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Gunasekera D, Vir P, Karim AF, Ragni MV, Pratt KP. Hemophilia A subjects with an intron-22 gene inversion mutation show CD4 + T-effector responses to multiple epitopes in FVIII. Front Immunol 2023; 14:1128641. [PMID: 36936969 PMCID: PMC10015889 DOI: 10.3389/fimmu.2023.1128641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
Background Almost half of severe hemophilia A (HA) is caused by an intron 22 inversion mutation (Int22Inv), which disrupts the 26-exon F8 gene. Inverted F8 mRNA exons 1-22 are transcribed, while F8B mRNA, containing F8 exons 23-26, is transcribed from a promoter within intron 22. Neither FVIII activity nor FVIII antigen (cross-reacting material, CRM) are detectable in plasma of patients with an intron-22 inversion. Objectives To test the hypothesis that (putative) intracellular synthesis of FVIII proteins encoded by inverted F8 and F8B mRNAs confers T-cell tolerance to almost the entire FVIII sequence, and to evaluate the immunogenicity of the region encoded by the F8 exon 22-23 junction sequence. Patients/Methods Peripheral blood mononuclear cells (PBMCs) from 30 severe or moderate HA subjects (17 with an Int22Inv mutation) were tested by ELISPOT assays to detect cytokine secretion in response to FVIII proteins and peptides and to map immunodominant T-cell epitopes. Potential immunogenicity of FVIII sequences encoded by the F8 exon 22-23 junction region was also tested using peptide-MHCII binding assays. Results Eight of the Int22Inv subjects showed robust cytokine secretion from PBMCs stimulated with FVIII proteins and/or peptides, consistent with earlier publications from the Conti-Fine group. Peptide ELISPOT assays identified immunogenic regions of FVIII. Specificity for sequences encoded within F8 mRNA exons 1-22 and F8B mRNA was confirmed by staining Int22Inv CD4+ T cells with peptide-loaded HLA-Class II tetramers. FVIII peptides spanning the F8 exon 22-23 junction (encoding M2124-V2125) showed limited binding to MHCII proteins and low immunogenicity, with cytokine secretion from only one Int22Inv subject. Conclusions PBMCs from multiple subjects with an Int22Inv mutation, with and without a current FVIII inhibitor, responded to FVIII epitopes. Furthermore, the FVIII region encoded by the exon 22-23 junction sequence was not remarkably immunoreactive and is therefore unlikely to contain an immunodominant, promiscuous CD4+ T-cell epitope. Our results indicate that putative intracellular expression of partial FVIII proteins does not confer T-cell tolerance to FVIII regions encoded by inverted F8 mRNA or F8B mRNA.
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Affiliation(s)
- Devi Gunasekera
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Pooja Vir
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Ahmad Faisal Karim
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Henry Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States
| | - Margaret V. Ragni
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kathleen P. Pratt
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- *Correspondence: Kathleen P. Pratt,
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Johnsen JM, Fletcher SN, Dove A, McCracken H, Martin BK, Kircher M, Josephson NC, Shendure J, Ruuska SE, Valentino LA, Pierce GF, Watson C, Cheng D, Recht M, Konkle BA. Results of genetic analysis of 11 341 participants enrolled in the My Life, Our Future hemophilia genotyping initiative in the United States. J Thromb Haemost 2022; 20:2022-2034. [PMID: 35770352 DOI: 10.1111/jth.15805] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemophilia A (HA) and hemophilia B (HB) are rare inherited bleeding disorders. Although causative genetic variants are clinically relevant, in 2012 only 20% of US patients had been genotyped. OBJECTIVES My Life, Our Future (MLOF) was a multisector cross-sectional US initiative to improve our understanding of hemophilia through widespread genotyping. METHODS Subjects and potential genetic carriers were enrolled at US hemophilia treatment centers (HTCs). Bloodworks performed genotyping and returned results to providers. Clinical data were abstracted from the American Thrombosis and Hemostasis Network dataset. Community education was provided by the National Hemophilia Foundation. RESULTS From 2013 to 2017, 107 HTCs enrolled 11 341 subjects (68.8% male, 31.2% female) for testing for HA (n = 8976), HB (n = 2358), HA/HB (n = 3), and hemophilia not otherwise specified (n = 4). Variants were detected in most male patients (98.2%% HA, 98.1% HB). 1914 unique variants were found (1482 F8, 431 F9); 744 were novel (610 F8, 134 F9). Inhibitor data were available for 6986 subjects (5583 HA; 1403 HB). In severe HA, genotypes with the highest inhibitor rates were large deletions (77/80), complex intron 22 inversions (9/17), and no variant found (7/14). In severe HB, the highest rates were large deletions (24/42). Inhibitors were reported in 27.3% of Black versus 16.2% of White patients. CONCLUSIONS The findings of MLOF are reported, the largest hemophilia genotyping project performed to date. The results support the need for comprehensive genetic approaches in hemophilia. This effort has contributed significantly towards better understanding variation in the F8 and F9 genes in hemophilia and risks of inhibitor formation.
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Affiliation(s)
- Jill M Johnsen
- Research Institute, Bloodworks, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | | | - Angela Dove
- Research Institute, Bloodworks, Seattle, Washington, USA
| | | | - Beth K Martin
- Genome Sciences, University of Washington, Seattle, Washington, USA
| | - Martin Kircher
- Genome Sciences, University of Washington, Seattle, Washington, USA
| | - Neil C Josephson
- Research Institute, Bloodworks, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jay Shendure
- Genome Sciences, University of Washington, Seattle, Washington, USA
| | - Sarah E Ruuska
- Research Institute, Bloodworks, Seattle, Washington, USA
| | | | | | - Crystal Watson
- American Thrombosis and Hemostasis Network, Rochester, New York, USA
| | - Dunlei Cheng
- American Thrombosis and Hemostasis Network, Rochester, New York, USA
| | - Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, New York, USA
| | - Barbara A Konkle
- Research Institute, Bloodworks, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
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Hart DP, Matino D, Astermark J, Dolan G, d’Oiron R, Hermans C, Jiménez-Yuste V, Linares A, Matsushita T, McRae S, Ozelo MC, Platton S, Stafford D, Sidonio RF, Tiede A. International consensus recommendations on the management of people with haemophilia B. Ther Adv Hematol 2022; 13:20406207221085202. [PMID: 35392437 PMCID: PMC8980430 DOI: 10.1177/20406207221085202] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/17/2022] [Indexed: 01/19/2023] Open
Abstract
Haemophilia B is a rare X-linked genetic deficiency of coagulation factor IX (FIX) that, if untreated, can cause recurrent and disabling bleeding, potentially leading to severe arthropathy and/or life-threatening haemorrhage. Recent decades have brought significant improvements in haemophilia B management, including the advent of recombinant FIX and extended half-life FIX. This therapeutic landscape continues to evolve with several non-factor replacement therapies and gene therapies under investigation. Given the rarity of haemophilia B, the evidence base and clinical experience on which to establish clinical guidelines are relatively sparse and are further challenged by features that are distinct from haemophilia A, precluding extrapolation of existing haemophilia A guidelines. Due to the paucity of formal haemophilia B-specific clinical guidance, an international Author Group was convened to develop a clinical practice framework. The group comprised 15 haematology specialists from Europe, Australia, Japan, Latin America and North America, covering adult and paediatric haematology, laboratory medicine and biomedical science. A hybrid approach combining a systematic review of haemophilia B literature with discussion of clinical experience utilized a modified Delphi format to develop a comprehensive set of clinical recommendations. This approach resulted in 29 recommendations for the clinical management of haemophilia B across five topics, including product treatment choice, therapeutic agent laboratory monitoring, pharmacokinetics considerations, inhibitor management and preparing for gene therapy. It is anticipated that this clinical practice framework will complement existing guidelines in the management of people with haemophilia B in routine clinical practice and could be adapted and applied across different regions and countries.
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Affiliation(s)
- Daniel P. Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Whitechapel Road, London E1 2AD, UK
| | - Davide Matino
- Department of Medicine, McMaster University and The Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Jan Astermark
- Institution of Translational Medicine and Department of Hematology, Oncology and Radiation Physics, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Gerard Dolan
- Centre for Haemostasis and Thrombosis, St Thomas’ Hospital, London, UK
| | - Roseline d’Oiron
- Centre for Haemophilia and Constitutional Bleeding Disorders, Hôpital Bicêtre AP-HP Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Cédric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | | | - Adriana Linares
- Grupo de Oncohematología Pediátrica, Universidad Nacional de Colombia, Bogotá, Colombia
- Programa de Hemofilia, Clínica Infantil Colsubsidio, Bogotá, Colombia
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Simon McRae
- Launceston General Hospital, Launceston, TAS, Australia
| | | | - Sean Platton
- The Royal London Hospital Haemophilia Centre, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Darrel Stafford
- Department of Biology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Robert F. Sidonio
- Aflac Cancer and Blood Disorders, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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Regling K, Callaghan MU, Sidonio R. Managing Severe Hemophilia A in Children: Pharmacotherapeutic Options. Pediatric Health Med Ther 2022; 13:27-35. [PMID: 35210899 PMCID: PMC8857990 DOI: 10.2147/phmt.s293246] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/27/2021] [Indexed: 12/22/2022] Open
Abstract
Hemophilia A is the most common severe inherited bleeding disorder in males. Initial treatment strategies focused on the use of factor concentrates to prevent joint bleeding and the development of long-term crippling arthropathy. The current standard of care has evolved from regular replacement of factor VIII concentrates which has significantly improved the quality of life for those with severe disease to include and consider novel therapies that augment or bypass the hemostatic pathway (ie, emicizumab, Mim8). Other pipeline therapies that suppress specific natural anticoagulant pathways (ie, antithrombin, TFPI) to reestablish hemostatic balance are under Phase 3 trial investigation. These novel therapeutics have allowed providers more variety in dosing regimens and ease of administration while also maintaining effective bleeding prevention. The possibility of "curative" gene therapy is under exploration, with ongoing clinical trials in adult males.
