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Ozelo MC, Hermans C, Carcao M, Guillet B, Gu J, Guerra R, Tang L, Khair K. The effectiveness and safety of octocog alfa in patients with hemophilia A: up to 7-year follow-up of the real-world AHEAD international study. Ther Adv Hematol 2024; 15:20406207231218624. [PMID: 38371314 PMCID: PMC10874143 DOI: 10.1177/20406207231218624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 11/16/2023] [Indexed: 02/20/2024] Open
Abstract
Background Real-world data assessing treatment outcomes in patients with hemophilia A in routine clinical practice are limited. Objective To evaluate the effectiveness and safety of octocog alfa in patients with moderate/severe hemophilia A receiving treatment in clinical practice. Design The international Antihemophilic Factor Hemophilia A Outcome Database study is an observational, noninterventional, prospective, multicenter study. Methods This planned interim data read-out was conducted following 7 years of observation of patients receiving octocog alfa (cut-off, 30 June 2020). The primary endpoint was joint health status, assessed by the Gilbert Score. Secondary endpoints included annualized bleeding rates (ABRs), Hemophilia Joint Health Score (HJHS), health-related quality of life, consumption, and safety. This post hoc analysis stratified data by hemophilia severity at baseline [moderate, factor VIII (FVIII) 1-5%; severe, FVIII <1%]. Results Of the 711 patients in this analysis, 582 (82%) were receiving prophylaxis with octocog alfa at enrollment, and 498 (70%) had severe disease. Median Gilbert Scores were higher with on-demand therapy versus prophylaxis and scores were comparable in moderate and severe disease. In patients receiving prophylaxis, there was an improvement in HJHS Global Gait Score over 7 years of follow-up overall and in patients with severe disease. ABRs and annualized joint bleeding rates were low across all 7 years. An ABR of zero was reported in 34-56% of prophylaxis patients versus 20-40% in the on-demand group. ABRs were similar in severe and moderate disease. In total, 13/702 (1.9%) patients experienced 18 treatment-related adverse events. Conclusion These data demonstrate the long-term effectiveness and safety of octocog alfa in patients with moderate and severe hemophilia A, especially in those receiving prophylaxis. The high number of patients receiving on-demand treatment experiencing zero bleeds could be due to selection bias within the study, with patients with less severe disease more likely to be receiving on-demand treatment. Trial registration ClinicalTrials.gov: NCT02078427.
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Affiliation(s)
| | - Cedric Hermans
- St-Luc University Hospital, Université catholique de Louvain, Louvain, Belgium
| | - Manuel Carcao
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Benoît Guillet
- Haemophilia Treatment Center, Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000 Rennes, France
| | - Joan Gu
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Randy Guerra
- Takeda Development Center Americas, Inc., 500 Kendal Street, Cambridge, MA 02142, USA
| | - Leilei Tang
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
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Kessler CM, Corrales-Medina FF, Mannucci PM, Jiménez-Yuste V, Tarantino MD. Clinical efficacy of simoctocog alfa versus extended half-life recombinant FVIII concentrates in hemophilia A patients undergoing personalized prophylaxis using a matching-adjusted indirect comparison method. Eur J Haematol 2023; 111:757-767. [PMID: 37587687 DOI: 10.1111/ejh.14073] [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: 05/12/2023] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES We aimed to indirectly compare the efficacy of personalized prophylaxis with simoctocog alfa (Nuwiq®) versus three extended half-life (EHL) recombinant FVIII (rFVIII) concentrates. METHODS Treatment effects were compared using matching-adjusted indirect comparisons after matching individual patient-level baseline characteristics for simoctocog alfa (pharmacokinetic [PK]-guided personalized prophylaxis) against published aggregate personalized prophylaxis data for efmoroctocog alfa, damoctocog alfa pegol, and rurioctocog alfa pegol. RESULTS A higher percentage (p < .001) of patients with zero bleeds was found with simoctocog alfa compared with efmoroctocog alfa (75% vs. 45%), damoctocog alfa pegol (77% vs. 38%), and rurioctocog alfa pegol (target trough level 1%-3%; 78% vs. 42%). Similar efficacy was found comparing simoctocog alfa against rurioctocog alfa pegol 8%-12% (77% vs. 62%). The mean total annualized bleeding rate was lower (p < .001) with simoctocog alfa than damoctocog alfa pegol (1.5 vs. 4.9). Consistent with approved dosing, the mean FVIII weekly dose was higher (p < .001) for simoctocog alfa than efmoroctocog alfa, damoctocog alfa pegol, or rurioctocog alfa pegol 1%-3%, but lower (p < .001) than rurioctocog alfa pegol 8%-12%. CONCLUSIONS Indirect comparisons demonstrated that PK-guided, personalized prophylaxis with simoctocog alfa can lead to higher zero bleed rates compared with personalized EHL rFVIII concentrate regimens, albeit with higher weekly doses, and a lower percentage of patients treated twice weekly or less.
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Affiliation(s)
- Craig M Kessler
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Fernando F Corrales-Medina
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, Florida, USA
- Hemophilia Treatment Center, University of Miami, Miami, Florida, USA
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Víctor Jiménez-Yuste
- Hospital Universitario La Paz-Hematology Department, Autónoma University, Madrid, Spain
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3
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Mathias M, Abraham A, Belletrutti MJ, Carcao M, Carvalho M, Chambost H, Chan AKC, Dubey L, Ducore J, Gattens M, Gresele P, Gruel Y, Guillet B, Jiménez-Yuste V, Kitanovski L, Klukowska A, Lohade S, Mancuso ME, Oldenburg J, Pollio B, Sigaud M, Vilchevska K, Wu JKM, Jansen M, Belyanskaya L, Walter O, Knaub S, Neufeld EJ. Simoctocog alfa (Nuwiq®) in previously untreated patients with severe haemophilia A-Final efficacy and safety results from the NuProtect study. Eur J Haematol 2023; 111:544-552. [PMID: 37439123 DOI: 10.1111/ejh.14040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 07/14/2023]
Abstract
INTRODUCTION Simoctocog alfa (Nuwiq®) is a 4th generation recombinant FVIII with proven efficacy for the prevention and treatment of bleeding episodes (BEs) in previously treated patients with severe haemophilia A. The NuProtect study assessed the immunogenicity, efficacy and safety of simoctocog alfa in 108 previously untreated patients (PUPs). The incidence of high-titre inhibitors was 16.2% and no patients with non-null F8 mutations developed inhibitors. AIM To report the efficacy and safety results from the NuProtect study. METHODS PUPs received simoctocog alfa for prophylaxis, treatment of BEs, or as surgical prophylaxis. The efficacy of prophylaxis (during inhibitor-free periods) was assessed using annualised bleeding rates (ABRs). The efficacy in treating BEs and in surgical prophylaxis was assessed using a 4-point scale. Adverse events were recorded throughout the study. RESULTS Of 108 PUPs treated with simoctocog alfa, 103 received at least one prophylactic dose and 50 received continuous prophylaxis for at least 24 weeks. In patients on continuous prophylaxis, the median ABR was 0 (mean 0.5) for spontaneous BEs and 2.5 (mean 3.6) for all BEs. In 85 patients who had BEs, efficacy of BE treatment was excellent or good for 92.9% (747/804) of rated BEs; 92.3% of BEs were treated with 1 or 2 infusions. The efficacy of surgical prophylaxis was excellent or good for 94.7% (18/19) of rated procedures. There were no safety concerns and no thromboembolic events. CONCLUSION Simoctocog alfa was efficacious and well tolerated as prophylaxis, surgical prophylaxis and for the treatment of BEs in PUPs with severe haemophilia A.
