Rate and appropriateness of polypharmacy in older patients with hemophilia compared with age-matched controls

Safety and efficacy of combined dual antiplatelet therapy and factor VIII prophylaxis in patients with haemophilia A after acute coronary syndrome

INTRODUCTION

The increased life expectancy of patients with haemophilia A (HA) has led to a growing prevalence of cardiovascular risk factors and events. There is still scarce evidence on the safety and appropriate duration of dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS) in HA patients.

AIM

We describe our experience on the clinical management of Italian HA patients after ACS.

METHODS

Nine patients with congenital HA treated with DAPT after a revascularization procedure performed for ACS have been enrolled and followed at the Angelo Bianchi Bonomi Haemophilia and Thrombosis Center in Milan between 2005 and September 2022. The safety and efficacy of DAPT with or without FVIII prophylaxis were assessed.

RESULTS

Ten ACS events occurred in the nine HA patients (four mild and five severe). All events were treated with percutaneous transluminal coronary angioplasty with deployment of 1 to 3 drug-eluting stents followed by DAPT for 1-12 months. All patients except one were treated with FVIII prophylaxis during DAPT aimed at achieving FVIII trough levels ≥20-30 IU/dL. DAPT was effective in all cases in preventing early ACS recurrence, with only a late recurrence. We observed two clinically relevant non-major bleeds (one in a patient without FVIII prophylaxis) and three minor bleeds. No venous thrombosis occurred.

CONCLUSION

The long-term secondary antithrombotic prevention consisting of DAPT and FVIII prophylaxis achieving a trough level of 20-30 IU/dL can be effective and safe in HA patients.

Multimorbidities and polypharmacy in ageing hemophilia patients

Aim: The aim of the study was to investigate whether multimorbidities, comorbidities, and therefore polypharmacy increase with age in hemophilia A and B patients followed in Ege University Adult Hemophilia and Thrombosis Center. Materials and Methods: Adult hemophilia A and B patients were retrospectively evaluated. Patients'demographic data, medical information about hemophilic arthropathy, viral infections hepatitis C virus (HCV), body mass index (BMI), smoking and alcohol consumption, concomitant diseases, and all medications except factor replacement therapy were analyzed. Polypharmacy was defined as ≥5 drug use. Patients were compared by dividing into two groups: ≤55 years and >55 years. Results: A total of 230 patients were evaluated (189 hemophilia A, 41 hemophilia B). There were 191 patients in ≤55 years (83%), and 39 patients in >55 years age groups (17%). The most common diseases in hemophilia patients were hypertension (19.5%), diabetes mellitus (10%), and gastroesophageal reflux disease-chronic gastritis (5.2%). The most common drugs that patients use regularly were non-steroidal anti-inflammatory drugs (14.3%), proton pump inhibitors (12.1%), and oral antidiabetics (9.5%). The number of diseases not related to hemophilia (multimorbidity) and polypharmacy in hemophilia patients aged >55 years was significantly higher than those aged

Polypharmacy and medication regimen complexity in older patients with hemophilia or von willebrand disease: the M'HEMORRH-AGE study

BACKGROUND

In older patients, multiple chronic conditions lead topolypharmacy which is associated with a higher risk of adverse drug events. Nowadays, the medication exposure of older patients with bleeding disorders has been poorly explored.

AIM

The aim of this study was to assess the prevalence of polypharmacy and the medication regimen complexity in older community-dwelling patients with hemophilia or von Willebrand Disease (VWD).

METHOD

The M'HEMORRH-AGE study (Medication in AGEd patients with HEMORRHagic disease) is a multicenter prospective observational study. Community-dwelling patients over 65 years with hemophilia or VWD were included in the study. The rate of polypharmacy (use of 5 to 9 drugs daily) and excessive polypharmacy (use of 10 or more medications daily) was assessed. The complexity of prescribed medication regimens was assessed using the Medication Regimen Complexity Index (MRCI).

