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Xu Y, Wang Y, Wu R, Zheng C, Zhang L, Xu W, Feng X, Wang H, Cao X, He L, Xue T, Jin M, Xie B, Ling J, Sun L, Su R, Cheng H, Fang Y, Poon MC, Liu W, Zhang L, Xue F, Yang R. Reduced doses of emicizumab achieve good efficacy: Results from a national-wide multicentre real-world study in China. Haemophilia 2024; 30:959-969. [PMID: 38853005 DOI: 10.1111/hae.15062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/13/2024] [Accepted: 04/19/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION Reduced doses of emicizumab improve the affordability among patients in developing countries. However, the relationship between variant dose selection and efficacy in the real world of China is still unclear. AIM This study aimed to investigate the efficacy and safety of emicizumab especially in those on reduced dose regimens in a real-world setting. METHODS We carried out a multicentre study from 28 hospitals between June 2019 and June 2023 in China and retrospectively analysed the characteristics including demographics, diagnosis, treatment, bleeding episodes, and surgical procedures. RESULTS In total, 127 patients with haemophilia A, including 42 with inhibitors, were followed for a median duration of 16.0 (IQR: 9.0-30.0) months. Median age at emicizumab initiation was 2.0 (IQR: 1.0-4.0) years. Median (IQR) consumption for loading and maintenance was 12.0 (8.0-12.0) and 4.2 (3.0-6.0) mg/kg/4 weeks, respectively. While on emicizumab, 67 (52.8%) patients had no bleeds, whereas 60 (47.2%) patients had any bleeds, including 26 with treated bleeds. Compared to previous treatments, patients on emicizumab had significantly decreased annualized bleeding rate, annualized joint bleeding rate, target joints and intracerebral haemorrhage. Different dosages had similar efficacy except the proportion of patients with treated spontaneous bleeds and target joints. Adverse events were reported in 12 (9.4%) patients. Postoperative excessive bleeding occurred following two of nine procedures. CONCLUSION This is the largest study describing patients with HA receiving emicizumab prophylaxis on variant dose regimens in China. We confirmed that nonstandard dose is efficacious and can be considered where full-dose emicizumab is ill affordable.
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Affiliation(s)
- Yuan Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Ying Wang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Shenzhen, China
| | - Runhui Wu
- Hematology Oncology Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Changcheng Zheng
- Department of Hematology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Li Zhang
- Department of Hematology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Weiqun Xu
- Division/Center of Pediatric Hematology-Oncology, the Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoqin Feng
- Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hua Wang
- Department of Hematology and Oncology, Xi'an Children's Hospital, Xi'an, China
| | - Xiangshan Cao
- Department of Hematology, Suzhou BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Suzhou, China
| | - Liya He
- Department of Pediatric, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | | | - Mingwei Jin
- Pediatrics, Xuzhou Star Hospital, Xuzhou, China
| | - Bingshou Xie
- Department of Hematology, Wenzhou People's Hospital, Wenzhou, China
| | - Jing Ling
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, China
| | - Lirong Sun
- Department of Pediatrics, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Rui Su
- Department of Hematology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Hongbo Cheng
- Department of Hematology, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, China
| | - Yongjun Fang
- Department of Hematology/Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Man-Chiu Poon
- Departments of Medicine, Paediatrics and Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
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Klukowska A, Sidonio RF, Young G, Mancuso ME, Álvarez-Román MT, Bhatnagar N, Jansen M, Knaub S. Simoctocog alfa (Nuwiq ®) in children: early steps in life's journey for people with severe hemophilia A. Ther Adv Hematol 2024; 15:20406207241245511. [PMID: 38737006 PMCID: PMC11085023 DOI: 10.1177/20406207241245511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/20/2024] [Indexed: 05/14/2024] Open
Abstract
People with severe hemophilia A usually experience their first bleed early in life. In children with severe hemophilia A, primary prophylaxis is recommended to prevent recurrent and potentially life-threatening bleeds that significantly impact day-to-day life. Factor VIII (FVIII) prophylaxis is well-established in children and has been shown to reduce the development of hemophilic arthropathy. However, a major challenge of FVIII therapy is the development of neutralizing anti-FVIII antibodies (FVIII inhibitors). Simoctocog alfa (Nuwiq®) is a human cell line-derived recombinant FVIII (rFVIII) whose immunogenicity, efficacy, and safety have been studied in 167 children with severe hemophilia A across two prospective clinical trials and their long-term extensions. In 105 previously untreated children, the inhibitor rate of 16.2% for high-titer inhibitors (26.7% for all inhibitors) was lower than published rates for hamster cell line-derived rFVIII products. There was no inhibitor development in previously untreated children with non-null F8 mutations and in previously treated children. In a case series of 10 inhibitor patients, 8 (80%) underwent successful immune tolerance induction with simoctocog alfa with a median time to undetectable inhibitor of 3.5 months. In an analysis of 96 children who enrolled in the extension studies and received long-term simoctocog alfa prophylaxis for up to 5 years, median spontaneous, joint, and total annualized bleeding rates were 0.3, 0.4, and 1.8, respectively. No thromboembolisms were reported in any of the 167 children, and there were no treatment-related deaths. Optimal care of children should consider several factors, including minimization of inhibitor development risk, maintaining tolerance to FVIII, highly effective bleed prevention and treatment, safety, and impact on long-term outcomes such as bone and joint health. In this context we review the pediatric clinical data and ongoing studies with simoctocog alfa.
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Affiliation(s)
- Anna Klukowska
- Haemostasis Group of the Polish Society of Haematology and Transfusiology, 14 Indira Gandhi Street, Warsaw 02-776, Poland
| | - Robert F. Sidonio
- Hemophilia of Georgia Center for Bleeding and Clotting Disorders, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Guy Young
- Hemostasis and Thrombosis Center, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Humanitas University, Pieve Emanuele, Italy
| | | | - Neha Bhatnagar
- Oxford Haemophilia and Thrombosis Comprehensive Care Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Martina Jansen
- Clinical Research and Development, Octapharma Pharmazeutika Produktionsges m.b.H., Vienna, Austria
| | - Sigurd Knaub
- Clinical Research and Development, Octapharma AG, Lachen, Switzerland
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Giacometto PC, Bavaresco MT, Alvares-Teodoro J, Camelo RM. Cholecystectomy in a man with hemophilia A and inhibitor on emicizumab prophylaxis: A case report. Hematol Transfus Cell Ther 2024; 46:201-204. [PMID: 36481198 DOI: 10.1016/j.htct.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/14/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- Paula Cella Giacometto
- Hospital Regional Universitário da Universidade Estadual de Maringá (HU UEM), Maringá, PR, Brazil; Centro de Hematologia e Hemoterapia do Paraná (HEMEPAR), Maringá, PR, Brazil
| | - Marcello Tortelli Bavaresco
- Hospital Regional Universitário da Universidade Estadual de Maringá (HU UEM), Maringá, PR, Brazil; Hospital Santa Casa de Maringá, Maringá, PR, Brazil; Faculdade de Medicina UniCesumar, Maringá, PR, Brazil
| | - Juliana Alvares-Teodoro
- Faculdade de Farmácia da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Ricardo Mesquita Camelo
- Faculdade de Farmácia da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.
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Gupta N, Dutta A, Ahmed B, Ross CR, S C, Dolan G, John MJ, Radhakrishnan N, Aggarwal S, Seth T, Kaul V, Shah V. Expert Opinions on the Management of Hemophilia A in India: The Role of Emicizumab. Cureus 2024; 16:e58941. [PMID: 38725780 PMCID: PMC11081140 DOI: 10.7759/cureus.58941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2024] [Indexed: 05/12/2024] Open
Abstract
Hemophilia A (HA) is a genetic disorder of hemostasis associated with a deficiency or reduced activity of clotting factor VIII (FVIII). This disorder remains unacceptably underdiagnosed in India. Early diagnosis and appropriate management of HA can substantially prevent morbidity and mortality. Currently, HA is managed with regular replacement therapy using standard or extended half-life FVIII concentrates or non-factor drug products. The challenges associated with FVIII concentrates include plateauing of drug effect, issues with its administration and adherence to treatment, breakthrough bleeds, and the development of inhibiting antibodies against administered clotting factors. Emicizumab is a bispecific antibody, launched in India in April 2019, for managing patients with HA. To investigate the role of emicizumab in Indian patients with HA, opinions were sought from 13 eminent hematologists and experts from India on the effectiveness of emicizumab in preventing all bleeds, spontaneous bleeds, perioperative bleeds, and intracranial hemorrhage; resolving target joints; and reducing the rate of hospitalizations and fatality associated with HA in children and adults, with or without inhibitors. The benefits of emicizumab over traditional FVIII concentrates include the subcutaneous route of delivery, less frequent dosing, and a lack of inhibitor development, in addition to providing sustained hemostasis without in-depth monitoring. It is a safe and effective management option for all HA patients, especially for patients with certain archetypes, such as those with inhibitors, those with high annualized bleed rates, those living far away from hemophilia care centers, pediatric patients and infants with intravenous access challenges, and those with a history of life-threatening bleeding events.
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Affiliation(s)
- Naresh Gupta
- Medicine and Surgery, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
- Haematology & Haemophilia, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, IND
| | - Anupam Dutta
- General Medicine, Assam Medical College and Hospital, Dibrugarh, IND
| | - Bilal Ahmed
- Pathology, Transfusion Medicine & Hemophilia, Government Medical College, Srinagar, IND
| | - Cecil R Ross
- Hematology, St. John's Medical College and Hospital, Bangalore, IND
| | - Chandrakala S
- Clinical Haematology, King Edward Memorial Hospital, Mumbai, IND
| | - Gerard Dolan
- Haematology, St. Thomas' Haemophilia Comprehensive Care Centre, Bournemouth, GBR
| | - M J John
- Clinical Hematology, Hemato-Oncology & Bone Marrow Transplant, Christian Medical College & Hospital, Ludhiana, IND
| | - Nita Radhakrishnan
- Hematology and Oncology, Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida, IND
| | | | - Tulika Seth
- Hematology, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
| | - Varun Kaul
- Pediatrics, Guru Gobind Singh Medical College & Hospital, Faridkot, IND
| | - Vijay Shah
- Pediatrics, Nirmal Hospital Pvt. Ltd., Surat, IND
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Kenet G, Fujii T. Safety of recombinant activated factor VII for treatment of breakthrough bleeds in patients with congenital haemophilia A and inhibitors receiving emicizumab prophylaxis: Review of the real-world evidence. Haemophilia 2024; 30:267-275. [PMID: 38291654 DOI: 10.1111/hae.14933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 12/20/2023] [Accepted: 01/02/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Emicizumab is used as a subcutaneous prophylaxis for prevention of bleeding episodes in patients with haemophilia A (HA) with and without inhibitors. While low bleeding rates were observed in clinical trials, patients still experience breakthrough bleeds (BTBs) with emicizumab in the real-world. Current guidelines recommend use of recombinant activated factor VII (rFVIIa) for treatment of BTBs in patients with inhibitors. Due to thrombotic events observed in the HAVEN 1 study, activated prothrombin complex concentrate (aPCC) should be used with caution. OBJECTIVES The objective of this review is to identify and discuss real-world data on the frequency of BTBs and the safety of concomitant rFVIIa use in patients with inhibitors on emicizumab prophylaxis. METHODS A search of the following databases was conducted on 15 July 2022: BIOSIS Previews® , Current Contents Search® , Embase® , MEDLINE® . Search terms included 'real world', 'haemophilia A', and 'emicizumab'. RESULTS AND CONCLUSIONS Eleven relevant publications were identified (seven original research articles and four congress abstracts). The frequency of BTBs specifically for HA patients with inhibitors was described in three publications with 5%-56% patients on emicizumab reporting ≥1 bleeding episode. Treatment of these BTBs appeared to be managed according to relevant guidelines. Importantly, no thrombotic complications occurred during concomitant rFVIIa use. Due to the nature of real-world studies, direct comparison of the results between studies is limited. However, real-world data show that BTBs in inhibitor patients during emicizumab prophylaxis can be safely treated with rFVIIa.
