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Romano LGR, Schütte LM, van Hest RM, Meijer K, Laros-van Gorkom BAP, Nieuwenhuizen L, Eikenboom J, Heubel-Moenen FCJI, Uitslager N, Coppens M, Fijnvandraat K, Driessens MHE, Polinder S, Cnossen MH, Leebeek FWG, Mathôt RAA, Kruip MJHA. Peri-operative desmopressin combined with pharmacokinetic-guided factor VIII concentrate in non-severe haemophilia A patients. Haemophilia 2024; 30:355-366. [PMID: 38343113 DOI: 10.1111/hae.14946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/10/2023] [Accepted: 01/13/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Non-severe haemophilia A patient can be treated with desmopressin or factor VIII (FVIII) concentrate. Combining both may reduce factor consumption, but its feasibility and safety has never been investigated. AIM We assessed the feasibility and safety of combination treatment in nonsevere haemophilia A patients. METHODS Non-severe, desmopressin responsive, haemophilia A patients were included in one of two studies investigating peri-operative combination treatment. In the single-arm DAVID study intravenous desmopressin (0.3 μg/kg) once-a-day was, after sampling, immediately followed by PK-guided FVIII concentrate, for maximally three consecutive days. The Little DAVID study was a randomized trial in patients undergoing a minor medical procedure, whom received either PK-guided combination treatment (intervention arm) or PK-guided FVIII concentrate only (standard arm) up to 2 days. Dose predictions were considered accurate if the absolute difference between predicted and measured FVIII:C was ≤0.2 IU/mL. RESULTS In total 32 patients (33 procedures) were included. In the DAVID study (n = 21), of the FVIII:C trough levels 73.7% (14/19) were predicted accurately on day 1 (D1), 76.5% (13/17) on D2. On D0, 61.9% (13/21) of peak FVIII:C levels predictions were accurate. In the Little DAVID study (n = 12), on D0 83.3% (5/6) FVIII:C peak levels for both study arms were predicted accurately. Combination treatment reduced preoperative FVIII concentrate use by 47% versus FVIII monotherapy. Desmopressin side effects were mild and transient. Two bleeds occurred, both despite FVIII:C > 1.00 IU/mL. CONCLUSION Peri-operative combination treatment with desmopressin and PK-guided FVIII concentrate dosing in nonsevere haemophilia A is feasible, safe and reduces FVIII consumption.
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Affiliation(s)
- Lorenzo G R Romano
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lisette M Schütte
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Reinier M van Hest
- Department of Hospital Pharmacy and Clinical Pharmacology, Amsterdam University Medical Centers-University of Amsterdam, Amsterdam, The Netherlands
| | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Nanda Uitslager
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel Coppens
- Department of Hematology, Amsterdam University Medical Centers-University of Amsterdam, Amsterdam, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Amsterdam University Medical Centers-University of Amsterdam, Emma Children's Hospital, Amsterdam, The Netherlands
- Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands
| | | | - Suzanne Polinder
- Department of Public Health, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy and Clinical Pharmacology, Amsterdam University Medical Centers-University of Amsterdam, Amsterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
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Akbarpour M, Jalali MM, Akbari M, Nasirmohtaram S, Haddadi S, Habibi AF, Azad F. Investigation of the effects of intranasal desmopressin on the bleeding of the patients during open septorhinoplasty: A randomized double-blind clinical trial. Heliyon 2023; 9:e17855. [PMID: 37455992 PMCID: PMC10344754 DOI: 10.1016/j.heliyon.2023.e17855] [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: 04/22/2022] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/18/2023] Open
Abstract
Objectives Rhinoplasty is one of the most common cosmetic surgeries in the world. Lack of adequate local homeostasis may lead to excessive bleeding during the operation, which increases the time of operation and recovery period, and the prevalence of complications. This study investigated the effects of nasal desmopressin on the quality of the surgical field and the volume of bleeding during rhinoplasty. Materials and methods This double-blind randomized clinical trial was performed on 120 patients aged 18-40 years who were candidates for rhinoplasty. Patients were randomly divided into three groups: low-dose desmopressin group and high-dose desmopressin group and placebo group. Hemodynamic changes and surgical field based on BOEZAART criteria, and the volume of bleeding were calculated. Results In this study 115 women (95.8%) and 5 men (4.2%) participated. The mean age of patients was (27 ± 6.8). Bleeding volume in high dose desmopressin group was (21.7 cc ± 12.3), (27.7 cc ± 12.3) in low dose group, and (38.3 cc ± 12.3) in the placebo group, The difference in blood volume among the three groups was statistically significant with p < 0.005. Clean surgical field according to BOEZAART classification was marginally significant in both desmopressin groups. The differences in blood pressure, heart rate, blood and urine sodium, and hemoglobin before and after surgery between groups there not statistically significant. Conclusion Based on the results of the present study topical nasal spray desmopressin can reduce surgical field bleeding during rhinoplasty. To generalize the results to other surgeries in the ENT field it is recommended to conduct studies.
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Affiliation(s)
- Maliheh Akbarpour
- Otorhinolaryngology Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Mir-Mohammad Jalali
- Otorhinolaryngology Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Maryam Akbari
- Otorhinolaryngology Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Sevil Nasirmohtaram
- Otorhinolaryngology Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Soudabeh Haddadi
- Anesthesiology Research Center, Department of Anesthesiology, Alzahra Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Ali Faghih Habibi
- Otorhinolaryngology Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Fateme Azad
- Otorhinolaryngology Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
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3
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Romano LG, van Vulpen LF, den Exter PL, Heubel-Moenen FC, Hooijmeijer HL, Coppens M, Fijnvandraat K, Schols SE, Ypma PF, Smit C, Driessens MH, Rosendaal FR, van der Bom JG, Gouw SC, Kruip MJ. Desmopressin in nonsevere hemophilia A: patient perspectives on use and efficacy. Res Pract Thromb Haemost 2023; 7:100281. [PMID: 37601028 PMCID: PMC10439392 DOI: 10.1016/j.rpth.2023.100281] [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: 01/10/2023] [Revised: 05/22/2023] [Accepted: 06/01/2023] [Indexed: 08/22/2023] Open
Abstract
Background Desmopressin increases plasma factor VIII and von Willebrand factor levels in persons with nonsevere hemophilia A. Patients' perspectives on desmopressin are relevant to increase and optimize its suboptimal use. However, patients' views on desmopressin are not reported. Objectives To evaluate the perspectives of persons with nonsevere hemophilia A on desmopressin use, barriers for its use, side effects, and their knowledge about desmopressin's efficacy and side effects. Methods Persons with nonsevere hemophilia A were included in a cross-sectional, national, multicenter study. Questionnaires were filled out by adult patients and children aged ≥12 years themselves. Caretakers filled out questionnaires for children aged <12 years. Results In total, 706 persons with nonsevere hemophilia A were included (544 mild, 162 moderate, [age range, 0-88 years]). Of 508 patients, 234 (50%) patients reported previous desmopressin use. Desmopressin was considered as at least moderately effective in 171 of 187 (90%) patients. Intranasal administration was the modality of choice for 138 of 182 (76%) patients. Flushing was the most reported side effect in 54 of 206 (26%) adults and 7 of 22 (32%) children. The most frequently reported advantage and disadvantage were the convenience of intranasal, out-of-hospital administration by 56% (126/227) and side effects in 18% (41/227), respectively. Patients' self-perceived knowledge was unsatisfactory or unknown in 28% (63/225). Conclusion Overall, desmopressin was most often used intranasally and considered effective, with flushing as the most common side effect. The most mentioned advantage was the convenience of intranasal administration and disadvantage was side effects. More information and education on desmopressin could answer unmet needs in patients with current or future desmopressin treatment.
