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Pipe S, Sadeghi-Khomami A, Konkle BA, Kitchen S, Negrier C, Liu M, Santagostino E, Willemze A, Abad-Franch L, Knobe K, Seth Chhabra E. A global comparative field study to evaluate the factor VIII activity of efanesoctocog alfa by one-stage clotting and chromogenic substrate assays at clinical haemostasis laboratories. Haemophilia 2024; 30:214-223. [PMID: 37902390 DOI: 10.1111/hae.14831] [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: 01/31/2023] [Revised: 05/09/2023] [Accepted: 06/27/2023] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Structural and chemical modifications of factor VIII (FVIII) products may influence their behaviour in FVIII activity assays. Hence, it is important to assess the performance of FVIII products in these assays. Efanesoctocog alfa is a new class of FVIII replacement therapy designed to provide both high sustained factor activity levels and prolonged plasma half-life. AIM Evaluate the accuracy of measuring efanesoctocog alfa FVIII activity in one-stage clotting assays (OSAs) and chromogenic substrate assays (CSAs). METHODS Human plasma with no detectable FVIII activity was spiked with efanesoctocog alfa or a full-length recombinant FVIII product comparator, octocog alfa, at nominal concentrations of 0.80 IU/mL, 0.20 IU/mL, or 0.05 IU/mL, based on labelled potency. Clinical haemostasis laboratories (N = 35) tested blinded samples using in-house assays. Data from 51 OSAs (14 activated partial thromboplastin time [aPTT] reagents) and 42 CSAs (eight kits) were analyzed. RESULTS Efanesoctocog alfa activity was reliably (±25% of nominal activity) measured across all concentrations using OSAs with Actin FSL and multiple other aPTT reagents. Under- and overestimation of FVIII activity occurred with some reagents. No specific trend was observed for any class of aPTT activators. A two- to three-fold overestimation was consistently observed using CSAs and the OSA with Actin FS as the aPTT reagent across evaluated concentrations. CONCLUSION Under- or overestimation occurred with some specific OSAs and most CSAs, which has been previously observed with other modified FVIII replacement products. Efanesoctocog alfa FVIII activity was measured with acceptable accuracy and reliability using several OSA methods and commercial plasma standards.
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Affiliation(s)
- Steven Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Barbara A Konkle
- Washington Center for Bleeding Disorders, Seattle, Washington, USA
- Division of Hematology, University of Washington, Seattle, Washington, USA
| | - Steve Kitchen
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Grabowska K, Grzelak M, Zhao LY, Płuciennik E, Pasieka Z, Kciuk M, Gielecińska A, Smakosz AK, Kałuzińska-Kołat Ż, Kołat D. Emicizumab as a Promising Form of Therapy for Type A Hemophilia - A Review of Current Knowledge from Clinical Trials. Curr Protein Pept Sci 2024; 25:719-737. [PMID: 38797909 DOI: 10.2174/0113892037294674240509094418] [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: 01/31/2024] [Revised: 04/05/2024] [Accepted: 04/16/2024] [Indexed: 05/29/2024]
Abstract
Hemophilia is a plasma bleeding disorder characterized by a deficiency of certain blood clotting factors. The most common forms of this disease, i.e., type A and type B, affect approximately 400,000 people worldwide. Without appropriate treatment ensuring the proper coagulation cascade, this disease may lead to serious disability. Minimizing patient discomfort is possible via replacement therapy, consisting of the substitution of a missing coagulation factor via intravenous administration. Frequent medication and the risk related to factor inhibitors are significant disadvantages, necessitating the improvement of current therapies or the development of novel ones. This review examines the humanized bispecific antibody Emicizumab which ensures hemostasis by mimicking the action of the coagulation factor VIII, a deficiency of which causes type A hemophilia. The paper outlines the topic and then summarizes available clinical trials on Emicizumab in type A hemophilia. Several interventional clinical trials have found Emicizumab to be effective in decreasing bleeding episodes and raising patient satisfaction among various hemophilia A populations. Current Emicizumab-related trials are forecast to be completed between 2024 and 2030, and in addition to congenital hemophilia A, the trials cover acquired hemophilia A and patients playing sports. Providing a more comprehensive understanding of Emicizumab may revolutionize the management of hemophilia type A and improve quality of life. Conclusively, Emicizumab is a gentler therapy owing to subcutaneous delivery and fewer injections, which reduces injection-site reactions and makes therapy less burdensome, ultimately decreasing hospital visits and indirect costs.
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Affiliation(s)
- Katarzyna Grabowska
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
| | - Michalina Grzelak
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
| | - Lin-Yong Zhao
- Department of General Surgery & Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy/Collaborative Innovation Center of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Elżbieta Płuciennik
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
| | - Zbigniew Pasieka
- Department of Biomedicine and Experimental Surgery, Medical University of Lodz, Narutowicza 60, 90-136, Lodz, Poland
| | - Mateusz Kciuk
- Department of Molecular Biotechnology and Genetics, University of Lodz, Banacha 12/16, 90-237, Lodz, Poland
| | - Adrianna Gielecińska
- Department of Molecular Biotechnology and Genetics, University of Lodz, Banacha 12/16, 90-237, Lodz, Poland
- Doctoral School of Exact and Natural Sciences, University of Lodz, Banacha 12/16, 90-237, Lodz, Poland
| | - Aleksander K Smakosz
- Department of Pharmaceutical Biology and Biotechnology, Wroclaw Medical University, 50-367, Wroclaw, Poland
| | - Żaneta Kałuzińska-Kołat
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
- Department of Biomedicine and Experimental Surgery, Medical University of Lodz, Narutowicza 60, 90-136, Lodz, Poland
| | - Damian Kołat
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
- Department of Biomedicine and Experimental Surgery, Medical University of Lodz, Narutowicza 60, 90-136, Lodz, Poland
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Konkle BA. Efanesoctocog alfa for the prevention and treatment of bleeding in patients with hemophilia A. Expert Rev Hematol 2023; 16:567-573. [PMID: 37289594 DOI: 10.1080/17474086.2023.2223925] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/06/2023] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Hemophilia A is an inherited bleeding disorder due to a deficiency of coagulation factor VIII (FVIII). Prevention and treatment of bleeding is traditionally through intravenous infusion of a FVIII concentrate. Modifications of recombinant FVIII (rFVIII) with an aim to prolong the half-life have been modest, thought because FVIII is dependent on plasma von Willebrand factor (VWF) for its half-life. Efanesoctocog alfa (ALTUVIIIO), approved by the Federal Drug Administration (FDA) in February 2023, was made independent of endogenous VWF by linking of the FVIII-binding D'D3 domain of VWF to B-domain deleted single chain FVIII. AREAS COVERED This review will outline the development of efanesoctocog alfa and the pharmacokinetic and safety data from clinical trials, as well as efficacy data from the phase 3 trials. These data formed the basis for the FDA approval. EXPERT OPINION Efanesoctocog alfa is a new type of FVIII replacement with an extended half-life allowing once weekly dosing to achieve hemostasis and FVIII trough levels of 13-15 IU/dL. This provides a highly effective option for treatment and prevention of bleeding in hemophilia A, where FVIII levels are easily measured. It also provides an option for treatment of bleeding and coverage for surgery with few infusions.
