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Peyvandi F, Kavakli K, El‐Beshlawy A, Rangarajan S. Management of haemophilia A with inhibitors: A regional cross-talk. Haemophilia 2022; 28:950-961. [PMID: 35868021 PMCID: PMC9796719 DOI: 10.1111/hae.14638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/04/2022] [Accepted: 07/09/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The development of inhibitors with factor VIII (FVIII) replacement therapy is one of the most common and challenging complications of haemophilia A (HA) treatment, jeopardising treatment efficacy and predisposing patients to high risks of morbidity and mortality. The management of patients with inhibitors is particularly challenging in countries where resources are limited. AIM To provide a comprehensive summary of the management of HA with inhibitors while focusing on differences in practice between Western and non-Western countries and how resource scarcity can impact HA management, leading to suboptimal outcomes in patients with inhibitors. METHODS Summary of key evidence and regional expert opinion. RESULTS We address, particularly, the diagnosis of and testing for inhibitors, as well as the epidemiology of inhibitors, including incidence, prevalence and disease burden. Secondly, we provide an overview of the current treatment landscape in HA with inhibitors regarding the eradication of inhibitors with immune tolerance induction and the treatment and prevention of bleeding with bypassing agents, non-factor replacement agents and other experimental therapies. This is complemented with insights from the authors around the applicability of, and challenges associated with, such therapies in their settings of practice. CONCLUSIONS We conclude by proposing some key steps towards bridging the gaps in the management of HA with inhibitors in resource-limited countries, including: (1) the collection of quality data that can inform healthcare reforms and policies; (2) improving disease knowledge among healthcare practitioners and patients with the aim of standardising disease management across centres and (3) working towards promoting equal access to HA care and therapies for everyone.
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Affiliation(s)
- Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly,Department of Pathophysiology and TransplantationUniversità degli Studi di MilanooMilanItaly
| | - Kaan Kavakli
- Department of Pediatric HematologyEge University Children's HospitalIzmirTurkey
| | - Amal El‐Beshlawy
- Department of Pediatric Hematology, Faculty of MedicineCairo UniversityCairoEgypt
| | - Savita Rangarajan
- Department of HaematologyUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK,Clinical Trials and Research UnitKJ Somaiya Super Specialty Hospital and Research CentreMumbaiIndia
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2
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Olasupo OO, Haddix C, Nakar C, Maahs J, Greist A, Ghafoor A, Donfield SM, Iorio A, Shapiro AD. Utilization of a surgical database to provide care and assess perioperative treatment and outcomes in patients with bleeding disorders. Eur J Haematol 2021; 108:232-243. [PMID: 34878676 DOI: 10.1111/ejh.13731] [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: 05/21/2021] [Revised: 11/24/2021] [Accepted: 11/29/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To describe the Indiana Hemophilia and Thrombosis Center (IHTC) surgical database, its key components, and exploratory analyses of surgeries conducted between 1998 and 2019. METHODS Surgical data across bleeding disorders collected retrospectively (1998-2006) and prospectively (2006-2019) were analyzed. Perioperative hemostasis, complications, and surgical plan deviations were compared by bleeding disorder diagnosis and data collection period. RESULTS Within the 21-year period, 3246 procedures were conducted in 1413 patients with a diagnosis of von Willebrand disease (vWD), hemophilia A (HA), hemophilia B (HB), and other bleeding disorders. Majority of the procedures were minor (63.3%), and median number of surgeries per patient was 1 (range: 1-22). Adequate perioperative hemostasis was achieved in 90.9%, complications occurred in 13.6%, and surgical plan deviations occurred in 31.3% of procedures. Inadequate perioperative hemostasis and surgical plan deviations occurred more frequently in procedures involving HB compared with other bleeding disorders. Complications were not significantly different across bleeding disorders (p = .164). The prospective data collection period was associated with higher rates of hemostatic efficacy (92.4% vs. 88.3%; p < .001), complications (14.3% vs. 12.3%; p < .001), and plan deviations (34.2% vs. 25.1%; p < .001). CONCLUSION The surgical database is an important resource in surgical management in patients with bleeding disorders. Further evaluation will facilitate use for the development of predictive models and principles of care.
