Management of haemophilia and its complications in developing countries

A challenging management of hemophilia B patient with inhibitors undergoing major orthopedic surgeries in a resource-constrained country

In this paper, we report a life-threatening condition and relate our experience in managing a hemophilia B patient who required three surgical procedures, highlighting the difficulties we encountered in our setting and propose some tangible.

A review of hyperfibrinolysis in cats and dogs

The fibrinolytic system is activated concurrently with coagulation; it regulates haemostasis and prevents thrombosis by restricting clot formation to the area of vascular injury and dismantling the clot as healing occurs. Dysregulation of the fibrinolytic system, which results in hyperfibrinolysis, may manifest as clinically important haemorrhage. Hyperfibrinolysis occurs in cats and dogs secondary to a variety of congenital and acquired disorders. Acquired disorders associated with hyperfibrinolysis, such as trauma, cavitary effusions, liver disease and Angiostrongylus vasorum infection, are commonly encountered in primary care practice. In addition, delayed haemorrhage reported in greyhounds following trauma and routine surgical procedures has been attributed to a hyperfibrinolytic disorder, although this has yet to be characterised. The diagnosis of hyperfibrinolysis is challenging and, until recently, has relied on techniques that are not readily available outside referral hospitals. With the recent development of point-of-care viscoelastic techniques, assessment of fibrinolysis is now possible in referral practice. This will provide the opportunity to target haemorrhage due to hyperfibrinolysis with antifibrinolytic drugs and thereby reduce associated morbidity and mortality. The fibrinolytic system and the conditions associated with increased fibrinolytic activity in cats and dogs are the focus of this review article. In addition, laboratory and point-of-care techniques for assessing hyperfibrinolysis and antifibrinolytic treatment for patients with haemorrhage are reviewed.

Abrogating fibrinolysis does not improve bleeding or rFVIIa/rFVIII treatment in a non-mucosal venous injury model in haemophilic rodents

Essentials The efficacy of systemic antifibrinolytics for hemophilic non-mucosal bleeding is undetermined. The effect of systemically inhibiting fibrinolysis in hemophilic mice and rats was explored. Neither bleeding nor the response to factor treatment was improved after inhibiting fibrinolysis. The non-mucosal bleeding phenotype in hemophilia A appears largely unaffected by fibrinolysis.

SUMMARY

Background Fibrinolysis may exacerbate bleeding in patients with hemophilia A (HA). Accordingly, antifibrinolytics have been used to help maintain hemostatic control. Although antifibrinolytic drugs have been proven to be effective in the treatment of mucosal bleeds in the oral cavity, their efficacy in non-mucosal tissues remain an open question of significant clinical interest. Objective To determine whether inhibiting fibrinolysis improves the outcome in non-mucosal hemophilic tail vein transection (TVT) bleeding models, and to determine whether a standard ex vivo clotting/fibrinolysis assay can be used as a predictive surrogate for in vivo efficacy. Methods A highly sensitive TVT model was employed in hemophilic rodents with a suppressed fibrinolytic system to examine the effect of inhibiting fibrinolysis on bleeding in non-mucosal tissue. In mice, induced and congenital hemophilia models were combined with fibrinolytic attenuation achieved either genetically or pharmacologically (tranexamic acid [TXA]). In hemophilic rats, tail bleeding was followed by whole blood rotational thromboelastometry evaluation of the same animals to gauge the predictive value of such assays. Results The beneficial effect of systemic TXA therapy observed ex vivo could not be confirmed in vivo in hemophilic rats. Furthermore, neither intravenously administered TXA nor congenital knockout of the fibrinolytic genes encoding plasminogen or tissue-type plasminogen activator markedly improved the TVT bleeding phenotype or response to factor therapy in hemophilic mice. Conclusions The findings here suggest that inhibition of fibrinolysis is not effective in limiting the TVT bleeding phenotype of HA rodents in non-mucosal tissues.

[Homeopathic Medicine Reduces Pain and Hemarthrosis in Moderate and Severe Hemophilia: A Multicentric Study]

BACKGROUND

Hemarthrosis is a common clinical presentation of patients with severe and moderately severe hemophilia. Severe pain, swelling, and loss of function involving knee, ankle, elbow, and shoulder joints are commonly seen. In India, except for paracetamol and some non-steroidal anti-inflammatory drugs (NSAIDs), opiate analgesics are not easily available even in the mainstay of treatment; i.e., factor concentrates are also not available regularly. Hence, there is an unmet need for exploring alternative management strategies in this condition in India.

OBJECTIVE

To assess the effect of homeopathic medicines on pain and acute hemarthrosis in hemophilia when factor concentrates are not available and paracetamol in adequate doses proves inadequate.

PATIENTS

343 patients with hemophilia (PWH) from Nashik, Mumbai, and Surat presenting with hemarthrosis were prescribed homeopathic medicines in addition to paracetamol and RICE (rest, immobilization, cold application, and elevation). They were assessed using standard techniques.

