1
|
Laffan M, McLaughlin P, Motwani J, Alamelu J, Austin S, Classey S, Dolan G, Eales M, Gooding R, Grainger J, Harrison C, Jones A, Kelly AM, Oyesiku L, Rodgers R, Stephensen D, Talks K, Sonecha S, Danquah A. Expert United Kingdom consensus on the preservation of joint health in people with moderate and severe haemophilia A: A modified Delphi panel. Haemophilia 2024; 30:306-319. [PMID: 38239180 DOI: 10.1111/hae.14934] [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: 11/07/2023] [Revised: 12/20/2023] [Accepted: 12/30/2023] [Indexed: 02/29/2024]
Abstract
AIM For people with haemophilia A (PwHA), bleeding in the joints leads to joint damage and haemophilia-related arthropathy, impacting range of motion and life expectancy. Existing guidelines for managing haemophilia A support healthcare professionals (HCPs) and PwHA in their efforts to preserve joint health. However, such guidance should be reviewed, considering emerging evidence and consensus as presented in this manuscript. METHODS Fifteen HCPs experienced in the management of PwHA in the UK participated in a three-round Delphi panel. Consensus was defined at ≥70% of panellists agreeing or disagreeing for Likert-scale questions, and ≥70% selecting the same option for multiple- or single-choice questions. Questions not reaching consensus were revised for the next round. RESULTS 26.8% (11/41), 44.8% (13/29) and 93.3% (14/15) of statements reached consensus in Rounds 1, 2 and 3, respectively. HCPs agreed that prophylaxis should be offered to patients with a baseline factor VIII (FVIII) level of ≤5 IU/dL and that, where there is no treatment burden, the aim of prophylaxis should be to achieve a trough FVIII level ≥15 IU/dL and maintain a longer period with FVIII levels of ≥20-30 IU/dL to provide better bleed protection. The aspirational goal for PwHA is to prevent all joint bleeds, which may be achieved by maintaining normalised (50-150 IU/dL) FVIII levels. CONCLUSION The panel of experts were largely aligned on approaches to preserving joint health in PwHA, and this consensus may help guide HCPs.
Collapse
Affiliation(s)
- Mike Laffan
- Centre for Haematology, Imperial College London, London, UK
| | - Paul McLaughlin
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | - Jayashree Motwani
- Department of Paediatric Haematology, Birmingham Children's Hospital, Birmingham, UK
| | - Jayanthi Alamelu
- Paediatric Haematology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Steve Austin
- Department of Haematology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Stephen Classey
- Centre for Haemostasis and Thrombosis, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Gerard Dolan
- Centre for Haemostasis and Thrombosis, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Marie Eales
- The Children's Team at Oxford Haemophilia and Thrombosis Comprehensive Care Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Richard Gooding
- Haematology Department, Belfast Health and Social Care Trust, Belfast, UK
| | - John Grainger
- Paediatric Haematology, Royal Manchester Children's Hospital, Manchester, UK
| | - Catherine Harrison
- Sheffield Haemophilia & Thrombosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - April Jones
- Newcastle Haemophilia Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Anne M Kelly
- Haemophilia Comprehensive Care Centre, Great Ormond Street Hospital, London, UK
| | - Lara Oyesiku
- Southern Haemophilia Network, Basingstoke and North Hampshire Hospital, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK
| | - Ryan Rodgers
- Department of Haematology, Glasgow Royal Infirmary, Glasgow, UK
| | - David Stephensen
- Kent Haemophilia Centre, Kent and Canterbury Hospital, Canterbury, Kent, UK
| | - Kate Talks
- Newcastle Haemophilia Centre, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | | |
Collapse
|
2
|
Agosti P, Siboni SM, Scardo S, Torri A, Gualtierotti R, Peyvandi F. Minimum factor VIII levels to prevent joint bleeding in mild hemophilia A. Blood Adv 2023; 7:7209-7215. [PMID: 37871302 PMCID: PMC10698262 DOI: 10.1182/bloodadvances.2023011366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/26/2023] [Accepted: 10/01/2023] [Indexed: 10/25/2023] Open
Abstract
The severity of the bleeding phenotype in patients with hemophilia A (HA) broadly correlates with the degree of coagulation factor VIII (FVIII) deficiency in plasma. However, the FVIII level necessary to achieve the goal of zero joint bleeds remains unclear. This study aimed to identify the minimum FVIII level necessary to prevent joint bleeds in patients with HA. In this retrospective study, patients with congenital mild HA treated on demand, aged ≥16 years, with no history of FVIII inhibitors, followed at the Angelo Bianchi Bonomi Hemophilia and Thrombosis Center in Milan, were enrolled. We investigated 270 male patients with a median age of 45 years (16-88) and median lifelong FVIII of 21 IU/dL. One hundred patients (37%) had a lifelong history of at least 1 joint bleed. The mean annualized joint bleeding rate (AJBR) and spontaneous AJBR were 0.016 (standard deviation [SD], 0.032) and 0.001 (SD, 0.010), respectively. After adjusting for age, for each IU/dL increase in FVIII, there was a 6% reduction in AJBR and an 11% reduction in spontaneous AJBR. The minimum FVIII levels needed to prevent lifelong any joint bleeds and spontaneous joint bleeds resulted to be 19.2 IU/dL and 17.7 IU/dL, respectively. In this large cohort of persons with mild HA, we identified the minimum FVIII levels needed to prevent total and spontaneous joint bleeds (19.2 IU/dL and 17.7 IU/dL, respectively). These findings could suggest important implications for the accurate design of prophylactic therapies for persons with moderate and severe HA, including gene therapy.
Collapse
Affiliation(s)
- Pasquale Agosti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione Luigi Villa, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Simona Maria Siboni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Sara Scardo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Adriana Torri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Roberta Gualtierotti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione Luigi Villa, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione Luigi Villa, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| |
Collapse
|
3
|
Malec L, Matino D. Targeting higher factor VIII levels for prophylaxis in haemophilia A: a narrative review. Haemophilia 2023; 29:1419-1429. [PMID: 37758651 DOI: 10.1111/hae.14866] [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: 03/13/2023] [Revised: 09/07/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION The standard of care in severe haemophilia A is prophylaxis, which has historically aimed for a factor VIII (FVIII) trough level of ≥1%. However, despite prophylactic treatment, people with haemophilia remain at risk of bleeds that have physical and quality of life implications, and that impact everyday life. AIM The aim of this review was to evaluate evidence supporting the relationship between targeting higher FVIII activity levels with prophylaxis and improved outcomes in people with haemophilia A. METHODS We conducted a narrative review that defined the unmet needs and treatment goals in people with haemophilia A, evaluated evidence to support targeting higher FVIII activity levels, and highlighted therapies that may support higher and sustained FVIII activity levels and improved outcomes for people with haemophilia A. RESULTS Despite recent advances in treatment, unmet needs remain, and people with haemophilia continue to experience joint and functional impairment, acute and chronic pain, and poor mental health. All these negatively impact their health-related quality of life. Evidence suggests that FVIII activity levels of up to 50% may be needed to achieve a near-zero joint bleed rate. However, achieving high FVIII activity levels with current standard and extended half-life (EHL) FVIII replacement therapies is associated with a high treatment burden. Innovative treatment options may provide high sustained FVIII activity levels and improved patient outcomes. CONCLUSION Evidence suggests that FVIII activity levels in people with haemophilia A should be sustained at higher levels to improve joint and patient outcomes and enable progression towards health equity.
Collapse
Affiliation(s)
- Lynn Malec
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- Division of Hematology & Oncology, Departments of Medicine and Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Davide Matino
- Division of Hematology & Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
4
|
Persson S, Berndt C, Engstrand S, Trinczek A, Carlsson KS, Berntorp E. Area under the curve: Comparing the value of factor VIII replacement therapies in haemophilia A. Haemophilia 2023; 29:145-155. [PMID: 36445343 PMCID: PMC10098947 DOI: 10.1111/hae.14691] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION In factor VIII (FVIII) prophylaxis for haemophilia A, cost comparisons have used price per international unit (IU) based on the once reasonable assumption of equivalent outcome per IU. Now, with several extended half-life (EHL) products available, new outcome-oriented ways to compare products are needed. Area under the curve (AUC) quantifies FVIII levels over time after infusion providing comparable data. AIM To develop a decision analytical model for making indirect comparisons of FVIII replacement products based on AUC. METHODS A literature search identified 11 crossover studies with relevant pharmacokinetic data. A common comparator FVIII level curve was calculated using pooled data from selected studies. Absolute curves for other products were estimated based on relative differences to the common comparator (% difference vs the anchor). Three scenarios were investigated: (1) Kogenate® versus Kovaltry® and Jivi® ; (2) Advate® versus Elocta® , NovoEight® , Kovaltry, Adynovate® , Afstyla® , and ReFacto® ; and (3) Jivi versus Elocta, Adynovate, and Kogenate. Sensitivity analyses investigated effects of assay type and dose. RESULTS In scenario 1, Jivi (+50%) and Kovaltry (+14%) showed larger AUCs versus Kogenate. In scenario 2, EHL products, Elocta and Adynovate, had the largest AUC (+64% and +58%, respectively) versus Advate. Compared with all other products in scenario 3, Jivi had the largest AUC by +13%-28%. CONCLUSION This analysis concludes that EHL products differ in relative AUC, have a larger AUC compared with standard half-life, and thus, different FVIII levels over time after infusion. This model may aid decision makers in the absence of head-to-head data.
Collapse
Affiliation(s)
- Sofie Persson
- Swedish Institute for Health Economics, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Malmö, Sweden
| | | | | | | | - Katarina Steen Carlsson
- Swedish Institute for Health Economics, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Malmö, Sweden
| | - Erik Berntorp
- Department of Translational Medicine, Lund University, Lund, Malmö, Sweden
| |
Collapse
|
5
|
Pipe SW, Arruda VR, Lange C, Kitchen S, Eichler H, Wadsworth S. Characteristics of BAY 2599023 in the Current Treatment Landscape of Hemophilia A Gene Therapy. Curr Gene Ther 2023; 23:81-95. [PMID: 36111754 DOI: 10.2174/1566523222666220914105729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/12/2022] [Accepted: 08/13/2022] [Indexed: 11/22/2022]
Abstract
Hemophilia A, a single gene disorder leading to deficient Factor VIII (FVIII), is a suitable candidate for gene therapy. The aspiration is for single administration of a genetic therapy that would allow the production of endogenous FVIII sufficient to restore hemostasis and other biological processes. This would potentially result in reliable protection from bleeding and its associated physical and emotional impacts. Gene therapy offers the possibility of a clinically relevant improvement in disease phenotype and transformational improvement in quality of life, including an opportunity to engage in physical activities more confidently. Gene therapy products for hemophilia A in advanced clinical development use adeno-associated viral (AAV) vectors and a codon-optimized B-domain deleted FVIII transgene. However, the different AAV-based gene therapies have distinct design features, such as choice of vector capsid, enhancer and promoter regions, FVIII transgene sequence and manufacturing processes. These, in turn, impact patient eligibility, safety and efficacy. Ideally, gene therapy technology for hemophilia A should offer bleed protection, durable FVIII expression, broad eligibility and limited response variability between patients, and long-term safety. However, several limitations and challenges must be overcome. Here, we introduce the characteristics of the BAY 2599023 (AAVhu37.hFVIIIco, DTX 201) gene therapy product, including the low prevalence in the general population of anti-AAV-hu37 antibodies, as well as other gene therapy AAV products and approaches. We will examine how these can potentially meet the challenges of gene therapy, with the ultimate aim of improving the lives of patients with hemophilia A.