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Affiliation(s)
- Lorenzo G.R. Romano
- Department of Hematology, Hemophilia Treatment Center, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lize F.D. van Vulpen
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Paul L. den Exter
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Helene L. Hooijmeijer
- Department of Pediatrics, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Amsterdam University Medical Center - Emma Children’s Hospital, University of Amsterdam, Amsterdam, The Netherlands
- Department of Molecular Cellular Hemostasis, Sanquin Research and Landsteiner Laboratory, Amsterdam, The Netherlands
| | - Saskia E.M. Schols
- Department of Hematology, Radboud University Medical Center and Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands
| | - Paula F. Ypma
- Department of Hematology, Haga Hospital, The Hague, The Netherlands
| | - Cees Smit
- Netherlands Hemophilia Patient Society (NVHP), Nijkerk, The Netherlands
| | | | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna G. van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Samantha C. Gouw
- Department of Pediatric Hematology, Amsterdam University Medical Center - Emma Children’s Hospital, University of Amsterdam, Amsterdam, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke J.H.A. Kruip
- Department of Hematology, Hemophilia Treatment Center, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
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Mohinani A, Patel S, Tan V, Kartika T, Olson S, DeLoughery TG, Shatzel J. Desmopressin as a hemostatic and blood sparing agent in bleeding disorders. Eur J Haematol 2023; 110:470-479. [PMID: 36656570 PMCID: PMC10073345 DOI: 10.1111/ejh.13930] [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: 05/23/2022] [Revised: 01/05/2023] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
Intranasal, subcutaneous, or intravenous desmopressin can be utilized to release von Willebrand Factor and Factor VIII into circulation, enhance platelet adhesion and shorten bleeding time. Due to these properties, desmopressin can be effective in controlling bleeding in mild hemophilia A, certain subtypes of von Willebrand disease and in acute bleeding from uremia, end stage renal disease, and liver disease. Its use, however, can be complicated by hyponatremia and rarely arterial thrombotic events. While desmopressin has also been used as a prophylactic blood sparing agent in orthopedic, renal, and hepatic procedures, clinical studies have shown limited benefit in these settings. The purpose of this article is to review the evidence for desmopressin in primary hematologic disorders, discuss its mechanism of action and evaluate its utility as a hemostatic and blood sparing product in various bleeding conditions.
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Affiliation(s)
- Ajay Mohinani
- Division of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Sarah Patel
- Division of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Virginia Tan
- Division of Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Thomas Kartika
- Division of Hematology & Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Sven Olson
- Division of Hematology & Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Thomas G. DeLoughery
- Division of Hematology & Oncology, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph Shatzel
- Division of Hematology & Oncology, Oregon Health & Science University, Portland, Oregon, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
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Eladly F, Miesbach W. Von Willebrand Disease—Specific Aspects in Women. Hamostaseologie 2022; 42:330-336. [DOI: 10.1055/a-1891-9976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
AbstractVon Willebrand disease (VWD) is the most common inherited bleeding disorder, which results from a deficiency or dysfunction of von Willebrand factor (VWF). The major symptoms of patients affected by VWD include mucocutaneous and gastrointestinal bleeding, easy bruising, and prolonged provoked bleeding due to injury or surgery. Although women and men are equally likely to be affected by VWD, women continue to be disproportionately affected by the bleeding challenges. Women with VWD suffer from sex-specific symptoms, such as menorrhagia, and are at higher risk of reproductive problems and recurrent miscarriage. Furthermore, pregnant women with VWD are more likely at higher risk of suffering from primary and secondary peripartal hemorrhage and anemia and the need for transfusions. Despite being affected by gynecologic and obstetrical bleeding, women face multiple barriers in obtaining an accurate diagnosis. This constitutes a problem that needs to be addressed, and early appropriate medical care should be ensured. There are several effective treatment options for women with VWD that can significantly improve their quality of life, including desmopressin, VWF concentrates, hormonal therapy, and antifibrinolytic therapy. During pregnancy, the monitoring of VWF activity levels is essential. The peripartal management depends on the type of VWD and on the measured levels of VWF levels and activity prior to delivery.
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Affiliation(s)
- Fagr Eladly
- Department of Medicine, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital, Goethe University, Frankfurt, Germany
| | - Wolfgang Miesbach
- Department of Medicine, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital, Goethe University, Frankfurt, Germany
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6
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Zwagemaker A, Kloosterman FR, Coppens M, Gouw SC, Boyce S, Bagot CN, Beckers EAM, Brons P, Castaman G, Eikenboom J, Jackson S, Kruip MJHA, Leebeek FWG, Meijer K, Nieuwenhuizen L, Pabinger I, Fijnvandraat K. Desmopressin for bleeding in non‐severe hemophilia A: Suboptimal use in a real‐world setting. Res Pract Thromb Haemost 2022; 6:e12777. [PMID: 36090159 PMCID: PMC9433315 DOI: 10.1002/rth2.12777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/28/2022] [Accepted: 06/23/2022] [Indexed: 12/03/2022] Open
Abstract
Background Desmopressin is an important treatment option in nonsevere hemophilia A because it has several benefits compared with factor (F) concentrates, including no inhibitor risk and much lower costs. Despite these advantages, data are limited on the real‐world use of desmopressin in the treatment of bleeds. Objective To describe the clinical use of desmopressin in relation to other therapeutic modalities in the treatment of bleeding episodes in patients with nonsevere hemophilia A. Methods Patients with nonsevere hemophilia A aged 12–55 years were included from the DYNAMO cohort study. Data on the desmopressin test response and treated bleeding events in the period January 2009 to July 2020 were retrospectively collected from medical files. An adequate desmopressin test response was defined based on a peak FVIII level of ≥30 IU/dl. Results A total of 248 patients with a median age of 38 years (interquartile range 25–49) were included. An adequate desmopressin test response was documented in 25% and 73% of patients with moderate and mild hemophilia, respectively. In adequate responders, 51% of bleeds were exclusively treated with FVIII concentrates, 24% exclusively with desmopressin, 21% with a combination of both and 4% with other treatments. In 54% of bleeds treated with a single dose of factor concentrates, the expected FVIII level after desmopressin exceeded the level targeted. Conclusion Most bleeds in patients with an adequate response to desmopressin are treated with factor concentrates. These findings may indicate a suboptimal use of desmopressin and that barriers to the use of desmopressin should be explored.
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Affiliation(s)
- Anne‐Fleur Zwagemaker
- Amsterdam UMC University of Amsterdam, Emma Children's Hospital, Pediatric Hematology Amsterdam The Netherlands
| | - Fabienne R. Kloosterman
- Amsterdam UMC University of Amsterdam, Emma Children's Hospital, Pediatric Hematology Amsterdam The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine Amsterdam University Medical Centers Amsterdam The Netherlands
| | - Samantha C. Gouw
- Amsterdam UMC University of Amsterdam, Emma Children's Hospital, Pediatric Hematology Amsterdam The Netherlands
| | - Sara Boyce
- Department of Haematology University Hospital Southampton Southampton UK
| | | | - Erik A. M. Beckers
- Department of Internal Medicine, Division of Hematology, CARIM School for Cardiovascular Diseases Maastricht University Medical Center Maastricht The Netherlands
| | - Paul Brons
- Department of Pediatric Hemato‐Oncology Radboud University Medical Center Nijmegen The Netherlands
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders Careggi University Hospital Florence Italy
| | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis Leiden University Medical Center Leiden The Netherlands
| | - Shannon Jackson
- Adult Bleeding Disorders Program of BC ‐ Adult Division St. Paul's Hospital Vancouver British Columbia Canada
| | - Marieke J. H. A. Kruip
- Department of Hematology Erasmus MC, Erasmus University Medical Center Rotterdam The Netherlands
| | - Frank W. G. Leebeek
- Department of Hematology Erasmus MC, Erasmus University Medical Center Rotterdam The Netherlands
| | - Karina Meijer
- Department of Hematology University Medical Center Groningen, University of Groningen Groningen The Netherlands
| | | | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology Medical University of Vienna Vienna Austria
| | - Karin Fijnvandraat
- Amsterdam UMC University of Amsterdam, Emma Children's Hospital, Pediatric Hematology Amsterdam The Netherlands
- Department of Molecular Cellular Hemostasis Sanquin Research and Landsteiner Laboratory Amsterdam The Netherlands
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7
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Akbarpour M, Jalali MM, Akbari M, Haddadi S, Fani G. Effect of desmopressin on bleeding during endoscopic sinus surgery: A randomized clinical trial. Laryngoscope Investig Otolaryngol 2022; 7:920-927. [PMID: 36000037 PMCID: PMC9392372 DOI: 10.1002/lio2.841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/27/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background This study aimed to evaluate the effect of local nasal desmopressin premedication on blood loss and the quality of surgical field in Functional Endoscopic Sinus Surgery (FESS). Material and methods In a randomized clinical trial, patients referred for FESS to treat their bilateral chronic rhinosinusitis were recruited. The participants were adults (≥18 years). They were randomly assigned (1:1:1) to receive low‐dose (20 μg) or high‐dose (40 μg) intranasal desmopressin (DDAVP) or placebo 60 min before the induction of general anesthesia. Standard FESS was performed by the same surgeon. The primary outcomes were volume of intraoperative bleeding and the quality of surgical field. Clean surgical field was defined as a score ≤2 on the Boezaart grading system. Results A total of 120 patients were included on an intention‐to‐treat basis (mean age: 41.0 years; 40 women, 80 men). There were no significant differences in primary outcomes between low‐dose DDAVP and placebo. As for the volume of blood loss, however, there was a significant difference between high‐dose DDAVP and placebo (mean difference: 29.6 ml; adjusted Cohen's d: −1.02; p < .001). Also, in the high‐dose DDAVP, the probability of having a good surgical field over time was about two times higher than in the placebo group (RRs for first and second surgical sides: 1.89 and 2.18). The number needed to treat for the two time points was 1.6 and 1.3, respectively. Conclusion The present study showed that the use of desmopressin at a dose of 40 μg 1 h before surgery can reduce bleeding and improve the quality of the surgical field. Further studies are recommended to be able to generalize these findings to other ENT surgeries. Level of evidence 1b.