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Affiliation(s)
- Katherine Regling
- Pediatric Hematology Oncology, Children’s Hospital of Michigan, Detroit, MI, USA
- Central Michigan University School of Medicine, Mount Pleasant, MI, USA
| | - Michael U Callaghan
- Pediatric Hematology Oncology, Children’s Hospital of Michigan, Detroit, MI, USA
- Central Michigan University School of Medicine, Mount Pleasant, MI, USA
- Agios Pharmaceuticals, Cambridge, MA, USA
| | - Robert Sidonio
- Emory University and Aflac Cancer and Blood Disorders, Atlanta, GA, USA
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Lagassé HAD, McCormick Q, Sauna ZE. Secondary failure: immune responses to approved protein therapeutics. Trends Mol Med 2021; 27:1074-1083. [PMID: 34493437 DOI: 10.1016/j.molmed.2021.08.003] [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] [Received: 05/18/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 12/23/2022]
Abstract
Recombinant therapeutic proteins are a broad class of biological products used to replace dysfunctional human proteins in individuals with genetic defects (e.g., factor VIII for hemophilia) or, in the case of monoclonal antibodies, bind to disease targets involved in cancers, autoimmune disorders, or other conditions. Unfortunately, immunogenicity (immune response to the drug) remains a key impediment, potentially affecting the safety and efficacy of these therapeutics. Immunogenicity risk is routinely evaluated during the licensure of therapeutic proteins. However, despite eliciting anti-drug immune responses in at least some patients, most protein drugs are nevertheless licensed as they address unmet medical needs. The pre-licensure immunogenicity assessments of therapeutic proteins are the subject of numerous reviews and white papers. However, observation and clinical management of the immunogenicity of approved therapeutic proteins face additional challenges. We survey the immunogenicity of approved therapeutic proteins, discuss the clinical management of immunogenicity, and identify the challenges to establishing clinically relevant immunogenicity assays for use in routine clinical practice.
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Affiliation(s)
- H A Daniel Lagassé
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, US Food and Drug Administration (FDA), Silver Spring, MD, USA
| | - Quinn McCormick
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, US Food and Drug Administration (FDA), Silver Spring, MD, USA
| | - Zuben E Sauna
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research, US Food and Drug Administration (FDA), Silver Spring, MD, USA.
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Pshenichnikova OS, Surin VL. Genetic Risk Factors for Inhibitor Development in Hemophilia A. RUSS J GENET+ 2021. [DOI: 10.1134/s1022795421080111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Remarkable changes are occurring in the diagnosis and management of individuals with hemophilia A. Genetic testing, including next-generation sequencing, enables family planning, carrier testing, and prenatal diagnosis. Musculoskeletal ultrasound examination facilitates the early detection of acute bleeds and joint disease in clinic, enabling more rapid bleed resolution and treatment planning. Novel therapies offer simpler weekly or monthly administration, some by subcutaneous injection, with better compliance and quality of life, as well as fewer bleeds. Gene therapy provides a 1-time phenotypic "cure" that is cost effective, but may be complicated by waning levels, vector immune responses, and hepatotoxicity.
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8
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The design of a Bayesian platform trial to prevent and eradicate inhibitors in patients with hemophilia. Blood Adv 2021; 4:5433-5441. [PMID: 33156923 DOI: 10.1182/bloodadvances.2020002789] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/22/2020] [Indexed: 02/02/2023] Open
Abstract
Among individuals with the rare congenital bleeding disorder hemophilia A, the major challenge is inhibitor formation, which is associated with significant morbidity and cost. Yet, as the optimal approach to prevent and eradicate inhibitors is not known, we are at equipoise. Because classic trial design is not practical in a rare disease setting, we designed 2 48-week randomized trials comparing ELOCTATE and emicizumab to prevent and eradicate inhibitors. To achieve statistical efficiency, we incorporated historic data (Bayesian priors) on inhibitor formation to allow preferential randomization to emicizumab, piecewise exponential survival models to determine mean and 95% confidence interval for inhibitor formation in each arm, and simulations to determine the best model design to optimize power. To achieve administrative efficiency, the trials will be performed with the same sites, staff, visit frequency, blood sampling, laboratories, and laboratory assays, with streamlined enrollment so patients developing inhibitors in the first trial may be enrolled on the second trial. The primary end point is the probability of inhibitor formation or inhibitor eradication, respectively. The design indicates early stopping rules for overwhelming evidence of superiority of the emicizumab arms. Simulations indicate that, with 66 subjects, the Prevention Trial will have 84% power to detect noninferiority of emicizumab to ELOCTATE with a margin of 10% if emicizumab is truly 10% superior to ELOCTATE; with 90 subjects, the Eradication Trial will have 80% power to detect 15% superiority of ELOCTATE immune tolerance induction with vs without emicizumab. Thus, a platform design provides statistical and administrative efficiency to conduct INHIBIT trials.
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9
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Inhibitor in Congenital Factor VII Deficiency; a Rare but Serious Therapeutic Challenge-A Systematic Literature Review. J Clin Med 2021; 10:jcm10020211. [PMID: 33435610 PMCID: PMC7827513 DOI: 10.3390/jcm10020211] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 12/28/2020] [Accepted: 12/31/2020] [Indexed: 12/03/2022] Open
Abstract
Background: Congenital factor (F) VII deficiency is a rare coagulation factor deficiency with an estimated incidence of 1 per 500,000 individuals. Patients with severe FVII deficiency present a broad range of clinical presentations. Alloimmunization against exogenous FVII, as the main challenge of replacement therapy, is an extremely rare phenomenon that is accompanied by a high rate of life-threatening bleeding, that renders replacement therapy less effective. Due to the importance of the issue, we performed a systematic literature review in order to assess incidence, molecular basis, clinical presentations, and therapeutic challenge and management of inhibitor in congenital FVII deficiency. Strategy of search: This systematic review was performed in accordance with PRISMA guidelines. We performed an English-language literature review in the PubMed, EMBASE, Scopus, and Google Scholar databases, using the following keywords: “factor VII inhibitor”, “factor VII inhibitors”, “FVII inhibitors”, “congenital FVII deficiency”, “recombinant factor VII”, “anti rFVIIa”, “replacement therapy”, and “alloantibody”. Results: Out of 380 patients in the 13 studies, 27 had inhibitor against FVII; 18 were male, 7 were female, while the sex of 2 was not stated. The majority (92%) developed a high-titer inhibitor (Bethesda Unit > 5). All patients had severe FVII deficiency (FVII:C < 10%), and the majority received recombinant FVII prior to inhibitor development (N: 24, 89%). Among ten patients with a detected mutation, three subjects had a common non-sense (30%), and two had a deletion (20%). Conclusions: Inhibitor development is a relatively rare phenomenon seen only in severe FVII deficiency, where it is associated with severe and life-threatening presentations, treatment challenge, and economic burden on the patients and their families.
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10
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Chuansumrit A, Sirachainan N, Natesirinilkul R, Srikala K, Masaya-Anon N. Real-world evidence on health resource use among patients with haemophilia and inhibitor exhibiting severe bleeding episodes. Haemophilia 2020; 27:69-80. [PMID: 33216428 DOI: 10.1111/hae.14194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/08/2020] [Accepted: 10/21/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE This study aimed to explore real-world evidence on health resource use (HRU) spending on patients with haemophilia and inhibitor. MATERIALS AND METHODS Medical records from 1990 to 2019 of patients with haemophilia and inhibitor from three comprehensive haemophilia treatment centres were retrospectively retrieved. RESULTS In all, 31 patients with haemophilia (A = 30, B = 1) and inhibitor ≥5 BU were included. The mean initial inhibitor of 95.4 BU was detected at the mean age of 6.7 years. The mean number of annual hospitalisations was 3.9. A total of 795 bleeding episodes (major =125, minor =670) were evaluated. The treatment included bypassing agents or plasma exchange before administering high-dose factor VIII concentrate and intervention or surgery. Six patients succumbed to bleeding at the mean age of 17.2 years. Nineteen surviving patients experienced multiple morbidity except six patients with successful and partially successful immune tolerance induction (ITI). The mean (SD) annual total medical consumption for episodic treatment and successful ITI per patient with haemophilia A were 30,804 (81,332) USD and 55,531 (100,566) USD, respectively. Only episodic treatment was paid by the government budget for limited amounts of bypassing agents. CONCLUSION Management for patients with haemophilia and inhibitor exhibiting severe bleeding is challenging for medical personnel in countries having limited resources over decades. The real-world data will be used to negotiate with the government to increase budget for adequate bypassing agents or nonreplacement therapy and to include ITI in the national haemophilia treatment.