Collapse
Affiliation(s)
- Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Valder R Arruda
- Division of Hematology, Department of Pediatrics, Center for Cell and Molecular Therapeutics at Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Stephen Kitchen
- Sheffield Haemophilia and Thrombosis Centre, Sheffield Teaching Hospitals, Sheffield, UK
| | - Hermann Eichler
- Institute of Clinical Hemostaseology and Transfusion Medicine, Saarland University and University Hospital, Homburg/Saar, Germany
| | | |
Collapse
|
6
|
Astermark J, Blatný J, Königs C, Hermans C, Jiménez-Yuste V, Hart DP. Considerations for shared decision management in previously untreated patients with hemophilia A or B. Ther Adv Hematol 2023; 14:20406207231165857. [PMID: 37113810 PMCID: PMC10126613 DOI: 10.1177/20406207231165857] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 01/04/2023] [Indexed: 04/29/2023] Open
Abstract
Recent advances in therapeutics are now providing a wide range of options for adults and children living with hemophilia. Although therapeutic choices are also increasing for the youngest individuals with severe disease, challenges remain about early management decisions, as supporting data are currently limited. Parents and healthcare professionals are tasked with helping children achieve an inclusive quality of life and maintain good joint health into adulthood. Primary prophylaxis is the gold standard to optimize outcomes and is recommended to start before 2 years of age. A range of topics need to be discussed with parents to aid their understanding of the decisions they can make and how these will affect the management of their child/children. For those with a family history of hemophilia, prenatal considerations include the possibility of genetic counseling, prenatal investigations, and planning for delivery, together with monitoring of the mother and neonate, as well as diagnosis of the newborn and treatment of any birth-associated bleeding. Subsequent considerations, which are also applicable to families where infant bleeding has resulted in a new diagnosis of sporadic hemophilia, involve explaining bleed recognition and treatment options, practical aspects of initiating/continuing prophylaxis, dealing with bleeds, and ongoing aspects of treatment, including possible inhibitor development. Over time, optimizing treatment efficacy, in which individualizing therapy around activities can play a role, and long-term considerations, including retaining joint health and tolerance maintenance, become increasingly important. The evolving treatment landscape is creating a need for continually updated guidance. Multidisciplinary teams and peers from patient organizations can help provide relevant information. Easily accessible, multidisciplinary comprehensive care remains a foundation to care. Equipping parents early with the knowledge to facilitate truly informed decision-making will help achieve the best possible longer-term health equity and quality of life for the child and family living with hemophilia. Plain language summary Points to be taken into account to help families make decisions to best care for children born with hemophilia Medical advances are providing a range of treatment options for adults and children with hemophilia. There is, however, relatively limited information about managing newborns with the condition. Doctors and nurses can help parents to understand the choices for infants born with hemophilia. We describe the various points doctors and nurses should ideally discuss with families to enable informed decision-making. We focus on infants who require early treatment to prevent spontaneous or traumatic bleeding (prophylaxis), which is recommended to start before 2 years of age. Families with a history of hemophilia may benefit from discussions before pregnancy, including how an affected child would be treated to protect against bleeds. When mothers are pregnant, doctors can explain investigations that can provide information about their unborn child, plan for the birth, and monitor mother and baby to minimize bleed risks at delivery. Testing will confirm whether the baby is affected by hemophilia. Not all infants with hemophilia will be born to families with a history of the condition. Identification of hemophilia for the first time in a family (which is 'sporadic hemophilia') occurs in previously undiagnosed infants who have bleeds requiring medical advice and possibly hospital treatment. Before any mothers and babies with hemophilia are discharged from hospital, doctors and nurses will explain to parents how to recognize bleeding and available treatment options can be discussed. Over time, ongoing discussions will help parents to make informed treatment decisions:• When and how to start, then continue, prophylaxis.• How to deal with bleeds (reinforcing previous discussions about bleed recognition and treatment) and other ongoing aspects of treatment. ○ For instance, children may develop neutralizing antibodies (inhibitors) to treatment they are receiving, requiring a change to the planned approach.• Ensuring treatment remains effective as their child grows, considering the varied needs and activities of their child.
Collapse
Affiliation(s)
| | - Jan Blatný
- Department of Pediatric Hematology, University
Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Christoph Königs
- Clinical and Molecular Hemostasis, Department
of Pediatrics, University Hospital Frankfurt, Goethe University, Frankfurt,
Germany
| | - Cédric Hermans
- Hemostasis and Thrombosis Unit, Division of
Hematology, Cliniques Universitaires Saint-Luc, Université catholique de
Louvain (UCLouvain), Brussels, Belgium
| | - Victor Jiménez-Yuste
- Hematology Department, Hospital Universitario
La Paz, Autónoma University, Madrid, Spain
| | | |
Collapse
|
7
|
Nagao A, Ioka A, Nakamura T, Murakami Y, Makishima M, Okada N, Sakai M. Burden of congenital hemophilia A requiring treatment in Japan: The HIKOBOSHI study. Res Pract Thromb Haemost 2022; 6:e12825. [PMID: 36320425 PMCID: PMC9615292 DOI: 10.1002/rth2.12825] [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: 01/07/2022] [Revised: 08/30/2022] [Accepted: 09/19/2022] [Indexed: 11/06/2022] Open
Abstract
Background Treatment of congenital hemophilia A (HA) in Japan has greatly improved with the widespread adoption of prophylactic factor (F)VIII concentrates. However, it is unknown if this has translated into a real‐world reduction in disease and treatment burden. Objectives To describe HA disease burden in Japan based on information from two medical information databases, JMDC and Real World Data Co., Ltd. (RWD). Methods Eligible individuals were diagnosed with congenital HA and prescribed FVIII concentrates, bypassing agents, or emicizumab. Treatment patterns and disease burden data were derived from health insurance claims and electronic medical records. Results Data on 459 people with HA were retrospectively collected from 2005 to 2020 in the JMDC database (median [min, max] of 37 [2, 186] months of available records), and 229 people with HA from 1985 to 2020 in the RWD database (median [min, max] of 154 [0, 409] months of available records). Mean (standard deviation) ages at the time of the first record were 25.0 (16.8) years (JMDC) and 19.2 (20.3) years (RWD). In the JMDC database, mean monthly FVIII dose increased from 2201 IU in 2005 to 8239 IU in 2013 to 11,377 IU in 2019; HA‐related drug costs increased accordingly. Mean (95% confidence interval) annual outpatient and out‐of‐hours visits decreased slightly between 2013 and 2019 (outpatient visits: from 22.9 [16.8–29.0] to 14.3 [12.6–16.1] per person; out‐of‐hours visits: from 1.3 [0.2–2.5] to 0.6 [0–1.4]). There was no change in mean number of hospitalizations. Conclusions Challenges remain in HA, including treatment burden, outpatient visits, and hospitalizations.
Collapse
Affiliation(s)
| | - Akiko Ioka
- Chugai Pharmaceutical Co., Ltd.TokyoJapan
| | | | | | | | | | | |
Collapse
|
8
|
Wu Y, Sun SX, Fan T. Comparison of Real-World Dose and Consumption for Two Extended Half-Life Recombinant Factor VIII Products for the Treatment of Hemophilia A in the United States. J Blood Med 2022; 13:517-524. [PMID: 36188439 PMCID: PMC9518681 DOI: 10.2147/jbm.s359510] [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: 03/21/2022] [Accepted: 08/30/2022] [Indexed: 11/29/2022] Open
Abstract
Background US patients with hemophilia A can receive prophylaxis with extended half-life recombinant factor VIII (rFVIII) products, including efmoroctocog alfa (fragment crystallizable fusion protein) and rurioctocog alfa pegol (antihemophilic factor [recombinant], PEGylated). Objective To evaluate dosing patterns and weekly consumption of extended half-life rFVIII products in the United States. Methods We performed a retrospective analysis using the US Specialty Pharmacy Database (2015–2018). Included patients had a diagnosis of hemophilia A, ≥2 consecutive monthly claims for efmoroctocog alfa or rurioctocog alfa pegol for prophylaxis, and weight data. Outcome measures included weekly dosing frequency and dispensed weekly dose. Results The analysis included 774 patients (efmoroctocog alfa, 506; rurioctocog alfa pegol, 268). Mean (SD) age was 24.2 (15.8) and 26.3 (14.9) years for patients receiving efmoroctocog alfa and rurioctocog alfa pegol, respectively; mean (SD) weight was 68.4 (36.8) and 79.8 (37.7) kg, respectively. The most frequent efmoroctocog alfa regimen was twice weekly (45.7%), followed by every 4 days (20.6%), every 3 days (9.1%), and 3 times per week (7.5%). The most frequent rurioctocog alfa pegol regimen was twice weekly (72.4%), followed by 3 times per week (8.7%), every 4 days (7.6%), and every 3 days (5.5%). The proportion of efmoroctocog alfa twice-weekly dispensing records increased from 31.5% to 50.9%, and every 4 days dispensing records decreased from 31.3% to 14.5% (2015–2018). The proportion of rurioctocog alfa pegol dispensing records remained broadly stable (2016–2018). Overall, mean (SD; median) weekly prophylactic dose was 105.4 (77.9; 92.6) IU/kg with efmoroctocog alfa, and 96.8 (41.9; 90.9) IU/kg with rurioctocog alfa pegol. Conclusion In this database study, the most frequently observed dosing frequency was twice weekly for patients receiving efmoroctocog alfa or rurioctocog alfa pegol. The observed mean weekly consumption was slightly higher, and variation was greater, in patients receiving efmoroctocog alfa versus rurioctocog alfa pegol.
Collapse
Affiliation(s)
- Yanyu Wu
- Global Evidence & Outcomes, Data Sciences Institute, Research and Development, Takeda Development Center Americas, Inc, Cambridge, MA, USA
| | - Shawn X Sun
- Global Evidence & Outcomes, Data Sciences Institute, Research and Development, Takeda Development Center Americas, Inc, Cambridge, MA, USA
| | - Tao Fan
- US Health Economics and Outcomes Research, Takeda Pharmaceuticals USA, Inc, Lexington, MA, USA
| |
Collapse
|
9
|
Arthropathy in people with mild haemophilia: Exploring risk factors. Thromb Res 2022; 211:19-26. [DOI: 10.1016/j.thromres.2022.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/03/2022] [Accepted: 01/10/2022] [Indexed: 11/18/2022]
|
10
|
Mahlangu J, Abdul Karim F, Stasyshyn O, Korczowski B, Salazar B, Lucas S, Suen A, Goldstein B, Chung T, Pabinger I. Recombinant single-chain factor VIII in severe hemophilia: Long-term safety and efficacy in previously treated patients in the AFFINITY extension study. Res Pract Thromb Haemost 2022; 6:e12665. [PMID: 35224416 PMCID: PMC8844480 DOI: 10.1002/rth2.12665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/21/2021] [Accepted: 12/30/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND rVIII-SingleChain is a recombinant single-chain factor VIII used to treat people with hemophilia A. OBJECTIVES The aim of this extension study was to investigate the long-term safety and efficacy of rVIII-SingleChain prophylaxis in ≥200 previously treated patients (PTPs) with hemophilia A with ≥100 exposure days (EDs). METHODS In total, 222 patients were enrolled, of which 204 rolled over from prior rVIII-SingleChain studies. The median age was 21 years (range, 2-65 years), including 155 patients ≥12 years and 67 patients <12 years. Patients continued with their previously assigned dose and regimen, or switched at the investigator's discretion. Patients were treated for a mean duration of 31 months (range, 1-47 months), the mean ED was 342 (standard deviation, 135.5), and 212 (95.5%) patients achieved >100 EDs. When the study ended, most patients were on either a prophylaxis regimen of 34.9 (17-62) IU/kg, 3×/week (N = 88; 39.6%), or 37.2 (13-65) IU/kg, 2×/week regimen (N = 72; 32.4%). RESULTS Hemostatic efficacy was rated excellent or good in 87.1% of assessed bleeds. The median (range) annualized bleeding rate was 1.21 (0.0-42.6), and the annualized spontaneous bleeding rate (AsBR) was 0.32 (0.0-33.0) for prophylaxis regimens. Median AsBR was similar for patients treated 3×/week and 2×/week (0.31 and 0.30, respectively). Surgical hemostatic efficacy was rated excellent or good in 100% of surgeries. No inhibitors, anaphylactic reactions, or thromboembolic events were reported in PTPs. CONCLUSION These results confirm the safety and efficacy of rVIII-SingleChain as a long-term prophylaxis treatment modality for PTPs with severe hemophilia A.
