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Moser MM, Schoergenhofer C, Jilma B. Progress in von Willebrand Disease Treatment: Evolution towards Newer Therapies. Semin Thromb Hemost 2024; 50:720-732. [PMID: 38331000 DOI: 10.1055/s-0044-1779485] [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: 02/10/2024]
Abstract
von Willebrand disease (VWD) is a very heterogenous disease, resulting in different phenotypes and different degrees of bleeding severity. Established therapies (i.e., desmopressin, antifibrinolytic agents, hormone therapy for heavy menstrual bleeding, and von Willebrand factor [VWF] concentrates) may work in some subtypes, but not in all patients. In recent years, progress has been made in improving the diagnosis of VWD subtypes, allowing for more specific therapy. The impact of VWD on women's daily lives has also come to the fore in recent years, with hormone therapy, tranexamic acid, or recombinant VWF as treatment options. New treatment approaches, including the replacement of lacking factor VIII (FVIII) function, may work in those subgroups affected by severe FVIII deficiency. Reducing the clearance of VWF is an alternative treatment pathway; for example, rondaptivon pegol is a VWFA1 domain-binding aptamer which not only improves plasma VWF/FVIII levels, but also corrects platelet counts in thrombocytopenic type 2B VWD patients. These approaches are currently in clinical development, which will be the focus of this review. In addition, half-life extension methods are also important for the improvement of patients' quality of life. Targeting specific mutations may further lead to personalized treatments in the future. Finally, a few randomized controlled trials, although relatively small, have been published in recent years, aiming to achieve a higher level of evidence in future guidelines.
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Affiliation(s)
- Miriam M Moser
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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2
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Giuffrida AC, Siboni SM, Baronciani L, Poli G, Gandini G, Peyvandi F. Emicizumab in Type 3 von Willebrand Disease: Report of a Case with an Alloantibody and Literature Review. Semin Thromb Hemost 2024. [PMID: 38936417 DOI: 10.1055/s-0044-1787662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Type 3 von Willebrand disease (VWD), the most severe form of VWD, is an inherited recessive bleeding disorder caused by the complete deficiency of von Willebrand factor (VWF). The reported prevalence is 1 per million but varies worldwide according to the frequency of consanguineous marriages. The clinical phenotype is characterized not only by mucocutaneous bleedings, but also by hemarthroses and muscle hematoma, as in patients with moderate hemophilia. Long-term prophylaxis with factor (F)VIII/VWF concentrates is recommended in patients with a history of severe and frequent bleeds. A rare complication of replacement therapy is the development of alloantibodies against VWF, with the consequences of an ineffective therapy and risk of anaphylactic reactions upon treatment. Emicizumab is the first bispecific monoclonal antibody that mimics FVIII coagulant activity and is approved for prophylaxis of bleeding in patients with inherited hemophilia A with or without inhibitors and recently also for acquired hemophilia. In this manuscript we report and discuss available data in the literature on the use of emicizumab in type 3 VWD and describe the case of a female patient with type 3 VWD with a history of alloantibodies against VWF and posttransfusion anaphylaxis, recently and successfully put on off-label prophylaxis with emicizumab.
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Affiliation(s)
- Anna C Giuffrida
- Transfusion Medicine Department, Hemophilia Center, Integrated University Hospital, Verona, Italy
| | - Simona M Siboni
- IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Luciano Baronciani
- IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Giovanni Poli
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Giorgio Gandini
- Transfusion Medicine Department, Hemophilia Center, Integrated University Hospital, Verona, Italy
| | - Flora Peyvandi
- IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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3
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Franchini M, Focosi D. Inhibitor eradication and treatment for acquired hemophilia A. Expert Rev Hematol 2024; 17:233-240. [PMID: 38708599 DOI: 10.1080/17474086.2024.2352505] [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: 01/08/2024] [Accepted: 05/03/2024] [Indexed: 05/07/2024]
Abstract
INTRODUCTION Acquired hemophilia A (AHA) is a rare hemorrhagic autoimmune disorder characterized by autoantibodies against coagulation factor VIII (FVIII). In approximately half of the cases AHA does not recognize any cause (idiopathic form), while in the other cases it may be triggered by autoimmune disorders, cancers, drugs, infections, or pregnancy. Besides treating the underlying disorder, specific AHA treatment includes management of bleeding, if necessary, and inhibitor eradication. AREAS COVERED This narrative review summarizes the main epidemiological, clinical, laboratory, and therapeutic characteristics of AHA. In particular, it is focused on the current therapeutic options for the inhibitor eradication, also showing the latest findings on the innovative therapies. A literature search strategy was performed, without temporal limits, through Medline and PubMed electronic databases. EXPERT OPINION Various first-line and second-line immunosuppressive agents are currently available for the management of AHA. Among the latter, the anti-CD20 monoclonal antibody rituximab has been the object of intense research during the last years from investigators as innovative promising eradicating therapy for AHA. Preliminary data from the studies support the use of this drug as a first-line option for newly diagnosed AHA cases.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
