suggests that malignancy might cause AHA.
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Affiliation(s)
- Takashi Sakai
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Yoko Azuma
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Atsushi Sano
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Sota Sadamoto
- Department of Surgical Pathology, Toho University School of Medicine, Tokyo, Japan
| | - Naobumi Tochigi
- Department of Surgical Pathology, Toho University School of Medicine, Tokyo, Japan
| | - Daisuke Nagase
- Division of Hematology and Oncology, Department of Internal Medicine, Toho University School of Medicine, Tokyo, Japan
| | - Akira Iyoda
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
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30
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Blatný J, Kardos M, Miljic P, Bilić E, Benedik-Dolničar M, Faganel-Kotnik B, Konstantinov D, Kovalova Z, Ovesná P. Incidence of inhibitor development in PUPs with severe Haemophilia A in the CEE region between 2005 and 2015. Thromb Res 2020; 198:196-203. [PMID: 33360154 DOI: 10.1016/j.thromres.2020.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/05/2020] [Accepted: 12/09/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION This study analyses real-world data on 144 previously untreated patients (PUPs) with severe Haemophilia A, from seven countries in Central and Eastern Europe (CEE: Bulgaria, Croatia, Czech Republic, Hungary, Latvia, Serbia, and Slovenia), over a period of 11 years. It analyses the risk factors associated with development of inhibitors to factor VIII concentrates. METHODS Cox proportional hazard models were used to estimate the hazard risk of factors possibly influencing the development of inhibitors. Patients were followed for up to 100 exposure days (EDs). RESULTS Cumulative inhibitor incidence at the time of 100 EDs was 18.7%, slightly lower than the 25-35% incidence reported in most studies. Of PUPs who developed inhibitors, a majority (56%) developed them within the first 20 EDs and 88% by the 50th ED. FVIII class (recombinant or plasma-derived) did not influence the inhibitors' incidence rate (p = 0.64). We found a significant protective effect of prophylaxis compared to on-demand treatment (p = 0.003). PUPs who had an intensive peak treatment during the first 50 EDs were at significantly higher risk for inhibitor development (HR (95% CI) 5.3 (2.3-12.5), p < 0.001). CONCLUSION Inhibitors are and will continue to be the most significant complication of haemophilia treatment with factor concentrates. This is particularly true for haemophilia A. In our cohort, we were able to show that the treatment regimen used during first 50EDs influenced significantly the inhibitor risk, but the class of the factor concentrate did not play an important role. Real world data will remain one of the important resources for improving our knowledge of haemophilia.
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Affiliation(s)
- Jan Blatný
- Department of Paediatric Haematology, University Hospital and Masaryk University Brno, Czech Republic.
| | - Mária Kardos
- Department of Paediatrics, Mohács Hospital, Mohács, Hungary
| | - Predrag Miljic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia
| | - Ernest Bilić
- Department of Pediatrics, University Hospital Centre Zagreb, School of Medicine, Zagreb, Croatia
| | - Majda Benedik-Dolničar
- Unit for Haematology and Oncology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Barbara Faganel-Kotnik
- Unit for Haematology and Oncology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Dobrin Konstantinov
- Pediatric Hematology & Oncology Department, University Hospital "Tsaritsa Johanna-ISUL", Sofia, Bulgaria
| | - Zhanna Kovalova
- Department of Hematology and Oncology, Children's Clinical University Hospital, Riga, Latvia
| | - Petra Ovesná
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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31
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Brackmann HH, Schramm W, Oldenburg J, Cano V, Turecek PL, Négrier C. Origins, Development, Current Challenges and Future Directions with Activated Prothrombin Complex Concentrate for the Treatment of Patients with Congenital Haemophilia with Inhibitors. Hamostaseologie 2020; 40:606-620. [PMID: 32717751 PMCID: PMC7772007 DOI: 10.1055/a-1159-4273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/16/2020] [Indexed: 12/17/2022] Open
Abstract
Congenital haemophilia A (HA) is caused by deficiency of coagulation factor VIII (FVIII) activity, leading to spontaneous or traumatic bleeding events. While FVIII replacement therapy can treat and prevent bleeds, approximately 30% of patients with severe HA develop inhibitor antibodies that render FVIII replacement therapy ineffective. The bypassing agents (BPAs), activated prothrombin complex concentrate (aPCC) and recombinant activated FVII, first approved in 1977 and 1996, respectively, act to generate thrombin independent of pathways that involve factors IX and VIII. Both may be used in patients with congenital haemophilia and inhibitors (PwHIs) for the treatment and prevention of acute bleeds and quickly became standard of care. However, individual patients respond differently to different agents. While both agents are approved for on-demand treatment and perioperative management for patients with congenital haemophilia with inhibitors, aPCC is currently the only BPA approved worldwide for prophylaxis in PwHI. Non-factor therapies (NFTs) have a mechanism of action distinct from BPAs and have reported higher efficacy rates as prophylactic regimens. Nonetheless, treatment challenges remain with NFTs, particularly regarding the potential for synergistic action on thrombin generation with concomitant use of other haemostatic agents, such as BPAs, for the treatment of breakthrough bleeds and in perioperative management. Concomitant use of NFTs with other haemostatic agents could increase the risk of adverse events such as thromboembolic events or thrombotic microangiopathy. This review focuses on the origins, development and on-going role of aPCC in the evolving treatment landscape in the management of PwHI.
