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da Silva Etges APB, Schneider NB, Roos EC, Marcolino MAZ, Ozelo MC, Midori Takahashi Hosokawa Nikkuni M, Elvira Mesquita Carvalho L, Oliveira Rebouças T, Hermida Cerqueira M, Mata V, Polanczyk CA. Cost of hemophilia A in Brazil: a microcosting study. HEALTH ECONOMICS REVIEW 2024; 14:62. [PMID: 39105856 PMCID: PMC11305066 DOI: 10.1186/s13561-024-00539-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Accepted: 07/16/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Patients with Hemophilia are continually monitored at treatment centers to avoid and control bleeding episodes. This study estimated the direct and indirect costs per patient with hemophilia A in Brazil and evaluated the cost variability across different age groups. METHODS A prospective observational research was conducted with retrospective data collection of patients assisted at three referral blood centers in Brazil. Time-driven Activity-based Costing method was used to analyze direct costs, while indirect costs were estimated based on interviews with family and caregivers. Cost per patient was analyzed according to age categories, stratified into 3 groups (0-11;12-18 or older than 19 years old). The non-parametric Mann-Whitney test was used to confirm the differences in costs across groups. RESULTS Data from 140 hemophilia A patients were analyzed; 53 were 0-11 years, 29 were 12-18 years, and the remaining were older than 19 years. The median cost per patient per year was R$450,831 (IQR R$219,842; R$785,149; $174,566), being possible to confirm age as a cost driver: older patients had higher costs than younger's (p = 0.001; median cost: 0-11 yrs R$299,320; 12-18 yrs R$521,936; ≥19 yrs R$718,969). CONCLUSION This study is innovative in providing cost information for hemophilia A using a microcosting technique. The variation in costs across patient age groups can sustain more accurate health policies driven to increase access to cutting-edge technologies and reduce the burden of the disease.
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Affiliation(s)
- Ana Paula Beck da Silva Etges
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (project: 465518/2014-1), Ramiro Barcelos, 2350, Building 21- 507, Porto Alegre, 90035-903, Brazil
- Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, RS, Brazil
| | - Nayê Balzan Schneider
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (project: 465518/2014-1), Ramiro Barcelos, 2350, Building 21- 507, Porto Alegre, 90035-903, Brazil
- Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, RS, Brazil
| | - Erica Caetano Roos
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (project: 465518/2014-1), Ramiro Barcelos, 2350, Building 21- 507, Porto Alegre, 90035-903, Brazil
- Graduate Program in Industrial Engineering, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Miriam Allein Zago Marcolino
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (project: 465518/2014-1), Ramiro Barcelos, 2350, Building 21- 507, Porto Alegre, 90035-903, Brazil
- Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, RS, Brazil
| | - Margareth Castro Ozelo
- Hemocentro UNICAMP, Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | | | | | | | | | | | - Carisi Anne Polanczyk
- National Institute of Science and Technology for Health Technology Assessment (IATS) - CNPq/Brazil (project: 465518/2014-1), Ramiro Barcelos, 2350, Building 21- 507, Porto Alegre, 90035-903, Brazil.
- Graduate Program in Epidemiology, Universidade Federal do Rio Grande do Sul School of Medicine, Porto Alegre, RS, Brazil.
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Zülfikar B, Mahlangu J, Nekkal SM, Ross C, Uaprasert N, Windyga J, Ettingshausen CE, Ploder B, Lelli A, Gazda HT. Reduced Volume and Faster Infusion Rate of Activated Prothrombin Complex Concentrate: A Phase 3b/4 Trial in Adults with Hemophilia A with Inhibitors. TH OPEN 2024; 8:e273-e282. [PMID: 38983688 PMCID: PMC11230701 DOI: 10.1055/s-0044-1787781] [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: 11/15/2023] [Accepted: 05/17/2024] [Indexed: 07/11/2024] Open
Abstract
Background Activated prothrombin complex concentrate (aPCC) is indicated for bleed treatment and prevention in patients with hemophilia with inhibitors. The safety and tolerability of intravenous aPCC at a reduced volume and faster infusion rates were evaluated. Methods This multicenter, open-label trial (NCT02764489) enrolled adults with hemophilia A with inhibitors. In part 1, patients were randomized to receive three infusions of aPCC (85 ± 15 U/kg) at 2 U/kg/min (the approved standard rate at the time of the study), in a regular or 50% reduced volume, and were then crossed over to receive three infusions in the alternative volume. In part 2, patients received three sequential infusions of aPCC in a 50% reduced volume at 4 U/kg/min and then at 10 U/kg/min. Primary outcome measures included the incidence of adverse events (AEs), allergic-type hypersensitivity reactions (AHRs), infusion-site reactions (ISRs), and thromboembolic events. Results Of the 45 patients enrolled, 33 received aPCC in part 1 and 30 in part 2. In part 1, 24.2 and 23.3% of patients with regular and reduced volumes experienced AEs, respectively; 11 AEs in eight patients were treatment related. AHRs and ISRs occurred in four (12.1%) and two (6.1%) patients, respectively. In part 2, 3.3 and 14.3% of patients with infusion rates of 4 and 10 U/kg/min experienced AEs, respectively; only one AE in one patient was treatment related; no AHRs or ISRs were reported. Most AEs were mild/moderate in severity. Overall, no thromboembolic events were reported. Conclusions aPCC was well tolerated at a reduced volume and faster infusion rates, with safety profiles comparable to the approved regimen.
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Affiliation(s)
- Bülent Zülfikar
- Hereditary Bleeding Disorders Unit in Oncology Institute, Istanbul University, Istanbul, Turkey
| | - Johnny Mahlangu
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand and NHLS, Johannesburg, South Africa
| | | | - Cecil Ross
- St John's Medical College Hospital, Bangalore, India
| | - Noppacharn Uaprasert
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | - Bettina Ploder
- Baxalta Innovations GmbH, a Takeda company, Vienna, Austria
| | - Aurelia Lelli
- PDT R&D Global Medical Affairs, Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | - Hanna T Gazda
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, United States
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Bakhsh E. Impact of Replacement Therapy on Pregnancy Outcomes in Hemophilia Carriers: A Historical Cohort Study in Saudi Arabia. Life (Basel) 2024; 14:623. [PMID: 38792643 PMCID: PMC11122275 DOI: 10.3390/life14050623] [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: 04/26/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
This retrospective cohort study evaluates the safety and efficacy of replacement therapy with regard to pregnancy outcomes in hemophilia carriers. Hemophilia carriers face elevated bleeding risks during pregnancy, necessitating meticulous management, including replacement therapy with clotting factors. This research examines the records of 64 pregnant hemophilia carriers at King Fahad Medical City, Riyadh, from January 2010 to December 2023, analyzing their demographic details, hemophilia type and severity, replacement therapy specifics, and pregnancy outcomes. The study found that 62.5% of the participants had hemophilia A, with 43.8% categorized as severe. Most subjects (87.5%) received recombinant factor VIII at a median dosage of 30 IU/kg weekly. Adverse pregnancy outcomes included gestational hypertension (15.6%), preterm labor (18.8%), and postpartum hemorrhage (12.5%). The cesarean section rate was 28.1%. Neonatal outcomes were generally favorable, with median birth weights at 3100 g and mean Apgar scores of 8.2 and 9.1 at 1 and 5 min, respectively. Logistic regression analysis revealed no significant association between adverse events and therapy type or dosage, though a trend towards significance was noted with once-weekly administration (p = 0.082). The study concludes that replacement therapy is a viable method for managing hemophilia in pregnant carriers, leading to generally favorable maternal and neonatal outcomes. However, it underscores the importance of individualized treatment plans and close monitoring to effectively manage the risks associated with hemophilia during pregnancy.
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Affiliation(s)
- Ebtisam Bakhsh
- Internal Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11564, Saudi Arabia
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4
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Prudente TP, Camelo RM, Guimarães RA, Roberti MDRF. Emicizumab prophylaxis in people with hemophilia A and inhibitors: a systematic review and meta-analysis. SAO PAULO MED J 2024; 142:e2023102. [PMID: 38747872 PMCID: PMC11087007 DOI: 10.1590/1516-3180.2023.0102.r1.20022024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/06/2023] [Accepted: 02/20/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Until recently, the treatment of people with hemophilia A and inhibitors (PwHAi) was based on the use of bypassing agents (BPA). However, the advent of emicizumab as prophylaxis has demonstrated promising results. OBJECTIVES We aimed to compare the bleeding endpoints between PwHAi on BPA and those on emicizumab prophylaxis. DESIGN AND SETTING Systematic review of interventions and meta-analysis conducted at the Universidade Federal de Goiás, Goiânia, Goiás, Brazil. METHODS The CENTRAL, MEDLINE, Scopus, and LILACS databases were searched on February 21, 2023. Two authors conducted the literature search, publication selection, and data extraction. The selected publications evaluated the bleeding endpoints between PwHAi on emicizumab prophylaxis and those on BPA prophylaxis. The risk of bias was evaluated according to the Joanna Briggs Institute criteria. A meta-analysis was performed to determine the annualized bleeding rate (ABR) for treated bleeds. RESULTS Five publications (56 PwHAi) were selected from the 543 retrieved records. Overall, bleeding endpoints were lower during emicizumab prophylaxis than during BPA prophylaxis. All the publications had at least one risk of bias. The only common parameter for the meta-analysis was the ABR for treated bleeds. During emicizumab prophylaxis, the ABR for treated bleeds was lower than during BPA prophylaxis (standard mean difference: -1.58; 95% confidence interval -2.50, -0.66, P = 0.0008; I2 = 68.4%, P = 0.0031). CONCLUSION Emicizumab was superior to BPA in bleeding prophylaxis in PwHAi. However, both the small population size and potential risk of bias should be considered when evaluating these results. SYSTEMATIC REVIEW REGISTRATION CRD42021278726, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278726.
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Affiliation(s)
- Tiago Paiva Prudente
- Medical student, Faculty of Medicine, Universidade Federal de Goiás (UFG), Goiânia (GO), Brazil
| | - Ricardo Mesquita Camelo
- MD, PhD. Physician, Postdoctoral associate, Faculty of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil
| | - Rafael Alves Guimarães
- RN, PhD. Epidemiologist, Professor, Faculty of Nursing, Universidade Federal de Goiás (UFG), Goiânia (GO), Brazil
| | - Maria do Rosário Ferraz Roberti
- MD, PhD. Physician, Professor, Faculty of Medicine, Universidade Federal de Goiás (UFG), Goiânia (GO), Brazil; Physician, Secretaria de Saúde do Estado de Goiás (SES/GERAT), Goiânia (GO), Brazil
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5
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Arvanitakis A, Jepsen C, Andersson NG, Baghaei F, Astermark J. Primary prophylaxis implementation and long-term joint outcomes in Swedish haemophilia A patients. Haemophilia 2024; 30:671-677. [PMID: 38575549 DOI: 10.1111/hae.15013] [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: 01/12/2024] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Primary prophylaxis is the gold standard in severe haemophilia A (SHA) but time to escalate the prophylaxis regimen varies. AIM Assess prophylaxis implementation and long-term joint health outcomes in SHA with primary prophylaxis. METHODS Adult male patients born after 1980, with SHA on primary prophylaxis, started before the age of 3 years and second joint bleed, and no history of FVIII inhibitors, were enrolled. Repeated joint-health examinations were performed with HJHS or HEAD-US; VERITAS-PRO assessed adherence. RESULTS Thirty patients were enrolled with, at inclusion, median age 33.5 years, annualized bleed rate and joint bleed rate 0, and FVIII consumption 4232 IU/kg/year, respectively. The median age was 1.2 years, at prophylaxis start once weekly with a median FVIII dose of 47.7 IU/kg, and 1.7 years, by the time escalation to a final regimen had occurred, with a median infusion frequency of thrice weekly and FVIII dose 41.7 IU/kg, respectively. Older age correlated with later transition to escalated prophylaxis (p < .001). Longer time to escalated prophylaxis correlated to more bleeds (p < .001). Median HJHS increased slowly, reaching 4 at 35-40 years. HJHS at 15-20 years correlated with higher HJHS afterwards. Median total HEAD-US score was 1 and correlated with HJHS (p < .001). Median VERITAS-PRO score was 36, indicating good treatment adherence. CONCLUSION Primary prophylaxis is effective but does not completely prevent the gradual development of arthropathy in SHA. Joint assessments with HJHS should start at an early age, as they correlate with arthropathy in later life. Prophylaxis escalation should proceed expeditiously to prevent bleeds.
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Affiliation(s)
- Alexandros Arvanitakis
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
| | - Caroline Jepsen
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Medicine, Coagulation Centre, Gothenburg, Sweden
| | - Nadine G Andersson
- Department for Paediatric Haematology and Oncology, Children's Hospital, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Paediatrics, Lund University, Malmö, Sweden
| | - Fariba Baghaei
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Medicine, Coagulation Centre, Gothenburg, Sweden
| | - Jan Astermark
- Department of Translational Medicine, Lund University, Malmö, Sweden
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
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Nanayakkara L, Yahaya N, Parreira M, Bajkin B. Dental management of people with complex or rare inherited bleeding disorders. Haemophilia 2024; 30 Suppl 3:128-134. [PMID: 38571337 DOI: 10.1111/hae.15005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/14/2024] [Accepted: 03/14/2024] [Indexed: 04/05/2024]
Abstract
Advances in haematological therapies for people with complex or rare inherited bleeding disorders (IBD) have resulted in them living longer, retaining their natural teeth with greater expectations of function and aesthetics. Dental management strategies need to evolve to meet these challenges. Utilising low level laser diode therapy to reduce pre-operative inflammation to reduce the intraoperative and postoperative burden on haemostasis is described in a case series of 12 patients. For these individuals who previously required further medical management to support haemostasis or experienced such prolonged haemorrhage sufficient to warrant hospital admission, haemostasis was achieved in the dental surgery such that they were able to return home with no further medical intervention or overnight stays. Global inequities in accessing novel treatments for complex or rare IBD necessitates a comprehensive understanding of the local haemostatic agents available to dentists and the most commonly used agents and techniques are described including the use of single tooth anaesthesia (STA). STA is a computerised delivery mechanism that allows routine dental procedures that would previously have required block injections needing factor replacement therapy to be undertaken safely and effectively with no additional haemostatic intervention. The challenges of inhibitors in oral surgery are explained and discussed although more research and evidence is required to establish new treatment protocols. The importance of establishing good dental health in the quality of life of people with complex or rare IBD is highlighted with respect to the dental specific impact that more novel therapies may have on people with IBD.