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Lévesque H, Viallard JF, Houivet E, Bonnotte B, Voisin S, Le Cam-Duchez V, Maillot F, Lambert M, Liozon E, Hervier B, Fain O, Guillet B, Schmidt J, Luca LE, Ebbo M, Ferreira-Maldent N, Babuty A, Sailler L, Duffau P, Barbay V, Audia S, Benichou J, Graveleau J, Benhamou Y. Cyclophosphamide vs rituximab for eradicating inhibitors in acquired hemophilia A: A randomized trial in 108 patients. Thromb Res 2024; 237:79-87. [PMID: 38555718 DOI: 10.1016/j.thromres.2024.03.012] [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: 11/07/2023] [Revised: 02/19/2024] [Accepted: 03/07/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a rare autoimmune disorder due to autoantibodies against Factor VIII, with a high mortality risk. Treatments aim to control bleeding and eradicate antibodies by immunosuppression. International recommendations rely on registers and international expert panels. METHODS CREHA, an open-label randomized trial, compared the efficacy and safety of cyclophosphamide and rituximab in association with steroids in patients with newly diagnosed AHA. Participants were treated with 1 mg/kg prednisone daily and randomly assigned to receive either 1.5-2 mg/kg/day cyclophosphamide orally for 6 weeks, or 375 mg/m2 rituximab once weekly for 4 weeks. The primary endpoint was complete remission over 18 months. Secondary endpoints included time to achieve complete remission, relapse occurrence, mortality, infections and bleeding, and severe adverse events. RESULTS Recruitment was interrupted because of new treatment recommendations after 108 patients included (58 cyclophosphamide, 50 rituximab). After 18 months, 39 cyclophosphamide patients (67.2 %) and 31 rituximab patients (62.0 %) were in complete remission (OR 1.26; 95 % CI, 0.57 to 2.78). In the poor prognosis group (FVIII < 1 IU/dL, inhibitor titer > 20 BU mL-1), significantly more remissions were observed with cyclophosphamide (22 patients, 78.6 %) than with rituximab (12 patients, 48.0 %; p = 0.02). Relapse rates, deaths, severe infections, and bleeding were similar in the 2 groups. In patients with severe infection, cumulative doses of steroids were significantly higher than in patients without infection (p = 0.03). CONCLUSION Cyclophosphamide and rituximab showed similar efficacy and safety. As first line, cyclophosphamide seems preferable, especially in poor prognosis patients, as administered orally and less expensive. FUNDING French Ministry of Health. CLINICALTRIALS gov number: NCT01808911.
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Affiliation(s)
- H Lévesque
- Normandie Univ, UNIROUEN, U 1096, CHU Rouen, Department of Internal Medicine, F-76000 Rouen, France.
| | - J F Viallard
- Service de Médecine Interne et Maladies Infectieuses Hôpital Haut-Lévêque, CHU Bordeaux, 5 avenue de Magellan, 33604 Pessac, France
| | - E Houivet
- Department of Biostatistics, CHU Rouen, F-76031 Rouen, France
| | - B Bonnotte
- Service de médecine interne et immunologie clinique, CHU Dijon-Bourgogne, Université de Dijon, F-21079 Dijon, France
| | - S Voisin
- Department of Internal Medicine, CHU Toulouse, F-31059 Toulouse. France
| | - V Le Cam-Duchez
- Normandie Univ, UNIROUEN, Hématologie biologique, F-76031 Rouen, France
| | - F Maillot
- Département de Médecine Interne et immunologie clinique, CHRU Tours, Université de Tours, F-37044 Tours, France
| | - M Lambert
- CHU Lille, Département de Médecine Interne et d'Immunologie Clinique, Centre National de Référence Maladies Systémiques et Auto-immunes Rares Nord et Nord-Ouest de France (CeRAINO), European Reerence Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNECT), F-59000 Lille, France
| | - E Liozon
- Department of Internal Medicine, Dupuytren Hospital, F-87000 Limoges, France
| | - B Hervier
- Service de Médecine Interne, Hôpital Saint-Louis, APHP, 75010 Paris & INSERM UMR-S 976, Human Immunology, Pathophysiology, Immunotherapy, Saint-Louis Research Institute, F-75000 Paris, France
| | - O Fain
- Sorbonne Université, APHP, Service de Médecine Interne-DMU i3, Hôpital Saint-Antoine, Paris F-75000, France
| | - B Guillet
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR-S 1085, F-35000 Rennes, France
| | - J Schmidt
- Department of Internal Medicine, Amiens University Hospital, F-80000 Amiens, France
| | - L E Luca
- Department of Internal Medicine, Poitiers University Hospital, F-86000 Poitiers, France
| | - M Ebbo
- Service de Médecine Interne, Hôpital La Timone, CHU Marseille, Aix-Marseille Université, F-13000 Marseille, France
| | - N Ferreira-Maldent
- Département de Médecine Interne et immunologie clinique, CHRU Tours, Université de Tours, F-37044 Tours, France
| | - A Babuty
- Service d'Hématologie Biologique, CRC-MHC, CHU de Nantes, Nantes Cedex 1, France
| | - L Sailler
- Department of Internal Medicine, CHU Toulouse, F-31059 Toulouse. France
| | - P Duffau
- Service de Médecine Interne-Immunologie Clinique Hôpital Saint-André, CHU Bordeaux, 1 rue Jean Burguet, 33075 Bordeaux, France
| | - V Barbay
- Normandie Univ, UNIROUEN, Hématologie biologique, F-76031 Rouen, France
| | - S Audia
- Service de médecine interne et immunologie clinique, CHU Dijon-Bourgogne, Université de Dijon, F-21079 Dijon, France
| | - J Benichou
- Department of Biostatistics, CHU Rouen and CESP UMR 1018, University of Rouen and University Paris-Saclay, F-76031 Rouen, France
| | - J Graveleau
- Nantes Université, CHU Nantes, Service de Médecine Interne, Nantes, France
| | - Y Benhamou
- Normandie Univ, UNIROUEN, U 1096, CHU Rouen, Department of Internal Medicine, F-76000 Rouen, France
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Iarossi M, Hermans C. Emicizumab as first-line therapy in acquired hemophilia A. Res Pract Thromb Haemost 2024; 8:102438. [PMID: 38953052 PMCID: PMC11215093 DOI: 10.1016/j.rpth.2024.102438] [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: 03/13/2024] [Revised: 04/30/2024] [Accepted: 05/01/2024] [Indexed: 07/03/2024] Open
