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Tardy B, Lambert T, Chamouni P, Montmartin A, Trossaert M, Claeyssens S, Berger C, Ardillon L, Gay V, Delavenne X, Harroche A, Chelle P. Revised terminal half-life of nonacog alfa as derived from extended sampling data: A real-world study involving 64 haemophilia B patients on nonacog alfa regular prophylaxis. Haemophilia 2022; 28:542-547. [PMID: 35420242 DOI: 10.1111/hae.14560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Nonacog alfa, a standard half-life recombinant factor IX (FIX), is used as a prophylactic treatment in severe haemophilia B (SHB) patients. Its half-life determined in clinical studies involving a limited sampling (72 h) was shown to be rather short. In our clinical practice, we suspected that its half-life could have been underestimated. OBJECTIVES We aimed to evaluate nonacog alfa pharmacokinetics in real world clinical practice based on FIX levels in patients receiving prophylaxis. METHODS We retrospectively collected data on patients with SHB receiving prophylaxis from eight centres across France. The terminal half-life (THL), time to reach 5-2 IU/dl and FIX activity at 48, 72 and 96 h were derived by Bayesian estimations using NONMEM analysis. RESULTS AND CONCLUSIONS Infusion data (n = 455) were collected from 64 patients with SHB. The median THL measured in 92 pharmacokinetic (PK) studies was 43.4 h. In 26 patients ≤12 years of age, 51 PK studies showed a median time to reach 5 IU/dl of FIX of 70.5 h and a median time to reach 2 IU/dl of 121.5 h. In 38 patients 13-75 years of age, 41 PK studies showed a median time to reach 5 IU/dl of FIX of 92.0 h and a median time to reach 2 IU/dl of 167.5 h. Extending the sampling beyond 72 h makes it possible to observe a plateau, with FIX remaining between 2 and 5 IU/dl for several days and shows that the THL of nonacog alfa might be longer than previously described. ESSENTIALS Nonacog alfa terminal half-life (THL) in patients receiving regular prophylaxis was evaluated in clinical practice. The median THL was estimated to be 36.9 h for patients aged .8-12 years. The median THL was estimated to be 49.9 h for patients aged 13-75 years. For patients aged ≤12 and >12 years, the median times to reach 5 IU/dl were 70.5 and 92 h, respectively; to reach 3 IU/dl, 95.5 and 131.5 h, respectively; to reach 2 IU/dl, 121.5 and 167.5 h, respectively. We suggest that the half-life of nonacog alfa might be longer than previously described in both younger and older patients.
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Affiliation(s)
- Brigitte Tardy
- Centre de Ressources et de Compétence Maladies hémorragiques, CHU Saint-Etienne, Hôpital Nord, Saint-Etienne, France.,Sainbiose, Inserm, U1059, Université Lyon, Saint-Etienne, France.,Inserm, CIC 1408, CHU Saint-Etienne Hôpital Nord, Saint-Etienne, France
| | - Thierry Lambert
- Centre de Référence Maladies hémorragiques CHU Paris Sud-Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Pierre Chamouni
- Laboratoire d'Hématologie, Institut de Biologie Clinique, CHU de Rouen, Rouen, France
| | | | - Marc Trossaert
- Centre de Ressources et de Compétence Maladies hémorragiques, CHU de Nantes, Nantes, France
| | - Ségolène Claeyssens
- Centre de Ressources et de Compétence Maladies hémorragiques, CHU Toulouse-Hôpital Purpan, Toulouse, France
| | - Claire Berger
- Centre de Ressources et de Compétence Maladies hémorragiques, CHU Saint-Etienne, Hôpital Nord, Saint-Etienne, France
| | - Laurent Ardillon
- Centre de Ressources et de Compétence Maladies hémorragiques, CHU Tours-Hôpital Trousseau, Tours, France
| | - Valérie Gay
- Centre de Ressources et de Compétence Maladies hémorragiques, Centre hospitalier Métropole Savoie, Chambéry, France
| | - Xavier Delavenne
- Sainbiose, Inserm, U1059, Université Lyon, Saint-Etienne, France
| | - Annie Harroche
- Centre de Référence Maladies hémorragiques, Hôpital Necker Enfants-Malades, Université Paris Descartes, Paris, France
| | - Pierre Chelle
- School of Pharmacy, University of Waterloo, Waterloo, Canada
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2
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Characterisation of recombinant factor IX before and after GlycoPEGylation. Int J Pharm 2020; 588:119654. [PMID: 32693290 DOI: 10.1016/j.ijpharm.2020.119654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/08/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022]
Abstract