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Affiliation(s)
- Gili Kenet
- The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center and the Amalia Biron Research Institute of Thrombosis and Hemostasis, Tel Aviv University, Tel Hashomer, Israel
| | - Teruhisa Fujii
- Division of Blood Transfusion, Hiroshima University Hospital, Hiroshima, Japan
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Abdelgawad HAH, Foster R, Otto M. Nothing short of a revolution: Novel extended half-life factor VIII replacement products and non-replacement agents reshape the treatment landscape in hemophilia A. Blood Rev 2024; 64:101164. [PMID: 38216442 DOI: 10.1016/j.blre.2023.101164] [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: 08/30/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/14/2024]
Abstract
Hemophilia A, an X-linked genetic disorder, is characterized by a deficiency or dysfunction of clotting Factor VIII. The treatment landscape has substantially changed by introducing novel extended half-life factor VIII (EHL-FVIII) replacement therapies such as efanesoctocog Alfa and non-factor replacement therapy such as emicizumab. These agents signal a shift from treatments requiring multiple weekly infusions to advanced therapies with long half-lives, offering superior protection against bleeding and improving patient adherence and quality of life. While EHL-FVIII treatment might lead to inhibitor development in some patients, non-factor replacement therapy carries thrombotic risks. Therefore, ongoing research and the generation of robust clinical evidence remain vital to guide the selection of optimal and cost-effective first-line therapies for hemophilia A patients.
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Affiliation(s)
- Hussien Ahmed H Abdelgawad
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA; Department of Child Health, University of Arizona College of Medicine, Phoenix, AZ, USA.
| | - Rachel Foster
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Mario Otto
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA; Department of Child Health, University of Arizona College of Medicine, Phoenix, AZ, USA.
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Olasupo OO, Noronha N, Lowe MS, Ansel D, Bhatt M, Matino D. Non-clotting factor therapies for preventing bleeds in people with congenital hemophilia A or B. Cochrane Database Syst Rev 2024; 2:CD014544. [PMID: 38411279 PMCID: PMC10897951 DOI: 10.1002/14651858.cd014544.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Management of congenital hemophilia A and B is by prophylactic or on-demand replacement therapy with clotting factor concentrates. The effects of newer non-clotting factor therapies such as emicizumab, concizumab, marstacimab, and fitusiran compared with existing standards of care are yet to be systematically reviewed. OBJECTIVES To assess the effects (clinical, economic, patient-reported, and adverse outcomes) of non-clotting factor therapies for preventing bleeding and bleeding-related complications in people with congenital hemophilia A or B compared with prophylaxis with clotting factor therapies, bypassing agents, placebo, or no prophylaxis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, electronic databases, conference proceedings, and reference lists of relevant articles and reviews. The date of the last search was 16 August 2023. SELECTION CRITERIA Randomized controlled trials (RCTs) evaluating people with congenital hemophilia A or B with and without inhibitors, who were treated with non-clotting factor therapies to prevent bleeds. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed studies for eligibility, assessed risk of bias, and extracted data for the primary outcomes (bleeding rates, health-related quality of life (HRQoL), adverse events) and secondary outcomes (joint health, pain scores, and economic outcomes). We assessed the mean difference (MD), risk ratio (RR), 95% confidence interval (CI) of effect estimates, and evaluated the certainty of the evidence using GRADE. MAIN RESULTS Six RCTs (including 397 males aged 12 to 75 years) were eligible for inclusion. Prophylaxis versus on-demand therapy in people with inhibitors Four trials (189 participants) compared emicizumab, fitusiran, and concizumab with on-demand therapy in people with inhibitors. Prophylaxis using emicizumab likely reduced annualized bleeding rates (ABR) for all bleeds (MD -22.80, 95% CI -37.39 to -8.21), treated bleeds (MD -20.40, 95% CI -35.19 to -5.61), and annualized spontaneous bleeds (MD -15.50, 95% CI -24.06 to -6.94), but did not significantly reduce annualized joint and target joint bleeding rates (AjBR and AtjBR) (1 trial; 53 participants; moderate-certainty evidence). Fitusiran also likely reduced ABR for all bleeds (MD -28.80, 95% CI -40.07 to -17.53), treated bleeds (MD -16.80, 95% CI -25.80 to -7.80), joint bleeds (MD -12.50, 95% CI -19.91 to -5.09), and spontaneous bleeds (MD -14.80, 95% CI -24.90 to -4.71; 1 trial; 57 participants; moderate-certainty evidence). No evidence was available on the effect of bleed prophylaxis using fitusiran versus on-demand therapy on AtjBR. Concizumab may reduce ABR for all bleeds (MD -12.31, 95% CI -19.17 to -5.45), treated bleeds (MD -10.10, 95% CI -17.74 to -2.46), joint bleeds (MD -9.55, 95% CI -13.55 to -5.55), and spontaneous bleeds (MD -11.96, 95% CI -19.89 to -4.03; 2 trials; 78 participants; very low-certainty evidence), but not target joint bleeds (MD -1.00, 95% CI -3.26 to 1.26). Emicizumab prophylaxis resulted in an 11.31-fold increase, fitusiran in a 12.5-fold increase, and concizumab in a 1.59-fold increase in the proportion of participants with no bleeds. HRQoL measured using the Haemophilia Quality of Life Questionnaire for Adults (Haem-A-QoL) physical and total health scores was improved with emicizumab, fitusiran, and concizumab prophylaxis (low-certainty evidence). Non-serious adverse events were higher with non-clotting factor therapies versus on-demand therapy, with injection site reactions being the most frequently reported adverse events. Transient antidrug antibodies were reported for fitusiran and concizumab. Prophylaxis versus on-demand therapy in people without inhibitors Two trials (208 participants) compared emicizumab and fitusiran with on-demand therapy in people without inhibitors. One trial assessed two doses of emicizumab (1.5 mg/kg weekly and 3.0 mg/kg bi-weekly). Fitusiran 80 mg monthly, emicizumab 1.5 mg/kg/week, and emicizumab 3.0 mg/kg bi-weekly all likely resulted in a large reduction in ABR for all bleeds, all treated bleeds, and joint bleeds. AtjBR was not reduced with either of the emicizumab dosing regimens. The effect of fitusiran prophylaxis on target joint bleeds was not assessed. Spontaneous bleeds were likely reduced with fitusiran (MD -20.21, 95% CI -32.12 to -8.30) and emicizumab 3.0 mg/kg bi-weekly (MD -15.30, 95% CI -30.46 to -0.14), but not with emicizumab 1.5 mg/kg/week (MD -14.60, 95% CI -29.78 to 0.58). The percentage of participants with zero bleeds was higher following emicizumab 1.5 mg/kg/week (50% versus 0%), emicizumab 3.0 mg/kg bi-weekly (40% versus 0%), and fitusiran prophylaxis (40% versus 5%) compared with on-demand therapy. Emicizumab 1.5 mg/kg/week did not improve Haem-A-QoL physical and total health scores, EQ-5D-5L VAS, or utility index scores (low-certainty evidence) when compared with on-demand therapy at 25 weeks. Emicizumab 3.0 mg/kg bi-weekly may improve HRQoL measured by the Haem-A-QoL physical health score (MD -15.97, 95% CI -29.14 to -2.80) and EQ-5D-5L VAS (MD 9.15, 95% CI 2.05 to 16.25; 1 trial; 43 participants; low-certainty evidence). Fitusiran may result in improved HRQoL shown as a reduction in Haem-A-QoL total score (MD -7.06, 95% CI -11.50 to -2.62) and physical health score (MD -19.75, 95% CI -25.76 to -11.94; 1 trial; 103 participants; low-certainty evidence). The risk of serious adverse events in participants without inhibitors also likely did not differ following prophylaxis with either emicizumab or fitusiran versus on-demand therapy (moderate-certainty evidence). Transient antidrug antibodies were reported in 4% (3/80) participants to fitusiran, with no observed effect on antithrombin lowering. A comparison of the different dosing regimens of emicizumab identified no differences in bleeding, safety, or patient-reported outcomes. No case of treatment-related cancer or mortality was reported in any study group. None of the included studies assessed our secondary outcomes of joint health, clinical joint function, and economic outcomes. None of the included studies evaluated marstacimab. AUTHORS' CONCLUSIONS Evidence from RCTs shows that prophylaxis using non-clotting factor therapies compared with on-demand treatment may reduce bleeding events, increase the percentage of individuals with zero bleeds, increase the incidence of non-serious adverse events, and improve HRQoL. Comparative assessments with other prophylaxis regimens, assessment of long-term joint outcomes, and assessment of economic outcomes will improve evidence-based decision-making for the use of these therapies in bleed prevention.