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune disease resulting from the development of autoantibodies directed against endogenous factor (F)VIII, leading to bleeding manifestations that can be life-threatening. The current standard hemostatic treatment involves the use of bypassing agents that circumvent FVIII (recombinant activated FVII, activated prothrombin complex concentrate, and recombinant porcine FVIII) that must be administered intravenously and possess a short half-life. These limitations and the risk of potentially fatal bleeding complications justify the early initiation of immunosuppressive treatment (IST) aimed at promptly eradicating the autoantibodies. IST is not without side effects, sometimes severe and possibly fatal, especially in persons with AHA who are generally older and have multiple comorbidities. Emicizumab, a bispecific antibody that mimics the action of FVIII, has emerged as an effective hemostatic therapy among persons with congenital hemophilia, whether complicated by the presence of anti-FVIII antibodies or not. Numerous arguments from recent clinical experiences suggest positioning emicizumab as a first-line treatment for AHA. This strategy has the potential to reduce bleeding complications and, importantly, the side effects associated with IST, which can be delayed and tailored to each patient.
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Affiliation(s)
- Michael Iarossi
- Division of Hematology, Hemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain, Brussels, Belgium
| | - Cedric Hermans
- Division of Hematology, Hemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain, Brussels, Belgium
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Meeks SL, Zimowski KL. Haemophilia in the era of novel therapies: Where do inhibitors feature in the new landscape? Haemophilia 2024; 30 Suppl 3:95-102. [PMID: 38539060 DOI: 10.1111/hae.14982] [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: 01/10/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION The advent of therapeutic recombinant factor VIII (FVIII) and factor IX (FIX) protein infusions revolutionized the care of persons with haemophilia in the 1990s. It kicked off an era with the increasing use of prophylactic factor infusions for patients and transformed conversations around the ideal trough activity levels as well as the ultimate goals in tailored, individualized care. Our knowledge surrounding the immunologic basis of inhibitor development and treatment derives from a time when patients were receiving frequent factor infusions and focused on immune tolerance induction following inhibitor development. DISCUSSION More recently, care was revolutionized again in haemophilia A with the approval of emicizumab, a bispecific antibody mimicking activated FVIII function, to prevent bleeding. The use of emicizumab prophylaxis has resulted in a significantly slower accumulation of factor exposure days and continued effective prophylaxis in the case of inhibitor development. While emicizumab is effective at reducing the frequency of bleeding events in patients with haemophilia A, management of breakthrough bleeds, trauma, and surgeries still requires additional treatment. Ensuring that FVIII is a therapeutic option, particularly for life-threatening bleeding events and major surgeries is critical to optimizing the care of persons with haemophilia A. Other novel non-factor concentrate therapies, including rebalancing agents, will dramatically change the landscape for persons with haemophilia B with inhibitors. CONCLUSION This review discusses the changing landscape regarding the timing of inhibitor development and management strategies after inhibitor development, stressing the importance of education across the community to continue to vigilantly monitor for inhibitors and be prepared to treat persons with inhibitors.
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Affiliation(s)
- Shannon L Meeks
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Karen L Zimowski
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
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7
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Franchini M, Focosi D. Innovative Therapies for Acquired Hemophilia A. Semin Thromb Hemost 2024. [PMID: 38395066 DOI: 10.1055/s-0044-1779737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder which can be life-threatening. AHA is due to autoantibodies against coagulation factor VIII. Disease onset may be idiopathic (approximately half of the cases) or triggered by autoimmune disorders, cancers, drugs, infections, or pregnancy. Besides treating the underlying disorder, specific AHA treatments include management of bleeding and inhibitor eradication. Various first-line and second-line hemostatic and immunosuppressive agents are currently available for the management of AHA. Recently, the hemostatic drug emicizumab and the immunosuppressive drug rituximab have been the object of intense research from investigators as innovative promising therapies for AHA. This narrative review will be focused on the current status of the clinical use of these two off-label therapeutic agents in AHA.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantua, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
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8
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Poston J, Kruse-Jarres R. The role of emicizumab in acquired hemophilia A. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:24-30. [PMID: 38066880 PMCID: PMC10727101 DOI: 10.1182/hematology.2023000462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Acquired hemophilia is a rare bleeding disorder that predominantly affects older people with potential underlying comorbidities, including cardiovascular and thrombotic risk factors. The current standard therapies with hemostatic agents for acute bleeding and immunosuppression often require inpatient management, are not approved for routine bleeding prophylaxis, and contribute to the high mortality in this population. Emicizumab is a factor VIII (FVIII) mimetic approved for bleeding prophylaxis in congenital hemophilia A with and without FVIII inhibitors. Given subcutaneously, it may allow easier outpatient bleeding prophylaxis and reduce intensity of immunosuppression. This article summarizes the currently available data on the efficacy and safety of emicizumab in acquired hemophilia A.
