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Ichinose A, Osaki T, Souri M. Diagnosis and Treatment of Autoimmune Acquired Coagulation Factor Deficiencies: An Evidence-Based Review of Japanese Practice. Semin Thromb Hemost 2024. [PMID: 38866039 DOI: 10.1055/s-0044-1787188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
Among the acquired coagulation factor deficiencies, autoimmune coagulation factor deficiencies (AiCFD) are rare and result from autoantibody production against coagulation factors. In Japan, a nationwide survey on AiCFD has been conducted since 2009. Autoimmune factor XIII, factor VIII, von Willebrand factor, factor V, and factor X deficiencies (AiF13D, AiF8D, AiVWFD, AiF5D, and AiF10D, respectively) have been enacted as "designated intractable disease-282." The incidence of AiF8D, AiF13D, and AiF5D was 1.83, 0.044, and 0.038 per million people/year, respectively, whereas that of AiVWFD and AiF10D was not calculable owing to the small number of patients. AiF13D and AiF8D were often idiopathic, whereas AiVWFD was often associated with plasma cell neoplasms. Epistaxis was a characteristic symptom of AiVWFD, intramuscular bleeding was frequent in AiF13D and AiF8D, and subcutaneous bleeding (purpura) was frequent in AiF13D and AiF10D, although none were specific to any one disease. Differential diagnosis cannot be made based on bleeding symptoms alone; therefore, rapid and accurate testing is mandatory. Definitive diagnosis of AiCFD necessitates identifying the presence of coagulation factor "inhibitors" and/or "autoantibodies." Therefore, these tests should be performed upon unexplained severe acquired coagulation factor deficiencies. The mainstay of treatment for AiCFD was hemostatic therapy and autoantibody eradication therapy, which included the replacement of coagulation factors or "bypass" agents and administration of immunosuppressants. The rate of hemorrhagic death was high in AiF13D (13%), followed by AiF5D (7%) and Ai10D (5%); therefore, early diagnosis and optimal treatment are essential for AiCFDs. Given the unknown long-term prognosis, "intractable disease platform registries" have begun to accumulate in Japan.
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Affiliation(s)
- Akitada Ichinose
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
- The Japanese Collaborative Research Group on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata University School of Medicine, Yamagata, Japan
| | - Tsukasa Osaki
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
- The Japanese Collaborative Research Group on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata University School of Medicine, Yamagata, Japan
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
| | - Masayoshi Souri
- Department of Molecular Patho-Biochemistry and Patho-Biology, Yamagata University School of Medicine, Yamagata, Japan
- The Japanese Collaborative Research Group on Autoimmune Acquired Coagulation Factor Deficiencies supported by the Japanese Ministry of Health, Labor and Welfare, Yamagata University School of Medicine, Yamagata, Japan
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
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2
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Ocaña Gómez MÁ, Esquivel Negrín J, Ríos De Paz M, De Dios García MD. Utilization of emicizumab in the treatment of a case of acquired hemophilia A. FARMACIA HOSPITALARIA 2024; 48:45-47. [PMID: 37468348 DOI: 10.1016/j.farma.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 07/21/2023] Open
Affiliation(s)
- María Ángeles Ocaña Gómez
- Servicio de Farmacia, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España.
| | - Jorge Esquivel Negrín
- Servicio de Farmacia, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Mario Ríos De Paz
- Servicio de Hematología, Unidad de Coagulopatías, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - María Dolores De Dios García
- Servicio de Hematología, Unidad de Coagulopatías, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
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3
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Ocaña Gómez MÁ, Esquivel Negrín J, Ríos De Paz M, De Dios García MD. [Translated article] Utilization of emicizumab in the treatment of a case of acquired haemophilia A. FARMACIA HOSPITALARIA 2024; 48:T45-T47. [PMID: 37884400 DOI: 10.1016/j.farma.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 10/28/2023] Open
Affiliation(s)
- María Ángeles Ocaña Gómez
- Servicio de Farmacia, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain.
| | - Jorge Esquivel Negrín
- Servicio de Farmacia, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain.
| | - Mario Ríos De Paz
- Servicio de Hematología, Unidad de Coagulopatías, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - María Dolores De Dios García
- Servicio de Hematología, Unidad de Coagulopatías, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
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Ragni MV. Rapidly loading emicizumab without immunosuppression in acquired haemophilia. Lancet Haematol 2023; 10:e870-e871. [PMID: 37858327 DOI: 10.1016/s2352-3026(23)00303-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Margaret V Ragni
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, and Hemophilia Center of Western PA, Pittsburgh, PA, USA.
