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Navarro R, Bojic S, Fatima R, El-Tahan M, El-Diasty M. Recombinant Activated Factor VII (rFVIIa) for Bleeding After Thoracic Aortic Surgery: A Scoping Review of Current Literature. J Cardiothorac Vasc Anesth 2024; 38:275-284. [PMID: 38036397 DOI: 10.1053/j.jvca.2023.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/11/2023] [Accepted: 09/27/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Bleeding after surgery on the thoracic aorta is a frequent complication, and can be associated with a significant increase in morbidity and mortality. Recombinant activated factor VII (rFVIIa) was developed initially for treating patients with hemophilia; however, it has been used increasingly "off-label" to achieve hemostasis after thoracic aortic procedures. OBJECTIVE This scoping review aimed to present the available literature on the role of rFVIIa in the management of refractory postoperative bleeding after thoracic aortic surgery. METHODS/RESULTS An electronic database search was conducted using Medline, Embase, Cochrane Library, and Google Scholar in June 2023. The authors included studies that reported the use of rFVIIa in patients undergoing surgical repair of ascending or descending aortic aneurysm or dissection. Single-case reports were excluded. Ten publications with a pooled number of 649 patients (319 patients received rFVIIa and 330 in the control groups) were identified: 3 case series, 6 retrospective studies, and 1 nonrandomized clinical trial. All studies reported the potential role of rFVIIa in correcting coagulopathy and reducing postoperative blood loss in this group of patients. Overall, there was not enough evidence to suggest that rFVIIa was associated with higher rates of thromboembolic complications or mortality. CONCLUSION Limited evidence suggests that rFVIIa may be useful in managing postoperative refractory bleeding in patients undergoing thoracic aortic surgery. However, the impact of rFVIIa on thromboembolic complications and mortality rates remains unclear.
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Affiliation(s)
- Ryan Navarro
- Faculty of Medicine, Queen's University, Kingston, ON, Canada
| | - Sandra Bojic
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Rubab Fatima
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | - Mohamed El-Tahan
- Anesthesiology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mohammad El-Diasty
- Cardiac Surgery Department, Harrington Heart Institute, University Hospitals, Cleveland, Ohio, USA.
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2
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Guzzardo GM, Sidonio R, Callaghan MU, Regling K. Early stage clinical trials for the treatment of hemophilia A. Expert Opin Investig Drugs 2022; 31:1169-1186. [PMID: 36265129 DOI: 10.1080/13543784.2022.2138742] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Hemophilia A is a severe bleeding disorder affecting about 1 in 5,000 males. The gold standard for prophylaxis and treatment of acute bleeding has been factor (F) VIII concentrate. A multitude of treatment modalities are now available and under clinical investigation. AREAS COVERED This review discusses ongoing/recently completed early-phase clinical trials registered on ClinicalTrials.gov in patients with hemophilia A through April 2022. These new pipeline therapies are focused on addressing the safety and efficacy of new factor-related products, non-factor related products, and gene therapy options for hemophilia. EXPERT OPINION Current standard of care effectively prevents and treats acute bleeding and has significantly improved the quality of life in hemophilia. The biggest challenges in the improvement of care are treatment-related burden and the burden of cost in developing countries. New drugs under development are likely to enter practice by the end of this decade and address many of the unmet needs particularly of those with severe disease. Data is limited in unique populations (e.g. congenital/inherited FVIII inhibitors, non-severe hemophilia A, women/girls with hemophilia and children) which are important areas for future research; additional clinical trials and long-term outcome data are necessary prior to incorporating these new therapies in our treatment arsenal.
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Affiliation(s)
- Gianna M Guzzardo
- Pediatric Hematology Oncology, Children's Hospital of Michigan, Detroit, MI, USA
| | - Robert Sidonio
- Pediatric Hematology Oncology, Emory University and Aflac Cancer and Blood Disorders, Atlanta, GA, USA
| | - Michael U Callaghan
- Agios Pharmaceuticals, Cambridge, MA, USA.,Department of Pediatrics, Central Michigan University School of Medicine, Mount Pleasant, MI, USA
| | - Katherine Regling
- Pediatric Hematology Oncology, Children's Hospital of Michigan, Detroit, MI, USA.,Department of Pediatrics, Central Michigan University School of Medicine, Mount Pleasant, MI, USA
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3
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Speybroeck J, Marsee M, Shariff F, Zackariya N, Grisoli A, Lune SV, Larson EE, Hatch J, McCauley R, Shariff F, Aversa JG, Son M, Agostini V, Campello E, Simioni P, Scărlătescu E, Kwaan H, Hartmann J, Fries D, Walsh M. Viscoelastic testing in benign hematologic disorders: Clinical perspectives and future implications of point-of-care testing to assess hemostatic competence. Transfusion 2021; 60 Suppl 6:S101-S121. [PMID: 33089936 DOI: 10.1111/trf.16088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/04/2020] [Accepted: 09/05/2020] [Indexed: 01/04/2023]
Abstract
Viscoelastic tests (VETs) have been used routinely for liver transplantation, cardiac surgery, and trauma, but only recently have found clinical utility in benign hematologic disorders. Therefore, guidelines for diagnosis and treatment of these disorders based on viscoelastic variables have been adapted from the existing transplant, cardiothoracic surgery, and trauma resuscitation literature. As a result, diagnostic and therapeutic strategies for benign hematologic disorders utilizing VETs are not uniform. Accordingly, even though there has been a recent increase in the utilization of VET for the diagnosis and treatment of such disorders, the literature is still in its early stages. Analysis of point-of-care viscoelastic tracings from benign hematologic disorders has the potential to allow prompt recognition of disease and to guide patient-specific intervention. Here we present a review describing the application of VETs to benign hematologic disorders.
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Affiliation(s)
- Jacob Speybroeck
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Mathew Marsee
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Faadil Shariff
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Nuha Zackariya
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Anne Grisoli
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Stefani Vande Lune
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Emilee E Larson
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Jordan Hatch
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Ross McCauley
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Faisal Shariff
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - John G Aversa
- Department of General Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael Son
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Vanessa Agostini
- Department of Transfusion Medicine, IRCC Polyclinic Hospital San Marino, Genoa, Italy
| | - Elena Campello
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Paolo Simioni
- Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padua University Hospital, Padua, Italy
| | - Escaterina Scărlătescu
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Hau Kwaan
- Department of Hematology Oncology, Northwestern University School of Medicine, Chicago, Illinois
| | - Jan Hartmann
- Department of Medical Affairs, Haemonetics Corporation, Boston, Massachusetts
| | - Dietmar Fries
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Mark Walsh
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana.,Saint Joseph Regional Medical Center, Mishawaka, Indiana
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4
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Abstract
The formation of membrane-bound complexes between specific coagulation factors at different cell surfaces is required for effective blood clotting. The most important of these complexes, the intrinsic Tenase and Prothrombinase complexes, are formed on the activated platelet surface during the propagation phase of coagulation. These two complexes are highly specific in their assembly mechanism and function modulated by anionic membranes, thus offering desirable targets for pharmaceutical interventions. Factor V (FV) and factor VIII (FVIII) are highly homologous non-enzymatic proteins. In their active state, FVa and FVIIIa serve as cofactors for the respective serine proteases factor Xa (FXa) and factor IXa (FIXa), significantly increasing their catalytic activity. This is achieved by forming well organized membrane-bound complexes at the phosphatidylserine rich activated platelet membrane in the presence of Ca2+ ions. The tenase (FVIIIa/FIXa) complex, catalyzes the proteolytic conversion of FX to FXa. Subsequently the prothrombinase (FVa/FXa) complex catalyzes the conversion of prothrombin to thrombin, required for efficient blood clotting. Although significant knowledge of FV and FVIII biochemistry and regulation has been achieved, the molecular mechanisms of their function are yet to be defined. Understanding the geometric assembly of the tenase and prothrombinase complexes is paramount in defining the structural basis of bleeding and thrombotic disorders. Such knowledge will enable the design of efficient pro- and anticoagulant therapies critical for regulating abnormal hemostasis. In this chapter, we will summarize the findings to date, showing our achievement in the field and outlining the future findings required to grasp the complexity of these proteins.
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Affiliation(s)
- Svetla Stoilova-McPhie
- Center for Nanoscale Systems (CNS), Laboratory For Integrated Sciences and Engineering (LISE), Faculty of Art and Sciences (FAS), Harvard University, 11 Oxford Street, Cambridge, MA, 02138, England, UK.
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5
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Chuansumrit A, Sirachainan N, Natesirinilkul R, Srikala K, Masaya-Anon N. Real-world evidence on health resource use among patients with haemophilia and inhibitor exhibiting severe bleeding episodes. Haemophilia 2020; 27:69-80. [PMID: 33216428 DOI: 10.1111/hae.14194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/08/2020] [Accepted: 10/21/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE This study aimed to explore real-world evidence on health resource use (HRU) spending on patients with haemophilia and inhibitor. MATERIALS AND METHODS Medical records from 1990 to 2019 of patients with haemophilia and inhibitor from three comprehensive haemophilia treatment centres were retrospectively retrieved. RESULTS In all, 31 patients with haemophilia (A = 30, B = 1) and inhibitor ≥5 BU were included. The mean initial inhibitor of 95.4 BU was detected at the mean age of 6.7 years. The mean number of annual hospitalisations was 3.9. A total of 795 bleeding episodes (major =125, minor =670) were evaluated. The treatment included bypassing agents or plasma exchange before administering high-dose factor VIII concentrate and intervention or surgery. Six patients succumbed to bleeding at the mean age of 17.2 years. Nineteen surviving patients experienced multiple morbidity except six patients with successful and partially successful immune tolerance induction (ITI). The mean (SD) annual total medical consumption for episodic treatment and successful ITI per patient with haemophilia A were 30,804 (81,332) USD and 55,531 (100,566) USD, respectively. Only episodic treatment was paid by the government budget for limited amounts of bypassing agents. CONCLUSION Management for patients with haemophilia and inhibitor exhibiting severe bleeding is challenging for medical personnel in countries having limited resources over decades. The real-world data will be used to negotiate with the government to increase budget for adequate bypassing agents or nonreplacement therapy and to include ITI in the national haemophilia treatment.
