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Casini A, Moerloose PD, Neerman-Arbez M. One Hundred Years of Congenital Fibrinogen Disorders. Semin Thromb Hemost 2022; 48:880-888. [PMID: 36055263 DOI: 10.1055/s-0042-1756187] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Congenital fibrinogen disorders encompass a broad range of fibrinogen defects characterized by a wide molecular and clinical spectrum. From the first clinical description of afibrinogenemia in 1920, many major achievements have contributed to a better understanding of these complex disorders. The finding of causative mutations in all three fibrinogen genes has contributed to reveal the molecular mechanisms involved in biosynthesis of the fibrinogen molecule and to clarify the basic processes of fibrin polymerization and fibrinolysis. The compilation of abundant cases with detailed genetic, biological, and clinical features has enabled the classification of congenital fibrinogen disorders into several types and subtypes. Thus, the recent classification of congenital fibrinogen disorder is based not only on the clottable and antigenic fibrinogen levels but also on the patient's clinical phenotype and genotype. Fibrinogen supplementation is the cornerstone of bleeding management in fibrinogen disorders. Since the discovery of blood fractionation, the method of production of fibrinogen concentrate has been progressively modified to significantly improve purity and safety. Nevertheless, the availability of such products is still limited to a few countries and the optimal threshold of fibrinogen to target is still not established. In this review, we describe the major advances that have characterized 100 years of congenital fibrinogen disorders, focusing on afibrinogenemia and dysfibrinogenemia.
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Affiliation(s)
- Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland.,Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Philippe de Moerloose
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marguerite Neerman-Arbez
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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2
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Huang LY, Zhang DL, Fu RF, Liu W, Chen YF, Xue F, Liu XF, Bi TT, Yang RC, Zhang L. [Analysis of gene mutation spectrum and pharmacokinetics of fibrinogen infusion in 146 cases of congenital fibrinogen disorders]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:555-562. [PMID: 34455742 PMCID: PMC8408493 DOI: 10.3760/cma.j.issn.0253-2727.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To investigate the clinical type and gene mutations, clinical manifestations, laboratory tests, diagnosis, and fibrinogen replacement therapy of congenital fibrinogen disorders. Methods: Clinical data of 146 patients with congenital fibrinogen disorders diagnosed from April 2000 to November 2020 were retrospectively analyzed. Results: Among the 146 patients, 61 (41.8%) men and 85 (58.2%) women had a median age of 33.5 years at the time of consultation. 34 patients (34.7%) were found to suffer from the disease due to bleeding symptoms, 33 patients (33.7%) due to preoperative examination. 55 patients (56.1%) had at least one bleeding symptom, and 42 patients (42.9%) had no bleeding symptoms. There is a negative correlation between fibrinogen activity concentration and bleeding ISTH-BAT score (rs=-0.412, P=0.001) . A total of 34 gene mutations were detected in 56 patients, of which 84.1% were missense mutations, and 16 new mutations were found. FGA Exon2 and FGG Exon8 mutations accounted for 71.4% of all mutation sites. Patients with afibrinogenemia were younger, with a median age of 2 (1-12) years, an ISTH-BAT score of 4, and patients with dysfibrinogenemia had significantly longer thrombin time (TT) , with a median of 28.5 (19.2-36.6) s. The 1 hour in vivo recovery (IVR) after fibrinogen infusion was (127.19±44.03) %, and the 24 hour IVR was (101.78±43.98) %. In addition to the obvious increase in the concentration of fibrinogen activity, the TT and the prothrombin time (PT) both decreased significantly, and the TT decreased more significantly, with an average decrease of 15.2% compared to the baseline after 24 hours of infusion. Conclusion: Most patients with congenital fibrinogen disorders have mild or no bleeding symptoms. Patients with afibrinogenemia have more severe symptoms. There is a negative correlation between the fibrinogen and the degree of bleeding. Genetic testing is helpful for the diagnosis of disease classification. FIB∶C/FIB∶Ag<0.7 can be used as a basis for clinical diagnosis. The TT can be used as the basis for the diagnosis of dysfibrinogenemia and the effectiveness of fibrinogen infusion.