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Affiliation(s)
- Mary Mathias
- Haemophilia Comprehensive Care Centre, Great Ormond Street Hospital for Children NHS Trust Haemophilia Centre, NIHR GOSH BRC, London, UK
| | - Aby Abraham
- Department of Hematology, Christian Medical College, Vellore, India
| | - Mark J Belletrutti
- Department of Pediatrics, Division of Hematology/Oncology/BMT, University of British Columbia and British Columbia Children's Hospital, Vancouver, Canada
| | - Manuel Carcao
- Department of Paediatrics, Division of Haematology/Oncology and Child Health Evaluative Sciences, Research Institute Hospital for Sick Children, Toronto, Canada
| | - Manuela Carvalho
- Congenital Coagulopathies Reference Centre, São João University Hospital Centre, Porto, Portugal
| | - Hervé Chambost
- AP-HM, Department of Pediatric Hematology Oncology, Children Hospital La Timone, Aix Marseille Univ INSERM, INRA, C2VN, Marseille, France
| | - Anthony K C Chan
- Department of Pediatrics, McMaster Centre of Transfusion Research, McMaster University, Hamilton, Canada
| | - Leonid Dubey
- Department of Paediatrics, Western Ukrainian Specialized Children's Medical Centre, Lviv, Ukraine
| | - Jonathan Ducore
- Department of Pediatrics, University of California Davis Medical Center, Sacramento, California, USA
| | - Michael Gattens
- Department of Paediatric Haematology and Oncology, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Paolo Gresele
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Yves Gruel
- Centre Régional de Traitement de l'Hémophilie, Hôpital Trousseau, Tours, France
| | - Benoit Guillet
- Haemophilia Treatment Centre, Univ Rennes, CHU Rennes, INSERM, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France
| | - Victor Jiménez-Yuste
- Servicio de Hematología, Hospital Univeristario La Paz, Autónoma, University of Madrid, Madrid, Spain
| | - Lidija Kitanovski
- Department of Haematooncology, Division of Paediatrics, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Anna Klukowska
- Haemostasis Group of the Polish Society of Haematology and Transfusiology, Warsaw, Poland
| | - Sunil Lohade
- Department of Hematology, Sahyadri Speciality Hospital, Pune, India
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Berardino Pollio
- Regional Reference Centre for Inherited Bleeding and Thrombotic Disorders, Regina Margherita Children Hospital, Turin, Italy
| | - Marianne Sigaud
- Centre Régional de Traitement de I'Hémophilie, University Hospital of Nantes, Nantes, France
| | - Kateryna Vilchevska
- Department of Hematology, OHMATDYT - National Specialized Children's Hospital, Kiev, Ukraine
| | - John K M Wu
- Department of Pediatrics, Division of Hematology/Oncology/BMT, University of British Columbia and British Columbia Children's Hospital, Vancouver, Canada
| | - Martina Jansen
- Octapharma Pharmazeutika Produktionsges m.b.H, Vienna, Austria
| | | | | | | | - Ellis J Neufeld
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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Nguyen NH, Jarvi NL, Balu-Iyer SV. Immunogenicity of Therapeutic Biological Modalities - Lessons from Hemophilia A Therapies. J Pharm Sci 2023; 112:2347-2370. [PMID: 37220828 DOI: 10.1016/j.xphs.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 05/25/2023]
Abstract
The introduction and development of biologics such as therapeutic proteins, gene-, and cell-based therapy have revolutionized the scope of treatment for many diseases. However, a significant portion of the patients develop unwanted immune reactions against these novel biological modalities, referred to as immunogenicity, and no longer benefit from the treatments. In the current review, using Hemophilia A (HA) therapy as an example, we will discuss the immunogenicity issue of multiple biological modalities. Currently, the number of therapeutic modalities that are approved or recently explored to treat HA, a hereditary bleeding disorder, is increasing rapidly. These include, but are not limited to, recombinant factor VIII proteins, PEGylated FVIII, FVIII Fc fusion protein, bispecific monoclonal antibodies, gene replacement therapy, gene editing therapy, and cell-based therapy. They offer the patients a broader range of more advanced and effective treatment options, yet immunogenicity remains the most critical complication in the management of this disorder. Recent advances in strategies to manage and mitigate immunogenicity will also be reviewed.
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Affiliation(s)
- Nhan H Nguyen
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA; Currently at Truvai Biosciences, Buffalo, NY, USA
| | - Nicole L Jarvi
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Sathy V Balu-Iyer
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.
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Nardi MA. Hemophilia A: Emicizumab monitoring and impact on coagulation testing. Adv Clin Chem 2023; 113:273-315. [PMID: 36858648 DOI: 10.1016/bs.acc.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Hemophilia A is an X-linked recessive bleeding disorder characterized by absent or ineffective coagulation factor VIII, a condition that could result in a severe and potentially life-threatening bleed. Although the current standard of care involves prophylactic replacement therapy of factor VIII, the development of neutralizing anti-factor VIII alloantibody inhibitors often complicates such therapeutic treatment. Emicizumab (Hemlibra®), a novel recombinant therapeutic agent for patients with hemophilia A, is a humanized asymmetric bispecific IgG4 monoclonal antibody designed to mimic activated factor VIII by bridging factor IXa and factor X thus effecting hemostasis. Importantly, this drug eliminates the need for factor VIII and complications associated with inhibitor generation. Emicizumab has been approved for use in several countries including the United States and Japan for prophylaxis of bleeding episodes in hemophilia A with and without FVIII inhibitors. Therapy is also approved in the European Union for routine prophylaxis of bleeds in hemophilia A with inhibitors or severe hemophilia A without inhibitors. Unfortunately, emicizumab therapy presents unique challenges for routine and specialty coagulation tests currently used to monitor hemophilia A. In this review, hemophilia A is presented, the biochemistry of factor VIII is discussed, and the impact of the therapeutic agent emicizumab is highlighted.
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Affiliation(s)
- Michael A Nardi
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, United States; Department of Pathology, New York University Grossman School of Medicine, New York, NY, United States.
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He X, Wang X, Dong C, Zhao M, Wu J. The long-term clinical benefits and economic costs associated with increased use of prophylaxis among patients with haemophilia A in China: Population-based predictions from 2018 to 2033. Haemophilia 2022; 28:726-736. [PMID: 35714660 DOI: 10.1111/hae.14603] [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: 01/25/2022] [Revised: 04/22/2022] [Accepted: 05/24/2022] [Indexed: 11/28/2022]
Abstract
AIM To predict the long-term benefits and economic costs of the improvements in haemophilia care in China demonstrated by increasing use of prophylaxis, compared with the current status. METHODS City-level predictions from 2018 to 2033 were conducted for five representative cities in China. The long-term clinical and economic outcomes in the scenario where haemophilia care has significantly improved and the existing scenario of haemophilia care were calculated and compared. The model input data were obtained from local records, expert interviews, published literature, and other sources. Outcome measures including number of bleeds and joint bleeds, number of target joints, disability rate, direct and indirect costs were calculated at the patient and population levels. RESULTS The long-term predictions for 2033 demonstrated significantly improved bleed control and joint outcomes due to increased use of prophylaxis. The total number of averted bleed events per patient ranged from 3.9 in Shenyang to 16.1 in Zhengzhou in 2033, and the population-level averted bleed events ranged from 1963 in Xiamen to 14,868 in Zhengzhou. The treatment improvement also leads to significant economic costs driven by increase in clotting factor costs (more than 90%). At the population level, the additional total costs were highest in Zhengzhou (CNY 177.4 million) and lowest in Shenyang (CNY 45.4 million), due to their different population sizes and various existing treatment regimens. The outpatient and hospitalization costs decreased, while the factor costs increased. CONCLUSION The long-term prophylaxis is associated with avoided bleed events and disabilities. The improved treatment regimens are also associated with a significant economic burden, driven by factor costs.
