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Rabichow L, Dinh J, Nguyen L, Qiao J. In vitro differential inhibition of the factor XI activity assay in the setting of a lupus anticoagulant. Blood Coagul Fibrinolysis 2024; 35:217-222. [PMID: 38358905 DOI: 10.1097/mbc.0000000000001287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Acquired factor XI deficiencies due to factor-specific inhibitors are rare and may be associated with lupus anticoagulant. We report a 63-year-old male with suspected postsurgical bleeding, prior surgical site infection, an isolated prolonged activated partial thromboplastin time, and a positive lupus anticoagulant. Although the factor II assay was normal, factor VIII and IX assays initially demonstrated nonparallelism with factor activity that consistently increased to normal reference ranges with serial dilutions. A discrepancy in factor XI activity results was discovered when the in-house method demonstrated undetectable activity (<3%); send-out testing using different instrument/reagent combinations revealed the presence of factor XI activity between 70% and 76%. The patient received surgical follow-up and was subsequently discharged home. Given the differential in vitro inhibition of factor XI activity on our initial in-house testing, this case highlights the importance of recognizing factor assay interference in the presence of a known lupus anticoagulant inhibitor, with strategies to mitigate potentially erroneous results.
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Affiliation(s)
| | | | | | - Jesse Qiao
- Department of Pathology and Laboratory Medicine, University of California, Irvine, Orange, California, USA
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Gupta D, Arya V, Dass J, Gupta N, Kalra M, Sachdeva A, Kotwal J. Assessment of the phenotypic severity of hemophilia A: using rotational thromboelastometry (ROTEM) and APTT-clot waveform analysis. Blood Res 2024; 59:19. [PMID: 38743166 PMCID: PMC11093952 DOI: 10.1007/s44313-024-00018-6] [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: 10/21/2023] [Accepted: 04/01/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Hemophilia A (HA) is an X-linked inherited bleeding disorder caused by reduced factor VIII (FVIII) levels. Approximately 10-15% of patients with severe HA (SHA) do not present with the anticipated bleeding pattern. Here, we assessed the phenotypic severity of hemophilia A using rotational thromboelastometry (ROTEM) and activated partial thromboplastin time-clot waveform analysis (APTT-CWA). METHODS Patients diagnosed with hemophilia A were enrolled. Clinical phenotype assignment was performed according to the published literature, and patients were classified into four phenotypic subgroups. The whole blood sample was first run on ROTEM in INTEM mode using platelet-poor plasma, APTT was run, and the APTT-CWA graph was simultaneously recorded. RESULTS A total of 66 patients were recruited for this study. Statistically significant differences were observed between the four phenotypically categorized groups using ROTEM and APTT-CWA. On comparing patients with mild/moderate-to-severe phenotypes (Group II) with SHA without inhibitors (Group IV), no significant difference was found for all parameters of ROTEM or APTT-CWA. The MCF, MA30, MAXV, and Alpha angle values using ROTEM were found to be the lowest in patients with SHA with inhibitors, which helped differentiate them from those with SHA without inhibitors. However, these two groups could not be differentiated using the APTT-CWA parameters. CONCLUSION ROTEM can be used to distinguish patients with SHA with inhibitors from those with SHA without inhibitors using a combination of parameters with high sensitivity and specificity. However, APTT-CWA cannot be used to differentiate these patient groups.
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Affiliation(s)
- Deepika Gupta
- Department of Hematology, Sir Gangaram Hospital, Old Rajinder Nagar, New Delhi, 110060, India
| | - Vandana Arya
- Department of Hematology, Sir Gangaram Hospital, Old Rajinder Nagar, New Delhi, 110060, India
| | - Jasmita Dass
- Department of Lab Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Nitin Gupta
- Department of Hematology, Sir Gangaram Hospital, Old Rajinder Nagar, New Delhi, 110060, India
| | - Manas Kalra
- Department of Pediatric Hemato Oncology, Sir Gangaram Hospital, New Delhi, India
| | - Anupam Sachdeva
- Department of Pediatric Hemato Oncology, Sir Gangaram Hospital, New Delhi, India
| | - Jyoti Kotwal
- Department of Hematology, Sir Gangaram Hospital, Old Rajinder Nagar, New Delhi, 110060, India.
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Castelli R, Berzuini A, Manetti R, Delitala AP, Castro D, Sanna G, Sircana MC, Profili NI, Bartoli A, La Cava L, Lambertenghi Deliliers G, Donadoni M, Gidaro A. ADAMTS13, von Willebrand Factor, Platelet Microparticles, Factor VIII, and Impact of Somatic Mutations in the Pathogenesis of Splanchnic Vein Thrombosis Associated with BCR-ABL-Negative Myeloproliferative Neoplasms. Life (Basel) 2024; 14:486. [PMID: 38672756 PMCID: PMC11051276 DOI: 10.3390/life14040486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/29/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Myeloproliferative neoplasms (MPNs) are often associated with splanchnic vein thrombosis (SVT). Not all the factors involved in the thrombotic tendency are currently known. OBJECTIVES This study aims to evaluate a possible association between ADAMTS13, von Willebrand factor (VWF), platelet microvesicles (MV), and factor VIII activity (FVIII:C) with thrombotic events in MPN patients. MATERIALS AND METHODS In total, 36 consecutive MPN patients with SVT were enrolled. The MPNs were diagnosed based on clinical characteristics and one or more gene mutations among JAK-2, CALR, and MPL. As controls, 50 randomly selected patients with MPN without thrombosis, 50 patients with deep vein thrombosis without MPNs, and 50 healthy blood donors were evaluated. Complete blood count, ADAMTS13, VWF, MV, and FVIII:C in plasma were measured in all the subjects. RESULTS The JAK-2 mutation was found in 94% of the patients with SVT, but none were triple-negative for genetic mutations (JAK2 V617F, CALR, MPL, and exon 12). Compared to the normal subjects, in all the MPN patients (with or without SVT), the levels of ADAMTS13 were found to be significantly lower (p < 0.001) and the MV concentrations were significantly higher (p < 0.001). Among the MPN patients, the VWF and FVIII:C levels were significantly higher in the patients with SVT than those without thrombosis (p = 0.007 and p = 0.04, respectively). Splenomegaly was present in 78% of MPN patients with SVT and in 30% of those without SVT (p < 0.001). The ADAMTS13/VWF ratio was reduced in all the patients, but not in the healthy blood donors (p < 0.001). CONCLUSIONS The significant increase in circulating MV, VWF, and FVIII:C in the MPN patients and in the patients with thrombosis supports the role of endothelium damage in promoting thrombotic events. In particular, a significant increase in VWF and FVIII:C levels was found in the MPN patients with SVT.
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Affiliation(s)
- Roberto Castelli
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | | | - Roberto Manetti
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Alessandro Palmerio Delitala
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Dante Castro
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Giuseppe Sanna
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Marta Chiara Sircana
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Nicia Isabella Profili
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy; (R.M.); (D.C.); (G.S.); (M.C.S.); (N.I.P.)
| | - Arianna Bartoli
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy; (A.B.); (L.L.C.); (M.D.)
| | - Leyla La Cava
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy; (A.B.); (L.L.C.); (M.D.)
| | | | - Mattia Donadoni
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy; (A.B.); (L.L.C.); (M.D.)
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences Luigi Sacco, Luigi Sacco Hospital, University of Milan, 20157 Milan, Italy; (A.B.); (L.L.C.); (M.D.)
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Jiménez-Yuste V, Álvarez-Román MT, Berrueco R, Bonanad S, Calvo-Villas JM, González-González R, Porras JRG, Núñez-Vázquez RJ, Rodríguez-López M. Management of Urgent Bleeding in Patients with Hemophilia A: Focus on the Use of Emicizumab. TH OPEN 2024; 8:e194-e201. [PMID: 38633730 PMCID: PMC11023713 DOI: 10.1055/s-0044-1785525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/23/2024] [Indexed: 04/19/2024] Open
Abstract
Management of patients with hemophilia A (HA) requires the knowledge and experience of specialized health care professionals. However, these patients may need to be attended in emergencies, outside the referral hospital, where health care professionals do not know about hemophilia and/or new innovative treatments. This study aimed to develop a simple and practical algorithm that could be used in emergency situations by nonspecialized treaters in HA and bleeding with or without factor VIII (FVIII) inhibitors under emicizumab prophylaxis. A group of experts agreed on a simple algorithm, easy to operate, adapted from previous international guidelines, and based on their clinical experience. The proposed algorithm starts with identifying the patient, confirming the diagnosis of HA, prophylaxis with emicizumab, and/or use of other treatments. After stabilizing the patient and stratifying the bleeding risk, the patient is managed according to the presence/absence of FVIII inhibitors. Patients without FVIII inhibitors should receive FVIII concentrate. Dose and follow-up depend on bleeding localization and severity. Patients with FVIII inhibitors should preferably receive recombinant activated factor VII as bypass agent. A basic coagulation assay, FVIII assessment, and FVIII inhibitors detection assays are necessary in an emergency. However, these tests should be interpreted with caution and appropriately chosen, as emicizumab may alter the results. The management of patients with HA is challenging in emergency situations, especially if they are treated with new agents. Nonspecialized in coagulopathies health care professionals have limited understanding of the disease, highlighting the need for an algorithm to assist them in making informed decisions.
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Affiliation(s)
- Víctor Jiménez-Yuste
- Hematology Department, La Paz University Hospital-IdiPaz, Universidad Autónoma, Madrid, Spain
| | - María T. Álvarez-Román
- Hematology Department, La Paz University Hospital-IdiPaz, Universidad Autónoma, Madrid, Spain
| | - Rubén Berrueco
- Pediatric Hematology Unit, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Santiago Bonanad
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | | | | | - Ramiro J. Núñez-Vázquez
- Hematology Department, Hospital Universitario Virgen del Rocío, Instituto deBiomedicina de Sevilla (IBIS), Sevilla, Spain
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Schmidt DE, Truedsson Å, Strålfors A, Hojbjerg JA, Soutari N, Holmström M, Ranta S, Letelier A, Bowyer A, Ljung R, Antovic J, Bruzelius M. Clinical Implications of Discrepancy between One-Stage Clotting and Chromogenic Factor IX Activity in Hemophilia B. Thromb Haemost 2024; 124:32-39. [PMID: 37494968 DOI: 10.1055/a-2142-0262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND Discrepancy in factor IX activity (FIX:C) between one-stage assay (OSA) and chromogenic substrate assay (CSA) in patients with hemophilia B (PwHB) introduces challenges for clinical management. AIM To study the differences in FIX:C using OSA and CSA in moderate and mild hemophilia B (HB), their impact on classification of severity, and correlation with genotype. METHODS Single-center study including 21 genotyped and clinically characterized PwHB. FIX:C by OSA was measured using ActinFSL (Siemens) and CSA by Biophen (Hyphen). In addition, in vitro experiments with wild-type FIX were performed. Reproducibility of CSA was assessed between three European coagulation laboratories. RESULTS FIX:C by CSA was consistently lower than by OSA, with 10/17 PwHB having a more severe hemophilia type by CSA. OSA displayed a more accurate description of the clinical bleeding severity, compared with CSA. A twofold difference between OSA:CSA FIX:C was present in 12/17 PwHB; all patients had genetic missense variants in the FIX serine protease domain. Discrepancy was also observed with diluted normal plasma, most significant for values below 0.10 IU/mL. Assessment of samples with low FIX:C showed excellent reproducibility of the CSA results between the laboratories. CONCLUSION FIX:C was consistently higher by OSA compared with the CSA. Assessing FIX:C by CSA alone would have led to diagnosis of a more severe hemophilia type in a significant proportion of patients. Our study suggests using both OSA and CSA FIX:C together with genotyping to classify HB severity and provide essential information for clinical management.
