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Morgan G, Back E, Rosa D, O’Hara J, Finnegan A. Assessing the value of bypassing agent therapy used prophylactic versus on-demand, during immune tolerance induction for treatment of inhibitors: a retrospective chart review. Orphanet J Rare Dis 2023; 18:47. [PMID: 36882773 PMCID: PMC9990186 DOI: 10.1186/s13023-023-02654-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 02/27/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Haemophilia A is a bleeding disorder caused by deficiency of coagulation factor VIII (FVIII) which leads to severe and repeated bleedings. There is a need to understand the optimal treatment pathway for FVIII inhibitors with the use of immune tolerance induction (ITI) and the role of haemostatic 'bypassing' agents (BPA) on-demand (OD) or prophylactically (Px). The aim of this study was to gain a better understanding of the real-world use of BPA therapy administered prophylactically or on-demand concomitant with ITI, for the treatment of an inhibitor to FVIII replacement therapy in patients with severe haemophilia A. METHODS Retrospective observational data were used to capture disease management information for patients who were aged 16 or under and had received ITI and BPA treatment for their most recent inhibitor from Jan-2015 to Jan-2019, for 47 patients in the UK and Germany. Descriptive comparisons of the clinical effectiveness and resource utilisation of Px and OD BPA therapy during ITI were conducted. RESULTS During ITI and BPA treatment, for an inhibitor, bleeding events averaged 1.5 and 1.2 for Px and OD treatment respectively. Compared to only BPA therapy we see 3.4 and 1.4 bleeding events for Px and OD respectively during an inhibitor. CONCLUSION Baseline disease characteristics differed between BPA therapy cohorts and this resulted in higher clinical effectiveness of ITI treatment alongside BPA Px than BPA OD during an inhibitor.
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Affiliation(s)
- George Morgan
- HCD Economics, The Innovation Centre, Keckwick Lane, Daresbury, WA4 4FS UK
| | - Emily Back
- HCD Economics, The Innovation Centre, Keckwick Lane, Daresbury, WA4 4FS UK
| | - Doug Rosa
- HCD Economics, The Innovation Centre, Keckwick Lane, Daresbury, WA4 4FS UK
| | - Jamie O’Hara
- HCD Economics, The Innovation Centre, Keckwick Lane, Daresbury, WA4 4FS UK
- grid.43710.310000 0001 0683 9016Faculty of Health and Social Care, University of Chester, Chester, UK
| | - Alan Finnegan
- grid.43710.310000 0001 0683 9016Faculty of Health and Social Care, University of Chester, Chester, UK
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2
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Camelo RM, Dias MM, Caram-Deelder C, Gouw S, de Magalhães LP, Zuccherato LW, Jardim LL, de Oliveira AG, de Albuquerque Ribeiro R, Franco VKB, do Rosário Ferraz Roberti M, de Araújo Callado FMR, Etto LY, de Cerqueira MAF, Cerqueira MH, Lorenzato CS, de Souza IS, Serafim ÉSS, Garcia AA, Anegawa TH, Neves DCF, Tan DM, van der Bom J, Rezende SM. Time between inhibitor detection and start of immune tolerance induction: Association with outcome in the BrazIT study. J Thromb Haemost 2022; 20:2526-2537. [PMID: 36102352 DOI: 10.1111/jth.15878] [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: 05/13/2022] [Revised: 08/26/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Immune tolerance induction (ITI) is the treatment of choice for eradication of anti-factor VIII (FVIII) neutralizing alloantibodies (inhibitors) in people with inherited hemophilia A and high-responding inhibitor (PwHA-HRi). The association between ITI outcome and time elapsed between inhibitor detection and start of ITI (∆tinhi-ITI ) is debatable. OBJECTIVE The aim of this study was to evaluate this association among a large cohort of severe PwHA-HRi. METHODS Severe (factor VIII activity level <1%) PwHA-HRi on ITI (n = 142) were enrolled in 15 hemophilia treatment centers. PwHA-HRi were treated according to the Brazilian ITI Protocol. ITI outcomes were defined as success (i.e., recovered responsiveness to exogenous FVIII) and failure (i.e., no responsiveness to exogenous FVIII and requirement of bypassing agents to control bleeding). RESULTS Median ages at inhibitor detection and at ITI start were 3.2 years (interquartile range [IQR], 1.6-8.1) and 6.9 years [IQR, 2.6-20.1), respectively. PwHA-HRi were stratified according to ∆tinhi-ITI quartiles: first (0.0-0.6 year), second (>0.6-1.7 year), third (>1.7-9.2 years), and fourth quartile (>9.2-24.5 years). The overall success rate was 65.5% (93/142), with no difference among first, second, third, and fourth quartiles (62.9%, 69.4%, 58.3%, and 71.4%, respectively) even after adjusting the analyses for potential confounders. CONCLUSION In conclusion, delayed ITI start is not associated with failure of ITI in PwHA-HRi. Therefore, ITI should be offered for these patients, regardless of the time elapsed between the detection of inhibitor and the ITI start.
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Affiliation(s)
- Ricardo Mesquita Camelo
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Maíse Moreira Dias
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Camila Caram-Deelder
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Center of Clinical Transfusion Research, Sanquin Research, Leiden, The Netherlands
| | - Samantha Gouw
- Amsterdam UMC, University of Amsterdam, Department of Pediatric Hematology, Amsterdam, the Netherlands
| | | | | | - Letícia Lemos Jardim
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Rosângela de Albuquerque Ribeiro
- Centro de Hematologia e Hemoterapia do Ceará (HEMOCE), Fortaleza, Brazil
- Hospital Universitário Walter Cantídeo, Universidade Federal do Ceará, Fortaleza, Brazil
| | | | | | | | - Leina Yukari Etto
- Hemocentro da Paraíba (HEMOÍBA), João Pessoa, Brazil
- Department of Internal Medicine, Center of Medical Sciences, Universidade Federal da Paraíba, João Pessoa, Brazil
| | | | | | | | - Ieda Solange de Souza
- Department of Clinical Haematology, Centro de Hematologia e Hemoterapia do Pará (HEMOPA), Belém, Brazil
- Universitary Hospital João de Barros Barreto, Universidade Federal do Pará, Belém, Brazil
| | | | - Andrea Aparecida Garcia
- Centro de Sangue de São José do Rio Preto, São José do Rio Preto, Brazil
- Fundação Faculdade Regional de Medicina de São José do Rio Preto, São José do Rio Preto, Brazil
| | - Tânia Hissa Anegawa
- Centro de Hematologia Regional de Londrina (HEMEPAR Londrina), Londrina, Brazil
- Faculty of Medicine, Universidade Estadual de Londrina, Londrina, Brazil
| | - Daniele Campos Fontes Neves
- Fundação Hemocentro de Rondônia (FHEMERON), Porto Velho, Brazil
- Department of Medicine, Universidade de Rondônia, Porto Velho, Brazil
| | - Doralice Marvulle Tan
- Department of Paediatric Onco-haematology, Faculdade de Medicina de Marília, Marília, Brazil
| | - Johanna van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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Holstein K, Albisetti M, Bidlingmaier C, Halimeh S, Heine S, Klamroth R, Königs C, Kurnik K, Male C, Oldenburg J, Streif W, Wermes C, Escuriola-Ettingshausen C. Practical Guidance of the GTH Haemophilia Board on the Use of Emicizumab in Patients with Haemophilia A. Hamostaseologie 2020; 40:561-571. [PMID: 32588417 DOI: 10.1055/a-1127-6476] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Emicizumab has been approved for bleeding prophylaxis in patients with haemophilia A (PWHAs) with or without inhibitors. Because of substantial differences between factor VIII (FVIII) and Emicizumab, the 'Ständige Kommission Hämophilie' of the German, Austrian, Swiss Society for Thrombosis and Haemostasis Research (GTH) established a practical guidance for the use of Emicizumab in PWHAs. A systematic literature research was conducted in PubMed. Based on this and on personal experience, this practical guidance has been developed. Each single statement has been discussed among members of the 'Ständige Kommission Hämophilie' and revised accordingly. The final set of recommendations has been approved by all authors analogous to the Delphi method. This practical guidance is provided for physicians treating PWHAs with regard to general aspects, patient education, bleeding treatment, surgery, use of Emicizumab in previously untreated patients (PUPs), patients with newly diagnosed inhibitors and elderly patients. Patients should be treated in expert centres and adequate laboratory tests to monitor Emicizumab levels, FVIII replacement and inhibitors should be available. Early experience of immune tolerance induction protocols integrating Emicizumab is reviewed, and the limited experience in PUPs and very young children is described. So far, no thromboembolic complications have been reported with the concomitant use of FVIII or recombinant activated FVII for bleeding treatment or surgery. Activated prothrombin complex concentrate doses of >100 U/kg for >24 hours should be avoided whenever possible because of the high risk of thrombosis and/or thrombotic microangiopathy. In conclusion, this study is designed to support haemophilia physicians using Emicizumab in physicians treating hemophilia and using (PWHAs). With further post-marketing experience and trials, regular updates are necessary.