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Affiliation(s)
- Barbara A Konkle
- Washington Center for Bleeding Disorders, Division of Hematology, University of Washington, Seattle, WA, USA
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Measurement of extended half-life recombinant FVIII molecules: In vitro and ex vivo evidence of relevant assay discrepancies. Res Pract Thromb Haemost 2023; 7:100070. [PMID: 36908765 PMCID: PMC9999201 DOI: 10.1016/j.rpth.2023.100070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/08/2023] [Accepted: 01/19/2023] [Indexed: 02/12/2023] Open
Abstract
Background Extended half-life recombinant FVIII products (EHL-rFVIIIs) have been engineered to improve the pharmacokinetic profile of FVIII, enabling better hemostatic protection with a reduced number of injections in persons with hemophilia. Previous studies showed several discrepancies in FVIII activity (FVIII:C) measurements for EHL-rFVIIIs comparing one-stage clotting assay (OSA) and chromogenic assay (CSA), although a systematic investigation of this phenomenon is still lacking. Objective Evaluation of the accuracy and precision of measurement of all available EHL-rFVIIIs with 5 different assays both in vitro and ex vivo. Methods Damoctocog alfa pegol, rurioctocog alfa pegol, turoctocog alfa pegol, and efmoroctocog alfa were tested with 3 OSA types: (1) aPTT-based commercial reagents with colloidal silica (Synthasil, Werfen-IL); (2) ellagic acid, Synthafax (Werfen-IL); and (3) OSA calibrated with each EHL-rFVIII product and colloidal silica. Measurements were also carried out with 2 different commercially available CSA reagents (Coamatic Factor VIII, Chromogenix-Werfen) and Trinichrom FVIII (Tcoag-Stago). A Bland-Altman analysis was performed to compare all assays. Results The simple OSA showed significant discrepancies between the expected and measured EHL-rFVIII concentrations as CSA methods, whereas the calibrated OSA assay was accurate and precise in determining the activity of all EHL-rFVIIIs in the in vitro setting. Comparable results were found using ex vivo plasma samples. Conclusion In this study, only OSA with a calibration curve constructed with each EHL-rFVIII product showed acceptable accuracy and precision in EHL-rFVIIIs measurements.
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Nummi V, Lehtinen AE, Iorio A, Szanto T, Lassila R. Switching from standard to extended half-life FVIII prophylaxis in haemophilia A: Comparison of factor product use, bleed rates and pharmacokinetics. Haemophilia 2022; 28:e237-e244. [PMID: 35939628 DOI: 10.1111/hae.14649] [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: 03/21/2022] [Revised: 07/16/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Majority of haemophilia A patients in our comprehensive care centre have switched from standard half-life (SHL) to extended half-life (EHL) FVIII products in a short time. AIM We compared the clinical and laboratory outcomes between SHL and EHL FVIII prophylaxis in product switchers. METHODS This is a retrospective inception cohort of all adult haemophilia A patients switched to EHL (rFVIIIFc or rFVIII-PEG) prophylaxis in our centre. Dosing, product utilization, annualized bleed rates (ABR), treatment regimen and pharmacokinetics by Web Accessible Population Pharmacokinetic Service (WAPPS)-Hemo were compared between SHL and EHL. RESULTS We included 38 patients, whose median age was 38 years (range 17-75). Median FVIII dose was 23 IU/kg for SHL versus 25 IU/kg for EHL. After switching, weekly infusions decreased by 29% from median 2.8 (every 2.5 days) to 2.0 (every 3.5 days) (P = <.001) and factor consumption for prophylaxis by 17% from 60 to 50 IU/kg/week (P = <.001). Weekly infusions decreased in 71% and FVIII utilization in 55% of patients. ABR remained low (1.0 for SHL and .5 for EHL, respectively). In pharmacokinetics, the half-life of FVIII increased from median 13 to 21 h after switching. Times above .01 and .03 IU/ml improved from 85 to 131 h and from 65 to 106 h. Half-lives of the SHL products and von Willebrand factor levels predicted half-lives with the EHL products. CONCLUSIONS Our cohort study confirms the successful experience of switching to EHL FVIII products, with decreased infusion frequency, factor consumption and excellent clinical efficacy.
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Affiliation(s)
- Vuokko Nummi
- Department of Hematology, Coagulation Disorders Unit, Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, Helsinki University, Helsinki, Finland
| | - Anna-Elina Lehtinen
- Department of Hematology, Coagulation Disorders Unit, Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, Helsinki University, Helsinki, Finland
| | - Alfonso Iorio
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Timea Szanto
- Department of Hematology, Coagulation Disorders Unit, Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, Helsinki University, Helsinki, Finland
| | - Riitta Lassila
- Department of Hematology, Coagulation Disorders Unit, Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, Helsinki University, Helsinki, Finland
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Correlation Analysis of DNA Methylation in the von Willebrand Factor Promoter Region and the Risk of Unexplained Recurrent Hemophilia: Systematic Review and Meta-Analysis. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:3977289. [PMID: 35711531 PMCID: PMC9187466 DOI: 10.1155/2022/3977289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/09/2022] [Indexed: 01/19/2023]
Abstract
This study systematically reviewed the effect of DNA methylation in the promoter region of the coagulation factor vWF gene on the risk of unexplained recurrent hemophilia. PubMed, Medline, Web of Science, and other computers were used to search the database, and the statistical randomized controlled trials of coagulation factor vWF in the risk analysis of unknown recurrent hemophilia were collected. The Cochrane systematic evaluation method was used to evaluate the quality of the included kinds of literature, and Revman5 software was used to sort out and analyze the kinds of literature. Meta-analysis showed that there was a statistical difference between the experimental group and the control group in case fatality rate (OR = 1.76, 95% CI (1.29, 2.39), P=0.0003, I2 = 0%, Z = 3.58), adverse events (OR = 2.38, 95% CI (1.65, 3.45), P < 0.00001, I2 = 0%, Z = 4.60), incidence of joint hemorrhage (OR = 2.52, 95% CI (1.62, 3.91), P < 0.00001, I2 = 0%, Z = 4.12), incidence of subcutaneous stasis (OR = 1.76, 95% CI (1.26, 2.45), P=0.0009, I2 = 5%, Z = 3.33), and hematoma volume (OR = 1.78, 95% CI (1.32, 2.40), P=0.0001, I2 = 23%, Z = 3.80). DNA methylation in the promoter region of the coagulation factor vWF gene was significantly associated with the risk of unexplained recurrent hemophilia. Whether demethylation can improve the bleeding index of patients with recurrent hemophilia remains to be further explored.