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Affiliation(s)
- Omotola O Olasupo
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Canada
| | - Noella Noronha
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Canada
| | - Megan S Lowe
- Department of Health Sciences, McMaster University, Hamilton, Canada
| | | | - Mihir Bhatt
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Davide Matino
- Department of Internal Medicine, McMaster University, Hamilton, Canada
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Ocaña Gómez MÁ, Ferrer Machín A, Vera Cabrera M, Álvarez Tosco KI, Ríos de Paz M, de Dios García MD. [Efficacy and safety of prophylaxis with emicizumab in hemophilia A: A study of 13 patients]. Med Clin (Barc) 2024; 162:134-137. [PMID: 37599198 DOI: 10.1016/j.medcli.2023.07.024] [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: 04/10/2022] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION Emicizumab is the first non-replacement therapy for prophylaxis in severe hemophilia A. AIMS The principal aim of this study is to describe the results of our patients in prophylaxis with emicizumab, according to the usual clinical practice. MATERIAL AND METHODS Follow-up of 13 patients from the start of prophylaxis, recording of bleeding, surgeries, adverse reactions and the need or not for factor therapy. Plasma levels were measured at follow-up visits, the technique was coagulative in one stage, modified by 1:20 dilution. RESULTS Median plasma levels were 52.2mg [30.7-71.9]. Prophylaxis was safe and effective; only one spontaneous haemorrhage was recorded over time and no treatment was required. There were no thromboembolic events or serious hypersensitivity, anaphylaxis or anaphylactoid reactions. The incidence of injection site reactions was 8%. Perioperative management in minor interventions was carried out without adjuvant factorial therapy, in 2 major surgeries a dose of plasmatic FVIII concentrate was required in the patient with hemophilia A without inhibitor and FVII in the patient with inhibitor, and it was sufficient to stop the bleeding. CONCLUSION This study demonstrated emicizumab pharmacokinetics and its half life ensure optimal levels with prophylaxis treatment at doses established in the technical data sheet.
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Affiliation(s)
- M Ángeles Ocaña Gómez
- Servicio de Farmacia Hospitalaria, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Alejandro Ferrer Machín
- Servicio de Farmacia Hospitalaria, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Martín Vera Cabrera
- Servicio de Farmacia Hospitalaria, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España.
| | - Karen Ilenia Álvarez Tosco
- Servicio de Farmacia Hospitalaria, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Mario Ríos de Paz
- Servicio de Hematología, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - M Dolores de Dios García
- Servicio de Hematología, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
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Yada K, Ogiwara K, Shimonishi N, Nakajima Y, Soeda T, Kitazawa T, Nogami K. Emicizumab-mediated hemostatic function assessed by thrombin generation assay in an in vitro model of factor VIII-depleted thrombophilia plasma. Int J Hematol 2024; 119:109-118. [PMID: 38112996 DOI: 10.1007/s12185-023-03683-y] [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: 06/01/2023] [Revised: 11/09/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023]
Abstract
Patients with hemophilia A (PwHA) may have concurrent deficiency of representative anticoagulant proteins, protein (P)C, PS, and antithrombin (AT), which reduces bleeding frequency. However, emicizumab-driven hemostasis in PwHA with such thrombophilic potential remains unclarified. This study investigated the influence of natural anticoagulants on emicizumab-driven coagulation in HA model plasma. Various concentrations of PS and AT were added to PS-deficient plasma and AT-deficient plasma in the presence of anti-FVIII antibody (FVIIIAb; 10BU/mL). PC-deficient plasma was mixed with normal plasma at various concentrations in the presence of FVIIIAb. Emicizumab (50 µg/mL) was added to these thrombophilic HA model plasmas, prior to tissue factor/ellagic acid-triggered thrombin generation assays. Co-presence of emicizumab increased peak thrombin values (PeakTh) dependent on PS, AT, and PC concentrations. Maximum coagulation potentials in the PS-reduced HA model plasmas remained normal in the presence of emicizumab. PeakTh were close to normal in the presence of 50%AT irrespective of emicizumab, but were higher than normal in the presence of 25%AT. Addition of recombinant FVIIa (corresponding to an administered dose of 90 μg/kg) enhanced coagulation potential to normal levels. Our findings provide novel information on hemostatic regulation in emicizumab-treated PwHA with a possible thrombophilic disposition.
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Affiliation(s)
- Koji Yada
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan.
- Division of Hemophilia, National Hospital Organization Osaka National Hospital, Osaka, Japan.
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Japan
| | - Tetsuhiro Soeda
- Research Division, Chugai Pharmaceutical Co., Ltd, Kamakura, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
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10
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Andreeva TA, Zharkov PA, Zozulya NI, Zorenko VY, Konstantinova VN, Lavrentieva IN, Davydkin IL, Petrov VY, Polyanskaya TY, Soldatenkov VE, Shutov SA. [Methodological recommendations for surgical care in patients with hemophilia A receiving prophylactic therapy with emicizumab]. Khirurgiia (Mosk) 2024:3-20. [PMID: 38591217 DOI: 10.17116/hirurgia20240323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Methodological recommendations for surgical care in patients with hemophilia A receiving prophylactic therapy with emicizumab. Recommendations of the expert group. Moscow, 2024.
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Affiliation(s)
- T A Andreeva
- GBUZ "City Polyclinic #37", City Hemophilia Treatment Center, St. Petersburg, Russian Federation
| | - P A Zharkov
- FGBU "National Medical Research Center of Pediatric Hematology, Oncology and Immunology named after Dmitry Rogachev", St. Petersburg, Russia
| | - N I Zozulya
- FGBU "National Medical Research Center of Hematology", Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - V Y Zorenko
- FGBU "National Medical Research Center of Hematology", Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - V N Konstantinova
- GBUZ "City Polyclinic #37", City Hemophilia Treatment Center, St. Petersburg, Russian Federation
| | - I N Lavrentieva
- GBUZ "Morozov Children's City Clinical Hospital of the Moscow City Health Department", Moscow, Russian Federation
| | - I L Davydkin
- FGBOU VO "Samara State Medical University", Ministry of Health of the Russian Federation, Samara, Russian Federation
| | - V Y Petrov
- GBUZ "Morozov Children's City Clinical Hospital of the Moscow City Health Department", Moscow, Russian Federation
| | - T Yu Polyanskaya
- FGBU "National Medical Research Center of Hematology", Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - V E Soldatenkov
- FGBU "Russian Research Institute of Hematology and Transfusiology FMBA", St. Petersburg, Russian Federation
| | - S A Shutov
- FGBU "National Medical Research Center of Hematology", Ministry of Health of the Russian Federation, Moscow, Russian Federation
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11
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Castaman G, Peyvandi F, Kremer Hovinga JA, Schutgens RE, Robson S, Moreno K, Jiménez-Yuste V. Surgical Experience from the STASEY Study of Emicizumab Prophylaxis in People with Hemophilia A with Factor VIII Inhibitors. TH OPEN 2024; 8:e42-e54. [PMID: 38222041 PMCID: PMC10786707 DOI: 10.1055/s-0043-1777766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/28/2023] [Indexed: 01/16/2024] Open
Abstract
Background Guidelines surrounding emicizumab prophylaxis and perioperative treatment for people with hemophilia A (PwHA) with factor (F)VIII inhibitors undergoing surgeries are limited. The phase IIIb multicenter, single-arm STASEY study evaluated safety and tolerability of emicizumab prophylaxis in PwHA aged ≥12 years with FVIII inhibitors. This analysis assesses surgeries during study conduct, associated hemophilia medications, and postoperative bleeds (treated and untreated). Methods PwHA with FVIII inhibitors received emicizumab 3.0 mg/kg/week for 4 weeks, then 1.5 mg/kg/week until 2 years. Surgeries were managed and documented by treating physicians. Bleeds and treatments were recorded by physicians and participants. Results Forty-six participants had ≥1 on-study surgery, 37 underwent 56 minor surgeries, and 13 underwent 22 major surgeries. Four participants underwent both minor and major surgeries. Of 18 (81.8%) and 4 (18.2%) major surgeries managed with/without additional hemostatic medication, 33.3 and 25.0% were associated with a treated postoperative bleed, respectively. Of 24 (42.9%) and 32 (57.1%) minor surgeries managed with/without additional hemostatic medication, 15.6 and 25.0% were associated with a treated postoperative bleed, respectively. Recombinant activated FVII was the most common medication for prophylaxis and bleed treatment. There were no thrombotic microangiopathies (TMAs). One hypertrophic clot, considered unrelated to emicizumab, occurred following tooth extraction. Conclusion In this challenging population with a high bleeding risk, major surgeries were performed in PwHA receiving emicizumab with/without additional hemostatic medication. Postoperative bleeds occurred following 59.1% of major surgeries; 53.8% were treated. No arterial/venous thrombotic events or TMAs occurred due to concomitant emicizumab and bypassing agents. Trial registration This trial is registered at ClinicalTrials.gov (NCT03191799).
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Affiliation(s)
- Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Flora Peyvandi
- IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Johanna A. Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roger E.G. Schutgens
- Center for Benign Haematology, Thrombosis and Haemostasis Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Susan Robson
- PD Data Science, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Katya Moreno
- Global Product Development/Medical Affairs, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Víctor Jiménez-Yuste
- Department of Hematology, Hospital Universitario La Paz, Autónoma University, Madrid, Spain
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12
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Grabowska K, Grzelak M, Zhao LY, Płuciennik E, Pasieka Z, Kciuk M, Gielecińska A, Smakosz AK, Kałuzińska-Kołat Ż, Kołat D. Emicizumab as a Promising Form of Therapy for Type A Hemophilia - A Review of Current Knowledge from Clinical Trials. Curr Protein Pept Sci 2024; 25:719-737. [PMID: 38797909 DOI: 10.2174/0113892037294674240509094418] [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: 01/31/2024] [Revised: 04/05/2024] [Accepted: 04/16/2024] [Indexed: 05/29/2024]
Abstract
Hemophilia is a plasma bleeding disorder characterized by a deficiency of certain blood clotting factors. The most common forms of this disease, i.e., type A and type B, affect approximately 400,000 people worldwide. Without appropriate treatment ensuring the proper coagulation cascade, this disease may lead to serious disability. Minimizing patient discomfort is possible via replacement therapy, consisting of the substitution of a missing coagulation factor via intravenous administration. Frequent medication and the risk related to factor inhibitors are significant disadvantages, necessitating the improvement of current therapies or the development of novel ones. This review examines the humanized bispecific antibody Emicizumab which ensures hemostasis by mimicking the action of the coagulation factor VIII, a deficiency of which causes type A hemophilia. The paper outlines the topic and then summarizes available clinical trials on Emicizumab in type A hemophilia. Several interventional clinical trials have found Emicizumab to be effective in decreasing bleeding episodes and raising patient satisfaction among various hemophilia A populations. Current Emicizumab-related trials are forecast to be completed between 2024 and 2030, and in addition to congenital hemophilia A, the trials cover acquired hemophilia A and patients playing sports. Providing a more comprehensive understanding of Emicizumab may revolutionize the management of hemophilia type A and improve quality of life. Conclusively, Emicizumab is a gentler therapy owing to subcutaneous delivery and fewer injections, which reduces injection-site reactions and makes therapy less burdensome, ultimately decreasing hospital visits and indirect costs.
