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Song G, Wang Y, Zhang L, Xia M. The Role of Clot Waveform Analysis and Related Parameters in the Diagnosis and Treatment of Hemophilia A. Thromb Haemost 2024; 124:852-860. [PMID: 38626899 DOI: 10.1055/s-0044-1786029] [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] [Indexed: 08/29/2024]
Abstract
BACKGROUND Hemophilia A (HA) is an inherited bleeding disorder caused by a deficiency or defect in factor VIII (FVIII). METHODS We investigated the role of clot waveform analysis (CWA) of activated partial thromboplastin time in the diagnosis and therapeutic monitoring of HA. The changes in CWA parameters the maximum clotting velocity (|Min1|), maximum clotting acceleration (|Min2|), and maximum clotting deceleration (|Max2|) were detected among mild, moderate, and severe HA groups. RESULTS As the severity of HA subtypes increased, the levels of |Min1|, |Min2|, and |Max2| progressively decreased (p < 0.05). Receiver operating characteristic curve analysis showed that |Max2| and |Min2| were more effective than |Min1| in distinguishing different types of HA patients, with higher diagnostic efficacy. The standard curves based on Actin FSL reagent for normal and low levels of FVIII:C-|Max2| were established, with R2 values of 0.98 and 0.99, respectively. These curves can be utilized for monitoring during replacement therapies involving full-length recombinant FVIII and B-domain-deleted FVIII. Thirty cases of HA patients utilized the FVIII-|Max2| standard curve to obtain individual pharmacokinetics characteristic parameters. The clearance, half-life (t1/2), time to FVIII:C of 1% above baseline (tt1%), and predicted dosage showed no statistically significant differences compared with one-stage assay (p > 0.05). CONCLUSION CWA is an economical and practical tool, and its related parameters are associated with the severity of HA. It has promising clinical prospects in predicting FVIII:C levels and individualized treatment when HA patients undergo replacement therapy.
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Affiliation(s)
- Guanghao Song
- Department of Laboratory Medicine, The Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yangbin Wang
- Department of Laboratory Medicine, The Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Lilei Zhang
- Department of Laboratory Medicine, The Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Mao Xia
- Department of Laboratory Medicine, The Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
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Xu Y, Wang Y, Wu R, Zheng C, Zhang L, Xu W, Feng X, Wang H, Cao X, He L, Xue T, Jin M, Xie B, Ling J, Sun L, Su R, Cheng H, Fang Y, Poon MC, Liu W, Zhang L, Xue F, Yang R. Reduced doses of emicizumab achieve good efficacy: Results from a national-wide multicentre real-world study in China. Haemophilia 2024; 30:959-969. [PMID: 38853005 DOI: 10.1111/hae.15062] [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: 02/08/2024] [Revised: 04/13/2024] [Accepted: 04/19/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION Reduced doses of emicizumab improve the affordability among patients in developing countries. However, the relationship between variant dose selection and efficacy in the real world of China is still unclear. AIM This study aimed to investigate the efficacy and safety of emicizumab especially in those on reduced dose regimens in a real-world setting. METHODS We carried out a multicentre study from 28 hospitals between June 2019 and June 2023 in China and retrospectively analysed the characteristics including demographics, diagnosis, treatment, bleeding episodes, and surgical procedures. RESULTS In total, 127 patients with haemophilia A, including 42 with inhibitors, were followed for a median duration of 16.0 (IQR: 9.0-30.0) months. Median age at emicizumab initiation was 2.0 (IQR: 1.0-4.0) years. Median (IQR) consumption for loading and maintenance was 12.0 (8.0-12.0) and 4.2 (3.0-6.0) mg/kg/4 weeks, respectively. While on emicizumab, 67 (52.8%) patients had no bleeds, whereas 60 (47.2%) patients had any bleeds, including 26 with treated bleeds. Compared to previous treatments, patients on emicizumab had significantly decreased annualized bleeding rate, annualized joint bleeding rate, target joints and intracerebral haemorrhage. Different dosages had similar efficacy except the proportion of patients with treated spontaneous bleeds and target joints. Adverse events were reported in 12 (9.4%) patients. Postoperative excessive bleeding occurred following two of nine procedures. CONCLUSION This is the largest study describing patients with HA receiving emicizumab prophylaxis on variant dose regimens in China. We confirmed that nonstandard dose is efficacious and can be considered where full-dose emicizumab is ill affordable.
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Affiliation(s)
- Yuan Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Ying Wang
- Department of Hematology and Oncology, Shenzhen Children's Hospital, Shenzhen, China
| | - Runhui Wu
- Hematology Oncology Center, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Changcheng Zheng
- Department of Hematology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Li Zhang
- Department of Hematology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Weiqun Xu
- Division/Center of Pediatric Hematology-Oncology, the Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoqin Feng
- Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hua Wang
- Department of Hematology and Oncology, Xi'an Children's Hospital, Xi'an, China
| | - Xiangshan Cao
- Department of Hematology, Suzhou BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Suzhou, China
| | - Liya He
- Department of Pediatric, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | | | - Mingwei Jin
- Pediatrics, Xuzhou Star Hospital, Xuzhou, China
| | - Bingshou Xie
- Department of Hematology, Wenzhou People's Hospital, Wenzhou, China
| | - Jing Ling
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, China
| | - Lirong Sun
- Department of Pediatrics, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Rui Su
- Department of Hematology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Hongbo Cheng
- Department of Hematology, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang, China
| | - Yongjun Fang
- Department of Hematology/Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Man-Chiu Poon
- Departments of Medicine, Paediatrics and Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
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Yada K, Fujitate N, Ogiwara K, Soeda T, Kitazawa T, Nogami K. Reduced plasma factor X is associated with a lack of response to recombinant activated factor VII in patients with hemophilia A and inhibitor, but does not impair emicizumab-driven hemostasis in vitro. Thromb Res 2024; 237:37-45. [PMID: 38547693 DOI: 10.1016/j.thromres.2024.03.023] [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: 10/29/2023] [Revised: 03/14/2024] [Accepted: 03/21/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND The hemostatic effect of recombinant (r) factor (F)VIIa after repetitive intermittent administration may be attenuated in patients with hemophilia A (PwHA) with inhibitors (PwHAwI) creating a clinically unresponsive status, although mechanism(s) remain to be clarified. In patients receiving prophylaxis treatment with emicizumab, concomitant rFVIIa is sometimes utilized in multiple doses for surgical procedures or breakthrough bleeding. AIM AND METHODS We identified 'unresponsiveness' to rFVIIa, based on global coagulation function monitored using rotational thromboelastometry (ROTEM) in 11 PwHAwI and 5 patients with acquired HA, and investigated possible mechanisms focusing on the association between plasma FX levels and rFVIIa-mediated interactions. RESULTS Our data demonstrated that FX antigen levels were lower in the rFVIIa-unresponsive group than in the rFVIIa-responsive group (0.46 ± 0.14 IU/mL vs. 0.87 ± 0.15 IU/mL, p < 0.01). This relationship was further examined by thrombin generation assays using a FX-deficient PwHAwI plasma model. The addition of FX with rFVIIa was associated with increased peak thrombin (PeakTh) generation. At low levels of FX (<0.5 IU/mL), rFVIIa failed to increase PeakTh to the normal range, consistent with clinical rFVIIa-unresponsiveness. In the presence of emicizumab (50 μg/mL), PeakTh was increased maximally to 80 % of normal, even at low levels of FX (0.28 IU/mL). CONCLUSIONS Unresponsiveness to rFVIIa was associated with reduced levels of FX in PwHAwI. Emicizumab exhibited in vitro coagulation potential in the presence of FX at concentrations that appeared to limit the clinical response to rFVIIa therapy.
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Affiliation(s)
- Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.
| | | | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Tetsuhiro Soeda
- Research Division, Chugai Pharmaceutical Co., Ltd., Yokohama, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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4
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Pfrepper C, Klamroth R, Ettingshausen CE, Petros S, Siegemund A, Siegemund T. Measurement of recombinant porcine factor VIII in patients with congenital haemophilia A and inhibitors in the presence of emicizumab. Haemophilia 2024; 30:545-553. [PMID: 38343119 DOI: 10.1111/hae.14955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Recombinant porcine factor VIII (rpFVIII) is a treatment option for break-through bleeds in patients with congenital haemophilia A with inhibitors (CHAwI) on emicizumab. However, there are limited data about the measurement of rpFVIII in the presence of emicizumab. AIM To analyse whether rpFVIII can be measured with a chromogenic assay with bovine component (bCSA) in plasma from CHAwI on emicizumab treatment. METHODS In the first part of the study, FVIII deficient plasma was spiked with rpFVIII, in the second part, commercial plasma from CHAwI was spiked with emicizumab and rpFVIII, and in the third part, plasma from CHAwI on emicizumab treatment was spiked with rpFVIII. FVIII was then measured with bCSA and a chromogenic assay with human component (hCSA). Thrombin generation (TG) and clot-waveform analysis (CWA) were also carried out. RESULTS The recovery of rpFVIII measured with bCSA is approximately 80% and is further influenced by the presence of an anti-porcine inhibitor. rpFVIII assessed with hCSA was influenced by emicizumab. CWA and TG showed a weak correlation with baseline emicizumab concentration, but peak thrombin and CWA correlated well with increasing emicizumab concentrations and rpFVIII activities. CONCLUSION This study indicates that rpFVIII can be measured in the presence of emicizumab with a bCSA. A calibration curve for the measurement of rpFVIII with bCSA should be established.
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Affiliation(s)
- Christian Pfrepper
- Division of Hemostaseology, Department of Hematology, Cellular Therapy, Hemostaseology and Infectiology, University of Leipzig Medical Centre, Leipzig, Germany
| | - Robert Klamroth
- Department for Internal Medicine Vascular Medicine and Hemostaseology Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | | | - Sirak Petros
- Division of Hemostaseology, Department of Hematology, Cellular Therapy, Hemostaseology and Infectiology, University of Leipzig Medical Centre, Leipzig, Germany
- Medical ICU, University of Leipzig Medical Centre, Leipzig, Germany
| | - Annelie Siegemund
- Division of Hemostaseology, Department of Hematology, Cellular Therapy, Hemostaseology and Infectiology, University of Leipzig Medical Centre, Leipzig, Germany
- MVZ Limbach Magdeburg, Magdeburg, Germany
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Teranishi-Ikawa Y, Soeda T, Koga H, Yamaguchi K, Kato K, Esaki K, Asanuma K, Funaki M, Ichiki M, Ikuta Y, Ito S, Joyashiki E, Komatsu SI, Muto A, Nishimura K, Okuda M, Sanada H, Sato M, Shibahara N, Wakabayashi T, Yamaguchi K, Matsusaki A, Sampei Z, Shiraiwa H, Konishi H, Kawabe Y, Hattori K, Kitazawa T, Igawa T. A bispecific antibody NXT007 exerts a hemostatic activity in hemophilia A monkeys enough to keep a nonhemophilic state. J Thromb Haemost 2024; 22:430-440. [PMID: 37940048 DOI: 10.1016/j.jtha.2023.09.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/09/2023] [Accepted: 09/25/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Emicizumab, a factor (F) VIIIa-function mimetic bispecific antibody (BsAb) to FIXa and FX, has become an indispensable treatment option for people with hemophilia A (PwHA). However, a small proportion of PwHA still experience bleeds even under emicizumab prophylaxis, as observed in the long-term outcomes of clinical studies. A more potent BsAb may be desirable for such patients. OBJECTIVES To identify a potent BsAb to FIXa and FX, NXT007, surpassing emicizumab by in vitro and in vivo evaluation. METHODS New pairs of light chains for emicizumab's heavy chains were screened from phage libraries, and subsequent antibody optimization was performed. For in vitro evaluation, thrombin generation assays were performed with hemophilia A plasma. In vivo hemostatic activity was evaluated in a nonhuman primate model of acquired hemophilia A. RESULTS NXT007 exhibited an in vitro thrombin generation activity comparable to the international standard activity of FVIII (100 IU/dL), much higher than emicizumab, when triggered by tissue factor. NXT007 also demonstrated a potent in vivo hemostatic activity at approximately 30-fold lower plasma concentrations than emicizumab's historical data. In terms of dose shift between NXT007 and emicizumab, the in vitro and in vivo results were concordant. Regarding pharmacokinetics, NXT007 showed lower in vivo clearance than those shown by typical monoclonal antibodies, suggesting that the Fc engineering to enhance FcRn binding worked well. CONCLUSION NXT007, a potent BsAb, was successfully created. Nonclinical results suggest that NXT007 would have a potential to keep a nonhemophilic range of coagulation potential in PwHA or to realize more convenient dosing regimens than emicizumab.
