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Kershaw G. Strategies for Performing Factor Assays in the Presence of Emicizumab or Other Novel/Emerging Hemostatic Agents. Semin Thromb Hemost 2024; 50:1163-1172. [PMID: 38866040 DOI: 10.1055/s-0044-1787189] [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: 06/14/2024]
Abstract
For several decades, therapeutic options for inherited deficiencies of factor VIII or IX (hemophilia A or B, respectively) have largely been the replacement of the missing clotting factor with plasma-derived or recombinant products. Hemostasis laboratories use standard activated partial thromboplastin time (aPTT)-based clotting or chromogenic assays to monitor plasma factor levels to guide therapy. The emergence in the past 10 years of extended half-life replacement products and other novel therapies for hemophilia has led to a reappraisal of assay suitability, with studies of product measurement showing some existing assay types or reagents to be unsuitable for some products. The hemostasis laboratory must adapt to the changing landscape by adding new assays or modifying existing assays to ensure accurate results for product measurement. These strategies include switching from a chromogenic assay to a clotting assay, or vice versa, changing an aPTT reagent brand, or introducing product specific calibrators. This article evaluates the effects of some of the newer treatment options on the laboratory testing of factor levels and related assays.
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Affiliation(s)
- Geoffrey Kershaw
- Institute of Haematology, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, Australia
- ANZAC Research Institute, University of Sydney, Hospital Road, Concord, NSW, Australia
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2
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Spannagl M. [Hemophilia: is a revolution in treatment options taking place?]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:1040-1043. [PMID: 39212790 DOI: 10.1007/s00108-024-01712-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 09/04/2024]
Abstract
Prophylactic replacement therapy for hemophilia A (hereditary factor VIII deficiency) is a success story of the production of coagulation factor concentrates from donor plasma. Recombinant factor concentrates, which are also produced with modified gene constructs for coagulation factor VIII in order to improve pharmacological properties, have since proven their worth. This successful development over many years of factor concentrates for the successful treatment of hemophilia patients has now been followed by the innovation of a factor VIII mimetic in the form of a monoclonal antibody, which was developed in Japan already some years back. Emicizumab is a humanized, bispecific monoclonal antibody for therapeutic use in hemophilia A. With this therapeutic agent, the treatment of the hereditary coagulation defect is based, for the first time, on a completely new active principle. The specific antibody simulates the properties of coagulation factor VIII as a cofactor for the formation of the tenase complex with the coagulation factors IX and X. As a result under steady state conditions almost normal thrombin and thus fibrin formation can be achieved.
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Affiliation(s)
- Michael Spannagl
- INSTAND e. V. Düsseldorf Gesellschaft zur Förderung der Qualitätssicherung in med. Laboratorien, Ubierstr 20, 40223, Düsseldorf, Deutschland.
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Ferri Grazzi E, Becker T, Brandt S, Duport G, Garcia Diego DA, Lupi A, McKeown W, Morgan D, Camp C, Hawes C, Blenkiron T, O'Hara J, Burke T. Clinical and Humanistic Burden of Non-inhibitor Haemophilia A in Five European Countries: Insights from the CHESS II Study. Adv Ther 2024; 41:3888-3904. [PMID: 39153051 DOI: 10.1007/s12325-024-02956-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 07/24/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION Haemophilia A (HA) is a congenital bleeding disorder caused by a deficiency/absence of factor VIII (FVIII) and characterised by frequent, acute and prolonged spontaneous or traumatic bleeding events, often leading to haemophilic arthropathy and progressive joint deterioration. HA severity is characterized by endogenous FVIII activity: mild (> 5-40%), moderate (1-5%), or severe (< 1%). HA poses a substantial clinical and socioeconomic burden on people with HA (PWHA), their caregivers, and society. This analysis evaluates clinical and patient-centric outcomes of a cohort of individuals with non-inhibitor HA sampled from France, Germany, Italy, Spain, and the UK in the 'Cost of Haemophilia in Europe: A Socioeconomic Survey II' (CHESS II) study. METHODS CHESS II was a cross-sectional burden-of-illness study collecting clinical and socioeconomic data on adult (≥ 18 years) individuals with haemophilia A or B of any severity with or without inhibitors from eight European countries. Descriptive analyses were conducted examining physician-reported demographics, clinical and health resource utilisation information. PWHA-reported health-related quality of life (HRQoL) using the EQ-5D-5L and Work Productivity and Activity Impairment (WPAI) were also examined. Outcomes were stratified by HA severity and reported at country level. RESULTS Demographics and clinical characteristics of the cohort (N = 880) were generally consistent across countries. Individuals with severe HA experienced more frequent bleeding events and joint disease despite broad use of factor replacement therapy long-term prophylaxis. A minority of those with mild or moderate HA also experienced such challenges. HRQoL and workforce participation diminished, and chronic pain increased, with increasing HA severity. CONCLUSION This analysis provides up-to-date insights on the impact of HA across five European countries. Increasing HA severity was generally associated with worse clinical outcomes, HRQoL and workforce participation. These findings suggest a place for continued evidence-based tailored treatment and clinical management approaches in addressing the residual burden of HA.