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Affiliation(s)
- Ampaiwan Chuansumrit
- Department of Paediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nongnuch Sirachainan
- Department of Paediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Kwannut Srikala
- Department of Paediatrics, Sunprasitthiprasong Hospital, Ubon Ratchathani, Thailand
| | - Narongrit Masaya-Anon
- Sirikit Medical Centre, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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11
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Observational study of recombinant factor VIII-Fc, rFVIIIFc, in hemophilia A. Thromb Res 2020; 195:51-54. [DOI: 10.1016/j.thromres.2020.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 06/03/2020] [Accepted: 07/03/2020] [Indexed: 01/05/2023]
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Abstract
INTRODUCTION The development of inhibitors against factors VIII/IX is the most serious complication in hemophilia. The best treatment strategy for inhibitor eradication is immune tolerance induction (ITI). The aim of this study was to evaluate patients treated with low-dose ITI at a single center with limited resources. MATERIALS AND METHODS In total, 29 (8.05%) of 360 hemophilia A patients exhibited inhibitors. The data from hemophilia patients with inhibitors undergoing ITI between 1999 and 2017 were collected and analyzed. RESULTS Seventeen ITIs administered to 15 hemophilia A patients with inhibitors were analyzed, and the data from 13 ITIs conducted in 12 patients were evaluated. The median age at ITI onset was 10 years (range: 1.25 to 52 y). The maximum inhibitor titer before ITI was 30 Bethesda Units (BU) (range: 4.48 to 135), and the median inhibitor titer was 1.25 BU (range: 0 to 5.6) at the onset of ITI. The median time interval between the inhibitor development and ITI onset was 60 months (range: 7 to 264 mo). The median inhibitor titer during ITI was 3.4 BU (range: 0 to 158.7). At the end of the treatment, 4 of the 12 patients (33.3%) exhibited a complete response, 4 (33.3%) had partial responses (with continuing ITI), and 4 (33.3%) exhibited ITI failure. CONCLUSIONS Treatment of hemophilia patients with inhibitors is challenging, and ITI is the best treatment method; however, a high-dose daily ITI regimen cannot be given to every patient in every country due to its high cost. Our results show that low-dose ITI may be a choice for selected patients with inhibitors.
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13
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Inpatient Health Care Utilization in Children With Hemophilia Before and After the Joint Outcome Study Publication. J Pediatr Hematol Oncol 2019; 41:e284-e289. [PMID: 30339654 DOI: 10.1097/mph.0000000000001329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The "Joint Outcomes Study" (JOS) demonstrated improved joint outcomes for patients receiving primary prophylaxis versus on-demand therapy. The impact of primary prophylaxis on inpatient health care utilization is not well-defined. To evaluate changes in hospitalization care of children with hemophilia before and after the 2007 JOS publication, this study utilized the Pediatric Health Information System (PHIS) to evaluate admissions for patients with hemophilia A or B (age, 2 to 7) admitted between January 2002 and 2006 (pre-JOS) and January 2010 and 2014 (post-JOS). Discharge diagnosis codes and clinical transaction classifications were used to differentiate bleeding episodes, infections, bypass agent use, length of stay, and intensive care unit (ICU) management. Overall, admissions for bleeding episodes did not change (26.5% of admissions pre-JOS vs. 23.6% post-JOS, P=0.10). However, admissions for suspected infections increased (3.0% of admissions pre-JOS vs. 7.2% post-JOS, P<0.01) while confirmed infections remained stable. Meanwhile, ICU utilization decreased (7.8% of admissions pre-JOS vs. 4.9% post-JOS, P<0.01). The necessity for ICU care in children with hemophilia has decreased since publication of the JOS. However, expanded adoption of primary prophylaxis is associated with more hospitalizations for suspected systemic infections, likely due to utilization of central venous catheters to deliver clotting factor concentrates.
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14
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Volkers P, Hanschmann K, Calvez T, Chambost H, Collins PW, Demiguel V, Hart DP, Hay CR, Goudemand J, Ljung R, Palmer BP, Santagostino E, van Hardeveld EM, van den Berg M, Keller‐Stanislawski B. Recombinant factor VIII products and inhibitor development in previously untreated patients with severe haemophilia A: Combined analysis of three studies. Haemophilia 2019; 25:398-407. [DOI: 10.1111/hae.13747] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 03/05/2019] [Accepted: 03/08/2019] [Indexed: 12/29/2022]
Affiliation(s)
| | | | - Thierry Calvez
- INSERM, Institut Pierre Louis d'Épidémiologie et de Santé publique Sorbonne Universités Paris France
| | - Hervé Chambost
- Service d'Hématologie Oncologie Pédiatrique, La Timone APHM and Aix Marseille Université Marseille France
| | - Peter W. Collins
- The University Department of Haematology University Hospital of Wales Hospital Cardiff UK
| | - Virginie Demiguel
- Santé publique France French National Public Health Agency Saint‐Maurice France
| | - Daniel P. Hart
- Barts and The London School of Medicine & Dentistry, The Royal London Hospital Haemophilia Centre QMUL London UK
| | - Charles R.M. Hay
- Department of Haematology, Manchester Royal Infirmary Manchester University Manchester UK
| | - Jenny Goudemand
- Service d'Hématologie et de Transfusion, Faculté de Médecine, Centre Hospitalier Universitaire de Lille Université Lille 2 Lille France
| | - Rolf Ljung
- Department of Clinical Sciences–Paediatrics Lund University Lund Sweden
| | - Ben P. Palmer
- The United Kingdom National Haemophilia Database Manchester UK
| | - Elena Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
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15
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Prevalence of factor VIII inhibitors among Afghan patients with hemophilia A: a first report. Blood Coagul Fibrinolysis 2018; 29:697-700. [PMID: 30439768 DOI: 10.1097/mbc.0000000000000780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
: Prevalence of inhibitors in Afghan hemophilia patients has not been reported previously. Our aim was to determine the prevalence of factor VIII inhibitors among hemophilia A patients from the Kabul province of Afghanistan to identify and characterize the pattern of inhibitor formation. Clinical information and blood samples were collected from three hemophilia centers in Kabul, Afghanistan. Plasma samples were obtained from 62 patients with severe (80.5%) and 15 patients with moderate hemophilia A (19.5%) in this cross-sectional study design. All the patients were receiving on-demand treatment. The Nijmegen modification of the Bethesda assay was used to detect inhibitors. Multiplex PCR, inverse-PCR, Multiplex ligation-dependent probe amplification and direct sequencing were performed for genotyping. Inhibitor activity was detected in one out of 15 (6.7%) patients with moderate hemophilia and in six out of 62 (9.7%) with severe disease. Apart from the intron 22 inversion, five different mutations including one missense, two large and two small deletions were detected. This is the first report showing that the prevalence of inhibitors in Afghan hemophilia A patients is much lower than in other populations.
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Arshad S, Singh A, Awasthi NP, Kumari S, Husain N. Clinicopathological parameters influencing inhibitor development in patients with hemophilia A receiving on-demand therapy. Ther Adv Hematol 2018; 9:213-226. [PMID: 30181842 PMCID: PMC6116755 DOI: 10.1177/2040620718785363] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/27/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Development of inhibitors to transfused factor VIII in patients with hemophilia A continues to be a challenge for professionals involved in hemophilia care. The majority of patients in India receive 'on-demand' rather than prophylactic therapy. The present study was done to assess the prevalence of factor VIII inhibitors in patients with hemophilia A (PWHA) receiving 'on-demand' therapy in a North Indian population and to study the clinicopathological parameters influencing the development of inhibitors. METHODS The study group comprised of 300 PWHA. Detailed clinical parameters, treatment history, bleeding profile including family history were recorded. Diagnosis of hemophilia A was confirmed by relevant coagulation tests. Inhibitors were screened using mixing based studies followed by quantification by Bethesda assay and Nijmegen modified Bethesda assay. Samples were collected from five cities in North India where a free supply of factor VIII was available and effectively used in three of these cities. RESULTS In the 300 PWHA, disease phenotype was severe in 219 (73%), moderate in 62 (20.67%) and mild in 19 (6.34%), based on the factor VIII bioassay. Inhibitor prevalence was 9.6% (n = 29) and seen only in the severe phenotype. Inhibitor titers ranged from 0.8 to 108.8 BU/ml. A total of 12 PWHA had low and 17 had high titers. Correlation of various clinicopathological parameters in inhibitor-positive versus negative PWHA showed significant correlation with age at onset of disease, severity of disease, age at first exposure to treatment, annual factor intake (IU/kg/year), intense treatment episodes and bleeding manifestations like central nervous system bleed and hematuria. The total study sample had blood group B in 33.34% PWHA, followed by O (27.34%), A (24.34%) and AB (15%), however, in inhibitor-positive samples, significant inhibitor formation was associated with the ABO subtype A (19/29, 65.51%). CONCLUSIONS Factor VIII inhibitor prevalence in PWHA receiving 'on-demand' therapy was 9.6%. Clinicopathological correlates of inhibitor development in such PWHA have been analyzed in this novel study.
