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Franchini M, Focosi D. Inhibitor eradication and treatment for acquired hemophilia A. Expert Rev Hematol 2024; 17:233-240. [PMID: 38708599 DOI: 10.1080/17474086.2024.2352505] [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: 01/08/2024] [Accepted: 05/03/2024] [Indexed: 05/07/2024]
Abstract
INTRODUCTION Acquired hemophilia A (AHA) is a rare hemorrhagic autoimmune disorder characterized by autoantibodies against coagulation factor VIII (FVIII). In approximately half of the cases AHA does not recognize any cause (idiopathic form), while in the other cases it may be triggered by autoimmune disorders, cancers, drugs, infections, or pregnancy. Besides treating the underlying disorder, specific AHA treatment includes management of bleeding, if necessary, and inhibitor eradication. AREAS COVERED This narrative review summarizes the main epidemiological, clinical, laboratory, and therapeutic characteristics of AHA. In particular, it is focused on the current therapeutic options for the inhibitor eradication, also showing the latest findings on the innovative therapies. A literature search strategy was performed, without temporal limits, through Medline and PubMed electronic databases. EXPERT OPINION Various first-line and second-line immunosuppressive agents are currently available for the management of AHA. Among the latter, the anti-CD20 monoclonal antibody rituximab has been the object of intense research during the last years from investigators as innovative promising eradicating therapy for AHA. Preliminary data from the studies support the use of this drug as a first-line option for newly diagnosed AHA cases.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
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2
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Tiede A, Susen S, Lisman T. Acquired bleeding disorders. Haemophilia 2024; 30 Suppl 3:29-38. [PMID: 38562115 DOI: 10.1111/hae.14995] [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: 01/23/2024] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 04/04/2024]
Abstract
Acquired bleeding disorders can develop in previously healthy people irrespective of age or gender but are particularly common in patients with certain underlying conditions. Here, we review recent advances in the management of acquired haemophilia A (AHA), acquired von Willebrand syndrome (AVWS), and patients with hemostatic abnormalities due to chronic liver disease (CLD). Patients with AHA can now benefit from prophylaxis with emicizumab, a therapeutic antibody that mimics the function of activated coagulation factor VIII. The treatment of AVWS remains challenging in many situations and requires careful consideration of the underlying condition. Haemostatic abnormalities in CLD are often compensated by proportional reduction in pro and anti-haemostatic factors resulting in sustained or even increased thrombin generation. Consequently, bleeding in CLD is rarely caused by haemostatic failure and infusion of plasma or coagulation factor concentrates may not be effective.
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Affiliation(s)
- Andreas Tiede
- Department of Haematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Sophie Susen
- Hemostasis and Transfusion Department, University of Lille, Lille University Hospital, Lille, France
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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Platton S. Diagnosis and laboratory monitoring of hemophilia A. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:11-18. [PMID: 38066923 PMCID: PMC10727114 DOI: 10.1182/hematology.2023000460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Acquired hemophilia A (AHA) is a rare disorder in which autoantibodies against factor VIII (FVIII) lead to a bleeding phenotype that varies from life-threatening to no bleeding at all. Prolonged activated partial thromboplastin times (APTT) in patients with a bleeding phenotype should be investigated to rule out AHA and should never be ignored in a preprocedure patient. Most inhibitors in AHA are heat and time dependent, so mixing studies performed only on an immediate mix are not useful: both lupus anticoagulants and treatment with direct oral anticoagulants can coexist with AHA and confound the diagnosis. Assays for intrinsic coagulation factors and von Willebrand factor should always be performed, regardless of the results of mixing studies. A Bethesda or modified Bethesda assay should be performed to quantify any inhibitor, and if susoctocog alfa (rpFVIII) is available, then an assay for cross-reacting antibodies should also be performed. At diagnosis and until complete remission, if the FVIII in the patient sample is >5 IU/dL, heat inactivation should be performed before the inhibitor assays are performed. While there are no conventional tests available to measure the effects of FVIII bypassing therapies, newer therapies may require monitoring, or their effects may need to be considered when choosing appropriate assays. Measurement of rpFVIII requires a 1-stage clotting assay, and measurement of patient FVIII while on emicizumab requires a chromogenic assay that does not contain human FX. Close communication is required between the treating clinicians and the laboratory to ensure that the correct tests are performed while patients are receiving treatments.
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Affiliation(s)
- Sean Platton
- The Royal London Hospital Haemophilia Centre, Bart Health NHS Trust, London, UK
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Marino R. Acquired Hemophilia A: Bleeding Pattern and Hemostatic Therapeutic Strategies. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1739. [PMID: 37893457 PMCID: PMC10608116 DOI: 10.3390/medicina59101739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023]
Abstract
Acquired Hemophilia A (AHA) is a rare autoimmune disorder characterized by the onset of a sudden and unexpected bleeding episode in a patient with no personal or family history of bleeding diathesis, and with a typical laboratory feature, i.e., a prolonged activated partial thromboplastin time that is not otherwise explained. This bleeding disorder is caused by autoantibodies directed against the coagulation factor VIII (FVIII). AHA is idiopathic in 50% of cases and is secondary to well-defined diseases in the remaining 50%. AHA affects elderly patients although it has also been observed in the post-partum period. Bleeding manifestations are heterogeneous, ranging from mild to life-threatening bleeds involving limbs and organs. Severe bleeding with a significant decrease in hemoglobin levels must be promptly and adequately treated in order to avoid a worsening of the hemorrhages and their complications. According to international recommendations, the bypass agents (i.e., activated prothrombin complex concentrate and activated recombinant factor VII) and the replacement therapy with recombinant porcine FVIII are considered as the first-line therapy for bleeding control, due to their proven clinical efficacy. Plasma-derived or recombinant FVIII concentrates could be used as second-line treatments. Emicizumab may represent a valid and interesting therapeutic option for prophylaxis of bleeding recurrences.
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Affiliation(s)
- Renato Marino
- Hemophilia and Thrombosis Centre, University Hospital of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
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Nguyen NH, Jarvi NL, Balu-Iyer SV. Immunogenicity of Therapeutic Biological Modalities - Lessons from Hemophilia A Therapies. J Pharm Sci 2023; 112:2347-2370. [PMID: 37220828 DOI: 10.1016/j.xphs.2023.05.014] [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: 02/10/2023] [Revised: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 05/25/2023]
Abstract
The introduction and development of biologics such as therapeutic proteins, gene-, and cell-based therapy have revolutionized the scope of treatment for many diseases. However, a significant portion of the patients develop unwanted immune reactions against these novel biological modalities, referred to as immunogenicity, and no longer benefit from the treatments. In the current review, using Hemophilia A (HA) therapy as an example, we will discuss the immunogenicity issue of multiple biological modalities. Currently, the number of therapeutic modalities that are approved or recently explored to treat HA, a hereditary bleeding disorder, is increasing rapidly. These include, but are not limited to, recombinant factor VIII proteins, PEGylated FVIII, FVIII Fc fusion protein, bispecific monoclonal antibodies, gene replacement therapy, gene editing therapy, and cell-based therapy. They offer the patients a broader range of more advanced and effective treatment options, yet immunogenicity remains the most critical complication in the management of this disorder. Recent advances in strategies to manage and mitigate immunogenicity will also be reviewed.
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Affiliation(s)
- Nhan H Nguyen
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA; Currently at Truvai Biosciences, Buffalo, NY, USA
| | - Nicole L Jarvi
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Sathy V Balu-Iyer
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.
