1
|
Horiguchi A, Arakawa Y, Mitani Y, Isobe K, Mori M, Fukuoka K, Oshima K, Koh K. Regular prophylaxis with activated prothrombin complex concentrates in pediatric hemophilia. Pediatr Int 2024; 66:e15774. [PMID: 38924603 DOI: 10.1111/ped.15774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 02/01/2024] [Accepted: 03/26/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Regular prophylaxis with activated prothrombin complex concentrates (aPCCs) is effective in adult patients with hemophilia with inhibitors; however, data in children are scarce. METHODS This was a single-center retrospective study at Saitama Children's Medical Center. Patients with severe and moderate hemophilia with inhibitors aged <15 years at the start of aPCCs prophylaxis were included. Medical records were retrospectively reviewed. RESULTS We treated nine pediatric patients with hemophilia with inhibitors (median age, 1.9 years; age range, 1.3-12.9 years; inhibitor titers before treatment with aPCCs, 5.9-69 BU/mL) using prophylactic aPCCs (doses, 50-100 U/kg; 2-3 times/week). The median prophylactic period was 13 months (range: 5-31 months). The median annualized bleeding rate (ABR) during prophylactic treatment with aPCCs was 2 (range, 0-17). In four patients, ABR was reduced by 19%-100% with prophylactic aPCCs compared to on-demand aPCCs. An adverse effect of treatment was that a patient with hemophilia B developed nephrotic syndrome 34 months after starting regular prophylaxis with aPCCs. CONCLUSIONS Regular prophylactic aPCCs reduced the ABR even in younger children with hemophilia A and B. Serious adverse events include nephrotic syndrome, which requires caution.
Collapse
Affiliation(s)
- Ayumi Horiguchi
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Yuki Arakawa
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Yuichi Mitani
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Kiyotaka Isobe
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Makiko Mori
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Kohei Fukuoka
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Koichi Oshima
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| |
Collapse
|
2
|
Radiosynovectomy for the Treatment of Chronic Hemophilic Synovitis: An Old Technique, but Still Very Effective. J Clin Med 2022; 11:jcm11247475. [PMID: 36556091 PMCID: PMC9788214 DOI: 10.3390/jcm11247475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/05/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
A radiosynovectomy (RS) should be indicated when recurrent articular bleeds related to chronic hemophilia synovitis (CHS) exist, established by clinical examination, and confirmed by imaging techniques that cannot be constrained with hematological prophylaxis. RS can be performed at any point in life, mainly in adolescents (>13−14 years) and adults. Intraarticular injection (IAI) of a radioactive material in children might be arduous since we need child collaboration which might include general anesthesia. RS is our initial option for management of CHS. For the knee joint we prescribe Yttrium-90, while for the elbow and ankle we prescribe Rhenium-186 (1 to 3 IAIs every 6 months). The procedure is greatly cost efficient when compared to surgical synovectomy. Chemical synovectomy with rifampicin has been reported to be efficacious, inexpensive, simple, and especially practical in developing countries where radioactive materials are not easily available. Rifampicin seems to be more efficacious when it is utilized in small joints (elbows and ankles), than when utilized in bigger ones (knees). When RS and/or chemical synovectomy fail, arthroscopic synovectomy (or open synovectomy in some cases) should be indicated. For us, surgery must be performed after the failure of 3 RSs with 6-month interims. RS is an effective and minimally invasive intervention for treatment of repeated articular bleeds due to CHS. Although it has been published that the risk of cancer does not increase, and that the amount of radioactive material used in RS is insignificant, the issue of chromosomal and/or deoxyribonucleic acid (DNA) changes remains a concern and continued surveillance is critical. As child and adulthood prophylaxis becomes more global, RS might become obsolete in the long-term.
Collapse
|
3
|
Valke LLFG, Rijpma S, Meijer D, Schols SEM, van Heerde WL. Thrombin generation assays to personalize treatment in bleeding and thrombotic diseases. Front Cardiovasc Med 2022; 9:1033416. [PMID: 36440026 PMCID: PMC9684194 DOI: 10.3389/fcvm.2022.1033416] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/26/2022] [Indexed: 07/30/2023] Open
Abstract
Treatment of bleeding and thrombotic disorders is highly standardized and based on evidence-based medicine guidelines. These evidence-based treatment schemes are well accepted but may lead to either insufficient treatment or over-dosing, because the individuals' hemostatic properties are not taken into account. This can potentially introduce bleeding or thrombotic complications in individual patients. With the incorporation of pharmacokinetic (PK) and pharmacodynamic (PK-PD) parameters, based on global assays such as thrombin generation assays (TGAs), a more personalized approach can be applied to treat either bleeding or thrombotic disorders. In this review, we will discuss the recent literature about the technical aspects of TGAs and the relation to diagnosis and management of bleeding and thrombotic disorders. In patients with bleeding disorders, such as hemophilia A or factor VII deficiency, TGAs can be used to identify patients with a more severe bleeding phenotype and also in the management with non-replacement therapy and/or bypassing therapy. These assays have also a role in patients with venous thrombo-embolism, but the usage of TGAs in patients with arterial thrombosis is less clear. However, there is a potential role for TGAs in the monitoring of (long-term) antithrombotic therapy, for example with the use of direct oral anticoagulants. Finally this review will discuss controversies, limitations and knowledge gaps in relation to the introduction of TGAs to personalize medicine in daily medical practice.