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Affiliation(s)
| | - Tetsuhiro Soeda
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Hikaru Koga
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan.
| | - Kazuki Yamaguchi
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Kazuki Kato
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Keiko Esaki
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Kentaro Asanuma
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Miho Funaki
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Mina Ichiki
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Yuri Ikuta
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Shunsuke Ito
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Eri Joyashiki
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | | | - Atsushi Muto
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Kei Nishimura
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Momoko Okuda
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Hisakazu Sanada
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Motohiko Sato
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Norihito Shibahara
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | | | - Koji Yamaguchi
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Akiko Matsusaki
- Translational Research Division, Chugai Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Zenjiro Sampei
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Hirotake Shiraiwa
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Hiroko Konishi
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Yoshiki Kawabe
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Kunihiro Hattori
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Takehisa Kitazawa
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Tomoyuki Igawa
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan; Translational Research Division, Chugai Pharmaceutical Co., Ltd., Tokyo, Japan
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Tsuchida T, Hayakawa M, Kumano O. Characterization and Usefulness of Clot-Fibrinolysis Waveform Analysis in Critical Care Patients with Enhanced or Suppressed Fibrinolysis. Thromb Haemost 2024; 124:40-48. [PMID: 37527783 PMCID: PMC10783976 DOI: 10.1055/a-2145-7139] [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: 03/05/2023] [Accepted: 07/10/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Recently, clot-fibrinolysis waveform analysis (CFWA), which is a coagulation and fibrinolysis global assay based on assessing the activated partial thromboplastin time with tissue-type plasminogen activator, was developed. This study aimed to investigate the characteristics of CFWA using plasma samples from patients in the critical care unit. MATERIALS AND METHODS The fibrinolysis times using CFWA were measured in 298 plasma samples. These samples were divided into three groups based on the reference interval (RI) of fibrinolysis time using CFWA: shortened group, less than RI; within group, within RI; prolonged group, more than RI. The coagulation and fibrinolysis markers, including D-dimer, plasmin-α2 plasmin inhibitor complex (PIC), fibrin monomer complex (FMC), plasmin-α2 plasmin inhibitor (α2-PI), plasminogen (Plg), and fibrinogen (Fbg) were analyzed and compared among the three groups. RESULTS The FMC level decreased in the order of shortened, within, and prolonged groups, and the decrease was statistically significant among all three group pairs. The opposite tendency was observed for Fbg and fibrinolysis-related markers of α2-PI and Plg, and significant differences were recognized in all pair comparisons except for between within and prolonged groups in Plg. The mean values of the fibrinolysis markers D-dimer and PIC in all three groups were higher than the cut-off values, and the PIC value differed significantly between the within and prolonged groups. CONCLUSION The fibrinolysis reaction was detected in all three groups, but the status differed. CFWA has the potential to reflect the fibrinolysis status in one global assay.
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Affiliation(s)
- Takumi Tsuchida
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Mineji Hayakawa
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Osamu Kumano
- Sysmex Corporation, Kobe, Japan
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Takamatsu, Japan
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Ozaki Y, Wakui M, Oka S, Fujimori Y, Kondo Y, Nakamura S, Osada E, Nakagawa T, Katagiri H, Matsushita H. Effects of DOAC-Stop on clot waveform analysis of plasma spiked with antithrombin-dependent and antithrombin-independent anticoagulants. Int J Lab Hematol 2023; 45:979-983. [PMID: 37344981 DOI: 10.1111/ijlh.14120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 06/02/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Yuko Ozaki
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Masatoshi Wakui
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shusaku Oka
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Yuta Fujimori
- Office of Clinical Laboratory Technology, Keio University Hospital, Tokyo, Japan
| | - Yoshino Kondo
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Shoko Nakamura
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Emiri Osada
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | | | | | - Hiromichi Matsushita
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
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Chikasawa Y, Amano K, Shinozawa K, Bingo M, Miyashita R, Yamaguchi T, Mitsuhashi A, Inaba H, Hagiwara T, Kinai E. Comprehensive comparison of global coagulation assays to differentiate lupus anticoagulant from acquired hemophilia A in patients with prolonged APTT. Int J Hematol 2023; 118:577-588. [PMID: 37751038 DOI: 10.1007/s12185-023-03659-y] [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: 05/10/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 09/27/2023]
Abstract
There is no established method for differentiating acquired hemophilia A (AHA) from lupus anticoagulant (LA) positivity because both present with prolonged activated partial thromboplastin time. We compared various parameters of rotational thromboelastometry (ROTEM), thrombin generation assay (TGA), and clot waveform analysis (CWA) in patients with AHA (n = 10) and LA (n = 44). Compared with AHA, possible (n = 12) and definite (n = 32) LA showed significantly shorter clotting time (CT) in NATEM mode of ROTEM (> 3600 vs. 501/533). In TGA, peak height was significantly lower in AHA (16 vs. 242/174 nM). In CWA, CT was significantly longer (81 vs. 36/41 s) and Ad|min1| was lower (2.1 vs. 8.7/6.7) in AHA. Notably, CT by NATEM and peak height in TGA completely discriminated between AHA and LA, whereas Ad|min1| did not discriminate between them in 4 cases of AHA and 1 of LA. Comparison of 3 patients with both AHA and LA against a patient with only LA and markedly low FVIII activity (3.5%) showed that both CT by NATEM and peak height of TGA precisely classified the former 3 cases as AHA and the latter 1 case as LA, whereas Ad|min1| classified all 4 cases as AHA. ROTEM and TGA can comparably distinguish between AHA and LA.
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Affiliation(s)
- Yushi Chikasawa
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Keiko Shinozawa
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Masato Bingo
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ryui Miyashita
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Tomoko Yamaguchi
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ayano Mitsuhashi
- Department of Gene Research of Coagulation Disorders, Tokyo Medical University, Tokyo, Japan
| | - Hiroshi Inaba
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Takeshi Hagiwara
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ei Kinai
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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Bertaggia Calderara D, Marchi Cappelletti R, Batista Mesquita Sauvage AP, Durual S, Gomez FJ, Zermatten MG, Aliotta A, Casini A, Alberio L. Pharmacodynamics Monitoring of Emicizumab in Patients with Hemophilia A. Thromb Haemost 2023; 123:955-965. [PMID: 37336473 DOI: 10.1055/s-0043-1769788] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Emicizumab is a bispecific antibody mimicking coagulation factor VIII (FVIII) employed to treat patients with hemophilia A (PwHA) regardless of FVIII inhibitor status. The identification of biological markers reflecting the hemostatic competence of patients under emicizumab therapy would have a great clinical value. Unfortunately, emicizumab over-corrects standard coagulation assays, precluding their use for evaluating the hemostatic correction achieved in vivo. Here, we investigated whether global coagulation assays (GCA) would allow monitoring the biological response to non-factor replacement therapy with emicizumab. MATERIALS AND METHODS Six adults PwHA received a weekly dose of emicizumab of 3 mg/kg during weeks (W) 1 4 and 1.5 mg/kg from W5 onwards. Response to treatment was monitored weekly by emicizumab plasma concentration, thrombin generation (TG), and fibrin clot formation (FCF) and structure. TG and FCF results were compared to patient baseline, FVIII replacement, and healthy donors. RESULTS TG and FCF significantly increased in PwHA after the loading period, reaching a plateau that lasted until the end of monitoring. Similarly, fibrin clot network became denser with thinner fibrin fibers. However, TG contrary to FCF remained at the lower limits of reference values. Remarkably, despite having similar plateau concentrations of emicizumab some patients showed markedly different degrees of TG and FCF improvement. CONCLUSION Our study enriches the knowledge on the use of GCA to monitor non-factor replacement therapy, indicating that TG and FCF could act as direct markers of emicizumab biological activity. GCA allow to capture and visualize the individually variable response to emicizumab, leading a step forward to the personalization of patient treatment.
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Affiliation(s)
- Debora Bertaggia Calderara
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Rita Marchi Cappelletti
- Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Ana Patricia Batista Mesquita Sauvage
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Stéphane Durual
- Biomaterials Laboratory, University Clinics of Dental Medicine, University of Geneva, Switzerland
| | - Francisco J Gomez
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Maxime G Zermatten
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alessandro Aliotta
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alessandro Casini
- Department of Medicine, University of Geneva, Geneva, Switzerland
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
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10
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Takeyama M, Matsumoto N, Abe H, Harada S, Ogiwara K, Furukawa S, Shimonishi N, Nakajima Y, Yada K, Soeda T, Nogami K. Coagulant potentials of emicizumab in the plasmas from infant and toddler patients with hemophilia A. Pediatr Blood Cancer 2023; 70:e30590. [PMID: 37467119 DOI: 10.1002/pbc.30590] [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: 04/04/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Emicizumab significantly reduces bleedings in patients with hemophilia A (PwHA). A clinical study (HAVEN 7; NCT04431726) for PwHA aged less than or equal to 12 months is ongoing, but emicizumab-driven coagulation potential in PwHA in early childhood remains to be clarified. AIM To investigate the in vitro or in vivo coagulation potential of emicizumab in plasmas obtained from infant and toddler PwHA. METHODS Twenty-seven plasma samples from 14 infant/toddler PwHA (aged 0-42 months, median 19 months) who received emicizumab (n = 9), factor (F)VIII products (n = 8), or no treatment (n = 10) were obtained. FVIII activity in FVIII-treated plasmas was cancelled by the addition of anti-FVIII monoclonal antibody (mAb). Emicizumab-treated plasmas (in vivo) and emicizumab-spiked plasmas (in vitro) were analyzed. Emicizumab-untreated plasma or emicizumab-treated plasma supplemented with two anti-emicizumab mAbs were used as references. Adjusted maximum coagulation velocity (Ad|min1|) by clot waveform analysis and peak thrombin (Peak-Th) by thrombin generation assay was assessed. RESULTS Ad|min1| values in 24 samples were improved by the presence of emicizumab. Values did not improve in the three remaining samples (aged 1, 23, and 31 months). Although the presence of emicizumab showed an age-dependent increase in Peak-Th in 20 samples, this increase was not observed in seven samples (aged 0, 1, 1, 2, 8, 19, and 36 months). Emicizumab-dependent increases in both Ad|min1| and Peak-Th were shown in 18 samples, and increases in either parameter were shown in eight samples. One sample (from patient aged 1 month) showed no increase in both, however. CONCLUSION Emicizumab could improve coagulant potential in plasmas from infant/toddler patients with hemophilia A.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | - Hiroto Abe
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | - Suguru Harada
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Division of Hemophilia, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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11
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Nogami K. Clot Waveform Analysis for Monitoring Hemostasis. Semin Thromb Hemost 2023; 49:592-599. [PMID: 36174610 DOI: 10.1055/s-0042-1756706] [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: 10/14/2022]
Abstract
Clot waveform analysis (CWA) is a recently developed global coagulation assessment, based on the continuous observation of changes in light transmittance, absorbance, or light scattering that occurs as fibrin formed in a plasma sample during routine clotting tests such as activated partial thromboplastin time (aPTT) and prothrombin time (PT). CWA can utilize qualitative waveform patterns as well as sensitive quantitative parameters and can be used as a simple method to assess global hemostasis, and can be applied to various challenging clinical situations. Although not all coagulation analyzers currently in use are able to provide CWA, the number of analyzers available to do so is increasing, as the usefulness of this process has become more widely recognized. CWA can be based on the coagulation mechanism of aPTT, an intrinsic trigger, and this has been reported in many studies, including diagnosis and treatment of patients with hemophilia, disseminated intravascular coagulation, and monitoring of anticoagulants and thrombosis. CWA using trace amounts of tissue factors also has the potential to expand the applications of this technology. Recently, there have been reports of the combined evaluation of fibrinolytic dynamics. Among the existing global coagulation assays, CWA may prove to be the easiest to standardize in clinical practice. However, more extensive testing using standardized methods in various clinical settings is needed to determine the true role of CWA in the evaluation of hemostasis and thrombosis in the future.
