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Sefiane T, Maynadié H, Ettingshausen CE, Muczynski V, Heiligenstein X, Dumont J, Christophe OD, Denis CV, Casari C, Lenting PJ. Differences in venous clot structures between hemophilic mice treated with emicizumab versus factor VIII or factor VIIIFc. Haematologica 2024; 109:1836-1848. [PMID: 38058210 PMCID: PMC11141652 DOI: 10.3324/haematol.2023.284142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/29/2023] [Indexed: 12/08/2023] Open
Abstract
Recombinant factor VIII (rFVIII), rFVIIIFc and emicizumab are established treatment options in the management of hemophilia A. Each has its unique mode of action, which can influence thrombin generation kinetics and therefore also the kinetics of thrombin substrates. Such differences may potentially result in clots with different structural and physical properties. A starting observation of incomplete wound closure in a patient on emicizumab prophylaxis led us to employ a relevant mouse model in which we noticed that emicizumab-induced clots appeared less stable compared to FVIII-induced clots. We therefore analyzed fibrin formation in vitro and in vivo. In vitro fibrin formation was faster and more abundant in the presence of emicizumab than in the presence of rFVIII/rFVIIIFc. Furthermore, the time-interval between the initiation of fibrin formation and factor XIII activation was twice as long for emicizumab than as for rFVIII/rFVIIIFc. Scanning electron microscopy and immunofluorescent spinning-disk confocal microscopy of in vivo-generated clots confirmed increased fibrin formation in the presence of emicizumab. Unexpectedly, we also detected a different morphology between rFVIII/rFVIIIFcand emicizumab-induced clots. Contrary to the regular fibrin mesh obtained with rFVIII/rFVIIIFc, fibrin fibers appeared to be fused into large patches upon emicizumab treatment. Moreover, fewer red blood cells were detected in regions in which these fibrin patches were present. The presence of highly dense fibrin structures associated with a diffuse fiber structure in emicizumab-induced clots was also observed when using super-resolution imaging. We hypothesize that the modified kinetics of thrombin, fibrin and factor XIIIa generation contribute to differences in structural and physical properties between clots formed in the presence of FVIII or emicizumab.
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Affiliation(s)
- Thibaud Sefiane
- Laboratory for Hemostasis, Inflammation and Thrombosis, Unité Mixed de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, 94276 Le Kremlin-Bicêtre
| | - Hortense Maynadié
- Laboratory for Hemostasis, Inflammation and Thrombosis, Unité Mixed de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, 94276 Le Kremlin-Bicêtre, France; Centre de Référence de l'Hémophilie et des Maladies Hémorragiques Constitutionnelles rares, Hôpital Bicêtre AP-HP, Université Paris-Saclay, Le Kremlin-Bicêtre
| | | | - Vincent Muczynski
- Laboratory for Hemostasis, Inflammation and Thrombosis, Unité Mixed de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, 94276 Le Kremlin-Bicêtre
| | | | - Julien Dumont
- Collège de France, Centre interdisciplinaire de recherche en biologie (CIRB), Unité Mixed de Recherche 1050, Paris
| | - Olivier D Christophe
- Laboratory for Hemostasis, Inflammation and Thrombosis, Unité Mixed de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, 94276 Le Kremlin-Bicêtre
| | - Cécile V Denis
- Laboratory for Hemostasis, Inflammation and Thrombosis, Unité Mixed de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, 94276 Le Kremlin-Bicêtre.
| | - Caterina Casari
- Laboratory for Hemostasis, Inflammation and Thrombosis, Unité Mixed de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, 94276 Le Kremlin-Bicêtre, France; CC and PJL contributed equally to this study
| | - Peter J Lenting
- Laboratory for Hemostasis, Inflammation and Thrombosis, Unité Mixed de Recherche 1176, Institut National de la Santé et de la Recherche Médicale, Université Paris-Saclay, 94276 Le Kremlin-Bicêtre, France; CC and PJL contributed equally to this study
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2
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Cho H, Yoo KY, Shin JY, Lee EK, Choi B. Comparison of thrombotic adverse events in patients treated with factor VIII products and emicizumab using the 2018-2022 US Food and Drug Administration Adverse Event Reporting System data. J Thromb Haemost 2024; 22:1640-1648. [PMID: 38395359 DOI: 10.1016/j.jtha.2024.02.009] [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: 10/25/2023] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Relatively little is known about thrombotic adverse events (AEs) of emicizumab in postmarketing real-world settings, particularly in comparison with factor VIII (FVIII) products. A recent European study reported a potentially greater thrombotic risk of emicizumab compared with FVIII products. OBJECTIVES This drug safety study aims to investigate whether thrombotic AEs are more frequently reported for emicizumab than for FVIII products and if so, whether it is independent of bypassing agents as coreporting drugs using the United States Food and Drug Administration Adverse Event Reporting System data. METHODS Disproportionality analyses for thrombotic AEs of emicizumab vs FVIII products were conducted. Three signal detection indicators were used: proportional reporting ratio (PRR), reporting odds ratio (ROR), and informational component (IC). RESULTS During 2018-2022, the proportions of thrombotic AEs among all AEs were 4.07% (97 out of 2383) and 1.44% (134 out of 9324) for emicizumab and FVIII products, respectively: PRR = 2.83 (2.19-3.66), ROR = 2.91 (2.23-3.79), and IC = 1.04 (0.70-1.28). Bypassing agents as coreporting drugs were identified in 36% and 15% of the total thrombotic AE reports associated with emicizumab and FVIII products, respectively. Even after thrombotic AE reports with bypassing agents were excluded, the reporting proportion of thrombotic AEs was still greater for emicizumab than for FVIII products: PRR = 2.19 (1.60-2.99). CONCLUSION Thrombotic AEs in the United States Food and Drug Administration Adverse Event Reporting System data were about 3 times more frequently reported for emicizumab than for FVIII products. More research and efforts in the future are warranted for monitoring, elucidating, and preventing the potential risk of thrombotic AEs in hemophilia therapy, including emicizumab.