Collapse
Affiliation(s)
- Lars L. F. G. Valke
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
| | - Sanna Rijpma
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Danielle Meijer
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia E. M. Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
| | - Waander L. van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
- Enzyre BV, Novio Tech Campus, Nijmegen, Netherlands
| |
Collapse
|
4
|
Verhagen MJA, Valke LLFG, Schols SEM. Thrombin generation for monitoring hemostatic therapy in hemophilia A: A narrative review. J Thromb Haemost 2022; 20:794-805. [PMID: 35034413 PMCID: PMC9305107 DOI: 10.1111/jth.15640] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/17/2021] [Accepted: 01/10/2022] [Indexed: 11/29/2022]
Abstract
Patients with severe hemophilia A (HA) have an increased risk of spontaneous and trauma-related bleeding because of a congenital absence of factor VIII (FVIII). Most severe HA patients use prophylactic FVIII concentrate, the effect of which can be monitored with FVIII activity level measurement. However, FVIII activity level is less valuable in predicting the potential clinical bleeding risk. Some patients still experience breakthrough bleeds despite adequate FVIII trough levels, whereas others do not bleed with trough levels below threshold. This difference may be caused by inter-individual differences in pro- and anticoagulant factors, the so-called hemostatic balance. Thrombin generation assays (TGAs) measure the hemostatic balance as a whole. Thereby, the TGAs may be a better tool in the guidance and monitoring of treatment in HA patients. In addition, TGAs offer the opportunity to determine the response to bypassing agents and treatment with non-factor replacement therapy, in which FVIII activity assays are not suitable for monitoring. This review summarizes the current knowledge about monitoring different HA treatment modalities by TGA, as a single treatment option and when used in a concomitant fashion.
Collapse
Affiliation(s)
- Marieke J. A. Verhagen
- Department of HematologyRadboud University Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐MaastrichtNijmegenThe Netherlands
| | - Lars L. F. G. Valke
- Department of HematologyRadboud University Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐MaastrichtNijmegenThe Netherlands
| | - Saskia E. M. Schols
- Department of HematologyRadboud University Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐MaastrichtNijmegenThe Netherlands
| |
Collapse
|
5
|
Brackmann HH, Schramm W, Oldenburg J, Cano V, Turecek PL, Négrier C. Origins, Development, Current Challenges and Future Directions with Activated Prothrombin Complex Concentrate for the Treatment of Patients with Congenital Haemophilia with Inhibitors. Hamostaseologie 2020; 40:606-620. [PMID: 32717751 PMCID: PMC7772007 DOI: 10.1055/a-1159-4273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/16/2020] [Indexed: 12/17/2022] Open
Abstract
Congenital haemophilia A (HA) is caused by deficiency of coagulation factor VIII (FVIII) activity, leading to spontaneous or traumatic bleeding events. While FVIII replacement therapy can treat and prevent bleeds, approximately 30% of patients with severe HA develop inhibitor antibodies that render FVIII replacement therapy ineffective. The bypassing agents (BPAs), activated prothrombin complex concentrate (aPCC) and recombinant activated FVII, first approved in 1977 and 1996, respectively, act to generate thrombin independent of pathways that involve factors IX and VIII. Both may be used in patients with congenital haemophilia and inhibitors (PwHIs) for the treatment and prevention of acute bleeds and quickly became standard of care. However, individual patients respond differently to different agents. While both agents are approved for on-demand treatment and perioperative management for patients with congenital haemophilia with inhibitors, aPCC is currently the only BPA approved worldwide for prophylaxis in PwHI. Non-factor therapies (NFTs) have a mechanism of action distinct from BPAs and have reported higher efficacy rates as prophylactic regimens. Nonetheless, treatment challenges remain with NFTs, particularly regarding the potential for synergistic action on thrombin generation with concomitant use of other haemostatic agents, such as BPAs, for the treatment of breakthrough bleeds and in perioperative management. Concomitant use of NFTs with other haemostatic agents could increase the risk of adverse events such as thromboembolic events or thrombotic microangiopathy. This review focuses on the origins, development and on-going role of aPCC in the evolving treatment landscape in the management of PwHI.
Collapse
Affiliation(s)
- Hans H. Brackmann
- Haemophilia Center, Institute of Experimental Haematology and Blood Transfusion, University of Bonn, Bonn, Germany
| | - Wolfgang Schramm
- Rudolf Marx-Stiftung für Hämostaseologie, Universität München and Bluterbetreuung Bayern e. V. (BBB) - Germany
| | - Johannes Oldenburg
- Haemophilia Center, Institute of Experimental Haematology and Blood Transfusion, University of Bonn, Bonn, Germany
| | - Viridiana Cano
- Shire International GmbH, a Takeda company, Zürich, Switzerland
| | | | - Claude Négrier
- Haemophilia and Thrombosis Centre, Louis Pradel Hospital, University Claude Bernard Lyon 1, Lyon, France
| |
Collapse
|
6
|
Khoo L, Matthews S, Kershaw G, Pidcock M, Phipps A, Kiialainen A, Chang T. Case report of a fatal rectal haemorrhage in a person with severe haemophilia A receiving emicizumab and high-dose bypassing agents in the HAVEN 1 study. Haemophilia 2020; 26:e340-e342. [PMID: 32700348 DOI: 10.1111/hae.14110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Liane Khoo
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Stephen Matthews
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Geoffrey Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | | | - Alex Phipps
- F. Hoffmann-La Roche Ltd, Welwyn Garden City, UK
| | | | | |
Collapse
|
7
|
Le Quellec S. Clinical Evidence and Safety Profile of Emicizumab for the Management of Children with Hemophilia A. DRUG DESIGN DEVELOPMENT AND THERAPY 2020; 14:469-481. [PMID: 32099331 PMCID: PMC7007498 DOI: 10.2147/dddt.s167731] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 01/22/2020] [Indexed: 01/03/2023]
Abstract
Emicizumab is a bispecific, humanized, monoclonal antibody mimicking the factor (F) VIII cofactor activity in mediating the generation of FXa by FIXa in patients with hemophilia A (HA). This subcutaneous non-factor agent has been recently extensively approved for the prophylaxis of patients of HA patients with and without FVIII-inhibitors of all ages, although few data are currently available in children. In Phase 3 clinical trials and case series, emicizumab prophylaxis significantly reduced bleeding rates compared to previous treatment in HA adolescents and children with or without FVIII-inhibitors and was generally well tolerated. In addition, subcutaneous administration of emicizumab provided beneficial effects on health-related quality of life, and lessened the burden of the disease in HA patients as well as in their caregivers. However, additional prospective studies are required to evaluate the long-term safety of emicizumab prophylaxis in very young patients, including previously untreated patients. The aim of this paper was to review the limited data available on the use of emicizumab prophylaxis in children and to highlight the need for further studies to address remaining concerns.