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Tarantino MD, Hardesty B, Metjian A, Ortel TL, Chen J, Badejo K, Ma A, Cuker A, Rajasekhar A, Friedman KD, Janbain M. Real-world safety and effectiveness of recombinant porcine sequence factor VIII in acquired haemophilia A: A non-interventional, post-authorization safety study. Haemophilia 2023; 29:1259-1268. [PMID: 37584309 DOI: 10.1111/hae.14832] [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: 10/27/2022] [Revised: 06/29/2023] [Accepted: 07/07/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Recombinant porcine factor VIII (rpFVIII, susoctocog alfa) is indicated for the treatment of bleeding episodes in adults with acquired haemophilia A (AHA). AIM To provide long-term real-world safety and effectiveness data for rpFVIII in the management of AHA bleeding episodes. METHODS US PASS (NCT02610127) was a multicentre, uncontrolled, open-label, post-marketing safety surveillance study conducted in adults with AHA. Data were collected retrospectively or prospectively for 180 days after rpFVIII treatment. The primary outcome was the incidence of treatment-related serious adverse events (SAEs). Secondary outcomes included haemostatic effectiveness of rpFVIII and rpFVIII utilization. RESULTS Fifty-three patients were enrolled from December 2015 to June 2019 (prospective, n = 30; retrospective, n = 23). Six patients experienced seven treatment-related SAEs (incidence 12.0%). The most common treatment-related SAE was FVIII inhibition (inhibiting antibodies to rpFVIII; incidence 8.0%, 95% CI: 2.2-19.2). Five patients reported seven thromboembolic events; one was an SAE and possibly related to rpFVIII. Of bleeding events treated with rpFVIII, 80.3% (57/71) of bleeds resolved with rpFVIII. The median (range) dose of rpFVIII per infusion was 50 (10-300) units/kg, with a median (range) of 6.0 (1-140) infusions and a median (range) time from bleed onset to bleed resolution of 14.0 (2.0-132.7) days. CONCLUSION In this real-world study of rpFVIII for AHA, no new safety signals were identified compared with previous clinical trial findings. Eighty percent of bleeds resolved with rpFVIII treatment.
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Affiliation(s)
| | - Brandon Hardesty
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Ara Metjian
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Jie Chen
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Kayode Badejo
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Alice Ma
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anita Rajasekhar
- Department of Hematology/Oncology, University of Florida Health, Gainesville, Florida, USA
| | - Kenneth D Friedman
- Medical College of Wisconsin and Versiti/Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
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Sella C, Bardetta M, Valeri F, Dainese C, Valpreda A, Massaia M, Grimaldi D, Porreca A, Bruno B, Borchiellini A. Surgery and Prophylaxis with Susoctocog-Alfa in Acquired Hemophilia: Case Series and Literature Review. J Clin Med 2023; 12:4590. [PMID: 37510704 PMCID: PMC10380857 DOI: 10.3390/jcm12144590] [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: 05/19/2023] [Revised: 07/02/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a rare bleeding disease due to autoantibodies directed against clotting factor VIII (FVIII). Treatment of AHA consists of inhibitor eradication with immunosuppressive therapy (IST) and prompt control of bleeding obtained with bypassing agents or recombinant porcine FVIII (rpFVIII). The latter has recently been licensed for management of acute bleeding in AHA. Unlike treatment with bypassing agents, rpFVIII can be monitored to provide a successful hemostatic effect and avoid overtreatment. Correlation between rpFVIII inhibitor titers and efficacy of rpFVIII treatment remains a matter of debate. METHODS We report three cases of AHA in which rpFVIII was successfully used with an unconventional schedule despite the presence of medium-high titers of the rpFVIII. The modified Nijmegen-Bethesda inhibitor assay (NBA) was used to dose porcine FVIII inhibitors. RESULT The presence of rpFVIII inhibitors prior to the exposition to susoctocog-alfa, that may suggest a cross-reactivity with human FVIII inhibitors, did not affect hemostasis. CONCLUSION In our experience, rpFVIII demonstrates safety and efficacy in the presence of rpFVIII inhibitors and using an unconventional schedule in both the perioperative and outpatient settings. Laboratory measurement of inhibitors against rpFVIII during treatment is described for the first time.
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Affiliation(s)
- Carola Sella
- Regional Centre for Hemorrhagic and Thrombotic Diseases, AOU Città della Salute e della Scienza, 10126 Turin, Italy
- Division of Hematology, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, 10124 Turin, Italy
| | - Marco Bardetta
- Regional Centre for Hemorrhagic and Thrombotic Diseases, AOU Città della Salute e della Scienza, 10126 Turin, Italy
- Division of Hematology, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, 10124 Turin, Italy
| | - Federica Valeri
- Regional Centre for Hemorrhagic and Thrombotic Diseases, AOU Città della Salute e della Scienza, 10126 Turin, Italy
- Division of Hematology, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
| | - Cristina Dainese
- Regional Centre for Hemorrhagic and Thrombotic Diseases, AOU Città della Salute e della Scienza, 10126 Turin, Italy
- Division of Hematology, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
| | - Alessandra Valpreda
- Central Laboratory Baldi and Riberi, AOU Città della Salute e della Scienza, University of Turin, 10124 Turin, Italy
| | - Massimo Massaia
- Hematology Unit, Santa Croce e Carle Hospital, 12100 Cuneo, Italy
| | - Daniele Grimaldi
- Hematology Unit, Santa Croce e Carle Hospital, 12100 Cuneo, Italy
| | - Annamaria Porreca
- Department of Medical, Oral and Biotechnologies Science, University of Chieti-Pescara, 66100 Chieti, Italy
| | - Benedetto Bruno
- Division of Hematology, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, 10124 Turin, Italy
| | - Alessandra Borchiellini
- Regional Centre for Hemorrhagic and Thrombotic Diseases, AOU Città della Salute e della Scienza, 10126 Turin, Italy
- Division of Hematology, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
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MacNeill M, Mansory EM, Lazo-Langner A, Phua CW. Acquired Hemophilia A Masquerading as Bleeding on Anticoagulation: A Case Report Including Key Laboratory Considerations. Cureus 2023; 15:e41029. [PMID: 37519483 PMCID: PMC10373513 DOI: 10.7759/cureus.41029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 08/01/2023] Open
Abstract
We report a case of a patient with recurrent hematomas while on anticoagulation for a pulmonary embolism and a prolonged hospital stay due to a delayed diagnosis for acquired hemophilia A. Acquired hemophilia A is a rare autoimmune bleeding disorder with autoantibodies directed against coagulation factor VIII (FVIII), leading to an acquired FVIII deficiency. A prolonged isolated activated partial thromboplastin time (aPTT) in a bleeding patient warrants workup for acquired hemophilia A. This is specifically challenging in patients with thrombosis on anticoagulation and can lead to significant delays in diagnosis and associated morbidities. The case highlights the need for further awareness of this disease, potential laboratory pitfalls when conducting and interpreting coagulation assays, and the management considerations in a patient with a simultaneous thrombotic and hemorrhagic condition.
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Affiliation(s)
- Michael MacNeill
- Medicine, Schulich School of Medicine & Dentistry, Western University, London, CAN
| | | | | | - Chai W Phua
- Hematology, Schulich School of Medicine & Dentistry, Western University, London, CAN
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Ruberti A, Kremer Hovinga JA, Nappi F, Vettese A, Bianchi E, Fernandes E, Galfetti E, Monotti R, Paul P, Regazzoni S, Valente D, Rossi D, Stussi G, Gerber B. Acquired haemophilia A in southern Switzerland from 2013 to 2019: a case series. Swiss Med Wkly 2023; 153:40048. [PMID: 37021783 DOI: 10.57187/smw.2023.40048] [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: 04/05/2023] Open
Abstract
AIMS OF THE STUDY: Acquired haemophilia A is a rare disease with an annual incidence of 1.48 per million. Based on clinical observations, we suspect a higher incidence in southern Switzerland, and aimed at providing local epidemiological data, and clinical information regarding diagnosis, treatment and outcome in our region.
METHODS: All adult patients with acquired haemophilia A treated between 2013 and 2019 in our facility were included in the present retrospective analysis.
RESULTS: We treated 11 patients with acquired haemophilia A between 2013 and 2019, resulting in an annual incidence of 4.5 per million (95% confidence interval [CI] 0–9.0). Median delay from first symptoms to diagnosis was 4.5 days, and the median age at diagnosis was 79 years (range 23–87). Possible causative conditions were: pregnancy (n = 1), polyarteritis nodosa (n = 1), myelodysplastic syndrome (n = 1), chronic human immunodeficiency virus (HIV) (n = 1), and HIV postexposure prophylaxis (n = 1). In five patients no underlying or associated condition was identified. Median activated partial thromboplastin time (aPTT)) at baseline was 79 seconds (65–117; ref. value <38 sec), and FVIII:C 2.15% (<1–3.75%). A FVIII:C <1% was present in 4/10 patients. Median FVIII-inhibitor titre was 10.3 BU/ml (2.4–75.0 BU/ml). All patients had bleeding symptoms, 5/10 patients had major bleedings, and 7/10 patients were treated with bypassing agents. All patients received corticosteroids; 7/10 patients received immunosuppressive combination therapy. FVIII levels of ≥50% were achieved after a median of 40 days (8–62). One patient had a severe immunosuppressive therapy-related infection. An 87-years-old woman died for reasons not related to acquired haemophilia A or immunosuppressive therapy.