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Affiliation(s)
- Hans H. Brackmann
- Haemophilia Center, Institute of Experimental Haematology and Blood Transfusion, University of Bonn, Bonn, Germany
| | - Wolfgang Schramm
- Rudolf Marx-Stiftung für Hämostaseologie, Universität München and Bluterbetreuung Bayern e. V. (BBB) - Germany
| | - Johannes Oldenburg
- Haemophilia Center, Institute of Experimental Haematology and Blood Transfusion, University of Bonn, Bonn, Germany
| | - Viridiana Cano
- Shire International GmbH, a Takeda company, Zürich, Switzerland
| | | | - Claude Négrier
- Haemophilia and Thrombosis Centre, Louis Pradel Hospital, University Claude Bernard Lyon 1, Lyon, France
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32
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Abdi A, Kloosterman FR, Eckhardt CL, Male C, Castaman G, Fischer K, Beckers EAM, Kruip MJHA, Peerlinck K, Mancuso ME, Santoro C, Hay CR, Platokouki H, van der Bom JG, Gouw SC, Fijnvandraat K, Hart DP. The factor VIII treatment history of non-severe hemophilia A. J Thromb Haemost 2020; 18:3203-3210. [PMID: 32877570 PMCID: PMC7756346 DOI: 10.1111/jth.15076] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 08/01/2020] [Accepted: 08/18/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND In patients with non-severe hemophilia A, we lack detailed knowledge on the timing of treatment with factor VIII (FVIII) concentrates. This knowledge could provide information about the expected treatment timing in patients with severe hemophilia A treated with non-replacement therapies. OBJECTIVE To assess the FVIII treatment history in patients with non-severe hemophilia A. METHODS Patients with non-severe hemophilia (baseline FVIII activity [FVIII:C] 2-40 IU/dL) were included from the INSIGHT study. The primary outcome was median age at first FVIII exposure (ED1). In a subgroup of patients for whom more detailed information was available, we analyzed the secondary outcomes: median age at first 20 EDs, annualized bleeding rate for all bleeds (ABR), joint bleeds (AJBR), and major spontaneous bleeds (ASmBR). RESULTS In the total cohort (n = 1013), median baseline FVIII activity was 8 IU/dL (interquartile range [IQR] 4-15) and the median age at ED1 was 3.7 years (IQR 1.4-7.7). Median age at ED1 rose from 2.5 years (IQR 1.2-5.7) in patients with FVIII:C 2-5 IU/dL to 9.7 years (IQR 4.8-16.0) in patients with FVIII:C 25-40 IU/dL. In the subgroup (n = 104), median age at ED1, ED5, ED10, and ED20 was 4.0 years (IQR 1.4-7.6), 5.6 years (IQR 2.9-9.3), 7.5 years (IQR 4.4-11.3), and 10.2 years (IQR 6.5-14.2), respectively. Median ABR, AJBR, and ASmBR were 1.1 (IQR 0.5-2.6), 0.3 (IQR 0.1-0.7), and 0 (IQR 0-0), respectively. CONCLUSION This study demonstrates that in non-severe hemophilia A, the age at first FVIII exposure increases with baseline FVIII:C and that major spontaneous bleeds rarely occur.
