1
|
Andersson NG, Kenet G. Intracranial Hemorrhages in Neonates: Incidence, Risk Factors and Treatment. Semin Thromb Hemost 2022; 49:409-415. [PMID: 36108647 DOI: 10.1055/s-0042-1756195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractHemostasis is a dynamic process that starts in utero. Neonates, especially those who are born preterm, are at high risk of bleeding. The coagulation system evolves with age, and the decreased levels of coagulation factors along with hypo-reactive platelets are counterbalanced with increased activity of von Willebrand factor, high hematocrit and mean corpuscular volume as well as low levels of coagulation inhibitors that promote hemostasis. Neonates with congenital bleeding disorders such as hemophilia are at even higher risk of bleeding complications. This review will focus upon one of the most devastating complications associated with neonatal bleeding: intracranial hemorrhages (ICH). While etiology may be multifactorial and impacted by maternal as well as fetal risk factors, the mode of delivery certainly plays an important role in the pathogenesis of ICH. We will address prematurity and congenital bleeding disorders such as hemophilia A and B and other rare bleeding disorders as risk factors and present an updated approach for treatment and possible prevention.
Collapse
Affiliation(s)
- Nadine G. Andersson
- Center for Thrombosis and Hemostasis and Department of Pediatric Hematology and Oncology, Skåne University Hospital, Malmö/Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Gili Kenet
- National Hemophilia Center, Institute of Thrombosis and Hemostasis and the Amalia Biron Research Institute, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
2
|
de Moerloose P, Davis JA, Benchikh El Fegoun S, Habis R, Klamroth R. Barriers and challenges for the fast treatment of bleeds in the non-haemophilia treatment centre hospital setting. Haemophilia 2020; 26:422-430. [PMID: 32147924 DOI: 10.1111/hae.13956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/19/2020] [Accepted: 02/24/2020] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Early treatment for acute bleeds in patients with haemophilia and inhibitors is feasible when patients are managed in haemophilia treatment centres (HTCs). Patients may need to attend non-HTCs for out-of-hours emergency care, especially if HTCs are not local and/or transport is difficult. AIM We evaluated the barriers to the fast treatment of bleeds in patients with haemophilia and inhibitors presenting at non-HTCs. METHODS Healthcare professionals (HCPs) from non-HTCs in the United States (n = 218) and Germany (n = 98) were selected from validated online panels and invited to participate in a survey (October-November 2017). RESULTS A mean of 6 (US) and 5 (German) patients with haemophilia and inhibitors were managed for bleeds by these HCPs over 12 months; patient characteristics were similar in both countries. The main HCPs involved in treating bleeds were emergency room specialists (94%) and haematologists (91%) (US); haematologists (79%) and anaesthesiologists (59%) (Germany). Only 26% (US) and 28% (Germany) of HCPs had access to treatment guidelines for these patients; access to bypassing agents was similarly limited: 44% (US) and 38% (Germany) of HCPs reported their institution did not stock these agents. In both countries, key reasons for delaying treatment were lack of bypassing agent availability, HCP experience/education of bleed disorders and internal process time. CONCLUSION Barriers to fast treatment of bleeds in patients with haemophilia and inhibitors were identified in non-HTCs in the United States and Germany. These could be reduced by improving the availability of treatment guidelines, bypassing agents and HCP education/training.