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Affiliation(s)
- Omotola O Olasupo
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Craig Haddix
- The Indiana Hemophilia & Thrombosis Center (IHTC), Indianapolis, Indiana, USA
| | - Charles Nakar
- The Indiana Hemophilia & Thrombosis Center (IHTC), Indianapolis, Indiana, USA
| | - Jennifer Maahs
- The Indiana Hemophilia & Thrombosis Center (IHTC), Indianapolis, Indiana, USA
| | - Anne Greist
- The Indiana Hemophilia & Thrombosis Center (IHTC), Indianapolis, Indiana, USA
| | - Azam Ghafoor
- The Indiana Hemophilia & Thrombosis Center (IHTC), Indianapolis, Indiana, USA
| | | | - Alfonso Iorio
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Amy D Shapiro
- The Indiana Hemophilia & Thrombosis Center (IHTC), Indianapolis, Indiana, USA
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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.
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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
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Soni P, Shanmukhaiah C, Patil R, Shetty S. Differential response to FEIBA is strongly associated with the prothrombotic microparticles. Blood Cells Mol Dis 2020; 84:102441. [PMID: 32388201 DOI: 10.1016/j.bcmd.2020.102441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/23/2020] [Accepted: 04/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Treatment of patients with hemophilia with an inhibitor is generally done using bypassing agents (BPA), wherein variability in response is observed. Due to lack of validated laboratory assays, monitoring is being carried out by clinical response only. Emerging biomarkers like procoagulant microparticles (MPs) may prove to be promising. AIM To analyze whether procoagulant MP levels correlate with clinical response to FEIBA therapy. MATERIALS AND METHODS Total phosphatidylserine (PS) expressing MPs along with different cell derived MPs were measured in blood samples obtained prior and 2 hour post-FEIBA infusion in 64 bleeding episodes associated with 43 severe hemophilia patients. RESULTS AND DISCUSSION Patients with excellent response showed statistically significant increase in %MP of PS-MPs (p < 0.0001; 95.0% CI Range: -64.33 to -24.42) when compared to those with moderate response; platelet %MP change was also found significantly associated (p < 0.05) with clinical response. In search of an assay for monitoring FEIBA, results though preliminary seem to be promising with increase in %PS-MP correlating well with the clinical response. Coagulation being multifactorial process involves multiple factors for balanced hemostasis, which needs to be accounted. Larger studies in this line may provide indications for usage of MPs as monitoring and dose adjustment tool of FEIBA therapy.
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Affiliation(s)
- Puja Soni
- National Institute of Immunohematology (NIIH-ICMR), 13th floor, KEM Hospital, Parel, Mumbai 400012, India
| | | | - Rucha Patil
- National Institute of Immunohematology (NIIH-ICMR), 13th floor, KEM Hospital, Parel, Mumbai 400012, India
| | - Shrimati Shetty
- National Institute of Immunohematology (NIIH-ICMR), 13th floor, KEM Hospital, Parel, Mumbai 400012, India.
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Perioperative laboratory monitoring in congenital haemophilia patients with inhibitors: a systematic literature review. Blood Coagul Fibrinolysis 2020; 30:309-323. [PMID: 31397688 DOI: 10.1097/mbc.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
: Although the use of clotting factor concentrates is the mainstay of haemophilia care, the development of inhibitors complicates disease management. Perioperative management of patients with inhibitors is therefore a challenge. A systematic literature review was performed to identify literature reporting on the perioperative monitoring and management of haemophilia. MEDLINE, Embase and Cochrane databases were searched from database inception to 26 March 2018. Recent congress proceedings were also searched. Titles and abstracts, then full texts, were screened for relevance by two reviewers. Quality of included studies was assessed using the Critical Appraisal Skills Programme checklist. Of the 2033 individual entries identified, 86 articles met the inclusion criteria. The identified studies were screened again to find articles reporting perioperative laboratory monitoring in patients with congenital haemophilia A or B, resulting in 24 articles undergoing data extraction. Routine perioperative assay monitoring practices were the most commonly reported (n = 20/24); thrombin generation assay was the least commonly reported (n = 2/24). Other monitoring practices described were factor VII and factor VIII coagulation activity (n = 8/24, n = 5/24, respectively), and thromboelastography or rotational thromboelastometry assessments (n = 3/24). The impact of monitoring on treatment decisions was, however, rarely reported. In conclusion, many methods of perioperative monitoring of haemophilia patients with inhibitors have been identified in this review, yet there is a lack of reporting in larger scale cohort studies. More detailed reporting on the impact of monitoring outcomes on treatment decisions is also needed to share best practice, particularly as new therapeutic agents emerge.
