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Mohsenian S, Mannucci PM, Menegatti M, Peyvandi F. Rare inherited coagulation disorders: no longer orphan and neglected. Res Pract Thromb Haemost 2024; 8:102460. [PMID: 39022653 PMCID: PMC11253144 DOI: 10.1016/j.rpth.2024.102460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/03/2024] [Accepted: 05/18/2024] [Indexed: 07/20/2024] Open
Abstract
Rare inherited coagulation disorders due to the deficiency or dysfunction of coagulation factors have until recently received less clinical attention than hemophilias and von Willebrand disease. This situation has changed in the last decades, mainly due to therapeutic progress with the availability of more and safer products for replacement therapy produced by plasma fractionation or recombinant DNA technology. This narrative review, based on the latest literature and expert opinion, emphasizes the progress achieved for each of the rare deficiencies, mentions the still unmet therapeutic needs, and sketches the perspectives for further progress.
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Affiliation(s)
- Samin Mohsenian
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Marzia Menegatti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Trossaert M, Chamouard V, Biron-Andreani C, Casini A, De Mazancourt P, De Raucourt E, Drillaud N, Frotscher B, Guillet B, Lebreton A, Roussel-Robert V, Rugeri L, Dargaud Y. Management of rare inherited bleeding disorders: Proposals of the French Reference Centre on Haemophilia and Rare Coagulation Disorders. Eur J Haematol 2023; 110:584-601. [PMID: 36748278 DOI: 10.1111/ejh.13941] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/25/2023] [Accepted: 01/31/2023] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The rare coagulation disorders may present significant difficulties in diagnosis and management. In addition, considerable inter-individual variation in bleeding phenotype is observed amongst affected individuals, making the bleeding risk difficult to assess in affected individuals. The last international recommendations on rare inherited bleeding disorders (RIBDs) were published by the United Kingdom Haemophilia Centre Doctors' Organisation in 2014. Since then, new drugs have been marketed, news studies on surgery management in patients with RIBD have been published, and new orphan diseases have been described. AIM Therefore, the two main objectives of this review, based on the recent recommendations published by the French Reference Centre on Haemophilia and Rare Bleeding Disorders, are: (i) to briefly describe RIBD (clinical presentation and diagnostic work-up) to help physicians in patient screening for the early detection of such disorders; and (ii) to focus on the current management of acute haemorrhages and long term prophylaxis, surgical interventions, and pregnancy/delivery in patients with RIBD.
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Affiliation(s)
- Marc Trossaert
- Haemophilia Treatment Centre, University Hospital of Nantes and French Reference Centre on Haemophilia, Nantes, France
| | - Valerie Chamouard
- Haemophilia Treatment Centre, University Hospital of Lyon and French Reference Centre on Haemophilia, Lyon, France
| | | | - Alessandro Casini
- Angiology and Haemostasis Division, Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Philippe De Mazancourt
- Laboratory of Biochemistry and Molecular Genetics, Hospital Ambroise Paré-GHU APHP, Université Paris-Saclay, Boulogne-Billancourt, France
| | | | - Nicolas Drillaud
- Haemophilia Treatment Centre, University Hospital of Nantes and French Reference Centre on Haemophilia, Nantes, France
| | - Birgit Frotscher
- Haemophilia Treatment Centre, University Hospital of Nancy, Nancy, France
| | - Benoit Guillet
- Haemophilia Treatment Centre, University Hospital of Rennes, Rennes, France
| | - Aurelien Lebreton
- Haemophilia Treatment Centre, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Lucia Rugeri
- Haemophilia Treatment Centre, University Hospital of Lyon and French Reference Centre on Haemophilia, Lyon, France
| | - Yesim Dargaud
- Haemophilia Treatment Centre, University Hospital of Lyon and French Reference Centre on Haemophilia, Lyon, France