CONCLUSIONS: Acquired haemophilia A is a rare disease, but manageable despite the advanced patient age and comorbidities. Its incidence in Southern Switzerland is higher than previously suspected.
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Affiliation(s)
- Andrea Ruberti
- Department of Internal Medicine, Ospedale La Carità, Locarno, Switzerland
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Johanna A Kremer Hovinga
- Department of Haematology and Central Haematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Federico Nappi
- Department of Internal Medicine, Ospedale La Carità, Locarno, Switzerland
| | - Aurora Vettese
- Department of Laboratory Medicine EOLAB, Bellinzona, Switzerland
| | - Elena Bianchi
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Eliana Fernandes
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Elena Galfetti
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Rita Monotti
- Department of Internal Medicine, Ospedale La Carità, Locarno, Switzerland
| | - Pamella Paul
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Stefano Regazzoni
- Department of Internal Medicine, Ospedale Civico, Lugano, Switzerland
| | | | - Davide Rossi
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- Laboratory of Experimental Haematology, Institute of Oncology Research, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Georg Stussi
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Bernhard Gerber
- Department of Laboratory Medicine EOLAB, Bellinzona, Switzerland
- Clinic of Haematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- University of Zurich, Switzerland
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Gelbenegger G, Traby L, Rahimi N, Knöbl P. Management of acquired haemophilia A in severe Covid-19: Haemostatic bridging with emicizumab to keep the balance between bleeding and thrombosis. Br J Clin Pharmacol 2023; 89:908-913. [PMID: 36369653 PMCID: PMC9877795 DOI: 10.1111/bcp.15598] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/05/2022] [Accepted: 11/06/2022] [Indexed: 11/15/2022] Open
Abstract
Acquired haemophilia A (AHA) is an autoimmune bleeding disorder caused by autoantibodies blocking coagulation factor VIII (FVIII). Haemostatic management of AHA and concomitant thrombotic risk is difficult. We cover the management of a 75-year-old male with severe Covid-19, a prothrombotic disease, and de novo AHA with severe muscle bleeding, a disease requiring highly thrombogenic haemostatic therapy and immunosuppression-a challenging combination. FVIII activity was measured using human and bovine reagents to differentiate between endo- and exogenous FVIII activity. For haemostatic control, recombinant human activated FVII was given, followed by emicizumab, as a less thrombogenic long-term haemostatic agent. Steroids were used as initial immunosuppressive therapy. Later, rituximab was used for inhibitor eradication. No thromboembolic events occurred, and bleeding was effectively controlled. Emicizumab achieved haemostatic balance in a patient under haemorrhagic and thrombogenic conditions. Individual risk assessment is needed to guide treatment decisions in patients threatened by simultaneous bleeding and thrombosis.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical PharmacologyMedical University of ViennaViennaAustria
| | - Ludwig Traby
- Department of Medicine I, Division of Infectious Diseases and Tropical MedicineMedical University of ViennaViennaAustria
| | - Nina Rahimi
- Department of Medicine I, Division of Infectious Diseases and Tropical MedicineMedical University of ViennaViennaAustria
| | - Paul Knöbl
- Department of Medicine I, Division of Hematology and HemostasisMedical University of ViennaViennaAustria
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Mingot-Castellano ME, Rodríguez-Martorell FJ, Nuñez-Vázquez RJ, Marco P. Acquired Haemophilia A: A Review of What We Know. J Blood Med 2022; 13:691-710. [PMID: 36447782 PMCID: PMC9701517 DOI: 10.2147/jbm.s342077] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/10/2022] [Indexed: 08/31/2023] Open
Abstract
Autoantibodies against plasma coagulation factors could be developed by some individuals inducing severe and sometimes fatal bleedings. This clinical entity is called acquired haemophilia. It should be suspected in subjects with acute abnormal bleedings, without personal or familiar history of congenital bleeding disorders with an unexplained prolonged aPTT. It is rare disease, although its incidence may be underestimated due to the low knowledge about it by many specialists, the frequent use of anticoagulant or antiplatelet therapies in the affected population that can mask the diagnosis and, sometimes, a so withering effect that avoid its confirmation. Mortality ranges between 9% and 33% depending on the series in the first 2 months after diagnosis. This mortality is attributed in up to 40% of the cases to infections in the context of immunosuppressive treatments used to eliminate the inhibitor. Factor VIII levels below 1% and high inhibitor titers are conditions of worse response rates. Advanced age, patient's ECOG, and underlying conditions are key prognostic factors for response to treatment and patient survival. To reduce morbidity and mortality in these patients, it is important to have clinical knowledge and access to guidelines to achieve an early diagnosis and to optimize the haemostatic and immunosuppressive treatment. This review aims to contribute to the dissemination of basic concepts on the epidemiology etiopathogenesis, diagnosis, treatment and management of these patients, as well as risk factors to get remission and the longest overall survival to allow individualized care. Especial awareness will be proposed in patients with some underlying conditions like cancer, autoimmune diseases, children, pregnancy or drugs.
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Affiliation(s)
- María Eva Mingot-Castellano
- Hematology Department, Hospital Universitario Virgen del Rocío. Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | | | - Ramiro José Nuñez-Vázquez
- Hematology Department, Hospital Universitario Virgen del Rocío. Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - Pascual Marco
- General Medicine Department, Universidad Miguel Hernández, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
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12
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Targets of autoantibodies in acquired hemophilia A are not restricted to factor VIII: data from the GTH-AH 01/2010 study. Blood Adv 2022; 7:122-130. [PMID: 35947142 PMCID: PMC9830154 DOI: 10.1182/bloodadvances.2022008071] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/25/2022] [Accepted: 07/25/2022] [Indexed: 01/14/2023] Open
Abstract
The root cause of autoantibody formation against factor VIII (FVIII) in acquired hemophilia A (AHA) remains unclear. We aimed to assess whether AHA is exclusively associated with autoantibodies toward FVIII or whether patients also produce increased levels of autoantibodies against other targets. A case-control study was performed enrolling patients with AHA and age-matched controls. Human epithelial cell (HEp-2) immunofluorescence was applied to screen for antinuclear (ANA) and anticytoplasmic autoantibodies. Screening for autoantibodies against extractable nuclear antigens was performed by enzyme immunoassay detecting SS-A/Ro, SS-B/La, U1RNP, Scl-70, Jo-1, centromere B, Sm, double-stranded DNA, and α-fodrin (AF). Patients with AHA were more often positive for ANA than control patients (64% vs 30%; odds ratio [OR] 4.02, 1.98-8.18) and had higher ANA titers detected than controls. Cytoplasmic autoantibodies and anti-AF immunoglobulin A autoantibodies were also more frequent in patients with AHA compared with controls. Autoantibodies against any target other than FVIII were found in 78% of patients with AHA compared with 46% of controls (OR 4.16, 1.98-8.39). Results were similar preforming sensitivity analyses (excluding either subjects with autoimmune disorders, cancer, pregnancy, or immunosuppressive medication at baseline) and in multivariable binary logistic regression. To exclude that autoantibody staining was merely a result of cross-reactivity of anti-FVIII autoantibodies, we tested a mix of 7 well-characterized monoclonal anti-FVIII antibodies. These antibodies did not stain HEp-2 cells used for ANA detection. In conclusion, a diverse pattern of autoantibodies is associated with AHA, suggesting that a more general breakdown of immune tolerance might be involved in its pathology.
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Tiede A, Zieger B, Lisman T. Acquired bleeding disorders. Haemophilia 2022; 28 Suppl 4:68-76. [PMID: 35521729 DOI: 10.1111/hae.14548] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/23/2020] [Indexed: 12/19/2022]
Abstract
Acquired bleeding disorders can accompany hematological, neoplastic, autoimmune, cardiovascular or liver diseases, but can sometimes also arise spontaneously. They can manifest as single factor deficiencies or as complex hemostatic abnormalities. This review addresses (a) acquired hemophilia A, an autoimmune disorder characterized by inhibitory autoantibodies against coagulation factor VIII; (b) acquired von Willebrand syndrome in patients with cardiovascular disorders, where shear stress abnormalities result in destruction of von Willebrand factor; and (c) liver function disorders that comprise complex changes in pro- and anti-hemostatic factors, whose clinical implications are often difficult to predict. The article provides an overview on the pathophysiology, diagnostic tests and state-of-the-art treatment strategies.