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Affiliation(s)
- Amal Abdi
- Department of Pediatric HematologyEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Fabienne R. Kloosterman
- Department of Pediatric HematologyEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Corien L. Eckhardt
- Department of Pediatric HematologyEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
| | - Christoph Male
- Department of PediatricsMedical University of ViennaViennaAustria
| | - Giancarlo Castaman
- Department of OncologyCenter for Bleeding DisordersCareggi University HospitalFlorenceItaly
| | - Kathelijn Fischer
- Van CreveldkliniekUniversity Medical Center UtrechtUtrechtthe Netherlands
| | - Erik A. M. Beckers
- Department of HematologyMaastricht University Medical CenterMaastrichtthe Netherlands
| | | | - Kathelijne Peerlinck
- Department of Cardiovascular SciencesHemophilia CenterUniversity of LeuvenUniversity Hospitals LeuvenLeuvenBelgium
| | - Maria Elisa Mancuso
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca' GrandaOspedale Maggiore PoliclinicoMilanItaly
| | | | - Charles R. Hay
- Department of HematologyManchester Royal InfirmaryManchester UniversityManchesterUK
| | - Helen Platokouki
- Haemophilia Centre‐Haemostasis UnitAghia Sophia Children's HospitalAthensGreece
| | - Johanna G. van der Bom
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Center for Clinical Transfusion ResearchSanquin ResearchLeidenthe Netherlands
| | - Samantha C. Gouw
- Department of Pediatric HematologyEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric HematologyEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
- Department of Molecular Cellular HemostasisSanquin Research and Landsteiner LaboratoryAmsterdamthe Netherlands
| | - Dan P. Hart
- The Royal London Haemophilia CentreQMULBarts and the London School of Medicine and DentistryLondonUK
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33
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Comerford C, Crowley M, Collins N, Booth-Fleming B, Ryan-Hall A, Firtear B, O'Shea S, Duggan C. Inhibitor development in an elderly patient with severe factor IX deficiency being treated with ALPROLIX, a recombinant factor IX Fc fusion protein. Haemophilia 2020; 27:e484-e486. [PMID: 33215798 DOI: 10.1111/hae.14198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/07/2020] [Accepted: 10/26/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Claire Comerford
- Haemophilia Comprehensive Care Centre, Cork University Hospital, Cork, Ireland
| | - Maeve Crowley
- Haemophilia Comprehensive Care Centre, Cork University Hospital, Cork, Ireland
| | - Norma Collins
- Haemophilia Comprehensive Care Centre, Cork University Hospital, Cork, Ireland
| | - Brid Booth-Fleming
- Haemophilia Comprehensive Care Centre, Cork University Hospital, Cork, Ireland
| | - Annmarie Ryan-Hall
- Haemophilia Comprehensive Care Centre, Cork University Hospital, Cork, Ireland
| | - Brid Firtear
- Haemophilia Comprehensive Care Centre, Cork University Hospital, Cork, Ireland
| | - Susan O'Shea
- Haemophilia Comprehensive Care Centre, Cork University Hospital, Cork, Ireland
| | - Cleona Duggan
- Haemophilia Comprehensive Care Centre, Cork University Hospital, Cork, Ireland
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34
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Chuansumrit A, Sirachainan N, Natesirinilkul R, Srikala K, Masaya-Anon N. Real-world evidence on health resource use among patients with haemophilia and inhibitor exhibiting severe bleeding episodes. Haemophilia 2020; 27:69-80. [PMID: 33216428 DOI: 10.1111/hae.14194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/08/2020] [Accepted: 10/21/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE This study aimed to explore real-world evidence on health resource use (HRU) spending on patients with haemophilia and inhibitor. MATERIALS AND METHODS Medical records from 1990 to 2019 of patients with haemophilia and inhibitor from three comprehensive haemophilia treatment centres were retrospectively retrieved. RESULTS In all, 31 patients with haemophilia (A = 30, B = 1) and inhibitor ≥5 BU were included. The mean initial inhibitor of 95.4 BU was detected at the mean age of 6.7 years. The mean number of annual hospitalisations was 3.9. A total of 795 bleeding episodes (major =125, minor =670) were evaluated. The treatment included bypassing agents or plasma exchange before administering high-dose factor VIII concentrate and intervention or surgery. Six patients succumbed to bleeding at the mean age of 17.2 years. Nineteen surviving patients experienced multiple morbidity except six patients with successful and partially successful immune tolerance induction (ITI). The mean (SD) annual total medical consumption for episodic treatment and successful ITI per patient with haemophilia A were 30,804 (81,332) USD and 55,531 (100,566) USD, respectively. Only episodic treatment was paid by the government budget for limited amounts of bypassing agents. CONCLUSION Management for patients with haemophilia and inhibitor exhibiting severe bleeding is challenging for medical personnel in countries having limited resources over decades. The real-world data will be used to negotiate with the government to increase budget for adequate bypassing agents or nonreplacement therapy and to include ITI in the national haemophilia treatment.
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Affiliation(s)
- Ampaiwan Chuansumrit
- Department of Paediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Department of Paediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Kwannut Srikala
- Department of Paediatrics, Sunprasitthiprasong Hospital, Ubon Ratchathani, Thailand
| | - Narongrit Masaya-Anon
- Sirikit Medical Centre, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Zheng J, Chen K, Liu F, Deng Y, Mao Z, Lv J, Xu Y, Chen B. Treatment of pelvic haemophilic pseudotumour: A retrospective study. Haemophilia 2020; 26:e308-e314. [PMID: 33141490 DOI: 10.1111/hae.14148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/29/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The incidence of a pelvic haemophilic pseudotumour is very low and is rarely seen in the clinic. Due to the lack of clear treatment standards, patients often suffer from the condition over a protracted period. The aim of this retrospective study was to present our institutional experience in the treatment of pelvic haemophilic pseudotumours over the past 8 years. METHODS We retrospectively analysed patients with a pelvic haemophilic pseudotumour who were treated in the Nanfang hospital between February 2012 and December 2019. The type and severity of haemophilia, the presence of inhibitors, comorbidities, pseudotumour imaging data, treatment and follow-up results were recorded and analysed. RESULTS Pelvic pseudotumours were identified in seven patients with haemophilia. Three patients had severe haemophilia, three had moderate haemophilia, one had mild haemophilia and inhibitors were present in two patients. Transfusion-related infectious diseases were noted in three patients. Spontaneous rupture and infection of the pseudotumour occurred in five patients. In addition, five patients underwent surgical treatment, two of whom healed well, two patients suffered recurrence of the pseudotumour, and one patient developed a postoperative haematoma twice. Two patients were treated conservatively, one of whom was unable to walk because of progression of the disease, while the other died from severe bleeding and infection. CONCLUSIONS Once a pelvic haemophilic pseudotumour is diagnosed, surgical resection should be performed as soon as possible. A delay in diagnosis and suboptimal treatment may lead to complications of the pelvic haemophilic pseudotumour.