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Affiliation(s)
- Maliheh Akbarpour
- Otorhinolaryngology Research Center, School of Medicine Guilan University of Medical Sciences Rasht Iran
| | - Mir Mohammad Jalali
- Otorhinolaryngology Research Center, School of Medicine Guilan University of Medical Sciences Rasht Iran
| | - Maryam Akbari
- Otorhinolaryngology Research Center, School of Medicine Guilan University of Medical Sciences Rasht Iran
| | - Soudabeh Haddadi
- Anesthesiology Research Center, Department of Anesthesiology, Alzahra Hospital Guilan University of Medical Sciences Rasht Iran
| | - Ghaffar Fani
- Otorhinolaryngology Research Center, School of Medicine Guilan University of Medical Sciences Rasht Iran
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8
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Heijdra JM, Cloesmeijer ME, Jager NC, Leebeek FW, Kruip MH, Cnossen MH, Mathôt RA. Quantification of the relationship between desmopressin concentration and Von Willebrand factor in Von Willebrand disease type 1: A pharmacodynamic study. Haemophilia 2022; 28:814-821. [DOI: 10.1111/hae.14582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/30/2022] [Accepted: 04/19/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Jessica M. Heijdra
- Department of Paediatric Haematology Erasmus MC Sophia Children's Hospital University Medical Centre Rotterdam The Netherlands
| | - Michael E. Cloesmeijer
- Department of Hospital Pharmacy – Clinical Pharmacology Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Nico C.B. Jager
- Department of Hospital Pharmacy – Clinical Pharmacology Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Frank W.G. Leebeek
- Department of Haematology Erasmus MC Erasmus University Medical Centre Rotterdam The Netherlands
| | - Marieke H.J.A. Kruip
- Department of Haematology Erasmus MC Erasmus University Medical Centre Rotterdam The Netherlands
| | - Marjon H. Cnossen
- Department of Paediatric Haematology Erasmus MC Sophia Children's Hospital University Medical Centre Rotterdam The Netherlands
| | - Ron A.A. Mathôt
- Department of Hospital Pharmacy – Clinical Pharmacology Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
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9
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von Willebrand disease: what does the future hold? Blood 2021; 137:2299-2306. [PMID: 33662989 DOI: 10.1182/blood.2020008501] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/09/2021] [Indexed: 12/12/2022] Open
Abstract
von Willebrand disease (VWD) is characterized by its heterogeneous clinical manifestation, which complicates its diagnosis and management. The clinical management of VWD has remained essentially unchanged over the last 30 years or so, using von Willebrand factor (VWF) concentrates, desmopressin, and anti-fibrinolytic agents as main tools to control bleeding. This is in contrast to hemophilia A, for which a continuous innovative path has led to novel treatment modalities. Despite current VWD management being considered effective, quality-of-life studies consistently reveal a higher than anticipated burden of VWD on patients, which is particularly true for women. Apparently, despite our perceived notion of current therapeutic efficiency, there is space for innovation with the goal of reaching superior efficacy. Developing innovative treatments for VWD is complex, especially given the heterogeneity of the disease and the multifunctional nature of VWF. In this perspective article, we describe several potential strategies that could provide the basis for future VWD treatments. These include genetic approaches, such as gene therapy using dual-vector adenoassociated virus and transcriptional silencing of mutant alleles. Furthermore, protein-based approaches to increase factor FVIII levels in VWD-type 3 or 2N patients are discussed. Finally, antibody-based options to interfere with VWF degradation (for congenital VWD-type 2A or acquired von Willebrand syndrome-type 2A) or increase endogenous VWF levels (for VWD-type 1) are presented. By highlighting these potential strategies, we hope to initiate an innovative path, which ultimately would allow us to better serve VWD patients and their specific needs.
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10
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Veen CSB, Huisman EJ, Romano LGR, Schipaanboord CWA, Cnossen MH, de Maat MPM, Leebeek FWG, Kruip MJHA. Outcome of Surgical Interventions and Deliveries in Patients with Bleeding of Unknown Cause: An Observational Study. Thromb Haemost 2021; 121:1409-1416. [PMID: 33853179 DOI: 10.1055/s-0041-1726344] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The most optimal management for patients with bleeding of unknown cause (BUC) is unknown, as limited data are available. OBJECTIVE Evaluate management and outcome of surgical procedures and deliveries in patients with BUC. MATERIALS AND METHODS All patients ≥12 years of age, referred to a tertiary center for a bleeding tendency, were included. Bleeding phenotype was assessed and hemostatic laboratory work-up was performed. Patients were diagnosed with BUC or an established bleeding disorder (BD). Data on bleeding and treatment during surgical procedures and delivery following diagnosis were collected. RESULTS Of 380 included patients, 228 (60%) were diagnosed with BUC and 152 (40%) with an established BD. In 14/72 (19%) surgical procedures major bleeding occurred and 14/41 (34%) deliveries were complicated by major postpartum hemorrhage (PPH). More specifically, 29/53 (55%) of the BUC patients who underwent surgery received prophylactic treatment to support hemostasis. Despite these precautions, 4/29 (14%) experienced major bleeding. Of BUC patients not treated prophylactically, bleeding occurred in 6/24 (25%). Of pregnant women with BUC, 2/26 (8%) received prophylactic treatment during delivery, one women with and 11 (46%) women without treatment developed major PPH. CONCLUSION Bleeding complications are frequent in BUC patients, irrespective of pre- or perioperative hemostatic treatment. We recommend a low-threshold approach toward administration of hemostatic treatment in BUC patients, especially during delivery.
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Affiliation(s)
- Caroline S B Veen
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Elise J Huisman
- Department of Paediatric Haematology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Lorenzo G R Romano
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - Marjon H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Moniek P M de Maat
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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11
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How I manage pregnancy in carriers of hemophilia and patients with von Willebrand disease. Blood 2021; 136:2143-2150. [PMID: 32797211 DOI: 10.1182/blood.2019000964] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 06/15/2020] [Indexed: 12/11/2022] Open
Abstract
Women with inherited bleeding disorders, including carriers of hemophilia A and B, or with von Willebrand disease, have an increased risk of bleeding during pregnancy and delivery. The unborn child may also be affected by the bleeding disorder for which specific measures have to be considered. This requires a multidisciplinary approach, with a team that includes a hematologist, a pediatric hematologist, a clinical geneticist, an obstetrician-perinatologist, and an anesthesiologist. An optimal approach includes prepregnancy genetic counseling, prenatal diagnostic procedures, and a treatment plan for delivery for both the mother and child. Recent retrospective studies show that even if strict guidelines are followed, these women are still at risk of postpartum bleeding. This occurs even if coagulation factor levels are normalized, either due to the pregnancy-induced rise of factor levels or by infusion of coagulation factor concentrates at the time of delivery. In this article, we describe our current diagnostic and clinical management of pregnancy and delivery in women with inherited bleeding disorders. We also briefly discuss possible interventions to improve the outcome of current strategies by increasing target factor levels during and after delivery.