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Takeyama M, Ozu N, Kasama S, Kasahara M, Matsumoto M, Shima M, Nogami K. Study protocol for assessment of the coagulation potential of concomitantly used factor VIII concentrates in patients with haemophilia A with emicizumab prophylaxis (CAGUYAMA Study): a multicentre open-label non-randomised clinical trial. BMJ Open 2023; 13:e072565. [PMID: 37429679 DOI: 10.1136/bmjopen-2023-072565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
INTRODUCTION Emicizumab prophylaxis substantially reduces bleeding episodes in patients with haemophilia A (HA). The haemostatic efficacy of emicizumab in patients with HA is estimated as approximately 15% based on mimic activity of factor (F) VIII. Although it has been proven effective in preventing bleeding, its haemostatic effect during breakthrough bleeding or surgery is considered insufficient. Therefore, haemostatic management of emicizumab-treated patients with HA without inhibitors frequently requires FVIII replacement therapy. In haemostatic management of emicizumab-treated patients with HA, conventional FVIII dosage calculations are used in clinical practice without considering the coagulant effects of emicizumab. METHODS AND ANALYSIS In the CAGUYAMA study, 100 patients with HA without inhibitors will be enrolled for a maximum duration of 1 year, and samples of 30 events following the concomitant use of FVIII concentrates (30±5 U/kg) with emicizumab will be collected. An 'event' is defined as obtaining blood samples at preadministration and postadministration of FVIII concentrates during a breakthrough bleeding or a surgical procedure. Global coagulation assays will be used to measure the coagulation potential of the obtained samples. Clot waveform analysis (CWA) is used to identify the primary end-point, that is, the degree of improvement in the maximum coagulation rate at preadministration and post-administration of fixed-dose FVIII concentrations. The parameter obtained from CWA, which is triggered by an optimally diluted mixture of prothrombin time reagent and activated partial thromboplastin time reagent, is reported to be an excellent marker for assessing the degree of improvement of the coagulation potential in emicizumab-treated plasmas. ETHICS AND DISSEMINATION The CAGUYAMA study was approved by the Japan-Certified Review Board of Nara Medical University (Approval ID; nara0031). The study results will be communicated through publication in international scientific journals and presentations at (inter)national conferences. TRIAL REGISTRATION NUMBER jRCTs051210137.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Naoki Ozu
- Institute of Clinical and Translational Science, Nara Medical University, Kashihara, Nara, Japan
| | - Shu Kasama
- Institute of Clinical and Translational Science, Nara Medical University, Kashihara, Nara, Japan
| | - Masato Kasahara
- Institute of Clinical and Translational Science, Nara Medical University, Kashihara, Nara, Japan
| | - Masanori Matsumoto
- Blood Transfusion Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Matsumoto N, Abe H, Kawasaki R, Tashiro Y, Noguchi-Sasaki M, Harada S, Yoneyama K, Niino T, Soeda T, Yoshimura Y. Characterization of Anti-Emicizumab Antibodies Using Repository Samples Obtained in Clinical Studies of Emicizumab Conducted in Japan. TH OPEN 2023; 7:e241-e243. [PMID: 37645671 PMCID: PMC10462426 DOI: 10.1055/a-2122-7887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Affiliation(s)
| | - Hiroto Abe
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | | | | | | | - Suguru Harada
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | | | - Tomomi Niino
- Chugai Pharmaceutical Co., Ltd., Chuo-ku, Tokyo, Japan