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Affiliation(s)
- Katharina Holstein
- Haematology and Clinical Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manuela Albisetti
- Division of Hematology, University Children's Hospital, Zurich, Switzerland
| | - Christoph Bidlingmaier
- Centre for Development and Complex Chronic Diseases in Children (iSPZHauner), Department of Paediatrics, Paediatric Haemophilia Centre, LMU Munich, Munich, Germany
| | | | - Sabine Heine
- Department of Paediatric Oncology/Haematology, Saarland University Hospital, Homburg, Germany
| | - Robert Klamroth
- Internal Medicine, Angiology and Haemostaseology, Haemophilia Centre, Vivantes Hospital Friedrichshain, Berlin, Germany
| | - Christoph Königs
- Department of Paediatrics and Adolescent Medicine, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Karin Kurnik
- Paediatric Haemophilia Centre, Department of Paediatrics, LMU Munich, Munich, Germany
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Johannes Oldenburg
- Institute for Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Werner Streif
- Department of Paediatrics 1, Medical University of Innsbruck (MUI), Innsbruck, Austria
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Nakar C, Shapiro A. Hemophilia A with inhibitor: Immune tolerance induction (ITI) in the mirror of time. Transfus Apher Sci 2019; 58:578-589. [PMID: 31447396 DOI: 10.1016/j.transci.2019.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Inhibitor (neutralizing antibodies) development remains the most significant complication in patients with severe congenital hemophilia A receiving exogenous factor VIII (FVIII). Although our understanding of the pathophysiology of inhibitor development has advanced, the knowledge gained has not yet translated into a robust decline in incidence, with the overall risk remaining at ∼30%. Immune Tolerance Induction (ITI) is the only current method to successfully eradicate an inhibitor and achieve long-term tolerance. Although current practice utilizes a wide variety of ITI regimens, identification of an optimal regimen has not emerged. Over the last decade, the number of replacement products available in hemophilia has greatly expanded. The cumulative evidence with each product for use in ITI is often lacking. Most recently emicizumab, a humanized monoclonal bi-specific antibody that substitutes for the scaffolding effect of FVIIIa was approved; this agent prevents bleeding in both inhibitor and non-inhibitor patients. The use of emicizumab will bring about a new era in care that will require clinicians to challenge current practice paradigms including use and administration of ITI. This review will summarize the main clinical ITI data and practices for patients with severe congenital hemophilia A with inhibitors (CHAwI) over the last four decades and will highlight current studies in the field, with attention to open questions.
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Affiliation(s)
- Charles Nakar
- The Indiana Hemophilia and Thrombosis Center (IHTC), Indianapolis, IN, USA.
| | - Amy Shapiro
- The Indiana Hemophilia and Thrombosis Center (IHTC), Indianapolis, IN, USA
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5
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Haya S, Solano C, Cid AR, Argilés B, Hervás D, Querol F, Bonanad S, Casaña P. Predictive factors of immune tolerance treatment response in severe haemophilia A patients with inhibitors: A real‐world report from a single centre, mixed retrospective‐prospective long‐term study. Haemophilia 2019; 25:e97-e100. [PMID: 30604912 PMCID: PMC7078961 DOI: 10.1111/hae.13660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Saturnino Haya
- Hemostasis and Thrombosis Unit, Hematology Service Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Carlos Solano
- Hematology Service Hospital Clínico de Valencia Valencia Spain
- Department of Medicine Universidad de Valencia Valencia Spain
| | - Ana Rosa Cid
- Hemostasis and Thrombosis Unit, Hematology Service Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Bienvenida Argilés
- Pediatric Hematology Unit Hospital Universitari i Politècnic La Fe Valencia Spain
| | - David Hervás
- Unit of Data Science, Biostatistics and Bioinformatics Instituto de Investigación Sanitaria La Fe Valencia Spain
| | - Felipe Querol
- Hemostasis and Thrombosis Unit, Hematology Service Hospital Universitari i Politècnic La Fe Valencia Spain
- Departament of Physiotherapy Universidad de Valencia Valencia Spain
| | - Santiago Bonanad
- Hemostasis and Thrombosis Unit, Hematology Service Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Pilar Casaña
- Hemostasis and Thrombosis Unit, Hematology Service Hospital Universitari i Politècnic La Fe Valencia Spain
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6
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Carpenter SL, Khair K, Gringeri A, Valentino LA. Prophylactic bypassing agent use before and during immune tolerance induction in patients with haemophilia A and inhibitors toFVIII. Haemophilia 2018; 24:570-577. [DOI: 10.1111/hae.13534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2018] [Indexed: 01/11/2023]
Affiliation(s)
- S. L. Carpenter
- Hematology/OncologyUniversity of Missouri Kansas City School of Medicine Kansas City MO USA
- Kansas City Regional Hemophilia Treatment Center Kansas City MO USA
- Children's Mercy Hospital Kansas City MO USA
| | - K. Khair
- Great Ormond Street Hospital London UK
- London South Bank University London UK
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7
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Roca CA, Álvarez-Román MT, Canaro Hirnyk MI, Mingot-Castellano ME, Jiménez-Yuste V, Cid Haro AR, Pérez-Garrido R, Sedano Balbas C, López-Fernández MF. Spanish Consensus Guidelines on prophylaxis with bypassing agents in patients with haemophilia and inhibitors. Thromb Haemost 2017; 115:872-95. [DOI: 10.1160/th15-07-0568] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 01/08/2016] [Indexed: 12/18/2022]
Abstract
SummaryProphylaxis with the blood clotting factor, factor VIII (FVIII) is ineffective for individuals with haemophilia A and high-titre inhibitors to FVIII. Prophylaxis with the FVIII bypassing agents activated prothrombin complex concentrates (aPCC; FEIBA® Baxalta) or recombinant activated factor VII (rFVIIa; Novo-Seven®, Novo Nordisk) may be an effective alternative. It was our aim to develop evidence -and expert opinion- based guidelines for prophylactic therapy for patients with high-titre inhibitors to FVIII. A panel of nine Spanish haematologists undertook a systematic review of the literature to develop consensusbased guidance. Particular consideration was given to prophylaxis in patients prior to undergoing immune tolerance induction (ITI) (a process of continued exposure to FVIII that can restore sensitivity for some patients), during the ITI period and for those not undergoing ITI or for whom ITI had failed. These guidelines offer guidance for clinicians in deciding which patients might benefit from prophylaxis with FVIII bypassing agents, the most appropriate agents in various clinical settings related to ITI, doses and dosing regimens and how best to monitor the efficacy of prophylaxis. The paper includes recommendations on when to interrupt or stop prophylaxis and special safety concerns during prophylaxis. These consensus guidelines offer the most comprehensive evaluation of the clinical evidence base to date and should be of considerable benefit to clinicians facing the challenge of managing patients with severe haemophilia A with high-titre FVIII inhibitors.