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Affiliation(s)
- Xiaoning He
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China.,Center for Social Science Survey and Data, Tianjin University, Tianjin, China
| | - Xu Wang
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China.,Center for Social Science Survey and Data, Tianjin University, Tianjin, China
| | - Chaohui Dong
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | - Mingyue Zhao
- The Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, China.,The Center for Drug Safety and Policy Research, Xi'an Jiaotong University, China
| | - Jing Wu
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China.,Center for Social Science Survey and Data, Tianjin University, Tianjin, China
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Lentz SR, Kavakli K, Klamroth R, Misgav M, Nagao A, Tosetto A, Jørgensen P, Zak M, Nemes L. Turoctocog alfa pegol (N8‐GP) in severe hemophilia A: Long‐term safety and efficacy in previously treated patients of all ages in the pathfinder8 study. Res Pract Thromb Haemost 2022; 6:e12674. [PMID: 35308099 PMCID: PMC8918113 DOI: 10.1002/rth2.12674] [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: 11/08/2021] [Revised: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 12/03/2022] Open
Abstract
Background N8‐GP (turoctocog alfa pegol; Esperoct) is a glycoPEGylated human recombinant factor VIII (FVIII). Objectives Pathfinder8 (NCT01480180) was a phase 3, multinational, open‐label, nonrandomized trial to investigate the long‐term safety and efficacy of N8‐GP in people of all ages with severe hemophilia A previously treated with N8‐GP. Patients/Method Patients were recruited from the completed phase 3 pathfinder2 and pathfinder5 trials to receive intravenous N8‐GP prophylaxis for up to 104 weeks, administered every 7 days, twice weekly, or three times weekly. Primary and secondary end points were the number of adverse events (AEs) reported and efficacy of treatment, respectively. Results Overall, 160 patients were exposed to N8‐GP for a mean of 179 exposure days and 681 calendar days (≈1.9 years) per patient. In total, 119 patients experienced 510 AEs, corresponding to a rate of 1.71 AEs per patient‐year of exposure; 97.5% of AEs were mild or moderate in severity, and no AEs led to withdrawal. No patients developed FVIII inhibitors during the trial. The Poisson estimate of mean annualized bleeding rate for all bleeds (excluding surgery) and across all regimens was 1.10 (median, 0.00), and for spontaneous bleeds was 0.61 (median, 0.00). Most (55.6%) patients experienced no bleeds that required FVIII treatment (excluding perioperative bleeds). The estimated hemostatic success rate for the treatment of 322 bleeding episodes (excluding surgery) was 95.8%, including missing values as failure. Conclusions Long‐term prophylactic use of N8‐GP appeared safe and efficacious across all age groups in people with severe hemophilia A previously treated with N8‐GP.
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Affiliation(s)
- Steven R. Lentz
- Division of Hematology, Oncology, and Blood & Marrow Transplantation Department of Internal Medicine University of Iowa Carver College of Medicine Iowa City Iowa USA
| | - Kaan Kavakli
- Department of Haematology Ege University Faculty of Medicine Children's Hospital Bornova Izmir Turkey
| | - Robert Klamroth
- Department for Internal Medicine Vascular Medicine and Haemostaseology Vivantes Klinikum im Friedrichshain Berlin Germany
| | - Mudi Misgav
- National Hemophilia Center Sheba Medical Center Tel Hashomer Israel
| | - Azusa Nagao
- Department of Blood Coagulation Ogikubo Hospital Tokyo Japan
| | - Alberto Tosetto
- Hemophilia and Thrombosis Center Hematology Department San Bortolo Hospital Vicenza Italy
| | | | - Marek Zak
- Medical and Science Biopharm Novo Nordisk A/S Bagsværd Denmark
| | - Laszlo Nemes
- National Hemophilia Center and Hemostasis Department Medical Center of the Hungarian Defence Forces Budapest Hungary
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Sun HL, Jiwajee A, Teitel J, Sholzberg M. Observational study of efficacy and safety of human cell line-derived recombinant factor VIII in Canadian adults with moderately severe and severe haemophilia A. Haemophilia 2021; 27:e419-e421. [PMID: 33866651 DOI: 10.1111/hae.14310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/26/2021] [Accepted: 03/29/2021] [Indexed: 01/19/2023]
Affiliation(s)
| | - Aziz Jiwajee
- St. Michael's Hospital, and University of Toronto, Toronto, ON, Canada
| | - Jerry Teitel
- St. Michael's Hospital, and University of Toronto, Toronto, ON, Canada
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Abstract
INTRODUCTION A number of new FVIII/IX concentrates enriched the portfolio of products available for the treatment of hemophilia A/B patients. Due to the large inter-patient variability, accurate tailoring of the therapy became essential to improve patients' adherence, clinical outcomes, and cost/effectiveness ratio. Recently, non-replacement therapies have taken the limelight and succeeded in decreasing the bleedings of patients. AREAS COVERED The PK characteristics, efficacy, and safety of the new rFVIII and rFIX concentrates and of non-replacement therapy, are reported in detail in the published clinical trials. EXPERT OPINION Outstanding improvements of rFIX concentrates' pharmacokinetics and pharmacodynamics have allowed to reduce the bleedings in hemophilia B patients, in order to increase their adherence to prophylaxis and quality of life. Less significant are the effects of pegylation or Fc fusion on the pharmacokinetics of the new rFVIII concentrates. The new non-replacement therapy is achieving the favor of many treaters and patients, in particular those with Factor VIII inhibitors. Great attention must be paid to the dangerous synergy of APCC and emicizumab, responsible for some fatal events during the clinical trials and compassionate use of this drug. So far, replacement therapy should be the standard of care for hemophilia patients without inhibitors or difficulties in venous access.
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Affiliation(s)
- Massimo Morfini
- Italian Association of Hemophilia Centres (AICE) , Milan, Italy
| | - Emanuela Marchesini
- Hemophilia Centre - SC Vascular and Emergency Department, University of Perugia , Perugia, Italy
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Schiavoni M, Napolitano M, Giuffrida G, Coluccia A, Siragusa S, Calafiore V, Lassandro G, Giordano P. Status of Recombinant Factor VIII Concentrate Treatment for Hemophilia a in Italy: Characteristics and Clinical Benefits. Front Med (Lausanne) 2019; 6:261. [PMID: 31850352 PMCID: PMC6901793 DOI: 10.3389/fmed.2019.00261] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/28/2019] [Indexed: 01/19/2023] Open
Abstract
The current interest in recombinant factor VIII (rFVIII) products stems from the fact that they offer a technological solution to prolonging the half-life of and reducing the risk of formation of alloantibodies (inhibitors) against FVIII in treated patients with hemophilia A (HA). The Italian health care system has authorized the use of a wide range of rFVIII concentrates of the first, second, and third generation, as well as new innovative rFVIII preparates with an extended half-life (EHL) (Kogenate FS®-Bayer, belonging to the second generation and replaced since 2017 by a product consisting of the same modified molecule; because it is only available until the end of the current year, it will not be considered in this review). Some of these products have unique pharmacodynamic and pharmacokinetic (PK) profiles, including an EHL. The first-generation full-length rFVIII (FL-rFVIII), octocog alfa (Recombinate® Baxter/BIOVIIIx), although the oldest rFVIII product, has several desirable features. Third-generation products include two modified octocog alfa molecules (Advate®, Shire; Kovaltry®, Bayer) as well as the B domain-deleted rFVIII (BDD-rFVIII) moroctocog alfa (ReFacto®-Pfizer). The B domain-truncated (BDT-rFVIII) turoctocog alfa (NovoEight®, Novo Nordisk), the BDD-rFVIII simoctocog alfa (Nuwiq®, Kedrion), the single-chain BDT-rVIII lonoctocog alfa (Afstyla®, CSL Behring), and the BDD-rFVIIIFc efmoroctocog alfa (Elocta®, Sobi-Biogen) are new, innovative products. Simoctocog alfa, because its peculiarities, is considered a fourth-generation rFVIII concentrate. Turoctocog alfa, simoctocog alfa, and lonoctocog alfa have a high affinity for von Willebrand factor (vWF) that reduces renal clearance and prolongs the half-life of rFVIII. Efmoroctocog alfa, a first-in-class rFVIII-Fc fusion protein (rFVIIIFc), has a half-life 1.5–1.8 times longer than that of conventional plasma-derived FVIII (pd-rFVIII) and other rFVIII products. Clinical studies have evaluated the efficacy, safety, and inhibitor development of all these innovative concentrates in both previously treated (PTPs) and untreated patients (PUPs). This review considers the rFVIII products that are indicated for the treatment of patients with severe HA, focusing on those that are commercially available in Italy. Their PK characteristics, immunogenicity, and clinical benefits are discussed and compared.
