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Jiang WM, Sanchez JG, Dhodapkar MM, Radford ZJ, Rubin LE, Grauer JN. Outcomes Following Total Hip Arthroplasty in Patients Who Have Von Willebrand Disease Depend on Postoperative Anticoagulation. J Arthroplasty 2024; 39:2088-2093. [PMID: 38462141 DOI: 10.1016/j.arth.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Von Willebrand disease (VWD) is the most common congenital bleeding disorder. This autosomal dominant condition arises from quantitative or qualitative defects of Von Willebrand factor. To our knowledge, this study leveraged a national database to characterize the largest VWD cohort of total hip arthroplasty (THA) patients to date, assessing 90-day postoperative adverse events and 5-year revision-free survival. METHODS Adult patients who underwent primary THA for osteoarthritis were identified from January 2010 to October 2021 in a nationwide database. Patients who had and did not have VWD were matched (4:1) on age, sex, and Elixhauser Comorbidity Index and compared with multivariable logistic regression. Patients were then categorized based upon venous thromboembolism (VTE) chemoprophylaxis prescription patterns to compare bleeding and thrombotic adverse events. RESULTS Of 544,851 THA patients, VWD was identified in 309 patients (0.06%). The matched cohorts contained 1,221 patients who did not have VWD and 306 patients who have VWD. On multivariable analysis, VWD patients had increased odds of 90-day VTE (odds ratio [OR] = 1.86) and hematoma (OR = 3.40) (P < .05 for all). No difference in 5-year revision-free survival was found. The VWD patients receiving aspirin or no prescriptions had greater odds of VTE (OR = 2.39, P = .048). Those on other chemoprophylaxis agents had greater odds of hematoma (OR = 4.84, P = .006). CONCLUSIONS Patients with VWD undergoing THA had increased odds of 90-day VTE if using aspirin or no prescriptions, or hematoma if using other chemoprophylaxis. There is a delicate balancing act of clotting versus bleeding that must be considered in managing such patients, but it was reassuring that no difference in overall 5-year revision-free survival was found.
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Affiliation(s)
- Will M Jiang
- Yale Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
| | - Joshua G Sanchez
- Yale Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
| | - Meera M Dhodapkar
- Yale Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
| | - Zachary J Radford
- Yale Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
| | - Lee E Rubin
- Yale Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
| | - Jonathan N Grauer
- Yale Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
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James P, Leebeek F, Casari C, Lillicrap D. Diagnosis and treatment of von Willebrand disease in 2024 and beyond. Haemophilia 2024; 30 Suppl 3:103-111. [PMID: 38481079 DOI: 10.1111/hae.14970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 04/22/2024]
Abstract
MANUSCRIPT BACKGROUND AND AIM The diagnosis and clinical care of patients with von Willebrand disease (VWD) has continued to evolve since the characterization of the von Willebrand factor (VWF) gene in 1985. This condition is almost certainly the most common inherited bleeding disorder, and the major symptomatic burden of the disease is experienced by females during their reproductive years. Diagnosis relies on the identification of a personal and family history of excessive mucocutaneous bleeding, and laboratory features consistent with quantitative and/or qualitative abnormalities of VWF. This review focuses on three aspects of VWD management, with current updates and a look into the future. MANUSCRIPT THEMES First, we will address the role of genetics in the diagnosis and possible therapies for VWD. With current technologies, VWD genetic diagnosis is usually confined to the confirmation of type 2 subtypes of the disease and type 3 VWD analysis for family planning. While type 3 VWD is a potential candidate for the application of gene therapy, no treatments are currently close to entering the clinic. Second, the peri-procedural management of patients with VWD remains an important element of care. The choice of product, its dose and schedule all require careful consideration depending upon the type and disruptive nature of the planned procedure. Lastly, in addition to gene therapy, several other novel therapeutic interventions are also being developed for bleeding and prophylaxis in VWD. These include a VWF aptamer interfering with VWF clearance and bioengineered forms of VWF.
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Affiliation(s)
- Paula James
- Departments of Medicine and Pathology and Molecular Medicine, Queen's University, Kingston, Canada
| | - Frank Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Caterina Casari
- University Paris-Saclay, INSERM, Hemostasis Inflammation Thrombosis HITH U1176, Le Kremlin-Bicêtre, France
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Canada
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Toenges R, Miesbach W, Ludwig K, Krammer-Steiner B. Perioperative hemostasis management in patients with von Willebrand disease: an institutional experience. Blood Coagul Fibrinolysis 2024; 35:49-55. [PMID: 38179696 DOI: 10.1097/mbc.0000000000001273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
OBJECTIVES Patients with von Willebrand disease (vWD) undergoing surgery are routinely treated with von Willebrand factor (vWF)/factor VIII (FVIII) concentrate to control bleeding risk, but consensus is lacking on optimal dosing. This study aimed to evaluate the efficacy and safety of tailored doses of vWF/FVIII concentrate according to intervention-associated bleeding risk in vWD patients undergoing surgery. METHODS This was a retrospective analysis of vWD patients who underwent surgical procedures at a haemophilia centre. Patients received vWF/FVIII concentrate with dosage and duration of treatment dependent on intervention type (dental, gynaecological, abdominal or orthopaedic/traumatic) and bleeding risk (moderate/high). RESULTS Eighty-three surgical procedures (42 patients) were included. Median preoperative loading doses of vWF/FVIII concentrate were 29.9 IU/kg and 35.7 IU/kg for interventions with moderate ( n = 16) or high ( n = 67) bleeding risk, respectively. The median perioperative dose was highest in orthopaedic or trauma-related surgery (140 IU/kg) and lowest in dental or gynaecological interventions (76.4 IU/kg and 80.0 IU/kg, respectively). During follow-up, no bleeding or other complications were observed in 95% of patients. CONCLUSIONS Individually tailored doses of vWF/FVIII concentrate according to intervention-associated bleeding risk were effective in preventing postoperative bleeding, with few complications observed. These doses may be used as guidance in routine clinical care.
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Affiliation(s)
- Rosa Toenges
- Goethe University Frankfurt, University Hospital, Department of Medicine, Hemostaseology, Frankfurt am Main
| | - Wolfgang Miesbach
- Goethe University Frankfurt, University Hospital, Department of Medicine, Hemostaseology, Frankfurt am Main
| | - Kaja Ludwig
- Department of Surgery, Klinikum Südstadt Rostock
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Horvais V, Beurrier P, Cussac V, Pan-Petesch B, Schirr-Bonnans S, Rose J, Bayart S, Ternisien C, Fouassier M, Sigaud M, Babuty A, Drillaud N, Guillet B, Trossaërt M. Key Drivers of Coagulation Factor Use in Von Willebrand Disease During Hospitalization: An Overview of the French BERHLINGO Cohort. Clin Drug Investig 2024; 44:35-49. [PMID: 38036930 DOI: 10.1007/s40261-023-01323-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Von Willebrand disease (VWD) is the most common inherited bleeding disorder. However, studies of hospitalisation patterns with replacement treatment are scarce. OBJECTIVES The aim of this study was to investigate the current therapeutic management of VWD and determine the key drivers of coagulation factor uses in patients during hospitalisation. METHODS Hopscotch-WILL was a multi-centric retrospective study conducted over a 48-month period in any patients with VWD. The data were collected from the BERHLINGO Research Database and the French Hospital database. RESULTS A total of 988 patients were included; 153 patients (15%) were hospitalised during 293 stays requiring treatment with von Willebrand factor (VWF) concentrates-pure or in association with Factor VIII (FVIII). Their median basal concentrations of VWF and FVIII were significantly lower than in untreated patients: VWF antigen < 30 IU/dL, VWF activity < 20 IU/dL and FVIII:C < 40 IU/dL. The median (interquartile range) concentrate consumption was similar between highly purified VWF or VWF combined with FVIII (72 [110] vs 57 [89] IU/kg/stay, p = 0.154). The use of VWF was highly heterogeneous by VWD type; type 3 had a particularly high impact on VWF consumption in non-surgical situations. The main admissions were for ear/nose/throat, hepato-gastroenterology, and trauma/orthopaedic conditions, besides gynaecological-obstetric causes in women. CONCLUSIONS The use of VWF concentrates is mostly influenced by low basal levels of VWF and FVIII, but also by VWD type or the cause for hospitalisation. These results could inform future studies of newly released recombinant VWF.
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Affiliation(s)
- Valérie Horvais
- Nantes Université, CHU Nantes, Unité d'Investigation Clinique 17, 44000, Nantes, France.
- Nantes Université, CHU Nantes, Centre de Ressources et de Compétences des Maladies Hémorragiques Constitutionnelles, 44000, Nantes, France.
