1
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Shima M. Current status and future prospects of activated recombinant coagulation factor VIIa, NovoSeven®, in the treatment of haemophilia and rare bleeding disorders. Ann Hematol 2024; 103:2647-2658. [PMID: 37391649 PMCID: PMC11283401 DOI: 10.1007/s00277-023-05287-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 05/19/2023] [Indexed: 07/02/2023]
Abstract
rFVIIa, a human recombinant activated coagulation factor VII, has been used worldwide for more than two decades for the treatment of bleeding episodes and prevention of bleeding in patients undergoing surgery/invasive procedures with congenital haemophilia A or B with inhibitors (CHwI A or B), acquired haemophilia (AH), congenital factor VII deficiency and Glanzmann thrombasthenia (GT), refractory to platelet transfusion. The approved dosage, administration and indication of rFVIIa in the US, Europe and Japan differ, depending on the needs of the patient population and regulatory practices. This review presents an overview of the current status and future prospects, including that from a Japanese perspective, of using rFVIIa in the treatment of approved indications. The efficacy and safety of rFVIIa in the approved indications has been demonstrated in several randomised and observational studies and data from registries. The overall incidence of thrombosis across all approved indications in a retrospective safety assessment of clinical trials and registries, prelicensure studies and postmarketing surveillance studies of rFVIIa use was 0.17%. Specifically, the risk of thrombotic events was 0.11% for CHwI, 1.77% for AH, 0.82% for congenital factor VII deficiency and 0.19% for GT. Emerging non-factor therapies such as emicizumab have changed the treatment landscape of haemophilia A, including preventing bleeding in patients with CHwI. However, rFVIIa will continue to play a significant role in the treatment of such patients, particularly during breakthrough bleeding or surgical procedures.
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Affiliation(s)
- Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, 840 Shijo‑cho, Kashihara City, Nara, 634-8522, Japan.
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2
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Krishnamoorthy Y, Govindan D, Kannan N, Majella MG, Hariharan VS, Valliappan V. Budget impact and cost-utility analysis of prophylactic emicizumab versus on-demand bypassing agents for adolescent severe haemophilia A patients with inhibitors in India. Heliyon 2024; 10:e27089. [PMID: 38468938 PMCID: PMC10926073 DOI: 10.1016/j.heliyon.2024.e27089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 03/13/2024] Open
Abstract
Introduction Severe Haemophilia A patients with inhibitors are currently being treated with bypassing agents like activated prothrombin complex concentrates (aPCC) and recombinant factor VIIa. Emicizumab is a recombinant humanized monoclonal antibody, introduced to reduce the bleeding events, improve treatment adherence, and quality of life. However, cost-effectiveness and long-term sustainability of the intervention is not studied in a low middle income setting like India. Aim The primary objective of this study was to evaluate the cost-utility of Emicizumab compared to traditional bypassing agents in the treatment of severe haemophilia A patients with inhibitors in India. Secondary objective was to analyze the budgetary impact of introducing Emicizumab for this patient population from the perspective of public health system in India. Methods Markov model was created to compare the prophylactic emicizumab therapy against bypassing agents for a hypothetical cohort of 10-year-old adolescents in India. The time horizon was 10 years and model built based on health system perspective. Cost utility was expressed as costs per quality-adjusted life-years (QALYs) gained. All costs were expressed as 2021 US dollars. Probabilistic sensitivity analysis was performed to check the robustness of the estimates. Results Prophylactic emicizumab was a cost saving intervention with negative Incremental Cost Utility Ratio (ICUR) against recombinant factor VIIa of -853,573 USD (INR -63,109,773), and negative ICUR of -211,675 USD (INR -15,650,403) against APCC. The estimated total budget for treating all the severe Haemophilia A patients with inhibitors in India was USD 59,042,000 (INR 4,365,329,312) for 10 years' time horizon (per patient cost of USD 295,210 [INR 21,826,646.56]). Conclusion Prophylactic emicizumab therapy is a cost saving intervention when compared to both the bypassing agents as it is less costly and more effective for severe Haemophilia A patients with inhibitors in India.
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Affiliation(s)
- Yuvaraj Krishnamoorthy
- PROPUL Evidence Synthesis Unit (PROPUL ESU), PROPUL (Partnership for Research Opportunity Planning Upskilling and Leadership) Evidence, Chennai, Tamilnadu, India
| | - Dhanajayan Govindan
- PROPUL Evidence Synthesis Unit (PROPUL ESU), PROPUL (Partnership for Research Opportunity Planning Upskilling and Leadership) Evidence, Chennai, Tamilnadu, India
| | - Narasimhapriyan Kannan
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Marie Gilbert Majella
- PROPUL Evidence Synthesis Unit (PROPUL ESU), PROPUL (Partnership for Research Opportunity Planning Upskilling and Leadership) Evidence, Chennai, Tamilnadu, India
| | | | - Vivek Valliappan
- Department of Pharmacology, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chengalpattu District, 603103, Tamilnadu, India
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3
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Arslan Davulcu E, Demirci Z, Yılmaz U, Ar MC, Teke HÜ, Karakuş V, Çiftçiler R, Selim C, Yavaşoğlu İ, Durusoy SS, Okan V, Akdeniz A, Yolcu A, Aydoğdu İ, Güney T, Yılmaz AF, Şahin F. Acquired Hemophilia A In Adults: A Multicenter Study from Turkey. Indian J Hematol Blood Transfus 2023; 39:107-115. [PMID: 36699428 PMCID: PMC9868199 DOI: 10.1007/s12288-022-01556-8] [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: 01/18/2022] [Accepted: 07/04/2022] [Indexed: 01/28/2023] Open
Abstract
Acquired hemophilia A (AHA) is a rare disease caused by autoantibodies inhibiting factor VIII (FVIII) activity. Although the conditionis usually idiopathic, there may be other underlying diseases. Treatment consists of two steps: treatment of acute bleeding and immunosuppression. In this multicenter study, we aimed to demonstrate the clinical characteristics, management details, and survival of AHA patients in Turkey. Data was collected from eleven centers in Turkey. aPTT, FVIII, FVIII inhibitor, and hemoglobin (HB) levels, mixing test results, and demographics at diagnosis, treatment information, adverse events, bleeding episodes during follow-up, relapses, and outcome were analyzed. Twenty-nine patients were analyzed (58.6% female). No underlying disorder could be detected in 14 patients. The most prevalent etiologies were pregnancy, malignancy and infections. The median FVIII activity and FVIII inhibitor titer at diagnosis were 0.7% (0.0-29.4%) and 32.6 BU (0.6-135.6 BU) respectively. Bleeding was severe in 44.8% of patients. The HB value was significantly lower in patients with severe bleeding. Most of the patients (n = 25, 86.2%) had only one bleeding episode without relapse, three patients (10.3%) had two bleeding episodes, and one patient had more than three bleedings. 21 (75%) patients received hemostatic therapy. The use of recombinant FVIIa was slightly higher than activated prothrombin complex concentrate (15 versus 10 patients). Immunosuppressive treatment was initiated in 26 (93%) patients. Regimens containing steroid, cyclophosphamide, and rituximab in different combinations were the most preferred. The median follow-up period was 13 months (2-156 months). Median overall survival was 154.97 months. Four and six-year survival were 90.9 ± 0.8% and 77.9 ± 14.1% respectively. This is a unique study that investigated the demographic characteristics, treatment approaches, and patient survival of AHA in Turkey.