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Affiliation(s)
- Lochana Nanayakkara
- Department of Restorative Dentistry, Royal London Hospital, BartsHealth NHS Trust, London, UK
- Institute of Dentistry Queen Mary University of London, London, UK
| | - Norjehan Yahaya
- Special Care Dentistry Unit, Department of Oral and Maxillofacial Surgery, Kuala Lumpur Hospital, Ministry of Health, Kuala Lumpur, Malaysia
| | - Miryam Parreira
- Dental Surgery Department, University of Buenos Aires, Buenos Aires, Argentina
- Foundation of Haemophilia, Buenos Aires, Argentina
| | - Branislav Bajkin
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
- Dental Clinic of Vojvodina, Novi Sad, Serbia
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7
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Donoso-Úbeda E, Ucero-Lozano R, Meroño-Gallut J, Cuesta-Barriuso R, Pérez-Llanes R. Safety and efficacy of myofascial release therapy in the treatment of patients with hemophilic ankle arthropathy. Single-blind randomized clinical trial. Physiother Theory Pract 2024:1-10. [PMID: 38530214 DOI: 10.1080/09593985.2024.2334752] [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: 12/20/2023] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Hemophilia is characterized by degenerative joint damage. Patients with hemophilic arthropathy present joint damage, reduced range of motion, and decreased strength and functional capacity. Myofascial release therapy aims to decrease pain and improve tissue mobility and functionality. OBJECTIVES To evaluate the safety and efficacy of myofascial release therapy in patients with hemophilic ankle arthropathy. METHOD Single-blind randomized controlled trial. Fifty-eight adult patients with hemophilia were randomly allocated to the experimental group (myofascial release therapy with foam roller) or the control group (no intervention whatsoever). The daily home protocol of myofascial release therapy for the lower limbs using a foam roller lasted eight consecutive weeks. The primary variable was the safety of myofascial release therapy (weekly telephone follow-up). The secondary variables were pain intensity (visual analog scale), range of motion (goniometer), functional capacity (2-Minute Walk Test) and muscle strength (dynamometer), at baseline and at 8 and 10 weeks. RESULTS During the experimental phase, none of the patients in the experimental group developed ankle hemarthrosis. There were statistically significant changes in time*group interaction in ankle dorsal flexion (F[1.75] = 10.72; p < .001), functional capacity (F[1.16] = 5.24; p = .009) and gastrocnemius strength (F[2] = 26.01; p < .001). The effect size of the changes after the intervention was medium-large in pain intensity (d = -1.77), functional capacity (d = 1.34) and gastrocnemius strength (d = 0.76). CONCLUSION Myofascial release therapy is a safe form of physical therapy for patients with hemophilia. Myofascial release therapy can effectively complement prophylactic pharmacological treatment in patients with hemophilic arthropathy, improving range of motion in dorsal flexion, functional capacity and gastrocnemius strength.
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Affiliation(s)
- Elena Donoso-Úbeda
- Department of Physiotherapy, Catholic University San Antonio-UCAM, Murcia, Spain
- InHeFis Research Group, Instituto Asturiano de Investigación ,Sanitaria (ISPA), Oviedo, Spain
| | - Roberto Ucero-Lozano
- InHeFis Research Group, Instituto Asturiano de Investigación ,Sanitaria (ISPA), Oviedo, Spain
- Department of Physiotherapy, European University of Madrid, Madrid, Spain
| | - Javier Meroño-Gallut
- InHeFis Research Group, Instituto Asturiano de Investigación ,Sanitaria (ISPA), Oviedo, Spain
- Tú. Bienestar 360°, Physiotherapy and Medical Center, San Javier, Murcia, Spain
| | - Rubén Cuesta-Barriuso
- InHeFis Research Group, Instituto Asturiano de Investigación ,Sanitaria (ISPA), Oviedo, Spain
- Department of Surgery and Medical-Surgical Specialties, University of Oviedo, Oviedo, Spain
| | - Raúl Pérez-Llanes
- InHeFis Research Group, Instituto Asturiano de Investigación ,Sanitaria (ISPA), Oviedo, Spain
- Department of Physiotherapy, University of Murcia, Murcia, Spain
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Xiao R, Chen Y, Hu Z, Tang Q, Wang P, Zhou M, Wu L, Liang D. Identification of the Efficient Enhancer Elements in FVIII-Padua for Gene Therapy Study of Hemophilia A. Int J Mol Sci 2024; 25:3635. [PMID: 38612447 PMCID: PMC11011560 DOI: 10.3390/ijms25073635] [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: 02/13/2024] [Revised: 03/13/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
Hemophilia A (HA) is a common X-linked recessive hereditary bleeding disorder. Coagulation factor VIII (FVIII) is insufficient in patients with HA due to the mutations in the F8 gene. The restoration of plasma levels of FVIII via both recombinant B-domain-deleted FVIII (BDD-FVIII) and B-domain-deleted F8 (BDDF8) transgenes was proven to be helpful. FVIII-Padua is a 23.4 kb tandem repeat mutation in the F8 associated with a high F8 gene expression and thrombogenesis. Here we screened a core enhancer element in FVIII-Padua for improving the F8 expression. In detail, we identified a 400 bp efficient enhancer element, C400, in FVIII-Padua for the first time. The core enhancer C400 extensively improved the transcription of BDDF8 driven by human elongation factor-1 alpha in HepG2, HeLa, HEK-293T and induced pluripotent stem cells (iPSCs) with different genetic backgrounds, as well as iPSCs-derived endothelial progenitor cells (iEPCs) and iPSCs-derived mesenchymal stem cells (iMSCs). The expression of FVIII protein was increased by C400, especially in iEPCs. Our research provides a novel molecular target to enhance expression of FVIII protein, which has scientific value and application prospects in both viral and nonviral HA gene therapy strategies.
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Affiliation(s)
| | | | | | | | | | | | | | - Desheng Liang
- Center for Medical Genetics, School of Life Sciences, Central South University, Changsha 410078, China; (R.X.); (Y.C.); (Z.H.); (M.Z.)
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Çelik HI, Akay E, Emeksiz ZŞ, Işık M, Yaralı HN, Mısırlıoğlu ED. Pediatric hemophilia patient: Successful desensitization for drug-induced fixed urticaria with prothrombin complex concentrate. Pediatr Allergy Immunol 2024; 35:e14105. [PMID: 38451071 DOI: 10.1111/pai.14105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/14/2024] [Accepted: 02/26/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Hatice Irmak Çelik
- Department of Pediatric Allergy/Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Eray Akay
- Department of Pediatric Hematology/Oncology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Zeynep Şengül Emeksiz
- Department of Pediatric Allergy/Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Melek Işık
- Department of Pediatric Hematology/Oncology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Hüsniye Neşe Yaralı
- Department of Pediatric Hematology/Oncology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Emine Dibek Mısırlıoğlu
- Department of Pediatric Allergy/Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
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Irsara C, Griesmacher A, Loacker L, Feistritzer C, Überbacher CA, Amiral J. Anti-Thrombin IgA in a Patient with Multiple Myeloma Leading to In Vitro Interference in Multiple Coagulation Tests and Confounding Diagnosis. Hamostaseologie 2024. [PMID: 38428837 DOI: 10.1055/a-2211-6841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND We report the case of a 59-year-old multiple myeloma patient in whom an anti-human thrombin IgA antibody led to prolonged in vitro coagulation times, suggesting inhibitors to all intrinsic coagulation factors in the absence of spontaneous bleeding. METHODS Routine and extensive special coagulation tests, in vivo bleeding time, and specific antibody testing were performed. RESULTS Although the patient did not suffer from spontaneous bleeding and had a normal in vivo bleeding time, the anti-human thrombin IgA autoantibody affected all coagulation assays involving human thrombin in vitro, mimicking inhibitors to intrinsic coagulation factors. As the IgA paraprotein and the IgA antibody virtually disappeared after autologous stem cell transplantation, the coagulation tests also largely normalized. CONCLUSION Antibodies to human thrombin may interfere with all coagulation assays involving thrombin, imitating a severe coagulopathy. However, in vivo they do not necessarily lead to strongly increased bleeding tendency. Complex and ambiguous coagulation abnormalities should be evaluated and treated in an interdisciplinary setting, including a highly specialized coagulation laboratory, from the beginning.
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Affiliation(s)
- Christian Irsara
- Central Institute of Medical and Chemical Laboratory Diagnostics (ZIMCL), University Hospital of Innsbruck, Innsbruck, Austria
| | - Andrea Griesmacher
- Central Institute of Medical and Chemical Laboratory Diagnostics (ZIMCL), University Hospital of Innsbruck, Innsbruck, Austria
| | - Lorin Loacker
- Central Institute of Medical and Chemical Laboratory Diagnostics (ZIMCL), University Hospital of Innsbruck, Innsbruck, Austria
| | - Clemens Feistritzer
- Department of Internal Medicine V, Hematology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Jean Amiral
- Scientific-Hemostasis Consulting, Franconville, France
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11
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Miesbach W, von Drygalski A, Smith C, Sivamurthy K, Pinachyan K, Bensen-Kennedy D, Drelich D, Kulkarni R. The current challenges faced by people with hemophilia B. Eur J Haematol 2024; 112:339-349. [PMID: 38082533 DOI: 10.1111/ejh.14135] [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: 03/10/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 02/17/2024]
Abstract
Hemophilia B (HB) is a rare, hereditary disease caused by a defect in the gene encoding factor IX (FIX) and leads to varying degrees of coagulation deficiency. The prevailing treatment for people with HB (PWHB) is FIX replacement product. The advent of recombinant coagulation products ushered in a new era of safety, efficacy, and improved availability compared with plasma-derived products. For people with severe HB, lifelong prophylaxis with a FIX replacement product is standard of care. Development of extended half-life FIX replacement products has allowed for advancements in the care of these PWHB. Nonetheless, lifelong need for periodic dosing and complex surveillance protocols pose substantive challenges in terms of access, adherence, and healthcare resource utilization. Further, some PWHB on prophylactic regimens continue to experience breakthrough bleeds and joint damage, and subpopulations of PWHB, including women, those with mild-to-moderate HB, and those with inhibitors to FIX, experience additional unique difficulties. This review summarizes the current challenges faced by PWHB, including the unique subpopulations; identifying the need for improved awareness, personalized care strategies, and new therapeutic options for severe HB, which may provide future solutions for some of the remaining unmet needs of PWHB.
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Affiliation(s)
| | | | | | | | | | | | | | - Roshni Kulkarni
- Michigan State University Center for Bleeding and Clotting Disorders, Lansing, Michigan, USA
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12
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van Heel DA, Foppen W, Fischer K. Arthropathy on X-rays in 363 persons with hemophilia: long-term development, and impact of birth cohort and inhibitor status. Res Pract Thromb Haemost 2024; 8:102355. [PMID: 38496709 PMCID: PMC10941006 DOI: 10.1016/j.rpth.2024.102355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 01/13/2024] [Accepted: 02/09/2024] [Indexed: 03/19/2024] Open
Abstract
Background Arthropathy following repeated bleeding is common in persons with hemophilia. Since the introduction of prophylaxis, treatment has intensified and joint health has improved. However, data on the long-term development of arthropathy are still scant. Objectives To evaluate long-term arthropathy development since the introduction of prophylaxis according to birth cohort, hemophilia severity, and inhibitor status. Methods This single-center historic cohort study included persons with severe and moderate hemophilia A and hemophilia B born between 1935 and 2005. Arthropathy on X-rays was evaluated using the Pettersson score. Patient and joint characteristics were studied per birth cohort (<1970, 1970-1980, 1981-1990, and >1990) and compared according to hemophilia severity. The distribution of affected joints and cumulative incidence of arthropathy were analyzed. The association of Pettersson score with birth cohort and inhibitor characteristics was explored using multivariable regression analyses adjusted for age at evaluation. Results In total, 1064 X-rays of 363 patients were analyzed. Of persons with severe hemophilia (n = 317, 87.3%), 244 (77.0%) developed arthropathy. Prophylaxis was started at younger ages over time, from a median of 18 to 2.1 years, and concomitantly, arthropathy decreased in consecutive birth cohorts. Ankles were most commonly affected in 188 of 258 (72.9%) patients. Persons with moderate hemophilia (n = 46, 12.7%) had a lower risk of arthropathy (27/46 [58.7%]), but a reduction over time was less pronounced. In the multivariable analyses, birth cohort and age at evaluation were predictors for the development of arthropathy, while inhibitor status showed no association. Conclusion The development and severity of arthropathy have decreased over the past decades. However, patients have remained at risk for developing arthropathy, especially in their ankles.
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Affiliation(s)
- Dayna A.M. van Heel
- Center of Expertise for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Wouter Foppen
- Department of Radiology and Nuclear Medicine, Division of Imaging and Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kathelijn Fischer
- Center of Expertise for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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13
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Jarvi NL, Balu-Iyer SV. A mechanistic marker-based screening tool to predict clinical immunogenicity of biologics. COMMUNICATIONS MEDICINE 2023; 3:174. [PMID: 38066254 PMCID: PMC10709359 DOI: 10.1038/s43856-023-00413-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 11/21/2023] [Indexed: 01/01/2024] Open
Abstract
BACKGROUND The efficacy and safety of therapeutic proteins are undermined by immunogenicity driven by anti-drug antibodies. Immunogenicity risk assessment is critically necessary during drug development, but current methods lack predictive power and mechanistic insight into antigen uptake and processing leading to immune response. A key mechanistic step in T-cell-dependent immune responses is the migration of mature dendritic cells to T-cell areas of lymphoid compartments, and this phenomenon is most pronounced in the immune response toward subcutaneously delivered proteins. METHODS The migratory potential of monocyte-derived dendritic cells is proposed to be a mechanistic marker for immunogenicity screening. Following exposure to therapeutic protein in vitro, dendritic cells are analyzed for changes in activation markers (CD40 and IL-12) in combination with levels of the chemokine receptor CXCR4 to represent migratory potential. Then a transwell assay captures the intensity of dendritic cell migration in the presence of a gradient of therapeutic protein and chemokine ligands. RESULTS Here, we show that an increased ability of the therapeutic protein to induce dendritic cell migration along a gradient of chemokine CCL21 and CXCL12 predicts higher immunogenic potential. Expression of the chemokine receptor CXCR4 on human monocyte-derived dendritic cells, in combination with activation markers CD40 and IL-12, strongly correlates with clinical anti-drug antibody incidence. CONCLUSIONS Mechanistic understanding of processes driving immunogenicity led to the development of a predictive tool for immunogenicity risk assessment of therapeutic proteins. These predictive markers could be adapted for immunogenicity screening of other biological modalities.
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Affiliation(s)
- Nicole L Jarvi
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, 14214, USA
| | - Sathy V Balu-Iyer
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, NY, 14214, USA.
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14
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Hamedani NS, Donners AAMT, van Luin M, Gasper S, Rühl H, Klein C, Albert T, El Amrani M, Pötzsch B, Oldenburg J, Müller J. Functional determination of emicizumab in presence of factor VIII activity. J Thromb Haemost 2023; 21:3490-3500. [PMID: 37741510 DOI: 10.1016/j.jtha.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Accurate measurement of emicizumab in the presence of factor (F) VIII is required in patients with severe hemophilia A treated with emicizumab, as well as additional need for FVIII substitution or emicizumab prophylaxis in patients with acquired or moderate to mild hemophilia A. However, the presence of FVIII potentially biases the results. OBJECTIVES To assess the impact of plasma FVIII activity on determined emicizumab levels and evaluate different strategies for correction for or preanalytical inhibition of FVIII. METHODS Evaluated strategies comprised of the following: (1) calculation of actual emicizumab plasma levels based on measured FVIII activities and FVIII-affected emicizumab values, (2) preanalytical heat treatment (56 °C for 40 minutes), and (3) neutralization of FVIII activity using FVIII inhibitors. Emicizumab levels and FVIII activities were measured using a modified FVIII one-stage clotting assay and a chromogenic FVIII assay based on bovine factors, respectively. RESULTS Spiking experiments revealed a consistent linear association between FVIII activities and determined (FVIII-affected) emicizumab results at different emicizumab input levels (∼0.12 μg/mL per IU/dL of FVIII). This principally allowed for mathematical correction of measured emicizumab levels in the presence of FVIII. While a 40% to 50% activity loss of intrinsic plasma emicizumab through heat treatment was observed in patient samples, emicizumab spiked into FVIII-deficient plasma was not or only marginally affected. Application of inhibitor-based FVIII neutralization led to good agreement of results when compared with direct quantification of emicizumab by liquid chromatography-tandem mass spectrometry. CONCLUSION Inhibitor-based FVIII neutralization appears to be a feasible strategy for accurate measurement of plasma emicizumab levels in the presence of FVIII activity.