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Affiliation(s)
- Katarzyna Grabowska
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
| | - Michalina Grzelak
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
| | - Lin-Yong Zhao
- Department of General Surgery & Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy/Collaborative Innovation Center of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Elżbieta Płuciennik
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
| | - Zbigniew Pasieka
- Department of Biomedicine and Experimental Surgery, Medical University of Lodz, Narutowicza 60, 90-136, Lodz, Poland
| | - Mateusz Kciuk
- Department of Molecular Biotechnology and Genetics, University of Lodz, Banacha 12/16, 90-237, Lodz, Poland
| | - Adrianna Gielecińska
- Department of Molecular Biotechnology and Genetics, University of Lodz, Banacha 12/16, 90-237, Lodz, Poland
- Doctoral School of Exact and Natural Sciences, University of Lodz, Banacha 12/16, 90-237, Lodz, Poland
| | - Aleksander K Smakosz
- Department of Pharmaceutical Biology and Biotechnology, Wroclaw Medical University, 50-367, Wroclaw, Poland
| | - Żaneta Kałuzińska-Kołat
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
- Department of Biomedicine and Experimental Surgery, Medical University of Lodz, Narutowicza 60, 90-136, Lodz, Poland
| | - Damian Kołat
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
- Department of Biomedicine and Experimental Surgery, Medical University of Lodz, Narutowicza 60, 90-136, Lodz, Poland
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13
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López-Jaime FJ, Benítez O, Díaz Jordán BL, Montaño A, Coll J, Quintana París L, Gómez-Del Castillo Solano MDC. Expert opinion paper on the treatment of hemophilia a with emicizumab. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2023; 28:2166334. [PMID: 36636993 DOI: 10.1080/16078454.2023.2166334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Prophylaxis with emicizumab, a bispecific monoclonal antibody that mimics FVIII function, has shown encouraging results in clinical trials in terms of efficacy and safety. However, current experience is limited, and many areas of concern to clinicians have yet to be reviewed. AREAS COVERED This paper reviews the experience of hemophilia A patients treated with emicizumab based on the results of clinical trials and real-life studies. The authors place special emphasis on issues such as the management of these patients in situations of hemorrhage and/or surgical interventions, joint health or laboratory monitoring. EXPERT OPINION Treatment with emicizumab has been shown to improve joint health and reduce bleeding, of particular interest to patients with inhibitors and high bleeding rates. However, there are still concerns about its administration in neonates and previously untreated patients due to limited reported experience. Laboratory monitoring is not strictly necessary due to the stable pharmacokinetics emicizumab has been shown to exhibit, however, tests that globally assess hemostasis may be useful especially in cases of bleeding or surgery. The authors are also of the opinion that prophylaxis before minor surgery is not necessary and that major surgeries can be safely performed with additional prophylactic coagulation factor.Trial registration ClinicalTrials.gov identifier: NCT04431726..
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Affiliation(s)
| | - Olga Benítez
- Departamento de Hematología Experimental, VHIO Vall d'Hebron Instituto de Oncología, Hospital Universitario Vall d'Hebron, Barcelona, Spain.,Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | - Adrián Montaño
- Unidad de Hemostasia y Trombosis, Hospital Universitario Regional de Málaga, IBIMA, Málaga, Spain.,Universidad de Salamanca, Salamanca, Spain
| | - Julia Coll
- Servicio de Hematología, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Laura Quintana París
- Servicio de Hematología, Hospital Universitario de Gran Canaria Dr. Negrín, Gran Canaria, Spain
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14
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Lee MW, Cheong MA, Ng HJ, Tien SL, Lam JCM. Real-world data on the use of emicizumab in patients with haemophilia A with and without inhibitors in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:580-589. [PMID: 38920147 DOI: 10.47102/annals-acadmedsg.2023100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction Emicizumab is a bispecific monoclonal antibody that mimics the function of factor VIII by binding to factor IXa and factor X to achieve haemostasis in haemophilia A. The long half-life and subcutaneous mode of administration makes emicizumab a compelling treatment option for bleeding prophylaxis. There is still limited real-world data on its use and management considerations, especially during surgical procedures. The objective of the study is to describe the real-world experience of emicizumab in a cohort of adult and paediatric haemophilia A patients in Singapore, including its use in the periprocedural setting. Method This was an observational study conducted at the 2 main haemophilia treatment centres in Singapore. All haemophilia A patients who commenced treatment with emicizumab before 1 July 2022 were recruited. Results A total of 18 patients with haemophilia A were included in this study. Ten (55.6%) patients had active inhibitors. The median annual bleeding rate for all patients before emicizumab use was 4.5 events (interquartile range [IQR] 2.8-8.3) compared with 0 events (IQR 0-0) after emicizumab was commenced (P=0). There were no adverse events of venous or arterial thrombosis, thrombotic microangiopathy, or death. A total of 6 procedures in 5 patients were performed during the study period with no major bleeding complications. Conclusion Emicizumab effectively protects against bleeding in haemophilia A patients with and without inhibitors, including in children less than 12 years old. More studies are required to address clinical nuances, such as periprocedural management and the role of immune tolerance in patients with inhibitors on emicizumab.
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Affiliation(s)
- Ming Wei Lee
- Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore
| | - May Anne Cheong
- Department of Haematology, Singapore General Hospital, Singapore
| | - Heng Joo Ng
- Department of Haematology, Singapore General Hospital, Singapore
| | - Sim Leng Tien
- Department of Haematology, Singapore General Hospital, Singapore
| | - Joyce Ching Mei Lam
- Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore
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15
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Rener K, Anžej Doma S, Fink M, Podgornik H, Preložnik Zupan I. Management and Outcomes of Invasive Procedures in Individuals with Hemophilia A on Emicizumab Prophylaxis: A Single Center Experience. Hematol Rep 2023; 15:597-607. [PMID: 37987318 PMCID: PMC10660500 DOI: 10.3390/hematolrep15040062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/12/2023] [Accepted: 10/25/2023] [Indexed: 11/22/2023] Open
Abstract
Prophylactic treatment with emicizumab has become an important and effective bleeding prevention for people with hemophilia A (PwHA). Perioperative management of PwHA using emicizumab prophylaxis is still challenging due to a lack of experience. Medical records of perioperative management and outcomes were reviewed, and data were collected for adult PwHA receiving emicizumab and undergoing surgical procedures between August 2019 and July 2022 at the University Medical Center Ljubljana. Twelve surgical procedures were performed in eight PwHA (one with FVIII inhibitors) while on emicizumab prophylaxis. Three minor procedures included cataract surgery, cystoscopic lithotripsy, and percutaneous coronary intervention. Nine major surgeries included four osteosyntheses, necrectomy of chronic osteomyelitis with new ankle arthrodesis, two below-knee amputations, total knee replacement, and placement of ventriculostomy after a spontaneous intraventricular hemorrhage. No major bleeds, thrombotic events or deaths, or new inhibitors appeared. Our real-world experience demonstrates that minor and major surgeries can be performed safely in PwHA on emicizumab prophylaxis. Additional data are needed to optimize dosing/duration of additional hemostatic agents in diverse invasive procedures and complex clinical situations.
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Affiliation(s)
- Karla Rener
- Department of Hematology, University Medical Center Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (K.R.); (S.A.D.); (M.F.); (H.P.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
| | - Saša Anžej Doma
- Department of Hematology, University Medical Center Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (K.R.); (S.A.D.); (M.F.); (H.P.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
| | - Martina Fink
- Department of Hematology, University Medical Center Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (K.R.); (S.A.D.); (M.F.); (H.P.)
| | - Helena Podgornik
- Department of Hematology, University Medical Center Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (K.R.); (S.A.D.); (M.F.); (H.P.)
- Faculty of Pharmacy, University of Ljubljana, Aškerčeva cesta 7, 1000 Ljubljana, Slovenia
| | - Irena Preložnik Zupan
- Department of Hematology, University Medical Center Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (K.R.); (S.A.D.); (M.F.); (H.P.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
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16
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Cohen O, Levy-Mendelovich S, Budnik I, Ludan N, Lyskov SK, Livnat T, Avishai E, Efros O, Lubetsky A, Lalezari S, Misgav M, Brutman-Barazani T, Kenet G, Barg AA. Management of surgery in persons with hemophilia A receiving emicizumab prophylaxis: data from a national hemophilia treatment center. Res Pract Thromb Haemost 2023; 7:102178. [PMID: 37876894 PMCID: PMC10593567 DOI: 10.1016/j.rpth.2023.102178] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 07/06/2023] [Accepted: 07/09/2023] [Indexed: 10/26/2023] Open
Abstract
Background Persons with hemophilia A may require surgical procedures. Real-world data on invasive procedures in persons with hemophilia A receiving emicizumab prophylaxis are limited. Objectives To evaluate the safety of invasive procedures in persons with hemophilia A receiving emicizumab prophylaxis and their outcomes in a longitudinally followed cohort. Methods Data from medical records of persons with hemophilia A with and without factor VIII (FVIII) inhibitors longitudinally followed at our tertiary center, who received emicizumab prophylaxis and underwent all types of invasive procedures, were retrieved. Outcomes of interest were bleeding and thrombotic complications. Results Overall, 35 patients underwent 56 invasive procedures, 18 (32.1%) were major. The median age was 36.3 years (IQR, 8.8-55.9 years); 12 patients (34.3%) were younger than 18 years at the time of procedure; 17 (48.6%) were patients with FVIII inhibitors. Among major procedures, orthopedic surgeries prevailed. All patients who underwent major procedures received factor replacement with either recombinant activated factor VII (patients with inhibitors) or FVIII (patients without inhibitors). Factor concentrates were administered prior to 32 (84.2%) of the minor procedures. Repeated doses were given according to international expert opinion recommendations and patients' condition.There were 7 bleeding events in 6 patients, 5 were major bleeds, including 1 patient who underwent a minor procedure without factor replacement. None of the patients experienced a thrombotic complication. Conclusion Invasive procedures can be performed safely in patients receiving emicizumab prophylaxis with close surveillance after surgery. Factor concentrates may be advised in selected patients undergoing minor procedures.