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Affiliation(s)
- David E Schmidt
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Paediatric Coagulation, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Åsa Truedsson
- Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - Annelie Strålfors
- Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Johanne Andersen Hojbjerg
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Nida Soutari
- Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Margareta Holmström
- Coagulation Unit, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Susanna Ranta
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Paediatric Coagulation, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Letelier
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Annette Bowyer
- Department of Coagulation, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Rolf Ljung
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Jovan Antovic
- Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Maria Bruzelius
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Coagulation Unit, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
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Meijer P, Peyvandi F, Young G, Pruthi R, de Lima Montalvão S, Kitchen S. International Council for Standardization in Haematology recommendations for laboratory measurement of factor VIII and FIX type I inhibitors. Int J Lab Hematol 2023; 45:413-424. [PMID: 37287431 DOI: 10.1111/ijlh.14109] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/12/2023] [Indexed: 06/09/2023]
Abstract
This guidance document has been prepared on behalf of the International Council for Standardisation in Hematology. The aim of the document is to provide guidance and recommendations on the measurement of factor VIII (FVIII) and factor IX (FIX) inhibitors. After an introduction on the clinical background and relevance of factor VIII and factor IX inhibitor testing, the following aspects of laboratory testing are included: screening for inhibitors, assay principle, sample requirements, testing requirements and interpretation, quality assurance, interferences and recent developments. This guidance document focusses on recommendations for a standardised procedure for the laboratory measurement of FVIII and FIX type I inhibitors. The recommendations are based on published data in peer-reviewed literature and expert opinion.
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Affiliation(s)
- Piet Meijer
- ECAT Foundation, Voorschoten, The Netherlands
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Guy Young
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Rajiv Pruthi
- Division of Hematology and Hematopathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Silmara de Lima Montalvão
- Laboratory Hemostasis, Hematology and Hemotherapy Center, University of Campinas UNICAMP, Campinas, São Paulo, Brazil
| | - Steve Kitchen
- Sheffield Haemophilia and Thrombosis Centre, Sheffield, UK
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Sree Bhgavathi M, Prakash S, Chhabra G, Sahu A, Mishra D, Mukherjee S. A Comparative Evaluation of the Quality of Cryoprecipitate Prepared from 350 ml Versus 450 ml of Whole Blood and Different Methods of Thawing of Plasma: A Prospective Observational Study. Transfus Clin Biol 2023:S1246-7820(23)00067-8. [PMID: 37321533 DOI: 10.1016/j.tracli.2023.06.002] [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: 04/19/2023] [Revised: 06/01/2023] [Accepted: 06/09/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Cryoprecipitate is used in conditions like hypofibrinogenemia, massive transfusion with bleeding, and factor XIII deficiency. The current guidelines support the preparation of cryoprecipitate from 450ml whole blood. But 350 ml of whole blood collection is expected from low body weight (< 55 kg) donors. However, no standardized criteria exist for preparing cryoprecipitate from 350 ml of whole blood. AIM of the study : This study compared the fibrinogen and factor VIII levels in cryoprecipitate units prepared from 350ml versus 450ml whole blood collection. The study also compared the fibrinogen and factor VIII levels prepared by circulating water bath versus blood bank refrigerator (BBR) thawing method. METHODOLOGY A total of 128 blood bags were equally divided into groups A and B for 450 and 350ml whole blood collection further subdivided into subgroups based on thawing methods. The fibrinogen and factor VIII yield were analyzed in the cryoprecipitates prepared from both groups. RESULTS The factor VIII levels were significantly higher in cryoprecipitate made from 450ml whole blood collection (P= 0.02). The BBR method of plasma thawing resulted in better fibrinogen recovery than the cryo bath method. Whereas vice versa in the case of factor VIII recovery. A weak but significant positive correlation was noted in factor VIII levels with the plasma volume. CONCLUSION Over 75% of the cryoprecipitates prepared from 350 ml whole blood passed the fibrinogen and factor VIII quality control criteria. So, 350ml whole blood collection from low body weight (<55 kg) donors could be utilized to prepare cryoprcipitates. However, future clinical studies should focus on the cryoprecipitate's clinical efficacy prepared from 350 ml of whole blood.
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Affiliation(s)
- M Sree Bhgavathi
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Bhubaneswar.
| | - Satya Prakash
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Bhubaneswar.
| | - Gaurav Chhabra
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Bhubaneswar.
| | - Ansuman Sahu
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Bhubaneswar.
| | - Debasish Mishra
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Bhubaneswar.
| | - Somnath Mukherjee
- Department of Transfusion Medicine, All India Institute of Medical Sciences, Bhubaneswar.
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Ferreira MV, Nogueira T, Rios RA, Lopes TJS. A graph-based machine learning framework identifies critical properties of FVIII that lead to hemophilia A. FRONTIERS IN BIOINFORMATICS 2023; 3:1152039. [PMID: 37235045 PMCID: PMC10206133 DOI: 10.3389/fbinf.2023.1152039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/10/2023] [Indexed: 05/28/2023] Open
Abstract
Introduction: Blood coagulation is an essential process to cease bleeding in humans and other species. This mechanism is characterized by a molecular cascade of more than a dozen components activated after an injury to a blood vessel. In this process, the coagulation factor VIII (FVIII) is a master regulator, enhancing the activity of other components by thousands of times. In this sense, it is unsurprising that even single amino acid substitutions result in hemophilia A (HA)-a disease marked by uncontrolled bleeding and that leaves patients at permanent risk of hemorrhagic complications. Methods: Despite recent advances in the diagnosis and treatment of HA, the precise role of each residue of the FVIII protein remains unclear. In this study, we developed a graph-based machine learning framework that explores in detail the network formed by the residues of the FVIII protein, where each residue is a node, and two nodes are connected if they are in close proximity on the FVIII 3D structure. Results: Using this system, we identified the properties that lead to severe and mild forms of the disease. Finally, in an effort to advance the development of novel recombinant therapeutic FVIII proteins, we adapted our framework to predict the activity and expression of more than 300 in vitro alanine mutations, once more observing a close agreement between the in silico and the in vitro results. Discussion: Together, the results derived from this study demonstrate how graph-based classifiers can leverage the diagnostic and treatment of a rare disease.
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Affiliation(s)
| | - Tatiane Nogueira
- Institute of Computing, Federal University of Bahia, Salvador, Brazil
| | - Ricardo A. Rios
- Institute of Computing, Federal University of Bahia, Salvador, Brazil
| | - Tiago J. S. Lopes
- Center for Regenerative Medicine, National Center for Child Health and Development Research Institute, Tokyo, Japan
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Nardi MA. Hemophilia A: Emicizumab monitoring and impact on coagulation testing. Adv Clin Chem 2023; 113:273-315. [PMID: 36858648 DOI: 10.1016/bs.acc.2022.12.001] [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: 01/18/2023]
Abstract
Hemophilia A is an X-linked recessive bleeding disorder characterized by absent or ineffective coagulation factor VIII, a condition that could result in a severe and potentially life-threatening bleed. Although the current standard of care involves prophylactic replacement therapy of factor VIII, the development of neutralizing anti-factor VIII alloantibody inhibitors often complicates such therapeutic treatment. Emicizumab (Hemlibra®), a novel recombinant therapeutic agent for patients with hemophilia A, is a humanized asymmetric bispecific IgG4 monoclonal antibody designed to mimic activated factor VIII by bridging factor IXa and factor X thus effecting hemostasis. Importantly, this drug eliminates the need for factor VIII and complications associated with inhibitor generation. Emicizumab has been approved for use in several countries including the United States and Japan for prophylaxis of bleeding episodes in hemophilia A with and without FVIII inhibitors. Therapy is also approved in the European Union for routine prophylaxis of bleeds in hemophilia A with inhibitors or severe hemophilia A without inhibitors. Unfortunately, emicizumab therapy presents unique challenges for routine and specialty coagulation tests currently used to monitor hemophilia A. In this review, hemophilia A is presented, the biochemistry of factor VIII is discussed, and the impact of the therapeutic agent emicizumab is highlighted.
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Affiliation(s)
- Michael A Nardi
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, United States; Department of Pathology, New York University Grossman School of Medicine, New York, NY, United States.
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Heubel-Moenen FCJI, Ansems LEM, Verhezen PWM, Wetzels RJH, van Oerle RGM, Straat RJMHE, Megy K, Downes K, Henskens YMC, Beckers EAM, Joore MA. Effectiveness and costs of a stepwise versus an all-in-one approach to diagnose mild bleeding disorders. Br J Haematol 2023; 200:792-801. [PMID: 36444397 DOI: 10.1111/bjh.18570] [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: 07/15/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 12/02/2022]
Abstract
The diagnostic work-up of patients referred to the haematologist for bleeding evaluation is performed in a stepwise way: bleeding history and results of screening laboratory tests guide further diagnostic evaluation. This can be ineffective, time-consuming and burdensome for patients. To improve this strategy, the initial laboratory investigation can be extended. In a model-based approach, effectiveness and costs of a conventional stepwise versus a newly proposed all-in-one diagnostic approach for bleeding evaluation were evaluated and compared, using data from an observational patient cohort study, including adult patients referred for bleeding evaluation. In the all-in-one approach, specialized platelet function tests, coagulation factors, and fibrinolysis tests were included in the initial investigation. Final diagnosis, hospital resource use and costs and patient burden were compared. A total of 150 patients were included. Compared to the stepwise approach, in the all-in-one approach, 19 additional patients reached a diagnosis and patient burden was lower, but total costs per patient were higher [€359, 95% bootstrapped confidence interval (BCI) 283-518, p = 0.001]. For bleeding evaluation of patients referred to the haematologist, an all-in-one diagnostic approach has a higher diagnostic yield and reduces patient burden, at a higher cost. This raises the question what costs justify the diagnosis of a bleeding disorder and a less burdensome diagnostic strategy.
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Affiliation(s)
- Floor C J I Heubel-Moenen
- Department of Hematology, Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Loes E M Ansems
- Department of Hematology, Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Paul W M Verhezen
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Rick J H Wetzels
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Rene G M van Oerle
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Ron J M H E Straat
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Karyn Megy
- National Institute for Health Research (NIHR) BioResource, Cambridge University Hospitals NHS Foundation, Cambridge Biomedical Campus, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Kate Downes
- National Institute for Health Research (NIHR) BioResource, Cambridge University Hospitals NHS Foundation, Cambridge Biomedical Campus, Cambridge, UK.,Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.,Cambridge University Hospitals Genomic Laboratory, Cambridge University Hospitals Foundation Trust, Cambridge Biomedical Campus, UK
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Unit for Hemostasis and Transfusion, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Erik A M Beckers
- Department of Hematology, Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Manuela A Joore
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
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Al Moosawi M, Nicolson H, Wong SK, Dallas KL, Jackson S. Treatment changes in hemophilia A with chromogenic factor VIII assay implementation. Res Pract Thromb Haemost 2023; 7:100098. [PMID: 37063773 PMCID: PMC10099308 DOI: 10.1016/j.rpth.2023.100098] [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: 07/02/2022] [Revised: 01/15/2023] [Accepted: 02/11/2023] [Indexed: 03/06/2023] Open
Abstract
Background The one-stage assay (OSA) and the chromogenic assay (CSA) are 2 factor VIII (FVIII) assays used for the diagnosis and classification of hemophilia A. Discrepancies between the 2 assays exist in approximately one-third of patients with mild hemophilia A. Objectives The objectives of this study were to report the proportion of patients with mild or moderate hemophilia A and OSA-CSA discrepancies and to report the observed changes in treatment approach prompted by the presence of assay discrepancy. The study aimed to identify OSA:CSA ratio associated with the highest sensitivity for identification of patients in whom modification of treatment approach may be recommended. Methods This is a retrospective cohort study including adult (>18-year-old) patients with mild or moderate hemophilia A who were followed up at the Adult British Columbia Hemophilia Program between January 2013 and March 2019. Results A total of 75 patients with mild and 23 with moderate hemophilia A based on baseline OSA were included. Overall, 52% of study patients had OSA-CSA discrepancies, and change in treatment approach was observed in 27% of patients with OSA-CSA discrepancy. The OSA:CSA ratio of 1.8 to 3.5 demonstrated the highest area under the receiver operating characteristics curve and sensitivity for identification of patients in which modification of treatment approach may be recommended (AUC 0.75; sensitivity 71%). Conclusion In our population, OSA-CSA discrepancy was observed in 52% of patients with mild or moderate hemophilia A, and the treatment approach in 27% of these patients had to be modified.