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Affiliation(s)
- Nasim Shahidi Hamedani
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Anouk Anna Marie Therese Donners
- Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Matthijs van Luin
- Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Simone Gasper
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Heiko Rühl
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Claudia Klein
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Thilo Albert
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Mohsin El Amrani
- Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bernd Pötzsch
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Jens Müller
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany.
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15
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Arandi N, Zekavat OR, Shokrgozar N, Shahsavani A, Golmoghaddam H, Kalani M. Altered frequency of FOXP3 + regulatory T cells is associated with development of inhibitors in patients with severe hemophilia A. Int J Lab Hematol 2023; 45:953-960. [PMID: 37488961 DOI: 10.1111/ijlh.14139] [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: 04/30/2023] [Accepted: 07/09/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION The development of anti-factor VIII (FVIII) antibodies or "inhibitors" is a major complication following FVIII replacement therapy in patients with severe hemophilia A (HA), rendering the treatment inefficient. Data on the role of regulatory T cells (Tregs) in inhibitor formation in these patients are rare. Herein, we aimed to investigate whether a difference in the FOXP3+ Tregs is linked to the formation of the inhibitors in severe HA patients. METHODS In this cross-sectional study, 32 patients with severe HA (8 patients with inhibitors and 24 without inhibitors) and 24 healthy controls were enrolled. The frequency of FOXP3+ Tregs was determined using multicolor flow cytometry method. RESULTS Our results showed that the median level of CD4+ CD25+ FOXP3+ Tregs did not significantly differ between HA patients and healthy controls and between HA patients with and without inhibitors (P > 0.05). However, patients with inhibitors had significantly lower amounts of CD4+ CD25- FOXP3+ Tregs compared to those without inhibitors as well as healthy controls (*P = 0.012 and *P = 0.004, respectively). The frequency of CD4+ CD25+ T cells was significantly higher in HA patients who developed inhibitors compared to the inhibitor-negative ones whereas they were lower in inhibitor-negative patients compared to the healthy controls (*P = 0.013 and *P = *0.029, respectively). The percentages of CD4+ CD25+ T cells were positively correlated with the levels of inhibitors in HA patients (r = 0.45, *P = 0.021). CONCLUSION Our data demonstrated for the first time that the CD4+ CD25- FOXP3+ Tregs might be implicated in the prevention of inhibitor formation in severe HA patients.
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Affiliation(s)
- Nargess Arandi
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Omid Reza Zekavat
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Negin Shokrgozar
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Shahsavani
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Golmoghaddam
- Department of Immunology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehdi Kalani
- Department of Immunology, Professor Alborzi Clinical Microbiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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16
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Lee MW, Cheong MA, Ng HJ, Tien SL, Lam JCM. Real-world data on the use of emicizumab in patients with haemophilia A with and without inhibitors in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:580-589. [PMID: 38920147 DOI: 10.47102/annals-acadmedsg.2023100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction Emicizumab is a bispecific monoclonal antibody that mimics the function of factor VIII by binding to factor IXa and factor X to achieve haemostasis in haemophilia A. The long half-life and subcutaneous mode of administration makes emicizumab a compelling treatment option for bleeding prophylaxis. There is still limited real-world data on its use and management considerations, especially during surgical procedures. The objective of the study is to describe the real-world experience of emicizumab in a cohort of adult and paediatric haemophilia A patients in Singapore, including its use in the periprocedural setting. Method This was an observational study conducted at the 2 main haemophilia treatment centres in Singapore. All haemophilia A patients who commenced treatment with emicizumab before 1 July 2022 were recruited. Results A total of 18 patients with haemophilia A were included in this study. Ten (55.6%) patients had active inhibitors. The median annual bleeding rate for all patients before emicizumab use was 4.5 events (interquartile range [IQR] 2.8-8.3) compared with 0 events (IQR 0-0) after emicizumab was commenced (P=0). There were no adverse events of venous or arterial thrombosis, thrombotic microangiopathy, or death. A total of 6 procedures in 5 patients were performed during the study period with no major bleeding complications. Conclusion Emicizumab effectively protects against bleeding in haemophilia A patients with and without inhibitors, including in children less than 12 years old. More studies are required to address clinical nuances, such as periprocedural management and the role of immune tolerance in patients with inhibitors on emicizumab.
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Affiliation(s)
- Ming Wei Lee
- Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore
| | - May Anne Cheong
- Department of Haematology, Singapore General Hospital, Singapore
| | - Heng Joo Ng
- Department of Haematology, Singapore General Hospital, Singapore
| | - Sim Leng Tien
- Department of Haematology, Singapore General Hospital, Singapore
| | - Joyce Ching Mei Lam
- Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore
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17
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Di Minno G, Spadarella G, Maldonato NM, De Lucia N, Castaman G, De Cristofaro R, Santoro C, Peyvandi F, Borrelli A, Lupi A, Follino M, Guerrino G, Morisco F, Di Minno M. Awareness of individual goals, preferences, and priorities of persons with severe congenital haemophilia A for a tailored shared decision-making approach to liver-directed gene therapy. A practical guideline. Blood Rev 2023; 62:101118. [PMID: 37544828 DOI: 10.1016/j.blre.2023.101118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/26/2023] [Accepted: 07/30/2023] [Indexed: 08/08/2023]
Abstract
In clinical medicine, shared decision making (SDM) is a well-recognized strategy to enhance engagement of both patients and clinicians in medical decisions. The success of liver-directed gene therapy (GT) to transform severe congenital haemophilia A (HA) from an incurable to a curable disease has launched a shift beyond current standards of treatment. However, GT acceptance remains low in the community of HA persons. We argue for both persons with haemophilia (PWH) and specialists in HA care including clinicians, as needing SDM-oriented educational programs devoted to GT. Here, we provide an ad hoc outline to implement education to SDM and tailor clinician information on GT to individual PWHs. Based on routine key components of SDM: patient priorities; recommendations based on individual risk reduction; adverse effects; drug-drug interactions; alternatives to GT; and ongoing re-assessment of the objectives as risk factors (and individual priorities) change, this approach is finalized to exploit efficacious communication.
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Affiliation(s)
| | - Gaia Spadarella
- Dipartimento di Scienze Mediche Traslazionali, Naples, Italy.
| | - Nelson Mauro Maldonato
- Dipartimento di Neuroscienze e di Scienze Riproduttive e Odontostomatologiche, "Federico II" University, Naples, Italy
| | - Natascia De Lucia
- Dipartimento di Neuroscienze e di Scienze Riproduttive e Odontostomatologiche, "Federico II" University, Naples, Italy.
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy.
| | - Raimondo De Cristofaro
- Section of Haemorrhagic and Thrombotic Diseases, Department of Medicine and Translational Surgery, Sacred Heart University, Rome, Italy..
| | - Cristina Santoro
- Ematologia, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Rome, Italy.
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy; Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy.
| | - Anna Borrelli
- Direzione Sanitaria, AOU "Federico II" Napoli, Italy
| | - Angelo Lupi
- Federazione delle Associazioni Emofilici (FedEmo), Milan, Italy.
| | | | | | | | - Matteo Di Minno
- Dipartimento di Medicina Clinica e Chirurgia, Naples, Italy.
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18
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Ettingshausen CE, Hermans C, Holme PA, Cid AR, Khair K, Oldenburg J, Négrier C, Botha J, Lelli A, Windyga J. Real-world data in patients with congenital hemophilia and inhibitors: final data from the FEIBA Global Outcome (FEIBA GO) study. Ther Adv Hematol 2023; 14:20406207231184323. [PMID: 37529276 PMCID: PMC10387704 DOI: 10.1177/20406207231184323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 06/08/2023] [Indexed: 08/03/2023] Open
Abstract
Background The bypassing agent, activated prothrombin complex concentrate [aPCC, FEIBA (factor VIII inhibitor bypass activity); Baxalta US Inc, a Takeda company, Lexington, MA, USA], is indicated for the treatment of bleeding episodes, perioperative management, and routine prophylaxis in patients with hemophilia A or B with inhibitors. In certain countries, aPCC is also indicated for the treatment of bleeding episodes and perioperative management in patients with acquired hemophilia A. Objectives To describe long-term, real-world effectiveness, safety, and quality-of-life outcomes for patients with congenital hemophilia A or B and high-responding inhibitors receiving aPCC treatment in routine clinical practice. Design FEIBA Global Outcome (FEIBA GO; EUPAS6691) was a prospective, observational study. Methods Investigators determined the treatment regimen and clinical monitoring frequency. The planned patient observation period was 4 years. Data are from the safety analysis set (patients who received ⩾1 aPCC infusion). Results Overall, 50 patients received either aPCC prophylaxis (n = 37) or on-demand therapy (n = 13) at screening [hemophilia A, n = 49; hemophilia B, n = 1; median (range) age, 16.5 [2-71] years). Mean ± standard deviation overall annualized bleeding rate and annualized joint bleeding rate for patients receiving prophylaxis were 6.82 ± 11.52 and 3.77 ± 5.71, respectively, and for patients receiving on-demand therapy were 10.94 ± 11.27 and 6.94 ± 7.39, respectively. Overall, 177 and 31 adverse events (AEs) were reported in 28 of 40 and 10 of 13 patients receiving prophylaxis or on-demand therapy, respectively. Two serious AEs were considered possibly related to aPCC: acute myocardial infarction due to coronary artery embolism in one patient receiving prophylaxis. No thrombotic microangiopathy was reported. No AEs resulted in death. Conclusion This study demonstrated the long-term, real-world effectiveness and consistent safety profile of aPCC as on-demand therapy and prophylactic treatment in patients with hemophilia and high-responding inhibitors. Trial registry FEIBA Global Outcome Study; EUPAS6691 https://www.encepp.eu/encepp/viewResource.htm?id=32774.
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Affiliation(s)
| | - Cedric Hermans
- Hemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Pål A. Holme
- Department of Haematology, Oslo University Hospital and Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ana R. Cid
- Unidad de Hemostasia y Trombosis, Hospital Universitario y Politécnico La Fe, València, Spain
| | - Kate Khair
- Centre for Outcomes and Experience Research in Children’s Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children, London, UK
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, Bonn University Clinic, Bonn, Germany
| | | | - Jaco Botha
- Takeda Pharmaceuticals International AG, Zürich, Switzerland
| | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
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19
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Mannucci PM, Kessler CM, Germini F, Nissen F, Ofori-Asenso R, Brocchieri C, Bendinelli S, Iorio A. Bleeding events in people with congenital haemophilia A without factor VIII inhibitors receiving prophylactic factor VIII treatment: A systematic literature review. Haemophilia 2023. [PMID: 37289855 DOI: 10.1111/hae.14803] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/28/2023] [Accepted: 05/14/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Evidence on bleeding rates in people with congenital haemophilia A (PwcHA) without inhibitors on factor VIII (FVIII) replacement products is inconsistent. AIM This systematic literature review assessed bleeding outcomes in PwcHA using FVIII-containing products as prophylactic treatment. METHODS A search was conducted using the bibliographic databases Medline, Embase and Cochrane Central Register of Controlled Trials on the Ovid platform. The search involved a bibliographic review of clinical trial studies, routine clinical care studies and registries and a search of ClinicalTrials.gov, EU Clinical Trials Register and conference abstracts. RESULTS The search yielded 5548 citations. A total of 58 publications were included for analysis. In 48 interventional studies, the pooled estimated mean (95% confidence interval [CI]) annualized bleeding rate (ABR), annualized joint bleeding rate (AJBR) and proportion of participants with zero bleeding events were 3.4 (3.0-3.7), 2.0 (1.6-2.5), and 38.5% (33.1-43.9), respectively. In 10 observational studies, the pooled estimated mean (95% CI) ABR, AJBR and proportion of participants with zero bleeding events were 4.8 (4.0-5.5), 2.6 (2.1-3.2), and 21.8% (19.9-47.5), respectively. A large variation in mean effect size for ABR, AJBR and zero bleeding event data across cohorts and cohort types was observed. Funnel plots indicated potential reporting bias for publications incorporating ABR and AJBR data across both interventional and observational studies. CONCLUSION This meta-analysis shows that PwcHA without inhibitors still have bleeds despite FVIII prophylaxis. Improved standardization on capturing and reporting bleeding outcomes is needed so that effective comparisons between treatments can be made.
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Affiliation(s)
- Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi, Hemophilia and Thrombosis Center, Milan, Italy
| | - Craig M Kessler
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington District of Columbia, USA
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Young G, Srivastava A, Kavakli K, Ross C, Sathar J, You CW, Tran H, Sun J, Wu R, Poloskey S, Qiu Z, Kichou S, Andersson S, Mei B, Rangarajan S. Efficacy and safety of fitusiran prophylaxis in people with haemophilia A or haemophilia B with inhibitors (ATLAS-INH): a multicentre, open-label, randomised phase 3 trial. Lancet 2023; 401:1427-1437. [PMID: 37003287 DOI: 10.1016/s0140-6736(23)00284-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 12/05/2022] [Accepted: 02/01/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Fitusiran, a subcutaneous investigational small interfering RNA therapeutic, targets antithrombin to rebalance haemostasis in people with haemophilia A or haemophilia B, irrespective of inhibitor status. We evaluated the efficacy and safety of fitusiran prophylaxis in people with haemophilia A or haemophilia B with inhibitors. METHODS This multicentre, randomised, open-label phase 3 study was done at 26 sites (primarily secondary or tertiary centres) in 12 countries. Men, boys, and young adults aged 12 years or older with severe haemophilia A or haemophilia B with inhibitors previously treated with on-demand bypassing agents were randomly assigned (2:1) to receive once-a-month 80 mg subcutaneous fitusiran prophylaxis (fitusiran prophylaxis group) or to continue with bypassing agents on-demand (bypassing agents on-demand group) for 9 months. The primary endpoint was mean annualised bleeding rate during the efficacy period in the intention-to-treat population estimated by negative binomial model. Safety was assessed as a secondary endpoint in the safety population. This trial is complete and is registered with ClinicalTrials.gov, NCT03417102. FINDINGS Between Feb 14, 2018, and June 23, 2021, 85 participants were screened for inclusion, of whom 57 (67%; 57 [100%] men; median age 27·0 years [IQR 19·5-33·5]) were randomly assigned: 19 (33%) participants to the bypassing agent on-demand group and 38 (67%) participants to the fitusiran prophylaxis. Negative binomial model-based mean annualised bleeding rate was significantly lower in the fitusiran prophylaxis group (1·7 [95% CI 1·0-2·7]) than in the bypassing agents on-demand group (18·1 [10·6-30·8]), corresponding to a 90·8% (95% CI 80·8-95·6) reduction in annualised bleeding rate in favour of fitusiran prophylaxis (p<0·0001). 25 (66%) participants had zero treated bleeds in the fitusiran prophylaxis group versus one (5%) in the bypassing agents on-demand group. The most frequent treatment-emergent adverse event in the fitusiran prophylaxis group was increased alanine aminotransferase in 13 (32%) of 41 participants in the safety population; there were no increased alanine aminotransferase treatment-emergent adverse events in the bypassing agents on-demand group. Suspected or confirmed thromboembolic events were reported in two (5%) participants in the fitusiran prophylaxis group. No deaths were reported. INTERPRETATION Subcutaneous fitusiran prophylaxis resulted in statistically significant reductions in annualised bleeding rate in participants with haemophilia A or haemophilia B with inhibitors, with two-thirds of participants having zero bleeds. Fitusiran prophylaxis might show haemostatic efficacy in participants with haemophilia A or haemophilia B with inhibitors; therefore, the therapeutic might have the potential to improve the management of people with haemophilia. FUNDING Sanofi.