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Affiliation(s)
- Jacqueline Poston
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Rebecca Kruse-Jarres
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
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9
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Platton S. Diagnosis and laboratory monitoring of hemophilia A. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:11-18. [PMID: 38066923 PMCID: PMC10727114 DOI: 10.1182/hematology.2023000460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Acquired hemophilia A (AHA) is a rare disorder in which autoantibodies against factor VIII (FVIII) lead to a bleeding phenotype that varies from life-threatening to no bleeding at all. Prolonged activated partial thromboplastin times (APTT) in patients with a bleeding phenotype should be investigated to rule out AHA and should never be ignored in a preprocedure patient. Most inhibitors in AHA are heat and time dependent, so mixing studies performed only on an immediate mix are not useful: both lupus anticoagulants and treatment with direct oral anticoagulants can coexist with AHA and confound the diagnosis. Assays for intrinsic coagulation factors and von Willebrand factor should always be performed, regardless of the results of mixing studies. A Bethesda or modified Bethesda assay should be performed to quantify any inhibitor, and if susoctocog alfa (rpFVIII) is available, then an assay for cross-reacting antibodies should also be performed. At diagnosis and until complete remission, if the FVIII in the patient sample is >5 IU/dL, heat inactivation should be performed before the inhibitor assays are performed. While there are no conventional tests available to measure the effects of FVIII bypassing therapies, newer therapies may require monitoring, or their effects may need to be considered when choosing appropriate assays. Measurement of rpFVIII requires a 1-stage clotting assay, and measurement of patient FVIII while on emicizumab requires a chromogenic assay that does not contain human FX. Close communication is required between the treating clinicians and the laboratory to ensure that the correct tests are performed while patients are receiving treatments.
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Affiliation(s)
- Sean Platton
- The Royal London Hospital Haemophilia Centre, Bart Health NHS Trust, London, UK
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10
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Pfrepper C, Klamroth R, Oldenburg J, Holstein K, Eichler H, Hart C, Moehnle P, Schilling K, Trautmann-Grill K, Alrifai M, Ay C, Miesbach W, Knoebl P, Tiede A. Emicizumab for the Treatment of Acquired Hemophilia A: Consensus Recommendations from the GTH-AHA Working Group. Hamostaseologie 2023. [PMID: 38049124 DOI: 10.1055/a-2197-9738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a severe bleeding disorder caused by autoantibodies against coagulation factor VIII (FVIII). Standard treatment consists of bleeding control with bypassing agents and immunosuppressive therapy. Emicizumab is a bispecific antibody that mimics the function of activated FVIII irrespective of the presence of neutralizing antibodies. Recently, the GTH-AHA-EMI study demonstrated that emicizumab prevents bleeds and allows to postpone immunosuppression, which may influence future treatment strategies. AIM To provide clinical practice recommendations on the use of emicizumab in AHA. METHODS A Delphi procedure was conducted among 33 experts from 16 German and Austrian hemophilia care centers. Statements were scored on a scale of 1 to 9, and agreement was defined as a score of ≥7. Consensus was defined as ≥75% agreement among participants, and strong consensus as ≥95% agreement. RESULTS Strong consensus was reached that emicizumab is effective for bleed prophylaxis and should be considered from the time of diagnosis (100% consensus). A fast-loading regimen of 6 mg/kg on day 1 and 3 mg/kg on day 2 should be used if rapid bleeding prophylaxis is required (94%). Maintenance doses of 1.5 mg/kg once weekly should be given (91%). Immunosuppression should be offered to patients on emicizumab if they are eligible based on physical status (97%). Emicizumab should be discontinued when remission of AHA is achieved (97%). CONCLUSION These GTH consensus recommendations provide guidance to physicians on the use of emicizumab in AHA and follow the results of clinical trials that have shown emicizumab is effective in preventing bleeding in AHA.