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Affiliation(s)
- Hyunjeong Cho
- Department of Research and Development, GC Biopharma, Yongin, South Korea; Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | | | - Ju-Young Shin
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea; School of Pharmacy, Sungkyunkwan University, Suwon, South Korea; Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, South Korea
| | - Eun-Kyoung Lee
- Department of Research and Development, GC Biopharma, Yongin, South Korea
| | - BongKyoo Choi
- Department of Research and Development, GC Biopharma, Yongin, South Korea; Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea.
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3
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Almomen AM, Alzahrani HA, AlSaeed HH, AlAseri Z, Mady AF, Owaidah T. Saudi expert consensus on acquired hemophilia A diagnosis and management. J Taibah Univ Med Sci 2024; 19:566-574. [PMID: 38736896 PMCID: PMC11087233 DOI: 10.1016/j.jtumed.2024.04.006] [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: 08/17/2023] [Revised: 03/05/2024] [Accepted: 04/16/2024] [Indexed: 05/14/2024] Open
Abstract
Objectives Acquired hemophilia affects approximately one in 1 million people. Timely diagnosis is key to appropriate disease management and the prevention of life-threatening complications. Patients with this condition may initially be seen by inexperienced physicians and remain underdiagnosed for several years. This consensus statement is aimed at providing guidelines for all practitioners in the Kingdom of Saudi Arabia (KSA) to diagnose and manage acquired hemophilia A. Methods This consensus statement reflects the opinions drafted by a group of hematology specialists, who used an explicit systematic process to identify areas of agreement and disagreement. Results This consensus statement provides a guide for all practitioners in the KSA regarding the diagnosis of clinical presentation, relevance, characteristics of bleeding symptoms, and case management; it additionally provides guidance for non-specialists. All management aspects, including diagnosis and treatment modalities, are discussed. Conclusions Patients with acquired hemophilia may initially be seen by physicians who lack appropriate expertise in diagnosing and managing this condition. This consensus statement from the premier experts on the disease in the KSA provides details for diagnosing and managing acquired hemophilia.
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Affiliation(s)
| | - Hazza A. Alzahrani
- Adult Hematology/HSCT, Oncology Centre, King Faisal Specialist Hospital and Research Center, Riyadh, KSA
| | - Hussein H. AlSaeed
- Department of Hematology, Qatif Central Hospital, Qatif Health Network, East Cluster Ministry of Health, KSA
| | - Zohair AlAseri
- Departments of Emergency Medicine and Critical Care, College of Medicine, King Saud University, Riyadh, KSA
- Department of Clinical Sciences, College of Medicine and Riyadh Hospital, Dar Al Uloom University, Riyadh, KSA
- Therapeutic Deputyship, Ministry of Health, Riyadh, KSA
| | - Ahmed F. Mady
- ICU, King Saud Medical City, Riyadh, KSA
- Department of Anesthesiology and ICU, Tanta University Hospital, Egypt
| | - Tarek Owaidah
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, KSA
- Alfaisal University, Riyadh, KSA
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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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5
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Mannucci PM, Hermans C. Low-dose emicizumab for more equitable access to prophylaxis in resource limited countries. Haemophilia 2024; 30:575-576. [PMID: 38415381 DOI: 10.1111/hae.14968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 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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6
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Young G, Pipe SW, Kenet G, Oldenburg J, Safavi M, Czirok T, Nissen F, Mahlangu J. Emicizumab is well tolerated and effective in people with congenital hemophilia A regardless of age, severity of disease, or inhibitor status: a scoping review. Res Pract Thromb Haemost 2024; 8:102415. [PMID: 38812987 PMCID: PMC11135026 DOI: 10.1016/j.rpth.2024.102415] [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: 01/22/2024] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 05/31/2024] Open
Abstract
Background With the treatment landscape continually evolving, it is vital that the hemophilia community have an overview of all published data for approved therapies, such as emicizumab, to support shared decision making. Objectives To bring together the clinical and real-world data for emicizumab use in people with congenital hemophilia A, regardless of age, disease severity, or factor VIII inhibitor status. Key focus areas were safety, efficacy, and quality of life (QoL). Methods This scoping review used citation databases (PubMed, Embase, and the Cochrane Library) and manual searches of abstract books. Publications reporting original data for emicizumab in people with hemophilia A, published in English after December 2014, and reporting select endpoints were included. This narrative synthesis focused on zero bleeds, treated annualized bleeding rate (ABR), adverse events, and QoL measures. Results Overall, 97 publications were included (cut-off: August 9, 2022). Treated ABR remained low (calculated mean and median treated ABRs ranged between 0.7-1.3 and 0.0-1.4, respectively), and the median percentage of people with zero treated bleeds was 66.7%. The proportion of people experiencing treatment-related adverse events ranged from 0.0% to 60.0%; most were injection-site reactions. Across 37 publications reporting on safety and enrolling >2300 individuals, 11 thrombotic events and 4 thrombotic microangiopathies were reported. Data from well-established tools show QoL benefits with emicizumab. Conclusion This scoping review consolidates the global published experience for emicizumab in people with hemophilia A and supports the fact that emicizumab has an acceptable safety profile, is effective and efficacious in bleed prevention, and is associated with improvements in QoL.