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Affiliation(s)
- Eren Arslan Davulcu
- University of Health Sciences Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Hematology Clinic, Istanbul, Turkey
| | - Zühal Demirci
- Hematology Department, Ege Adult Haemophilia and Thrombosis Center, Ege University Medical Faculty, İzmir, Turkey
| | - Umut Yılmaz
- Division of Hematology, Department of Internal Medicine, Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
| | - Muhlis Cem Ar
- Division of Hematology, Department of Internal Medicine, Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
| | - Hava Üsküdar Teke
- Internal Medicine, Hematology Department, Eskişehir Osmangazi University Medical Faculty, Istanbul, Turkey
| | - Volkan Karakuş
- Hematology Clinic, University of Health Sciences Antalya Training and Research Hospital, Istanbul, Turkey
| | - Rafiye Çiftçiler
- Hematology Clinic, Aksaray University Training and Research Hospital, Aksaray, Turkey
| | - Cem Selim
- Internal Medicine Hematology Department, Aydın Adnan Menderes University Medical Faculty, Istanbul, Turkey
| | - İrfan Yavaşoğlu
- Internal Medicine Hematology Department, Aydın Adnan Menderes University Medical Faculty, Istanbul, Turkey
| | | | - Vahap Okan
- Department of Hematology, Gaziantep University School of Medicine, Gaziantep, Turkey
| | - Aydan Akdeniz
- Medical Faculty Hematology Department, Mersin University, Mersin, Turkey
| | - Alkım Yolcu
- Department of Internal Medicine, Faculty of Medicine, Manisa Celal Bayar University, Manisa, Turkey
| | - İsmet Aydoğdu
- Hematology Department, Faculty of Medicine, Manisa Celal Bayar University, Mersin, Turkey
| | - Tekin Güney
- Department of Hematology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Asu Fergün Yılmaz
- Hematology Depertmet, Marmara University Pendik Training and Research Hospital, Istanbul, Turkey
| | - Fahri Şahin
- Hematology Department, Ege Adult Haemophilia and Thrombosis Center, Ege University Medical Faculty, İzmir, Turkey
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4
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Escobar M, Castaman G, Boix SB, Callaghan M, de Moerloose P, Ducore J, Hermans C, Journeycake J, Leissinger C, Luck J, Mahlangu J, Miesbach W, Mitha IH, Négrier C, Quon D, Recht M, Schved JF, Shapiro AD, Sidonio R, Srivastava A, Stasyshyn O, Vilchevska KV, Wang M, Young G, Alexander WA, Al-Sabbagh A, Bonzo D, Macie C, Wilkinson TA, Kessler C. The safety of activated eptacog beta in the management of bleeding episodes and perioperative haemostasis in adult and paediatric haemophilia patients with inhibitors. Haemophilia 2021; 27:921-931. [PMID: 34636112 PMCID: PMC9292935 DOI: 10.1111/hae.14419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/31/2021] [Accepted: 09/06/2021] [Indexed: 01/19/2023]
Abstract
Introduction Haemophilia patients with inhibitors often require a bypassing agent (BPA) for bleeding episode management. Eptacog beta (EB) is a new FDA‐approved recombinant activated human factor VII BPA for the treatment and control of bleeding in haemophilia A or B patients with inhibitors (≥12 years of age). We describe here the EB safety profile from the three prospective Phase 3 clinical trials performed to date. Aim To assess EB safety, immunogenicity and thrombotic potential in children and adults who received EB for treatment of bleeding and perioperative care. Methods Using a randomized crossover design, 27 subjects in PERSEPT 1 (12‐54 years) and 25 subjects in PERSEPT 2 (1‐11 years) treated bleeding episodes with 75 or 225 μg/kg EB initially followed by 75 μg/kg dosing at predefined intervals as determined by clinical response. Twelve PERSEPT 3 subjects (2‐56 years) received an initial preoperative infusion of 75 μg/kg (minor procedures) or 200 μg/kg EB (major surgeries) with subsequent 75 μg/kg doses administered intraoperatively and post‐operatively as indicated. Descriptive statistics were used for data analyses. Results Sixty subjects who received 3388 EB doses in three trials were evaluated. EB was well tolerated, with no allergic, hypersensitivity, anaphylactic or thrombotic events reported and no neutralizing anti‐EB antibodies detected. A death occurred during PERSEPT 3 and was determined to be unlikely related to EB treatment by the data monitoring committee. Conclusion Results from all three Phase 3 trials establish an excellent safety profile of EB in haemophilia A or B patients with inhibitors for treatment of bleeding and perioperative use.
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Affiliation(s)
- Miguel Escobar
- Gulf States Hemophilia and Thrombophilia Center, Houston, Texas, USA
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | | | | | | | - Jonathan Ducore
- Hematology/Oncology Clinic, University of California at Davis, Sacramento, California, USA
| | - Cédric Hermans
- Cliniques Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Janna Journeycake
- Oklahoma Bleeding and Clotting Disorders Center at OU Health, Oklahoma City, Oklahoma, USA
| | - Cindy Leissinger
- Section of Hematology/Oncology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - James Luck
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Johnny Mahlangu
- Hemophilia Comprehensive Care Center, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | | | | | | | - Doris Quon
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, New York, USA.,Oregon Health & Science University, Portland, Oregon, USA
| | - Jean François Schved
- Haemophilia Treatment Centre, University Hospital Montpellier, Montpellier, France
| | - Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Robert Sidonio
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, Georgia, USA
| | | | | | | | - Michael Wang
- Hemophilia and Thrombosis Center, University of Colorado, Aurora, Colorado, USA
| | - Guy Young
- Children's Hospital Los Angeles, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | | | | | | | | | - Craig Kessler
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
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5
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Wang CP, Young G, Thornburg CD. Safety evaluation of emicizumab prophylaxis in individuals with haemophilia A. Expert Opin Drug Saf 2021; 20:387-396. [PMID: 33612049 DOI: 10.1080/14740338.2021.1893303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Emicizumab is a bispecific-humanized monoclonal antibody that improves hemostasis by bridging activated factor IX and factor X to substitute for the function of missing activated FVIII. It is an alternative to prophylaxis with factor VIII replacement and is associated with improved outcomes in individuals with hemophilia A with and without inhibitors. AREAS COVERED Emicizumab is efficacious in reducing bleeding events when compared to on-demand treatment and factor-based prophylaxis. Except for the few thrombotic microangiopathy and thrombotic event cases mainly seen in the HAVEN 1 trial, emicizumab has an overall excellent safety profile with minimal side effects. EXPERT OPINION Knowledge gaps include the efficacy and safety of emicizumab in younger age groups and those with mild or moderate hemophilia A. Future directions for research include exploring the risk of inhibitor recurrence in patients with a history of high titer inhibitor who have been successfully tolerized, who switch from factor prophylaxis to emicizumab, as well as conducting 'real world studies' to evaluate the patient's perception of emicizumab in regard to ease and tolerability in order to optimize individualized treatment plans.