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Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Sarina Levy-Mendelovich
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sheba Talpiot Medical leadership program, Sheba Medical Center, Tel Hashomer, Israel
| | - Ivan Budnik
- Division of Hematology/Oncology, Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Noa Ludan
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Tami Livnat
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Einat Avishai
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Efros
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aharon Lubetsky
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shadan Lalezari
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mudi Misgav
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Brutman-Barazani
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assaf A. Barg
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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17
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Schutgens RE, Jimenez-Yuste V, Escobar M, Falanga A, Gigante B, Klamroth R, Lassila R, Leebeek FW, Makris M, Owaidah T, Sholzberg M, Tiede A, Werring DJ, van der Worp HB, Windyga J, Castaman G. Antithrombotic Treatment in Patients With Hemophilia: an EHA-ISTH-EAHAD-ESO Clinical Practice Guidance. Hemasphere 2023; 7:e900. [PMID: 37304933 PMCID: PMC10256340 DOI: 10.1097/hs9.0000000000000900] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 06/13/2023] Open
Abstract
Cardiovascular disease is an emerging medical issue in patients with hemophilia (PWH) and its prevalence is increasing up to 15% in PWH in the United States. Atrial fibrillation, acute and chronic coronary syndromes, venous thromboembolism, and cerebral thrombosis are frequent thrombotic or prothrombotic situations, which require a careful approach to fine-tune the delicate balance between thrombosis and hemostasis in PWH when using both procoagulant and anticoagulant treatments. Generally, PWH could be considered as being naturally anticoagulated when clotting factors are <20 IU/dL, but specific recommendations in patients with very low levels according to the different clinical situations are lacking and mainly based on the anecdotal series. For PWH with baseline clotting factor levels >20 IU/dL in need for any form of antithrombotic therapy, usually treatment without additional clotting factor prophylaxis could be used, but careful monitoring for bleeding is recommended. For antiplatelet treatment, this threshold could be lower with single-antiplatelet agent, but again factor level should be at least 20 IU/dL for dual antiplatelet treatment. In this complex growing scenario, the European Hematology Association in collaboration with the International Society on Thrombosis and Haemostasis, the European Association for Hemophilia and Allied Disorders, the European Stroke Organization, and a representative of the European Society of Cardiology Working Group on Thrombosis has produced this current guidance document to provide clinical practice recommendations for health care providers who care for PWH.
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Affiliation(s)
- Roger E.G. Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Victor Jimenez-Yuste
- Hematology Department, La Paz University Hospital, Autonoma University, Madrid, Spain
| | - Miguel Escobar
- University of Texas Health Science Center at Houston, TX, USA
| | - Anna Falanga
- University of Milano Bicocca, School of Medicine, Monza, Italy
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Solna, Sweden
- Department of Clinical Science, Danderyd Hospital, Karolinska institutet, Stockholm, Sweden
| | - Robert Klamroth
- Department of Internal Medicine Angiology and Coagulation Disorders at the Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Germany
| | - Riitta Lassila
- Department of Hematology, Coagulation Disorders Unit, and Research Program Unit in Systems Oncology Oncosys, Medical Faculty, University of Helsinki, Finland
| | - Frank W.G. Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Michael Makris
- Haemophilia and Thrombosis Centre, University of Sheffield, United Kingdom
| | - Tarek Owaidah
- King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
| | - Michelle Sholzberg
- Division of Hematology-Oncology, Departments of Medicine, and Laboratory Medicine and Pathobiology, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Canada
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Germany
| | - David J. Werring
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom
| | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
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Escobar M, Bullano M, Mokdad AG, Caicedo J, Schultz BG, Fan Q, Verma S. A real-world evidence analysis of the impact of switching from factor VIII to emicizumab prophylaxis in patients with hemophilia A without inhibitors. Expert Rev Hematol 2023:1-8. [PMID: 37114481 DOI: 10.1080/17474086.2023.2198207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
BACKGROUND This study retrospectively compared annualized billed bleed rates (ABRb) in people with hemophilia A (PwHA) without inhibitors who switched from factor VIII (FVIII) prophylaxis to emicizumab. RESEARCH DESIGN AND METHODS A real-world comparison study was performed on the effect of switching from FVIII to emicizumab prophylaxis in male, non-inhibitor patients on ABRb using an all-payer claims database (APCD) dataset from 1 January 2014, to 31 March 2021. The identification period was from 1 November 2017, to 30 September 2020. RESULTS One hundred and thirty-one patients were included with a total of 82 and 45 bleeds in the pre- and post-switch periods, respectively. The average follow-up period pre-switch was 978.37 days (SD 555.03), whereas the average follow-up period post-switch was 522.26 days (SD 191.36). No significant differences in mean ABRb were observed pre-/post-switch (0.25 and 0.20, respectively; P = 0.4456). CONCLUSIONS The results of this study demonstrate no significant reduction in ABRb, suggesting that switching from FVIII to emicizumab may not deliver incremental benefits to PwHA receiving prophylactic care.
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Affiliation(s)
- Miguel Escobar
- University of Texas Health Science Center, Houston, TX, USA
| | | | | | | | | | - Qi Fan
- Takeda Pharmaceuticals USA, Lexington, MA, USA
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19
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Escobar M, Agrawal N, Chatterjee S, Bhattacharya S, Caicedo J, Bullano M, Schultz BG. Impact of switching prophylaxis treatment from factor VIII to emicizumab in hemophilia A patients without inhibitors. J Med Econ 2023; 26:574-580. [PMID: 36989380 DOI: 10.1080/13696998.2023.2196922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
BACKGROUND Factor VIII (FVIII) replacement and emicizumab are effective at preventing bleeds in patients with hemophilia A (HA). Though benefits of emicizumab among inhibitor patients with HA (PwHA) are well established, more real-world evidence among non-inhibitor patients is needed. METHODS Using a United States healthcare claims database, we compared billed annualized bleed rates (ABRb) and the total cost of care (TCC) before and after switching from FVIII prophylaxis to emicizumab among non-inhibitor male PwHA. Bayesian inferences were used to assess the difference in ABRb and TCC per patient per year (PPPY) pre versus post prophylaxis switch. We included 101 non-inhibitor male PwHA aged between 3 and 63 years old who switched from FVIII prophylaxis to emicizumab prophylaxis in 2018 or 2019. RESULTS The ABRb increased from 0.52 to 0.62 (p = 0.83) after switch. The posterior probability of the mean ABRb increasing after the switch was 75.54%. The TCC PPPY increased from $517,143 to $627,005 (p < 0.0001) after switch and the posterior probability of mean costs increasing after the switch was 99.80%. CONCLUSIONS Personalization of care through the identification of the most appropriate therapy for each patient can optimize clinical and economic outcomes. Future real-world evidence research could help establish the value of prophylactic options in targeted populations such as the non-inhibitor male PwHA.
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Affiliation(s)
- Miguel Escobar
- University of Texas Health Science Center, Houston, Texas, USA
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20
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Castaman G, Linari S, Pieri L, Carulli C, Prosperi P, Tonelli P, Demartis F, Fjerza R, Attanasio M, Coppo M, Salvianti F. Safe and Successful Surgical Outcome in Persons with Hemophilia A with and without Inhibitors Treated with Emicizumab: A Large, Single Center, Real-World Experience. J Clin Med 2023; 12:jcm12062317. [PMID: 36983317 PMCID: PMC10055920 DOI: 10.3390/jcm12062317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
Emicizumab is a humanized recombinant bispecific antibody, bridging together activated factor IX (FIXa) and factor X (FX), thus mimicking the activity of FVIII in vivo. Emicizumab is designed for long-term prophylaxis in patients with severe hemophilia A with and without inhibitors. This approach provides constant protection, with significant reduction in bleeding rate and improved quality of life. However, protection provided by emicizumab is not absolute, and clotting factor concentrates (FVIII, rFVIIa, aPCC) may be necessary for post-traumatic bleeding or surgery, with a potential thrombotic risk or difficulty in preventing bleeding. Real world evidence is still scanty, especially for managing major surgery. In this study, 75 surgeries were managed in 28 patients (27 major procedures in 15 patients and 48 minor procedures in 20 patients. In 17 patients without inhibitors, 30 minor surgeries were carried out by using FVIII in 5, with only a bleeding event, which was successfully treated with FVIII concentrate. Six major surgeries were uneventfully performed with FVIII concentrate. Eleven PWHA and high-titer inhibitors underwent 39 surgical procedures (18 minor and 21 major surgeries). Minor surgeries were mostly performed without prophylaxis with rFVIIa, with only a single bleeding complication. All 21 major surgeries were covered with a homogeneous protocol using rFVIIa. In four instances, bleeding complications occurred, treated with rFVIIa. Of them, a single patient only failed to respond and died because of an uncontrollable bleeding from a large ruptured retroperitoneal pseudotumor. Surgery in patients with emicizumab can be safely carried out with the use of appropriate replacement therapy protocols.
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Affiliation(s)
- Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
- Correspondence: ; Tel.: +39-55-7947587
| | - Silvia Linari
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
| | - Lisa Pieri
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
| | - Christian Carulli
- Department of Orthopedic Surgery, University Hospital of Florence, 50139 Florence, Italy
| | - Paolo Prosperi
- Emergency Surgery Department, Careggi University Hospital, 50134 Florence, Italy
| | - Paolo Tonelli
- Department of Surgery and Translational Medicine, University of Florence, 50121 Florence, Italy
| | - Francesco Demartis
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
| | - Rajmonda Fjerza
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
| | - Monica Attanasio
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
| | - Mirella Coppo
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
| | - Francesca Salvianti
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
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Camelo RM, Barbosa MM, Araújo MS, Muniz RL, Guerra AA, Godman B, Rezende SM, Acurcio FDA, Martin AP, Alvares-Teodoro J. Economic Evaluation of Immune Tolerance Induction in Children With Severe Hemophilia A and High-Responding Inhibitors: A Cost-Effectiveness Analysis of Prophylaxis With Emicizumab. Value Health Reg Issues 2023; 34:31-39. [PMID: 36463835 DOI: 10.1016/j.vhri.2022.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/20/2022] [Accepted: 10/19/2022] [Indexed: 12/02/2022]
Abstract
OBJECTIVE This study aimed to measure the cost-effectiveness of prophylaxis with emicizumab in PsHAhri on ITI in Brazil. METHODS A cost-effectiveness modeling analysis was used to estimate the costs per PsHAhri on ITI and the number of prevented bleedings from undertaking one intervention (prophylaxis with BpA) over another (prophylaxis with emicizumab), based on the Brazilian Ministry of Health perspective. Costs of ITI with recombinant FVIII, prophylaxis with BpA or emicizumab, and treated bleeding episodes with BpA costs were evaluated for PsHAhri who had ITI success or failure. This study was conducted with the perspective of the Brazilian Ministry of Health (payer). RESULTS During ITI, prophylaxis with BpA cost US $924 666/PsHAhri/ITI, whereas prophylaxis with emicizumab cost US $488 785/PsHAhri/ITI. During ITI, there was an average of 9.32 bleeding episodes/PsHAhri/ITI when BpA were used as prophylaxis and 0.67 bleeding/PsHAhri/ITI when emicizumab was used. By univariate deterministic sensitivity analysis, emicizumab remained dominant whichever variable was modified. CONCLUSION In this study, prophylaxis with emicizumab during ITI is a dominant option compared with prophylaxis with BpA during ITI.