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Affiliation(s)
- Mario Schiavoni
- Associazione per la Lotta alle Malattie Emorragiche e Trombotiche, Maglie, Italy
| | - Mariasanta Napolitano
- Internal Medicine and Medical Specialities, Haematology Unit, Department of Health Promotion, Mother and Child Care, Reference Regional Center for Thrombosis and Haemostasis, University of Palermo, Palermo, Italy
| | - Gaetano Giuffrida
- U.O.C. di Ematologia, A.O.U. Policlinico "Vittorio Emanuele", Catania, Italy
| | - Antonella Coluccia
- U.O.C di Medicina Interna, Centro Emofilia e Coagulopatie Rare-Ospedale "I.Veris delli Ponti", Scorrano-ASL, Lecce, Italy
| | - Sergio Siragusa
- U.O.C. di Ematologia, Università degli Studi, Palermo, Italy
| | - Valeria Calafiore
- U.O.C. di Ematologia, A.O.U. Policlinico "Vittorio Emanuele", Catania, Italy
| | - Giuseppe Lassandro
- Dipartimento di Scienza Biomedica e Oncologia Umana, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Paola Giordano
- Dipartimento di Scienza Biomedica e Oncologia Umana, Università degli Studi di Bari "Aldo Moro", Bari, Italy
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Sudevan R, Beenakumari AA, Ganapathy R, Unni M, Vidyadharan G, Sidharthan N. Intermediate Dose Prophylaxis in Adults with Haemophilia: A Clinical Audit from a Resource Limited Setting. Indian J Hematol Blood Transfus 2019; 36:374-376. [PMID: 32425392 DOI: 10.1007/s12288-019-01189-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/13/2019] [Indexed: 11/27/2022] Open
Abstract
To address the scarcity of real world data on adult prophylaxis from developing world, a short term intermediate dose prophylaxis in adult haemophilia A patients was initiated. A total of eight patients aged > 18 years with moderate/severe haemophilia A were given an average dose of 23 IU/kg recombinant factor VIII (rFVIII) concentrate twice weekly for 2 months. A clinical audit was done on completion of four months. The mean age of the participants was 31.63 (± 6.98) years. The mean bleed rate during two months of episodic versus prophylactic regimen was 5.13 versus 0.63 (p = 0.01) and that of work days lost, hospital visits for hemophilia care were 30.63 (± 24.69) versus zero days, 20.63 (± 16.19) versus zero days respectively. The mean of factor VIII consumed during prophylaxis was 13,500 IU/month (i.e., 23 IU/kg/dose).The median time gap between prophylactic infusion to trough level was 67.50 h (60-74 h) and the median trough level observed was 2.50% (range 1-5%). The results of our clinical audit show that Intermediate dose prophylaxis with rFVIII concentrates in young adult patients with moderate/severe haemophilia A appears to be effective in reducing the frequency of bleeds.
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Affiliation(s)
- Remya Sudevan
- 1Department of Health Sciences Research, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Aswathy Ashok Beenakumari
- 2Department of Hemato-Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Rema Ganapathy
- 2Department of Hemato-Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Manoj Unni
- 2Department of Hemato-Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Geeta Vidyadharan
- 3Department of Hematopathology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Neeraj Sidharthan
- 2Department of Hemato-Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
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12
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Lissitchkov T, Klukowska A, Pasi J, Kessler CM, Klamroth R, Liesner RJ, Belyanskaya L, Walter O, Knaub S, Bichler J, Jansen M, Oldenburg J. Efficacy and safety of simoctocog alfa (Nuwiq®) in patients with severe hemophilia A: a review of clinical trial data from the GENA program. Ther Adv Hematol 2019; 10:2040620719858471. [PMID: 31263528 PMCID: PMC6595650 DOI: 10.1177/2040620719858471] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 05/13/2019] [Indexed: 01/19/2023] Open
Abstract
Simoctocog alfa (human-cl rhFVIII, Nuwiq®) is a 4th generation recombinant FVIII (rFVIII), without chemical modification or fusion with any other protein/fragment. Nuwiq® is produced in a human embryonic kidney cell line (HEK293F), which ensures human-specific post-translational protein processing. Nuwiq® was evaluated in seven prospective clinical studies in 201 adult and pediatric previously treated patients (PTPs) with severe hemophilia A. The NuProtect study in 110 previously untreated patients (PUPs) is ongoing. The mean half-life of Nuwiq® was 15.1–17.1 h in PTP studies with adults and adolescents, and 12.5 h in children aged 2–12 years. Clinical trials in PTPs demonstrated the efficacy and safety of Nuwiq® in the prevention and treatment of bleeds and as surgical prophylaxis. In the NuPreviq study of pharmacokinetic (PK)-guided personalized prophylaxis in 66 adult PTPs, 83% of patients had no spontaneous bleeds during 6 months of personalized prophylaxis and 57% were treated ⩽2 per week. No FVIII inhibitors were detected in PTPs after treatment with 43,267 injections and >80 million IU of Nuwiq®. Interim data for 66 PUPs with ⩾20 exposure days to Nuwiq® in NuProtect demonstrated a low cumulative high-titer inhibitor rate of 12.8% [actual incidence 12.1% (8/66)] and convincing efficacy and safety.
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Affiliation(s)
| | - Anna Klukowska
- Department of Pediatrics, Hematology and Oncology, Warsaw Medical University, Poland
| | - John Pasi
- The Royal London Hospital Barts and The London School of Medicine and Dentistry, UK
| | - Craig M Kessler
- Hemophilia and Thrombosis Comprehensive Treatment Center and The Division of Coagulation, Georgetown University Medical Center, Washington DC, USA
| | - Robert Klamroth
- Department for Internal Medicine, Vascular Medicine and Haemostaseology, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Raina J Liesner
- Great Ormond Street Hospital for Children, NHS Trust Haemophilia Centre, London, UK
| | | | | | | | | | - Martina Jansen
- Octapharma Pharmazeutika Produktionsges mbH, Vienna, Austria
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Sigmund-Freud Strasse 25, 53105 Bonn, Germany
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13
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Delavenne X, Dargaud Y, Ollier E, Négrier C. Dose tailoring of human cell line-derived recombinant factor VIII simoctocog alfa: Using a limited sampling strategy in patients with severe haemophilia A. Br J Clin Pharmacol 2019; 85:771-781. [PMID: 30633808 PMCID: PMC6422655 DOI: 10.1111/bcp.13858] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/19/2018] [Accepted: 12/24/2018] [Indexed: 01/19/2023] Open
Abstract
AIMS The use of factor VIII (FVIII) prophylaxis in haemophilia A is considered the standard of care, particularly in children. Despite adjustment of doses for body weight and/or age, a large pharmacokinetic (PK) variability between patients has been observed. PK-tailored prophylaxis may help clinicians adjust coagulation factor FVIII activity (FVIII:C) to the desired level, which may differ in individual patients. The objective was to develop a population PK model for simoctocog alfa based on pooled clinical trial data and to develop a Bayesian estimator to allow PK parameters in individual patients to be estimated using a reduced number of blood samples. METHODS PK data from 86 adults and 29 children/adolescents with severe haemophilia A were analysed. The FVIII data measured using 2 different assays (chromogenic and the 1-stage clotting assay) were fit to separate develop population PK models using nonlinear mixed-effect models. A Bayesian estimator was then developed to estimate the time above the threshold of 1%. RESULTS The PK data for chromogenic and the 1-stage clotting assays were both best described by a 2-compartment models. Simulations demonstrated good predictive capacity. The limited sampling strategy using blood sample at 3 and 24 hours allowed an accurate estimation of the time above the threshold of 1% FVIII:C (mean bias 0.01 and 0.11, mean precision 0.18 and 0.45 for 2 assay methods). CONCLUSION In this study, we demonstrated that a Bayesian approach can help to reduce the number of samples required to estimate the time above the threshold of 1% FVIII:C with good accuracy.