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Affiliation(s)
- L Y Huang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - D L Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - R F Fu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - W Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - Y F Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - F Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - X F Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - T T Bi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - R C Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
| | - L Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300020, China
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3
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Validation of an analytical method for the quantification of human fibrinogen in pharmaceutical products by size-exclusion liquid chromatography (SEC-HPLC). Int J Hematol 2021; 113:480-492. [PMID: 33635532 DOI: 10.1007/s12185-020-03050-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
Fibrinogen plays a vital role in normal homeostasis by promoting platelet aggregation, clot formation and fibrinolysis. It is quantified in finished pharmaceutical products using different methods described in pharmacopoeia, but these are inaccurate, difficult to validate and do not allow for identification of aggregates or protein products of the same formulation. The aim of this study was to develop and validate a method for quantification of the content of fibrinogen and other proteins present in pharmaceutical formulations by comparing it with current pharmacopeial methods. Fibrinogen was quantified in two commercial products and compared to a pharmacopeial method using a validated method for size-exclusion high-pressure liquid chromatography (SEC-HPLC). The fibrinogen level was in accordance with both products' specifications. The SEC-HPLC method showed that the percentage of fibrinogen was 94.88 for one product and 50.68 for the other, and detected high molecular weight aggregates in the second product. The SEC-HPLC method that we developed is an improvement to the current pharmacopeial method, because it allows for quantification of fibrinogen and determination of product purity. This is important because greater purity can reduce potential adverse effects of pharmaceutical products in patients.
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Pharmacokinetics, surrogate efficacy and safety evaluations of a new human plasma-derived fibrinogen concentrate (FIB Grifols) in adult patients with congenital afibrinogenemia. Thromb Res 2021; 199:110-118. [PMID: 33486319 DOI: 10.1016/j.thromres.2020.12.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 12/04/2020] [Accepted: 12/29/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIMS Congenital afibrinogenemia is a rare coagulation disorder resulting from a deficiency in fibrinogen. This study assessed the pharmacokinetics, surrogate efficacy and safety of FIB Grifols, a new human plasma-derived fibrinogen concentrate, to treat congenital afibrinogenemia. METHODS Eleven adult patients from a multinational, phase 1-2, prospective, open-label, single-arm, uncontrolled clinical study received a single infusion of FIB Grifols, 70 mg/kg bw. Fibrinogen pharmacokinetics (fibrinogen activity: Clauss method; antigen plasma concentrations: ELISA) and efficacy parameters were determined over 14 days after infusion. Efficacy endpoints were the mean change on plasma maximum clot firmness (MCF) on viscoelastic testing and coagulation tests 1-hour post-infusion, and correlation with fibrinogen levels throughout. Safety parameters were also assessed. RESULTS For the Clauss method, (mean [standard deviation]) baseline adjusted Cmax was 1.99 (0.40) g/L, reached 1.76 (1.00) h after infusion, and half-life was 76.94 (20.21) h. Using ELISA, Cmax after FIB Grifols infusion was 2.88 (0.86) mg/mL, with a tmax of 3.06 (2.24) h. Fibrinogen activity and antigen concentrations showed statistically significant correlation of 0.9120 (P < 0.001). Surrogate efficacy was demonstrated by a significant increase of 12.35 (3.85) mm in MCF. Prothrombin time, activated partial thromboplastin time and thrombin time, returned to normal ranges over time, indicating restoration of functionally active fibrinogen. There were no treatment-related adverse events, allergic reactions, serious adverse events, or discontinuations. CONCLUSIONS The pharmacokinetic profile of functionally active FIB Grifols was established, hemostasis was restored, and FIB Grifols was safe and well tolerated in fibrinogen-deficient patients.
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Abstract
BACKGROUND AND OBJECTIVE The use of fibrinogen concentrate to treat or prevent major bleeding with regard to potential adverse reactions has not been free of controversy. Our objective was to perform a post-authorization safety study to describe the use of Clottafact® (LFB Biomedicaments) fibrinogen concentrate in real-life medical practice in Mexico. METHODS This was a prospective, observational study that collected and evaluated information between January 2017 and June 2019 related to suspected serious adverse reactions (SUSARs) during and after Clottafact® infusion. RESULTS Information from 40 subjects was analyzed; 43% were women (n = 17), mean age was 39.05 ± 26.8 years (range 0-91 years). The medical specialties included in this analysis were cardiac surgery - 52.5% of the cases, gynecology/obstetrics - 17.5%, general surgery and orthopedics - 12.5% each, and hematology and neurosurgery - 2.5%, respectively. Mean plasma fibrinogen levels before and after Clottafact® infusion were 2.58 g/L and 4.02 g/L; p = 0.001, respectively. The mean Clottafact® dose was 2.20 ± 0.77 g. One patient presented SUSARs (dry mouth and dysgeusia) with drug administration, which ceased after treatment discontinuation. CONCLUSIONS In this real-life post-marketing study, the safety profile of Clottafact® was very similar to previous reports. Thus, Clottafact® shows a favorable safety profile in clinical practice.