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Kreuz W, Escuriola Ettingshausen C, Vdovin V, Zozulya N, Plyushch O, Svirin P, Andreeva T, Bubanská E, Campos M, Benedik-Dolničar M, Jiménez-Yuste V, Kitanovski L, Klukowska A, Momot A, Osmulskaya N, Prieto M, Šalek SZ, Velasco F, Pavlova A, Oldenburg J, Knaub S, Jansen M, Belyanskaya L, Walter O. First prospective report on immune tolerance in poor risk haemophilia A inhibitor patients with a single factor VIII/von Willebrand factor concentrate in an observational immune tolerance induction study. Haemophilia 2015. [PMID: 26202305 DOI: 10.1111/hae.12774] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION/BACKGROUND Development of neutralizing inhibitors against factor VIII (FVIII) is a major complication of haemophilia A treatment. AIM The ongoing, international, open-label, uncontrolled, observational immune tolerance induction (ObsITI) study evaluates ITI, the standard of care in patients with inhibitors. PATIENTS/METHODS Forty-eight prospective patients in this interim analysis received a single plasma-derived, von Willebrand factor-stabilized, FVIII concentrate (pdFVIII/VWF) for ITI. According to recommended Bonn protocol, 'low responders' at ITI start (<5 BU) received 50-100 IU FVIII kg(-1) daily, or every other day; 'high responders' (≥5 BU) received 100 IU FVIII kg(-1) every 12 h. RESULTS Forty of 48 patients (83.3%), had at least one risk factor for poor ITI-prognosis at ITI start (i.e. age ≥7 years, >2 years since inhibitor diagnosis, inhibitor titre ≥10 BU at the start of ITI, or prior ITI failure). Nonetheless, 34 patients (70.8%) achieved complete success, 3 (6.3%) partial success, 1 (2.1%) partial response; ITI failed in 10 patients (20.8%), all with poor prognosis factors. All six low responders achieved complete success. ITI outcome was significantly associated with inhibitor titre level at ITI start (P = 0.0068), number of poor prognosis factors for ITI success (P = 0.0187), monthly bleeding rate during ITI (P = 0.0005) and peak inhibitor titre during ITI (P = 0.0007). Twenty-two of 35 high responder patients (62.9%) with ≥1 poor prognosis factor achieved complete success. CONCLUSION Treatment with a single pdFVIII/VWF concentrate, mainly according to the Bonn protocol, resulted in a high ITI success rate in haemophilia A patients with inhibitors and poor prognosis for ITI success.
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Affiliation(s)
- W Kreuz
- HZRM, Hämophilie-Zentrum Rhein Main Frankfurt-Mörfelden, Mörfelden-Walldorf, Germany
| | | | - V Vdovin
- Izmaylovo Children's Hospital Haematological Centre, Moscow, Russia
| | - N Zozulya
- The State Haematological Scientific Centre RAMS, Moscow, Russia
| | - O Plyushch
- The State Haematological Scientific Centre RAMS, Moscow, Russia
| | - P Svirin
- Izmaylovo Children's Hospital Haematological Centre, Moscow, Russia
| | - T Andreeva
- St. Petersburg State Healthcare Institution, St. Petersburg, Russia
| | - E Bubanská
- Children Faculty Hospital with Policlinic, Banská Bystrica, Slovakia
| | - M Campos
- Centro Hospitalar Porto, Hospital de Santo António, Porto, Portugal
| | - M Benedik-Dolničar
- Children's Hospital Oncology-Hematology Unit, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - L Kitanovski
- Children's Hospital Oncology-Hematology Unit, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - A Momot
- Altai Hematological Center, Altai, Russia
| | - N Osmulskaya
- State Healthcare Institution of Omsk Region, Omsk, Russia
| | - M Prieto
- Hospital General Yagüe, Castilla Leon, Spain
| | - S Z Šalek
- University Hospital REBRO, Zagreb, Croatia
| | - F Velasco
- Hospital Reina Sofía, Córdoba, Spain
| | - A Pavlova
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - J Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - S Knaub
- Octapharma AG, Lachen, Switzerland
| | - M Jansen
- Octapharma Pharmazeutika Produktionsges.mbH, Vienna, Austria
| | | | - O Walter
- Octapharma AG, Lachen, Switzerland
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Nakar C, Manco-Johnson MJ, Lail A, Donfield S, Maahs J, Chong Y, Blades T, Shapiro A. Prompt immune tolerance induction at inhibitor diagnosis regardless of titre may increase overall success in haemophilia A complicated by inhibitors: experience of two US centres. Haemophilia 2015; 21:365-373. [DOI: 10.1111/hae.12608] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2014] [Indexed: 01/19/2023]
Affiliation(s)
- C. Nakar
- The Indiana Hemophilia and Thrombosis Center (IHTC); Indianapolis IN USA
| | - M. J. Manco-Johnson
- The University of Colorado Hemophilia & Thrombosis Center (UCHTC); Aurora CO USA
| | - A. Lail
- Rho, Inc.; Chapel Hill NC USA
| | | | - J. Maahs
- The Indiana Hemophilia and Thrombosis Center (IHTC); Indianapolis IN USA
| | - Y. Chong
- The Indiana Hemophilia and Thrombosis Center (IHTC); Indianapolis IN USA
| | - T. Blades
- The University of Colorado Hemophilia & Thrombosis Center (UCHTC); Aurora CO USA
| | - A. Shapiro
- The Indiana Hemophilia and Thrombosis Center (IHTC); Indianapolis IN USA
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11
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Escuriola Ettingshausen C, Kreuz W. A review of immune tolerance induction with Haemate
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P in haemophilia A. Haemophilia 2013; 20:333-9. [DOI: 10.1111/hae.12288] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2013] [Indexed: 01/19/2023]
Affiliation(s)
| | - W. Kreuz
- HZRM – Haemophilia Centre Rhein Main Frankfurt‐Moerfelden Germany
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12
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Abstract
Acquired hemophilia is a rare disorder with an estimated annual incidence of 0.2-1 cases per million individuals. The etiology of the disorder remains obscure, although approximately half of all cases are associated with other underlying conditions. In acquired hemophilia, the severe hemorrhagic diathesis is caused by the development of autoantibodies directed against a clotting factor, most commonly factor VIII. These autoantibodies inhibit normal coagulation and lead to bleeding complications, which can be life-threatening in a high percentage of cases. Prompt diagnosis and appropriate management of the disorder enable effective control; the short- and long-term aims of therapy are to terminate the acute bleed and eliminate or reduce the inhibitor, respectively. Immune tolerance therapy has been shown to successfully eradicate or suppress inhibitors in patients with congenital hemophilia A and may be applicable to patients with acquired hemophilia. Here we present preliminary data on the use of immune tolerance therapy in patients with acquired hemophilia and discuss possible treatment strategies.
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Affiliation(s)
- Mario von Depka
- Department of Hematology, Haemostasis and Oncology, Hannover Medical School, Germany.
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13
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Ettingshausen CE, Kreuz W. The immune tolerance induction (ITI) dose debate: does the International ITI Study provide a clearer picture? Haemophilia 2013; 19 Suppl 1:12-7. [PMID: 23278995 DOI: 10.1111/hae.12051] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2012] [Indexed: 01/19/2023]
Abstract
Among the proposed predictors for immune tolerance induction (ITI) outcome, the therapeutic regimen - specifically the dose and frequency of administered factor VIII (FVIII) as well as FVIII product type - is intensely debated. Are there any advantages for low-dose regimens (50 IU FVIII kg(-1) three times a week) over high-dose regimens (200 IU FVIII kg day(-1)) or vice versa? Are von Willebrand factor (VWF)-containing plasma-derived concentrates superior to recombinant FVIII concentrates for tolerance induction? A review of the available literature indicates that patients with good prognostic factors can achieve success with either low-dose or high-dose ITI regimens. Retrospective data suggest that patient characteristics such as maximum historical inhibitor titres and pre-ITI inhibitor titres are better predictors of treatment success than dose. Results of the prospective International ITI Study have recently become available. In inhibitor patients with good prognosis, success rates were similar between low-dose (50 IU FVIII kg(-1) three times a week) and high-dose (200 IU FVIII kg(-1) daily) regimens. However, patients receiving low-dose ITI took longer to achieve various ITI milestones and had a significantly higher bleed rate per month compared with the high-dose group (0.62 vs. 0.28; P = 0.00024), findings with important clinical implications. Inhibitor patients with poor prognostic features should be treated with a high-dose protocol. This conclusion is supported by a meta-analysis of the International Immune Tolerance Registry and North American Immune Tolerance Registry and by data from Germany showing good success rates with the high-dose, high-frequency Bonn protocol in poor prognosis patients. Type of concentrate also appears to have an influence on ITI success rates in this patient subgroup, with evidence suggesting an advantage for VWF-containing plasma-derived FVIII concentrates over recombinant or VWF-free concentrates. The ongoing prospective studies REScue Immunotolerance STudy and Observational Immune Tolerance Induction are evaluating ITI outcome with respect to product type and are expected to answer this important clinical question as well as provide greater insight into patient- and therapy-related variables in inhibitor patients with poor prognostic features.