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Abstract
Remarkable changes are occurring in the diagnosis and management of individuals with hemophilia A. Genetic testing, including next-generation sequencing, enables family planning, carrier testing, and prenatal diagnosis. Musculoskeletal ultrasound examination facilitates the early detection of acute bleeds and joint disease in clinic, enabling more rapid bleed resolution and treatment planning. Novel therapies offer simpler weekly or monthly administration, some by subcutaneous injection, with better compliance and quality of life, as well as fewer bleeds. Gene therapy provides a 1-time phenotypic "cure" that is cost effective, but may be complicated by waning levels, vector immune responses, and hepatotoxicity.
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Cortesi PA, Giampaolo A, Abbonizio F, Molinari AC, Castaman G, Biffoni M, Mantovani LG. Variability of treatment modalities and intensity in patients with severe haemophilia A on prophylaxis: Results from the Italian national registry. Eur J Haematol 2021; 107:408-415. [PMID: 34110639 DOI: 10.1111/ejh.13676] [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: 04/08/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND A shift from a standard to a personalized prophylaxis has been increasingly adopted in patients with severe haemophilia A (SHA). This approach has raised the likelihood of a significant variability in the prophylactic approaches and the relative Factor VIII (FVIII) consumptions. The aim of our study was to assess the treatment variability of SHA patients without inhibitors and on prophylaxis regimen in Italy. MATERIAL AND METHODS Data reported in the National Registry of Congenital Coagulopathies (NRCC) were analysed to assess treatment distribution within SHA patients without inhibitors, focussing on FVIII consumption in 2017, associated with prophylaxis regimen. The analysis was stratified based on age groups and Italian regions to describe the variability of FVIII consumption in Italy. RESULTS In 2017, the Registry reported the therapeutic plans of 1068 SHA patients without inhibitors on prophylaxis. The mean (95% CI) individual consumption ranges from 123 127 IU (99 736-146 518) in the age group 0-6 years to 345 000 IU (336 000-354 000) in the age group >20 years. A significant FVIII consumption variability was identified within the adult population. Regions with less than 50 patients reported the higher variability in mean FVIII consumption per patient-year within the different age groups. Similar difference in FVIII consumption variability was reported also in the age groups comparing "low," "middle" and "high" patient volume regions. DISCUSSION A reliable estimation of FVIII consumption for patients' treatment is necessary to manage and plan the appropriate budget and keep treatment's costs affordable. However, without the implementation of a methodology aiming to assess the overall value produced by these FVIII consumptions, the scenario will keep driven by FVIII consumptions, its costs and the budget available. An effort by haemophilic community, haemophilia treatment centres and institutions is required to develop and share this cultural shift in improving haemophilia management and assessment.
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Affiliation(s)
- Paolo Angelo Cortesi
- Value-Based Healthcare Unit, IRCCS MultiMedica, Sesto San Giovanni, Italy.,Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | - Adele Giampaolo
- Department of Oncology and Molecular Medicine, Italian National Institute of Health, Rome, Italy
| | - Francesca Abbonizio
- Department of Oncology and Molecular Medicine, Italian National Institute of Health, Rome, Italy
| | - Angelo Claudio Molinari
- Regional Reference Center for Hemorrhagic Diseases, Giannina Gaslini Institute, Genova, Italy
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Mauro Biffoni
- Department of Oncology and Molecular Medicine, Italian National Institute of Health, Rome, Italy
| | - Lorenzo Giovanni Mantovani
- Value-Based Healthcare Unit, IRCCS MultiMedica, Sesto San Giovanni, Italy.,Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
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Di Minno A, Spadarella G, Esposito S, Mathew P, Di Minno G, Mannucci PM. Perspective - The case for zero bleeds and drug bioequivalence in the treatment of congenital hemophilia A in 2021. Blood Rev 2021; 50:100849. [PMID: 34024681 DOI: 10.1016/j.blre.2021.100849] [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: 02/02/2021] [Revised: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 01/19/2023]
Abstract
Not all patients with severe hemophilia A (HA) respond optimally to a given dose of a given product. Within-individual variance in cross-over studies makes each patient unique in the response to each standard half-life (SHL) factor VIII (FVIII) product in pharmacokinetic (PK) terms. This hampers the prediction of efficacy when a SHL FVIII product is employed. PK data showing that half-lives of SHL rFVIII are unsatisfactory to achieve zero bleeding in individual HA patients provide the rationale for switching from SHL to extended half-life (EHL) products. However, not all subjects receiving prophylaxis with EHL products achieve zero bleeding, the most cogent objective of personalized prophylaxis. Known determinants of FVIII half-life (age, von Willebrand factor [VWF] levels, blood group) cumulatively account for one third of the total inter-individual variation in FVIII clearance in subjects with severe HA. Investigations into precision, and accuracy of laboratory measurement to be employed; newer pathways for the clearance of both free-FVIII and VWF-bound FVIII, and adequately powered studies on omics and phenotypic heterogeneity, are likely to provide additional information on the remaining two thirds of inter-individual variation in FVIII clearance in HA. Variability in the clinical response has also been documented in patients when FVIII activity is mimicked by fixed subcutaneous doses of the bispecific antibody emicizumab. National registries that collect PK data of available FVIII products and ad hoc information on the individual response to emicizumab should be encouraged, to establish newer standards of care and ease personalized clinical decisions to achieve zero bleeding.
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Affiliation(s)
- Alessandro Di Minno
- Dipartimento di Farmacia, Università degli Studi di Napoli "Federico II", Italy; CEINGE-Biotecnologie Avanzate, Università degli Studi di Napoli "Federico II", Italy.
| | - Gaia Spadarella
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli "Federico II", Italy
| | - Salvatore Esposito
- Dipartimento di Medicina Clinica e Chirurgia and Centro Hub per le Malattie Emorragiche Congenite e le Trombofilie, Università degli Studi di Napoli "Federico II", Italy
| | | | - Giovanni Di Minno
- Dipartimento di Medicina Clinica e Chirurgia and Centro Hub per le Malattie Emorragiche Congenite e le Trombofilie, Università degli Studi di Napoli "Federico II", Italy.