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Affiliation(s)
- Guy Young
- Cancer and Blood Disorders Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Steven W. Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Gili Kenet
- The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel
- The Amalia Biron Thrombosis Research Institute, Tel Aviv University, Tel Aviv, Israel
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Mariam Safavi
- Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Tuende Czirok
- Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Francis Nissen
- Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - 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, Gauteng, South Africa
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7
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Alcedo Andrade PE, Mannucci PM, Kessler CM. Emicizumab: the hemophilia A game-changer. Haematologica 2024; 109:1334-1347. [PMID: 37916312 PMCID: PMC11063855 DOI: 10.3324/haematol.2022.282099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/26/2023] [Indexed: 11/03/2023] Open
Abstract
In hemophilia, the unmet needs regarding adherence to prophylaxis and lack of effective long-term prophylaxis regimens, especially in patients with inhibitors, led to the production of emicizumab, the first non-factor medicine for subcutaneous administration in patients with severe and moderate hemophilia A with or without factor VIII inhibitors. This review describes the research steps behind the development of this game-changing medication as well as its success in the prophylaxis of bleeding episodes, as witnessed by the results of pivotal clinical trials but also by real-life use in the frame of a still expanding global market. We also discuss potential and actual adverse events and the nuances related to clinical use, such as laboratory monitoring, development of neutralizing antidrug antibodies, risk of thrombosis/hypercoagulability and role in the management of surgical operations. The potential of emicizumab to prevent bleeding in other congenital and acquired coagulation disorders is also outlined.
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Affiliation(s)
- Pedro E Alcedo Andrade
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC,
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi, Hemophilia and Thrombosis Center, Milan
| | - Craig M Kessler
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, District of Columbia.
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Peyvandi F, Seidizadeh O, Mohsenian S, Garagiola I. Exploring nonreplacement therapies' impact on hemophilia and other rare bleeding disorders. Res Pract Thromb Haemost 2024; 8:102434. [PMID: 38873363 PMCID: PMC11169453 DOI: 10.1016/j.rpth.2024.102434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 06/15/2024] Open
Abstract
The management of hemophilia, von Willebrand disease (VWD), and rare coagulation disorders traditionally relied on replacement therapies, such as factor concentrates, to address clotting factor deficiencies. However, in recent years, the emergence of nonreplacement therapies has shown promise as an adjunctive approach, especially in hemophilia, and also for patients with VWD and rare bleeding disorders. This review article offers an overview of nonreplacement therapies, such as FVIII-mimicking agents and drugs aimed at rebalancing hemostasis by inhibiting natural anticoagulants, particularly in the management of hemophilia. The utilization of nonreplacement therapies in VWD and rare bleeding disorders has recently attracted attention, as evidenced by presentations at the International Society on Thrombosis and Haemostasis 2023 Congress. Nonreplacement therapies provide alternative methods for preventing bleeding episodes and enhancing patients' quality of life, as many of them are administered subcutaneously and allow longer infusion intervals, resulting in improved quality of life and comfort for patients.
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Affiliation(s)
- Flora Peyvandi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
- Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Omid Seidizadeh
- Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Samin Mohsenian
- Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Isabella Garagiola
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
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9
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Agarwal S, Hermans C, Miesbach W, Peyvandi F, Sidonio R, Osmond D, Newman V, Henshaw J, Pipe S. Transitioning from emicizumab prophylaxis to valoctocogene roxaparvovec gene therapy: A simulation study for individuals with severe haemophilia A. Haemophilia 2024. [PMID: 38684460 DOI: 10.1111/hae.15025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/27/2024] [Accepted: 03/19/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION Valoctocogene roxaparvovec, a gene therapy evaluated in the phase 3 GENEr8-1 trial, supports endogenous factor VIII (FVIII) production to prevent bleeding in people with severe haemophilia A. Individuals receiving emicizumab, an antibody mimicking the function of activated FVIII, were excluded from GENEr8-1 enrolment since emicizumab was an investigational therapy at the time of trial initiation. AIM Utilize pharmacokinetic simulations to provide guidance on best practices for maintaining haemostatic control while transitioning from emicizumab prophylaxis to valoctocogene roxaparvovec. METHODS To estimate bleeding risk at weekly intervals following valoctocogene roxaparvovec infusion, a published emicizumab pharmacokinetic model was used to simulate emicizumab concentrations and merged with FVIII activity time-course data for participants in GENEr8-1. The analysis investigated three approved emicizumab dosing regimens for two transition scenarios that varied whether the last dose of emicizumab was administered on the same day or 4 weeks after valoctocogene roxaparvovec infusion. RESULTS Simulations demonstrated administering the last emicizumab dose the day of valoctocogene roxaparvovec infusion and 4 weeks after offered similar levels of haemostatic control, and bleeding risk was similar for all emicizumab dosing regimens. An algorithm was developed to provide guidance for discontinuation of emicizumab. Theoretical cases based on GENEr8-1 participants are presented to illustrate how decisions may vary among individuals. CONCLUSION Pharmacokinetic simulations demonstrated no clinically meaningful difference in bleeding risk caused by decaying emicizumab levels and rising gene therapy-derived endogenous FVIII for all examined emicizumab doses and dosing regimens. Therefore, multiple approaches can safely transition individuals from emicizumab prophylaxis to valoctocogene roxaparvovec.
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Affiliation(s)
| | - Cedric Hermans
- Division of Adult Haematology, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | | | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Robert Sidonio
- Hemostasis and Thrombosis Program, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Dane Osmond
- BioMarin Pharmaceutical Inc., Novato, California, USA
| | | | - Josh Henshaw
- BioMarin Pharmaceutical Inc., Novato, California, USA
| | - Steven Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
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10
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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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11
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Tiede A, Susen S, Lisman T. Acquired bleeding disorders. Haemophilia 2024; 30 Suppl 3:29-38. [PMID: 38562115 DOI: 10.1111/hae.14995] [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: 01/23/2024] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 04/04/2024]
Abstract
Acquired bleeding disorders can develop in previously healthy people irrespective of age or gender but are particularly common in patients with certain underlying conditions. Here, we review recent advances in the management of acquired haemophilia A (AHA), acquired von Willebrand syndrome (AVWS), and patients with hemostatic abnormalities due to chronic liver disease (CLD). Patients with AHA can now benefit from prophylaxis with emicizumab, a therapeutic antibody that mimics the function of activated coagulation factor VIII. The treatment of AVWS remains challenging in many situations and requires careful consideration of the underlying condition. Haemostatic abnormalities in CLD are often compensated by proportional reduction in pro and anti-haemostatic factors resulting in sustained or even increased thrombin generation. Consequently, bleeding in CLD is rarely caused by haemostatic failure and infusion of plasma or coagulation factor concentrates may not be effective.