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Affiliation(s)
- Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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12
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Takeyama M, Ozu N, Kasama S, Kasahara M, Matsumoto M, Shima M, Nogami K. Study protocol for assessment of the coagulation potential of concomitantly used factor VIII concentrates in patients with haemophilia A with emicizumab prophylaxis (CAGUYAMA Study): a multicentre open-label non-randomised clinical trial. BMJ Open 2023; 13:e072565. [PMID: 37429679 DOI: 10.1136/bmjopen-2023-072565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
INTRODUCTION Emicizumab prophylaxis substantially reduces bleeding episodes in patients with haemophilia A (HA). The haemostatic efficacy of emicizumab in patients with HA is estimated as approximately 15% based on mimic activity of factor (F) VIII. Although it has been proven effective in preventing bleeding, its haemostatic effect during breakthrough bleeding or surgery is considered insufficient. Therefore, haemostatic management of emicizumab-treated patients with HA without inhibitors frequently requires FVIII replacement therapy. In haemostatic management of emicizumab-treated patients with HA, conventional FVIII dosage calculations are used in clinical practice without considering the coagulant effects of emicizumab. METHODS AND ANALYSIS In the CAGUYAMA study, 100 patients with HA without inhibitors will be enrolled for a maximum duration of 1 year, and samples of 30 events following the concomitant use of FVIII concentrates (30±5 U/kg) with emicizumab will be collected. An 'event' is defined as obtaining blood samples at preadministration and postadministration of FVIII concentrates during a breakthrough bleeding or a surgical procedure. Global coagulation assays will be used to measure the coagulation potential of the obtained samples. Clot waveform analysis (CWA) is used to identify the primary end-point, that is, the degree of improvement in the maximum coagulation rate at preadministration and post-administration of fixed-dose FVIII concentrations. The parameter obtained from CWA, which is triggered by an optimally diluted mixture of prothrombin time reagent and activated partial thromboplastin time reagent, is reported to be an excellent marker for assessing the degree of improvement of the coagulation potential in emicizumab-treated plasmas. ETHICS AND DISSEMINATION The CAGUYAMA study was approved by the Japan-Certified Review Board of Nara Medical University (Approval ID; nara0031). The study results will be communicated through publication in international scientific journals and presentations at (inter)national conferences. TRIAL REGISTRATION NUMBER jRCTs051210137.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Naoki Ozu
- Institute of Clinical and Translational Science, Nara Medical University, Kashihara, Nara, Japan
| | - Shu Kasama
- Institute of Clinical and Translational Science, Nara Medical University, Kashihara, Nara, Japan
| | - Masato Kasahara
- Institute of Clinical and Translational Science, Nara Medical University, Kashihara, Nara, Japan
| | - Masanori Matsumoto
- Blood Transfusion Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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13
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Yoneyama K, Schmitt C, Portron A, Kiialainen A, Kotani N, Jaminion F, Retout S, Adamkewicz JI. Clinical pharmacology of emicizumab for the treatment of hemophilia A. Expert Rev Clin Pharmacol 2023; 16:775-790. [PMID: 37529848 DOI: 10.1080/17512433.2023.2243213] [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: 04/14/2023] [Revised: 06/22/2023] [Accepted: 07/28/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Emicizumab is a humanized bispecific antibody approved for the routine prophylaxis of bleeding episodes in patients with hemophilia A (PwHA) regardless of the presence of factor VIII (FVIII) inhibitors. It mimics the cofactor function of missing activated FVIII by bridging activated factor IX and factor X, thereby restoring hemostasis. AREAS COVERED This review covers the clinical pharmacology of emicizumab and the translation of its pharmacokinetics (PK) and pharmacodynamics (PD) to clinical efficacy and safety. The PK of emicizumab is linear, with an approximately 1-month half-life. Once-weekly to every-4-week subcutaneous (SC) administrations maintain effective trough concentrations throughout the dosing intervals, associated with a coagulation potential analogous to that in patients with mild hemophilia A. In combination with activated prothrombin complex concentrate, and to a lesser extent with recombinant activated factor VII, emicizumab exerts a synergistic effect, whereas combination with FVIII may result in a non-additive coagulation potential at normal FVIII activity. EXPERT OPINION The translation of emicizumab PK/PD into clinical effects was demonstrated in several phase III studies, which showed remarkable bleed control and a favorable safety profile in PwHA. These emicizumab attributes, together with the convenience of use (infrequent SC injections), offer a novel paradigm for the management of PwHA.
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14
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Awane M, Wakui M, Ozaki Y, Kondo Y, Oka S, Fujimori Y, Yatabe Y, Arai T, Yamada Y, Hori S, Obara H, Hasegawa Y, Matsushita H. Clot waveform analysis for perioperative hemostatic monitoring in a hemophilia A patient on emicizumab undergoing liver transplantation. Clin Chim Acta 2023; 544:117339. [PMID: 37076096 DOI: 10.1016/j.cca.2023.117339] [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: 12/23/2022] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 04/21/2023]
Abstract
How to optimize perioperative factor VIII (FVIII) replacement through hemostatic monitoring is critically important to manage hemophilia A patients. The bispecific antibody emicizumab binds activated FIX (FIXa) and FX to functionally mimic FVIIIa. While being used for hemostatic control in hemophilia A, this therapeutic antibody inconveniently interferes with coagulation tests using human FIXa and FX, such as activated partial thromboplastin time (APTT) and FVIII activity measurement based on one-stage clotting assays. Clot waveform analysis (CWA) extends the interpretation of measurement curves for coagulation time to provide global information. We performed APTT-CWA to monitor perioperative hemostasis in a hemophilia A patient on emicizumab undergoing liver transplantation. Plasma samples were treated with anti-idiotype monoclonal antibodies against emicizumab to enable accurate coagulation assays. Kinetics of maximum coagulation velocity and acceleration mimicked that of FVIII activity. These CWA parameters better correlated with FVIII activity than APTT. The plateaus of them were observed at FVIII activity of 100% or more, supporting the protocol for perioperative FVIII replacement. Thus, CWA may measure coagulation potential in hemophilia A patients undergoing liver transplantation, aiding in optimizing perioperative hemostasis.
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Affiliation(s)
- Mai Awane
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Masatoshi Wakui
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan.
| | - Yuko Ozaki
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Yoshino Kondo
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Shusaku Oka
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Yuta Fujimori
- Office of Clinical Laboratory Technology, Keio University Hospital, Tokyo, Japan
| | - Yoko Yatabe
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Tomoko Arai
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Yohei Yamada
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shutaro Hori
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiromichi Matsushita
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
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15
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Nardi MA. Hemophilia A: Emicizumab monitoring and impact on coagulation testing. Adv Clin Chem 2023; 113:273-315. [PMID: 36858648 DOI: 10.1016/bs.acc.2022.12.001] [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: 01/18/2023]
Abstract
Hemophilia A is an X-linked recessive bleeding disorder characterized by absent or ineffective coagulation factor VIII, a condition that could result in a severe and potentially life-threatening bleed. Although the current standard of care involves prophylactic replacement therapy of factor VIII, the development of neutralizing anti-factor VIII alloantibody inhibitors often complicates such therapeutic treatment. Emicizumab (Hemlibra®), a novel recombinant therapeutic agent for patients with hemophilia A, is a humanized asymmetric bispecific IgG4 monoclonal antibody designed to mimic activated factor VIII by bridging factor IXa and factor X thus effecting hemostasis. Importantly, this drug eliminates the need for factor VIII and complications associated with inhibitor generation. Emicizumab has been approved for use in several countries including the United States and Japan for prophylaxis of bleeding episodes in hemophilia A with and without FVIII inhibitors. Therapy is also approved in the European Union for routine prophylaxis of bleeds in hemophilia A with inhibitors or severe hemophilia A without inhibitors. Unfortunately, emicizumab therapy presents unique challenges for routine and specialty coagulation tests currently used to monitor hemophilia A. In this review, hemophilia A is presented, the biochemistry of factor VIII is discussed, and the impact of the therapeutic agent emicizumab is highlighted.
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Affiliation(s)
- Michael A Nardi
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, United States; Department of Pathology, New York University Grossman School of Medicine, New York, NY, United States.
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16
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Négrier C, Mahlangu J, Lehle M, Chowdary P, Catalani O, Bernardi RJ, Jiménez-Yuste V, Beckermann BM, Schmitt C, Ventriglia G, Windyga J, d'Oiron R, Moorehead P, Koparkar S, Teodoro V, Shapiro AD, Oldenburg J, Hermans C. Emicizumab in people with moderate or mild haemophilia A (HAVEN 6): a multicentre, open-label, single-arm, phase 3 study. Lancet Haematol 2023; 10:e168-e177. [PMID: 36716761 DOI: 10.1016/s2352-3026(22)00377-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Clinical trial data are scarce for the use of prophylaxis in people with non-severe haemophilia A. The HAVEN 6 study aims to assess safety and efficacy of emicizumab prophylaxis in people with non-severe haemophilia A without factor VIII (FVIII) inhibitors. METHODS HAVEN 6 is a multicentre, open-label, single-arm, phase 3 study taking place in 22 specialty clinics and hospitals in Europe, North America, and South Africa. Eligible participants were people of all ages weighing at least 3 kg with a diagnosis of moderate (FVIII activity ≥1%-≤5%) or mild (FVIII >5%-<40%) haemophilia A without FVIII inhibitors requiring prophylaxis as assessed by the treating physician. Participants received subcutaneous emicizumab 3 mg/kg of bodyweight once weekly for 4 weeks, followed by the participant's choice of maintenance dose: 1·5 mg/kg once weekly, 3 mg/kg every 2 weeks, or 6 mg/kg every 4 weeks. Safety was the primary objective of the study. Safety endpoints included adverse events, serious adverse events, and adverse events of special interest including thromboembolic events and thrombotic microangiopathies. The primary efficacy endpoint was the annualised bleed rate for treated bleeds. Analyses were done for participants who received at least one dose of emicizumab. This study is registered with ClinicalTrials.gov, number NCT04158648, and is active but not recruiting. FINDINGS Between Feb 10, 2020, and Aug 31, 2021, we assigned 73 people to treatment. 72 participants received at least one dose of emicizumab (51 moderate [71%]; 21 mild [29%]; 69 male [96%]; three female [4%]; and 61 White [85%]). Median age was 23·5 years (IQR 12·0-36·0); median follow-up was 55·6 weeks (IQR 52·3-61·6) weeks. At baseline, 24 participants (33%) had target joints and 37 (51%) were receiving FVIII prophylaxis. 60 participants (83%) had at least one adverse event; the most common adverse events were headache (in 12 participants [17%]), injection-site reaction (12 [17%]), and arthralgia (11 [15%]). 15 (21%) had at least one emicizumab-related adverse event; no adverse events led to treatment withdrawal, modification, or interruption. Eight participants (11%) reported ten serious adverse events in total, none emicizumab-related. There were no deaths or thrombotic microangiopathies. One participant had grade 1 thrombosed haemorrhoids (classified as a thromboembolic event), unrelated to emicizumab. The annualised bleed rate was 0·9 (95% CI 0·55-1·52) for treated bleeds. 48 participants (67%) had no treated bleeds. All-bleed annualised bleed rates were 10·1 (95% CI 6·93-14·76) from 24 weeks pre-study and 2·3 (1·67-3·12) on-study after a median follow-up of 55·6 weeks. INTERPRETATION These data show efficacy and a favourable safety profile of emicizumab in people with non-severe haemophilia A without FVIII inhibitors who warrant prophylaxis, confirming emicizumab as a valuable treatment option in this population. FUNDING F Hoffmann-La Roche.
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Affiliation(s)
| | - Johnny Mahlangu
- University of the Witwatersrand and NHLS, Johannesburg, South Africa
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London, London, UK
| | | | | | | | | | | | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Roseline d'Oiron
- Bicêtre Hospital AP-HP, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, Paris, France
| | - Paul Moorehead
- Memorial University of Newfoundland, St John's, NL, Canada
| | | | | | - Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, USA
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, Germany
| | - Cedric Hermans
- University Clinic of Saint Luke, Catholic University of Louvain, Brussels, Belgium
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Furukawa S, Ogiwara K, Yada K, Takeyama M, Niino T, Shima M, Keiji N. Decrease in in vivo coagulant potential of emicizumab in a patient with hemophilia A and inhibitor complicated with infectious mononucleosis. Blood Coagul Fibrinolysis 2023; 34:122-128. [PMID: 36719809 DOI: 10.1097/mbc.0000000000001177] [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: 02/01/2023]
Abstract
Emicizumab prophylaxis significantly reduces bleeding episodes in patients with hemophilia A (PwHA). There is little information on coagulant potentials in emicizumab-treated PwHA with infection, however. We encountered an emicizumab-treated PwHA with inhibitor, complicated with Epstein-Barr virus-associated infectious mononucleosis (IM) in phase 1/2 study (ACE001JP/ACE002JP). Although it was a typical clinical course of IM, activated partial thromboplastin time was mildly prolonged but rotational thromboelastometry revealed severely impaired coagulant potential. The blood concentration of emicizumab decreased moderately in the low concentration range, resulting in an increased risk of bleeding and possibly leading to severe ileocecal bleeds requiring coil embolization. The blood concentrations of factors IX/X little decreased and antiemicizumab antibodies did not develop, however. After the influence by IM resolved, his coagulant potentials gradually recovered with the recovery of emicizumab concentration, and parameters by global coagulation assays improved. An IM case for emicizumab-treated PwHA may need to monitor using global coagulation assays.