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Affiliation(s)
- Muntadhar Al Moosawi
- Department of Pathology and Laboratory Medicine, University of British Columbia, British Columbia, Canada
| | - Hamish Nicolson
- Department of Pathology and Laboratory Medicine, University of British Columbia, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, St. Paul's Hospital, British Columbia, Canada
| | - Steven K.W. Wong
- Department of Pathology and Laboratory Medicine, St. Paul's Hospital, British Columbia, Canada
| | - Karen L. Dallas
- Department of Pathology and Laboratory Medicine, University of British Columbia, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, St. Paul's Hospital, British Columbia, Canada
| | - Shannon Jackson
- Department of Medicine, University of British Columbia, British Columbia, Canada
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12
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Martin M, Augustsson C, Lind V, Al-Sabti R, Lam MC, Andersson NG, Strandberg K. Methods for anti-factor VIII antibody levels in haemophilia A patients - validation of a multiplex immunoassay and comparability with assays measuring non-neutralising and neutralising antibodies (inhibitors). Haemophilia 2023; 29:336-347. [PMID: 36193002 DOI: 10.1111/hae.14669] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/14/2022] [Accepted: 09/18/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION The development of neutralising (inhibitors) and non-neutralising antibodies (NNAs) is a complication to factor replacement therapy in haemophilia. The diagnostic methods available lack standardisation, have high inter-laboratory variation, and false-negative as well as false-positive results may affect treatment. Both functional inhibitors and NNAs may be detected with higher reproducibility, sensitivity and specificity using the immunological Luminex xMAP-based fluorescence-immunoassay (xFLI). AIM Validation of our xFLI and comparability with enzyme-linked immunosorbent assay (ELISA) and chromogenic Nijmegen-Bethesda assay (CBA) for anti-FVIII antibodies in haemophilia A (HA) patients. METHODS The xFLI method was developed with full-length and B-domain deleted factor coupled to magnetic beads, optimised and validated for performance characteristics. Comparability with ELISA and CBA was evaluated in HA patient samples (n = 112), serial samples in six inhibitor patients and reference interval and decision-limits in healthy donors (n = 44). RESULTS The intra- and inter-assay precision (CV%) for the xFLI method was below 6% and detection limit (LLOQ) .084 ng/mL (NovoEight). All ELISA-positive samples were positive with either Advate or NovoEight. Additionally, 10.7%-14.3% were xFLI-positive and ELISA-negative. All but one CBA-positive sample was above 3SD with xFLI; one was between 2 and 3SD. 29.1% were xFLI-positive and CBA negative. The overall concordance between xFLI and ELISA was 82.1% and xFLI and CBA 77.9%. CONCLUSION The anti-FVIII antibody xFLI method is adaptable to clinical practice and more sensitive and reproducible than ELISA and CBA. Actual NNA titers are determined to both full-length and B-domain deleted FVIII. The xFLI is thus valuable for confirmation of all anti-FVIII antibodies.
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Affiliation(s)
- Myriam Martin
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation Laboratory, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Cecilia Augustsson
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation Laboratory, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Vivian Lind
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation Laboratory, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Riam Al-Sabti
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation Laboratory, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - My Chi Lam
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation Laboratory, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Nadine G Andersson
- Department of Thrombosis and Haemostasis, Hematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
| | - Karin Strandberg
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation Laboratory, University and Regional Laboratories Region Skåne, Malmö, Sweden
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13
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Gunasekera D, Vir P, Karim AF, Ragni MV, Pratt KP. Hemophilia A subjects with an intron-22 gene inversion mutation show CD4 + T-effector responses to multiple epitopes in FVIII. Front Immunol 2023; 14:1128641. [PMID: 36936969 PMCID: PMC10015889 DOI: 10.3389/fimmu.2023.1128641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
Background Almost half of severe hemophilia A (HA) is caused by an intron 22 inversion mutation (Int22Inv), which disrupts the 26-exon F8 gene. Inverted F8 mRNA exons 1-22 are transcribed, while F8B mRNA, containing F8 exons 23-26, is transcribed from a promoter within intron 22. Neither FVIII activity nor FVIII antigen (cross-reacting material, CRM) are detectable in plasma of patients with an intron-22 inversion. Objectives To test the hypothesis that (putative) intracellular synthesis of FVIII proteins encoded by inverted F8 and F8B mRNAs confers T-cell tolerance to almost the entire FVIII sequence, and to evaluate the immunogenicity of the region encoded by the F8 exon 22-23 junction sequence. Patients/Methods Peripheral blood mononuclear cells (PBMCs) from 30 severe or moderate HA subjects (17 with an Int22Inv mutation) were tested by ELISPOT assays to detect cytokine secretion in response to FVIII proteins and peptides and to map immunodominant T-cell epitopes. Potential immunogenicity of FVIII sequences encoded by the F8 exon 22-23 junction region was also tested using peptide-MHCII binding assays. Results Eight of the Int22Inv subjects showed robust cytokine secretion from PBMCs stimulated with FVIII proteins and/or peptides, consistent with earlier publications from the Conti-Fine group. Peptide ELISPOT assays identified immunogenic regions of FVIII. Specificity for sequences encoded within F8 mRNA exons 1-22 and F8B mRNA was confirmed by staining Int22Inv CD4+ T cells with peptide-loaded HLA-Class II tetramers. FVIII peptides spanning the F8 exon 22-23 junction (encoding M2124-V2125) showed limited binding to MHCII proteins and low immunogenicity, with cytokine secretion from only one Int22Inv subject. Conclusions PBMCs from multiple subjects with an Int22Inv mutation, with and without a current FVIII inhibitor, responded to FVIII epitopes. Furthermore, the FVIII region encoded by the exon 22-23 junction sequence was not remarkably immunoreactive and is therefore unlikely to contain an immunodominant, promiscuous CD4+ T-cell epitope. Our results indicate that putative intracellular expression of partial FVIII proteins does not confer T-cell tolerance to FVIII regions encoded by inverted F8 mRNA or F8B mRNA.
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Affiliation(s)
- Devi Gunasekera
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Pooja Vir
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Ahmad Faisal Karim
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Margaret V. Ragni
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kathleen P. Pratt
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- *Correspondence: Kathleen P. Pratt,
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14
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Anandani G, Patel T, Parmar R. The Implication of New Developments in Hemophilia Treatment on Its Laboratory Evaluation. Cureus 2022; 14:e30212. [DOI: 10.7759/cureus.30212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 11/07/2022] Open
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15
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Uster DW, Chowdary P, Riddell A, Garcia C, Aradom E, Musarara M, Wicha SG. Dosing for Personalized Prophylaxis in Hemophilia A Highly Varies on the Underlying Population Pharmacokinetic Models. Ther Drug Monit 2022; 44:665-673. [PMID: 35358115 DOI: 10.1097/ftd.0000000000000983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/21/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Model-informed personalized prophylaxis with factor VIII (FVIII) replacement therapy aimed at higher trough levels is becoming indispensable for patients with severe hemophilia A. This study aimed to identify the most suitable population pharmacokinetic (PK) models for personalized prophylaxis using various FVIII products and 2 clinical assays and to implement the most suitable one in open-access software. METHODS Twelve published population PK models were systematically compared to predict the time above target (TaT) for a reference dosing occasion. External validation was performed using a 5-point PK data from 39 adult patients with hemophilia A with FVIII measured by chromogenic substrate (CSA) and 1-stage assays (OSAs) using NONMEM under 3 different conditions: a priori (with all FVIII samples blinded), a posteriori (with 1 trough sample), and general model fit (with all FVIII samples including the reference dosing occasion provided). RESULTS On average, the baseline covariate models overpredicted TaT (a priori; bias -3.8 hours to 49.6 hours). When additionally including 1 previous trough FVIII sample before the reference dosing occasion (a posteriori), only 50% of the models improved in bias (-1.0 hours to 36.5 hours) and imprecision (22.4 hours and 60.7 hours). Using all the time points (general model fit), the models accurately predicted (individual TaT less than ±12 hours compared with the reference) 62%-90% and 33%-74% of the patients using CSA and OSA data, respectively. Across all scenarios, predictions using CSA data were more accurate than those using the OSA data. CONCLUSIONS One model performed best across the population (bias: -3.8 hours a priori, -1.0 hours a posteriori , and 0.6 hours general model fit ) and acceptably predicted 44% (a priori) to 90% ( general model fit ) of the patients. To allow the community-based evaluation of patient-individual FVIII dosing, this model was implemented in the open-access model-informed precision dosing software "TDMx."
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Affiliation(s)
- David W Uster
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany ; and
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, United Kingdom
| | - Anne Riddell
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, United Kingdom
| | - Cecilia Garcia
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, United Kingdom
| | - Elsa Aradom
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, United Kingdom
| | - Molly Musarara
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, United Kingdom
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany ; and
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16
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Osaki T, Souri M, Ogawa Y, Sato H, Mitsui T, Ichinose A. Retrospective examination of coagulation parameters in 33 patients with autoimmune coagulation factor deficiencies in Japan: A single-center analysis. Thromb Res 2022; 213:154-162. [DOI: 10.1016/j.thromres.2022.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/22/2022] [Accepted: 03/07/2022] [Indexed: 11/25/2022]
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17
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Bukkems LH, Valke LLFG, Barteling W, Laros-van Gorkom BAP, Blijlevens NMA, Cnossen MH, van Heerde WL, Schols SEM, Mathôt RAA. Combining factor VIII levels and thrombin/plasmin generation: a population pharmacokinetic-pharmacodynamic model for patients with hemophilia A. Br J Clin Pharmacol 2021; 88:2757-2768. [PMID: 34921439 PMCID: PMC9304184 DOI: 10.1111/bcp.15185] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/07/2021] [Accepted: 12/05/2021] [Indexed: 11/28/2022] Open
Abstract
Aims Prophylactic treatment of haemophilia A patients with factor VIII (FVIII) concentrate focuses on maintaining a minimal trough FVIII activity level to prevent bleeding. However, due to differences in bleeding tendency, the pharmacokinetic (PK)‐guided dosing approach may be suboptimal. An alternative approach could be the addition of haemostatic pharmacodynamic (PD) parameters, reflecting a patient's unique haemostatic balance. Our aim was to develop a population PK/PD model, based on FVIII activity levels and Nijmegen Haemostasis Assay (NHA) patterns, a global haemostatic assay that measures thrombin/plasmin generation simultaneously. Methods PK/PD measurements were collected from 30 patients treated with standard half‐life FVIII concentrate. The relationship between FVIII activity levels and the thrombin/plasmin generation parameters (thrombin potential, thrombin peak height and plasmin peak height), were described by sigmoidal Emax functions. Results The obtained EC50 value was smallest for the normalized thrombin potential (11.6 IU/dL), followed by normalized thrombin peak height (56.6 IU/dL) and normalized plasmin peak height (593 IU/dL), demonstrating that normalized thrombin potential showed 50% of the maximal effect at lower FVIII activity levels. Substantial inter‐individual variability in the PD parameters, such as EC50 of thrombin potential (86.9%) was observed, indicating that, despite similar FVIII activity levels, haemostatic capacity varies significantly between patients. Conclusion These data suggest that dosing based on patients' individual PK/PD parameters may be beneficial over dosing solely on individual PK parameters. This model could be used as proof‐of‐principle to examine the application of PK/PD‐guided dosing. However, the relation between the PD parameters and bleeding has to be better defined.