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Affiliation(s)
- Andreas Tiede
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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14
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Négrier C, Oldenburg J, Kenet G, Meeks SL, Bordet JC, Müller J, Le Quellec S, Turecek PL, Tripkovic N, Dargaud Y. Recombinant porcine factor VIII corrects thrombin generation in vitro in plasma from patients with congenital hemophilia A and inhibitors. Res Pract Thromb Haemost 2022; 6:e12731. [PMID: 35765670 PMCID: PMC9207117 DOI: 10.1002/rth2.12731] [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: 08/09/2021] [Revised: 03/16/2022] [Accepted: 04/10/2022] [Indexed: 11/21/2022] Open
Abstract
Background Neutralizing factor VIII (FVIII) antibodies are a major complication in hemophilia A. Antihemophilic factor VIII (recombinant), porcine sequence (rpFVIII; susoctocog alfa; Baxalta US Inc., a Takeda company) has low cross‐reactivity to anti‐human FVIII antibodies and can provide functional FVIII activity in the presence of FVIII inhibitors. Objectives Evaluate in vitro thrombin generation and clot formation responses to rpFVIII in blood from patients with congenital hemophilia A. Methods In this multicenter study, blood was obtained for in vitro analyses that included human and porcine FVIII inhibitors, low <5 Bethesda units (BU)/ml or high ≥5 BU/ml titer (Nijmegen‐modified Bethesda assay); thrombin generation assay (TGA), clot viscoelasticity (thromboelastography), fibrin clot structure analysis (scanning electron microscopy), and epitope mapping. Results Blood samples were from 20 patients with congenital hemophilia A (FVIII activity <1%, mean [range] inhibitor titers: anti‐human FVIII, 14 [1–427] BU/ml [n = 13 high, n = 6 low, n = 1 data unavailable]); anti‐porcine FVIII, 12 (0–886) BU/ml (n = 11 high, n = 8 low, n = 1 data unavailable). Porcine inhibitor titer and TGA response measured by endogenous thrombin potential showed an inverse correlation (2.7–10.8 U/ml rpFVIII Spearman correlation coefficient: −0.594 to −0.773; p < 0.01). Clot structures in low anti‐porcine inhibitor titer plasmas were similar to those in noninhibitor plasma. Conclusions Recombinant porcine factor VIII demonstrated a dose‐dependent correction of thrombin generation and clot formation in vitro, dependent on the anti‐porcine FVIII inhibitor titer. Procoagulant responses to rpFVIII occurred in plasma containing FVIII inhibitors.
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Affiliation(s)
- Claude Négrier
- Unite d'Hemostase Clinique Centre National de Reference de l'Hemophilie Hopital Louis Pradel Universite Lyon1 Lyon France
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine University Clinic Bonn Bonn Germany
| | - Gili Kenet
- National Hemophilia Center Sheba Medical Center Tel Hashomer and The Amalia Biron Thrombosis Research Institute Tel Aviv University Tel Aviv Israel
| | - Shannon L Meeks
- Aflac Cancer and Blood Disorders Center Emory University School of Medicine Children's Healthcare of Atlanta Atlanta Georgia USA
| | - Jean-Claude Bordet
- Unite d'Hemostase Clinique Centre National de Reference de l'Hemophilie Hopital Louis Pradel Universite Lyon1 Lyon France
| | - Jens Müller
- Institute of Experimental Haematology and Transfusion Medicine University Clinic Bonn Bonn Germany
| | - Sandra Le Quellec
- Unite d'Hemostase Clinique Centre National de Reference de l'Hemophilie Hopital Louis Pradel Universite Lyon1 Lyon France
| | | | | | - Yesim Dargaud
- Unite d'Hemostase Clinique Centre National de Reference de l'Hemophilie Hopital Louis Pradel Universite Lyon1 Lyon France
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15
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Nardella J, Comitangelo D, Marino R, Malcangi G, Barratta MD, Sabba C, Perrone A. Acquired Hemophilia A After SARS-CoV-2 Infection: A Case Report. J Med Cases 2022; 13:197-201. [PMID: 35655623 PMCID: PMC9119369 DOI: 10.14740/jmc3921] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/14/2022] [Indexed: 11/17/2022] Open
Abstract
Acquired hemophilia A is a rare autoimmune coagulation disorder associated to the development of neutralizing antibodies directed towards coagulation factor VIII, known as factor VIII inhibitors, in subjects with previous normal clotting system homeostasis and personal and family history negative for bleeding episodes. This condition, although variable in severity and clinical presentation, may lead to severe and life-threatening hemorrhages which can be either spontaneous or associated with traumatic events and invasive procedures. Here we report the case of a 53-year-old woman who was admitted to our Internal Medicine Unit "Cesare Frugoni", Policlinico di Bari, in July 2021, and diagnosed with acquired hemophilia A. We aim to raise awareness about this rare condition, its clinical presentation and therapeutic management options in order to obtain a quick diagnosis and an effective therapeutic intervention.
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Affiliation(s)
- Jennifer Nardella
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Domenico Comitangelo
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Renato Marino
- Hemophilia and Transfusion Center, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Giuseppe Malcangi
- Hemophilia and Transfusion Center, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Marco Damiano Barratta
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Carlo Sabba
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
| | - Antonio Perrone
- DIM - Interdisciplinary Department of Medicine, Internal Medicine Unit “Cesare Frugoni”, University of Bari “Aldo Moro” School of Medicine, Policlinico Hospital, Bari, Italy
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16
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Bowyer A, Gray E, Lowe A, Murphy P, Platton S, Riddell A, Chowdary P, Lester W, Jenkins PV. Laboratory coagulation tests and recombinant porcine factor VIII: A United Kingdom Haemophilia Centre Doctors’ Organisation guideline. Haemophilia 2022; 28:515-519. [DOI: 10.1111/hae.14536] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/18/2022] [Accepted: 02/25/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Annette Bowyer
- Department of Coagulation Royal Hallamshire Hospital Sheffield UK
| | - Elaine Gray
- Haemostasis Section National Institute for Biological Standards and Control Potters Bar UK
| | - Anna Lowe
- UK National External Quality Assurance Scheme for Blood Coagulation Sheffield UK
| | - Paul Murphy
- Department of Haematology Newcastle Upon Tyne Hospitals Newcastle upon Tyne UK
| | - Sean Platton
- The Royal London Hospital Haemophilia Centre Barts Health NHS Trust London UK
| | - Anne Riddell
- Katharine Dormandy Haemophilia Centre Royal Free Hospital London UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre Royal Free Hospital London UK
| | - Will Lester
- Haemophilia Unit University Hospitals Birmingham Birmingham UK
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17
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Müller J, Miesbach W, Prüller F, Siegemund T, Scholz U, Sachs UJ. An Update on Laboratory Diagnostics in Haemophilia A and B. Hamostaseologie 2022; 42:248-260. [PMID: 35104901 PMCID: PMC9388220 DOI: 10.1055/a-1665-6232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Haemophilia A (HA) and B (HB) are X-linked hereditary bleeding disorders caused by lack of activity of coagulation factors VIII (FVIII) or IX (FIX), respectively. Besides conventional products, modern replacement therapies include FVIII or FIX concentrates with an extended half-life (EHL-FVIII/FIX). Two main strategies for measuring plasma FVIII or FIX activity are applied: the one-stage clotting assay (OSCA) and the chromogenic substrate assay (CSA), both calibrated against plasma (FVIII/FIX) standards. Due to the structural modifications of EHL-FVIII/FIX, reagent-dependent assay discrepancies have been described when measuring the activity of these molecules. Assay discrepancies have also been observed in FVIII/FIX gene therapy approaches. On the other hand, nonfactor replacement by the bispecific antibody emicizumab, a FVIIIa-mimicking molecule, artificially shortens activated partial thromboplastin time–based clotting times, making standard OSCAs inapplicable for analysis of samples from patients treated with this drug. In this review, we aim to give an overview on both, the currently applied and future therapies in HA and HB with or without inhibitors and corresponding test systems suitable for accompanying diagnostics.