Collapse
Affiliation(s)
| | - Joanna A Davis
- Pediatric Haemophilia Treatment Center, Univerity of Miami, Miami, FL, USA
| | | | | | - Robert Klamroth
- Haemophiliezentrum, Klinik für Innere Medizin, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| |
Collapse
|
3
|
Meeks SL, Leissinger CA. The evolution of factor VIIa in the treatment of bleeding in haemophilia with inhibitors. Haemophilia 2019; 25:911-918. [PMID: 31489759 PMCID: PMC6899648 DOI: 10.1111/hae.13845] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/07/2019] [Accepted: 08/19/2019] [Indexed: 01/19/2023]
Abstract
The use of activated factor VII (FVIIa) for the treatment of bleeding events in haemophilia patients with inhibitors was first reported over 30 years ago. Since then clinical trials, registries, case series, real‐world experience and an understanding of its mechanism of action have transformed what was originally a scientific curiosity into one of the major treatments for inhibitor patients, with innovative therapeutic regimens, dose optimization and individualized care now widely practiced. Given current understanding and use, it might be easy to forget the years of clinical research that led up to this point; in this review, we lay out changes based on broad eras of rFVIIa use. These eras cover the original uncertainty associated with dosing, efficacy and safety; the transformation of care ushered in with its widespread use; and the optimization and individualization of patient care and the importance of specialized support provided by haemophilia treatment centres. Today with the introduction of novel prophylactic agents such as emicizumab, we once again find ourselves dealing with the uncertainties of how best to utilize rFVIIa and newer investigational variants such as marzeptacog alfa and eptacog beta; we hope that the experiences of the past three decades will serve as a guide for this new era of care.
Collapse
Affiliation(s)
- Shannon L Meeks
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Cindy A Leissinger
- Section of Hematology/Oncology, Tulane University School of Medicine, New Orleans, LA, USA
| |
Collapse
|
4
|
Shapiro AD, Mitchell IS, Nasr S. The future of bypassing agents for hemophilia with inhibitors in the era of novel agents. J Thromb Haemost 2018; 16:2362-2374. [PMID: 30264916 DOI: 10.1111/jth.14296] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Indexed: 01/19/2023]
Abstract
Bypassing agents are presently the standard of care for the treatment of bleeding episodes in patients with hemophilia and high-titer inhibitors and are also used for bleed prevention. Only two bypassing agents are available to patients, and these products trace their lineage to the 1970s (activated prothrombin complex concentrates) and the 1980s (recombinant factor VIIa). Given the limited repertoire of available products, clinicians have relied on experience, empirical observation, registry data and individualized care to improve clinical outcomes on a case-by-case basis. Research over the past two decades has culminated in a greatly improved understanding of human coagulation; resulting from this, new products have been developed that offer treatment options and mechanisms of actions that differ from current bypassing agents. The most advanced in clinical development is emicizumab, a bispecific antibody that mimics the function of FVIIIa in the intrinsic Xase complex and is indicated for once-weekly or every-other-week prophylactic dosing in inhibitor patients. Other non-traditional products in clinical development include fitusiran and antibodies directed against tissue factor pathway inhibitor. As non-factor-based therapies become more widely utilized over time, the use of bypassing agents may be expected to decrease; however, bypassing agents will remain essential for the foreseeable future. As such, clinical development of bypassing agents continues, with some products (e.g. eptacog beta) under regulatory review. In this review we examine the optimal use of bypassing agents and their mechanism of action. We also discuss newer products and how these might theoretically be administered in conjunction with traditional bypassing agents.
Collapse
Affiliation(s)
- A D Shapiro
- Indiana Hemophilia and Thrombosis Center, Inc., Indianapolis, IN, USA
| | | | - S Nasr
- GLOVAL, LLC, Broomfield, CO, USA
| |
Collapse
|
5
|
Schut A, Hyseni A, Adelmeijer J, Meijers JCM, de Groot PG, Lisman T. Sustained pro-haemostatic activity of rFVIIa in plasma and platelets in non-bleeding pigs may explain the efficacy of a once-daily prophylaxis in humans. Thromb Haemost 2017; 112:304-10. [DOI: 10.1160/th13-09-0798] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 03/08/2014] [Indexed: 11/05/2022]
Abstract
SummaryRecombinant factor VIIa (rFVIIa) is registered for treatment of inhibitor-complicated haemophilia, and a once-daily prophylactic administration of rFVIIa is successful in reducing the number of bleeding events. This suggests that a single rFVIIa dose has a pro-haemostatic effect up to 24 hours (h), which is difficult to explain given its half-life of 2 h. In this study, six pigs received a 90 µg/kg rFVIIa bolus. Plasma was collected and platelets were isolated at various time points up to 48 h, and analysed for FVIIa levels and associated haemostatic activity. Elevated plasma FVIIa levels were detected up to 24 h post-administration (36 (32–56) mU/ml [median (interquartile range [IQR]), 24 h] vs 2 (2–14) mU/ml [baseline]). Corresponding prothrombin time (PT) values remained shortened compared to baseline until 24 h post-administration (9.4 (9.3–9.9) seconds (s) [24 h] vs 10.5 (10.2–11.0) s [baseline], p ≤0.01). The lag time in thrombin generation testing as well as clotting times in plasma-based assays were shortened up to 12 or 24 h post-administration, respectively (lag times 1.8 (1.7–2.1) minutes (min) [12 h] vs 2.3 (2.3–2.6) min [baseline], p ≤0.01 and clotting times 3.8 (3.2–3.9) min [24 h] vs 5.2 (4.6–5.5) min [baseline], p ≤0.001). Platelet FVIIa levels were elevated up to 48 h (7.7 (3.4–9.0) ng VIIa/mg actin [48 h] vs 2.5 (0.7–4.8) ng VIIa/mg actin [baseline]). In conclusion, elevated and haemostatically active plasma and platelet FVIIa levels are detectable up to 24–48 h following rFVIIa administration in pigs. This prolonged pro-haemostatic effect of FVIIa may explain the prophylactic efficacy of a once-daily rFVIIa treatment.