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Affiliation(s)
- Laura H Bukkems
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Lars L F G Valke
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Hemophilia Treatment Centre, Nijmegen Eindhoven Maastricht, The Netherlands
| | - Wideke Barteling
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Britta A P Laros-van Gorkom
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Hemophilia Treatment Centre, Nijmegen Eindhoven Maastricht, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Waander L van Heerde
- Hemophilia Treatment Centre, Nijmegen Eindhoven Maastricht, The Netherlands.,Enzyre BV, Novio Tech Campus, Nijmegen, The Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Hemophilia Treatment Centre, Nijmegen Eindhoven Maastricht, The Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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18
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Marlar RA, Gausman JN, Rollins-Raval MA. Guidance for establishing a factor VIII testing protocol for the myriad of factor VIII products. Int J Lab Hematol 2021; 44:414-423. [PMID: 34786864 DOI: 10.1111/ijlh.13763] [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: 06/02/2021] [Revised: 10/14/2021] [Accepted: 10/31/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Management of hemophilia A has changed significantly in the past few years with the expansion of new and/or modified products as treatment options. Unfortunately, many of the standard factor VIII assays do not always accurately measure all available treatment products; therefore, the laboratory must investigate various assay algorithms to ensure the reporting of the correct results. METHODS Requirements for factor testing, diagnosis and severity levels, product testing, factor VIII inhibitor detection and titers, are evaluated, and potential algorithms are created for optimal assessment of patients with hemophilia A. RESULTS The potential for inaccurate result reporting for patients with hemophilia A or those being treated with the myriad of products has left many laboratories uncertain as to which assay algorithm to implement to ensure reporting the correct results for all products used in their hemophilia program. Algorithms for using either One-stage Clotting assays or Chromogenic assays or a combination of both types of assays are presented for each laboratory to implement based on their clinical situation. CONCLUSIONS Several algorithms are considered based on the needs of the clinical providers and their patients. Each laboratory must select a testing algorithm that is cost-effective and within available resources, yet that encompasses the needs of their providers and patients. Laboratory personnel must consider all assay uses (factor VIII levels, different products, interfering products, and inhibitor titers) in determining the best algorithm for their laboratory. This paper is a starting guide for developing the best factor VIII testing assays and protocols for your laboratory.
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Affiliation(s)
- Richard A Marlar
- Department of Pathology, University of New Mexico, TriCore Reference Laboratories, Albuquerque, New Mexico, USA
| | - Jana N Gausman
- OU Medicine, Inc., Laboratory, University of Oklahoma Medical Center, Oklahoma City, Oklahoma, USA
| | - Marian A Rollins-Raval
- Department of Pathology, University of New Mexico, TriCore Reference Laboratories, Albuquerque, New Mexico, USA
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19
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Inaba H, Nishikawa S, Shinozawa K, Shinohara S, Nakazawa F, Amano K, Kinai E. Coagulation assay discrepancies in Japanese patients with non-severe hemophilia A. Int J Hematol 2021; 115:173-187. [PMID: 34751920 DOI: 10.1007/s12185-021-03256-x] [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: 07/21/2021] [Revised: 10/29/2021] [Accepted: 10/29/2021] [Indexed: 11/29/2022]
Abstract
Patients with non-severe hemophilia A often show discrepancies in factor VIII (FVIII) activity. However, information on variant-specific coagulation assay characteristics in Japanese patients is limited. Pathogenic variants were classified into three groups, thrombin-cleavage site (TC), A1-A2-A3 interface (IF), and non-discrepant, with reference to previous studies. Cutoff values for the one-stage assay (OSA)/chromogenic substrate assay (CSA) ratio, which is suitable for distinguishing discrepancies, were determined for all five aPTT reagents. TGA and CWA parameters and bleeding scores were compared between groups. Two of the 39 patients with non-severe hemophilia A (5%) were classified as TC, 10 (26%) as IF, and 27 (69%) as non-discrepant. The OSA/CSA cutoff values between the groups varied widely by aPTT reagent and tended to be relatively low compared to previous studies. As an indicator of bleeding tendency, TGA had a low correlation coefficient for the IF variant, but this was not significant and was comparable to FVIII activity and CWA. Moreover, various parameters and bleeding tendency differed among patients with the same variants. Thus, our findings suggest that it is difficult to adequately assess the bleeding tendency of individual patients, even with the various assessments currently available.
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Affiliation(s)
- Hiroshi Inaba
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Satomi Nishikawa
- Scientific Research, Scientific Affairs, Sysmex Corporation, Kobe, Japan
| | - Keiko Shinozawa
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Sho Shinohara
- Reagent Engineering, Sysmex Corporation, Kobe, Japan
| | - Fumie Nakazawa
- Scientific Research, Scientific Affairs, Sysmex Corporation, Kobe, Japan
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ei Kinai
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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20
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Yokota Y, Inatomi O, Nakagawa M, Kakuda K, Hiroe K, Sakai S, Osaki R, Iwasa M, Kawahara M, Kito K, Andoh A, Bamba H. Acquired Coagulation Factor V Inhibitor That Was Successfully Treated with Oral Corticosteroid Therapy. Intern Med 2021; 60:2663-2666. [PMID: 34121013 PMCID: PMC8429299 DOI: 10.2169/internalmedicine.7453-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Acquired coagulation factor V (FV) inhibitors are rare disorders in which antibodies against FV develop under various conditions. We herein report the case of a 71-year-old woman with FV inhibitor during radiochemotherapy for pancreatic cancer. Multiple purpuras suddenly appeared on her bilateral upper limbs with prolonged coagulation data (APTT 97.3 seconds). The FV activity was less than 3% and the FV inhibitor was positive (1.7 B.U./mL). Oral prednisolone induced a rapid normalization of the coagulation data and FV activity and a rapid disappearance of FV inhibitor within 7 days. Early diagnosis and treatment may therefore be important in cases of FV inhibitor.
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Affiliation(s)
- Yoshihiro Yokota
- Department of Gastroenterology, Nagahama Red Cross Hospital, Japan
| | - Osamu Inatomi
- Department of Medicine, Shiga University of Medical Science, Japan
| | - Minami Nakagawa
- Department of Clinical Laboratory Medicine, Nagahama Red Cross Hospital, Japan
| | - Kazuki Kakuda
- Department of Gastroenterology, Nagahama Red Cross Hospital, Japan
| | - Kousuke Hiroe
- Department of Gastroenterology, Nagahama Red Cross Hospital, Japan
| | - Shigeki Sakai
- Department of Gastroenterology, Nagahama Red Cross Hospital, Japan
| | - Rie Osaki
- Department of Gastroenterology, Nagahama Red Cross Hospital, Japan
| | - Masaki Iwasa
- Department of Medicine, Shiga University of Medical Science, Japan
| | | | - Katsuyuki Kito
- Department of Medicine, Shiga University of Medical Science, Japan
| | - Akira Andoh
- Department of Medicine, Shiga University of Medical Science, Japan
| | - Hiromichi Bamba
- Department of Gastroenterology, Nagahama Red Cross Hospital, Japan
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21
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Abstract
Remarkable changes are occurring in the diagnosis and management of individuals with hemophilia A. Genetic testing, including next-generation sequencing, enables family planning, carrier testing, and prenatal diagnosis. Musculoskeletal ultrasound examination facilitates the early detection of acute bleeds and joint disease in clinic, enabling more rapid bleed resolution and treatment planning. Novel therapies offer simpler weekly or monthly administration, some by subcutaneous injection, with better compliance and quality of life, as well as fewer bleeds. Gene therapy provides a 1-time phenotypic "cure" that is cost effective, but may be complicated by waning levels, vector immune responses, and hepatotoxicity.
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22
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Wang LY, Shen Y, Zeng HQ, Zhang Y, Lou SF, Deng JC, Luo Y. Feasibility of therapeutic plasma exchange-based combination therapy in the treatment of acquired hemophilia A: A retrospective 6 case series. Medicine (Baltimore) 2021; 100:e26587. [PMID: 34398013 PMCID: PMC8294921 DOI: 10.1097/md.0000000000026587] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 06/17/2021] [Indexed: 01/04/2023] Open
Abstract
Poor availability and a lack of affordability of bypassing agents (recombinant activated factor VII and activated prothrombin complex concentrate) in west China prompted us to investigate an alternative cost-effective combination therapy. We aimed to explore the feasibility of therapeutic plasma exchange (TPE)-based combination therapy in the treatment of acquired hemophilia A (AHA).We retrospectively investigated the clinical features of AHA in 6 patients who were treated with a combination of TPE, corticosteroids, and rituximab in our department for 9 years between January, 2011 and December, 2019.We examined 1 male and 5 female patients. The median age at diagnosis of AHA was 51 years (18-66 years). In all patients, FVIII activity levels were low (median: 1.5%; 1-3%), FVIII inhibitor titers were high (median: 24.5 BU/mL; 13.2-48.6 BU/mL), and activated partial thromboplastin time was markedly prolonged (median: 99.4 s; 60.9-110.1 s). They underwent 2 to 8 cycles of plasma exchange and were given varying combinations of dexamethasone, methylprednisolone, prednisone, and rituximab. After TPE bleeding gradually stopped, and activated partial thromboplastin time decreased. After 3 months of treatment, FVIII inhibitors completely disappeared.TPE when combined with corticosteroids and rituximab, as adjunctive immunosuppressive agents, may be an effective and reliable treatment for AHA. When there is no alternative, intensive first-line treatment including TPE may be lifesaving.
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23
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Valikhani A, Mirakhorly M, Namvar A, Rastegarlari G, Toogeh G, Shirayeh FV, Ahmadinejad M. Genetic analysis of non-severe hemophilia A phenotype with A discrepancy between one-stage and chromogenic factor VIII activity assays. Transfus Apher Sci 2021; 60:103194. [PMID: 34275734 DOI: 10.1016/j.transci.2021.103194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/26/2021] [Accepted: 06/11/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The diagnosis of hemophilia A (HA) is based on the measurement of factor VIII activity (VIII:C). About one-third of non-severe HA patients show a discrepancy of VIII:C measured by one-stage (VIII:C 1st) and chromogenic (VIII:C chr) assays. Different mutations in the F8 gene may cause the discrepancy in results of the FVIII activity assay. The aim of this study was to investigate F8 gene mutations in patients with assay discrepancies and to evaluate their impact on the results of VIII:C assays. METHODS Mutation analysis was performed on 41 individuals with a discrepancy in VIII:C 1st and FVIII: C chr assays by direct sequencing. In addition, the effect of the variants on FVIII macromolecule structure was investigated by in silico and bioinformatics tools. RESULTS Genetic analysis disclosed 22 different variants, of which 19 were identified for the first time to be involved in the phenotype of VIII:C discrepancy. Most of the variants related to the higher VIII:C 1st were found in A1, A2, A3 domains. The variant related to VIII:C chr > VIII:C 1st was located in the thrombin cleavage site. In silico analysis showed the effect of variants on FVIII macromolecule stability, which may be the possible mechanism causing the discrepancy. CONCLUSION Our data shed light on the impact of genetic defects on VIII:C assay and provided evidence that the consideration of these mutations may open a new window to the proper diagnosis and treatment monitoring of non-severe HA patients.
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Affiliation(s)
- Amir Valikhani
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | | | - Ali Namvar
- Iranian Comprehensive Haemophilia Care Center, Tehran, Iran
| | | | - Gholamreza Toogeh
- Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Vossough Shirayeh
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Minoo Ahmadinejad
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran.