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Affiliation(s)
- Andreas Tiede
- Department of Haematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Sophie Susen
- Hemostasis and Transfusion Department, University of Lille, Lille University Hospital, Lille, France
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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12
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Camelo RM, Barbosa MM, Henriques LCM, Martin AP, Godman B, Guerra Júnior AA, Acurcio FDA, Alvares-Teodoro J. Emicizumab prophylaxis for people with hemophilia A: Waste estimation and the Brazilian perspective. Saudi Pharm J 2023; 31:101867. [PMID: 38028212 PMCID: PMC10661532 DOI: 10.1016/j.jsps.2023.101867] [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: 08/04/2023] [Accepted: 11/05/2023] [Indexed: 12/01/2023] Open
Abstract
Costs of hemophilia A treatment are increasing. Waste of clotting products should be avoided. To estimate the first-year waste of emicizumab prophylaxis for people with hemophilia A and inhibitors (PwHAi) who failed immune tolerance induction (ITI), in Brazil. We evaluated the manufacturer and the Brazilian Ministry of Health (MoH) protocol-recommended regimens in a budget impact model. The loading dose consisted of 3.0 mg/kg/Q1W for 4 weeks, for both recommendations. The manufacturer maintenance regimens comprised 1.5 mg/kg/Q1W, 3.0 mg/kg/Q2W, and 6.0 mg/kg/Q4W. The MoH protocol maintenance regimen encompassed a hybrid Q1W/Q2W administration, depending on the body weight. The Q4W regimen was not recommended by the MoH protocol. Analyses were performed to estimate waste given its expense based on the World Health Organization body weight range (percentiles [P] 15, 50, and 85). The first-year emicizumab waste was estimated individually and for the disclosed PwHAi who failed ITI (n = 114). The highest emicizumab waste was estimated for the lowest body weights and the Q1W regimen. The Q4W regimen resulted in the lowest emicizumab waste, followed by the MoH protocol regimen. The total reconstituted costs estimated for the PwHAi who failed ITI according to the hybrid MoH protocol ranged from US$32,858,777 (P15) to US$47,186,858 (P85), with emicizumab waste ranging from 7.9 % (US$2,594,515) to 3.7 % (US$1,738,750), respectively. Lost resources due to current protocols for emicizumab prophylaxis for PwHAi who failed ITI in Brazil are considerable. Waste was more pronounced due to lower body weight and shorter administration intervals.
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Affiliation(s)
| | | | | | - Antony Paul Martin
- QC Medica, Liverpool, United Kingdom
- Faculty of Health and Life Science, University of Liverpool, Liverpool, United Kindgom
| | - Brian Godman
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
- Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
- Strathclyde Institute of Pharmacy and Biomedical Science, University of Strathclyde, Glasgow, United Kingdom
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13
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Bertaggia Calderara D, Marchi Cappelletti R, Batista Mesquita Sauvage AP, Durual S, Gomez FJ, Zermatten MG, Aliotta A, Casini A, Alberio L. Pharmacodynamics Monitoring of Emicizumab in Patients with Hemophilia A. Thromb Haemost 2023; 123:955-965. [PMID: 37336473 DOI: 10.1055/s-0043-1769788] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Emicizumab is a bispecific antibody mimicking coagulation factor VIII (FVIII) employed to treat patients with hemophilia A (PwHA) regardless of FVIII inhibitor status. The identification of biological markers reflecting the hemostatic competence of patients under emicizumab therapy would have a great clinical value. Unfortunately, emicizumab over-corrects standard coagulation assays, precluding their use for evaluating the hemostatic correction achieved in vivo. Here, we investigated whether global coagulation assays (GCA) would allow monitoring the biological response to non-factor replacement therapy with emicizumab. MATERIALS AND METHODS Six adults PwHA received a weekly dose of emicizumab of 3 mg/kg during weeks (W) 1 4 and 1.5 mg/kg from W5 onwards. Response to treatment was monitored weekly by emicizumab plasma concentration, thrombin generation (TG), and fibrin clot formation (FCF) and structure. TG and FCF results were compared to patient baseline, FVIII replacement, and healthy donors. RESULTS TG and FCF significantly increased in PwHA after the loading period, reaching a plateau that lasted until the end of monitoring. Similarly, fibrin clot network became denser with thinner fibrin fibers. However, TG contrary to FCF remained at the lower limits of reference values. Remarkably, despite having similar plateau concentrations of emicizumab some patients showed markedly different degrees of TG and FCF improvement. CONCLUSION Our study enriches the knowledge on the use of GCA to monitor non-factor replacement therapy, indicating that TG and FCF could act as direct markers of emicizumab biological activity. GCA allow to capture and visualize the individually variable response to emicizumab, leading a step forward to the personalization of patient treatment.