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Poulsen LH, Kerlin BA, Castaman G, Molinari AC, Menegatti M, Nugent D, Dey S, Garly M, Carcao M. Safety and effectiveness of recombinant factor XIII-A 2 in congenital factor XIII deficiency: Real-world evidence. Res Pract Thromb Haemost 2022; 6:e12628. [PMID: 35243202 PMCID: PMC8882239 DOI: 10.1002/rth2.12628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 10/06/2021] [Accepted: 10/31/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Regular factor XIII (FXIII) prophylaxis is standard treatment for congenital FXIII A-subunit deficiency (FXIII-A CD). Recombinant factor XIII-A2 (rFXIII-A2) was extensively evaluated in the mentor trials. OBJECTIVE To assess real-world safety and treatment effectiveness of rFXIII-A2 prophylaxis from the mentor 6 trial. PATIENTS/METHODS mentor 6 was a noninterventional, postauthorization safety study investigating rFXIII-A2 prophylaxis in FXIII-A CD. rFXIII-A2 treatment was observed for 2 to 6 years per patient. The primary end point was documentation of adverse drug reactions (including anti-FXIII antibody development). Secondary end points were serious adverse events (SAEs), medical events of special interest (MESIs), and annualized bleeding rate (ABR). RESULTS Among 30 patients (mean age, 25.5 years), there were 44 adverse events (AEs) (30 mild, 13 moderate, 1 severe). Eleven AEs were possibly/probably related to rFXIII-A2. Of four MESIs, two were unlikely related to rFXIII-A2 (accidental overdose, deep vein thrombosis), and two were possibly/probably related (nonneutralizing anti-FXIII antibody, decreased therapeutic response). All 10 SAEs were unlikely related to rFXIII-A2. Over a follow-up of 75.4 patient-years, there were six treatment-requiring bleeds (all trauma-related with no spontaneous bleeds), giving a treatment-requiring ABR of 0.066; five bleeds were treated successfully with rFXIII-A2. Eight of nine minor surgeries performed during rFXIII-A2 prophylaxis reported successful hemostatic outcomes (one missing evaluation). CONCLUSIONS These data confirm that rFXIII-A2 prophylaxis is well tolerated as long-term care. There were no spontaneous bleeds, ABR was low, and rFXIII-A2 successfully treated bleeds in patients receiving rFXIII-A2 prophylaxis.
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Affiliation(s)
| | - Bryce A. Kerlin
- The Ohio State University College of MedicineNationwide Children’s HospitalColumbusOhioUSA
| | - Giancarlo Castaman
- Center for Bleeding Disorders and CoagulationDepartment of OncologyCareggi University HospitalFirenzeItaly
| | - Angelo Claudio Molinari
- Regional Reference Center for Hemorrhagic DiseasesGiannina Gaslini Children’s HospitalGenoaItaly
| | - Marzia Menegatti
- IRCCS Fondazione Ca’ GrandaOspedale Maggiore PoliclinicoAngelo Bianchi Bonomi Hemophilia and Thrombosis CenterMilanItaly
| | - Diane Nugent
- Children's Hospital of Orange CountyUniversity of California at Irvine, and Center for Inherited Blood DisordersOrangeCaliforniaUSA
| | - Sohan Dey
- Novo Nordisk Service Centre India Private LtdBangaloreIndia
| | | | - Manuel Carcao
- Division of Haematology/OncologyDepartment of Paediatrics and Child Health Evaluative SciencesResearch Institute, Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
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Cojutti PG, Zanon E, Pasca S, Pea F. Real-Life Population Pharmacokinetics of Recombinant Factor XIII and Dosing Considerations for Preventing the Risk of Bleeding in Patients with FXIII Congenital Deficiency. Clin Pharmacokinet 2021; 61:505-513. [PMID: 34718987 DOI: 10.1007/s40262-021-01079-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Recombinant factor XIII (rFXIII) at the recommended dosage of 35 IU/kg every 4 weeks is currently used for prophylaxis of bleeding in patients affected by FXIII deficiency. The aim of this study was to describe the population pharmacokinetics of rFXIII in patients with FXIII deficiency being treated with rFXIII in real-life and to assess, using Monte Carlo simulations, the attainment of defined FXIII concentration thresholds associated with prevention of the risk of bleeding over time. METHODS A nonlinear mixed-effects model approach was used for population analysis. Monte Carlo simulations were used to generate 10,000 FXIII concentration-time profiles associated with incremental doses of 25, 30, 35, 40, 45 and 50 IU/kg of rFXIII. The probability of target attainment (PTA) of FXIII concentrations at thresholds of > 0.05, > 0.10 and > 0.15 IU/mL were calculated weekly, from days 7 to 49. RESULTS A total of 18 patients provided 99 FXIII concentrations; most patients (77.8%, 14/18) had severe FXIII deficiency. A