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Shima M, Amano K, Ogawa Y, Yoneyama K, Ozaki R, Kobayashi R, Sakaida E, Saito M, Okamura T, Ito T, Hattori N, Higasa S, Suzuki N, Seki Y, Nogami K. A prospective, multicenter, open-label phase III study of emicizumab prophylaxis in patients with acquired hemophilia A. J Thromb Haemost 2023; 21:534-545. [PMID: 36696195 DOI: 10.1016/j.jtha.2022.10.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/09/2022] [Accepted: 10/05/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Emicizumab is a bispecific antibody that mimics the cofactor function of activated factor (F) VIII. It prevents bleeds in patients with congenital hemophilia A regardless of the inhibitor status; however, no prospective clinical studies have been conducted for emicizumab in patients with acquired hemophilia A (PwAHA). OBJECTIVES To describe the primary analysis results from a prospective, multicenter, open-label phase III study evaluating the efficacy, safety, and pharmacokinetics of emicizumab in PwAHA (AGEHA; JapicCTI-205151). METHODS Emicizumab was administered subcutaneously at 6 mg/kg on day 1 and 3 mg/kg on day 2, followed by 1.5 mg/kg once weekly from day 8 onward. Predefined criteria for the completion of dosing included FVIII activity of >50 IU/dL. RESULTS By the cutoff date (April 23, 2021), 12 patients on immunosuppressive therapy were enrolled, and 11 of them (91.7%) completed emicizumab treatment. The mean trough plasma emicizumab concentration rapidly reached a steady state (1 week), achieving the efficacious level that was established in patients with congenital hemophilia A (>30 μg/mL). Before first emicizumab administration, 7 patients (58.3%) experienced 77 major bleeds. During emicizumab treatment, no major bleeds occurred in any patient. Neither death due to bleeding or infection nor any study treatment-related serious adverse event was reported. One asymptomatic, nonserious deep vein thrombosis was discovered with no laboratory findings indicating any trend toward hypercoagulation. CONCLUSION These results suggest that emicizumab prophylaxis with the tested dosing regimen and completion criteria may have a favorable benefit-risk profile in PwAHA.
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Affiliation(s)
- Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, Kashihara, Japan; Department of Pediatrics, Nara Medical University, Kashihara, Japan.
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yoshiyuki Ogawa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | | | | | - Emiko Sakaida
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Makoto Saito
- Blood Disorders Center, Aiiku Hospital, Sapporo, Japan
| | - Takashi Okamura
- Department of Hematology, St. Mary's Hospital, Kurume, Japan
| | - Toshihiro Ito
- Department of Infectious Diseases, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Norimichi Hattori
- Division of Hematology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Satoshi Higasa
- Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Nobuaki Suzuki
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Yoshinobu Seki
- Department of Hematology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-uonuma, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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Nogami K, Shima M. Current and future therapies for haemophilia-Beyond factor replacement therapies. Br J Haematol 2023; 200:23-34. [PMID: 35869698 DOI: 10.1111/bjh.18379] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 12/01/2022]
Abstract
Some non-factor products that work by facilitating the coagulation pathway (emicizumab) and blocking the anticoagulant pathway (fitusiran, concizumab and marstacimab) for patients with haemophilia (H) have been developed, and clinical trials using these products are currently ongoing. Prophylaxis using non-factor products by subcutaneous administration provides marked reductions of bleeding episodes in patients with HA or HB, regardless of the presence of inhibitor. Emicizumab has already been approved globally. Emicizumab alters the phenotype of patients with HA from severe to mild by maintaining trough levels of equivalent factor VIII activity (15-20 iu/dl). Phase 3 clinical trials and long-term observations assessing emicizumab revealed tolerable safety and efficacy. However, thrombotic events have occurred in patients receiving these non-factor products. Furthermore, monitoring of the haemostatic function of these products with concomitant therapy is also required in clinical practice. These products have promising haemostatic efficiency, but wider clinical experience is needed to provide optimal therapeutic strategies in the future.