| | - Philippe Beurrier
- CHU Angers, Centre de Traitement des Maladies Hémorragiques Constitutionnelles, 49000, Angers, France
| | - Vincent Cussac
- CH Le Mans, Centre de Traitement des Maladies Hémorragiques Constitutionnelles, 72000, Le Mans, France
| | | | - Solène Schirr-Bonnans
- Nantes Université, CHU Nantes, Service Evaluation Economique et Développement des Produits de Santé, 44000, Nantes, France
| | - Johann Rose
- CH Le Mans, Centre de Traitement des Maladies Hémorragiques Constitutionnelles, 72000, Le Mans, France
| | - Sophie Bayart
- Rennes Université, CHU Rennes, Centre de Ressources et de Compétences des Maladies Hémorragiques Constitutionnelles, 35000, Rennes, France
| | - Catherine Ternisien
- Nantes Université, CHU Nantes, Centre de Ressources et de Compétences des Maladies Hémorragiques Constitutionnelles, 44000, Nantes, France
| | - Marc Fouassier
- Nantes Université, CHU Nantes, Centre de Ressources et de Compétences des Maladies Hémorragiques Constitutionnelles, 44000, Nantes, France
| | - Marianne Sigaud
- Nantes Université, CHU Nantes, Centre de Ressources et de Compétences des Maladies Hémorragiques Constitutionnelles, 44000, Nantes, France
| | - Antoine Babuty
- Nantes Université, CHU Nantes, Centre de Ressources et de Compétences des Maladies Hémorragiques Constitutionnelles, 44000, Nantes, France
| | - Nicolas Drillaud
- Nantes Université, CHU Nantes, Centre de Ressources et de Compétences des Maladies Hémorragiques Constitutionnelles, 44000, Nantes, France
| | - Benoît Guillet
- Rennes Université, CHU Rennes, Centre de Ressources et de Compétences des Maladies Hémorragiques Constitutionnelles, 35000, Rennes, France
- Inserm, EHESP, IRSET (Institut de recherche en santé, environnement et travail)-UMR_S 1085, F-35000, Rennes, France
| | - Marc Trossaërt
- Nantes Université, CHU Nantes, Centre de Ressources et de Compétences des Maladies Hémorragiques Constitutionnelles, 44000, Nantes, France
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Goedhart TMHJ, Janssen A, Mathôt RAA, Cnossen MH. The road to implementation of pharmacokinetic-guided dosing of factor replacement therapy in hemophilia and allied bleeding disorders. Identifying knowledge gaps by mapping barriers and facilitators. Blood Rev 2023; 61:101098. [PMID: 37321952 DOI: 10.1016/j.blre.2023.101098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 04/02/2023] [Accepted: 05/07/2023] [Indexed: 06/17/2023]
Abstract
Clinical guidelines and expert groups recommend the use of pharmacokinetic (PK)-guided dosing of factor replacement therapy for the treatment of bleeding disorders, especially for patients with hemophilia. Although PK-guided dosing is increasingly applied, it is generally not considered standard clinical practice. The aim of this scoping review is to map barriers and facilitators for the implementation of PK-guided dosing in clinical practice and to identify knowledge gaps. A literature search was performed and 110 articles were included that describe PK-guided dosing in patients with bleeding disorders, mostly hemophilia A. We defined two overarching themes, efficacy and feasibility, and discuss five topics within each theme. For each topic, barriers, facilitators and knowledge gaps were described. Although consensus was found with regard to some topics, contradicting reports were found for others, especially with respect to the efficacy of PK-guided dosing. These contradictions highlight the need for future research to elucidate current ambiguities.
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Affiliation(s)
- Tine M H J Goedhart
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - A Janssen
- Department of Clinical Pharmacology - Hospital Pharmacy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Ron A A Mathôt
- Department of Clinical Pharmacology - Hospital Pharmacy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Franchini M, Focosi D. Targeting von Willebrand disease: the current status and future directions of management therapies. Expert Rev Hematol 2023; 16:871-878. [PMID: 37800892 DOI: 10.1080/17474086.2023.2268282] [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: 08/02/2023] [Accepted: 10/04/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION von Willebrand disease (VWD) is the commonest inherited bleeding disorder, and is typically caused by deficits in the quantity or quality of von Willebrand factor (VWF). AREAS COVERED This review describes the main clinical, diagnostic, and therapeutic aspects of VWD, with particular attention to its management. In addition, standard and avant-garde replacement therapies based on the use of VWF are discussed. EXPERT OPINION The goal of treatment for VWD is to reverse the double hemostatic defect resulting from the abnormal or reduced expression of VWF and the concomitant factor VIII (FVIII) deficiency. Treatment consists of managing any bleeds and both short-term prophylaxis (i.e. for surgery or invasive procedures) and long-term prophylaxis. While desmopressin is suitable for most patients with type 1 VWD, VWF/FVIII concentrates are the treatment of choice for the other types of VWD. Beside plasma-derived VWF/FVIII concentrates, whose safety and efficacy have been demonstrated by several clinical trials, products containing only VWF, obtained by plasma fractionation and recombinant DNA technology, have become available and marketed more recently. The clinical use of these VWF-only products is particularly attractive in the setting of surgery and long-term prophylaxis, such as the prevention of recurrent gastrointestinal bleeding in cases of angiodysplasia.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
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Bauer A, Friberg-Hietala S, Smania G, Wolfsegger M. Pharmacokinetic-Pharmacodynamic Comparison of Recombinant and Plasma-Derived von Willebrand Factor in Patients with von Willebrand Disease Type 3. J Blood Med 2023; 14:399-411. [PMID: 37332615 PMCID: PMC10276593 DOI: 10.2147/jbm.s395845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 05/26/2023] [Indexed: 06/20/2023] Open
Abstract
Background Recombinant von Willebrand factor (rVWF, vonicog alfa, Vonvendi/Veyvondi, Takeda Pharmaceuticals USA, Lexington, MA) and several plasma-derived VWF/factor VIII (pdVWF/FVIII) concentrates are available for treating bleeding episodes in patients with von Willebrand disease (VWD). Purpose To develop population pharmacokinetic (PK)/pharmacodynamic (PD) models that describe VWF:ristocetin cofactor (VWF:RCo) activity and its relationship with FVIII activity (FVIII:C) over time following intravenous administration of either rVWF or a pdVWF/FVIII concentrate (VWF:RCo/FVIII:C 2.4:1) in patients with VWD; to use the final PK/PD models for an in silico comparison of rVWF and pdVWF/FVIII. Methods The population PK model for rVWF was based on data from four clinical studies in which rVWF was administered to adult patients with VWD type 1, 2 or 3 (phase 1: NCT00816660; phase 3: NCT01410227 and NCT02283268) or severe hemophilia A (phase 1: EudraCT 2011-004314-42). The PK and PK/PD models for pdVWF/FVIII were based on data from the phase 1 study (NCT00816660) in patients with type 3 VWD who received either rVWF plus recombinant FVIII (rFVIII, octocog alfa, ADVATE®, Takeda Pharmaceuticals USA, Lexington, MA, USA) or pdVWF/FVIII. Results There was a marked difference in clearance following rVWF administration compared with pdVWF/FVIII in type 3 VWD, leading to a ~1.75 longer mean residence time (ie, persistence of VWF:RCo activity in the body) and half-life for rVWF versus pdVWF/FVIII. Simulations showed that following repeated administration of rVWF (50 IU/kg), a FVIII:C activity of >40 IU/dL can be maintained for the full 72 h dosing interval. Conclusion The slower elimination of VWF:RCo following rVWF administration results in a prolonged effect on FVIII turnover compared with pdVWF/FVIII administration.
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Affiliation(s)
- Alexander Bauer
- Statistical and Quantitative Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | | | | | - Martin Wolfsegger
- Statistical and Quantitative Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
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Rhoades R, French Z, Yang A, Walsh K, Drelich DA, McKenzie SE. Perioperative Outcomes of Patients with Bleeding Disorders Undergoing Major Surgery at an Academic Hemophilia Treatment Center. Clin Appl Thromb Hemost 2023; 29:10760296231165056. [PMID: 36972481 PMCID: PMC10052468 DOI: 10.1177/10760296231165056] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Persons with bleeding disorders (PwBD) are at high risk for bleeding with invasive procedures. However, the risk of bleeding in PwBD undergoing major surgery and outcomes of patients managed perioperatively at a hemophilia treatment center (HTC) are not well described. We performed a retrospective review of surgical outcomes among PwBD undergoing major surgery between January 1st, 2017 and December 31st, 2019 at the Cardeza Foundation Hemophilia and Thrombosis Center in Philadelphia, PA. The primary outcome was postoperative bleeding, assessed according to the ISTH-SSC's 2010 definition. Secondary outcomes included use of unplanned postoperative hemostatic therapy, LOS, and 30-day readmission rate. Results were compared to non-PwBD population from a surgical database, matched for surgery, age, and sex. During the study period, 50 PwBD underwent 63 major surgeries. The most common diagnoses were VWD (64%) and hemophilia A (20.0%). The most common surgical procedure category was orthopedic (33.3%), predominantly arthroplasties. Postoperatively,4.8% of procedures were complicated by major bleeding and 1.6% by non-major bleeding. The mean LOS was 1.65 days, and 30-day readmission rate was 1.6%. In comparison to matched, non-PwBD patients in a national surgical database undergoing the same procedures, study patients had a similar rate of bleeding complications per procedure (5.0% vs 1.04% P = .071, Fisher's exact test). PwBD undergoing major surgeries have low rates of major bleeding when receiving comprehensive care at an HTC. Bleeding and hospital readmission rates were similar to non-PwBD baseline in a large database.
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Affiliation(s)
- Ruben Rhoades
- Division of Hematology, Department of Medicine, Cardeza Foundation for Hematologic Research, 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - Zachary French
- Division of Hematology, Department of Medicine, Cardeza Foundation for Hematologic Research, 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - Amy Yang
- College of Population Health, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Douglass A Drelich
- Division of Hematology, Department of Medicine, Cardeza Foundation for Hematologic Research, 6559Thomas Jefferson University, Philadelphia, PA, USA
- CSL Behring, King of Prussia, PA, USA
| | - Steven E McKenzie
- Division of Hematology, Department of Medicine, Cardeza Foundation for Hematologic Research, 6559Thomas Jefferson University, Philadelphia, PA, USA
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Castaman G, Borchiellini A, Coppola A, Cultrera D, Marino R, Federici AB, Giuffrida AC, Marchesini E, Molinari AC, Maria SS, Zanon E. Use of the von Willebrand factor concentrate with low factor VIII content to manage patients with inherited von Willebrand disease requiring surgical or secondary long-term prophylaxis: An expert opinion paper from an Italian panel. Eur J Haematol 2022; 109:121-128. [PMID: 35531770 DOI: 10.1111/ejh.13785] [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: 01/05/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The present review aims to summarize the state-of-the-art von Willebrand disease (VWD) treatment focusing on specific clinical settings (obstetrics, surgery, long-term prophylaxis and comorbidities) as well as on the use of a Von Willebrand factor (VWF) concentrate with low FVIII content. METHODS Literature research and case reports. RESULTS AND CONCLUSIONS Considering that patients affected by VWD have an intact ability to synthesize FVIII, in order to avoid excessive levels of FVIII, a highly purified plasma VWF concentrate with low FVIII content could be particularly useful in those patients and clinical circumstances at high thrombotic risk as well as for long-term prophylaxis. When deciding the optimal therapeutic strategy, physicians should take into account both the patient's history and the differences among available concentrates according to the clinical situations requiring treatment.