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Affiliation(s)
- Jens Müller
- Institute for Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
| | - Wolfgang Miesbach
- Department of Haemostaseology and Hemophilia Center, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Thomas Siegemund
- Division of Hemostaseology, Department of Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Ute Scholz
- Center of Hemostasis, MVZ Labor Leipzig, Leipzig, Germany
| | - Ulrich J Sachs
- Department of Thrombosis and Haemostasis, Giessen University Hospital, Giessen, Germany
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18
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El Demerdash DM, Ayad A, Tawfik N. Acquired hemophilia A (AHA): underreported, underdiagnosed, undertreated medical condition. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2022; 34:12. [PMID: 35095264 PMCID: PMC8788911 DOI: 10.1186/s43162-021-00074-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 09/28/2021] [Indexed: 11/25/2022] Open
Abstract
Background Acquired hemophilia A (AHA) is a rare acquired bleeding disorder occurred due to the formation of inhibitory antibodies neutralizing endogenous factor VIII. Main body About half the cases are idiopathic. Symptoms include severe and unexpected bleeding that could be life-threatening. High index of suspicion should be raised when unexplained subcutaneous or post-surgical bleeding with isolated prolonged APTT. Conclusions Acquired hemophilia A is a rare underdiagnosed underreported acquired hemostatic disorder that presents with sudden usually life-threatening bleeding; it is crucial to raise awareness and suspicion index of clinicians for early diagnosis and treatment to avoid morbidity and mortality.
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19
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Buczma A, Baran B, Korwin M, Odnoczko E, Windyga J. Successful perioperative prophylaxis with susoctocog alfa in a patient with acquired haemophilia A: A case study. Haemophilia 2021; 28:e39-e41. [PMID: 34878208 DOI: 10.1111/hae.14468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 11/04/2021] [Accepted: 11/21/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Anna Buczma
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Beata Baran
- Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | - Edyta Odnoczko
- Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland.,Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
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20
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Dargaud Y, Escuriola‐Ettingshausen C. Recombinant porcine factor VIII: Lessons from the past and place in the management of hemophilia A with inhibitors in 2021. Res Pract Thromb Haemost 2021; 5:e12631. [PMID: 34849451 PMCID: PMC8606027 DOI: 10.1002/rth2.12631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 10/25/2021] [Accepted: 10/31/2021] [Indexed: 11/09/2022] Open
Abstract
The most serious complication of factor VIII (FVIII) replacement therapy is the occurrence of anti-FVIII alloantibodies that can strongly reduce or abolish the effect of human FVIII products. Bypassing agents to control bleeding episodes are recommended for these patients, but their efficacy is difficult to predict and monitor. FVIII products derived from porcine plasma had an important role in the treatment of hemophilia A for 50 years, from 1954 to 2004. Indeed, porcine FVIII could achieve hemostasis in patients in whom human FVIII products were ineffective. A recombinant porcine FVIII product is now available. This highly purified protein has the same biochemical and hemostatic properties, but much lower risks of infection and toxicity compared with plasma-derived porcine FVIII. The product is licensed in the United States and Europe for the treatment of acquired hemophilia A. However, this recombinant molecule could also be of clinical interest for people with inherited hemophilia A and inhibitors, particularly for the management of bleeding episodes in people receiving emicizumab as prophylactic treatment in the absence of anti-porcine FVIII antibodies.
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Affiliation(s)
- Yesim Dargaud
- Unite d’Hemostase CliniqueCentre National de Reference de l'HemophilieHôpital Louis PradelLyonFrance
- UR 4609 Hemostase and ThromboseUniversite Claude Bernard Lyon 1LyonFrance
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21
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[Chinese guidelines on the diagnosis and treatment of acquired hemophilia A (2021)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:793-799. [PMID: 34788917 PMCID: PMC8607020 DOI: 10.3760/cma.j.issn.0253-2727.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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22
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Diagnosis and Management of Acquired Hemophilia A: Case Reports and a Literature Review. Case Rep Med 2021; 2021:5554664. [PMID: 34567128 PMCID: PMC8457949 DOI: 10.1155/2021/5554664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/20/2021] [Accepted: 08/26/2021] [Indexed: 11/17/2022] Open
Abstract
Background Acquired hemophilia A (AHA) is a potentially life-threatening autoimmune hemostatic disorder where autoantibodies that disrupt the functions of factor VIII (FVIII) are present in the circulation. The early diagnosis of AHA is difficult since the symptoms of AHA differ from those of congenital hemophilia A. Furthermore, the management of AHA is also more complex due to the presence of autoantibodies against FVIII (FVIII inhibitors). Here, we present three case reports and conduct a literature review of AHA with the aim to increase awareness and knowledge regarding the diagnosis and treatment of AHA. Case Presentations. We present three patients diagnosed with AHA in these case reports. The first patient was a young female, while the second and third patients were middle-aged and elderly males, respectively. All patients presented with a chief complaint of bruises without hemarthrosis and a history of bleeding. Laboratory examinations of the patients revealed isolated prolonged aPTT, normal PT, and the presence of autoantibodies against factor VIII, which are characteristics of AHA. Patients were then treated with corticosteroids to reduce the titer level of autoantibodies and received factor VIII transfusion to stop bleeding. Conclusion AHA can be suspected in patients presenting with symptoms of bruises without hemarthrosis and without the history of bleeding. Isolated aPTT elevation with normal PT should raise high suspicion of AHA. The presence of FVIII inhibitors can help to confirm the diagnosis of AHA. Treatment consists of factor VIII transfusion and corticosteroid therapy. Bypassing agents are recommended as an alternative to FVIII transfusion.
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23
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New Developments in Diagnosis and Management of Acquired Hemophilia and Acquired von Willebrand Syndrome. Hemasphere 2021; 5:e586. [PMID: 34095769 PMCID: PMC8171371 DOI: 10.1097/hs9.0000000000000586] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/15/2021] [Indexed: 12/30/2022] Open
Abstract
Acquired hemophilia A and acquired von Willebrand syndrome are rare, but life-threatening bleeding disorders that require prompt diagnosis and treatment by hematologists. Acquired hemophilia A is defined as an acquired severe bleeding tendency caused by autoantibody formation against coagulation factor VIII. Acquired von Willebrand syndrome is characterized by a new onset bleeding tendency caused by a reduced concentration and/or function of von Willebrand factor. These disorders are associated with a variety of underlying disorders, including various hematological malignancies, for example, plasma cell disorders, lymphoproliferative disorders, monoclonal gammopathy of undetermined significance, and myeloproliferative neoplasms. It is of utmost important to recognize these acquired bleeding disorders in these patients who are at risk for severe bleeding, and to perform additional diagnostic hemostasis laboratory evaluation. This will enable immediate diagnosis of the acquired bleeding disorder and management of both the bleeding episodes and the causative underlying disorder. In recent years, several new etiological factors for acquired hemophilia A, such as treatment with immune checkpoint inhibitors or DPP-4 inhibitors and SARS-CoV2 infection, and for acquired von Willebrand syndrome, for example, left ventricular assist devices, have been identified and also new treatment options have become available. In this concise review, the most recent data on etiology, diagnosis, and treatment of acquired bleeding disorders are presented and discussed.
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Fernández-Oliveira C, Rotea-Salvo S, Fernández-Docampo M, González-Piñeiro S, Martín-Herranz I. Treatment of high-risk bleeding with susoctocog alfa in a patient with acquired haemophilia A and a nosocomial severe acute respiratory syndrome coronavirus 2 infection. Eur J Hosp Pharm 2021; 30:177-179. [PMID: 34011555 PMCID: PMC10176986 DOI: 10.1136/ejhpharm-2021-002805] [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: 04/01/2021] [Accepted: 04/26/2021] [Indexed: 11/03/2022] Open
Abstract
We report the case of a man in his early 70s with idiopathic acquired haemophilia A and persistent high-titre type II inhibitors on immunosuppressive treatment to eradicate the inhibitor. As complications, he had a nosocomial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which caused severe pneumonia and an explosive inflammatory reaction that required tocilizumab and remdesivir treatment, and a high-risk retroperitoneal haematoma. Recombinant porcine factor VIII, susoctocog alfa, was requested from the Pharmacy Service in view of the extreme risk of thromboembolism resulting from the concomitant inflammatory storm caused by SARS-CoV-2. Improvement in the SARS-CoV-2 infection made it possible to complete the immunosuppressive treatment with rituximab. The patient was discharged with mycophenolate mofetil as immunosuppressive treatment after 89 days in hospital and 22 days of treatment with susoctocog alfa. His SARS-CoV-2 infection resolved and the haematoma evolved favourably.