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy..
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Augustsson C, Norström E, Lind V, Martin M, Astermark J, Strandberg K. Validation of factor VIII activity for monitoring standard and extended half-life products and correlation to thrombin generation assays. Haemophilia 2021; 27:494-500. [PMID: 33866649 DOI: 10.1111/hae.14317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/17/2021] [Accepted: 04/07/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Monitoring replacement therapy with standard and extended half-life (EHL) products is challenging, since one-stage assay (OSA) and chromogenic substrate assay (CSA) results may differ significantly. Recent recommendations include local validation of each new product with recovery within 20-30%, depending on activity level. AIM To validate factor VIII (FVIII) activity for monitoring products in clinical use on Atellica Coag and to correlate it with thrombin generation. METHODS Plasma samples spiked with Advate® , Elocta® , Adynovi® , Nuwiq® , NovoEight® and Afstyla® (0.05, 0.20, 0.50 and 0.80 IU/ml) were analysed using Atellica Coag 360 with CSA-1 (Coatest SP) and CSA-2 (FVIII chromogenic), and OSA (Actin FS). Thrombin generation was performed using two thrombin generation assays (TGA-1 (Thrombinoscope) and TGA-2 (Technothrombin). RESULTS All products at levels above 0.05 IU/ml, except Adynovi, showed acceptable recovery using CSA-1, whereas measurements using CSA-2 gave more results outside the target level. All products, except Afstyla, showed acceptable recovery using OSA. Correlation between CSA-1 and OSA was excellent (r2 =1.0) with biases of 6-32%, depending on FVIII product. A clear dose-response was seen for all thrombin generation parameters and products using both methods, except at low levels for lag time using TGA-1. With CSA-1 as an independent variable, the correlations to thrombin peak (measured with TGA-2) were good (r2 = .8-.9). CONCLUSION Our data revealed good correlation and acceptable bias between CSA and OSA using our sets of reagents, methods and analyser in spiked samples. Thrombin generation gave good correlation to CSA-1 factor activity and is a possible complement to factor activity assays.
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Affiliation(s)
- Cecilia Augustsson
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Eva Norström
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Vivian Lind
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Myriam Martin
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Jan Astermark
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, and Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Karin Strandberg
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation, University and Regional Laboratories Region Skåne, Malmö, Sweden
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Activity of transgene-produced B-domain-deleted factor VIII in human plasma following AAV5 gene therapy. Blood 2021; 136:2524-2534. [PMID: 32915950 DOI: 10.1182/blood.2020005683] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 08/25/2020] [Indexed: 12/18/2022] Open
Abstract
Adeno-associated virus (AAV)-based gene therapies can restore endogenous factor VIII (FVIII) expression in hemophilia A (HA). AAV vectors typically use a B-domain-deleted FVIII transgene, such as human FVIII-SQ in valoctocogene roxaparvovec (AAV5-FVIII-SQ). Surprisingly, the activity of transgene-produced FVIII-SQ was between 1.3 and 2.0 times higher in one-stage clot (OS) assays than in chromogenic-substrate (CS) assays, whereas recombinant FVIII-SQ products had lower OS than CS activity. Transgene-produced and recombinant FVIII-SQ showed comparable specific activity (international units per milligram) in the CS assay, demonstrating that the diverging activities arise in the OS assay. Higher OS activity for transgene-produced FVIII-SQ was observed across various assay kits and clinical laboratories, suggesting that intrinsic molecular features are potential root causes. Further experiments in 2 participants showed that transgene-produced FVIII-SQ accelerated early factor Xa and thrombin formation, which may explain the higher OS activity based on a kinetic bias between OS and CS assay readout times. Despite the faster onset of coagulation, global thrombin levels were unaffected. A correlation with joint bleeds suggested that both OS and CS assay remained clinically meaningful to distinguish hemophilic from nonhemophilic FVIII activity levels. During clinical development, the CS activity was chosen as a surrogate end point to conservatively assess hemostatic efficacy and enable comparison with recombinant FVIII-SQ products. Relevant trials are registered on clinicaltrials.gov as #NCT02576795 and #NCT03370913 and, respectively, on EudraCT (European Union Drug Regulating Authorities Clinical Trials Database; https://eudract.ema.europa.eu) as #2014-003880-38 and #2017-003215-19.
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12
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Aquino CC, Borg Debono V, Germini F, Pete D, Kempton CL, Young G, Sidonio R, Croteau SE, Dunn AL, Key NS, Iorio A. Outcomes for studies assessing the efficacy of hemostatic therapies in persons with congenital bleeding disorders. Haemophilia 2021; 27:211-220. [PMID: 33550614 DOI: 10.1111/hae.14247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 12/17/2020] [Accepted: 12/21/2020] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Management strategies and hemostatic treatments to achieve control of bleeding are relevant across many disease areas. Identification of primary outcomes for studies assessing hemostatic intervention was the objective of a National Heart, Lung and Blood Institute (NHLBI) sponsored multidisciplinary initiative. The aim of this report is to summarize the evidence reviewed, and the outcomes identified by the subgroup tasked to assess outcomes for inherited bleeding disorders. METHODS The subgroup decided to focus on haemophilia, the prototypal congenital bleeding disorder and the one with the largest available body of evidence. MEDLINE, EMBASE and PsycINFO, The Cochrane Review, CINAHL, and Web of Science were searched for systematic and narrative reviews on outcomes used in haemophilia clinical trials. Three different clinical goals were identified as typical objectives of future research. RESULTS Out of 1322 unique citations, 24 reviews published in the period 2002-2019 were included. We identified 113 outcome measures, categorized in 6 domains: health-related quality of life (HRQoL), comorbidities and mortality, overall physical functioning and participation, bleeding and hemostasis, joint health, and costs and resource use. Three different clinical goals were identified as typical objectives of future research: Episodic 'on demand' replacement therapy, prevention of bleeding (Prophylaxis), and long-term and overall impact of bleeding. For each of these scenarios, specific outcomes were recommended. CONCLUSIONS Primary outcomes for clinical trials assessing the efficacy of hemostatic treatment in achieving control, prevention and limiting long-term consequences of bleeding in inherited bleeding disorders are suggested, and their strength and limitations discussed.