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Affiliation(s)
- Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Alessandra Borchiellini
- RRC Thrombosis & Haemophilia Centre, AOU Città della Salute e della Scienza - Molinette Hospital, Turin, Italy
| | - Antonio Coppola
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | - Dorina Cultrera
- Department of Haematology, Haemophilia Regional Reference Centre, University Hospital of Catania, Catania, Italy
| | - Renato Marino
- Haemophilia and Thrombosis Centre, Policlinico Giovanni XXIII, Bari, Italy
| | - Augusto B Federici
- Division of Haematology and Transfusion Medicine, L. Sacco University Hospital and Department of Oncology and Haematology Oncology, University of Milan, Milan, Italy
| | | | - Emanuela Marchesini
- Department of Vascular and Emergency Medicine, Santa Maria della Misericordia University Hospital, Perugia, Italy
| | - Angelo Claudio Molinari
- Regional Reference Centre for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Siboni Simona Maria
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Milan, Italy
| | - Ezio Zanon
- Haemophilia Center, General Medicine, Department of Medicine, University of Padua Medical School, Padua, Italy
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Heijdra JM, Al Arashi W, de Jager NCB, Cloesmeijer ME, Bukkems LH, Zwaan CM, Leebeek FWG, Mathôt RAA, Cnossen MH. Is pharmacokinetic-guided dosing of desmopressin and von Willebrand factor-containing concentrates in individuals with von Willebrand disease or low von Willebrand factor reliable and feasible? A protocol for a multicentre, non-randomised, open label cohort trial, the OPTI-CLOT: to WiN study. BMJ Open 2022; 12:e049493. [PMID: 35168962 PMCID: PMC8852670 DOI: 10.1136/bmjopen-2021-049493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Von Willebrand disease (VWD) is a bleeding disorder, caused by a deficiency or defect of von Willebrand factor (VWF). In case of medical procedures or bleeding, patients are treated with desmopressin and/or VWF-containing concentrates to increase plasma VWF and factor VIII (FVIII). However, in many cases these factor levels are outside the targeted range. Therefore, population pharmacokinetic (PK) models have been developed, which aim to quantify and explain intraindividual and interindividual differences in treatment response. These models enable calculation of individual PK parameters by Bayesian analysis, based on an individual desmopressin test or PK profile with a VWF-containing concentrate. Subsequently, the dose necessary for an individual to achieve coagulation factor target levels can be calculated. METHODS AND ANALYSIS Primary aim of this study is to assess the predictive performance (the difference between predicted and measured von VWF activity and FVIII levels) of Bayesian forecasting using the developed population PK models in four different situations: (A) desmopressin testing (n≥30); (B) medical procedures (n=70; 30 receiving desmopressin, 30 receiving VWF-containing concentrate and 10 receiving a combination of both); (C) bleeding episodes (n=20; 10 receiving desmopressin and 10 receiving VWF-containing concentrate) and (D) prophylaxis with a VWF-containing concentrate (n=3 to 5). Individuals with all types of VWD and individuals with low VWF (VWF 0.30-0.60 IU/mL) will be included. Reliability and feasibility of PK-guided dosing will be tested by assessing predictive performance, treatment duration, haemostasis, patient satisfaction and physician satisfaction. ETHICS AND DISSEMINATION The OPTI-CLOT:to WiN study was approved by the medical ethics committee of the Erasmus MC, University Medical Centre Rotterdam, the Netherlands. Results of the study will be communicated through publication in international scientific journals and presentation at (inter)national conferences. TRIAL REGISTRATION NUMBER NL7212 (NTR7411); Pre-results, EudraCT 2018-001631-46.
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Affiliation(s)
- Jessica M Heijdra
- Department of Pediatric Hematology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Wala Al Arashi
- Department of Pediatric Hematology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Nico C B de Jager
- Hospital Pharmacy - Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Michael E Cloesmeijer
- Hospital Pharmacy - Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Laura H Bukkems
- Hospital Pharmacy - Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Christian M Zwaan
- Department of Pediatric Oncology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy - Clinical Pharmacology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Franchini M, Seidizadeh O, Mannucci PM. Prophylactic management of patients with von Willebrand disease. Ther Adv Hematol 2022; 12:20406207211064064. [PMID: 34987743 PMCID: PMC8721401 DOI: 10.1177/20406207211064064] [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: 09/15/2021] [Accepted: 11/15/2021] [Indexed: 01/19/2023] Open
Abstract
Von Willebrand disease, the most common inherited bleeding disorder that affects both males and females, is due to quantitative or qualitative defects of the multimeric glycoprotein von Willebrand factor, which cause mucous membrane bleeding but also soft tissue bleeding owing to the secondary deficiency of factor VIII. The aim of treatment is to correct this dual defect of hemostasis. In addition to the episodic management of bleeding episodes, therapy includes their short- or long-term prevention. Short-term prophylaxis is mainly warranted in order to provide effective hemostatic coverage to patients undergoing surgery or invasive procedures and to affected women at the time of delivery or during menstruations associated with excessive bleeding. The aim of long-term prophylaxis is to prevent bleeding in particular categories of patients at increased risk of frequent and spontaneous bleeding in the joints, nose, and gastrointestinal tract.
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Affiliation(s)
- Massimo Franchini
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, 46100 Mantova, Italy
| | - Omid Seidizadeh
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Milan, Italy
| | - Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Milan, Italy
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12
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Schmidt J, Kruppa P, Georgiou I, Ghods M. Management of large volume liposuction in lipedema patients with von Willebrand disease: A systematic review and treatment algorithm. Clin Hemorheol Microcirc 2021; 78:311-324. [PMID: 33814418 DOI: 10.3233/ch-201063] [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: 11/15/2022]
Abstract
BACKGROUND When performing large volume liposuction, perioperative management of lipedema patients with coagulation disorders remains challenging due to a lack of clinical experience. With a prevalence of 1% of von Willebrand disease (VWD) in the general population, basic knowledge on diagnostic and adapted surgical strategies are essential for patients' safety. OBJECTIVE Based on a selective literature review, the purpose of this article is to present a standardized algorithm for diagnosis and perioperative treatment of VWD patients undergoing large volume liposuction. METHODS The databases MEDLINE (via PubMed) and Web of Science were selectively searched with the term "(((liposuction) OR (surgery)) OR (lipectomy)) AND (((VWD) OR (hemostaseology)) OR (von Willebrand disease))". Included were articles published in English or German until November 2020. RESULTS The evidence for large volume liposuctions in patients with VWD is limited. Experience is largely based on operations with similar bleeding risks. A safe performance requires an adjustment of the surgical technique and a customized perioperative drug substitution plan. According to the current literature, perioperative thromboembolic events appear to be rare with adequate drug treatment. CONCLUSION The implementation of the developed diagnostic and treatment algorithm may help further reducing bleeding complications and improve the safety for treated patients.
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Affiliation(s)
- Jeremias Schmidt
- Department of Plastic, Aesthetic and Reconstructive Microsurgery/ Hand surgery, Hospital Ernst von Bergmann Clinic Potsdam, Berlin, Germany
| | - Philipp Kruppa
- Department of Plastic, Aesthetic and Reconstructive Microsurgery/ Hand surgery, Hospital Ernst von Bergmann Clinic Potsdam, Berlin, Germany
| | - Iakovos Georgiou
- Department of Plastic, Aesthetic and Reconstructive Microsurgery/ Hand surgery, Hospital Ernst von Bergmann Clinic Potsdam, Berlin, Germany
| | - Mojtaba Ghods
- Department of Plastic, Aesthetic and Reconstructive Microsurgery/ Hand surgery, Hospital Ernst von Bergmann Clinic Potsdam, Berlin, Germany
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13
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Sholzberg M, Khair K, Yaish H, Rodgers G, Cruz MS, Mejía CM, Čermáková Z, Matino D, Teitel J, Barrie A, Werner S, Prondzinski MVD. Real-World Data on the Effectiveness and Safety of wilate for the Treatment of von Willebrand Disease. ACTA ACUST UNITED AC 2021; 5:e264-e272. [PMID: 34235395 PMCID: PMC8255103 DOI: 10.1055/s-0041-1730283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/17/2021] [Indexed: 01/19/2023]
Abstract
Background
The efficacy and safety of wilate (human von Willebrand factor/coagulation factor VIII) in patients with von Willebrand disease (VWD) has been demonstrated in clinical trials. Here, we present real-world data on the use of wilate for the routine care of patients with VWD.
Objectives
The objectives of this observational, prospective, phase 4 study were to evaluate the safety, tolerability, and effectiveness of wilate in on-demand treatment of bleeding episodes (BEs), long-term prophylaxis, and surgical prophylaxis among patients with any type of VWD.
Methods
Patients were enrolled at 31 study centers in 11 countries and followed for up to 2 years. Safety endpoints included adverse drug reactions (ADRs) and drug tolerability. Effectiveness was assessed using annualized bleeding rates (ABRs) during prophylaxis and predefined criteria for the treatment of BEs and surgical prophylaxis.
Results
A total of 111 patients (76 [68%] female) including 41 (37%) children were treated with wilate. Twenty-five patients received prophylaxis, 29 on-demand treatment, and 62 surgical prophylaxis. Tolerability was rated by patients as “excellent” for 96.2% of 6,497 infusions. No unexpected ADRs or thrombotic events were reported. Median ABR during prophylaxis was 1.9. Effectiveness was assessed as “excellent” or “good” by patients and investigators for 100% of BEs treated on-demand, 98% (patient rating) and 99% (investigator rating) of breakthrough BEs, and 99% of surgical procedures (investigator rating).
Conclusion
wilate was safe, well tolerated, and effective for the prevention and treatment of bleeding in pediatric and adult VWD patients in a real-world setting.