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Affiliation(s)
- Cassandra P Wang
- Department of Pediatrics, University of California-San Diego School of Medicine, La Jolla, CA, USA
| | - Guy Young
- Division of Pediatric Hematology/Oncology, Children's Hospital Los Angeles/University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Courtney D Thornburg
- Division of Pediatric Hematology/Oncology, Rady Children's Hospital San Diego/University of California, San Diego, CA, USA
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6
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Biron‐Andreani C, Diaz‐Cau I, Ranc A, Navarro R, Leonardi C, Dischino M, Guy R, Theron A, Garcia‐Gournay C, Santagostino E, Schved J. Major surgery management in patients with haemophilia A and inhibitors on emicizumab prophylaxis without global coagulation monitoring. Br J Haematol 2020; 189:e100-e103. [DOI: 10.1111/bjh.16512] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Christine Biron‐Andreani
- Hemophilia Treatment Centre University Hospital Montpellier France
- Departement of Haematology University Hospital Montpellier France
| | | | - Alexandre Ranc
- Departement of Haematology University Hospital Montpellier France
| | - Robert Navarro
- Hemophilia Treatment Centre University Hospital Montpellier France
| | | | - Marion Dischino
- Departement of Surgery Clinique Les Franciscaines Nîmes France
| | - Romuald Guy
- Department of Physical Reeducation Clinique le Castelet Montpellier France
| | - Alexandre Theron
- Hemophilia Treatment Centre University Hospital Montpellier France
| | - Corinne Garcia‐Gournay
- Hemophilia Treatment Centre University Hospital Montpellier France
- Departement of Haematology University Hospital Montpellier France
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7
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Rajpurkar M, Croteau SE, Boggio L, Cooper DL. Thrombotic events with recombinant activated factor VII (rFVIIa) in approved indications are rare and associated with older age, cardiovascular disease, and concomitant use of activated prothrombin complex concentrates (aPCC). J Blood Med 2019; 10:335-340. [PMID: 31572039 PMCID: PMC6757140 DOI: 10.2147/jbm.s219573] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 08/23/2019] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Recombinant activated factor VII (rFVIIa; NovoSeven® RT; Novo Nordisk A/S, Bagsvaerd, Denmark) is approved in the United States for the treatment of bleeding and perioperative management in congenital hemophilia with inhibitors (CHwI), acquired hemophilia (AH), congenital factor VII (FVII) deficiency, and Glanzmann's thrombasthenia (GT) with refractoriness to platelets. The aim of the current analysis was to review clinical trials and registries pre- and post-licensure for each indication to establish the estimated rate of thrombosis and then to establish the association of all reported thrombotic events (TEs) with certain risk factors listed for many years in the prescribing information (PI). PATIENTS AND METHODS A retrospective safety assessment of both clinical trials and registries used to support licensure and postmarketing surveillance was performed. The rate of thrombosis was calculated in the 4 indicated disorders and an assessment of TE risk factors was conducted through a review of all narratives within those indications in the safety database. RESULTS In clinical trials and registries used to support licensure and in postmarketing surveillance, the overall rate of thrombosis was 0.17% of 12,288 bleeding and surgical episodes. The specific risk by indication was 0.11% for CHwI, 0.82% for FVII deficiency, 0.19% for GT, and 1.77% for AH. The most common associated risk factor-"elderly" (29%), defined in the PI as age ≥65 years-was particularly prevalent in patients with AH. TE was also frequently reported with concomitant cardiac or vascular disease (18%) and use of activated prothrombin complex concentrates (18%). CONCLUSION Data show that the rate of TEs within the 4 licensed indications is low, as was originally described in the US PI from 1999 to 2009. It has remained stable over time during postapproval surveillance in multiple US and global registries with active surveillance for safety information across the 4 approved indications.
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Affiliation(s)
- Madhvi Rajpurkar
- Carman and Ann Adams Department of Pediatrics, Children’s Hospital of Michigan/Wayne State University, Detroit, MI, USA
| | - Stacy E Croteau
- Department of Pediatrics, Boston Children’s Hospital/Harvard Medical School, Boston, MA, USA
| | - Lisa Boggio
- Hemophilia and Thrombophilia Center, Rush University Medical Center, Chicago, IL, USA
| | - David L Cooper
- Clinical Development and Medical Affairs – Biopharm, Novo Nordisk Inc., Plainsboro, NJ, USA
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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: 12] [Impact Index Per Article: 2.4] [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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Levy GG, Asikanius E, Kuebler P, Benchikh El Fegoun S, Esbjerg S, Seremetis S. Safety analysis of rFVIIa with emicizumab dosing in congenital hemophilia A with inhibitors: Experience from the HAVEN clinical program. J Thromb Haemost 2019; 17:1470-1477. [PMID: 31124272 DOI: 10.1111/jth.14491] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/20/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Recombinant activated factor VII (rFVIIa; eptacog alfa activated, NovoSeven® , Novo Nordisk A/S) is a bypassing agent used in congenital hemophilia A patients with inhibitors. Emicizumab (Hemlibra® ; F Hoffmann-La Roche Ltd) is a recombinant, humanized, bispecific monoclonal antibody used for routine prophylaxis in patients with congenital hemophilia A with inhibitors. Concomitant use of the hemostatic agents rFVIIa and emicizumab carries a theoretical increased risk of thrombotic complications. Roche and Novo Nordisk collaboratively analyzed all available data on the use of rFVIIa in patients receiving emicizumab prophylaxis in the Study to Evaluate the Efficacy, Safety, and Pharmacokinetics of Prophylactic Emicizumab Versus no Prophylaxis in Hemophilia A Participants With Inhibitors (HAVEN) clinical development program. OBJECTIVE Obtain further insights into the concomitant clinical use and safety of rFVIIa and emicizumab. METHODS The initial individual rFVIIa dose, dosing intervals and cumulative dosing were evaluated in the HAVEN 1, HAVEN 2, and HAVEN 4 trials. All adverse events reported in each of the three trials in patients treated with rFVIIa, including available narratives, were assessed. RESULTS The vast majority of bleeds occurred in HAVEN 1. When rFVIIa was used to treat a bleeding episode, a 100 ± 20 μg/kg dose was used to initiate treatment in the majority of cases. The dosing interval, as well as cumulative dosing were consistent with prescribing information and current practice. No serious adverse events, no thrombotic microangiopathy cases, or thromboembolic events were assessed to be associated with rFVIIa when used in conjunction with emicizumab prophylaxis in the HAVEN trials. CONCLUSION rFVIIa use in the context of emicizumab prophylaxis does not change the rFVIIa safety profile as described in the product information.
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MESH Headings
- Antibodies, Bispecific/administration & dosage
- Antibodies, Bispecific/adverse effects
- Antibodies, Bispecific/therapeutic use
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Blood Loss, Surgical/prevention & control
- Clinical Trials as Topic/statistics & numerical data
- Dose-Response Relationship, Drug
- Drug Synergism
- Drug Therapy, Combination
- Factor VIII/immunology
- Factor VIIa/administration & dosage
- Factor VIIa/adverse effects
- Factor VIIa/therapeutic use
- Hemophilia A/drug therapy
- Hemorrhage/drug therapy
- Hemorrhage/etiology
- Hemorrhage/prevention & control
- Humans
- Isoantibodies/immunology
- Multicenter Studies as Topic/statistics & numerical data
- Postoperative Hemorrhage/prevention & control
- Recombinant Proteins/administration & dosage
- Recombinant Proteins/adverse effects
- Recombinant Proteins/therapeutic use
- Retrospective Studies
- Risk
- Thrombosis/chemically induced
- Thrombosis/prevention & control
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10
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Batsuli G, Zimowski KL, Tickle K, Meeks SL, Sidonio RF. Immune tolerance induction in paediatric patients with haemophilia A and inhibitors receiving emicizumab prophylaxis. Haemophilia 2019; 25:789-796. [DOI: 10.1111/hae.13819] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/17/2019] [Accepted: 06/17/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Glaivy Batsuli
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, Department of Pediatrics Emory University Atlanta Georgia
| | - Karen L. Zimowski
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, Department of Pediatrics Emory University Atlanta Georgia
| | - Kelly Tickle
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta Atlanta Georgia
| | - Shannon L. Meeks
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, Department of Pediatrics Emory University Atlanta Georgia
| | - Robert F. Sidonio
- Aflac Cancer and Blood Disorders Center of Children’s Healthcare of Atlanta, Department of Pediatrics Emory University Atlanta Georgia
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11
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Leksa NC, Aleman MM, Goodman AG, Rabinovich D, Peters R, Salas J. Intrinsic differences between FVIIIa mimetic bispecific antibodies and FVIII prevent assignment of FVIII-equivalence. J Thromb Haemost 2019; 17:1044-1052. [PMID: 30887655 PMCID: PMC6850022 DOI: 10.1111/jth.14430] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 03/08/2019] [Indexed: 12/11/2022]
Abstract
Essentials Non-factor VIII (FVIII) therapies for hemophilia A, such as bispecific antibodies (bsAbs), are in development. Bispecific antibodies are intrinsically different from FVIII and lack many of the same regulatory mechanisms. These differences complicate assignment and interpretation of FVIII-equivalent activity. Inability to assign FVIII equivalence compromises our capacity to assess hemostatic potential of bsAb therapies. BACKGROUND Activated factor VIII (FVIIIa) mimetic bsAbs aim to enable prophylactic treatment of hemophilia A patients with and without inhibitors. With different mechanisms of action, benchmarking their activity against FVIII to determine efficacious yet safe dosage is difficult. OBJECTIVE To compare the activities of sequence identical emicizumab (SI-Emi) and another bsAb, BS-027125, to recombinant FVIII (rFVIII) using clinical and nonclinical assays and to evaluate our ability to assign a FVIII-equivalent value to bsAbs and implications thereof. METHODS Activities of SI-Emi, BS-027125, and rFVIII were measured by one-stage clotting assay, chromogenic factor Xa generation assay, and thrombin generation assay. We also assessed the activity of anti-FIXa and anti-FX bivalent homodimers of each bsAb and probed the effect of different reagents in thrombin generation assay (TGA). RESULTS The FVIII-like activity of SI-Emi and BS-027125 ranged greatly across each assay, varying both by parameter measured within an assay and by reagents used. Notably, SI-Emi anti-FIXa bivalent homodimer had meaningful activity in several assays, whereas BS-027125 anti-FIXa bivalent homodimer only had activity in the chromogenic assay. Surprisingly, SI-Emi displayed activity in the absence of phospholipids, while BS-027125 had minimal phospholipid-independent activity. CONCLUSIONS Bispecific antibodies demonstrate little consistency between assays tested here owing to intrinsic differences between FVIII and bsAbs. While some trends are shared, the bsAbs also differ in mechanism. These inconsistencies complicate assignment of FVIII-equivalent values to bsAbs. Ultimately, a deeper mechanistic understanding of bsAbs as well as bsAb-tailored assays are needed to monitor and predict their hemostatic potential and long-term efficacy and safety confidently.