The effect of the GlycoPEGylation process used for prolonging the half-life of recombinant factor IX (rFIX) has no impact on the primary and higher order structure of activated factor IX. Characterisation work performed on recombinant factor IX and on the GlycoPEGylated form of rFIX (N9-GP), confirm that the primary structure as well as the post translational modifications (PTMs) (disulphide bonds, γ-carboxylation, β-hydroxylation, sulphation and O- and N-linked glycan structures) were comparable for rFIX and N9-GP. Three O-linked glycan sites were identified in the activation peptide (Thr159, Thr163 and Thr169), where Thr163 has not been reported previously. For N9-GP, the mono GlycoPEGylation is directed toward one of the two N-linked glycans present at Asn157 and Asn167 in the activation peptide in a one to one ratio. Spectroscopic techniques, such as far and near UV Circular Dichroism studies show comparable secondary and tertiary structures of rFIX and N9-GP. The thermally induced unfolding of rFIX and N9-GP shows that the unfolding temperature is approximately 1 °C higher for N9-GP than that of the rFIX. Furthermore, the pH dependent degradation was reduced due to the GlycoPEGylation of rFIX. GlycoPEGylated rFIX (N9-GP) is used for the manufacturing of Refixia® (nonacog beta pegol, Rebinyn®, Novo Nordisk A/S, Bagsvaerd, Denmark).
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3
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Yu JK, Iorio A, Edginton AN. Using pharmacokinetics for tailoring prophylaxis in people with hemophilia switching between clotting factor products: A scoping review. Res Pract Thromb Haemost 2019; 3:528-541. [PMID: 31294337 PMCID: PMC6611373 DOI: 10.1002/rth2.12204] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/28/2019] [Accepted: 03/21/2019] [Indexed: 01/19/2023] Open
Abstract
The objective of this scoping review is to summarize the current use of pharmacokinetics for tailoring prophylaxis in hemophilia patients switching between clotting factor products. Patients with hemophilia may require switching of clotting factor concentrates due to a variety of factors, but there have been perceived risks associated with switching, such as inhibitor development or suboptimal protection due to inadequate dosing while titrating treatment. Studies that look at patients switching from one clotting factor concentrate to another are categorized in terms of their primary and/or secondary objectives, notably biosimilarity and comparative pharmacokinetic studies and inhibitor development studies. Research on how best to switch concentrates with respect to dosing regimen are lacking, and currently a trial‐and‐error approach is used for dosing the new factor concentrate. In the future, studies looking at the predictability of pharmacokinetics (PK) of a new factor concentrate based on individual PK knowledge of the original factor concentrate may offer clinical benefit by providing a safer switching approach and protocol.
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Affiliation(s)
- Jacky K Yu
- School of Pharmacy University of Waterloo Waterloo Ontario Canada
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact McMaster University Hamilton Ontario Canada.,McMaster-Bayer Research Chair in Clinical Epidemiology of Congenital Bleeding Disorders Department of Medicine McMaster University Hamilton Ontario Canada
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4
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Abstract
Haemophilia is a rare disease for which the approved therapeutic options have remained virtually unchanged for 50 years. In the past decade, however, there has been an explosion of innovation in the treatment options that are either in development or have been approved for haemophilia, including engineered clotting factors and an extensive pipeline of new approaches and modalities. Several of these new modalities, especially gene therapy, demonstrate proof of principle in haemophilia but could have broader applications. These advances, in combination with better diagnostics, are now enabling clinicians to improve the standard of care for people with haemophilia. The different mechanisms of action and modifications used in these therapies have implications for their safe and efficacious use, which must be balanced with their therapeutic utility. This Review focuses on the biological aspects of the most advanced and innovative approaches for haemophilia treatment and considers their future use.