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Affiliation(s)
- Jianxiong Zheng
- Devision of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Keyu Chen
- Devision of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fei Liu
- Devision of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yihang Deng
- Devision of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zexiong Mao
- Devision of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jiaxin Lv
- Devision of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yaowen Xu
- Department of Health Management, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Bin Chen
- Devision of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Baker P, Platton S, Gibson C, Gray E, Jennings I, Murphy P, Laffan M. Guidelines on the laboratory aspects of assays used in haemostasis and thrombosis. Br J Haematol 2020; 191:347-362. [PMID: 32537743 DOI: 10.1111/bjh.16776] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Peter Baker
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sean Platton
- Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Claire Gibson
- Specialist Haemostasis, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elaine Gray
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Controls, Hertfordshire, UK
| | | | - Paul Murphy
- Department of Haematology, the Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mike Laffan
- Centre for Haematology, Imperial College and Hammersmith Hospital, London, UK
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37
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Escuriola-Ettingshausen C, Auerswald G, Königs C, Kurnik K, Scholz U, Klamroth R, Oldenburg J. Optimizing the management of patients with haemophilia A and inhibitors in the era of emicizumab: Recommendations from a German expert panel. Haemophilia 2020; 27:e305-e313. [PMID: 32937002 DOI: 10.1111/hae.14010] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
Standard treatment of haemophilia A is based on replacing the missing coagulation factor VIII (FVIII) to treat and prevent bleeding episodes. The most challenging complication of FVIII therapy is the development of neutralizing antibodies (inhibitors) that can render treatment ineffective. Eradication of the inhibitor through immune tolerance induction (ITI) remains the most effective strategy for managing these patients. Bypassing agents can be used to help restore haemostasis in inhibitor patients. Several novel agents have recently been developed, such as the FVIII mimetic agent emicizumab, which has been effective in reducing the annualized bleeding rate in haemophilia A patients with inhibitors. When coadministered with repetitive high doses of activated prothrombin complex concentrate (ie >100 U/kg/d for ≥24 hours), emicizumab was associated with thrombotic microangiopathy and thrombosis events. As a consequence the United Kingdom Haemophilia Centres Doctors' Organisation (UKHCDO) issued the first guidance on the treatment of bleeding episodes in patients receiving emicizumab. To build on and extend this work, a panel of German haemophilia specialists met to discuss the UK guidance, review current evidence and provide additional guidance for German healthcare professionals on how to optimize the management of patients with haemophilia A receiving emicizumab. Recommendations are provided on the use of bypassing and other agents to manage breakthrough bleeding, ITI in the emicizumab era, haemostatic support during surgery and issues relating to laboratory monitoring.