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13
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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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14
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Toyama K, Yasumoto A, Nakamura F, Arai S, Kurokawa M. The Development of Acute Systemic Multiple Thrombosis after Achieving Remission during Systemic Glucocorticoid Therapy for Acquired Hemophilia A. Intern Med 2018; 57. [PMID: 29526954 PMCID: PMC6120840 DOI: 10.2169/internalmedicine.0450-17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Acquired hemophilia A (AHA) is a hemorrhagic disorder. Whether or not severe thrombotic events can develop without the use of bypassing agents in AHA patients is unclear. An 80-year-old woman with AHA underwent immunosuppressive therapy with prednisolone at 1 mg/kg daily. After achieving remission, she suddenly developed multiple organ failure due to acute systemic thrombosis and died within a few hours of the diagnosis. Patients with AHA, especially those with risk factors for thrombosis, have a considerable risk of developing thrombosis during the recovery phase of factor VIII activity and should be carefully monitored by coagulation testing.
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Affiliation(s)
- Kazuhiro Toyama
- Department of Cell Therapy and Transplantation Medicine, The University of Tokyo Hospital, Japan
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Atsushi Yasumoto
- Department of Clinical Laboratory Medicine, The University of Tokyo Hospital, Japan
| | - Fumihiko Nakamura
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Shunya Arai
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
| | - Mineo Kurokawa
- Department of Cell Therapy and Transplantation Medicine, The University of Tokyo Hospital, Japan
- Department of Hematology and Oncology, Graduate School of Medicine, The University of Tokyo, Japan
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15
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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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Galstyan GM, Polevodova OA, Gavrish AY, Polyanskaya TY, Zorenko VY, Sampiev MS, Biryukova LS, Model SV, Gorgidze LA, Savchenko VG. [Thrombotic events in patients with hemophilia]. TERAPEVT ARKH 2017; 89:76-84. [PMID: 28766545 DOI: 10.17116/terarkh201789776-84] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The paper describes 4 clinical cases of thrombotic events (pulmonary embolism, deep vein thrombophlebitis, acute myocardial infarction, ischemic stroke) that have occurred in patients with hemophilia. It discusses the possible causes of their development and methods for their prevention and treatment. Controlled natural hypocoagulation, in which the dose of an administered deficient factor decreases to such an extent that in order to maintain the safe level of hypocoagulation (plasma factor activity is 15-20%; activated partial thromboplastin time is 1.5-2 times normal values), is proposed as one of the treatment options.
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Affiliation(s)
- G M Galstyan
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - O A Polevodova
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - A Yu Gavrish
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - T Yu Polyanskaya
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - V Yu Zorenko
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - M S Sampiev
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - L S Biryukova
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - S V Model
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - L A Gorgidze
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - V G Savchenko
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
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17
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Sequential bypassing agents during major orthopedic surgery: a new approach to hemostasis. Blood Adv 2017; 1:1309-1311. [PMID: 29296773 DOI: 10.1182/bloodadvances.2017008409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 06/14/2017] [Indexed: 01/12/2023] Open
Abstract
Sequential bypassing agents may be a safe and effective treatment during major orthopedic surgery in hemophilia patients with inhibitors.
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18
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The role of recombinant activated factor VII in the haematological management of elective orthopaedic surgery in haemophilia A patients with inhibitors. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2017; 15:478-486. [PMID: 28686157 DOI: 10.2450/2017.0369-16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/13/2017] [Indexed: 01/19/2023]
Abstract
The clinical profile and expectations of haemophilic patients with inhibitors have changed over the last three decades, mainly because of the prolongation of life-expectancy, often resulting in an increase of the orthopaedic burden. Recombinant activated factor VII (rFVIIa) is the most frequently used bypassing agent in haemophilia patients with inhibitors during elective orthopaedic surgery. For nearly 30 years, rFVIIa has been successfully used to control haemostasis in several major and minor surgical procedures. Clinical trials, case series, reports and surveys were progressively aimed at optimising rFVIIa usage in very demanding conditions managed in highly specialised centres. Recommendations from consensus opinions and guidelines have been provided on the basis of this clinical experience.
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Hay CRM, Sharpe T, Dolan G. Use of the UKHCDO Database for a postmarketing surveillance study of different doses of recombinant factor VIIa in haemophilia. Haemophilia 2016; 23:376-382. [PMID: 28026073 DOI: 10.1111/hae.13139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Recombinant factor VIIa (rFVIIa) is recommended in Europe at standard (3 × 90 μg kg-1 ) or high (1 × 270 μg kg-1 ) doses. When granting the license for the high dose, the European Medicines Agency (EMA) requested postmarketing surveillance for thrombosis. This was conducted by the United Kingdom National Haemophilia Database (NHD) on behalf of Novo Nordisk and the EMA. AIM To assess the use and safety of rFVIIa utilizing prospective data collected by the NHD (1 January 2008 to 30 June 2011). RESULTS Data were obtained from 67 haemophilia A/B patients with inhibitors treated for 1057 bleeds and 31 acquired haemophilia patients treated for 70 bleeds. Initial rFVIIa dose was categorized post hoc as low (<90 μg kg-1 ), intermediate (≥90-<180 μg kg-1 ) or high (≥180-<270 or ≥270 μg kg-1 ). For haemophilia A/B, high and lower initial rFVIIa dose was used for 38.4% and 51.4% of episodes, respectively, while for acquired haemophilia, the values were 11.4% and 77.1% respectively. Median initial doses were higher for haemophilia A/B (146.3 μg kg-1 ) than acquired haemophilia (90.5 μg kg-1 ). A single administration of rFVIIa was the most frequently used regimen for haemophilia A/B, in contrast with standard recommendations and previous reports. For acquired haemophilia, most episodes were treated with multiple doses. No adverse drug reactions or thromboembolic events were reported for any rFVIIa dose. CONCLUSION The novel use of a national database for postmarketing surveillance has demonstrated acceptable safety for all recommended doses of rFVIIa.