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Affiliation(s)
- Guy Young
- Hemostasis and Thrombosis Center, Cancer and Blood Disease Institute, Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA.
| | - Alok Srivastava
- Department of Haematology, Christian Medical College & Centre for Stem Cell Research, a unit of inStem, Bengaluru, Christian Medical College Campus, Vellore, India
| | - Kaan Kavakli
- Department of Pediatric Hematology and Oncology, Ege University Faculty of Medicine Children's Hospital, Izmir, Turkey
| | - Cecil Ross
- Department of Hematology, St John's Medical College Hospital, Bangalore, India
| | - Jameela Sathar
- Department of Haematology, Ampang Hospital, Kuala Lumpur, Malaysia
| | - Chur-Woo You
- Department of Pediatrics, Eulji University School of Medicine, Seoul, South Korea
| | - Huyen Tran
- Ronald Sawers Hemophilia Treatment Center, The Alfred, Monash University, Melbourne, Victoria, Australia
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Runhui Wu
- National Center for Children's Health, Beijing Children's Hospital, Beijing, China
| | - Stacey Poloskey
- Pharmacovigilance, Sanofi, Cambridge, MA, USA; Clinical Development, Sanofi, Cambridge, MA, USA
| | - Zhiying Qiu
- Biostatistics & Programming, Sanofi, Bridgewater, NJ, USA
| | | | | | - Baisong Mei
- Clinical Development, Sanofi, Cambridge, MA, USA
| | - Savita Rangarajan
- Advanced Centre for Oncology, Haematology & Rare Diseases KJ Somaiya Super Specialty, Hospital, Mumbai, India; Faculty of Medicine, University of Southampton, Southampton, UK
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Camelo RM, Barbosa MM, Araújo MS, Muniz RL, Guerra AA, Godman B, Rezende SM, Acurcio FDA, Martin AP, Alvares-Teodoro J. Economic Evaluation of Immune Tolerance Induction in Children With Severe Hemophilia A and High-Responding Inhibitors: A Cost-Effectiveness Analysis of Prophylaxis With Emicizumab. Value Health Reg Issues 2023; 34:31-39. [PMID: 36463835 DOI: 10.1016/j.vhri.2022.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/20/2022] [Accepted: 10/19/2022] [Indexed: 12/02/2022]
Abstract
OBJECTIVE This study aimed to measure the cost-effectiveness of prophylaxis with emicizumab in PsHAhri on ITI in Brazil. METHODS A cost-effectiveness modeling analysis was used to estimate the costs per PsHAhri on ITI and the number of prevented bleedings from undertaking one intervention (prophylaxis with BpA) over another (prophylaxis with emicizumab), based on the Brazilian Ministry of Health perspective. Costs of ITI with recombinant FVIII, prophylaxis with BpA or emicizumab, and treated bleeding episodes with BpA costs were evaluated for PsHAhri who had ITI success or failure. This study was conducted with the perspective of the Brazilian Ministry of Health (payer). RESULTS During ITI, prophylaxis with BpA cost US $924 666/PsHAhri/ITI, whereas prophylaxis with emicizumab cost US $488 785/PsHAhri/ITI. During ITI, there was an average of 9.32 bleeding episodes/PsHAhri/ITI when BpA were used as prophylaxis and 0.67 bleeding/PsHAhri/ITI when emicizumab was used. By univariate deterministic sensitivity analysis, emicizumab remained dominant whichever variable was modified. CONCLUSION In this study, prophylaxis with emicizumab during ITI is a dominant option compared with prophylaxis with BpA during ITI.
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Affiliation(s)
- Ricardo Mesquita Camelo
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Maiara Silva Araújo
- Faculty of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Roberto Lúcio Muniz
- Faculty of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, Scotland, UK; Centre of Medical and Bio-allied Health Sciences Research, Ajman University, United Arab Emirates; School of Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, Pretoria, South Africa
| | | | | | - Antony P Martin
- Faculty of Health and Life Sciences, Liverpool, England, UK; QC Medica, York, England, UK
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22
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Di Minno G, Castaman G, De Cristofaro R, Brunetti-Pierri N, Pastore L, Castaldo G, Trama U, Di Minno M. Progress, and prospects in the therapeutic armamentarium of persons with congenital hemophilia. Defining the place for liver-directed gene therapy. Blood Rev 2023; 58:101011. [PMID: 36031462 DOI: 10.1016/j.blre.2022.101011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 02/07/2023]
Abstract
In persons with congenital severe hemophilia A (HA) living in high-income countries, twice weekly intravenous infusions of extended half-life (EHL) factor VIII (FVIII) products, or weekly/biweekly/monthly subcutaneous injections of emicizumab are the gold standard home treatments to grant days without hurdles and limitations. Once weekly/twice monthly infusions of EHL Factor IX (FIX) products achieve the same target in severe hemophilia B (HB). Gene therapy, which is likely to be licensed for clinical use within 1-2 years, embodies a shift beyond these standards. At an individual patient level, a single functional gene transfer leads to a > 10-yr almost full correction of the hemostatic defect in HB and to a sustained (3-6-yrs) expression of FVIII sufficient to discontinue exogenous clotting factor administrations. At the doses employed, the limited liver toxicity of systemically infused recombinant adeno-associated virus (rAAV) vectors is documented by long-term (12-15 yrs) follow-ups, and pre-existing high-titer neutralizing antibodies to the AAV5 vector are no longer an exclusion criterion for effective transgene expression with this vector. A safe durable treatment that converts a challenging illness to a phenotypically curable disease, allows persons to feel virtually free from the fears and the obligations of hemophilia for years/decades. Along with patient organizations and health care professionals, communicating to government authorities and reimbursement agencies the liberating potential of this substantial innovation, and disseminating across the Centers updated information on benefits and risks of this strategy, will align expectations of different stakeholders and establish the notion of a potentially lifelong cure of hemophilia.
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Affiliation(s)
- Giovanni Di Minno
- Hub Center for Hemorrhagic and Thrombotic Disorders, Dep. of Clinical Medicine and Surgery, School of Medicine, Federico II University, Naples, Italy.
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy.
| | - Raimondo De Cristofaro
- Center for Hemorrhagic and Thrombotic Diseases, Foundation University Hospital A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy.
| | - Nicola Brunetti-Pierri
- Telethon Institute of Genetics and Medicine, Pozzuoli, Italy; Dept of Translational Medicine, School of Medicine, Università degli Studi di Napoli "Federico II", Italy.
| | - Lucio Pastore
- CEINGE-Biotecnologie Avanzate, and Department of Molecular Medicine and Medical Biotechnology, School of Medicine, University of Naples Federico II, 80131 Naples, Italy.
| | - Giuseppe Castaldo
- CEINGE-Biotecnologie Avanzate, and Department of Molecular Medicine and Medical Biotechnology, School of Medicine, University of Naples Federico II, 80131 Naples, Italy.
| | - Ugo Trama
- Coordination of the Regional Health System, General Directorate for Health Protection, Naples, Italy.
| | - Matteo Di Minno
- Hub Center for Hemorrhagic and Thrombotic Disorders, Dep. of Clinical Medicine and Surgery, School of Medicine, Federico II University, Naples, Italy.
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23
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Xu Z, Spencer HJ, Harris VA, Perkins SJ. An updated interactive database for 1692 genetic variants in coagulation factor IX provides detailed insights into hemophilia B. J Thromb Haemost 2023; 21:1164-1176. [PMID: 36787808 DOI: 10.1016/j.jtha.2023.02.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/24/2023] [Accepted: 02/06/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND Genetic variants in coagulation factor IX (FIX) are associated with hemophilia B, a rare bleeding disease. F9 variants are widespread across the gene and were summarized in our FIX variant database introduced in 2013. OBJECTIVES We aimed to rationalize the molecular basis for 598 new F9 variants and 1645 new clinical cases, totaling 1692 F9 variants and 5358 related patient cases. METHODS New F9 variants were identified from publications and online resources, and compiled into a MySQL database for comparison with the human FIXa protein structure. RESULTS The new total of 1692 F9 variants correspond to 406 (88%) of the 461 FIX residues and now include 70 additional residues. They comprise 945 unique point variants, 281 deletions, 352 polymorphisms, 63 insertions, and 51 others. Most FIX variants were point variants, although their proportion (56%) has reduced compared to 2013 (73%); at the same time, the proportion of polymorphisms has increased from 5% to 21%. The 764 unique mild severity variants in the mature protein with known phenotypes include 74 (9.7%) quantitative type I variants and 116 (15.2%) predominantly qualitative type II variants. The remaining 574 variants types are unspecified. Inhibitors are associated with 152 hemophilia B cases out of 5358 patients (2.8%), an increase of 93 from the previous database. CONCLUSION The even distribution of the F9 variants revealed few mutational hotspots, and most variants were associated with small perturbations in the FIX protein structure. The updated database will assist clinicians and researchers in assessing treatments for patients with hemophilia B.
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Affiliation(s)
- Ziqian Xu
- Research Department of Structural and Molecular Biology, University College London, London, UK
| | - Holly J Spencer
- Research Department of Structural and Molecular Biology, University College London, London, UK
| | - Victoria A Harris
- Research Department of Structural and Molecular Biology, University College London, London, UK
| | - Stephen J Perkins
- Research Department of Structural and Molecular Biology, University College London, London, UK.
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24
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Lv SJ, Wang ZM, Wang R, Jin HK, Tong PJ, Liu X. Total knee arthroplasty and femoral osteotomy with a patient-specific cutting guide to treat haemophilic arthritis with severe extra-articular deformity: A case report and review of literatures. Front Surg 2023; 9:1067306. [PMID: 36684182 PMCID: PMC9852490 DOI: 10.3389/fsurg.2022.1067306] [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: 10/11/2022] [Accepted: 11/07/2022] [Indexed: 01/09/2023] Open
Abstract
Background Total knee arthroplasty (TKA) is recommended for haemophilic patients with end-stage arthritis. TKA combined with a one-stage extraarticular osteotomy is uncommon in the treatment of haemophilic arthritis (HA) with severe extra-articular deformities (EADs) and a history of inhibitors under the guidance of a patient-specific cutting guide (PSI). Case presentation We reported a 20-year-old male patient with severe haemophilia, limited knee functionality, a 30° sagittal deformity on the femoral side and a history of inhibitors. We adopted the Van Creveld protocol to decrease the inhibitors. TKA and extra-articular osteotomy (EAO) were performed simultaneously and sequentially under the guidance of PSI. An appropriate central alignment of the lower limb was restored by using cement prostheses with antibiotics and femur shaft locking compression plates. The last follow-up showed that the knee function was good, the VAS score was 0, the WOMAC score was 18 and the ROM was 0°-95°. Conclision Regular haematology management can reduce the perioperative bleeding risk in haemophilic patients treated with inhibitors. PSI plays an important role in guiding the TKA and EAO of end-stage HA patients with severe EAD.
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Affiliation(s)
- Shuai-Jie Lv
- Orthopedics and Traumatology, The First Affiliated Hospital of Zhejiang Chinese Medical University(Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Zheng-Ming Wang
- Shi's Center of Orthopedics and Traumatology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Rui Wang
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Heng-Kai Jin
- The First School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Pei-Jian Tong
- Orthopedics and Traumatology, The First Affiliated Hospital of Zhejiang Chinese Medical University(Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Xun Liu
- Orthopedics and Traumatology, The First Affiliated Hospital of Zhejiang Chinese Medical University(Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China,Correspondence: Xun Liu
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25
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Dou X, Zhang W, Poon MC, Zhang X, Wu R, Feng X, Yang L, Cheng P, Chen S, Wang Y, Zhou H, Huang M, Song Y, Jin C, Zhang D, Chen L, Liu W, Zhang L, Xue F, Yang R. Factor IX inhibitors in haemophilia B: A report of National Haemophilia Registry in China. Haemophilia 2023; 29:123-134. [PMID: 36163649 DOI: 10.1111/hae.14665] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/25/2022] [Accepted: 09/12/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION The development of inhibitors against factor FIX (FIX) is the most serious complication of FIX replacement therapy in haemophilia B (HB) patients. Currently, only few cohorts of HB inhibitor patients have been reported worldwide. AIM This Chinese nationwide study of HB inhibitor patients explored their risk factors for FIX inhibitor development and experience on their management. METHODS We retrospectively analysed patient characteristics, F9 genotypes, treatment strategies and outcomes of HB inhibitor patients registered to the Chinese National Registry and Patient Organization Registry. RESULTS Forty-four unique HB inhibitor patients were identified in 4485 unique HB patients registered by year 2021 to the two Registries. Inhibitor diagnosis were usually delayed and the low prevalence (.98%) may suggest some inhibitor patients were not identified. Their median age at inhibitor diagnosis was 7.5 (IQR, 3.0-14.8) years. Most patients (95.5%) had high-titre inhibitors. Allergic/Anaphylactic reactions occurred in 59.1% patients. Large deletions and nonsense mutations were the most common F9 mutation types in our FIX inhibitor patients. Patients with large F9 gene deletions were more likely to develop inhibitors (p = .0002), while those with missense mutations had a low risk (p < .0001). Thirteen (29.5%) patients received immune tolerance induction (ITI) therapy using low-dose prothrombin complex concentrate regimens. Twelve completed ITI with three (25.0%) achieving success. Nephrotic syndrome developed in two (16.7%) patients during ITI. CONCLUSION This study reports the largest Chinese cohort of HB inhibitor patients. Large deletions were most significantly associated with inhibitor development. Low-dose ITI might be feasible for FIX inhibitor eradication.