Collapse
Affiliation(s)
- Sandra Le Quellec
- Unité d'hémostase Clinique - Hôpital Cardiologique Louis Pradel - Hospices Civils de Lyon, Lyon, France.,Service d'hématologie biologique, Groupement Hospitalier Est - Hospices Civils de Lyon, Lyon, France
| |
Collapse
|
8
|
Emicizumab should be prescribed independent of immune tolerance induction. Blood Adv 2019; 2:2783-2786. [PMID: 30352952 DOI: 10.1182/bloodadvances.2018015859] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 09/14/2018] [Indexed: 01/01/2023] Open
Abstract
Abstract
This article has a companion Point by Young.
Collapse
|
9
|
Prophylactic treatment in hemophilic patients with inhibitors. Blood Coagul Fibrinolysis 2019; 30:S14-S18. [DOI: 10.1097/mbc.0000000000000823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
10
|
Rodriguez-Merchan EC. Radiosynovectomy in haemophilia. Blood Rev 2019; 35:1-6. [DOI: 10.1016/j.blre.2019.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/05/2018] [Accepted: 01/25/2019] [Indexed: 12/19/2022]
|
11
|
Oldenburg J, Mahlangu JN, Bujan W, Trask P, Callaghan MU, Young G, Asikanius E, Peyvandi F, Santagostino E, Kruse-Jarres R, Negrier C, Kessler C, Xu J, Windyga J, Shima M, von Mackensen S. The effect of emicizumab prophylaxis on health-related outcomes in persons with haemophilia A with inhibitors: HAVEN 1 Study. Haemophilia 2018; 25:33-44. [PMID: 30427582 DOI: 10.1111/hae.13618] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/14/2018] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Persons with haemophilia A (PwHA) with inhibitors to factor VIII often experience decreased health-related outcomes. In HAVEN 1 (NCT02622321), there was a statistically significant reduction in bleeding with emicizumab prophylaxis versus no prophylaxis. AIM Describe health-related outcomes in PwHA with inhibitors in HAVEN 1. METHODS PwHA with inhibitors aged ≥12 years previously on episodic bypassing agents (BPAs) were randomized to emicizumab prophylaxis (Arm A; n = 35) or no prophylaxis (Arm B; n = 18); participants previously on BPA prophylaxis received emicizumab prophylaxis (Arm C; n = 49). Health-related outcomes assessed at baseline and monthly thereafter: Haemophilia Quality of Life Questionnaire for Adults (Haem-A-QoL), Haemophilia-specific Quality of Life Questionnaire for Children Short Form (Haemo-QoL SF), EuroQol 5-Dimensions 5-Levels (EQ-5D-5L) index utility score (IUS) and visual analogue scale (EQ-VAS) and work/school days. Days hospitalized also recorded. RESULTS At week 25, differences (ANCOVA) in adjusted mean scores (95% confidence interval) favoured Arm A versus B for Haem-A-QoL "Total" score (14.0 [5.6, 22.5]; P = 0.002) and "Physical Health" (21.6 [7.9, 35.2]; P = 0.003); EQ-VAS (-9.7 [-17.6, -1.82]; P = 0.017); and IUS (-0.16 [-0.25, -0.07]; P = 0.001); mean scores are comparable in Arms A and C. Throughout the study, a greater proportion of participants on emicizumab prophylaxis than no prophylaxis exceeded questionnaire-specific responder thresholds. Mean proportion of missed work days and number of days hospitalized were lower with emicizumab prophylaxis than no prophylaxis. CONCLUSIONS In PwHA with inhibitors, emicizumab prophylaxis was associated with substantial and meaningful improvements in health-related outcomes.
Collapse
Affiliation(s)
- Johannes Oldenburg
- Department of Experimental Haematology and Transfusion Medicine, Universitätsklinikum University Clinic Bonn, Bonn, Germany
| | - Johnny N Mahlangu
- Haemophilia Comprehensive Care Centre, Faculty of Health Sciences, University of the Witwatersrand and NHLS, Johannesburg, South Africa
| | - Willem Bujan
- Instituto de Costarricense de Investigaciones Científicas, San Jose, Costa Rica
| | - Peter Trask
- Genentech, Inc., South San Francisco, California
| | | | - Guy Young
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California
| | | | - Flora Peyvandi
- IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Santagostino
- IRCCS Ca' Granda Foundation, Ospedale Maggiore Policlinico, Milan, Italy
| | - Rebecca Kruse-Jarres
- Washington Center for Bleeding Disorders at BloodWorks NW, University of Washington, Seattle, Washington
| | | | - Craig Kessler
- Georgetown University Medical Center, N.W., Washington, District of Columbia
| | - Jin Xu
- Genentech, Inc., South San Francisco, California
| | - Jerzy Windyga
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | | |
Collapse
|
12
|
Thromboembolic event rate in patients exposed to anti-inhibitor coagulant complex: a meta-analysis of 40-year published data. Blood Adv 2017; 1:2637-2642. [PMID: 29296916 DOI: 10.1182/bloodadvances.2017011536] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 11/09/2017] [Indexed: 11/20/2022] Open
Abstract
Anti-inhibitor coagulant complex (AICC), an activated prothrombin complex concentrate, has been available for the treatment of patients with inhibitors since 1977, and thromboembolic events (TEEs) have been reported after infusion of AICC in patients with congenital or acquired hemophilia. With the aim of estimating the TEE incidence rate (IR) related to AICC exposure in these patients, a systematic review of the literature was carried out in Medline, according to PRISMA guidelines, from inception date to March 2017. The IR of TEEs was estimated through a meta-analytic approach by using a generalized linear mixed model based on a Poisson distribution. Thirty-nine studies were included (1980-2016). Overall, 46 TEEs were reported; of these, 13 were reported as disseminated intravascular coagulations, 11 as myocardial infarctions, and 3 as thrombotic cerebrovascular accidents. The pooled TEE IR was 2.87 (95% confidence interval [CI], 0.32-25.40) per 100 000 AICC infusions (5.42 in retrospective studies [95% CI, 0.92-31.82]; 1.09 in prospective studies [95% CI, 0.01-238.77]). The TEE rate was 5.09 (95% CI, 0.01-1795.60) per 100 000 AICC infusions administered on demand, whereas no TEEs were reported with prophylaxis. Interestingly, the estimated IR in patients with congenital hemophilia was <0.01 per 100 000 infusions. These findings provide robust evidence of safety of AICC over almost 40 years of published studies.