two-compartment pharmacokinetic model with linear elimination from the central compartment best described rFXIII data. No covariates were associated with rFXIII disposition. Pharmacokinetic parameter estimates were 0.16 mL/h/kg for clearance, 57.35 mL/kg for volume of distribution at steady-state, and 11.72 days for elimination half-life. The standard 35 IU/kg dose resulted in PTAs of the pharmacodynamic thresholds of FXIII concentrations of > 0.05, > 0.10 and > 0.15 IU/mL at day 28 that were equal to 89.9%, 68.9% and 47.8%, respectively. CONCLUSIONS Intensive FXIII monitoring from day 14, and/or shortening the dosing interval between rFXIII administrations, should be considered to minimise the risk of bleeding.
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Affiliation(s)
- Pier Giorgio Cojutti
- SSD Clinical Pharmacology, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy.
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
| | - Ezio Zanon
- Department of Medicine, DIMED, Thrombotic and Haemorrhagic and Coagulation Diseases Unit, Veneto Regional Centre for Haemophilia and Thrombophilia, Padova University Hospital, Padua, Italy
| | - Samantha Pasca
- Department of Medicine, DIMED, Thrombotic and Haemorrhagic and Coagulation Diseases Unit, Veneto Regional Centre for Haemophilia and Thrombophilia, Padova University Hospital, Padua, Italy
| | - Federico Pea
- SSD Clinical Pharmacology, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Iyengar V, Montcrieff C, Pels S. Patient-centered approach to managing factor XIII deficiency. BMJ Case Rep 2021; 14:e241501. [PMID: 34531230 PMCID: PMC8449938 DOI: 10.1136/bcr-2020-241501] [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] [Accepted: 08/31/2021] [Indexed: 11/04/2022] Open
Abstract
Factor XIII (FXIII) is a thrombin-activated protransglutaminase that plays a key role in blood clot formation. Congenital FXIII A-subunit deficiency represents a rare bleeding disorder that affects one in 2-3 million individuals worldwide and is treated with recombinant FXIII (rFXIII). However, due to the rarity of the disease, clinicians are often left to weigh individual variation in FXIII activity and/or symptoms to optimally guide dosing. Cases often become further complicated when patients experience refractory bleeding, which can be difficult to treat. This report describes an approach to rFXIII dosing in two patients who required deviation from standard protocols to maintain therapeutic FXIII troughs. We highlight limitations in our understanding of FXIII deficiency management, while also providing an example of the application of pharmacokinetic data to individualise therapy for improved outcomes. Finally, the case reminds us of the importance of patient-centered, cost-conscious care and multidisplinary teamwork in complex cases.
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Affiliation(s)
- Varun Iyengar
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Salley Pels
- Hasbro Children's Hospital, Providence, Rhode Island, USA
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Hemorrhagic Shock after Neonatal Circumcision: Severe Congenital Factor XIII Deficiency. Case Rep Pediatr 2021; 2021:5550199. [PMID: 34007504 PMCID: PMC8110377 DOI: 10.1155/2021/5550199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 11/21/2022] Open
Abstract
A Caucasian male infant born full term via normal spontaneous vaginal delivery was given vitamin K after birth, circumcised on day of life (DOL) 1, and discharged from the nursery on DOL 2. At the time of circumcision, oozing from the surgical site was noted and initially resolved with silver nitrate. Over the next two days, he presented to local emergency rooms multiple times for recurrent bleeding, eventually developing hemorrhagic shock resulting in admission to the neonatal intensive care unit. After extensive work up, he was ultimately diagnosed with severe congenital factor XIII deficiency. Congenital factor XIII deficiency is a rare bleeding disorder characterized by normal prothrombin time (PT) and activated partial thromboplastin time (aPTT) coagulation labs on routine screening, and has a high risk of complications, such as spontaneous intracranial hemorrhage. Although uncommon, when caring for a child with bleeding, physicians must have a high index of suspicion to make this diagnosis in order to initiate proper treatment and start prophylaxis given the risk of morbidity and mortality in untreated patients.