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Affiliation(s)
- Xueqing Dou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China.,National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wenhui Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Man-Chiu Poon
- Departments of Medicine, Pediatrics and Oncology, Cumming School of Medicine, University of Calgary, and the Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Hospital, Alberta Health Services, Calgary, Alberta, Canada
| | - Xinsheng Zhang
- Shandong Hemophilia Treatment Center, Shandong Blood Center, Jinan, China
| | - Runhui Wu
- Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoqin Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Linhua Yang
- Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Peng Cheng
- Department of Hematology, Guangxi Medical University First Affiliated Hospital, Nanning, China
| | - Shu Chen
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Wang
- Shenzhen Children's Hospital, Shenzhen, China
| | - Hu Zhou
- The Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer hospital, Zhengzhou, China
| | - Meijuan Huang
- Fujian Medical University Union Hospital, Fujian Institute of Haematology, Fuzhou, China
| | | | - Chenghao Jin
- Department of Hematology, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Donglei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Lingling Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
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26
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Chozie NA, Gatot D, Sudarmanto B, Susanah S, Purnamasari R, Widjajanto PH, Nugroho S, Rasiyanti O, Puspitasari D, Riza M, Larasati MCS, Adiyanti SS, Saraswati MC, Primacakti F. FVIII inhibitor surveillance in children with hemophilia A in Indonesia: a report from the Indonesian Pediatric Hematology-Oncology Working Group. Blood Res 2022; 57:272-277. [PMID: 36535639 PMCID: PMC9812731 DOI: 10.5045/br.2022.2022153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/20/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Background Factor VIII (FVIII) inhibitor diagnosis and surveillance in Indonesia are challenging owing to geographic conditions and the lack of laboratory facilities nationwide for inhibitor assays. This study aimed to determine the prevalence of FVIII inhibitors in children diagnosed with hemophilia A (HA) in Indonesia. Methods A cross-sectional study was conducted in 12 hospitals in eight provinces of Indonesia between 2020 and 2021. Factor VIII inhibitor screening was performed in a central hemostasis laboratory for all children with HA (≤18 yr) who had received a minimum of 10 exposure days to clotting factor concentrates. The FVIII inhibitor titer was determined using the Bethesda assay. Results Children (388) were enrolled in this study, including 219 (56.4%), 131 (33.8%), and 38 (9.4%) with severe, moderate, and mild HA, respectively. The prevalence of children who developed FVIII inhibitors was 37 out of 388 (9.6%). Factor VIII inhibitors were found in 25/219 (11.4%) severe, 11/131 (8.3%) moderate, and 1/38 (2.6%) children with mild HA. Thirteen children had low-titer inhibitors and 24 had high-titer inhibitors, with a median of 9.44 (1.48‒412.0) Bethesda Units. Among 13 children with low-titer inhibitors, eight underwent a confirmation test, of which five tested negative and were classified as transient. A significant difference in annual joint bleeding rate was found between patients with low and high inhibitor titers and those without inhibitors (P<0.001). Conclusion Factor VIII inhibitor prevalence in Indonesia was relatively low. However, the risk factors that may contribute to FVIII inhibitor development among Indonesian patients require further study.
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Affiliation(s)
- Novie Amelia Chozie
- Department of Child Health, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia,Correspondence to Novie Amelia Chozie, M.D., Ph.D. , Pediatric Hematology-Oncology Division, Department of Child Health, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Diponegoro street No. 71, Jakarta Pusat, DKI Jakarta 10430, Indonesia, E-mail:
| | - Djajadiman Gatot
- Department of Child Health, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Bambang Sudarmanto
- Department of Child Health, Dr. Kariadi Hospital, Faculty of Medicine, Universitas Diponegoro, Semarang, Indonesia
| | - Susi Susanah
- Department of Child Health, Dr. Hasan Sadikin General Hospital, Bandung, Faculty of Medicine, Universitas Padjajaran, West Java, Indonesia
| | - Rini Purnamasari
- Department of Child Health, Tangerang General Hospital, Banten, Indonesia
| | - Pudjo Hagung Widjajanto
- Department of Child Health, Dr. Sardjito Hospital, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Susanto Nugroho
- Department of Child Health, Dr. Saiful Anwar Hospital, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Olga Rasiyanti
- Department of Child Health, H. Adam Malik General Hospital, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia
| | - Dian Puspitasari
- Department of Child Health, Dr. Moh. Hoesin General Hospital, Faculty of Medicine, Universitas Sriwijaya, Palembang, Indonesia
| | - Muhammad Riza
- Department of Child Health, Dr. Moewardi Hospital, Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia
| | | | - Sri Suryo Adiyanti
- Department of Clinical Pathology, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Made Citra Saraswati
- Department of Child Health, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Fitri Primacakti
- Department of Child Health, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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27
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Yamaguti-Hayakawa GG, Ozelo MC. Gene therapy for hemophilia: looking beyond factor expression. Exp Biol Med (Maywood) 2022; 247:2223-2232. [PMID: 36691324 PMCID: PMC9899988 DOI: 10.1177/15353702221147565] [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: 01/25/2023] Open
Abstract
Hemophilia A (factor VIII [FVIII] deficiency) and hemophilia B (factor IX [FIX] deficiency) are the X-linked recessive bleeding disorders that clinically manifest with recurrent bleeding, predominantly into muscles and joints. In its severe presentation, when factor activity is less than 1% of normal, hemophilia presents with spontaneous musculoskeletal bleeds and may progress to debilitating chronic arthropathy. Management of hemophilia has changed profoundly in the past decades. From on-demand to prophylactic factor concentrate replacement, the treatment goal shifted from controlling bleeds to preventing bleeds and improving quality of life. In this new scenario, gene therapy has arisen as a paradigm-changing therapeutic option, a one-time treatment with the potential to achieve sustained coagulation FVIII or FIX expression even within the normal range. This review discusses the critical impact of adeno-associated virus (AAV) gene transfer in hemophilia care, including the recent clinical outcomes, changes in disease perceptions, and its treatment burden. We also discuss the challenging scenario of the AAV-directed immune response in the clinical setting and potential strategies to improve the long-lasting efficacy of hemophilia gene therapy efficacy.
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Affiliation(s)
- Gabriela G Yamaguti-Hayakawa
- Department of Internal Medicine,
School of Medical Sciences, University of Campinas, UNICAMP, Campinas
13083-878, Brazil,Hemocentro UNICAMP, University of
Campinas, Campinas 13083-878, Brazil
| | - Margareth C Ozelo
- Department of Internal Medicine,
School of Medical Sciences, University of Campinas, UNICAMP, Campinas
13083-878, Brazil,Hemocentro UNICAMP, University of
Campinas, Campinas 13083-878, Brazil,Margareth C Ozelo.
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28
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Cuesta-Barriuso R, Donoso-Úbeda E, Meroño-Gallut J, Ucero-Lozano R, Pérez-Llanes R. Hemophilic Arthropathy: Barriers to Early Diagnosis and Management. J Blood Med 2022; 13:589-601. [PMID: 36277171 PMCID: PMC9586168 DOI: 10.2147/jbm.s343924] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022] Open
Abstract
Hemophilia is a congenital coagulopathy characterized by a deficiency of one of the clotting factors. It is characterized by the development of hematomas and hemarthrosis, either spontaneously or after minor trauma. The recurrence of hemarthroses leads to progressive and degenerative joint damage from childhood (hemophilic arthropathy). This arthropathy is characterized by disabling physical effects that limit the functionality and quality of life of these patients. Medical progress achieved over the last decade in the drug treatment of hemophilia has improved the medium and long-term prospects of patients with more effective and long-lasting drugs. The universal use of safer, more effective and prolonged prophylactic treatments may promote the prevention of bleeding, and also therefore, of the development of hemarthrosis and joint damage. A number of imaging instruments have been developed for the assessment of hemarthrosis and hemophilic arthropathy, using ultrasound, magnetic resonance imaging and simple radiology. Different physical examination scores and questionnaires allow the assessment of joint health, self-perceived activity and functionality of patients with hemophilia. The approach to these patients should be interdisciplinary. Assessment of the processes that affect pain in these patients and the development of pain education models should be implemented. Expert advice and information to patients with hemophilia should be based on individual functional prevention diagnoses, advice on available therapies and sports practice, as well as health recommendations.
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Affiliation(s)
- Rubén Cuesta-Barriuso
- Department of Surgery and Medical-Surgical Specialties, University of Oviedo, Oviedo, Spain,Royal Victoria Eugenia Foundation, Madrid, Spain,Correspondence: Rubén Cuesta-Barriuso, Department of Surgery and Medical-Surgical Specialties, University of Oviedo, Campus de El Cristo s/n, Faculty of Medicine, Oviedo, 33006, Spain, Tel +34 985 103 386, Email
| | - Elena Donoso-Úbeda
- Department of Physiotherapy, Catholic University San Antonio-UCAM, Murcia, Spain
| | | | | | - Raúl Pérez-Llanes
- Department of Physiotherapy, Catholic University San Antonio-UCAM, Murcia, Spain
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29
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Factor IX antibodies and tolerance in hemophilia B in the Nordic countries - The impact of F9 variants and complications. Thromb Res 2022; 217:22-32. [PMID: 35842956 DOI: 10.1016/j.thromres.2022.06.015] [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: 02/24/2022] [Revised: 06/19/2022] [Accepted: 06/23/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The development of inhibitory antibodies (inhibitors) in persons with hemophilia B (PwHB) causes significant morbidity. Data on the impact of the F9 variant and immune tolerance induction (ITI) outcome are limited. The aim of this study was to investigate the presence of neutralizing and non-neutralizing antibodies (NNA) in severe hemophilia B (HB) and to evaluate ITI outcome and complications in relation to the pathogenic F9 variant. MATERIALS AND METHODS Persons with severe HB in the Nordic countries were enrolled and information on F9 variants, inhibitors, ITI and complications were collected. Analyses of anti-FIX antibodies with a fluorescence-immunoassay (xFLI) and an ELISA method were conducted. RESULTS Seventy-nine PwHB were enrolled. Null variants were seen in 33 (42 %) PwHB and 12 (15 %) had a current or former inhibitor. Eleven (92 %) of the inhibitor patients had experienced allergic manifestations and three (25 %) nephrotic syndrome. Of 10 PwHB with at least one ITI attempt, eight (80 %) were considered tolerant at enrolment. Immunosuppression was included in seven of eight successful or partially successful attempts. Five PwHB had at least one ITI failure before a successful or partially successful ITI. No NNA could be identified. CONCLUSION A high proportion of severe F9 gene defects among persons with severe HB in the Nordic countries may explain the observed relatively high prevalence of inhibitors. ITI success was independent of the F9 variant and attained despite allergic manifestations and previous ITI failures. Inclusion of immunosuppression tentatively enhances the chances of ITI success. No NNA were observed.
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30
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Jain N, Oldenburg J, Ozelo MC, Sun SX, Tang L, Tzivelekis S. Recent advances in therapeutic options for rare hemostatic disorders: selected poster extracts of recent research in hemophilia A, congenital hemophilia with inhibitors, von Willebrand disease, and thrombotic thrombocytopenic purpura presented at the 29th congress of the International Society on Thrombosis and Haemostasis (ISTH 2021, Jul 17-21; virtual congress). Expert Rev Hematol 2022; 15:1-18. [PMID: 35748691 DOI: 10.1080/17474086.2022.2074395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Hemophilia, von Willebrand disease (VWD), and thrombotic thrombocytopenic purpura (TTP) are rare diseases affecting normal hemostasis. Although they differ in their pathogenesis and clinical manifestation, if left undiagnosed and untreated, all these conditions can result in severe long-term consequences and can be potentially life-threatening. This article summarizes a poster series funded by Takeda and presented virtually at the 29th annual congress of the International Society on Thrombosis and Haemostasis (ISTH) in 2021: Data from real-world evidence highlight the importance of joint health and personalized prophylaxis to prevent bleeding for patients with hemophilia, the need to further raise disease awareness in support of timely diagnosis and access to treatment in general practice settings for patients with VWD, and describe the clinical burden for patients with TTP and the importance to advance treatment options for these patients.
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Affiliation(s)
- Nisha Jain
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Johannes Oldenburg
- Institute for Experimental Hematology and Transfusion Medicine, Bonn University Clinic, Bonn, Germany
| | - Margareth C Ozelo
- Hemocentro UNICAMP, Department of Internal Medicine, School of Medical Sciences, University of Campinas, São Paulo, Brazil
| | - Shawn X Sun
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Leilei Tang
- Takeda Pharmaceuticals International AG, Zürich, Switzerland
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Escuriola Ettingshausen C, Vdovin V, Zozulya N, Svirin P, Andreeva T, Benedik-Dolničar M, Jiménez-Yuste V, Kitanovski L, Zupancic-Šalek S, Pavlova A, Bátorová A, Montaño Mejía C, Abdilova G, Knaub S, Jansen M, Lowndes S, Belyanskaya L, Walter O, Oldenburg J. Immune Tolerance Induction (ITI) with a pdFVIII/VWF Concentrate (octanate) in 100 Patients in the Observational ITI (ObsITI) Study. TH OPEN 2022; 6:e124-e134. [PMID: 35707623 PMCID: PMC9135478 DOI: 10.1055/s-0042-1748756] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 02/02/2022] [Indexed: 11/15/2022] Open
Abstract
Background
Immune tolerance induction (ITI) with repeated factor VIII (FVIII) administration is the only strategy proven to eradicate inhibitors. The observational ITI study is evaluating ITI with a range of FVIII products.
Methods
This subgroup analysis reports prospective interim data for patients treated with a plasma-derived, von Willebrand factor-stabilized FVIII concentrate (pdFVIII/VWF, octanate). Complete success (CS) of ITI required achievement of three criteria: inhibitor titer < 0.6 BU/mL; FVIII recovery ≥ 66%; FVIII half-life ≥6 hours. Partial success (PS) required achievement of two criteria and partial response (PR) one. ITI success was defined as CS or PS. Data were analyzed for patients who achieved CS, had 36 months' observation, or failed ITI.
Results
One-hundred prospectively enrolled patients were included in the analysis; 91 had poor prognosis factors for ITI success. The mean (standard deviation) daily ITI dose was 116.4 (61.1) IU FVIII/kg in 14 low responders (< 5 BU/mL) and 173.7 (112.0) IU FVIII/kg in 86 high responders (≥ 5 BU/mL). Inhibitor titers < 0.6 BU/mL were achieved in 71% of patients in a median of 4.01 months, accompanied by a 93% reduction in bleeding rate. ITI success was achieved by 70% of patients and 56 of 72 (78%) primary (first-line) ITI patients. PR was achieved by 5 patients; ITI failed in 25 patients. PS and CS were achieved in a median of 5.55 and 11.25 months, respectively.
Conclusions
ITI with pdFVIII/VWF led to rapid eradication of FVIII inhibitors, normalization of FVIII pharmacokinetics in the majority of patients, and a significant reduction in bleeding rates.
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Affiliation(s)
| | - Vladimír Vdovin
- Morozovskaya Children's Hospital, Moscow, Russian Federation
| | - Nadezhda Zozulya
- National Research Center for Hematology, Moscow, Russian Federation
| | - Pavel Svirin
- Morozovskaya Children's Hospital, Moscow, Russian Federation
| | - Tatiana Andreeva
- City Center for the Treatment of Hemophilia Patients, City Polyclinic N° 37, St. Petersburg, Russian Federation
| | - Majda Benedik-Dolničar
- Children's Hospital Oncology-Hematology Unit, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Victor Jiménez-Yuste
- Servicio de Hematología, Hospital Univeristario La Paz, Autónoma University, Madrid, Spain
| | - Lidija Kitanovski
- Children's Hospital Oncology-Hematology Unit, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Silva Zupancic-Šalek
- Division of Haematology, Haemophilia Centre, University Hospital REBRO, Zagreb, Croatia
| | - Anna Pavlova
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Angelika Bátorová
- Department of Hematology and Transfusion Medicine, National Hemophilia Center, Faculty of Medicine of the Comenius University and University Hospital, Bratislava, Slovak Republic
| | | | - Gulnara Abdilova
- Scientific Center of Pediatrics and Pediatric Surgery, Almaty, Kazakhstan
| | | | - Martina Jansen
- Octapharma Pharmazeutika Produktionsges.mbH, Vienna, Austria
| | | | | | | | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
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32
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Dettoraki A, Michalopoulou A, Mazarakis M, Saslis S, Stamati I, Kapsimali Z, Pergantou H. Clinical application of extended half-life factor VIII in children with severe haemophilia A. Haemophilia 2022; 28:619-624. [PMID: 35503081 DOI: 10.1111/hae.14576] [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: 03/02/2021] [Revised: 04/09/2022] [Accepted: 04/10/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Only few studies have presented results from real-world clinical use of Extended Half-Life (EHL) products in children with haemophilia (CWH). AIM To retrospectively examine real-life experience with EHL factor VIII products use in CWH A, comparing with clinical experience from standard half-life products (SHL). METHODS A retrospective review of medical records of CWH A who have been prescribed EHL factor concentrates was conducted. All before/after comparisons were performed with the Wilcoxon matched-pairs signed-ranks test. RESULTS Twenty-three children with severe haemophilia A were enrolled in the study (3-6 years old: n = 4, 7-12 years old: n = 7 and 13-18 years old: n = 12). Median length of time that patients were treated with EHL products was 78 weeks. Median dosing interval was significantly lengthened from 2.3 to 3.5 days after switching from SHL to EHL concentrates. Mean trough FVIII levels were significantly increased from 2.3% to 4.1% after treatment with EHL products. Also, CWH A had a reduction of mean annual bleeding rate (ABR) and mean annual joint bleeding rate (AJBR) from 1 and .8 to .3 and .2, respectively, following treatment with EHL concentrates (ABR: p = .02, AJBR: p = .05). However, after switching to factor EHL, actual FVIII consumption, including bleeds, was significantly increased from 94 IU/kg/week to 118 IU/kg/week in CWH A. There was no inhibitor development. CONCLUSION This study demonstrates the successful transition of 23 CWH A from SHL to EHL factor concentrates.