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Affiliation(s)
- C R M Hay
- University Department of Haematology, Manchester Royal Infirmary, Manchester, UK.,UK National Haemophilia Database, Manchester, UK
| | - T Sharpe
- UK National Haemophilia Database, Manchester, UK
| | - G Dolan
- Department of Haematology, Guys and St Thomas' Hospital, London, UK
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20
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Meeks SL, Batsuli G. Hemophilia and inhibitors: current treatment options and potential new therapeutic approaches. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:657-662. [PMID: 27913543 PMCID: PMC6142469 DOI: 10.1182/asheducation-2016.1.657] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
The immune response to infused factor concentrates remains a major source of morbidity and mortality in the treatment of patients with hemophilia A and B. This review focuses on current treatment options and novel therapies currently in clinical trials. After a brief review of immune tolerance regimens, the focus of the discussion is on preventing bleeding in patients with hemophilia and inhibitors. Recombinant factor VIIa and activated prothrombin complex concentrates are the mainstays in treating bleeds in patients with inhibitors. Both agents have been shown to reduce bleeding episodes to a similar degree when infused prophylactically; however, individual patients may respond better to one agent over the other at any given time. The international immune tolerance trial revealed that a high-dose factor VIII regimen provided significantly better bleeding protection than the low-dose regimen. Given the high cost of treatment and the potential for a high-dose immune tolerance regimen to prevent bleeding in some patients, we discuss how we treat patients to maximize the prevention of bleeds while minimizing cost. Novel approaches to treatment of these patients are in development. These include agents that mimic factor VIII or augment thrombin generation by bypassing the inhibitor, as well as agents that inhibit the natural anticoagulants.
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Affiliation(s)
- Shannon L Meeks
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Glaivy Batsuli
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
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21
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Saito M, Kanaya M, Izumiyama K, Mori A, Irie T, Tanaka M, Morioka M, Ieko M. Treatment of bleeding in acquired hemophilia A with the proper administration of recombinant activated factor VII: single-center study of 7 cases. Int J Gen Med 2016; 9:393-399. [PMID: 27843336 PMCID: PMC5098745 DOI: 10.2147/ijgm.s118422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Recombinant activated factor VII (rFVIIa) is the bypassing agent used in the first-line hemostatic therapy for acquired hemophilia A (AHA); however, the occurrence of thrombotic complications in rFVIIa-treated AHA patients was recently reported to be 2.9–6.5%. Therefore, the investigation of the proper administration of rFVIIa for AHA is needed. In the present study, we retrospectively investigated the clinical features of AHA with regards to the use of rFVIIa (presence or absence of use and total amount) in 7 AHA patients encountered in our department for 7 years between January 2008 and December 2014. Ages were 63–89 years old (median: 79 years old), and there were 5 male and 2 female patients. The coexistence of cardiovascular risk factors and arteriosclerotic diseases, such as hypertension, diabetes mellitus, and cerebral infarction were present in 6 patients. Anemia progressed to less than 7 g/dL of hemoglobin and required red blood cell transfusion in 5 patients, showing “severe” hemorrhage. Factor VIII inhibitors were removed by immunological treatments in 6 patients. As a hemostatic therapy, rFVIIa was used in 4 patients. rFVIIa was not administered or was administered at a very low dose (20 mg) to 3 and 1 patient, respectively, and bleeding stopped as inhibitor titers decreased and disappeared in these patients. Inhibitors did not disappear in 1 patient and the control of hemostasis became poor and was accompanied by intestinal hemorrhage. Although a large amount of rFVIIa (265 mg in total) was administered, the patient bled to death. Therefore, bleeding may be stopped without the administration of rFVIIa in some AHA cases, while the dose of rFVIIa is not necessarily related to hemostatic effects in other cases. Since the main aim of AHA treatments is the removal of inhibitors, caution is needed to ensure that more than the necessary amount of rFVIIa is not administered.
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Affiliation(s)
- Makoto Saito
- Department of Internal Medicine and Hematology, Aiiku Hospital, Japan
| | - Minoru Kanaya
- Department of Internal Medicine and Hematology, Aiiku Hospital, Japan
| | - Koh Izumiyama
- Department of Internal Medicine and Hematology, Aiiku Hospital, Japan
| | - Akio Mori
- Department of Internal Medicine and Hematology, Aiiku Hospital, Japan
| | - Tatsuro Irie
- Department of Internal Medicine and Hematology, Aiiku Hospital, Japan
| | - Masanori Tanaka
- Department of Internal Medicine and Hematology, Aiiku Hospital, Japan
| | - Masanobu Morioka
- Department of Internal Medicine and Hematology, Aiiku Hospital, Japan
| | - Masahiro Ieko
- Department of Internal Medicine, Health Sciences University of Hokkaido, Japan
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22
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Croteau SE, Nakar C, Neufeld EJ, Shapiro A, Cooper DL. Safety and efficacy of recombinant factor VIIa by pediatric age cohort: reassessment of compassionate use and trial data supporting US label. Pediatr Blood Cancer 2016; 63:1822-8. [PMID: 27232114 DOI: 10.1002/pbc.26082] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND The relative safety and efficacy of recombinant activated coagulation factor VII (rFVIIa, NovoSeven® RT) across pediatric age cohorts is poorly defined. The objective of this analysis was to assess the safety and efficacy of rFVIIa in pediatric patients with congenital hemophilia with inhibitors (CHwI) in the clinical studies supporting the U.S. labeling. PROCEDURE Pediatric data were derived from seven studies (five acute and two perioperative treatments) and pooled. All data were stratified by age (<2, 2 to <6, 6 to <12, and 12-16 years) and study category (acute treatment of bleeding episodes or surgery). RESULTS The pediatric dataset included 172 patients; 144 received rFVIIa for the treatment of bleeding episodes and 28 for the control of bleeding perioperatively. Recombinant FVIIa was effective for 95.4% (1,026/1,076) of the evaluable bleeding episodes and had similar treatment effectiveness across pediatric age groups (range, 94.1-97.2%). The majority received doses of 90 mcg/kg. rFVIIa was effective in achieving perioperative hemostasis across pediatric age groups (range, 91-100%), with greater efficacy observed with the recommended (90 mcg/kg) versus lower dose (35 mcg/kg). A total of 88 pediatric patients experienced a total of 285 adverse drug reactions, similar in type to those reported among adult patients. A total of seven thrombotic events were recorded in seven pediatric patients; only one was confirmed related to rFVIIa upon individual case review. CONCLUSIONS rFVIIa is safe and effective in the treatment of bleeding episodes and prevention of periprocedure bleeding in CHwI with no apparent differences observed among pediatric age groups.
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Affiliation(s)
- Stacy E Croteau
- Dana-Farber/Boston Children's Cancer & Blood Disorders Center, Boston Hemophilia Center, Boston Children's Hospital, Boston, Massachusetts
| | - Charles Nakar
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana
| | - Ellis J Neufeld
- Dana-Farber/Boston Children's Cancer & Blood Disorders Center, Boston Hemophilia Center, Boston Children's Hospital, Boston, Massachusetts
| | - Amy Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana
| | - David L Cooper
- Clinical, Medical and Regulatory Affairs, Novo Nordisk Inc, Plainsboro, New Jersey
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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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Carcao M, Hilliard P, Escobar MA, Solimeno L, Mahlangu J, Santagostino E. Optimising musculoskeletal care for patients with haemophilia. Eur J Haematol 2015; 95 Suppl 81:11-21. [DOI: 10.1111/ejh.12581] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2014] [Indexed: 12/31/2022]
Affiliation(s)
- Manuel Carcao
- Division of Haematology/Oncology and Child Health Evaluative Sciences; Research Institute; The Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - Pamela Hilliard
- Department of Rehabilitation; The Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - Miguel A. Escobar
- Gulf States Hemophilia and Thrombophilia Center; Department of Hematology; University of Texas Health Science Center; Houston TX USA
| | - Luigi Solimeno
- Ortho Trauma Unit; Emergency Department; IRCCS Cà Granda Foundation; Maggiore Hospital; Milan Italy
| | - Johnny Mahlangu
- Haemophilia Comprehensive Care Centre; Faculty of Health Sciences; University of the Witwatersrand and National Health Laboratory Service; Johannesburg South Africa
| | - Elena Santagostino
- Hemophilia and Thrombosis Center ‘A. Bianchi Bonomi’; IRCCS Cà Granda Foundation; Maggiore Hospital; Milan Italy
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25
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Ekezue BF, Sridhar G, Ovanesov MV, Forshee RA, Izurieta HS, Selvam N, Parunov LA, Jain N, Mintz PD, Epstein JS, Anderson SA, Menis MD. Clotting factor product administration and same-day occurrence of thrombotic events, as recorded in a large healthcare database during 2008-2013. J Thromb Haemost 2015; 13:2168-79. [PMID: 26414338 DOI: 10.1111/jth.13155] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 09/12/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Thrombotic events (TEs) are serious adverse events that can occur following administration of clotting factors (CFs). OBJECTIVES To evaluate occurrence of same-day TEs for different CF products and potential risk factors. METHODS A retrospective cohort study of individuals exposed to CF products during 2008-2013 was conducted using a large commercial insurance database. CF products were identified by procedure codes, and TEs were ascertained via diagnosis codes. Crude same-day TE rates (per 1000 persons exposed) were estimated overall and by congenital factor deficiency (CFD) status, CF products, age and gender. Multivariable logistic regression analyses were used to control for confounding. Laboratory analysis was used to compare the procoagulant activities of FIX products. RESULTS Of 3801 individuals exposed to CFs, 117 (30.8 per 1000) had same-day TEs recorded. The crude same-day TE rate was higher for CF users without CFD, 70.2 (102 of 1452), as compared with those with CFD, 6.4 (15 of 2349) (RR, 11.0; 95% CI, 6.4-18.9). For individuals without CFD, a significantly increased same-day TE risk was identified for factor IX complex (OR, 6.92; 95% CI, 3.11-15.40), factor VIIa (OR, 9.42; 95% CI, 4.99-17.78) and other products when compared with fibrin sealant. An increased risk of a TE was found with older age (≥ 45 years), history of TEs and underlying health conditions. The laboratory identified elevated procoagulant activity in Profilnine(®) and Benefix(®) . CONCLUSIONS The study shows an increased same-day TE risk for CF users without CFD and suggests substantial off-label CF use. The study findings also show elevated same-day TE rates for different CF products and suggest the importance of product properties and patient factors.