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Carcao M, Altisent C, Castaman G, Fukutake K, Kerlin BA, Kessler C, Lassila R, Nugent D, Oldenburg J, Garly ML, Rosholm A, Inbal A. Recombinant FXIII (rFXIII-A2) Prophylaxis Prevents Bleeding and Allows for Surgery in Patients with Congenital FXIII A-Subunit Deficiency. Thromb Haemost 2018; 118:451-460. [PMID: 29448295 PMCID: PMC6260112 DOI: 10.1055/s-0038-1624581] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recombinant factor XIII-A
2
(rFXIII-A
2
) was developed for prophylaxis and treatment of bleeds in patients with congenital FXIII A-subunit deficiency. mentor™2 (NCT00978380), a multinational, open-label, single-arm, multiple-dosing extension to the pivotal mentor™1 trial, assessed long-term safety and efficacy of rFXIII-A
2
prophylaxis in eligible patients (patients with severe [<0.05 IU/mL] congenital FXIII subunit A deficiency) aged ≥6 years. Patients received 35 IU/kg rFXIII-A
2
(exact dosing) every 28 ± 2 days for ≥52 weeks. Primary endpoint was safety (adverse events including immunogenicity); secondary endpoints were rate of bleeds requiring FXIII treatment, haemostatic response after one 35 IU/kg rFXIII-A
2
dose for breakthrough bleeds and withdrawals due to lack of rFXIII-A
2
efficacy. Steady-state pharmacokinetic variables were also summarized. Elective surgery was permitted during the treatment period. Sixty patients were exposed to rFXIII-A
2
; their median age was 26.0 years (range: 7.0–77.0). rFXIII-A
2
was well tolerated without any safety concerns. No non-neutralizing or neutralizing antibodies (inhibitors) against FXIII were detected. Mean annualized bleeding rate (ABR) was 0.043/patient-year. Mean spontaneous ABR was 0.011/patient-year. No patients withdrew due to lack of efficacy. Geometric mean FXIII trough level was 0.17 IU/mL. Geometric terminal half-life was 13.7 days. rFXIII-A
2
prophylaxis provided sufficient haemostatic coverage for 12 minor surgeries without the need for additional FXIII therapy; eight procedures were performed within 7 days of the patient's last scheduled rFXIII-A
2
dose, and four were performed 10 to 21 days after the last dose.
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Affiliation(s)
- Manuel Carcao
- Division of Haematology/Oncology and Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Carmen Altisent
- Haemophilia Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Giancarlo Castaman
- Department of Oncology, Careggi University Hospital, Center for Bleeding Disorders and Coagulation, Firenze, Italy
| | - Katsuyuki Fukutake
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Bryce A Kerlin
- Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Craig Kessler
- Georgetown University Medical Center, Washington, DC, United States
| | - Riitta Lassila
- Coagulation Disorders Unit, Hematology and Comprehensive Cancer Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Diane Nugent
- Center for Inherited Blood Disorders and UC Irvine Medical School, Children's Hospital of Orange County, Orange, California, United States
| | - Johannes Oldenburg
- Institute for Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - May-Lill Garly
- Medical & Science, Biopharm, Global Development, Novo Nordisk A/S, Søborg, Denmark
| | - Anders Rosholm
- Biostatistics, Biopharm, Global Development, Novo Nordisk A/S, Søborg, Denmark
| | - Aida Inbal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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