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Connell NT, Flood VH, Brignardello-Petersen R, Abdul-Kadir R, Arapshian A, Couper S, Grow JM, Kouides P, Laffan M, Lavin M, Leebeek FWG, O'Brien SH, Ozelo MC, Tosetto A, Weyand AC, James PD, Kalot MA, Husainat N, Mustafa RA. ASH ISTH NHF WFH 2021 guidelines on the management of von Willebrand disease. Blood Adv 2021; 5:301-325. [PMID: 33570647 PMCID: PMC7805326 DOI: 10.1182/bloodadvances.2020003264] [Citation(s) in RCA: 130] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/27/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND von Willebrand disease (VWD) is a common inherited bleeding disorder. Significant variability exists in management options offered to patients. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH), the International Society on Thrombosis and Haemostasis (ISTH), the National Hemophilia Foundation (NHF), and the World Federation of Hemophilia (WFH) are intended to support patients, clinicians, and health care professionals in their decisions about management of VWD. METHODS ASH, ISTH, NHF, and WFH formed a multidisciplinary guideline panel. Three patient representatives were included. The panel was balanced to minimize potential bias from conflicts of interest. The University of Kansas Outcomes and Implementation Research Unit and the McMaster Grading of Recommendations Assessment, Development and Evaluation (GRADE) Centre supported the guideline development process, including performing and updating systematic evidence reviews (through November 2019). The panel prioritized clinical questions and outcomes according to their importance to clinicians and patients. The panel used the GRADE approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 12 recommendations and outlined future research priorities. CONCLUSIONS These guidelines make key recommendations regarding prophylaxis for frequent recurrent bleeding, desmopressin trials to determine therapy, use of antiplatelet agents and anticoagulant therapy, target VWF and factor VIII activity levels for major surgery, strategies to reduce bleeding during minor surgery or invasive procedures, management options for heavy menstrual bleeding, management of VWD in the context of neuraxial anesthesia during labor and delivery, and management in the postpartum setting.
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Affiliation(s)
- Nathan T Connell
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Veronica H Flood
- Versiti Blood Research Institute, Medical College of Wisconsin, Milwaukee, WI
| | | | - Rezan Abdul-Kadir
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Foundation Hospital and Institute for Women's Health, University College London, London, United Kingdom
| | | | | | - Jean M Grow
- Department of Strategic Communication, Marquette University, Milwaukee, WI
| | - Peter Kouides
- Mary M. Gooley Hemophilia Treatment Center, University of Rochester, Rochester, NY
| | - Michael Laffan
- Centre for Haematology, Imperial College London, London, United Kingdom
| | - Michelle Lavin
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland and National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sarah H O'Brien
- Division of Hematology/Oncology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | | | - Alberto Tosetto
- Hemophilia and Thrombosis Center, Hematology Department, S. Bortolo Hospital, Vicenza, Italy
| | - Angela C Weyand
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Paula D James
- Department of Medicine, Queen's University, Kingston, ON, Canada; and
| | - Mohamad A Kalot
- Outcomes and Implementation Research Unit, Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Nedaa Husainat
- Outcomes and Implementation Research Unit, Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Reem A Mustafa
- Outcomes and Implementation Research Unit, Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS
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13
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Schütte LM, van Hest RM, Cnossen MH, Stoof SCM, Leebeek FWG, Mathôt RAA, Kruip MJHA. The association between desmopressin exposure, FVIII response and side effects. Haemophilia 2020; 27:e506-e509. [PMID: 33314458 DOI: 10.1111/hae.14227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/13/2020] [Accepted: 11/24/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Lisette M Schütte
- Department of Haematology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Reinier M van Hest
- Hospital Pharmacy - Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Rotterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Paediatric Haematology, Erasmus MC, University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sara C M Stoof
- Department of Haematology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Haematology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy - Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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14
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A Novel Quantitative Method for Analyzing Desmopressin in Human Plasma Using Liquid Chromatography–Tandem Mass Spectrometry. Ther Drug Monit 2020; 42:880-885. [DOI: 10.1097/ftd.0000000000000791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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15
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Hyponatremia in Patients with Hematologic Diseases. J Clin Med 2020; 9:jcm9113721. [PMID: 33228240 PMCID: PMC7699475 DOI: 10.3390/jcm9113721] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 11/10/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022] Open
Abstract
Hyponatremia is the most common electrolyte disorder in clinical practice and is associated with increased morbidity and mortality. It is frequently encountered in hematologic patients with either benign or malignant diseases. Several underlying mechanisms, such as hypovolemia, infections, toxins, renal, endocrine, cardiac, and liver disorders, as well as the use of certain drugs appear to be involved in the development or the persistence of hyponatremia. This review describes the pathophysiology of hyponatremia and discusses thoroughly the contributing factors and mechanisms that may be encountered specifically in patients with hematologic disorders. The involvement of the syndrome of inappropriate antidiuretic hormone (SIADH) secretion and renal salt wasting syndrome (RSWS) in the development of hyponatremia in such patients, as well as their differential diagnosis and management, are also presented. Furthermore, the distinction between true hyponatremia and pseudohyponatremia is explained. Finally, a practical algorithm for the evaluation of hyponatremia in hematologic patients, as well as the principles of hyponatremia management, are included in this review.
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Abstract
The management of von Willebrand disease (VWD) is based upon the dual correction of the primary hemostasis defect, due to the inherited deficiency of von Willebrand factor (VWF), and of the secondary defect of factor VIII coagulant activity (FVIII:C), due to the loss of binding and stabilization by VWF of this intrinsic coagulation factor in flowing blood. The traditional therapeutic weapons (the synthetic derivative of the antidiuretic hormone desmopressin and plasma-derived VWF/FVIII concentrates) are able to transiently correct both the defects. With the goal of tackling the primary deficiency in the disease, that is, VWF, but at the same time exploiting the normal capacity of patients to produce FVIII, the novel approach of replacing only VWF was implemented in the last 10 years. Following the manufacturing of a concentrate fractionated from human plasma and of one obtained by recombinant DNA technology, clinical studies have shown that VWF-only products correct not only the primary VWF deficiency but also the secondary FVIII:C deficiency. The demonstrated efficacy of these products in various clinical situations and, ultimately, in such a hemostasis-challenging context as surgery testifies to the effectiveness and safety of this approach. It remains to be seen whether VWF-only products are efficacious and safe in still-unexplored situations, such as use in children; the long-term use for prophylaxis; and in recurrent gastrointestinal (GI) bleeding due to angiodysplasia, a major therapeutic problem in VWD.
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17
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de Jager NCB, Heijdra JM, Kieboom Q, Kruip MJHA, Leebeek FWG, Cnossen MH, Mathôt RAA. Population Pharmacokinetic Modeling of von Willebrand Factor Activity in von Willebrand Disease Patients after Desmopressin Administration. Thromb Haemost 2020; 120:1407-1416. [PMID: 32746466 DOI: 10.1055/s-0040-1714349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Most von Willebrand disease (VWD) patients can be treated with desmopressin during bleeding or surgery. Large interpatient variability is observed in von Willebrand factor (VWF) activity levels after desmopressin administration. The aim of this study was to develop a pharmacokinetic (PK) model to describe, quantify, and explain this variability. METHODS Patients with either VWD or low VWF, receiving an intravenous desmopressin test dose of 0.3 µg kg-1, were included. A PK model was derived on the basis of the individual time profiles of VWF activity. Since no VWF was administered, the VWF dose was arbitrarily set to unity. Interpatient variability in bioavailability (F), volume of distribution (V), and clearance (Cl) was estimated. RESULTS The PK model was developed using 951 VWF activity level measurements from 207 patients diagnosed with a VWD type. Median age was 28 years (range: 5-76), median predose VWF activity was 0.37 IU/mL (range: 0.06-1.13), and median VWF activity response at peak level was 0.64 IU/mL (range: 0.04-4.04). The observed PK profiles were best described using a one-compartment model with allometric scaling. While F increased with age, Cl was dependent on VWD type and sex. Inclusion resulted in a drop in interpatient variability in F and Cl of 81.7 to 60.5% and 92.8 to 76.5%, respectively. CONCLUSION A PK model was developed, describing VWF activity versus time profile after desmopressin administration in patients with VWD or low VWF. Interpatient variability in response was quantified and partially explained. This model is a starting point toward more accurate prediction of desmopressin dosing effects in VWD.