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Affiliation(s)
- Ricardo Mesquita Camelo
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Maiara Silva Araújo
- Faculty of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Roberto Lúcio Muniz
- Faculty of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, Scotland, UK; Centre of Medical and Bio-allied Health Sciences Research, Ajman University, United Arab Emirates; School of Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, Pretoria, South Africa
| | | | | | - Antony P Martin
- Faculty of Health and Life Sciences, Liverpool, England, UK; QC Medica, York, England, UK
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22
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Pipe SW, Trzaskoma B, Minhas M, Lehle M, Ko RH, Gao L, Mahlangu J, Kempton CL, Kessler CM, Kruse-Jarres R. Efficacy of emicizumab is maintained throughout dosing intervals for bleed prophylaxis. Res Pract Thromb Haemost 2023; 7:100077. [PMID: 36908770 PMCID: PMC9992752 DOI: 10.1016/j.rpth.2023.100077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/05/2022] [Accepted: 12/29/2022] [Indexed: 02/09/2023] Open
Abstract
Background Across the HAVEN clinical trial program, the efficacy of emicizumab has been demonstrated in children, adolescents, and adults with hemophilia A, with or without factor VIII inhibitors. After the 4-week loading dose period, emicizumab concentrations are expected to remain at levels that provide bleed protection throughout the entire dosing interval, regardless of the chosen maintenance dosing regimen, ie, weekly, every 2 weeks, or every 4 weeks. Objectives The objective of this study was to examine the timing of treated bleeds within the dosing intervals for emicizumab administered during the HAVEN 1 to 4 studies. Methods In this post hoc analysis, we pooled data from all the participants of the HAVEN 1 to 4 studies and analyzed the timing of treated bleeds in relation to the emicizumab dose. Results A total of 392 participants were included in this analysis, with a median (range) age of 28.0 years (1.1-77.0 years). Target joints were identified in 237 of 392 (60.5%) participants before the study entry. Overall, 211 of 392 (53.8%) participants experienced 907 treated bleeding events. The total mean (SD) annualized bleeding rate across the 4 studies was 1.6 (5.9). There was no evidence that bleeding events clustered on any 1 particular day in any dosing schedule from HAVEN 1 to 4 (P > .05 for all 3 treatment regimens). Conclusion Data from the HAVEN 1 to 4 trials show consistent bleed prevention within the dosing interval, regardless of the dosing regimen chosen. These findings provide further evidence of the sustained efficacy of emicizumab across all approved dosing regimens to reduce bleeding in people with hemophilia A.
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Affiliation(s)
- Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ben Trzaskoma
- US Medical Affairs, Genentech Inc, South San Francisco, California, USA
| | - Miranda Minhas
- US Medical Affairs, Genentech Inc, South San Francisco, California, USA
| | - Michaela Lehle
- Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Richard H Ko
- US Medical Affairs, Genentech Inc, South San Francisco, California, USA
| | - Ling Gao
- Analystat Corporation, Point Roberts, Washington, USA
| | - Johnny Mahlangu
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | - Christine L Kempton
- Department of Hematology and Medical Oncology and Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Craig M Kessler
- The Division of Coagulation, Georgetown University School of Medicine, Washington, DC, USA
| | - Rebecca Kruse-Jarres
- Division of Hematology, University of Washington and Washington Center for Bleeding Disorders, Seattle, Washington, USA
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23
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Belletrutti M, Bhatt M, Samji N. Management of children with hemophilia A on emicizumab who need surgery. Front Pediatr 2023; 11:1155853. [PMID: 37082707 PMCID: PMC10110896 DOI: 10.3389/fped.2023.1155853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/14/2023] [Indexed: 04/22/2023] Open
Abstract
The introduction of emicizumab into the treatment regime of persons with hemophilia A has dramatically reduced frequency of bleeding in patients with and without inhibitors. However, in children with Hemophilia A (CwHA) who require surgical or other invasive procedures, additional treatment with factor replacement or other hemostatic agents may still be needed to prevent intraoperative or postoperative bleeding. This review will look at the reported outcomes in CwHA on emicizumab who have had surgery and propose recommendations for the best perioperative management of major and minor procedures.
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Affiliation(s)
- Mark Belletrutti
- BC Children’s Hospital, Oncology/Hematology/BMT, University of British Columbia, Vancouver, BC, Canada
- Correspondence: Mark Belletrutti
| | - Mihir Bhatt
- McMaster Children’s Hospital, Hematology/Oncology, McMaster University, Hamilton, ON, Canada
| | - Nasrin Samji
- McMaster Children’s Hospital, Hematology/Oncology, McMaster University, Hamilton, ON, Canada
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24
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Two pediatric cases of severe hemophilia A in which emicizumab prophylaxis failed to prevent traumatic extra-articular hemorrhage. Int J Hematol 2022; 117:607-612. [PMID: 36370317 PMCID: PMC9660161 DOI: 10.1007/s12185-022-03490-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/02/2022] [Accepted: 11/06/2022] [Indexed: 11/15/2022]
Abstract
Emicizumab reduces bleeding episodes in patients with severe hemophilia A (PwHA). Little information is available on hemostatic management of severe traumatic hemorrhages in emicizumab-treated pediatric PwHA. We assessed therapeutic efficacy and global coagulation potentials in two pediatric cases of emicizumab-treated pediatric PwHA with intracranial or retroperitoneal/iliopsoas hemorrhage. A modified clot waveform analysis (CWA) triggered by mixtures of tissue factor and ellagic acid was used to assess coagulant potentials, and maximum coagulant velocity (Ad|min1|) was calculated. One patient with intracranial hemorrhage was treated with continuous infusions of recombinant factor VIII (rFVIII) at a dose of 4-4.6 IU/kg/hr for 9 days, followed by bolus infusion at 66 IU/kg/day for 2 days and 33 IU/kg/day for an additional 2 days. The Ad|min1| was increased from 5.5 (at baseline) to 7.0-8.1 under concomitant treatment and maintained within or near normal range (IQR; 6.9-7.7). The other patient with retroperitoneal/iliopsoas hemorrhage received bolus infusions of rFVIII at 50 IU/kg/day for 20 days and every-other-day infusion of rFVIII for 8 days. The Ad|min1| was increased from 5.2 (at baseline) to 5.8-6.8 under concomitant treatment and maintained within the normal range. We successfully managed a treatment plan for severe traumatic bleeding in emicizumab-treated pediatric PwHA using modified CWA.
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Mazurkiewicz Ł, Czernikiewicz K, Rupa-Matysek J, Gil L. Emicizumab: a novel drug in hemophilia A prophylaxis - a narrative review. Expert Rev Hematol 2022; 15:933-942. [PMID: 36191306 DOI: 10.1080/17474086.2022.2131526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Hemophilia A is a genetically conditioned disease leading to hemostatic disorders due to factor VIII (FVIII) deficiency. The treatment of hemophilia has evolved throughout the past years and has significantly changed. One of the newest drugs for prophylactic treatment is the humanized bispecific IgG antibody - emicizumab, which binds with factor IXa and factor X, bridging those factors and thus mimicking the activity of factor VIII. AREAS COVERED The literature search was made via PubMed database, with the emphasis on clinical trials and case reports, describing the off-label emicizumab use. This review presents an extensive summary and considers advantages and disadvantages (side-effects) of emicizumab, describing additional clinical situations, where emicizumab has been successfully used. In our review we cover information about the mechanisms of action, indications, efficacy and discuss some chosen case reports about off-label emicizumab use. EXPERT OPINION Its convenient administration method (subcutaneous) and frequency of injections (from once a week to once a month) makes it a more comfortable treatment, limiting injection-site reactions, hospital stays, costs of prophylaxis, and significantly increasing patients' quality of life. Adverse effects are scarce and rarely serious - the most common ones are reactions at the injection-site and upper respiratory tract infections.
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Affiliation(s)
- Łukasz Mazurkiewicz
- Department of Hematology and Bone Marrow Transplantation, Poznań University of Medical Sciences, Poznań, Poland
| | - Krystian Czernikiewicz
- Department of Hematology and Bone Marrow Transplantation, Poznań University of Medical Sciences, Poznań, Poland
| | - Joanna Rupa-Matysek
- Department of Hematology and Bone Marrow Transplantation, Poznań University of Medical Sciences, Poznań, Poland
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznań University of Medical Sciences, Poznań, Poland
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Batt K, Schultz BG, Caicedo J, Hollenbeak CS, Agrawal N, Chatterjee S, Bullano M. A real-world study comparing pre-post billed annualized bleed rates and total cost of care among non-inhibitor patients with hemophilia A switching from FVIII prophylaxis to emicizumab. Curr Med Res Opin 2022; 38:1685-1693. [PMID: 35880468 DOI: 10.1080/03007995.2022.2105072] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Factor VIII (FVIII) replacement and emicizumab have demonstrated efficacy for prevention of bleeds among patients with hemophilia A (PwHA) compared to on-demand (OD) use. Evidence investigating clinical outcomes and healthcare costs of non-inhibitor PwHA switching from prophylaxis with FVIII concentrates to emicizumab has not been well-established within large real-world datasets. This study aimed to investigate billed annualized bleed rates (ABRb) and total cost of care (TCC) among non-inhibitor PwHA switching from FVIII-prophylaxis to emicizumab-prophylaxis. METHODS This retrospective, observational study was conducted using IQVIA PharMetrics Plus, a US administrative claims database. The date of first claim for emicizumab was defined as the index date. OD patients and inhibitor patients were excluded. Bleeds were identified using a list of 535 diagnosis codes. Bayesian models were developed to estimate the probability ABRb worsens and TCC increases after switching to emicizumab. Wilcoxon rank-sum tests were used to test statistical significance of changes in ABRb and TCC after switch. RESULTS Among the 121 identified patients, the difference in mean ABRb between FVIII-prophylaxis (0.68 [SD = 1.28]) and emicizumab (0.55 [SD = 1.48]) was insignificant (p = .142). The mean annual TCC significantly increased for patients switching from FVIII-prophylaxis ($518,151 [SD = $289,934]) to emicizumab ($652,679 [SD = $340,126]; p < .0001). The Bayesian models estimated a 21.0% probability of the ABRb worsening and a 99.9% probability of increasing TCC after switch. CONCLUSIONS This study found that in male non-inhibitor PwHA, switching from FVIII prophylaxis to emicizumab incurs substantial cost increase with no significant benefit in ABRb. This evidence may help guide providers, payers, and patients in shared decision-making conversations around best treatment options.