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5
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Morfini M, Gherardini S. Pharmacokinetic-based prediction of real-life dosing of extended half-life clotting factor concentrates on hemophilia. Ther Adv Hematol 2018; 9:149-162. [PMID: 29899890 PMCID: PMC5992810 DOI: 10.1177/2040620718774258] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/09/2018] [Indexed: 01/12/2023] Open
Abstract
The improvement of clotting factor concentrates (CFCs) has undergone an impressive boost during the last six years. Since 2010, several new recombinant factor (rF)VIII/IX concentrates entered phase I/II/III clinical trials. The improvements are related to the culture of human embryonic kidney (HEK) cells, post-translational glycosylation, PEGylation, and co-expression of the fragment crystallizable (Fc) region of immunoglobulin (Ig)G1 or albumin genes in the manufacturing procedures. The extended half-life (EHL) CFCs allow an increase of the interval between bolus administrations during prophylaxis, a very important advantage for patients with difficulties in venous access. Although the inhibitor risk has not been fully established, phase III studies have provided standard prophylaxis protocols, which, compared with on-demand treatment, have achieved very low annualized bleeding rates (ABRs). The key pharmacokinetics (PK) parameter to tailor patient therapy is clearance, which is more reliable than the half-life of CFCs; the clearance considers the decay rate of the drug concentration-time profile, while the half-life considers only the half concentration of the drug at a given time. To tailor the prophylaxis of hemophilia patients in real-life, we propose two formulae (expressed in terms of the clearance, trough and dose interval between prophylaxis), respectively based on the one- and two-compartmental models (CMs), for the prediction of the optimal single dose of EHL CFCs. Once the data from the time decay of the CFCs are fitted by the one- or two-CMs after an individual PK analysis, such formulae provide to the treater the optimal trade-off among trough and time-intervals between boluses. In this way, a sufficiently long time-interval between bolus administration could be guaranteed for a wider class of patients, with a preassigned level of the trough. Finally, a PK approach using repeated dosing is discussed, and some examples with new EHL CFCs are shown.
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Affiliation(s)
| | - Stefano Gherardini
- Department of Physics and Astronomy, LENS, and
QSTAR, University of Florence, Sesto Fiorentino (Italy)
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6
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Brennan Y, Curnow J, Favaloro EJ. Trenonacog alfa for prophylaxis, on-demand and perioperative management of hemophilia B. Expert Opin Biol Ther 2017; 18:95-100. [PMID: 29172774 DOI: 10.1080/14712598.2018.1407311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Current treatment for hemophilia B involves replacing the missing coagulation factor IX (FIX) with either plasma-derived or recombinant (r) FIX. Trenonacog alfa is the third normal half-life rFIX that has been granted FDA approval. Area covered: In this review, the authors examine trenonacog alfa for the treatment of hemophilia B including prophylaxis, on-demand and perioperative hemostasis. They compare the PK profile to nonacog alfa and evaluate the drug's efficacy and safety from published studies. Expert opinion: Trenonacog alfa appears to be an effective and safe treatment option for patients with hemophilia B with a PK profile similar to that of nonacog alfa. Despite the advent of extended half-life rFIX and other novel therapeutic approaches, normal half-life rFIX products, including trenonacog alfa, are likely to continue to have a place in hemophilia B treatment for at least the immediate future while the new landscape takes shape, particularly in countries that cannot afford the newer treatments.
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Affiliation(s)
- Yvonne Brennan
- a Department of Haematology , Westmead Hospital , Sydney , Australia
| | - Jennifer Curnow
- a Department of Haematology , Westmead Hospital , Sydney , Australia.,b Sydney Medical School , The University of Sydney , Sydney , Australia.,c Sydney Centres for Thrombosis and Haemostasis , Westmead , Sydney , Australia
| | - Emmanuel J Favaloro
- c Sydney Centres for Thrombosis and Haemostasis , Westmead , Sydney , Australia.,d Diagnostic Haemostasis Laboratory, Laboratory Haematology, Institute of Clinical Pathology and Medical Research, NSW Health Pathology , Westmead Hospital , Westmead , Australia
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7