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25
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Recombinant porcine FVIII for bleed treatment in acquired hemophilia A: findings from a single-center, 18-patient cohort. Blood Adv 2021; 4:6240-6249. [PMID: 33351122 DOI: 10.1182/bloodadvances.2020002977] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/09/2020] [Indexed: 12/17/2022] Open
Abstract
Acquired hemophilia A (AHA) is a rare bleeding disorder in which acquired autoantibodies to endogenous factor VIII (FVIII) decrease FVIII activity and lead to a bleeding phenotype. A substantial majority of individuals who develop AHA present with severe bleeding. Effective treatment requires both immunosuppressive therapy and prompt hemostatic treatment. Bleeding is commonly treated with bypassing agents (BPAs) such as recombinant activated FVII (rFVIIa) or activated prothrombin complex concentrates Disadvantages to BPAs include the inability to monitor response with standard laboratory assays, inconsistent hemostatic efficacy, and thrombosis. Recombinant porcine FVIII (rpFVIII: Obizur, Baxter, Deerfield, IL) was approved by the US Food and Drug Administration (FDA) for bleed treatment in AHA in 2014, and has the advantage of laboratory monitoring of FVIII activity levels and known hemostatic efficacy in the presence of anti-human FVIII inhibitors and after failure of BPAs. Using an algorithm-based approach, rpFVIII has been used to successfully treat 18 patients with AHA at our center with substantially lower doses than the current FDA-recommended dosing. Additionally, data from our cohort show that the preexposure anti-porcine Bethesda titer does not reliably predict the clinical response to rpFVIII treatment and is not correlated with the anti-human Bethesda titer. We also present data showing lower total rpFVIII use for initial bleed resolution when rpVIII is used upfront, as compared with use as rescue therapy. We validated our dosing algorithm, which uses much lower than FDA-recommended doses with 14 more patients than in our previously reported patient series.
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26
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Emicizumab for the treatment of acquired hemophilia A. Blood 2021; 137:410-419. [PMID: 32766881 DOI: 10.1182/blood.2020006315] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023] Open
Abstract
Acquired hemophilia A (AHA) is a severe bleeding disorder caused by inhibiting autoantibodies to coagulation factor VIII (FVIII). For hemostatic treatment, bypassing agents and human or porcine FVIII are currently standard of care. Emicizumab is a bispecific, FVIII-mimetic therapeutic antibody that reduced the annualized bleeding rates in congenital hemophiliacs. Here, we report on 6 male and 6 female patients with AHA treated with emicizumab (all data medians and interquartile range), age 74 (64-80) years, initial FVIII <1%; inhibitor titer 22.3 Bethesda units (BU)/mL (range, 3-2000). Eight patients had severe bleeding. Emicizumab was started, 3 mg/kg subcutaneously, weekly for 2 to 3 doses, followed by 1.5 mg/kg every 3 weeks to keep the lowest effective FVIII levels. For FVIII monitoring, chromogenic assays with human and bovine reagents were used. All patients received immunosuppression with steroids and/or rituximab. After the first dose of emicizumab, activated partial thromboplastin time normalized in 1 to 3 days, FVIII (human reagents) exceeded 10% after 11 (7.5-12) days. Hemostatic efficacy was obtained and bypassing therapy stopped after 1.5 (1-4) days. FVIII (bovine reagents) exceeded 50%, indicating complete remission after 115 (67-185) days, and emicizumab was stopped after 31 (15-79) days. A median of 5 injections (range, 3-9) were given. No patient died of bleeding or thromboembolism, and no breakthrough bleeding was observed after the first dose of emicizumab. In conclusion, emicizumab seems to be an effective hemostatic therapy for AHA, with the advantages of subcutaneous therapy, good hemostatic efficacy, early discharge, and reduction of immunosuppression and adverse events.
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27
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Coxon CH, Yu X, Beavis J, Diaz-Saez L, Riches-Duit A, Ball C, Diamond SL, Raut S. Characterisation and application of recombinant FVIII-neutralising antibodies from haemophilia A inhibitor patients. Br J Haematol 2021; 193:976-987. [PMID: 33973229 DOI: 10.1111/bjh.17227] [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: 08/05/2020] [Accepted: 10/16/2020] [Indexed: 12/20/2022]
Abstract
The development of anti-drug antibodies (ADAs) is a serious outcome of treatment strategies involving biological medicines. Coagulation factor VIII (FVIII) is used to treat haemophilia A patients, but its immunogenicity precludes a third of severe haemophiliac patients from receiving this treatment. The availability of patient-derived anti-drug antibodies can help us better understand drug immunogenicity and identify ways to overcome it. Thus, there were two aims to this work: (i) to develop and characterise a panel of recombinant, patient-derived, monoclonal antibodies covering a range of FVIII epitopes with varying potencies, kinetics and mechanism of action, and (ii) to demonstrate their applicability to assay development, evaluation of FVIII molecules and basic research. For the first objective we used recombinant antibodies to develop a rapid, sensitive, flexible and reproducible ex vivo assay that recapitulates inhibitor patient blood using blood from healthy volunteers. We also demonstrate how the panel can provide important information about the efficacy of FVIII products and reagents without the need for patient or animal material. These materials can be used as experimental exemplars or controls, as well as tools for rational, hypothesis-driven research and assay development in relation to FVIII immunogenicity and FVIII-related products.
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Affiliation(s)
- Carmen H Coxon
- National Institute for Biological Standards and Control, Hertfordshire, UK
| | - Xinren Yu
- University of Pennsylvania, Philadelphia, PA, USA
| | - James Beavis
- Oxford Haemophilia Centre, Churchill Hospital, Oxford, UK
| | | | - Andrew Riches-Duit
- National Institute for Biological Standards and Control, Hertfordshire, UK
| | - Chris Ball
- National Institute for Biological Standards and Control, Hertfordshire, UK
| | | | - Sanj Raut
- National Institute for Biological Standards and Control, Hertfordshire, UK
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28
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Dolan G, Benson G, Bowyer A, Eichler H, Hermans C, Jiménez-Yuste V, Ljung R, Pollard D, Santagostino E, Šalek SZ. Principles of care for acquired hemophilia. Eur J Haematol 2021; 106:762-773. [PMID: 33527471 PMCID: PMC8252574 DOI: 10.1111/ejh.13592] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 01/26/2021] [Indexed: 12/20/2022]
Abstract
Objective To establish clear priorities for the care of patients with acquired hemophilia A (AHA) by proposing 10 key principles of practical, holistic AHA management. Method These principles were developed by the Zürich Haemophilia Forum, an expert panel of European hemophilia specialists comprising physicians and nursing and laboratory specialists. Results The 10 proposed principles for AHA care are as follows: (a) Improving initial diagnosis of AHA; (b) Differential diagnosis of AHA: laboratory assessment of patients with unusual bleeding; (c) Effective communication between laboratories, physicians, and specialists; (d) Improving clinical care: networking between healthcare professionals in the treating hospital and specialist hemophilia centers; (e) Comprehensive assessment of bleeding; (f) Appropriate use of bypassing agents; (g) Long‐term follow‐up and monitoring for efficacy and safety of immunosuppressive treatment; (h) Inpatient/outpatient settings; (i) Access to innovative and disruptive treatments; (j) Promotion of international collaborative research. Conclusion The proposed principles for holistic AHA care aim to ensure swift diagnosis and optimal patient management. Key to achieving this goal is training for healthcare personnel in non‐specialist hospitals and collaboration between different specialists. We hope these principles will increase awareness of AHA in the wider medical community and catalyze efforts toward improving its practical, multidisciplinary management.
