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Arruda VR, Lillicrap D, Herzog RW. Immune complications and their management in inherited and acquired bleeding disorders. Blood 2022; 140:1075-1085. [PMID: 35793465 PMCID: PMC9461471 DOI: 10.1182/blood.2022016530] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/23/2022] [Indexed: 02/06/2023] Open
Abstract
Disorders of coagulation, resulting in serious risks for bleeding, may be caused by autoantibody formation or by mutations in genes encoding coagulation factors. In the latter case, antidrug antibodies (ADAs) may form against the clotting factor protein drugs used in replacement therapy, as is well documented in the treatment of the X-linked disease hemophilia. Such neutralizing antibodies against factors VIII or IX substantially complicate treatment. Autoantibody formation against factor VIII leads to acquired hemophilia. Although rare, antibody formation may occur in the treatment of other clotting factor deficiencies (eg, against von Willebrand factor [VWF]). The main strategies that have emerged to address these immune responses include (1) clinical immune tolerance induction (ITI) protocols; (2) immune suppression therapies (ISTs); and (3) the development of drugs that can improve hemostasis while bypassing the antibodies against coagulation factors altogether (some of these nonfactor therapies/NFTs are antibody-based, but they are distinct from traditional immunotherapy as they do not target the immune system). Choice of immune or alternative therapy and criteria for selection of a specific regimen for inherited and autoimmune bleeding disorders are explained. ITI serves as an important proof of principle that antigen-specific immune tolerance can be achieved in humans through repeated antigen administration, even in the absence of immune suppression. Finally, novel immunotherapy approaches that are still in the preclinical phase, such as cellular (for instance, regulatory T cell [Treg]) immunotherapies, gene therapy, and oral antigen administration, are discussed.
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Affiliation(s)
- Valder R Arruda
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics at The Children's Hospital of Philadelphia, Philadelphia, PA
- Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada; and
| | - Roland W Herzog
- Herman B Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
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2
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Poon MC, Goodyear MD, Rydz N, Lee A. Surgery in mild haemophilia A patients with a history of inhibitor antibodies against factor VIII: Individualized management. Haemophilia 2021; 27:e768-e771. [PMID: 34529880 DOI: 10.1111/hae.14415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/26/2021] [Accepted: 09/03/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Man-Chiu Poon
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,The Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - M Dawn Goodyear
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,The Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Natalia Rydz
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,The Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada
| | - Adrienne Lee
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,The Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Alberta, Canada
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3
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Nonsevere hemophilia A: often overlooked, but not forgotten. Curr Opin Hematol 2021; 27:295-301. [PMID: 32701616 DOI: 10.1097/moh.0000000000000600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Nonsevere hemophilia A (NSHA) patients have received relatively little clinical and research attention as compared with their severe counterparts. There is increasing recognition that despite their milder bleeding phenotype, the management of NSHA can be a challenge, with most management decisions largely inferred from severe hemophilia A data. This review focuses on some of the more recent developments in the field of NSHA. RECENT FINDINGS Epidemiologic studies suggest that NSHA remain under-recognized and under-diagnosed globally. As the NSHA population ages, they are susceptible to age-related comorbidities. Large cohort studies of NSHA report that the most common primary cause of death is malignancy. NSHA patients have a lifetime risk of inhibitor development with increasing exposure to factor VIII concentrate. Even so, not all patients with inhibitors will require eradication treatment, irrespective of bleeding phenotype at time of inhibitor development. SUMMARY As there are currently no evidence-based strategies for inhibitor eradication in NSHA patients, preventive strategies are critical to mitigate inhibitor risk in NSHA. There is a need for active surveillance of NSHA patients by hemophilia treatment centers to address hemophilia-related issues and other age-related comorbidities, in collaboration with primary care physicians and other subspecialists.
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4
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Perioperative laboratory monitoring in congenital haemophilia patients with inhibitors: a systematic literature review. Blood Coagul Fibrinolysis 2020; 30:309-323. [PMID: 31397688 DOI: 10.1097/mbc.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
: Although the use of clotting factor concentrates is the mainstay of haemophilia care, the development of inhibitors complicates disease management. Perioperative management of patients with inhibitors is therefore a challenge. A systematic literature review was performed to identify literature reporting on the perioperative monitoring and management of haemophilia. MEDLINE, Embase and Cochrane databases were searched from database inception to 26 March 2018. Recent congress proceedings were also searched. Titles and abstracts, then full texts, were screened for relevance by two reviewers. Quality of included studies was assessed using the Critical Appraisal Skills Programme checklist. Of the 2033 individual entries identified, 86 articles met the inclusion criteria. The identified studies were screened again to find articles reporting perioperative laboratory monitoring in patients with congenital haemophilia A or B, resulting in 24 articles undergoing data extraction. Routine perioperative assay monitoring practices were the most commonly reported (n = 20/24); thrombin generation assay was the least commonly reported (n = 2/24). Other monitoring practices described were factor VII and factor VIII coagulation activity (n = 8/24, n = 5/24, respectively), and thromboelastography or rotational thromboelastometry assessments (n = 3/24). The impact of monitoring on treatment decisions was, however, rarely reported. In conclusion, many methods of perioperative monitoring of haemophilia patients with inhibitors have been identified in this review, yet there is a lack of reporting in larger scale cohort studies. More detailed reporting on the impact of monitoring outcomes on treatment decisions is also needed to share best practice, particularly as new therapeutic agents emerge.