RESULTS

Overall, 142 older community-dwelling patients with hemophilia (n = 89) or VWD (n = 53) were included (mean age: 72.8 (5.8) years). Prevalence of polypharmacy and excessive polypharmacy were 40.8% and 17.6%, respectively. The mean MRCI score was 16.9 (6.1). The mean MRCI score related to bleeding disorders medications was 6.9 (1.1). There was no significant difference between older hemophilia patients and VWD patients.

CONCLUSION

The M'HEMORRH-AGE study showed that more than half of older community-dwelling patients were affected by polypharmacy. In addition, the high medication regimen complexity in this older population suggests that interventions focusing on medication review and deprescribing should be conducted to reduce polypharmacy with its negative health-related outcomes.

Evaluation of the U.S. Adherence Questionnaires VERITAS-PRO and VERITAS-PRN for Use in Patients with Hemophilia in the German Healthcare System

AIM

 Since the U.S. adherence instruments VERITAS-PRO and VERITAS-PRN were developed in another healthcare system, we assumed that they are not appropriate for the German solidarity healthcare system. This study aims to evaluate the relevance of these instruments for the German healthcare system both by people with hemophilia (PWH) and by healthcare professionals (HCP).

METHODS

 A total of 50 PWH (23 adult hemophilia patients and 27 parents of children with hemophilia) and 25 HCP rated the relevance of the single items of the VERITAS-PRO and VERITAS-PRN on a 5-point Likert scale. In addition, both groups were asked to make suggestions for additional adherence questions. To investigate the relevance of these instruments, the accordance between the raters' evaluations was determined calculating the content validity index (CVI) and the content validity ratio (CVR) based on the critical values of the CVR (CVR_critical) to exclude chance and subjectivity.

RESULTS

 CVI (CVR) calculations revealed three (5) "very important" items for PWH and six (11) items for HCP. Only two (3) "very important" items were evaluated by both groups. Four domains were considered not important by both groups. Six PWH made 14 suggestions and 14 HCP made 24 suggestions for additional adherence questions.

CONCLUSION

 VERITAS-PRO and VERITAS-PRN have only very limited benefits for the German healthcare system. Since nonadherence has a great impact on the morbidity of PWH and on the costs for the healthcare system, there is a need for adherence instruments that are adapted to the specific needs of PWH in the German healthcare system.

Aging with Hemophilia: The Challenge of Appropriate Drug Prescription

In high-income countries persons with severe hemophilia (PWH) A and B are aging, like their age-matched peers without hemophilia from the general population. Aging is associated not only with the comorbidities stemming from their inherited bleeding disorder (arthropathy, chronic viral infections such as hepatitis and AIDS) but also with the multiple chronic ailments associated with aging (cancer, cardiovascular disease, COPD). Multimorbidity is inevitably associated with polypharmacy, i.e., the chronic daily intake of at least five drugs, and with the related risk of severe adverse events associated with the use of inappropriate drugs and drug-drug interactions. Information on the pattern of drug prescription and usage by PWH is relatively scanty, but on the whole, the available data indicate that the rate of polypharmacy, as well as the risk of drug-drug interaction, is relatively low in PWH and better than that in their age peers without hemophilia followed by general practitioners. It is believed that this advantage results from the collaborative coordination on drug prescribing exerted, through their integration with practitioners and organ specialists, by specialized hemophilia treatment centers in the frame of comprehensive care programs. However, the available cross-sectional data were mainly obtained in relatively young PWH, so that there is a need to obtain more accurate data from the ongoing prospective studies that are being carried out in more and more progressively aging PWH.

Haemophilia and ageing

Advances in the development of effective and safe treatments for haemophilia over the last 50 years have resulted in a significant increase in the life expectancy of persons with haemophilia (PWH). The management of this new cohort of middle-aged and elderly PWH is challenging because of the opposing risks of haemophilia and age-related cardiovascular disease and malignancy. Furthermore, this cohort of ageing PWH has the additional comorbidities of human immunodeficiency virus/hepatitis C and chronic haemophilic arthropathy. This article reviews the prevalence, underlying mechanisms and treatment strategies for managing these comorbidities. International collaboration is essential for registry data and further prospective trials to inform optimal evidence-based management for this rare disorder in the future.