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24
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Laboratory monitoring of hemophilia A treatments: new challenges. Blood Adv 2021; 4:2111-2118. [PMID: 32396619 DOI: 10.1182/bloodadvances.2019000849] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/04/2020] [Indexed: 12/12/2022] Open
Abstract
Monitoring factor VIII (FVIII) activity has traditionally been complicated by discrepancies between assays for the various sorts of FVIII molecules. The advent of novel nonfactor therapies (emicizumab, fitusiran, and anti-tissue factor pathway inhibitor antibodies) in hemophilia A poses a new level of difficulty on the laboratory monitoring of these patients. To use the correct assays and for a proper interpretation of their results, it is pertinent to understand the mode of action of these nonfactor agents. Furthermore, the biochemical consequences for the different types of activity assays (whether it be specific FVIII activity assays or global coagulation assays) should be taken into account as well. In this review, these aspects will be discussed. In addition, the use of various animal models to estimate FVIII-equivalence of the nonfactor therapies will be presented.
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25
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Robinson MM, George LA, Carr ME, Samelson‐Jones BJ, Arruda VR, Murphy JE, Rybin D, Rupon J, High KA, Tiefenbacher S. Factor IX assay discrepancies in the setting of liver gene therapy using a hyperfunctional variant factor IX-Padua. J Thromb Haemost 2021; 19:1212-1218. [PMID: 33636038 PMCID: PMC8130854 DOI: 10.1111/jth.15281] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Limited information exists regarding the factor IX (FIX) coagulant activity (FIX:C) measured by different assays following FIX-Padua gene therapy. OBJECTIVE Assess for the first time FIX:C in five commonly used coagulation assays in plasma samples from hemophilia B subjects receiving FIX-Padua gene transfer. METHODS FIX:C was compared between central (n = 1) and local laboratories (n = 5) in the study, and across four commonly used FIX:C one-stage assays and one FIX:C chromogenic assay. For comparison, samples of pooled congenital FIX-deficient plasma spiked with purified recombinant human FIX (rHFIX)-Padua protein or rHFIX (nonacog alfa) to obtain FIX:C concentrations from ~20% to ~40% were tested. RESULTS FIX:C results at local laboratories strongly correlated with central laboratory results. However, absolute values at the central laboratory were consistently lower than those at local laboratories. Across five different FIX:C assays, a consistent pattern of FIX:C was observed for subjects receiving fidanacogene elaparvovec-expressed gene transfer. Use of Actin FSL activated partial thromboplastin time (APTT) reagent in the central laboratory resulted in lower FIX:C values compared with other APTT reagents tested. The chromogenic assay determined lower FIX:C than any of the one-stage assays. The rHFIX-Padua protein-spiked samples showed similar results. In contrast, FIX:C results for rHFIX-nonacog alfa measured within 25% of expected for all one-stage assays and below 25% in the chromogenic assay. CONCLUSIONS Assay-based differences in FIX:C were observed for fidanacogene elaparvovec transgene product and rHFIX-Padua protein, suggesting the variable FIX:C determined with different assay reagents is inherent to the FIX-Padua protein and is not specific to gene therapy-derived FIX-Padua.
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Affiliation(s)
- Mary M. Robinson
- Colorado CoagulationLaboratory Corporation of America HoldingsEnglewoodCOUSA
| | - Lindsey A. George
- Children’s Hospital of PhiladelphiaPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | | | - Benjamin J. Samelson‐Jones
- Children’s Hospital of PhiladelphiaPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Valder R. Arruda
- Children’s Hospital of PhiladelphiaPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | | | | | | | - Katherine A. High
- Children’s Hospital of PhiladelphiaPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
- Spark Therapeutics IncPhiladelphiaPAUSA
| | - Stefan Tiefenbacher
- Colorado CoagulationLaboratory Corporation of America HoldingsEnglewoodCOUSA
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26
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Arvanitakis A, Berntorp E, Astermark J. A comparison of MyPKFiT and WAPPS-Hemo as dosing tools for optimizing prophylaxis in patients with severe haemophilia A treated with Octocog alfa. Haemophilia 2021; 27:417-424. [PMID: 33751755 DOI: 10.1111/hae.14295] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 01/18/2023]
Abstract
INTRODUCTION MyPKFiT and the Web-Accessible Population Pharmacokinetic service-Hemophilia (WAPPS-Hemo) are web-based population-based applications developed for helping physicians individualize and optimize replacement therapy. Although MyPKFiT is intended for Octocog alfa and Rurioctocog alfa pegol use only, the WAPPS-Hemo is applicable to all factor VIII concentrates. AIM To compare MyPKFiT and WAPPS-Hemo as dosing tools for optimizing treatment of patients with severe haemophilia A on regular prophylaxis with Octocog alfa in a real-world setting. METHODS Fourteen patients with severe haemophilia A (median age 30.8 years; range 20-71) were enrolled. The FVIII activity was measured twice after a regular dose of Octocog alfa by the chromogenic and the one-stage assays. PK analyses were performed using each tool and dosing estimations to reach trough levels of 1%, 3% or 5% after 48 h. Findings were calculated and compared. RESULTS The two PK algorithms yielded similar t½ independent of the type of FVIII assay used. However, there were significant differences in the time to reach 1%, 3% and 5%. The WAPPS-Hemo generated 10-12 h longer time to a trough of 1% and up to 4 h for the troughs of 3% and 5%. Accordingly, the doses estimated by WAPPS-Hemo for a daily regimen were between 28% and 100% of those proposed by MyPKFiT. CONCLUSIONS MyPKFiT and WAPPS-Hemo provided similar half-life estimations for Octocog alfa independent of the FVIII assay used. The doses suggested by WAPPS-Hemo to reach specific troughs were overall lower, which may have implications for treatment optimization.
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Affiliation(s)
- Alexandros Arvanitakis
- Department of Translational Medicine, Lund University, Malmö, Sweden.,Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
| | - Erik Berntorp
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Jan Astermark
- Department of Translational Medicine, Lund University, Malmö, Sweden.,Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
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27
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Baronciani L, Peyvandi F. How we make an accurate diagnosis of von Willebrand disease. Thromb Res 2020; 196:579-589. [DOI: 10.1016/j.thromres.2019.07.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/27/2019] [Accepted: 07/14/2019] [Indexed: 11/28/2022]
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28
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X Chromosome inactivation: a modifier of factor VIII and IX plasma levels and bleeding phenotype in Haemophilia carriers. Eur J Hum Genet 2020; 29:241-249. [PMID: 33082527 DOI: 10.1038/s41431-020-00742-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 09/16/2020] [Accepted: 09/30/2020] [Indexed: 02/01/2023] Open
Abstract
Haemophilia A and B are X-linked hemorrhagic disorders caused by gene variants in the F8 and F9 genes. Due to recessive inheritance, males are affected, while female carriers are usually asymptomatic with a wide range of factor VIII (FVIII) or IX (FIX) levels. Bleeding tendency in female carriers is extremely variable and may be associated with low clotting factor levels. This could be explained by F8 or F9 genetic variations, numerical or structural X chromosomal anomalies, or epigenetic variations such as irregular X chromosome inactivation (XCI). The aim of the study was to determine whether low FVIII or FIX coagulant activity in haemophilia carriers could be related to XCI and bleeding symptoms. HUMARA assay was performed on 73 symptomatic carriers with low clotting activity ≤50 IU/dL. Bleeding Assessment Tool (BAT) from the International Society on Thrombosis and Haemostasis (ISTH) was used to describe symptoms in the cohort of carriers. In 97% of haemophilia carriers, a specific gene variant in heterozygous state was found, which alone could not justify their low FVIII or FIX levels (≤50 IU/dL). A statistical association between XCI pattern and FVIII and FIX levels was observed. Moreover, female carriers with low coagulant activity (≤20 IU/dL) and high degree of XCI ( ≥ 80:20) had a higher ISTH-BAT score than the carriers with the opposite conditions (>20 IU/dL and <80:20). In our cohort of haemophilia carriers, XCI was significantly skewed, which may contribute to the low expression of clotting factor levels and bleeding symptoms.
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29
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Augustsson C, Norström E, Andersson NG, Zetterberg E, Astermark J, Strandberg K. Monitoring standard and extended half-life products in hemophilia: Assay discrepancies for factor VIII and IX in pre- and postinfusion samples. Res Pract Thromb Haemost 2020; 4:1114-1120. [PMID: 33134777 PMCID: PMC7590307 DOI: 10.1002/rth2.12421] [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: 05/29/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Monitoring hemophilia treatment with extended half-life products is challenging for coagulation laboratories since factor assays may show substantial differences between results obtained with the one-stage assay (OSA) and the chromogenic substrate assay (CSA). OBJECTIVES The aim of this study was to evaluate and compare different factor assays and global coagulation methods. METHODS Factor VIII (FVIII) and IX (FIX) activities and global assay parameters were analyzed in pre- and postinfusion samples (5 patients 2 samples/product/method). RESULTS Samples containing FVIII products (NovoEight, Elocta, and Nuwiq) gave higher levels when measured with CSA compared to OSA. The correlation was excellent (r 2 ≥ .97) while biases of 42%-72% of mean (CSA-OSA) were obtained. With FVIII (OSA) as independent variable, the correlations to kaolin clot time (CT) and thrombin generation assay (TGA) peak were modest (r2 = .71-.72 and .64-.65, respectively), except for Nuwiq for which there was a poor correlation to TGA peak (r 2 = .08). Samples containing Alprolix, a FIX product, gave a smaller difference between activity levels (CSA-OSA), and the correlation was excellent (r 2 = .96). With FIX (CSA) as independent variable for both Alprolix and Refixia, the correlations to Innovin CT and TGA peaks were weak (r 2 = .33-.45 and .44-.76, respectively). CONCLUSIONS Our data show that factor activity assays differ between methods used and agents. These discrepancies indicate the value of having more than one type of assay available in the coagulation laboratory when monitoring hemophilia treatment with extended half-life products. Global assays gave complementary information indicated by the modest correlations to factor activities.
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Affiliation(s)
- Cecilia Augustsson
- Division of Laboratory Medicine, CoagulationDepartment of Clinical Chemistry and PharmacologyUniversity and Regional Laboratories Region SkåneMalmöSweden
| | - Eva Norström
- Division of Laboratory Medicine, CoagulationDepartment of Clinical Chemistry and PharmacologyUniversity and Regional Laboratories Region SkåneMalmöSweden
| | - Nadine Gretenkort Andersson
- Department of Hematology, Oncology and Radiation PhysicsCenter for Thrombosis and HemostasisSkåne University HospitalLund UniversityMalmöSweden
| | - Eva Zetterberg
- Department of Hematology, Oncology and Radiation PhysicsCenter for Thrombosis and HemostasisSkåne University HospitalLund UniversityMalmöSweden
| | - Jan Astermark
- Department of Hematology, Oncology and Radiation PhysicsCenter for Thrombosis and HemostasisSkåne University HospitalLund UniversityMalmöSweden
| | - Karin Strandberg
- Division of Laboratory Medicine, CoagulationDepartment of Clinical Chemistry and PharmacologyUniversity and Regional Laboratories Region SkåneMalmöSweden
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Preijers T, Schütte LM, Kruip MJHA, Cnossen MH, Leebeek FWG, van Hest RM, Mathôt RAA. Population Pharmacokinetics of Clotting Factor Concentrates and Desmopressin in Hemophilia. Clin Pharmacokinet 2020; 60:1-16. [PMID: 32936401 PMCID: PMC7808974 DOI: 10.1007/s40262-020-00936-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hemophilia A and B are bleeding disorders caused by a deficiency of clotting factor VIII and IX, respectively. Patients with severe hemophilia (< 0.01 IU mL−1) and some patients with moderate hemophilia (0.01–0.05 IU mL−1) administer clotting factor concentrates prophylactically. Desmopressin (d-amino d-arginine vasopressin) can be applied in patients with non-severe hemophilia A. The aim of administration of factor concentrates or desmopressin is the prevention or cessation of bleeding. Despite weight-based dosing, it has been demonstrated that factor concentrates still exhibit considerable pharmacokinetic variability. Population pharmacokinetic analyses, in which this variability is quantified and explained, are increasingly performed in hemophilia research. These analyses can assist in the identification of important patient characteristics and can be applied to perform patient-tailored dosing. This review aims to present and discuss the population pharmacokinetic analyses that have been conducted to develop population pharmacokinetic models describing factor levels after administration of factor VIII or factor IX concentrates or d-amino d-arginine vasopressin. In total, 33 publications were retrieved from the literature. Two approaches were applied to perform population pharmacokinetic analyses, the standard two-stage approach and non-linear mixed-effect modeling. Using the standard two-stage approach, four population pharmacokinetic models were established describing factor VIII levels. In the remaining 29 analyses, the non-linear mixed-effect modeling approach was applied. NONMEM was the preferred software to establish population pharmacokinetic models. In total, 18 population pharmacokinetic analyses were conducted on the basis of data from a single product. From all available population pharmacokinetic analyses, 27 studies also included data from pediatric patients. In the majority of the population pharmacokinetic models, the population pharmacokinetic parameters were allometrically scaled using actual body weight. In this review, the available methods used for constructing the models, key features of these models, patient population characteristics, and established covariate relationships are described in detail.