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6
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Bellon A, Fuseau E, Roumanie O, Lamazure J, Stevens W, Dahmane A, Barthez-Toullec M, Golly D, Henriet C, Bridey F. Population pharmacokinetics of a triple-secured fibrinogen concentrate administered to afibrinogenaemic patients: Observed age- and body weight-related differences and consequences for dose adjustment in children. Br J Clin Pharmacol 2020; 86:329-337. [PMID: 31658379 PMCID: PMC7015754 DOI: 10.1111/bcp.14147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/09/2019] [Accepted: 09/21/2019] [Indexed: 11/28/2022] Open
Abstract
Aims The pharmacokinetics (PK) of a triple‐secured fibrinogen concentrate (FC) was assessed in patients ≥40 kg by noncompartmental analysis over a period of 14 days with multiple blood samples. Limited PK time point assessments in children lead to consideration of using Bayesian estimation for paediatric data. The objectives were (i) to define the population PK of FC in patients with afibrinogenaemia; (ii) to detect age‐ and body weight‐related differences and consequences for dose adjustment. Methods A population PK model was built using plasma fibrinogen activity data collected in 31 patients aged 1 to 48 years who had participated in a single‐dose PK study with FC 0.06 g kg–1. Results A 1‐compartment model with allometric scaling accounting for body weight was found to best describe the kinetics of FC. Addition of age and sex as covariates did not improve the model. Incremental in vivo recovery assessed at the end of infusion with the predicted maximal concentrations was lower, weight‐adjusted clearance was higher, and fibrinogen elimination half‐life was shorter in patients <40 kg than patients ≥40 kg. Interpatient variability was similar in both groups. Conclusion Dosing in patients ≥40 kg based on the previous empirical finding using noncompartmental analysis where FC 1 g kg–1 raises the plasma fibrinogen activity by 23 g L–1 was confirmed. In patients <40 kg, (covering the age range from birth up to about 12 years old) FC 1 g kg–1 raises the plasma fibrinogen by 19 g L–1. Dosing should be adapted accordingly unless therapy is individualized.
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Affiliation(s)
- Anne Bellon
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | | | | | - Jennifer Lamazure
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Wil Stevens
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Amel Dahmane
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Malika Barthez-Toullec
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Dominique Golly
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Céline Henriet
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Françoise Bridey
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
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7
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Casini A, Moerloose P. Fibrinogen concentrates in hereditary fibrinogen disorders: Past, present and future. Haemophilia 2019; 26:25-32. [DOI: 10.1111/hae.13876] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Alessandro Casini
- Division of Angiology and Hemostasis Faculty of Medicine Geneva University Hospitals Geneva Switzerland
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8
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Djambas Khayat C, El Khorassani M, Lambert T, Gay V, Barthez-Toullec M, Lamazure J, Bellon A, Henriet C, Bridey F, Négrier C. Clinical pharmacology, efficacy and safety study of a triple-secured fibrinogen concentrate in adults and adolescent patients with congenital fibrinogen deficiency. J Thromb Haemost 2019; 17:635-644. [PMID: 30661302 DOI: 10.1111/jth.14392] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Indexed: 11/29/2022]
Abstract
Essentials A novel fibrinogen concentrate was evaluated in patients with congenital fibrinogen deficiency. An open-label, phase 2-3 trial studied pharmacology, efficacy, and safety in patients >6 years. The product offers safe and effective therapy in the treatment and prophylaxis of bleeding. Data in recovery show the need of adjusted treatment and further investigation in children. SUMMARY: Background Single-factor replacement therapy is considered the most suitable treatment option for hereditary fibrinogen deficiency. A triple-secured plasma-derived human fibrinogen product was developed to increase the safety of the former fibrinogen concentrate. Objectives This non-randomized, open-label, prospective study investigated pharmacokinetics, efficacy, and safety of a novel fibrinogen concentrate (FibCLOT® /CLOTTAFACT® LFB, France) in inherited deficiency. Patients/Methods Fourteen patients ≥40 kg received fibrinogen concentrate for pharmacology and 16 ≥ 23 kg received treatment for bleeding or surgery. Each treatment was followed by a 3-week safety observation period. Key outcomes included number of infusions, dose, bleeding control, daily assessment, hemoglobin, blood loss, transfusions, and physicians' global assessment of response. Results Incremental recovery was 2.35 mg mL-1 per mg kg-1 and maximal concentration 1.41 g L-1 (geometric mean) after 0.060 g kg-1 infusion in 14 afibrinogenemic patients. Terminal half-life was 69.3 h (non-compartmental analysis). The maximum clot firmness was increased by a mean of 10.3 mm from baseline to maximal effect. Sixteen patients participated to the efficacy phase: 32 bleeding episodes were treated in 9 patients, and 15 patients underwent 38 surgical/invasive procedures. All patients achieved appropriate hemostasis: response to treatment was successful in all bleeds (95% CI, 0.89-1.00) and procedures (95% CI, 0.91-1.00). Most (94%) bleeds were controlled with a single infusion (median 0.050 g kg-1 ). Two patients experienced asymptomatic distal venous thromboses identified by systematic ultrasound. Conclusion FibCLOT® /CLOTTAFACT® showed a pharmacokinetic profile comparable to that of other fibrinogen concentrates and provides safe and clinically effective substitution therapy for fibrinogen-deficient patients.