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Affiliation(s)
- Gerry Dolan
- Centre for Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - Gary Benson
- Haemophilia and Thrombosis Centre, Belfast City Hospital, Belfast, Northern Ireland
| | - Annette Bowyer
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, UK
| | - Hermann Eichler
- Institute of Clinical Haemostaseology and Transfusion Medicine, University and University Hospital of the Saarland, Homburg, Germany
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Victor Jiménez-Yuste
- Hospital Universitario La Paz, Unidad de Coagulopatías, Servicio de Hematología, Autonoma University, Madrid, Spain
| | - Rolf Ljung
- Department of Clinical Sciences - Pediatrics, Lund University, Lund, Sweden
| | - Debra Pollard
- Katharine Dormandy Haemophilia & Thrombosis Centre, Royal Free London NHS Foundation Trust, London, UK
| | - Elena Santagostino
- Fondazione IRCCS Cá Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Silva Zupančić Šalek
- University Hospital Centre Zagreb, School of Medicine, University of Osijek and Medical School University of Zagreb, Croatia
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29
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Franchini M, Schiavulli M, Liumbruno GM. Hemostatic therapy as a management strategy for acquired hemophilia: what does the future hold? Expert Rev Hematol 2021; 14:263-270. [PMID: 33655810 DOI: 10.1080/17474086.2021.1892483] [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: 10/22/2022]
Abstract
Introduction: Acquired hemophilia A (AHA) is a rare autoimmune disease caused by autoantibodies that bind and inactivate factor VIII (FVIII), predisposing to a potentially life-threatening bleeding.Areas covered: The main epidemiological, clinical, laboratory and therapeutic features of AHA are critically discussed. In particular, we focus on the hemostatic management of AHA patients analyzing the currently available treatment options and showing the latest data on the innovative hemostatic agents still under investigation. Authors searched the Medline and PubMed electronic databases for publication on AHA in the last twenty years.Expert opinion: While a rapid recognition of suspected cases of AHA is essential to make a correct diagnosis and appropriately and timely treat the hemorrhagic manifestations, the multidisciplinary approach to this challenging, rare and life-threatening bleeding disorder is of equal importance to improve patients' outcome. Although promising, the safety and efficacy of the clinical use of emicizumab in AHA needs to be validated by trials including an adequate number of patients, before registering the drug also for this indication.
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Affiliation(s)
- Massimo Franchini
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantova, Italy
| | - Michele Schiavulli
- Regional Reference Center for Coagulation Disorders, Santobono-Pausilipon Hospital, Naples, Italy
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30
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Tiede A, Kemkes-Matthes B, Knöbl P. Should emicizumab be used in patients with acquired hemophilia A? J Thromb Haemost 2021; 19:637-644. [PMID: 33306259 DOI: 10.1111/jth.15208] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/05/2020] [Accepted: 12/01/2020] [Indexed: 12/18/2022]
Abstract
Emicizumab is currently approved to prevent bleeding in patients with congenital hemophilia A with or without neutralizing antibodies (inhibitors) against factor VIII (FVIII). Here, we present a case-based discussion of its potential use in acquired hemophilia A (AHA), a severe bleeding disorder caused by autoantibodies against FVIII. State-of-the-art management is based on bypassing agents (recombinant factor VIIa, activated prothrombin complex concentrate) and recombinant porcine FVIII; immunosuppressive therapy (corticosteroids, rituximab, cyclophosphamide) is used to suppress autoantibody formation. Case reports and one series suggest that emicizumab can reduce the risk of bleeding and the requirement for hemostatic therapy until remission of AHA is achieved. Further, it may allow to postpone the start of immunosuppressive therapy or to use less intense regimens. However, the risk-benefit assessment of emicizumab in AHA is difficult because demographic and clinical characteristics are different compared with congenital hemophilia. Prospective clinical trials are needed before the use of emicizumab can be recommended in AHA.
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Affiliation(s)
- Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | | | - Paul Knöbl
- Department of Medicine 1, Division for Hematology and Hemostasis, Medical University of Vienna, Vienna, Austria
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31
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Campbell S, Mason J, Prasad R, Ambrose H, Hunt S, Tran H. Acquired haemophilia and haemostatic control with recombinant porcine factor VIII: case series. Intern Med J 2021; 51:215-219. [DOI: 10.1111/imj.14773] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 12/06/2019] [Accepted: 12/10/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Sally Campbell
- Haemophilia Treatment Centre Alfred Hospital Melbourne Victoria Australia
- Australian Centre for Blood Diseases Monash University Melbourne Victoria Australia
| | - Jane Mason
- Queensland Haemophilia Centre Royal Brisbane and Women's Hospital Brisbane Queensland Australia
| | - Ritam Prasad
- Haematology Department, Calvary Mater Hospital Newcastle New South Wales Australia
| | - Harriet Ambrose
- Haematology Department, Calvary Mater Hospital Newcastle New South Wales Australia
| | - Stewart Hunt
- Queensland Haemophilia Centre Royal Brisbane and Women's Hospital Brisbane Queensland Australia
| | - Huyen Tran
- Haemophilia Treatment Centre Alfred Hospital Melbourne Victoria Australia
- Australian Centre for Blood Diseases Monash University Melbourne Victoria Australia
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Bowyer A, Shepherd F, Platton S, Guy S, Kitchen S, Maclean R. Cross-reacting recombinant porcine FVIII inhibitors in patients with acquired haemophilia A. Haemophilia 2020; 26:1181-1186. [PMID: 32997894 DOI: 10.1111/hae.14162] [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: 05/06/2020] [Revised: 08/29/2020] [Accepted: 09/08/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Acquired haemophilia A (AHA) is a rare bleeding disorder caused by the development of autoantibodies to endogenous human factor VIII (hFVIII). If treatment of bleeding is required, one option is recombinant porcine FVIII (rpFVIII). Cross-reactivity between factor VIII inhibitors and rpFVIII has previously been described. AIM The aim of this study was to retrospectively assess the incidence of cross-reacting anti-porcine inhibitors in patients diagnosed with AHA in two UK centres. METHODS The plasma of fifty-one patients diagnosed with AHA via reduced FVIII:C and positive FVIII inhibitor titre as detected with a Nijmegen-Bethesda assay (NBA) was also tested by a porcine Bethesda assay (PBA). The NBA was modified by replacement of human FVIII with rpFVIII in the PBA, with determination of residual FVIII by one-stage clotting assay. RESULTS The median FVIII inhibitor titre by NBA was 22.8 BU/mL (range: 0.8-1000 BU/mL). 37% of samples exhibited linear, type 1 kinetics in the NBA. Negative PBA was observed in 26 patients, and 25 were positive (median PBA: 3.5 BU/mL; range: 0.8-120 BU/mL). Type 1 kinetics were observed in 40% of PBA-positive patients. At NBA tires of greater than 100 BU/mL, the positive predictive value for the presence of porcine cross-reactivity was 100%. At NBA below 5 BU/mL, the negative predictive value for the presence of porcine cross-reactivity was 71%. CONCLUSION Cross-reactivity between FVIII inhibitors and rpFVIII was observed in 49% of patients. The presence of inhibitors to rpFVIII may influence the treatment choice for patients with acquired haemophilia A.
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Affiliation(s)
- Annette Bowyer
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, UK
| | - Fiona Shepherd
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, UK
| | - Sean Platton
- The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Susan Guy
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, UK
| | - Steve Kitchen
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, UK
| | - Rhona Maclean
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, UK
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Tiede A, Alberio L. The Art of Detecting Antibodies against Factor VIII. Hamostaseologie 2020; 40:485-490. [DOI: 10.1055/a-1223-3353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AbstractAntibodies against factor VIII (FVIII) can be detected based on their ability to neutralize the procoagulant activity of FVIII (neutralizing antibodies, inhibitors), or based on their specific binding capacity to FVIII protein. This article reviews the available assays and their clinical interpretation in patients with congenital and acquired hemophilia.
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Affiliation(s)
- Andreas Tiede
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Lorenzo Alberio
- Service et Laboratoire Central d'Hématologie, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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Tiede A. Critical Bleeding in Acquired Hemophilia A: Bypassing Agents or Recombinant Porcine Factor VIII? Hamostaseologie 2020; 41:240-245. [PMID: 32916754 DOI: 10.1055/a-1171-0522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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Tiede A, Collins P, Knoebl P, Teitel J, Kessler C, Shima M, Di Minno G, d'Oiron R, Salaj P, Jiménez-Yuste V, Huth-Kühne A, Giangrande P. International recommendations on the diagnosis and treatment of acquired hemophilia A. Haematologica 2020; 105:1791-1801. [PMID: 32381574 PMCID: PMC7327664 DOI: 10.3324/haematol.2019.230771] [Citation(s) in RCA: 163] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 04/07/2020] [Indexed: 12/18/2022] Open
Abstract
Acquired hemophilia A (AHA), a rare bleeding disorder caused by neutralizing autoantibodies against coagulation factor VIII (FVIII), occurs in both men and women without a previous history of bleeding. Patients typically present with an isolated prolonged activated partial thromboplastin time due to FVIII deficiency. Neutralizing antibodies (inhibitors) are detected using the Nijmegen-modified Bethesda assay. Approximately 10% of patients do not present with bleeding and, therefore, a prolonged activated partial thromboplastin time should never be ignored prior to invasive procedures. Control of acute bleeding and prevention of injuries that may provoke bleeding are top priorities in patients with AHA. We recommend treatment with bypassing agents, including recombinant activated factor VII, activated prothrombin complex concentrate, or recombinant porcine FVIII in bleeding patients. Autoantibody eradication can be achieved with immunosuppressive therapy, including corticosteroids, cyclophosphamide and rituximab, or combinations thereof. The median time to remission is 5 weeks, with considerable interindividual variation. FVIII activity at presentation, inhibitor titer and autoantibody isotype are prognostic markers for remission and survival. Comparative clinical studies to support treatment recommendations for AHA do not exist; therefore, we provide practical consensus guidance based on recent registry findings and the authors' clinical experience in treating patients with AHA.