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Affiliation(s)
- Sanya Arshad
- Dr. Ram Manohar Lohia Institute of Medical
Sciences, Lucknow, Uttar Pradesh, India
| | - Anshima Singh
- Dr. Ram Manohar Lohia Institute of Medical
Sciences, Lucknow, Uttar Pradesh, India
| | - Namrata Punit Awasthi
- Department of Pathology, Dr. Ram Manohar Lohia
Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow 226010,
India
| | - Swati Kumari
- Dr. Ram Manohar Lohia Institute of Medical
Sciences, Lucknow, Uttar Pradesh, India
| | - Nuzhat Husain
- Dr. Ram Manohar Lohia Institute of Medical
Sciences, Lucknow, Uttar Pradesh, India
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17
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Ethnicity-specific impact of HLA I/II genotypes on the risk of inhibitor development: data from Korean patients with severe hemophilia A. Ann Hematol 2018; 97:1695-1700. [PMID: 29766236 DOI: 10.1007/s00277-018-3358-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/29/2018] [Indexed: 01/01/2023]
Abstract
Inhibitor development is the most serious complication in patients with hemophilia. We investigated association of HLA genotypes with inhibitor development in Korean patients with severe hemophilia A (HA). HLA genotyping was done in 100 patients with severe HA including 27 patients with inhibitors. The allele frequencies between inhibitor-positive and inhibitor-negative patients were compared. HLA class I alleles were not associated with the inhibitor status. In HLA class II, DRB1*15 [n = 100, odds ratio (OR) 0.217, P = 0.028] and DPB1*05:01 [OR 0.461, P = 0.026] were negatively associated with inhibitor development. In a subgroup of patients with intron 22 inversion, C*07:02 was positively associated with inhibitor development [n = 30, OR 5.500, P = 0.043]. In the subgroup of patients without intron 22 inversion, the negative association between DPB1*05:01 and inhibitor development was reinforced [n = 70, OR 0.327, P = 0.010], and positive association of DRB1*13:02 and DPB1*04:01 with inhibitor development was identified [OR 3.059, P = 0.037 for both]. Previously reported risk alleles were not consistently associated with inhibitor risk in our series. This study demonstrated the profile of HLA alleles associated with inhibitor risk in Korean patients with severe HA was different from that in patients of other ethnicities, which needs to be considered in risk assessment and management.
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18
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Ljung RCR. How I manage patients with inherited haemophilia A and B and factor inhibitors. Br J Haematol 2017; 180:501-510. [DOI: 10.1111/bjh.15053] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Rolf C. R. Ljung
- Department of Clinical Sciences - Paediatrics; Lund University; Lund Sweden
- Centre for Thrombosis and Haemostasis; Skåne University Hospital Malmö; Malmo Sweden
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19
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Hartholt RB, van Velzen AS, Peyron I, Ten Brinke A, Fijnvandraat K, Voorberg J. To serve and protect: The modulatory role of von Willebrand factor on factor VIII immunogenicity. Blood Rev 2017; 31:339-347. [PMID: 28716211 DOI: 10.1016/j.blre.2017.07.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 05/26/2017] [Accepted: 07/03/2017] [Indexed: 12/23/2022]
Abstract
Hemophilia A is a bleeding disorder characterized by the absence or dysfunction of blood coagulation factor VIII (FVIII). Patients are treated with regular infusions of FVIII concentrate. In response to treatment, approximately 30% of patients with severe hemophilia A develop inhibitory antibodies targeting FVIII. Both patient and treatment related risk factors for inhibitor development have been described. Multiple studies comparing the immunogenicity of recombinant and plasma-derived FVIII have yielded conflicting results. The randomized controlled SIPPET (Survey of Inhibitors in Plasma-Product Exposed Toddlers) trial demonstrated an increased risk of inhibitor development of recombinant FVIII when compared to von Willebrand factor (VWF)-containing plasma-derived FVIII. Presently, it is unclear which mechanism underlies the reduced immunogenicity of plasma-derived FVIII. In this review we address the potential role of VWF on FVIII immunogenicity and we discuss how VWF affects the immune recognition, processing and presentation of FVIII. We also briefly discuss the potential impact of glycan-composition on FVIII immunogenicity. It is well established that VWF shields the uptake of FVIII by antigen presenting cells. We have recently shown that VWF binds to the surface of dendritic cells. Here, we present a novel model in which surface bound FVIII-VWF complexes regulate the internalization of FVIII. Binding of FVIII to VWF is critically dependent on sulfation of Tyr1699 (HVGS numbering) in the light chain of FVIII. Incomplete sulfation of Tyr1699 has been suggested to occur in several recombinant FVIII products resulting in a loss of VWF binding. We hypothesize that this results in alternative pathways of FVIII internalization by antigen presenting cells which are not regulated by VWF. This hypothetical mechanism may explain the reduced immunogenicity of VWF containing plasma-derived FVIII concentrates as found in the SIPPET study.
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Affiliation(s)
- Robin B Hartholt
- Department of Plasma Proteins, Sanquin Research, Plesmanlaan 125, 1066 CX Amsterdam, The Netherlands.
| | - Alice S van Velzen
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands.
| | - Ivan Peyron
- Department of Plasma Proteins, Sanquin Research, Plesmanlaan 125, 1066 CX Amsterdam, The Netherlands.
| | - Anja Ten Brinke
- Department of Plasma Proteins, Sanquin Research, Plesmanlaan 125, 1066 CX Amsterdam, The Netherlands.
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands.
| | - Jan Voorberg
- Department of Plasma Proteins, Sanquin Research, Plesmanlaan 125, 1066 CX Amsterdam, The Netherlands.
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20
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Assessment of acquired hemophilia patient demographics in the United States: the Hemostasis and Thrombosis Research Society Registry. Blood Coagul Fibrinolysis 2017; 27:761-769. [PMID: 27467981 PMCID: PMC5054949 DOI: 10.1097/mbc.0000000000000582] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The Hemostasis and Thrombosis Research Society (HTRS) Registry was used to monitor the postapproval use of recombinant factor VIIa. The objective of this manuscript is to provide key insights on the demographics of patients with acquired hemophilia in the HTRS Registry. Acquired hemophilia patient registration in HTRS captured age; sex; comorbidities and predisposing conditions; first bleeding location; laboratory parameters; exposure to blood products, factor, and bypassing agents; and initiation of immune suppression/tolerance therapy. Overall, 166 patients with acquired hemophilia were registered in HTRS (83 women, 73 men, median age 70 years); the majority were non-Hispanic whites (61.4%). The most common comorbidities were autoimmune disease (28.4%) and malignancy (14.5%). The most common first site of bleeding was subcutaneous (27.1%); this was more common in whites (29.1%) than blacks (12.5%) and in non-Hispanics (26.4%) than Hispanics (11.8%). Blood product exposure was reported for 33.1% of patients; the most commonly reported product was packed red blood cells (28%). Of the 57 patients with outcome data available for immune tolerance therapy, 26 patients (46%) reported successful treatment, 13 reported unsuccessful treatment (23%), and 18 (32%) were receiving active treatment at the time of registration. The HTRS Registry final analysis provides the only current comprehensive look at acquired hemophilia in the US population, including details on underlying autoimmune diseases and malignancies. Pertinent to recognition and diagnosis of the disease, subcutaneous bleeding as a presenting bleeding symptom was more common in white and non-Hispanic individuals.
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21
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Owaidah T, Momen AA, Alzahrani H, Almusa A, Alkasim F, Tarawah A, Nouno RA, Batniji FA, Alothman F, Alomari A, Abu-Herbish S, Abu-Riash M, Siddiqui K, Ahmed M, Mohamed SY, Saleh M. The prevalence of factor VIII and IX inhibitors among Saudi patients with hemophilia: Results from the Saudi national hemophilia screening program. Medicine (Baltimore) 2017; 96:e5456. [PMID: 28079788 PMCID: PMC5266150 DOI: 10.1097/md.0000000000005456] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Hemophilia A and B are X-linked diseases that predominantly affect male patients. Patients can develop coagulation factor inhibitors, which exponentially increases the treatment cost. However, the prevalence of factor VIII and IX inhibitors in Saudi Arabia is unclear.This study aimed to determine the Saudi prevalence of factor VIII and IX inhibitors.This 4-year, 7-center, cross-sectional study evaluated the Saudi prevalences of hemophilia A and B. We collected the patients' clinical data, evaluated their disease, and tested for factor inhibitors.We included 202 patients with hemophilia (median age at diagnosis: 0.13 years, range: birth-34.8 years). The patients included 198 male patients (98%), 148 patients with hemophilia A (73.3%), and 54 patients with hemophilia B (26.7%). The patients exhibited severe factor VIII activity (<1%; 121 patients; 5.2%), moderate activity (1-5%; 7 patients; 4.9%), and mild activity (14 patients; 9.9%). Among the patients with care-related data, most patients were treated for episodic bleeding (76.8%) or received prophylaxis (22.6%); 1 patient received both treatments. Among the patients with source-related data, the factor replacements were derived from plasma (48.4%), recombinant concentrates (22.9%), both sources (14.6%), or fresh frozen plasma (14.1%). Factor VIII inhibitors were observed in 43 (29.3%) of the 147 patients, and only 1 of the 54 patients developed factor IX inhibitors. Most patients who developed inhibitors had severe hemophilia (40/44; 90.9%), and inhibitors were also common among patients who received recombinant products (14/43; 32.6%).The Saudi prevalence of factor inhibitors was similar to those among other ethnic populations.