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Affiliation(s)
| | - Günter Auerswald
- Department of Comprehensive Care in Haemostasis and Thrombosis, Professor Hess Children's Hospital, Bremen, Germany
| | - Christoph Königs
- Department of Pediatrics and Adolescent Medicine, Centre for Hemostasis, University Hospital Frankfurt, Frankfurt, Germany
| | - Karin Kurnik
- Department of Paediatric Haemostasis, University Children's Hospital, Munich, Germany
| | | | - Robert Klamroth
- Department for Internal Medicine, Vascular Medicine and Haemostaseology, Vivantes Klinikum, Berlin, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
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38
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Gandhi T, Lawler P, Foxton E, Chowdary P, Riddell A. Clinical utility of sample preheat treatment in a modified Nijmegen-Bethesda assay (mNBA) for inhibitor monitoring in congenital and acquired haemophilia A: A single-centre four-year experience. Haemophilia 2020; 26:e300-e307. [PMID: 32892451 DOI: 10.1111/hae.14090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Laboratory monitoring for factor VIII inhibitors ideally requires samples with the lowest possible factor VIII (FVIII) level, potentially challenging in patients with congenital haemophilia A (CHA) receiving regular prophylaxis and acquired haemophilia A (AHA) patients with endogenous FVIII. Inactivation of FVIII by preheating (preheat treatment, PHT) of patient plasma has been suggested to facilitate monitoring. AIM To evaluate the clinical utility of PHT prior to inhibitor analysis by modified Nijmegen-Bethesda assay (mNBA) in patients with CHA and AHA. METHODS Inhibitor screening by mNBA under standard conditions and with PHT at 56°C for 30, 60 and 90 minutes was evaluated. FVIII inhibitor results between 2007 and 2010 without PHT (720 results from 222 CHA and AHA patients), and between 2011 and 2014 post-PHT (1102 results from 302 patients) were available for analysis. RESULTS Of total 1822 results available, 61% were from severe HA patients, 22% from mild and moderate HA and 16% from AHA. Pre-PHT, 74% of samples were analysed by the mNBA, and the remaining 26% were not tested as FVIII levels were >20 IU/dL as per local protocol. Postintroduction of PHT (90 and 60 minutes), 96% of samples received were analysed for an inhibitor. Post-PHT in patients with AHA (n = 26), 69% of samples tested with factor VIII levels >20 IU/dL were found to have detectable inhibitor. CONCLUSION FVIII inhibitor testing using PHT at 56°C for 60 minutes facilitates inhibitor surveillance of CHA on prophylaxis. Potentially, 30 minutes at 56°C might be equally efficacious. In AHA receiving immunosuppression, monitoring of inhibitor titre after initial factor VIII response might enable personalized immunosuppression.
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Affiliation(s)
- Tejas Gandhi
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London, UK
| | - Pura Lawler
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London, UK
| | - Eleanor Foxton
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia & Thrombosis Centre, Royal Free Hospital, London, UK
| | - Anne Riddell
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London, UK
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Kwak J, Mazzeffi M, Boggio LN, Simpson ML, Tanaka KA. Hemophilia: A Review of Perioperative Management for Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 36:246-257. [DOI: 10.1053/j.jvca.2020.09.118] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 02/08/2023]
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40
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Levy‐Mendelovich S. Emicizumab for infants and children with haemophilia A. Br J Haematol 2020; 191:145-146. [DOI: 10.1111/bjh.16965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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41
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Acquired Haemophilia A: An Intriguing Disease. Mediterr J Hematol Infect Dis 2020; 12:e2020045. [PMID: 32670523 PMCID: PMC7340240 DOI: 10.4084/mjhid.2020.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/18/2020] [Indexed: 12/31/2022] Open
Abstract
Abstract. Acquired Haemophilia A is a rare acquired bleeding disorder caused by Factor VIII autoantibodies, which neutralise FVIII activity. These inhibitors differ from alloantibodies against FVIII, which can occur in congenital Haemophilia A after repeated exposures to plasma-derived or recombinant FVIII products. In most cases, the disease occurs suddenly in subjects without a personal or familiar history of bleedings, with symptoms that may be mild, moderate, or severe. However, only laboratory alterations are present in ~ 30% of patients. The incidence varies from 1 to 4 cases per million/year; more than 80% of patients are elderly, males and females are similarly affected. There is a small peak of incidence related to pregnancy in young women aged 20–40 years. The disease may be underdiagnosed in the elderly. The diagnostic algorithm is based on an isolated prolonged activated partial thromboplastin time, normal thrombin time, absence of Lupus Anticoagulant, and a mixing test that reveals the presence of an inhibitor: the finding of reduced FVIII activity and the detection of neutralising autoantibodies against FVIII lead to the diagnosis. The disease is idiopathic in 44%–63% of cases, while in the others etiological factors are present. Bleeding prevention and treatment are based on therapeutic tools as by-passing agents, recombinant porcine FVIII concentrate or, in a limited number of cases, FVIII concentrates and desmopressin. As soon as the diagnosis has been made, immunosuppressive therapy must be started to eradicate the inhibitor. Better knowledge of the disease, optimal management of bleeding and eradication of the inhibitor have significantly reduced morbidity and mortality in most patients.
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van den Berg HM, Mancuso ME, Königs C, D'Oiron R, Platokouki H, Mikkelsen TS, Motwani J, Nolan B, Santagostino E. ITI Treatment is not First-Choice Treatment in Children with Hemophilia A and Low-Responding Inhibitors: Evidence from a PedNet Study. Thromb Haemost 2020; 120:1166-1172. [PMID: 32572865 DOI: 10.1055/s-0040-1713097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Limited data exist on the clinical impact of low-responding inhibitors and the requirement for immune tolerance induction (ITI) treatment to establish tolerance, reduce bleeding, and improve outcome. The aim of this article is to describe the therapeutic management of children with severe hemophilia A and low-responding inhibitors and its effect on bleeding phenotype. METHODS The REMAIN (Real-life Management of Inhibitors) study is a satellite study of the PedNet registry. It included unselected children with severe hemophilia A (factor VIII [FVIII] < 0.01 IU/mL) born between January 1, 1990 and December 31, 2009 who developed clinically relevant inhibitors and were followed-up for at least 3 years after the first positive inhibitor test. RESULTS A total of 260 patients with inhibitors were identified and 68 of them (26%) had low-responding inhibitors (peak < 5 BU/mL). Five patients were lost to follow-up and 63 were included in this study. The median follow-up was 3.7 years (interquartile range: 3.0-7.5). ITI was started in 51/63 (81%) patients. The median time from ITI start to first negative inhibitor titer was similar with low-dose and high-dose ITI regimens (2.5 and 3.1 months, respectively). Ten of the 12 patients who did not receive ITI were treated with regular prophylaxis and reached a negative titer after a median of 6.5 months. Bleeding rate was low in all patients with no difference between treatment regimens. CONCLUSION In children with low-responding inhibitors negative titers were reached with regular FVIII treatment irrespective of the regimen (i.e., prophylaxis or ITI).