Collapse
|
6
|
Wang M, Lawrence JB, Quon DV, Ducore J, Simpson ML, Boggio LN, Mitchell IS, Yuan G, Alexander WA, Schved JF. PERSEPT 1: a phase 3 trial of activated eptacog beta for on-demand treatment of haemophilia inhibitor-related bleeding. Haemophilia 2017; 23:832-843. [DOI: 10.1111/hae.13301] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 01/19/2023]
Affiliation(s)
- M. Wang
- Hemophilia and Thrombosis Center; University of Colorado; Aurora CO USA
| | | | - D. V. Quon
- Orthopaedic Hemophilia Treatment Center; Orthopaedic Institute for Children; Los Angeles CA USA
| | - J. Ducore
- University of California, Davis; Comprehensive Cancer Center; Hematology/Oncology Clinic; Sacramento CA USA
| | | | | | | | - G. Yuan
- LFB USA Inc.; Framingham MA USA
| | | | - J.-F. Schved
- Département d'Hématologie Biologique; Hôpital Saint-Eloi; CHU Montpellier; Montpellier France
| |
Collapse
|
7
|
Morfini M. Rapid rFVIIa enhanced on-demand dosing in haemophilia inhibitor patients. Eur J Haematol 2015; 96:111-8. [PMID: 26172449 DOI: 10.1111/ejh.12631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2015] [Indexed: 01/19/2023]
Abstract
Recombinant factor VII activated (rFVIIa) is a bypassing agent widely used in haemophilia A and B patients with antibodies against coagulation factors VIII or IX. When used according to the correct doses, rFVIIa may control bleeding, subclinical bleeding and rebleeding, avoiding the effect of neutralising inhibitors. Because of the fast action of the rFVIIa, haemostasis occurs promptly and enables a fast bleeding control with on-demand treatment in home or in surgical setting. Rapidity is also a distinguishing feature in preparation and injection of rFVIIa to cope the restraining times of busy patients and parents. The effective haemostatic activity of rFVIIa enables a sustained bleeding control, which is implemented with every other day (eod) administration and suited for enhanced on-demand therapy and short-term repeated infusions use of rFVIIa to prevent microhaemorrhages or rebleeding. Comprehensive appreciation of these pharmacological and pharmacodynamic' characteristics will likely be a further stimulus to the wider enhanced on-demand use of rFVIIa.