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Affiliation(s)
- Tarek Owaidah
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center
- Center of Excellence in Thrombosis and Hemostasis, King Saud University
| | | | | | - Abdulrahman Almusa
- Department of Pediatric Hematology, King Faisal Specialist Hospital and Research Center
| | - Fawaz Alkasim
- Department of Pediatric Hematology, Ministry of Health, Riyadh
| | - Ahmed Tarawah
- Department of Pediatric Hematology, Ministry of Health, Medina
| | - Randa Al Nouno
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center
| | | | - Fahad Alothman
- Department of Pediatric Hematology, Security Force Hospital
| | - Ali Alomari
- Department of Pediatric Hematology, National Guard Hospital
| | - Saud Abu-Herbish
- Department of Oncology, Security Forces Hospital, Riyadh, Saudi Arabia
| | | | - Khawar Siddiqui
- Department of Pediatric Hematology, King Faisal Specialist Hospital and Research Center
| | - Mansor Ahmed
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center
| | | | - Mahasen Saleh
- Department of Pediatric Hematology, King Faisal Specialist Hospital and Research Center
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22
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Lövgren KM, Søndergaard H, Skov S, Wiinberg B. Non-genetic risk factors in haemophilia A inhibitor management - the danger theory and the use of animal models. Haemophilia 2016; 22:657-66. [DOI: 10.1111/hae.13075] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2016] [Indexed: 12/20/2022]
Affiliation(s)
- K. M. Lövgren
- Department of Veterinary Disease Biology; University of Copenhagen; Frederiksberg Denmark
- Translational Haemophilia Pharmacology, Global Research; Novo Nordisk A/S; Maaloev Denmark
| | - H. Søndergaard
- Diabetes Complications Pharmacology; Global Research; Novo Nordisk A/S; Maaloev Denmark
| | - S. Skov
- Department of Veterinary Disease Biology; University of Copenhagen; Frederiksberg Denmark
| | - B. Wiinberg
- Haemophilia Translational Biology, Global Research; Novo Nordisk A/S; Maaloev Denmark
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23
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Abstract
In this issue of Blood, Chen et al demonstrate that platelets expressing factor VIII (FVIII) shield FVIII from immune detection. In the naive FVIII null hemophilia A (HA) mouse, platelet-derived VIII prevents both a primary and memory anti-FVIII immune response, and together with total body irradiation, suppresses anti-FVIII immune response.
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24
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Maratea D, Fadda V, Trippoli S, Messori A. Economic analysis of not running tenders for recombinant Factor VIII procurement: a simplified analysis to estimate an otherwise unknown pharmacoeconomic index. Eur J Hosp Pharm 2016; 23:219-223. [PMID: 31156852 DOI: 10.1136/ejhpharm-2015-000728] [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: 06/02/2015] [Revised: 11/17/2015] [Accepted: 11/23/2015] [Indexed: 11/04/2022] Open
Abstract
Background Two approaches to the procurement of recombinant Factor VIII products are used by health systems: (A) the most common approach where acquisition tenders are not carried out; (B) the approach tested in the UK in which procurement is based on tenders. The respective cost-effectiveness is not known. Objective To estimate the incremental cost-effectiveness ratio (ICER) for the comparison A vs B. Methods The analysis evaluated: (i) Factor VIII cost with/without tenders; (ii) inhibitor development caused by switching between products; (iii) clinical and economic consequences of inhibitors. Information on these items was obtained from a literature search. Because of the scarce evidence available on some items, our analysis considered the 'most favourable' scenario-that is, some extreme though reasonable assumptions were adopted that were intentionally biased towards improving the ICER of the no-tender option. Results and discussion We estimated an ICER for A vs B of £486 409 (€657 139; £1=€1.351) per quality-adjusted life year (QALY). Since pharmacoeconomic thresholds are ∼£30 000 per QALY, our results indicate that the cost-effectiveness of acquisition strategies that avoid tenders is prohibitive. Because of the simplified nature of our analysis, this estimate is preliminary. Conclusions The 'true' ICER of A vs B remains unknown, but its value is likely to be even worse than the unfavourable ICER of £486 409 (€657 139) per QALY.
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Affiliation(s)
- Dario Maratea
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Valeria Fadda
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Sabrina Trippoli
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Andrea Messori
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
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25
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Ragni MV. New and Emerging Agents for the Treatment of Hemophilia: Focus on Extended Half-Life Recombinant Clotting Proteins. Drugs 2016; 75:1587-600. [PMID: 26310188 DOI: 10.1007/s40265-015-0451-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Hemophilia A and B are X-linked disorders caused by deficient or defective clotting factor VIII (FVIII) or IX factor (FIX) proteins, and characterized by spontaneous or traumatic bleeding into joints and muscles. Previous use of plasma and plasma-derived clotting factors that lacked appropriate viral inactivation steps in manufacturing led to significant morbidity associated with transfusion-transmitted HIV and hepatitis C virus (HCV). The development of recombinant proteins revolutionized their treatment, and, with no new HIV or HCV infection via clotting proteins for nearly 30 years, greatly improved their lifespan, which now approaches that of the general population, and with the same risks for aging complications. Novel long-acting factor proteins are being licensed to extend FVIII and FIX half-life, thereby reducing infusion frequency and potentially bleed frequency and associated morbidity. Further, novel therapeutics which take advantage of new technologies, including siRNA, monoclonal antibody, and small peptide inhibition technologies, have the potential to simplify treatment and improve outcomes for those with inhibitors.
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Affiliation(s)
- Margaret V Ragni
- Division Hematology/Oncology, Department of Medicine, Hemophilia Center of Western Pennsylvania, University of Pittsburgh, 3636 Boulevard of the Allies, Pittsburgh, PA, 15213-4306, USA.
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26
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Guido N, Starostina E, Leake D, Saaem I. Improved PCR Amplification of Broad Spectrum GC DNA Templates. PLoS One 2016; 11:e0156478. [PMID: 27271574 PMCID: PMC4896431 DOI: 10.1371/journal.pone.0156478] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 05/16/2016] [Indexed: 11/28/2022] Open
Abstract
Many applications in molecular biology can benefit from improved PCR amplification of DNA segments containing a wide range of GC content. Conventional PCR amplification of DNA sequences with regions of GC less than 30%, or higher than 70%, is complex due to secondary structures that block the DNA polymerase as well as mispriming and mis-annealing of the DNA. This complexity will often generate incomplete or nonspecific products that hamper downstream applications. In this study, we address multiplexed PCR amplification of DNA segments containing a wide range of GC content. In order to mitigate amplification complications due to high or low GC regions, we tested a combination of different PCR cycling conditions and chemical additives. To assess the fate of specific oligonucleotide (oligo) species with varying GC content in a multiplexed PCR, we developed a novel method of sequence analysis. Here we show that subcycling during the amplification process significantly improved amplification of short template pools (~200 bp), particularly when the template contained a low percent of GC. Furthermore, the combination of subcycling and 7-deaza-dGTP achieved efficient amplification of short templates ranging from 10-90% GC composition. Moreover, we found that 7-deaza-dGTP improved the amplification of longer products (~1000 bp). These methods provide an updated approach for PCR amplification of DNA segments containing a broad range of GC content.
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Affiliation(s)
- Nicholas Guido
- Research & Development, Gen9 Inc, Cambridge, Massachusetts, United States of America
| | - Elena Starostina
- Research & Development, Gen9 Inc, Cambridge, Massachusetts, United States of America
| | - Devin Leake
- Research & Development, Gen9 Inc, Cambridge, Massachusetts, United States of America
| | - Ishtiaq Saaem
- Research & Development, Gen9 Inc, Cambridge, Massachusetts, United States of America
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27
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Klintman J, Berntorp E. Epidemiological aspects of inhibitor development in hemophilia and strategies of management. Expert Opin Orphan Drugs 2016. [DOI: 10.1517/21678707.2016.1127157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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28
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The immunogenicity of platelet-derived FVIII in hemophilia A mice with or without preexisting anti-FVIII immunity. Blood 2015; 127:1346-54. [PMID: 26668132 DOI: 10.1182/blood-2015-08-662916] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 12/09/2015] [Indexed: 01/04/2023] Open
Abstract
Evidence shows that factor VIII (FVIII) ectopically expressed in platelets (2bF8) is therapeutic in FVIII(null) mice even with anti-FVIII inhibitory antibodies (inhibitors). If current efforts to generate platelets in vitro succeed, genetically manipulated platelets containing FVIII may be used therapeutically in hemophilia A patients with inhibitors. One important concern is the immunogenicity of platelet-derived FVIII. To address this concern, we infused 2bF8 transgenic (2bF8(Tg)) platelets into naïve FVIII(null) mice weekly for 8 weeks. No anti-FVIII antibodies were detected in the infused animals during the study course. We then explored whether platelet-derived FVIII is immunogenic in FVIII(null) mice with inhibitors. The 2bF8(Tg) platelets were transfused into rhF8-primed FVIII(null) mice, resulting in no augmentation of anti-FVIII antibodies. To investigate whether preconditioning affects the immune response, animals were sublethally irradiated and subsequently transfused with 2bF8(Tg) platelets. No anti-FVIII antibodies were detected in the recipients after platelet infusions. Following further challenge with rhF8, the inhibitor titer in this group was significantly lower than in naïve FVIII(null) mice utilizing the same immunization protocol. Thus, our data demonstrate that infusion of platelets containing FVIII triggers neither primary nor memory anti-FVIII immune response in FVIII(null) mice and that sublethal irradiation plus 2bF8(Tg) platelet infusion suppresses anti-FVIII immune response in FVIII(null) mice.