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Affiliation(s)
- Ampaiwan Chuansumrit
- Department of Paediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Department of Paediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Kwannut Srikala
- Department of Paediatrics, Sunprasitthiprasong Hospital, Ubon Ratchathani, Thailand
| | - Narongrit Masaya-Anon
- Sirikit Medical Centre, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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6
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Marsh K, Green D, Raco V, Papadopoulos J, Ahuja T. Antithrombotic and hemostatic stewardship: evaluation of clinical outcomes and adverse events of recombinant factor VIIa (Novoseven ®) utilization at a large academic medical center. Ther Adv Cardiovasc Dis 2020; 14:1753944720924255. [PMID: 32449469 PMCID: PMC7249557 DOI: 10.1177/1753944720924255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Background: Recombinant factor VIIa (rFVIIa) (Novoseven®) is utilized for the reversal of anticoagulation-associated bleeding and refractory bleeding in cardiac surgery. In August 2015, rFVIIa was transferred from the blood bank to the pharmacy at New York University (NYU) Langone Health. Concordantly, an off-label dosing guideline was developed. The objective of this study was to describe utilization and cost of rFVIIa and assess compliance to our dosing guideline. Methods: We performed a retrospective, observational review of rFVIIa administrations post-implementation of an off-label dosing guideline. All patients who received rFVIIa between September 2015 and June 2017 were evaluated. For each rFVIIa administration, anticoagulation and laboratory values, indications for use, dosing, ordering and administration times, concomitant blood products, and adverse events were collected. Adverse events included venous thromboembolism, stroke, myocardial infarction, and death due to systemic embolism and mortality. The primary endpoint was the utilization of rFVIIa in accordance with the off-label dosing guideline. Secondary endpoints included hemostatic efficacy of rFVIIa, adverse events, blood products administered, and cost-effectiveness of rFVIIa transition to pharmacy. Results: A total of 63 patients [pediatric (n = 6), adult (n = 57)] received rFVIIa, with the majority of use for refractory bleeding after cardiac surgery. The utilization of rVIIa decreased after development of the off-label dosing guideline and transition from blood bank to pharmacy. The total incidence of thromboembolic events within 30 days was 19.6%; 17.6% arterial and 2% venous; 70% of patients with an adverse event were over 70 years of age. Use of rFVIIa reduced the median number of units of blood products administered. Conclusion: Administration of rFVIIa for cardiac surgery appears to be effective for hemostasis. Transitioning rFVIIa from the blood bank to pharmacy and implementation of a dosing guideline appears to have reduced utilization. Patients receiving rFVIIa should be monitored for thromboembolic events. Elderly patients may be at higher risk for thromboembolic events.
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Affiliation(s)
| | - David Green
- Department of Medicine, Division of Hematology, NYU Langone Health, NY, USA
| | | | | | - Tania Ahuja
- Department of Pharmacy, NYU Langone Health, 550 First Avenue, New York, NY 10016, USA
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7
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Soni P, Shanmukhaiah C, Patil R, Shetty S. Differential response to FEIBA is strongly associated with the prothrombotic microparticles. Blood Cells Mol Dis 2020; 84:102441. [PMID: 32388201 DOI: 10.1016/j.bcmd.2020.102441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/23/2020] [Accepted: 04/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Treatment of patients with hemophilia with an inhibitor is generally done using bypassing agents (BPA), wherein variability in response is observed. Due to lack of validated laboratory assays, monitoring is being carried out by clinical response only. Emerging biomarkers like procoagulant microparticles (MPs) may prove to be promising. AIM To analyze whether procoagulant MP levels correlate with clinical response to FEIBA therapy. MATERIALS AND METHODS Total phosphatidylserine (PS) expressing MPs along with different cell derived MPs were measured in blood samples obtained prior and 2 hour post-FEIBA infusion in 64 bleeding episodes associated with 43 severe hemophilia patients. RESULTS AND DISCUSSION Patients with excellent response showed statistically significant increase in %MP of PS-MPs (p < 0.0001; 95.0% CI Range: -64.33 to -24.42) when compared to those with moderate response; platelet %MP change was also found significantly associated (p < 0.05) with clinical response. In search of an assay for monitoring FEIBA, results though preliminary seem to be promising with increase in %PS-MP correlating well with the clinical response. Coagulation being multifactorial process involves multiple factors for balanced hemostasis, which needs to be accounted. Larger studies in this line may provide indications for usage of MPs as monitoring and dose adjustment tool of FEIBA therapy.
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Affiliation(s)
- Puja Soni
- National Institute of Immunohematology (NIIH-ICMR), 13th floor, KEM Hospital, Parel, Mumbai 400012, India
| | | | - Rucha Patil
- National Institute of Immunohematology (NIIH-ICMR), 13th floor, KEM Hospital, Parel, Mumbai 400012, India
| | - Shrimati Shetty
- National Institute of Immunohematology (NIIH-ICMR), 13th floor, KEM Hospital, Parel, Mumbai 400012, India.
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8
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Meeks SL, Leissinger CA. The evolution of factor VIIa in the treatment of bleeding in haemophilia with inhibitors. Haemophilia 2019; 25:911-918. [PMID: 31489759 PMCID: PMC6899648 DOI: 10.1111/hae.13845] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/07/2019] [Accepted: 08/19/2019] [Indexed: 01/19/2023]
Abstract
The use of activated factor VII (FVIIa) for the treatment of bleeding events in haemophilia patients with inhibitors was first reported over 30 years ago. Since then clinical trials, registries, case series, real‐world experience and an understanding of its mechanism of action have transformed what was originally a scientific curiosity into one of the major treatments for inhibitor patients, with innovative therapeutic regimens, dose optimization and individualized care now widely practiced. Given current understanding and use, it might be easy to forget the years of clinical research that led up to this point; in this review, we lay out changes based on broad eras of rFVIIa use. These eras cover the original uncertainty associated with dosing, efficacy and safety; the transformation of care ushered in with its widespread use; and the optimization and individualization of patient care and the importance of specialized support provided by haemophilia treatment centres. Today with the introduction of novel prophylactic agents such as emicizumab, we once again find ourselves dealing with the uncertainties of how best to utilize rFVIIa and newer investigational variants such as marzeptacog alfa and eptacog beta; we hope that the experiences of the past three decades will serve as a guide for this new era of care.
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Affiliation(s)
- Shannon L Meeks
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Cindy A Leissinger
- Section of Hematology/Oncology, Tulane University School of Medicine, New Orleans, LA, USA
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9
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Ramiz S, Hartmann J, Young G, Escobar MA, Chitlur M. Clinical utility of viscoelastic testing (TEG and ROTEM analyzers) in the management of old and new therapies for hemophilia. Am J Hematol 2019; 94:249-256. [PMID: 30328141 DOI: 10.1002/ajh.25319] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/28/2018] [Accepted: 10/15/2018] [Indexed: 01/19/2023]
Abstract
Hemophilia A and B are rare inherited bleeding disorders resulting from deficiency of coagulation factors VIII and IX respectively. In the past few decades, the field of hemophilia has witnessed pivotal management challenges and therapeutic advances. Routine coagulation and factor assays, while useful in the classification of severity and treatment monitoring in hemophilia patients, have been shown to be of limited use in managing clinical presentations and outcomes. This prompted the investigation of viscoelastic studies in hemophilia care, which have established their utility in various bleeding and thrombotic states. In this review, we will discuss and critically assess the current literature highlighting the use of viscoelastic studies in various aspects of hemophilia including the determination of clinical phenotype, management of patients with inhibitors, perioperative management, and monitoring of novel agents.
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Affiliation(s)
- Sarah Ramiz
- Wayne State University School of MedicineChildren's Hospital of Michigan Detroit Michigan
| | | | - Guy Young
- University of Southern California Keck School of Medicine, Children's Hospital Los Angeles Los Angeles California
| | - Miguel A. Escobar
- University of Texas Health Science Center and the McGovern Medical School Houston Texas
| | - Meera Chitlur
- Wayne State University School of MedicineChildren's Hospital of Michigan Detroit Michigan
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10
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Erturan G, Guevel B, Alvand A, Goddard NJ. Over two decades of orthopaedic surgery in patients with inhibitors-Quantifying the complication of bleeding. Haemophilia 2018; 25:21-32. [PMID: 30507046 DOI: 10.1111/hae.13647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/28/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022]
Abstract
Patients with haemophilia who have developed inhibitors against factor VIII (FVIII) or factor IX present a significant concern to those surgeons who operate on them. The evidence base for bypassing agents such as recombinant factor VIIa and activated prothrombin complex concentrate has amassed over several decades. The literature is open to positive interpretation on the successful use of these agents in the treatment of inhibitor-positive patients. However, there are equally persistent concerns amongst surgeons, in particular orthopaedic surgeons, regarding the high complication rate of bleeding. To explore and quantify this concern, we present a literature review spanning two decades of publications on haemophilia patients with inhibitors undergoing orthopaedic surgery. Irrespective of the progress made with haemostatic protocols, trepidation on embarking on surgery is valid. The high risk of bleeding is a function of the inherent complexity of the disease and rightfully translates into difficulties in its management. Combined with the prospect of orthopaedic surgery, those involved in the care of such patients are justified in their continued anxiety and diligence when considering the benefits in quality of life against the prevalent complications.