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Affiliation(s)
- Debora Bertaggia Calderara
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Rita Marchi Cappelletti
- Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Ana Patricia Batista Mesquita Sauvage
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Stéphane Durual
- Biomaterials Laboratory, University Clinics of Dental Medicine, University of Geneva, Switzerland
| | - Francisco J Gomez
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Maxime G Zermatten
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alessandro Aliotta
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alessandro Casini
- Department of Medicine, University of Geneva, Geneva, Switzerland
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
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van der Lans RJL, Otten JJ, Adriaensen GFJPM, Hoven DR, Benoist LB, Fokkens WJ, Reitsma S. Two-year results of tapered dupilumab for CRSwNP demonstrates enduring efficacy established in the first 6 months. Allergy 2023; 78:2684-2697. [PMID: 37394895 DOI: 10.1111/all.15796] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/29/2023] [Accepted: 05/18/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Dupilumab is an anti-T2-inflammatory biological registered for chronic rhinosinusitis (CRS) with nasal polyps (CRSwNP), indicated by integrated CRS-care pathways when optimal medico-surgical treatment yields insufficient CRS control. This study aims to evaluate long-term results with focus on established therapeutic efficacy while tapering dupilumab. METHODS Real-life, prospective observational cohort study in single tertiary referral center with add-on dupilumab as primary biological treatment in adult (≥18 years) biological-naïve CRSwNP patients per the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS)2020-indication with a 2-year follow-up. Tapering (increasing interdose interval) applied every 24 weeks, conditional to sufficient treatment response and CRS control. RESULTS Mean scores (s.d.) of all co-primary outcomes improved significantly from baseline ( 228) to the 48 ( 214) and 96-weeks ( 99) timepoints: Nasal Polyp Score (0-8) improved from 5,3 (1,9) to 1,4 (1,8) and 1,3 (1,7); SinoNasal Outcome Test (SNOT)-22 (0-110) improved from 53,6 (19,6) to 20,2 (15,4) and 21,2 (15,6); Sniffin'Sticks-12 identification test (0-12; 0-6 anosmia, 7-10 hyposmia, 11-12 normosmia) improved from 3,7 (2,4) to 7,7 (2,9) and 7,3 (3,04); Asthma Control Test (5-25; >19 indicating well-controlled asthma) improved from 18,5 (4,8) to 21,8 (3,8) and 21,4 (3,9). Tapering was feasible in 79,5% of the patients at the 24-weeks timepoint, and in 93,7% and 95,8% at the 48- and 96-weeks timepoints, respectively. One-way repeated-measures ANOVA demonstrated no significant alterations of individual co-primary outcome mean-scores from 24 weeks onward. CONCLUSION This first long-term real-life prospective observational cohort study shows high therapeutic efficacy of dupilumab for severe CRswNP in the first 2 years. Therapeutic efficacy is principally established within 24 weeks and endures while tapering dupilumab conditional to treatment response and CRS control.
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Affiliation(s)
| | - Josje Janna Otten
- Department of Otorhinolaryngology and Head and Neck Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Dinand Rienk Hoven
- Department of Otorhinolaryngology and Head and Neck Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Linda Berendina Benoist
- Department of Otorhinolaryngology and Head and Neck Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Wytske Johanna Fokkens
- Department of Otorhinolaryngology and Head and Neck Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sietze Reitsma
- Department of Otorhinolaryngology and Head and Neck Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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15
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Goedhart TMHJ, Janssen A, Mathôt RAA, Cnossen MH. The road to implementation of pharmacokinetic-guided dosing of factor replacement therapy in hemophilia and allied bleeding disorders. Identifying knowledge gaps by mapping barriers and facilitators. Blood Rev 2023; 61:101098. [PMID: 37321952 DOI: 10.1016/j.blre.2023.101098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 04/02/2023] [Accepted: 05/07/2023] [Indexed: 06/17/2023]
Abstract
Clinical guidelines and expert groups recommend the use of pharmacokinetic (PK)-guided dosing of factor replacement therapy for the treatment of bleeding disorders, especially for patients with hemophilia. Although PK-guided dosing is increasingly applied, it is generally not considered standard clinical practice. The aim of this scoping review is to map barriers and facilitators for the implementation of PK-guided dosing in clinical practice and to identify knowledge gaps. A literature search was performed and 110 articles were included that describe PK-guided dosing in patients with bleeding disorders, mostly hemophilia A. We defined two overarching themes, efficacy and feasibility, and discuss five topics within each theme. For each topic, barriers, facilitators and knowledge gaps were described. Although consensus was found with regard to some topics, contradicting reports were found for others, especially with respect to the efficacy of PK-guided dosing. These contradictions highlight the need for future research to elucidate current ambiguities.
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Affiliation(s)
- Tine M H J Goedhart
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - A Janssen
- Department of Clinical Pharmacology - Hospital Pharmacy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Ron A A Mathôt
- Department of Clinical Pharmacology - Hospital Pharmacy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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16
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Hermans C, Pierce GF. Towards achieving a haemophilia-free mind. Haemophilia 2023; 29:951-953. [PMID: 37262437 DOI: 10.1111/hae.14807] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/08/2023] [Accepted: 05/21/2023] [Indexed: 06/03/2023]
Affiliation(s)
- Cedric Hermans
- Division of Haematology, Haemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain (UCLouvain), Brussels, Belgium
- World Federation of Hemophilia, Montreal, Canada
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17
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Donners A, van der Zwet K, Egberts ACG, Fijnvandraat K, Mathôt R, Kruis I, Cnossen MH, Schutgens R, Urbanus RT, Fischer K. DosEmi study protocol: a phase IV, multicentre, open-label, crossover study to evaluate non-inferiority of pharmacokinetic-guided reduced dosing compared with conventional dosing of emicizumab in people with haemophilia A. BMJ Open 2023; 13:e072363. [PMID: 37369395 PMCID: PMC10410934 DOI: 10.1136/bmjopen-2023-072363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION Emicizumab effectively prevents bleeding in people with haemophilia A (PwHA), but is a burden for national healthcare budgets and consequently may limit access. According to the drug label, dosing of emicizumab is based on body weight with fixed intervals of 7, 14 or 28 days, which leads to mean plasma concentrations of 55 µg/mL (SD 15 µg/mL). However, a moderate variability of concentrations and a minimal effective concentration of 30 µg/mL have been suggested in studies. Therefore, a dose of emicizumab that targets a trough concentration of 30 µg/mL is hypothesised to be equally effective as conventional dosing in the prevention of bleeding. METHODS AND ANALYSIS We designed a phase IV, multicentre, open-label, crossover study to evaluate non-inferiority of bleed control of ≥6 months on conventional dosing in comparison to ≥6 months on dose intervention. This dose intervention consists of reducing the dose of emicizumab to target a trough concentrations of 30 µg/mL using individual pharmacokinetic (PK) parameters. Ninety-five PwHA aged >1 years who received conventional dosing of emicizumab for ≥12 months with good bleeding control during the last 6 months will be recruited from all Dutch haemophilia treatment centres. The study is powered to detect a clinically relevant decrease (risk difference) of 15% in the proportion of patients without treated bleeds during follow-up. Secondary endpoints are spontaneous joint or muscle bleeds, and annualised treated bleeding rates (using negative binomial regression). Cost-effectivity between conventional dosing and individualised PK-guided dosing of emicizumab will be compared. ETHICS AND DISSEMINATION The DosEmi study was approved by the Medical Ethics Review Committee NedMec of the University Medical Center of Utrecht, The Netherlands. Study results will be communicated through publications in international scientific journals and presentations at (inter)national conferences. TRIAL REGISTRATION NUMBER EUCTR2021-004039-10-NL at https://trialsearch.who.int. PROTOCOL VERSION V.4.1 on 28 October 2022 (DosEmi protocol_V4.1; NL81112.041.22).