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Abstract
Haemophilia is a group of coagulation disorders inherited in an X-linked recessive pattern. Nearly three-quarters of all haemorrhages in haemophilia occur in the musculoskeletal system, usually in the large muscles and joints of the lower extremity. While prevention of bleeding with active prophylaxis is the recommended optimal therapy for severe haemophilia, there are many patients suffering from musculoskeletal system complications subsequent to uncontrolled bleeding. Recombinant clotting factor concentrates led to home treatment of acute bleeding episodes as well as allowing for minor and major surgical interventions. Avoiding of further complications by radiosynoviorthesis is the first-line recommendation, and arthroplasty is regarded as the effective salvage procedure for patients presenting with severe disability. Physiotherapy and rehabilitation in haemophilia patients are important to return the normal status of joint motion, to regain the muscle strength, to obtain the optimal functional levels and to improve patients’ quality of life.
Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180068
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Affiliation(s)
- Bülent Atilla
- Hacettepe University Faculty of Medicine, Department of Orthopaedics and Traumatology, Ankara, Turkey
| | - Hande Güney-Deniz
- Hacettepe University Faculty of Physical Therapy and Rehabilitation, Ankara, Turkey
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Erturan G, Guevel B, Alvand A, Goddard NJ. Over two decades of orthopaedic surgery in patients with inhibitors-Quantifying the complication of bleeding. Haemophilia 2018; 25:21-32. [PMID: 30507046 DOI: 10.1111/hae.13647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/28/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022]
Abstract
Patients with haemophilia who have developed inhibitors against factor VIII (FVIII) or factor IX present a significant concern to those surgeons who operate on them. The evidence base for bypassing agents such as recombinant factor VIIa and activated prothrombin complex concentrate has amassed over several decades. The literature is open to positive interpretation on the successful use of these agents in the treatment of inhibitor-positive patients. However, there are equally persistent concerns amongst surgeons, in particular orthopaedic surgeons, regarding the high complication rate of bleeding. To explore and quantify this concern, we present a literature review spanning two decades of publications on haemophilia patients with inhibitors undergoing orthopaedic surgery. Irrespective of the progress made with haemostatic protocols, trepidation on embarking on surgery is valid. The high risk of bleeding is a function of the inherent complexity of the disease and rightfully translates into difficulties in its management. Combined with the prospect of orthopaedic surgery, those involved in the care of such patients are justified in their continued anxiety and diligence when considering the benefits in quality of life against the prevalent complications.
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Affiliation(s)
- Gurhan Erturan
- Department of Trauma & Orthopaedics, Royal Free Hospital, London, UK
| | - Borna Guevel
- Department of Trauma & Orthopaedics, Royal Free Hospital, London, UK
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Rodríguez-Zepeda MDC, González L, Bravo A, Pompa T, Silva S, Paredes R, García J, Ramos M, Wilkinson L, Lamotte M. Cost-Effectiveness of rFVIIa versus pd-aPCC in the Management of Mild to Moderate Bleeds in Pediatric Patients with Hemophilia A with Inhibitors in Mexico. Value Health Reg Issues 2018; 17:164-173. [PMID: 30317158 DOI: 10.1016/j.vhri.2018.06.007] [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: 12/20/2017] [Revised: 06/04/2018] [Accepted: 06/15/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To compare the costs and clinical consequences of treating mild-to-moderate joint bleeds with recombinant activated factor VII (rFVIIa) versus plasma-derived activated prothrombin complex concentrate (pd-aPCC) in pediatric patients with hemophilia A with inhibitors in Mexico. METHODS A cost-effectiveness model was developed using TreeAge Pro v14.2.2 software (licensed in the USA) and adapted from a previously published model, with adjustments to reflect local clinical practice. Expert opinion was sought regarding patients' clinical management and resource utilization in Mexico to ensure that the current model was appropriate and relevant. The model compared rFVIIa and pd-aPCC for the treatment of mild-to-moderate joint bleeds in children <14 years old (assumed average weight: 30 kg). The analysis outcome was incremental cost per resolved mild-to-moderate joint bleed. One-way sensitivity analysis and probabilistic sensitivity analysis were used to assess specific assumptions and to address any uncertainty in the model. RESULTS The cost of treating mild-to-moderate joint bleeds was lower for rFVIIa versus pd-aPCC after 7 days (MX$105,581 vs. MX$132,024), assuming complete bleed resolution. After 48 hours, rFVIIa was associated with an 8% improvement in bleed resolution versus pd-aPCC, resulting in cost savings of MX$16,754. Probabilistic sensitivity analysis indicated that rFVIIa treatment was more cost-effective than pd-aPCC in 67% (at 7 days) and 72% (at 48 hours) of Monte Carlo simulations. CONCLUSION Accounting for model uncertainty, rFVIIa provided cost savings over pd-aPCC for the Mexican public health care payer in the management of mild-to-moderate joint bleeds in pediatric hemophilia A with inhibitors.