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Collins PW, Quon DVK, Makris M, Chowdary P, Kempton CL, Apte SJ, Ramanan MV, Hay CRM, Drobic B, Hua Y, Babinchak TJ, Gomperts ED. Pharmacokinetics, safety and efficacy of a recombinant factor IX product, trenonacog alfa in previously treated haemophilia B patients. Haemophilia 2017; 24:104-112. [DOI: 10.1111/hae.13324] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2017] [Indexed: 01/01/2023]
Affiliation(s)
- P. W. Collins
- Arthur Bloom Haemophilia Centre; School of Medicine Cardiff University; Cardiff UK
| | - D. V. K. Quon
- Hemophilia Treatment Center; Orthopaedic Hospital; Los Angeles CA USA
| | - M. Makris
- Department of Haematology; Royal Hallamshire Hospital; Sheffield UK
| | - P. Chowdary
- Katharine Dormandy Haemophilia Care and Thrombosis Unit; Royal Free Hospital NHS Trust; London UK
| | - C. L. Kempton
- Department of Hematology and Medical Oncology; Emory University; Atlanta GA USA
| | | | - M. V. Ramanan
- Jehangir Clinical Development Centre; Jehangir Hospital; Pune India
| | - C. R. M. Hay
- Manchester Haemophilia Comprehensive Care Centre; Manchester UK
| | - B. Drobic
- Clinical Research; Emergent BioSolutions Canada Inc.; Winnipeg MB Canada
| | - Y. Hua
- Clinical Research; Emergent BioSolutions Canada Inc.; Winnipeg MB Canada
| | - T. J. Babinchak
- Clinical Development and Medical Affairs; Emergent BioSolutions Inc.; Berwyn IL USA
| | - E. D. Gomperts
- Consultant for Emergent BioSolutions Inc.; Montrose CO USA
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8
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Young G, Mahlangu JN. Extended half-life clotting factor concentrates: results from published clinical trials. Haemophilia 2017; 22 Suppl 5:25-30. [PMID: 27405672 DOI: 10.1111/hae.13028] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2016] [Indexed: 01/08/2023]
Abstract
Extended half-life clotting factor concentrates have been recently introduced into the armamentarium of treatments for patients with haemophilia A and B. In general, the data from published studies have demonstrated these products to be safe with no inhibitors reported in previously treated patients and efficacious with the advantage of a longer half-life allowing for less frequent intravenous infusions of factor. This enhanced convenience has led to some patients not previously on prophylaxis to begin prophylaxis while for others, especially children, has led to the ability to provide prophylaxis with reduced use of central venous catheters. The extended half-life factor IX products are now allowing patients to dose every 1-2 weeks while maintaining higher trough levels while the extended half-life factor VIII products have reduced the frequency of administration for patients on prophylaxis to as infrequent as once per week for some patients and to twice per week for all patients including younger children. It is important to note that data from previously untreated patients have not been published yet and the incidence for inhibitors in this patient population is as of yet unknown. The era of extended half-life clotting factor products has begun and the challenge for the haemophilia community will be how to best integrate these products into haemophilia clinical practice.
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Affiliation(s)
- G Young
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - J N Mahlangu
- Haemophilia Comprehensive Care Centre, Charlotte Maxeke Johannesburg Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
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9
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Abstract
INTRODUCTION Replacement therapy with clotting factor concentrates is the most appropriate and effective way to treat bleedings of Hemophilia A&B to prevent chronic arthropathy. Unfortunately, the short half-life (HL) of FVIII/IX concentrates obliges the patients to receive frequent infusions, a big concern for children. The development of inhibitors in about 30-45% of hemophilia A and in 3-5% of hemophilia B patient is the major adverse event of replacement therapy. AREAS COVERED In the last few years, new rFIX have been developed with HL. New rFVIII concentrates are displaying small increase of PK characteristics. The new bio-engineering methods allowed the production of molecules fused with Fc fragment of IgG or Albumin or linked to PEG. A new approach to improve hemostasis is represented by Mab against TFPI and small RNA interfering with Antithrombin synthesis. Another innovative drug seems to be the new bi-specific antibody which mimics FVIII function in linking FXa and FX to tenase production. EXPERT OPINION The emerging drugs for hemophilia treatment seem to be very promising. The extended half-life will improve the adherence of patients to therapy. Accurate post-marketing surveillance studies will be necessary to check the efficacy, safety and immunogenicity of these new molecules.