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Affiliation(s)
- Nico C B de Jager
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jessica M Heijdra
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Quincy Kieboom
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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18
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Schütte LM, Hodes LS, van Moort I, Stoof SCM, Leebeek FWG, Cnossen MH, de Maat MPM, Kruip MJHA. The one-stage assay or chromogenic assay to monitor baseline factor VIII levels and desmopressin effect in non-severe haemophilia A: Superiority or non-inferiority? Haemophilia 2020; 26:916-922. [PMID: 32713129 PMCID: PMC7590113 DOI: 10.1111/hae.14106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/28/2020] [Accepted: 06/23/2020] [Indexed: 12/01/2022]
Abstract
Introduction Diagnosis, treatment monitoring and assessment of desmopressin effect in haemophilia A patients are performed by measurement of factor VIII activity (FVIII). The two assays commonly applied are the one‐stage assay and the chromogenic assay. Especially in non‐severe haemophilia A, discrepancies between these assays are common. It is still unestablished which assay corresponds best with bleeding phenotype and desmopressin effect. Aim To correlate FVIII levels measured by the one‐stage assay and by the chromogenic assay with bleeding phenotype and, additionally, to compare FVIII assay discrepancies before and after desmopressin administration. Method Factor VIII was measured in 130 non‐severe haemophilia A patients during routine visits to the outpatient clinic and/or during desmopressin testing. FVIII was measured by both the one‐stage assay and the chromogenic assay. Discrepancies between assays were defined as at least a twofold difference of FVIII or an absolute FVIII difference between measurements of ≥0.10 IU/mL. Bleeding phenotype was defined as annual number of treated bleedings (adjusted ABR). Results Hundred and thirty non‐severe haemophilia A patients were included. In 31/130 patients, assay results were discrepant. However, FVIII measurements with both assays correlated adequately with adjusted ABR. In addition, in 27/130 patients FVIII measurements at baseline and after desmopressin administration were analysed. In 13/27 patients, all measurements were either equivalent or discrepant when results were compared. In 14/27 patients, this was not the case as both equivalent measurements and discrepant measurements at different time points within one patient were observed. Conclusion Neither the one‐stage assay nor the chromogenic assay is superior in predicting bleeding phenotype. In addition, equivalent or discrepant FVIII results measured before desmopressin do not always predict FVIII assay results after desmopressin administration.
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Affiliation(s)
- Lisette M Schütte
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Luca S Hodes
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Iris van Moort
- Department of Paediatric Haematology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Sara C M Stoof
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Moniek P M de Maat
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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19
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Wang LC, Hu YF, Chen L, Xing R, Lin XF, Kou QY. Desmopressin acetate decreases blood loss in patients with massive hemorrhage undergoing gastrointestinal surgery. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 31:474-481. [PMID: 32721919 DOI: 10.5152/tjg.2020.19021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND/AIMS Intraoperative blood loss more than 400 mL during gastrointestinal surgery is an independent predictor of mortality. Desmopressin acetate (DDAVP) could reduce perioperative blood loss. Few studies have prompted concerning the effects of DDAVP on gastrointestinal surgery. This study was to investigate whether DDAVP can decrease blood loss in patients with massive hemorrhage undergoing gastrointestinal surgery. MATERIALS AND METHODS A multiple-centers, double-blind clinical trial was conducted, patients who underwent gastrointestinal surgery were recruited from 3 hospitals, randomly assigned to two different groups. Patients in the treatment group received desmopressin 0.3 ug/kg,30 min once a day after surgery, patients in the control group received 50 ml saline for 30 min. The primary outcome was the changes of hemoglobin at 24 hours after the surgery. And the secondary outcomes included coagulation function, urine volume, serum creatinine, and safety. RESULTS There were 59 patients enrolled between 1 June 2015 and 1 June 2017. At 24hr.after surgery, a decrease in hemoglobin in the DDAVP group was significantly lower than that in the NS group (-5.0±6.9 g/L vs. -10.2±9.3g/L, p=0.03). Sonoclot® showed that the platelet function in the DDAVP group was higher than that in NS group at 24 hr. (2.56 ±0.59 vs. 1.91 ±0.72, p<0.05). There was no difference in urine volume and serum creatinine at 24 hr. between two group. CONCLUSION DDAVP could reduce post-operation blood loss in patients with massive hemorrhage undergoing surgery by improving the platelet function. We observed no difference in urine volume and serum creatinine in two groups.
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Affiliation(s)
- Li-Chun Wang
- Department of Intensive Care Unit, the Sixth Affiliated Hospital of Sun Yat-Sen University,Guangzhou, China
| | - Ying-Fang Hu
- Department of Intensive Care Unit, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Lei Chen
- Department of Intensive Care Unit, the Sixth Affiliated Hospital of Sun Yat-Sen University,Guangzhou, China
| | - Rui Xing
- Department of Intensive Care Unit, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Xin-Feng Lin
- Department of Intensive Care Unit, The fist affiliated hospital of Guangzhou university of Chinese medicine, Guangzhou, China
| | - Qiu-Ye Kou
- Department of Intensive Care Unit, the Sixth Affiliated Hospital of Sun Yat-Sen University,Guangzhou, China
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Tebo C, Gibson C, Mazer-Amirshahi M. Hemophilia and von Willebrand Disease: A Review of Emergency Department Management. J Emerg Med 2020; 58:756-766. [PMID: 32249010 DOI: 10.1016/j.jemermed.2020.02.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 01/19/2020] [Accepted: 02/16/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemophilia and von Willebrand disease (VWD) are the most common congenital coagulation factor deficiencies. Patients with these disorders who experience bleeding complications are often initially managed in the emergency department (ED). OBJECTIVE OF THE REVIEW This review will focus on the emergency department management of patients with these disorders and provide an update on current treatment options. DISCUSSION The mainstay of management is initial stabilization, control of bleeding when possible, and administration of specific factors. Early coordination of care with hematology is critical. CONCLUSIONS Emergency medicine providers must have an understanding of the pathophysiology, clinical presentation, and management strategies in order to optimally care for these complex patients.
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Affiliation(s)
- Collin Tebo
- Georgetown University School of Medicine, Washington, DC
| | - Colin Gibson
- Georgetown University School of Medicine, Washington, DC
| | - Maryann Mazer-Amirshahi
- Georgetown University School of Medicine, Washington, DC; Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC
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21
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Ho QY, Lim CC, Thangaraju S, Siow B, Chin YM, Hao Y, Lee PH, Foo M, Tan CS, Kee T. Bleeding Complications and Adverse Events After Desmopressin Acetate for
Percutaneous Renal Transplant Biopsy. ANNALS ACADEMY OF MEDICINE SINGAPORE 2020. [DOI: 10.47102/annals-acadmedsg.2019164] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: Percutaneous renal biopsy remains critical for the workup of renal
allograft dysfunction but is associated with the risk of bleeding. Prophylactic intravenous desmopressin has been proposed to reduce bleeding risk in native renal biopsies, but its efficacy in the renal transplant population is unclear and adverse events such as severe hyponatraemia have been reported. Materials and Methods: We conducted a single-centre retrospective cohort study involving adult (≥21 years old) renal transplant recipients with impaired renal function (serum creatinine ≥150 μmol/L) who underwent ultrasound-guided renal allograft biopsies from 2011‒2015 to investigate the effect of prebiopsy desmopressin on the risk of bleeding and adverse events. Results: Desmopressin was administered to 98 of 195 cases who had lower renal function, lower haemoglobin and more diuretic use.Postbiopsy bleeding was not significantly different between the 2 groups (adjusted odds ratio [OR] 0.79, 95% confidence interval [CI] 0.26‒2.43, P = 0.68) but desmopressin increased the risk of postbiopsy hyponatraemia (sodium [Na] <135 mmol/L) (adjusted OR 2.24, 95% CI 1.10‒4.59, P = 0.03). Seven cases of severe hyponatraemia (Na <125 mmol/L) developed in the desmopressin group, while none did in the non-desmopressin group. Amongst those who received desmopressin, risk of hyponatraemia was lower (OR 0.26, 95% CI 0.09‒0.72, P = 0.01) if fluid intake was <1 L on the day of biopsy. Conclusion: Prophylactic desmopressin for renal allograft biopsy may be associated with significant hyponatraemia but its effect on bleeding risk is unclear. Fluid restriction (where feasible)
should be recommended when desmopressin is used during renal allograft biopsy. A
randomised controlled trial is needed to clarify these outcomes.