Collapse
|
13
|
Roca CA, Álvarez-Román MT, Canaro Hirnyk MI, Mingot-Castellano ME, Jiménez-Yuste V, Cid Haro AR, Pérez-Garrido R, Sedano Balbas C, López-Fernández MF. Spanish Consensus Guidelines on prophylaxis with bypassing agents in patients with haemophilia and inhibitors. Thromb Haemost 2017; 115:872-95. [DOI: 10.1160/th15-07-0568] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 01/08/2016] [Indexed: 12/18/2022]
Abstract
SummaryProphylaxis with the blood clotting factor, factor VIII (FVIII) is ineffective for individuals with haemophilia A and high-titre inhibitors to FVIII. Prophylaxis with the FVIII bypassing agents activated prothrombin complex concentrates (aPCC; FEIBA® Baxalta) or recombinant activated factor VII (rFVIIa; Novo-Seven®, Novo Nordisk) may be an effective alternative. It was our aim to develop evidence -and expert opinion- based guidelines for prophylactic therapy for patients with high-titre inhibitors to FVIII. A panel of nine Spanish haematologists undertook a systematic review of the literature to develop consensusbased guidance. Particular consideration was given to prophylaxis in patients prior to undergoing immune tolerance induction (ITI) (a process of continued exposure to FVIII that can restore sensitivity for some patients), during the ITI period and for those not undergoing ITI or for whom ITI had failed. These guidelines offer guidance for clinicians in deciding which patients might benefit from prophylaxis with FVIII bypassing agents, the most appropriate agents in various clinical settings related to ITI, doses and dosing regimens and how best to monitor the efficacy of prophylaxis. The paper includes recommendations on when to interrupt or stop prophylaxis and special safety concerns during prophylaxis. These consensus guidelines offer the most comprehensive evaluation of the clinical evidence base to date and should be of considerable benefit to clinicians facing the challenge of managing patients with severe haemophilia A with high-titre FVIII inhibitors.
Collapse
|
14
|
Furukawa S, Nogami K, Ogiwara K, Yada K, Shima M. Successful prophylaxis using activated prothrombin complex concentrates (aPCC) in a severe haemophilia A patient with inhibitor previously unresponsive to on-demand daily infusions of aPCC. Haemophilia 2017; 23:e481-e484. [PMID: 28771891 DOI: 10.1111/hae.13310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2017] [Indexed: 06/07/2023]
Affiliation(s)
- S Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - K Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - K Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - K Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - M Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| |
Collapse
|
15
|
Rocino A, Franchini M, Coppola A. Treatment and Prevention of Bleeds in Haemophilia Patients with Inhibitors to Factor VIII/IX. J Clin Med 2017; 6:jcm6040046. [PMID: 28420167 PMCID: PMC5406778 DOI: 10.3390/jcm6040046] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Revised: 04/06/2017] [Accepted: 04/10/2017] [Indexed: 01/02/2023] Open
Abstract
The development of alloantibodies neutralising therapeutically administered factor (F) VIII/IX (inhibitors) is currently the most severe complication of the treatment of haemophilia. When persistent and at a high titre, inhibitors preclude the standard replacement treatment with FVIII/FIX concentrates, making patients’ management challenging. Indeed, the efficacy of bypassing agents, i.e., activated prothrombin complex concentrates (aPCC) and recombinant activated factor VII (rFVIIa), needed to overcome the haemostatic interference of the inhibitor, is not comparable to that of factor concentrates. In addition, the therapeutical response is unpredictable, with a relevant inter-individual and even intra-individual variability, and no laboratory assay is validated to monitor the efficacy and safety of the treatment. As a result, inhibitor patients have a worse joint status and quality of life compared to inhibitor-free subjects and the eradication of the inhibitor by immune tolerance induction is the preeminent therapeutic goal, particularly in children. However, over the last decades, treatment with bypassing agents has been optimised, allowing home treatment and the individualisation of regimens aimed at improving clinical outcomes. In this respect, a growing body of evidence supports the efficacy of prophylaxis with both bypassing agents in reducing bleeding rates and improving the quality of life, although the impact on long-term outcomes (in particular on preventing/reducing joint deterioration) is still unknown. This review offers an update on the current knowledge and practice of the use of bypassing agents in haemophiliacs with inhibitors, as well as on debated issues and unmet needs in this challenging setting.
Collapse
Affiliation(s)
- Angiola Rocino
- Haemophilia and Thrombosis Centre, San Giovanni Bosco Hospital, Napoli 80144, Italy.
| | - Massimo Franchini
- Department of Transfusion Medicine and Haematology, Carlo Poma Hospital, Mantova 46100, Italy.
| | - Antonio Coppola
- Regional Reference Centre for Coagulation Disorders, Federico II University Hospital, Napoli 80131, Italy.
| |
Collapse
|
16
|
Meeks SL, Batsuli G. Hemophilia and inhibitors: current treatment options and potential new therapeutic approaches. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:657-662. [PMID: 27913543 PMCID: PMC6142469 DOI: 10.1182/asheducation-2016.1.657] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
The immune response to infused factor concentrates remains a major source of morbidity and mortality in the treatment of patients with hemophilia A and B. This review focuses on current treatment options and novel therapies currently in clinical trials. After a brief review of immune tolerance regimens, the focus of the discussion is on preventing bleeding in patients with hemophilia and inhibitors. Recombinant factor VIIa and activated prothrombin complex concentrates are the mainstays in treating bleeds in patients with inhibitors. Both agents have been shown to reduce bleeding episodes to a similar degree when infused prophylactically; however, individual patients may respond better to one agent over the other at any given time. The international immune tolerance trial revealed that a high-dose factor VIII regimen provided significantly better bleeding protection than the low-dose regimen. Given the high cost of treatment and the potential for a high-dose immune tolerance regimen to prevent bleeding in some patients, we discuss how we treat patients to maximize the prevention of bleeds while minimizing cost. Novel approaches to treatment of these patients are in development. These include agents that mimic factor VIII or augment thrombin generation by bypassing the inhibitor, as well as agents that inhibit the natural anticoagulants.