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Affiliation(s)
- Gurhan Erturan
- Department of Trauma & Orthopaedics, Royal Free Hospital, London, UK
| | - Borna Guevel
- Department of Trauma & Orthopaedics, Royal Free Hospital, London, UK
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11
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Ljung R, Auerswald G, Benson G, Dolan G, Duffy A, Hermans C, Jiménez-Yuste V, Lambert T, Morfini M, Zupančić-Šalek S, Santagostino E. Inhibitors in haemophilia A and B: Management of bleeds, inhibitor eradication and strategies for difficult-to-treat patients. Eur J Haematol 2018; 102:111-122. [PMID: 30411401 PMCID: PMC6936224 DOI: 10.1111/ejh.13193] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/25/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022]
Abstract
The standard therapy for patients with haemophilia is prophylactic treatment with replacement factor VIII (FVIII) or factor IX (FIX). Patients who develop inhibitors against FVIII/FIX face an increased risk of bleeding, and the likelihood of early development of progressive arthropathy, alongside higher treatment-related costs. Bypassing agents can be used to prevent and control bleeding, as well as the recently licensed prophylaxis, emicizumab, but their efficacy is less predictable than that of factor replacement therapy. Antibody eradication, by way of immune tolerance induction (ITI), is still the preferred management strategy for treating patients with inhibitors. This approach is successful in most patients, but some are difficult to tolerise and/or are unresponsive to ITI, and they represent the most complicated patients to treat. However, there are limited clinical data and guidelines available to help guide physicians in formulating the next treatment steps in these patients. This review summarises currently available treatment options for patients with inhibitors, focussing on ITI regimens and those ITI strategies that may be used in difficult-to-treat patients. Some alternative, non-ITI approaches for inhibitor management, are also proposed.
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Affiliation(s)
- Rolf Ljung
- Department of Clinical Sciences-Paediatrics, Lund University, Lund, Sweden.,Malmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden
| | - Guenter Auerswald
- Klinikum Bremen-Mitte, Professor Hess Children's Hospital, Bremen, Germany
| | - Gary Benson
- Haemophilia and Thrombosis Centre, Belfast City Hospital, Belfast, UK
| | - Gerry Dolan
- Centre for Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - Anne Duffy
- WFH Psychosocial Committee, Irish Haemophilia Society, Dublin, Ireland
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | - Thierry Lambert
- Hemophilia Care Center, Faculté de Médecine Paris XI, Bicêtre AP-HP Hospital, Paris, France
| | | | - Silva Zupančić-Šalek
- University Hospital Centre Zagreb, School of Medicine, University of Osijek and Medical School University of Zagreb, Zagreb, Croatia
| | - Elena Santagostino
- Foundation IRCCS Cà Granda, Maggiore Hospital Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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12
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Rajpurkar M, Cooper DL. Continuous infusion of recombinant activated factor VII: a review of data in congenital hemophilia with inhibitors and congenital factor VII deficiency. J Blood Med 2018; 9:227-239. [PMID: 30568523 PMCID: PMC6276614 DOI: 10.2147/jbm.s184040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Introduction Continuous infusion (CI) of clotting factors as a replacement therapy for perioperative hemostatic protection has been performed for many years, including with factors VIII and IX and recombinant activated factor VII (rFVIIa). This approach provides steady factor levels without requiring frequent administration of bolus doses. Aim To review safety, efficacy, and dosing data regarding CI of rFVIIa for hemostatic management of patients with congenital hemophilia with inhibitors (CHwI) or congenital factor VII deficiency (C7D). Materials and methods A literature review identified instances of CI of rFVIIa in patients with CHwI or C7D undergoing surgery or experiencing bleeding episodes. Data regarding safety, efficacy, and dosing were extracted. Results The safety and efficacy of 50 mcg/kg/h CI of rFVIIa following a 90 mcg/kg bolus injection, vs a standard bolus injection regimen, was reported for 24 patients with CHwI undergoing elective surgery in an open-label, randomized, Phase III trial. Efficacy was similar between CI and bolus injection groups at all postoperative time points assessed. Additionally, a postmarketing surveillance study reported effective (80%) and partially effective (20%) CI of rFVIIa in a Japanese cohort of ten patients with CHwI who underwent 15 surgical procedures. Finally, the safety and dosing of rFVIIa CI in 193 and 26 patients with CHwI and C7D, respectively, were reported in 11 prospective studies, 10 retrospective studies, and 30 case reports. No unexpected safety findings were reported. Conclusion rFVIIa CI has been performed safely and effectively in patients with CHwI and C7D undergoing surgery and during bleeding episodes in patients with CHwI.
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Affiliation(s)
- Madhvi Rajpurkar
- Division of Hematology/Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, USA,
| | - David L Cooper
- Clinical, Medical and Regulatory Affairs, Novo Nordisk Inc., Plainsboro, NJ, USA
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13
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Gruppo RA, Malan D, Kapocsi J, Nemes L, Hay CRM, Boggio L, Chowdary P, Tagariello G, von Drygalski A, Hua F, Scaramozza M, Arkin S. Phase 1, single-dose escalating study of marzeptacog alfa (activated), a recombinant factor VIIa variant, in patients with severe hemophilia. J Thromb Haemost 2018; 16:1984-1993. [PMID: 30151972 DOI: 10.1111/jth.14247] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Indexed: 11/29/2022]
Abstract
Essentials Marzeptacog alfa (activated) [MarzAA] is a novel variant of activated human factor VII. A phase 1 dose escalation trial of MarzAA was conducted in subjects with severe hemophilia. MarzAA was safe and tolerated at intravenous doses up to 30 μg kg-1 Data observed support further trials for hemophilia patients with inhibitors to factors VIII/IX. SUMMARY Background Marzeptacog alfa (activated) (MarzAA), a new recombinant activated human factor VII (rFVIIa) variant with four amino acid substitutions, was developed to provide increased procoagulant activity and a longer duration of action in people with hemophilia. Objectives To investigate the safety, tolerability, immunogenicity, pharmacokinetics (PK) and pharmacodynamics (PD) of single ascending intravenous bolus doses of MarzAA in non-bleeding patients with congenital hemophilia A or B with or without inhibitors. Methods This international, phase 1, open-label study (NCT01439971) enrolled males aged 18-64 years with severe hemophilia A or B, with or without FVIII or FIX inhibitors. Subjects were assigned to single-dose MarzAA cohorts (0.5, 4.5, 9, 18 or 30 μg kg-1 ). Blood sampling was performed predose and postdose, and subjects were monitored for 60 days postdose. Safety endpoints included adverse events, vital sign changes, electrocardiograms, laboratory abnormalities, and immunogenicity; secondary endpoints included evaluation of PK and PD. Results Overall, in 25 patients, MarzAA was well tolerated at all dose levels tested, and was not associated with dose-limiting toxicity. No treatment-emergent severe or serious adverse events occurred. MarzAA showed linear dose-response PK across the 4.5-30 μg kg-1 dose range, with a terminal half-life of ⁓ 3.5 h. Dose-dependent shortening of the activated partial thromboplastin time and prothrombin time, and evidence of an increase in peak thrombin as determined with a thrombin generation assay, were observed at all doses. Conclusions MarzAA was tolerated at doses up to 30 μg kg-1 . The safety profile and pharmacological effects observed support further clinical trials for the treatment of hemophilic patients with inhibitors.