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Affiliation(s)
- Christian Pfrepper
- Division of Hemostaseology, Department of Hematology, Cellular Therapy, Hemostaseology and Infectiology, University Hospital Leipzig, Leipzig, Germany
| | - Robert Klamroth
- Department of Internal Medicine, Vascular Medicine and Coagulation Disorders, Vivantes Clinic Friedrichshain, Berlin, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Katharina Holstein
- Department of Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Eichler
- Clinical Hemostaseology and Transfusion Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Christina Hart
- Department of Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Patrick Moehnle
- Division of Transfusion Medicine, Cell Therapeutics and Hemostaseology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Kristina Schilling
- Department of Hematology and Oncology, University Hospital Jena, Jena, Germany
| | | | - Mohammed Alrifai
- Department of Thrombosis and Hemostasis, University Hospital Giessen and Marburg GmbH, Giessen Germany
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | | | - Paul Knoebl
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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11
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Wu JF, Malec LM, Pandit S, Abid H, Jha P, Baumann Kreuziger LM. A 10-year single-institution retrospective review of treatment for acquired hemophilia A. Haemophilia 2023; 29:1656-1660. [PMID: 37694801 DOI: 10.1111/hae.14856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 09/12/2023]
Affiliation(s)
- James F Wu
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lynn M Malec
- Blood Research Institute, Versiti Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sarbagya Pandit
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Haisam Abid
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Pinky Jha
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lisa M Baumann Kreuziger
- Blood Research Institute, Versiti Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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12
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Bannow BS, Konkle BA. How I approach bleeding in hospitalized patients. Blood 2023; 142:761-768. [PMID: 36652635 PMCID: PMC10562531 DOI: 10.1182/blood.2021014766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 01/05/2023] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Excessive bleeding is relatively common in adult inpatients, whether as the primary reason for admission or as a development during the hospital stay. Common causes include structural issues, medication effects, and systemic illnesses; occasionally, unexpected bleeding can develop as a result of an undiagnosed or newly acquired bleeding disorder. The first step in caring for the inpatient who is bleeding is to determine whether the bleeding symptom is truly new or whether the patient has a history of abnormal bleeding. Patients with a history of abnormal bleeding may warrant evaluation for inherited bleeding disorders, such as platelet function disorders, von Willebrand disease, hemophilia, or rare factor deficiencies. Patients with no history of bleeding, for whom other causes, such as liver dysfunction, medication effect, disseminated intravascular coagulation, or certain vitamin deficiencies have been ruled out may require evaluation for acquired coagulopathies, such as acquired hemophilia or acquired von Willebrand disease. Here, we present 3 cases to discuss the diagnosis and management of the 2 most common acquired bleeding disorders as well as a patient with a congenital bleeding disorder with a historical diagnosis.
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Affiliation(s)
- Bethany Samuelson Bannow
- Division of Hematology/Medical Oncology, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Barbara A Konkle
- Division of Hematology, Department of Medicine, Washington Center for Bleeding Disorders, University of Washington, Seattle, WA
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13
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Franchini M, Focosi D. Targeting von Willebrand disease: the current status and future directions of management therapies. Expert Rev Hematol 2023; 16:871-878. [PMID: 37800892 DOI: 10.1080/17474086.2023.2268282] [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: 08/02/2023] [Accepted: 10/04/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION von Willebrand disease (VWD) is the commonest inherited bleeding disorder, and is typically caused by deficits in the quantity or quality of von Willebrand factor (VWF). AREAS COVERED This review describes the main clinical, diagnostic, and therapeutic aspects of VWD, with particular attention to its management. In addition, standard and avant-garde replacement therapies based on the use of VWF are discussed. EXPERT OPINION The goal of treatment for VWD is to reverse the double hemostatic defect resulting from the abnormal or reduced expression of VWF and the concomitant factor VIII (FVIII) deficiency. Treatment consists of managing any bleeds and both short-term prophylaxis (i.e. for surgery or invasive procedures) and long-term prophylaxis. While desmopressin is suitable for most patients with type 1 VWD, VWF/FVIII concentrates are the treatment of choice for the other types of VWD. Beside plasma-derived VWF/FVIII concentrates, whose safety and efficacy have been demonstrated by several clinical trials, products containing only VWF, obtained by plasma fractionation and recombinant DNA technology, have become available and marketed more recently. The clinical use of these VWF-only products is particularly attractive in the setting of surgery and long-term prophylaxis, such as the prevention of recurrent gastrointestinal bleeding in cases of angiodysplasia.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
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Nardi MA. Hemophilia A: Emicizumab monitoring and impact on coagulation testing. Adv Clin Chem 2023; 113:273-315. [PMID: 36858648 DOI: 10.1016/bs.acc.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Hemophilia A is an X-linked recessive bleeding disorder characterized by absent or ineffective coagulation factor VIII, a condition that could result in a severe and potentially life-threatening bleed. Although the current standard of care involves prophylactic replacement therapy of factor VIII, the development of neutralizing anti-factor VIII alloantibody inhibitors often complicates such therapeutic treatment. Emicizumab (Hemlibra®), a novel recombinant therapeutic agent for patients with hemophilia A, is a humanized asymmetric bispecific IgG4 monoclonal antibody designed to mimic activated factor VIII by bridging factor IXa and factor X thus effecting hemostasis. Importantly, this drug eliminates the need for factor VIII and complications associated with inhibitor generation. Emicizumab has been approved for use in several countries including the United States and Japan for prophylaxis of bleeding episodes in hemophilia A with and without FVIII inhibitors. Therapy is also approved in the European Union for routine prophylaxis of bleeds in hemophilia A with inhibitors or severe hemophilia A without inhibitors. Unfortunately, emicizumab therapy presents unique challenges for routine and specialty coagulation tests currently used to monitor hemophilia A. In this review, hemophilia A is presented, the biochemistry of factor VIII is discussed, and the impact of the therapeutic agent emicizumab is highlighted.