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Affiliation(s)
- Athina Dettoraki
- Haemophilia Centre/Haemostasis and Thrombosis Unit, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Aikaterini Michalopoulou
- Haemophilia Centre/Haemostasis and Thrombosis Unit, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Michalis Mazarakis
- Haemophilia Centre/Haemostasis and Thrombosis Unit, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Stefanos Saslis
- Haemophilia Centre/Haemostasis and Thrombosis Unit, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Ioanna Stamati
- Haemophilia Centre/Haemostasis and Thrombosis Unit, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Zoey Kapsimali
- Haemophilia Centre/Haemostasis and Thrombosis Unit, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Helen Pergantou
- Haemophilia Centre/Haemostasis and Thrombosis Unit, "Aghia Sophia" Children's Hospital, Athens, Greece
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Li Z, Liu G, Yao W, Chen Z, Li G, Cheng X, Zhen Y, Ai D, Huang K, Sun J, Poon MC, Wu R. Eradication of FIX inhibitor in haemophilia B children using low-dose immune tolerance induction with rituximab-based immunosuppressive agent(s) in China. Haemophilia 2022; 28:625-632. [PMID: 35503087 DOI: 10.1111/hae.14577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/10/2022] [Accepted: 04/13/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Development of haemophilia B inhibitors (HBI) results in the ineffectiveness of FIX replacement therapy. Inhibitor eradication by immune tolerance induction (ITI) is therefore necessary. In HBI, ITI even at high FIX dose is less effective and has a higher risk of severe complications. AIM To characterize clinical features and outcome of ITI on HBI. METHODS This retrospective study was conducted in Haemophilia Paediatric Comprehensive Care Centre of China. We used low-dose ITI (25-50 FIX IU/kg/three-times-weekly to every-other-day) with domestic prothrombin complex concentrate (PCC), combined with two successive immunosuppressive (IS) regimens. RESULTS Sixteen HBI children, representing 5.7% of all and 14.4% of our severe registered HB patients, were enroled. Seven cases reported allergic reactions (ARs) proximal to inhibitor development. The historic peak inhibitor titre was median 54.2 (range 4.7-512) BU, and 15 (93.8%) had high-titre inhibitors. Twelve patients adherent to ITI were analysable. Of the nine ITI patients who received rituximab/prednisone (IS Regimen-1), four achieved tolerization in 1.4-43.3 months. Two subsequently relapsed but re-tolerized after a second course of IS Regimen-1. During ITI, the median treated bleed was .39/month (82.7% reduction from before ITI), and the incidence of AR and nephrotic syndrome (NS) complications was each at 22% (2/9). Three ITI patients received modified 'Beutel' protocol (IS Regimen-2) using multiple-IS-drugs, and two had rapid tolerization (.8 and 1.8 months). CONCLUSIONS Inhibitor eradication could be achieved by low-dose ITI protocol using PCC combined with IS. Larger studies are needed to confirm if ITI with IS Regimen-2 is more effective with less complications.
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Affiliation(s)
- Zekun Li
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Guoqing Liu
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Wanru Yao
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Zhenping Chen
- Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Gang Li
- Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Cheng
- Pharmacology Department, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yingzi Zhen
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Di Ai
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Kun Huang
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jie Sun
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Man-Chiu Poon
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Oncology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Hospital, Alberta Health Services, Calgary, Alberta, Canada
| | - Runhui Wu
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
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34
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Pipe SW, Hermans C, Chitlur M, Carcao M, Castaman G, Davis JA, Ducore J, Dunn AL, Escobar M, Journeycake J, Khan O, Mahlangu J, Meeks SL, Mitha IH, Négrier C, Nowak-Göttl U, Recht M, Chrisentery-Singleton T, Stasyshyn O, Vilchevska KV, Martinez LV, Wang M, Windyga J, Young G, Alexander WA, Bonzo D, Macie C, Mitchell IS, Sauty E, Wilkinson TA, Shapiro AD. Eptacog beta efficacy and safety in the treatment and control of bleeding in paediatric subjects (<12 years) with haemophilia A or B with inhibitors. Haemophilia 2022; 28:548-556. [PMID: 35475308 PMCID: PMC9542908 DOI: 10.1111/hae.14563] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/12/2022] [Accepted: 03/27/2022] [Indexed: 01/19/2023]
Abstract
Introduction Eptacog beta is a new recombinant activated human factor VII bypassing agent approved in the United States for the treatment and control of bleeding in patients with haemophilia A or B with inhibitors 12 years of age or older. Aim To prospectively assess in a phase 3 clinical trial (PERSEPT 2) eptacog beta efficacy and safety for treatment of bleeding in children <12 years of age with haemophilia A or B with inhibitors. Methods Using a randomised crossover design, subjects received initial doses of 75 or 225 μg/kg eptacog beta followed by 75 μg/kg dosing at predefined intervals (as determined by clinical response) to treat bleeding episodes (BEs). Treatment success criteria included a haemostasis evaluation of ‘excellent’ or ‘good’ without use of additional eptacog beta, alternative haemostatic agent or blood product, and no increase in pain following the first ‘excellent’ or ‘good’ assessment. Results Treatment success proportions in 25 subjects (1–11 years) who experienced 546 mild or moderate BEs were 65% in the 75 μg/kg initial dose regimen (IDR) and 60% in the 225 μg/kg IDR 12 h following initial eptacog beta infusion. By 24 h, the treatment success proportions were 97% for the 75 μg/kg IDR and 98% for the 225 μg/kg IDR. No thrombotic events, allergic reactions, neutralising antibodies or treatment‐related adverse events were reported. Conclusion Both 75 and 225 μg/kg eptacog beta IDRs provided safe and effective treatment and control of bleeding in children <12 years of age.
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Affiliation(s)
| | - Cédric Hermans
- Cliniques Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Meera Chitlur
- Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan, USA
| | - Manuel Carcao
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Joanna A Davis
- Pediatric Hemophilia Treatment Center, University of Miami, Miami, Florida, USA
| | - Jonathan Ducore
- Hematology/Oncology Clinic, University of California at Davis, Sacramento, California, USA
| | - Amy L Dunn
- Nationwide Children's Hospital, Department of Pediatrics at The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Miguel Escobar
- University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Janna Journeycake
- Oklahoma Center for Bleeding and Clotting Disorders at OU Health, Oklahoma City, Oklahoma, USA
| | - Osman Khan
- Oklahoma Center for Bleeding and Clotting Disorders at OU Health, Oklahoma City, Oklahoma, USA
| | - Johnny Mahlangu
- Hemophilia Comprehensive Care Center, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | - Shannon L Meeks
- Emory University and Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | | | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, New York, USA.,Oregon Health & Science University, Portland, Oregon, USA
| | | | | | | | | | - Michael Wang
- Hemophilia and Thrombosis Center, University of Colorado, Aurora, Colorado, USA
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Guy Young
- Children's Hospital Los Angeles, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | | | | | | | - Evelyne Sauty
- LFB, Laboratoire français du fractionnement et des biotechnologies, Les Ulis, France
| | | | - Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
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Skinner MW, Dolan G, Eichler H, O'Mahony B. A preliminary application of a haemophilia value framework to emerging therapies in haemophilia. Haemophilia 2022; 28 Suppl 2:9-18. [PMID: 35318780 DOI: 10.1111/hae.14511] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Emergence of new therapies are anticipated to improve clinical outcomes and quality of life of persons with haemophilia. Challenges in conducting randomized clinical trials in rare diseases have resulted in a lack of direct head-to-head comparisons to support value-based decision-making between different treatments. METHODS We conducted a literature review for new and emerging haemophilia A and B therapies (extended half-life [EHL] replacement factor, non-replacement therapies [NRT], and gene therapies [GT]) to identify differentiating patient-centred outcomes defined previously in a haemophilia value framework. Since the literature included all publication types (e.g., surveys, modelling studies, commentaries/reviews), collected data were assigned level of evidence scores. RESULTS Across different classes of therapies, bleeding was determined as the most frequently reported differentiating outcome, with EHL, NRT, and GT each demonstrating an advantage over comparator replacement therapies. EHL therapies for haemophilia A and B and NRT for haemophilia A showed good representation across Tier 1 outcomes (health status achieved/retained), while more publications were identified with Tier 2 (process of recovery) outcomes for NRT than EHL or GT. In Tier 3 (sustainability of health), frequency of breakthrough bleeds represented a differentiating outcome for EHL (both haemophilia A and B), NRT (haemophilia A only), and GT (haemophilia B only), whereas sustained good health was differentiating for most comparisons. CONCLUSIONS We demonstrate the utility of the haemophilia value framework as a common core outcome set for effectively comparing therapies. Application of this framework will serve as a useful decision-making tool for patients, clinicians, and within health technology assessments. KEY POINTS OF CONSIDERATION With the emergence of high-cost, paradigm changing treatments across multiple areas of medicine, we, the haemophilia community, need to be equipped to meet the growing demands for more rigorous evidence-based value assessments using the tools expected by assessors. The traditional access toolbox needs to evolve to meet the paradigm shift in treatment options. Value can no longer be defined by annualized bleed rates alone. To realize the full impact of new therapies, we need to utilize tools, such as a value framework, to organize evidence, identify data gaps, and assess patient-defined, meaningful outcomes across a multi-faceted dimension. The haemophilia value framework is an effective tool for organizing the available evidence and identifying gaps in the evidence. This can be used for assessing the value of emerging therapies in haemophilia utilizing data generated through randomized clinical trials and real world evidence generation. This is a call for incorporating the Value Framework into official submissions to authorities, as it captures a broader range of outcomes, including patient meaningful outcomes, in ways that better assess the potential benefits of new therapies.
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Affiliation(s)
- Mark W Skinner
- Institute for Policy Advancement, Ltd., Washington, DC, USA.,McMaster University, Hamilton, Canada
| | | | - Hermann Eichler
- Institute of Clinical Haemostaseology and Transfusion Medicine, Saarland University, Homburg, Germany
| | - Brian O'Mahony
- Irish Haemophilia Society, Dublin, Ireland.,Trinity College, Dublin, Ireland
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36
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Páramo JA. [Treatment of haemophilia: From replacement to gene therapy]. Med Clin (Barc) 2021; 157:583-587. [PMID: 34509300 DOI: 10.1016/j.medcli.2021.04.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 01/15/2023]
Abstract
Haemophilia A and B are congenital bleeding disorders characterized by missing or defective factor VIII or factor IX, respectively. Factor replacement therapy has been the gold standard for prophylaxis and treatment of bleeding complications. However, the inconvenience of regular intravenous administration, along with progression of arthropathy and development of inhibitors has driven the need for alternative treatment options, such as extended half-life products, non-factor coagulation products, such as subcutaneous emicizumab, blocking natural anticoagulants (rebalancing haemostatic agents) and gene therapy, which have been useful to control bleeding or are currently under late-phase clinical investigation.
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Affiliation(s)
- José A Páramo
- Servicio de Hematología y Hemoterapia, Clínica Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Navarra, España; CIBERCV.
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37
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Holstein K, Le Quellec S, Klamroth R, Batorova A, Holme PA, Jiménez-Yuste V, Astermark J. Immune tolerance induction in the era of emicizumab - still the first choice for patients with haemophilia A and inhibitors? Haemophilia 2021; 28:215-222. [PMID: 34918839 DOI: 10.1111/hae.14470] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/12/2021] [Accepted: 11/29/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The development of inhibitory antibodies is a severe complication of clotting factor replacement therapy in patients with severe haemophilia A (HA). Current World Federation of Hemophilia (WFH) guidelines for haemophilia care indicate that eradication of inhibitors is best achieved through immune tolerance induction (ITI) therapy. AIM The European Collaborative Haemophilia Network conducted a survey to determine whether ITI is still used in the routine management of patients with HA, and whether the availability of emicizumab prophylaxis has influenced treatment decisions. METHODS The survey was conducted in late 2020/early 2021 in 18 centres representing 17 countries in the Europe/Middle East region treating a total of 4955 patients, and included sections specific to patient and centre demographics, treatment protocols (both ITI and prophylactic), inhibitor development and initiation of ITI, treatment success, and the incidence of adverse events. RESULTS While our results indicate that ITI can still be considered a mainstay of treatment for patients with HA with inhibitors, less than daily dosing of ITI in combination with emicizumab prophylaxis is becoming commonplace across the spectrum of disease severity, with initiation being guided by bleeding patterns. The most frequently cited reasons for not initiating emicizumab prophylaxis were availability or reimbursement issues. CONCLUSION ITI remains a mainstay for haemophilia treatment of patients with HA with inhibitors, but emicizumab has become a preferred first-line approach to protect against bleeds and represents an alternative to burdensome ITI in certain patient groups.