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29
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Ragni MV, DiMichele DM, Hay CM, Malec LM, Seaman CD, Li J, Yabes JG, Butenas S, Brummel-Ziedins K. Thrombin generation and bleeding in haemophilia inhibitor patients during immune tolerance induction. Haemophilia 2015; 22:240-247. [PMID: 26517283 DOI: 10.1111/hae.12830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/09/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Inhibitor formation complicates haemophilia treatment and requires immune tolerance induction to rid inhibitors over 5 BU. In the prospective, randomized International Immune Tolerance Study, immune tolerance induction was equally effective with high-dose (HD) (200 IU kg-1 day-1 ) and low-dose (LD) (50 IU kg-1 3× per week) factor VIII, but haemorrhages were twofold higher in the LD arm. This finding was unexpected as inhibitors neutralize FVIII activity. We hypothesized that the thrombin generation assay (TGA), a global measure of clot formation, might predict bleeding better than FVIII levels. METHODS We evaluated TGA using relipidated tissue factor (TF) on 83 thawed, recalcified corn trypsin inhibitor/citrate plasma samples from 31 subjects (17 HD, 14 LD) who participated on the ITI study, and who had sufficient sample available and appropriate informed consent. RESULTS There were no significant differences in peak thrombin, estimated thrombin potential, maximum rate or lag time between HD and LD arms; between pre-, during and post-ITI time points, or after FVIII spiking. In 19 subjects (12 HD, 7 LD) with anti-FVIII<1.0 BU, the prevalence of non-neutralizing antibody (NNA) and neutralizing antibody (NA) was 89.5% (17/19), and the latter strongly correlated with anti-VIII titer, r = 0.73 [95% CI: 0.55, 0.88]. CONCLUSION In haemophilia inhibitor patients, thrombin generation is present, but does not predict bleeding risk. Following tolerance induction, NNA remains detectable in the majority.
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Affiliation(s)
- M V Ragni
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - D M DiMichele
- Division of Blood Diseases and Resources, National Heart Blood Lung Institute, Bethesda, MD, USA
| | - C M Hay
- Department of Hematology, Manchester University Royal Infirmary, Manchester, UK
| | - L M Malec
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - C D Seaman
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA
| | - J Li
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - J G Yabes
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - S Butenas
- Department of Biochemistry, University of Vermont, Colchester, VT, USA
| | - K Brummel-Ziedins
- Department of Biochemistry, University of Vermont, Colchester, VT, USA
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30
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Leissinger CA. Advances in the clinical management of inhibitors in hemophilia A and B. Semin Hematol 2015; 53:20-7. [PMID: 26805903 DOI: 10.1053/j.seminhematol.2015.10.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2004] [Revised: 11/05/2004] [Accepted: 12/01/2005] [Indexed: 01/25/2023]
Abstract
Inhibitors to factor (F)VIII or FIX are the most serious and challenging complication of hemophilia treatment, increasing morbidity and mortality because bleeds no longer respond to standard clotting factor replacement therapy. For patients with high-titer inhibitors, immune tolerance induction achieved through regular factor exposure is the only proven therapy capable of Inhibitor eradication and is almost always indicated for inhibitors of recent onset. Bypassing therapy is used to treat and prevent bleeding, but neither of the two currently available bypassing agents has the predictable hemostatic efficacy of factor replacement in hemophilia patients without inhibitors. Major research efforts are focused on the development of new, more potent therapies for the management of patients with inhibitors.
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Affiliation(s)
- Cindy A Leissinger
- Departments of Medicine, Pediatrics, and Pathology, Tulane University School of Medicine, New Orleans, LA, USA.
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31
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Jacquemin M, Saint-Remy JM. T cell response to FVIII. Cell Immunol 2015; 301:8-11. [PMID: 26435345 DOI: 10.1016/j.cellimm.2015.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 09/16/2015] [Accepted: 09/16/2015] [Indexed: 10/23/2022]
Abstract
Several lines of evidence indicate that the immune response to Factor VIII (FVIII) in patients with hemophilia A is T cell-dependent. This review highlights the link between the epitope specificity of FVIII-specific T cells and their potential roles in different categories of patients. FVIII-specific T cells able to recognize wild-type (i.e. therapeutic) FVIII but not the mutated self FVIII of hemophilia patients have been identified in patients with mild/moderate hemophilia carrying some point mutations. Such T cells likely contribute to the higher frequency of neutralizing anti-FVIII antibodies (inhibitors) development in these patients. In contrast, as yet no T cells have been identified that can differentiate between FVIII molecules with non-hemophilia-causing single amino acid variants encoded by non-synonymous single-nucleotide polymorphisms in the F8 gene. Other mechanisms are therefore still to be identified that will explain the clinically noted differences in the incidence of inhibitor development between patients of different races who are known to have differences at these sites. Beside information about the mechanism of inhibitor development, the analysis of FVIII-specific T cells has provided tools to develop novel diagnostic and therapeutic approaches, such as the generation of FVIII-specific regulatory T cells that may be useful in preventing or suppressing the immune response to FVIII.
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Affiliation(s)
- Marc Jacquemin
- University of Leuven, Center for Molecular and Vascular Biology, Herestraat 49 Bus 913, B3000 Leuven, Belgium.
| | - Jean-Marie Saint-Remy
- University of Leuven, Center for Molecular and Vascular Biology, Herestraat 49 Bus 913, B3000 Leuven, Belgium; ImCyse s.a.-n.v., Bioincubator II, Gaston Geenslaan 1, B-3001 Leuven, Belgium.
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Carcao M, Re W, Ewenstein B. The role of previously untreated patient studies in understanding the development of FVIII inhibitors. Haemophilia 2015; 22:22-31. [PMID: 26315604 DOI: 10.1111/hae.12790] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2015] [Indexed: 01/01/2023]
Abstract
Development of inhibitors against factor VIII (FVIII), the major complication of haemophilia A treatment today, is influenced by multiple factors. Genetic (F8 mutation, family history, ethnicity, polymorphisms in immune modulating genes) and non-genetic (intensive exposure to FVIII, presence of pro-inflammatory signals as might occur with large bleeds, infections, surgery, or other immune stimulants [e.g. vaccines]) risk factors as well as their complex inter-relationships contribute to the inhibitor risk profile of haemophilia patients, particularly in the previously untreated patient (PUP) population. Studies in PUPs have been fundamental to furthering the understanding of FVIII inhibitor development, as well as discovering previously unappreciated risk factors. The multi-factorial nature of inhibitor development makes it difficult to ascertain the contribution of FVIII products in inhibitor development through individual PUP studies. Sufficiently powered studies of large cohorts may overcome these limitations but interpretations should be conducted cautiously. Proper design and implementation of PUP safety studies will become even more important with the introduction of new molecules, such as extended half-life or human cell-line derived FVIII that propose reduced immunogenicity. Despite these difficulties, carefully performed clinical studies in PUPs may provide important insights into the natural history of the immune response to FVIII and may suggest targets for intervention to reduce immunogenicity.
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Affiliation(s)
- M Carcao
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - W Re
- Baxter Healthcare Corporation, West Lake, CA, USA
| | - B Ewenstein
- Baxter Healthcare, Clinical Research and Development, Westlake Village, CA, USA
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Ghosh K, Ghosh K. Management of Haemophilia in Developing Countries: Challenges and Options. Indian J Hematol Blood Transfus 2015; 32:347-55. [PMID: 27429529 DOI: 10.1007/s12288-015-0562-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 06/04/2015] [Indexed: 12/13/2022] Open
Abstract
There are significant challenges in managing haemophilia patients in developing countries. These challenges are (i) Lack of proper health care infrastructure and human resources suitable for haemophilia care (ii) Competing health care priorities of the government. (iii) Lack of penetrance of medical insurance in the population. (iv) Lesser visibility of the haemophilia patients in health care system (v) Low awareness across the medical profession, population and the policy makers about the condition (vi) Non availability of factor concentrates (vii) Inadequate utilization of knowledge for reducing factor concentrate use. (viii) Inadequate pain relief (ix) Challenges due to inhibitor developing (x) Viral hepatitis & (xi) Lack of research publications relevant to the country are some of the challenges faced by PWH for their management in developing country. The solutions are not easy but development of a strong patient organization with linkages with World Federation of Haemophilia is an important initial step. Following that internal and international twinning, use of internal sources, strong advocacy programme targeting government, doctors, opinion makers will solve many of the challenges in the time to come.