Collapse
Affiliation(s)
- Johnny Mahlangu
- University of the WitwatersrandNHLS and Charlotte Maxeke HospitalJohannesburgSouth Africa
| | | | - Oleksandra Stasyshyn
- Institute of Blood Pathology and Transfusion MedicineNational Academy of Medical Sciences of UkraineLvivUkraine
| | - Bartosz Korczowski
- Department of PediatricsRegional HospitalUniversity of RzeszówRzeszówPoland
| | | | | | - Amy Suen
- CSL BehringKing of PrussiaPennsylvaniaUSA
| | | | | | - Ingrid Pabinger
- Clinical Division of Haematology and HaemostaseologyMedical Clinic IMedical University ViennaViennaAustria
| |
Collapse
|
11
|
Huang K, Zhen Y, Li G, Wu X, Chen Z, Wu R. Enhanced pharmacokinetics and reduced bleeds in boys with hemophilia A after switching to Kovaltry from other standard half-life factor VIII concentrates. Res Pract Thromb Haemost 2022; 6:e12686. [PMID: 35356665 PMCID: PMC8956787 DOI: 10.1002/rth2.12686] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/11/2022] [Accepted: 02/21/2022] [Indexed: 01/25/2023] Open
Abstract
Background BAY81-8973 (Kovaltry; Bayer, Berkeley, CA, USA) was reported with enhanced pharmacokinetic (PK) profiles compared with some other standard half-life (SHL) factor VIII (FVIII) concentrates. Limited head-to-head comparative studies were conducted in a real-world setting. Objective To make head-to-head comparisons of PK and clinical outcomes between Kovaltry and three other SHL FVIII concentrates. Methods Forty-seven boys with severe hemophilia A were enrolled and divided into three groups according to their previously used FVIII concentrates (Kogenate FS, N = 22; Advate, N = 14; GreenMono, N = 11). Two separate PK tests were conducted in each participant with a five-point assay during the study period from 6 months before switching to 6 months after switching. FVIII levels were detected by one-stage assay, and PK profiles were calculated by noncompartmental assay. Annualized bleeding rates were collected through participant' bleed logs. Results Longer half-life time (Kogenate FS group: 14.4 vs 11.9 hours, P < .0001; Advate group: 13.4 vs 9.7 hours, P < .0001; GreenMono group: 15.1 vs 10.7 hours, P < .001]) and lower clearance (Kogenate FS group: 3.3 vs 3.9 mL/kg/h, P < .01; Advate group: 3.7 vs 5.9 mL/kg/h, P < .01; GreenMono group: 3.0 vs 5.1 mL/kg/h, P < .01) were observed with Kovaltry. In addition, longer mean residential time (P < .01) and higher area under the curve (P < .01) were demonstrated. No statistical difference was found in in vivo recovery between Kovaltry and the other FVIII products. Participants who switched to Kovaltry from three other FVIII concentrates with the same dosing regimens obtained higher trough FVIII levels and better protection with reduced annualized bleeding rates. Conclusion Compared with Kogenate FS, Advate, and GreenMono, Kovaltry showed enhanced PK profiles, which contributed to reduced bleeding rates.
Collapse
Affiliation(s)
- Kun Huang
- Hematology CenterNational Center for Children's HealthBeijing Children’s HospitalCapital Medical UniversityBeijingChina
| | - Yingzi Zhen
- Hematology CenterNational Center for Children's HealthBeijing Children’s HospitalCapital Medical UniversityBeijingChina
| | - Gang Li
- Hematologic Disease LaboratoryBeijing Pediatric Research InstituteNational Center for Children's HealthBeijing Children's HospitalCapital Medical UniversityBeijingChina
| | - Xinyi Wu
- Hematology CenterNational Center for Children's HealthBeijing Children’s HospitalCapital Medical UniversityBeijingChina
| | - Zhenping Chen
- Hematologic Disease LaboratoryBeijing Pediatric Research InstituteNational Center for Children's HealthBeijing Children's HospitalCapital Medical UniversityBeijingChina
| | - Runhui Wu
- Hematology CenterNational Center for Children's HealthBeijing Children’s HospitalCapital Medical UniversityBeijingChina
| |
Collapse
|
12
|
Singkham N, Punyawudho B, Yu M, Cheng S, Chen S, Chang H, Chen C, Hsiao C, Hou J, Fang Y, Wang H, Lin J, Yu LH, Chen Y. Influence of blood group and von Willebrand factor on population pharmacokinetics and dose individualization of recombinant factor VIII in Taiwanese patients with haemophilia A. Haemophilia 2022; 28:230-238. [DOI: 10.1111/hae.14493] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Noppaket Singkham
- Department of Pharmaceutical Care, School of Pharmaceutical Sciences University of Phayao Phayao Thailand
| | - Baralee Punyawudho
- Department of Pharmaceutical Care, Faculty of Pharmacy Chiang Mai University Chiang Mai Thailand
| | - Ming‐Sun Yu
- Division of Hematology Conde S. Januário Hospital Macau China
| | - Shin‐Nan Cheng
- Hemophilia and Rare Disease Treatment Center Tungs’ Taichung MetroHarbor Hospital Taichung Taiwan
| | - Shu‐Huey Chen
- Department of Pediatrics, School of Medicine, College of Medicine Taipei Medical University Taipei Taiwan
- Department of Pediatrics, Shuang Ho Hospital, Ministry of Health and Welfare Taipei Medical University Taipei Taiwan
| | - Hung Chang
- Division of Hematology and Oncology Chang Gung Memorial Hospital at Linkou Taoyuan Taiwan
| | - Chih‐Cheng Chen
- Division of Hematology and Oncology, Department of Medicine Chang Gung Memorial Hospital, Chiayi Branch Chiayi Taiwan
- College of Medicine Chang Gung University Tao‐Yuan Taiwan
| | - Chih‐Cheng Hsiao
- Division of Hematology/Oncology, Department of Pediatrics Kaohsiung Chang Gung Memorial Hospital Kaohsiung Taiwan
- College of Medicine Chang Gung University Kaohsiung Taiwan
| | - Jen‐Yin Hou
- Division of Pediatric Hematology‐Oncology MacKay Children's Hospital Taipei Taiwan
| | - Yi‐Ping Fang
- School of Pharmacy, College of Pharmacy Kaohsiung Medical University Kaohsiung Taiwan
- Department of Medical Research Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Regeneration Medicine and Cell Therapy Research Center, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan
| | | | - Jia‐Hong Lin
- Medical Affairs Department Panco Healthcare Taipei Taiwan
| | | | - Yeu‐Chin Chen
- Division of Hematology and Oncology, Department of Medicine Tri‐Service General Hospital, National Defense Medical Center Taipei Taiwan
| |
Collapse
|
13
|
Ai D, Huang K, Li G, Zhen Y, Wu X, Zhang N, Huo A, Chen Z, Wu R. Exploration of the minimum necessary FVIII level at different physical activity levels in pediatric patients with hemophilia A. Front Pediatr 2022; 10:1045070. [PMID: 36389359 PMCID: PMC9665406 DOI: 10.3389/fped.2022.1045070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/13/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Physical activity can increase joint stability and reduce the risk of injury in hemophilia patients. There is limited clinical data on target trough FVIII levels during physical activity in hemophilia A patients. Hence, this study aimed to explore the target trough FVIII level required to avoid bleeding during different physical activities in hemophilia A patients. METHODS Patients with severe or moderate hemophilia A, who underwent pharmacokinetics (PK) tests at our center were enrolled in this study. Physical activities and clinical information such as bleeding were recorded. The FVIII level during physical activity was calculated by the WAPPS-Hemo. RESULTS A total of 105 patients were enrolled in this study. A total of 373 physical activities were recorded, of which 57.6% (215/373) was low-risk activities and the remaining 42.4% (158/373) was medium-risk activities. Most common physical activities were bicycling (59.0%), swimming (43.8%), running (48.6%), and jumping rope (41.0%). The FVIII trough level of low-risk physical activity was 3.8 IU/dl (AUC = 0.781, p = 0.002) and moderate-risk physical activity was 7.7 IU/dl (AUC = 0.809, p < 0.001). FVIII trough levels [low-risk activities: 6.1 (3.1, 13.2) IU/dl vs. 7.7 (2.3, 10.5) IU/dl, moderate-risk activities: 9.6 (5.8, 16.9) IU/dl vs. 10.2 (5.5, 11.0) IU/dl] were not statistically different between the mild arthropathy group and the moderate-severe arthropathy group. Multiple bleeding risk tended to increase with physical activities classified as moderate-risk (OR [95% CI]: 3.815 [1.766-8.238], p = 0.001). CONCLUSION The minimum necessary FVIII level increased with higher risk physical activity, irrespective of arthropathy.
Collapse
Affiliation(s)
- Di Ai
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Kun Huang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Gang Li
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yingzi Zhen
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xinyi Wu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Ningning Zhang
- Department of Radiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Aihua Huo
- Department of Radiology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhenping Chen
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Runhui Wu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| |
Collapse
|
14
|
Chowdary P, Hampton K, Jiménez-Yuste V, Young G, Benchikh El Fegoun S, Cooper A, Scalfaro E, Tiede A. Predictive Modeling Identifies Total Bleeds at 12-Weeks Postswitch to N8-GP Prophylaxis as a Predictor of Treatment Response. Thromb Haemost 2021; 122:913-925. [PMID: 34865209 PMCID: PMC9251711 DOI: 10.1055/s-0041-1739514] [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] [Indexed: 11/29/2022]
Abstract
Background
Predicting annualized bleeding rate (ABR) during factor VIII (FVIII) prophylaxis for severe hemophilia A (SHA) is important for long-term outcomes. This study used supervised machine learning-based predictive modeling to identify predictors of long-term ABR during prophylaxis with an extended half-life FVIII.
Methods
Data were from 166 SHA patients who received N8-GP prophylaxis (50 IU/kg every 4 days) in the pathfinder 2 study. Predictive models were developed to identify variables associated with an ABR of ≤1 versus >1 during the trial's main phase (median follow-up of 469 days). Model performance was assessed using area under the receiver operator characteristic curve (AUROC). Pre-N8-GP prophylaxis models learned from data collected at baseline; post-N8-GP prophylaxis models learned from data collected up to 12-weeks postswitch to N8-GP, and predicted ABR at the end of the outcome period (final year of treatment in the main phase).
Results
The predictive model using baseline variables had moderate performance (AUROC = 0.64) for predicting observed ABR. The most performant model used data collected at 12-weeks postswitch (AUROC = 0.79) with cumulative bleed count up to 12 weeks as the most informative variable, followed by baseline von Willebrand factor and mean FVIII at 30 minutes postdose. Univariate cumulative bleed count at 12 weeks performed equally well to the 12-weeks postswitch model (AUROC = 0.75). Pharmacokinetic measures were indicative, but not essential, to predict ABR.
Conclusion
Cumulative bleed count up to 12-weeks postswitch was as informative as the 12-week post-switch predictive model for predicting long-term ABR, supporting alterations in prophylaxis based on treatment response.
Collapse
Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, United Kingdom
| | - Kingsley Hampton
- Department of Cardiovascular Science, University of Sheffield, Sheffield, United Kingdom
| | - Victor Jiménez-Yuste
- Department of Hematology, La Paz University Hospital-IdiPaz, Autónoma University, Madrid, Spain
| | - Guy Young
- Hemostasis and Thrombosis Center, Cancer and Blood Disorders Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, United Sates
| | | | - Aidan Cooper
- Predictive Analytics, Real World Solutions, IQVIA, London, United Kingdom
| | | | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hanover, Germany
| |
Collapse
|
15
|
Population Pharmacokinetic Analysis and Exploratory Exposure-Bleeding Rate Relationship of Emicizumab in Adult and Pediatric Persons with Hemophilia A. Clin Pharmacokinet 2021; 59:1611-1625. [PMID: 32504271 PMCID: PMC7717049 DOI: 10.1007/s40262-020-00904-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Emicizumab is a bispecific monoclonal antibody developed for routine prophylaxis of bleeding in people with hemophilia A (PwHA). This work characterizes the pharmacokinetics of emicizumab in adult and pediatric PwHA, identifies factors contributing to its between-person variabilities, compares the pharmacokinetics following different dosing regimens, and makes a descriptive assessment of the exposure–bleeding events relationship. Methods A population pharmacokinetic model was developed, using a database of 389 PwHA from five clinical studies. Potential baseline covariate effects were assessed, including body size, age, race, presence of factor VIII inhibitors, and albumin levels. Using the population pharmacokinetic model, the estimated individual average exposures over the administration period were compared across categories of annualized bleeding rate. Results A linear one-compartment model with first-order absorption and elimination processes and no lag time best described the emicizumab pharmacokinetics. Body weight, albumin levels, age, and black race were statistically correlated with primary pharmacokinetic parameters, but only body weight had an important influence on exposure. Dosing regimens of 1.5 mg/kg weekly, 3 mg/kg every 2 weeks, or 6 mg/kg every 4 weeks provided similar average concentrations at steady state. A trend for lower exposure was observed in the small proportion of PwHA having an annualized bleeding rate > 4 (11.9%), suggesting that reducing exposure to lower levels may potentially increase the bleeding risk. Conclusions Emicizumab pharmacokinetics in PwHA was described with dose-independent parameters. Body weight was an important predictor of emicizumab pharmacokinetics. All three dosing regimens are predicted to achieve similar exposure associated with clinically meaningful prevention of bleeding. Electronic supplementary material The online version of this article (10.1007/s40262-020-00904-z) contains supplementary material, which is available to authorized users.