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Affiliation(s)
- Massimo Morfini
- a Past President of Italian Association of Haemophilia Centres , Firenze , Italy
| | - Ezio Zanon
- b Internal Medicine Department, University of Padua Medical School , Padua , Italy
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10
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Morfini M, Dragani A, Paladino E, Radossi P, Di Minno G, Mazzucconi MG, Rossetti G, Barillari G, Napolitano M, Tagariello G. Correlation between FIX genotype and pharmacokinetics of Nonacog alpha according to a multicentre Italian study. Haemophilia 2016; 22:537-42. [DOI: 10.1111/hae.12916] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 01/03/2023]
Affiliation(s)
- M. Morfini
- Past President of Italian Association of Haemophilia Centres (AICE); Firenze Italy
| | - A. Dragani
- Haemophilia & Thrombosis Centre; Haematology Department; Regional Hospital; Pescara Italy
| | - E. Paladino
- Atherothrombotic Diseases; Cardio-Vascular Department; University Hospital of Florence; Florence Italy
| | - P. Radossi
- Haematology and Haemophilia Centre; Regional Hospital; Castelfranco Veneto Italy
| | - G. Di Minno
- Reference Centre for Haemophilia and Thrombosis; Department of Clinical and Experimental Medicine; Federico II University; Naples Italy
| | - M. G. Mazzucconi
- Haemophilia & Thrombosis Centre; Haematology Department; La Sapienza University; Rome Italy
| | - G. Rossetti
- Haemophilia Centre; Santa Chiara Hospital; Trento Italy
| | - G. Barillari
- Haemophilia Centre; S. Maria della Misericordia Hospital; Udine Italy
| | - M. Napolitano
- Haemophilia & Thrombosis Centre; Haematology Department; University of Palermo; Palermo Italy
| | - G. Tagariello
- Haematology and Haemophilia Centre; Regional Hospital; Castelfranco Veneto Italy
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11
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Monroe DM, Jenny RJ, Van Cott KE, Buhay S, Saward LL. Characterization of IXINITY® (Trenonacog Alfa), a Recombinant Factor IX with Primary Sequence Corresponding to the Threonine-148 Polymorph. Adv Hematol 2016; 2016:7678901. [PMID: 26997955 PMCID: PMC4779506 DOI: 10.1155/2016/7678901] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/14/2016] [Indexed: 11/17/2022] Open
Abstract
The goal of these studies was to extensively characterize the first recombinant FIX therapeutic corresponding to the threonine-148 (Thr-148) polymorph, IXINITY (trenonacog alfa [coagulation factor IX (recombinant)]). Gel electrophoresis, circular dichroism, and gel filtration were used to determine purity and confirm structure. Chromatographic and mass spectrometry techniques were used to identify and quantify posttranslational modifications. Activity was assessed as the ability to activate factor X (FX) both with and without factor VIIIa (FVIIIa) and in a standard clotting assay. All results were consistent across multiple lots. Trenonacog alfa migrated as a single band on Coomassie-stained gels; activity assays were normal and showed <0.002 IU of activated factor IX (FIXa) per IU of FIX. The molecule has >97% γ-carboxylation and underwent the appropriate structural change upon binding calcium ions. Trenonacog alfa was activated normally with factor XIa (FXIa); once activated it bound to FVIIIa and FXa. When activated to FIXa, it was inhibited efficiently by antithrombin. Glycosylation patterns were similar to plasma-derived FIX with sialic acid content consistent with the literature reports of good pharmacokinetic performance. These studies have shown that trenonacog alfa is a highly pure product with a primary sequence and posttranslational modifications consistent with the common Thr-148 polymorphism of plasma-derived FIX.
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Affiliation(s)
- Dougald M. Monroe
- School of Medicine, Department of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Richard J. Jenny
- Haematologic Technologies, Incorporated, Essex Junction, VT 05452, USA
| | - Kevin E. Van Cott
- Department of Chemical and Biomolecular Engineering, University of Nebraska-Lincoln, Lincoln, NE 68588, USA
| | - Shelly Buhay
- Biosciences Division, Emergent BioSolutions Incorporated, Winnipeg, MB, Canada R3T 5Y3
| | - Laura L. Saward
- Biosciences Division, Emergent BioSolutions Incorporated, Winnipeg, MB, Canada R3T 5Y3
- University of Manitoba, Winnipeg, MB, Canada R3T 2N2
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12
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Berntorp E, Dolan G, Hermans C, Laffan M, Santagostino E, Tiede A. Pharmacokinetics, phenotype and product choice in haemophilia B: how to strike a balance? Haemophilia 2015; 20 Suppl 7:1-11. [PMID: 25370925 DOI: 10.1111/hae.12556] [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] [Accepted: 09/08/2014] [Indexed: 12/24/2022]
Abstract
At the 7th Annual Congress of the European Association for Haemophilia and Allied Disorders (EAHAD) held in Brussels, Belgium, in February 2014, Pfizer sponsored a satellite symposium entitled: "Pharmacokinetics, phenotype and product choice in haemophilia B: How to strike a balance?" Co-chaired by Cedric Hermans (Cliniques Universitaires Saint Luc, Brussels, Belgium) and Mike Laffan (Imperial College, London, UK), the symposium provided an opportunity to debate whether pharmacokinetic (PK) parameters are good surrogates for clinical efficacy for haemophilia B in clinical practice, consider the perceptions and evidence of disease severity, and examine how these considerations can inform approaches to balancing the potential risks and benefits of the currently available treatment options for haemophilia B. PK parameters are routinely measured in clinical practice and are a requirement of regulatory bodies to demonstrate the clinical efficacy of products; however, the relationship between measured PK parameters and clinical efficacy is yet to be determined, an issue that was debated by Gerry Dolan (University Hospital, Queen's Medical Centre, Nottingham, UK) and Erik Berntorp (Lund University, Malmö Centre for Thrombosis and Haemostasis, Malmö, Sweden). Elena Santagostino (Universita degli Studi di Milano, Milano, Italy) reviewed how differing perceptions on the severity of haemophilia B compared with haemophilia A may have an impact on clinical decision-making. Finally, Andreas Tiede (Hannover Medical School, Hannover, Germany), examined the considerations for balancing the potential risks and benefits of the currently available treatment options for haemophilia B. Although the pathophysiology of haemophilia B has been widely studied and is largely understood, continued investigation and discussion around the optimal management course and appropriate therapeutic choice is warranted.