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14
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Di Minno G, Coppola A. Management of patients with long-term inhibitors: is immune tolerance an underestimated life-long solution? Haemophilia 2013; 19 Suppl 1:18-23. [PMID: 23278996 DOI: 10.1111/hae.12052] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2012] [Indexed: 01/19/2023]
Abstract
Immune tolerance induction (ITI) is recognized as the first choice treatment in haemophilic patients with inhibitors, with the aim of restoring safe and effective standard factor VIII replacement and, particularly, prophylaxis in children. For the latter, literature data and clinical practice support the optimal cost utility ratio of ITI. Indeed, the high success rate, the low incidence of inhibitor recurrence after successful ITI and the possibility of preventing joint deterioration, enable one to predict a considerable long-term reduction of costs in the majority of treated patients. Therefore, in spite of high costs and open issues about optimal regimens, ITI is actually attempted in virtually all children with inhibitors. Few patients with long-standing inhibitors presently undergo ITI, particularly in the case of severe bleeding tendency. In this setting, uncertainties concerning management are amplified by the paucity of literature data and psychological reluctance by both patients and treaters due to the perceived poor prognosis and the demanding treatment (also in terms of costs). However, clinical data suggest that the role of age at ITI start and of time interval from inhibitor diagnosis, as predictors of ITI outcome, should be considered in a larger framework of proposed and more established prognostic factors. Moreover, optimising ITI management, particularly with respect to inhibitor titre at ITI start and avoidance of adverse events or interruption of treatment, may also contribute to improve outcomes. Although the economic constraints of the present era significantly affect resources for such a high-cost treatment, the individual cost-utility ratio (bleeding tendency and risk of fatal bleeding, arthropathy and need for orthopaedic surgery, comorbidities, quality of life) should be assessed carefully to determine whether ITI is a suitable option and thus not preclude adults from the opportunity of inhibitor eradication.
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Affiliation(s)
- G Di Minno
- Regional Reference Centre for Coagulation Disorders, Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy.
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15
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Valentino LA, Allen G, Gill JC, Hurlet A, Konkle BA, Leissinger CA, Luchtman-Jones L, Powell J, Reding M, Stine K. Case studies in the management of refractory bleeding in patients with haemophilia A and inhibitors. Haemophilia 2013; 19:e151-66. [DOI: 10.1111/hae.12095] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2012] [Indexed: 12/01/2022]
Affiliation(s)
- L. A. Valentino
- Hemophilia and Thrombophilia Center; Rush University Medical Center; Chicago; IL; USA
| | - G. Allen
- Hasbro Children's Hospital and Brown University Alpert School of Medicine; Providence; RI; USA
| | - J. C. Gill
- Medical College of Wisconsin and Blood Center of Wisconsin; Milwaukee; WI; USA
| | - A. Hurlet
- Mount Sinai Medical Center; New York; NY; USA
| | - B. A. Konkle
- Puget Sound Blood Center and the University of Washington; Seattle; WA; USA
| | - C. A. Leissinger
- Louisiana Center for Bleeding and Clotting Disorders; Tulane University Medical Center; New Orleans; LA; USA
| | | | - J. Powell
- University of California Davis; Sacramento; CA; USA
| | - M. Reding
- Center for Bleeding and Clotting Disorders; University of Minnesota; Minneapolis; MN; USA
| | - K. Stine
- University of Arkansas for Medical Sciences; Little Rock; AR; USA
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16
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Santagostino E. More than a decade of international experience with a pdFVIII/VWF concentrate in immune tolerance. Haemophilia 2012; 19 Suppl 1:8-11. [DOI: 10.1111/hae.12050] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2012] [Indexed: 01/19/2023]
Affiliation(s)
- E. Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda Foundation; Ospedale Maggiore Policlinico; Milan; Italy
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17
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Collins PW, Chalmers E, Hart DP, Liesner R, Rangarajan S, Talks K, Williams M, Hay CR. Diagnosis and treatment of factor VIII and IX inhibitors in congenital haemophilia: (4th edition). Br J Haematol 2012; 160:153-70. [DOI: 10.1111/bjh.12091] [Citation(s) in RCA: 159] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Peter W. Collins
- School of Medicine; Cardiff University; University Hospital of Wales; Wales; UK
| | | | - Daniel P. Hart
- The London School of Medicine and Dentistry; Royal London Hospital; Barts, Queen Mary University; London; UK
| | - Ri Liesner
- Great Ormond Street NHS Trust; London; UK
| | - Savita Rangarajan
- Hampshire Hospital NHS Foundation Trust; Basingstoke & North Hampshire Hospital; Basingstoke; UK
| | - Kate Talks
- Royal Victoria Infirmary; Newcastle upon Tyne; UK
| | - Mike Williams
- Birmingham Childrens' Hospital NHS Foundation Trust; Birmingham; UK
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18
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Rothschild C, D'oiron R, Borel-derlon A, Gruel Y, Navarro R, Negrier C. Use of Haemate®P as immune tolerance induction in patients with severe haemophilia A who failed previous induction attempts: a multicentre observational study. Haemophilia 2012; 19:281-6. [DOI: 10.1111/hae.12018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2012] [Indexed: 11/29/2022]
Affiliation(s)
- C. Rothschild
- Centre de Référence de l'Hémophilie; Hôpital Necker - Enfants Malades AP-HP; Paris; France
| | - R. D'oiron
- Centre de Référence de l'Hémophilie; Hôpital Bicêtre AP-HP; Le Kremlin-Bicêtre; France
| | - A. Borel-derlon
- Centre Régional de Traitement de l'Hémophilie; Hôpital de la Côte de Nacre; Caen; France
| | - Y. Gruel
- Centre Régional de Traitement de l'Hémophilie; Hôpital Trousseau; Chambray-lès-Tours; France
| | - R. Navarro
- Centre Régional de Traitement de l'Hémophilie; Hôpital Saint-Eloi; Montpellier; France
| | - C. Negrier
- Centre de Référence de l'Hémophilie; Hôpital Edouard Herriot - Hospices Civils de Lyon; Lyon; France
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19
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Immune tolerance induction for patients with severe hemophilia A: a critical literature review. J Thromb Thrombolysis 2012; 32:439-47. [PMID: 21818664 DOI: 10.1007/s11239-011-0624-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The development of inhibitors that neutralize the function of clotting factor VIII (FVIII) is currently the most challenging complication associated with the treatment of hemophilia A as it increases the disease-related morbidity and mortality. Immune tolerance induction (ITI) is the only documented strategy to eradicate persistent inhibitors in severe hemophilia A patients. Several studies have been conducted so far to identify patient- and treatment-related factors associated with greater ITI success. The currently available literature on ITI in hemophilia A will be critically reviewed in this article. In particular, we will focus on the role of the type of FVIII product on ITI outcome by analyzing the clinical and experimental data.
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20
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The von Willebrand factor from basic mechanisms to clinical practice. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2012; 9 Suppl 2:s1-2. [PMID: 21839027 DOI: 10.2450/2011.001s] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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21
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Verbruggen B, Dardikh M, Polenewen R, van Duren C, Meijer P. The factor VIII inhibitor assays can be standardized: results of a workshop. J Thromb Haemost 2011; 9:2003-8. [PMID: 21854536 DOI: 10.1111/j.1538-7836.2011.04479.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND The Bethesda and the Nijmegen assays are commonly used for the measurement of inhibitor levels in hemophilia A patients. Despite test innovations, the between-laboratory coefficient of variation (CVb) of factor VIII inhibitor test data in external quality surveys remains very high (40-60%) with a high degree of false-negative and false-positive results resulting in undesired effects on treatment. OBJECTIVES Organization of a workshop in order to address the causes of this phenomenon and to suggest ways to improve the assays. METHODS Fifteen laboratories showing a high CVb in regular surveys and using a variety of methods participated in the wet workshop, which included four different sessions where variables probably contributing to the high CVb (e.g. use of [non-]buffered plasma, FVIII-deficient plasma, sample dilution and APTT reagents) were investigated. RESULTS The CVb varied from 30% to 70% in the first session of the workshop when the participants used their own test settings and reagents. The use of buffered normal pooled plasma and FVIII-deficient plasma as a reference sample by all participants did not significantly alter the CVb (35-50%) but decreased the number of false positives. However, the use of buffered pooled plasma in combination with standardized sample dilution procedures by all participants showed a significant improvement (CVb, 10-20%). CONCLUSIONS These results may contribute to improvement of FVIII inhibitor testing. However, improved inter-laboratory comparison of factor VIII inhibitor assay results can only be reached when further local standardization is implemented.