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Affiliation(s)
- Michael A Nardi
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, United States; Department of Pathology, New York University Grossman School of Medicine, New York, NY, United States.
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Mihaila RG. From a bispecific monoclonal antibody to gene therapy: A new era in the treatment of hemophilia A. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023; 167:1-8. [PMID: 36413008 DOI: 10.5507/bp.2022.046] [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: 08/19/2022] [Accepted: 11/02/2022] [Indexed: 11/23/2022] Open
Abstract
The treatment of hemophilia A has progressed amazingly in recent years. Emicizumab, a bispecific-humanized monoclonal antibody, is able to improve coagulation by bridging activated factor IX and factor X. Emicizumab is administered subcutaneously and much less often compared to factor VIII products. It has low immunogenicity, does not require dose adjustment, and can be administered regardless of the presence of factor VIII inhibitors. Thrombin generation assays but not factor VIII activity are indicated to guide and monitor the treatment. Emicizumab has enabled the conversion of patients with severe forms into patients with milder forms of hemophilia A. It has reduced the number of bleeding episodes compared to both on-demand and prophylactic substitution therapy and has an excellent safety profile. Gene therapy can elevate factor VIII plasma levels for many years after a single treatment course, could offer long-term protection from bleeding episodes, and minimize or eliminate the need for substitutive treatment with factor VIII concentrates. Gene therapy can provoke an immune response, manifested by an increase in common liver enzymes, that require immunotherapy. Long term monitoring is necessary to identify possible adverse effects. Future objectives are: the development of an ideal viral vector, the possibility of its re-administration, the use of gene therapy in hemophiliac children, and determining whether it can be successfully used to induce immune tolerance to factor VIII ceteri paribus. The future will determine the place of each type of treatment and group of patients for which it is indicated.
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Shima M, Amano K, Ogawa Y, Yoneyama K, Ozaki R, Kobayashi R, Sakaida E, Saito M, Okamura T, Ito T, Hattori N, Higasa S, Suzuki N, Seki Y, Nogami K. A prospective, multicenter, open-label phase III study of emicizumab prophylaxis in patients with acquired hemophilia A. J Thromb Haemost 2023; 21:534-545. [PMID: 36696195 DOI: 10.1016/j.jtha.2022.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/09/2022] [Accepted: 10/05/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Emicizumab is a bispecific antibody that mimics the cofactor function of activated factor (F) VIII. It prevents bleeds in patients with congenital hemophilia A regardless of the inhibitor status; however, no prospective clinical studies have been conducted for emicizumab in patients with acquired hemophilia A (PwAHA). OBJECTIVES To describe the primary analysis results from a prospective, multicenter, open-label phase III study evaluating the efficacy, safety, and pharmacokinetics of emicizumab in PwAHA (AGEHA; JapicCTI-205151). METHODS Emicizumab was administered subcutaneously at 6 mg/kg on day 1 and 3 mg/kg on day 2, followed by 1.5 mg/kg once weekly from day 8 onward. Predefined criteria for the completion of dosing included FVIII activity of >50 IU/dL. RESULTS By the cutoff date (April 23, 2021), 12 patients on immunosuppressive therapy were enrolled, and 11 of them (91.7%) completed emicizumab treatment. The mean trough plasma emicizumab concentration rapidly reached a steady state (1 week), achieving the efficacious level that was established in patients with congenital hemophilia A (>30 μg/mL). Before first emicizumab administration, 7 patients (58.3%) experienced 77 major bleeds. During emicizumab treatment, no major bleeds occurred in any patient. Neither death due to bleeding or infection nor any study treatment-related serious adverse event was reported. One asymptomatic, nonserious deep vein thrombosis was discovered with no laboratory findings indicating any trend toward hypercoagulation. CONCLUSION These results suggest that emicizumab prophylaxis with the tested dosing regimen and completion criteria may have a favorable benefit-risk profile in PwAHA.
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Affiliation(s)
- Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, Kashihara, Japan; Department of Pediatrics, Nara Medical University, Kashihara, Japan.
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yoshiyuki Ogawa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | | | | | - Emiko Sakaida
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Makoto Saito
- Blood Disorders Center, Aiiku Hospital, Sapporo, Japan
| | - Takashi Okamura
- Department of Hematology, St. Mary's Hospital, Kurume, Japan
| | - Toshihiro Ito
- Department of Infectious Diseases, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Norimichi Hattori
- Division of Hematology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Satoshi Higasa
- Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Nobuaki Suzuki
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Yoshinobu Seki
- Department of Hematology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-uonuma, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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Nogami K, Shima M. Current and future therapies for haemophilia-Beyond factor replacement therapies. Br J Haematol 2023; 200:23-34. [PMID: 35869698 DOI: 10.1111/bjh.18379] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 12/01/2022]
Abstract
Some non-factor products that work by facilitating the coagulation pathway (emicizumab) and blocking the anticoagulant pathway (fitusiran, concizumab and marstacimab) for patients with haemophilia (H) have been developed, and clinical trials using these products are currently ongoing. Prophylaxis using non-factor products by subcutaneous administration provides marked reductions of bleeding episodes in patients with HA or HB, regardless of the presence of inhibitor. Emicizumab has already been approved globally. Emicizumab alters the phenotype of patients with HA from severe to mild by maintaining trough levels of equivalent factor VIII activity (15-20 iu/dl). Phase 3 clinical trials and long-term observations assessing emicizumab revealed tolerable safety and efficacy. However, thrombotic events have occurred in patients receiving these non-factor products. Furthermore, monitoring of the haemostatic function of these products with concomitant therapy is also required in clinical practice. These products have promising haemostatic efficiency, but wider clinical experience is needed to provide optimal therapeutic strategies in the future.