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Affiliation(s)
- Xavier Delavenne
- INSERM, UMR 1059, Dysfonction Vasculaire et de l'HémostaseUniversité de LyonSaint EtienneFrance
| | - Yesim Dargaud
- Unité d'Hémostase Clinique, Hôpital Cardiologique Louis PradelUniversité Lyon 1LyonFrance
| | - Edouard Ollier
- INSERM, UMR 1059, Dysfonction Vasculaire et de l'HémostaseUniversité de LyonSaint EtienneFrance
| | - Claude Négrier
- Unité d'Hémostase Clinique, Hôpital Cardiologique Louis PradelUniversité Lyon 1LyonFrance
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Rodriguez-Merchan EC, Valentino LA. Emicizumab: Review of the literature and critical appraisal. Haemophilia 2018; 25:11-20. [PMID: 30431213 DOI: 10.1111/hae.13641] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/15/2018] [Accepted: 10/29/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Emicizumab-kywh (ACE910) is a recombinant, humanized, asymmetric bispecific antibody that functions to bring activated FIX (FIXa) and zymogen FX into an appropriate steric conformation to medicate the activation of FX to FXa thereby mimicking the cofactor function of FVIIIa. AIM The objective of this manuscript was to review the development and potential role for emicizumab in the treatment of patients with haemophilia A with and without inhibitors. METHODS A Cochrane Library and PubMed (MEDLINE) search focusing on emicizumab in haemophilia was conducted. RESULTS In total, 37 citations were retrieved and serve as the database for the literature reviewed herein. Once-weekly subcutaneous injection of emicizumab at three dose levels has been shown to be effective as prophylaxis to prevent bleeding in a majority haemophilia A patients with inhibitors to FVIII. Likewise, prevention of bleeding was also observed in more than two thirds of patients without inhibitors to FVIII. One antidrug antibody to emicizumab has been reported in over 600 treated patients, two have developed thromboembolic events and three thrombotic microangiopathy. These thrombotic complications have occurred in conjunction with FVIII-bypassing agents, and none have been observed following recommendations from the manufacturer regarding concomitant use of bypassing agents. The median annual treated bleeding rates were decreased in patients with as well as those without an inhibitor to FVIII. CONCLUSION The principal advantage of emicizumab is subcutaneous administration and effectiveness irrespective of the presence of inhibitors. Emicizumab could conceivably represent a new epoch in the treatment of people with haemophilia A.
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15
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Holme PA, Tjønnfjord GE. Continuous infusion of simoctocog alfa in haemophilia A patients undergoing surgeries. Haemophilia 2018; 25:54-59. [PMID: 30394617 DOI: 10.1111/hae.13625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/04/2018] [Accepted: 10/04/2018] [Indexed: 01/19/2023]
Abstract
INTRODUCTION There are two major principles for coagulation factor replacement in the clinical management of surgical procedures in patients with haemophilia, repetitive bolus injections every 6-12 hours or administration of coagulation factor concentrates by continuous infusion. AIM The aim was to investigate the efficacy of simoctocog alfa (human-cl rhFVIII) delivered by continuous infusion for bleeding prophylaxis during surgery in patients with haemophilia A. METHODS We investigated the use of continuous infusion with simoctocog alfa in haemophilia A patients undergoing major surgical procedures at Oslo University Hospital from September 2015 to March 2018. The objectives were haemostatic outcome, in vivo recovery, stability over time at room temperature (3 days) and inhibitor development. RESULTS Simoctocog alfa demonstrated treatment success in terms of haemostatic efficacy in 100% of major surgeries used as CI: 87% (n=21) excellent; 13% (n=3) good. No erythrocyte transfusions were required in any patient, no adverse events occurred and no inhibitors developed. The product was stable for 3 days at room temperature without loss of activity. Mean in vivo recovery was 1.8 (0.3) (IU/mL/IU/kg). CONCLUSION Continuous infusion with simoctocog alfa was found to achieve good/excellent haemostatic efficacy in all procedures. No adverse events occurred and no inhibitors developed.
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Affiliation(s)
- Pål Andre Holme
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Geir E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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16
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Hassan S, Cannavò A, Gouw SC, Rosendaal FR, van der Bom JG. Factor VIII products and inhibitor development in previously treated patients with severe or moderately severe hemophilia A: a systematic review. J Thromb Haemost 2018; 16:1055-1068. [PMID: 29665204 DOI: 10.1111/jth.14124] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Indexed: 02/02/2023]
Abstract
Essentials Data on product-related immunogenicity in previously treated haemophilia A patients is scarce. A systematic review and meta-analysis of all currently available evidence was conducted. The overall incidence rate was 2.06 per 1000 person-years (95% confidence interval: 1.06-4.01). Some recombinant factor VIII products were associated with increased immunogenicity. SUMMARY Background Patients with severe hemophilia A who have been treated extensively with factor VIII products have a low but potentially serious risk of inhibitor development. It is unknown why these patients develop inhibitors, and data on product-related immunogenicity are scarce. Aims To summarize the currently available evidence on the relationship between inhibitor development and recombinant FVIII product type in previously treated patients (PTPs) with severe hemophilia A. Methods Longitudinal studies were included that reported on de novo inhibitor formation in patients with baseline FVIII activity levels of < 0.02 IU mL-1 who had been treated with FVIII for at least 50 days. Pooled incidence rates of inhibitor development according to product types were calculated with a random intercept Poisson regression model. Results Forty-one independent cohorts were included; 39 patients developed de novo inhibitors during 19 157 person-years of observation. The overall incidence rate was 2.06 per 1000 person-years, with a 95% confidence interval (CI) of 1.06-4.01. According to product type, the pooled incidence rates were 0.99 (95% CI 0.37-2.70) per 1000 person-years for patients treated with Advate, 5.86 (95% CI 0.25-134.92) per 1000 person-years for those treated with Kogenate/Helixate, 1.35 (95% CI 0.66-2.77) per 1000 person-years for those treated with Kogenate FS/Helixate NexGen, 12.05 (95% CI 1.53-94.78) per 1000 person-years for those treated with Refacto, and 4.64 (95% CI 0.82-26.43) per 1000 person-years for those treated with Refacto AF. Conclusion These results suggest that some products may be associated with increased immunogenicity. However, the low incidence of inhibitors in PTPs and the differences in study design may cause significant variation in estimates of risk.
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Affiliation(s)
- S Hassan
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - A Cannavò
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Luigi Villa Foundation, Milan, Italy
| | - S C Gouw
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Pediatric Hematology, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - F R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - J G van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands
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17
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Gupta H, Dutta UP, Sengupta PP. The Socioeconomic Dimensions for the Management of Haemophilia in India. JOURNAL OF HEALTH MANAGEMENT 2018. [DOI: 10.1177/0972063417747699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: Haemophilia is an X-lined recessive disorder of coagulation that can affect any section of the society. Haemophilia is incurable and expensive lifelong disease; hence, the patient always brings in a financial crisis to manage its medication. In developing country like India the per capita health expenditure is 58 USD/year in 2012. The AHF therapy has been negligibly used in critical conditions of the disease. This study was undertaken to identify the social and economic dimensions that can influence the attitude of the medical practitioners for the choice of treatment therapy for a patient with haemophilia (PwH) in India. Design/methodology/approach: A cross-sectional study was conducted by collecting the primary data from the randomly selected 50 medical practitioners who were having at least one PwH on weekly basis. The EFA method was applied to determine the major socioeconomic dimensions of the choice of therapy. Findings: Four major dimensions were explored in the study that have significant impact on the attitude of medical practitioners. The availability of the AHF therapy is the most important dimension for consideration of a therapy for PwH in India. Moreover, the patient safety profile, patient affordability profile, and the experience of medical practitioners are three more dimensions that established the positive impact on attitude. Research limitations/implications: The methodology has socioeconomic tools for analysis and applied instrument has only 15 items for factor analysis. Practical implications: Governing bodies to rectify the policies on rare diseases because of inadequate supply of medicines. Academics would also benefit greatly since it will add value to existing body of literature on haemophilia in Indian context.