Collapse
Affiliation(s)
- Shannon L Meeks
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Glaivy Batsuli
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA
| |
Collapse
|
17
|
Varadi K, Tangada S, Loeschberger M, Montsch P, Schrenk G, Ewenstein B, Turecek PL. Pro‐ and anticoagulant factors facilitate thrombin generation and balance the haemostatic response to FEIBA
®
in prophylactic therapy. Haemophilia 2016; 22:615-24. [DOI: 10.1111/hae.12873] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2015] [Indexed: 11/28/2022]
|
18
|
Pabinger I, Heistinger M, Muntean W, Reitter-Pfoertner SE, Rosenlechner S, Schindl T, Schuster G, Streif W, Thom K, Male C. [Treatment of haemophilia in Austria]. Wien Klin Wochenschr 2015; 127 Suppl 3:S115-30. [PMID: 26525378 DOI: 10.1007/s00508-015-0872-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 09/16/2015] [Indexed: 11/30/2022]
Abstract
This guideline which is endorsed by the Austrian Society of Haemophilia, the Austrian Society of Paediatrics, and the Austrian Society of Haematology & Medical Oncology is intended to give a clear and practical guidance for diagnosing and treating haemophilia in Austria. In the treatment of haemophilia there are few controlled interventional trials, and recommendations usually have a rather low level of evidence.The main basis for this paper are the new international guidelines by the World Federation of Hemophilia, published in 2013. These were adapted according to the local situation and experience.Covered topics are diagnostics, control visits, pharmacological treatment options, prophylaxis and treatment in children and adults, possible problems arising in haemophilia carriers and special aspects like home therapy, options for venous catheters, management of various traumas, bleedings and interventions, including dental procedures, and last not least inhibitors and their treatment.
Collapse
Affiliation(s)
- Ingrid Pabinger
- Klinische Abteilung für Hämatologie und Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - Max Heistinger
- 1. Medizinische Abteilung, LKH Klagenfurt, Klagenfurt, Österreich
| | - Wolfgang Muntean
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Graz, Österreich
| | - Sylvia-Elisabeth Reitter-Pfoertner
- Klinische Abteilung für Hämatologie und Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | | | - Thomas Schindl
- Österreichische Hämophilie Gesellschaft, Wien, Österreich
| | | | - Werner Streif
- Department für Kinder- und Jugendheilkunde, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Katharina Thom
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Wien, Österreich
| | - Christoph Male
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Wien, Österreich
| |
Collapse
|
19
|
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.
Collapse
Affiliation(s)
- Cindy A Leissinger
- Departments of Medicine, Pediatrics, and Pathology, Tulane University School of Medicine, New Orleans, LA, USA.
| |
Collapse
|
20
|
Kreuz W, Escuriola Ettingshausen C, Vdovin V, Zozulya N, Plyushch O, Svirin P, Andreeva T, Bubanská E, Campos M, Benedik-Dolničar M, Jiménez-Yuste V, Kitanovski L, Klukowska A, Momot A, Osmulskaya N, Prieto M, Šalek SZ, Velasco F, Pavlova A, Oldenburg J, Knaub S, Jansen M, Belyanskaya L, Walter O. First prospective report on immune tolerance in poor risk haemophilia A inhibitor patients with a single factor VIII/von Willebrand factor concentrate in an observational immune tolerance induction study. Haemophilia 2015. [PMID: 26202305 DOI: 10.1111/hae.12774] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION/BACKGROUND Development of neutralizing inhibitors against factor VIII (FVIII) is a major complication of haemophilia A treatment. AIM The ongoing, international, open-label, uncontrolled, observational immune tolerance induction (ObsITI) study evaluates ITI, the standard of care in patients with inhibitors. PATIENTS/METHODS Forty-eight prospective patients in this interim analysis received a single plasma-derived, von Willebrand factor-stabilized, FVIII concentrate (pdFVIII/VWF) for ITI. According to recommended Bonn protocol, 'low responders' at ITI start (<5 BU) received 50-100 IU FVIII kg(-1) daily, or every other day; 'high responders' (≥5 BU) received 100 IU FVIII kg(-1) every 12 h. RESULTS Forty of 48 patients (83.3%), had at least one risk factor for poor ITI-prognosis at ITI start (i.e. age ≥7 years, >2 years since inhibitor diagnosis, inhibitor titre ≥10 BU at the start of ITI, or prior ITI failure). Nonetheless, 34 patients (70.8%) achieved complete success, 3 (6.3%) partial success, 1 (2.1%) partial response; ITI failed in 10 patients (20.8%), all with poor prognosis factors. All six low responders achieved complete success. ITI outcome was significantly associated with inhibitor titre level at ITI start (P = 0.0068), number of poor prognosis factors for ITI success (P = 0.0187), monthly bleeding rate during ITI (P = 0.0005) and peak inhibitor titre during ITI (P = 0.0007). Twenty-two of 35 high responder patients (62.9%) with ≥1 poor prognosis factor achieved complete success. CONCLUSION Treatment with a single pdFVIII/VWF concentrate, mainly according to the Bonn protocol, resulted in a high ITI success rate in haemophilia A patients with inhibitors and poor prognosis for ITI success.