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Affiliation(s)
- R A Gruppo
- Comprehensive Hemophilia and Thrombosis Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - D Malan
- Phoenix Pharma Pty Ltd, Mount Croix, Port Elizabeth, South Africa
| | - J Kapocsi
- Semmelweis University 1st Department of Medicine, Budapest, Hungary
| | - L Nemes
- National Hemophilia Center and Hemostasis Department, Medical Center of the Hungarian Defense Forces, Budapest, Hungary
| | - C R M Hay
- University Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - L Boggio
- Hemophilia and Thrombophilia Center, Rush University Medical Center, Chicago, IL, USA
| | - P Chowdary
- KD Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - G Tagariello
- Department of Medicine, Hemophilia Center, Castelfranco Veneto Hospital, Castelfranco, Italy
| | | | - F Hua
- Applied BioMath, Concord, MA, USA
| | - M Scaramozza
- Early Clinical Development, Pfizer Worldwide R&D, Pfizer Inc., Cambridge, MA, USA
| | - S Arkin
- Rare Disease Research Unit, Pfizer Inc., Cambridge, MA, USA
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Teitel JM. Treatment and prevention of bleeding in congenital hemophilia A patients with inhibitors. Transfus Apher Sci 2018; 57:466-471. [DOI: 10.1016/j.transci.2018.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Hartmann R, Feenstra T, Valentino L, Dockal M, Scheiflinger F. In vitro studies show synergistic effects of a procoagulant bispecific antibody and bypassing agents. J Thromb Haemost 2018; 16:S1538-7836(22)02222-X. [PMID: 29888855 DOI: 10.1111/jth.14203] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Indexed: 12/15/2022]
Abstract
Essentials Patients with hemophilia A and inhibitors receiving emicizumab experience breakthrough bleeding. Safety concerns may exist when combining emicizumab with bypassing agents. Combined bypassing agent and bispecific antibody increased thrombin generation up to 17-fold. Thrombotic effects should be considered when combining emicizumab with plasma bypassing agent. SUMMARY Background Investigational non-factor products such as emicizumab offer a treatment option for patients with hemophilia and inhibitors. However, their mechanism of action raises questions regarding safety when they are combined with treatments for breakthrough bleeding. Objectives To evaluate in vitro thrombin generation (TG) and clot formation for combinations of activated prothrombin complex concentrate (aPCC), recombinant activated factor VII (rFVIIa), and a sequence-identical analog of emicizumab (SIA). Methods Therapeutic concentrations of SIA (20-600 nm) alone or with aPCC (0.05-1 U mL-1 ), isolated aPCC components or rFVIIa (0.88-5.25 μg mL-1 ) were tested for TG and compared with reference ranges for healthy donor plasma. Coagulation of FVIII-inhibited blood was determined with a widely established method, i.e. rotational thromboelastometry (ROTEM), and confirmed with the Total Thrombus-formation Analysis System. Results and conclusions SIA (600 nm) or aPCC (0.5 U mL-1 ) alone resulted in peak thrombin levels of 21.4 nm and 38.6 nm, respectively, both of which are lower than normal (83.7 ± 29.8 nm). SIA plus aPCC (0.5 U mL-1 ) increased the peak thrombin level 17-fold over SIA alone, exceeding the reference plasma value by 4.2-fold. This hypercoagulable effect occurred with 600 nmSIA combined with as little as 0.25 U mL-1 aPCC, confirmed by ROTEM. FIX was the main driver for enhanced TG. SIA plus rFVIIa (1.75 μg mL-1 ) induced a 1.8-fold increase in the peak thrombin level in platelet-rich plasma, but it did not reach the normal range. These in vitro experiments demonstrate excessive TG after administration of a combination of aPCC and SIA at clinically relevant doses. Careful judgement may be required when breakthrough bleeding is treated in patients receiving emicizumab.
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Demartis F, Batorova A, Chambost H, Eshghi P, Karimi M, Kavakli K, El Fegoun SB, Cepo K, Vestergaard LS, Benson G. Real-World Early Treatment with Room Temperature-Stable Recombinant Factor VIIa in Hemophilia A/B and Inhibitors: SMART-7™ Post Hoc Analyses. TH OPEN 2017; 1:e130-e138. [PMID: 31249918 PMCID: PMC6524848 DOI: 10.1055/s-0037-1608943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/02/2017] [Indexed: 01/23/2023] Open
Abstract
Treating hemophilia A or B patients with inhibitors is particularly challenging, as they do not respond to replacement therapy with factor VIII or factor IX concentrates. A room temperature–stable formulation of recombinant activated factor VII (rFVIIa; NovoSeven
®
), which provides improved convenience and treatment access to patients compared with the earlier formulation of rFVIIa, was shown to be safe and effective in a post-authorization, multinational, observational study (Study Monitoring Antibodies against Room Temperature–stable factor 7 [SMART-7™]). In post hoc, subgroup analyses of SMART-7™ data, the hemostatic response following rFVIIa monotherapy in patients with hemophilia A or B with inhibitors by time to first treatment and in different age cohorts was assessed. A total of 482/618 bleeding episodes treated with rFVIIa monotherapy and with (1) valid efficacy assessment, (2) no missing time for bleed start, (3) no missing time for any dose administration, and (4) valid time to first treatment were included in the analyses. Data on the type and location of bleeding episodes treated with rFVIIa monotherapy were also collected. The majority of bleeding episodes treated with rFVIIa monotherapy were treated within 1 hour after bleeding onset (318/482 [66%]) and, among them, 96.5% (307/318) were effectively treated (i.e., bleeding stopped). Hemostatic efficacy remained high for bleeding episodes treated >1 to ≤4 hours after the onset, with 94/101 (93.1%) treated effectively. Cause and location of bleeding varied across the different age groups assessed. Real-world evidence from post hoc, subgroup analyses of SMART-7™ data confirmed that patients were able to treat themselves quickly and that early treatment with rFVIIa was associated with high efficacy.
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Affiliation(s)
- Francesco Demartis
- Agenzia per l'Emofilia, Centro Malattie Emorragiche, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | - Angelika Batorova
- National Hemophilia Centre, Department of Hematology and Transfusion Medicine, Medical School of Comenius University, University Hospital, Bratislava, Slovakia
| | - Hervé Chambost
- Service d'Hématologie Oncologie Pédiatrique, La Timone, APHM, and Inserm, UMR 1062, Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Peyman Eshghi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehran Karimi
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kaan Kavakli
- Department of Hematology, Ege University Children's Hospital, Izmir, Turkey
| | | | - Katarina Cepo
- Medical & Science Biopharm, Novo Nordisk A/S, Søborg, Denmark
| | | | - Gary Benson
- Northern Ireland Haemophilia Comprehensive Care Centre, Belfast City Hospital, Belfast, United Kingdom
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Young G, Escobar MA, Pipe SW, Cooper DL. Safety and efficacy of recombinant activated coagulation factor VII in congenital hemophilia with inhibitors in the home treatment setting: A review of clinical studies and registries. Am J Hematol 2017; 92:940-945. [PMID: 28589615 DOI: 10.1002/ajh.24811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 05/26/2017] [Accepted: 06/01/2017] [Indexed: 01/19/2023]
Abstract
Self-administration of factor and bypassing agents by persons with hemophilia in the home setting is recommended to facilitate earlier intervention after bleeding episodes. The objective of this review was to summarize recombinant activated coagulation factor VII (rFVIIa) safety and efficacy data from clinical trials and patient registries documenting use in the home treatment setting in people with congenital hemophilia with inhibitors (CHwI). A total of 16 studies and registries were identified for inclusion; 14 evaluated on-demand treatment of acute bleeding episodes (865 patients, 9024 bleeding episodes) and 2 evaluated use for secondary prophylaxis (108 patients, 42,861 prophylaxis days). In the on-demand studies, efficacy was consistently high (81%-96%), and thrombotic events were uncommon (n = 3). In the secondary prophylaxis studies, rFVIIa was associated with a 45% to 59% reduction in bleeding episodes and no thrombotic events. These data support the clinical practice of administering rFVIIa in patients in the home treatment setting after initiation under a physician's care.
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Affiliation(s)
- Guy Young
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine; Los Angeles California
| | - Miguel A. Escobar
- University of Texas Health Science Center and the Gulf States Hemophilia and Thrombophilia Center; Houston Texas
| | - Steven W. Pipe
- Hemophilia and Coagulation Disorders Program; University of Michigan; Ann Arbor Michigan
| | - David L. Cooper
- Clinical, Medical and Regulatory Affairs; Novo Nordisk Inc; Plainsboro New Jersey
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Fernández-Bello I, Stenmo C, Butta N, Lind V, Ezban M, Jiménez-Yuste V. The pharmacokinetics and pharmacodynamics of single-dose and multiple-dose recombinant activated factor VII in patients with haemophilia A or B. Haemophilia 2017; 23:868-876. [DOI: 10.1111/hae.13312] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - N. Butta
- University Hospital La Paz-IdiPaz; Madrid Spain
| | - V. Lind
- Novo Nordisk A/S; Måløv Denmark
| | | | - V. Jiménez-Yuste
- University Hospital La Paz-IdiPaz; Madrid Spain
- Autonoma University; Madrid Spain
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19
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Tomita E, Takase H, Tajima K, Suematsu Y. Change of coagulation after NovoSeven® use for bleeding during cardiac surgery. Asian Cardiovasc Thorac Ann 2017; 25:99-104. [PMID: 28114794 DOI: 10.1177/0218492317689901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Recombinant activated factor VII has been used for the treatment of hemophilia, factor VII deficiency, and Glanzmann's thrombasthenia. Off-label uses have recently been increasing, and there are reports that recombinant activated factor VII is effective for the treatment of excessive bleeding during or after cardiovascular surgery. We retrospectively reviewed the effectiveness of recombinant activated factor VII and its influence on the coagulation system as a treatment for uncontrollable bleeding during cardiovascular surgery. Methods Between April 2009 and May 2015, recombinant activated factor VII was used to treat uncontrollable bleeding during cardiovascular surgery in 17 patients at our hospital. The indications for recombinant activated factor VII administration were critical uncontrollable bleeding during surgery and normal platelet and fibrinogen levels. Results Blood loss significantly decreased in every case after recombinant activated factor VII administration ( p < 0.05). No adverse thromboembolic events were encountered. The prothrombin time-international normalized ratio, activated partial thromboplastin time, fibrin degradation product and D-dimer levels decreased significantly after recombinant activated factor VII administration. One day later, all blood coagulation test values were almost within the normal ranges. Conclusions Recombinant activated factor VII has a strong hemostatic action, but it is necessary to exclude surgical bleeding to exhibit the hemostatic effect. Administration that does not comply with the indications for recombinant activated factor VII may lead to serious complications such as thromboembolism. In properly selected patients, recombinant activated factor VII is an effective agent for the treatment of uncontrollable bleeding during cardiovascular surgery.