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Affiliation(s)
- E Berntorp
- Malmö Centre for Thrombosis and Haemostasis, Lund University, Malmö, Sweden
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13
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Abstract
Hemophilia, when severe, leads to spontaneous life-threatening bleeding episodes. Current therapy requires frequent intravenous infusions. Most patients must limit their physical activities to avoid bleeding when the factor activity levels are below normal. In 2014, new therapeutic factor VIII and IX products were approved in Canada and the U.S. Over the next couple of years, other new factor products will likely be approved. These new factors have been engineered to have improved pharmacokinetic properties, including extended half-life in circulation, thus providing major therapeutic advances for patients with hemophilia. In the completed clinical trials, over 700 patients have successfully used these longer acting products regularly for more than one year. These promising new therapies should allow patients with hemophilia to use fewer infusions to prevent spontaneous bleeding or to treat bleeding episodes, and to provide appropriate clotting factor levels for different physical activities.
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Affiliation(s)
- J S Powell
- Division of Hematology and Oncology, University of California Davis Medical Center, Sacramento, CA, USA
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14
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Turecek PL, Abbühl B, Tangada SD, Chapman M, Gritsch H, Rottensteiner H, Schrenk G, Mitterer A, Dietrich B, Höllriegl W, Schiviz A, Horling F, Reipert BM, Muchitsch EM, Pavlova BG, Scheiflinger F. Nonacog gamma, a novel recombinant factor IX with low factor IXa content for treatment and prophylaxis of bleeding episodes. Expert Rev Clin Pharmacol 2015; 8:163-77. [PMID: 25660348 DOI: 10.1586/17512433.2015.1011126] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Nonacog gamma is a new recombinant factor IX to treat factor IX deficiency. It is indicated for control of bleeding episodes, perioperative management and routine prophylaxis to prevent or reduce the frequency of bleeding episodes in adults and children with hemophilia B. Nonacog gamma was first approved in the USA in June 2013 under the trade name RIXUBIS followed by market approvals in Australia and the EU in 2014, and marketing authorization decision is pending in Japan. Nonacog gamma is derived from a recombinant Chinese hamster ovary cell line using a state of the art biotechnological manufacturing process. Recombinant factor IX is produced by Baxter's protein-free fermentation technology, which was first developed for ADVATE. The product is purified and formulated in the absence of any human or animal-derived protein. Nonacog gamma was characterized both in comprehensive in vitro and in vivo non-clinical studies as well as in an extensive clinical trial program.