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Affiliation(s)
| | | | | | | | - Malika Barthez-Toullec
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Jennifer Lamazure
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Anne Bellon
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Céline Henriet
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Françoise Bridey
- Clinical Development, Laboratoire français du Fractionnement et des Biotechnologies (LFB), Les Ulis, France
| | - Claude Négrier
- Hematology Division, Hemophilia Comprehensive Care Center, Louis Pradel Hospital, University Lyon1, Bron, France
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Schenk B, Lindner AK, Treichl B, Bachler M, Hermann M, Larsen OH, Fenger-Eriksen C, Wally D, Tauber H, Velik-Salchner C, Fries D. Fibrinogen supplementation ex vivo increasesclot firmness comparable to platelet transfusion in thrombocytopenia. Br J Anaesth 2018; 117:576-582. [PMID: 27799172 DOI: 10.1093/bja/aew315] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Fibrinogen concentrate can improve clot firmness and offers a better safety profile than platelet concentrates. Reduction or avoidance of blood transfusions represents a strategy to reduce associated risks. We investigated whether supplementation of fibrinogen concentrate ex vivo can compensate for clot strength as compared with platelet transfusion in vivo METHODS: One hundred patients in need of platelet transfusion (PT) were enrolled. Blood samples were collected immediately before PT and at 1 h and 24 h after PT. Fibrinogen concentrate was added to these citrated whole blood samples at concentrations of 50, 100, 200 and 400 mg kg-1 and the maximum clot firmness (MCF) was analysed using ROTEM thromboelastometry. RESULTS Fibrinogen supplementation increased MCF significantly and dose-dependently before and after PT. The effect of fibrinogen concentrate (equivalent to doses of 100 and 200 mg kg-1) ex vivo was comparable to that of PT in vivo, whereas 400 mg kg-1 fibrinogen significantly improved MCF compared with PT (P < 0.001). CONCLUSIONS Fibrinogen concentrate can match the effect of PT on MCF in thrombocytopenia. This potential alternative haemostatic intervention should be evaluated in clinical trials.
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Affiliation(s)
- B Schenk
- Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - A K Lindner
- Department of Anaesthesiology and General Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - B Treichl
- Department of Anaesthesiology and General Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - M Bachler
- Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - M Hermann
- Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - O H Larsen
- Center for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Skejby - Brendstrupgårdsvej 100, 8200 Aarhus, Denmark
| | - C Fenger-Eriksen
- Center for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Skejby - Brendstrupgårdsvej 100, 8200 Aarhus, Denmark.,Department of Anaesthesiology, Aarhus University Hospital, Skejby - Brendstrupgårdsvej 100, 8200 Aarhus, Denmark
| | - D Wally
- Department of Anaesthesiology and General Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - H Tauber
- Department of Anaesthesiology and General Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - C Velik-Salchner
- Department of Anaesthesiology and General Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - D Fries
- Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
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Ross C, Rangarajan S, Karimi M, Toogeh G, Apte S, Lissitchkov T, Acharya S, Manco-Johnson MJ, Srivastava A, Brand B, Schwartz BA, Knaub S, Peyvandi F. Pharmacokinetics, clot strength and safety of a new fibrinogen concentrate: randomized comparison with active control in congenital fibrinogen deficiency. J Thromb Haemost 2018; 16:253-261. [PMID: 29220876 DOI: 10.1111/jth.13923] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Indexed: 11/26/2022]
Abstract
Essentials Congenital afibrinogenemia causes a potentially life-threatening bleeding and clotting tendency. Two human fibrinogen concentrates (HFCs) were compared in a randomized pharmacokinetic study. Bioequivalence was not shown for AUCnorm , which was significantly larger for the new HFC. Increases in clot strength were comparable, and no thromboses or deaths occurred in the study. SUMMARY Background Human fibrinogen concentrate (HFC) corrects fibrinogen deficiency in congenital a-/hypofibrinogenemia. Objectives To assess pharmacokinetics (PK), effects on thromboelastometry maximum clot firmness (MCF), and safety of a new double virus-inactivated/eliminated, highly purified HFC vs. active control. Patients/Methods In this multinational, randomized, phase II, open-label, crossover study in 22 congenital afibrinogenemia patients aged ≥ 12 years, 70 mg kg-1 of new HFC (FIBRYGA, Octapharma AG) or control (Haemocomplettan® P/RiaSTAP™, CSL Behring GmbH) were administered, followed by crossover to the other concentrate. Fibrinogen activity, PK and MCF in plasma were assessed. Results The concentrates were not bioequivalent for the primary endpoint, AUCnorm (mean ratio, 1.196; 90% confidence interval [CI], 1.117, 1.281). Remaining PK parameters (Cmaxnorm , IVR, t1/2 , MRT) reflected bioequivalence between concentrates, except for clearance (mean ratio, 0.836; 90% CI, 0.781, 0.895) and Vss (mean ratio, 0.886; 90% CI, 0.791, 0.994). Mean AUCnorm was significantly larger for the new HFC (1.62 ± 0.45 vs. 1.38 ± 0.47 h kg g L-1 mg-1 , P = 0.0001) and mean clearance was significantly slower (0.665 ± 0.197 vs. 0.804 ± 0.255 mL h-1 kg-1 , P = 0.0002). Mean MCF increased from 0 mm to 9.68 mm (new HFC) and 10.00 mm (control) 1-hour post-infusion (mean difference, -0.32 mm; 95% CI, -1.70, 1.07, n.s.). No deaths, thromboses, viral seroconversions or serious related adverse events occurred. Conclusions Bioequivalence was not demonstrated for AUCnorm , clearance and Vss . Larger AUCnorm and slower clearance were observed for the new HFC. Remaining pharmacokinetic parameters reflected bioequivalence to control. Safety profiles and increases in clot strength were comparable between concentrates.