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Affiliation(s)
- Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara
- Department of Haemophilia, National Hospital Organization Osaka National Hospital, Osaka
| | | | | | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara
| | - Nogami Keiji
- Department of Pediatrics, Nara Medical University, Kashihara, Nara
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18
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Yamaguchi T, Shinozawa K, Nagatoishi S, Mitsuhashi A, Bingo M, Inaba H, Amano K, Tsumoto K, Kinai E. In vitro validation of chromogenic substrate assay for evaluation of surrogate FVIII-activity of emicizumab. Thromb Res 2023; 222:131-139. [PMID: 36657269 DOI: 10.1016/j.thromres.2023.01.007] [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: 10/17/2022] [Revised: 12/09/2022] [Accepted: 01/05/2023] [Indexed: 01/15/2023]
Abstract
[Introduction] Emicizumab, a bispecific antibody mimicking activated factor VIII (FVIII), is increasingly used in prophylaxis against bleeding in hemophilia A. Human factor-based chromogenic substrate assay (hCSA) shows concentration-dependency between emicizumab and reported FVIII activity. However, the assay measurement settings have not been optimized for emicizumab, and the reported FVIII activity cannot be directly referred as surrogate FVIII activity. [Materials and Methods] For in vitro validation of hCSA-reported surrogate FVIII activity, we compared the equation curves for emicizumab concentration with surrogate FVIII activity using spiked plasma in the thrombin generation assay (TGA), hCSA, and clot waveform analysis (CWA). Then, we generated conversion equations for hCSA-reported surrogate FVIII value to that of TGA. We also assessed the additive effect of rFVIII onto 340 nM (i.e., 50 μg/mL) emicizumab using the same assays. [Results] With 1:20 diluted plasma, halving hCSA-reported surrogate FVIII activity can be approximated to that in TGA triggered by the extrinsic pathway reagent (27.3 IU/dL vs. 13.9 IU/dL) under therapeutic emicizumab concentration. Both in TGA and hCSA, the additive effect of added FVIII on therapeutic emicizumab concentration (340 nM) was maintained at low levels of FVIII but gradually decreased at higher levels. [Conclusions] Surrogate FVIII activity can be estimated simply by halving hCSA-reported FVIII value, and the additive effect of FVIII on emicizumab diminishes at high concentrations. Based on our in vitro study, a clinical study is currently being conducted to compare individual variation of surrogate FVIII activity in hCSA and TGA.
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Affiliation(s)
- Tomoko Yamaguchi
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Keiko Shinozawa
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Satoru Nagatoishi
- The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Ayano Mitsuhashi
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan; Research Resident Fellowship, Japan Foundation for AIDS Prevention, Tokyo, Japan
| | - Masato Bingo
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Hiroshi Inaba
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Kohei Tsumoto
- The Institute of Medical Science, The University of Tokyo, Tokyo, Japan; Department of Bioengineering, Graduate School of Engineering, The University of Tokyo, Tokyo, Japan
| | - Ei Kinai
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan.
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19
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Ogiwara K, Furukawa S, Shinohara S, Tabuchi Y, Arai N, Noguchi-Sasaki M, Soeda T, Shima M, Nogami K. Anti-idiotype monoclonal antibodies against emicizumab enable accurate procoagulant and anticoagulant assays, irrespective of the test base, in the presence of emicizumab. Haemophilia 2023; 29:329-335. [PMID: 36137299 DOI: 10.1111/hae.14662] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/15/2022] [Accepted: 09/06/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Emicizumab markedly shortens the activated partial thromboplastin time (aPTT), resulting in inaccurate measurements of procoagulant and anticoagulant factor activities. We have recently reported that mixtures of two different anti-idiotype monoclonal antibodies against emicizumab (anti-emicizumab-mAbs) allow measurement of factor (F)VIII activity (FVIII:C) and FVIII inhibitor in emicizumab-containing plasmas. It is unknown whether anti-emicizumab mAbs can work for other aPTT-based procoagulant and anticoagulant assays. AIM To investigate whether anti-emicizumab mAbs were measured by all of the aPTT-based assays tested. METHODS Two anti-emicizumab-mAbs (300 μg/mL each) were preincubated with emicizumab (200 μg/mL)-spiked FVIII-deficient plasma; we then measured FVIII:C, FIX:C, FXI:C, FXII:C, protein (P)C:C, PS:C, global PC-FV (aPTT-based), and prothrombin time (PT), diluted Russel's viper venom time (dRVVT), chromogenic-based FVIII:C, FIX:C and PC:C (non-aPTT-based). Emicizumab (100 μg/mL)-spiked haemophilia (H)A plasmas from patients (n = 23) were also measured. RESULTS Emicizumab shortened the clotting time in all aPTT-based assays, resulting in high levels of FVIII:C, FIX:C, FXI:C and FXII:C; low levels of PC:C and PS:C; and false-positive results for activated PC resistance. The addition of anti-emicizumab-mAbs to emicizumab-added plasma restored all factors to the initial levels without emicizumab. Chromogenic FVIII:C measurement by human FIXa/FX was affected by emicizumab, but anti-emicizumab mAbs cancelled this effect. PT-based assays and dRVVT, chromogenic FIX:C and PC:C assays showed no effect with emicizumab. Twenty-three plasma samples from HA patients also showed similar patterns. CONCLUSION Anti-emicizumab mAbs in vitro could cancel the effect of emicizumab, irrespective of the test base, resulting in accurate measurements of procoagulant and anticoagulant factor activity.
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Affiliation(s)
- Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Sho Shinohara
- Reagent Engineering, Sysmex Corporation, Kobe, Japan
| | - Yuka Tabuchi
- System Engineering, Sysmex Corporation, Kobe, Japan
| | - Nobuo Arai
- Reagent Engineering, Sysmex Corporation, Kobe, Japan
| | | | - Tetsuhiro Soeda
- Chugai Pharmaceutical Co., Research Division, Gotemba, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Center of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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20
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Nogami K, Shima M. Current and future therapies for haemophilia-Beyond factor replacement therapies. Br J Haematol 2023; 200:23-34. [PMID: 35869698 DOI: 10.1111/bjh.18379] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 12/01/2022]
Abstract
Some non-factor products that work by facilitating the coagulation pathway (emicizumab) and blocking the anticoagulant pathway (fitusiran, concizumab and marstacimab) for patients with haemophilia (H) have been developed, and clinical trials using these products are currently ongoing. Prophylaxis using non-factor products by subcutaneous administration provides marked reductions of bleeding episodes in patients with HA or HB, regardless of the presence of inhibitor. Emicizumab has already been approved globally. Emicizumab alters the phenotype of patients with HA from severe to mild by maintaining trough levels of equivalent factor VIII activity (15-20 iu/dl). Phase 3 clinical trials and long-term observations assessing emicizumab revealed tolerable safety and efficacy. However, thrombotic events have occurred in patients receiving these non-factor products. Furthermore, monitoring of the haemostatic function of these products with concomitant therapy is also required in clinical practice. These products have promising haemostatic efficiency, but wider clinical experience is needed to provide optimal therapeutic strategies in the future.
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Affiliation(s)
- Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,Thrombosis and Hemostasis Research Centre, Nara Medical University, Kashihara, Nara, Japan
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21
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Yagyuu T, Furukawa S, Zaizen M, Yata S, Imada M, Nogami K, Kirita T. Peri-operative hemostatic management of tooth extraction in patients with hemophilia A, with and without inhibitors, receiving emicizumab prophylaxis. Haemophilia 2023; 29:172-179. [PMID: 36163647 PMCID: PMC10087157 DOI: 10.1111/hae.14667] [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: 07/05/2022] [Revised: 09/08/2022] [Accepted: 09/11/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Emicizumab treatment may allow patients with hemophilia A without (PwHA) and with inhibitors (PwHA-I) to undergo some minor surgeries, such as tooth extraction, without peri-operative factor infusions. However, criteria for determining the necessity of factor infusions before minor surgeries are unknown. AIM We report the peri-operative hemostatic management and outcomes of emicizumab-treated PwHA and PwHA-I cases who underwent tooth extractions using our institutional protocol. METHODS We retrospectively evaluated PwHA and PwHA-I who underwent tooth extraction with emicizumab prophylaxis at our institution. Local bleeding risk was assessed based on the method, number, and site of tooth extraction. Hemostasis was monitored peri-operatively by rotational thromboelastometry (ROTEM). Hemostatic agents and a mouth splint were used. RESULTS Twenty-nine extractions (17 interventions) were performed in eight PwHA and two PwHA-I. Based on ROTEM, pre-operative factor infusions were used in ten PwHA and four PwHA-I interventions. Among nine low local bleeding risk interventions, three (33.3%) each received no infusions, one dose of factor infusion pre-operatively, and pre- and post-operative factor infusions. All eight high local bleeding risk interventions involved planned factor infusions. Absorbable hemostats were used in all extractions. A mouth splint was used in 21/25 (84.0%) PwHA and in 4/4 (100%) PwHA-I extractions. No post-extraction bleeding or thrombotic events occurred. CONCLUSIONS Use of a systemic hemostatic treatment plan according to the local bleeding risk, peri-operative coagulation status assessment using ROTEM, filling the extraction socket with hemostats, and use of a mouth splint can achieve effective and safe hemostatic management in emicizumab-treated PwHA and PwHA-I.
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Affiliation(s)
- Takahiro Yagyuu
- Department of Oral and Maxillofacial Surgery, Nara Medical University, Kashihara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Miki Zaizen
- Department of Oral and Maxillofacial Surgery, Nara Medical University, Kashihara, Japan
| | - Sachiko Yata
- Department of Oral and Maxillofacial Surgery, Nara Medical University, Kashihara, Japan
| | - Mitsuhiko Imada
- Department of Oral and Maxillofacial Surgery, Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Tadaaki Kirita
- Department of Oral and Maxillofacial Surgery, Nara Medical University, Kashihara, Japan
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22
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Two pediatric cases of severe hemophilia A in which emicizumab prophylaxis failed to prevent traumatic extra-articular hemorrhage. Int J Hematol 2022; 117:607-612. [PMID: 36370317 PMCID: PMC9660161 DOI: 10.1007/s12185-022-03490-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/02/2022] [Accepted: 11/06/2022] [Indexed: 11/15/2022]
Abstract
Emicizumab reduces bleeding episodes in patients with severe hemophilia A (PwHA). Little information is available on hemostatic management of severe traumatic hemorrhages in emicizumab-treated pediatric PwHA. We assessed therapeutic efficacy and global coagulation potentials in two pediatric cases of emicizumab-treated pediatric PwHA with intracranial or retroperitoneal/iliopsoas hemorrhage. A modified clot waveform analysis (CWA) triggered by mixtures of tissue factor and ellagic acid was used to assess coagulant potentials, and maximum coagulant velocity (Ad|min1|) was calculated. One patient with intracranial hemorrhage was treated with continuous infusions of recombinant factor VIII (rFVIII) at a dose of 4-4.6 IU/kg/hr for 9 days, followed by bolus infusion at 66 IU/kg/day for 2 days and 33 IU/kg/day for an additional 2 days. The Ad|min1| was increased from 5.5 (at baseline) to 7.0-8.1 under concomitant treatment and maintained within or near normal range (IQR; 6.9-7.7). The other patient with retroperitoneal/iliopsoas hemorrhage received bolus infusions of rFVIII at 50 IU/kg/day for 20 days and every-other-day infusion of rFVIII for 8 days. The Ad|min1| was increased from 5.2 (at baseline) to 5.8-6.8 under concomitant treatment and maintained within the normal range. We successfully managed a treatment plan for severe traumatic bleeding in emicizumab-treated pediatric PwHA using modified CWA.