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Affiliation(s)
| | - G Sridhar
- HealthCore Inc, Silver Spring, MD, USA
| | - M V Ovanesov
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - R A Forshee
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - H S Izurieta
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - N Selvam
- HealthCore Inc, Silver Spring, MD, USA
| | - L A Parunov
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - N Jain
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - P D Mintz
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - J S Epstein
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - S A Anderson
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - M D Menis
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
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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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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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28
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Milošević D, Bilić E, Batinić D, Poropat M, Štern-Padovan R, Galić S, Turudić D. Renal thromboembolism during treatment with recombinant activated factor VII (rFVIIa) in a child with hemophilia B with factor IX inhibitors. BMC Pediatr 2014; 14:315. [PMID: 25515020 PMCID: PMC4279815 DOI: 10.1186/s12887-014-0315-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Accepted: 12/11/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Serious thromboembolic events connected with rFVIIa therapy in hemophilia patients are rare. Only three cases are reported in children, all of them with hemophilia A. CASE PRESENTATION We present unique case of patient with hemophilia B and high titer inhibitors to coagulation FIX, who developed severe renal damage due to thromboembolic event during rFVIIa therapy, associated with unsuspected renovascular anomalies. CONCLUSION Caution is necessary if hematuria B requires administration of rFVIIa. US color doppler renal imaging before and after drug administration should be sufficient as an early warning.
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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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Shapiro AD, Hedner U. Advances in bypassing agent therapy for hemophilia patients with inhibitors to close care gaps and improve outcomes. Ther Adv Drug Saf 2014; 2:213-25. [PMID: 25083214 DOI: 10.1177/2042098611415566] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In the past, patients with hemophilia and inhibitors have had less-than-optimal treatment and have experienced more orthopedic complications than patients without inhibitors. Bypassing agents offer the potential to close treatment gaps between inhibitor and noninhibitor patients by helping the former better attain key treatment goals, including: facilitating early initiation of treatment and hemostatic control in hemarthroses; providing effective treatment in serious hemorrhagic episodes; and performance of major surgery. Effective treatment with a bypassing agent minimizes joint and/or muscle damage and potentially can serve as an effective prophylactic agent to minimize the number of hemarthroses experienced per year, thereby mitigating the development of arthropathy. The reported efficacy of the currently available bypassing agents ranges from approximately 50-80% (50-64% in controlled studies) for plasma-derived activated prothrombin complex concentrate (pd-aPCC) and 81-91% (in controlled studies) for recombinant activated factor VII (rFVIIa), including use in major orthopedic surgery. Both bypassing agents have undergone key improvements in their formulation and/or properties in recent years. The nanofiltered, vapor-heated formulation of pd-aPCC has diminished the risk of acquiring blood-borne viral infections and the room temperature stable formulation of rFVIIa allows more convenient storage, increased ease to dissolve and inject, and smaller volumes, thereby increasing overall ease of administration. Use of recommended dosing has been demonstrated to provide effective hemostasis with a minimal number of injections for both agents. In this paper, we review the individual characteristics of pd-aPCC and rFVIIa and discuss clinical data from studies conducted in inhibitor patients that demonstrate the potential benefits of these bypassing agents in this difficult-to-treat population, and underscore the potential opportunities to close the gap in care between inhibitor and noninhibitor hemophilic patients.
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Affiliation(s)
- Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, 8402 Harcourt Road, Suite 500, Indianapolis, IN 46260, USA
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31
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Alfirevic A, Duncan A, You J, Lober C, Soltesz E. Recombinant factor VII is associated with worse survival in complex cardiac surgical patients. Ann Thorac Surg 2014; 98:618-24. [PMID: 24968771 DOI: 10.1016/j.athoracsur.2014.04.126] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/28/2014] [Accepted: 04/30/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recombinant activated factor VII (rFVIIa) decreases requirements for allogeneic blood transfusion and chest reexploration in patients undergoing cardiac surgery. Whether rFVIIa increases the risk of postoperative adverse events is unclear. We tested whether rFVIIa administration was associated with increased mortality and neurologic and renal morbidity in patients undergoing cardiac surgery. Risk of thromboembolic complications and the dose-response of rFVIIa on mortality and morbidity were also evaluated. METHODS Of 27,977 patients who had complex cardiac surgery, 164 patients (0.59%) received rFVIIa perioperatively. Using propensity-matching techniques, patients were matched to a maximum of 3 control patients. Patients who received rFVIIa were compared with control patients on risk of mortality, neurologic and renal morbidity, and thromboembolic complications, including a composite of myocardial infarction, pulmonary embolism, and deep venous thrombosis. A corresponding dose-response analysis using multivariable logistic regression was also performed. RESULTS Propensity techniques successfully matched 144 patients (88%) with 359 control patients. Of patients who received rFVIIa, 40% experienced in-hospital mortality compared with 18% of control patients (odds ratio, 2.82; 98.3% confidence interval, 1.64 to 4.87; p<0.001). Furthermore, 31% of patients treated with rFVIIa versus 17% of control patients experienced renal morbidity (odds ratio, 2.07; 98.3% confidence interval, 1.19 to 3.62; p=0.002); however, neurologic morbidity and thromboembolic complications were not different among groups. High-dose rFVIIa (>60 μg/kg) did not increase the risk for mortality compared with treatment with low-dose rFVIIa (<60 μg/kg). CONCLUSIONS Administration of rFVIIa is associated with increased mortality and renal morbidity in patients undergoing cardiac surgery.