Collapse
|
16
|
Allen G, Du P, Khair K, Lee HY, Ozelo MC, Berthoz FT, Windyga J. Addressing unmet needs in rare bleeding disorders: selected poster extracts of recent research in hemophilia A and von Willebrand disease presented at the 14th Annual Congress of the European Association for Haemophilia and Allied Disorders (EAHAD) (Feb 3-5, 2021; virtual congress). Expert Rev Hematol 2021; 14:1-18. [PMID: 34369834 DOI: 10.1080/17474086.2021.1963706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Hemophilia A and von Willebrand disease (VWD) are inherited rare bleeding disorders affecting normal hemostasis. Patients with VWD, especially those with severe disease types, share some similarities to patients with hemophilia A in their burden of disease: they suffer from an increased risk of potentially severe and life-threatening bleeds and associated long-term consequences, such as impaired joint health and overall lower quality of life. However, the two bleeding disorders differ in their primary cause and affected patient population, and comprise a range of different bleeding phenotypes with varying unmet needs. Generating scientific evidence to advance health care for patients with rare bleeding disorders is challenging due to the low prevalence and heterogeneity of affected populations, including patient demographics and symptom severities. Innovative study designs are needed to adequately answer relevant scientific questions and address patients' unmet needs. In support of advancing clinical outcomes and treatment options for these patients, at the recent EAHAD 2021 annual congress, novel approaches and data from clinical and real-world observational studies, as well as systematic literature analyses, were presented. Herein, extracts from seven selected posters reporting research in hemophilia A and VWD funded by Takeda are discussed.
Collapse
Affiliation(s)
- Geoffrey Allen
- Takeda Development Center Americas, Inc, Cambridge, MA, USA
| | - Ping Du
- Millennium Pharmaceuticals, Inc, a Takeda Company, Cambridge, MA, USA
| | - Kate Khair
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children, London, UK
| | - Hye-Youn Lee
- Baxalta GmbH, a Takeda Company, Zürich, Switzerland
| | | | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| |
Collapse
|
17
|
Wu R, Li X, Yao W, Zhang Q, Zhou M, Zhang N, Yang S, Chen Z, Wang Y, Kuang Y, Tang L, Zhen Y, Abad A, Doria AS, Hilliard P, Ignas DM, Mathew P, Stephens D, Blanchette VS, Luke K. Significant reduction in hemarthrosis in boys with severe hemophilia A: The China hemophilia individualized low-dose secondary prophylaxis study. Res Pract Thromb Haemost 2021; 5:e12552. [PMID: 34568725 PMCID: PMC8449287 DOI: 10.1002/rth2.12552] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/23/2021] [Accepted: 04/29/2021] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION In countries with restricted access to clotting factor concentrates, early implementation of low-dose prophylaxis is recommended over episodic treatment. OBJECTIVE The objective of this 1-year prospective secondary prophylaxis study was to evaluate the efficacy of a dose/frequency escalating protocol in young boys with hemophilia A in China. METHODS Boys were started on a low-dose protocol (minimum 10-15 IU/kg of factor VIII [FVIII] twice weekly). Escalation was based on index joint bleeding, swelling/persistent joint swelling, and serial ultrasound (gray scale and color Doppler) examinations of index joints. RESULTS Thirty-three boys, median age 4.8 years (interquartile range, 3.8-6.1) were enrolled in a 3-month observation period that preceded a 1-year prophylaxis phase. A significant reduction in total bleeding events (43.0%, P = .001), index joint bleeds (53.2%, P = .002), and target index joint bleeds (70.0%, P = 0.02) was observed during the prophylaxis phase. During the prophylaxis period, 40% of target joints resolved. The percentage of boys with zero index joint bleeds increased significantly (P = .004) from 51.5% during the observation phase to 81.8% in last quarter of the prophylaxis phase (months 10-12). There was no progression of arthropathy based on physical examination (Hemophilia Joint Health Score), X-ray, and ultrasound obtained at entry into the prophylaxis phase and at study exit. The median FVIII consumption over the prophylaxis phase was 1786 IU/kg/y. CONCLUSION A low-dose, individualized prophylaxis protocol, guided by individual bleeding profiles and serial assessment of joint status, enables escalation of treatment intensity in boys with severe hemophilia A, leading to a significant reduction in bleeding events and reduction in target joint bleeding.
Collapse
Affiliation(s)
- Runhui Wu
- Hemophilia Comprehensive Care CenterHematology DepartmentBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Xiaojing Li
- Hemophilia Diagnosis and Treatment CenterDepartment of Hematology and OncologyChengdu Women’s and Children’s Central HospitalSchool of MedicineUniversity of Electronic Science and Technology of ChinaChengduChina
- Hemophilia Treatment CenterDepartment of PediatricsNew Century Women’s and Children’s HospitalChengduChina
| | - Wanru Yao
- Hemophilia Comprehensive Care CenterHematology DepartmentBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Qing Zhang
- Hemophilia Diagnosis and Treatment CenterDepartment of Hematology and OncologyChengdu Women’s and Children’s Central HospitalSchool of MedicineUniversity of Electronic Science and Technology of ChinaChengduChina
| | - Min Zhou
- Hemophilia Diagnosis and Treatment CenterDepartment of Hematology and OncologyChengdu Women’s and Children’s Central HospitalSchool of MedicineUniversity of Electronic Science and Technology of ChinaChengduChina
| | - Ningning Zhang
- Hemophilia Comprehensive Care Center, Radiology CenterBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Sheng Yang
- Hemophilia and Diagnosis Treatment CenterDepartment of UltrasoundChengdu Women’s and Children’s Central HospitalSchool of MedicineUniversity of Electronic Science and Technology of ChinaChengduChina
| | - Zhenping Chen
- Hemophilia Comprehensive Care CenterHematology DepartmentBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Yan Wang
- Hemophilia Comprehensive Care Center, Rehabilitation DepartmentBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Yangying Kuang
- Hemophilia Diagnosis and Treatment CenterDepartment of RadiologyChengdu Women’s and Children’s Central HospitalSchool of MedicineUniversity of Electronic Science and Technology of ChinaChengduChina
| | - Ling Tang
- Hemophilia Comprehensive Care CenterHematology DepartmentBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Yingzi Zhen
- Hemophilia Comprehensive Care CenterHematology DepartmentBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Audrey Abad
- Child Health Evaluative Sciences, Research InstituteThe Hospital for Sick ChildrenTorontoONCanada
| | - Andrea S. Doria
- Department of Diagnostic ImagingMedical Imaging DepartmentThe Hospital for Sick ChildrenUniversity of TorontoTorontoCanada
- The Hospital for Sick ChildrenResearch InstituteUniversity of TorontoTorontoONCanada
| | - Pamela Hilliard
- Child Health Evaluative Sciences, Research InstituteThe Hospital for Sick ChildrenTorontoONCanada
| | - Danial M. Ignas
- Child Health Evaluative Sciences, Research InstituteThe Hospital for Sick ChildrenTorontoONCanada
| | - Prasad Mathew
- Division of Pediatric Hematology/OncologyPresbyterian Health Services HospitalAlbuquerqueNMUSA
| | - Derek Stephens
- The Hospital for Sick ChildrenResearch InstituteUniversity of TorontoTorontoONCanada
| | - Victor S. Blanchette
- Division of Hematology/OncologyThe Hospital for Sick Children and Department of PediatricsUniversity of TorontoTorontoONCanada
| | - Koon‐Hung Luke
- Department of PediatricsLaboratory Medicine and PathologyDivision of Hematology and OncologyUniversity of OttawaChildren Hospital of Eastern OntarioOttawaONCanada
| |
Collapse
|
18
|
Megías-Vericat JE, Bonanad S, Haya S, Cid AR, Marqués MR, Ferrada A, Monte-Boquet E, Pérez-Alenda S, Bosch P, Querol-Giner F, Poveda JL. Clinical benefits of a Bayesian model for plasma-derived factor VIII/VWF after one year of pharmacokinetic-guided prophylaxis in severe/moderate hemophilia A patients. Thromb Res 2021; 205:99-105. [PMID: 34293540 DOI: 10.1016/j.thromres.2021.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/05/2021] [Accepted: 07/12/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Individual pharmacokinetic (PK) profiling in hemophilia A (HA) helps to individualize prophylaxis using population PK models (popPK). A specific popPK model for plasma-derived factor VIII containing von-Willebrand Factor (pdFVIII/VWF) was developed. AIM To compare standard versus PK-driven prophylaxis, using a generic or a specific popPK model for pdFVIII/VWF. MATERIALS AND METHODS A prospective study conducted in HA patients in prophylaxis with pdFVIII/VWF (Fanhdi®) comparing three one-year study periods: (1) standard prophylaxis, (2) PK-guided prophylaxis using a generic pdFVIII popPK model which described FVIII activity irrespective of FVIII concentrate, and (3) PK-guided prophylaxis with specific pdFVIII/VWF popPK model. PK parameters analyzed were half-life, trough levels (TL) at 24, 48 and 72 h, and time to reach FVIII levels of 1, 2, 5% (T5%). Clinical outcomes were dose/kg, FVIII consumption, annualized bleeding rate (ABR), annualized joint bleeding rate (AJBR), spontaneous and traumatic bleeds. RESULTS Of the 30 analyzed patients, 28 had severe HA and the median age was 31.2. Fifteen patient's prophylaxis doses were PK-adjusted. After the generic PK-guided prophylaxis period, younger patients showed more joint bleeds, a shorter half-life, and lower TL48, TL72 and T5%. Using the specific pdFVIII/VWF popPK model compared with standard prophylaxis, a lower spontaneous AJBR was observed in the entire cohort and in patients aged >15 years. Additionally, lower spontaneous ABR was reported in patients aged ≤15 years comparing specific and generic models. CONCLUSIONS PK-guided prophylaxis with a specific pdFVIII/VWF popPK model allowed treatment individualization and improved bleeding control in routine clinical practice, especially in younger patients with short pdFVIII/VWF half-lives.
Collapse
Affiliation(s)
- Juan Eduardo Megías-Vericat
- Hospital Universitari i Politècnic La Fe, Pharmacy Department, Valencia, Spain; Hospital Universitari i Politècnic La Fe, Haemostasis and Thrombosis Unit, Valencia, Spain.