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Affiliation(s)
- Camila C Aquino
- Health Information Research Unit, Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,Hotchkiss Brain Institute, Calgary, Canada
| | - Victoria Borg Debono
- Health Information Research Unit, Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.,Department of Anesthesiology, McMaster University, Hamilton, ON, Canada.,Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - Federico Germini
- Health Information Research Unit, Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Drashti Pete
- Health Information Research Unit, Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Christine L Kempton
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA.,Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, Emory University School of Medicine, Atlanta, GA, USA
| | - Guy Young
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Robert Sidonio
- Department of Pediatrics, Emory University School of Medicine, Aflac Cancer and Blood Disorders, Atlanta, GA, USA
| | - Stacy E Croteau
- Boston Children's Hospital, Boston Hemophilia Center, Harvard Medical School, Boston, MA, USA
| | - Amy L Dunn
- Hemophilia Treatment Center, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Nigel S Key
- Division of Hematology and Blood Research Center, University of North Carolina School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Alfonso Iorio
- Health Information Research Unit, Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
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13
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Bukkems LH, Preijers T, van Spengler MWF, Leebeek FWG, Cnossen MH, Mathôt RAA. Comparison of the Pharmacokinetic Properties of Extended Half-Life and Recombinant Factor VIII Concentrates by In Silico Simulations. Thromb Haemost 2021; 121:731-740. [PMID: 33506481 DOI: 10.1055/s-0040-1721484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The pharmacokinetic (PK) properties of extended half-life (EHL) factor VIII (FVIII) concentrates differ, leading to variation in the optimal dosing regimen for the individual patient. The aim of this study was to establish these PK differences for various EHL FVIII concentrates by in silico simulations. METHODS FVIII level over time profiles of rFVIII-SC, BAY 81-8973, rFVIII-Fc, BAX 855, BAY 94-9027, and standard half-life (SHL) rFVIII concentrates were simulated for 1,000 severe hemophilia A patients during steady-state dosing of 40 IU/kg every 72 hours or dosing as advised in the summary of product characteristics (SmPC). RESULTS Although the elimination half-life values were comparable for rFVIII-FC, BAX 855, and BAY 94-9027, a higher area under the curve (AUC; 2,779 IU/h/dL) for BAY 94-9027 was obtained. During steady-state dosing of 40 IU/kg every 72 hours, 58.5% (rFVIII-SC), 69.3% (BAY 81-8972), 89.0% (rFVIII-Fc), 83.9% (BAX 855), and 93.7% (BAY 94-9027) of the patients maintained a trough level of 1 IU/dL, compared with 56.0% for SHL rFVIII. Following dosing schemes described in the SmPC, between 51.0 and 65.4% or 23.2 and 31.1% of the patients maintained a target trough level of 1 IU/dL or 3 IU/dL, respectively. CONCLUSION BAY 94-9027 showed the largest increase of AUC and best target attainment compared with SHL rFVIII, followed closely by BAX 855 and rFVIII-Fc. BAY 81-8973 and rFVIII-SC showed smaller PK improvements. Although our analyses increase insight into the PK of these FVIII concentrates, more studies evaluating the relation between factor levels and bleeding risk are needed.
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Affiliation(s)
- Laura H Bukkems
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Tim Preijers
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Max W F van Spengler
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus University Medical Center-Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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14
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He S, Cao H, Thålin C, Svensson J, Blombäck M, Wallén H. The Clotting Trigger Is an Important Determinant for the Coagulation Pathway In Vivo or In Vitro-Inference from Data Review. Semin Thromb Hemost 2020; 47:63-73. [PMID: 33348413 DOI: 10.1055/s-0040-1718888] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Blood coagulation comprises a series of enzymatic reactions leading to thrombin generation and fibrin formation. This process is commonly illustrated in a waterfall-like manner, referred to as the coagulation cascade. In vivo, this "cascade" is initiated through the tissue factor (TF) pathway, once subendothelial TF is exposed and bound to coagulation factor VII (FVII) in blood. In vitro, a diminutive concentration of recombinant TF (rTF) is used as a clotting trigger in various global hemostasis assays such as the calibrated automated thrombogram, methods that assess fibrin turbidity and fibrin viscoelasticity tests such as rotational thromboelastometry. These assays aim to mimic in vivo global coagulation, and are useful in assessing hyper-/hypocoagulable disorders or monitoring therapies with hemostatic agents. An excess of rTF, a sufficient amount of negatively charged surfaces, various concentrations of exogenous thrombin, recombinant activated FVII, or recombinant activated FIXa are also used to initiate activation of specific sub-processes of the coagulation cascade in vitro. These approaches offer important information on certain specific coagulation pathways, while alterations in pro-/anticoagulants not participating in these pathways remain undetectable by these methods. Reviewing available data, we sought to enhance our knowledge of how choice of clotting trigger affects the outcome of hemostasis assays, and address the call for further investigations on this topic.
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Affiliation(s)
- Shu He
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.,Division of Coagulation Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Honglie Cao
- Division of Coagulation Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Charlotte Thålin
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Jan Svensson
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Margareta Blombäck
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.,Division of Coagulation Research, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Wallén
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
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15
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Gardiner C, Coleman R, de Maat MPM, Dorgalaleh A, Echenagucia M, Gosselin RC, Ieko M, Kitchen S. International Council for Standardization in Haematology (ICSH) laboratory guidance for the evaluation of haemostasis analyser-reagent test systems. Part 1: Instrument-specific issues and commonly used coagulation screening tests. Int J Lab Hematol 2020; 43:169-183. [PMID: 33249720 DOI: 10.1111/ijlh.13411] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/12/2020] [Accepted: 11/06/2020] [Indexed: 12/01/2022]
Abstract
Before a new method is used for clinical testing, it is essential that it is evaluated for suitability for its intended purpose. This document gives guidance for the performance of verification, validation and implementation processes required by regulatory and accreditation bodies. It covers the planning and execution of an evaluation of the commonly performed screening tests (prothrombin time, activated partial thromboplastin time, thrombin time and fibrinogen assay), and instrument-specific issues. Advice on selecting an appropriate haemostasis analyser, planning the evaluation, and assessing the reference, interval, precision, accuracy, and comparability of a haemostasis test system are also given. A second companion document will cover specialist haemostasis testing.