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Affiliation(s)
- Katharina Holstein
- II. Medical Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sandra Le Quellec
- Unité d'hémostase Clinique - Hôpital Cardiologique Louis Pradel - Hospices Civils de Lyon, Lyon, France
| | - Robert Klamroth
- Department for Internal Medicine - vascular medicine and coagulation disorders at the Vivantes Hospital im Friedrichshain, Berlin, Germany
| | - Angelika Batorova
- National Hemophilia Centre, Dept. of Hematology and Transfusion Medicine, Faculty of Medicine of Comenius University and University Hospital, Bratislava, Slovakia
| | - Pål Andre Holme
- Department of Haematology, Oslo University Hospital and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Victor Jiménez-Yuste
- Servicio de Hematología, Hospital Universitario La Paz, Paseo de la Castellana, Autónoma University, Madrid, Spain
| | - Jan Astermark
- Department for Translational Medicine, Lund University and Department for Hematology Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
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38
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Hammami E, Borgi WE, Hajer EM, Houda B, Achour M, Zahra K, Meddeb B, Gouider E. Is immune tolerance induction conceivable in haemophilia with inhibitors in a low-middle income country? Real-world data from Tunisia. Haemophilia 2021; 28:e32-e35. [PMID: 34820981 DOI: 10.1111/hae.14464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Emna Hammami
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
| | - Wijden El Borgi
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
| | - El Mahmoudi Hajer
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
| | - Bouattour Houda
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
| | - Mariem Achour
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
| | - Kaouther Zahra
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
| | - Balkis Meddeb
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
| | - Emna Gouider
- Aziza Othmana Hospital, Haemophilia Centre, Tunis medical school, Tunis, Tunisia
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Di Minno G, Coppola A, Margaglione M, Rocino A, Mancuso ME, Tagliaferri A, Linari S, Zanon E, Santoro C, Biasoli C, Castaman G, Santagostino E, Mannucci PM. Predictors of inhibitor eradication by primary immune tolerance induction in severe haemophilia A with high responding inhibitors. Haemophilia 2021; 28:55-64. [PMID: 34727394 DOI: 10.1111/hae.14431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 09/24/2021] [Accepted: 09/26/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND Immune tolerance induction (ITI) is the only proven strategy to eradicate factor VIII inhibitors in patients with haemophilia A (HA). AIM To identify patients and treatment options with the highest chance of inhibitor eradication by primary ITI. PATIENTS AND METHODS In the frame of the Italian ITI Registry, carried out from 1995 to 2015 (last follow-up 2018), 137 primary ITI courses in severe HA patients (90/137 with poor prognosis) were analysed for predictors of outcome (complete/partial response or failure). Sixty-six of them (48%) were prospectively evaluated. RESULTS ITI was successful in 91/137 patients (66.4%) and 70 (51.1%) achieved complete response within 11 months (median). Historical peak titres ≤200 BU/ml (P = .033), inhibitor titres ≤5 BU/ml at ITI start (P = .001), peak titres ≤100 BU/ml during ITI (P < .001) and missense mutations and small insertions/deletions of FVIII gene (P = .027) predicted complete inhibitor eradication. A score that considers the cumulative number of these variables predicted complete response with positive predictive values up to .81 at ITI start and .91 during ITI, respectively. Patients who had no bleeding (OR, 3.45, 95% CI: 1.4-8.6) nor other adverse events (OR 2.6, 95%CI: 1.3-5.3) during ITI had higher chances of complete response. During the 120-month follow-up (median), 2/70 patients who had achieved complete response relapsed (2.9%). CONCLUSIONS This Registry, with a centralized review of outcomes, homogeneous data collection (half of which prospective) and long-term follow-up, provides insights for optimizing ITI, with a rationale for further studies in the currently evolving scenario of inhibitor management in HA patients.
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Affiliation(s)
- Giovanni Di Minno
- Hub Centre for Haemorrhagic and Thrombotic Disorders, Dep. of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Antonio Coppola
- Hub Centre for Haemorrhagic and Thrombotic Disorders, Dep. of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | | | - Angiola Rocino
- Hemophilia and Thrombosis Centre, Ospedale del Mare, Naples, Italy
| | - Maria Elisa Mancuso
- IRCCS Ca' Granda Ospedale Maggiore Policlinico Foundation, Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Milan, Italy
| | - Annarita Tagliaferri
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Italy
| | - Silvia Linari
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Ezio Zanon
- Hemophilia Centre, Internal Medicine, University of Padua, University Hospital of Parma, Italy
| | | | - Chiara Biasoli
- Hemophilia and Transfusion Centre, Bufalini Hospital, Cesena, Italy
| | - Giancarlo Castaman
- Hematology, Centre for Bleeding and Thrombosis Disorders, S. Bortolo Hospital, Vicenza, Italy
| | - Elena Santagostino
- IRCCS Ca' Granda Ospedale Maggiore Policlinico Foundation, Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Milan, Italy
| | - Pier Mannuccio Mannucci
- IRCCS Ca' Granda Ospedale Maggiore Policlinico Foundation, Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Milan, Italy
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40
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Escobar M, Castaman G, Boix SB, Callaghan M, de Moerloose P, Ducore J, Hermans C, Journeycake J, Leissinger C, Luck J, Mahlangu J, Miesbach W, Mitha IH, Négrier C, Quon D, Recht M, Schved JF, Shapiro AD, Sidonio R, Srivastava A, Stasyshyn O, Vilchevska KV, Wang M, Young G, Alexander WA, Al-Sabbagh A, Bonzo D, Macie C, Wilkinson TA, Kessler C. The safety of activated eptacog beta in the management of bleeding episodes and perioperative haemostasis in adult and paediatric haemophilia patients with inhibitors. Haemophilia 2021; 27:921-931. [PMID: 34636112 PMCID: PMC9292935 DOI: 10.1111/hae.14419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/31/2021] [Accepted: 09/06/2021] [Indexed: 01/19/2023]
Abstract
Introduction Haemophilia patients with inhibitors often require a bypassing agent (BPA) for bleeding episode management. Eptacog beta (EB) is a new FDA‐approved recombinant activated human factor VII BPA for the treatment and control of bleeding in haemophilia A or B patients with inhibitors (≥12 years of age). We describe here the EB safety profile from the three prospective Phase 3 clinical trials performed to date. Aim To assess EB safety, immunogenicity and thrombotic potential in children and adults who received EB for treatment of bleeding and perioperative care. Methods Using a randomized crossover design, 27 subjects in PERSEPT 1 (12‐54 years) and 25 subjects in PERSEPT 2 (1‐11 years) treated bleeding episodes with 75 or 225 μg/kg EB initially followed by 75 μg/kg dosing at predefined intervals as determined by clinical response. Twelve PERSEPT 3 subjects (2‐56 years) received an initial preoperative infusion of 75 μg/kg (minor procedures) or 200 μg/kg EB (major surgeries) with subsequent 75 μg/kg doses administered intraoperatively and post‐operatively as indicated. Descriptive statistics were used for data analyses. Results Sixty subjects who received 3388 EB doses in three trials were evaluated. EB was well tolerated, with no allergic, hypersensitivity, anaphylactic or thrombotic events reported and no neutralizing anti‐EB antibodies detected. A death occurred during PERSEPT 3 and was determined to be unlikely related to EB treatment by the data monitoring committee. Conclusion Results from all three Phase 3 trials establish an excellent safety profile of EB in haemophilia A or B patients with inhibitors for treatment of bleeding and perioperative use.
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Affiliation(s)
- Miguel Escobar
- Gulf States Hemophilia and Thrombophilia Center, Houston, Texas, USA
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | | | | | | | - Jonathan Ducore
- Hematology/Oncology Clinic, University of California at Davis, Sacramento, California, USA
| | - Cédric Hermans
- Cliniques Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Janna Journeycake
- Oklahoma Bleeding and Clotting Disorders Center at OU Health, Oklahoma City, Oklahoma, USA
| | - Cindy Leissinger
- Section of Hematology/Oncology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - James Luck
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Johnny Mahlangu
- Hemophilia Comprehensive Care Center, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | | | | | | | - Doris Quon
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, New York, USA.,Oregon Health & Science University, Portland, Oregon, USA
| | - Jean François Schved
- Haemophilia Treatment Centre, University Hospital Montpellier, Montpellier, France
| | - Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Robert Sidonio
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, Georgia, USA
| | | | | | | | - Michael Wang
- Hemophilia and Thrombosis Center, University of Colorado, Aurora, Colorado, USA
| | - Guy Young
- Children's Hospital Los Angeles, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | | | | | | | | | - Craig Kessler
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
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41
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Srinivasan A, Herzog RW, Khan I, Sherman A, Bertolini T, Wynn T, Daniell H. Preclinical development of plant-based oral immune modulatory therapy for haemophilia B. PLANT BIOTECHNOLOGY JOURNAL 2021; 19:1952-1966. [PMID: 33949086 PMCID: PMC8486253 DOI: 10.1111/pbi.13608] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/02/2021] [Accepted: 04/14/2021] [Indexed: 05/03/2023]
Abstract
Anti-drug antibody (ADA) formation is a major complication in treatment of the X-linked bleeding disorder haemophilia B (deficiency in coagulation factor IX, FIX). Current clinical immune tolerance protocols are often not effective due to complications such as anaphylactic reactions against FIX. Plant-based oral tolerance induction may address this problem, as illustrated by the recent first regulatory approval of orally delivered plant cells to treat peanut allergy. Our previous studies showed that oral delivery of plant cells expressing FIX fused to the transmucosal carrier CTB (cholera toxin subunit B) in chloroplasts suppressed ADA in animals with haemophilia B. We report here creation of the first lettuce transplastomic lines expressing a coagulation factor, in the absence of antibiotic resistance gene. Stable integration of the CTB-FIX gene and homoplasmy (transformation of ˜10 000 copies in each cell) were maintained in both T1 and T2 generation marker-free plants. CTB-FIX expression in lyophilized leaves of T1 and T2 marker-free plants was 1.0-1.5 mg/g dry weight, confirming that the marker excision did not affect antigen levels. Oral administration of CTB-FIX to Sprague Dawley rats at 0.25, 1 or 2.5 mg/kg did not produce overt adverse effects or toxicity. The no-observed-adverse-effect level (NOAEL) is at least 2.5 mg/kg for a single oral administration in rats. Oral administration of CTB-FIX at 0.3 or 1.47 mg/kg either mixed in food or as an oral suspension to Beagle dogs did not produce any observable toxicity. These toxicology studies should facilitate filing of regulatory approval documents and evaluation in haemophilia B patients.
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Affiliation(s)
- Aparajitha Srinivasan
- Department of Basic and Translational SciencesSchool of Dental MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Roland W. Herzog
- Department of PediatricsHerman B Wells Center for Pediatric ResearchIndiana University School of MedicineIndianapolisINUSA
| | - Imran Khan
- Department of Basic and Translational SciencesSchool of Dental MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Alexandra Sherman
- Department of PediatricsHerman B Wells Center for Pediatric ResearchIndiana University School of MedicineIndianapolisINUSA
| | - Thais Bertolini
- Department of PediatricsHerman B Wells Center for Pediatric ResearchIndiana University School of MedicineIndianapolisINUSA
| | - Tung Wynn
- Department of PediatricsUniversity of FloridaGainesvilleFLUSA
| | - Henry Daniell
- Department of Basic and Translational SciencesSchool of Dental MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
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42
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Escuriola Ettingshausen C, Sidonio RF. Design of an international investigator-initiated study on MOdern Treatment of Inhibitor-positiVe pATiEnts with haemophilia A (MOTIVATE). Ther Adv Hematol 2021; 12:20406207211032452. [PMID: 34589194 PMCID: PMC8474305 DOI: 10.1177/20406207211032452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/25/2021] [Indexed: 02/01/2023] Open
Abstract
Background: Inhibitor development is the most serious treatment-related complication of
replacement coagulation factor VIII (FVIII) therapy for patients with
haemophilia A. Immune tolerance induction (ITI), which involves intensive
and prolonged treatment with plasma-derived or recombinant FVIII, is the
only clinically proven strategy for eradication of inhibitors. The
bispecific antibody emicizumab is approved for use in patients with and
without inhibitors to prevent bleeding but does not eliminate inhibitors.
MOTIVATE (www.motivate-study.com) aims to capture different approaches
to the treatment and management of patients with haemophilia A and
inhibitors, document current ITI approaches from real-world clinical
experience, and evaluate the efficacy and safety of ITI, emicizumab
prophylaxis and ITI with emicizumab prophylaxis. Methods: The investigator-initiated MOTIVATE study [ClinicalTrials.gov identifier:
NCT04023019; EudraCT 2019-003427-38] will investigate in real-life clinical
practice the management of patients with haemophilia A of any severity who
have developed inhibitors to FVIII. All treatment is at the investigator’s
discretion. The following treatment approaches will be evaluated: Group 1 –
ITI with Nuwiq®, octanate® or wilate® and
aPCC/rFVIIa if needed to treat bleeding episodes (BEs) or during surgery or
for prophylaxis; Group 2 – ITI with Nuwiq®, octanate®
or wilate® and emicizumab prophylaxis and aPCC/rFVIIa if needed
to treat BEs or during surgery; Group 3 – routine prophylaxis with
emicizumab, aPCC or rFVIIa without ITI and aPCC/rFVIIa if needed to treat
BEs or during surgery. Patients will not be randomised to a treatment group
and may change groups during the study. Conclusions: It is planned to enrol 120 patients who will be followed for up to 5 years.
Optional sub-studies will explore factors that may influence ITI results as
well as the impact of different treatment approaches on important aspects of
patient health, including joint and bone health and the risk of thrombotic
events.
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Affiliation(s)
| | - Robert F Sidonio
- Hemophilia of Georgia Center for Bleeding and Clotting Disorders, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
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43
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Astermark J, Ay C, Carvalho M, D'Oiron R, Moerloose PD, Dolan G, Fontana P, Hermans C, Holme PA, Katsarou O, Kenet G, Klamroth R, Mancuso ME, Marquardt N, Núñez R, Pabinger I, Tait R, Valk PVD. New Inhibitors in the Ageing Population: A Retrospective, Observational, Cohort Study of New Inhibitors in Older People with Hemophilia. Thromb Haemost 2021; 122:905-912. [PMID: 34507368 DOI: 10.1055/a-1642-4067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION A second peak of inhibitors has been reported in patients with severe hemophilia A (HA) aged >50 years in the United Kingdom. The reason for this suggested breakdown of tolerance in the aging population is unclear, as is the potential impact of regular exposure to the deficient factor by prophylaxis at higher age. No data on hemophilia B (HB) have ever been reported. AIM The ADVANCE Working Group investigated the incidence of late-onset inhibitors and the use of prophylaxis in patients with HA and HB aged ≥40 years. METHODS A retrospective, observational, cohort, survey-based study of all patients aged ≥40 years with HA or HB treated at an ADVANCE hemophilia treatment center. RESULTS Information on 3,095 people aged ≥40 years with HA or HB was collected. Of the 2,562 patients with severe HA, the majority (73% across all age groups) received prophylaxis. In patients with severe HA, the inhibitor incidence per 1,000 treatment years was 2.37 (age 40-49), 1.25 (age 50-59), and 1.45 (age 60 + ). Overall, the inhibitor incidence was greatest in those with moderate HA (5.77 [age 40-49], 6.59 [age 50-59], and 4.69 [age 60 + ]) and the majority of inhibitor cases were preceded by a potential immune system challenge. No inhibitors in patients with HB were reported. CONCLUSION Our data do not identify a second peak of inhibitor development in older patients with hemophilia. Prophylaxis may be beneficial in older patients with severe, and possibly moderate HA, to retain a tolerant state at a higher age.