| | - Santiago Bonanad
- Hospital Universitari i Politècnic La Fe, Haemostasis and Thrombosis Unit, Valencia, Spain
| | - Saturnino Haya
- Hospital Universitari i Politècnic La Fe, Haemostasis and Thrombosis Unit, Valencia, Spain
| | - Ana Rosa Cid
- Hospital Universitari i Politècnic La Fe, Haemostasis and Thrombosis Unit, Valencia, Spain
| | | | - Alejandra Ferrada
- Hospital Universitari i Politècnic La Fe, Pharmacy Department, Valencia, Spain
| | - Emilio Monte-Boquet
- Hospital Universitari i Politècnic La Fe, Pharmacy Department, Valencia, Spain
| | - Sofía Pérez-Alenda
- Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), Department of Physiotherapy, University of Valencia
| | - Pau Bosch
- Hospital Universitari i Politècnic La Fe, Haemostasis and Thrombosis Unit, Valencia, Spain
| | - Felipe Querol-Giner
- Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), Department of Physiotherapy, University of Valencia
| | - Jose Luis Poveda
- Hospital Universitari i Politècnic La Fe, Pharmacy Department, Valencia, Spain
| |
Collapse
|
19
|
Tiede A, Abdul Karim F, Jiménez-Yuste V, Klamroth R, Lejniece S, Suzuki T, Groth A, Santagostino E. Factor VIII activity and bleeding risk during prophylaxis for severe hemophilia A: a population pharmacokinetic model. Haematologica 2021; 106:1902-1909. [PMID: 32327501 PMCID: PMC8252934 DOI: 10.3324/haematol.2019.241554] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Indexed: 11/21/2022] Open
Abstract
During factor VIII prophylaxis for severe hemophilia A, bleeding risk increases with time when factor VIII activity is below 1%. However, maintaining trough activity above 1% does not protect all patients from bleeding. The relationship between factor VIII activity during prophylaxis and bleeding risk has not been thoroughly studied. We investigated factor VIII activity and annualized bleeding rate for spontaneous bleeds during prophylaxis. A population pharmacokinetic model derived from three clinical trials was combined with dosing data and information on bleeding from patients’ diaries. Each patient’s time on prophylaxis was divided into five categories of predicted activity (0-1%, >1-5%, >5-15%, >15-50%, and >50%). Exposure time, mean factor VIII activity, and number of bleeds (from the patients’ diaries) were calculated for each activity category, and annualized bleeding rates estimated using negative binomial regression and a parametric model. Relationships between these bleeding rates and factor VIII activity were evaluated by trial phase (pivotal vs. extension) and age (adults/adolescents [≥12 years] vs. children [0-<12 years]). In total (n=187 patients; 815 patient-years’ exposure), factor VIII activity was predicted to be >1% for 85.64% of the time. The annualized bleeding rate decreased as factor VIII activity increased in each trial phase and age group. However, for a given activity level, bleeding rate differed substantially by trial phase and age. This suggests that bleeding risk can change over time and is influenced by factors independent of factor VIII pharmacokinetics and trough levels. When making decisions regarding target trough levels and the prophylactic regimen, the patients’ age, joint disease activity, and other bleeding risk determinants should be taken into consideration. Clinical trial registration numbers: NCT00840086; NCT01138501; NCT00984126
Collapse
Affiliation(s)
- Andreas Tiede
- Hannover Medical School (MHH), Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover, Germany
| | | | | | - Robert Klamroth
- Haemophiliezentrum, Klinik für Innere Medizin, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Sandra Lejniece
- Rîga East Clinical University Hospital, Chemotherapy and Hematology Clinic, Rîga, Latvia
| | - Takashi Suzuki
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | | | - Elena Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda Foundation, Maggiore Hospital Policlinic, Milan, Italy
| |
Collapse
|
20
|
Marchesini E, Morfini M, Valentino L. Recent Advances in the Treatment of Hemophilia: A Review. Biologics 2021; 15:221-235. [PMID: 34163136 PMCID: PMC8214539 DOI: 10.2147/btt.s252580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/10/2021] [Indexed: 01/19/2023]
Abstract
Progress in hemophilia therapy has been remarkable in the first 20 years of the third millennium, but the innovation began with the description the fractionation of plasma in 1946. The first concentrates followed the discovery of FVIII in the cryoprecipitate of frozen plasma and FIX in the supernatant in the early 1960s, which led to the initial attempts at replacement therapy. Unfortunately, the lack of screening methods for viral pathogens resulted in people with hemophilia (PWH) receiving concentrates contaminated by hepatitis A virus, hepatitis C virus, and human immunodeficiency virus, as these concentrates were made from large industrial pools of plasma derived from thousands of donors. Fortunately, by 1985, viral screening methods and proper virucidal techniques were developed that made concentrates safe. Increasingly pure products followed the introduction of chromatography steps with monoclonal antibodies in the production process. The problem of immunogenicity of exogenously administered concentrates has not yet had a complete solution. The development of alloantibodies against FVIII in about 25-35% of PWH is the most serious adverse effect of replacement therapy. The next major advance followed the cloning of the F8 gene and later the F9 genes, which paved the way to produce concentrates of factors obtained by the recombinant DNA technology. The injected FVIII and FIX molecules had a relatively short circulating half-life in the plasma of people with hemophilia A and B, approximately 12 and 18 hours, respectively. The ability to prolong the plasma half-life and extend the interval between injections followed the application of methods to conjugate the factor molecule with the fragment crystallizable of IgG1 or albumin or by adding polyethylene glycol, which has led to an increase in the half-life of concentrates, especially for rFIX. The next frontier in hemophilia therapy is the application of durable and potentially curative therapies such as with gene addition therapy. Experiments in hemophilia B have demonstrated durable responses. Unfortunately, the results with gene therapy for hemophilia A have not been as remarkable and the durability must still be demonstrated. Nonetheless, the long-term safety, predictability, durability, and efficacy of gene therapy for hemophilia A and B remain an open question. At present, only healthy adult PWH have been enrolled in gene therapy clinical trials. The application of gene therapy to children and those with pre-existing antibodies against the delivery vector must also be studied before this therapy becomes widespread.
Collapse
Affiliation(s)
- Emanuela Marchesini
- Hemophilia Centre, SC Vascular and Emergency Department, University of Perugia, Perugia, Italy
| | - Massimo Morfini
- Italian Association of Haemophilia Centres (AICE), Naples, Italy
| | - Leonard Valentino
- National Hemophilia Foundation, New York, NY, USA
- Rush University, Chicago, IL, USA
| |
Collapse
|
21
|
Berntorp E, Hermans C, Solms A, Poulsen L, Mancuso ME. Optimising prophylaxis in haemophilia A: The ups and downs of treatment. Blood Rev 2021; 50:100852. [PMID: 34243987 DOI: 10.1016/j.blre.2021.100852] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 01/19/2023]
Abstract
The classical goals of haemophilia A treatment are to prevent bleeds, minimise the risk of long-term complications associated with joint damage, and improve quality of life by maintaining appropriate factor VIII [FVIII] levels. The dose and frequency of FVIII replacement therapies required to reduce bleeds is now known to vary amongst individuals, and may change for the same individual over time, meaning that a standardised dose and regimen may not provide optimal protection to all patients. Here we review the evolving treatment landscape for haemophilia A, and discuss how an increased understanding of the pharmacology and pharmacokinetics underlying FVIII replacement and non-factor replacement therapies could improve patient outcomes. We also review the strengths and weaknesses of current treatments and explore the benefits of personalised therapy and review how this may best be achieved with current treatment options. The key points of our review are summarised in this accompanying short video.
Collapse
Affiliation(s)
- Erik Berntorp
- Malmö Center for Thrombosis and Haemostasis, Lund University, Sweden.
| | - Cédric Hermans
- Division of Adult Haematology, Haemostasis and Thrombosis Unit, Université Catholique de Louvain (UCLouvai), Brussels, Belgium
| | | | - Lone Poulsen
- Haemophilia Center, Aarhus University Hospital, Denmark
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| |
Collapse
|
22
|
Katragadda S, Neelakantan S, Diao L, Wong N. Population Pharmacokinetic Analysis of Recombinant Factor VIII Fc Fusion Protein in Subjects With Severe Hemophilia A: Expanded to Include Pediatric Subjects. J Clin Pharmacol 2021; 61:889-900. [PMID: 33719084 DOI: 10.1002/jcph.1854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 03/04/2021] [Indexed: 01/19/2023]
Abstract
Recombinant factor VIII Fc fusion protein (rFVIIIFc) has been indicated for adults and children with hemophilia A. The objective of this article was to build a population pharmacokinetic (PK) model using adult and pediatric data sets and explore relevant dosing scenarios across all ages. The activity-time profiles of rFVIIIFc from 3 clinical studies (all trials registered at https://www.clinicaltrials.gov: NCT01027377, NCT01181128, and NCT01458106) were characterized, and covariates that determine variability of rFVIIIFc PK in children and adults were identified and implemented. Data sets were pooled to estimate population PK parameters. Simulations were conducted to generate activity-time profiles at steady state (SS). The proportion of subjects maintaining SS trough >1 and >3 IU/dL and time >10 IU/dL were estimated. The rFVIIIFc model was a two-compartment model that identified weight and von Willebrand factor as significant covariates. Model-predicted SS peaks and troughs of rFVIIIFc activity-time profiles confirmed the necessity of modifying dosing in pediatric subjects. The model also predicted that the average subject in the adult and adolescent group dosed with 40 IU/kg every 2 days maintained factor VIII activity >10 IU/dL for the entire duration. Children aged <6 years and aged 6 to <12 years receiving this dose maintained factor VIII activity of >10 IU/dL for nearly two-thirds and three-quarters of their time, respectively. In conclusion, these population PK analyses characterize activity-time profiles for rFVIIIFc among pediatric and adult subjects. The model was used for simulation of clinically relevant dosing scenarios, which can provide better protection and better clinical outcomes.
Collapse
Affiliation(s)
| | | | - Lei Diao
- EpimAb Biotherapeutics, Shanghai, China
| | | |
Collapse
|
23
|
Rurioctocog alfa pegol PK-guided prophylaxis in hemophilia A: results from the phase 3 PROPEL study. Blood 2021; 137:1818-1827. [PMID: 33150384 DOI: 10.1182/blood.2020005673] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 10/13/2020] [Indexed: 01/19/2023] Open
Abstract
Rurioctocog alfa pegol prophylaxis targeting factor VIII (FVIII) troughs ≥1% has shown to be efficacious with an acceptable safety profile in people with hemophilia A (PwHA). The PROPEL trial compared safety and efficacy of 2 target FVIII troughs in PwHA aged 12 to 65 years, with severe disease, annualized bleeding rate ≥2, and previous FVIII treatment. PwHA were randomized to 12 months' pharmacokinetic (PK)-guided rurioctocog alfa pegol prophylaxis targeting FVIII troughs of 1% to 3% (reference arm) or 8% to 12% (elevated arm); first 6 months was treatment-adjustment period. The primary endpoint was absence of bleeds during the second 6 months, analyzed using multiple imputations (full analysis set [FAS]). In the 1% to 3% and 8% to 12% arms, respectively, point estimates (95% confidence interval) of proportions of PwHA with zero total bleeds were 42% (29% to 55%) and 62% (49% to 75%) in FAS (N = 115; P = .055) and 40% (27% to 55%) and 67% (52% to 81%) in per-protocol analysis set (N = 95; P = .015). Dosing frequency and consumption varied in each arm. Adverse events (AEs) occurred in 70/115 (60.9%) PwHA; serious AEs in 7/115 (6%) PwHA, including 1 treatment-related in 8% to 12% arm (transient anti-FVIII inhibitor). There were no deaths, serious thrombotic events, or AE-related discontinuations. PK-guided prophylaxis was achievable and efficacious in both arms. No new safety signals were observed in the 8% to 12% arm. These results demonstrate elevated FVIII troughs can increase the proportion of PwHA with zero bleeds and emphasize the importance of personalized treatment. This trial was registered at www.clinicaltrials.gov as #NCT02585960.
Collapse
|
24
|
Collins PW, Obaji SG, Roberts H, Gorsani D, Rayment R. Clinical phenotype of severe and moderate haemophilia: Who should receive prophylaxis and what is the target trough level? Haemophilia 2021; 27:192-198. [PMID: 33639027 DOI: 10.1111/hae.14201] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION One of the most often stated tenets of haemophilia care is that prophylaxis converts a person from a severe to a moderate phenotype. In this review, we argue that this is not an accurate assumption and that people on prophylaxis predominantly have factor VIII/IX levels in the mild range. MODERATE HAEMOPHILIA AND PROPHYLAXIS People with moderate haemophilia, who are treating with on-demand regimens, experience joint bleeds and often develop significant arthropathy. This is especially true for people with a baseline level of 1-3 IU/dl, as first reported 55 years ago, and confirmed in more recent studies. Evidence is emerging suggesting that people with severe haemophilia who are using prophylaxis have better musculoskeletal outcomes than people with moderate haemophilia treated episodically. TROUGH LEVELS The debate around the optimum trough level whilst on prophylaxis is ongoing. It is not appropriate to extrapolate information about baseline levels to recommendations about target trough levels on prophylaxis because these are different situations. Studies are emerging that support higher target trough levels than previously used, but in spite of this, the aim of achieving zero bleeds remains elusive with both factor replacement and non-replacement therapies. CONCLUSIONS We recommend that people with moderate haemophilia, especially those with a baseline of 1-3 IU/dl, should be offered prophylaxis based on the same criteria as people with severe haemophilia. Trough levels should be maintained above 3 IU/dl or higher if a level of 3 IU/dl does not control breakthrough bleeding and prophylaxis should be tailored to the bleeding phenotype. This advice is in line with recently published guidelines from the World Federation of Haemophilia and the UK Haemophilia Centre Doctors' Organisation.