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Affiliation(s)
- Katharine Batt
- Department of Hematology and Medical Oncology, Wake Forest Baptist School of Medicine, Winston-Salem, NC, USA
| | - Bob G Schultz
- Outcomes Research, Takeda Pharmaceuticals U.S.A., Inc., Lexington, MA, USA
| | - Jorge Caicedo
- Outcomes Research, Takeda Pharmaceuticals U.S.A., Inc., Lexington, MA, USA
| | - Christopher S Hollenbeak
- Department of Health Policy and Administration, The Pennsylvania State University, College of Health and Human Development, University Park, PA, USA
| | | | | | - Michael Bullano
- Outcomes Research, Takeda Pharmaceuticals U.S.A., Inc., Lexington, MA, USA
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Surgical outcomes in people with hemophilia A taking emicizumab prophylaxis: experience from the HAVEN 1-4 studies. Blood Adv 2022; 6:6140-6150. [PMID: 35939785 PMCID: PMC9768240 DOI: 10.1182/bloodadvances.2022007458] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/21/2022] [Accepted: 07/21/2022] [Indexed: 12/30/2022] Open
Abstract
Many people with hemophilia A (PwHA) undergo surgery in their lifetime, often because of complications of their disease. Emicizumab is the first bispecific monoclonal antibody prophylactic therapy for PwHA, and its efficacy and safety have been previously demonstrated; however, there is a need to build an evidence base on the management of PwHA on emicizumab undergoing surgery. Data from the HAVEN 1-4 phase 3 clinical trials were pooled to provide a summary of all minor and major surgeries in PwHA with or without factor VIII (FVIII) inhibitors who were receiving emicizumab prophylaxis. Overall, 233 surgeries were carried out during the HAVEN 1-4 trials: 215 minor surgeries (including minor dental and joint procedures, central venous access device placement or removal, and endoscopies) in 115 PwHA (64 with FVIII inhibitors) and 18 major surgeries (including arthroplasty and synovectomy) in 18 PwHA (10 with FVIII inhibitors). Perioperative hemostatic support was at the discretion of the treating physician. Overall, the median (interquartile range [IQR]) age was 33.5 (13.0-49.0) years and the median (IQR) emicizumab exposure time before surgery was 278.0 (177.0-431.0) days. Among the 215 minor surgeries, 141 (65.6%) were managed without additional prophylactic factor concentrate, and of those, 121 (85.8%) were not associated with a postoperative bleed. The majority (15 of 18 [83.3%]) of major surgeries were managed with additional prophylactic factor concentrate. Twelve (80.0%) of these 15 surgeries were associated with no intraoperative or postoperative bleeds. The data demonstrate that minor and major surgeries can be performed safely in PwHA receiving emicizumab prophylaxis. These trials are registered at www.clinicaltrials.gov as #NCT02622321, #NCT02795767, #NCT02847637, and #NCT03020160.
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Rodriguez-Merchan EC. Past, present and future of orthopedic surgery in hemophilia: looking to a world without bleeding and arthropathy in the near future. Expert Rev Hematol 2022; 15:821-831. [PMID: 35930399 DOI: 10.1080/17474086.2022.2110063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The purpose of this article is to review the literature on orthopedic surgery in people with hemophilia (PWH), to better understand its past and present and attempt to predict the future. AREAS COVERED A Cochrane Library and PubMed (MEDLINE) search of studies related to orthopedic surgery in PWH was analyzed. A downward trend in orthopedic surgery in PWH has been observed. Patients on continuous prophylaxis are less likely to require orthopedic surgery. In patients with hemophilia, the risk of major bleeding remains high after total joint arthroplasty, even with factor replacement. Cases of acute compartment syndrome, pseudotumors and even limb amputations are still observed in PWH. EXPERT OPINION Orthopedic surgery for PWH should always be performed in specialized centers with multidisciplinary expertise in the correct management of hemophilia. It is paramount to perform an accurate preoperative coagulation screening before surgery. The availability of prophylaxis through replacement and the recent non-replacement therapy in the well-developed countries will diminish substantially or hopefully abolish completely the need for surgery in the treatment of PWH. Therefore, we are looking to a world without bleeding and arthropathy in the next future. Unfortunately, this is not true for the under-development countries.
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Affiliation(s)
- E Carlos Rodriguez-Merchan
- Department of Orthopedic Surgery, La Paz University Hospital, Madrid, Spain.,Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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29
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Raso S, Napolitano M, Sirocchi D, Siragusa S, Hermans C. The important impact of dental care on haemostatic treatment burden in patients with mild haemophilia. Haemophilia 2022; 28:996-999. [PMID: 35879819 DOI: 10.1111/hae.14626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mild haemophilia (MH) is mainly characterized by haemorrhages secondary to surgery/invasive procedures or trauma. Haemostatic treatment in MH ranges from on demand to short prophylaxis according to the type of bleeding events and the basal clotting factor level. Oral surgery and dental extractions can represent a frequent haemostatic challenge in MH requiring appropriate treatment. However, only few studies on limited numbers of patients are available in the literature regarding the implications of dental management in patients with MH. OBJECTIVES The purpose of the study was to evaluate the impact of dental care on the burden of haemostatic treatment in patients affected by MH. METHODS We conducted a retrospective multicentre study evaluating adult patients with MH regularly examined at the Haemophilia Treatment Centres (HTCs) of the Saint-Luc University Hospital, Brussels (Belgium) and of Paolo Giaccone Hospital, Palermo (Italy). The population consisted of 107 male patients with MH, with a mean age of 39 years (range 18-81 years). RESULTS The majority of patients (86/107, 79%) needed at least one treatment within the study period, and 44% (38/86) of them received haemostatic therapy for dental care. Haemostatic therapy in our study varied from antifibrinolytic therapy alone and perioperative factor replacement to the absence of treatment at all. The great majority of oral interventions (27/42, 64%) were managed with clotting factor concentrate. CONCLUSION This study demonstrates that dental care currently represents a major reason for haemostatic treatments in patients with MH. Maintaining good oral health appears as a priority to minimize avoidable replacement therapy and optimize resources.
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Affiliation(s)
- Simona Raso
- Department of Hematology and Rare Diseases, V Cervello, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy.,Division of Haematology, Department of Surgical, Oncological and Stomatological Disciplines (Di.Chir.On.S.), University Hospital Paolo Giaccone Hospital, Palermo, Italy
| | - Mariasanta Napolitano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Davide Sirocchi
- Division of Haematology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University Hospital Paolo Giaccone Hospital, Palermo, Italy
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UC Louvain), Brussels, Belgium
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Xu R, Kalluri AL, Sun LR, Lawrence CE, Lee JK, Kannan S, Cohen AR. The neurosurgical management of Severe Hemophilia A and Moyamoya (SHAM): challenges, strategies, and literature review. Childs Nerv Syst 2022; 38:1077-1084. [PMID: 35262754 DOI: 10.1007/s00381-022-05489-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/03/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Severe Hemophilia A and Moyamoya arteriopathy (SHAM syndrome) is a rare genetic disorder caused by deletion of portions of the cytogenic band Xq28. A case of SHAM syndrome requiring bilateral cerebral revascularization is described with an emphasis on perioperative management. CASE REPORT A 5-year-old boy with severe hemophilia A complicated by factor VIII inhibition presented with right-sided weakness. Imaging revealed multiple strokes and vascular changes consistent with Moyamoya disease. The patient underwent two-staged indirect cerebral bypass revascularizations, first on the left side and several months later on the right. Perioperative management required balancing the administration of agents to prevent coagulopathy and perioperative hemorrhage while mitigating the risk of thromboembolic events associated with bypass surgery. Despite a multidisciplinary effort by the neurosurgery, hematology, critical care, and anesthesiology teams, the post-operative course after both surgeries was complicated by stroke. Fortunately, the patient recovered rapidly to his preoperative functional baseline. CONCLUSION We describe a rare case of SHAM syndrome in a pediatric patient who required bilateral revascularizations and discuss strategies for managing the perioperative risk of hemorrhage and stroke. We also review existing literature on SHAM syndrome.
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Affiliation(s)
- Risheng Xu
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Anita L Kalluri
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Lisa R Sun
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Courtney E Lawrence
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Jennifer K Lee
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Sujatha Kannan
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Alan R Cohen
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA.
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Harrison C, Chase J, Fawcett K, Shoemark R, Valderrama Y. Into a brave new world: Haemophilia A & von Willebrand Disease Surgery with novel therapies. Haemophilia 2022; 28 Suppl 4:125-131. [PMID: 35521734 DOI: 10.1111/hae.14543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/25/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Haemophilia & von Willebrand disease are both recognised inherited bleeding disorders. With increased access to highly efficient and safe replacement and novel therapies, management of surgical interventions in this group can be safely managed by experienced multidisciplinary teams. AIM To review the evidence for managing surgery in the era of novel therapies. METHOD We explore four cases and establish the role of the clinical nurse specialist within the surgical pathway. RESULTS All of these cases evidence the continued important role of both the multidisciplinary planning prior to any surgical interventions in people with bleeding disorders and the key role of the Nurse Specialist in ensuring this plan is then implemented. Key focuses of communication with all parties involved in the patient journey, performing education for the patient, family and wider healthcare team about the underlying bleeding disorder and the importance of time critical medicines being given on time is essential. CONCLUSION These cases demonstrate that individuals with bleeding disorders are at risk of developing other rare conditions alongside their life long condition, in addition to comorbidities associated with ageing. Evidence for rare plus rare is likely to be minimal as demonstrated within the cases, and recognition of how to reach out to international peers in the field is important. Sharing complex case management at national & international meetings and in publication has never been so important.