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Affiliation(s)
- Michelle Sholzberg
- Departments of Medicine and Laboratory Medicine & Pathobiology, St. Michael's Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Canada.,Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kate Khair
- Research in Children's Health, Illness and Disability (ORCHID), NIHR Biomedical Research Centre, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Hassan Yaish
- University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - George Rodgers
- University of Utah School of Medicine, Salt Lake City, Utah, United States
| | | | | | - Zuzana Čermáková
- Blood Center, University Hospital Ostrava, Ostrava-Poruba, Czech Republic
| | - Davide Matino
- McMaster University Medical Center, Hamilton, Ontario, Canada
| | - Jerome Teitel
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alpha Barrie
- Research in Children's Health, Illness and Disability (ORCHID), NIHR Biomedical Research Centre, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Sylvia Werner
- Octapharma USA, Inc., Paramus, New Jersey, United States
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14
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Population pharmacokinetics of the von Willebrand factor-factor VIII interaction in patients with von Willebrand disease. Blood Adv 2021; 5:1513-1522. [PMID: 33683340 DOI: 10.1182/bloodadvances.2020003891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/21/2021] [Indexed: 01/19/2023] Open
Abstract
Recent studies have reported that patients with von Willebrand disease treated perioperatively with a von Willebrand factor (VWF)/factor VIII (FVIII) concentrate with a ratio of 2.4:1 (Humate P/Haemate P) often present with VWF and/or FVIII levels outside of prespecified target levels necessary to prevent bleeding. Pharmacokinetic (PK)-guided dosing may resolve this problem. As clinical guidelines increasingly recommend aiming for certain target levels of both VWF and FVIII, application of an integrated population PK model describing both VWF activity (VWF:Act) and FVIII levels may improve dosing and quality of care. In total, 695 VWF:Act and 894 FVIII level measurements from 118 patients (174 surgeries) who were treated perioperatively with the VWF/FVIII concentrate were used to develop this population PK model using nonlinear mixed-effects modeling. VWF:Act and FVIII levels were analyzed simultaneously using a turnover model. The protective effect of VWF:Act on FVIII clearance was described with an inhibitory maximum effect function. An average perioperative VWF:Act level of 1.23 IU/mL decreased FVIII clearance from 460 mL/h to 264 mL/h, and increased FVIII half-life from 6.6 to 11.4 hours. Clearly, in the presence of VWF, FVIII clearance decreased with a concomitant increase of FVIII half-life, clarifying the higher FVIII levels observed after repetitive dosing with this concentrate. VWF:Act and FVIII levels during perioperative treatment were described adequately by this newly developed integrated population PK model. Clinical application of this model may facilitate more accurate targeting of VWF:Act and FVIII levels during perioperative treatment with this specific VWF/FVIII concentrate (Humate P/Haemate P).
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15
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O'Donnell JS. Toward Personalized Treatment for Patients with Low von Willebrand Factor and Quantitative von Willebrand Disease. Semin Thromb Hemost 2021; 47:192-200. [PMID: 33636750 DOI: 10.1055/s-0041-1722864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The biological mechanisms involved in the pathogenesis of type 2 and type 3 von Willebrand disease (VWD) have been studied extensively. In contrast, although accounting for the majority of VWD cases, the pathobiology underlying partial quantitative VWD has remained somewhat elusive. However, important insights have been attained following several recent cohort studies that have investigated mechanisms in patients with type 1 VWD and low von Willebrand factor (VWF), respectively. These studies have demonstrated that reduced plasma VWF levels may result from either (1) decreased VWF biosynthesis and/or secretion in endothelial cells and (2) pathological increased VWF clearance. In addition, it has become clear that some patients with only mild to moderate reductions in plasma VWF levels in the 30 to 50 IU/dL range may have significant bleeding phenotypes. Importantly in these low VWF patients, bleeding risk fails to correlate with plasma VWF levels and inheritance is typically independent of the VWF gene. Although plasma VWF levels may increase to > 50 IU/dL with progressive aging or pregnancy in these subjects, emerging data suggest that this apparent normalization in VWF levels does not necessarily equate to a complete correction in bleeding phenotype in patients with partial quantitative VWD. In this review, these recent advances in our understanding of quantitative VWD pathogenesis are discussed. Furthermore, the translational implications of these emerging findings are considered, particularly with respect to designing personalized treatment plans for VWD patients undergoing elective procedures.
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Affiliation(s)
- James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland.,National Coagulation Centre, St. James's Hospital, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital at Crumlin, Dublin, Ireland
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16
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Miesbach W. Perioperative management for patients with von Willebrand disease: Defining the optimal approach. Eur J Haematol 2020; 105:365-377. [DOI: 10.1111/ejh.13462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/28/2020] [Accepted: 05/29/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Wolfgang Miesbach
- Haemophilia Centre Medical Clinic II Institute of Transfusion Medicine Goethe University Hospital Frankfurt am Main Germany
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17
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de Jager NCB, Bukkems LH, Heijdra JM, Hazendonk CHCAM, Fijnvandraat K, Meijer K, Eikenboom J, Laros ‐ van Gorkom BAP, Leebeek FWG, Cnossen MH, Mathôt RAA. One piece of the puzzle: Population pharmacokinetics of FVIII during perioperative Haemate P ® /Humate P ® treatment in von Willebrand disease patients. J Thromb Haemost 2020; 18:295-305. [PMID: 31557387 PMCID: PMC7028136 DOI: 10.1111/jth.14652] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/18/2019] [Accepted: 09/20/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Many patients with von Willebrand disease (VWD) are treated on demand with von Willebrand factor and factor VIII (FVIII) containing concentrates present with VWF and/or FVIII plasma levels outside set target levels. This carries a risk for bleeding and potentially for thrombosis. Development of a population pharmacokinetic (PK) model based on FVIII levels is a first step to more accurate on-demand perioperative dosing of this concentrate. METHODS Patients with VWD undergoing surgery in Academic Haemophilia Treatment Centers in the Netherlands between 2000 and 2018 treated with a FVIII/VWF plasma-derived concentrate (Haemate® P/Humate P®) were included in this study. Population PK modeling was based on measured FVIII levels using nonlinear mixed-effects modeling (NONMEM). RESULTS The population PK model was developed using 684 plasma FVIII measurements of 97 VWD patients undergoing 141 surgeries. Subsequently, the model was externally validated and reestimated with independent clinical data from 20 additional patients undergoing 31 surgeries and 208 plasma measurements of FVIII. The observed PK profiles were best described using a one-compartment model. Typical values for volume of distribution and clearance were 3.28 L/70 kg and 0.037 L/h/70 kg. Increased VWF activity, decreased physical status according to American Society of Anesthesiologists (ASA) classification (ASA class >2), and increased duration of surgery were associated with decreased FVIII clearance. CONCLUSION This population PK model derived from real world data adequately describes FVIII levels following perioperative administration of the FVIII/VWF plasma-derived concentrate (Haemate® P/Humate P® ) and will help to facilitate future dosing in VWD patients.
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Affiliation(s)
- Nico C. B. de Jager
- Hospital Pharmacy ‐ Clinical PharmacologyAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Laura H. Bukkems
- Hospital Pharmacy ‐ Clinical PharmacologyAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Jessica M. Heijdra
- Department of Paediatric HematologyErasmus University Medical Center – Sophia Children's HospitalRotterdamThe Netherlands
| | - Carolien H. C. A. M. Hazendonk
- Department of Paediatric HematologyErasmus University Medical Center – Sophia Children's HospitalRotterdamThe Netherlands
| | - Karin Fijnvandraat
- Amsterdam UMCEmma Children's HospitalPediatric HematologyUniversity of AmsterdamAmsterdamNetherlands
| | - Karina Meijer
- Department of HaematologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Jeroen Eikenboom
- Department of Internal MedicineDivision of Thrombosis and HaemostasisLeiden University Medical CenterLeidenThe Netherlands
| | | | - Frank W. G. Leebeek
- Department of HematologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Marjon H. Cnossen
- Department of Paediatric HematologyErasmus University Medical Center – Sophia Children's HospitalRotterdamThe Netherlands
| | - Ron A. A. Mathôt
- Hospital Pharmacy ‐ Clinical PharmacologyAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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18
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Peyvandi F, Kouides P, Turecek PL, Dow E, Berntorp E. Evolution of replacement therapy for von Willebrand disease: From plasma fraction to recombinant von Willebrand factor. Blood Rev 2019; 38:100572. [DOI: 10.1016/j.blre.2019.04.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 03/27/2019] [Accepted: 04/02/2019] [Indexed: 01/19/2023]
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19
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Leebeek FWG, Atiq F. How I manage severe von Willebrand disease. Br J Haematol 2019; 187:418-430. [PMID: 31498884 PMCID: PMC6899759 DOI: 10.1111/bjh.16186] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/16/2019] [Indexed: 12/29/2022]
Abstract
Von Willebrand disease (VWD) is the most common inherited bleeding disorder. Most patients with mild and moderate VWD can be treated effectively with desmopressin. The management of severe VWD patients, mostly affected by type 2 and type 3 disease, can be challenging. In this article we review the current diagnosis and treatment of severe VWD patients. We will also discuss the management of severe VWD patients in specific situations, such as pregnancy, delivery, patients developing alloantibodies against von Willebrand factor and VWD patients with recurrent gastrointestinal bleeding. Moreover, we review emerging treatments that may be applied in future management of patients with severe VWD.