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Affiliation(s)
| | - Maria Elisa Mancuso
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
| | - Christoph Königs
- Department of Paediatrics and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Roseline D'Oiron
- Centre de Référence pour le Traitement des Maladies Hémorragiques, Hôpital Bicêtre, Paris, France
| | - Helen Platokouki
- Haemophilia Centre, Haemostasis Unit, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Torben Stamm Mikkelsen
- Division of Pediatric and Adolescent Medicine, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Jayashree Motwani
- Haematology Department, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | | | - Elena Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
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Rayment R, Chalmers E, Forsyth K, Gooding R, Kelly AM, Shapiro S, Talks K, Tunstall O, Biss T. Guidelines on the use of prophylactic factor replacement for children and adults with Haemophilia A and B. Br J Haematol 2020; 190:684-695. [PMID: 32390158 DOI: 10.1111/bjh.16704] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/04/2020] [Accepted: 04/08/2020] [Indexed: 01/19/2023]
Affiliation(s)
| | | | | | | | - Anne M Kelly
- Cambridge University Hospitals NHS foundation Trust, Cambridge, UK
| | - Susan Shapiro
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kate Talks
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Oliver Tunstall
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Tina Biss
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Gene-based FVIIa prophylaxis modulates the spontaneous bleeding phenotype of hemophilia A rats. Blood Adv 2020; 3:301-311. [PMID: 30705032 DOI: 10.1182/bloodadvances.2018027219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/07/2019] [Indexed: 11/20/2022] Open
Abstract
A sizable proportion of hemophilia inhibitor patients fails immune tolerance induction and requires bypass agents for long-term bleed management. Recombinant human-activated coagulation Factor VII (rhFVIIa) is an on-demand bypass hemostatic agent for bleeds in hemophilia inhibitor patients. Prophylactic use of rhFVIIa may enable sustained hemostatic management of inhibitor patients, but the critical relationship of rhFVIIa circulating levels and clinical outcome in that setting remains unclear. To address this in vivo, we used the rat hemophilia A (HA) model that exhibits spontaneous bleeds and allows longitudinal studies with sufficient statistical power. We simulated activated Factor VII (FVIIa) prophylaxis by adeno-associated virus (AAV) gene transfer of a rat FVIIa transgene. Compared with naive HA animals, rat FVIIa continuous expression affected the overall observed bleeds, which were resolved with on-demand administration of recombinant rat FVIIa. Specifically, although 91% of naive animals exhibited bleeds, this was reduced to 83% and 33% in animals expressing less than 708 ng/mL (<14 nM) and at least 708 ng/mL (≥14 nM) rat FVIIa, respectively. No bleeds occurred in animals expressing higher than 1250 ng/mL (>25 nM). Rat FVIIa expression of at least 708 ng/mL was also sufficient to normalize the blood loss after a tail vein injury. Continuous, AAV-mediated rat FVIIa transgene expression had no apparent adverse effects in the hemostatic system of HA rats. This work establishes for the first time a dose dependency and threshold of circulating FVIIa antigen levels for reduction or complete elimination of bleeds in a setting of FVIIa-based HA prophylaxis.
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De la Corte-Rodriguez H, Rodriguez-Merchan EC, Alvarez-Roman MT, Martin-Salces M, Jimenez-Yuste V. 'Do not Do' Recommendations in Hemophilia. Cardiovasc Hematol Disord Drug Targets 2020; 20:168-174. [PMID: 32133968 DOI: 10.2174/1871529x20666200305111323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/20/2020] [Accepted: 02/17/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND It is important to discard those practices that do not add value. As a result, several initiatives have emerged. All of them try to improve patient safety and the use of health resources. PURPOSE To present a compendium of "do not do recommendations" in the context of hemophilia. METHODS A review of the literature and current clinical guidelines has been made, based on the best evidence available to date. RESULTS The following 13 recommendations stand out: 1) Do not delay the administration of factor after trauma; 2) do not use fresh frozen plasma or cryoprecipitate; 3) do not use desmopressin in case of hematuria; 4) do not change the product in the first 50 prophylaxis exposures; 5) do not interrupt immunotolerance; 6) do not administer aspirin or NSAIDs; 7) do not administer intramuscular injections; 8) do not do routine radiographs of the joint in case of acute hemarthrosis; 9) Do not apply closed casts for fractures; 10) do not discourage the performance of physical activities; 11) do not deny surgery to a patient with an inhibitor; 12) do not perform instrumental deliveries in fetuses with hemophilia; 13) do not use factor IX (FIX) in patients with hemophilia B with inhibitor and a history of anaphylaxis after administration of FIX. CONCLUSION The information mentioned previously can be useful in the management of hemophilia, from different levels of care. As far as we know, this is the first initiative of this type regarding hemophilia.