Key words: Adverse effects, Deamino arginine vasopressin, Haematoma, Haemorrhage,
Hyponatraemia
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Affiliation(s)
| | | | | | | | | | - Ying Hao
- Singapore General Hospital, Singapore
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22
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Mannucci PM. New therapies for von Willebrand disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:590-595. [PMID: 31808884 PMCID: PMC6913470 DOI: 10.1182/hematology.2019000368] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
The management of von Willebrand disease (VWD) is based upon the dual correction of the primary hemostasis defect, due to the inherited deficiency of von Willebrand factor (VWF), and of the secondary defect of factor VIII coagulant activity (FVIII:C), due to the loss of binding and stabilization by VWF of this intrinsic coagulation factor in flowing blood. The traditional therapeutic weapons (the synthetic derivative of the antidiuretic hormone desmopressin and plasma-derived VWF/FVIII concentrates) are able to transiently correct both the defects. With the goal of tackling the primary deficiency in the disease, that is, VWF, but at the same time exploiting the normal capacity of patients to produce FVIII, the novel approach of replacing only VWF was implemented in the last 10 years. Following the manufacturing of a concentrate fractionated from human plasma and of one obtained by recombinant DNA technology, clinical studies have shown that VWF-only products correct not only the primary VWF deficiency but also the secondary FVIII:C deficiency. The demonstrated efficacy of these products in various clinical situations and, ultimately, in such a hemostasis-challenging context as surgery testifies to the effectiveness and safety of this approach. It remains to be seen whether VWF-only products are efficacious and safe in still-unexplored situations, such as use in children; the long-term use for prophylaxis; and in recurrent gastrointestinal (GI) bleeding due to angiodysplasia, a major therapeutic problem in VWD.
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Affiliation(s)
- Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Maggiore Policlinico Hospital Foundation, Milan, Italy
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23
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Desmopressin is a transfusion sparing option to reverse platelet dysfunction in patients with severe traumatic brain injury. J Trauma Acute Care Surg 2019; 88:80-86. [DOI: 10.1097/ta.0000000000002521] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Lim CC, Siow B, Choo JCJ, Chawla M, Chin YM, Kee T, Lee PH, Foo M, Tan CS. Desmopressin for the prevention of bleeding in percutaneous kidney biopsy: efficacy and hyponatremia. Int Urol Nephrol 2019; 51:995-1004. [PMID: 31028561 DOI: 10.1007/s11255-019-02155-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 04/16/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Desmopressin is used to reduce bleeding complications for kidney biopsies with azotemia but little is known about desmopressin-induced hyponatremia in these individuals. We aimed to evaluate the impact of desmopressin prophylaxis on severe hyponatremia and bleeding after kidney biopsies in individuals with renal impairment. METHOD This is a single-center retrospective cohort study of consecutive adults with serum creatinine ≥ 150 µmol/L and had ultrasound-guided percutaneous native or transplant kidney biopsies between June 2011 and July 2015. Data were retrieved from electronic medical records. Primary outcomes were the use of desmopressin prophylaxis and severe hyponatremia (serum sodium ≤ 125 mmol/L) within 7 days post-biopsy. Secondary outcome was post-biopsy bleeding. RESULTS 240 native kidney and 196 allograft biopsies were performed. Median age was 51 (IQR 42.3, 60) years and eGFR was 21.9 (12.9, 30.1) ml/min/1.73 m2. Although patients prescribed desmopressin prophylaxis (n = 226) had higher serum creatinine [279 (201, 392) vs. 187 (160, 241), p < 0.001], bleeding (15.0% vs. 13.3%, p = 0.60) was not significantly different with and without desmopressin. Severe hyponatremia occurred in 30 biopsies (6.9%) with nadir serum sodium level of 122 (119, 124) mmol/L at 3 (2, 5) days after biopsy, more frequently among those with desmopressin prophylaxis (10.7% vs. 3.0%, p = 0.002). Multi-variate analysis found that pre-biopsy serum sodium level [adjusted OR 0.80 (95% CI 0.72, 0.90), p < 0.001] and desmopressin prophylaxis [adjusted OR 4.02 (95% CI 1.58, 10.21), p = 0.003] were independently associated with severe hyponatremia after kidney biopsy. CONCLUSION Pre-biopsy desmopressin was associated with severe hyponatremia in individuals with renal impairment; hence, susceptible patients given desmopressin should be closely monitored.
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Affiliation(s)
- Cynthia C Lim
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore.
| | - Benson Siow
- Pharmacy, Singapore General Hospital, 1 Hospital Drive, Outram Road, Singapore, Singapore
| | - Jason C J Choo
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Mayank Chawla
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Yok Mooi Chin
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Terence Kee
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Puay Hoon Lee
- Pharmacy, Singapore General Hospital, 1 Hospital Drive, Outram Road, Singapore, Singapore
| | - Marjorie Foo
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Academia Level 3, 20 College Road, Singapore, 169856, Singapore
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Schütte LM, Cnossen MH, van Hest RM, Driessens MHE, Fijnvandraat K, Polinder S, Beckers EAM, Coppens M, Eikenboom J, Laros-van Gorkom BAP, Meijer K, Nieuwenhuizen L, Mauser-Bunschoten EP, Leebeek FWG, Mathôt RAA, Kruip MJHA. Desmopressin treatment combined with clotting factor VIII concentrates in patients with non-severe haemophilia A: protocol for a multicentre single-armed trial, the DAVID study. BMJ Open 2019; 9:e022719. [PMID: 31015264 PMCID: PMC6500101 DOI: 10.1136/bmjopen-2018-022719] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Haemophilia A is an inherited bleeding disorder characterised by factor VIII (FVIII) deficiency. In patients with non-severe haemophilia A, surgery and bleeding are the main indications for treatment with FVIII concentrate. A recent study reported that standard dosing frequently results in FVIII levels (FVIII:C) below or above FVIII target ranges, leading to respectively a bleeding risk or excessive costs. In addition, FVIII concentrate treatment carries a risk of development of neutralising antibodies. An alternative is desmopressin, which releases endogenous FVIII and von Willebrand factor. In most patients with non-severe haemophilia A, desmopressin alone is not enough to achieve FVIII target levels during surgery or bleeding. We hypothesise that combined pharmacokinetic (PK)-guided administration of desmopressin and FVIII concentrate may improve dosing accuracy and reduces FVIII concentrate consumption. METHODS AND ANALYSIS In the DAVID study, 50 patients with non-severe haemophilia A (FVIII:C ≥0.01 IU/mL) with a bleeding episode or undergoing surgery will receive desmopressin and FVIII concentrate combination treatment. The necessary dose of FVIII concentrate to reach FVIII target levels after desmopressin administration will be calculated with a population PK model. The primary endpoint is the proportion of patients reaching FVIII target levels during the first 72 hours after start of the combination treatment. This approach was successfully tested in one pilot patient who received perioperative combination treatment. ETHICS AND DISSEMINATION The DAVID study was approved by the medical ethics committee of the Erasmus MC. Results of the study will be communicated trough publication in international scientific journals and presentation at (inter)national conferences. TRIAL REGISTRATION NUMBER NTR5383; Pre-results.
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Affiliation(s)
- Lisette M Schütte
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Reinier M van Hest
- Department of Hospital Pharmacy-Clinical Pharmacology Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Karin Fijnvandraat
- Department of Paediatric Haematology, Amsterdam UMC, Emma Children's Hospital, Amsterdam, The Netherlands
- Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Erik A M Beckers
- Department of Haematology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeroen Eikenboom
- Department of Thrombosis and Haemostasis, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | | | - Karina Meijer
- Department of Haematology, Universitair Medisch Centrum Groningen, Groningen, The Netherlands
| | - Laurens Nieuwenhuizen
- Department of Haematology, Maxima Medical Centre, Eindhoven, Eindhoven, Noord-Brabant, The Netherlands
| | | | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy-Clinical Pharmacology Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Das SK, Reddy MM, Ray S. Hemostatic Agents in Critically Ill Patients. Indian J Crit Care Med 2019; 23:S226-S229. [PMID: 31656384 PMCID: PMC6785814 DOI: 10.5005/jp-journals-10071-23258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Das SK, Reddy MM, Ray S. Hemostatic Agents in Critically Ill Patients. Indian J Crit Care Med 2019;23(Suppl 3):S226–S229.