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Affiliation(s)
- Anouk Donners
- Department of Clinical Pharmacy, University Medical Centre, Utrecht University, Utrecht, The Netherlands
| | - Konrad van der Zwet
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Antoine C G Egberts
- Department of Clinical Pharmacy, University Medical Centre, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Ron Mathôt
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Ilmar Kruis
- Netherlands Haemophilia Society, Nijkerk, The Netherlands
| | - Marjon H Cnossen
- Department of Paediatric Haematology and Oncology, Erasmus MC Sophia Children's Hospital, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Principal Investigator SYMPHONY NWO-NWA Consortium, Rotterdam, The Netherlands
| | - Roger Schutgens
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rolf T Urbanus
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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18
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Veizaj D, den Exter PL, Bos MHA. Russell's viper venom: from diagnostic to bypassing agent for hemophilia? J Thromb Haemost 2023; 21:1429-1431. [PMID: 37179074 DOI: 10.1016/j.jtha.2023.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Dejvid Veizaj
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Paul L den Exter
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Mettine H A Bos
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, the Netherlands.
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Hermans C, Pierce GF. Bispecific antibodies mimicking factor VIII in hemophilia A: converting innovation to an essential medicine. Res Pract Thromb Haemost 2023; 7:100173. [PMID: 37538493 PMCID: PMC10394560 DOI: 10.1016/j.rpth.2023.100173] [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: 03/20/2023] [Accepted: 05/02/2023] [Indexed: 08/05/2023] Open
Abstract
Preventive subcutaneous treatment of severe hemophilia A with bispecific antibodies that mimic the action of coagulation factor VIII (FVIII) is emerging as an effective alternative to replacement therapy with intravenous administration of FVIII concentrates, either derived from plasma or produced by biotechnology. Access to this innovative therapeutic approach for a growing number of patients worldwide increasingly appears to be a priority public health strategy. Inclusion of FVIII mimetic bispecific antibodies on the World Health Organization essential medicines list would contribute to health equity in lower-income countries.
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Affiliation(s)
- Cedric Hermans
- Division of Haematology, Haemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain, Brussels, Belgium
- World Federation of Haemophilia, Montreal, Quebec, Canada
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20
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Rodriguez-Merchan EC. Synovitis in hemophilia: preventing, detecting, and treating joint bleeds. Expert Rev Hematol 2023:1-10. [PMID: 37119182 DOI: 10.1080/17474086.2023.2209717] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
INTRODUCTION Most bleeding events in individuals with hemophilia occur within the ankle, knee, and elbow joints. Should the bleeding persist, the synovial membrane starts to hypertrophy and a vicious cycle of chronic hemophilic synovitis (CHS) occurs, leading to joint destruction. AREAS COVERED This article covers the prompt diagnosis of CHS by point-of-care ultrasonography (POC-US) and its treatment by means of several types of synovectomy. EXPERT OPINION It is essential to prevent, detect and treat hemophilic synovitis, because it indicates that the joint has bled and is at risk of bleeding further. Prophylaxis with standard half life (SHL) factor VIII (FVIII) concentrate is the standard of care for individuals with severe hemophilia A and can also be considered for selected patients with moderate disease. Several years of real-world experience with extended half life (EHL) FVIII, emicizumab, and other drugs in development will be needed to ascertain their final effect on bleeding and its complications. We must look for synovitis in individuals declaring joint pain and in asymptomatic patients, and POC-US is the most reasonable imaging instrument with which to carry out periodic joint screening. Radiosynovectomy, chemical synovectomy, and arthroscopic synovectomy markedly reduce bleeding events.
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21
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Dahra A, Mehdi Z, Gupta M, Patle V, Sharan S. Congenital Bleeding Disorders: Managing Central Nervous System Bleeding in an Adult Hemophiliac. Cureus 2023; 15:e36906. [PMID: 37128522 PMCID: PMC10148606 DOI: 10.7759/cureus.36906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Congenital bleeding disorders remain a challenge to healthcare in the developing world. Despite the initiation of gene therapy almost five decades ago, the natural history of hemophilia remains the same. The cost of concentrated plasma factors, the development of a high titer of inhibitors in severe hemophilia A (HA), and the associated enhanced propensity of ICH make advancements in disease management questionable. Severe cases of hemophilia die young due to spontaneous central nervous system bleeds due to the lack of standard guidelines for plasma concentrate replacement and the limited availability of products due to the associated economic burden. Monoclonal antibodies, although a promising option as a standardized prophylactic treatment, remain underutilized due to availability and accessibility issues. Here, we report the case of a 28-year-old male with HA who presented to the emergency with a progressively worsening headache, nausea, and elevated blood pressure. He had an intracerebral hemorrhage (ICH) successfully managed with decongestants and factor VIII supplementation.