Collapse
Affiliation(s)
- Massimo Morfini
- Past President of Italian Association of Haemophilia Centers (AICE), Florence, Italy
| |
Collapse
|
8
|
Zhang XH, Zhu XL, Niu T, Sun J, Liu H, Feng R, Yang LH, Wei Q, Ma QH, Wang QM, Feng FE, Fu HX, Mo XD, Lv M, Huang XJ. Combination of FVIII and low-dose rFVIIa improves haemostasis in acquired haemophilia A patients: a collaborative controlled study. Thromb Res 2015; 135:835-40. [PMID: 25747536 DOI: 10.1016/j.thromres.2015.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 02/11/2015] [Accepted: 02/17/2015] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Acquired haemophilia A (AHA) is an autoimmune disease that potentially leads to severe bleeding and has a high rate of mortality. This collaborative study aimed to assess the efficacy of the co-administration of FVIII and low-dose rFVIIa in patients with AHA. MATERIALS AND METHODS This study retrospectively compared the combined FVIII/low-dose rFVIIa therapy (initial dose range of 25-55μg/Kg) with the combined FVIII/PCC therapy and low-dose rFVIIa monotherapy. Adverse drug reactions and recurrent bleeding episodes were also monitored. Crude comparisons and the exact conditional logistic regression were performed to compare the outcomes between three treatment groups. RESULTS First bleeding episodes of 56 consecutive patients from 5 centres were analyzed, and 37 bleeding episodes (66.1%) were determined to be severe. Specifically, the rate of bleeding control was significantly higher with the FVIII/low-dose rFVIIa therapy compared to that of the low-dose rFVIIa alone therapy or the FVIII/PCC therapy (58.3% vs. 41.7% vs. 95.0%, respectively). Analyzing of total 236 bleeding episodes showed a clear positive association between the early initiation of haemostatic treatment and efficacy. No therapy-related adverse events in which thrombosis predominated were reported. CONCLUSIONS The combination of FVIII and low-dose rFVIIa offers an ideal haemostatic cover and may be promoted as a feasible and safe therapy protocol for patients with AHA.
Collapse
Affiliation(s)
- Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C..
| | - Xiao-Lu Zhu
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C
| | - Ting Niu
- Department of haematology, West China Hospital, West China School of Clinical Medicine, Sichuan University, Chengdu, Sichuan, P.R.C
| | - Jing Sun
- Department of haematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P.R.C
| | - Hui Liu
- Department of haematology, Beijing Hospital, Beijing, P.R.C
| | - Ru Feng
- Department of haematology, Beijing Hospital, Beijing, P.R.C
| | - Lin-Hua Yang
- Department of haematology, the Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, P.R.C
| | - Qing Wei
- Department of haematology, West China Hospital, West China School of Clinical Medicine, Sichuan University, Chengdu, Sichuan, P.R.C
| | - Qing-Hui Ma
- Department of haematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, P.R.C
| | - Qing-Ming Wang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C
| | - Fei-Er Feng
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C
| | - Hai-Xia Fu
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C
| | - Meng Lv
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Haematology, Beijing, P.R.C..
| |
Collapse
|
9
|
Key issues in inhibitor management in patients with haemophilia. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 12 Suppl 1:s319-29. [PMID: 24333092 DOI: 10.2450/2013.0246-12] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 05/16/2013] [Indexed: 12/13/2022]
|
10
|
Tran HTT, Sørensen B, Rea CJ, Bjørnsen S, Ueland T, Pripp AH, Tjønnfjord GE, Holme PA. Tranexamic acid as adjunct therapy to bypassing agents in haemophilia A patients with inhibitors. Haemophilia 2013; 20:369-75. [DOI: 10.1111/hae.12318] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2013] [Indexed: 12/25/2022]
Affiliation(s)
- H. T. T. Tran
- Research Institute of Internal Medicine; Oslo University Hospital; Rikshospitalet; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Department of Haematology; Oslo University Hospital; Rikshospitalet; Oslo Norway
| | - B. Sørensen
- Baxter Healthcare Corporation; Westlake Village CA USA
- Haemostasis Research Unit; Guy's and St Thomas' Hospital; London UK
| | - C. J. Rea
- Haemostasis Research Unit; Guy's and St Thomas' Hospital; London UK