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Affiliation(s)
- Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,Thrombosis and Hemostasis Research Centre, Nara Medical University, Kashihara, Nara, Japan
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9
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Takeyama M, Furukawa S, Onishi T, Noguchi-Sasaki M, Shima M, Nogami K. Heterogeneous coagulant potential of emicizumab in neonatal factor VIII-deficient plasma. Pediatr Blood Cancer 2022; 69:e29731. [PMID: 35441786 DOI: 10.1002/pbc.29731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/01/2022] [Accepted: 03/27/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Emicizumab prophylaxis reduces bleeding in hemophilia A (HA) patients. However, there are few data on emicizumab treatment in neonates with HA (neonate-HA), and the procoagulant effects of emicizumab in these patients are unknown. AIM To investigate the coagulation activity of emicizumab in vitro in a plasma model of neonate-HA. METHODS Plasmas from 84 neonates with non-HA were enrolled. However, due to the limited plasma volumes in some cases, 50 plasmas were assigned to two different assay groups. To prepare the neonate-HA model, plasma was first preincubated with an antifactor (F) VIII A2 monoclonal antibody (mAb). After further incubation with emicizumab, global coagulation activity was measured: adjusted maximum coagulation velocity (Ad|min1|) in clot waveform analysis (CWA) and peak thrombin in thrombin generation assay (TGA). RESULTS Because the addition of anti-FVIII mAb to 22 of 43 samples showed little decrease in Ad|min1|, the remaining 21 samples were analyzed by CWA. The addition of emicizumab increased Ad|min1| in 18 of the 19 cases (effective group) but not in the remaining 3 cases (noneffective group). Similarly, TGA found that emicizumab (effective group) improved peak thrombin in seven of the nine samples tested, but two cases did not respond (noneffective group). Although the effective group had lower levels of FX, there was no significant difference between the effective and noneffective groups in terms of FIX, protein S, protein C, antithrombin, and fibrinogen. CONCLUSIONS The in vitro coagulant potentials of emicizumab in the neonate-HA model were more heterogeneous than those recorded in the adult-HA model.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Nara, Japan
| | - Tomoko Onishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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10
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Utilization of Emicizumab in Acquired Hemophilia A: A Case Report. Transfus Apher Sci 2022; 61:103457. [DOI: 10.1016/j.transci.2022.103457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/30/2022] [Accepted: 05/09/2022] [Indexed: 11/21/2022]
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11
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Monitoring of new therapies for hemophilia. Blood Coagul Fibrinolysis 2022; 33:S3-S4. [PMID: 35088769 DOI: 10.1097/mbc.0000000000001108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nonreplacement therapies, such as emicizumab (Hemlibra, Roche) and other myriad of molecules are still under study as concizumab (and other anti-TFPI) and fitusiran are transforming the quality of life and treatment of this group of patients. So far, laboratory monitorization has not been an obligate condition for the use of these novel therapies, though in some cases like their combination with bypassing agents to control breakthrough/surgical bleeds may seek for laboratory assays to ensure a well tolerated and effective utilization withing these special scenarios. In the next pages, application of global coagulation assays, for example, thrombinography or rotational thrombelastography will be referred looking to the works of some groups from around the world including our own experience.
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Comprehensive blood coagulation potential in patients with acquired hemophilia A: retrospective analyses of plasma samples obtained from nationwide centers across Japan. Int J Hematol 2021; 115:163-172. [PMID: 34724152 DOI: 10.1007/s12185-021-03249-w] [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: 09/07/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 10/20/2022]
Abstract
Global coagulation potential was assessed in 59 patients with acquired hemophilia A (PwAHA) by clot waveform analysis (CWA) and/or thrombin and plasmin generation assay. Relationships between factor VIII activity (FVIII:C) and the parameters from CWA and T/P-GA in patients with congenital HA were compared by grading coagulation potential related to FVIII:C: T1 (FVIII:C < 1 IU/dL), T2 (1 ≤ , ≤ 5 IU/dL), T3 (5 < , 12 ≤ IU/dL), and T4 (12 < , ≤ 50 IU/dL). The median FVIII:C and inhibitor titers in PwAHA on admission were 3.3 IU/dL and 63.0 BU/mL, respectively, but global coagulation parameters corresponded to T1 or less. Median FVIII:C levels during follow-up in PwAHA were 1.7-9.6-6.7-40.0-21.7 IU/dL on days 0-14-28-56-93, respectively. CWA-based data corresponded to less than T2 until day 28, but more closely reflected FVIII:C after day 56. Peak thrombin was severely low (near T1) until day 28 and improved modestly after day 56 but remained less than T2. Peak plasmin was lower than T1 until day 56, and returned to T4 on day 93. In conclusion, global coagulation function in PwAHA was impaired to a greater extent than could be anticipated from assays of FVIII:C, until approximately 1 month after immunosuppression and treatment with FVIII-bypassing agents.