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Affiliation(s)
- Chris Gardiner
- Haemostasis Research Unit, University College London, London, UK
| | - Robyn Coleman
- Department of Haematology, Sullivan Nicolaides Pathology, Bowen Hills, QLD, Australia
| | - Moniek P M de Maat
- Department of Haematology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Akbar Dorgalaleh
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Marión Echenagucia
- Centro Nacional de Hemofilia, Banco Municipal de Sangre del Distrito Capital, Caracas, Venezuela
| | - Robert C Gosselin
- Thrombosis and Hemostasis Center, University of California, Davis Health System, Sacramento, CA, USA
| | - Masahiro Ieko
- Health Sciences University of Hokkaido, Ishikari-Tobetsu, Japan
| | - Steve Kitchen
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
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16
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Müller J, Goldmann G, Marquardt N, Pötzsch B, Oldenburg J. Extended Half-Life Factor VIII/Factor IX Products: Assay Discrepancies and Implications for Hemophilia Management. Hamostaseologie 2020; 40:S15-S20. [PMID: 33187006 DOI: 10.1055/a-1282-2251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Due to structural differences between extended half-life (EHL) factor VIII (FVIII) or FIX products and equivalent plasma wild-type molecules used for assay calibration, reagent-dependent discrepancies during monitoring of FVIII- and FIX-replacement therapies with EHL products have been described. To assess the performance of available one-stage clotting and chromogenic substrate assays on the Siemens Atellica COAG 360 analyzer, an in vitro study using spiked plasma samples was performed. The described results confirm previously described findings and allowed allocation of each EHL product to an appropriate assay. In addition, corresponding EHL product-specific analytes were defined within the order entry system of the University Hospital Bonn. The requirement of product-specific FVIII and FIX assays complicates patient monitoring and demonstrates the need for both continuous education and communication between treating physicians and the coagulation laboratory.
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Affiliation(s)
- Jens Müller
- University Hospital Bonn, Institute of Experimental Haematology and Transfusion Medicine, Bonn, Germany
| | - Georg Goldmann
- University Hospital Bonn, Institute of Experimental Haematology and Transfusion Medicine, Bonn, Germany
| | - Natascha Marquardt
- University Hospital Bonn, Institute of Experimental Haematology and Transfusion Medicine, Bonn, Germany
| | - Bernd Pötzsch
- University Hospital Bonn, Institute of Experimental Haematology and Transfusion Medicine, Bonn, Germany
| | - Johannes Oldenburg
- University Hospital Bonn, Institute of Experimental Haematology and Transfusion Medicine, Bonn, Germany
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17
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Baker P, Platton S, Gibson C, Gray E, Jennings I, Murphy P, Laffan M. Guidelines on the laboratory aspects of assays used in haemostasis and thrombosis. Br J Haematol 2020; 191:347-362. [PMID: 32537743 DOI: 10.1111/bjh.16776] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Peter Baker
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sean Platton
- Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Claire Gibson
- Specialist Haemostasis, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elaine Gray
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Controls, Hertfordshire, UK
| | | | - Paul Murphy
- Department of Haematology, the Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mike Laffan
- Centre for Haematology, Imperial College and Hammersmith Hospital, London, UK
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18
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Ovanesov MV, Williams SC, Nübling C, Dodt J, Hilger A, Maryuningsih Y, Gray E. Summary of the WHO hearing on the development of product-specific reference materials for coagulation factor VIII and factor IX products. Biologicals 2020; 67:88-93. [DOI: 10.1016/j.biologicals.2020.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 11/26/2022] Open
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19
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Wilmot HV, Rakowski K, Gray E. The traceability of commercial plasma calibrators to the plasma International Standards for factor VIII and factor IX. Int J Lab Hematol 2020; 42:810-818. [PMID: 32638532 PMCID: PMC7754292 DOI: 10.1111/ijlh.13277] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 01/19/2023]
Abstract
Accurate measurement of coagulation factors is essential, especially for diagnosis of deficiency. Clinical laboratories use commercially available plasma calibrators, which should be traceable to the relevant plasma International Standard (IS). This study assessed the relationship between the plasma IS for factors IX (FIX) and VIII (FVIII) and some commonly used commercial calibrators. Calibrators from seven manufacturers were assayed for FIX and FVIII activity by one‐stage clotting assay (OSCA) using different activated partial thromboplastin time (APTT) reagents and deficient plasmas, or chromogenic assay (CA). Results were calculated relative to the 4th IS Factors II,VII,IX,X, Plasma or the 6th IS Factor VIII/VWF, Plasma. Results for each calibrator were similar across the APTT reagents and deficient plasmas used. All calibrators showed a recovery of 90%‐111% of the manufacturers’ values, except calibrator C, which had recovery of around 85%. CA gave similar results, with good recovery for all but calibrator C. Similar low recoveries for OSCA and CA were found for a different lot of calibrator C and for a different calibrator product from manufacturer C. When all calibrators from manufacturer C were assayed by OSCA using the manufacturer's own deficient plasmas and APTT reagents, the mean recovery was still below 90%. Overall, there was good traceability of the international unit between the IS and commercial calibrator plasmas. Calibrators from one manufacturer consistently yielded lower than expected values for FIX and FVIII. This could lead to an over‐estimation of the coagulation factor content in patient samples and demonstrates the importance of careful choice of calibrator.
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Affiliation(s)
- Helen V Wilmot
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Control (NIBSC), Potters Bar, Hertfordshire, United Kingdom
| | - Kajetan Rakowski
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Control (NIBSC), Potters Bar, Hertfordshire, United Kingdom
| | - Elaine Gray
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Control (NIBSC), Potters Bar, Hertfordshire, United Kingdom
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20
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Peyvandi F, Kenet G, Pekrul I, Pruthi RK, Ramge P, Spannagl M. Laboratory testing in hemophilia: Impact of factor and non-factor replacement therapy on coagulation assays. J Thromb Haemost 2020; 18:1242-1255. [PMID: 32115865 DOI: 10.1111/jth.14784] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/20/2020] [Accepted: 02/20/2020] [Indexed: 02/06/2023]
Abstract
The advent of extended half-life (EHL) recombinant clotting factors and innovative non-factor replacement therapeutics, such as emicizumab, offers several advantages over existing products for the prophylactic treatment of people living with hemophilia (PwH). These include low annual bleeding rates with less frequent dosing, higher trough plasma concentrations, and a more convenient route of administration. However, increasing use of these therapies poses challenges to clinicians and coagulation laboratories due to the lack of standardized assays for monitoring of hemostatic parameters, and the potential for misinterpretation of test results, which may jeopardize patient safety. Definitive diagnosis of hemophilia and treatment monitoring is reliant on demonstrating factor VIII (FVIII; hemophilia A) or factor IX (FIX; hemophilia B) deficiency using a functional coagulation assay. The most frequently used assays are based on activated partial thromboplastin time, using a one-stage or two-stage process. While one-stage and chromogenic assays have performed well with human-derived FVIII and FIX and full-length recombinant products, EHL recombinant factors are heterogeneous in structure and mode of action and therefore show wide variation in activity levels between different one-stage assays, and between one-stage and chromogenic assays. In the context of the recommended stepwise approach for laboratory diagnosis of hemophilia, we examine the diagnostic challenges associated with the use of EHL factors and novel non-factor therapeutics and consider the optimal diagnostic approach in PwH who are receiving these treatments. Ultimately, accurate diagnostic solutions are a prerequisite for personalized therapy to minimize treatment burden and improve quality of life in PwH.