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23
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Nakajima Y, Takami E, Nakano H, Nogami K. In vitro evaluation of global coagulation potentials in the co-presence of plasma-derived factors Viia/X products (Byclot ® ) and emicizumab in patients with haemophilia A and inhibitors and acquired haemophilia A: A pilot study. Haemophilia 2022; 28:e149-e152. [PMID: 35947585 DOI: 10.1111/hae.14650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 07/16/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Eisuke Takami
- Medical Affairs Section, KM Biologics Co., Ltd, Kumamoto, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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24
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Nishiyama A, Ogiwara K, Mizumachi K, Hashimoto N, Takeyama M, Nogami K. Activated partial thromboplastin time-based clot waveform analysis enables measurement of very low levels of factor IX activity in patients with severe hemophilia B. Int J Hematol 2022; 116:778-786. [PMID: 35864291 DOI: 10.1007/s12185-022-03419-4] [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: 05/07/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/30/2022]
Abstract
The precise measurement of very low levels of factor IX activity (FIX:C < 1 IU/dL) is essential for understanding clinical severity and risk of inhibitor development in patients with severe hemophilia B (Pw-SHB). However, such measurement sensitivity has not yet been achieved. We aimed to establish a measurement method using clot waveform analysis (CWA). Residual FIX:C by adding anti-FIX monoclonal antibody, FIX:C by adding recombinant (r)FIX to the commercial Pw-SHB plasmas, and FIX:C in our Pw-SHB were determined by CS-2000i™/CS-2400™, followed by analysis of CWA parameters. The presence of anti-FIX antibody in the commercial Pw-SHB plasmas significantly decreased coagulation potential compared to its absence. The addition of rFIX to these innate plasma samples produced significant changes in three parameters upon adding FIX:C at 0.1-1 IU/dL, supporting the presence of trace FIX:C in Pw-SHB. Therefore, appropriate FIX-depleted plasma containing minimum residual FIX:C was chosen from reference curves of FIX:C (0.01-1 IU/dL). Among patients with untreated Pw-SHB, two had FIX:C 0.6-0.7 IU/dL and two had lower than detectable levels using FIX-depleted plasma. One of the latter had detectable trough levels post-rFIX administration. In conclusion, CWA enabled measurement of very low levels of FIX:C using appropriate FIX-deficient plasma.
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Affiliation(s)
- Atsuko Nishiyama
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Kuniyoshi Mizumachi
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Naoki Hashimoto
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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25
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Hashimoto N, Ogiwara K, Shimonishi N, Nakagawa T, Nakajima Y, Furukawa S, Takeyama M, Nogami K. Screening of the protein C pathway abnormality-related thrombophilia by using thrombomodulin-mediated tissue factor-triggered clot waveform analysis. Eur J Haematol Suppl 2022; 109:100-108. [PMID: 35430749 DOI: 10.1111/ejh.13777] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Absolute or relative protein (P)C pathway abnormalities (PC deficiency, PS deficiency, antiphospholipid syndrome (APS), factor (F)V-abnormality, and high FVIII level) cause thrombophilia. Although screening assays for these thrombophilias are available, one utilizing clot waveform analysis (CWA) remains unknown. We aimed to establish a CWA-based screening assay to distinguish PC pathway abnormality-related thrombophilia. METHODS Samples were reacted with tissue factor (TF)/phospholipids and recombinant thrombomodulin (rTM; optimal 20 nM), followed by CWA measurement. The peak ratio (with/without rTM) of the first derivative curve of clot waveform was calculated. RESULTS The peak ratio in healthy plasmas (n = 35) was 0.36 ± 0.13; hence, the cutoff value was set to 0.49. The peak ratios in plasmas with PC deficiency, PS deficiency, high-FVIII (spiked 300 IU/dl), and APS were higher than the cutoff values (0.79/0.97/0.50/0.93, respectively). PC-deficient plasma or PS-deficient plasma mixed with normal plasma (25%/50%/75%/100% PC or PS level) showed dose-dependent decreases in the peak ratios (PC deficient: 0.85/0.64/0.44/0.28; PS deficient: 0.69/0.53/0.40/0.25), suggesting that the peak ratio at ≤50% of PC or PS level exceeded the cutoff value. The peak ratio in FV deficiency with FV ≤25% was higher than the cutoff value. FV-deficient plasma spiked with 40 IU/dl rFV-R506Q (FVLeiden ) or rFV-W1920R (FVNara ) showed >90% peak ratios. CONCLUSIONS rTM-mediated TF-triggered CWA might be useful for screening PC pathway abnormality-related thrombophilia.
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Affiliation(s)
- Naoki Hashimoto
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Japan.,The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Japan
| | - Takashi Nakagawa
- Division of Neonatal Intensive Care, Nara Medical University Hospital, Center of Perinatal Medicine, Kashihara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan.,Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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26
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Takeyama M, Furukawa S, Onishi T, Noguchi-Sasaki M, Shima M, Nogami K. Heterogeneous coagulant potential of emicizumab in neonatal factor VIII-deficient plasma. Pediatr Blood Cancer 2022; 69:e29731. [PMID: 35441786 DOI: 10.1002/pbc.29731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/01/2022] [Accepted: 03/27/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Emicizumab prophylaxis reduces bleeding in hemophilia A (HA) patients. However, there are few data on emicizumab treatment in neonates with HA (neonate-HA), and the procoagulant effects of emicizumab in these patients are unknown. AIM To investigate the coagulation activity of emicizumab in vitro in a plasma model of neonate-HA. METHODS Plasmas from 84 neonates with non-HA were enrolled. However, due to the limited plasma volumes in some cases, 50 plasmas were assigned to two different assay groups. To prepare the neonate-HA model, plasma was first preincubated with an antifactor (F) VIII A2 monoclonal antibody (mAb). After further incubation with emicizumab, global coagulation activity was measured: adjusted maximum coagulation velocity (Ad|min1|) in clot waveform analysis (CWA) and peak thrombin in thrombin generation assay (TGA). RESULTS Because the addition of anti-FVIII mAb to 22 of 43 samples showed little decrease in Ad|min1|, the remaining 21 samples were analyzed by CWA. The addition of emicizumab increased Ad|min1| in 18 of the 19 cases (effective group) but not in the remaining 3 cases (noneffective group). Similarly, TGA found that emicizumab (effective group) improved peak thrombin in seven of the nine samples tested, but two cases did not respond (noneffective group). Although the effective group had lower levels of FX, there was no significant difference between the effective and noneffective groups in terms of FIX, protein S, protein C, antithrombin, and fibrinogen. CONCLUSIONS The in vitro coagulant potentials of emicizumab in the neonate-HA model were more heterogeneous than those recorded in the adult-HA model.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Nara, Japan
| | - Tomoko Onishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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27
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Miyashita R, Shinozawa K, Inaba H, Amano K, Kinai E. Prolonged α-thrombin-related activation and delayed active protein C-associated degradation confer mild phenotype in a patient with severe hemophilia A with F8 p.H118R. Int J Hematol 2022; 116:489-499. [PMID: 35590009 DOI: 10.1007/s12185-022-03381-1] [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: 12/24/2021] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
Abstract
In hemophilia A, bleeding mostly correlates with factor VIII activity (FVIII:C), although some patients show discrepancy in bleeding severity and FVIII:C. We report a novel procoagulant mechanism associated with F8 p.H118R (c.353A > G) in a young Japanese man with few bleeding episodes despite low levels of FVIII:C (< 1 IU/dL). Plasma FVIII:C was < 1 IU/dL measured by one-stage clotting assay (OSA) and chromogenic substrate assay (CSA), whereas FVIII antigen (FVIII:Ag) was 9.7%. The global coagulation assay showed higher max speed in clot waveform analysis (CWA), shorter clotting time in rotation thromboelastometry (ROTEM) (1605 vs. > 5000 s), shorter lag time (4.87 vs. 12.47 min) and larger ETP (207.9 vs. 53.3 nM*min) in thrombin generation assay, compared with FVIII-deficient control. Expressed recombinant H118R mutant in culture media showed low FVIII:C (1-5 IU/dL) by OSA, with non-hemophilia level of FVIII:Ag. Western blot analysis using recombinant H118R showed longer persistence of heavy-chain of H118R after incubation with α-thrombin, compared with wild-type. Incubation of H118R with activated protein C (APC) also showed longer persistence of A1-A2 domain. In conclusion, H118R showed prolonged activation by α-thrombin and delayed APC-related FVIII degradation. These properties may confer the procoagulant activity and few bleeding episodes despite low FVIII:C.
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Affiliation(s)
- Ryui Miyashita
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Keiko Shinozawa
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Hiroshi Inaba
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ei Kinai
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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28
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Song J. Advances in laboratory assessment of thrombosis and hemostasis. Blood Res 2022; 57:93-100. [PMID: 35483933 PMCID: PMC9057656 DOI: 10.5045/br.2022.2022048] [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: 02/23/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/17/2022] Open
Abstract
Technologies in laboratory diagnostics are changing fast with progress in understanding and therapy of diseases. Unfortunately, new analyzers are often needed to be installed in a clinical laboratory to implement such techniques. The demand for new hardware is a bottleneck in improving the diagnostic services for many facilities with limited resources. In this regard, hemostasis laboratories take a slightly different position. Because many in vitro diagnostic tests target the functional aspects of hemostasis, further meaningful information can be obtained from the same analyzers as in current use. Automated coagulometers are good candidates for such further utilization. Clot waveform analysis is a leading example. Behind the simple values reported as clotting time, clotting curves exist that represent the process of fibrin clot formation. Clot waveform analysis examines the clotting curves and derives new parameters other than clotting times. The clot waveform parameters are now in active use in assessing the hemostatic potential of hemorrhagic patients. Clinical application of coagulometers can also be widened by modifying the reagent formulation. For example, the chromogenic factor VIII assay with bovine source reagent compositions has recently been introduced for hemophilia A patients on emicizumab prophylaxis. Also, new immunoturbidimetric functional assays for von Willebrand factor have been developed recently. Thus, new clinically relevant information can be mined from the automated coagulometers that are based on old technology.
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Affiliation(s)
- Jaewoo Song
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
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29
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Cheong MA, Tan CW, Wong WH, Kong MC, See E, Yeang SH, Koh SK, Shim YT, Lee LH, Ng HJ. A correlation of thrombin generation assay and clot waveform analysis in patients on warfarin. Hematology 2022; 27:337-342. [PMID: 35255239 DOI: 10.1080/16078454.2022.2043573] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Thrombin generation assays and activated partial thromboplastin time (aPTT)-based clot waveform analysis (CWA), are some examples of global coagulation assays. Each modality evaluates different aspects of the clot forming process to globally define haemostasis with exclusive measurement parameters. Data on CWA are emerging, but its performance against other haemostatic assays is yet to be ascertained. This study evaluates the correlation between aPTT-based CWA and CAT parameters across a range of INR in warfarin-treated patients. PATIENTS/METHODS A prospective study consisting of patients on warfarin anticoagulation with varying INR levels. CWA and CAT were performed for the study subjects. RESULTS 54 samples were included covering an INR range from 1.33-6.89, with a mean of 4.31 +/- 1.13. For CAT parameters, endogenous thrombin potential (ETP) and peak thrombin were assessed. Both unadjusted and adjusted (adjusted for final plateau transmittance) aPTT-based CWA were evaluated for parameters min1 (maximum velocity), min2 (maximum acceleration) and max2 (maximum deceleration). Peak thrombin showed significant correlation with all CWA parameters (min1: r = 0.435, P<0.001; min2: r = 0.485, P<0.001; max2: r = 0.578, P<0.001; adjusted min1: r = 0.734, P<0.001, adjusted min2: r = 0.693, P<0.001; adjusted max2: r = 0.751, P<0.001). ETP correlated significantly with all CWA parameters except unadjusted min1 (min1: r = 0.235, P = 0.087; min2: r = 0.326, P = 0.016; max2: r = 0.437, P<0.001; adjusted min1: r = 0.610, P<0.001, adjusted min2: r = 0.563, P<0.001; adjusted max2: r = 0.642, P<0.001). CONCLUSION We demonstrated a modest correlation between CAT and CWA parameters. Adjusted CWA improved this correlation. These findings provide additional understanding of CWA and it's role in the evaluation of global haemostatic function.
