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Takahashi M, Morita Y, Hayashi T, Higashihara T, Kawasaki K, Sato S, Yokose S, Sasaki S, Funakoshi K, Sasaki T, Zhou D, Ichinose A, Ohtsuka H, Ishibasi Y, Hatao F, Shimizu K, Isono N, Sasaki N, Kozai Y, Okada H, Chikasawa Y. A case of acquired hemophilia A after pancreaticoduodenectomy for distal cholangiocarcinoma. Biomed Rep 2023; 19:61. [PMID: 37614988 PMCID: PMC10442756 DOI: 10.3892/br.2023.1643] [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: 05/16/2023] [Accepted: 07/17/2023] [Indexed: 08/25/2023] Open
Abstract
Acquired hemophilia A (AHA) is a rare disease that results from factor VIII inhibitors causing abnormal coagulation, and certain cases may develop after highly invasive surgery. The present case study reports on a 68-year-old male patient who developed AHA after undergoing a subtotal stomach-preserving pancreatoduodenectomy for distal cholangiocarcinoma. The patient experienced complications after surgery, requiring reoperation on postoperative day (PD) 5 due to rupture of the Braun's enterostomy. On PD 6, angiography was performed after bleeding was detected in the jejunal limb, but hemostasis occurred spontaneously during the examination. Bleeding was observed again on PD 8 and direct surgical ligation was performed. On PD 14, bleeding recurred in the jejunal limb and angiography was performed to embolize the periphery of the second jejunal artery. During the procedure, the prothrombin time was normal, but only the activated partial thromboplastin time was prolonged. A close examination of the coagulation system revealed a decrease in factor VIII levels and the presence of factor VIII inhibitors, resulting in the diagnosis of AHA. Administration of steroids was initiated on PD 15 and, in addition to daily blood transfusions, activated prothrombin complex concentrate was administered to achieve hemostasis. The patient was discharged from the intensive care unit on PD 36 but later developed an intractable labial fistula due to suture failure at the gastrojejunostomy site. As the use of factor VIII inhibitors continued despite the administration of steroids, cyclophosphamide (CPA) pulse therapy was added at PD 58. However, CPA was ineffective and the administration of rituximab was initiated on PD 98. After 12 courses of rituximab, the patient tested negative for factor VIII inhibitors on PD 219. On PD 289, labial fistula closure was performed with continuous replacement of factor VIII and the patient was discharged on PD 342.
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Affiliation(s)
- Makoto Takahashi
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Yasuhiro Morita
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Tatsuya Hayashi
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Taku Higashihara
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Keishi Kawasaki
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Shunsuke Sato
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Shota Yokose
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Shu Sasaki
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Kaoruko Funakoshi
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Takayoshi Sasaki
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Daren Zhou
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Akinori Ichinose
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Hideo Ohtsuka
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Yuji Ishibasi
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Fumihiko Hatao
- Department of Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Keiki Shimizu
- Department of Critical Care and Emergency Medicine, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Nobuo Isono
- Department of Plastic Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Naomi Sasaki
- Department of Nursing, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Yasuji Kozai
- Department of Hematology, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Haruka Okada
- Department of Pathology, Tokyo Metropolitan Tama Medical Center, Tokyo 183-8524, Japan
| | - Yushi Chikasawa
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo 183-8524, Japan
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Versloot O, Iserman E, Chelle P, Germini F, Edginton AN, Schutgens REG, Iorio A, Fischer K. Terminal half-life of FVIII and FIX according to age, blood group and concentrate type: Data from the WAPPS database. J Thromb Haemost 2021; 19:1896-1906. [PMID: 34013558 PMCID: PMC8361743 DOI: 10.1111/jth.15395] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/26/2021] [Accepted: 05/11/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Real-life data on pharmacokinetics of factor (F) VIII/IX concentrates, especially extended half-life (EHL), concentrates in large cohorts of persons with hemophilia are currently lacking. OBJECTIVES This cross-sectional study aimed to establish reference values for terminal half-life (THL) for FVIII/IX concentrates according to concentrate type, age, blood group and inhibitor history. PATIENTS/METHODS Data were extracted from the Web-Accessible Population Pharmacokinetics Service database. Groups were compared by nonparametric tests. THL was modelled according to patient characteristics and concentrate type. RESULTS Infusion data (n = 8022) were collected from 4832 subjects (including 2222 children) with severe hemophilia (age: 1 month-85 years; 89% hemophilia A; 34% using EHL concentrates, 9.8% with history of inhibitors). THL of FVIII-EHL was longer than of FVIII standard half-life (SHL; median 15.1 vs. 11.1 h). FVIII-THL was dependent on age, concentrate type, blood group, and inhibitor history. THL of FIX-EHL was longer than of FIX-SHL (median 106.9 vs. 36.5 h). FIX-THL increased with age until 30 years and remained stable thereafter. FVIII-THL was shorter in subjects with blood group O. THL was decreased by 1.3 h for FVIII and 22 h for FIX in subjects with a positive inhibitor history. CONCLUSIONS We established reference values for FVIII/IX concentrates according to patient characteristics and concentrate type in a large database of hemophilia patients. These reference values may inform clinical practice (e.g., assessment of immune tolerance success), economic implications of procurement processes and value attribution of novel treatments (e.g., mimetics, gene therapy).