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Affiliation(s)
- Tim Preijers
- Hospital Pharmacy-Clinical Pharmacology, Academic University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Lisette M Schütte
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Reinier M van Hest
- Hospital Pharmacy-Clinical Pharmacology, Academic University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy-Clinical Pharmacology, Academic University Medical Centers, Location AMC, Amsterdam, The Netherlands. .,Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Meibergdreef 9, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands.
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31
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Suzuki A, Suzuki N, Kanematsu T, Okamoto S, Tamura S, Kikuchi R, Katsumi A, Kiyoi H, Kojima T, Matsushita T. Impact of variation in reagent combinations for one-stage clotting assay on assay discrepancy in nonsevere haemophilia A. Int J Lab Hematol 2020; 43:131-138. [PMID: 32915508 DOI: 10.1111/ijlh.13335] [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: 06/29/2020] [Revised: 08/01/2020] [Accepted: 08/17/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Factor VIII activity (FVIII:C) is measured by one-stage clotting assay (OSA) or chromogenic substrate assay (CSA). Significant differences in FVIII:C between OSA (FVIII:C1st ) and CSA (FVIII:CChr ) are described as assay discrepancy in nonsevere haemophilia A (HA). A large number of reagent combinations (APTT reagent and FVIII-deficient plasma) are used for OSA, but the impact of variations in reagent combinations on assay discrepancy has not been fully characterized. AIM To clarify the variations in FVIII:C1st /FVIII:CChr ratios according to OSA reagent combination in HA subjects with/without assay discrepancy. METHODS Thirty-nine patients previously diagnosed with nonsevere HA were enrolled, and their FVIII genes were investigated and FVIII:C levels were assessed by a single CSA reagent and 11 OSA reagent combinations. Receiver operating characteristic (ROC) curve analysis was used to predict possible cut-off values of the FVIII:C1st /FVIII:CChr ratio to define FVIII assay discrepancy for each reagent combination. RESULTS Patients were categorized into nondiscrepant (n = 25), discrepant (n = 5) and unclassified (n = 9) groups according to their genotypes and information in the database. The FVIII:C1st /FVIII:CChr ratio in nondiscrepant HA varied widely, depending on the APTT reagents and FVIII-deficient plasma used. The ratio in discrepant HA patients differed with respect to their genotype and the reagent combination used. ROC curve analyses revealed that cut-off values to distinguish the assay discrepancy differed depending on the reagents used, but revealed two novel genotype variants, p.Cys573Gly and p.Gly582Arg, associated with FVIII assay discrepancy. CONCLUSION Our findings showed that the FVIII:C1st /FVIII:CChr ratio is dependent on the reagent combination used for OSA.
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Affiliation(s)
- Atsuo Suzuki
- Department of Medical Technique, Nagoya University Hospital, Nagoya, Japan
| | - Nobuaki Suzuki
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Takeshi Kanematsu
- Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan
| | - Shuichi Okamoto
- Department of Haematology-Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shogo Tamura
- Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryosuke Kikuchi
- Department of Medical Technique, Nagoya University Hospital, Nagoya, Japan
| | - Akira Katsumi
- Department of Haematology, National Centre for Geriatrics and Gerontology, Obu, Japan
| | - Hitoshi Kiyoi
- Department of Haematology-Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tetsuhito Kojima
- Department of Pathophysiological Laboratory Sciences, 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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Assessing the Performance of Extended Half-Life Coagulation Factor VIII, FC Fusion Protein by Using Chromogenic and One-Stage Assays in Saudi Hemophilia A Patients. Adv Hematol 2020; 2020:8768074. [PMID: 32963537 PMCID: PMC7499282 DOI: 10.1155/2020/8768074] [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] [Received: 04/21/2020] [Revised: 06/25/2020] [Accepted: 07/15/2020] [Indexed: 11/19/2022] Open
Abstract
Background The one-stage assay is the most common method to measure factor VIII activity (FVIII : C) in hemophilia A patients. The chromogenic assay is another two-stage test involving purified coagulation factors followed by factor Xa-specific chromogenic substrate. Aim This study aimed to assess the discrepancy and correlation between the chromogenic and one-stage assays in measuring FVIII : C levels in hemophilia patients receiving Extended Half-Life Elocta® as a recombinant extended half-life coagulation factor. Methods We performed a study comparing the measurements of FVIII : C levels by the chromogenic versus the one-stage assays at different drug levels. Data of FVIII : C levels, dosage, and the time interval from administration to measurement were retrieved from the hospital records. The correlation, mean differences, and discrepancy between the two assays were calculated. The linear regression analysis was used to predict the time interval till reaching 1% FVIII : C. Results Fourteen patients with 56 samples were included in the study. Of them, 13 patients were receiving Elocta® as a prophylactic, while one was receiving Elocta® on demand. One-third of these samples showed a discrepancy between the chromogenic and one-stage assays. The two assays were well correlated. Mean differences were significant at the individual and the time interval level. The time since the last Elocta® injection could significantly predict FVIII : C levels (β = 0.366, P < 0.001). Conclusion Our findings suggested a significant difference between both methods; the FVIII : C levels measured by the one-stage assay were less than those estimated by the chromogenic assay. However, the measurements of FVIII levels by the two assays were well correlated but discrepant in one-third of the samples. The levels of FVIII : C reach 1% after 5.4 days since the last Elocta® administration.
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33
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Ovanesov MV, Williams SC, Nübling C, Dodt J, Hilger A, Maryuningsih Y, Gray E. Summary of the WHO hearing on the development of product-specific reference materials for coagulation factor VIII and factor IX products. Biologicals 2020; 67:88-93. [DOI: 10.1016/j.biologicals.2020.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 11/26/2022] Open
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34
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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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35
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Strålfors A, Mikovic D, Schmidt D, Onelöv L, Soutari NMH, Berndtson M, Chaireti R, Holmström M, Antovic JP, Bruzelius M. Genetics and Hemostatic Potential in Persons with Mild to Moderate Hemophilia A with a Discrepancy between One-Stage and Chromogenic FVIII Assays. Thromb Haemost 2020; 121:27-35. [PMID: 32791533 DOI: 10.1055/s-0040-1715443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Factor VIII (FVIII) activity (FVIII:C) can be measured by different methods including one-stage clotting assays (OSAs) and chromogenic assays (CSAs). Discrepancy between FVIII:C assays is known and associated with genetic variations causing mild and moderate hemophilia A (HA). We aimed to study the discrepancy phenomenon and to identify associated genetic alterations. Further, we investigated if hemostatic global assays could discriminate the group with discrepant FVIII:C from them. METHODS The study contained plasma samples from 45 patients with HA (PwHA) from Hemophilia Centers in Stockholm, Sweden, and Belgrade, Serbia. We measured FVIII:C with OSA and CSA, sequenced the F8 gene, and performed two global hemostatic assays; endogenous thrombin potential and overall hemostatic potential. RESULTS Nineteen of 45 PwHA had a more than twofold higher FVIII:C using OSA compared to CSA and were considered discrepant. Thirty-four causal mutations were detected, where of five had not previously been associated with assay discrepancy. These novel mutations were p.Tyr25Cys, p.Phe698Leu, p.Met699Leu, p.Ile1698Thr, and Ala2070Val. We found no difference between discrepant and nondiscrepant cases with either of the global assays. CONCLUSION There was a discrepancy between FVIII:C assays in almost half of the PwHA, which for some could lead to missed HA diagnoses or misclassification of severity. Genotyping confirmed that mutations associated with FVIII:C discrepancy cluster in the A domains of F8, and five mutations not previously associated with FVIII:C discrepancy was identified. Global hemostatic assays did not contribute to distinguish assay discrepancy in PwHA.
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Affiliation(s)
- Annelie Strålfors
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Clinical Chemistry, Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
| | - Danijela Mikovic
- Hemostasis Department and Hemophilia Center, Blood Transfusion Institute of Serbia, Belgrade, Serbia
| | - David Schmidt
- Coagulation Unit, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Liselotte Onelöv
- Clinical Chemistry, Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
| | - Nida Mahmoud Hourani Soutari
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Clinical Chemistry, Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Berndtson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Clinical Chemistry, Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
| | - Roza Chaireti
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Coagulation Unit, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Margareta Holmström
- Coagulation Unit, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jovan P Antovic
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Clinical Chemistry, Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Bruzelius
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Coagulation Unit, Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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36
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Schütte LM, Hodes LS, van Moort I, Stoof SCM, Leebeek FWG, Cnossen MH, de Maat MPM, Kruip MJHA. The one-stage assay or chromogenic assay to monitor baseline factor VIII levels and desmopressin effect in non-severe haemophilia A: Superiority or non-inferiority? Haemophilia 2020; 26:916-922. [PMID: 32713129 PMCID: PMC7590113 DOI: 10.1111/hae.14106] [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: 04/14/2020] [Revised: 05/28/2020] [Accepted: 06/23/2020] [Indexed: 12/01/2022]
Abstract
Introduction Diagnosis, treatment monitoring and assessment of desmopressin effect in haemophilia A patients are performed by measurement of factor VIII activity (FVIII). The two assays commonly applied are the one‐stage assay and the chromogenic assay. Especially in non‐severe haemophilia A, discrepancies between these assays are common. It is still unestablished which assay corresponds best with bleeding phenotype and desmopressin effect. Aim To correlate FVIII levels measured by the one‐stage assay and by the chromogenic assay with bleeding phenotype and, additionally, to compare FVIII assay discrepancies before and after desmopressin administration. Method Factor VIII was measured in 130 non‐severe haemophilia A patients during routine visits to the outpatient clinic and/or during desmopressin testing. FVIII was measured by both the one‐stage assay and the chromogenic assay. Discrepancies between assays were defined as at least a twofold difference of FVIII or an absolute FVIII difference between measurements of ≥0.10 IU/mL. Bleeding phenotype was defined as annual number of treated bleedings (adjusted ABR). Results Hundred and thirty non‐severe haemophilia A patients were included. In 31/130 patients, assay results were discrepant. However, FVIII measurements with both assays correlated adequately with adjusted ABR. In addition, in 27/130 patients FVIII measurements at baseline and after desmopressin administration were analysed. In 13/27 patients, all measurements were either equivalent or discrepant when results were compared. In 14/27 patients, this was not the case as both equivalent measurements and discrepant measurements at different time points within one patient were observed. Conclusion Neither the one‐stage assay nor the chromogenic assay is superior in predicting bleeding phenotype. In addition, equivalent or discrepant FVIII results measured before desmopressin do not always predict FVIII assay results after desmopressin administration.