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Affiliation(s)
- Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Ferdows Atiq
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, the Netherlands
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20
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Seaman CD, Ragni MV. Periprocedural management of von Willebrand disease: An institutional experience. Haemophilia 2019; 25:e199-e203. [PMID: 30994216 DOI: 10.1111/hae.13718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 08/30/2018] [Accepted: 02/02/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Craig D Seaman
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania
| | - Margaret V Ragni
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania
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21
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Sasaki R, Horimoto Y, Mizuno J, Edahiro Y, Ohmori T, Komatsu N, Saito M. Administration of plasma-derived coagulation factor VIII during the perioperative period of mastectomy for breast cancer with acquired von Willebrand syndrome. Surg Case Rep 2018; 4:118. [PMID: 30225530 PMCID: PMC6141413 DOI: 10.1186/s40792-018-0528-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 09/10/2018] [Indexed: 11/10/2022] Open
Abstract
Background Acquired von Willebrand syndrome (aVWS) is a rare bleeding disorder with laboratory findings similar to those of congenital von Willebrand disease (VWD). Patients with aVWS may require prophylactic treatment to prevent excessive bleeding following surgery. To our knowledge, to date, there have been no reports on perioperative management for breast cancer patients with aVWS. Case presentation A 60-year-old woman with breast cancer was diagnosed with aVWS due to polycythemia vera. Pre-operative laboratory testing showed a high platelet count and low von Willebrand factor (VWF) activity. The VWF activity did not improve despite an attempt to suppress platelet count with hydroxyurea. Therefore, we decided to perioperatively supplement with plasma-derived factor VIII (FVIII) containing von Willebrand factor (FVIII/VWF concentrates) to perform curative surgery for breast cancer safely. Consequently, the patient did not develop hemorrhage during/after surgery and was discharged on postoperative day 7, as planned, without problems. Conclusions For a patient with aVWS, which carries a high risk of hemorrhage during the perioperative period, initiation of appropriate management like supplementation of FVIII/VWF concentrates might enable safe curative surgery for breast cancer, and collaboration with the hematology department is critical.
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Affiliation(s)
- Ritsuko Sasaki
- Department of Breast Oncology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Yoshiya Horimoto
- Department of Breast Oncology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Ju Mizuno
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Yoko Edahiro
- Department of Hematology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Tsukasa Ohmori
- Department of Biochemistry, Jichi Medical University School of Medicine, Tochigi, 329-0498, Japan
| | - Norio Komatsu
- Department of Hematology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Mitsue Saito
- Department of Breast Oncology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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22
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Berntorp E. Replacement therapy during surgery in von Willebrand disease needs personalization. Haemophilia 2018; 24:338-340. [PMID: 29665194 DOI: 10.1111/hae.13488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2018] [Indexed: 01/19/2023]
Affiliation(s)
- E Berntorp
- Centre for Thrombosis and Haemostasis, Lund University, Skåne University Hospital, Malmö, Sweden
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23
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Hazendonk HCAM, Heijdra JM, de Jager NCB, Veerman HC, Boender J, van Moort I, Mathôt RAA, Meijer K, Laros-van Gorkom BAP, Eikenboom J, Fijnvandraat K, Leebeek FWG, Cnossen MH. Analysis of current perioperative management with Haemate ® P/Humate P ® in von Willebrand disease: Identifying the need for personalized treatment. Haemophilia 2018; 24:460-470. [PMID: 29573506 DOI: 10.1111/hae.13451] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Patients with Von Willebrand disease (VWD) are regularly treated with VWF-containing concentrates in case of acute bleeding, trauma and dental or surgical procedures. AIM In this multicentre retrospective study, current perioperative management with a von Willebrand factor (VWF)/Factor VIII (FVIII) concentrate (Haemate® P) in patients with VWD was evaluated. PATIENTS/METHODS Patients with VWD undergoing minor or major surgery between 2000 and 2015, requiring treatment with a VWF/FVIII concentrate (Haemate® P), were included. Achieved VWF activity (VWF:Act) and FVIII during FVIII-based treatment regimens were compared to predefined target levels in national guidelines. RESULTS In total, 103 patients with VWD (148 surgeries) were included: 54 type 1 (73 surgeries), 43 type 2 (67 surgeries) and 6 type 3 (8 surgeries). Overall, treatment resulted in high VWF:Act and FVIII levels, defined as ≥0.20 IU/mL above predefined levels. In patients with type 1 VWD, respectively, 65% and 91% of trough VWF:Act and FVIII levels were higher than target levels. In patients with type 2 and type 3 VWD, respectively, 53% and 57% of trough VWF:Act and 72% and 73% of trough FVIII levels were higher than target level. Furthermore, FVIII accumulation over time was observed, while VWF:Act showed a declining trend, leading to significantly higher levels of FVIII than VWF:Act. CONCLUSION High VWF:Act and accumulation of FVIII were observed after perioperative FVIII-based replacement therapy in patients with VWD, both underlining the necessity of personalization of dosing regimens to optimize perioperative treatment.
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Affiliation(s)
- H C A M Hazendonk
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital Rotterdam, Rotterdam, Netherlands
| | - J M Heijdra
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital Rotterdam, Rotterdam, Netherlands
| | - N C B de Jager
- Hospital Pharmacy - Clinical Pharmacology, Academic Medical Centre Amsterdam, Amsterdam, Netherlands
| | - H C Veerman
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital Rotterdam, Rotterdam, Netherlands
| | - J Boender
- Department of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - I van Moort
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital Rotterdam, Rotterdam, Netherlands
| | - R A A Mathôt
- Hospital Pharmacy - Clinical Pharmacology, Academic Medical Centre Amsterdam, Amsterdam, Netherlands
| | - K Meijer
- Department of Haematology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | | | - J Eikenboom
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, Netherlands
| | - K Fijnvandraat
- Department of Paediatric Haematology, Academic Medical Centre Amsterdam, Amsterdam, Netherlands
| | - F W G Leebeek
- Department of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - M H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital Rotterdam, Rotterdam, Netherlands
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24
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25
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Baldeo CM, Rivera CE, Tun HW, Vishnu P. Pharmacokinetics-based clinical management of acquired von Willebrand syndrome: a case report. J Blood Med 2018; 9:9-13. [PMID: 29403324 PMCID: PMC5783106 DOI: 10.2147/jbm.s152663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
von Willebrand disease (VWD) is a common bleeding disorder caused by defective or low levels of von Willebrand factor (VWF). Although most cases of VWD are caused by genetic mutations, some are acquired due to various disease states. In managing VWD, the aim is to normalize plasma levels of both VWF and factor VIII (FVIII), as this aids in hemostasis. Desmopressin usually corrects VWF level in type 1 VWD by inducing the release of endogenous VWF. In cases where desmopressin is ineffective or cannot be used, transfusion of virally inactivated, plasma-derived VWF/FVIII concentrate or infusion of recombinant VWF (Vonvendi) is indicated. Treatment of acquired von Willebrand syndrome (AVWS) aims to control the underlying disease while regulating life-threatening hemorrhages with infusions of VWF/FVIII concentrate. Wide intrasubject variability in VWF and FVIII levels, particularly in AVWS, necessitates verification of response to treatment by frequent monitoring of the plasmatic VWF level. Clinical pharmacokinetics of VWF may facilitate calculation of the necessary loading and maintenance doses of VWF/FVIII concentrate in the management of AVWS patients undergoing surgery, thereby avoiding unnecessary infusion of coagulation factor concentrate.
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Affiliation(s)
- Candice M Baldeo
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Candido E Rivera
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Han W Tun
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Prakash Vishnu
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL, USA
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26
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Depka-Prondzinski MV, Windyga J. Efficacy and safety of a new generation von Willebrand factor/factor VIII concentrate (Wilate®) in the management of perioperative haemostasis in von Willebrand disease patients undergoing surgery. Thromb Haemost 2017; 105:1072-9. [DOI: 10.1160/th10-10-0631] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2010] [Accepted: 02/11/2011] [Indexed: 11/05/2022]
Abstract
SummaryThe aim of this study was to assess the efficacy of Wilate®, a new generation, plasma-derived, high-purity, double virus-inactivated von Willebrand factor (VWF) and factor VIII (FVIII) concentrate (ratio close to physiological 1:1) in the perioperative management of haemostasis in von Willebrand disease (VWD). Data for VWD patients who received Wilate® for perioperative management were obtained from four European, prospective, open-label, non-controlled, non-randomised, multicentre phase II or III clinical trials. A total of 57 surgical procedures were performed (major: n = 27; minor n = 30) in 32 patients. The majority of patients (n = 19, 59.4%) had type 3 VWD, 9 (28.1%) had type 2 VWD and four (12.5%) had type 1 VWD. During major surgery, median daily FVIII dose and mean number of infusions were 25 IU•kg-1 FVIII (VWF:RCô23 IU•kg-1) and 11.0, respectively. Corresponding values for minor surgery were 35 IU•kg-1 (VWF:RCo ~32 IU•kg-1) and 1.5. The efficacy of Wilate® was rated by the investigator as excellent or good in 51 of 53 (96%) procedures. Tolerability was rated as very good or good in 100% of major surgeries (27 of 27) and minor surgeries (29 of 29). Wilate® is an effective and well-tolerated VWF/FVIII replacement therapy in the perioperative management of haemostasis in patients with VWD. It can be administered at a similar FVIII dose, but at a lower VWF dose, as compared to older generation products. Clinical benefits were shown in a population with a high proportion of type 3 VWD patients.
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Heijdra JM, Cnossen MH, Leebeek FWG. Current and Emerging Options for the Management of Inherited von Willebrand Disease. Drugs 2017; 77:1531-1547. [PMID: 28791655 PMCID: PMC5585291 DOI: 10.1007/s40265-017-0793-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Von Willebrand disease (VWD) is the most common inherited bleeding disorder with an estimated prevalence of ~1% and clinically relevant bleeding symptoms in approximately 1:10,000 individuals. VWD is caused by a deficiency and/or defect of von Willebrand factor (VWF). The most common symptoms are mucocutaneous bleeding, hematomas, and bleeding after trauma or surgery. For decades, treatment to prevent or treat bleeding has consisted of desmopressin in milder cases and of replacement therapy with plasma-derived concentrates containing VWF and Factor VIII (FVIII) in more severe cases. Both are usually combined with supportive therapy, e.g. antifibrinolytic agents, and maximal hemostatic measures. Several developments such as the first recombinant VWF concentrate, which has been recently licensed for VWD, will make a more "personalized" approach to VWD management possible. As research on new treatment strategies for established therapies, such as population pharmacokinetic-guided dosing of clotting factor concentrates, and novel treatment modalities such as aptamers and gene therapy are ongoing, it is likely that the horizon to tailor therapy to the individual patients' needs will be extended, thus, further improving the already high standard of care in VWD in most high-resource countries.