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Affiliation(s)
- C Ross
- Department of Hematology, St John's Medical College and Hospital, Bangalore, India
| | - S Rangarajan
- Centre For Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - M Karimi
- Hematology Research Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - G Toogeh
- Thrombosis Hemostasis Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - S Apte
- Sahyadri Speciality Hospital, Pune, Maharashtra, India
| | - T Lissitchkov
- Department of Hemorrhagic Diathesis and Anemia, Specialized Hospital for Active Treatment (SHAT) 'Joan Pavel', Sofia, Bulgaria
| | - S Acharya
- Cohen Children's Medical Center of New York, Northwell Health, New Hyde Park, NY, USA
| | - M J Manco-Johnson
- Hemophilia and Thrombosis Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - A Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | - B Brand
- Department of Haematology, University Hospital Zurich, Zurich, Switzerland
| | - B A Schwartz
- Clinical Research and Development, Octapharma, Hoboken, NJ, USA
| | - S Knaub
- Research and Development Department, Octapharma, Lachen, Switzerland
| | - F Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Luigi Villa Foundation, Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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11
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Négrier C, Ducloy-Bouthors AS, Piriou V, De Maistre E, Stieltjes N, Borel-Derlon A, Colson P, Picard J, Lambert T, Claeyssens S, Boileau S, Bertrand A, André MH, Fourrier F, Ozier Y, Sié P, Gruel Y, Tellier Z. Postauthorization safety study of Clottafact®
, a triply secured fibrinogen concentrate in acquired fibrinogen deficiency: a prospective observational study. Vox Sang 2017; 113:120-127. [DOI: 10.1111/vox.12624] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 09/26/2017] [Accepted: 11/14/2017] [Indexed: 01/02/2023]
Affiliation(s)
| | | | - V. Piriou
- South University Hospital; Lyon France
| | | | | | | | - P. Colson
- University Hospital; Montpellier France
| | - J. Picard
- University Hospital; Grenoble France
| | - T. Lambert
- Bicêtre Hospital; Kremlin Bicêtre France
| | | | | | - A. Bertrand
- Medical Affairs; LFB Biomédicaments; Les Ulis France
| | - M.-H. André
- Medical Affairs; LFB Biomédicaments; Les Ulis France
| | | | - Y. Ozier
- University Hospital; Brest France
| | - P. Sié
- Rangueil Hospital; Toulouse France
| | - Y. Gruel
- Trousseau Hospital; Tours France
| | - Z. Tellier
- Medical Affairs; LFB Biomédicaments; Les Ulis France
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Strauss E, Mazzeffi M, Williams B, Key N, Tanaka K. Perioperative management of rare coagulation factor deficiency states in cardiac surgery. Br J Anaesth 2017; 119:354-368. [DOI: 10.1093/bja/aex198] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2017] [Indexed: 01/21/2023] Open
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Stanciakova L, Kubisz P, Dobrotova M, Stasko J. Congenital afibrinogenemia: from etiopathogenesis to challenging clinical management. Expert Rev Hematol 2017; 9:639-48. [PMID: 27291795 DOI: 10.1080/17474086.2016.1200967] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Congenital afibrinogenemia belongs to the group of autosomal recessive bleeding disorders and represents the absolute deficiency of fibrinogen detected by an antigenic test. This can lead to severe clinical manifestations of the disorder. Therefore, it is very important to take afibrinogenemia into account in the process of the differential diagnostics of the patients. AREAS COVERED The authors provide a summary of currently available literature about afibrinogenemia. They collected the information from the scientific journals dedicated to thrombosis and hemostasis and searched world-wide databases. Expert commentary: The most frequent clinical manifestation of this disorder is mucosal bleeding, but musculoskeletal bleeding pattern, gynecologic and obstetric issues, spontaneous bleeding, episodes provoked by minor injury or any other intervention, and even paradoxical thromboembolic events have been published. Afibrinogenemia is the consequence of mutations of the homozygous or compound heterozygous type in gene FGA, FGB or FGG encoding fibrinogen. Pregnant women with a family history, or with a history of consanguinity ought to be properly counselled. However, primary prophylaxis of bleeding events is not suggested. The article deals with actual information about afibrinogenemia contributing to its early diagnosis and effective treatment, which in many cases requires multidisciplinary approach.