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Hansenne A, Hermans C. Emicizumab in acquired haemophilia A: about two clinical cases and literature review. Ther Adv Hematol 2021; 12:20406207211038193. [PMID: 34471508 PMCID: PMC8404634 DOI: 10.1177/20406207211038193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 07/19/2021] [Indexed: 01/31/2023] Open
Abstract
Acquired haemophilia A (AHA) is a rare and severe haemorrhagic autoimmune disease caused by autoantibodies directed against factor VIII (FVIII). Treatment is based on two principles, including haemostatic control to compensate FVIII inhibition and eradication of inhibiting antibodies using immunosuppressive therapy. Rapid recognition and proper management are essential to avoid excess morbidity and mortality. Effective and safe treatments can be challenging, given that AHA patients are often elderly, with multiple comorbidities. Emicizumab, a bispecific antibody that mimics the action of FVIII, has proven effective in managing patients with congenital haemophilia, with or without inhibitors. Likewise, its mode of action suggests theoretical efficacy in AHA patients. We herein describe two AHA cases with comorbidities that were treated effectively using emicizumab combined with immunosuppressive therapy. We have also reviewed the current literature regarding the promising use of emicizumab in this indication.
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Affiliation(s)
- Amandine Hansenne
- Division of Haematology, Hemostasis-Thrombosis Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Cedric Hermans
- Division of Haematology, Hemostasis-Thrombosis Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), 10 avenue Hippocrate, 1200 Brussels, Belgium
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Abstract
The serine protease thrombin, a naturally derived enzyme, plays a key role in hemostasis by converting fibrinogen to fibrin and activating coagulation factor XIII whereby the fibrin clot is stabilized. Furthermore, thrombin activates platelets through protease-activated receptors on the platelet surface. Conversely, thrombin also exerts anticoagulant effects, enhancing the protein C activity while complexed with thrombomodulin. During recent years, it has become evident that thrombin has significant effects beyond hemostasis, as it contributes also to modulation of the endothelium, promotes inflammation and angiogenesis, and plays a role in tumor progression. Yet, due to the very short half-life and almost immediate inhibition in fluid phase by antithrombin, thrombin itself remains elusive, and only indirect measurement of thrombin generation is possible. This review provides a description of structure and mechanisms of action of thrombin both in physiological and pathological processes. Furthermore, it summarizes laboratory tests that measure in vivo or ex vivo thrombin generation, and presents knowledge on the value of these biomarkers in bleeding disorders, cardiopulmonary bypass surgery, and thromboembolic risk assessment in different patient populations. Finally, this review outlines further perspectives on using thrombin generation biomarkers for research purposes and in clinical practice.
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Affiliation(s)
- Julie Brogaard Larsen
- Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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16
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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: 25] [Impact Index Per Article: 8.3] [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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17
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Takeyama M, Furukawa S, Yada K, Ogiwara K, Shimonishi N, Nakajima Y, Mizumachi K, Noguchi-Sasaki M, Shima M, Nogami K. Ex Vivo Prediction of Comprehensive Coagulation Potential Using Simulated Blood Concentrations of Emicizumab in Patients with Acquired Hemophilia A. Thromb Haemost 2021; 121:1289-1298. [PMID: 33641138 DOI: 10.1055/s-0041-1725009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Emicizumab prophylaxis improves coagulation function in congenital hemophilia A, regardless of inhibitor presence. We recently reported that emicizumab enhanced the coagulant potentials, ex vivo, in plasmas from patients with acquired hemophilia A (PwAHAs) at diagnosis. However, coagulant effects of emicizumab in PwAHAs during the clinical course remain unclear. AIM To assess ex vivo coagulant effects of emicizumab in PwAHAs during the clinical course. METHODS/RESULTS Blood samples were obtained from 14 PwAHAs on (median) days 0 and 6 during a severe-bleeding phase, and days 27 and 59 during a reduced-bleeding phase with elevated endogenous factor VIII (FVIII) and decreased inhibitor titers. If administered a single dose of 3 or 6 mg/kg, or two doses at 6 mg/kg followed by 3 mg/kg, estimated plasma emicizumab concentrations (10/5/2.5, 20/10/5, and 30/15/7.5 µg/mL on days 0-7/30/60, respectively) could be used to represent potential changes, based on the half-life (T 1/2: ∼30 days). Emicizumab concentrations that covered maximum plasma concentrations of each dosage were used for spiking on day 0. Ex vivo addition of estimated emicizumab to PwAHA's plasma containing endogenous FVIII and/or inhibitor, without and with recombinant (r)FVIIa administration during immunosuppressive therapy, increased the calculated Ad|min1| values, assessed by clot waveform analysis, and their coagulant potentials were below normal levels. Rotational thromboelastometry revealed that ex vivo emicizumab addition resulted in the further improvement of coagulant potentials in whole bloods when combined with rFVIIa administration. CONCLUSION Based on ex vivo and in vitro data, emicizumab has the potential to be effective in clinical situations for PwAHAs.