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Ljung R, Auerswald G, Benson G, Dolan G, Duffy A, Hermans C, Jiménez-Yuste V, Lambert T, Morfini M, Zupančić-Šalek S, Santagostino E. Inhibitors in haemophilia A and B: Management of bleeds, inhibitor eradication and strategies for difficult-to-treat patients. Eur J Haematol 2018; 102:111-122. [PMID: 30411401 PMCID: PMC6936224 DOI: 10.1111/ejh.13193] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/25/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022]
Abstract
The standard therapy for patients with haemophilia is prophylactic treatment with replacement factor VIII (FVIII) or factor IX (FIX). Patients who develop inhibitors against FVIII/FIX face an increased risk of bleeding, and the likelihood of early development of progressive arthropathy, alongside higher treatment-related costs. Bypassing agents can be used to prevent and control bleeding, as well as the recently licensed prophylaxis, emicizumab, but their efficacy is less predictable than that of factor replacement therapy. Antibody eradication, by way of immune tolerance induction (ITI), is still the preferred management strategy for treating patients with inhibitors. This approach is successful in most patients, but some are difficult to tolerise and/or are unresponsive to ITI, and they represent the most complicated patients to treat. However, there are limited clinical data and guidelines available to help guide physicians in formulating the next treatment steps in these patients. This review summarises currently available treatment options for patients with inhibitors, focussing on ITI regimens and those ITI strategies that may be used in difficult-to-treat patients. Some alternative, non-ITI approaches for inhibitor management, are also proposed.
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Affiliation(s)
- Rolf Ljung
- Department of Clinical Sciences-Paediatrics, Lund University, Lund, Sweden.,Malmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden
| | - Guenter Auerswald
- Klinikum Bremen-Mitte, Professor Hess Children's Hospital, Bremen, Germany
| | - Gary Benson
- Haemophilia and Thrombosis Centre, Belfast City Hospital, Belfast, UK
| | - Gerry Dolan
- Centre for Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - Anne Duffy
- WFH Psychosocial Committee, Irish Haemophilia Society, Dublin, Ireland
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | - Thierry Lambert
- Hemophilia Care Center, Faculté de Médecine Paris XI, Bicêtre AP-HP Hospital, Paris, France
| | | | - Silva Zupančić-Šalek
- University Hospital Centre Zagreb, School of Medicine, University of Osijek and Medical School University of Zagreb, Zagreb, Croatia
| | - Elena Santagostino
- Foundation IRCCS Cà Granda, Maggiore Hospital Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Hvas AM, Poulsen LH. Inhibitor screening in non-severe haemophilia patients; a major challenge. Br J Haematol 2017; 176:683-685. [PMID: 28182257 DOI: 10.1111/bjh.14546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 11/29/2016] [Indexed: 01/06/2023]
Affiliation(s)
- Anne-Mette Hvas
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Lone H Poulsen
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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Liu W, Xue F, Zhang L, Liu XF, Chen YF, Huang YT, Fu RF, Yang RC. [Study on risk factors and follow-up of 26 hemophilia A children with inhibitors]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:474-7. [PMID: 27431071 PMCID: PMC7348347 DOI: 10.3760/cma.j.issn.0253-2727.2016.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To study the risk factors, characteristics and treatment of factor Ⅷ (F Ⅷ) inhibitor in Chinese children with hemophilia A (HA) through a retrospective case-control survey; To investigate the bleeding phenotype before and after inhibitor formation. METHODS The clinical data of outpatients and inpatients with HA children from January 2010 to December 2014 were collected. A case control study was performed to investigate the risk factors for inhibitor formation. RESULTS A total of 445 HA children were enrolled with 82(18.4%) severe, 269(60.5%) moderate, and 94(21.1%) mild cases; 26(5.8% ) patients, among whom 13 were severe HA and 13 moderate HA, had inhibitor (9 low titer inhibitors, and 17 high titer inhibitors). No inhibitor was found in mild HA patients. Intensive treatment (P= 0.030, HR=4.435, 95% CI 1.150-17.094) was a risk factor for inhibitor generation. After inhibitor formation, 2 patients received small dose rituximab for inhibitor eradication, and one of them also received ITI therapy. When bleeding, 65.2% (15/23) inhibitors received PCC treatment to stop the bleeding, 8.7% (2/23) inhibitors didn't receive any medication, and 26.1% (6/23) inhibitors chose intermittent small dose FⅧ treatment; Among those patients who didn't received inhibitor eradication, 87.5%(7/8) patients with low titer inhibitor showed gradual disappearance, and the median time was 3 months; 84.6% (11/13) patients with high-titer inhibitors remained positive in 12-48 months showing a gradual decrease with time; 7.7% (1/13) high titer inhibitors showed gradual disappearance in 2 years. The annual traumatic and provoked bleeding frequency for joints, skin and soft tissue showed no difference after inhibitor formation. CONCLUSION Intensive F Ⅷ treatment was a risk factor for inhibitor formation. The inhibitor didn' t increase bleeding frequency in HA children.
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Affiliation(s)
- W Liu
- Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
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8
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Buckner TW, Nielsen BI, Key NS, Ma A. Factor VIII inhibitory antibody in a patient with combined factor V/factor VIII deficiency. Haemophilia 2014; 21:e77-80. [PMID: 25472918 DOI: 10.1111/hae.12557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2014] [Indexed: 01/23/2023]
Affiliation(s)
- T W Buckner
- Harold R. Roberts Comprehensive Hemophilia and Thrombosis Center, University of North Carolina, Chapel Hill, NC, USA
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