Collapse
Affiliation(s)
- Peter W Collins
- Cardiff Haemophilia Centre, Cardiff and Vale University Health Board, Cardiff, UK.,Institute of Infection and Immunity, School of Medicine Cardiff University, Cardiff, UK
| | - Samya G Obaji
- Cardiff Haemophilia Centre, Cardiff and Vale University Health Board, Cardiff, UK.,Institute of Infection and Immunity, School of Medicine Cardiff University, Cardiff, UK
| | - Heledd Roberts
- Cardiff Haemophilia Centre, Cardiff and Vale University Health Board, Cardiff, UK
| | - Deepan Gorsani
- Cardiff Haemophilia Centre, Cardiff and Vale University Health Board, Cardiff, UK
| | - Rachel Rayment
- Cardiff Haemophilia Centre, Cardiff and Vale University Health Board, Cardiff, UK
| |
Collapse
|
25
|
Mahlangu JN, Blanchette V, Klamroth R. Redefining prophylaxis in the modern era. Haemophilia 2021; 27 Suppl 3:21-27. [PMID: 32469108 DOI: 10.1111/hae.14035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/23/2020] [Accepted: 04/27/2020] [Indexed: 11/29/2022]
Abstract
Prophylaxis is the globally accepted standard of care for persons with haemophilia and presents many advantages over episodic treatment. The prophylaxis benefits include bleed reduction, reduction in musculoskeletal complications and improvement in the quality of life. The currently evolving novel therapies for the management of haemophilia has ushered a new era characterized by improved prophylaxis targets and outcomes. These redefined targets and outcomes have necessitated the need to also redefine prophylaxis. In this state-of-the-art review, we redefine prophylaxis in the modern era by revisiting its definition, presenting data to support higher trough levels to achieve with prophylaxis and introducing steady-state haemostasis as a possible new target for prophylaxis.
Collapse
Affiliation(s)
- Johnny N Mahlangu
- Faculty of Health Sciences, Haemophilia Comprehensive Care, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand and the NHLS, Johannesburg, South Africa
| | - Victor Blanchette
- Department of Pediatrics, Division of Hematology/Oncology Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Robert Klamroth
- Department of Internal Medicine, Hemophilia Treatment Centre, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| |
Collapse
|
26
|
Mancuso ME, Reding MT, Negrier C, Kerlin BA, Rangarajan S, Simpson ML. Decreased Bleeding Rates in Patients with Hemophilia A Switching from Standard-Half-Life FVIII to BAY 94-9027 Prophylaxis. Thromb Haemost 2020; 121:1079-1086. [PMID: 33296943 PMCID: PMC8322588 DOI: 10.1055/a-1333-5536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BAY 94-9027 (damoctocog alfa pegol, Jivi) is an extended-half-life recombinant factor VIII (rFVIII) shown to be well-tolerated and efficacious in bleeding prevention in previously treated patients with severe hemophilia A. During the PROTECT VIII study, prophylaxis patients received BAY 94-9027 at intervals determined based on their bleeding phenotype, observed during a 10-week run-in treatment period with twice-weekly dosing. Those with ≤ 1 spontaneous joint or muscle bleed were randomized to either 45 to 60 IU/kg every 5 days or 60 IU/kg every 7 days; patients could increase dosing frequency to every 5 days or twice weekly in the case of bleeds. Those enrolled after the randomization arms were full, and those with ≥ 2 bleeds in the run-in period, received 30 to 40 IU/kg twice weekly. Patients completing the main study could receive open-label BAY 94-9027 in the extension phase. Dosing regimen, total, and joint annualized bleeding rates were analyzed over three periods: prestudy, main study, and extension. A total of 80 patients who were on prophylaxis treatment prior to and during the study and had prior bleed data available were evaluated in this post hoc analysis of PROTECT VIII. Most patients (> 80%) required fewer infusions with BAY 94-9027 prophylaxis versus their previous standard-half-life (SHL) rFVIII product. Lower bleeding and joint bleeding rates were observed over time from the prestudy to the extension study period in all treatment regimens. Compared with SHL FVIII, BAY 94-9027 prophylaxis allows patients to reduce infusion frequency with maintained or improved protection from bleeds.
Collapse
Affiliation(s)
- Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Mark T Reding
- University of Minnesota Medical Center, Minneapolis, Minnesota, United States
| | - Claude Negrier
- Louis Pradel University Hospital, University Claude Bernard Lyon 1, Lyon, France
| | - Bryce A Kerlin
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, United States
| | - Savita Rangarajan
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Mindy L Simpson
- Rush University Medical Center, Chicago, Illinois, United States
| |
Collapse
|
27
|
Pierce GF. Uncertainty in an era of transformative therapy for haemophilia: Addressing the unknowns. Haemophilia 2020; 27 Suppl 3:103-113. [PMID: 32484283 DOI: 10.1111/hae.14023] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/24/2020] [Indexed: 12/12/2022]
Abstract
Haemophilia is at the dawn of a new era in therapeutic management, one that can generate greater protection from bleeding and a functional cure in some individuals. Prior advances in protein engineering and monoclonal antibody technology have facilitated therapeutic options to maintain decreased risk of bleeding and less burdensome treatment. The use of gene transfer, first proposed in 1971 for monogenic diseases, is emerging as an effective long-term treatment for a variety of diseases. Transfer of functional factor VIII (FVIII) and factor IX (FIX) genes has witnessed a series of advances and setbacks since the first non-clinical experiments in animals were initiated nearly 30 years ago. More recently, multiyear therapeutic levels of FVIII and FIX activity have been achieved in human clinical trials, translated into meaningful clinical benefit and a functional cure. While clinical progress has been definitive, many questions remain unanswered as prelicensure phase 3 clinical trials are underway. These unanswered questions translate into a state of uncertainty about the known unknowns and unknown unknowns intrinsic to any new therapeutic platform. Accepting this modality as a means to functionally cure haemophilia also means accepting the uncertainty regarding the biology of viral vector-mediated gene transfer, which remains inadequately understood. Gene therapy is a far more complex biological 'drug' than small molecule and protein drugs, where manufacturing processes and the drugs themselves are now well characterized. Extent of community acceptance of uncertainty and acknowledgement of the need for an uncompromising drive for answers to the unknowns will characterize the introduction of this first generation of gene therapy for haemophilia to the wider patient population in both resource-rich and resource-poor countries.
Collapse
|
28
|
Delavenne X, Dargaud Y. Pharmacokinetics for haemophilia treaters: Meaning of PK parameters, interpretation pitfalls, and use in the clinic. Thromb Res 2020; 192:52-60. [PMID: 32450448 DOI: 10.1016/j.thromres.2020.05.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/03/2020] [Accepted: 05/04/2020] [Indexed: 01/19/2023]
Abstract
Replacement therapy with concentrates of factor VIII or IX remains the gold standard for severe haemophilia management. The recent development of clotting factor products with extended half-life, widely available on the market since 2 years, facilitates adherence, improves considerably the patients' quality of life, and simplifies the management of breakthrough bleedings or surgery. These molecules have also brought to the limelight the concepts of optimization and personalization of anti-haemophilic prophylaxis. Pharmacokinetics (PK) is one of the tools that can help haematologists to adapt in a more objective and precise manner the prophylaxis regimen to each individual patient's specific needs. For many years, clinicians at haemophilia centres have been using some simple PK parameters, such as recovery and residual level. However, recently, they have been confronted with an important number of new PK parameters they were not familiar with, but that can be used to improve patient management. Due to the accumulation of PK data and their relative complexity, it is now necessary to analyse the relevance of the different PK parameters relative to haemophilia specificities, and also to know their limits to better use them.
Collapse
Affiliation(s)
- Xavier Delavenne
- INSERM, UMR 1059, Dysfonction Vasculaire et de l'Hémostase, Université de Lyon, Saint Etienne, France; Laboratoire de Pharmacologie - Toxicologie, CHU de Saint-Etienne, Saint-Etienne, France.
| | - Yesim Dargaud
- Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, Université Lyon 1, Lyon, France
| |
Collapse
|
29
|
Rayment R, Chalmers E, Forsyth K, Gooding R, Kelly AM, Shapiro S, Talks K, Tunstall O, Biss T. Guidelines on the use of prophylactic factor replacement for children and adults with Haemophilia A and B. Br J Haematol 2020; 190:684-695. [PMID: 32390158 DOI: 10.1111/bjh.16704] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/04/2020] [Accepted: 04/08/2020] [Indexed: 01/19/2023]
Affiliation(s)
| | | | | | | | - Anne M Kelly
- Cambridge University Hospitals NHS foundation Trust, Cambridge, UK
| | - Susan Shapiro
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kate Talks
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Oliver Tunstall
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Tina Biss
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | |
Collapse
|
30
|
Martin AP, Burke T, Asghar S, Noone D, Pedra G, O'Hara J. Understanding minimum and ideal factor levels for participation in physical activities by people with haemophilia: An expert elicitation exercise. Haemophilia 2020; 26:711-717. [PMID: 32268007 DOI: 10.1111/hae.13985] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/11/2020] [Accepted: 03/12/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The benefits of physical activity (PA) for people with haemophilia (PWH) may include improvements in joint, bone and muscle health. However, the factor VIII activity level required to avoid a bleeding episode associated with PA is unknown. AIM To elicit the opinion of clinical experts on the minimum level and ideal factor VIII activity ('level') required to avoid a bleeding episode during participation in different types of PA for PWH. METHODS Based on the 2017 National Hemophilia Foundation PA descriptions, clinical experts estimated a minimally acceptable and an ideal factor level at which a bleed could be avoided. The uncertainty around estimates was quantified using an approach to construct a probability distribution to represent expert opinion. RESULTS Minimum and ideal factor level increased with higher risk PA, whether or not joint morbidity was present, as did the experts' uncertainty in their estimates (ie the range between lowest and highest estimates for minimum and ideal levels). Mean minimum levels ranged from 4% to 48% for low to high risk for people without joint morbidity, and from 7% to 47% for those with joint morbidity. For ideal factor levels, corresponding figures were 9%-52% and 12%-64%, respectively. CONCLUSION To support a patient-centric outcome, expert opinion indicates that the clinical norm of 0.01 IU/mL (1%) trough level is insufficient. It is anticipated that introducing a more targeted approach to meet the needs of patients who are increasingly physically active will benefit patients further in addition to recent treatment advances.
Collapse
Affiliation(s)
| | | | | | | | | | - Jamie O'Hara
- HCD Economics, Daresbury, UK.,Faculty of Health and Social Care, University of Chester, Chester, UK
| |
Collapse
|
31
|
Qvigstad C, Tait RC, de Moerloose P, Holme PA. Hematuria in aging men with hemophilia: Association with factor prophylaxis. Res Pract Thromb Haemost 2020; 4:309-317. [PMID: 32110762 PMCID: PMC7040553 DOI: 10.1002/rth2.12298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/17/2019] [Accepted: 11/22/2019] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Macroscopic hematuria is considered a significant risk factor for urologic disease, and it is highly prevalent in people with hemophilia. AIM To determine whether prophylactic factor replacement therapy is associated with reduced occurrence of macroscopic hematuria in people with hemophilia in a post hoc analysis using data from a cross-sectional study conducted by the Age-Related Developments and Comobordities in Hemophilia (ADVANCE) Working Group that included males with hemophilia ≥40 years of age. METHODS Data from 16 contributing centers, in 13 European countries and Israel, were analyzed using logistic regression. Of 532 recruited individuals, this analysis included 370 patients with moderate or severe hemophilia who received on-demand or prophylactic therapy. RESULTS For patients with a history of macroscopic hematuria, we analyzed the association between prophylaxis and reoccurrence of macroscopic hematuria within the past 5 years (n = 235 patients). Frequent (≥3 times/wk) prophylaxis was negatively associated with a recent episode of macroscopic hematuria (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.18-0.76). We also analyzed whether prophylaxis corresponded to a lower lifetime number of macroscopic hematuria episodes (n = 285 patients). Frequent prophylaxis for >15 years was associated with a lower number of episodes compared to on-demand treatment (OR, 0.29; 95% CI, 0.16-0.54), whereas nonsteroidal anti-inflammatory drugs (NSAIDs) and severe hemophilia were associated with a higher number. There was no association of prophylaxis <3 times/wk with hematuria. CONCLUSION Frequent prophylaxis was negatively associated with the number of episodes of macroscopic hematuria in people with hemophilia. Prevalence of macroscopic hematuria was higher among individuals with severe hemophilia and those regularly using NSAIDs.