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Affiliation(s)
- Lucia Stanciakova
- a National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology , Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital , Martin , Slovakia
| | - Peter Kubisz
- a National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology , Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital , Martin , Slovakia
| | - Miroslava Dobrotova
- a National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology , Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital , Martin , Slovakia
| | - Jan Stasko
- a National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology , Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin University Hospital , Martin , Slovakia
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Casini A, de Moerloose P. Management of congenital quantitative fibrinogen disorders: a Delphi consensus. Haemophilia 2016; 22:898-905. [PMID: 27640400 DOI: 10.1111/hae.13061] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2016] [Indexed: 12/17/2022]
Abstract
INTRODUCTION No evidence-based guidelines for the management of patients suffering from afibrinogenaemia and hypofibrinogenaemia are available. AIM AND METHOD The aim of this study was to harmonize patient's care among invited haemophilia experts from Belgium, France and Switzerland. A Delphi-like methodology was used to reach a consensus on: prophylaxis, bleeding, surgery, pregnancy and thrombosis management. RESULTS The main final statements are as follows: (i) a secondary fibrinogen prophylaxis should be started after a first life-threatening bleeding in patients with afibrinogenaemia; (ii) during prophylaxis the target trough fibrinogen level should be 0.5 g L-1 ; (iii) if an adaptation of dosage is required, the frequency of infusions rather than the fibrinogen amount should be modified; (iv) afibrinogenaemic patients undergoing a surgery at high bleeding risk should receive fibrinogen concentrates regardless of the personal or family history of bleeding; (v) moderate hypofibrinogenaemic patients (i.e. ≥0.5 g L-1 ) without previous bleeding (despite haemostatic challenges) undergoing a surgery at low bleeding risk may not receive fibrinogen concentrates as prophylaxis; (vi) monitoring the trough fibrinogen levels should be performed at least once a month throughout the pregnancy and a foetal growth and placenta development close monitoring by ultrasound is recommended; (vii) fibrinogen replacement should be started concomitantly to the introduction of anticoagulation in afibrinogenaemic patients suffering from a venous thromboembolic event; and (viii) low-molecular-weight heparin is the anticoagulant of choice in case of venous thromboembolism. CONCLUSION The results of this initiative should help clinicians in the difficult management of patients with congenital fibrinogen disorders.