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15
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Berger K, Schopohl D, Hilger A, Behr Gross ME, Giangrande P, Peyvandi F, Seitz R, Schramm W. Research in haemophilia B - approaching the request for high evidence levels in a rare disease. Haemophilia 2014; 21:4-20. [DOI: 10.1111/hae.12603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2014] [Indexed: 01/01/2023]
Affiliation(s)
- K. Berger
- Department of Haematology/Oncology; University Hospital of Munich; Munich Germany
| | - D. Schopohl
- Department of Haematology/Oncology; University Hospital of Munich; Munich Germany
| | - A. Hilger
- Paul-Ehrlich-Institute; Langen Germany
| | - M. -E. Behr Gross
- European Directorate for the Quality of Medicines & HealthCare (EDQM); Council of Europe; Strasbourg France
| | - P. Giangrande
- Oxford Haemophilia & Thrombosis Centre; Oxford University Hospitals NHS Trust; Oxford Oxfordshire UK
| | - F. Peyvandi
- Department of Pathophysiology and Transplantation; Angelo Bianchi Bonomi Haemophilia and Thrombosis Center; Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico; Università degli Studi di Milano; Luigi Villa Foundation; Milan Italy
| | - R. Seitz
- Paul-Ehrlich-Institute; Langen Germany
| | - W. Schramm
- Rudolf-Marx-Foundation; University of Munich; Munich Germany
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16
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Powell JS. Lasting power of new clotting proteins. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:355-363. [PMID: 25696879 DOI: 10.1182/asheducation-2014.1.355] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Hemophilia is a genetic disease caused by a deficiency of one of the coagulation proteins. The term usually refers to either hemophilia A, factor VIII (FVIII), with an incidence of ∼1 in 5000 male births, or hemophilia B, factor IX (FIX), with an incidence of ∼1 in 30 000 male births. When severe, the disease leads to spontaneous life-threatening bleeding episodes. Current therapy requires frequent intravenous infusions of therapeutic factor concentrates. Most patients administer the infusions at home every few days and must limit their physical activities to avoid bleeding when the factor activity levels are below normal. In March 2014, a new therapeutic FIX preparation was approved for clinical use in Canada and the United States and, in June 2014, a new FVIII preparation was approved for clinical use in the United States. Over the next couple of years, other new factor products for FIX, FVIIa, and FVIII, which are currently in late stages of clinical trials, will likely also be approved. These new factors have been engineered to extend their half-life in circulation, thus providing major therapeutic advances for patients with hemophilia primarily by allowing treatment with fewer infusions per month. In the clinical trials so far, >500 patients have successfully used these extended half-life products regularly for >1 year to prevent spontaneous bleeding, to treat successfully any bleeding episodes, and to provide effective coagulation for major surgery. Essentially all infusions were well tolerated and effective. These promising new therapies should allow patients to use fewer infusions to maintain appropriate clotting factor activity levels in all clinical settings.
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Affiliation(s)
- Jerry S Powell
- Division of Hematology and Oncology, University of California Davis Medical Center, Sacramento, CA
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Ducore JM, Miguelino MG, Powell JS. Alprolix (recombinant Factor IX Fc fusion protein): extended half-life product for the prophylaxis and treatment of hemophilia B. Expert Rev Hematol 2014; 7:559-71. [DOI: 10.1586/17474086.2014.951322] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Windyga J, Abbuehl BE, Hafeman AE. BAX326 (recombinant coagulation factor IX) for the treatment and prophylaxis of hemophilia B. Expert Rev Hematol 2014; 7:333-42. [DOI: 10.1586/17474086.2014.903153] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Wilmot HV, Hogwood J, Gray E. Recombinant factor IX: discrepancies between one-stage clotting and chromogenic assays. Haemophilia 2014; 20:891-7. [PMID: 24800651 DOI: 10.1111/hae.12449] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2014] [Indexed: 11/30/2022]
Abstract
New and modified recombinant factor IX (rFIX) products are in development and accurate potency estimation is important to ensure the consistency of production and efficacy of these therapeutics. Collaborative study data obtained during the replacement of the 3rd International Standard (IS) for FIX concentrate suggested that there was a discrepancy between potency estimates for rFIX using clotting and chromogenic methods, when the rFIX candidate was measured against the plasma-derived FIX (pdFIX) IS. This study explores potential chromogenic and one-stage clotting method discrepancies in more detail. Five batches each of rFIX and pdFIX were assayed against the 4th IS FIX concentrate (a pdFIX) by activated partial thromboplastin time (APTT) one-stage clotting assay and specific functional chromogenic assay. The potency of rFIX by chromogenic assay was consistently around 70% of the one-stage clotting potency (average 78 and 108 IU mL(-1) respectively). These differences were not observed with pdFIX, which had similar potencies (average 96 IU mL(-1) ) by each assay method. In addition, different APTT reagents yielded different potency estimates for rFIX when assayed against the pdFIX IS, with a variation of up to 23%. In all cases, the differences were largely resolved when a rFIX reference was used as the standard. This study highlights some of the challenges associated with assay of rFIX products in the laboratory and that careful consideration needs to be given to the choice of reference material used. This is especially important with the imminent arrival of new and modified rFIX products.