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22
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Coppola A, Di Minno MND, Santagostino E. Optimizing management of immune tolerance induction in patients with severe haemophilia A and inhibitors: towards evidence-based approaches. Br J Haematol 2010; 150:515-28. [DOI: 10.1111/j.1365-2141.2010.08263.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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23
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Kaveri S, Gringeri A, Heisel-Kurth M, Kreuz W. Inhibitors in haemophilia A: the role of VWF/FVIII concentrates--a meeting report. Haemophilia 2009; 15:587-91. [PMID: 19347997 DOI: 10.1111/j.1365-2516.2008.01944.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- S Kaveri
- Institut National de la Santé et de la Recherche Médicale (INSERM), U872, Centre de Recherche des Cordeliers, Paris, France.
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24
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25
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Traitement de l’hémophilie - Défis actuels et futurs. Presse Med 2009. [DOI: 10.1016/s0755-4982(09)75294-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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26
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Schramm W. Haemate P von Willebrand factor/factor VIII concentrate: 25 years of clinical experience. Haemophilia 2008; 14 Suppl 5:3-10. [PMID: 18786006 DOI: 10.1111/j.1365-2516.2008.01847.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Although von Willebrand disease (VWD) has a very long history, our understanding and treatment of the bleeding disorder has only evolved during the past 50 years or so. It was not until the 1920s that VWD was first recognized as a disease separate from that of classical haemophilia. It then took another 30 years before the first effective treatment was developed. Since then, the medical management of VWD has evolved considerably, but not without its ups and downs. One of the key milestones in the evolution of the treatment of VWD was the development of Haemate P/Humate-P (CSL Behring) - the first virus-inactivated factor VIII plasma product. For 25 years, this concentrate has demonstrated excellent clinical efficacy and safety for patients with VWD and for those with haemophilia. This article provides an historical overview of the early landmark efforts to ensure a safe plasma-derived replacement product and outlines the clinical evolution in the use of Haemate P.
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Affiliation(s)
- W Schramm
- Department of Transfusion Medicine and Haematology, University Clinic Munich, Munich, Germany.
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27
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Kessel C, Königs C, Linde R, Escuriola-Ettinghausen C, Stoll H, Klingebiel T, Dietrich U, Kreuz W. Humoral immune responsiveness to a defined epitope on factor VIII before and after B cell ablation with rituximab. Mol Immunol 2008; 46:8-15. [DOI: 10.1016/j.molimm.2008.06.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 06/12/2008] [Accepted: 06/13/2008] [Indexed: 11/24/2022]
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28
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Dimichele D. The North American Immune Tolerance Registry: contributions to the thirty-year experience with immune tolerance therapy. Haemophilia 2008; 15:320-8. [PMID: 18976249 DOI: 10.1111/j.1365-2516.2008.01880.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The North American Immune Tolerance Registry (NAITR) began in 1992 as a project of the ISTH Factor VIII/IX Subcommittee with the goal of further determining immune tolerance induction (ITI) practices in Canada and the United States. This retrospective registry study, published in 2002, was limited in its capacity to provide definitive answers to many unresolved ITI practice issues. Nonetheless, it played a role in developing guidelines for current ITI practice and in generating hypotheses that must now be examined through rigorous prospective data collection efforts. For haemophilia A, the logical next step has been the initiation of international prospective randomized studies of ITI outcome relative to factor VIII (FVIII) dose and purity for subjects with high titre inhibitors. Both trials will additionally provide platforms for translational study of the immunology of tolerance, a prelude to the next generation of safe and effective tolerizing strategies. For the less common problem of FIX inhibitor eradication, prospective randomized studies will not be a feasible way to confirm the NAITR observations. Coordinated international efforts will still be required to prospectively collect data on ITI outcome to document new potentially effective therapeutic strategies for inhibitor eradication. These registries will hopefully also serve to identify potential subjects for scientific studies of immunology of haemophilia B-related allergic phenomena, a devastating complication of FIX antibody development.
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Affiliation(s)
- D Dimichele
- Weill Cornell Medical College, New York, NY, USA.
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29
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Berntorp E, Archey W, Auerswald G, Federici AB, Franchini M, Knaub S, Kreuz W, Lethagen S, Mannucci PM, Pollmann H, Scharrer I, Hoots K. A systematic overview of the first pasteurised VWF/FVIII medicinal product, Haemate P/ Humate -P: history and clinical performance. Eur J Haematol 2008:3-35. [PMID: 18380871 DOI: 10.1111/j.1600-0609.2008.01049.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Patients with von Willebrand disease (VWD) and haemophilia A (HA) lack, to varying degrees, the von Willebrand factor (VWF) and coagulation factor VIII (FVIII) that are critical for normal haemostasis. These conditions in turn make patients prone to uncontrolled bleeding. Historically, patients with severe forms of VWD or HA were crippled before adulthood and their life expectancy was significantly reduced. Over the past decades, specific coagulation factor replacement therapies including Haemate P, have been developed to help patients achieve and maintain normal haemostasis. Haemate P is a human, plasma-derived VWF/FVIII medicinal product, which was first licensed in Germany in 1981 for the treatment of HA-associated bleeding. It has since then come to be accepted as the gold standard for both the treatment and prophylaxis of bleeding in VWD, especially in cases where desmopressin [1-deamino-8-D-arginine vasopressin (DDAVP)] has been ineffective. Haemate P was the first effectively virus-inactivated (pasteurisation: 60 degrees C for 10 h in aqueous solution) FVIII product, whereby the risk of potentially threatening infective complications of plasma-derived products was reduced. Haemate P was also shown to have a VWF multimer profile remarkably close to that of normal plasma. This bibliographic review presents previously unpublished clinical data of Haemate P, based upon internal clinical study reports of the proprietor, CSL Behring, in addition to data already presented in other publications. The data demonstrate a predictable and well-characterised pharmacokinetic profile, and a proven record of short- and long-term safety, while effectively correcting the haemostatic defects in VWD and HA. Recently available data have also shown Haemate P to be of haemostatic value in exceptional clinical circumstances including surgical interventions. By virtue of its plasma-derived combination of VWF and FVIII, in addition to its high VWF:FVIII content ratio (2.4:1), Haemate P is also associated with successful immune tolerance induction in those patients developing inhibitor antibodies. Although the theoretical risk of thromboembolic complications does exist while receiving Haemate P, as it does with any FVIII replacement therapy, the incidence of such complications has remained notably low. Given the robust data that have accumulated for the use of Haemate P, dosing recommendations are also described in this review; the recommendations are tailored to patient-specific contexts including baseline VWF and FVIII levels in plasma and the type of surgical intervention being undertaken. A wide variety of studies have also provided data on paediatric and geriatric populations, all of which have suggested that Haemate P can be safely and effectively used in a wide variety of clinical circumstances.
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Affiliation(s)
- Erik Berntorp
- Centre for Thrombosis and Haemostasis, Malmö University Hospital, Malmö, Sweden
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30
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Hay CRM, Baglin TP, Collins PW, Hill FGH, Keeling DM. THE DIAGNOSIS and MANAGEMENT OF FACTOR VIII and IX INHIBITORS: A GUIDELINE FROM THE UK HAEMOPHILIA CENTRE DOCTORS' ORGANIZATION (UKHCDO). Br J Haematol 2008. [DOI: 10.1111/j.1365-2141.2000.02327.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Rocino A, Papa ML, Salerno E, Capasso F, Miraglia E, De Biasi R. Immune tolerance induction in haemophilia A patients with high-responding inhibitors to factor VIII: experience at a single institution. Haemophilia 2008. [DOI: 10.1111/j.1365-2516.2001.00461.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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32
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UNUVAR A, KAVAKLI K, BAYTAN B, KAZANCI E, SAYLI T, OREN H, CELKAN T, GURSEL T. Low-dose immune tolerance induction for paediatric haemophilia patients with factor VIII inhibitors. Haemophilia 2008; 14:315-22. [DOI: 10.1111/j.1365-2516.2007.01621.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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34
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HAYA S, MORET A, CID AR, CORTINA V, CASAÑA P, CABRERA N, AZNAR JA. Inhibitors in haemophilia A: current management and open issues. Haemophilia 2007; 13 Suppl 5:52-60. [DOI: 10.1111/j.1365-2516.2007.01574.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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35
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DiMichele DM, Hoots WK, Pipe SW, Rivard GE, Santagostino E. International workshop on immune tolerance induction: consensus recommendations. Haemophilia 2007; 13 Suppl 1:1-22. [PMID: 17593277 DOI: 10.1111/j.1365-2516.2007.01497.x] [Citation(s) in RCA: 196] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Although immune tolerance induction (ITI) has been used for 30 years to eliminate inhibitors and restore normal factor pharmacokinetics in patients with hemophilia, there is a paucity of scientific evidence to guide therapeutic decision-making. In an effort to provide direction for physicians and hemophilia treatment center staff members, an international panel of hemophilia opinion leaders met to develop consensus recommendations for ITI in patients with severe and mild hemophilia A and hemophilia B. These recommendations draw on the available published literature and the collective clinical experience of the group and are rated based on the level of supporting evidence.