Collapse
Affiliation(s)
- W Kreuz
- HZRM, Hämophilie-Zentrum Rhein Main Frankfurt-Mörfelden, Mörfelden-Walldorf, Germany
| | | | - V Vdovin
- Izmaylovo Children's Hospital Haematological Centre, Moscow, Russia
| | - N Zozulya
- The State Haematological Scientific Centre RAMS, Moscow, Russia
| | - O Plyushch
- The State Haematological Scientific Centre RAMS, Moscow, Russia
| | - P Svirin
- Izmaylovo Children's Hospital Haematological Centre, Moscow, Russia
| | - T Andreeva
- St. Petersburg State Healthcare Institution, St. Petersburg, Russia
| | - E Bubanská
- Children Faculty Hospital with Policlinic, Banská Bystrica, Slovakia
| | - M Campos
- Centro Hospitalar Porto, Hospital de Santo António, Porto, Portugal
| | - M Benedik-Dolničar
- Children's Hospital Oncology-Hematology Unit, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - L Kitanovski
- Children's Hospital Oncology-Hematology Unit, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - A Momot
- Altai Hematological Center, Altai, Russia
| | - N Osmulskaya
- State Healthcare Institution of Omsk Region, Omsk, Russia
| | - M Prieto
- Hospital General Yagüe, Castilla Leon, Spain
| | - S Z Šalek
- University Hospital REBRO, Zagreb, Croatia
| | - F Velasco
- Hospital Reina Sofía, Córdoba, Spain
| | - A Pavlova
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - J Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - S Knaub
- Octapharma AG, Lachen, Switzerland
| | - M Jansen
- Octapharma Pharmazeutika Produktionsges.mbH, Vienna, Austria
| | | | - O Walter
- Octapharma AG, Lachen, Switzerland
| | | | | |
Collapse
|
21
|
How I use bypassing therapy for prophylaxis in patients with hemophilia A and inhibitors. Blood 2015; 126:153-9. [DOI: 10.1182/blood-2014-10-551952] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 03/25/2015] [Indexed: 11/20/2022] Open
Abstract
Abstract
Inhibitor development poses a significant challenge in the management of hemophilia because once an inhibitor is present, bleeding episodes can no longer be treated with standard clotting factor replacement therapy. Consequently, patients with inhibitors are at increased risk for difficult-to-control bleeding and complications, particularly arthropathy and physical disability. Three clinical trials in patients with inhibitors have demonstrated that prophylaxis with a bypassing agent reduces joint and other types of bleeding and improves health-related quality of life compared with on-demand bypassing therapy. In hemophilia patients without inhibitors, the initiation of prophylaxis with factor (F) VIII or FIX prior to the onset of recurrent hemarthroses can prevent the development of joint disease. Whether this is also true for bypassing agent prophylaxis remains to be determined.
Collapse
|
22
|
Principles of treatment and update of recommendations for the management of haemophilia and congenital bleeding disorders in Italy. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 12:575-98. [PMID: 25350962 DOI: 10.2450/2014.0223-14] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
23
|
Ramakrishnan R, Davidowitz A, Balu-Iyer SV. Exposure of FVIII in the Presence of Phosphatidyl Serine Reduces Generation of Memory B-Cells and Induces Regulatory T-Cell-Mediated Hyporesponsiveness in Hemophilia A Mice. J Pharm Sci 2015; 104:2451-6. [PMID: 26038127 DOI: 10.1002/jps.24513] [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: 12/30/2014] [Revised: 05/01/2015] [Accepted: 05/04/2015] [Indexed: 01/19/2023]
Abstract
A major complication of replacement therapy with Factor VIII (FVIII) for hemophilia A (HA) is the development of unwanted immune responses. Previous studies showed that administration of FVIII in the presence of phosphatidyl serine (PS) reduced the development of anti-FVIII antibodies in HA mice. However, the impact of PS-mediated effects on immunological memory, such as generation of memory B-cells, is not clear. The effect of PS on memory B-cells was therefore investigated using adoptive transfer approach in FVIII(-/-) HA mice. Adoptive transfer of memory B-cells from a PS-FVIII-treated group to naïve mice followed by challenge of the recipient mice with FVIII showed a significantly reduced anti-FVIII antibody response in the recipient mice, compared with animals that received memory B-cells from free FVIII and FVIII-charge matched phosphatidyl glycerol (PG) group. The decrease in memory B-cell response is accompanied by an increase in FoxP3 expressing regulatory T-cells (Tregs). Flow cytometry studies showed that the generation of Tregs is higher in PS-treated animals as compared with FVIII and FVIII-PG treated animals. The PS-mediated hyporesponsiveness was found to be antigen-specific. The PS-FVIII immunization showed hyporesponsiveness toward FVIII rechallenge but not against ovalbumin (OVA) rechallenge, an unrelated antigen. This demonstrates that PS reduces immunologic memory of FVIII and induces antigen-specific peripheral tolerance in HA mice.
Collapse
Affiliation(s)
- Radha Ramakrishnan
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, 14215
| | - Andrew Davidowitz
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, 14215
| | - Sathy V Balu-Iyer
- Department of Pharmaceutical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, 14215
| |
Collapse
|
24
|
Leissinger CA, Konkle BA, Antunes SV. Prevention of bleeding in hemophilia patients with high-titer inhibitors. Expert Rev Hematol 2015; 8:375-82. [DOI: 10.1586/17474086.2015.1036733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
25
|
Villarrubia R, Oyagüez I, Álvarez-Román MT, Mingot-Castellano ME, Parra R, Casado MA. Cost analysis of prophylaxis with activated prothrombin complex concentrate vs. on-demand therapy with activated factor VII in severe haemophilia A patients with inhibitors, in Spain. Haemophilia 2015; 21:320-329. [DOI: 10.1111/hae.12681] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2015] [Indexed: 11/29/2022]
Affiliation(s)
- R. Villarrubia
- Pharmacoeconomics & Outcomes Research Iberia; Madrid Spain
| | - I. Oyagüez
- Pharmacoeconomics & Outcomes Research Iberia; Madrid Spain
| | | | | | - R. Parra
- Vall d'Hebron University Hospital; Barcelona Spain
| | - M. A. Casado
- Pharmacoeconomics & Outcomes Research Iberia; Madrid Spain
| |
Collapse
|
26
|
Ewing N, Escuriola‐Ettingshausen C, Kreuz W. Prophylaxis with FEIBA in paediatric patients with haemophilia A and inhibitors. Haemophilia 2015; 21:358-364. [DOI: 10.1111/hae.12602] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2014] [Indexed: 11/28/2022]
Affiliation(s)
- N. Ewing
- City of Hope National Medical Center Duarte CA USA
| | | | - W. Kreuz
- HZRM ‐ Hemophilia Centre Rhein Main Moerfelden‐Waldorf Germany
| |
Collapse
|
27
|
Abstract
Numerous challenges confront adult hemophilia patients with inhibitors, including difficulty in controlling bleeding episodes, deterioration of joints, arthritic pain, physical disability, emotional turmoil, and social issues. High-intensity treatment regimens often used in the treatment of patients with inhibitors also impose significant scheduling, economic, and emotional demands on patients and their families or primary caregivers. A comprehensive multidisciplinary assessment of the physical, emotional, and social status of adult hemophilia patients with inhibitors is essential for the development of treatment strategies that can be individualized to address the complex needs of these patients.