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Affiliation(s)
- Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gili Kenet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Israeli National Hemophilia Center and Thrombosis Unit, The Amalia Biron Thrombosis Research Institute, Sheba Medical Center, Tel Hashomer, Israel
| | - Isabell Pekrul
- Hämostaseologie, Campus Innenstadt, Klinikum der Universität München, München, Germany
| | - Rajiv K Pruthi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, MN, USA
- Division of Hematopathology and Laboratory Genetics, Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Peter Ramge
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | - Michael Spannagl
- Hämostaseologie, Campus Innenstadt, Klinikum der Universität München, München, Germany
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21
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Sinegre T, Trayaud A, Tardieu M, Fourneyron V, Talon L, Berger MG, Tillier M, Senectaire S, Gembara P, Barbin AL, Vaissade A, Lebreton A. Measurements of eftrenonacog alfa by 19 different combinations reagents/instrument: A single-centre study. Haemophilia 2020; 26:543-552. [PMID: 32314511 DOI: 10.1111/hae.14003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/19/2020] [Accepted: 03/30/2020] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Recombinant factor IX Fc fusion protein (rFIXFc) is an extended half-life concentrate for the treatment of haemophilia B (HB). rFIXFc activity monitoring is crucial in several clinical situations. However, differences were observed between one-stage clotting (OSC) and chromogenic assays, but not for all factor IX (FIX) concentrations. AIMS To compare rFIXFc measurements obtained using different instruments and common OSC and chromogenic asssays. METHODS FIX:C measurements were performed in rFIXFc-spiked plasma aliquots (targeted FIX levels of 1.5, 1, 0.5, 0.2, 0.05, 0.02 and 0.01 IU/mL) and plasma samples collected from two patients with HB at various time points after rFIXFc infusion, using three instruments (STA-R MAX, ACLTOP700 and CS2100i) and common clotting and chromogenic FIX:C assays. RESULTS The same reagent could give different FIX:C measurements when adapted to different instruments. Moreover, the same reagent/instrument combination could give different results depending of the FIX concentration. For OSC assays, only STA-Cephascreen on STA-R MAX and CS2100i, SynthAFax on ACLTOP 700 and Actin on CS2100i provided acceptable recoveries for all rFIXFc concentrations. The chromogenic assays ROX-FIX and Biophen FIX:C underestimated rFIXFc for concentrations lower than 0.05 and 0.2 IU/mL, respectively. CONCLUSIONS Our study demonstrates that the same reagent adapted to different instruments could lead to different rFIXFc values. As rFIXFc under/overestimation could be associated with inappropriate treatment or biased calculation of pharmacokinetic parameters, the reagent/instrument combination used by haemostasis laboratories should be considered and regularly evaluated by external quality assessment programmes.
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Affiliation(s)
- Thomas Sinegre
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France.,INRA UMR 1019, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Adeline Trayaud
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Maryse Tardieu
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Virginie Fourneyron
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Laurie Talon
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Marc G Berger
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Maxence Tillier
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Stéphanie Senectaire
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Piotr Gembara
- Centre de Ressources et Compétences des Maladies Hémorragiques Constitutionnelles, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Anne-Lise Barbin
- Centre de Ressources et Compétences des Maladies Hémorragiques Constitutionnelles, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Aurélie Vaissade
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Aurélien Lebreton
- Service d'Hématologie Biologique, CHU Clermont-Ferrand, Clermont-Ferrand, France.,INRA UMR 1019, Université Clermont Auvergne, Clermont-Ferrand, France.,Centre de Ressources et Compétences des Maladies Hémorragiques Constitutionnelles, CHU Clermont-Ferrand, Clermont-Ferrand, France
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22
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Hajducek DM, Chelle P, Hermans C, Iorio A, McEneny-King A, Yu J, Edginton A. Development and evaluation of the population pharmacokinetic models for FVIII and FIX concentrates of the WAPPS-Hemo project. Haemophilia 2020; 26:384-400. [PMID: 32281726 DOI: 10.1111/hae.13977] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 02/14/2020] [Accepted: 03/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Web-Accessible Population Pharmacokinetic Service (WAPPS) project generates individually predicted pharmacokinetic (PK) profiles and tailored prophylactic treatment regimens for haemophilic patients, which rely on a set of population PK (PopPK) models providing concentrate-specific priors for the Bayesian forecasting methodology. AIM To describe the predictive performance of the WAPPS PopPK models in use on the WAPPS-Hemo platform. METHODS Data for modelling include dense PK data obtained from industry sponsored and independent PK studies, and dense and sparse data accumulated through WAPPS-Hemo. WAPPS PopPK models were developed via non-linear mixed-effect modelling taking into account the effects of covariates and between-individual-and sometimes between-occasion-variability. Model evaluation consisted of (a) prediction-corrected Visual Predictive Check (pcVPC), (b) Limited Sampling Analysis (LSA) and (c) repeated hold-out cross-validation. RESULTS Thirty-three WAPPS PopPK models built on data from 3188 patients (ages 1-78 years) under treatment by factor VIII or IX products (FVIII, FIX) were evaluated. Overall, models exhibit excellent performance characteristics. The pcVPC shows that the observed PK data fall within acceptable 90% interpercentile predictive bands. A slight overprediction beyond the expected half-life, an anticipated result of using sparse data, occurs for some models. The LSA results in lower than 3% of relative error for FVIII and FIX products and 16% for engineered FIX products. Cross-Validation analysis yields relative errors lower than 1.5% and 1.4% in estimates of half-life and time to 0.02 IU/mL, respectively. CONCLUSION The WAPPS-Hemo models consistently showed excellent performance characteristics for the intended use for Bayesian forecasting of individual PK profiles.