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22
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Donners AAMT, van der Zwet K, Rademaker CMA, Egberts TCG, Schutgens REG, Fischer K. The efficacy of the entire-vial dosing of emicizumab: Real-world evidence on plasma concentrations, bleeds, and drug waste. Res Pract Thromb Haemost 2023; 7:100074. [PMID: 36915864 PMCID: PMC10005899 DOI: 10.1016/j.rpth.2023.100074] [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: 10/25/2022] [Revised: 12/14/2022] [Accepted: 12/27/2022] [Indexed: 02/10/2023] Open
Abstract
Background Prophylaxis with emicizumab provides effective bleeding protection in persons with hemophilia A (PwHA) but pressures healthcare budgets. The body weight-adjusted dosing at 7-, 14-, or 28-day intervals, according to the label, often mismatches the vial content. Entire-vial dosing resulted in therapeutic concentrations according to pharmacokinetic simulations and was introduced to avoid waste. Objectives The objective of this study was to evaluate the efficacy of entire-vial dosing of emicizumab by investigating real-world evidence of plasma concentrations, bleeds, and drug waste. Methods This is a single-center, observational study with PwHA receiving emicizumab in mg/kg doses according to label but dosing interval extrapolated to the nearest vial size. Patient characteristics and bleeds were compared 1 year before starting emicizumab and during emicizumab until January 2022. Concentrations were assessed at weeks 4, 12, and annually. The mean (95% CI) annualized bleed rates were compared by using negative binomial regression. Drug waste between label-based dosing and entire-vial dosing was compared. Results A total of 112 individuals (94% severe phenotype and 9% positive FVIII inhibitors) were followed for a median of 56 weeks (interquartile range [IQR] 52-68) before and 51 weeks (IQR 29-75) after starting emicizumab. The median emicizumab dose was 5.9 (IQR 5.5-6.2) mg/kg/4 wk with median concentrations of 63 (IQR 51-80) μg/mL. The annualized bleed rate of treated bleeds before emicizumab was 3.6 (95% CI 2.9-4.4) and was 0.8 (95% CI 0.6-1.1) during emicizumab (P < .001). Drug waste was reduced by 9%. Conclusion The entire-vial dosing of emicizumab is an attractive treatment option for PwHA leading to therapeutic plasma concentrations, good bleeding control, and drug waste avoidance.
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Affiliation(s)
- Anouk A M T Donners
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Konrad van der Zwet
- Van Creveldkliniek, Center for Benign Haematology, Thrombosis and Haemostasis, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Carin M A Rademaker
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Toine C G Egberts
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, Center for Benign Haematology, Thrombosis and Haemostasis, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, Center for Benign Haematology, Thrombosis and Haemostasis, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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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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Klamroth R, Ay C, De Moerloose P, Fontana P, Windyga J, Astermark J, Berntorp E, Carvalho M, Dolan G, Hermans C, Holme PA, Kenet G, Mancuso ME, Marquardt N, Nunez R, Pabinger I, Rodgers R, Valk PVD, Yuste VJ, Zupan IP. Applicability of the European Society of Cardiology Guidelines on the management of acute coronary syndromes to older people with haemophilia A - A modified Delphi consensus by the ADVANCE Working Group. Haemophilia 2023; 29:21-32. [PMID: 36271497 DOI: 10.1111/hae.14674] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION As people with haemophilia (PWH) receive better treatment and live longer they are more likely to encounter cardiovascular disease (CVD) and other comorbidities. ESC guidelines for the acute management of patients presenting with acute coronary syndrome (ACS) are based on the non-haemophilia population. AIM To review the guidelines and propose relevant adaptations for PWHA without inhibitors who are treated with prophylaxis and present with ACS. METHODS As part of the ADVANCE Group, 20 European haemophilia experts used a modified Delphi approach to develop and gain consensus on proposed adaptations of the ESC guidelines for PWHA without inhibitors. RESULTS Of the 32 Class I recommendations across both guidelines, adaptions were considered necessary and proposed for 15. The adaptions highlight the need to provide sufficient FVIII trough levels at the time of antithrombotic treatment in people with haemophilia A (HA) without inhibitors. Patients receiving emicizumab prophylaxis and requiring oral anticoagulation therapy or combined single antiplatelet plus oral anticoagulation therapy will require additional FVIII replacement therapy. CONCLUSION In the absence of high-quality clinical evidence, the combined expert opinion used to develop these adaptions to the current ESC guidelines may help to guide clinicians in their treatment decisions when a PWHA presents with ACS.
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Affiliation(s)
| | - Cihan Ay
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | | | - Pierre Fontana
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | | | - Manuela Carvalho
- Congenital Coagulopathies Reference Center, Centro Hospitalar Universitário de São João, E.P.E., Porto, Portugal
| | | | | | | | - Gili Kenet
- Sheba Medical Center, Tel Hashomer & The Amalia Biron Thrombosis Research Institute, Tel Aviv University, Israel
| | | | - Natascha Marquardt
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | | | - Ingrid Pabinger
- Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | | | - Paul van der Valk
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, University of Utrecht, The Netherlands
| | | | - Irena Preložnik Zupan
- University Medical Centre Ljubljana, Department of Haematology, University of Ljubljana, Faculty of Medicine, Ljubljana, Slovenia
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Cardiovascular Risk Factors in Patients with Congenital Hemophilia: A Focus on Hypertension. Diagnostics (Basel) 2022; 12:diagnostics12122937. [PMID: 36552943 PMCID: PMC9776547 DOI: 10.3390/diagnostics12122937] [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: 10/31/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022] Open
Abstract
Aging hemophiliacs face cardiovascular disease. Lots of evidence has been gathered that hemophiliacs have a more unfavorable cardiovascular profile than the general population does, especially due to the increased prevalence of hypertension (HTN). Among the existing scattered evidence, our study provides the most comprehensive and systematized analysis of the determinants of HTN in hemophiliacs. We discussed the contribution to the HTN substrate of hemophilia-specific factors, such as type, severity and the presence of inhibitors. The complex mechanism of kidney dysfunction in relation to hematuria and viral infections was meticulously addressed. Furthermore, we highlighted the new pathogenic concepts of endothelial dysfunction and the association between HTN and hemophilic arthropathy. The clustering of cardiovascular risk factors is common in hemophiliacs, and it enhances the negative vascular effect of HTN and aggravates HTN. It usually leads to an increased risk for coronary and cerebrovascular events. Our work provides reliable evidence to guide and improve the management of HTN in hemophiliacs.