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Affiliation(s)
- May Anne Cheong
- Department of Haematology, Singapore General Hospital, Singapore
| | - Chuen Wen Tan
- Department of Haematology, Singapore General Hospital, Singapore
| | - Wan Hui Wong
- Department of Haematology, Singapore General Hospital, Singapore
| | - Ming Chai Kong
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Edmund See
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Shu Hui Yeang
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Sei Keng Koh
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Yuan Tying Shim
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Lai Heng Lee
- Department of Pharmacy, Singapore General Hospital, Singapore
| | - Heng Joo Ng
- Department of Pharmacy, Singapore General Hospital, Singapore
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30
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Hatayama Y, Motokura T, Hosoda Y, Suzuki S, Namba H, Kato K, Kojima N, Horie T, Iwamoto T, Yamashita N, Ichikawa H, Fukuda T. Regression Analysis to Estimate the Factor VIII Activity of Patients with Hemophilia A Without Inhibitor who Received Emicizumab Therapy. Clin Appl Thromb Hemost 2022; 28:10760296221082992. [PMID: 35225012 PMCID: PMC8894944 DOI: 10.1177/10760296221082992] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Emicizumab, a bispecific monoclonal antibody for hemophilia A (HA), has strong pharmacodynamic effects in several coagulation assays resulting in dosing difficulties with Factor VIII (FVIII) concentrates during bleeding emergencies. MATERIALS AND METHODS Single and multiple regression models were studied to estimate FVIII activity using 27 archived plasma samples from three patients with HA without inhibitor under emicizumab treatment. Explanatory variables were FVIII chromogenic assay (CSA), Ad|min1|, Ad|min2|, the number of seconds of APTT, and the FVIII one-stage assay (OSA), which were measured without idiotype antibodies. The response variable was FVIII OSA measured with idiotype antibodies. RESULTS In the simple linear model, the FVIII CSA regression coefficient was 1.04 and the intercept was -14.55 (r2 = 0.95; p < 0.001). In the multiple regression model, FVIII OSA and FVIII CSA were selected based on the Akaike Information Criterion, with regression coefficients of 1.74 and 1.15, respectively, and an intercept of -92.03 (r2 = 0.96, p < 0.001). CONCLUSIONS The regression models can estimate the FVIII:C levels in patients with HA receiving emicizumab and would be useful in a bleeding emergency and/or surgery.
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Affiliation(s)
- Yuki Hatayama
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan.,Division of Clinical Laboratory Medicine, Department of Multidisciplinary Internal Medicine, School of Medicine, 34827Tottori University Faculty of Medicine, Yonago, Tottori, Japan
| | - Toru Motokura
- Division of Clinical Laboratory Medicine, Department of Multidisciplinary Internal Medicine, School of Medicine, 34827Tottori University Faculty of Medicine, Yonago, Tottori, Japan.,Department of Hematology, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Yuzuru Hosoda
- Department of Hematology, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Sayaka Suzuki
- Department of Hematology, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Hiroya Namba
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Konami Kato
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Nao Kojima
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Takuya Horie
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Takuya Iwamoto
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Noriko Yamashita
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Hitomi Ichikawa
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Tetsuya Fukuda
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan.,Department of Hematology, 68353Tottori University Hospital, Yonago, Tottori, Japan
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Ogiwara K, Taki M, Suzuki T, Takedani H, Matsushita T, Amano K, Matsumoto M, Nishio K, Shima M, Kasahara M, Nogami K. Assessment of global coagulation function under treatment with emicizumab concomitantly with bypassing agents in haemophilia A with inhibitor (UNEBI Study): multicentre open-label non-randomised clinical trial. BMJ Open 2022; 12:e056922. [PMID: 35177463 PMCID: PMC8860020 DOI: 10.1136/bmjopen-2021-056922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Subcutaneous emicizumab prophylaxis substantially reduces bleeding episodes in patients with haemophilia A (PwHA) and factor VIII inhibitor. However, thrombotic events occurred in some PwHA with inhibitor who had received high cumulative doses of activated prothrombin complex concentrates at their breakthrough bleeds, when they were also given prophylactic emicizumab. After that, although the recommended guidance was proposed for bypassing agents (BPAs) therapy under emicizumab prophylaxis for haemostatic management, detailed investigation(s) is(are) required to elucidate the safe and appropriate dose of BPAs to use concomitantly with emicizumab prophylaxis. METHODS AND ANALYSIS In the UNEBI Study, 60 PwHA with inhibitor will be enrolled for a maximum duration of 3 years, and samples of 20 events following concomitant use of BPAs with emicizumab will be collected. An 'event' is defined as obtaining blood samples before and after administration of BPA when a breakthrough bleed or a surgical procedure occurs. The coagulation potential in the obtained samples will be measured by global coagulation assays. The primary endpoint is the degree of improvement in the maximum coagulation rate by clot waveform analysis (CWA) before and after administration of fixed-dose BPAs. This parameter obtained from CWA, which is triggered with an optimally diluted mixture of prothrombin time/activated partial thromboplastin time-reagents, is reported to be an excellent marker for assessing the degree of improvement in coagulation potential in emicizumab-treated plasma. ETHICS AND DISSEMINATION The UNEBI Study was approved by the Japan Certified Review Board of Nara Medical University. The results of the study will be communicated through publication in international scientific journals and presentations at (inter)national conferences. TRIAL REGISTRATION NUMBER jRCTs051190119.
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Affiliation(s)
| | - Masashi Taki
- Pediatrics, Sei Marianna University School of Medicine Yokohama Seibu Hospital, Yokohama, Japan
| | - Takashi Suzuki
- Blood Coagulation, Medical Corporation Foundation Ogikubo Hospital, Suginami-ku, Japan
| | | | | | - Kagehiro Amano
- Laboratory Medicine, Tokyo Medical University, Shinjuku-ku, Japan
| | | | - Kenji Nishio
- General Medicine, Nara Medical University, Kashihara, Japan
| | - Midori Shima
- Pediatrics, Nara Medical University, Kashihara, Japan
| | - Masato Kasahara
- Institute for Clinical and Translational Science, Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- Pediatrics, Nara Medical University, Kashihara, Japan
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Nakajima Y, Mizumachi K, Shimonishi N, Furukawa S, Yada K, Ogiwara K, Takeyama M, Shima M, Nogami K. Comparisons of global coagulation potential and bleeding episodes in emicizumab-treated hemophilia A patients and mild hemophilia A patients. Int J Hematol 2022; 115:489-498. [PMID: 35043383 DOI: 10.1007/s12185-021-03276-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 12/18/2022]
Abstract
Emicizumab reduces bleeding events in patients with severe hemophilia A (HA). The coagulation potential of emicizumab at a clinical dose appears to correspond to about 15 IU/dL of factor VIII activity (FVIII:C), the equivalent of converting from a severe to mild phenotype. However, the clinical and laboratory characteristics of HA patients receiving emicizumab (Emi-PwHA) compared with patients with mild HA (PwMHA) remain to be determined. We reviewed clinical data from Emi-PwHA (n = 63) and PwMHA (n = 15) and evaluated comprehensive coagulation function using Ca2+-triggered rotational thromboelastometry (ROTEM) and ellagic acid/tissue factor-triggered clot waveform analysis (modified CWA). The median FVIII:C in PwMHA was 13.0 (IQR 8.5-17.0) IU/dL. Bleeding patterns in both groups were similar and classified into three categories: (1) spontaneous bleeding, post-traumatic, (2) bleeding within 1-2 days, and (3) delayed bleeding after 1-2 weeks. The coagulation potential in Emi-PwHA with and without breakthrough bleeds was comparable. Furthermore, coagulation function in Emi-PwHA was equivalent to PwMHA, although time between treatment and hospitalization for breakthrough bleeds in PwMHA appeared to be longer than those in Emi-PwHA. The coagulation potential and bleeding patterns appeared to be similar in Emi-PwHA and PwMHA, indicating that emicizumab-driven coagulation potential reflected mild HA.
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Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Japan.
| | - Kuniyoshi Mizumachi
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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Kato K, Hatayama Y, Shimohiro H, Ichikawa H, Fukuda T. Differences in the Composition of Activated Partial Thromboplastin Time (APTT) Reagents Affect Clot Waveform Analysis. Yonago Acta Med 2022. [DOI: 10.33160/yam.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Konami Kato
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
| | - Yuki Hatayama
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
| | - Hisashi Shimohiro
- Department of Pathobiological Science and Technology, School of Health Sciences, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Hitomi Ichikawa
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
| | - Tetsuya Fukuda
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
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Kato K, Hatayama Y, Shimohiro H, Ichikawa H, Fukuda T. Differences in the Composition of Activated Partial Thromboplastin Time (APTT) Reagents Affect Clot Waveform Analysis. Yonago Acta Med 2022; 65:226-230. [DOI: 10.33160/yam.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/08/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Konami Kato
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
| | - Yuki Hatayama
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
| | - Hisashi Shimohiro
- Department of Pathobiological Science and Technology, School of Health Sciences, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Hitomi Ichikawa
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
| | - Tetsuya Fukuda
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
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Inaba H, Nishikawa S, Shinozawa K, Shinohara S, Nakazawa F, Amano K, Kinai E. Coagulation assay discrepancies in Japanese patients with non-severe hemophilia A. Int J Hematol 2021; 115:173-187. [PMID: 34751920 DOI: 10.1007/s12185-021-03256-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/29/2021] [Accepted: 10/29/2021] [Indexed: 11/29/2022]
Abstract
Patients with non-severe hemophilia A often show discrepancies in factor VIII (FVIII) activity. However, information on variant-specific coagulation assay characteristics in Japanese patients is limited. Pathogenic variants were classified into three groups, thrombin-cleavage site (TC), A1-A2-A3 interface (IF), and non-discrepant, with reference to previous studies. Cutoff values for the one-stage assay (OSA)/chromogenic substrate assay (CSA) ratio, which is suitable for distinguishing discrepancies, were determined for all five aPTT reagents. TGA and CWA parameters and bleeding scores were compared between groups. Two of the 39 patients with non-severe hemophilia A (5%) were classified as TC, 10 (26%) as IF, and 27 (69%) as non-discrepant. The OSA/CSA cutoff values between the groups varied widely by aPTT reagent and tended to be relatively low compared to previous studies. As an indicator of bleeding tendency, TGA had a low correlation coefficient for the IF variant, but this was not significant and was comparable to FVIII activity and CWA. Moreover, various parameters and bleeding tendency differed among patients with the same variants. Thus, our findings suggest that it is difficult to adequately assess the bleeding tendency of individual patients, even with the various assessments currently available.
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Affiliation(s)
- Hiroshi Inaba
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Satomi Nishikawa
- Scientific Research, Scientific Affairs, Sysmex Corporation, Kobe, Japan
| | - Keiko Shinozawa
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Sho Shinohara
- Reagent Engineering, Sysmex Corporation, Kobe, Japan
| | - Fumie Nakazawa
- Scientific Research, Scientific Affairs, Sysmex Corporation, Kobe, Japan
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ei Kinai
- Department of Laboratory Medicine, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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36
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Jiménez‐Yuste V, Rodríguez‐Merchán EC, Matsushita T, Holme PA. Concomitant use of bypassing agents with emicizumab for people with haemophilia A and inhibitors undergoing surgery. Haemophilia 2021; 27:519-530. [PMID: 33988293 PMCID: PMC8359827 DOI: 10.1111/hae.14322] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Surgery in people with haemophilia and factor VIII inhibitors is typically managed with perioperative administration of haemostatic agents to prevent or control the occurrence of bleeding events. Practical experience of surgery in patients with inhibitors who are receiving treatment with emicizumab is growing; however, the novelty of the situation means that standardised guidelines are lacking with regard to the concomitant administration of haemostatic agents, including dose and laboratory monitoring. AIM To review approaches to haemostatic management during major and minor invasive procedures in patients with haemophilia A and inhibitors, and to provide recommendations for controlling bleeding events. METHODS A search was conducted, limited to the past 4 years (January 2016-April 2020), pertaining to published evidence of surgery for patients receiving emicizumab. Publications identified from the search were manually reviewed to determine studies and case reports relevant for inclusion. RESULTS Identified literature and practical experience of the authors were used to build a consensus of practical recommendations for the concomitant administration of haemostatic agents during the perioperative period for elective surgery in patients with inhibitors who are receiving emicizumab. CONCLUSIONS The current evidence base indicates that surgery can be successfully performed in patients with inhibitors who are receiving emicizumab and that bypassing agents can be used concomitantly. Data from prospective studies are required to further support recommendations for haemostatic management of surgery in patients receiving emicizumab.