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Affiliation(s)
- Hemant Gupta
- Research Scholar, Department of Management Studies, National Institute of Technology Durgapur, Durgapur, West Bengal, India
| | - Ujjal Protim Dutta
- Research Scholar, Department of Humanities, and Social Sciences, National Institute of Technology Durgapur, Durgapur, West Bengal, India
| | - Partha Pratim Sengupta
- Professor, Department of Humanities, and Social Sciences, National Institute of Technology Durgapur, Durgapur, West Bengal, India
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18
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Santagostino E, Young G, Carcao M, Mannucci PM, Halimeh S, Austin S. A contemporary look at FVIII inhibitor development: still a great influence on the evolution of hemophilia therapies. Expert Rev Hematol 2018; 11:87-97. [PMID: 29258406 DOI: 10.1080/17474086.2018.1419862] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The development of inhibitors against factor VIII (FVIII) replacement therapy remains the most important challenge for clinicians in the treatment of hemophilia patients. This review focusses on risk factors and management of FVIII inhibitors, particularly in light of SIPPET study findings and subsequent analyses. Areas covered: A brief history and evolution of hemophilia therapies is provided, including an overview of conventional and new (including investigational) therapeutic approaches for the treatment of hemophilia. The SIPPET study, the first randomized clinical trial to demonstrate a lower incidence of inhibitors in previously untreated patients treated with plasma-derived FVIII products compared with recombinant FVIII products, has generated much debate. We review the SIPPET trial and reactions, in addition to preliminary observations from a single center's experience, the cost impact of inhibitors, recent findings from SIPPET subanalyses, and inhibitor development in previously-treated patients. Expert commentary: Despite recent advances in potential new treatment options for hemophilia, conventional factor replacement concentrates currently remain the cornerstone of treatment. It is paramount that clinicians familiarize themselves with the findings from the SIPPET trial and substudies, in order to better inform their patients and families on inhibitor risk factors and to aid the treatment decision-making process.
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Affiliation(s)
- Elena Santagostino
- a Angelo Bianchi Bonomi Hemophilia and Thrombosis Center , University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Guy Young
- b Hemostasis and Thrombosis Center, Children's Hospital Los Angeles , University of Southern California Keck School of Medicine , Los Angeles , CA , USA
| | - Manuel Carcao
- c Division of Hematology/Oncology; Department of Pediatrics and Child Health Evaluative Sciences , Research Institute Hospital for Sick Children , Toronto , ON , Canada
| | - Pier Mannuccio Mannucci
- d Scientific Direction , IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan , Milan , Italy
| | - Susan Halimeh
- e Gerinnungszentrum Rhein-Ruhr (GZRR) , Duisburg , Germany
| | - Steve Austin
- f St. George's Healthcare NHS Trust Haemophilia Centre , London , UK
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Abstract
INTRODUCTION Hemophilia A is the most frequent inherited bleeding disorder and most challenging coagulation disorder. To combat this, a number of new improved rFVIII/IX concentrates have recently been approved. Some of them are derived from protein fusion biotechnology or pegylation to extend their half-life (HL). However, prophylaxis has become a standard of care to prevent arthropathy in hemophiliacs though the need of frequent venipunctures is a major obstacle to primary prophylaxis. The new Extended Half-Life (EHL) rFIX concentrates allow increased intervals, while the improved HL of new rFVIII was moderate. rFVIII Simoctocog alfa is produced in Human Embryonic Kidney (HEK) cells and the post-translational modifications performed by HEK cells are very similar to those occurring in the native FVIII. Areas covered: Herein, the author provides a review of simoctocog alfa with its contents including information on simoctocog alfa's manufacturing, clinical trials, safety and tolerability. They also give their expert opinion and future perspectives on this therapy. Expert opinion: An important advantage of simoctocog alfa is the possibility to omit at least 30% of venipunctures with prophylaxis. Consequently, the standard three times weekly bolus administrations may be reduced to twice weekly, meaning approximately 50 fewer venipunctures per year. This may be particularly helpful to children.
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Affiliation(s)
- Massimo Morfini
- a Italian Association of Haemophilia Centres - AICE , Firenze , Italy
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20
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Zozulya N, Kessler CM, Klukowska A, von Depka M, Hampton K, Hay CRM, Jansen M, Bichler J, Knaub S, Rangarajan S. Efficacy and safety of Nuwiq ® (human-cl rhFVIII) in patients with severe haemophilia A undergoing surgical procedures. Haemophilia 2017; 24:70-76. [PMID: 29048712 DOI: 10.1111/hae.13351] [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] [Accepted: 09/04/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Haemophilia A patients are at a high risk of excess bleeding during surgeries. The aim of haemostatic therapy during the perioperative period is to normalize FVIII level perioperatively and postoperatively to maintain normal haemostasis until wound healing is complete. AIMS/METHODS To examine the efficacy of Nuwiq® (simoctocog alfa, human-cl rhFVIII), a 4th generation recombinant FVIII produced in a human cell line, for surgical prophylaxis in patients with severe haemophilia A. This analysis assessed the efficacy of Nuwiq® during surgical procedures and in the postoperative period in seven clinical studies of previously treated patients (PTPs) with severe haemophilia A. RESULTS Thirty-six patients, aged 3-55 years, received surgical prophylaxis with Nuwiq® for 60 surgeries (28 major and 32 minor). Efficacy was evaluated for 52 surgeries (25 major and 27 minor). The success rate of Nuwiq® treatment was 98.1% (51 of 52 evaluated surgeries); haemostatic efficacy was assessed as "excellent" or "good" in all but one major surgery (assessed as "moderate"). The number of infusions ranged from 1 to 19 for minor surgeries and from 3 to 76 for major surgeries. The median (range) daily doses were 42.0 (28.2-100.9) IU kg-1 for minor surgeries and 69.3 (43.3-135.6) IU kg-1 for major surgeries. There were no serious treatment-related adverse events, and none of the patients developed FVIII inhibitors. CONCLUSIONS The results of this pooled analysis show that Nuwiq® was efficacious in maintaining haemostasis during and after major and minor surgical procedures in PTPs with severe haemophilia A.
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Affiliation(s)
- N Zozulya
- Federal State-Funded Institution "National Research Center for Hematology" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - C M Kessler
- Division of Coagulation, Hemophilia and Thrombosis Comprehensive Treatment Center, Georgetown University Medical Center, Washington, DC, USA
| | - A Klukowska
- Department of Pediatrics, Hematology and Oncology, Warsaw Medical University, Warsaw, Poland
| | - M von Depka
- Werlhof-Institut für Hämostaseologie GmbH, Hannover, Germany
| | - K Hampton
- Royal Hallamshire Hospital, Sheffield, UK
| | - C R M Hay
- Department of Haematology, Manchester University, Manchester Royal Infirmary, Manchester, UK
| | - M Jansen
- Octapharma Pharmazeutika Produktionsges.mbH, Vienna, Austria
| | | | - S Knaub
- Octapharma AG, Lachen, Switzerland
| | - S Rangarajan
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
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21
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Li C, Zhang X, Zhao Y, Wu R, Hu Q, Xu V, Sun J, Yang R, Li X, Zhou R, Lian S, Gu J, Wu J, Hou Q. Status and trend analysis of prophylactic usage of recombinant factor VIII in Chinese pediatric patients with hemophilia A: ReCare - a retrospective, phase IV, non-interventional study. Curr Med Res Opin 2017; 33:1571-1578. [PMID: 28532239 DOI: 10.1080/03007995.2017.1333489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND No study has reported the status and chronological trend of prophylactic recombinant factor VIII (rFVIII) use in Chinese pediatric patients with hemophilia A (HA). OBJECTIVE We aimed to analyze the status and trend of rFVIII-containing prophylaxis in Chinese pediatric patients with HA. METHODS ReCARE (Retrospective study in Chinese pediatric hemophilia A patients with rFVIII contained REgular prophylaxis) was a retrospective study conducted in 12 hemophilia treatment centers across China. The trend of prophylaxis was evaluated by determining the mean duration of prophylaxis, mean injection frequency (per week), mean dose of each injection (IU/kg), mean total dose injected/week (IU) and proportion of rFVIII consumption relative to factor VIII (FVIII) consumption over the study period. RESULTS We analyzed 183 male pediatric patients with HA (mean age, 7.1 ± 4.23 years), who received intermittent prophylaxis between 1 November 2007 and 31 May 2013. The mean duration of prophylaxis with rFVIII increased from 16.72 weeks in 2008 to 32.77 in 2012. Per injection dose of rFVIII increased significantly from 2008 to 2013 (25.89 to 28.31 IU/kg, p < .001). An increase was also reported in the mean total FVIII consumed (699.97 ± 173.25 IU in 2008 and 891.30 ± 730.341 in 2013) and mean proportion of rFVIII used (33.33 ± 57.73% in 2008 to 85.50 ± 29.077% in 2013). CONCLUSION Our data revealed an overall improvement in treatment dosage and duration with an increase in the number of patients receiving prophylaxis. The total proportion of rFVIII also increased gradually indicating the development of economy and safety awareness. TRIAL REGISTRATION The trial is registered at ClinicalTrials.gov (CT.gov identifier: NCT02263066).