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Affiliation(s)
- D M DiMichele
- Department of Pediatrics, Weill Medical College of Cornell University, New York, NY 10021, USA.
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36
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Gringeri A, Musso R, Mazzucconi MG, Piseddu G, Schiavoni M, Pignoloni P, Mannucci PM. Immune tolerance induction with a high purity von Willebrand factor/VIII complex concentrate in haemophilia A patients with inhibitors at high risk of a poor response. Haemophilia 2007; 13:373-9. [PMID: 17610550 DOI: 10.1111/j.1365-2516.2007.01484.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Immune tolerance induction (ITI) is effective in approximately 70% of haemophilia patients with inhibitors. Poor prognostic factors are age >6 years, ITI started >1 year from inhibitor development, inhibitor peaks >200 BU, inhibitor titre >10 BU when ITI is started and previously failed ITI. The objective of this study was to identify the effectiveness in ITI of a high purity von Willebrand factor/factor VIII (VWF/FVIII) complex concentrate in inhibitor patients at high risk of failure. Patients with severe or moderate haemophilia A and high responding inhibitors who had at least one poor prognostic factor for ITI failure were prospectively followed-up. Success was defined by undetectable inhibitor, recovery and half life >66% of expected values. ITI dose regimens were chosen by each haemophilia centre. Seventeen haemophiliacs (16 severe, one moderate), aged 4-54 years (median 23) were followed-up for 6-71 months. Poor prognostic factors were delayed-onset ITI (n = 16), age >6 years (n = 16), previously failed ITI (n = 4), inhibitor peak >200 BU (n = 2) and inhibitor >10 BU when ITI was started (n = 4). Complete success was obtained in nine patients (53%) after 4-30 months of treatment (median 24), including two of four patients who had previously failed ITI. Seven patients achieved a partial success, with sustained low inhibitor titres (median 1.5 BU, range 1.1-2.8) but abnormal recovery and/or half-life, while the remaining patient withdrew ITI after 12 months when the inhibitor titer was still 70 BU. These findings suggest that high purity VWF/FVIII complex concentrates are effective in ITI, even in patients at high risk of failure.
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Affiliation(s)
- A Gringeri
- A. Bianchi Bonomi Haemophilia and Thrombosis Centre, Department of Medicine and Medical Specialties, University of Milan and IRCCS Maggiore Hospital, Milan, Italy.
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37
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Hay CRM, Brown S, Collins PW, Keeling DM, Liesner R. The diagnosis and management of factor VIII and IX inhibitors: a guideline from the United Kingdom Haemophilia Centre Doctors Organisation. Br J Haematol 2006; 133:591-605. [PMID: 16704433 DOI: 10.1111/j.1365-2141.2006.06087.x] [Citation(s) in RCA: 214] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The revised UKHCDO factor (F) VIII/IX Inhibitor Guidelines (2000) are presented. A schema is proposed for inhibitor surveillance, which varies according to the severity of the haemophilia and the treatment type and regimen used. The methodological and pharmacokinetic approach to inhibitor surveillance in congenital haemophilia has been updated. Factor VIII/IX genotyping of patients is recommended to identify those at increased risk. All patients who develop an inhibitor should be considered for immune tolerance induction (ITI). The decision to attempt ITI for FIX inhibitors must be carefully weighed against the relatively high risk of reactions and the nephrotic syndrome and the relatively low response rate observed in this group. The start of ITI should be deferred until the inhibitor has declined below 10 Bethesda Units/ml, where possible. ITI should continue, even in resistant patients, where it is well tolerated and so long as there is a convincing downward trend in the inhibitor titre. The choice of treatment for bleeding in inhibitor patients is dictated by the severity of the bleed, the current inhibitor titre, the previous anamnestic response to FVIII/IX, the previous clinical response and the side-effect profile of the agents available. We have reviewed novel dose-regimens and modes of administration of FEIBA (factor VIII inhibitor bypassing activity) and recombinant activated FVII (rVIIa) and the extent to which these agents may be used for prophylaxis and surgery. Bleeding in acquired haemophilia is usually treated with FEIBA or rVIIa. Immunosuppressive therapy should be initiated at the time of diagnosis with Prednisolone 1 mg/kg/d +/- cyclophosphamide. In the absence of a response to these agents within 6 weeks, second-line therapy with Rituximab, Ciclosporin A, or other multiple-modality regimens may be considered.
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Affiliation(s)
- Charles R M Hay
- University Department of Haematology, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
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38
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Ettingshausen CE, Kreuz W. Role of von Willebrand factor in immune tolerance induction. Blood Coagul Fibrinolysis 2005; 16 Suppl 1:S27-31. [PMID: 15849524 DOI: 10.1097/01.mbc.0000167660.30886.e9] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with hemophilia who develop inhibitors present a particular challenge in therapeutic management. Although such patients are at high risk for severe bleeding episodes, the optimal treatment approach--prophylaxis--is ineffective unless inhibitors are eliminated. Several protocols for immune tolerance induction have been used. Success rates may vary depending both on patient variables and on factors related to the therapeutic regimen, including concentrate purity and von Willebrand factor (VWF) content. Several in vitro studies testing inhibitor plasma samples against various factor VIII (FVIII) concentrates have shown lower FVIII inhibitor titer compared with concentrates with greater VWF content. Recent in vivo observations also support the importance of VWF content, based on evidence of reduced rates of success of immune tolerance induction with use of the high-purity FVIII products that became available in the early 1990s. Current data thus support use of FVIII concentrates containing VWF in immune tolerance induction; other variables may also contribute to the relative success of this treatment. Studies are needed to delineate these variables in order to improve management of this potentially devastating complication of hemophilia treatment.
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Affiliation(s)
- Carmen Escuriola Ettingshausen
- Centre of Pediatrics, Department of Hematology, Oncology and Hemostasis, Comprehensive Care Centre of Thrombosis and Hemostasis, Johann-Wolfgang-Goethe University Hospital, Frankfurt am Main, Germany.
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39
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Auerswald G, von Depka Prondzinski M, Ehlken B, Kreuz W, Kurnik K, Lenk H, Scharrer I, Schramm W, Zimmermann R. Treatment patterns and cost-of-illness of severe haemophilia in patients with inhibitors in Germany. Haemophilia 2004; 10:499-508. [PMID: 15357777 DOI: 10.1111/j.1365-2516.2004.00950.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To evaluate current treatment patterns and resource utilization as well as related cost in the management of severe haemophilia patients with inhibitors in Germany, a cost-of-illness study was conducted. Generally, data were generated by structured literature search. Missing data were collected by expert interviews. All data were validated by a panel of German experts in haemophilia care. In Germany, immune tolerance therapy (ITT) is first-line therapy in inhibitor management for children in the initial year after inhibitor development, particularly for high responders (HR). In adult HR patients ITT is applied but to a remarkably lower extent than in children. To treat bleeding episodes, factor VIII (FVIII) is first-line therapy in low responders (LR). For paediatric HR patients, bleeds are mainly treated with recombinant FVIIa (rFVIIa). In adult HR patients, activated prothrombin complex concentrate (aPCC) and rFVIIa are more equally distributed as treatment options. Treatment costs were calculated for paediatric patients (15 kg) and adult patients (75 kg) from third party payers' perspective. Cost for ITT ranges from Euro 70,290 (2 months; LR) to Euro 3 812,400 (24 months; with aPCC; HR) in a paediatric patient. For an adult patient ITT cost ranges from Euro 287,500 (6 months; LR) to Euro 17,253,000 (36 months; HR). For on average 12.5 acute bleeds, average annual treatment costs amount to Euro 77,000 for a child and Euro 354,000 for an adult. Assessing the results it has been taken into consideration that ITT can last longer and annual number of bleeds can be extremely higher than on average 12.5 episodes. This indicates more health care resource consumption in some patients.