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Affiliation(s)
- Victor Jiménez‐Yuste
- Department of HematologyLa Paz University Hospital‐IdiPaz, Autónoma UniversityMadridSpain
| | | | | | - Pål Andrè Holme
- Department of HematologyOslo University HospitalOsloNorway
- Institute of Clinical MedicineUniversity of OsloOsloNorway
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Abstract
INTRODUCTION Emicizumab is a bispecific antibody exerting cofactor function of FVIIIa irrespective of the presence of FVIII inhibitors. Long-term data of phase 1/2 and phase 3 studies have been accumulated. Various questions such as indicated patients, ITI, application to PUPs, hemostatic treatment including surgeries, and emicizumab-related morbidity remain to be solved. AREAS COVERED The review describes the mode of action, data from pre-/post-marketing and ongoing clinical studies according to PubMed search and our own works. EXPERT OPINION For patients with a persistent inhibitor, emicizumab is a definite therapeutic option, although the possibility of BPAs-associated thromboembolic/TMA events raises concerns. The use of ITI together with emicizumab prophylaxis is being examined in clinical trials. For non-inhibitor, especially pediatric patients, emicizumab prophylaxis can be an option. Outcome assessment 'beyond ABR' such as joint health, physical/mental activity, QOL is required. Furthermore, continuous data collection for emicizumab-related adverse events and morbidity would be recommended.
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Affiliation(s)
- Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, Kashihara-shi, Japan
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38
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Wada H, Matsumoto T, Ohishi K, Shiraki K, Shimaoka M. Update on the Clot Waveform Analysis. Clin Appl Thromb Hemost 2021; 26:1076029620912027. [PMID: 32862666 PMCID: PMC7466886 DOI: 10.1177/1076029620912027] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The activated partial thromboplastin time (APTT)–clot waveform analysis (CWA) was previously reported to be associated with the early detection of disseminated intravascular coagulation and was also reported to be able to measure very low levels of coagulation factor VIII activity. The software program for the analysis for the APTT-CWA allows the associated first and second derivative curves (first and second DCs) to be displayed. The first and second DC reflect the velocity and acceleration, respectively. The height of the first DC reflects the “thrombin burst” and bleeding risk, while that of the second DC is useful for detecting any coagulation factor deficiency and abnormal enhancement of coagulation by phospholipids. Activated partial thromboplastin time-CWA aids in making a differential diagnosis which is difficult to do using only the routine APTT. The CWA is currently used for many applications in the clinical setting, including the monitoring of hemophilia patients and patients receiving anticoagulant therapy and the differential diagnosis of diseases.
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Affiliation(s)
- Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan.,Associated Department with Mie Graduate School of Medicine, Tsu, Japan
| | - Takeshi Matsumoto
- Department of Transfusion Medicine and Cell Therapy, Mie University Hospital, Tsu, Japan
| | - Kohshi Ohishi
- Department of Transfusion Medicine and Cell Therapy, Mie University Hospital, Tsu, Japan
| | - Katsuya Shiraki
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan.,Associated Department with Mie Graduate School of Medicine, Tsu, Japan
| | - Motomu Shimaoka
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu, Japan
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Takeyama M, Furukawa S, Yada K, Ogiwara K, Shimonishi N, Nakajima Y, Mizumachi K, Noguchi-Sasaki M, Shima M, Nogami K. Ex Vivo Prediction of Comprehensive Coagulation Potential Using Simulated Blood Concentrations of Emicizumab in Patients with Acquired Hemophilia A. Thromb Haemost 2021; 121:1289-1298. [PMID: 33641138 DOI: 10.1055/s-0041-1725009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Emicizumab prophylaxis improves coagulation function in congenital hemophilia A, regardless of inhibitor presence. We recently reported that emicizumab enhanced the coagulant potentials, ex vivo, in plasmas from patients with acquired hemophilia A (PwAHAs) at diagnosis. However, coagulant effects of emicizumab in PwAHAs during the clinical course remain unclear. AIM To assess ex vivo coagulant effects of emicizumab in PwAHAs during the clinical course. METHODS/RESULTS Blood samples were obtained from 14 PwAHAs on (median) days 0 and 6 during a severe-bleeding phase, and days 27 and 59 during a reduced-bleeding phase with elevated endogenous factor VIII (FVIII) and decreased inhibitor titers. If administered a single dose of 3 or 6 mg/kg, or two doses at 6 mg/kg followed by 3 mg/kg, estimated plasma emicizumab concentrations (10/5/2.5, 20/10/5, and 30/15/7.5 µg/mL on days 0-7/30/60, respectively) could be used to represent potential changes, based on the half-life (T 1/2: ∼30 days). Emicizumab concentrations that covered maximum plasma concentrations of each dosage were used for spiking on day 0. Ex vivo addition of estimated emicizumab to PwAHA's plasma containing endogenous FVIII and/or inhibitor, without and with recombinant (r)FVIIa administration during immunosuppressive therapy, increased the calculated Ad|min1| values, assessed by clot waveform analysis, and their coagulant potentials were below normal levels. Rotational thromboelastometry revealed that ex vivo emicizumab addition resulted in the further improvement of coagulant potentials in whole bloods when combined with rFVIIa administration. CONCLUSION Based on ex vivo and in vitro data, emicizumab has the potential to be effective in clinical situations for PwAHAs.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Course of Hemophilia Education, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | | | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Wang CP, Young G, Thornburg CD. Safety evaluation of emicizumab prophylaxis in individuals with haemophilia A. Expert Opin Drug Saf 2021; 20:387-396. [PMID: 33612049 DOI: 10.1080/14740338.2021.1893303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Emicizumab is a bispecific-humanized monoclonal antibody that improves hemostasis by bridging activated factor IX and factor X to substitute for the function of missing activated FVIII. It is an alternative to prophylaxis with factor VIII replacement and is associated with improved outcomes in individuals with hemophilia A with and without inhibitors. AREAS COVERED Emicizumab is efficacious in reducing bleeding events when compared to on-demand treatment and factor-based prophylaxis. Except for the few thrombotic microangiopathy and thrombotic event cases mainly seen in the HAVEN 1 trial, emicizumab has an overall excellent safety profile with minimal side effects. EXPERT OPINION Knowledge gaps include the efficacy and safety of emicizumab in younger age groups and those with mild or moderate hemophilia A. Future directions for research include exploring the risk of inhibitor recurrence in patients with a history of high titer inhibitor who have been successfully tolerized, who switch from factor prophylaxis to emicizumab, as well as conducting 'real world studies' to evaluate the patient's perception of emicizumab in regard to ease and tolerability in order to optimize individualized treatment plans.
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Affiliation(s)
- Cassandra P Wang
- Department of Pediatrics, University of California-San Diego School of Medicine, La Jolla, CA, USA
| | - Guy Young
- Division of Pediatric Hematology/Oncology, Children's Hospital Los Angeles/University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Courtney D Thornburg
- Division of Pediatric Hematology/Oncology, Rady Children's Hospital San Diego/University of California, San Diego, CA, USA
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Nakajima Y, Tonegawa H, Noguchi-Sasaki M, Nogami K. Predicted coagulation potential using an in vitro simulated model of emicizumab prophylaxis and immune tolerance induction therapy in hemophilia A patients with inhibitor. Int J Hematol 2021; 113:789-796. [PMID: 33635530 DOI: 10.1007/s12185-021-03108-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/05/2021] [Accepted: 02/18/2021] [Indexed: 11/29/2022]
Abstract
Emicizumab reduces bleeding in hemophilia A patients with inhibitor (HA-inh). A combination of immune tolerance induction therapy (ITI) and emicizumab prophylaxis may provide additional benefits, but coagulation potential during this treatment remains unknown. We assessed coagulation potentials in simulated ITI models in vitro using modified-clot waveform analysis. Factor (F)VIII-deficient plasma preincubated with anti-A2 and anti-C2 monoclonal antibodies was reacted with emicizumab (50 µg/mL) (emicizumab-HA-plasma), then spiking bypassing agents (BPAs): activated prothrombin complex concentrates (aPCC 1.3 IU/mL; 50 IU/kg), recombinant factor (rF)VIIa (2.2 µg/mL; 90 µg/kg), and FVIIa/FX (1.5 µg/mL; 60 µg/kg), and/or FVIII (100, 200 IU/dL). Coagulation potentials in emicizumab-HA-plasma (10 BU/mL) remained within the normal range when BPA and FVIII were both present. In emicizumab-HA-plasma (1 BU/mL) with BPA and FVIII (200 IU/dL), they were near or beyond the normal range, but those with a half concentration of rFVIIa based on the half-life in blood were within the normal range. In samples without inhibitor, coagulation potentials with combined BPA and FVIII were far beyond the normal range but with FVIII (100 IU/dL) and rFVIIa at half concentration they remained within the normal range. These results may provide information on the feasibility of concurrent ITI under emicizumab prophylaxis.
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Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Hitoshi Tonegawa
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
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Mizumachi K, Tsumura Y, Nakajima Y, Koh K, Nogami K. Clot waveform analysis for perioperative hemostatic monitoring of arthroscopic synovectomy in a pediatric patient with hemophilia A and inhibitor receiving emicizumab prophylaxis. Int J Hematol 2021; 113:930-935. [PMID: 33566316 DOI: 10.1007/s12185-021-03095-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 11/25/2022]
Abstract
Emicizumab reduces bleeding in patients with hemophilia A and inhibitors (PwHA-I). Coagulation potential during the perioperative period in emicizumab-treated PwHA-I undergoing surgery remains to be evaluated. We describe a 14-year-old boy with HA-I receiving emicizumab prophylaxis who experienced arthroscopic synovectomy. He was treated with a bolus infusion of recombinant factor VIIa (rFVIIa; 80 μg/kg) immediately before surgery, and treatment continued at the same dose every 3 h on day 1, every 4 h on day 2, and every 6 h on day 3. Treatment with rFVIIa was discontinued on day 4. No perioperative bleeding or thrombotic events were observed. Coagulation potential throughout the perioperative period was retrospectively assessed with an easy-to-use clot waveform analysis (CWA). Measurements from CWA returned to within or near the normal range, suggesting successful hemostatic management. Coagulation potentials assessed by CWA showed a significant correspondence with those from a thrombin generation assay (TGA) that is already in use. CWA and TGA could both provide useful data for assessing coagulation potential in the perioperative hemostatic management of emicizumab-treated PwHA-I.
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Affiliation(s)
- Kuniyoshi Mizumachi
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Yusuke Tsumura
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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Escuriola-Ettingshausen C, Auerswald G, Königs C, Kurnik K, Scholz U, Klamroth R, Oldenburg J. Optimizing the management of patients with haemophilia A and inhibitors in the era of emicizumab: Recommendations from a German expert panel. Haemophilia 2020; 27:e305-e313. [PMID: 32937002 DOI: 10.1111/hae.14010] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
Standard treatment of haemophilia A is based on replacing the missing coagulation factor VIII (FVIII) to treat and prevent bleeding episodes. The most challenging complication of FVIII therapy is the development of neutralizing antibodies (inhibitors) that can render treatment ineffective. Eradication of the inhibitor through immune tolerance induction (ITI) remains the most effective strategy for managing these patients. Bypassing agents can be used to help restore haemostasis in inhibitor patients. Several novel agents have recently been developed, such as the FVIII mimetic agent emicizumab, which has been effective in reducing the annualized bleeding rate in haemophilia A patients with inhibitors. When coadministered with repetitive high doses of activated prothrombin complex concentrate (ie >100 U/kg/d for ≥24 hours), emicizumab was associated with thrombotic microangiopathy and thrombosis events. As a consequence the United Kingdom Haemophilia Centres Doctors' Organisation (UKHCDO) issued the first guidance on the treatment of bleeding episodes in patients receiving emicizumab. To build on and extend this work, a panel of German haemophilia specialists met to discuss the UK guidance, review current evidence and provide additional guidance for German healthcare professionals on how to optimize the management of patients with haemophilia A receiving emicizumab. Recommendations are provided on the use of bypassing and other agents to manage breakthrough bleeding, ITI in the emicizumab era, haemostatic support during surgery and issues relating to laboratory monitoring.