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Affiliation(s)
- Saurabh Kumar Das
- Department of Critical Care, Artemis Hospital, Gurugram, Haryana, India
| | | | - Sumit Ray
- Department of Critical Care, Artemis Hospital, Gurugram, Haryana, India
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Hossain T, Ghazipura M, Reddy V, Rivera PJ, Mukherjee V. Desmopressin-Induced Severe Hyponatremia with Central Pontine Myelinolysis: A Case Report. DRUG SAFETY - CASE REPORTS 2018; 5:19. [PMID: 29696555 PMCID: PMC5918148 DOI: 10.1007/s40800-018-0084-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Desmopressin, a synthetic vasopressin analog, is used to treat central diabetes insipidus, hemostatic disorders such as von Willebrand’s disease, and nocturnal enuresis. We present the case of a 69-year-old man who developed severe hyponatremia during treatment with intranasal desmopressin at 10 µg twice daily for chronic polyuria and nocturia thought to be due to central diabetes insipidus. After 5 months of therapy, the patient noticed progressive fatigue, anorexia, dizziness, weakness, light-headedness, decreased concentration, and new-onset falls. At 6 months of therapy, the patient was brought to the emergency department for altered mental status and was found to be severely hyponatremic with a serum sodium level of 96 mmol/L, down from a value of 134 mmol/L at the initiation of therapy. The intranasal desmopressin was discontinued and the patient was admitted to the intensive care unit where the hyponatremia was slowly corrected over the next week to 132 mmol/L, never increasing by more than 8 mmol/L a day, with careful fluid management. This included infusion of over 11 L of 5% dextrose to account for a high urine output, which peaked at 7.4 L in 1 day. However, while the recommended rate for sodium correction was followed, the patient’s magnetic resonance imaging of the brain obtained after discharge displayed evidence of central pontine myelinolysis. Despite this finding, the patient eventually returned to his baseline mental status with no permanent neurologic deficits.
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Affiliation(s)
- Tanzib Hossain
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, 462 First Avenue, NBV 7N24, New York, NY, 10016, USA.
| | - Marya Ghazipura
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Vineet Reddy
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, 462 First Avenue, NBV 7N24, New York, NY, 10016, USA
| | - Pedro J Rivera
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, 462 First Avenue, NBV 7N24, New York, NY, 10016, USA
| | - Vikramjit Mukherjee
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, 462 First Avenue, NBV 7N24, New York, NY, 10016, USA
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Ferrara P, Ianniello F, Vescovo ED, Sodero G, Gatto A, Ruggiero A. Oral Desmopressin Lyophilisate Formulation (MELT): Efficacy and Safety in Children and Adults. BIOMEDICAL AND PHARMACOLOGY JOURNAL 2018; 11:171-177. [DOI: 10.13005/bpj/1359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Nocturnal enuresis (NE) is a common disorder in childhood and desmopressin is one of the most widely and well-tolerated medications for NE. The recent oral lyophilisate formulation of desmopressin (MELT) is effective in the treatment of NE in children and nocturia in adults. A MEDLINE literature search MEDLINE (2000-July 2017) was performed using the search terms MELT enuresis, MELT desmopressin, sublingual desmopressin, lyophilisate desmopressin. Twenty articles were analyzed with a number of patients of 3448. In 12 articles were reported 1275 pediatric patients (<18 years old), and in 8 articles 2213 adult patients. In pediatric population the indication was enuresis in 1269 patients and central diabetes insipidus in 6 patients. In adult population the indication was nocturia in 1941 patients, renal colic in 259 patients, healthy volunteers 13 patients. In 17 studies desmopressin was administered alone while in 3 studies in association respectively with Tolterodina, Ketorolac and Tamsulosin. In 7 studies were reported side effects in only 81 patients, 60 in pediatric population and 21 in adult population. The reported side effects in pediatric population were nausea, lethargy, lower limb weakness, headache, diarrhea, viral gastroenteritis. The reported side effects in adult population were asymptomatic hyponatriemia, nausea, diarrhea, dizziness, symptomatic hyponatriemia. Our review confirm that the MELT formulation of desmopressin guarantee the same response of other formulations with a lower doses and a lowest number of side effects. We believe according with the literature that this formulation is actually the first line and safety treatment for nocturnal enuresis and nocturia.
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Affiliation(s)
- P. Ferrara
- Institute of Pediatrics, Catholic University Medical School, Rome, Italy
| | - F. Ianniello
- Institute of Pediatrics, Catholic University Medical School, Rome, Italy
| | | | - G. Sodero
- Campus Bio-Medico University, Rome, Italy
| | - A. Gatto
- Institute of Pediatrics, Catholic University Medical School, Rome, Italy
| | - A. Ruggiero
- Institute of Pediatrics, Catholic University Medical School, Rome, Italy
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How I treat type 2B von Willebrand disease. Blood 2018; 131:1292-1300. [PMID: 29378695 DOI: 10.1182/blood-2017-06-742692] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 01/04/2018] [Indexed: 12/26/2022] Open
Abstract
Type 2B von Willebrand disease (VWD) is an inherited bleeding disorder caused by changes in von Willebrand factor (VWF) that enhance binding of VWF to GPIb on platelets. Although this disorder is seemingly well defined because of this single molecular defect, in reality type 2B VWD is a clinically heterogeneous disorder that can be difficult to identify and manage. Diagnostic criteria include a history of mucocutaneous bleeding, laboratory studies showing enhanced VWF binding of platelets and/or a 2B VWD genetic variant, and a family history consistent with autosomal dominant inheritance. Thrombocytopenia, although not always present, is common and can be exacerbated by physiologic stressors such as pregnancy. The mainstay of therapy for type 2B VWD is VWF replacement therapy. Adjunct therapies useful in other types of VWD, such as antifibrinolytics, are also used in type 2B VWD. 1-Desamino-8-d-arginine vasopressin (DDAVP) is controversial because of exacerbation of thrombocytopenia, but is, in practice, sometimes used for minor bleeding. Here we review the available evidence and provide 3 clinical cases to illustrate the intricacies of diagnosing type 2B VWD to describe the response to DDAVP and to review complexities and management during pregnancy.
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Heijdra JM, Cnossen MH, Leebeek FWG. Current and Emerging Options for the Management of Inherited von Willebrand Disease. Drugs 2017; 77:1531-1547. [PMID: 28791655 PMCID: PMC5585291 DOI: 10.1007/s40265-017-0793-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Von Willebrand disease (VWD) is the most common inherited bleeding disorder with an estimated prevalence of ~1% and clinically relevant bleeding symptoms in approximately 1:10,000 individuals. VWD is caused by a deficiency and/or defect of von Willebrand factor (VWF). The most common symptoms are mucocutaneous bleeding, hematomas, and bleeding after trauma or surgery. For decades, treatment to prevent or treat bleeding has consisted of desmopressin in milder cases and of replacement therapy with plasma-derived concentrates containing VWF and Factor VIII (FVIII) in more severe cases. Both are usually combined with supportive therapy, e.g. antifibrinolytic agents, and maximal hemostatic measures. Several developments such as the first recombinant VWF concentrate, which has been recently licensed for VWD, will make a more "personalized" approach to VWD management possible. As research on new treatment strategies for established therapies, such as population pharmacokinetic-guided dosing of clotting factor concentrates, and novel treatment modalities such as aptamers and gene therapy are ongoing, it is likely that the horizon to tailor therapy to the individual patients' needs will be extended, thus, further improving the already high standard of care in VWD in most high-resource countries.
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Affiliation(s)
- Jessica M Heijdra
- Department of Pediatric Hematology, Erasmus University Medical Center - Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus University Medical Center - Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
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Stoof SCM, Schütte LM, Leebeek FWG, Cnossen MH, Kruip MJHA. Desmopressin in haemophilia: The need for a standardised clinical response and individualised test regimen. Haemophilia 2017. [PMID: 28636264 DOI: 10.1111/hae.13295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Due to interindividual variation in desmopressin response, non-severe haemophilia A patients require desmopressin testing prior to therapeutic treatment. However, adequate response or frequency of blood sampling is not standardised in international guidelines. Consequently, various definitions and blood sampling protocols are currently applied. Interestingly, sustainability of desmopressin response is not incorporated into these definitions. AIM To study desmopressin response rates in a cohort of non-severe haemophilia A patients using currently accepted desmopressin response definitions. This, in order to formulate a standardised, uniform response which includes information on sustainability and to design a standardised blood sampling protocol. METHODS Currently used desmopressin responses in non-severe haemophilia A patients were derived from a literature search. Actual desmopressin response rates were individualised in 105 non-severe HA patients from the Erasmus University Medical Centre and classified according to current varying definitions. RESULTS Five response definitions were evaluated, three of which included only factor VIII (FVIII):C cut-off levels and two also incorporated FVIII:C-fold increase over baseline. FVIII C-fold increase showed no association with desmopressin response sustainability. FVIII C 1 hour after infusion (<0.30, ≥0.30-0.49, ≥0.50-0.79 and ≥0.80 IU/mL) was, however, indicative of desmopressin response after 6 hours. CONCLUSION We suggest standardised desmopressin response based on clinically relevant FVIII:C levels, e.g. 0.30 and 0.50 IU/mL. In addition, patients with <0.30 IU/mL FVIII:C after 1 hour (non-responder) or ≥0.80 IU/mL (sustained responder) do not require subsequent blood sampling. However, patients with ≥0.30-0.79 IU/mL FVIII:C after 1 hour should undergo blood sampling after 6 hours to additionally determine response sustainability.