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Affiliation(s)
- Changgang Li
- a Department of Hematology and Oncology , Shenzhen Children's Hospital , Shenzhen , China
| | - Xinsheng Zhang
- b Hemophilia Treatment Centre, Shandong Blood Centre , Jinan , China
| | - Yongqiang Zhao
- c Department of Hematology , Peking Union Medical College Hospital , Beijing , China
| | - Runhui Wu
- d Hematology/Oncology Centre, Beijing Children's Hospital , Capital Medical University , Beijing , China
| | - Qun Hu
- e Department of Hematology , Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology (HUST) , Hankou , Wuhan , China
| | - Vicky Xu
- f Department of Hematology , The Children's Hospital, Zhengjiang University School of Medicine , Hangzhou , China
| | - Jing Sun
- g Department of Hematology , Nan fang Hospital, Southern Medical University , Guangzhou , China
| | - Renchi Yang
- h Thrombosis and Hemostasis Centre , Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Tianjin , China
| | - Xiaojing Li
- i Department of Hematology , Chengdu Women & Children's Central Hospital , Chengdu , China
| | - Rongfu Zhou
- j Department of Hematology , Nanjing Drum Tower Hospital, Nanjing University Medical School , Nanjing , China
| | - Shinmei Lian
- k Department of Hematology , Dalian Municipal Central Hospital, Dalian Medical University , Dalian , China
| | - Jian Gu
- l Department of Hematology , Northern Jiangsu People's Hospital, Clinical Medical School of Yangzhou University , Yangzhou , China
| | - Junde Wu
- m Bayer HealthCare Pharmaceuticals Inc. , Beijing , China
| | - Qingsong Hou
- m Bayer HealthCare Pharmaceuticals Inc. , Beijing , China
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22
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Liesner RJ, Abashidze M, Aleinikova O, Altisent C, Belletrutti MJ, Borel-Derlon A, Carcao M, Chambost H, Chan AKC, Dubey L, Ducore J, Fouzia NA, Gattens M, Gruel Y, Guillet B, Kavardakova N, El Khorassani M, Klukowska A, Lambert T, Lohade S, Sigaud M, Turea V, Wu JKM, Vdovin V, Pavlova A, Jansen M, Belyanskaya L, Walter O, Knaub S, Neufeld EJ. Immunogenicity, efficacy and safety of Nuwiq®
(human-cl rhFVIII) in previously untreated patients with severe haemophilia A-Interim results from the NuProtect Study. Haemophilia 2017; 24:211-220. [PMID: 28815880 DOI: 10.1111/hae.13320] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2017] [Indexed: 01/19/2023]
Affiliation(s)
- R. J. Liesner
- Great Ormond Hospital for Children NHS Trust Haemophilia Centre; London UK
| | - M. Abashidze
- JSC Institute of Haematology and Transfusiology; Tbilisi Georgia
| | - O. Aleinikova
- Republican Scientific and Practical Centre of Children Oncology, Hematology and Immunology; Minsk Belarus
| | - C. Altisent
- Unitat d'Hemofilia; Hospital Vall D'Hebron; Barcelona Spain
| | - M. J. Belletrutti
- Pediatric Hematology; Department of Pediatrics; University of Alberta; Edmonton AB Canada
| | | | - M. Carcao
- Hospital for Sick Children; Toronto ON Canada
| | - H. Chambost
- Department of Pediatric Hematology Oncology; Children Hospital La Timone; APHM and Inserm; UMR 1062; Aix Marseille University; Marseille France
| | - A. K. C. Chan
- Division of Pediatric Hematology/Oncology; McMaster University; Hamilton ON Canada
| | - L. Dubey
- Western Ukrainian Specialized Children's Medical Centre; Lviv Ukraine
| | - J. Ducore
- Department of Pediatrics; UC Davis Medical Center; Sacramento CA USA
| | - N. A. Fouzia
- Christian Medical College Vellore; Vellore India
| | - M. Gattens
- Cambridge University Hospital NHS Foundation Trust; Cambridge UK
| | - Y. Gruel
- Hôpital Trousseau; Centre Régional de Traitement de l'Hémophilie; Tours France
| | - B. Guillet
- Haemophilia Treatment Centre of Rennes-Brittany; University Hospital of Rennes; Rennes France
| | - N. Kavardakova
- National Children's Specialized Clinic “OHMATDET”; Kiev Ukraine
| | - M. El Khorassani
- Centre de traitement de l'hémophilie; University Mohamed V; Rabat Morocco
| | | | - T. Lambert
- CRTH Hôpital Universitaire Bicêtre APHP; Le Kremlin Bicêtre France
| | - S. Lohade
- Sahyadri Speciality Hospital; Pune India
| | - M. Sigaud
- Centre Régional de Traitement de I'Hémophilie; University Hospital of Nantes; Nantes France
| | - V. Turea
- Scientific Research Institute of Mother and Child Health Care; Chişinău Moldova
| | - J. K. M. Wu
- B.C. Children's Hospital; Vancouver BC Canada
| | - V. Vdovin
- Morozovskaya Children's Hospital; Moscow Russia
| | - A. Pavlova
- Institute of Experimental Haematology and Transfusion Medicine; University Clinic Bonn; Bonn Germany
| | - M. Jansen
- Octapharma Pharmazeutika Produktionsges.mbH; Vienna Austria
| | | | | | - S. Knaub
- Octapharma AG; Lachen Switzerland
| | - E. J. Neufeld
- St. Jude Children’s Research Hospital; Memphis TN USA
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23
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Lissitchkov T, Rusen L, Georgiev P, Windyga J, Klamroth R, Gercheva L, Nemes L, Tiede A, Bichler J, Knaub S, Belyanskaya L, Walter O, Pasi KJ. PK-guided personalized prophylaxis with Nuwiq®(human-cl rhFVIII) in adults with severe haemophilia A. Haemophilia 2017; 23:697-704. [DOI: 10.1111/hae.13251] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2017] [Indexed: 11/27/2022]
Affiliation(s)
- T. Lissitchkov
- Department of Clinical Haematology in Haemorrhagic Diathesis and Anaemia; Specialized Hospital for Active Treatment “Joan Pavel”; Sofia Bulgaria
| | | | - P. Georgiev
- Clinic of Haematology; University Multiprofile Hospital for Active Treatment “Sveti Georgi” and Medical University; Plovdiv Bulgaria
| | - J. Windyga
- Department of Disorders of Haemostasis and Internal Medicine; Institute of Haematology and Transfusion Medicine; Warsaw Poland
| | - R. Klamroth
- Department for Internal Medicine, Vascular Medicine and Haemostaseology; Vivantes Klinikum im Friedrichshain; Berlin Germany
| | - L. Gercheva
- Clinic of Clinical Haematology; Multiple Hospital for Active Treatment “Sveta Marina”; Varna Bulgaria
| | - L. Nemes
- Medical Centre; Hungarian Defence Forces; National Haemophilia Centre; Budapest Hungary
| | - A. Tiede
- Clinic for Haematology, Haemostaseology, Oncology and Stem Cell Transplantation; Hannover Medical School; Hannover Germany
| | | | - S. Knaub
- Octapharma AG; Lachen Switzerland
| | | | | | - K. J. Pasi
- The Royal London Hospital; Barts and the London School of Medicine and Dentistry; London UK
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24
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Swiech K, Picanço-Castro V, Covas DT. Production of recombinant coagulation factors: Are humans the best host cells? Bioengineered 2017; 8:462-470. [PMID: 28277160 DOI: 10.1080/21655979.2017.1279767] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The main treatment option for Hemophilia A/B patients involves the administration of recombinant coagulation factors on-demand or in a prophylactic approach. Despite the safety and efficacy of this replacement therapy, the development of antibodies against the coagulation factor infused, which neutralize the procoagulant activity, is a severe complication. The production of recombinant coagulation factors in human cell lines is an efficient approach to avoid such complication. Human cell lines can produce recombinant proteins with post translation modifications more similar to their natural counterpart, reducing potential immunogenic reactions. This review provides a brief overview of the most important characteristics of recombinant FVIII and FIX products available on the market and the improvements that have recently been achieved by the production using human cell lines.