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Affiliation(s)
| | | | - Amalia Bravo
- Instituto Nacional de Pediatría, Secretaría de Salud, Mexico
| | - Teresa Pompa
- Hospital de Especialidades del IMSS en Monterrey N.L., Mexico
| | | | - Rogelio Paredes
- Instituto Nacional de Pediatría, Secretaría de Salud, Mexico
| | - Jaime García
- Hospital de Especialidades, Centro Médico Nacional La Raza, IMSS, Mexico
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9
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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.
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Mingot-Castellano ME, Álvarez-Román MT, López-Fernández MF, Altisent-Roca C, Canaro-Hirnyk MI, Jiménez-Yuste V, Cid-Haro AR, Pérez-Garrido R, Sedano-Balbas C. Spanish consensus guidelines on prophylaxis with bypassing agents for surgery in patients with haemophilia and inhibitors. Eur J Haematol 2016; 96:461-74. [DOI: 10.1111/ejh.12730] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2015] [Indexed: 01/18/2023]
Affiliation(s)
| | | | | | | | | | | | - Ana Rosa Cid-Haro
- Thrombosis and Haemostasis Unit; Hospital Universitario La Fe; Valencia Spain
| | | | - Carmen Sedano-Balbas
- Haematology Department; Hospital Universitario Marqués de Valdecilla; Cantabria Spain
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12
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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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13
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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
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14
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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]
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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.
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Affiliation(s)
- M Makris
- Department of Cardiovascular Science, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK.
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Rangarajan S, Austin S, Goddard NJ, Négrier C, Rodriguez-Merchan EC, Stephensen D, Yee TT. Consensus recommendations for the use of FEIBA®in haemophilia A patients with inhibitors undergoing elective orthopaedic and non-orthopaedic surgery. Haemophilia 2012; 19:294-303. [DOI: 10.1111/hae.12028] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2012] [Indexed: 01/18/2023]
Affiliation(s)
| | - S. Austin
- St George's Healthcare NHS Trust Haemophilia Centre; St George's Hospital; London; UK
| | - N. J. Goddard
- Department of Orthopaedic Surgery; Royal Free Hospital NHS Foundation Trust; London; UK
| | - C. Négrier
- Haemostasis Division; Hôpital Edouard Herriot; Lyon; France
| | | | - D. Stephensen
- Kent Haemophilia Centre; Kent & Canterbury Hospital; Canterbury; Kent; UK
| | - T. T. Yee
- The Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital NHS Foundation Trust; London; UK
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Kulkarni R. Comprehensive care of the patient with haemophilia and inhibitors undergoing surgery: practical aspects. Haemophilia 2012; 19:2-10. [PMID: 22925397 DOI: 10.1111/j.1365-2516.2012.02922.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2012] [Indexed: 11/30/2022]
Abstract
Congenital haemophilia is a rare and complex condition for which dedicated specialized and comprehensive care has produced measurable improvements in clinical outcomes and advances in patient management. Among these advances is the ability to safely perform surgery in patients with inhibitor antibodies to factors VIII and IX, in whom all but the most necessary of surgeries were once avoided due to the risk for uncontrollable bleeding due to ineffectiveness of replacement therapy. Nevertheless, surgery continues to pose a major challenge in this relatively rare group of patients because of significantly higher costs than in patients without inhibitors, as well as a high risk for bleeding and other complications. Because of the concentration of expertise and experience, it is recommended that any surgery in patients with haemophilia and inhibitors be planned in conjunction with a haemophilia treatment centre (HTC) and performed in a hospital that incorporates a HTC. Coordinated, standard pre-, intra- and postoperative assessments and planning are intended to optimize surgical outcome and utilization of resources, including costly factor concentrates and other haemostatic agents, while minimizing the risk for bleeding and other adverse consequences both during and after surgery. This article will review the special considerations for patients with inhibitors as they prepare for and move through surgery and recovery, with an emphasis on the roles and responsibilities of individual members of the multidisciplinary team in facilitating this process.
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Affiliation(s)
- R Kulkarni
- Division of Pediatric and Adolescent Hematology/Oncology, Department of Pediatrics and Human Development, Michigan State University College of Human Medicine, East Lansing, MI 48824, USA.
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