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Affiliation(s)
- Jessica M Heijdra
- Department of Pediatric Hematology, Erasmus University Medical Center - Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus University Medical Center - Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, 's-Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands.
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Kouides P, Wawra-Hehenberger K, Sajan A, Mead H, Simon T. Safety of a pasteurized plasma-derived Factor VIII and von Willebrand factor concentrate: analysis of 33 years of pharmacovigilance data. Transfusion 2017; 57:2390-2403. [PMID: 28691218 DOI: 10.1111/trf.14241] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 05/18/2017] [Accepted: 06/04/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Haemate-P/Humate-P (Humate-P) is a pasteurized human plasma-derived concentrate containing both Factor VIII and von Willebrand factor for treatment of hemophilia A and von Willebrand disease (VWD). STUDY DESIGN AND METHODS We analyzed the safety of Humate-P based on more than 33 years of postmarketing pharmacovigilance data, representing an estimated exposure of approximately 25,000 patient-years. The analysis comprises reports of potential adverse drug reactions (ADRs) from all sources, reported as part of routine pharmacovigilance at CSL Behring. ADRs considered clinically relevant or potential risks of Humate-P were identified based on defined and standardized Medical Dictionary for Regulatory Activities queries. Recognizing the limitations of spontaneous reporting, we also reviewed the literature, including clinical trials with mandatory reporting. RESULTS From 1982 to 2015, a total of 670 postmarketing cases had been reported via pharmacovigilance, for an overall reporting rate of approximately one ADR per 3900 administered standard doses. Of these cases, 343 involved ADRs considered clinically relevant risks (33 thromboembolic complications, 97 inhibitor formation, 110 hypersensitivity or allergic reactions) or potential risks (103 suspected virus transmissions) for Humate-P. Most thromboembolic complications occurred in patients undergoing surgery or with other known risk factors. Inhibitor formation occurred mostly in patients with hemophilia A (24 cases were high titer). Most patients with hypersensitivity or allergic reactions had VWD. None of the reported suspected virus transmission cases were confirmed to be associated with Humate-P. Reported results of company-sponsored studies showed a low incidence of adverse events possibly or probably related to Humate-P. CONCLUSIONS More than 33 years of pharmacovigilance data continue to support the safety of Humate-P.
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Affiliation(s)
- Peter Kouides
- Department of Medicine, University of Rochester School of Medicine, Rochester, New York
| | | | - Anna Sajan
- CSL Behring, King of Prussia, Pennsylvania
| | - Henry Mead
- CSL Behring, King of Prussia, Pennsylvania
| | - Toby Simon
- CSL Behring, King of Prussia, Pennsylvania
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29
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Ragni MV, Machin N, James AH, Seaman CD, Malec LM, Kessler CM, Konkle BA, Kouides PA, Neff AT, Philipp CS, Brooks MM. Feasibility of the Von Willebrand disease PREVENT trial. Thromb Res 2017; 156:8-13. [PMID: 28577390 DOI: 10.1016/j.thromres.2017.05.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 04/20/2017] [Accepted: 05/23/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite treatment, women with von Willebrand disease (VWD) have lower von Willebrand factor (VWF) levels and greater blood loss at delivery than controls. Current weight-based dosing does not account for the ~1.5-fold increase in blood volume in pregnancy. METHODS To evaluate the feasibility of a trial to prevent postpartum hemorrhage (PPH), we reviewed pre-pregnancy and 8th month VWF levels in women with VWD with and without PPH following vaginal delivery, assessed VWF concentrate use at delivery by U.S. hemophilia treatment center physician survey, and reviewed thrombosis risk with VWF concentrate by literature review. We determined trial interest and acceptability by structured interviews of physicians and patients. Analysis was by Student's t-test for continuous data, and chi-square or Fisher's exact test for discrete data. RESULTS PPH was associated with lower pre-pregnancy VWF:RCo, p<0.005; higher pre-pregnancy, 8th and 9th-month weight, each p<0.001; a family bleeding history, p=0.036; and VWF concentrate treatment, p=0.005. Surveyed physicians reported first-line therapy at delivery was VWF concentrate, at a mean dose 50IU/kg. A trial of a 1.5-fold volume-based dose increase was acceptable to physicians and patients, if it is safe and if costs and visits are minimized. A literature review determined thrombosis risk with VWF concentrate is low, 0.4%. CONCLUSIONS This study suggests pre-pregnancy VWF:RCo may predict PPH, but 50-80IU/kg VWF concentrate dosing may not prevent PPH. If pharmacokinetic modeling confirms volume-based dosing achieves VWF levels comparable to pregnant controls, it may be possible to determine if volume-modified VWF concentrate dosing will reduce PPH in VWD.
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Affiliation(s)
- Margaret V Ragni
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States; Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, United States.
| | - Nicoletta Machin
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Andra H James
- Duke University Medical Center, Durham, NC, United States
| | - Craig D Seaman
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States; Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, United States
| | - Lynn M Malec
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States; Hemophilia Center of Western Pennsylvania, Pittsburgh, PA, United States
| | - Craig M Kessler
- Georgetown University Medical Center, Washington, DC, United States
| | | | | | - Anne T Neff
- Cleveland Clinic Foundation, Cleveland, OH, United States
| | - Claire S Philipp
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Maria M Brooks
- Graduate School of Public Health, Pittsburgh, PA, United States
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Mannucci PM, Franchini M. Laboratory monitoring of replacement therapy for major surgery in von Willebrand disease. Haemophilia 2017; 23:182-187. [PMID: 28111840 DOI: 10.1111/hae.13165] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2016] [Indexed: 12/25/2022]
Abstract
Von Willebrand disease (VWD) is an inherited haemorrhagic disorder caused by a quantitative or qualitative defect of von Willebrand factor (VWF), a multimeric plasma glycoprotein that plays a key role in platelet adhesion to the subendothelium and acts as a carrier of factor VIII (FVIII) in blood. Patients with VWD experience bleeding symptoms that are mainly localized in mucous membranes and soft tissues, and their severity depends on the degree of the primary reduction in VWF and the secondary deficiency of FVIII in plasma. Because VWD patients are also at increased risk of perioperative bleeding, a prophylactic treatment aimed to correct the dual haemostatic defect (i.e. VWF and FVIII) is warranted. This review summarizes knowledge on the current management of patients undergoing major surgery, focusing on the peri-surgical laboratory monitoring of replacement therapy with VWF/FVIII concentrates. We suggest to monitor plasma levels of FVIII coagulant activity in the postoperative period rather than a surrogate maker of platelet-binding VWF activity as the ristocetin cofactor assay and its recent modifications.
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Affiliation(s)
- P M Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Milan, Italy
| | - M Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
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Srivastava A, Serban M, Werner S, Schwartz BA, Kessler CM. Efficacy and safety of a VWF/FVIII concentrate (wilate®) in inherited von Willebrand disease patients undergoing surgical procedures. Haemophilia 2016; 23:264-272. [PMID: 28026130 DOI: 10.1111/hae.13106] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2016] [Indexed: 01/19/2023]
Affiliation(s)
- A. Srivastava
- Department of Haematology; Christian Medical College; Vellore India
| | - M. Serban
- University Emergency Pediatric Hospital Louis Turcanu; Timisoara Romania
| | - S. Werner
- Octapharma Clinical Research; Hoboken NJ USA
| | | | - C. M. Kessler
- Hemophilia and Thrombosis Comprehensive Treatment Center and the Division of Coagulation; Georgetown University Medical Center; Washington DC USA
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Miesbach W, Berntorp E. Von Willebrand disease - the ‘Dos’ and ‘Don'ts’ in surgery. Eur J Haematol 2016; 98:121-127. [DOI: 10.1111/ejh.12809] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Wolfgang Miesbach
- Haemophilia Centre; Medical Clinic II; Institute of Transfusion Medicine; Goethe University Hospital; Frankfurt am Main Germany
| | - Erik Berntorp
- Centre for Thrombosis and Haemostasis; Skane University Hospital; Lund University; Malmö Sweden
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Rugeri L, Ashrani AA, Nichols WL, Trousdale RT, Pruthi RK. A single-centre study of haemostatic outcomes of joint replacement in von Willebrand disease and control patients and an analysis of the literature. Haemophilia 2016; 22:934-942. [PMID: 27385645 DOI: 10.1111/hae.13027] [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] [Accepted: 05/25/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Haemostatic assessments of patients with von Willebrand disease (VWD) who undergo total knee arthroplasty (TKA) and total hip arthroplasty (THA) have mainly relied on subjective parameters. AIMS To compare objective haemostatic outcomes of TKA/THA in VWD patients and controls without bleeding disorders. METHODS We retrospectively analysed haemostatic outcomes in VWD patients undergoing TKA/THA from 1993 to 2011 and compared them with two matched controls per operation. Using one-way analysis of variance, we tested the effect of VWD on bleeding risk after TKA and THA. RESULTS Twelve VWD patients (6 type 1, 3 type 2M, 1 each of types 2A/2B/3) undergoing 19 operations (12 TKA, 7 THA) were matched to 38 controls. One (5%) of 19 operations in VWD patients and none of the control operations met clinical criteria for major bleeding. Baseline and postoperative day 1 haemoglobin levels, postoperative blood loss, transfused red blood cells (RBCs) and mean hospitalization days were not significantly different. More VWD patients than controls received RBC transfusions [12 (63%) vs. 12 (32%)]. Only 9 (47%) VWD patients vs. 38 (100%) controls received pharmacologic VTE prophylaxis. No postoperative symptomatic VTE occurred in either group. CONCLUSION In this largest, single-institutional study, von Willebrand factor replacement based on daily levels resulted in low frequency of major bleeding in VWD patients after TKA/THA. RBC transfusion was more frequent compared with matched controls, but other objective measures of haemostasis were similar. Lack of sufficient details in published reports precluded comparison of haemostatic outcomes.