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Affiliation(s)
- Kamilla Swiech
- a Department of Pharmaceutical Sciences , School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo , São Paulo , Brazil.,b Center for Cell-based Therapy , Regional Blood Center of Ribeirão Preto, University of São Paulo, Ribeirão Preto-SP , Brazil
| | - Virgínia Picanço-Castro
- b Center for Cell-based Therapy , Regional Blood Center of Ribeirão Preto, University of São Paulo, Ribeirão Preto-SP , Brazil
| | - Dimas Tadeu Covas
- b Center for Cell-based Therapy , Regional Blood Center of Ribeirão Preto, University of São Paulo, Ribeirão Preto-SP , Brazil.,c Department of Internal Medicine , Ribeirão Preto Medical School, University of São Paulo , São Paulo , Brazil
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25
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Franchini M, Mannucci PM. Efficacy and safety of a recombinant factor VIII produced from a human cell line (simoctocog alfa). Expert Opin Drug Saf 2017; 16:405-410. [DOI: 10.1080/14740338.2017.1285281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico and University of Milan, Milan, Italy
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26
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Bleß HH, Schönfelder T, Talaschus A. [Rapid Report Hemophilia - Evidence in treatment of hemophilia from the IQWiG's perspective]. Hamostaseologie 2017; 37:S32-S41. [PMID: 29582923 DOI: 10.5482/hamo-16-02-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The German Institute for Quality and Efficiency in Health Care (IQWiG) conducted a rapid report to assess the therapy of hemophilia patients. Based on a systematic literature search the IQWiG identified 16 studies which show that there is now sufficient information regarding questions that previously lacked data. A benefit assessment of prophylactic and on-demand-treatment concerning different treatment outcomes shows the superiority of the prophylactic therapy regarding major bleedings for all age groups. For the group of youths and adults the analysis shows additional benefits concerning health status and pain within the preceding four weeks. The alignment of guidelines with the identified evidence shows minor correspondence between the guidelines' references and included studies. However, the guidelines' statements primarily correspond with the results of the conducted benefit assessment. CONCLUSION The IQWiG's rapid report shows prophylactic therapy to be superior to on-demand therapy. These findings represent a clear indication for attending physicians and payers for prophylaxis in patients with severe hemophilia A.
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27
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Ustinnikova OB, Runova OB, Novikova EV, Bondarev VP, Lebedinskaya EV. Critical Development Needs for Recombinant Blood-Coagulation Factors. Pharm Chem J 2016. [DOI: 10.1007/s11094-016-1492-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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28
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Hartmann J, Croteau SE. 2017 Clinical trials update: Innovations in hemophilia therapy. Am J Hematol 2016; 91:1252-1260. [PMID: 27563744 DOI: 10.1002/ajh.24543] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 08/18/2016] [Accepted: 08/24/2016] [Indexed: 01/19/2023]
Abstract
A surge in therapeutic clinical trials over recent years is paving the way for transformative treatment options for patients with hemophilia. The introduction of recombinant factor concentrates in the early 1990s facilitated the use of prophylactic replacement as standard care for hemophilia rather than on-demand treatment. This has revolutionized health outcomes for hemophilia patients, enabling participation in physical activities and reducing debilitating, chronic joint damage. Challenges of prophylactic factor infusion include the frequency of infusions needed to maintain factor levels greater than 1%, patient adherence, reliable intravenous access, and development of neutralizing alloantibodies ("inhibitors"). Novel therapeutics seek to improve upon current factor concentrates by several different mechanisms: (1) extending the half-life of circulating exogenous factor protein, (2) replacing the gene necessary for production of endogenous factor protein, (3) employing bispecific antibody technology to mimic the coagulation function of factor VIII, (4) disrupting anticoagulant proteins, such as tissue factor pathway inhibitor (TFPI) or antithrombin (AT3) with antibodies, aptamers, or RNA interference technology. Emerging treatment options may reduce the frequency of (extended half-life products) or eliminate (gene therapy) the need for scheduled factor concentrate infusions, or provide a subcutaneous administration option (bispecific antibody, AT3, and TFPI targeting therapies). In addition, the nonfactor replacement strategies provide a promising treatment option for patients with inhibitors, presently the greatest unmet medical need in hemophilia. This review highlights current and recently completed clinical trials that are driving a paradigm shift in our approach to hemophilia care for patients with and without inhibitors. Am. J. Hematol. 91:1252-1260, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jan Hartmann
- Haemonetics Corporation400 Wood RoadBraintree Massachusetts02184
| | - Stacy E. Croteau
- Dana Farber/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School450 Brookline Ave, Dana 3Boston Massachusetts02215
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29
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Tabriznia-Tabrizi S, Gholampour M, Mansouritorghabeh H. A close insight to factor VIII inhibitor in the congenital hemophilia A. Expert Rev Hematol 2016; 9:903-13. [PMID: 27367203 DOI: 10.1080/17474086.2016.1208554] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Hemophilia A (HA) has an X-linked pattern of inheritance and is the most common of the hemorrhagic disorders. HA is caused by a decreased or deficiency of the functional clotting factor VIII (FVIII) and effects 1 in 5000-10,000 male births. The common treatment for hemophilia is replacement therapy by plasma-derived or recombinant FVIII. Approximately 20-30% of people with a severe type of HA develop an inhibitor and this phenomenon is the main challenge in the management of these patients. Genetic factors and environmental determinants contribute to inhibitor development. Here, the roles of various genetic and environmental factors such as the type of FVIII concentrate used, the number of exposure days, and peak treatment time will be discussed in detail. It seems this information is helpful for hematologists. AREAS COVERED A literature review was done in January 2016 on PubMed and Scopus using the following keywords:' h(a)emophilia A & factor VIII inhibitor', 'h(a)emophilia A & factor VIII alloantibody', 'h(a)emophilia A & inhibitor'. There was no time limitation; however, there was an English language limitation placed on the articles selected. Expert commentary: Influential genetic and environmental factors in developing inhibitors have been discussed. Most of the risk factors are related to previously untreated patients with hemophili.
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Affiliation(s)
| | - Marzie Gholampour
- a Haematology , Mashhad University of Medical sciences (MUMS) , Mashhad , Iran
| | - Hassan Mansouritorghabeh
- b Allergy Research Center, Ghaem hospital, School of Medicine , Mashhad University of Medical Sciences , Mashhad , Iran
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