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Affiliation(s)
- Andreas Tiede
- Hannover Medical School, Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover, Germany
| | - Peter Collins
- Arthur Bloom Haemophilia Centre, University Hospital of Wales School of Medicine, Cardiff University, Cardiff, UK
| | - Paul Knoebl
- Department of Medicine 1, Division of Hematology and Hemostasis, Medical University of Vienna, Vienna, Austria
| | - Jerome Teitel
- Division of Hematology and Oncology, St. Michael's Hospital, Toronto, and Department of Medicine, University of Toronto, Toronto, Canada
| | - Craig Kessler
- Georgetown University Hospital, Lombardi Cancer Center, Division of Hematology/Oncology, Washington, DC, USA
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Nara, Japan
| | - Giovanni Di Minno
- Regional Reference Center for Coagulation Disorders, Federico II University Hospital, Naples, Italy
| | - Roseline d'Oiron
- Centre de Référence de l'Hémophilie et des Maladies Hémorragiques Constitutionnelles Rares, Hôpitaux Universitaires Paris Sud, Hôpital Bicêtre APHP, Le Kremlin-Bicêtre, France
| | - Peter Salaj
- Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | - Victor Jiménez-Yuste
- Hematology Department, La Paz University Hospital, Autonoma University, Madrid, Spain
| | - Angela Huth-Kühne
- SRH Kurpfalzkrankenhaus Heidelberg GmbH and Hemophilia Center, Heidelberg, Germany
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Susoctocog-alfa (Obizur ®) in the treatment of nine elderly patients with acquired haemophilia A: an Italian multicentre real world experience. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:312-321. [PMID: 32698943 DOI: 10.2450/2020.00006-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 03/19/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND In 2016, a new recombinant B-domain deleted porcine FVIII (rpFVIII) was licensed in Italy for the treatment of acquired haemophilia A (AHA), but only a few cases of patients receiving this have been reported in the literature. Here we report the largest registry of the use of rpFVIII for the treatment of AHA. The objective of this retrospective study was to describe the efficacy and the safety of susoctocog-alfa for AHA. MATERIAL AND METHODS We studied a population of nine patients, recruited in five Italian haemophilia centres presenting AHA, and treated with Obizur® as first- or second-line therapy. RESULTS rpFVIII was used as a first-line therapy in one-third of the patients. The median delay between clinical onset and diagnosis was 16 days. Initial bolus of infused susoctocog-alfa was 100 IU/kg, lower than the recommended dose. The treatment was maintained for a median of four days. Only one patient with serious co-morbidities and recurrent infections was treated for 32 days. All patients reached a complete resolution of AHA, and no recurrences were reported. Two patients developed a low-titre inhibitor against rpFVIII, neither experienced any complications. DISCUSSION In our real world experience, susoctocog-alfa was proven to be an effective and safe therapeutic option for patients with AHA, also at a lower than recommended dosage. In our report, the appearance of low-titre inhibitors against rpFVIII, was not found to be clinically significant.
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37
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Tiede A, Zieger B, Lisman T. Acquired bleeding disorders. Haemophilia 2020; 27 Suppl 3:5-13. [PMID: 32476241 DOI: 10.1111/hae.14033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/23/2020] [Indexed: 12/19/2022]
Abstract
Acquired bleeding disorders can accompany hematological, neoplastic, autoimmune, cardiovascular or liver diseases, but can sometimes also arise spontaneously. They can manifest as single factor deficiencies or as complex hemostatic abnormalities. This review addresses (a) acquired hemophilia A, an autoimmune disorder characterized by inhibitory autoantibodies against coagulation factor VIII; (b) acquired von Willebrand syndrome in patients with cardiovascular disorders, where shear stress abnormalities result in destruction of von Willebrand factor; and (c) liver function disorders that comprise complex changes in pro- and anti-hemostatic factors, whose clinical implications are often difficult to predict. The article provides an overview on the pathophysiology, diagnostic tests and state-of-the-art treatment strategies.
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Affiliation(s)
- Andreas Tiede
- Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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38
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Abou‐Ismail MY, Vuyyala S, Prunty J, Schmaier AH, Nayak L. Short term efficacy of recombinant porcine factor VIII in patients with factor VIII inhibitors. Haemophilia 2020; 26:601-606. [DOI: 10.1111/hae.14014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/30/2020] [Accepted: 04/07/2020] [Indexed: 12/14/2022]
Affiliation(s)
| | | | - Jeremy Prunty
- University Hospitals Cleveland Medical Center Cleveland OH
| | - Alvin H. Schmaier
- Case Western Reserve University Cleveland OH
- University Hospitals Cleveland Medical Center Cleveland OH
| | - Lalitha Nayak
- Case Western Reserve University Cleveland OH
- University Hospitals Cleveland Medical Center Cleveland OH
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Franchini M, Marano G, Cruciani M, Mengoli C, Pati I, Masiello F, Veropalumbo E, Pupella S, Vaglio S, Liumbruno GM. Advances in managing rare acquired bleeding disorders. Expert Rev Hematol 2020; 13:599-606. [PMID: 32286895 DOI: 10.1080/17474086.2020.1756259] [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: 12/14/2022]
Abstract
INTRODUCTION Rare acquired bleeding disorders include a wide spectrum of coagulopathies characterized by spontaneous or post-trauma and post-surgery hemorrhages in patients without a previous personal or family history of bleeding. AREAS COVERED This review, based on a Medline/PubMed search during the last 20 years, will focus mainly on rare acquired bleeding disorders caused by autoantibodies against coagulation factors, including autoantibodies against factor VIII (acquired hemophilia A), von Willebrand factor (acquired von Willebrand syndrome) and other coagulation factors (factors V, X, XI, and XIII). The pathogenic, laboratory, and clinical features of these rare hemorrhagic conditions will be discussed, with particular attention to their management. EXPERT OPINION The treatment of rare acquired bleeding disorders includes the control of bleeding and the elimination of the autoantibody and of the underlying disease, when present. As the bleeding clinical phenotype is often severe, the management of affected patients is particularly challenging. Thus, while an early diagnosis of the acquired coagulopathy is essential to start the most appropriate treatment and to improve patients' outcomes, the support of specialized centers is equally important to provide a correct management of such complicated cases.
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Affiliation(s)
- Massimo Franchini
- Italian National Blood Centre, National Institute of Health , Rome, Italy.,Department of Hematology and Transfusion Medicine, Carlo Poma Hospital , Mantua, Italy
| | - Giuseppe Marano
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Mario Cruciani
- Italian National Blood Centre, National Institute of Health , Rome, Italy.,Infection Control Committee and Antibiotic Stewardship Programme, AULSS9 Scaligera , Verona, Italy
| | - Carlo Mengoli
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Ilaria Pati
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Francesca Masiello
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Eva Veropalumbo
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Simonetta Pupella
- Italian National Blood Centre, National Institute of Health , Rome, Italy
| | - Stefania Vaglio
- Italian National Blood Centre, National Institute of Health , Rome, Italy
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40
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Ruan GJ, Mao JJ, Sytsma TT, Akogyeram II, Wang Y, Ashrani AA, Pruthi RK. Continuous infusion of recombinant porcine factor VIII for neurosurgical management of intracranial haemorrhage in a patient with severe haemophilia A with factor VIII inhibitor. Haemophilia 2020; 26:e141-e144. [PMID: 32180301 DOI: 10.1111/hae.13966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/18/2020] [Accepted: 03/02/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Gordon J Ruan
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jimmy J Mao
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Terin T Sytsma
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Yucai Wang
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Rajiv K Pruthi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
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41
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Al Mahmasani L, Finianos A, Bou-Fakhredin R, Elias J, Taher A. Acquired hemophilia A: when an overlooked autoimmune disorder causes significant bleeding. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1740682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Layal Al Mahmasani
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Antoine Finianos
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rayan Bou-Fakhredin
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Joseph Elias
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Taher
- Division of Hematology-Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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