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Affiliation(s)
- Jan Astermark
- Department for Translational Medicine, Skane University Hospital, Lund University, Malmö, Sweden
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University Vienna, Vienna, Austria
| | - Manuela Carvalho
- Department of Immunohemotherapy, Centro Hospitalar de Sao Joao, Porto, Portugal
| | | | | | - Gerard Dolan
- Centre for Haemostasis and Thrombosis, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Pierre Fontana
- Haemostasis Unit and Laboratory, University Hospitals of Geneva, Geneva, Switzerland
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Saint-Luc University Hospital, Brussels, Belgium
| | - Pål Andre Holme
- Department of Haematology, Institute of Clinical Medicine, Oslo Universit Hospital, Rikshospitalet, Oslo, Norway
| | - Olga Katsarou
- Department of Hematology, Laiko University Hospital, Athens, Attica, Greece
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Sackler Faculty of Medicine, The Amalia Biron Thrombosis Research Institute, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Robert Klamroth
- Department of Angiology and Coagulation Disorders, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Maria Elisa Mancuso
- Hemophilia and Thrombosis Center, Fondazione Ospedale Maggiore Policlinico, Milan, Italy.,Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Natascha Marquardt
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Ramiro Núñez
- Hemophilia Unit, Hospital Universitario Virgen del Rocio, Sevilla, Andalucía, Spain
| | - Ingrid Pabinger
- Department of Haematology and Haemostaseology, Allgemeines Krankenhaus (AKH) - Innere Medizin, Wien, Austria
| | - Robert Tait
- Haemophilia and Thrombosis Centre, Royal Infirmary Glasgow, Glasgow, Strathclyde, United Kingdom of Great Britain and Northern Ireland
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Gualtierotti R, Solimeno LP, Peyvandi F. Hemophilic arthropathy: Current knowledge and future perspectives. J Thromb Haemost 2021; 19:2112-2121. [PMID: 34197690 PMCID: PMC8456897 DOI: 10.1111/jth.15444] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/15/2021] [Accepted: 06/30/2021] [Indexed: 02/06/2023]
Abstract
Hemophilia A and B are rare X-linked inherited bleeding disorders caused by complete or partial deficiency in or the absence of coagulation factors VIII and IX. Recurrent joint bleeding (hemarthrosis) is the most frequent clinical manifestation of severe hemophilia. Unless appropriately managed, even subclinical hemarthrosis can lead to the development of hemophilic arthropathy, a disabling condition characterized by joint remodelling, chronic pain, and a reduced quality of life, and eventually requires joint replacement. Given the lack of specific treatments to reduce blood-induced synovitis, the prevention of bleeding is pivotal to the maintenance of joint health. Prophylactic coagulation factor replacement therapy using extended half-life recombinant drugs has significantly improved patients' quality of life by reducing the burden of intravenous injections, and the more recent introduction of nonreplacement therapies such as subcutaneous emicizumab injections has improved treatment adherence and led to the greater protection of patients with hemophilia A. However, despite these advances, chronic arthropathy is still a significant problem. The introduction of point-of-care ultrasound imaging has improved the diagnosis of acute hemarthrosis and early hemophilic arthropathy, and allowed the better monitoring of progressive joint damage, but further research into the underlying mechanisms of the disease is required to allow the development of more targeted treatment. In the meantime, patient management should be based on the risk factors for the onset and progression of arthropathy of each individual patient, and all patients should be collaboratively cared for by multidisciplinary teams of hematologists, rheumatologists, orthopedic surgeons, and physiotherapists at comprehensive hemophilia treatment centers.
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Affiliation(s)
- Roberta Gualtierotti
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Luigi Piero Solimeno
- Traumatology and Orthopedic UnitFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Flora Peyvandi
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
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45
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Liu W, Xue F, Poon MC, Chen L, Jin Z, Zhang L, Yang R. Current status of haemophilia inhibitor management in mainland China: a haemophilia treatment centres survey on treatment preferences and real-world clinical practices. Br J Haematol 2021; 194:750-758. [PMID: 34340252 DOI: 10.1111/bjh.17677] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/12/2021] [Indexed: 01/26/2023]
Abstract
To investigate the current experience and expertise for haemophilia inhibitor patient management in haemophilia treatment centres (HTCs) in mainland China. Questionnaires were distributed to 'tertiary tier A' hospital HTCs across China to collect information on treatment preferences for bleeding control, prophylaxis and inhibitor eradication, as well as their regimens in real-world clinical practice. Of 40 questionnaires distributed, 39 were returned. In all, 38 were analysable for treatment preferences and 34 for actual clinical practice. For haemostatic treatment, 76·3% (29/38) HTCs preferred activated recombinant human Factor VII (rFVIIa). In clinical practice, the most widely used by-pass agent was prothrombin complex concentrate (26 HTCs). Although 65·8% (25/38) of HTCs believed prophylaxis treatment was necessary, it was prescribed in only 12. Similarly, 65·8% (25/38) of HTCs believed immune tolerance induction (ITI) therapy was necessary but only 14·8% (92/622) of patients in 19 HTCs received low-dose ITI treatment. HTCs in relatively economically developed cities (with higher-than-average per-capita gross domestic product) had better access to haemostatic treatment, coagulation testing and were more likely to provide prophylaxis and ITI in practice. The present survey showed there were gaps in haemophilia inhibitor care between the HTC physicians' preferences and their actual clinical practice. More specific care guidelines, education and clinical decision support tools are needed to guide clinical practice.
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Affiliation(s)
- Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Man-Chiu Poon
- Departments of Medicine, Pediatrics and Oncology, University of Calgary Cumming School of Medicine, Calgary, Canada.,Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Canada
| | - Lingling Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Zhaona Jin
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
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46
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Abstract
Haemophilia A and B are rare congenital, recessive X-linked disorders caused by lack or deficiency of clotting factor VIII (FVIII) or IX (FIX), respectively. The severity of the disease depends on the reduction of levels of FVIII or FIX, which are determined by the type of the causative mutation in the genes encoding the factors (F8 and F9, respectively). The hallmark clinical characteristic, especially in untreated severe forms, is bleeding (spontaneous or after trauma) into major joints such as ankles, knees and elbows, which can result in the development of arthropathy. Intracranial bleeds and bleeds into internal organs may be life-threatening. The median life expectancy was ~30 years until the 1960s, but improved understanding of the disorder and development of efficacious therapy based on prophylactic replacement of the missing factor has caused a paradigm shift, and today individuals with haemophilia can look forward to a virtually normal life expectancy and quality of life. Nevertheless, the potential development of inhibitory antibodies to infused factor is still a major hurdle to overcome in a substantial proportion of patients. Finally, gene therapy for both types of haemophilia has progressed remarkably and could soon become a reality.
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47
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Marchesini E, Morfini M, Valentino L. Recent Advances in the Treatment of Hemophilia: A Review. Biologics 2021; 15:221-235. [PMID: 34163136 PMCID: PMC8214539 DOI: 10.2147/btt.s252580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/10/2021] [Indexed: 01/19/2023]
Abstract
Progress in hemophilia therapy has been remarkable in the first 20 years of the third millennium, but the innovation began with the description the fractionation of plasma in 1946. The first concentrates followed the discovery of FVIII in the cryoprecipitate of frozen plasma and FIX in the supernatant in the early 1960s, which led to the initial attempts at replacement therapy. Unfortunately, the lack of screening methods for viral pathogens resulted in people with hemophilia (PWH) receiving concentrates contaminated by hepatitis A virus, hepatitis C virus, and human immunodeficiency virus, as these concentrates were made from large industrial pools of plasma derived from thousands of donors. Fortunately, by 1985, viral screening methods and proper virucidal techniques were developed that made concentrates safe. Increasingly pure products followed the introduction of chromatography steps with monoclonal antibodies in the production process. The problem of immunogenicity of exogenously administered concentrates has not yet had a complete solution. The development of alloantibodies against FVIII in about 25-35% of PWH is the most serious adverse effect of replacement therapy. The next major advance followed the cloning of the F8 gene and later the F9 genes, which paved the way to produce concentrates of factors obtained by the recombinant DNA technology. The injected FVIII and FIX molecules had a relatively short circulating half-life in the plasma of people with hemophilia A and B, approximately 12 and 18 hours, respectively. The ability to prolong the plasma half-life and extend the interval between injections followed the application of methods to conjugate the factor molecule with the fragment crystallizable of IgG1 or albumin or by adding polyethylene glycol, which has led to an increase in the half-life of concentrates, especially for rFIX. The next frontier in hemophilia therapy is the application of durable and potentially curative therapies such as with gene addition therapy. Experiments in hemophilia B have demonstrated durable responses. Unfortunately, the results with gene therapy for hemophilia A have not been as remarkable and the durability must still be demonstrated. Nonetheless, the long-term safety, predictability, durability, and efficacy of gene therapy for hemophilia A and B remain an open question. At present, only healthy adult PWH have been enrolled in gene therapy clinical trials. The application of gene therapy to children and those with pre-existing antibodies against the delivery vector must also be studied before this therapy becomes widespread.
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Affiliation(s)
- Emanuela Marchesini
- Hemophilia Centre, SC Vascular and Emergency Department, University of Perugia, Perugia, Italy
| | - Massimo Morfini
- Italian Association of Haemophilia Centres (AICE), Naples, Italy
| | - Leonard Valentino
- National Hemophilia Foundation, New York, NY, USA
- Rush University, Chicago, IL, USA
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48
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Di Minno A, Spadarella G, Esposito S, Mathew P, Di Minno G, Mannucci PM. Perspective - The case for zero bleeds and drug bioequivalence in the treatment of congenital hemophilia A in 2021. Blood Rev 2021; 50:100849. [PMID: 34024681 DOI: 10.1016/j.blre.2021.100849] [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: 02/02/2021] [Revised: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 01/19/2023]
Abstract
Not all patients with severe hemophilia A (HA) respond optimally to a given dose of a given product. Within-individual variance in cross-over studies makes each patient unique in the response to each standard half-life (SHL) factor VIII (FVIII) product in pharmacokinetic (PK) terms. This hampers the prediction of efficacy when a SHL FVIII product is employed. PK data showing that half-lives of SHL rFVIII are unsatisfactory to achieve zero bleeding in individual HA patients provide the rationale for switching from SHL to extended half-life (EHL) products. However, not all subjects receiving prophylaxis with EHL products achieve zero bleeding, the most cogent objective of personalized prophylaxis. Known determinants of FVIII half-life (age, von Willebrand factor [VWF] levels, blood group) cumulatively account for one third of the total inter-individual variation in FVIII clearance in subjects with severe HA. Investigations into precision, and accuracy of laboratory measurement to be employed; newer pathways for the clearance of both free-FVIII and VWF-bound FVIII, and adequately powered studies on omics and phenotypic heterogeneity, are likely to provide additional information on the remaining two thirds of inter-individual variation in FVIII clearance in HA. Variability in the clinical response has also been documented in patients when FVIII activity is mimicked by fixed subcutaneous doses of the bispecific antibody emicizumab. National registries that collect PK data of available FVIII products and ad hoc information on the individual response to emicizumab should be encouraged, to establish newer standards of care and ease personalized clinical decisions to achieve zero bleeding.
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Affiliation(s)
- Alessandro Di Minno
- Dipartimento di Farmacia, Università degli Studi di Napoli "Federico II", Italy; CEINGE-Biotecnologie Avanzate, Università degli Studi di Napoli "Federico II", Italy.
| | - Gaia Spadarella
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli "Federico II", Italy
| | - Salvatore Esposito
- Dipartimento di Medicina Clinica e Chirurgia and Centro Hub per le Malattie Emorragiche Congenite e le Trombofilie, Università degli Studi di Napoli "Federico II", Italy
| | | | - Giovanni Di Minno
- Dipartimento di Medicina Clinica e Chirurgia and Centro Hub per le Malattie Emorragiche Congenite e le Trombofilie, Università degli Studi di Napoli "Federico II", Italy.
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy..
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49
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Muratova F, Mussabekova Z, Kazymov M, Sturov V. A Rare Case of Severe Hemophilia B Combined with Hematomesenchymal Dysplasia. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.5753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: The prevalence of hemophilia B in the global population is approximately 1:60,000. Undifferentiated systemic mesenchymal dysplasia (uSMD) is diagnosed rather frequently, about 1:5, according to Russian authors; no data on uSMD prevalence in other countries are available. The combination of hemophilia and uSMD has grouped under the term hematomesenchymal dysplasia (HMD). This combination significantly worsens the clinical picture, prognosis, and quality of life of the patient.
AIM: In this article, we present a rare clinical case of a child with a combination of hemophilia B and HMD.
CASE REPORT: A clinical case of a male patient, 5 years old with hemophilia B, severe form combined with HMD, complicated by hemothorax, abscessed pulmonary lobe hematoma has presented. The presence of HMD and the above complications had an unfavorable effect on the severity of the clinical picture and the abnormal response to treatment. The main diagnostic procedures were the assessment of the phenotypic signs of HMD in combination with laboratory and instrumental examination methods such as ultrasound, computed tomography (CT) scan, and echocardiography. Vital treatment is factor IX replacement therapy and supportive one.
CONCLUSION: This clinical example highlights the importance of clinical alertness to hereditary coagulopathies, which often lead to life threatening, sometimes disabling complications that significantly reduce the quality of life of children with hemophilia. Consequently, full-scale epidemiological studies of the prevalence of HMD in the population are an urgent task for the near future.
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50
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You CW, Hong SB, Kim S, Shin HJ, Kim JS, Han JW, Kim SJ, Kim DY, Lee M, Levy H. Safety, pharmacokinetics, and pharmacodynamics of a next-generation subcutaneously administered coagulation factor IX variant, dalcinonacog alfa, in previously treated hemophilia B patients. J Thromb Haemost 2021; 19:967-975. [PMID: 33540485 DOI: 10.1111/jth.15259] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/15/2020] [Accepted: 12/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Dalcinonacog alfa (DalcA), a next-generation, recombinant human factor IX (FIX) variant, was developed using a rational design approach for increased procoagulant activity and longer duration of action to be administered subcutaneously (SC) for prophylaxis of hemophilia B bleeding episodes. OBJECTIVES To investigate the safety, pharmacokinetics (PK), and pharmacodynamics (PD) of DalcA. METHODS This multicenter, phase 1/2a study (NCT03186677) was conducted in 11 males aged 12 to 65 years with severe hemophilia B. In cohort 1, subjects received intravenous (IV) 75 IU/kg BeneFIX and DalcA. Cohorts 2 and 3 had DalcA IV 75 IU/kg and SC 75 IU/kg or 150 IU/kg. Cohort 4 was omitted. Cohort 5 received daily SC 150 IU/kg DalcA for 6 days and cohort 6 received IV 75 IU/kg and daily SC 150 IU/kg DalcA for 9 days. Blood sampling was performed for chemistry, hematology, PK, PD, and anti-drug antibody measurement. Subjects were monitored for safety endpoints for 30 days postdosing. RESULTS DalcA demonstrated a 24-fold greater potency over BeneFIX and longer mean residence time (33.8 h). SC bioavailability 8.2% to 20.3%, beta half-life 53.9 to 106.9 h and Tmax 24 to 48 h. A median 15.7% FIX activity level (interquartile range, 14.9%-16.6%) was reached after 6 daily doses. Neutralizing antibodies to ISU304, but not wild-type FIX, occurred in two cousins. CONCLUSIONS The data demonstrated that DalcA achieved protective FIX activity levels between 11% and 18%, corresponding to a reduced chance of spontaneous bleeds. Based on the results, a phase 2b trial to assess the safety and efficacy of 28 daily SC doses of DalcA was performed.
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Affiliation(s)
- Chur Woo You
- Eulji University Hospital Seo-gu, Daejeon, Korea
| | | | | | - Ho-Jin Shin
- Pusan National University Hospital, Busan, Korea
| | - Jin Seok Kim
- Yonsei University College of Medicine, Severance Hospital, Korea
| | - Jung Woo Han
- Yonsei University College of Medicine, Severance Hospital, Korea
| | - Soo-Jeong Kim
- Yonsei University College of Medicine, Severance Hospital, Korea
| | - Do Young Kim
- Pusan National University Hospital, Busan, Korea
| | - Martin Lee
- Fielding School of Public Health, University of California Los Angeles, Los Angeles, California, USA
| | - Howard Levy
- Catalyst Biosciences, South San Francisco, California, USA
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