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Affiliation(s)
- Lisette M Schütte
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Luca S Hodes
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Iris van Moort
- Department of Paediatric Haematology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sara C M Stoof
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Moniek P M de Maat
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Wilmot HV, Rakowski K, Gray E. The traceability of commercial plasma calibrators to the plasma International Standards for factor VIII and factor IX. Int J Lab Hematol 2020; 42:810-818. [PMID: 32638532 PMCID: PMC7754292 DOI: 10.1111/ijlh.13277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 01/19/2023]
Abstract
Accurate measurement of coagulation factors is essential, especially for diagnosis of deficiency. Clinical laboratories use commercially available plasma calibrators, which should be traceable to the relevant plasma International Standard (IS). This study assessed the relationship between the plasma IS for factors IX (FIX) and VIII (FVIII) and some commonly used commercial calibrators. Calibrators from seven manufacturers were assayed for FIX and FVIII activity by one‐stage clotting assay (OSCA) using different activated partial thromboplastin time (APTT) reagents and deficient plasmas, or chromogenic assay (CA). Results were calculated relative to the 4th IS Factors II,VII,IX,X, Plasma or the 6th IS Factor VIII/VWF, Plasma. Results for each calibrator were similar across the APTT reagents and deficient plasmas used. All calibrators showed a recovery of 90%‐111% of the manufacturers’ values, except calibrator C, which had recovery of around 85%. CA gave similar results, with good recovery for all but calibrator C. Similar low recoveries for OSCA and CA were found for a different lot of calibrator C and for a different calibrator product from manufacturer C. When all calibrators from manufacturer C were assayed by OSCA using the manufacturer's own deficient plasmas and APTT reagents, the mean recovery was still below 90%. Overall, there was good traceability of the international unit between the IS and commercial calibrator plasmas. Calibrators from one manufacturer consistently yielded lower than expected values for FIX and FVIII. This could lead to an over‐estimation of the coagulation factor content in patient samples and demonstrates the importance of careful choice of calibrator.
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Affiliation(s)
- Helen V Wilmot
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Control (NIBSC), Potters Bar, Hertfordshire, United Kingdom
| | - Kajetan Rakowski
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Control (NIBSC), Potters Bar, Hertfordshire, United Kingdom
| | - Elaine Gray
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Control (NIBSC), Potters Bar, Hertfordshire, United Kingdom
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Al-Huniti A, Sharathkumar A, Krantz M, Watkinson K, Bhagavathi S. Discrepant Hemophilia A: An Underdiagnosed Disease Entity. Am J Clin Pathol 2020; 154:78-87. [PMID: 32232366 DOI: 10.1093/ajcp/aqaa024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The term discrepant hemophilia A (DHA) denotes the discrepancy between factor VIII activity (FVIII:C) measured by different assay methodologies in patients with nonsevere hemophilia A (HA). The objective was to review the characteristics and the current understanding of mechanisms contributing to assay discrepancy in DHA. METHODS Characteristics of the DHA patients treated were examined by retrospective chart review. In addition, a literature review was performed to determine the current understanding of DHA. RESULTS Three cases of DHA were diagnosed based on bleeding phenotype: 2 cases represented missed diagnoses of HA, and 1 represented misclassification of hemophilia severity. The revised diagnosis and classification of hemophilia directly affected clinical management. Review of the literature identified 18 articles with an estimated pooled prevalence of 36% (95% CI, 23%-56%; I2 = 85%; P < .01) among nonsevere HA. Furthermore, literature indicated that DHA is a feature of how different FVIII gene mutations affect FVIII:C activity within different assay methodologies. CONCLUSIONS Our experience and literature review suggested that DHA is not only a laboratory phenomenon-it can affect clinical management in a subset of patients. A high index of suspicion for DHA is necessary while evaluating bleeding patients and/or classifying nonsevere HA.
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Affiliation(s)
- Ahmad Al-Huniti
- Division of Hematology Oncology, Stead Family Children’s Hospital, University of Iowa, Iowa City
| | - Anjali Sharathkumar
- Division of Hematology Oncology, Stead Family Children’s Hospital, University of Iowa, Iowa City
| | - Michelle Krantz
- Division of Hematology Oncology, Stead Family Children’s Hospital, University of Iowa, Iowa City
| | - Karla Watkinson
- Division of Hematology Oncology, Stead Family Children’s Hospital, University of Iowa, Iowa City
| | - Sharathkumar Bhagavathi
- Department of Pathology and Laboratory Medicine, University of Iowa Carver College of Medicine, Iowa City
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Delavenne X, Dargaud Y. Pharmacokinetics for haemophilia treaters: Meaning of PK parameters, interpretation pitfalls, and use in the clinic. Thromb Res 2020; 192:52-60. [PMID: 32450448 DOI: 10.1016/j.thromres.2020.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/03/2020] [Accepted: 05/04/2020] [Indexed: 01/19/2023]
Abstract
Replacement therapy with concentrates of factor VIII or IX remains the gold standard for severe haemophilia management. The recent development of clotting factor products with extended half-life, widely available on the market since 2 years, facilitates adherence, improves considerably the patients' quality of life, and simplifies the management of breakthrough bleedings or surgery. These molecules have also brought to the limelight the concepts of optimization and personalization of anti-haemophilic prophylaxis. Pharmacokinetics (PK) is one of the tools that can help haematologists to adapt in a more objective and precise manner the prophylaxis regimen to each individual patient's specific needs. For many years, clinicians at haemophilia centres have been using some simple PK parameters, such as recovery and residual level. However, recently, they have been confronted with an important number of new PK parameters they were not familiar with, but that can be used to improve patient management. Due to the accumulation of PK data and their relative complexity, it is now necessary to analyse the relevance of the different PK parameters relative to haemophilia specificities, and also to know their limits to better use them.
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Affiliation(s)
- Xavier Delavenne
- INSERM, UMR 1059, Dysfonction Vasculaire et de l'Hémostase, Université de Lyon, Saint Etienne, France; Laboratoire de Pharmacologie - Toxicologie, CHU de Saint-Etienne, Saint-Etienne, France.
| | - Yesim Dargaud
- Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, Université Lyon 1, Lyon, France
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40
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Higher FVIII:C measured by chromogenic substrate assay than by one-stage assay is associated with silent hemophilic arthropathy. Thromb Res 2020; 188:103-105. [DOI: 10.1016/j.thromres.2020.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 11/12/2019] [Accepted: 01/06/2020] [Indexed: 11/18/2022]
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Kloosterman F, Zwagemaker A, Abdi A, Gouw S, Castaman G, Fijnvandraat K. Hemophilia management: Huge impact of a tiny difference. Res Pract Thromb Haemost 2020; 4:377-385. [PMID: 32211572 PMCID: PMC7086468 DOI: 10.1002/rth2.12314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 12/27/2019] [Indexed: 12/22/2022] Open
Abstract
Hemophilia A and B are inherited X-linked disorders of hemostasis, associated with an increased bleeding tendency. Patients with severe hemophilia have undetectable clotting factor levels and experience spontaneous bleeds. In patients with nonsevere hemophilia, the clotting factor levels are 2% to 40% of normal and bleeds predominantly occur after provocative events such as trauma and surgery. Despite this milder phenotype, patients with nonsevere hemophilia may suffer from considerable morbidity and have an increased mortality risk. However, many aspects of the course of disease and treatment remain unclear. Information on the factors influencing interindividual differences in bleeding phenotype is lacking, and misdiagnosis may occur due to assay discrepancies in the diagnostic workup. Desmopressin is the preferred treatment modality, but some patients and indications require treatment with clotting factor concentrates. This may elicit inhibitor formation, which is associated with an increased burden of disease and a higher mortality rate. It has been found that patients with nonsevere hemophilia A carry a lifelong risk for this serious complication. In this review, we provide an overview of the current knowledge of the diagnosis and management of nonsevere hemophilia. A report of science presented at the International Society on Thrombosis and Haemostasis 2019 Annual Congress is also provided.
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Affiliation(s)
- Fabienne Kloosterman
- Pediatric HematologyAmsterdam UMCEmma Children's HospitalUniversity of AmsterdamAmsterdamThe Netherlands
| | - Anne‐Fleur Zwagemaker
- Pediatric HematologyAmsterdam UMCEmma Children's HospitalUniversity of AmsterdamAmsterdamThe Netherlands
| | - Amal Abdi
- Pediatric HematologyAmsterdam UMCEmma Children's HospitalUniversity of AmsterdamAmsterdamThe Netherlands
| | - Samantha Gouw
- Pediatric HematologyAmsterdam UMCEmma Children's HospitalUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Giancarlo Castaman
- Department of OncologyCenter for Bleeding DisordersCareggi University HospitalFlorenceItaly
| | - Karin Fijnvandraat
- Pediatric HematologyAmsterdam UMCEmma Children's HospitalUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Molecular Cellular HemostasisSanquin ResearchAmsterdamThe Netherlands
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42
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Marlar RA, Strandberg K, Shima M, Adcock DM. Clinical utility and impact of the use of the chromogenic vs one-stage factor activity assays in haemophilia A and B. Eur J Haematol 2019; 104:3-14. [PMID: 31606899 PMCID: PMC6916414 DOI: 10.1111/ejh.13339] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 10/08/2019] [Accepted: 10/10/2019] [Indexed: 02/06/2023]
Abstract
Treatment of haemophilia A/B patients comprises factor VIII (FVIII) or factor IX (FIX) concentrate replacement therapy, respectively. FVIII and FIX activity levels can be measured in clinical laboratories using one‐stage activated partial thromboplastin time (aPTT)‐based clotting or two‐stage chromogenic factor activity assays. We discuss strengths and limitations of these assays, providing examples of clinical scenarios to highlight some of the challenges associated with their current use for diagnostic and monitoring purposes. Substantial inter‐laboratory variability has been reported for one‐stage assays when measuring the activity of factor replacement products due to the wide range of currently available aPTT reagents, calibration standards, factor‐deficient plasmas, assay conditions and instruments. Chromogenic activity assays may avoid some limitations associated with one‐stage assays, but their regulatory status, perceived higher cost, and lack of laboratory expertise may influence their use. Haemophilia management guidelines recommend the differential application of one or both assays for initial diagnosis and disease severity characterisation, post‐infusion monitoring and replacement factor potency labelling. Efficient communication between clinical and laboratory staff is crucial to ensure application of the most appropriate assay to each clinical situation, correct interpretation of assay results and, ultimately, accurate diagnosis and optimal and safe treatment of haemophilia A or B patients.
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Affiliation(s)
| | - Karin Strandberg
- Department of Clinical Chemistry, Center for Thrombosis and Hemostasis, SUS Malmö, Malmö, Sweden
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Nara, Japan
| | - Dorothy M Adcock
- Colorado Coagulation, Laboratory Corporation of America® Holdings, Englewood, CO, USA
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43
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Quantification of coagulation factor VIII in human plasma with liquid chromatography tandem mass spectrometry using a selective sample purification with camelid nanobodies. J Pharm Biomed Anal 2019; 175:112781. [PMID: 31398627 DOI: 10.1016/j.jpba.2019.112781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 06/20/2019] [Accepted: 07/17/2019] [Indexed: 01/26/2023]
Abstract
Patients with hemophilia A are currently diagnosed and monitored by measuring the activity of coagulation factor VIII (FVIII) in plasma mostly with the one-stage clotting assay (OSA). Although the OSA is routinely available in many clinical laboratories, it has in some circumstances relatively low sensitivity and specificity. Therefore, the FVIII activity as a biomarker does not always correlate with the bleeding phenotype. Therefore, we have developed a liquid chromatography tandem mass spectrometry method to quantify the concentration of coagulation FVIII in plasma which would allow us to investigate the relation between FVIII plasma concentration, FVIII activity and bleeding tendency in future studies. LC-MS/MS method was set up by firstly dissociation Von Willebrand factor (VWF) from coagulation factor VIII by triggering the coagulation cascade to occur thus generating active factor VIII (FVIIIa). FVIIIa was then selectively extracted by means of immunoaffinity interaction using anti-FVIII camelid nanobody, after which FVIIIa was eluted, heat denatured and trypsin digested. Finally, a FVIII specific peptide was used as a surrogate for quantification by mass spectrometry. Critical method parameters such as antibody amount, incubation time, sample volume and type of streptavidin 96 well plate were optimized. The method was validated according to European Medicines Agency (EMA) guidelines where an LLOQ of 1 ng/mL was obtained using 50 μL of citrate plasma sample. Within-run and between-run accuracy and precision for quality control (QC) samples, LLOQ (1 ng/mL), QC Low (5 ng/mL), QC Med (150 ng/mL), QC High (300 ng/mL) were within the threshold of 15% relative standard deviation (RSD) and Bias. The selective immunoaffinity method which was used in combination with a highly sensitive mass spectrometer allowed for an unpresented LLOQ of 1 ng/mL utilizing 50 μL plasma sample. This method will be used to investigate the beneficial value of FVIII plasma concentration which may be used in conjunction with FVIII activity for patient diagnosis and dosage optimization.