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Affiliation(s)
- Emi Tomita
- 1 Department of Anesthesiology, Tsukuba Memorial Hospital, Ibaraki, Japan
| | - Hajime Takase
- 1 Department of Anesthesiology, Tsukuba Memorial Hospital, Ibaraki, Japan
| | - Keiichi Tajima
- 1 Department of Anesthesiology, Tsukuba Memorial Hospital, Ibaraki, Japan
| | - Yoshihiro Suematsu
- 2 Department of Cardiovascular Surgery, Tsukuba Memorial Hospital, Ibaraki, Japan
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20
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Lamberth K, Reedtz-Runge SL, Simon J, Klementyeva K, Pandey GS, Padkjær SB, Pascal V, León IR, Gudme CN, Buus S, Sauna ZE. Post hoc assessment of the immunogenicity of bioengineered factor VIIa demonstrates the use of preclinical tools. Sci Transl Med 2017; 9:9/372/eaag1286. [DOI: 10.1126/scitranslmed.aag1286] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 05/12/2016] [Accepted: 12/05/2016] [Indexed: 12/20/2022]
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21
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The potential correlation between patient-reported symptoms and the use of additional haemostatic medication for joint bleeding in haemophilia patients with inhibitors: a post hoc exploratory analysis of recombinant activated factor VII data from the ADEPT2 trial. Blood Coagul Fibrinolysis 2016; 28:224-229. [PMID: 27427786 PMCID: PMC5407628 DOI: 10.1097/mbc.0000000000000584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: Haemophilia treatment guidelines advocate early home-based treatment of acute bleeds. In the ADEPT2 trial, data were collected on the home treatment of bleeds with recombinant activated factor VII (rFVIIa) in haemophilia patients with inhibitors and self-reported bleeding-related symptoms. A total of 93% of all bleeds, and 91.5% of joint bleeds, were treated successfully with one to three doses of 90 μg/kg rFVIIa. However, some patients self-administered additional haemostatic medication (AHM) up to 48 h after the first rFVIIa treatment. The aim of this trial was to investigate the relationship between patient-reported symptoms, time to treatment initiation, and the use of AHM. A post hoc analysis was conducted on 177 joint bleeds and the patient-reported categorical symptoms of pain, swelling, mobility, tingling, and warmth, and the pain visual analogue scale (VAS) score. Analyses were descriptive and used logistic regression modelling. Complete symptom data were available for 141, 136, and 129 joint bleeds at 0 or 1, 3, and 6 h, respectively. Pain and pain VAS assessments were the best predictors of AHM use. Patients who self-administered AHM had higher mean pain VAS scores at each time point; both pain and pain VAS scores declined over time. Time to treatment initiation was an independent predictor for AHM use. Higher initial pain scores and longer time to treatment were the best predictors for administration of AHM. The observation that some patients chose to self-infuse in the face of declining levels of pain warrants further study to better understand the reasons behind patient decision-making.
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Sousos N, Gavriilaki E, Vakalopoulou S, Garipidou V. Understanding cardiovascular risk in hemophilia: A step towards prevention and management. Thromb Res 2016; 140:14-21. [DOI: 10.1016/j.thromres.2016.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 01/31/2016] [Accepted: 02/01/2016] [Indexed: 01/03/2023]
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23
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Klintman J, Berntorp E. Epidemiological aspects of inhibitor development in hemophilia and strategies of management. Expert Opin Orphan Drugs 2016. [DOI: 10.1517/21678707.2016.1127157] [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: 01/19/2023]
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24
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Beyond stopping the bleed: short-term episodic prophylaxis with recombinant activated factor FVII in haemophilia patients with inhibitors. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 15:77-84. [PMID: 26674816 DOI: 10.2450/2015.0127-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 07/30/2015] [Indexed: 12/28/2022]
Abstract
Preventing haemarthroses and arthropathy is a major challenge in patients with haemophilia and inhibitors, as treatment options are limited. One potential strategy is short-term episodic prophylaxis, which extends bypassing agent therapy beyond the resolution of bleeding to include the post-bleed inflammatory phase. At the 13th Zürich Haemophilia Forum, an expert panel reviewed the rationale behind this strategy, explored its current use with recombinant activated factor VII (rFVIIa) and considered treatment monitoring and optimisation. Two protocols are currently used for short-term episodic prophylaxis, both of which stipulate on-demand rFVIIa until resolution of bleeding, followed by daily dosing for ≥3 days to prevent re-bleeds. Short-term episodic prophylaxis should be individualised to optimise outcomes, perhaps through early treatment initiation or by combining rFVIIa with other treatments (e.g. factor VIII, tranexamic acid). Encouraging treatment compliance can also improve outcomes. Additionally, there is a need to develop objective clinical outcome measures, biomarkers and imaging protocols that can monitor treatment outcomes and joint disease in patients with inhibitors. A proactive approach incorporating a systematic package of care is needed. Currently, short-term episodic prophylaxis with rFVIIa may be an alternative treatment option to on-demand treatment for patients with inhibitors.
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25
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Mahlangu JN, Weldingh KN, Lentz SR, Kaicker S, Karim FA, Matsushita T, Recht M, Tomczak W, Windyga J, Ehrenforth S, Knobe K. Changes in the amino acid sequence of the recombinant human factor VIIa analog, vatreptacog alfa, are associated with clinical immunogenicity. J Thromb Haemost 2015; 13:1989-98. [PMID: 26362483 DOI: 10.1111/jth.13141] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 08/10/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Vatreptacog alfa, a recombinant human factor VIIa (rFVIIa) analog developed to improve the treatment of bleeds in hemophilia patients with inhibitors, differs from native FVIIa by three amino acid substitutions. In a randomized, double-blind, crossover, confirmatory phase III trial (adept(™) 2), 8/72 (11%) hemophilia A or B patients with inhibitors treated for acute bleeds developed anti-drug antibodies (ADAs) to vatreptacog alfa. OBJECTIVES To characterize the formation of anti-vatreptacog alfa ADAs in hemophilia patients with inhibitors. METHODS/PATIENTS This was a post hoc analysis of adept(™) 2. Immunoglobulin isotype determination, specificity analysis of rFVIIa cross-reactive antibodies, epitope mapping of rFVIIa single mutant analogs and pharmacokinetic (PK) profiling were performed to characterize the ADAs. RESULTS Immunoglobulin isotyping indicated that the ADAs were of the immunoglobulin G subtype. In epitope mapping, none of the rFVIIa single mutant analogs (V158D, E296V or M298Q) contained the complete antibody epitope, confirming that the antibodies were specific for vatreptacog alfa. In two patients, for whom PK profiling was performed both before and after the development of ADAs, vatreptacog alfa showed a prolonged elimination phase following ADA development. During the follow-up evaluation, the rFVIIa cross-reactivity disappeared after the last vatreptacog alfa exposure, despite continued exposure to rFVIIa as part of standard care. CONCLUSIONS Results from the vatreptacog alfa phase III trial demonstrate that the specific changes made, albeit relatively small, to the FVIIa molecule alter its clinical immunogenicity.
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Affiliation(s)
- J N Mahlangu
- Haemophilia Comprehensive Care Centre, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | | | - S R Lentz
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - S Kaicker
- Maimonides Medical Centre, New York, NY, USA
| | - F A Karim
- Haemophilia Centre, National Blood Centre, Kuala Lumpur, Malaysia
| | - T Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - M Recht
- Hemophilia Center, Oregon Health and Science University, Portland, OR, USA
| | - W Tomczak
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - J Windyga
- Department of Disorders of Haemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | - K Knobe
- Novo Nordisk A/S, Bagsvaerd, Denmark
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Introduction and overview. Blood Rev 2015; 29 Suppl 1:S1-3. [DOI: 10.1016/s0268-960x(15)30001-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Cost-utility analysis of an adjunctive recombinant activated factor VIIa for on-demand treatment of bleeding episodes in dengue haemorrhagic fever. Blood Coagul Fibrinolysis 2015; 26:403-7. [PMID: 25692521 DOI: 10.1097/mbc.0000000000000280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The present study aimed to assess the cost-utility analysis of using an adjunctive recombinant activated factor VIIa (rFVIIa) in children for controlling life-threatening bleeding in dengue haemorrhagic fever (DHF)/dengue shock syndrome (DSS). We constructed a decision-tree model, comparing a standard care and the use of an additional adjuvant rFVIIa for controlling life-threatening bleeding in children with DHF/DSS. Cost and utility benefit were estimated from the societal perspective. The outcome measure was cost per quality-adjusted life years (QALYs). Overall, treatment with adjuvant rFVIIa gained QALYs, but the total cost was higher. The incremental cost-utility ratio for the introduction of adjuvant rFVIIa was $4241.27 per additional QALY. Sensitivity analyses showed the utility value assigned for calculation of QALY was the most sensitive parameter. We concluded that despite high cost, there is a role for rFVIIa in the treatment of life-threatening bleeding in patients with DHF/DSS.