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Affiliation(s)
| | - Pierre Chelle
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Alfonso Iorio
- McMaster-Bayer Endowed Research Chair for Clinical Epidemiology of Congenital Bleeding Disorders, Department of Medicine, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Jacky Yu
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Andrea Edginton
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
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23
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Sommer JM, Sadeghi-Khomami A, Barnowski C, Wikén M, Willemze AJ. Real-world assay variability between laboratories in monitoring of recombinant factor IX Fc fusion protein activity in plasma samples. Int J Lab Hematol 2020; 42:350-358. [PMID: 32202380 PMCID: PMC7318191 DOI: 10.1111/ijlh.13189] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/25/2020] [Accepted: 02/28/2020] [Indexed: 02/06/2023]
Abstract
Introduction Monitoring of factor IX (FIX) replacement therapy in haemophilia B relies on accurate coagulation assays. However, considerable interlaboratory variability has been reported for one‐stage clotting (OSC) assays. This study aimed to evaluate the real‐world, interlaboratory variability of routine FIX activity assays used in clinical haemostasis laboratories for the measurement of recombinant FIX Fc fusion protein (rFIXFc) activity. Methods Human FIX‐depleted plasma was spiked with rFIXFc at 0.80, 0.20 or 0.05 IU/mL based on label potency. Participating laboratories tested samples using their own routine OSC or chromogenic substrate (CS) assay protocols, reagents and FIX plasma standards. Laboratories could perform more than one measurement and method, and were not fully blinded to nominal activity values. Results A total of 142 laboratories contributed OSC results from 175 sample kits using 11 different activated partial thromboplastin time (aPTT) reagents. The median recovered FIX activity for the 0.80, 0.20 and 0.05 IU/mL samples was 0.72 IU/mL, 0.21 IU/mL and 0.060 IU/mL, respectively. Across all OSC reagents, interlaboratory variability (% CV) per aPTT reagent ranged from 9.4% to 32.1%, 8.2% to 32.6% and 12.2% to 42.0% at the 0.80, 0.20 and 0.05 IU/mL levels, respectively. CS results showed excellent median recoveries at all nominal levels (87.5% to 115.0%; n = 11) with low interlaboratory variability (CV 3.6% to 15.4%). Conclusion This large, real‐world data set indicates that rFIXFc activity in plasma samples can be accurately measured with the majority of routine OSC and CS assay methods. Given the variation in FIX assay procedures between sites, it is important that individual laboratories qualify their in‐house methods for monitoring of rFIXFc activity.
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Williams SC, Gray E. Activity measurements of dalcinonacog alfa. Haemophilia 2020; 26:346-353. [PMID: 32142203 PMCID: PMC7891335 DOI: 10.1111/hae.13949] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/03/2020] [Accepted: 02/10/2020] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Many recombinant and modified FIX products have been, and continue to be, developed with the aim of improving treatment for patients with haemophilia B. One such new product is dalcinonacog alfa, a recombinant FIX with modifications to provide improved features such as subcutaneous administration. AIM In view of previously observed assay discrepancies with modified FIX therapeutics, the aim of this study was to assess potential discrepancies in potency measurement of dalcinonacog alfa between and within different assay methods. METHODS Potency of dalcinonacog alfa was measured against the 5th International Standard (IS) for FIX Concentrate and the 4th IS for FIX Plasma by One-Stage Clotting Assay, using 9 different APTT reagents and 2 commercially available FIX chromogenic kits. Plasma-derived concentrate and recombinant FIX samples were also included for comparison in every assay. RESULTS Substantial discrepancies were observed when assaying dalcinonacog alfa using the one-stage clotting assay against both standards. No statistically valid results were obtained when testing dalcinonacog alfa using either chromogenic kit. Increasing the incubation time with the activation reagent in both chromogenic kits resulted in valid assays and increased the potency to become more in line with potencies by one-stage clotting assays. Increasing the incubation time in the chromogenic kits had no effect on the potencies of the plasma-derived or recombinant samples. However, incubation time influenced in the one-stage clotting assay using Dapttin. CONCLUSIONS Within and between assay method discrepancy was found when assaying dalcinonacog alfa. Methods for potency labelling and clinical monitoring should be given careful consideration.
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Affiliation(s)
- Stella C Williams
- The National Institute for Biological Standards and Control, Potter Bar, UK
| | - Elaine Gray
- The National Institute for Biological Standards and Control, Potter Bar, UK
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Rosén S, Bryngelhed P. FIX potency of rFIX‐Albumin fusion protein is underestimated by one‐stage methods using silica‐based APTT reagents. Haemophilia 2020; 26:340-345. [DOI: 10.1111/hae.13915] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/20/2019] [Accepted: 12/03/2019] [Indexed: 01/22/2023]
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Ezban M, Hansen M, Kjalke M. An overview of turoctocog alfa pegol (N8-GP; ESPEROCT ® ) assay performance: Implications for postadministration monitoring. Haemophilia 2019; 26:156-163. [PMID: 31809565 PMCID: PMC7028088 DOI: 10.1111/hae.13897] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 10/21/2019] [Accepted: 11/11/2019] [Indexed: 01/22/2023]
Abstract
Factor replacement therapy with factor VIII (FVIII) concentrates is the current standard of care for patients with haemophilia A. Postadministration monitoring of FVIII activity during on‐demand or prophylactic treatment is important, for example to guide a suitable dosing regimen. While the use of two‐stage chromogenic substrate (CS) assays is increasing, activated partial thromboplastin time (APTT)‐based one‐stage clotting (OSC) assays are most commonly used to measure FVIII activity in clinical laboratories. Substantial variations in activity measurements have been observed in association with some OSC assay reagents when assessing extended half‐life FVIII molecules. Certain silica‐based APTT reagents have previously been shown to underestimate FVIII activity with the polyethylene glycol (PEG)‐conjugated product turoctocog alfa pegol (N8‐GP [ESPEROCT®]; Novo Nordisk A/S). As a wide range of assay reagents are used in clinical laboratories worldwide, it is essential to establish which can be used to accurately measure activity with modified FVIII concentrates. Here, we describe the approach taken by Novo Nordisk to determine the suitability and accuracy of assays and reagents to measure FVIII activity in samples that contain N8‐GP. While accurate activity measurements were possible with all tested CS assays and most of the OSC APTT reagents tested, three APTT reagents that contain silica as a contact activator were found to underestimate N8‐GP recovery (APTT‐SP, TriniCLOT™, STA® PTT‐Automate). The data demonstrate the importance of characterizing the accuracy of each FVIII activity assay. Any limitations should be communicated to treating physicians and the clinical laboratories that test samples containing N8‐GP.
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