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Affiliation(s)
- G Auerswald
- Prof.-Hess-Kinderklinik, Zentrum für Kinderheilkunde und Jugendmedizin, Bremen, Germany.
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40
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Wight J, Paisley S, Knight C. Immune tolerance induction in patients with haemophilia A with inhibitors: a systematic review. Haemophilia 2003; 9:436-63. [PMID: 12828679 DOI: 10.1046/j.1365-2516.2003.00781.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In some patients with haemophilia A, therapeutically administered factor VIII (FVIII) comes to stimulate the production of antibodies (inhibitors) which react with FVIII to render it ineffective. As a result, FVIII cannot be used prophylactically and patients become liable to recurrent bleeds. There are two elements to the management of patients with inhibitors: the treatment of bleeding episodes, and attempts to abolish inhibitor production through the induction of immune tolerance. This paper reports a systematic review of the best available evidence of clinical effectiveness in relation to immune tolerance induction (ITI) in patients with haemophilia A with inhibitors. Owing to the lack of randomized controlled trials on this topic, broad inclusion criteria with regard to study design were applied in order to assess the best available evidence for each intervention. As a result of the clinical and methodological heterogeneity of the evidence, it was not appropriate to pool data across studies; instead, data were synthesized using tabulation and qualitative narrative assessment. The International Registry provides the most reliable estimate of the proportion of successful cases of ITI [48.7%, 95% confidence interval (CI) 42.6-52.7%]. The duration of effect is unclear, but relapses appear to be infrequent. The International Registry shows a rate of relapse of 15% at 15 years. The comparative effectiveness of different protocols is uncertain, as no trials have been undertaken which compare them directly. However, the evidence suggests that the Bonn protocol may be more effective than the Malmö or low-dose protocols. There is no good evidence that immunosuppressive drug regimens are effective.
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Affiliation(s)
- J Wight
- ScHARR, University of Sheffield, Sheffield, S1 4DA, UK.
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41
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Abstract
The question of dose as a successful ITT outcome predictor in haemophilia A and B is an important one on many levels. Increased morbidity associated with inhibitor development has been documented. Currently, immune tolerance is the only proven method for inhibitor eradication. Furthermore, given the morbidity and the high cost of less effective bypass therapy, a study by Harvard health economists using Markov decision analysis predicted an increased life expectancy of 4.5 years at a lifetime cost savings of $1.6 million with the use of ITT rather than lifelong APCC therapy. However, the immediate short-term cost of this expensive therapeutic intervention has the capacity to strain the financial resources of many countries in the developed world, regardless of the system of medical reimbursement. It also assures the inaccessibility of this treatment modality to most of the world's inhibitor patients living in the developing world. Cost aside, recent experience has taught us that clotting factor supply is precarious, not inexhaustible as previously assumed. Finally, in the paediatric patient who is most likely to require and undergo ITT, venous access for daily infusions is problematic with or without a central venous access device. Indeed, for these reasons alone, finding the answer to the question of optimal cost-effective dosing immune tolerance is a matter of medical urgency and moral obligation to the global haemophilia community.
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Affiliation(s)
- Donna DiMichele
- New York Presbyterian Hospital Weill Cornell Center, New York, NY 10021, USA.
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42
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Kallas A, Pooga M, Benhida A, Jacquemin M, Saint-Remy JM. Epitope specificity of anti-FVIII antibodies during immune tolerance therapy with factor VIII preparation containing von Willebrand factor. Thromb Res 2002; 107:291-302. [PMID: 12565716 DOI: 10.1016/s0049-3848(02)00352-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The study aimed at characterizing the putative changes in the epitope specificity of anti-FVIII antibodies during a successful immune tolerance treatment of the haemophilia A patient with the factor VIII (FVIII) preparation containing the von Willebrand factor (VWF). At the beginning of treatment, anti-FVIII inhibitory antibodies recognizing predominantly the light chain of FVIII were prevalent and persisted throughout the treatment. More detailed characterization of the FVIII antibody epitope specificity by using GST-fusion proteins corresponding to different FVIII domains revealed the prevalence of C1-domain-specific antibodies, while a remarkably lower amount of antibodies were targeted at the C2 and the a3 domains of the FVIII light chain and towards the A2 and the A1 domain of the FVIII heavy chain. The epitope specificity of antibodies remained rather unchanged throughout treatment except the elevated level of C2-domain-specific FVIII antibodies after a temporary interruption of treatment. The patient's antibodies were unable to interfere with the FVIII binding to VWF or to phospholipids, but inhibited FXa generation and the binding of FX to FVIII on the phospholipid monolayer. Thus, a unique pattern of the epitope specificity of FVIII antibodies and the mechanism to inhibit FVIII:C activity by FVIII-light-chain-specific antibodies were characterized.
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Affiliation(s)
- Ade Kallas
- Department of Pharmacy, University of Tartu, Jakobi 2, Tartu, 51014, Estonia.
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43
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O'Connell N, Mc Mahon C, Smith J, Khair K, Hann I, Liesner R, Smith OP. Recombinant factor VIIa in the management of surgery and acute bleeding episodes in children with haemophilia and high responding inhibitors. Br J Haematol 2002; 116:632-5. [PMID: 11849223 DOI: 10.1046/j.0007-1048.2001.03324.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The management of acute and surgical bleeding episodes in children with severe factor VIII or IX deficiency who develop high responding inhibitors presents a major therapeutic challenge to clinicians. Recombinant factor VIIa (rVIIa) is an effective, reliable and safe treatment that can be used to treat acute bleeding episodes prior to commencing an immune tolerance programme and to cover surgical procedures until the immune tolerance programme is successful. In a significant minority of patients, immune tolerance therapy is ineffective and an alternative haemostatic agent such as rVIIa is required for life-long treatment. The present study evaluated the use of rVIIa in a paediatric setting. Twelve children, aged 1-16 years, were treated successfully with rVIIa to prevent surgical bleeding in 20 surgical procedures (19 central venous access device insertion or removal, 1 dental extraction). Minor postoperative haematomata developed in 2 out of 20 cases after regular rVIIa therapy had been discontinued and resolved with a short course of rVIIa in both cases. Three children had six life- or limb-threatening bleeding episodes. All bleeding episodes resolved with regular rVIIa treatment although topical fibrin glue was needed in one child with a frenulum tear. One patient required two red cell transfusions for symptomatic anaemia resulting from two separate bleeding episodes. The rVIIa therapy was well tolerated and there was no evidence of treatment-related complications. We conclude that rVIIa is the treatment of choice for the management of surgery and acute life- or limb-threatening bleeding in children with haemophilia and high responding inhibitors.
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Affiliation(s)
- Niamh O'Connell
- The National Centre for Hereditary Coagulation Disorders, The National Children's Hospital, Tallaght, Dublin, Ireland
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44
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Rocino A, Papa ML, Salerno E, Capasso F, Miraglia E, de Biasi R. Immune tolerance induction in haemophilia A patients with high-responding inhibitors to factor VIII: experience at a single institution. Haemophilia 2001; 7:33-8. [PMID: 11136378 DOI: 10.1046/j.1365-2516.2001.00461.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Inhibitor antibodies to transfused factor VIII pose significant challenges in the management of haemophilia A patients. The main concern is the inefficacy of replacement therapy in patients with high-titre antibodies, who have a shorter life-span and a greater morbidity compared to subjects without inhibitors. The ultimate goal in treating these patients is to eliminate the inhibitor antibody entirely, allowing the recommencement of specific replacement therapy. The results of an immune tolerance regimen based on pharmacokinetic parameters are reported here. In 12 high-responder haemophilia A patients immune tolerance induction (ITI) was attempted with daily administration of factor VIII concentrates of very high purity, either plasma-derived or produced by recombinant-DNA technology. Patients were given 100 IU kg(-1) day(-1) until the inhibitor was shown to be absent by at least two negative assays 1 month apart, with normal recovery of infused factor VIII and normal half-life (> 6 h), as assessed after a 3-day washout period. After the patient was judged to be inhibitor-free, immune tolerance treatment was continued with unmodified factor VIII doses for 2 months. Doses were thereafter gradually reduced and finally, regular prophylaxis by administration of 25 IU kg(-1) three times weekly was instituted. Immune tolerance was achieved in 10 of the 12 patients (including six of seven with long-standing inhibitors) within a median time of 8 months. Outcome of immune tolerance was not influenced by age at start of ITI nor by the interval between inhibitor development and ITI. The success rate and the inhibitor disappearance time of our immune tolerance regimen, utilizing high-purity factor VIII, agrees with those reported by other investigators.