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Neufeld EJ, Négrier C, Arkhammar P, el Fegoun SB, Simonsen MD, Rosholm A, Seremetis S. Safety update on the use of recombinant activated factor VII in approved indications. Blood Rev 2015; 29 Suppl 1:S34-41. [PMID: 26073367 DOI: 10.1016/s0268-960x(15)30006-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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29
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Recombinant activated factor VII in the treatment of bleeds and for the prevention of surgery-related bleeding in congenital haemophilia with inhibitors. Blood Rev 2015; 29 Suppl 1:S9-18. [DOI: 10.1016/s0268-960x(15)30003-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Golestani M, Eshghi P, Rasekh HR, Cheraghali AM, Salamzadeh J, Imani A. Comparison of bypassing agents in bleeding reduction in treatment of bleeding episodes in patients with haemophilia and inhibitors. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 16:e24551. [PMID: 25763245 PMCID: PMC4341353 DOI: 10.5812/ircmj.24551] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 11/16/2014] [Accepted: 11/17/2014] [Indexed: 11/16/2022]
Abstract
CONTEXT Mild-to-moderate bleeding disorders in haemophilia are primarily treated via recombinant activated factor VII a (rFVIIa) or activated prothrombin complex concentrate (aPCC). However, the efficacy of each bypassing agents may vary and none of them is universally effective. EVIDENCE ACQUISITION After reviewing the databases of PubMed, Scopus, MD Consult, Ovid, Trip database, Google Scholar, ProQuest and the Cochrane Library, finally, 17 papers published from 2000 to 2013 were extracted. We used as a random effect model in meta-analysis. Comprehensive meta-analysis (CMA) software was used for calculating and estimating the mean of bleeding reduction and performing meta-analysis. RESULTS The mean of bleeding reduction in aPCC and rFVIIa were 71.2% with CI 95% (lower limit 86.8% and upper limit 82%) and 72.3% with CI 95% (lower limit 57.6% and upper limit 83.4%), respectively. CONCLUSIONS Although differences between the two products were very close to each other, they reported similar effects on joint bleeds. Further clinical studies should be performed by incorporating a standardized measurement in comparative efficacy of aPCC and rFVIIa.
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Affiliation(s)
- Mina Golestani
- School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Mina Golestani, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran. Tel: +98-9125160488, Fax: +98-4133351048, E-mail:
| | - Peyman Eshghi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Hamid Reza Rasekh
- School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | | | - Jamshid Salamzadeh
- School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Ali Imani
- Iranian Center of Excellence in Health Management, Faculty of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, IR Iran
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Faranoush M, Abolghasemi H, Mahboudi F, Toogeh G, Karimi M, Eshghi P, Managhchi M, Hoorfar H, Dehdezi BK, Mehrvar A, khoeiny B, Vaziri B, Kamyar K, Heshmat R, Baghaeipour MR, Mirbehbahani NB, Fayazfar R, Ahmadinejad M, Naderi M. A Comparison of Efficacy Between Recombinant Activated Factor VII (Aryoseven) and Novoseven in Patients With Hereditary FVIII Deficiency With Inhibitor. Clin Appl Thromb Hemost 2014; 22:184-90. [DOI: 10.1177/1076029614555902] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Introduction: This study compared the efficacy of Aryoseven with Novoseven to control bleeding episodes in patients with hemophilia A with inhibitors. Methods: Sixty-six patients were randomized into 2 groups, with 4 consecutive block randomization. These groups received Aryoseven and Novoseven dosages of 90 to 120 μg/kg intravenously every 2 hours. Results: Median (interquartile range) level of factor VIII (FVIII) inhibitor in groups A and B was 15.0 and 19.0 Bethesda Unit (BU) preadministration. Bleeding onset in group A was 1246 ± 1104 minutes and in group B was 2301 ± 1693 minutes ( P = .311). The Kavakli global response scores and treatment success rate was comparable in both the groups. The side effects in groups A (9.7%) and B (2.9%) were comparable. Conclusion: Biosimilar recombinant activated FVII is found to be as effective as Novoseven in the treatment of acute joint bleeding in patients with hemophilia with inhibitors. Its usage will decrease the gaps in hemophilia.
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Affiliation(s)
- M. Faranoush
- Iran university of Medical Sciences, Rasool Akram Hospital, Tehran, Iran
| | - H. Abolghasemi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - F. Mahboudi
- Biotechnology Research Center, Pasteur Institute of Iran, Tehran Iran
| | - Gh. Toogeh
- Thrombosis and Hemostasis Research Center, Tehran University of Medical Sciences, Imam Khomeini Hospital, Tehran, Iran
| | - M. Karimi
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - P. Eshghi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M. Managhchi
- Thrombosis and Hemostasis Research Center, Tehran University of Medical Sciences, Imam Khomeini Hospital, Tehran, Iran
| | - H. Hoorfar
- Isfahan University of Medical Sciences, Isfahan, Iran
| | | | | | | | - B. Vaziri
- Biotechnology Research Center, Pasteur Institute of Iran, Tehran Iran
| | - K. Kamyar
- Aryogen Zist Darou Company, Karaj, Iran
| | - R. Heshmat
- Thrombosis and Hemostasis Research Center, Tehran University of Medical Sciences, Imam Khomeini Hospital, Tehran, Iran
| | | | | | - R. Fayazfar
- MD, Kerman University of Medical Sciences, Kerman, Iran
| | - M. Ahmadinejad
- High Institute of Research, Iranian Blood Transfusion Organization, Tehran, Iran
| | - M. Naderi
- Zahedan University of Medical Sciences, Ahwaz, Iran
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Young G, Teitel J, d'Oiron R, Leissinger C, Berntorp E. Evaluation of algorithms for the treatment of problem bleeding episodes in patients with hemophilia having inhibitors. Clin Appl Thromb Hemost 2014; 21:10-8. [PMID: 25343956 DOI: 10.1177/1076029614554993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The correlation between real-world clinical decisions and adherence to published treatment algorithms for problem bleeding episodes in patients with severe hemophilia and inhibitors and the resultant impact on clinical outcomes were assessed. Nine cases documenting treatment for problem bleeding episodes in patients with severe hemophilia and inhibitors were retrospectively reviewed. Adherence to treatment algorithms was rated on a scale of 1 to 5, 1 being no adherence and 5 being very high adherence. Adherence ratings >3 were assigned to 7 cases in which high adherence was associated with ≤4 days to achieve hemostatic control; hospitalization for ≤7 days was noted in 6 of these cases. In cases rated ≤3 (n = 2), time to hemostatic control ranged from 5 to 8 days and hospitalization duration ranged from 10 to 16 days. These findings suggest that adherence to treatment algorithms may be beneficial in treating problem bleeding events in patients with hemophilia and inhibitors.
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Affiliation(s)
- Guy Young
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Jerome Teitel
- Division of Hematology and Oncology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Roseline d'Oiron
- Haemophilia Centre, APHP Bicêtre Hospital, University Paris XI, Le Kremlin-Bicêtre, France
| | - Cindy Leissinger
- Louisiana Center for Bleeding and Clotting Disorders, Tulane University School of Medicine, New Orleans, LA, USA
| | - Erik Berntorp
- Malmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Lund University, Lund, Sweden
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Lentz SR, Ehrenforth S, Karim FA, Matsushita T, Weldingh KN, Windyga J, Mahlangu JN. Recombinant factor VIIa analog in the management of hemophilia with inhibitors: results from a multicenter, randomized, controlled trial of vatreptacog alfa. J Thromb Haemost 2014; 12:1244-53. [PMID: 24931322 PMCID: PMC4238784 DOI: 10.1111/jth.12634] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 05/30/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND Vatreptacog alfa, a recombinant factor VIIa (rFVIIa) analog with three amino acid substitutions and 99% identity to native FVIIa, was developed to improve the treatment of hemophilic patients with inhibitors. OBJECTIVES To confirm the safety and assess the efficacy of vatreptacog alfa in treating bleeding episodes in hemophilic patients with inhibitors. PATIENTS AND METHODS In this international, multicenter, randomized, double-blind, active-controlled, crossover, confirmatory phase III trial (adept(™) 2) in patients with hemophilia A or B and inhibitors, bleeds were randomized 3 : 2 to treatment with vatreptacog alfa (one to three doses at 80 μg kg(-1) ) or rFVIIa (one to three doses at 90 μg kg(-1) ). Treatment failures after three doses of trial product (TP) were managed according to the local standard of care. RESULTS In the 72 patients enrolled, 567 bleeds were treated with TP. Both vatreptacog alfa and rFVIIa gave 93% effective bleeding control at 12 h. Vatreptacog alfa was superior to rFVIIa in secondary efficacy outcomes, including the number of doses used to treat a bleed and sustained bleeding control 24-48 h after the first dose. Eight patients (11%) developed antibodies against vatreptacog alfa, including four with cross-reactivity against rFVIIa and one with an in vitro neutralizing effect to vatreptacog alfa. CONCLUSIONS This large randomized controlled trial confirmed the well-established efficacy and safety profile of rFVIIa, and showed that vatreptacog alfa had similar or better efficacy than rFVIIa. However, because of the development of anti-drug antibodies, a positive benefit-risk profile is unlikely to be achieved with vatreptacog alfa.
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Affiliation(s)
- S R Lentz
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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34
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Shibeko AM, Woodle SA, Mahmood I, Jain N, Ovanesov MV. Predicting dosing advantages of factor VIIa variants with altered tissue factor-dependent and lipid-dependent activities. J Thromb Haemost 2014; 12:1302-12. [PMID: 24913469 DOI: 10.1111/jth.12628] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 05/28/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) is an FX-cleaving coagulation enzyme licensed for the treatment of bleeding episodes in hemophiliacs with inhibitory antibodies. Even though the optimal dosing and comparative dose efficacy of rFVIIa remain poorly understood, genetic or chemical modifications of rFVIIa have been proposed, with the goal of achieving faster and longer hemostatic action. No ongoing trial is currently comparing rFVIIa variants with each other. OBJECTIVES AND METHODS We used mathematical modeling to compare the pharmacokinetics, dose-response (pharmacodynamics) and dose-effect duration (pharmacokinetics/pharmacodynamics) of rFVIIa variants to predict their optimal doses. The pharmacodynamic (PD) model of FXa generation by FVIIa in complexes with tissue factor (TF) and procoagulant lipids (PLs) was validated against published ex vivo and in vitro thrombin generation (TG) experiments. To compare variants' safety profiles, the highest non-thrombogenic doses were estimated from the clinical evidence reported for the licensed rFVIIa product. RESULTS The PD model correctly described the biphasic TF-dependent and PL-dependent dose response observed in TG experiments in vitro. The pharmacokinetic/PD simulations agreed with published ex vivo TG data for rFVIIa and the BAY 86-6150 variant, and explained the similar efficacies of a single dose of 270 μg kg(-1) (as reported in the literature) and repeated doses of 90 μg kg(-1) of unmodified rFVIIa. The duration of the simulated hemostatic effect after a single optimal dose was prolonged for rFVIIa variants with increased TF affinity or extended half-lives, but not for those with modulated PL activity. CONCLUSIONS Some modifications of the rFVIIa molecule may not translate into a prolonged hemostatic effect.