RESULTS

1,679 episodes of hemarthrosis in major joints were encountered between December 2007 and March 2014, in 343 patients. In 1,580 of the 1,679 hemarthrosis episodes (94.1%), bleeding/inflammation was arrested and pain relieved with homeopathic medication. Additional factor concentrate was required in 99 patients (4.48%). The mean pain score improved from 6.88 ± 2.118 to 1.5 ± 0.34 over 6-24 h following the homeopathic medicines (p < 0.0001). The swellings were also substantially reduced (p < 0.001). The number of joint bleeds per month was reduced significantly under the influence of therapy (p < 0.0001), showing the long-term disease-modifying effect of the treatment.

CONCLUSION

Homeopathic medicines without factor concentrates appeared to reduce bleeding and pain in PWH presenting with hemarthrosis and could have influenced the long-term frequency of bleeding.

Management of Haemophilia in Developing Countries: Challenges and Options

There are significant challenges in managing haemophilia patients in developing countries. These challenges are (i) Lack of proper health care infrastructure and human resources suitable for haemophilia care (ii) Competing health care priorities of the government. (iii) Lack of penetrance of medical insurance in the population. (iv) Lesser visibility of the haemophilia patients in health care system (v) Low awareness across the medical profession, population and the policy makers about the condition (vi) Non availability of factor concentrates (vii) Inadequate utilization of knowledge for reducing factor concentrate use. (viii) Inadequate pain relief (ix) Challenges due to inhibitor developing (x) Viral hepatitis & (xi) Lack of research publications relevant to the country are some of the challenges faced by PWH for their management in developing country. The solutions are not easy but development of a strong patient organization with linkages with World Federation of Haemophilia is an important initial step. Following that internal and international twinning, use of internal sources, strong advocacy programme targeting government, doctors, opinion makers will solve many of the challenges in the time to come.

Pelvic haemophilic pseudotumour: a case report

We report on a 30-year-old haemophilic man with a pelvic pseudotumour compressing adjacent structures causing pain and swelling and destruction of surrounding soft tissues and bones. He underwent evacuation of the pseudotumour, acetabular reconstruction using the Harrington procedure, and total hip arthroplasty.

Quantitative correlation between transcriptional levels of ER chaperone, peroximal protein and FVIII productivity in human Hek-293 cell line

Hek-293 cell line presents good production platform for recombinant therapeutic proteins, however little is known about the components that contribute to the cellular control of recombinant protein production. In this study, we generated a Hek-293 producing recombinant factor VIII (FVIII) and we evaluated the immunoglobulin-binding protein (BiP) and phytanoil-CoA α-hydroxylase (PAHX) expression levels which are known for diminishing FVIII production. Our analyses showed that the recombinant cell population expresses 3.1 ± 1.4 fold of BIP mRNA (P = 0.0054) and 97.8 ± 0.5 fold of PAHX mRNA (P = 0.0016) compared to nontransduced cells. The amount of these proteins was inversely correlated to the secreted FVIII. In conclusion, BIP and PAHX expression are augmented in human cells producing FVIII and they antagonize the amount of therapeutic factor VIII in the cell culture.

Homeopathic medicines substantially reduce the need for clotting factor concentrates in haemophilia patients: results of a blinded placebo controlled cross over trial

BACKGROUND

Modern management of haemophilia patients is expensive: 90% of expenditure is on clotting factor concentrates. Any intervention which reduces the need for clotting factor concentrates in these patients without compromising the quality of life is of interest.

AIMS AND OBJECTIVES

To investigate the effectiveness of individualised homeopathic medicines in reducing the requirement of factor concentrates in haemophilia patients.

MATERIALS AND METHODS

In a single blind placebo controlled cross over trial 28 consecutive persons with haemophilia (PWH) with severe (24) or moderately severe (4) disease received standard management with placebo homeopathy for 1 year and active homeopathic treatment in the subsequent year with the same conventional management. There was no wash out period. They received standard managements for any acute emergency during the study period. Development of inhibitor during the study period was a withdrawal criterion. Sample size for the trial was calculated as 24 PWH. Transfusion requirements, bleeding scores, pain scores were evaluated blind by independent experts. Homeopathic medicines were selected by experienced homeopathic physicians depending on clinical condition of the patient. Chi-squared and paired t tests were used in statistical analysis.

RESULTS

28 patients were recruited. Homeopathic medicines improved frequency of bleeding, extent of bleeding, blood products consumed and pain scores (P<0.0001). There was also significant improvement in well being. Plasma levels of clotting factors did not change. No patients developed inhibitors during the study there were no dropouts.

CONCLUSION

Individualised homeopathic medicines may have an important supportive role in the management of PWH, where blood products and factor concentrates are not easily available. Larger, perhaps multicentric trials are warranted.