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Affiliation(s)
- L Rugeri
- Divisions of Hematology and Hematopathology, Mayo Clinic, Rochester, MN, USA
| | - A A Ashrani
- Divisions of Hematology and Hematopathology, Mayo Clinic, Rochester, MN, USA
| | - W L Nichols
- Divisions of Hematology and Hematopathology, Mayo Clinic, Rochester, MN, USA
| | - R T Trousdale
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - R K Pruthi
- Divisions of Hematology and Hematopathology, Mayo Clinic, Rochester, MN, USA
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37
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Castaman G, Linari S. Human von Willebrand factor/factor VIII concentrates in the management of pediatric patients with von Willebrand disease/hemophilia A. Ther Clin Risk Manag 2016; 12:1029-37. [PMID: 27445481 PMCID: PMC4936816 DOI: 10.2147/tcrm.s87543] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Several plasma-derived intermediate and high-purity concentrates containing von Willebrand factor (VWF) and factor VIII (FVIII) are currently available. The main role of these products in the management of the pediatric population is represented by the replacement therapy in patients with severe or intermediate forms of von Willebrand disease, in whom other treatments are ineffective or contraindicated. Another important role of VWF/FVIII concentrates in children may be their use in immune tolerance induction (ITI) protocols. ITI is particularly recommended for hemophilia A children who have developed an inhibitor against FVIII, currently the most serious complication of substitutive treatment in hemophilia. Although recombinant concentrates may represent the preferred option in children with hemophilia A, VWF/FVIII concentrates may offer an advantage in rescuing patients who failed previous ITI.
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Affiliation(s)
- Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders, Careggi University Hospital, Florence, Italy
| | - Silvia Linari
- Department of Oncology, Center for Bleeding Disorders, Careggi University Hospital, Florence, Italy
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Windyga J, Dolan G, Altisent C, Katsarou O, López Fernández MF, Zülfikar B. Practical aspects of factor concentrate use in patients with von Willebrand disease undergoing invasive procedures: a European survey. Haemophilia 2016; 22:739-51. [PMID: 27292438 DOI: 10.1111/hae.12955] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The bleeding propensity in von Willebrand disease (VWD) is usually moderate or mild and patients with VWD do not need continuous treatment, but do require extra increased haemostatic cover when undergoing dental or surgical procedures. Desmopressin can be effective in certain patient groups and this has been considered in a previous publication. AIM This paper now seeks to evaluate current knowledge and practice in the use of factor concentrate in the management of VWD patients undergoing invasive procedures. METHODS A literature search was performed on the use of factor concentrates to cover invasive procedures and a survey of current practice in a number of specialist haematology centres across Europe represented by the European Haemophilia Strategy Board was conducted. RESULTS Our review of the literature and the results of the survey showed considerable heterogeneity in treatment regimens, and a lack of consistency in reporting of the variables that determine factor concentrate dosing and monitoring. CONCLUSION By analysing the literature, examining guidelines and using consensus deliberation, this survey allowed the group to develop recommendations for management of VWD patients undergoing invasive procedures.
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Affiliation(s)
- J Windyga
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland.
| | - G Dolan
- Haemophilia Unit, St Thomas' Hospital, London, UK
| | - C Altisent
- Servicio de Hematologia - Unidad de Hemofilia, Hospital Vall D'Hebron, Barcelona, Spain
| | - O Katsarou
- Thrombosis and Haemostasis Unit, Laikon General Hospital, Athens, Greece
| | - M-F López Fernández
- Servicio Hematologia, Complexo, Hospitalario A Coruña, INIBIC, La Coruña, Spain
| | - B Zülfikar
- Department of Pediatric Hematology, Cerrahpasa Faculty of Medicine, Istanbul University, Cerrahpasa, Istanbul, Turkey
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Hemostatic efficacy, safety, and pharmacokinetics of a recombinant von Willebrand factor in severe von Willebrand disease. Blood 2015; 126:2038-46. [PMID: 26239086 DOI: 10.1182/blood-2015-02-629873] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 06/25/2015] [Indexed: 01/09/2023] Open
Abstract
This phase 3 trial evaluated the safety and hemostatic efficacy of a recombinant von Willebrand factor (rVWF) for treatment of bleeds in severe von Willebrand disease (VWD). rVWF was initially administered together with recombinant factor VIII (rFVIII) and subsequently alone, as long as hemostatic factor VIII activity (FVIII : C) levels were maintained. Pharmacokinetics (PK) were evaluated in a randomized cross-over design (rVWF vs rVWF:rFVIII at 50 IU VWF:ristocetin cofactor activity [RCo]/kg). Bleed control for all treated bleeds (N = 192 bleeds in 22 subjects) was rated good or excellent (96.9% excellent; 119 of 122 minor, 59 of 61 moderate, and 6 of 7 major bleeds) on a 4-point scale (4 = none to 1 = excellent). A single infusion was effective in 81.8% of bleeds. Treatment success, defined as the number of subjects with a mean efficacy rating of <2.5, was 100%. The PK profile of rVWF was not influenced by rFVIII (mean VWF:RCo terminal half-life: 21.9 hours for rVWF and 19.6 hours for rVWF:rFVIII). FVIII : C levels increased rapidly after rVWF alone, with hemostatic levels achieved within 6 hours and sustained through 72 hours after infusion. Eight adverse events (AEs; 6 nonserious AEs in 4 subjects and 2 serious AEs [chest discomfort and increased heart rate, without cardiac symptomatology] concurrently in 1 subject) were associated with rVWF. There were no thrombotic events or severe allergic reactions. No VWF or FVIII inhibitors, anti-VWF binding antibodies, or antibodies against host cell proteins were detected. These results show that rVWF was safe and effective in treating bleeds in VWD patients and stabilizes endogenous FVIII : C, which may eliminate the need for rFVIII after the first infusion. This trial was registered at www.clinicaltrials.gov as #NCT01410227.
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Reininger AJ. The function of ultra-large von Willebrand factor multimers in high shear flow controlled by ADAMTS13. Hamostaseologie 2015; 35:225-33. [PMID: 25983111 DOI: 10.5482/hamo-14-12-0077] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 02/06/2015] [Indexed: 12/18/2022] Open
Abstract
The paradigm that platelet aggregation, which contributes to bleeding arrest and also to thrombovascular disorders, initiates after signaling-induced platelet activation has been refuted in past recent years. Platelets can form aggregates independently of activation when soluble von Willebrand factor (VWF) is present and the shear rate exceeds a certain threshold where active A1 domains become exposed in soluble VWF multimers and can bind to platelet glycoprotein Ib. Subsequently - fostering each other - VWF can self-assemble into large nets combining with platelets into large conglomerates, which are entirely reversible when they enter a flow region with shear rates below the threshold. In addition the threshold changes from approximately 20 000 s⁻¹ in wall parallel flow to approximately 10 000 s⁻¹ in stagnation point flow. VWF containing ultra-large multimers - as when just released from endothelial storage sites - has been shown to have the highest binding potential to platelets and to each other, thus facilitating rapid platelet accrual to sites of vessel injury and exposed subendothelial structures, i.e. collagen. The VWF nets as well as the platelet-VWF conglomerates are controlled by the cleaving protease ADAMTS13 within minutes under high shear flow. Therewith the hemostatic potential is delivered where needed and the thrombogenic potential is highly controlled twofold: by flow and enzymatic proteolytic cleavage.
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Affiliation(s)
- A J Reininger
- Prof. Dr. med. Armin Reininger, MD, PhD, Head Medical Affairs Europe, Middle East, Africa, Hemophilia and Blood Disorders, Baxalta Innovations GmbH, Industriestrasse 67, 1221 Vienna, Austria, Tel. +43/1/20 10 02 47-25 11, Fax -57 33, E-mail:
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Successful aortic aneurysm repair in a woman with severe von Willebrand (type 3) disease. Case Rep Hematol 2015; 2015:703803. [PMID: 25960895 PMCID: PMC4417585 DOI: 10.1155/2015/703803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 03/18/2015] [Accepted: 03/19/2015] [Indexed: 11/28/2022] Open
Abstract
von Willebrand disease type 3 (VWD3) is a rare but the most severe form of von Willebrand disease; it is due to almost complete lack of von Willebrand factor activity (VWF:RCo). It is inherited as autosomal recessive trait; whilst heterozygote carriers have mild, or no symptoms, patients with VWD3 show severe bleeding symptoms. In the laboratory, this is characterised by undetectable VWF:Ag, VWF:RCo, and reduced levels of factor VIII < 0.02 IU/dL. The bleeding is managed with von Willebrand/FVIII factor concentrate replacement therapy. In this rare but challenging case we report on the successful excision and repair of an ascending aortic aneurysm following adequate VWF/FVIII factor concentrate replacement using Haemate-P.
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Groeneveld DJ, van Bekkum T, Cheung KL, Dirven RJ, Castaman G, Reitsma PH, van Vlijmen B, Eikenboom J. No evidence for a direct effect of von Willebrand factor's ABH blood group antigens on von Willebrand factor clearance. J Thromb Haemost 2015; 13:592-600. [PMID: 25650553 DOI: 10.1111/jth.12867] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 01/24/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND One of the major determinants of von Willebrand factor (VWF) plasma levels is ABO blood group status, and individuals with blood group O have ~ 25% lower plasma levels. The exact mechanism behind this relationship remains unknown, although effects on clearance have been postulated. OBJECTIVES To determine whether clearance of VWF is directly dependent on the presence of ABH antigens on VWF. METHODS Three type 3 von Willebrand disease (VWD) patients were infused with Haemate-P, and the relative loading of VWF with ABH antigens at different time points was measured. VWF-deficient mice were injected with purified plasma-derived human VWF obtained from donors with either blood group A, blood group B, or blood group O. RESULTS In mice, we found no difference in clearance rate between plasma-derived blood group A, blood group B and blood group O VWF. Faster clearance of the blood group O VWF present in Haemate-P infused in type 3 VWD patients would have resulted in a relative increase in the loading of VWF with A and B antigens over time. However, we observed a two-fold decrease in the loading with A and B antigens in two out of three patients, and stable loading in the third patient. CONCLUSION There is no direct effect of ABH antigens on VWF in VWF clearance. We demonstrate that, in a direct comparison within one individual, blood group O VWF is not cleared faster than blood group A or blood group B VWF. Clearance differences between blood group O and non-blood group O individuals may therefore be related to the blood group status of the individual rather than the ABH antigen loading on VWF itself.