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44
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Núñez-Navarro NE, Santana FM, Parra LP, Zacconi FC. Surfing the Blood Coagulation Cascade: Insight into the Vital Factor Xa. Curr Med Chem 2019; 26:3175-3200. [PMID: 29376487 DOI: 10.2174/0929867325666180125165340] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 12/28/2017] [Accepted: 01/11/2018] [Indexed: 01/19/2023]
Abstract
Factor Xa (FXa) plays a key role in haemostasis, it is a central part of the blood coagulation cascade which catalyzes the production of thrombin and leads to clot formation and wound closure. Therefore, FXa is an attractive target for the development of new anticoagulant agents. In this review, we will first describe the molecular features of this fundamental protein in order to understand its mechanism of action, an essential background for the design of novel inhibitors by means of synthetic organic chemistry or using peptides obtained from recombinant methodologies. Then, we will review the current state of the synthesis of novel direct FXa inhibitors along with their mechanisms of action. Finally, approved reversal agents that aid in maintaining blood haemostasis by using these commercial drugs will also be discussed.
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Affiliation(s)
- Nicolás E Núñez-Navarro
- Department of Organic Chemistry, Faculty of Chemistry, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Department of Chemical and Bioprocesses Engineering, School of Engineering, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Fabián M Santana
- Department of Organic Chemistry, Faculty of Chemistry, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Loreto P Parra
- Department of Chemical and Bioprocesses Engineering, School of Engineering, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Flavia C Zacconi
- Department of Organic Chemistry, Faculty of Chemistry, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Research Center for Nanotechnology and Advanced Materials "CIEN-UC", Pontificia Universidad Catolica de Chile, Santiago, Chile
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45
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Negrier C, Shima M, Hoffman M. The central role of thrombin in bleeding disorders. Blood Rev 2019; 38:100582. [PMID: 31164248 DOI: 10.1016/j.blre.2019.05.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 05/10/2019] [Accepted: 05/20/2019] [Indexed: 01/25/2023]
Abstract
Maintaining normal hemostasis relies on a regulated system of procoagulant and anticoagulant pathways, and disruption of these processes leads to the loss of hemostatic control, with the potential for excessive bleeding or thrombosis. Evaluation of bleeding disorders has conventionally been achieved by laboratory assays that measure the activity of individual coagulation factors. While such assays have proven effective for detecting abnormalities of the coagulation system and aiding diagnosis, inherent limitations prevent them from capturing a complete picture of hemostatic function. An improved understanding of thrombin activity and its central role in hemostasis and bleeding disorders has led to the clinical development of global assays that are more physiologically relevant than traditional assays; furthermore, these global assays are able to monitor responses to therapy. In this review, we provide an overview of the role of thrombin in hemostasis, and describe the clinical benefits of thrombin monitoring in patients with bleeding disorders. Moreover, we discuss recent advances in thrombin-targeting therapeutic strategies that aim to correct thrombin deficiency and prevent bleeding in patients with hemophilia and other rare bleeding disorders.
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Affiliation(s)
- Claude Negrier
- Haematology Department, Louis Pradel University Hospital, University Claude Bernard, Lyon, France
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Maureane Hoffman
- Department of Pathology, Duke University Medical Center, Durham, NC, USA.
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46
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Tiefenbacher S, Albisetti M, Baker P, Kappert G, Kitchen S, Kremer Hovinga JA, Pouplard C, Scholz U, Ternisien C, Borgvall C, Vicente T, Belyanskaya L, Walter O, Oldenburg J. Estimation of Nuwiq ® (simoctocog alfa) activity using one-stage and chromogenic assays-Results from an international comparative field study. Haemophilia 2019; 25:708-717. [PMID: 31106957 PMCID: PMC6851970 DOI: 10.1111/hae.13763] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 03/21/2019] [Accepted: 04/04/2019] [Indexed: 01/19/2023]
Abstract
Background Accurate determination of coagulation factor VIII activity (FVIII:C) is essential for effective and safe FVIII replacement therapy. FVIII:C can be measured by one‐stage and chromogenic substrate assays (OSAs and CSAs, respectively); however, there is significant interlaboratory and interassay variability. Aims This international comparative field study characterized the behaviour of OSAs and CSAs used in routine laboratory practice to measure the activity of Nuwiq® (human‐cl rhFVIII, simoctocog alfa), a fourth‐generation recombinant human FVIII produced in a human cell line. Methods FVIII‐deficient plasma was spiked with Nuwiq® or Advate® at 1, 5, 30 and 100 international units (IU)/dL. Participating laboratories analysed the samples using their routine procedures and equipment. Accuracy, inter‐ and intralaboratory variation, CSA:OSA ratio and the impact of different OSA and CSA reagents were assessed. Results Forty‐nine laboratories from 9 countries provided results. Mean absolute FVIII:C was comparable for both products at all concentrations with both OSA and CSA, with interproduct ratios (Nuwiq®:Advate®) of 1.02‐1.13. Mean recoveries ranged from 97% to 191% for Nuwiq®, and from 93% to 172% for Advate®, with higher recoveries at lower concentrations. Subgroup analyses by OSA and CSA reagents showed minor variations depending on reagents, but no marked differences between the two products. CSA:OSA ratios based on overall means ranged from 0.99 to 1.17 for Nuwiq® and from 1.01 to 1.17 for Advate®. Conclusions Both OSAs and CSAs are suitable for the measurement of FVIII:C of Nuwiq® in routine laboratory practice, without the need for a product‐specific reference standard.
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Affiliation(s)
- Stefan Tiefenbacher
- Colorado Coagulation, Laboratory Corporation of America® Holdings, Englewood, Colorado
| | - Manuela Albisetti
- Hematology Department, University Children's Hospital, Zürich, Switzerland
| | - Peter Baker
- Oxford Haemophilia and Thrombosis Centre, Oxford, UK
| | - Guenther Kappert
- Coagulation Centre Rhine-Ruhr, Medical Thrombosis and Haemophilia Treatment Centre and Specialized Laboratory for Coagulation Disorders/Haemophilia, Duisburg, Germany
| | | | - Johanna A Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claire Pouplard
- Department of Haematology-Haemostasis, University Hospital of Tours, Tours, France
| | - Ute Scholz
- Center of Haemostasis, MVZ Labor Leipzig, Leipzig, Germany
| | | | | | | | | | | | - Johannes Oldenburg
- Institut für Experimentelle Hämatologie und Transfusionsmedizin, Universitätsklinikum Bonn, Bonn, Germany
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Ar MC, Balkan C, Kavaklı K. Extended Half-Life Coagulation Factors: A New Era in the Management of Hemophilia Patients. Turk J Haematol 2019; 36:141-154. [PMID: 31088040 PMCID: PMC6682782 DOI: 10.4274/tjh.galenos.2019.2018.0393] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Despite effective factor replacement and various treatment schedules, there remain several challenges and unmet needs in the prophylactic treatment of hemophilia limiting its adoption and thereby posing an increased risk of spontaneous bleeding. In this regard, extended half-life (EHL) recombinant factor VIII (rFVIII) and factor IX (rFIX) products promise optimal prophylaxis by decreasing the dose frequency, increasing the compliance, and improving the quality of life without compromising safety and efficacy. EHL products might lead to higher trough levels without increasing infusion frequency, or could facilitate the ability to maintain trough levels while reducing infusion frequency. This paper aims to provide a comprehensive review of the rationale for developing EHL coagulation factors and their utility in the management of hemophilia, with special emphasis on optimal techniques for half-life extension and criteria for defining EHL coagulation factors, as well as indications, efficacy, and safety issues of the currently available EHL-rFVIII and EHL-rFIX products. Potential impacts of these factors on quality of life, health economics, and immune tolerance treatment will also be discussed alongside the challenges in pharmacokinetic-driven prophylaxis and difficulties in monitoring the EHL products with laboratory assays.
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Affiliation(s)
- Muhlis Cem Ar
- İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine Department of Internal Medicine, Division of Hematology, İstanbul, Turkey
| | - Can Balkan
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Hemato-Oncology, İzmir, Turkey
| | - Kaan Kavaklı
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Hemato-Oncology, İzmir, Turkey
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48
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Novembrino C, Boscolo Anzoletti M, Mancuso ME, Shinohara S, Peyvandi F. Evaluation of an automated chromogenic assay for Factor VIII clotting activity measurement in patients affected by haemophilia A. Haemophilia 2019; 25:521-526. [PMID: 31044485 DOI: 10.1111/hae.13746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 02/27/2019] [Accepted: 03/07/2019] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The original one-stage clotting assay is still the most widely used method to measure Factor VIII clotting activity (FVIII:C) in patients with haemophilia A (HA), although the use of chromogenic assays is increasing significantly. AIM Evaluation of the analytical performance and diagnostic accuracy of BIOPHEN™ FVIII:C (HYPHEN BioMed, Neuville-sur-Oise, France) assay on Sysmex CS-2400 (Sysmex, Kobe, Japan) analyser. METHODS Sixty patients with haemophilia A (HA; any severity) and 120 healthy Italian subjects were included. All the assays were performed on citrate platelet-poor plasmas stored at -80°C. Chromogenic BIOPHEN™ FVIII:C was compared with the one-stage assay using Actin FS and Factor VIII deficient plasma (Siemens Healthcare Diagnostics, Marburg, Germany) on Sysmex CS-2400 and with another chromogenic automated assay (COAMATIC™ Factor VIII, CHROMOGENIX on ACL TOP analyzer; Instrumentation Laboratory, Milan, Italy). RESULTS Intra-assay and inter-assay coefficient of variation were <6%. Linearity was good up to 1/128 dilution (r = 0.99); mean recovery was 91.7% and limit of detection was 0.2%. BIOPHEN™ FVIII:C assay showed a good correlation and diagnostic agreement with the chromogenic COAMATIC™ assay: the Spearmen's Rank correlation coefficient was 0.98 and the inter-rate agreement K Cohen coefficient was 0.61. The K coefficient was 0.91 when BIOPHEN™ FVIII:C was compared with the historical classification of the patients, demonstrating an optimal diagnostic accuracy in HA. CONCLUSIONS BIOPHEN™ FVIII:C showed good analytical performance and diagnostic accuracy and could be considered suitable for the introduction in routine analytical panel of coagulation for the diagnosis of HA patients.
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Affiliation(s)
- Cristina Novembrino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Boscolo Anzoletti
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Elisa Mancuso
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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49
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In silico and in vitro evaluation of the impact of mutations in non-severe haemophilia A patients on assay discrepancies. Ann Hematol 2019; 98:1855-1865. [DOI: 10.1007/s00277-019-03691-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 04/07/2019] [Indexed: 11/25/2022]
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50
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Strategies for Individualized Dosing of Clotting Factor Concentrates and Desmopressin in Hemophilia A and B. Ther Drug Monit 2019; 41:192-212. [DOI: 10.1097/ftd.0000000000000625] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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