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Course of Hemophilia Education, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | | | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Nakajima Y, Minami H, Nogami K. Acidic Region Residues 1680-1684 in the A3 Domain of Factor VIII Contain a Thrombin-Interactive Site Responsible for Proteolytic Cleavage at Arg1689. Thromb Haemost 2021; 121:1274-1288. [PMID: 33592631 DOI: 10.1055/s-0041-1723996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Factor VIII (FVIII) is activated by thrombin-catalyzed cleavage at Arg372, Arg740, and Arg1689. Our previous studies suggested that thrombin interacted with the FVIII C2 domain specific for cleavage at Arg1689. An alternative report demonstrated, however, that a recombinant (r)FVIII mutant lacking the C2 domain retained >50% cofactor activity, indicating the presence of other thrombin-interactive site(s) associated with cleavage at Arg1689. We have focused, therefore, on the A3 acidic region of FVIII, similar to the hirugen sequence specific for thrombin interaction (54-65 residues). Two synthetic peptides, spanning residues 1659-1669 with sulfated Tyr1664 and residues 1675-1685 with sulfated Try1680, inhibited thrombin-catalyzed FVIII activation and cleavage at Arg1689. Treatment with 1-ethyl-3-(3-dimethylaminopropyl)-carbodiimide to cross-link thrombin with either peptide showed possible contributions of both 1664-1666 and 1683-1684 residues for thrombin interaction. Thrombin-catalyzed activation and cleavage at Arg1689 in the alanine-substituted rFVIII mutants within 1663-1666 residues were similar to those of wild type (WT). Similar studies of 1680-1684 residues, however, demonstrated that activation and cleavage by thrombin of the FVIII mutant with Y1680A or D1683A/E1684A, in particular, were severely or moderately reduced to 20 to 30% or 60 to 70% of WT, respectively. Surface plasmon resonance-based analysis revealed that thrombin interacted with both Y1680A and D1683A/E1684A mutants with approximately sixfold weaker affinities of WT. Cleavage at Arg1689 in the isolated light-chain fragments from both mutants was similarly depressed, independently of the heavy-chain subunit. In conclusion, the 1680-1684 residues containing sulfated Tyr1680 in the A3 acidic region also contribute to a thrombin-interactive site responsible for FVIII activation through cleavage at Arg1689.
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Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Hiroaki Minami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Dobbelstein C, Moschovakis GL, Tiede A. Reduced-intensity, risk factor-stratified immunosuppression for acquired hemophilia A: single-center observational study. Ann Hematol 2020; 99:2105-2112. [PMID: 32621181 PMCID: PMC7419459 DOI: 10.1007/s00277-020-04150-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/15/2020] [Indexed: 12/26/2022]
Abstract
Immunosuppressive therapy (IST) is administered to patients with acquired hemophilia A (AHA) to eradicate autoantibodies against coagulation factor VIII (FVIII). Data from registries previously demonstrated that IST is often complicated by adverse events, in particular infections. This pilot study was set out to assess the feasibility of reduced-intensity, risk factor–stratified IST. We followed a single-center consecutive cohort of twenty-five patients with AHA receiving IST according to a new institutional treatment standard. Based on results from a previous study, GTH-AH 01/2020, patients were stratified into “poor risk” (FVIII < 1 IU/dl or inhibitor ≥ 20 Bethesda units (BU)/ml) or “good risk” (FVIII ≥ 1 IU/dl and inhibitor < 20 BU/ml). Outcomes were compared between the current cohort and the GTH registry as a historic control (n = 102). Baseline characteristics of the cohort were not different from the historic control. Partial remission, defined as FVIII recovered to > 50 IU/dl, was achieved by 68% of patients after a median time of 112 days, which was lower and significantly later than in the historic control (hazard ratio: 1.8, 95% confidence interval 1.2–2.8). Complete remission, overall survival, and frequency of fatal infections were not different. Grade 3 and 4 infections were more frequent. The impact of risk factors that was observed in the historic cohort was no longer apparent, as partial and complete remission and overall survival were similar in “good risk” and “poor risk” patients. In conclusion, reduced-intensity, risk factor–stratified IST is feasible in AHA but did not decrease the risk of infections and mortality in this cohort.