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Affiliation(s)
- Catherine Harrison
- Sheffield Haemophilia & Thrombosis Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, England
| | - Jaime Chase
- John Hunter Children's Hospital, Newcastle, New South Wales, Australia
| | | | - Robyn Shoemark
- Haemophilia Treatment Centre, The Children's Hospital, Westmead, New South Wales, Australia
| | - Yadira Valderrama
- Comprehensive Haemophilia Treatment Center of Colsubidio Children's Clinic, Colombia
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Mancuso ME, Apte S, Hermans C. Managing invasive procedures in haemophilia patients with limited resources, extended half-life concentrates or non-replacement therapies in 2022. Haemophilia 2022; 28 Suppl 4:93-102. [PMID: 35521735 DOI: 10.1111/hae.14551] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 01/15/2023]
Abstract
New treatment possibilities and modalities are now available globally for patients with haemophilia requiring surgery or invasive procedures. The first is the appropriate application of low-dose protocols of clotting factor concentrates (CFC) achieving adequate perioperative haemostasis in resources constraint environments. The increasing availability of CFC through humanitarian aid programs allows more invasive surgeries to be performed for which efficacy and safety data should be more widely collected and reported. Second, extended half-life CFC that are increasingly available in many countries represent valuable alternatives to standard half-life products in surgical patients allowing reduced number of infusions and lower consumption, in particular for extended half-life factor IX. Third, in the era of recently introduced nonfactor prophylaxis, some minor surgical procedures can now be performed without additional haemostatic treatment, others with few low-dose administrations of CFC or bypassing agents. Additional factor VIII/IX or recombinant activated factor VII has proven to be safe and effective in association with emicizumab for major surgeries and it was effectively given at low doses in association with fitusiran (including activated prothrombin complex concentrate). No thrombotic complications have been reported in the surgical setting so far. A multidisciplinary team/facility remains crucial to manage major surgery in patients on prophylaxis with these new agents.
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Affiliation(s)
- Maria Elisa Mancuso
- Center for Thrombosis and Haemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Cedric Hermans
- Division of Haematology, Haemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain (UCLouvain), Brussels, Belgium
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Escobar M, Dunn A, Quon D, Trzaskoma B, Lee L, Ko RH, Carpenter SL. A phase IV, multicentre, open-label study of emicizumab prophylaxis in people with haemophilia A with or without FVIII inhibitors undergoing minor surgical procedures. Haemophilia 2022; 28:e105-e108. [PMID: 35510949 PMCID: PMC9544354 DOI: 10.1111/hae.14574] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/17/2022] [Accepted: 04/09/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Miguel Escobar
- University of Texas Health Science Center, Houston, Texas, USA
| | - Amy Dunn
- Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Doris Quon
- Orthopedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Ben Trzaskoma
- Genentech, Inc., South San Francisco, California, USA
| | - Lucy Lee
- Genentech, Inc., South San Francisco, California, USA
| | - Richard H Ko
- Genentech, Inc., South San Francisco, California, USA
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Nakajima Y, Mizumachi K, Shimonishi N, Furukawa S, Yada K, Ogiwara K, Takeyama M, Shima M, Nogami K. Comparisons of global coagulation potential and bleeding episodes in emicizumab-treated hemophilia A patients and mild hemophilia A patients. Int J Hematol 2022; 115:489-498. [PMID: 35043383 DOI: 10.1007/s12185-021-03276-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 12/18/2022]
Abstract
Emicizumab reduces bleeding events in patients with severe hemophilia A (HA). The coagulation potential of emicizumab at a clinical dose appears to correspond to about 15 IU/dL of factor VIII activity (FVIII:C), the equivalent of converting from a severe to mild phenotype. However, the clinical and laboratory characteristics of HA patients receiving emicizumab (Emi-PwHA) compared with patients with mild HA (PwMHA) remain to be determined. We reviewed clinical data from Emi-PwHA (n = 63) and PwMHA (n = 15) and evaluated comprehensive coagulation function using Ca2+-triggered rotational thromboelastometry (ROTEM) and ellagic acid/tissue factor-triggered clot waveform analysis (modified CWA). The median FVIII:C in PwMHA was 13.0 (IQR 8.5-17.0) IU/dL. Bleeding patterns in both groups were similar and classified into three categories: (1) spontaneous bleeding, post-traumatic, (2) bleeding within 1-2 days, and (3) delayed bleeding after 1-2 weeks. The coagulation potential in Emi-PwHA with and without breakthrough bleeds was comparable. Furthermore, coagulation function in Emi-PwHA was equivalent to PwMHA, although time between treatment and hospitalization for breakthrough bleeds in PwMHA appeared to be longer than those in Emi-PwHA. The coagulation potential and bleeding patterns appeared to be similar in Emi-PwHA and PwMHA, indicating that emicizumab-driven coagulation potential reflected mild HA.
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Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Japan.
| | - Kuniyoshi Mizumachi
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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Cohen CT, Diaz R. Emicizumab in pediatric hemophilia: Bleeding and surgical outcomes from a single-center retrospective study. Pediatr Blood Cancer 2021; 68:e29325. [PMID: 34490988 DOI: 10.1002/pbc.29325] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/26/2021] [Accepted: 08/21/2021] [Indexed: 01/03/2023]
Abstract
Real-world data describing emicizumab prophylaxis in pediatric hemophilia A is limited with current literature providing a heterogenous approach to procedural management. We performed a retrospective review on the 28 patients who have been treated with emicizumab prophylaxis at Texas Children's Hospital from 2018 to 2021. After starting emicizumab, the mean annualized bleeding rate reduced from 3.61 to 0.44. Seven surgical procedures were performed in the cohort, and all treated with pre- and postoperative factor replacement resulting in one minor bleeding event. We demonstrate a successful experience with emicizumab prophylaxis and safe perioperative approach with a focus on minimizing postoperative bleeding.
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Affiliation(s)
- Clay T Cohen
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas, USA
| | - Rosa Diaz
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas, USA
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Mahlangu J. An update of the current pharmacotherapeutic armamentarium for hemophilia A. Expert Opin Pharmacother 2021; 23:129-138. [PMID: 34404300 DOI: 10.1080/14656566.2021.1961742] [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] [Indexed: 02/07/2023]
Abstract
INTRODUCTION For several decades, we have seen unprecedented advances in novel therapy development for hemophilia A. These advances address the unmet need of replacement therapy, and they include the development of recombinant products with improved pharmacokinetics, subcutaneously administered products, and those with better efficacy and safety profiles in hemophilia A management. AREAS COVERED In this update of hemophilia A treatment, the author summarizes data from completed standard half-life FVIII products, extended half-life FVIII products and FVIII mimetic studies. All products have an acceptable safety profile. The standard half-life products, EHL-FVIII products and emicizumab are efficacious in the prevention and treatment of bleeds and for EHL-FVIII in the perisurgical setting. EXPERT OPINION Advances in pharmacotherapy for hemophilia A have been characterized by changing care goals from supportive care to eliminating infections, preventing inhibitors, and more recently achieving zero bleeds in many patients. While gene therapy has the potential for functional cure in hemophilia A, it has many limitations which need to be addressed. Therefore, pharmacotherapy is likely to remain the mainstay in the management of hemophilia A and promises to get better with currently available therapies. Evolving factor and non-factor replacement therapies may also improve current unmet needs in hemophilia A management.
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Affiliation(s)
- Johnny Mahlangu
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand and NHLS, Parktown, South Africa
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Krumb E, Fijnvandraat K, Makris M, Peyvandi F, Ryan A, Athanasopoulos A, Hermans C. Adoption of emicizumab (Hemlibra®) for hemophilia A in Europe: Data from the 2020 European Association for Haemophilia and Allied Disorders survey. Haemophilia 2021; 27:736-743. [PMID: 34191397 DOI: 10.1111/hae.14372] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/05/2021] [Accepted: 06/17/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Emicizumab, a bispecific monoclonal antibody administered subcutaneously, mimicking the action of activated coagulation factor VIII, has been approved in Europe for use in patients with severe hemophilia of all ages. AIMS To assess availability, acceptance, adverse events, efficacy and laboratory monitoring of emicizumab and the effect of the coronavirus disease 2019 (COVID-19) pandemic on its use. METHODS Online questionnaire sent to 144 hemophilia treatment centres (November 2020 to January 2021). RESULTS Forty-six physicians from 21 countries responded, with a total of 3420 patients with severe HA under their care. Emicizumab was widely available, for 100% of inhibitor patients and 88% of non-inhibitor patients. No major adverse events were reported. Four reported deaths in patients on emicizumab were not thought to be related to emicizumab. An annualized bleeding rate (ABR) of zero was achieved in 73% of inhibitors patients. Haemostasis was satisfactory in the majority of minor (93.7%) and major (90.7%) surgical procedures performed while on emicizumab. Inhibitor titers were monitored in 78.4% of inhibitor patients on emicizumab, but chromogenic FVIII assay was only available in 73% of centres. The COVID-19 pandemic did not have a major impact on the adoption of emicizumab in most centres (64.9%). CONCLUSION Three years after its rollout in Europe, emicizumab is widely available. Clinical efficacy and safety were evaluated to be very good, keeping in mind the inherent limitations of the study. Unmet needs include establishment of treatment guidelines for surgery and breakthrough bleeding, limited expertise, especially in young children, and availability of laboratory assays.
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Affiliation(s)
- Evelien Krumb
- Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Karin Fijnvandraat
- Pediatric Hematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Michael Makris
- Sheffield Haemophilia and Thrombosis Centre, Sheffield, UK
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Aislin Ryan
- European Association for Haemophilia and Allied Disorders (EAHAD), Brussels, Belgium
| | | | - Cedric Hermans
- Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
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Abstract
Haemophilia A and B are rare congenital, recessive X-linked disorders caused by lack or deficiency of clotting factor VIII (FVIII) or IX (FIX), respectively. The severity of the disease depends on the reduction of levels of FVIII or FIX, which are determined by the type of the causative mutation in the genes encoding the factors (F8 and F9, respectively). The hallmark clinical characteristic, especially in untreated severe forms, is bleeding (spontaneous or after trauma) into major joints such as ankles, knees and elbows, which can result in the development of arthropathy. Intracranial bleeds and bleeds into internal organs may be life-threatening. The median life expectancy was ~30 years until the 1960s, but improved understanding of the disorder and development of efficacious therapy based on prophylactic replacement of the missing factor has caused a paradigm shift, and today individuals with haemophilia can look forward to a virtually normal life expectancy and quality of life. Nevertheless, the potential development of inhibitory antibodies to infused factor is still a major hurdle to overcome in a substantial proportion of patients. Finally, gene therapy for both types of haemophilia has progressed remarkably and could soon become a reality.
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Hassan E, Motwani J. Management and outcomes of paediatric patients on emicizumab prophylaxis undergoing surgical procedures: Experience from a large haemophilia centre in the UK. Haemophilia 2021; 27:e620-e623. [PMID: 34118116 DOI: 10.1111/hae.14358] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/23/2021] [Accepted: 05/31/2021] [Indexed: 01/16/2023]
Affiliation(s)
- Eman Hassan
- Department of Paediatric Haematology, Birmingham Children's Hospital, Birmingham, UK.,Department of Pediatrics, Haematology and Oncology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Jayashree Motwani
- Department of Paediatric Haematology, Birmingham Children's Hospital, Birmingham, UK
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