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Affiliation(s)
- Andrej Alfirevic
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, Ohio.
| | - Andra Duncan
- Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, Ohio
| | - Jing You
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Cheryl Lober
- Pharmacy Department, Cleveland Clinic, Cleveland, Ohio
| | - Edward Soltesz
- Cardiothoracic Surgery, Cleveland Clinic, Cleveland, Ohio
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Rajpurkar M, Chitlur M, Recht M, Cooper DL. Use of recombinant activated factor VII in patients with Glanzmann's thrombasthenia: a review of the literature. Haemophilia 2014; 20:464-71. [DOI: 10.1111/hae.12473] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2014] [Indexed: 11/28/2022]
Affiliation(s)
- M. Rajpurkar
- Division of Hematology/Oncology; Carman and Ann Adams Department of Pediatrics; Children's Hospital of Michigan; Detroit MI USA
- Wayne State University; Detroit MI USA
| | - M. Chitlur
- Division of Hematology/Oncology; Carman and Ann Adams Department of Pediatrics; Children's Hospital of Michigan; Detroit MI USA
| | - M. Recht
- The Hemophilia Center at Oregon Health & Science University; Portland OR USA
| | - D. L. Cooper
- Clinical; Medical and Regulatory Affairs; Novo Nordisk Inc.; Plainsboro NJ USA
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Lee KS, Shim YJ, Jang KM, Hyun SY. Second case of postpartum acquired hemophilia A in a Korean female. Blood Res 2014; 49:205-7. [PMID: 25325045 PMCID: PMC4188791 DOI: 10.5045/br.2014.49.3.205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 08/22/2014] [Accepted: 09/19/2014] [Indexed: 11/17/2022] Open
Affiliation(s)
- Kun Soo Lee
- Department of Pediatrics, Kyungpook National University Hospital and Kyungpook National University School of Medicine, Daegu, Korea
| | | | - Kyoung Mi Jang
- Department of Pediatrics, Kyungpook National University Hospital and Kyungpook National University School of Medicine, Daegu, Korea
| | - Shin Young Hyun
- Department of Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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34
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Vanhuyse F, Frotscher B, Lecompte T, Maureira P, Villemot JP, Folliguet T, Toussaint-Hacquard M. [Use of rFVIIa in intractable hemorrhage in patients on central veno-arterial ECMO]. ACTA ACUST UNITED AC 2013; 32:665-9. [PMID: 23993217 DOI: 10.1016/j.annfar.2013.07.794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 07/09/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The purpose of our study is to describe the use of recombinant factor VIIa (rFVIIa) in patients on central veno-arterial ECMO with a particular attention on associated thrombotic complications. STUDY DESIGN Monocentric retrospective study. PATIENTS AND METHODS We examined 91 files of patients on ECMO between 2005 and 2010. During this period, eight patients presented refractory bleeding and benefited from rFVIIa treatment. RESULTS In six of the eight patients, the bleeding stopped. A decrease of the bleeding was noticed after the treatment of rFVIIa (before rFVIIa: 40.1±33.1mL/kg per 3 hours after rFVIIa: 5.4±3.2mL/kg per 3 hours (P=0.01). The transfusional needs were decreased after administration of rFVIIa. No thrombotic event was detected. Fibrinogen, d-dimers, platelet count and lactate were not modified by the treatment. Two patients were weaned from ECMO. One patient died 17 days after the weaning. The other patient survived without neurological damages. CONCLUSION The rFVIIa is a treatment of exception for patients on central veno-arterial ECMO and could be a last-resort treatment in the presence of a not curable massive bleeding.
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Affiliation(s)
- F Vanhuyse
- Département de chirurgie cardiovasculaire et transplantation, université de Lorraine, institut Louis-Mathieu du cœur et des vaisseaux, CHU de Nancy, 54511 Nancy, France.
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35
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Palsson R, Vidarsson B, Gudmundsdottir BR, Larsen OH, Ingerslev J, Sorensen B, Onundarson PT. Complementary effect of fibrinogen and rFVIIa on clottingex vivoin Bernard-Soulier syndrome and combined use during three deliveries. Platelets 2013; 25:357-62. [DOI: 10.3109/09537104.2013.819971] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Frumkin K. Rapid reversal of warfarin-associated hemorrhage in the emergency department by prothrombin complex concentrates. Ann Emerg Med 2013; 62:616-626.e8. [PMID: 23829955 DOI: 10.1016/j.annemergmed.2013.05.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 05/23/2013] [Accepted: 05/29/2013] [Indexed: 10/26/2022]
Abstract
Life-threatening warfarin-associated hemorrhage is common, with a high mortality. In the United States, the most commonly used therapies--fresh frozen plasma and vitamin K--are slow and unpredictable and can result in volume overload. Outside of the United States, prothrombin complex concentrates are often used instead; these pooled plasma products reverse warfarin anticoagulation in minutes rather than hours. This article reviews the literature relating to warfarin reversal with fresh frozen plasma, prothrombin complex concentrates, and recombinant factor VIIa and provides elements for a management protocol based on this literature.
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Affiliation(s)
- Kenneth Frumkin
- Emergency Medicine Department, Naval Medical Center Portsmouth, VA.
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37
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Neufeld EJ, Saxena K, Kessler CM, Cooper DL. Dosing, efficacy, and safety of recombinant factor VIIa (rFVIIa) in pediatric versus adult patients: the experience of the Hemostasis and Thrombosis Research Society (HTRS) Registry (2004-2008). Pediatr Blood Cancer 2013; 60:1178-83. [PMID: 23335449 DOI: 10.1002/pbc.24472] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 12/17/2012] [Indexed: 01/19/2023]
Abstract
BACKGROUND The longitudinal registry of the Hemostasis and Thrombosis Research Society (HTRS) provided data on treatment of bleeding episodes for pediatric and adult patients with congenital hemophilia complicated by inhibitors to factor VIII or IX. PROCEDURE Data from 2,041 recombinant factor VIIa (rFVIIa)-treated episodes were recorded in the HTRS Registry between January 2004 and November 2008 and included in this retrospective analysis. The authors compared dosing, efficacy, and safety in 1,712 episodes in 284 children (age ≤18 years) and 329 episodes in 145 adults (>18 years). RESULTS Patients were predominantly non-Hispanic white (52% of children, 68% of adults) with hemophilia A (91%). The majority of bleeds were spontaneous (55% pediatric, 69% adult) and occurred in the joint (55% pediatric, 65% adult). rFVIIa was used first line in most episodes (90% pediatric, 93% adult); 27% of episodes in both age groups were treated with a single dose. Children and adults received comparable median number of doses (three) and duration of therapy (1 day); adults had lower median [range] initial doses (90 [46-400] µg/kg vs. 120 [37-400] µg/kg) and median [range] total doses (270 [46-21,392] µg/kg vs. 480 [50-43,200] µg/kg) than children. Effectiveness was comparable between the groups. No thromboembolic complications were reported. CONCLUSIONS Dosing of rFVIIa was somewhat higher in pediatric than adult patients in the HTRS registry population, with similar effectiveness. Safety assessment, demonstrating lack of thromboembolic events associated with treatment of bleeding episodes, was similar between the children and adults in this retrospective registry.
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Affiliation(s)
- Ellis J Neufeld
- Boston Children's Hospital, Boston, Massachusetts 02115, USA.
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38
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Fazavana J, Bianchini EP, Saller F, Smadja C, Picard V, Taverna M, Borgel D. A chemically-modified inactive antithrombin as a potent antagonist of fondaparinux and heparin anticoagulant activity. J Thromb Haemost 2013; 11:1128-36. [PMID: 23581397 DOI: 10.1111/jth.12249] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Heparin and its analogs, mediating their anticoagulant activity through antithrombin (AT) activation, remain largely used for the preventive and curative treatment of thrombosis. The major adverse reaction of these drugs is the bleeding risk associated with overdose. Unfractionnated heparin (UFH) can be efficiently and rapidly neutralized by protamine sulfate, but this reversal partially neutralizes low-molecular-weight heparin (LMWH) and is inefficient in reversing fondaparinux. To secure administration of AT-mediated anticoagulants and counteract bleeding disorders, we previously designed a recombinant inactive AT as an antidote to heparin derivatives. OBJECTIVES To get around the limited production level of recombinant AT, we propose in this study an alternative strategy to produce a chemically modified inactive AT, exhibiting increased heparin affinity, as an antagonist of heparin analogs. METHODS Plasma-derived AT was chemically modified with 2,3 butanedione, a diketone known to specifically react with the arginine side chain. The chemical reaction was conducted in the presence of heparin to preserve basic residues within the heparin binding site from modifications. RESULTS AT treated by butanedione and selected for its high heparin affinity (AT-BD) was indeed modified on reactive Arg393 and thus exhibited decreased anticoagulant activity and increased heparin affinity. AT-BD was able to neutralize anticoagulant activity of heparin derivatives in vitro and in vivo and was devoid of intrinsic anticoagulant activity, as assessed by activated partial thromboplastin time assay. CONCLUSIONS AT-BD appears to be as efficient as protamine to neutralize UFH in vivo but could be more largely used because it also reverses fondaparinux and LMWH.