Collapse
Affiliation(s)
- Christian Qvigstad
- Department of HaematologyOslo University HospitalOsloNorway
- Institute of Clinical MedicineUniversity of OsloOsloNorway
| | | | | | - Pål Andre Holme
- Department of HaematologyOslo University HospitalOsloNorway
- Institute of Clinical MedicineUniversity of OsloOsloNorway
| | | |
Collapse
|
32
|
Chowdary P. Extended half-life recombinant products in haemophilia clinical practice - Expectations, opportunities and challenges. Thromb Res 2019; 196:609-617. [PMID: 31883700 DOI: 10.1016/j.thromres.2019.12.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/03/2019] [Accepted: 12/18/2019] [Indexed: 02/06/2023]
Abstract
Extended half-life (EHL) products have shown robust efficacy in clinical trials, whilst allowing for less intense treatment regimens when compared with standard half-life products. Regimen optimisation with EHL products could lead to further improvements in bleeding rates, quality of life and reductions in treatment burden. Patients now expect good efficacy, a lower treatment burden and equivalent safety when compared with standard half-life products. As our knowledge base grows these expectations have evolved and targeting an annualised bleeding rate of zero has become a more realistic clinical goal. Personalised prophylaxis can help patients achieve these goals. However, a number of challenges still remain, including cost, challenges in predicting outcomes for patients and differences in patients' and clinicians' expectations. When switching a patient, comprehensive patient care can reduce the impact of these issues. This review presents in brief the protein therapeutics with an extended half-life, including key trial results, challenges of chronic care that impact on patients' outcomes and how the modified proteins might help address some of these issues. In addition, practical steps for managing the switch to EHL products are presented.
Collapse
Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK.
| |
Collapse
|
33
|
Abrantes JA, Solms A, Garmann D, Nielsen EI, Jönsson S, Karlsson MO. Bayesian Forecasting Utilizing Bleeding Information to Support Dose Individualization of Factor VIII. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2019; 8:894-903. [PMID: 31668021 PMCID: PMC6930854 DOI: 10.1002/psp4.12464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/08/2019] [Indexed: 01/19/2023]
Abstract
Bayesian forecasting for dose individualization of prophylactic factor VIII replacement therapy using pharmacokinetic samples is challenged by large interindividual variability in the bleeding risk. A pharmacokinetic‐repeated time‐to‐event model‐based forecasting approach was developed to contrast the ability to predict the future occurrence of bleeds based on individual (i) pharmacokinetic, (ii) bleeding, and (iii) pharmacokinetic, bleeding and covariate information using observed data from the Long‐Term Efficacy Open‐Label Program in Severe Hemophilia A Disease (LEOPOLD) clinical trials (172 severe hemophilia A patients taking prophylactic treatment). The predictive performance assessed by the area under receiver operating characteristic (ROC) curves was 0.67 (95% confidence interval (CI), 0.65–0.69), 0.78 (95% CI, 0.76–0.80), and 0.79 (95% CI, 0.77–0.81) for patients ≥ 12 years when using pharmacokinetics, bleeds, and all data, respectively, suggesting that individual bleed information adds value to the optimization of prophylactic dosing regimens in severe hemophilia A. Further steps to optimize the proposed tool for factor VIII dose adaptation in the clinic are required.
Collapse
Affiliation(s)
- João A Abrantes
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | | | | | - Elisabet I Nielsen
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Siv Jönsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| |
Collapse
|
34
|
Shah A, Solms A, Wiegmann S, Ahsman M, Berntorp E, Tiede A, Iorio A, Mancuso ME, Zhivkov T, Lissitchkov T. Direct comparison of two extended-half-life recombinant FVIII products: a randomized, crossover pharmacokinetic study in patients with severe hemophilia A. Ann Hematol 2019; 98:2035-2044. [PMID: 31236667 PMCID: PMC6700041 DOI: 10.1007/s00277-019-03747-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/15/2019] [Indexed: 11/25/2022]
Abstract
BAY 94-9027 is an extended-half-life, recombinant factor VIII (rFVIII) product conjugated with a 60-kDa branched polyethylene glycol (PEG) molecule indicated for use in previously treated patients (aged ≥ 12 years) with hemophilia A. This randomized, open-label, two-way crossover study compared the pharmacokinetics (PK) of BAY 94-9027 and rFVIII Fc fusion protein (rFVIIIFc) in patients with hemophilia A. Patients aged 18-65 years with FVIII < 1% and ≥ 150 exposure days to FVIII were randomized to receive intravenous single-dose BAY 94-9027 60 IU/kg followed by rFVIIIFc 60 IU/kg or vice versa, with ≥ 7-day wash-out between doses. FVIII activity was measured by one-stage assay. PK parameters, including area under the curve from time 0 to the last data point (AUClast, primary parameter), half-life, and clearance were calculated. Eighteen patients were randomized and treated. No adverse events were observed. In the analysis set excluding one outlier, geometric mean (coefficient of variation [%CV, 95% confidence interval {CI}]) AUClast was significantly higher for BAY 94-9027 versus rFVIIIFc (2940 [37.8, 2440-3550] IU h/dL versus 2360 [31.8, 2010-2770] IU h/dL, p = 0.0001). A population PK model was developed to simulate time to reach FVIII threshold levels; median time to 1 IU/dL was approximately 13 h longer for BAY 94-9027 versus rFVIIIFc after a single infusion of 60 IU/kg. In conclusion, BAY 94-9027 had a superior PK profile versus rFVIIIFc. ClinicalTrials.gov : NCT03364998.
Collapse
Affiliation(s)
| | | | | | | | - Erik Berntorp
- Centre for Thrombosis and Haemostasis, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence and Impact, and Department of Medicine, McMaster University, Hamilton, Canada
| | - Maria Elisa Mancuso
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | | | | |
Collapse
|
35
|
Abrantes JA, Solms A, Garmann D, Nielsen EI, Jönsson S, Karlsson MO. Relationship between factor VIII activity, bleeds and individual characteristics in severe hemophilia A patients. Haematologica 2019; 105:1443-1453. [PMID: 31371418 PMCID: PMC7193498 DOI: 10.3324/haematol.2019.217133] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 07/23/2019] [Indexed: 01/19/2023] Open
Abstract
Pharmacokinetic-based prophylaxis of replacement factor VIII (FVIII) products has been encouraged in recent years, but the relationship between exposure (factor VIII activity) and response (bleeding frequency) remains unclear. The aim of this study was to characterize the relationship between FVIII dose, plasma FVIII activity, and bleeding patterns and individual characteristics in severe hemophilia A patients. Pooled pharmacokinetic and bleeding data during prophylactic treatment with BAY 81-8973 (octocog alfa) were obtained from the three LEOPOLD trials. The population pharmacokinetics of FVIII activity and longitudinal bleeding frequency, as well as bleeding severity, were described using non-linear mixed effects modeling in NONMEM. In total, 183 patients [median age 22 years (range, 1-61); weight 60 kg (11-124)] contributed with 1,535 plasma FVIII activity observations, 633 bleeds and 11 patient/study characteristics [median observation period 12 months (3.1-13.1)]. A parametric repeated time-to-categorical bleed model, guided by plasma FVIII activity from a 2-compartment population pharmacokinetic model, described the time to the occurrence of bleeds and their severity. Bleeding probability decreased with time of study, and a bleed was not found to affect the time of the next bleed. Several covariate effects were identified, including the bleeding history in the 12-month pre-study period increasing the bleeding hazard. However, unexplained inter-patient variability in the phenotypic bleeding pattern remained large (111%CV). Further studies to translate the model into a tool for dose individualization that considers the individual bleeding risk are required. Research was based on a post-hoc analysis of the LEOPOLD studies registered at clinicaltrials.gov identifiers: 01029340, 01233258 and 01311648.
Collapse
Affiliation(s)
- João A Abrantes
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | | | | | - Elisabet I Nielsen
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Siv Jönsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| |
Collapse
|
36
|
Morfini M, Farrugia A. Pharmacokinetic and safety considerations when switching from standard to extended half-life clotting factor concentrates in hemophilia. Expert Rev Hematol 2019; 12:883-892. [DOI: 10.1080/17474086.2019.1645002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Massimo Morfini
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Italian Association of Haemophilia Centres (AICE), Milan, Italy
| | - Albert Farrugia
- Faculty of Medicine, Dentistry & Health Sciences, University of Western Australia, Crawley, Australia
| |
Collapse
|
37
|
Strategies for Individualized Dosing of Clotting Factor Concentrates and Desmopressin in Hemophilia A and B. Ther Drug Monit 2019; 41:192-212. [DOI: 10.1097/ftd.0000000000000625] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
38
|
Megías-Vericat J, Bonanad S, Haya S, Cid A, Marqués M, Monte E, Pérez-Alenda S, Bosch P, Querol F, Poveda J. Bayesian pharmacokinetic-guided prophylaxis with recombinant factor VIII in severe or moderate haemophilia A. Thromb Res 2019; 174:151-162. [DOI: 10.1016/j.thromres.2018.12.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 12/17/2018] [Accepted: 12/31/2018] [Indexed: 01/19/2023]
|
39
|
Abstract
Hemophilia A (HA) and hemophilia B (HB) are the most common severe bleeding disorders. Replacement therapy, providing the missing coagulation factor, has been the mainstay of treatment both prophylactically and to treat bleeding. Despite widespread availability of safe and effective replacement therapy, patients with HA and HB continue to experience a tremendous burden of treatment, breakthrough bleeding, and progressive joint disease, as well as high rates of inhibitor development. These remaining challenges are now being addressed by incredible advances in bioengineering. Recombinant bioengineering has led to replacement therapies with easier modes of administration, decreased immunogenicity, increased efficacy, and extended half-lives. Emicizumab, a bispecific antibody that acts as a substitutive therapy for HA, has been approved for patients with and without inhibitors. Novel compounds are in development to exploit the natural balance of hemostasis by targeting the natural anticoagulants protein C, protein S, tissue factor pathway inhibitor, and antithrombin. The substitution and rebalancing therapies provide an opportunity for steady-state hemostatic control without exposure to immunogenic clotting factor proteins. As such, they may have broader applications outside those being investigated in the clinical trial programs.
Collapse
|
40
|
Yoneyama K, Schmitt C, Kotani N, Levy GG, Kasai R, Iida S, Shima M, Kawanishi T. A Pharmacometric Approach to Substitute for a Conventional Dose-Finding Study in Rare Diseases: Example of Phase III Dose Selection for Emicizumab in Hemophilia A. Clin Pharmacokinet 2018; 57:1123-1134. [PMID: 29214439 PMCID: PMC6061395 DOI: 10.1007/s40262-017-0616-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Emicizumab (ACE910) is a bispecific antibody mimicking the cofactor function of activated coagulation factor VIII. In phase I-I/II studies, emicizumab reduced the bleeding frequency in patients with severe hemophilia A, regardless of the presence of factor VIII inhibitors, at once-weekly subcutaneous doses of 0.3, 1, and 3 mg/kg. METHODS Using the phase I-I/II study data, population pharmacokinetic and repeated time-to-event (RTTE) modeling were performed to quantitatively characterize the relationship between the pharmacokinetics of emicizumab and reduction in bleeding frequency. Simulations were then performed to identify the minimal exposure expected to achieve zero bleeding events for 1 year in at least 50% of patients and to select the dosing regimens to be tested in phase III studies. RESULTS The RTTE model adequately predicted the bleeding onset over time as a function of plasma emicizumab concentration. Simulations suggested that plasma emicizumab concentrations of ≥ 45 μg/mL should result in zero bleeding events for 1 year in at least 50% of patients. This efficacious exposure provided the basis for selecting previously untested dosing regimens of 1.5 mg/kg once weekly, 3 mg/kg every 2 weeks, and 6 mg/kg every 4 weeks for phase III studies. CONCLUSIONS A pharmacometric approach guided the phase III dose selection of emicizumab in hemophilia A, without conducting a conventional dose-finding study. Phase III studies with the selected dosing regimens are currently ongoing. This case study indicates that a pharmacometric approach can substitute for a conventional dose-finding study in rare diseases and will streamline the drug development process.