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Affiliation(s)
- A M Shibeko
- Center for Theoretical Problems of Physicochemical Pharmacology RAS, Moscow, Russia
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Faranoush M, Abolghasemi H, Toogeh G, Karimi M, Eshghi P, Managhchi M, Hoorfar H, Dehdezi BK, Mehrvar A, Khoeiny B, Kamyar K, Heshmat R, Baghaeipour MR, Mirbehbahani NB, Fayazfar R, Ahmadinejad M, Naderi M. A Comparison Between Recombinant Activated Factor VII (Aryoseven) and Novoseven in Patients With Congenital Factor VII Deficiency. Clin Appl Thromb Hemost 2014; 21:724-8. [DOI: 10.1177/1076029614522545] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In order to establish the efficacy and biosimilar nature of AryoSeven to NovoSeven in the treatment of congenital factor VII (FVII) deficiency, patients received either agent at 30 μg/kg, intravenously per week for 4 weeks, in a randomized fashion. The primary aim was to compare FVII:coagulation activity (FVII:C), 20 minutes after recombinant activated FVII (rFVIIa) injection, in the 2 groups. A secondary measure was self-reported bleeding. The median interquartile baseline range of the plasma level of activated FVII (FVIIa) activity in the 2 groups was 1.6 (1.1-14.0) IU/dL and 5.0 (1.1-25.5) IU/dL. All patients achieved levels of FVIIa (FVII:C) >30 IU/dL, 20 minutes after the injection of rFVIIa. Bleeding was similar between the 2 groups, with a comparable decrease in severity and frequency compared to the last month prior to treatment. AryoSeven is similar to NovoSeven in increasing postinjection FVIIa activity as well as in clinical safety and efficacy.
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Affiliation(s)
- M. Faranoush
- High Institute of Research, Iranian Blood Transfusion Organization, Iran University of Medical Sciences, Rasool Akram Hospital, Tehran, Iran
| | | | - Gh. Toogeh
- Tehran University of Medical Sciences, Thrombosis and Hemostasis Research Center, Tehran, Iran
| | - M. Karimi
- Shiraz University of Medical Sciences, Shiraz, Iran
| | - P. Eshghi
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M. Managhchi
- Tehran University of Medical Sciences, Thrombosis and Hemostasis Research Center, Tehran, Iran
| | - H. Hoorfar
- Isfahan University of Medical Sciences, Isfahan, Iran
| | | | | | | | - K. Kamyar
- Aryogen Zist Darou Company, Karaj, Iran
| | - R. Heshmat
- Tehran University of Medical Sciences, Thrombosis and Hemostasis Research Center, Tehran, Iran
| | | | | | - R. Fayazfar
- Kerman University of Medical Sciences, Kerman, Iran
| | | | - M. Naderi
- Zahedan University of Medical Sciences, Ahwaz, Iran
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36
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Abstract
In this issue of Blood, Feng et al shed incisive light on how recombinant activated factor VII (rFVIIa) corrects the bleeding defect in hemophilia.1
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37
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The successful management of dabigatran-associated critical end-organ bleeding with recombinant factor VIIa. Ann Hematol 2014; 93:1785-6. [PMID: 24584995 DOI: 10.1007/s00277-014-2039-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 02/15/2014] [Indexed: 12/23/2022]
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Saeki N, Mochizuki S, Fujii T, Kawamoto M. Postsurgical coagulopathy in a hemophilia A patient with inhibitors: efficacy of recombinant factor VIIa. J Anesth 2014; 28:621-4. [PMID: 24389884 DOI: 10.1007/s00540-013-1779-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 12/17/2013] [Indexed: 11/29/2022]
Abstract
Perioperative hemostatic management in patients with hemophilia A who develop the coagulation factor VIII (FVIII) inhibitor is challenging, because exogenous FVIII is neutralized, which boosts the inhibitor to provoke postoperative coagulopathy. Recombinant activated factor VII (rFVIIa) has become available for this type of patient, although FVIII is sometimes required. We treated a 56-year-old male patient with hemophilia A with FVIII inhibitor scheduled for total hip arthroplasty (THA) and total knee arthroplasty (TKA). We used rFVIIa for THA; however, the amount of bleeding was 2,500 ml and blood transfusion was required, which boosted FVIII inhibitor after surgery. The TKA was then scheduled for 19 months later, after the level of the inhibitor had reduced to the preoperative level. Unfortunately, rFVIIa failed to improve PT/APTT, and thus we used recombinant factor VIII (rFVIII). The amount of bleeding during TKA was 1,340 ml, while the level of the inhibitor increased to a greater level than that after THA, provoking uncontrollable bleeding. For anesthetic management in hemophilia A patients with FVIII inhibitor, anesthesiologists must pay attention to postoperative coagulopathy, and every effort should be used to minimize exposure to FVIII. Furthermore, when rFVIIa is ineffective, postponement of surgery until rFVIIa regains its efficacy may be beneficial as compared to an operation with FVIII.
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Affiliation(s)
- Noboru Saeki
- Department of Anesthesiology and Critical Care, Hiroshima University School of Medicine, 1-2-3, Kasumi, Minami, Hiroshima, 734-8551, Japan,
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Shapiro AD, Neufeld EJ, Blanchette V, Salaj P, Gut RZ, Cooper DL. Safety of recombinant activated factor VII (rFVIIa) in patients with congenital haemophilia with inhibitors: overall rFVIIa exposure and intervals following high (>240 μg kg−1) rFVIIa doses across clinical trials and registries. Haemophilia 2013; 20:e23-31. [PMID: 24354484 DOI: 10.1111/hae.12329] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2013] [Indexed: 01/19/2023]
Affiliation(s)
- A. D. Shapiro
- Indiana Hemophilia and Thrombosis Center; Indianapolis IN USA
| | - E. J. Neufeld
- Division of Hematology/Oncology; Boston Children's Hospital; Boston MA USA
| | - V. Blanchette
- Department of Pediatrics, Hospital for Sick Children; Toronto Canada
| | - P. Salaj
- Institute of Hematology and Blood Transfusion; Prague Czech Republic
| | - R. Z. Gut
- Clinical Development and Medical Affairs - Biopharm, Novo Nordisk Inc.; Plainsboro NJ USA
| | - D. L. Cooper
- Clinical Development and Medical Affairs - Biopharm, Novo Nordisk Inc.; Plainsboro NJ USA
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40
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Lambing AY. Unexpected hemorrhage: an unusual and potentially catastrophic clinical challenge. J Am Assoc Nurse Pract 2013; 25:342-50. [PMID: 24170617 DOI: 10.1111/j.1745-7599.2012.00807.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Unexpected bleeding or hemorrhage related to the development of acquired factor VIII inhibitors is an emerging clinical challenge in patients. Symptoms can occur suddenly with bleeding and/or bruising that is excessive relative to the degree of injury or severity of a comorbid condition. Diagnosis is difficult, and bleeding can quickly become life threatening if not treated promptly. This review provides current information, using a patient case scenario, to improve awareness and recognition of patients presenting unexpectedly with excessive bleeding of unknown etiology. DATA SOURCES To complete this review, a search of English-language publications was conducted using Medline and CINAHL databases (1966-2010). CONCLUSIONS Although development of acquired factor VIII inhibitors is rare, its incidence is increasing in many different patient care settings. Improved awareness and recognition is needed to mitigate the significant patient morbidity and mortality that can occur without rapid and timely treatment by experienced hematology specialists. IMPLICATIONS FOR PRACTICE Nurse practitioners, as front-line clinicians treating patients in various therapeutic areas, may be the first healthcare professionals who see patients with this disorder. Increased knowledge and awareness of this rare but potentially catastrophic cause of excessive bleeding can improve prompt treatment and optimize patient outcomes.
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Affiliation(s)
- Angela Y Lambing
- Department of Hematology and Oncology, Hemophilia and Thrombosis Treatment Center, Henry Ford Health System, Detroit, Michigan
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41
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Almomen A, Aleem A, Alshaik M, Hasanato R. Intrapulmonary rFVIIa for life threatening pulmonary hemorrhage in a case of relapsing acute lymphoblastic leukemia and platelet refractoriness. Platelets 2013; 25:452-4. [PMID: 24102447 DOI: 10.3109/09537104.2013.835797] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Platelet refractoriness may lead to life-threatening gastro-intestinal, intracranial or pulmonary hemorrhage that is difficult to control despite massive platelet and red cell transfusion, antifibrinolytic agents, high dose corticosteroids, immunoglobulin and intravenous (I.V.) recombinant activated factor VII (rFVIIa). In cases with pulmonary hemorrhage, intrapulmonary administration of rFVIIa may be more effective in non-responsive cases. We report a 51-year-old man with relapsing acute lymphoblastic leukemia (ALL) and platelet refractoriness, who suffered a life-threatening pulmonary hemorrhage that was refractory to massive platelet transfusion, tranexamic acid, high dose corticosteroids, immunoglobulin and intravenous rFVIIa, but responded immediately to a single intrapulmonary dose of rFVIIa that was inhaled with a jet nebulizer assistance through the endotracheal tube.