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Affiliation(s)
- Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,Thrombosis and Hemostasis Research Centre, Nara Medical University, Kashihara, Nara, Japan
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ORIHIME study: real-world treatment patterns and clinical outcomes of 338 patients with acquired hemophilia A from a Japanese administrative database. Int J Hematol 2023; 117:44-55. [PMID: 36331704 PMCID: PMC9813148 DOI: 10.1007/s12185-022-03467-w] [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: 07/22/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a rare disorder, and clinical practices for treating AHA have not been fully clarified in Japan. OBJECTIVES This study aims to investigate the epidemiology of AHA and real-world treatment practices in Japan. PATIENTS/METHODS This observational study was based on a health administrative database of hospitalized patients diagnosed with AHA who were treated with immunosuppressants. RESULTS The study included 214 males and 124 females (mean age 75.7 years). The most frequently used bypassing agent was recombinant activated factor VII. The predominant choice of immunosuppressant for first-line treatment was steroid monotherapy. Median days from the index date to the start of rehabilitation was 65.0 for cardiovascular, 35.5 for respiratory and 23.0 for locomotor. The proportion of patients with an activities of daily living (ADL) score < 70 points was high at both first admission and final discharge (47.4% and 38.8%). The percentage of deaths during hospitalization was 18.6%. CONCLUSIONS This study clarified the treatment patterns and clinical outcomes of AHA in a large population in Japan. This was the first study showing ADL score distribution and time to rehabilitation. Further investigation is needed to develop better clinical practices for treatment of AHA.
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Poston JN, Kruse-Jarres R. Advances in Acquired Hemophilia A. Transfus Med Rev 2022; 36:215-219. [DOI: 10.1016/j.tmrv.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 10/14/2022]
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Mingot-Castellano ME, García Candel F, Benítez Hidalgo O, Marco A, Navarro GAM, Pérez-Montes R, Donas GG, Canaro M, Paloma MJ, Asenjo B, Calle-Gordo VM, González NP, González RR, Caparrón Miranda IS, París LQ, Herrero S, Nuñez R. Activated Prothrombin Complex Concentrate to Treat Bleeding Events in Acquired Hemophilia A: Bahas Study. Eur J Haematol 2022; 109:686-695. [PMID: 36029160 DOI: 10.1111/ejh.13853] [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: 06/05/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Activated prothrombin complex concentrate (aPCC) is a bypassing agent indicated to treat bleeds in patients with acquired hemophilia A (AHA). Nevertheless, its efficacy and safety in the real-world setting has not often been addressed. METHODS We report the experience of Spanish reference centers for coagulation disorders and from acquired haemophilia Spanish Registry (AHASR), from August 2012 to February 2021. Follow-up period of 30 days after aPCC withdrawal. RESULTS Thirty patients with a median age of 70 years old, suffering from 51 bleeds treated with aPCC were finally evaluated. As first line treatment, aPCC stopped bleed in 13 of 14 (92.9%) cases. aPCC as second line after recombinant factor VIIa failure, stopped bleeding in the all cases. In 17 patients aPCC was used far from initial bleed control as prophylaxis of rebleeding with 94% effectiveness. No thromboembolic episodes was communicated. One patient developed hypofibrinogenemia, which did not prevent aPCC from halting bleeding. No other serious adverse events possibly or probably associated with aPCC were reported. CONCLUSIONS this data support aPCC as haemostatic treatment in AHA with high effectiveness and excellent safety profile in acute bleeds and as extended use to prevent rebleedings, even in anging people with high cardiovascular risk. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- María Eva Mingot-Castellano
- Hematology Department, Hospital Universitario Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain.,Hematology Department, Hospital Regional Universitario de Málaga, Málaga, Spain
| | | | | | - Ana Marco
- Hematology Department, Hospital General de Alicante4, Alicante, Spain
| | | | | | - Gloria García Donas
- Hematology Department, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Mariana Canaro
- Hematology Department, Hospital Son Espases, Palma de Mallorca, Spain
| | - María José Paloma
- Hematology Department, Hospital Universitario Virgen del Camino, Pamplona, Spain
| | - Beatríz Asenjo
- Hematology Department, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | | | | | | | - Laura Quintana París
- Hematology Department, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
| | - Sonia Herrero
- Hematology Department, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Ramiro Nuñez
- Hematology Department, Hospital Universitario Virgen del Rocio, Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
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21
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Schmalzing M. Hemmkörperhämophilie: aktuelle
Aspekte. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1876-2742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
ZusammenfassungDie erworbene Hämophilie A stellt die häufigste
Hemmkörperhämophilie dar. Sie kann idiopathisch, in Zusammenhang
mit anderen Erkrankungen oder post partum auftreten. In einem Großteil
der Fälle treten ausgeprägte Blutungszeichen auf, die
lebensbedrohlich verlaufen können. Wichtige Differentialdiagnosen werden
genannt. Die Diagnose wird ausgehend von der verlängerten aPTT durch
Plasmamischversuche und den Bethesda-Test gestellt. Die Therapie erfolgt
einerseits neben lokalen Maßnahmen zur Blutungskontrolle durch
Gerinnungsfaktorpräparate sowie Tranexamsäure zur Blutstillung
sowie andererseits durch Immunsuppression mit Glukokortikoiden, Rituximab
und/oder Cyclophosphamid zur Elimination des inhibitorischen
Autoantikörpers. Alternative Immunsuppressive Therapieoptionen
für refraktäre Fälle werden aufgezeigt. Die Prognose
scheint vor allem davon abhängig zu sein wie stark Faktor VIII initial
reduziert ist.