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Affiliation(s)
- D J Groeneveld
- Einthoven Laboratory for Experimental Vascular Medicine, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Utility of a high VWF: FVIII ratio in preventing FVIII accumulation: a study in VWF-deficient mice. Blood Coagul Fibrinolysis 2015; 26:515-21. [PMID: 25767894 PMCID: PMC4500654 DOI: 10.1097/mbc.0000000000000269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Treatment of von Willebrand disease typically requires multiple infusions of von Willebrand factor (VWF)/factor VIII (FVIII) concentrate. Accumulation of FVIII is a clinical concern due to potential risk for thromboembolism. This study sought to determine whether VWF/FVIII concentrate of high VWF:FVIII ratio can prevent FVIII accumulation. VWF-deficient knockout mice received four 150 IU/kg VWF:ristocetin cofactor (RCo) infusions at 3-h intervals, with VWF/FVIII concentrates of a high (Haemate P/Humate-P) or low (Wilate) VWF:FVIII ratio. After each infusion, trough FVIII and VWF levels in plasma were determined. Separately, pharmacokinetic analysis was performed after single 250-IU/kg VWF:RCo infusions of each concentrate. Over the course of the four infusions, trough FVIII increased significantly in the group receiving Wilate (P < 0.001), but not Haemate P/Humate P (P = 0.058). After the first infusion, mean trough FVIII level in the Wilate group (31.7 IU/dl) was greater by 82% (P = 0.017) than that in the Haemate P/Humate P group (17.4 IU/dl). After the final infusion, mean trough FVIII of animals receiving Wilate (55.1 IU/dl) continued to exceed that of Haemate P/Humate P recipients (30.2 IU/dl) significantly (P < 0.001). Trough VWF levels were similar in the two groups. The VWF pharmacokinetics of the two concentrates coincided closely; however, the FVIII peak concentration and area under the curve were approximately twice as great in the mice treated with Wilate. In a murine model of severe von Willebrand disease, a VWF/FVIII concentrate with a high VWF:FVIII ratio prevented persistent exposure to elevated trough FVIII levels.
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Miesbach W, Berntorp E. Interaction between VWF and FVIII in treating VWD. Eur J Haematol 2015; 95:449-54. [DOI: 10.1111/ejh.12514] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Wolfgang Miesbach
- Medical Clinic III; Institute of Transfusion Medicine; Goethe University; Frankfurt Germany
| | - Erik Berntorp
- Centre for Thrombosis and Haemostasis; Skane University Hospital; Lund University; Malmö Sweden
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Venous thrombosis in von Willebrand disease as observed in one centre and as reported in the literature. Blood Coagul Fibrinolysis 2015; 26:54-8. [DOI: 10.1097/mbc.0000000000000179] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Vinayagam S, Simons LR, Chowdary P, Thurlow P, Brooks SV, Riddell AF. Evaluation of a rapid von Willebrand factor activity latex immuno assay for monitoring of patients with von Willebrand disease (VWD) receiving DDAVP or VWF replacement therapy. Haemophilia 2014; 20:e304-10. [PMID: 24758424 DOI: 10.1111/hae.12437] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2014] [Indexed: 11/28/2022]
Abstract
Haemostatic management of surgery in patients with von Willebrand disease (VWD) includes DDAVP or von Willebrand factor (VWF)-containing concentrates. Although the recommendations are for monitoring by VWF activity assays, it is quite common for clinicians to use factor VIII due usually to longer turnaround times required for VWF ristocetin cofactor assay (VWF:RCo) measurements. The aim of this study was to evaluate use of the rapid HaemosIL VWF activity (VWF:Act) latex immuno assay (LIA) on an automated coagulometer (ACL TOP(™) 700; Instrumentation Laboratory, Bedford, MA, USA) compared to platelet-based VWF:RCo assays in this setting. One hundred and sixty-seven plasma samples from 42 patients [Type 1 (n = 22), Type 2A (n = 2), Type 2B (n = 3), Type 2M (n = 10), Type 3 (n = 3)] and acquired von Willebrand syndrome (n = 2) with VWD treated with DDAVP or VWF-containing concentrates were included in the study. Method comparison and method bias were evaluated by Bland-Altman analysis (BA) and Passing and Bablok regression modelling respectively. BA of baseline samples (n = 39) showed a mean difference of -3.0 (±1.96 SD -25.2 to +19.4). Post (treatment) samples (n = 120) were separated into two groups. Group 1 contained samples with VWF:RCo levels 10 to ≤175 IU dL(-1) (n = 97) and group 2, samples with VWF:RCo levels >175 IU dL(-1) (n = 23). BA of group 1 postsamples showed a mean difference of +3.4 (±1.96 SD -44.6 to +51.5), and the BA of Group 2 samples was -23.9 (±1.96 SD -136.1 to +88.3). In conclusion, use of HaemosIL VWF:Act LIA test on an automated coagulometer is a reproducible and rapid assay that can be used as an alternative test for monitoring VWF replacement therapy, facilitating dose adjustments on a real-time basis.
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Affiliation(s)
- S Vinayagam
- Katharine Dormandy Haemophilia Centre & Thrombosis Unit, Royal Free London NHS Foundation Trust, London, United Kingdom
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Nowak-Göttl U, Krümpel A, Russo A, Jansen M. Efficacy and safety of Wilate in paediatric VWD patients under 6 years of age - results of a prospective multicentre clinical study including recovery information. Haemophilia 2013; 19:887-92. [PMID: 23919249 DOI: 10.1111/hae.12237] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2013] [Indexed: 11/30/2022]
Abstract
Treatment with exogenous von Willebrand factor (VWF) is indicated in patients with von Willebrand disease (VWD) in whom treatment with 1-deamino-8-d-arginine vasopressin/desmopressin is contraindicated. Wilate is a new generation plasma-derived concentrate of native VWF and coagulation factor VIII (FVIII) (in a physiological 1:1 ratio) developed for the treatment of VWD. This is the first study to report safety, efficacy and in vivo recovery (IVR) data from 15 paediatric patients less than 6 years of age who received Wilate for either prophylaxis, on-demand treatment or for treatment in surgical procedures during a prospective open-label trial (VWD type 1: 5, type 2A: 1, type 2B: 2, type 3: 6, unknown type: 1 patients). Analysis of IVR for VWF and FVIII suggested an appropriate and consistent rise in coagulation activity after Wilate administration. Overall efficacy was rated as excellent or good for 99.7% [prophylactic infusions] and 100% [bleeding episodes/surgical procedures]. More than 82% of bleeding episodes resolved after 1 day of treatment, and a Wilate dosage of 20-50 IU kg(-1) was sufficient to achieve haemostasis in 97% of bleeding episodes. All surgical procedures were successfully managed with Wilate. No thromboembolic events were observed during the study, and no patient developed anti-VWF antibodies or FVIII inhibitors. In conclusion, this study confirms both the expected IVR profile in paediatric patients and the excellent efficacy, tolerability and safety profile of Wilate observed previously in adults. Wilate showed excellent efficacy in the treatment of bleeding when used prophylactically or on-demand, and in the treatment of surgical procedures.
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Affiliation(s)
- U Nowak-Göttl
- Institute of Clinical Chemistry, Thrombosis & Hemostasis Treatment Center, University Hospital Schleswig-Holstein, Kiel, Germany; Department of Pediatrics, University Hospital Münster, Münster, Germany
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Franchini M, Lippi G. Pharmacotherapy of von Willebrand disease. Expert Opin Orphan Drugs 2013. [DOI: 10.1517/21678707.2013.801315] [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: 11/05/2022]
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Kahlon A, Grabell J, Tuttle A, Engen D, Hopman W, Lillicrap D, James P. Quantification of perioperative changes in von Willebrand factor and factor VIII during elective orthopaedic surgery in normal individuals. Haemophilia 2013; 19:758-64. [PMID: 23711418 DOI: 10.1111/hae.12185] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2013] [Indexed: 12/12/2022]
Abstract
von Willebrand's disease (VWD) patients undergoing major surgery are prophylactically treated to promote haemostasis. There is variability in perioperative clinical practice; however, most guidelines suggest replacing the deficient factor to a level of 1.0 IU mL(-1) (or 100%). A review of the literature reveals a paucity of well constructed descriptive data quantifying the changes in coagulation that occur in response to surgical stress. The aim of this study was to quantify the changes in haemostatic variables occurring in response to elective orthopaedic surgery in normal individuals. Eligible subjects >18 years of age undergoing total hip or knee replacement were recruited. Blood samples were drawn at five time points: baseline, preoperatively, 30 min after surgical incision, 30 min postoperatively, postoperative day (POD) 1. Analyses included t-tests and repeated measures anova. Overall 30 patients, 21 women and 9 men, with a mean age of 65 were included in the final analysis. All von Willebrand factor (VWF) variables were seen to significantly decrease intraoperatively and increase postoperatively. VWF multimers showed a statistically significant decrease in high molecular weight multimers intraoperatively and an increase postoperatively. On subgroup analysis, age, gender and anaesthesia type were significantly correlated with changes in VWF parameters. Data presented in the current study establish a physiological baseline for VWF parameters in the normal population and demonstrate mean VWF/factor VIII levels greater than 1.0 IU mL(-1) intraoperatively. As such, current management in VWD patients does not appear to mimic the normal physiological response to surgery.
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Affiliation(s)
- A Kahlon
- Medicine, Kingston General Hospital, Kingston, ON, Canada
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