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Affiliation(s)
- A Casini
- Division of Angiology and Haemostasis, University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - P de Moerloose
- Division of Angiology and Haemostasis, University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Négrier C, Rothschild C, Borg JY, Lambert T, Claeyssens S, Sanhes L, Stieltjes N, Bertrand A, André MH, Sié P, Gruel Y, Tellier Z. Post-authorization safety study of Clottafact®, a triply secured fibrinogen concentrate in congenital afibrinogenemia. A prospective observational study. Vox Sang 2016; 111:383-390. [DOI: 10.1111/vox.12424] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 11/25/2022]
Affiliation(s)
| | - C. Rothschild
- Hemophilia Centre; Necker Enfants Malades University Hospital - APHP Paris; Paris France
| | | | - T. Lambert
- Bicêtre Hospital; Kremlin Bicêtre France
| | | | - L. Sanhes
- Saint-Jean Hospital; Perpignan France
| | | | - A. Bertrand
- Medical Affairs; LFB Biomédicaments; Les Ulis France
| | - M.-H. André
- Medical Affairs; LFB Biomédicaments; Les Ulis France
| | - P. Sié
- Rangueil Hospital; Toulouse France
| | - Y. Gruel
- Trousseau Hospital; Tours France
| | - Z. Tellier
- Medical Affairs; LFB Biomédicaments; Les Ulis France
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17
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Casini A, de Moerloose P. Factor concentrates for rare congenital coagulation disorders: where are we now? Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2016.1108188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Anderson MA, Glazebrook B, Cutts B, Stevenson L, Bielby L, Borosak M. When do we transfuse cryoprecipitate? Intern Med J 2014; 43:896-902. [PMID: 23425520 DOI: 10.1111/imj.12104] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Accepted: 02/08/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND The 2001 National Health and Medical Research Council/Australasian Society of Blood Transfusion Clinical Practice Guidelines for cryoprecipitate are being updated, and cryoprecipitate has been incorporated into new Patient Blood Management modules. AIMS This clinical audit sought to clarify current cryoprecipitate use in Victoria, Tasmania and the Australian Capital Territory; assess adherence to guidelines; and gain insights into deviations from recommended practice. This information can be utilised in updating guidelines to make them more relevant, to identify areas for clinician education and to form a baseline of practice prior to release of the 2011 guidelines. METHODS Participating institutions were invited to audit up to 30 consecutive episodes of cryoprecipitate transfusion over an 11-month period in 2008. The audits were conducted using a standardised pro forma and involved review of patient records. These were collated electronically using algorithms to determine alignment versus non-alignment with guidelines. RESULTS Cryoprecipitate is used in a variety of situations with surgery accounting for the highest volume. Twenty-six per cent (26%) of transfusions were aligned with 2001 guidelines rising to 61% with a modified fibrinogen trigger. Fibrinogen levels did not appear to dictate all clinical decisions regarding cryoprecipitate use perhaps owing to the acuity of many cases. Additional bleeding risk together with low fibrinogen levels (e.g. thrombocytopenic patients) may contribute to empiric cryoprecipitate use. CONCLUSIONS These results highlight discrepancies between guidelines and practice, providing rationale for the update of the guidelines that is currently underway. Cryoprecipitate has attendant risks, and it is appropriate that transfusion be restricted to situations with good evidence or sound principles to underpin use.
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Affiliation(s)
- M A Anderson
- Transfusion Medicine, Australian Red Cross Blood Service, Melbourne, Victoria, Australia
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Levy JH, Welsby I, Goodnough LT. Fibrinogen as a therapeutic target for bleeding: a review of critical levels and replacement therapy. Transfusion 2013; 54:1389-405; quiz 1388. [DOI: 10.1111/trf.12431] [Citation(s) in RCA: 213] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 08/14/2013] [Accepted: 08/14/2013] [Indexed: 12/12/2022]
Affiliation(s)
- Jerrold H. Levy
- Department of Anesthesiology; Duke University School of Medicine; Durham North Carolina
| | - Ian Welsby
- Department of Anesthesiology; Duke University School of Medicine; Durham North Carolina
| | - Lawrence T. Goodnough
- Department of Pathology; Stanford University School of Medicine, Stanford Medical Center; Palo Alto California
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Complex Pharmacokinetics of a Humanized Antibody Against Human Amyloid Beta Peptide, Anti-Abeta Ab2, in Nonclinical Species. Pharm Res 2011; 28:1696-706. [DOI: 10.1007/s11095-011-0405-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 02/21/2011] [Indexed: 12/26/2022]
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23
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Pharmacokinetics, tissue distribution and excretion of porcine fibrinogen after intraperitoneal injection of a porcine-derived fibrin glue to rats. J Pharm Biomed Anal 2011; 54:148-53. [DOI: 10.1016/j.jpba.2010.07.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 07/26/2010] [Accepted: 07/31/2010] [Indexed: 11/21/2022]
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Bevan DH. Cryoprecipitate: no longer the best therapeutic choice in congenital fibrinogen disorders? Thromb Res 2010; 124 Suppl 2:S12-6. [PMID: 20109651 DOI: 10.1016/s0049-3848(09)70159-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Congenital abnormalities of fibrinogen are rare disorders classified as quantitative (afibrinogenemia and hypofibrinogenemia) or qualitative types (dysfibrinogenemia and hypodysfibrinogenemia). Fibrinogen is essential to haemostasis as the substrate for fibrin clot formation and also acts in primary haemostasis as a key ligand in platelet aggregation. Quantitative deficiency of fibrinogen can result in severe bleeding, or arterial and venous thromboembolism, and poor wound healing. Dysfibrinogenemia is characterized by functional abnormalities of fibrinogen, which may be asymptomatic (in 50% of cases), or cause bleeding (25%) or thrombosis (25%). Replacement of the deficient or abnormal fibrinogen with frozen plasma, cryoprecipitate, or fibrinogen concentrate has been found to be effective in practice in treating haemostatic complications of these disorders. Although cryoprecipitate is the most commonly used replacement material, pathogen-reduced fibrinogen concentrates have several advantages, most importantly a lower potential risk of viral transmission and standardized fibrinogen content allowing accurate dosing. They also avoid transfusing unwanted clotting factors, platelet microparticles and immunoglobulins, and can be administered rapidly without thawing. The use of fibrinogen concentrate to treat congenital fibrinogen disorders is strongly supported in principle and increasingly by practical experience and evidence.