Hemophilia care in India: a review and experience from a tertiary care centre in uttar pradesh

Approximately 14,000 people with hemophilia are registered at the Hemophilia Federation of India; however, hemophilia remains under-diagnosed and many cases are not registered. In June 2009, the Government of Uttar Pradesh made anti-hemophilic factors available at a few centers, including the Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow. Consequently, the level of hemophilia care has improved considerably in recent times. Amongst the many challenges facing people with hemophilia, the development of inhibitors, which neutralize clotting factors provided by replacement therapy, is the most feared one. Healthcare professionals who treat people with hemophilia should not only be knowledgeable about the condition and committed to bettering the management of hemophilia, but also take responsibility for the judicious allocation of resources for various aspects of managing hemophilia. This manuscript aims to raise awareness regarding the detection and management of inhibitors in hemophilia based on the experience of a tertiary care hemophilia treatment centre in Uttar Pradesh, India.

Haemophilia in the developing countries: the Iranian experience

INTRODUCTION

Management of haemophilia and inherited bleeding disorders is a major challenge especially in developing countries, because of a shortage or absence of products, the cost and the infrastructural health problems. Development of local expertise which results in an improved outlook and reduction in mortality and morbidity in these countries can be helpful for advocators in other developing countries. However, very little information on demography and organizational models for haemophilia care in developing countries are available in the literature. Our aim is a comprehensive report of haemophilia status and its management in Iran.

MATERIAL AND METHODS

THE MANAGEMENT CENTER OF TRANSPLANTATION AND SPECIAL DISEASES (MCTSD) OF THE MINISTRY OF HEALTH OF IRAN DECIDED TO CARRY OUT A COMPLETE REVIEW AND COMPILATION OF ALL OF THE PUBLISHED OR AVAILABLE DATA ABOUT PATIENTS WITH HAEMOPHILIA (PWH) IN IRAN: their health status, their management planning, organizations, treatment products, facilities and care problems during 2007.

RESULTS

6496 patients with congenital bleeding disorders were registered. Most of them had haemophilia A and B and von Willebrand disease (vWD). However, rare bleeding disorders are seen more than expected. Inhibitor development is 14-28%. There are different data about virological status of PWH. Factor products and facilities are fairly available with more than 1.5 units per capita of inhabitant factor consumption.

CONCLUSIONS

A national formulary based on facilities of the country should be considered and followed by collaboration among the Ministry Of Health, universities and non-governmental organizations.

Management of chronic synovitis in patients with hemophilia: with special reference to developing countries

Chronic synovitis in severe hemophilia is a painful debilitating condition eventually affecting greater than 20% severe hemophilia patients in developing countries. Though this complication is all but eliminated in the countries with advanced hemophilia care and having access to generous factor concentrate replacement, the same can not be said for 80% of the hemophilia patients in the world who live in developing countries. In developing countries chronic synovitis can be treated conservatively with short course of steroid, factor replacement, physiotherapy and splintage. Failing this, chemical or radioactive synoviorthesis give worthwhile remission and relief in 70-80% of the severely affected patients who fail to respond to conservative therapy. We found a short course of Cox-2 (etoricoxib) inhibitor to be an extremely useful adjunct. The role of d-Pencillamine, Thalidomide and inhibitors of matrix metalloproteinases needs to be explored. HLA-B27 was found to be strongly associated with chronic synovitis in hemophilia in one of the studies and this marker in a hemophilia patient may suggest need for more intensive replacement and other therapy in these patients to prevent chronic synovitis.

Cryoprecipitate production: the use of additives to enhance the yield

Cryoprecipitate is still widely used to treat hemophilia A in developing countries. However, the yield of factor VIII is relatively low averaging, i.e. only 50%. We have attempted to enhance the yield by adding sodium citrate to the plasma following the method of Shanbrom and Owens (Blood 98, 2001, 60a). Fresh-frozen plasma (FFP) units were processed either as control plasma or after the addition of 10% sodium citrate. Cryoprecipitate was produced from both. After resuspension, calcium chloride was added to the citrated cryoprecipitate to correct for excess citrate prior to testing. The levels of FVIII and fibrinogen were determined in both preparations. The citrated cryoprecipitates had varying yields of fibrinogen and FVIII in the cryoprecipitate. The FVIII levels varied from 34% to 215% recovery. Fibrinogen ranged from 55.5% to 121.4%. We found that the addition of increasing amounts of CaCl2 to normal plasma raised the FVIII values from 1.0 to 4 U/ml. To determine the possibility of assay influence we added different quantities of CaCl2 to control plasma and measured the FVIII and activated partial thromboplastin time levels. Addition of citrate to plasma resulted in an increased total amount of cryoprecipitate much of which was citrate. Assays showed considerable ranges in the quantity of FVIII and fibrinogen. Activation of FVIII can be caused by addition of excess calcium.

Haemophilia A: from mutation analysis to new therapies

Haemophilia is caused by hundreds of different mutations and manifests itself in clinical conditions of varying severity. Despite being inherited in monogenic form, the clinical features of haemophilia can be influenced by other genetic factors, thereby confounding the boundary between monogenic and multifactorial disease. Unlike sufferers of other genetic diseases, haemophiliacs can be treated successfully by intravenous substitution of coagulation factors. Haemophilia is also the most attractive model for developing gene-therapy protocols, as the normal life expectancy of haemophiliacs allows the side effects of gene therapy, as well as its efficiency, to be monitored over long periods.