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Affiliation(s)
- H V Wilmot
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Control, Potters Bar, UK
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Powell JS, Pasi KJ, Ragni MV, Ozelo MC, Valentino LA, Mahlangu JN, Josephson NC, Perry D, Manco-Johnson MJ, Apte S, Baker RI, Chan GC, Novitzky N, Wong RS, Krassova S, Allen G, Jiang H, Innes A, Li S, Cristiano LM, Goyal J, Sommer JM, Dumont JA, Nugent K, Vigliani G, Brennan A, Luk A, Pierce GF. Phase 3 study of recombinant factor IX Fc fusion protein in hemophilia B. N Engl J Med 2013; 369:2313-23. [PMID: 24304002 DOI: 10.1056/nejmoa1305074] [Citation(s) in RCA: 263] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prophylactic factor replacement in patients with hemophilia B improves outcomes but requires frequent injections. A recombinant factor IX Fc fusion protein (rFIXFc) with a prolonged half-life was developed to reduce the frequency of injections required. METHODS We conducted a phase 3, nonrandomized, open-label study of the safety, efficacy, and pharmacokinetics of rFIXFc for prophylaxis, treatment of bleeding, and perioperative hemostasis in 123 previously treated male patients. All participants were 12 years of age or older and had severe hemophilia B (endogenous factor IX level of ≤2 IU per deciliter, or ≤2% of normal levels). The study included four treatment groups: group 1 received weekly dose-adjusted prophylaxis (50 IU of rFIXFc per kilogram of body weight to start), group 2 received interval-adjusted prophylaxis (100 IU per kilogram every 10 days to start), group 3 received treatment as needed for bleeding episodes (20 to 100 IU per kilogram), and group 4 received treatment in the perioperative period. A subgroup of group 1 underwent comparative sequential pharmacokinetic assessments of recombinant factor IX and rFIXFc. The primary efficacy end point was the annualized bleeding rate, and safety end points included the development of inhibitors and adverse events. RESULTS As compared with recombinant factor IX, rFIXFc exhibited a prolonged terminal half-life (82.1 hours) (P<0.001). The median annualized bleeding rates in groups 1, 2, and 3 were 3.0, 1.4, and 17.7, respectively. In group 2, 53.8% of participants had dosing intervals of 14 days or more during the last 3 months of the study. In groups 1, 2 and 3, 90.4% of bleeding episodes resolved after one injection. Hemostasis was rated as excellent or good during all major surgeries. No inhibitors were detected in any participants receiving rFIXFc; in groups 1, 2, and 3, 73.9% of participants had at least one adverse event, and serious adverse events occurred in 10.9% of participants. These events were mostly consistent with those expected in the general population of patients with hemophilia. CONCLUSIONS Prophylactic rFIXFc, administered every 1 to 2 weeks, resulted in low annualized bleeding rates in patients with hemophilia B. (Funded by Biogen Idec; ClinicalTrials.gov number, NCT01027364.).
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Escobar MA. Advances in the treatment of inherited coagulation disorders. Haemophilia 2013; 19:648-59. [DOI: 10.1111/hae.12137] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2013] [Indexed: 01/16/2023]
Affiliation(s)
- M. A. Escobar
- Department of Pediatrics and Internal Medicine; Division of Hematology; University of Texas Medical School at Houston; Houston; Texas
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Franchini M, Frattini F, Crestani S, Sissa C, Bonfanti C. Treatment of hemophilia B: focus on recombinant factor IX. Biologics 2013; 7:33-8. [PMID: 23430394 PMCID: PMC3575125 DOI: 10.2147/btt.s31582] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Hemophilia B is a recessive X-linked bleeding disorder characterized by deficiency of the coagulation factor IX (FIX). In hemophilia B patients the severity of the bleeding phenotype is related to the degree of the FIX defect. Hemophilia B treatment has improved greatly in the last 20 years with the introduction first of plasma-derived and then of recombinant FIX concentrates. Replacement therapy may be administered through on-demand or prophylaxis regimens, but the latter treatment modality has been shown to be superior in prevention of hemophilic arthropathy and in improvement of patients' quality of life. The purpose of this narrative review is to summarize the current knowledge on treatment strategies for hemophilia B, focusing on recombinant FIX products either clinically used or in development. There is only one rFIX product that is licensed to treat hemophilia B patients; from the analysis of the literature data presented in this review, the authors conclude that this rFIX product has demonstrated an excellent safety profile and excellent clinical efficacy for halting and preventing bleeds in hemophilia B patients. While prophylaxis has emerged as the best therapeutic strategy for such patients because of its ability to prevent hemophilic arthropathy and to improve patients' quality of life, the pharmacokinetically tailored dosing of rFIX is another key point when planning hemophilia B treatment, as it allows optimization of the factor concentrate usage. Further clinical studies are needed to better assess the safety and efficacy (ie, the incidence of adverse reactions and inhibitor development) of newer rFIX products.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantua, Italy
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