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Affiliation(s)
- Kanjaksha Ghosh
- National Institute of Immunohaematology, 13 Th Fl KEM Hospital, Parel Mumbai, 400012 India ; Haemophilia Federation of India, New Delhi, India
| | - Kinjalka Ghosh
- National Institute of Immunohaematology, 13 Th Fl KEM Hospital, Parel Mumbai, 400012 India ; Department of Biochemistry, Seth GS Medical College and KEM Hospital, Parel Mumbai, 400012 India
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Valentino LA, Kempton CL, Kruse-Jarres R, Mathew P, Meeks SL, Reiss UM. US Guidelines for immune tolerance induction in patients with haemophilia a and inhibitors. Haemophilia 2015; 21:559-67. [DOI: 10.1111/hae.12730] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2015] [Indexed: 01/19/2023]
Affiliation(s)
| | - C. L. Kempton
- Emory University School of Medicine; Atlanta GA USA
- Aflac Cancer and Blood Disorders Center; Emory University/Children's Healthcare of Atlanta; Atlanta GA USA
| | - R. Kruse-Jarres
- Puget Sound Blood Center/University of Washington; Seattle WA USA
| | - P. Mathew
- University of New Mexico; Albuquerque NM USA
| | - S. L. Meeks
- Aflac Cancer and Blood Disorders Center; Emory University/Children's Healthcare of Atlanta; Atlanta GA USA
| | - U. M. Reiss
- St. Jude Children's Research Hospital; Memphis TN USA
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Auerswald G, Kurnik K, Aledort LM, Chehadeh H, Loew-Baselli A, Steinitz K, Reininger AJ. The EPIC study: a lesson to learn. Haemophilia 2015; 21:622-8. [DOI: 10.1111/hae.12666] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2015] [Indexed: 12/01/2022]
Affiliation(s)
- G. Auerswald
- Prof. Hess Children's Hospital; Klinikum Bremen-Mitte; Bremen Germany
| | - K. Kurnik
- Klinikum der Universitaet Muenchen; Dr von Haunersches Children's Hospital; Munich Germany
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Factor VIII gene variants and inhibitor risk in African American hemophilia A patients. Blood 2015; 126:895-904. [PMID: 25617427 DOI: 10.1182/blood-2014-09-599365] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 01/02/2015] [Indexed: 01/05/2023] Open
Abstract
African American hemophilia A (HA) patients experience a higher incidence of neutralizing anti-factor VIII (FVIII) antibodies ("inhibitors") vis-à-vis white patients. Nonsynonymous single-nucleotide polymorphisms (ns-SNPs) in the F8 gene encoding FVIII-H484, FVIII-E1241, and FVIII-V2238 are more prevalent in African Americans. This study tested the hypothesis that immune responses to these sites provoke inhibitors. Blood samples were obtained from 174 African American and 198 white HA subjects and their F8 gene sequences determined. Major histocompatibility complex class II binding and T-cell recognition of polymorphic sequences were evaluated using quantitative binding assays and HLA-DRB1 tetramers. Peptides corresponding to 4 common ns-SNPs showed limited binding to 11 HLA-DRB1 proteins. CD4 T cells from 22 subjects treated with FVIII products having sequences at residues FVIII-484, 1241, and 2238 differing from those of putative proteins encoded by their F8 genes did not show high-avidity tetramer binding, whereas positive-control staining of tetanus-specific CD4 T cells was routinely successful. African Americans with an intron-22 inversion mutation showed a 2-3 times-higher inhibitor incidence than whites with the same mutation (odds ratio = 2.3 [1.1-5.0, P = .04]), but this did not correlate with any of the ns-SNPs. We conclude that immune responses to "sequence-mismatched" FVIII products are unlikely to contribute appreciably to the inhibitor incidence in African Americans.
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Auxiliary Partial Orthotopic Liver Transplantation as a Treatment for Hemophilia A: A Case Report. Transplant Proc 2015; 47:161-4. [DOI: 10.1016/j.transproceed.2014.08.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 07/11/2014] [Accepted: 08/19/2014] [Indexed: 11/23/2022]
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Osooli M, Berntorp E. Inhibitors in haemophilia: what have we learned from registries? A systematic review. J Intern Med 2015; 277:1-15. [PMID: 25169114 DOI: 10.1111/joim.12301] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Congenital haemophilia A and B are genetic disorders affecting factor VIII and factor IX production, respectively. Factor replacement is the only effective treatment for these deficiencies, but a patient's immune system can develop inhibitory antibodies which bind and interfere with the function of the replaced factor in a variety of ways. The main treatment goal for patients with inhibitors is to induce immune tolerance to the injected factor. If not successful, a different treatment termed bypass therapy is needed to treat bleeds. The goal of this review is to demonstrate the usefulness of haemophilia registries as information sources to supplement available evidence regarding predictors of inhibitor development and immune tolerance induction (ITI) outcomes. In this systematic review, relevant keywords were used to search online academic databases during February 2014. Inclusion criteria were original publication and data obtained from a haemophilia or ITI registry with a minimum of 30 patients. A data collection form was created to extract information from selected manuscripts. Titles, abstracts and then full texts were screened to determine the eligibility of reports for this review. Eleven manuscripts from nine registries were determined eligible and included in the study. Registries have reported on some core variables, but are inconsistent in reporting less practiced predicting variables. Variables that may affect inhibitor and ITI outcomes were each divided into two categories: patient characteristics (such as age and family history) and treatment-related variables (including exposure days, treatment duration and dose). It is recommended that, in addition to exploratory hypothesis testing, a minimum set of variables should be collected and reported by registries. International collaboration and well-designed prospective registries are of major importance to advance this field in order to determine inhibitor risks and ITI outcomes and facilitate the development of new treatments.
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Affiliation(s)
- M Osooli
- Centre for Thrombosis and Haemostasis, Skåne University Hospital, Lund University, Malmö, Sweden
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Ragni MV, Malec LM. Design of the INHIBIT trial: preventing inhibitors by avoiding 'danger', prolonging half-life and promoting tolerance. Expert Rev Hematol 2014; 7:747-55. [PMID: 25374055 DOI: 10.1586/17474086.2014.963550] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Inhibitor formation is among the most serious complications of hemophilia treatment. With the US FDA licensure of the novel long-lasting recombinant factor VIII (FVIII) Fc fusion protein, Eloctate, which prolongs FVIII half-life, we propose an innovative approach to prevent inhibitor formation. In this paper, we describe a multicenter, Phase II, single-arm, 48-week trial, the INHIBIT trial, to determine if Eloctate, begun before a bleed and continued as once weekly prophylaxis, will reduce inhibitor formation in children with hemophilia A. We hypothesize that avoiding 'danger,' that is, immune activation by a bleed at first factor exposure and prolonging FVIII half-life will prevent inhibitors and promote FVIII-specific T-cell tolerance. If successful, this approach will suggest a new paradigm in clinical practice.
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Affiliation(s)
- Margaret V Ragni
- Department of Medicine, Division Hematology/Oncology, University of Pittsburgh, 3636 Boulevard of the Allies, Pittsburgh, 15213-4306, PA, USA
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Kurnik K, Auerswald G, Kreuz W. Inhibitors and prophylaxis in paediatric haemophilia patients: Focus on the German experience. Thromb Res 2014; 134 Suppl 1:S27-32. [DOI: 10.1016/j.thromres.2013.10.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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41
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Factor VIII mutations and inhibitor formation in a southern Brazilian population. Blood Coagul Fibrinolysis 2013; 25:125-7. [PMID: 23963097 DOI: 10.1097/mbc.0b013e328364cc83] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A total of 110 patients with severe (n = 43), moderate (n = 15) or mild (n = 52) haemophilia A were studied in relation to their F8 gene mutation and inhibitor status. Nineteen percentage of them had anti-factor VIII antibodies. Significant heterogeneity in inhibitor prevalence considering the location of the patients' mutation was found, with higher frequencies in carriers of mutations in the C1 and B domains. Twelve specific mutations showed associations with inhibitor formation, seven deletions, two nonsense, two insertions and one missense changes. Bioinformatic analysis of the missense mutation confirmed the formation of a B-cell epitope in the protein. This information is important for comparative purposes with series of other ethnic constitutions, as well as for individual prevention of this serious clinical problem in the patient population.
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Witmer C, Young G. Factor VIII inhibitors in hemophilia A: rationale and latest evidence. Ther Adv Hematol 2013; 4:59-72. [PMID: 23610614 DOI: 10.1177/2040620712464509] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Factor VIII (FVIII) replacement therapy is the foundation of treatment in hemophilia A and is effective unless a patient develops an alloantibody (inhibitor) against exogenous FVIII. Inhibitor development is currently the most significant treatment complication seen in patients with hemophilia and is associated with considerable morbidity and a decreased quality of life. The development of an inhibitor is the result of a complex interaction between a patient's immune system and genetic and environmental risk factors. The mainstay of treatment is the eradication of the inhibitor through immune tolerance. This review summarizes the current evidence regarding inhibitor risk factors, eradication, and hemostatic bypassing agents.
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Affiliation(s)
- Char Witmer
- Division of Hematology, The Children's Hospital of Philadelphia, 3501 Civic Center Boulevard, CTRB 11th Floor, Room 11026, Philadelphia, PA 19104, USA
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Pergantou H, Varela I, Moraloglou O, Economou M, Spanou K, Kapsimali Z, Constantinidou N, Platokouki H. Impact of HLA alleles and cytokine polymorphisms on inhibitors development in children with severe haemophilia A. Haemophilia 2013; 19:706-10. [PMID: 23607306 DOI: 10.1111/hae.12168] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2013] [Indexed: 11/30/2022]
Abstract
Human Leucocyte Antigen (HLA) alleles, cytokine polymorphisms and the type of factor VIII (FVIII) gene mutation are among predisposing factors for inhibitors (inh) development in children with severe haemophilia A (HA). The aim was to investigate the correlations among (i) FVIII gene intron-22 inversion, (ii) HLA alleles and haplotypes and (iii) certain cytokine polymorphisms, with the risk for FVIII inhibitors development in 52 Greek severe HA children, exclusively treated with recombinant concentrates. We performed Long-Range PCR for detection of intron-22 inversion and PCR-SSP, PCR-SSO for genotyping of HLA-A, B, C, DRB1, DQB1 alleles and also for cytokine polymorphisms of TNF-α, TGF-β1, IL-10, IL-6 and IFN-γ. Chi-squared test and Fischer's exact test were used for statistical analysis. A total of 28 children had developed inhibitors (Group I), 71.4% high responding, while 24 had not (Group II). No statistically increased intron-22 inversion prevalence was found in Group I compared with Group II (P = 0.5). Comparison of HLA allele frequencies between the two groups showed statistically significant differences in the following genotypes (i) promoting inhibitors development: DRB1*01(P = 0.014), DRB1*01:01(P = 0.011) and DQB1*05:01 (P = 0.005) and (ii) possibly protecting from inhibitors development: DRB1*11 (P = 0.011), DRB1*11:01 (P = 0.031), DQB1*03 (P = 0.004) and DQB1*03:01 (P = 0.014). Analysis of cytokines revealed a higher incidence of inhibitor detection only in homozygotes of the haplotypes ACC and ATA for IL-10 polymorphisms (P = 0.05). There is evidence that HLA alleles and cytokine polymorphisms play an important role in FVIII inh development. On the contrary, no statistically significant results were obtained for intron-22 inversion and its impact on FVIII inhibitors formation.