| | - S. Bjørnsen
- Research Institute of Internal Medicine; Oslo University Hospital; Rikshospitalet; Oslo Norway
| | - T. Ueland
- Faculty of Medicine; University of Oslo; Oslo Norway
| | - A. H. Pripp
- Department of Biostatistics and Epidemiology; Oslo University Hospital; Oslo Norway
| | - G. E. Tjønnfjord
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Department of Haematology; Oslo University Hospital; Rikshospitalet; Oslo Norway
| | - P. A. Holme
- Research Institute of Internal Medicine; Oslo University Hospital; Rikshospitalet; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
- Department of Haematology; Oslo University Hospital; Rikshospitalet; Oslo Norway
| |
Collapse
|
11
|
Golor G, Bensen-Kennedy D, Haffner S, Easton R, Jung K, Moises T, Lawo JP, Joch C, Veldman A. Safety and pharmacokinetics of a recombinant fusion protein linking coagulation factor VIIa with albumin in healthy volunteers. J Thromb Haemost 2013; 11:1977-85. [PMID: 24112951 DOI: 10.1111/jth.12409] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Development of neutralizing antibodies remains the most problematic complication in treating congenital hemophilia. Control and prevention of bleeding events in such patients with recombinant factor VIIa (rFVIIa) is limited by the short half-life of the available product. Here, we report on the pharmacokinetics and safety of a novel, recombinant fusion protein linking coagulation FVIIa with albumin (rVIIa-FP) in a first-in-human study in healthy male subjects. METHODS Forty healthy male subjects between 18 and 35 years of age were included and dosed in five consecutive cohorts. In each cohort, six subjects were randomized to a single dose of rVIIa-FP (140, 300, 500, 750, or 1000 μg kg(-1) ) and two to placebo. All subjects received anticoagulation with an oral vitamin K antagonist to reach an international normalized ratio between 2 and 3 prior to dosing with rVIIa-FP/placebo. Dosing with oral vitamin K antagonist was continued at a fixed dose for 6 days after injection of rFVIIa. RESULTS AND CONCLUSIONS Tolerance of rVIIa-FP was good at all dose levels. No serious adverse events were observed. None of the subjects developed anti-drug antibodies. The maximum baseline-corrected mean (SD) FVIIa plasma activity increased in a dose-proportional manner. Across the dose range, the median half-life was consistent, ranging from 6.1 to 9.7 h. At the highest dose of 1000 μg kg(-1) , the median FVIIa activity-based half-life was 8.5 h. Clearance ranged from 7.62 to 12.74 mL h(-1) kg(-1) . Compared with the commercially available rFVIIa product, rVIIa-FP had a reduced clearance resulting in an approximately 3- to 4-fold increase in half-life.
Collapse
Affiliation(s)
- G Golor
- PAREXEL International GmbH, Berlin, Germany
| | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Abstract
Early treatment of bleeds in hemophilia patients, both with and without inhibitors, has been shown to be of immense benefit in the overall clinical outcome. Despite the advantages of treating the bleeding episodes early, significant barriers and limitations remain. The aim of this review is to highlight the various barriers and perceived limitations to early therapy of bleeding episodes, especially in patients who have developed inhibitors to factor VIII. The peer-reviewed literature was searched for articles on hemophilia patients, with and without inhibitors, and early treatment, to identify the barriers to early treatment and potential impact on patient outcomes. The most important barrier is the educational barrier, which involves lack of awareness among patients regarding the signs of a bleed, as well as importance of early therapy. It is also common for parents or caregivers of school-age children to exhibit inconvenience and scheduling barriers. Distance to the treatment center can also play a role here. Some patients experience financial barriers related to cost of clotting factor products, insurance coverage, or insurance caps and out-of-pocket costs. Rarely, there can also be problems related to venous access or home infusion. Lastly, multiple psychosocial barriers can prevent adherence to treatment regimens. Identification and addressing these individual barriers will result in improved compliance rates, prevent joint damage, be more cost-effective, and lead to better overall health of these patients.