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Affiliation(s)
| | - Günter Auerswald
- Department of Comprehensive Care in Haemostasis and Thrombosis, Professor Hess Children's Hospital, Bremen, Germany
| | - Christoph Königs
- Department of Pediatrics and Adolescent Medicine, Centre for Hemostasis, University Hospital Frankfurt, Frankfurt, Germany
| | - Karin Kurnik
- Department of Paediatric Haemostasis, University Children's Hospital, Munich, Germany
| | | | - Robert Klamroth
- Department for Internal Medicine, Vascular Medicine and Haemostaseology, Vivantes Klinikum, Berlin, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
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Yaoi H, Shida Y, Kitazawa T, Shima M, Nogami K. Emicizumab Augments Thrombus Formation in Whole Blood from Patients with Hemophilia A under High Shear Flow Conditions. Thromb Haemost 2020; 121:279-286. [PMID: 32906155 DOI: 10.1055/s-0040-1716542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Emicizumab is a bispecific antibody to factor (F) IXa and FX that mimics the FVIIIa cofactor function. Emicizumab prophylaxis markedly decreases bleeding episodes in patients with hemophilia A (PwHAs), irrespective of the presence of FVIII inhibitors. However, thrombotic microangiopathy (TMA) was reported when repeated high doses of activated prothrombin complex concentrates (aPCC) were concomitantly used with emicizumab. Although bypassing agents (BPAs) are vital in the hemostatic treatment for PwHAs with inhibitors, the mechanism of emicizumab-related TMA remains unclear. AIM To assess the risk of excessive thrombus formation associated with BPAs and emicizumab under high shear conditions. METHODS Perfusion flow-chamber experiments under high shear conditions were performed using whole blood from PwHAs in the presence of emicizumab without or together with FVIII or BPAs ex vivo. RESULTS Emicizumab (100 μg/mL) added ex vivo to whole blood from PwHAs improved defective thrombus formation in a similar manner to that observed with the addition of recombinant FVIII at the early phase, while FVIII continued to be important at the later stages. aPCC (1.2 U/mL equivalent to 100 U/kg) or recombinant FVIIa (1.1 µg/mL; equivalent to 90 µg/kg) together with emicizumab further promoted platelet interactions and fibrin formation ex vivo but did not induce excessive thrombus formation. CONCLUSION Emicizumab enhanced thrombin generation at local sites and improved defective hemostasis in whole blood from PwHAs under high shear conditions. Simple concomitant use of BPAs with emicizumab did not mediate excessive thrombus formation and remains an option for hemostatic management of emicizumab-treated PwHAs with inhibitors.
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Affiliation(s)
- Hiroaki Yaoi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Yasuaki Shida
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Takehisa Kitazawa
- Research Division, Chugai Pharmaceutical Co., Kamakura, Kanagawa, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Shimonishi N, Ogiwara K, Oda Y, Kawabe T, Okazaki S, Shima M, Nogami K. A Novel Assessment of Factor VIII Activity by Template Matching Utilizing Weighted Average Parameters from Comprehensive Clot Waveform Analysis. Thromb Haemost 2020; 121:164-173. [PMID: 32828071 DOI: 10.1055/s-0040-1715838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Activated partial thromboplastin time (aPTT)-based clot waveform analysis is used to evaluate the comprehensive dynamics of fibrin clot formation. In addition, the technique can be usefully utilized for the rapid assessment of factor (F)VIII procoagulant activity in various clinical settings in patients with hemophilia A (HA). We defined a novel algorithm based on the weighted average parameters from aPTT-based waveforms to devise a template-matching procedure for assessing FVIII activity (FVIII:C). METHODS The first derivatives of original clot waveforms triggered by the aPTT reagent (Coagpia APTT-N) were used to determine weighted averages of areas surrounded by the waveform at different percentages of maximum height in various clotting factor-deficient plasmas. Prepared templates based on 50 weighted average-related parameters were compared with 78 aPTT-prolonged plasmas. RESULTS Original nonsmoothed waveforms of the various clotting factor-deficient plasmas with prolonged aPTTs demonstrated a variety of shapes. The weighted averages were calculated after adjustments for different baselines, and the patterns seemed to be governed by the specific clotting factor deficiency. The weighted average-related parameters including baseline wedge (r 2 = 0.998) and aspect ratio (r 2 = 0.998) were highly correlated with FVIII:C levels. Template-matching analyses based on weighted average-related waveform parameters obtained from 158 samples demonstrated that the sensitivity was 97.2% and specificity was 83.3% in aPTT-prolonged plasmas (n = 78). CONCLUSION This novel algorithm based on weighted averages of aPTT-based waveforms together with template-matching may support clinical usefulness for judging of HA and may aid clinical management in the patients in the absence of specific clotting factor assays.
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Affiliation(s)
- Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Yukio Oda
- Sekisui Medical Co., Ltd., Tokyo, Japan
| | | | | | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Ogiwara K, Nogami K, Matsumoto N, Noguchi-Sasaki M, Hirata M, Soeda T, Shima M. A modified thrombin generation assay to evaluate the plasma coagulation potential in the presence of emicizumab, the bispecific antibody to factors IXa/X. Int J Hematol 2020; 112:621-630. [DOI: 10.1007/s12185-020-02959-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/18/2020] [Accepted: 07/21/2020] [Indexed: 11/25/2022]
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Gelbenegger G, Schoergenhofer C, Knoebl P, Jilma B. Bridging the Missing Link with Emicizumab: A Bispecific Antibody for Treatment of Hemophilia A. Thromb Haemost 2020; 120:1357-1370. [PMID: 32717759 PMCID: PMC7649063 DOI: 10.1055/s-0040-1714279] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hemophilia A, characterized by absent or ineffective coagulation factor VIII (FVIII), is a serious bleeding disorder that entails severe and potentially life-threatening bleeding events. Current standard therapy still involves replacement of FVIII, but is often complicated by the occurrence of neutralizing alloantibodies (inhibitors). Management of patients with inhibitors is challenging and necessitates immune tolerance induction for inhibitor eradication and the use of bypassing agents (activated prothrombin complex concentrates or recombinant activated factor VII), which are expensive and not always effective. Emicizumab is the first humanized bispecific monoclonal therapeutic antibody designed to replace the hemostatic function of activated FVIII by bridging activated factor IX and factor X (FX) to activate FX and allow the coagulation cascade to continue. In the majority of hemophilic patients with and without inhibitors, emicizumab reduced the annualized bleeding rate to almost zero in several clinical trials and demonstrated a good safety profile. However, the concurrent use of emicizumab and activated prothrombin complex concentrate imposes a high risk of thrombotic microangiopathy and thromboembolic events on patients and should be avoided. Yet, the management of breakthrough bleeds and surgery remains challenging with only limited evidence-based recommendations being available. This review summarizes published clinical trials and preliminary reports of emicizumab and discusses the clinical implications of emicizumab in treatment of hemophilia A.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Paul Knoebl
- Division of Hematology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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48
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Shima M, Sidonio RF. Substitution therapy. Haemophilia 2020; 27 Suppl 3:53-59. [PMID: 32558019 DOI: 10.1111/hae.14072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/19/2020] [Accepted: 05/19/2020] [Indexed: 01/20/2023]
Abstract
Emicizumab is a bispecific antibody that recognizes FIX(a)/FX, and mimics FVIIIa cofactor activity. Due to its unique characteristics including longer half-life and subcutaneous injectability, treatment for haemophilia A dramatically improved regardless of the presence of FVIII inhibitor. Protection from pathological change in joints, avoidance of inhibitor development and intra-cranial haemorrhage could be expected by introduction of emicizumab in early childhood. Applications in mild/moderate patients should be also considered. Clinical assessment tool should be standardized; however, since there are limitations to conventional ABR-based assessment. Laboratory monitoring is another practical issue due to the mode of action of emicizumab. Chromogenic assays and global assays could be utilized. The other emicizumab-related practical issue is immune tolerance induction for the inhibitor patients, since ITI remains the only effective means to inhibitor eradication. With the recently introduced Atlanta protocol, emicizumab prophylaxis is given in combination with 50-100 IU/kg FVIII three times a week. A single manuscript has been published, and multiple clinical trials are open to address the efficacy of this strategy. Whether the Atlanta protocol will be fully embraced is yet to be seen, but there is widespread consensus about attempts to tolerize every haemophilia A patient with an inhibitor.
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Affiliation(s)
- Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, Kashihara, Japan
| | - Robert F Sidonio
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
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Wada H, Shiraki K, Matsumoto T, Ohishi K, Shimpo H, Shimaoka M. Effects of platelet and phospholipids on clot formation activated by a small amount of tissue factor. Thromb Res 2020; 193:146-153. [PMID: 32559572 DOI: 10.1016/j.thromres.2020.06.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Physiological coagulation is considered to activate coagulation factor IX (FIX) by a small amount of tissue factor (TF) and activated coagulation factor VII (FVIIa) with the presence of platelets. A Clot waveform analysis (CWA) may be useful for evaluating physiological coagulation. MATERIAL AND METHODS A CWA using a small amount of TF (CWA/sTF) was performed in platelet-rich plasma (PRP), platelet-poor plasma (PPP), several phospholipids (PLs) and patients with lupus anticoagulant (LA), idiopathic thrombocytopenic purpura (ITP) or inhibitor for FVIII. RESULTS The CWA/sTF without PLs showed a shorter peak time and higher peak height in PRP than in PPP. The effect of PRP on the CWA/sTF depended on the platelet count, and PLs showed a similar effect on the CWA/sTF results in PPP. The peak time of the CWA/sTF in PRP was prolonged in patient with ITP. The CWA/sTF in PRP showed a prolonged peak time and decreased peak height of the second derivative in patient with LA. Both a shortened peak time and elevated peak height were observed in the CWA/sTF of patient with inhibitor after treatment with activated recombinant human FVII. CONCLUSION A CWA can be conducted using a small amount of TF and platelets or PL without contact activation and may be able to detect not only hemostatic abnormalities but also changes in platelet counts.
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Affiliation(s)
- Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan; Associated Department with Mie Graduate School of Medicine, Tsu, Japan.
| | - Katsuya Shiraki
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan; Associated Department with Mie Graduate School of Medicine, Tsu, Japan
| | - Takeshi Matsumoto
- Department of Transfusion Medicine and Cell Therapy, Mie University Hospital, Tsu, Japan
| | - Kohshi Ohishi
- Department of Transfusion Medicine and Cell Therapy, Mie University Hospital, Tsu, Japan
| | - Hideto Shimpo
- Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Motomu Shimaoka
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of medicine, Tsu, Japan
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Bowyer AE, Lowe AE, Tiefenbacher S. Laboratory issues in gene therapy and emicizumab. Haemophilia 2020; 27 Suppl 3:142-147. [PMID: 32469128 DOI: 10.1111/hae.13976] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/24/2020] [Accepted: 03/04/2020] [Indexed: 12/23/2022]
Abstract
The treatment options for the haemostatic disorders, haemophilia A and haemophilia B, have progressed rapidly over the last decade. The introduction of extended half-life recombinant factor VIII (FVIII) and factor IX (FIX) concentrates to replace these missing clotting factors highlighted discordance between one-stage activated partial thromboplastin time (APTT)-based clotting factor assays and chromogenic factor assays with some products. This raised awareness of the importance of investigation of potential reagent or assay differences by pharmaceutical companies. In 2017, the FVIII mimetic, emicizumab, was approved as a prophylactic treatment for haemophilia A patients with anti-FVIII inhibitors. The mechanism of action of emicizumab causes interference with some commonly used haemostasis tests including the APTT and its associated one-stage APTT-based clotting assays. Chromogenic assays may also be affected but this is dependent on the particular constituents of the reagents. Chromogenic assays containing human factor IXa (FIXa) and factor X (FX) are sensitive to the presence of emicizumab but those containing bovine FIXa and FX are unaffected. Many haemostasis laboratories have been required to evaluate new assays to enable accurate monitoring of emicizumab in patient plasma. A number of gene therapy approaches have been trialled in both haemophilia A and haemophilia B but there are scant data published on the measurement of FVIII and FIX in these patients and whether there are discrepancies between reagents or assay methodologies.
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Affiliation(s)
- Annette E Bowyer
- Department of Coagulation, Sheffield Haemophilia and Thrombosis Centre, Sheffield, UK
| | - Anna E Lowe
- UK National External Quality Assurance Scheme (NEQAS) for Blood Coagulation, Sheffield, UK
| | - Stefan Tiefenbacher
- Colorado Coagulation, Laboratory Corporation of America® Holdings, Englewood, CO, USA
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