Collapse
MESH Headings
- Adolescent
- Adult
- Antibodies, Bispecific/administration & dosage
- Antibodies, Bispecific/pharmacokinetics
- Antibodies, Bispecific/therapeutic use
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- Antibodies, Monoclonal, Humanized/therapeutic use
- Dose-Response Relationship, Drug
- Factor VIII/antagonists & inhibitors
- Factor VIII/immunology
- Hemophilia A/drug therapy
- Hemorrhage/prevention & control
- Humans
- Male
- Models, Biological
- Rare Diseases/drug therapy
- Young Adult
Collapse
Affiliation(s)
- Koichiro Yoneyama
- Chugai Pharmaceutical Co., Ltd., 2-1-1 Nihonbashi-Muromachi, Chuo-ku, Tokyo, 103-8324, Japan.
| | | | - Naoki Kotani
- Chugai Pharmaceutical Co., Ltd., 2-1-1 Nihonbashi-Muromachi, Chuo-ku, Tokyo, 103-8324, Japan
| | | | - Ryu Kasai
- Chugai Pharmaceutical Co., Ltd., 2-1-1 Nihonbashi-Muromachi, Chuo-ku, Tokyo, 103-8324, Japan
| | - Satofumi Iida
- Chugai Pharmaceutical Co., Ltd., 2-1-1 Nihonbashi-Muromachi, Chuo-ku, Tokyo, 103-8324, Japan
| | | | - Takehiko Kawanishi
- Chugai Pharmaceutical Co., Ltd., 2-1-1 Nihonbashi-Muromachi, Chuo-ku, Tokyo, 103-8324, Japan
| |
Collapse
|
41
|
Shah A, Coyle T, Lalezari S, Fischer K, Kohlstaedde B, Delesen H, Radke S, Michaels LA. BAY 94-9027, a PEGylated recombinant factor VIII, exhibits a prolonged half-life and higher area under the curve in patients with severe haemophilia A: Comprehensive pharmacokinetic assessment from clinical studies. Haemophilia 2018; 24:733-740. [DOI: 10.1111/hae.13561] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2018] [Indexed: 11/28/2022]
Affiliation(s)
| | - T. Coyle
- TriHealth Cancer Institute; Cincinnati OH USA
| | - S. Lalezari
- Israel National Hemophilia Center; Chaim Sheba Medical Center; Tel-Hashomer, and Sackler School of Medicine; Tel-Aviv University; Israel
| | - K. Fischer
- Van Creveldkliniek; University Medical Center Utrecht; Utrecht University; Utrecht The Netherlands
| | | | | | | | | |
Collapse
|
42
|
Ragni MV, Croteau SE, Morfini M, Cnossen MH, Iorio A. Pharmacokinetics and the transition to extended half-life factor concentrates: communication from the SSC of the ISTH. J Thromb Haemost 2018; 16:1437-1441. [PMID: 29762905 DOI: 10.1111/jth.14153] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Indexed: 02/06/2023]
Abstract
Extended half-life proteins (EHL) are increasingly used in clinical practice, but there is no standardized approach to sampling, interpretation and implementation of pharmacokinetics (PK) data to maximize treatment benefit. The goal of EHL treatment is to attain a trough level sufficient to protect against spontaneous bleeds and reduce infusion frequency and limitations on individual activity and lifestyle. Performing classical PK assessments requires multiple blood samples, which is burdensome for patients and providers. Herein we review a population pharmacokinetic (popPK) approach to estimate individual PK parameters to transition patients from standard half-life (SHL) to EHL concentrates. We propose that a minimum of two to four post-infusion samples is sufficient to estimate individual PK profiles, with sufficient certainty to maintain factor levels above 1% and achieve bleed-free lifestyles. We also survey current PK use in patients transitioning to EHL, review key PK parameters and popPK models, and recommend an approach to using PK in patients initiating or switching to EHL.
Collapse
Affiliation(s)
- M V Ragni
- Department of Medicine, Division Hematology Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - S E Croteau
- Division of Hematology-Oncology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - M Morfini
- Italian Association of Haemophilia Centers, Florence, Italy
| | - M H Cnossen
- Department of Pediatric Hematology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - A Iorio
- Department of Health Research, Methods, Evidence and Impact, and Department of Medicine, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
43
|
Morfini M, Gherardini S. Pharmacokinetic-based prediction of real-life dosing of extended half-life clotting factor concentrates on hemophilia. Ther Adv Hematol 2018; 9:149-162. [PMID: 29899890 PMCID: PMC5992810 DOI: 10.1177/2040620718774258] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/09/2018] [Indexed: 01/12/2023] Open
Abstract
The improvement of clotting factor concentrates (CFCs) has undergone an impressive boost during the last six years. Since 2010, several new recombinant factor (rF)VIII/IX concentrates entered phase I/II/III clinical trials. The improvements are related to the culture of human embryonic kidney (HEK) cells, post-translational glycosylation, PEGylation, and co-expression of the fragment crystallizable (Fc) region of immunoglobulin (Ig)G1 or albumin genes in the manufacturing procedures. The extended half-life (EHL) CFCs allow an increase of the interval between bolus administrations during prophylaxis, a very important advantage for patients with difficulties in venous access. Although the inhibitor risk has not been fully established, phase III studies have provided standard prophylaxis protocols, which, compared with on-demand treatment, have achieved very low annualized bleeding rates (ABRs). The key pharmacokinetics (PK) parameter to tailor patient therapy is clearance, which is more reliable than the half-life of CFCs; the clearance considers the decay rate of the drug concentration-time profile, while the half-life considers only the half concentration of the drug at a given time. To tailor the prophylaxis of hemophilia patients in real-life, we propose two formulae (expressed in terms of the clearance, trough and dose interval between prophylaxis), respectively based on the one- and two-compartmental models (CMs), for the prediction of the optimal single dose of EHL CFCs. Once the data from the time decay of the CFCs are fitted by the one- or two-CMs after an individual PK analysis, such formulae provide to the treater the optimal trade-off among trough and time-intervals between boluses. In this way, a sufficiently long time-interval between bolus administration could be guaranteed for a wider class of patients, with a preassigned level of the trough. Finally, a PK approach using repeated dosing is discussed, and some examples with new EHL CFCs are shown.
Collapse
Affiliation(s)
| | - Stefano Gherardini
- Department of Physics and Astronomy, LENS, and
QSTAR, University of Florence, Sesto Fiorentino (Italy)
| |
Collapse
|
44
|
Dargaud Y, Negrier C, Rusen L, Windyga J, Georgiev P, Bichler J, Solomon C, Knaub S, Lissitchkov T, Klamroth R. Individual thrombin generation and spontaneous bleeding rate during personalized prophylaxis with Nuwiq®(human-cl rhFVIII) in previously treated patients with severe haemophilia A. Haemophilia 2018; 24:619-627. [DOI: 10.1111/hae.13493] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/19/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Y. Dargaud
- Hopital Cardiologique Louis Pradel; University of Lyon; Lyon France
| | - C. Negrier
- Hopital Cardiologique Louis Pradel; University of Lyon; Lyon France
| | | | - J. Windyga
- Department of Disorders of Haemostasis and Internal Medicine; Institute of Haematology and Transfusion Medicine; Warsaw Poland
| | - P. Georgiev
- Clinic of Haematology; University Multiprofile Hospital for Active Treatment “Sveti Georgi” and Medical University; Plovdiv Bulgaria
| | | | - C. Solomon
- Octapharma AG; Lachen Switzerland
- Department of Anesthesiology; Perioperative Care and General Intensive Care; Salzburg University Hospital; Paracelsus Medical University; Salzburg Austria
| | - S. Knaub
- Octapharma AG; Lachen Switzerland
| | - T. Lissitchkov
- Department of Clinical Haematology in Haemorrhagic Diathesis and Anaemia; Specialized Hospital for Active Treatment “Joan Pavel”; Sofia Bulgaria
| | - R. Klamroth
- Vivantes Klinikum im Friedrichshain; Berlin Germany
| |
Collapse
|
45
|
Hazendonk HCAM, van Moort I, Mathôt RAA, Fijnvandraat K, Leebeek FWG, Collins PW, Cnossen MH. Setting the stage for individualized therapy in hemophilia: What role can pharmacokinetics play? Blood Rev 2018; 32:265-271. [PMID: 29426727 DOI: 10.1016/j.blre.2018.01.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 01/16/2018] [Accepted: 01/23/2018] [Indexed: 02/06/2023]
Abstract
Replacement therapy with clotting factor concentrates (CFC) is the mainstay of treatment in hemophilia. Its widespread application has led to a dramatic decrease in morbidity and mortality in patients, with concomitant improvement of quality of life. However, dosing is challenging and costs are high. This review discusses benefits and limitations of pharmacokinetic (PK)-guided dosing of replacement therapy as an alternative for current dosing regimens. Dosing of CFC is now primarily based on body weight and based on its in vivo recovery (IVR). Benefits of PK-guided dosing include individualization of treatment with better targeting, more flexible blood sampling, increased insight into association of coagulation factor levels and bleeding, and potential overall lowering of overall costs. Limitations include a slight burden for the patient, and availability of closely collaborating, experienced clinical pharmacologists.
Collapse
Affiliation(s)
- H C A M Hazendonk
- Department of Pediatric Hematology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - I van Moort
- Department of Pediatric Hematology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - R A A Mathôt
- Hospital Pharmacy - Clinical Pharmacology, Academic Medical Center, Amsterdam, The Netherlands
| | - K Fijnvandraat
- Department of Pediatric Hematology, Academic Medical Center, Amsterdam, The Netherlands; Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands
| | - F W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - P W Collins
- Department of Haematology, School of Medicine, Cardiff University, United Kingdom
| | - M H Cnossen
- Department of Pediatric Hematology, Erasmus University Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands.
| | | |
Collapse
|
46
|
Dunn AL, Ahuja SP, Mullins ES. Real-world experience with use of Antihemophilic Factor (Recombinant), PEGylated for prophylaxis in severe haemophilia A. Haemophilia 2018; 24:e84-e92. [DOI: 10.1111/hae.13403] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2017] [Indexed: 11/28/2022]
Affiliation(s)
- A. L. Dunn
- Nationwide Children's Hospital and The Ohio State University School of Medicine; Columbus OH USA
| | - S. P. Ahuja
- Rainbow Babies & Children's Hospital; Cleveland OH USA
| | - E. S. Mullins
- Cincinnati Children's Hospital Medical Center; Cincinnati OH USA
| |
Collapse
|
47
|
Iorio A. Using pharmacokinetics to individualize hemophilia therapy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:595-604. [PMID: 29222309 PMCID: PMC6142544 DOI: 10.1182/asheducation-2017.1.595] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Prevention and treatment of bleeding in hemophilia requires that plasma clotting factor activity of the replaced factor exceeds a defined target level. Most clinical decisions in hemophilia are based on implicit or explicit application of pharmacokinetic measures. The large interindividual variability in pharmacokinetics of factor concentrates suggests that relying on the average pharmacokinetic characteristics of factor concentrates would not allow optimizing the treatment of individual patients; for example, adjusting the frequency of infusions and targeting a specific clotting factor activity level on a case-by-case basis. However, individual pharmacokinetic profiles are seldom assessed as part of routine clinical care. Population pharmacokinetics provide options for precise and convenient characterization of pharmacokinetics characteristics of factor concentrates, simplified individual pharmacokinetic profiling, and individualized dosing. Population pharmacokinetics allow for the incorporation of determinants of interpatient variability and reduces the need for extensive postinfusion plasma sampling. Barriers to the implementation of population pharmacokinetics are the need for concentrate-specific pharmacokinetic models, Bayesian calculation power, and specific expertise for production, validation, and appraisal of forecasted estimates. Population pharmacokinetics provide an important theoretical and practical contribution to tailoring the treatment of hemophilia. The need remains for prospective exploration of the clinical impact of tailoring hemophilia treatment based on individual pharmacokinetics, and for the systematic validation of existing software solutions and concentrate-specific models.
Collapse
Affiliation(s)
- Alfonso Iorio
- Department of Health Research, Methods, Evidence, and Impact, and
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
48
|
Iorio A, Blanchette V, Blatny J, Collins P, Fischer K, Neufeld E. Estimating and interpreting the pharmacokinetic profiles of individual patients with hemophilia A or B using a population pharmacokinetic approach: communication from the SSC of the ISTH. J Thromb Haemost 2017; 15:2461-2465. [PMID: 29119666 DOI: 10.1111/jth.13867] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Indexed: 01/19/2023]
Affiliation(s)
- A Iorio
- Department of Health Research, Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - V Blanchette
- Division of Hematology/Oncology, Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - J Blatny
- Department of Pediatric Hematology, University Hospital Brno, Brno, Czech Republic
| | - P Collins
- Arthur Bloom Haemophilia Centre, School of Medicine, University Hospital of Wales, Cardiff University, Cardiff, UK
| | - K Fischer
- Van Creveldkliniek, University Medical Center, Utrecht, the Netherlands
| | - E Neufeld
- St Jude Children's Research Hospital, Memphis, TN, USA
| |
Collapse
|
49
|
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.
Collapse
Affiliation(s)
- Massimo Morfini
- a Italian Association of Haemophilia Centres - AICE , Firenze , Italy
| |
Collapse
|
50
|
van den Berg HM. From treatment to prevention of bleeds: what more evidence do we need? Haemophilia 2017; 23:494-496. [DOI: 10.1111/hae.13256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 01/04/2023]
Affiliation(s)
- H. M. van den Berg
- Julius Centre for Health Sciences and Primary Care; University Hospital Utrecht; Utrecht Netherlands
| |
Collapse
|