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Affiliation(s)
- Christiane Dobbelstein
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Carl Neuberg Str. 1, 30625, Hannover, Germany
| | - Georgios Leandros Moschovakis
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Carl Neuberg Str. 1, 30625, Hannover, Germany
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Carl Neuberg Str. 1, 30625, Hannover, Germany.
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Acquired Haemophilia A: An Intriguing Disease. Mediterr J Hematol Infect Dis 2020; 12:e2020045. [PMID: 32670523 PMCID: PMC7340240 DOI: 10.4084/mjhid.2020.045] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/18/2020] [Indexed: 12/31/2022] Open
Abstract
Abstract. Acquired Haemophilia A is a rare acquired bleeding disorder caused by Factor VIII autoantibodies, which neutralise FVIII activity. These inhibitors differ from alloantibodies against FVIII, which can occur in congenital Haemophilia A after repeated exposures to plasma-derived or recombinant FVIII products. In most cases, the disease occurs suddenly in subjects without a personal or familiar history of bleedings, with symptoms that may be mild, moderate, or severe. However, only laboratory alterations are present in ~ 30% of patients. The incidence varies from 1 to 4 cases per million/year; more than 80% of patients are elderly, males and females are similarly affected. There is a small peak of incidence related to pregnancy in young women aged 20–40 years. The disease may be underdiagnosed in the elderly. The diagnostic algorithm is based on an isolated prolonged activated partial thromboplastin time, normal thrombin time, absence of Lupus Anticoagulant, and a mixing test that reveals the presence of an inhibitor: the finding of reduced FVIII activity and the detection of neutralising autoantibodies against FVIII lead to the diagnosis. The disease is idiopathic in 44%–63% of cases, while in the others etiological factors are present. Bleeding prevention and treatment are based on therapeutic tools as by-passing agents, recombinant porcine FVIII concentrate or, in a limited number of cases, FVIII concentrates and desmopressin. As soon as the diagnosis has been made, immunosuppressive therapy must be started to eradicate the inhibitor. Better knowledge of the disease, optimal management of bleeding and eradication of the inhibitor have significantly reduced morbidity and mortality in most patients.
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Yada K, Nogami K. Novel Insights and New Developments Regarding Coagulation Revealed by Studies of the Anti-Factor IXa (Activated Factor IX)/Factor X Bispecific Antibody, Emicizumab. Arterioscler Thromb Vasc Biol 2020; 40:1148-1154. [PMID: 32237902 DOI: 10.1161/atvbaha.120.312919] [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] [Indexed: 11/16/2022]
Abstract
Emicizumab is a humanized anti-FIXa/FX (factor IXa/X) bispecific monoclonal antibody that mimics FVIIIa (activated factor VIII) cofactor function. The hemostatic efficacy of emicizumab has been confirmed in clinical studies of patients with hemophilia A, irrespective of the presence of FVIII inhibitors. Emicizumab differs in some properties from FVIIIa molecule. Emicizumab requires no activation by thrombin and is not inactivated by activated protein C, but emicizumab-mediated coagulation is regulatable and maintains hemostasis. A small amount of FIXa (activated factor IX) is required to initiate emicizumab-mediated hemostasis, whereas tissue factor/FVIIa (activated factor VII)-mediated FXa (activated factor X) and thrombin activation initiates FVIIIa-mediated hemostasis. Fibrin formation, followed by fibrinolysis, appears to be similar between emicizumab- and FVIIIa-mediated hemostasis. These results suggest possible future uses of emicizumab for treating hemorrhagic diseases other than hemophilia A and reveal previously unobservable behaviors of procoagulation and anticoagulation factors in conventional hemostasis. Here, we have reviewed novel insights and new developments regarding coagulation highlighted by emicizumab.
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Affiliation(s)
- Koji Yada
- From the Department of Pediatrics (K.Y., K.N.), Nara Medical University, Kashihara, Japan.,The Course of Hemophilia Education (K.Y.), Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- From the Department of Pediatrics (K.Y., K.N.), Nara Medical University, Kashihara, Japan
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