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Affiliation(s)
- S C M Stoof
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - L M Schütte
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - F W G Leebeek
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - M H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Centre/Sophia Children's Hospital, Rotterdam, The Netherlands
| | - M J H A Kruip
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Kapila V, Kapila AK, Tailly T, Rappe B, Juul KV, Everaert K. The analgesic action of desmopressin in renal colic. Acta Clin Belg 2017; 72:179-185. [PMID: 27658643 DOI: 10.1080/17843286.2016.1230569] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Urolithiasis is a frequent problem causing a significant clinical, psychological and socio-economic burden. Analgesia remains the most important element in the medical treatment of renal colic. Nonetheless, both NSAIDs and opiates have a side effect profile which can cause further complications. As such, the use of desmopressin for renal colic has received increased attention in the last two decades. This paper provides an overview of current evidence on the use of desmopressin as an analgesic strategy in renal colic.
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Affiliation(s)
- Vansh Kapila
- Academic Department of Urology, University Hospital Ghent, University of Ghent, Belgium
| | | | - Thomas Tailly
- Academic Department of Urology, University Hospital Ghent, University of Ghent, Belgium
| | - Bernard Rappe
- Department of Urology, General City Hospital of Aalst, Geraardsbergen and Wetteren, Belgium
| | | | - Karel Everaert
- Academic Department of Urology, University Hospital Ghent, University of Ghent, Belgium
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Jahangirifard A, Razavi MR, Ahmadi ZH, Forozeshfard M. Effect of Desmopressin on the Amount of Bleeding and Transfusion Requirements in Patients Undergoing Heart Transplant Surgery. Basic Clin Pharmacol Toxicol 2017; 121:175-180. [PMID: 28326680 DOI: 10.1111/bcpt.12780] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 03/15/2017] [Indexed: 11/29/2022]
Abstract
One of the most common risks after a heart transplant is bleeding. In this study, the effect of desmopressin administration on the amount of bleeding and transfusion requirements after heart transplant surgery was investigated. In a double-blind clinical trial, 48 patients who were candidates for heart transplant surgery were randomly assigned to two groups. In the intervention group, patients received desmopressin of 0.3 μg/kg, 30 min. before surgery. Patients in the control group received normal saline at the same amount and time. Homeostasis was evaluated using activated clotting time (ACT), PT, PTT and PLT before, 12 and 24 hr after surgery, and also, chest tube drainage, blood products transfusion requirements during the first day in both groups. No significant differences were found between the groups in terms of ACT, PT, PTT and PLT at all times. Transfusion of packed red blood cells and the mean drainages of chest tube during the first 24 hr after surgery were significantly lower in the desmopressin group compared to the saline group. Desmopressin may reduce post-operative bleeding in patients undergoing heart transplant surgery. Further studies are required to confirm the potential effect of desmopressin on establishing haemostasis after heart transplantation.
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Affiliation(s)
- Alireza Jahangirifard
- Cardiac Anesthesiology, Tracheal Diseases Research Center, NRITLD, Shaheed Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Razavi
- Nursing Care Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Zargham Hosein Ahmadi
- Department of Surgery, Masih Daneshvari Hospital, Shaheed Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Forozeshfard
- Cancer Research Center and Department of Anesthesiology, Semnan University of Medical Sciences, Semnan, Iran
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Korkmaz U, Demir E, Yazici H, Sever MS. Hypertensive pulmonary edema related to desmopressin acetate. Nefrologia 2017. [DOI: 10.1016/j.nefro.2016.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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36
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Loomans JI, van Velzen AS, Eckhardt CL, Peters M, Mäkipernaa A, Holmstrom M, Brons PP, Dors N, Haya S, Voorberg J, van der Bom JG, Fijnvandraat K. Variation in baseline factor VIII concentration in a retrospective cohort of mild/moderate hemophilia A patients carrying identical F8 mutations. J Thromb Haemost 2017; 15:246-254. [PMID: 27943580 DOI: 10.1111/jth.13581] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 11/14/2016] [Indexed: 02/05/2023]
Abstract
Essentials Factor VIII levels vary in mild and moderate hemophilia A (MHA) patients with the same mutation. We aimed to estimate the variation and determinants of factor VIII levels among MHA patients. Age and genotype explain 59% of the observed inter-individual variation in factor VIII levels. Intra-individual variation accounted for 45% of the variation in the three largest mutation groups. SUMMARY Background The bleeding phenotype in patients with mild/moderate hemophilia A (MHA) is inversely associated with the residual plasma concentration of factor VIII (FVIII:C). Within a group of patients with the same F8 missense mutation, baseline FVIII:C may vary, because, in healthy individuals, von Willebrand factor (VWF) levels, ABO blood group and age are also known to influence baseline FVIII:C. Our understanding of the pathophysiologic process of the causative genetic event leading to reduced baseline FVIII:C in MHA patients is still limited. Objectives To estimate the variation and determinants of baseline FVIII:C among MHA patients with the same F8 missense mutation. Methods Three hundred and forty-six patients carrying mutations that were present in at least 10 patients in the cohort were selected from the INSIGHT and the RISE studies, which are cohort studies including data of 3534 MHA patients from Europe, Canada, and Australia. Baseline FVIII:C was measured with a one-stage clotting assay. We used Levene's test, univariate and multivariate linear regression, and mixed-model analyses. Results For 59% of patients, the observed variation in baseline FVIII:C was explained by age and genotype. Compared to FVIII:C in patients with Arg612Cys, FVIII:C was significantly different in patients with eight other F8 missense mutations. Intra-individual variation explained 45% of the observed variance in baseline FVIII:C among patients with the same mutation. Conclusion Our results indicate that baseline FVIII:C levels are not exclusively determined by F8 genotype in MHA patients. Insights into other factors may provide potential novel targets for the treatment of MHA.
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Affiliation(s)
- J I Loomans
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam, the Netherlands
| | - A S van Velzen
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam, the Netherlands
| | - C L Eckhardt
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam, the Netherlands
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - M Peters
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam, the Netherlands
| | - A Mäkipernaa
- Children's Hospital and Hematology, Comprehensive Cancer Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - M Holmstrom
- Coagulation Unit, Hematology Center, Karolinska University Hospital and Department of Medicine Karolinska Inisitutet, Stockholm, Sweden
| | - P P Brons
- Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - N Dors
- Catharina Hospital, Eindhoven, the Netherlands
| | - S Haya
- University Hospital la Fe, Valencia, Spain
| | - J Voorberg
- Department of Plasma Proteins, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
| | - J G van der Bom
- Leiden University Hospital, Leiden, the Netherlands
- Sanquin Research, Leiden, the Netherlands
| | - K Fijnvandraat
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam, the Netherlands
- Department of Plasma Proteins, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
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37
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Affiliation(s)
- Frank W G Leebeek
- From the Department of Hematology, Erasmus University Medical Center, Rotterdam (F.W.G.L.), and the Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden (J.C.J.E.) - both in the Netherlands
| | - Jeroen C J Eikenboom
- From the Department of Hematology, Erasmus University Medical Center, Rotterdam (F.W.G.L.), and the Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden (J.C.J.E.) - both in the Netherlands
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Boender J, Kruip MJHA, Leebeek FWG. A diagnostic approach to mild bleeding disorders. J Thromb Haemost 2016; 14:1507-16. [PMID: 27208505 DOI: 10.1111/jth.13368] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Indexed: 01/02/2023]
Abstract
Mild inherited bleeding disorders are relatively common in the general population. Despite recent advances in diagnostic approaches, mild inherited bleeding disorders still pose a significant diagnostic challenge. Hemorrhagic diathesis can be caused by disorders in primary hemostasis (von Willebrand disease, inherited platelet function disorders), secondary hemostasis (hemophilia A and B, other (rare) coagulant factor deficiencies) and fibrinolysis, and in connective tissue or vascular formation. This review summarizes the currently available diagnostic methods for mild bleeding disorders and their pitfalls, from structured patient history to highly specialized laboratory diagnosis. A comprehensive framework for a diagnostic approach to mild inherited bleeding disorders is proposed.
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Affiliation(s)
- J Boender
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M J H A Kruip
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - F W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
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