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Affiliation(s)
- Olav Versloot
- Van CreveldkliniekUniversity Medical Centre UtrechtUtrechtThe Netherlands
| | - Emma Iserman
- Department of Health Research Methods, Evidence, and ImpactMcMaster UniversityHamiltonONCanada
| | - Pierre Chelle
- School of PharmacyUniversity of WaterlooWaterlooONCanada
| | - Federico Germini
- Department of Health Research Methods, Evidence, and ImpactMcMaster UniversityHamiltonONCanada
- Department of MedicineMcMaster UniversityHamiltonONCanada
| | | | | | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and ImpactMcMaster UniversityHamiltonONCanada
- Department of MedicineMcMaster UniversityHamiltonONCanada
- McMaster‐Bayer Endowed Research Chair in Clinical Epidemiology of Congenital bleeding DisordersDepartment of MedicineMcMasterHamiltonONCanada
| | - Kathelijn Fischer
- Van CreveldkliniekUniversity Medical Centre UtrechtUtrechtThe Netherlands
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Pabinger I, Mamonov V, Windyga J, Engl W, Doralt J, Tangada S, Spotts G, Ewenstein B. Results of a randomized phase III/IV trial comparing intermittent bolus versus continuous infusion of antihaemophilic factor (recombinant) in adults with severe or moderately severe haemophilia A undergoing major orthopaedic surgery. Haemophilia 2021; 27:e331-e339. [PMID: 33772963 PMCID: PMC8252548 DOI: 10.1111/hae.14219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 12/01/2022]
Abstract
Introduction In patients with haemophilia A undergoing surgery, factor VIII (FVIII) replacement therapy by continuous infusion (CI) may offer an alternative to bolus infusion (BI). Aim To compare the perioperative haemostatic efficacy and safety of antihaemophilic factor (recombinant) (ADVATE®; Baxalta US Inc., a Takeda company, Lexington, MA, USA) CI or BI administration. Methods In this multicentre, phase III/IV, controlled study (NCT00357656), 60 previously treated adult patients with severe or moderately severe disease undergoing elective unilateral major orthopaedic surgery (knee replacement, n = 48; hip surgery, n = 4; other, n = 8) requiring drain placement were randomized to receive antihaemophilic factor (recombinant) CI (n = 29) or BI (n = 31) through postoperative day 7. Primary outcome measure was cumulative packed red blood cell (PRBC)/blood volume in the drainage fluid within 24 h after surgery, used to establish non‐inferiority of CI to BI. Results CI:BI ratio of cumulative PRBC volume in the 24‐h drainage fluid was 0.92 (p‐value <.001 for non‐inferiority; 95% confidence interval, 0.82–1.05). Total antihaemophilic factor (recombinant) dose per kg body weight received in the combined trans‐ and postoperative periods was similar with CI and BI to maintain targeted FVIII levels during/after surgery. Treatment‐related adverse events (AEs) were reported in five patients treated by CI (eight events) and five treated by BI (six events), including two serious AEs in each arm. Conclusion CI administration of antihaemophilic factor (recombinant) is a viable alternative to BI in patients with haemophilia A undergoing major orthopaedic surgery, providing comparable efficacy and safety.
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Affiliation(s)
| | | | - Jerzy Windyga
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Werner Engl
- Baxalta Innovations GmbH, a Takeda company, Vienna, Austria
| | | | - Srilatha Tangada
- Baxalta US Inc., a Takeda company, Cambridge, Massachusetts, USA
| | - Gerald Spotts
- Baxalta US Inc., a Takeda company, Cambridge, Massachusetts, USA
| | - Bruce Ewenstein
- Baxalta US Inc., a Takeda company, Cambridge, Massachusetts, USA
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Holme PA, Tjønnfjord GE, Batorova A. Continuous infusion of coagulation factor concentrates during intensive treatment. Haemophilia 2017; 24:24-32. [PMID: 28873263 DOI: 10.1111/hae.13331] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2017] [Indexed: 01/12/2023]
Abstract
In clinical management of bleeds and surgical procedures in patients suffering from bleeding disorders either repetitive bolus injections (BI) or continuous infusion (CI) can be used for coagulation factor replacement. Continuous infusion seems to be an attractive route of administration and may be considered if replacement therapy is required for more than 3 days. The strongest argument favouring continuous infusion is its superiority in providing the patient with a safe and constant level of the deficient coagulation factor by balancing input with clearance. Furthermore, several studies have shown that coagulation factor consumption may be reduced by CI compared to repetitive bolus injections (BI) since unnecessary peaks of factor level are avoided. Concerns have been raised whether continuous infusion of coagulation concentrates is associated with an increased risk of developing inhibitors. However, available data have so far not shown an increased risk for inhibitor development in severe haemophilia patients with more than 50 exposure days of coagulation factor concentrates. Further, previously reported complications when using CI such as phlebitis at the infusion site and pump failure are nowadays very seldom seen when small amounts of heparin are added to the infusion bag, and increased quality of the pumps are available. Over the last decades, numerous reports have confirmed CI to be a safe and effective mode of coagulation factor replacement even in the most challenging surgical procedures, such as total joint arthroplasties.
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Affiliation(s)
- P A Holme
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - G E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - A Batorova
- Faculty of Medicine of Comenius University, Department of Haematology and Transfusion Medicine, National Haemophilia Centre, University Hospital, Bratislava, Slovakia
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