Collapse
Affiliation(s)
- Sue duTreil
- Louisiana Center for Bleeding and Clotting Disorders, Tulane University Health Sciences Center, New Orleans, LA, USA
| |
Collapse
|
28
|
Traore AN, Chan AKC, Webert KE, Heddle N, Ritchie B, St‐Louis J, Teitel J, Lillicrap D, Iorio A, Walker I. First analysis of 10‐year trends in national factor concentrates usage in haemophilia: data from
CHARMS
, the Canadian Hemophilia Assessment and Resource Management System. Haemophilia 2014; 20:e251-9. [PMID: 24948405 PMCID: PMC4140609 DOI: 10.1111/hae.12477] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2014] [Indexed: 11/27/2022]
Affiliation(s)
- A. N. Traore
- McMaster Transfusion Research ProgramMcMaster University Hamilton Ontario Canada
| | - A. K. C. Chan
- Department of PediatricsMcMaster University Hamilton Ontario Canada
| | - K. E. Webert
- Department of Medicine McMaster University Hamilton OntarioCanada
| | - N. Heddle
- Department of Medicine McMaster University Hamilton OntarioCanada
| | - B. Ritchie
- Department of Medicine University of Alberta Edmonton AlbertaCanada
| | - J. St‐Louis
- Department of Hematology Hôpital Maisonneuve‐Rosemont and Université de Montréal Montreal QuebecCanada
| | - J. Teitel
- St. Michael's Hospital Toronto & Central Ontario Hemophilia Program TorontoOntario Canada
| | - D. Lillicrap
- Department of Pathology and Molecular Medicine Queen's University KingstonOntario Canada
| | - A. Iorio
- Clinical Epidemiology and Biostatistics McMaster University Hamilton Ontario Canada
| | - I. Walker
- Department of Medicine McMaster University Hamilton OntarioCanada
| |
Collapse
|
29
|
Antunes SV, Tangada S, Stasyshyn O, Mamonov V, Phillips J, Guzman-Becerra N, Grigorian A, Ewenstein B, Wong WY. Randomized comparison of prophylaxis and on-demand regimens with FEIBA NF in the treatment of haemophilia A and B with inhibitors. Haemophilia 2013; 20:65-72. [PMID: 23910578 PMCID: PMC4216433 DOI: 10.1111/hae.12246] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2013] [Indexed: 11/27/2022]
Abstract
Factor replacement therapy for the treatment of moderate to severe haemophilia A and B can be complicated by the production of inhibitory alloantibodies to factor VIII (FVIII) or factor IX. Treatment with the nanofiltered anti-inhibitor coagulant complex, Factor Eight Inhibitor Bypassing Activity (FEIBA NF), is a key therapeutic option for controlling acute haemorrhages in patients with high-titre inhibitors or low-titre inhibitors refractory to replacement therapy. Given the high risk for morbidity and mortality in haemophilia patients with inhibitors to FVIII or FIX, we conducted this Phase 3 prospective study to evaluate whether prophylaxis with FEIBA NF is a safe and effective treatment option. Over a 1-year period, 17 subjects were treated prophylactically (85 ± 15 U kg−1 every other day) while 19 subjects were treated on demand. The median (IQR) annualized bleeding rate (ABR) during prophylaxis was 7.9 (8.1), compared to 28.7 (32.3) during on-demand treatment, which amounts to a 72.5% reduction and a statistically significant difference in ABRs between arms (P = 0.0003). Three (17.6%) subjects (ITT) on prophylaxis experienced no bleeding episodes, whereas none treated on demand were bleeding episode-free. Total utilization of FEIBA NF for the treatment of bleeding episodes was significantly higher during on-demand therapy than prophylaxis (P = 0.0067). There were no differences in the rates of related adverse events between arms. This study demonstrates that FEIBA prophylaxis significantly reduces all types of bleeding compared with on-demand treatment, and the safety of prophylaxis is comparable to that of on-demand treatment.
Collapse
|
30
|
Teitel JM, Sholzberg M. Current status and future prospects for the prophylactic management of hemophilia patients with inhibitor antibodies. Blood Rev 2013; 27:103-9. [DOI: 10.1016/j.blre.2013.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|
31
|
2013 revised edition : hemostatic treatment guidelines for inhibitors possess congenital hemophilia patients. ACTA ACUST UNITED AC 2013. [DOI: 10.2491/jjsth.24.640] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
32
|
Abstract
The management of patients with inhibitors is the greatest challenge facing haemophilia health professionals. Immune tolerance induction (ITI) can be successful in eliminating the inhibitor in the majority of patients, provided it is started soon after the inhibitor develops and the titre of the inhibitor is <10 BU at commencement of ITI. Acute bleeding is treated using one of two bypassing agents, which exhibit similar efficacy and safety. Surgery in inhibitor patients is challenging and should only be carried out in experienced centres.
Collapse
Affiliation(s)
- M Makris
- Department of Cardiovascular Science, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK.
| | | | | | | |
Collapse
|
33
|
Gelhorn H, Merikle E, Krishnan S, Nemes L, Leissinger C, Valentino L. Physician preferences for medication attributes for the prophylactic treatment of patients with severe haemophilia A with inhibitors to factor VIII. Haemophilia 2012; 19:119-25. [PMID: 23005041 DOI: 10.1111/hae.12011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2012] [Indexed: 11/30/2022]
Abstract
Prophylaxis may be beneficial for patients with severe haemophilia A who have developed inhibitors to factor VIII. The aim of this study was to determine physicians' preferences for medication attributes in the prophylactic treatment of this patient population. Haematologists from Europe (EU) and the United States (US) participated in a discrete choice exercise to explore their preferences for medication attributes (efficacy, cost, scientific evidence, dosing frequency and administration time) associated with prophylaxis for severe haemophilia A in patients with inhibitors to factor VIII. Physicians' preferences for medication attributes were assessed through completion of 25 trade-off tasks that included a choice between two hypothetical medications each comprised of one randomized level of each medication attribute. Participants also completed a sociodemographic questionnaire. Data were analysed using a random effects logit model. Participants (N = 36: US = 19; EU = 17) were 80.6% men, had a mean of 19.8 years (SD ± 8.1) [range 6-35] of practice experience. The physicians treated an average of 5.7 (± 5.5) patients with severe haemophilia A and inhibitors per month and reported treating 36.2% of these patients prophylactically. The most important medication attributes for prophylactic treatment were efficacy [Relative Importance (RI) = 35.0%] and scientific evidence (RI = 34.1%), whereas treatment cost (12.0%), dosing frequency (10.8%) and administration time (8.2%) were less important. Results were similar across the EU and US. Efficacy and scientific evidence are the primary considerations for physicians' choice of prophylactic medications for use in this patient population.