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Perioperative laboratory monitoring in congenital haemophilia patients with inhibitors: a systematic literature review. Blood Coagul Fibrinolysis 2020; 30:309-323. [PMID: 31397688 DOI: 10.1097/mbc.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
: Although the use of clotting factor concentrates is the mainstay of haemophilia care, the development of inhibitors complicates disease management. Perioperative management of patients with inhibitors is therefore a challenge. A systematic literature review was performed to identify literature reporting on the perioperative monitoring and management of haemophilia. MEDLINE, Embase and Cochrane databases were searched from database inception to 26 March 2018. Recent congress proceedings were also searched. Titles and abstracts, then full texts, were screened for relevance by two reviewers. Quality of included studies was assessed using the Critical Appraisal Skills Programme checklist. Of the 2033 individual entries identified, 86 articles met the inclusion criteria. The identified studies were screened again to find articles reporting perioperative laboratory monitoring in patients with congenital haemophilia A or B, resulting in 24 articles undergoing data extraction. Routine perioperative assay monitoring practices were the most commonly reported (n = 20/24); thrombin generation assay was the least commonly reported (n = 2/24). Other monitoring practices described were factor VII and factor VIII coagulation activity (n = 8/24, n = 5/24, respectively), and thromboelastography or rotational thromboelastometry assessments (n = 3/24). The impact of monitoring on treatment decisions was, however, rarely reported. In conclusion, many methods of perioperative monitoring of haemophilia patients with inhibitors have been identified in this review, yet there is a lack of reporting in larger scale cohort studies. More detailed reporting on the impact of monitoring outcomes on treatment decisions is also needed to share best practice, particularly as new therapeutic agents emerge.
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Okamoto S, Suzuki N, Suzuki A, Suzuki S, Tamura S, Suzuki M, Takahashi N, Kojima T, Kanematsu T, Kojima T, Kiyoi H, Ishiguro N, Matsushita T. Successful Perioperative Combination of High-Dose FVIII Therapy Followed by Emicizumab in a Patient with Hemophilia A with Inhibitors. TH OPEN 2019; 3:e364-e366. [PMID: 31815248 PMCID: PMC6894946 DOI: 10.1055/s-0039-3401001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/25/2019] [Indexed: 12/26/2022] Open
Abstract
We managed perioperative hemostasis for a 72-year-old man with hemophilia A and low inhibitor titers (3 BU/mL), who underwent osteosynthesis for supracondylar fracture of the left humerus. He was treated perioperatively using the combination of high doses of factor VIII (FVIII) with recombinant human Factor VIII Fc fusion protein (rFVIIIFc), followed by emicizumab. On the day of surgery (day 0), he was administered bolus infusion of 150 IU/kg rFVIIIFc, followed by continuous infusion at a dose of 4 IU/kg/h. Emicizumab, 3 mg/kg, was injected subcutaneously once a week, on days 5, 12, 19, and 26. Inhibitors were detected on day 6 at a titer of 4 BU/mL and FVIII:C decreased to below assay sensitivity limits on day 10. The rate of increase in inhibitor titers was high, with inhibitors increasing to 343.4 BU/mL on day 14. The transition of thrombin production by thrombin generation assay (TGA) showed temporary decrease in thrombin production on day 7, although it was restored by day 10, i.e., five days after commencement of emicizumab therapy. Rotational thromboelastometry displayed consistent results with TGA, showing that clotting time was prolonged and the alpha angle decreased to less than measurable levels on day 6, although they were improved by day 10. There were no bleeding-related events or other adverse events throughout the perioperative period. In conclusion, emicizumab was effective for the management of perioperative hemostasis after development of an anamnestic response in a patient with hemophilia A with inhibitors. Combination therapy with high doses of FVIII followed by emicizumab could be a workable alternative for patients with hemophilia A with inhibitors.