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Affiliation(s)
- Marc Schmalzing
- Rheumatology/Clinical Immunology, Department of Internal
Medicine II, University of Würzburg, Würzburg,
Germany
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22
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Lenting PJ, Kizlik-Manson C, Casari C. Towards novel treatment options in von Willebrand disease. Haemophilia 2022; 28 Suppl 4:5-10. [PMID: 35521728 DOI: 10.1111/hae.14518] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 11/29/2022]
Abstract
Deficiency or dysfunction of von Willebrand factor (VWF) is associated with a bleeding disorder known as von Willebrand disease (VWD). The clinical manifestations of VWD are heterogeneous, and are in part dictated by the structural or functional defects of VWF. The tools to control bleeding in VWD are dominated by VWF concentrates, desmopressin and antifibrinolytic therapy. In view of these treatments being considered as effective, it is surprising that quality-of-life studies consistently demonstrate a significant mental and physical burden in VWD patients, particularly in women. Apparently, the current weaponry to support the management of VWD is insufficient to fully address the needs of the patients. It is important therefore to continue to search for innovative treatment options which could better serve the VWD patients. In this short review, two of such options are discussed in more detail: emicizumab to correct for the deficiency of factor VIII (FVIII), and the pegylated aptamer BT200 to increase endogenous levels of the VWF/FVIII complex.
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Affiliation(s)
- Peter J Lenting
- Laboratory for Hemostasis, Inflammation & Thrombosis, Unité Mixed de Recherche (UMR)-1176, Institut National de la Santé et de la Recherche Médicale (Inserm), Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Claire Kizlik-Manson
- Laboratory for Hemostasis, Inflammation & Thrombosis, Unité Mixed de Recherche (UMR)-1176, Institut National de la Santé et de la Recherche Médicale (Inserm), Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Caterina Casari
- Laboratory for Hemostasis, Inflammation & Thrombosis, Unité Mixed de Recherche (UMR)-1176, Institut National de la Santé et de la Recherche Médicale (Inserm), Université Paris-Saclay, Le Kremlin-Bicêtre, France
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Acquired hemophilia A following allogeneic stem cell transplantation for acute lymphoblastic leukemia. Ann Hematol 2022; 101:1861-1863. [PMID: 35312797 PMCID: PMC8935119 DOI: 10.1007/s00277-022-04819-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/13/2022] [Indexed: 12/02/2022]
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Nowak KM, Carpinteiro A, Szalai C, Saner FH. Acquired Hemophilia A: A Permanent Challenge for All Physicians. MEDICINES (BASEL, SWITZERLAND) 2022; 9:medicines9030021. [PMID: 35323720 PMCID: PMC8950178 DOI: 10.3390/medicines9030021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 12/12/2022]
Abstract
Acquired hemophilia A (AHA) is a rare disease with a prevalence in Europe of 1.5 per million. This diagnosis is significantly delayed in about one-third of all cases, leading to deferred treatment. The main signs of AHA are spontaneous bleeding seen in about two-thirds of all patients. AHA can be lethal in 20% of all symptomatic cases. This patient population’s main standard laboratory finding is a prolonged aPTT (activated prothrombin Time) with otherwise normal coagulation results. In addition, antibodies against FVIII (in Bethesda Units) and a quantitative reduction of FVIII activity are necessary to confirm AHA. The therapy of acute bleeding related to AHA is based on the following main principles: Pharmacologic control of the bleeding is of absolute importance. It can be achieved by administering either recombinant activated FVIIa “bypass therapy”; activated prothrombin complex; or Emicizumab, a bispecific monoclonal antibody. Eradication of the FVIII antibodies should be initiated simultaneously. The combination of steroids with cyclophosphamide leads to the highest eradication rates. Causes of AHA may be related to neoplasms, autoimmune diseases, and pregnancy. We report on a patient who underwent four surgical procedures before the diagnosis of AHA was established.
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Affiliation(s)
- Knut M. Nowak
- Department of General, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany;
| | - Alexander Carpinteiro
- Department of Hematology and Stem Cell Transplantation, Medical Center University Duisburg-Essen, 45147 Essen, Germany;
| | - Cynthia Szalai
- Department of Anesthesiology and Critical Care, Medical Center University Duisburg-Essen, 45147 Essen, Germany;
| | - Fuat H. Saner
- Department of General, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, 45147 Essen, Germany;
- Correspondence: ; Tel.: +49-201-723-84008; Fax: +49-201-723-1145
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