Collapse
Affiliation(s)
- Kapil Saxena
- Boston Hemophilia Center, Boston Children's Hospital, Boston, MA, USA
| |
Collapse
|
13
|
Livnat T, Martinowitz U, Azar-Avivi S, Zivelin A, Brutman-Barazani T, Lubetsky A, Kenet G. Combined administration of FVIII and rFVIIa improves haemostasis in haemophilia A patients with high-responding inhibitors - a thrombin generation-guided pilot study. Haemophilia 2013; 19:782-9. [DOI: 10.1111/hae.12181] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2013] [Indexed: 11/29/2022]
Affiliation(s)
- T. Livnat
- The Israeli National Hemophilia Center and Thrombosis Unit; Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University; Tel Hashomer; Israel
| | - U. Martinowitz
- The Israeli National Hemophilia Center and Thrombosis Unit; Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University; Tel Hashomer; Israel
| | - S. Azar-Avivi
- The Israeli National Hemophilia Center and Thrombosis Unit; Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University; Tel Hashomer; Israel
| | - A. Zivelin
- The Israeli National Hemophilia Center and Thrombosis Unit; Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University; Tel Hashomer; Israel
| | - T. Brutman-Barazani
- The Israeli National Hemophilia Center and Thrombosis Unit; Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University; Tel Hashomer; Israel
| | - A. Lubetsky
- The Israeli National Hemophilia Center and Thrombosis Unit; Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University; Tel Hashomer; Israel
| | - G. Kenet
- The Israeli National Hemophilia Center and Thrombosis Unit; Sheba Medical Center, Tel Hashomer and Sackler School of Medicine, Tel Aviv University; Tel Hashomer; Israel
| |
Collapse
|
14
|
Dolatkhah R, Bazavar MR, Poureisa M, Asvadi Kermani I, Vaez Gharamaleki J, Sanaat Z, Eivazi Ziaei J, Nikanfar A, Esfahani A, Chavoshi SH. Successful management of total knee replacement in a high responder hemophilia patient with a history of inhibitor. IRANIAN RED CRESCENT MEDICAL JOURNAL 2013; 15:18-20. [PMID: 23486529 PMCID: PMC3589773 DOI: 10.5812/ircmj.3406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 05/17/2012] [Accepted: 05/19/2012] [Indexed: 11/16/2022]
Abstract
The development of inhibitors against administered clotting factors may render replacement therapy ineffective for some hemophilia patients. Such patients are therefore at the highest risk of developing arthropathy. Elective orthopedic surgery (EOS) in hemophilic patients having such inhibitors remains a rare, expensive, and difficult surgery, whose management represents a significant challenge. We report the case of a 35-year-old man with a severe form of hemophilia A (factor VIII < 1%), who was suffering from repetitive spontaneous hemarthrosis, especially in his knee joints that had consequently become more susceptible to bleeding. The patient had a history of high levels of factor VIII inhibitor (> 5.0 Bethesda Unit [BU]/ml) as shown by the factor VIII inhibitor assay; therefore, we began treatment with factor VIIa for his mild-to-moderate bleeding (90 µg/kg intravenous bolus injections). The interval between injections varied with the severity of the hemorrhage in each bleeding episode. The inhibitor level reduced to 3.1 BU/ml after three months, to 1.6 BU/ml after six months, and disappeared completely after one year of treatment. We administered factor VIII at a dose of 50 IU/kg every eight hours during the first three post-operative days, then continued administration with a dose of 40 IU/kg every 12 hours for another four days, and observed a very good response to treatment with no bleeding. Recombinant activated factor VII (rFVIIa) is not an inhibitor-removal strategy, but an inhibitor-bypassing product. However, in our patient, the treatment of mild-to-moderate bleeding with short-term use of rFVIIa and no exposure to factor VIII caused a gradual reduction in the inhibitor level over a period of 1 year.
Collapse
Affiliation(s)
- Roya Dolatkhah
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| | - Mohammad Reza Bazavar
- Department of Orthopedic, Tabriz University of Medical Sciences, Tabriz, IR Iran
- Corresponding author: Mohammad Reza Bazavar, Department of Orthopedic, Tabriz University of Medical Sciences, Tabriz, IR Iran. Tel.: +98-4113859314, Fax: +98-4113859314, E-mail:
| | - Masoud Poureisa
- Radiology Department, Tabriz University of Medical Sciences, Tabriz, IR Iran
| | - Iraj Asvadi Kermani
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| | - Jalil Vaez Gharamaleki
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| | - Zohreh Sanaat
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| | - Jamal Eivazi Ziaei
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| | - Alireza Nikanfar
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| | - Ali Esfahani
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| | - Seyed Hadi Chavoshi
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Hemophilia and Thalassemia Department, Tabriz, IR Iran
| |
Collapse
|