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Affiliation(s)
- Shuichi Okamoto
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuaki Suzuki
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Atsuo Suzuki
- Department of Medical Technique, Nagoya University Hospital, Nagoya, Japan
| | - Sachiko Suzuki
- Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Nursing and Health, Aichi Prefectural University, Aichi, Japan
| | - Shogo Tamura
- Department of Orthopaedics/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mochihito Suzuki
- Department of Orthopaedics/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobunori Takahashi
- Department of Orthopaedics/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshihisa Kojima
- Department of Orthopaedics/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Kanematsu
- Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan
| | - Tetsuhito Kojima
- Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hitoshi Kiyoi
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Ishiguro
- Department of Orthopaedics/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan.,Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan
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Hart DP, Kessler CM, Aledort L. Re-personalization and stratification of hemophilia care in an evolving treatment landscape. Hematology 2019; 24:737-741. [DOI: 10.1080/16078454.2019.1687798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
- Daniel P. Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine, QMUL, London, UK
| | - Craig M. Kessler
- Division of Hematology and Oncology (MedStar), Georgetown University, Washington, DC, USA
| | - Lou Aledort
- Mount Sinai School of Medicine, New York, NY, USA
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Li Z, Chen Z, Cheng X, Wu X, Li G, Zhen Y, Cai S, Poon M, Wu R. Low-dose immune tolerance induction for children with hemophilia A with poor-risk high-titer inhibitors: A pilot study in China. Res Pract Thromb Haemost 2019; 3:741-748. [PMID: 31624794 PMCID: PMC6781932 DOI: 10.1002/rth2.12248] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 06/12/2019] [Accepted: 06/18/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Immune tolerance induction (ITI) therapy is currently unaffordable in China. Management of hemophilia A children with high-titer inhibitor is therefore a challenge. AIM To describe the ITI strategy using plasma-derived factor VIII/von Willebrand factor concentrate (pdFVIII/VWF) +/- immunosuppression and to report its efficacy in children with hemophilia A having poor-risk status for ITI success. METHODS A prospective pilot study on children with hemophilia A having poor-risk status (all with at least inhibitor titer > 10 BU pre-ITI initiation). Patients received ~50 IU/kg FVIII every other day using domestic intermediate purity pdFVIII/VWF products, either alone or in combination with rituximab +/- prednisone. RESULTS Sixteen patients with median age 2.9 (range, 2.2-13.2) years and median pre-ITI inhibitor titer 30.7 (range, 10.4-128) BU were enrolled. Analysis at median 14.7 (range, 12.4-22.6) months' follow-up showed a total response rate of 87.5%. This included success (achieving inhibitor < 0.6 BU) in 13 patients (81.3%) in a median of 8.8 (range, 3.2-11.8) months, and partial success (achieving inhibitor < 5 BU but > 0.6BU) in 1 (6.3%). Compared to the pre-ITI period, the mean bleeds/month during ITI was 0.51 (64.0% reduction), and joint bleeds/month was 0.34 (64.3% reduction). This low-dose ITI strategy cost less by 70% to 87% than that for the high-dose FVIII regimen. No severe adverse events were observed. CONCLUSION This low-dose ITI strategy of pdFVIII/VWF +/- immunosuppression achieved relatively satisfactory outcomes in children with hemophilia A inhibitor having poor-risk status. This low-dose regimen showed economic advantages and is therefore suitable for using in China. However, further study in a larger cohort with a longer follow-up time is needed.
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Affiliation(s)
- Zekun Li
- Hemophilia Work GroupHematology Oncology CenterBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Zhenping Chen
- Hemophilia Work GroupHematology Oncology CenterBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Xiaoling Cheng
- Hemophilia Work GroupHematology Oncology CenterBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Xinyi Wu
- Hemophilia Work GroupHematology Oncology CenterBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Gang Li
- Hemophilia Work GroupHematology Oncology CenterBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Yingzi Zhen
- Hemophilia Work GroupHematology Oncology CenterBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Siyu Cai
- Epidemiology DepartmentBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Man‐Chiu Poon
- Departments of Medicine, Pediatrics and OncologyUniversity of Calgary Cumming School of Medicine, and Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care ProgramFoothills HospitalAlberta Health ServicesCalgaryAlbertaCanada
| | - Runhui Wu
- Hemophilia Work GroupHematology Oncology CenterBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
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Acquired Hemophilia A (FVIII Deficiency) Associated with Papillary Thyroid Cancer: Treatment with Recombinant Porcine FVIII. Case Rep Hematol 2019; 2019:9026121. [PMID: 31559096 PMCID: PMC6735189 DOI: 10.1155/2019/9026121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/08/2019] [Indexed: 12/05/2022] Open
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune disorder caused by autoantibodies against Factor VIII (FVIII). It has a high mortality due to bleeding complications. FVIIa-based bypassing agents are the first line of treatment but not always effective. Recombinant porcine (rp) FVIII (Obizur®) was recently approved for rescue treatment but with little evidence-based information regarding efficacy. We report a case of papillary thyroid cancer associated with AHA malignancy that responded to a single dose of rpFVIII after failure to achieve hemostasis with FVIIa-based bypassing products.
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