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Affiliation(s)
- Abdulkareem Almomen
- Center of Excellence in Thrombosis and Hemostasis, College of Medicine and King Khalid University Hospital, King Saud University , Riyadh , Saudi Arabia
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42
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Bakhtiari K, Kamphuisen PW, Mancuso ME, Hamulyak K, Schutgens REG, Santagostino E, Meijers JCM. Clot lysis phenotype and response to recombinant factor VIIa in plasma of haemophilia A inhibitor patients. Br J Haematol 2013; 162:827-35. [DOI: 10.1111/bjh.12470] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 06/12/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Kamran Bakhtiari
- Department of Experimental Vascular Medicine; Academic Medical Centre; Amsterdam; The Netherlands
| | - Pieter W. Kamphuisen
- Department of Vascular Medicine; Academic Medical Centre; Amsterdam; The Netherlands
| | - Maria E. Mancuso
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre; Fondazione IRCCS Ca’ Granda; Ospedale Maggiore Policlinico; Milan; Italy
| | - Karly Hamulyak
- Department of Haematology; University Hospital; Maastricht; The Netherlands
| | - Roger E. G. Schutgens
- Department of Haematology/van Creveldkliniek; University Medical Centre; Utrecht; The Netherlands
| | - Elena Santagostino
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre; Fondazione IRCCS Ca’ Granda; Ospedale Maggiore Policlinico; Milan; Italy
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43
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Birschmann I, Klamroth R, Eichler H, Schenk J, Kirchmaier CM, Halimeh S. Results of the WIRK prospective, non-interventional observational study of recombinant activated factor VII (rFVIIa) in patients with congenital haemophilia with inhibitors and other bleeding disorders. Haemophilia 2013; 19:679-85. [DOI: 10.1111/hae.12156] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2013] [Indexed: 12/01/2022]
Affiliation(s)
- I. Birschmann
- Institute for Laboratory and Transfusion Medicine; Heart and Diabetes Center; Ruhr University Bochum; Bad Oeynhausen; Germany
| | - R. Klamroth
- Department of Internal Medicine - Angiology; Haemostasis and Coagulation Disorders; Vivantes Hospital im Friedrichshain; Berlin; Germany
| | - H. Eichler
- Institute of Clinical Hemostaseology and Transfusion Medicine; Saarland University Hospital; Homburg/Saar; Germany
| | - J. Schenk
- Institute of Clinical Hemostaseology and Transfusion Medicine; Saarland University Hospital; Homburg/Saar; Germany
| | - C. M. Kirchmaier
- Section Internal Medicine I - Angiology and Haemostaseology; German Diagnostic Clinic; Wiesbaden; Germany
| | - S. Halimeh
- Coagulation Centre Rhine-Ruhr, Outpatient and Specialist Laboratory for Coagulation Disorders/Haemophilia; Duisburg; Germany
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44
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Chambost H, Santagostino E, Laffan M, Kavakli K. Real-world outcomes with recombinant factor VIIa treatment of acute bleeds in haemophilia patients with inhibitors: results from the international ONE registry. Haemophilia 2013; 19:571-7. [PMID: 23557542 DOI: 10.1111/hae.12140] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2013] [Indexed: 01/04/2023]
Abstract
The ONE Registry (OR) was an international prospective observational study of on-demand recombinant factor VIIa (rFVIIa) treatment for mild to moderate bleeds in haemophilia A/B patients with inhibitors. To describe real-world use of single and multi dose rFVIIa and to compare outcomes, including effectiveness, safety, quality of life and treatment satisfaction associated with treatment. Baseline data included demographics, treatment, medical and bleed history and patient/caregiver-reported outcomes regarding bleeds. rFVIIa was prescribed according to routine practice; regimens varied and initial dose was categorized as low (LD, ≤ 120 μg kg(-1) ), intermediate (ID, >120 and <250 μg kg(-1) ) or high (HD, ≥ 250 μg kg(-1) ). OR included 102 patients and 85 (83%) reported 494 bleeds overall. Mean age was 23 years (SD 16.4), with 52% ≥ 18 years. Majority of bleeds (n = 350, 71%) involved ≥ 1 joints; 46% involved a target joint. Median initial dose was 90 μg kg(-1) in LD (range 87-120, n = 156), 174 μg kg(-1) in ID, (range 121-249, n = 127) and 270 μg kg(-1) in HD, (range 250-375, n = 211). For spontaneous bleeds, effective haemostasis rate at 9 h was 63% LD, 60% ID and 56% HD. Rates of combined partially effective/effective haemostasis was 85% LD, 96% ID and 86% HD. Median number of doses in HD was one (range 1-7), compared with two in LD (range 1-17) and ID (range 1-23). No thromboembolic events were reported in 1145 doses given. These observational data in real life are consistent with previous studies which have shown similar overall effectiveness of rFVIIa and similar effectiveness and safety across different patterns of standard initial dosing.
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Affiliation(s)
- H Chambost
- Paediatric Haematology Department, APHM, Children's Hospital La Timone, Marseille, France; Inserm, UMR 1062, Aix Marseille University, Marseille, France.
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45
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Teitel JM, Sholzberg M. Current status and future prospects for the prophylactic management of hemophilia patients with inhibitor antibodies. Blood Rev 2013; 27:103-9. [DOI: 10.1016/j.blre.2013.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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46
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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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47
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Brown SA, Barnes C, Curtin J, Dunkley S, Ockelford P, Phillips J, Rowell J, Smith M, Tran H. How we use recombinant activated Factor VII in patients with haemophilia A or B complicated by inhibitors. Intern Med J 2012; 42:1243-50. [DOI: 10.1111/j.1445-5994.2012.02942.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 08/16/2012] [Indexed: 01/19/2023]
Affiliation(s)
- S. A. Brown
- Department of Haematology and Oncology; Royal Children's Hospital; Brisbane
- Department of Haematology; Pathology Queensland; Brisbane Queensland Australia
| | - C. Barnes
- Haemophilia Treatment Centre; Royal Childrens' Hospital; Parkville Victoria
| | - J. Curtin
- Haematology Department; Childrens' Hospital; Westmead
| | - S. Dunkley
- Haemophilia Treatment Centre; Royal Prince Alfred Hospital; Camperdown New South Wales Australia
| | - P. Ockelford
- Adult Haemophilia Treatment Centre; Auckland Hospital; Auckland
| | - J. Phillips
- Haematology; Wellington Hospital; Wellington New Zealand
| | - J. Rowell
- Haemophilia Centre; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - M. Smith
- Haematology, Canterbury District Health Board; Christchurch Hospital; Christchurch New Zealand
| | - H. Tran
- Haemophilia Treatment Centre; Prahran Victoria Australia
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Mamtani R, Nascimento B, Rizoli S, Pinto R, Lin Y, Tien H. The utility of recombinant factor VIIa as a last resort in trauma. World J Emerg Surg 2012; 7 Suppl 1:S7. [PMID: 23531130 PMCID: PMC3424973 DOI: 10.1186/1749-7922-7-s1-s7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Introduction The use of recombinant factor VII (rFVIIa) as a last resort for the management of coagulopathy when there is severe metabolic acidosis during large bleedings in trauma might be deemed inappropriate. The objective of this study was to identify critical degrees of acidosis and associated factors at which rFVIIa might be considered of no utility. Methods All massively transfused (≥ 8 units of red blood cells within 12 hours) trauma patients from Jan 2000 to Nov 2006. Demographic, baseline physiologic and rFVIIa dosage data were collected. Rate of red blood cell transfusion in the first 6 hours of hospitalization (RBC/hr) was calculated and used as a surrogate for bleeding. Last resort use of rFVIIa was defined by a pH≤ 7.02 based on ROC analysis for survival. In-hospital mortality was analyzed in last resort and non-last resort groups. Univariate analysis was performed to assess for differences between groups and identify factors associates with no utility of rFVIIa. Results 71 patients who received rFVIIa were analyzed. The pH> 7.02 had 100% sensitivity for the identification of potential survivors. All 11 coagulopathic, severely acidotic (pH ≤ 7.02) patients with high rates of bleeding (4RBC/hr) died despite administration of rFVIIa. The financial cost of administering rFVIIa as a last resort to these 11 severely acidotic and coagulophatic cases was $75,162 (CA). Conclusions Our study found no utility of rFVIIa in treating severely acidotic, coagulopathic trauma patients with high rates of bleeding; and thus restrictions should be set on its usage in these circumstances.
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Affiliation(s)
- Rishi Mamtani
- Trauma Services, Division of General Surgery, Sunnybrook Health Sciences Centre and Canadian Forces Health Services, 2075 Bayview Avenue, Room H1 86, Toronto, ON M4N 3M5, USA.
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Abstract
In this issue of Blood, Shibeko et al have used a variety of experimental studies and mathematical models to investigate the mechanism of action of high-dose factor VIIa as a bypassing agent in hemophilia.1
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MONAHAN PAULE, DORIA ANDREAS, LJUNG ROLF, JIMÉNEZ-YUSTE VICTOR. Optimizing joint function: new knowledge and novel tools and treatments. Haemophilia 2012; 18 Suppl 5:17-26. [DOI: 10.1111/j.1365-2516.2012.02888.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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