Collapse
Affiliation(s)
- H Gelhorn
- United BioSource Corporation, Bethesda, MD, USA.
| | | | | | | | | | | |
Collapse
|
34
|
Abstract
Haemophilia care has undergone substantial improvements during the past 40-50 years. Early clotting factor concentrates were not sufficiently refined to enable self-administered treatment at home until the 1970s. Unfortunately, these advances led to transmission of viral diseases including HIV and hepatitis, resulting in an increased burden of morbidity and mortality, especially during the 1980s. Throughout the past two decades, product development, including the advent of recombinant concentrates, has greatly improved the safety and availability of therapy and the focus of care is shifting towards prevention and management of disease sequelae. Long-term substitution therapy (prophylaxis) of the missing clotting factor is the recommended treatment in severe haemophilia, but several research issues remain to be elucidated such as when to start and how to optimise these regimens, and when or whether to stop this expensive treatment. The major side-effect of treatment, development of inhibitors to the infused concentrate, is the main threat to the health of patients and consequently the goal of intense research. Development of new products with improved pharmacokinetics is the next step to improved therapy.
Collapse
Affiliation(s)
- Erik Berntorp
- Lund University, Malmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden.
| | | |
Collapse
|
35
|
Cost effectiveness of prophylactic treatment with activated prothrombin complex concentrate in a patient with inhibitor-positive hemophilia A. Blood Coagul Fibrinolysis 2012; 23:235-7. [PMID: 22322137 DOI: 10.1097/mbc.0b013e32834fb582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients with hemophilia and high titers of inhibitors are hard to treat during bleeding events and consequently are more likely to incur high treatment costs and to experience deterioration in quality of life. We report here the case of a boy with hemophilia A and high titers of inhibitors who responded well to prophylactic activated prothrombin complex concentrate (APCC) treatment. Previously, he had to be hospitalized frequently because of painful bleeding of target joints of the knee and ankle. At the age of 4 years and 3 months, APCC prophylaxis at a dose of 60 U/kg, three times a week, was initiated together with on-demand therapy with recombinant factor VIIa. This reduced the frequency and severity of bleeding and ended the need for hospitalization. This, together with a decreased requirement for bypass agents, APCC treatment significantly reduced the cost of treatment for this patient.
Collapse
|
36
|
Leissinger C, Gringeri A, Antmen B, Berntorp E, Biasoli C, Carpenter S, Cortesi P, Jo H, Kavakli K, Lassila R, Morfini M, Négrier C, Rocino A, Schramm W, Serban M, Uscatescu MV, Windyga J, Zülfikar B, Mantovani L. Anti-inhibitor coagulant complex prophylaxis in hemophilia with inhibitors. N Engl J Med 2011; 365:1684-92. [PMID: 22047559 DOI: 10.1056/nejmoa1104435] [Citation(s) in RCA: 175] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with severe hemophilia A and factor VIII inhibitors are at increased risk for serious bleeding complications and progression to end-stage joint disease. Effective strategies to prevent bleeding in such patients have not yet been established. METHODS We enrolled patients with hemophilia A who were older than 2 years of age, had high-titer inhibitors, and used concentrates known as bypassing agents for bleeding in a prospective, randomized, crossover study comparing 6 months of anti-inhibitor coagulant complex (AICC), infused prophylactically at a target dose of 85 U per kilogram of body weight (±15%) on 3 nonconsecutive days per week, with 6 months of on-demand therapy (AICC at a target dose of 85 U per kilogram [±15%] used for bleeding episodes). The two treatment periods were separated by a 3-month washout period, during which patients received on-demand therapy for bleeding. The primary outcome was the number of bleeding episodes during each 6-month treatment period. RESULTS Thirty-four patients underwent randomization; 26 patients completed both treatment periods and could be evaluated per protocol for the efficacy analysis. As compared with on-demand therapy, prophylaxis was associated with a 62% reduction in all bleeding episodes (P<0.001), a 61% reduction in hemarthroses (P<0.001), and a 72% reduction in target-joint bleeding (≥3 hemarthroses in a single joint during a 6-month treatment period) (P<0.001). Thirty-three randomly assigned patients received at least one infusion of the study drug and were evaluated for safety. One patient had an allergic reaction to the study drug. CONCLUSIONS AICC prophylaxis at the dosage evaluated significantly and safely decreased the frequency of joint and other bleeding events in patients with severe hemophilia A and factor VIII inhibitors. (Funded by Baxter BioScience; Pro-FEIBA ClinicalTrials.gov number, NCT00221195.).
Collapse
Affiliation(s)
- Cindy Leissinger
- Louisiana Center for Bleeding and Clotting Disorders, Tulane University, New Orleans, LA, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
TEITEL J, BERNTORP E, DOLAN G, FISCHER K, GRINGERI A, KESSLER C, LAMBERT T, LEISSINGER C, NEMES L, SHIMA M. A consensus statement on clinical trials of bypassing agent prophylaxis in inhibitor patients. Haemophilia 2011; 17:516-21. [DOI: 10.1111/j.1365-2516.2010.02440.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
38
|
Ewenstein BM, Wong WY, Schoppmann A. Bleeding reduction during secondary prophylaxis with bypassing agents in inhibitor patients. Thromb Res 2011; 127:174-5. [DOI: 10.1016/j.thromres.2010.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 06/01/2010] [Accepted: 06/01/2010] [Indexed: 10/19/2022]
|
39
|
VALENTINO LA. Assessing the benefits of FEIBA prophylaxis in haemophilia patients with inhibitors. Haemophilia 2009; 16:263-71. [DOI: 10.1111/j.1365-2516.2009.02126.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|