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Samelson-Jones BJ. A new harmony for hemorrhagic disorders: The Dutch SYMPHONY consortium. J Thromb Haemost 2022; 20:1984-1985. [PMID: 35968793 DOI: 10.1111/jth.15786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/08/2022] [Accepted: 06/11/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Benjamin J Samelson-Jones
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- The Raymond G. Perelman Center for Cellular and Molecular Therapeutics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Hematology, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Burnouf T, Epstein J, Faber JC, Tayou Tagny C, Somuah D, Smid WM. Rationale for supporting stepwise access to safe plasma proteins through local production in low- and middle-income countries: A commentary of an international workshop. Biologicals 2022; 79:27-30. [DOI: 10.1016/j.biologicals.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/21/2022] [Indexed: 11/02/2022] Open
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Pablo-Moreno JAD, Serrano LJ, Revuelta L, Sánchez MJ, Liras A. The Vascular Endothelium and Coagulation: Homeostasis, Disease, and Treatment, with a Focus on the Von Willebrand Factor and Factors VIII and V. Int J Mol Sci 2022; 23:ijms23158283. [PMID: 35955419 PMCID: PMC9425441 DOI: 10.3390/ijms23158283] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/22/2022] [Accepted: 07/23/2022] [Indexed: 11/27/2022] Open
Abstract
The vascular endothelium has several important functions, including hemostasis. The homeostasis of hemostasis is based on a fine balance between procoagulant and anticoagulant proteins and between fibrinolytic and antifibrinolytic ones. Coagulopathies are characterized by a mutation-induced alteration of the function of certain coagulation factors or by a disturbed balance between the mechanisms responsible for regulating coagulation. Homeostatic therapies consist in replacement and nonreplacement treatments or in the administration of antifibrinolytic agents. Rebalancing products reestablish hemostasis by inhibiting natural anticoagulant pathways. These agents include monoclonal antibodies, such as concizumab and marstacimab, which target the tissue factor pathway inhibitor; interfering RNA therapies, such as fitusiran, which targets antithrombin III; and protease inhibitors, such as serpinPC, which targets active protein C. In cases of thrombophilia (deficiency of protein C, protein S, or factor V Leiden), treatment may consist in direct oral anticoagulants, replacement therapy (plasma or recombinant ADAMTS13) in cases of a congenital deficiency of ADAMTS13, or immunomodulators (prednisone) if the thrombophilia is autoimmune. Monoclonal-antibody-based anti-vWF immunotherapy (caplacizumab) is used in the context of severe thrombophilia, regardless of the cause of the disorder. In cases of disseminated intravascular coagulation, the treatment of choice consists in administration of antifibrinolytics, all-trans-retinoic acid, and recombinant soluble human thrombomodulin.
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Affiliation(s)
- Juan A. De Pablo-Moreno
- Department of Genetics, Physiology and Microbiology, School of Biology, Complutense University, 28040 Madrid, Spain; (J.A.D.P.-M.); (L.J.S.)
| | - Luis Javier Serrano
- Department of Genetics, Physiology and Microbiology, School of Biology, Complutense University, 28040 Madrid, Spain; (J.A.D.P.-M.); (L.J.S.)
| | - Luis Revuelta
- Department of Physiology, School of Veterinary Medicine, Complutense University of Madrid, 28040 Madrid, Spain;
| | - María José Sánchez
- Centro Andaluz de Biología del Desarrollo (CABD), Consejo Superior de Investigaciones Científicas (CSIC), Junta de Andalucía, Pablo de Olavide University, 41013 Sevilla, Spain;
| | - Antonio Liras
- Department of Genetics, Physiology and Microbiology, School of Biology, Complutense University, 28040 Madrid, Spain; (J.A.D.P.-M.); (L.J.S.)
- Correspondence:
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Prezotti ANL, Frade-Guanaes JO, Yamaguti-Hayakawa GG, Ozelo MC. Immunogenicity of Current and New Therapies for Hemophilia A. Pharmaceuticals (Basel) 2022; 15:ph15080911. [PMID: 35893734 PMCID: PMC9331070 DOI: 10.3390/ph15080911] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023] Open
Abstract
Anti-drug antibody (ADA) development is a significant complication in the treatment of several conditions. For decades, the mainstay of hemophilia A treatment was the replacement of deficient coagulation factor VIII (FVIII) to restore hemostasis, control, and prevent bleeding events. Recently, new products have emerged for hemophilia A replacement therapy, including bioengineered FVIII molecules with enhanced pharmacokinetic profiles: the extended half-life (EHL) recombinant FVIII products. However, the main complication resulting from replacement treatment in hemophilia A is the development of anti-FVIII neutralizing alloantibodies, known as inhibitors, affecting approximately 25–30% of severe hemophilia A patients. Therefore, the immunogenicity of each FVIII product and the mechanisms that could help increase the tolerance to these products have become important research topics in hemophilia A. Furthermore, patients with inhibitors continue to require effective treatment for breakthrough bleedings and procedures, despite the availability of non-replacement therapy, such as emicizumab. Herein, we discuss the currently licensed treatments available for hemophilia A and the immunogenicity of new therapies, such as EHL-rFVIII products, compared to other products available.
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Affiliation(s)
- Alessandra N. L. Prezotti
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- HEMOES, Hematology and Hemotherapy Center Dr. Marcos Daniel Santos, Av. Marechal Campos, 1468, Maruípe, Vitória 29047-105, ES, Brazil
| | - Jéssica O. Frade-Guanaes
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
| | - Gabriela G. Yamaguti-Hayakawa
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
| | - Margareth C. Ozelo
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
- Correspondence: ; Tel.: +55-(19)-3521-8395
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