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Affiliation(s)
- A Rocino
- Divisione di Ematologia, Centro Emofilia e Trombosi, Ospedale San Giovanni Bosco, Napoli, Italy.
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45
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Carlborg E, Astermark J, Lethagen S, Ljung R, Berntorp E. The Malmö model for immune tolerance induction: impact of previous treatment on outcome. Haemophilia 2000; 6:639-42. [PMID: 11122389 DOI: 10.1046/j.1365-2516.2000.00436.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Ten patients, who had been treated according to the Malmö model for immune tolerance induction (ITI), were analysed regarding treatment with clotting factors and chemotherapy during the time period between inhibitor detection and ITI. Of the patients who were successfully rendered tolerant (n=6) all but one had received treatment with FVIII, either alone (n=1), or combined with cyclophosphamide (n=4). Of the patients who did not become tolerant, three of four had received treatment with FVIII during the inhibitor period but only one with FVIII and chemotherapy. The total amount of treatment received was in general much lower in the group that did not become tolerant. In individual cases, it appeared very clear that the inhibitor level and anamnestic response was substantially reduced prior to the ITI using the Malmö treatment model. We conclude that treatment of acute bleeds during the inhibitor period may be of importance for ITI and that the different response rates published for different immune tolerance regimens most likely do not reflect the true response rate for the respective regimen.
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Affiliation(s)
- E Carlborg
- Department of Coagulation Disorders, Lund University, University Hospital, Malmö, Sweden
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46
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Hay CR, Baglin TP, Collins PW, Hill FG, Keeling DM. The diagnosis and management of factor VIII and IX inhibitors: a guideline from the UK Haemophilia Centre Doctors' Organization (UKHCDO). Br J Haematol 2000; 111:78-90. [PMID: 11091185 DOI: 10.1046/j.1365-2141.2000.02327.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- C R Hay
- Manchester Haemophilia Comprehensive Care Centre, University Department of Haematology, Manchester Royal Infirmary, UK.
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47
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Unuvar A, Warrier I, Lusher JM. Immune tolerance induction in the treatment of paediatric haemophilia A patients with factor VIII inhibitors. Haemophilia 2000; 6:150-7. [PMID: 10792472 DOI: 10.1046/j.1365-2516.2000.00379.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The development of an inhibitor to transfused factor VIII (FVIII) is a serious treatment-related problem in haemophiliac children. The management of patients with high titre FVIII inhibitors is difficult, and immune tolerance induction (ITI) is the only method available for the eradication of these inhibitors. The results of the ITI regimen used at the Children's Hospital of Michigan Haemophilia Treatment Center are described and discussed. ITI was attempted in 14 children with severe haemophilia A (13 high responders, one low responder), with daily doses of FVIII alone. FVIII dosage was chosen according to the patient's historical peak inhibitor titre. ITI included three phases; induction phase, dose reduction phase and maintenance phase. During the first phase, the starting dose was 50 or 100 U kg-1 d-1; during the second phase the FVIII dosage was reduced gradually to 25 U kg-1 every other day according to the inhibitor titre, FVIII recovery and/or half-life study. In the third (maintenance) phase, the children received either prophylactic therapy or episodic therapy for 12 months. The inhibitor elimination was defined as the time taken to achieve a negative inhibitor assay with no anamnestic response and normal FVIII recovery and/or normal half-life. Immune tolerance was achieved in 11 of 14 patients (79%) patients within a median time of 6 months; two children are still on therapy, three failed ITI. We observed either failure or prolongation of immune tolerance if the historical peak titre or the maximum titre during ITI was >200 BU. The success rate of our low dose ITI regimen is not different from that reported by other investigators and the inhibitor elimination time is similar to some of the studies reported previously.
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Affiliation(s)
- A Unuvar
- Children's Hospital of Michigan, Division of Haematology/Oncology, Detroit, MI 48201-2196, USA
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48
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Koestenberger M, Raith W, Muntean W. High titre inhibitor after continuous factor VIII administration for surgery in a young infant. Haemophilia 2000; 6:120. [PMID: 10781202 DOI: 10.1046/j.1365-2516.2000.00377.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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49
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Batlle J, Lopez MF, Brackmann HH, Gaillard S, Goudemand J, Humbert J, De Moerloose P, Maass E, Mauz-Körholz C, Sultan Y, Stieltjes N. Induction of immune tolerance with recombinant factor VIII in haemophilia A patients with inhibitors. Haemophilia 1999; 5:431-5. [PMID: 10583531 DOI: 10.1046/j.1365-2516.1999.00354.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report on 11 patients (nine unrelated and a brother pair) with severe haemophilia A and factor VIII (FVIII) inhibitor, in whom immune tolerance (IIT) was induced with recombinant FVIII (r-FVIII). Their age ranged from 11 months to 47 years. The number of exposure days (ED) at inhibitor detection varied from 11 to 130. Nine of the 11 patients were high responders ¿>10 Bethesda units (BU) with peak inhibitor levels ranging from 10 to 566 BU. The other two were low responders with peak levels between 0.7 and 2 BU. Before inhibitor detection, the patients had been receiving products of various purities. The IIT regimens were very heterogeneous, and the treatment schedule varied from a short period with 50 IU kg-1 every 2 days, followed by 100 IU kg-1 every 2 days and then 220 IU kg-1 daily. The outcome was considered successful when the inhibitor level fell to 0.6 BU or lower after IIT treatment. The outcome overall was successful in nine out of 11 patients (81.8%), with the nine successful cases comprising seven of the nine high responders (77.8%) and the two low responders. Definite failure of IIT was observed in one high responder after two different IIT regimens. A second high responder is still on IIT treatment. All patients in whom IIT was successful are currently receiving r-FVIII on demand or prophylactically at various dosages. Despite the variability of the patient characteristics and the IIT schedules, this study demonstrates that r-FVIII represents an effective alternative for the eradication of inhibitors through IIT.
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Affiliation(s)
- J Batlle
- Hemophilia Units at the hospitals in La Coruna, Spain
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50
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Brackmann HH, Lenk H, Scharrer I, Auerswald G, Kreuz W. German recommendations for immune tolerance therapy in type A haemophiliacs with antibodies. Haemophilia 1999; 5:203-6. [PMID: 10444288 DOI: 10.1046/j.1365-2516.1999.00311.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Haemophilia A is the most common X-chromosomal-linked congenital bleeding disorder and is caused by decreased activity of blood coagulation factor VIII. Affected individuals develop a variable phenotype of haemorrhages, mainly into joints and muscles depending on the amount of the residual factor VIII. The exogenous factor VIII-substitution by plasma-derived or recombinant products are the only treatments either on demand or prophylactically. The most important complication of treatment is the development of inhibitors that affect about 20%-50% of the severe cases. These antibodies neutralize the therapeutic effect of factor VIII-concentrates, leading to recurrent bleeding episodes, progredient joint damages and sometimes life-threatening situations. The only chance for a complete and permanent eradication of the inhibitors in these patients is the induction of Immune-Tolerance (ITT) to substituted factor VIII by the application of high-doses of factor VIII. The treatment demands a strict compliance of the patient and a much higher effort of the physician, to non-compared inhibitor patients. Requirements for a consistent realization of the ITT to increase the successful outcome was carried out by German Haemophilia Center Directors.
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Affiliation(s)
- H H Brackmann
- Haemophilia Centre, Institute for Experimental Haematology and Transfusion Medicine, Bonn, Germany
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