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Affiliation(s)
- David H Bevan
- St Thomas' Hospital Haemophilia Reference Centre, London, UK.
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Peyvandi F. Results of an international, multicentre pharmacokinetic trial in congenital fibrinogen deficiency. Thromb Res 2009; 124 Suppl 2:S9-11. [DOI: 10.1016/s0049-3848(09)70158-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Manco-Johnson MJ, Dimichele D, Castaman G, Fremann S, Knaub S, Kalina U, Peyvandi F, Piseddu G, Mannucci P. Pharmacokinetics and safety of fibrinogen concentrate. J Thromb Haemost 2009; 7:2064-9. [PMID: 19804533 DOI: 10.1111/j.1538-7836.2009.03633.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although fibrinogen concentrate has been available for the treatment of congenital fibrinogen deficiency for years, knowledge of its pharmacokinetics comes from only two small studies. OBJECTIVES To assess the pharmacokinetic (PK) profile, clot integrity and safety of fibrinogen concentrate (human) (FCH) in patients with afibrinogenemia. PATIENTS AND METHODS A multinational, prospective, open-label, uncontrolled study of patients with afibrinogenemia > or = 6 years of age was conducted in the USA and Italy. Plasma was collected before and after infusion for PK analyses and evaluation by rotational thromboelastometry of maximum clot firmness (MCF) to assess clot integrity. Safety was assessed on the basis of adverse events and laboratory parameters. RESULTS After a single dose of 70 mg kg(-1) body weight (b.w.) FCH in 14 patients, median incremental in vivo recovery was a 1.7 mg dL(-1) increase per mg kg(-1) b.w., and median levels were 1.3 g L(-1) for fibrinogen activity and antigen 1 h after infusion. Median half-life (t(1/2)) was 77.1 h for fibrinogen activity and 88.0 h for antigen. Plasma recovery in children < 16 years old was similar to that in adults aged 16 to < 65 years, but the t(1/2) and area under the curve were decreased, with an increased steady-state volume and clearance. MCF increased by a mean of 8.9 mm from baseline to 1 h after infusion of FCH (P < 0.0001). All four adverse events reported were mild, and none was serious or related to study drug. CONCLUSIONS These PK findings confirm a rapid increase in plasma fibrinogen levels after infusion with FCH. Together with the clot integrity and safety data and published data on efficacy, the results support the idea that FCH substitution can restore hemostasis with a good safety profile.
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Affiliation(s)
- M J Manco-Johnson
- Mountain States Regional Hemophilia & Thrombosis Center, Department of Pediatrics, University of Colorado Denver, Aurora, CO 80010, USA.
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Tziomalos K, Vakalopoulou S, Perifanis V, Garipidou V. Treatment of congenital fibrinogen deficiency: overview and recent findings. Vasc Health Risk Manag 2009; 5:843-8. [PMID: 19851522 PMCID: PMC2762433 DOI: 10.2147/vhrm.s5305] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Afibrinogenemia is a rare bleeding disorder with an estimated prevalence of 1:1,000,000. It is an autosomal recessive disease resulting from mutations in any of the 3 genes that encode the 3 polypeptide chains of fibrinogen and are located on the long arm of chromosome 4. Spontaneous bleeding, bleeding after minor trauma and excessive bleeding during interventional procedures are the principal manifestations. We review the management of afibrinogenemia. Replacement therapy is the mainstay of treatment of bleeding episodes in these patients and plasma-derived fibrinogen concentrate is the agent of choice. Cryoprecipitate and fresh frozen plasma are alternative treatments that should be used only when fibrinogen concentrate is not available. Secondary prophylactic treatment may be considered after life-threatening bleeding whereas primary prophylactic treatment is not currently recommended. We also discuss alternative treatment options and the management of surgery, pregnancy and thrombosis in these patients. The development of new tests to identify higher risk patients and of safer replacement therapy will improve the management of afibrinogenemia in the future.
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Affiliation(s)
- Konstantinos Tziomalos
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece.
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