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Affiliation(s)
- H Pergantou
- Haemophilia Centre/Haemostasis Unit, Aghia Sophia Children's Hospital, Athens, Greece.
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Banugaria SG, Prater SN, McGann JK, Feldman JD, Tannenbaum JA, Bailey C, Gera R, Conway RL, Viskochil D, Kobori JA, Rosenberg AS, Kishnani PS. Bortezomib in the rapid reduction of high sustained antibody titers in disorders treated with therapeutic protein: lessons learned from Pompe disease. Genet Med 2012; 15:123-31. [PMID: 23060045 DOI: 10.1038/gim.2012.110] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE High sustained antibody titers complicate many disorders treated with a therapeutic protein, including those treated with enzyme replacement therapy, such as Pompe disease. Although enzyme replacement therapy with alglucosidase alfa (Myozyme) in Pompe disease has improved the prognosis of this otherwise lethal disorder, patients who develop high sustained antibody titers to alglucosidase alfa enter a prolonged phase of clinical decline resulting in death despite continued enzyme replacement therapy. Clinically effective immune-tolerance induction strategies have yet to be described in the setting of an entrenched immune response characterized by high sustained antibody titers, wherein antibody-producing plasma cells play an especially prominent role. METHODS We treated three patients with infantile Pompe disease experiencing marked clinical decline due to high sustained antibody titers. To target the plasma cell source of high sustained antibody titers, a regimen based on bortezomib (Velcade) was used in combination with rituximab, methotrexate, and intravenous immunoglobulin. RESULTS The treatment regimen was well tolerated, with no obvious side effects. Patient 1 had a 2,048-fold, and patients 2 and 3 each had a 64-fold, reduction in anti-alglucosidase alfa antibody titer, with concomitant sustained clinical improvement. CONCLUSION The addition of bortezomib to immunomodulatory regimens is an effective and safe treatment strategy in infantile Pompe disease, with potentially broader clinical implications.
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Affiliation(s)
- Suhrad G Banugaria
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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Abstract
The development of alloantibodies or inhibitors is the most serious complication a patient with severe hemophilia can experience from treatment with clotting factor concentrates. Although common in previously untreated patients, inhibitor development is rare in multiply exposed, well-tolerized patients. There has been a nonevidence-based reluctance to change concentrate because of a perceived greater inhibitor risk after the switch, even though most patients are now likely to be using a concentrate on which they did not begin. Inhibitors in previously treated patients are observed in approximately 2 per 1000 patient/years, which makes it difficult to study and compare rates among different products. Because the baseline inhibitor risk in previously treated patients may vary over time, it is important to compare the risk in patients switching to a new product with that in a parallel control group of nonswitching patients or within a case-controlled study. The study designs imposed by regulators are suboptimal in detecting immunogenicity signals. The issue of immunogenicity of new products is likely to gain more relevance in the near future, with a call for effective postmarketing surveillance studies for all of the new engineered factor VIII concentrates with prolonged half-lives that are likely to enter clinical practice.
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CARPENTER SL, MICHAEL SOUCIE J, STERNER S, PRESLEY R. Increased prevalence of inhibitors in Hispanic patients with severe haemophilia A enrolled in the Universal Data Collection database. Haemophilia 2012; 18:e260-5. [DOI: 10.1111/j.1365-2516.2011.02739.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Monahan PE, Baker JR, Riske B, Soucie JM. Physical functioning in boys with hemophilia in the U.S. Am J Prev Med 2011; 41:S360-8. [PMID: 22099359 DOI: 10.1016/j.amepre.2011.09.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 08/12/2011] [Accepted: 09/12/2011] [Indexed: 10/15/2022]
Abstract
BACKGROUND Hemophilia is the most common inherited severe bleeding disorder. Although the most frequent complication of repeated hemorrhages is a crippling joint disease that begins in childhood, the extent of resultant joint functional impairment varies widely within the hemophilia population. PURPOSE The goal of this exploratory analysis was to examine a national database that collects information on boys with hemophilia, an X-linked severe congenital bleeding disorder, to determine characteristics associated with increased risk of developing limitations in physical functioning as an outcome of recurrent hemorrhages. METHODS A standard set of data is collected annually at ∼130 U.S. comprehensive hemophilia treatment centers (HTCs) in a voluntary surveillance program called the Universal Data Collection (UDC) program. Fifteen potential predictors for poor outcomes of physical functioning related to bleeding were examined for boys (aged ≤ 18 years) from 1998 to 2008. Bivariate and multivariate analyses of these predictors performed in 2009 examined associations with self-reported limitation of activities, absenteeism from work or school, and reliance on assistive devices for ambulation and mobility. RESULTS Multiple characteristics of underlying hemophilia severity and disease chronicity (in particular, increasing age, presence of joint bleeding, and inhibitor antibodies) were independently associated with increased risk of limitations of physical function. Nonwhite race/ethnicity was associated with each of the poorer functional outcomes in bivariate analyses. After controlling for the potential confounding effects of the multiple population characteristics on race, only African-American race was independently associated with activity restrictions, and African-American and Asian/Pacific Island ethnicity with absenteeism. With the exception of indicators of underlying disease severity, only obesity and medical insurance coverage with Medicaid rather than commercial insurance were independently associated with multiple poor outcomes. CONCLUSIONS Interventions focused on eliminating inhibitors, improving outcomes for African-American children with hemophilia, and maintaining healthy body weight are warranted. In addition, strategies are needed to assure adequate insurance coverage for all people with hemophilia to eliminate economic barriers to optimal functional outcomes.
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Affiliation(s)
- Paul E Monahan
- Department of Pediatrics, Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7016, USA.
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Miller CH, Benson J, Ellingsen D, Driggers J, Payne A, Kelly FM, Soucie JM, Craig Hooper W. F8 and F9 mutations in US haemophilia patients: correlation with history of inhibitor and race/ethnicity. Haemophilia 2011; 18:375-82. [PMID: 22103590 DOI: 10.1111/j.1365-2516.2011.02700.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Both genetic and treatment-related risk factors contribute to the development of inhibitors in haemophilia. An inhibitor surveillance system piloted at 12 US sites has the goal of assessing risk factors through prospective data collection. This report examines the relationship of genotype and race/ethnicity to history of inhibitor in a large cohort of US haemophilia patients. Mutation analysis was performed on 676 haemophilia A (HA) and 153 haemophilia B (HB) patients by sequencing, Multiplex Ligation-dependent Probe Amplification, and PCR for inversions in F8 introns 22 (inv22) and 1 (inv1). Two HB patients with deletions had history of inhibitor. In severe HA, frequency of history of inhibitor was: large deletion 57.1%, splice site 35.7%, inv22 26.8%, nonsense 24.5%, frameshift 12.9%, inv1 11.1% and missense 9.5%. In HA, 19.6% of 321 White non-Hispanics (Whites), 37.1% of 35 Black non-Hispanics (Blacks) and 46.9% of 32 Hispanics had history of inhibitor (P = 0.0003). Mutation types and novel mutation rates were similar across ethnicities. When F8 haplotypes were constructed, Whites and Hispanics showed only H1 and H2. Within H1, history of inhibitor was 12.4% in Whites, 40.0% in Blacks (P = 0.009) and 32.4% in Hispanics (P = 0.002). Inhibitor frequency is confirmed to vary by mutation type and race in a large US population. White patients with history of inhibitor did not exhibit rare F8 haplotypes. F8 gene analysis did not reveal a cause for the higher inhibitor frequencies in Black and Hispanic patients.
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Affiliation(s)
- C H Miller
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
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Ragni MV. Rationale for a randomized controlled trial comparing two prophylaxis regimens in adults with severe hemophilia A: the Hemophilia Adult Prophylaxis Trial. Expert Rev Hematol 2011; 4:495-507. [PMID: 21939418 DOI: 10.1586/ehm.11.52] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A major goal of comprehensive hemophilia care is to prevent occurrence of bleeds by prophylaxis or regular preventive factor, one or more times weekly. Although prophylaxis is effective in reducing bleeding and joint damage in children, whether it is necessary to continue into adulthood is not known. The purpose of this article is to describe a Phase III randomized controlled trial to evaluate prophylaxis comparing two dose regimens in adults with severe hemophilia A. I hypothesize that adults with mature cartilage and joints are less susceptible to joint bleeds and joint damage, and that once-weekly recombinant factor VIII prophylaxis, with up to two rescue doses per week, is as effective as thrice-weekly prophylaxis in reducing bleeding frequency, but less costly and more acceptable, with higher quality of life. The ultimate goal of this project is to determine whether once-weekly prophylaxis is any worse than thrice-weekly prophylaxis in reducing joint bleeding frequency, while potentially utilizing less factor, at lower cost, leading to a better quality of life. This is an innovative concept, as it challenges the current paradigm of thrice-weekly prophylaxis in adults, which is based on dosing in children. Furthermore, this trial will assess interdose thrombin generation, a novel tissue factor-based assay of hemostasis, to determine if individualized thrombin generation can predict more individualized prophylaxis dosing, which would be practice changing.
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Affiliation(s)
- Margaret V Ragni
- University of Pittsburgh Medical Center, Department of Medicine, Division Hematology/Oncology, and Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, USA.
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