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Affiliation(s)
- J Fazavana
- Laboratoire d'Hématologie, University Paris-Sud-XI, Châtenay-Malabry Cedex, France
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40
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Borg JY, Guillet B, Le Cam-Duchez V, Goudemand J, Lévesque H. Outcome of acquired haemophilia in France: the prospective SACHA (Surveillance des Auto antiCorps au cours de l'Hémophilie Acquise) registry. Haemophilia 2013; 19:564-70. [PMID: 23574453 DOI: 10.1111/hae.12138] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2013] [Indexed: 01/24/2023]
Abstract
Although extremely rare, acquired haemophilia A (AHA) can cause severe bleeding, which may be fatal. The underlying causes of autoantibody development are not fully understood. Treatment goals are bleeding control and autoantibody eradication. At the time of our study, there was no consensus on a standard treatment strategy for AHA. Previous data were mainly retrospective or from single-centre cohorts. We conducted a prospective, controlled, registry-based study of patients with AHA in France. The prospective French registry (Surveillance des Auto antiCorps au cours de l'Hémophilie Acquise [SACHA]) collected data on prevalence, clinical course, disease associations and outcomes for haemostatic treatment and autoantibody eradication in 82 patients with a 1-year follow-up. Similar to earlier studies, the prevalence of AHA was higher in the elderly, with two thirds of patients aged >70 years. Around half of AHA cases were associated with underlying disease, most commonly autoimmune disease and cancer in younger and older patients respectively. Haemostatic treatment was initially administered to 46% of patients. Complete resolution or improvement of initial bleeding occurred in 22/27 (81%) rFVIIa-treated patients and in all six cases receiving pd-aPCC. The majority of patients (94%) received immunosuppressive therapy, with complete remission at 3 months in 61% (36/59) and in 98% (50/51) at 1 year. Overall mortality was 33%: secondary to bleeding in only three patients but to sepsis in 10. Bypassing agents were effective at controlling bleeding in patients with AHA. Immunosuppressive therapy should be used early but with caution, particularly in elderly patients.
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Affiliation(s)
- J Y Borg
- Haematology Laboratory, Rouen University Hospital and INSERM CIC-CRB 0204, Rouen, France
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41
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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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42
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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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SHIRAHATA A, KUWAHARA M, FUKUTAKE K, HIGASA S, SAKAI M, SHIMA M, FUJII T, HORIKOSHI Y, TAKI M, HANABUSA H, YOSHIOKA A. Long-term safety and efficacy of recombinant activated factor VII (NovoSevenⓇ) for treatment of acute bleeding episodes in congenital hemophilia with inhibitors:analysis from 10-year japanese post-marketing surveillance. ACTA ACUST UNITED AC 2013. [DOI: 10.2491/jjsth.24.593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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44
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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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Zanon E, Milan M, Brandolin B, Barbar S, Spiezia L, Saggiorato G, Simioni P, Baudo F. High dose of human plasma-derived FVIII-VWF as first-line therapy in patients affected by acquired haemophilia A and concomitant cardiovascular disease: four case reports and a literature review. Haemophilia 2012; 19:e50-3. [PMID: 23051581 DOI: 10.1111/hae.12033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2012] [Indexed: 11/29/2022]
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CAVIGLIA H, NARAYAN P, FORSYTH A, GIANGRANDE P, GILBERT M, GODDARD N, MULDER K, RAHIM S. Musculoskeletal problems in persons with inhibitors: How do we treat? Haemophilia 2012; 18 Suppl 4:54-60. [DOI: 10.1111/j.1365-2516.2012.02874.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Management of bleeding in acquired hemophilia A: results from the European Acquired Haemophilia (EACH2) Registry. Blood 2012; 120:39-46. [PMID: 22618709 DOI: 10.1182/blood-2012-02-408930] [Citation(s) in RCA: 249] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Acquired hemophilia A is a rare bleeding disorder caused by autoantibodies to coagulation FVIII. Bleeding episodes at presentation are spontaneous and severe in most cases. Optimal hemostatic therapy is controversial, and available data are from observational and retrospective studies only. The EACH2 registry, a multicenter, pan-European, Web-based database, reports current patient management. The aim was to assess the control of first bleeding episodes treated with a bypassing agent (rFVIIa or aPCC), FVIII, or DDAVP among 501 registered patients. Of 482 patients with one or more bleeding episodes, 144 (30%) received no treatment for bleeding; 31 were treated with symptomatic therapy only. Among 307 patients treated with a first-line hemostatic agent, 174 (56.7%) received rFVIIa, 63 (20.5%) aPCC, 56 (18.2%) FVIII, and 14 (4.6%) DDAVP. Bleeding was controlled in 269 of 338 (79.6%) patients treated with a first-line hemostatic agent or ancillary therapy alone. Propensity score matching was applied to allow unbiased comparison between treatment groups. Bleeding control was significantly higher in patients treated with bypassing agents versus FVIII/DDAVP (93.3% vs 68.3%; P = .003). Bleeding control was similar between rFVIIa and aPCC (93.0%; P = 1). Thrombotic events were reported in 3.6% of treated patients with a similar incidence between rFVIIa (2.9%) and aPCC (4.8%).
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COPPOLA A, FRANCHINI M, MAKRIS M, SANTAGOSTINO E, DI MINNO G, MANNUCCI PM. Thrombotic adverse events to coagulation factor concentrates for treatment of patients with haemophilia and von Willebrand disease: a systematic review of prospective studies. Haemophilia 2012; 18:e173-87. [DOI: 10.1111/j.1365-2516.2012.02758.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Elmer J, Wittels KA. Emergency reversal of pentasaccharide anticoagulants: a systematic review of the literature. Transfus Med 2011; 22:108-15. [DOI: 10.1111/j.1365-3148.2011.01125.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Lin PC, Liao YM, Tsai SP, Chang TT. Immune tolerance induction therapy for patients with hemophilia A and FVIII inhibitors particularly using low-dose regimens. Pediatr Blood Cancer 2011; 57:1029-33. [PMID: 21793191 DOI: 10.1002/pbc.23291] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 06/30/2011] [Indexed: 11/09/2022]
Abstract
BACKGROUND Inhibitory antibodies against infused clotting factor VIII concentrates (FVIII) developed in 20-30% of patients with hemophilia A. Bypass therapy may control the bleeds in patients with FVIII inhibitors, however, immune tolerance induction (ITI) therapy is the only proven modality for eradicating FVIII inhibitors. Since the cost of high-dose (200 IU/kg) ITI is extremely expansive, we conducted this study to identify whether low-dose ITI can be an alternative strategy besides high-dose ITI or bypass therapy. PROCEDURE Patients with hemophilia A and FVIII inhibitors treated by ITI in Kaohsiung Medical University Hospital from January 2000 to January 2010 were enrolled. Regimens of ITI therapy included high-dose (100 IU/kg) and low-dose (30-50 IU/kg). RESULTS High-dose ITI therapy for two high responders (HRs) and low-dose ITI therapy for three HRs and all low responders (LRs) were performed. Complete tolerance was achieved in 2 HRs with high-dose regimen, and in one HR and 19 LRs with low-dose regimens. We administered low-dose ITI combined with immune suppressants treatment for one of the patient with extremely high FVIII inhibitor titers and the inhibitor level markedly declined and no spontaneous bleeding episode was noticed during the treatment period. CONCLUSIONS The outcome of ITI in our study was satisfactory without clinically significant complications. Low-dose ITI regimens can effectively treat patients with high responder inhibitors, including one patient with extremely high inhibitor levels over 700 BU. Low-dose ITI may be an alternative modality for FVIII inhibitors management, especially in countries with limited resources.
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Affiliation(s)
- Pei-Chin Lin
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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