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Affiliation(s)
| | - Tobias Becker
- Interessengemeinschaft Hämophiler e.V., Rottenburg, Germany
| | | | - Gaetan Duport
- Association Française des Hémophiles (AFH), Paris, France
| | | | - Angelo Lupi
- Federazione delle Associazioni Emofilici (FedEmo), Rome, Italy
| | | | | | | | | | - Tom Blenkiron
- HCD Economics, Brook St, Cheshire, Knutsford, WA16 8GP, UK.
| | - Jamie O'Hara
- HCD Economics, Brook St, Cheshire, Knutsford, WA16 8GP, UK
- University of Chester, Chester, UK
| | - Tom Burke
- HCD Economics, Brook St, Cheshire, Knutsford, WA16 8GP, UK
- University of Chester, Chester, UK
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Wada H, Shiraki K, Matsumoto T, Shimpo H, Sakano Y, Nishii H, Tamaki S, Suzuki K, Tawara I, Yamashita Y, Shimaoka M. Evaluating Factor VIII Concentrates Using Clot Waveform Analysis. J Clin Med 2024; 13:3857. [PMID: 38999423 PMCID: PMC11242304 DOI: 10.3390/jcm13133857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 06/18/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: FVIII reagent activity varies across different assays, as well as activated partial thromboplastin time (APTT) reagents. The hemostatic ability of various FVIII reagents was examined via clot waveform analysis (CWA). Methods: APTT was measured using 12 APTT reagents, a small amount of tissue factor-induced FIX activation (sTF/FIXa) and a small amount of thrombin time (sTT) in order to examine 10 FVIII reagents and reference plasma (RP) using CWA. FVIII activity was measured using CWA-APTT, a chromogenic assay, or CWA-sTT. Results: Although the peak time (PT) and peak height (PH) of the CWA-APTT were markedly different in different FVIII reagents using several APTT reagents, the PTs of CWA-APTT were generally normal or shortened and the PHs of CWA-APTT were generally lower than those of RP. The FVIII activity varied, as evaluated using APTT, and was higher when using the CWA-sTT method than the APTT or chromogenic methods. CWA-sTT showed an elevated second peak of first DPH in all FVIII reagents, and both CWA-sTF/FIXa and CWA-sTT were enhanced using APTT reagents. Conclusions: Our evaluation of the hemostatic ability of FVIII reagents varied among APTT reagents. CWA-sTT can be used to further evaluate the hemostatic ability of an FVIII concentrate based on thrombin burst.
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Affiliation(s)
- Hideo Wada
- Associated Department with Mie Graduate School of Medicine, Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan;
| | - Katsuya Shiraki
- Associated Department with Mie Graduate School of Medicine, Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan;
- Department of General Medicine, Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan
| | - Takeshi Matsumoto
- Department of Transfusion Medicine and Cell Therapy, Mie University Hospital, Tsu 514-8507, Japan;
| | - Hideto Shimpo
- Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan;
| | - Yumi Sakano
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu 514-8507, Japan; (Y.S.); (H.N.); (M.S.)
| | - Hiroko Nishii
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu 514-8507, Japan; (Y.S.); (H.N.); (M.S.)
| | - Shigehisa Tamaki
- Department of Hematology, Japanese Red Cross Ise Hospital, Ise 516-8512, Japan;
| | - Kei Suzuki
- The Advanced Emergency and Critical Care Center, Mie University Hospital, Tsu 514-8507, Japan;
| | - Isao Tawara
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu 514-8507, Japan; (I.T.); (Y.Y.)
| | - Yoshiki Yamashita
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu 514-8507, Japan; (I.T.); (Y.Y.)
| | - Motomu Shimaoka
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu 514-8507, Japan; (Y.S.); (H.N.); (M.S.)
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Evangelidis N, Kotsiou N, Evangelidis P, Alevizopoulos VI, Dermitzakis I, Chissan S, Vakalopoulou S, Gavriilaki E. Genetics and Epigenetics in Acquired Hemophilia A: From Bench to Bedside. Curr Issues Mol Biol 2024; 46:5147-5160. [PMID: 38920981 PMCID: PMC11201880 DOI: 10.3390/cimb46060309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 05/14/2024] [Accepted: 05/21/2024] [Indexed: 06/27/2024] Open
Abstract
Acquired hemophilia A (AHA) is a bleeding disorder characterized by the immunological inhibition of factor VIII (FVIII) of the hemostatic pathway leading to hemorrhagic events. Different domains of FVIII are the target of autoantibodies (mainly immunoglobulin (Ig) G) leading to the deficiency of FVIII. Several factors have been associated with the activation of the auto-immunity towards FVIII. Emerging evidence implicates CD4+ T cell activation in mediating this autoimmune response, with their involvement like that observed in congenital hemophilia A. Several genes such as HLA II DRB*16, DQB1*0502, and CTLA-4 + 49 are responsible for the pathogenesis of AHA. Epigenetic modifications and mainly long-coding RNAS (lncRNAs) are potentially contributing to the pathogenesis of AHA. The treatment approach of AHA includes the management of acute bleeding events and the administration of immunosuppressive medications. This review aimed to summarize the published data on the genetics and epigenetics of AHA. The severity and the mortality of this disease are creating an emerging need for further research in the field of the genetics and epigenetics of acquired hemorrhagic disorder.
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Affiliation(s)
- Nikolaos Evangelidis
- Hematology Unit-Hemophilia Centre, 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (N.E.); (N.K.); (P.E.); (V.I.A.); (S.C.); (S.V.)
| | - Nikolaos Kotsiou
- Hematology Unit-Hemophilia Centre, 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (N.E.); (N.K.); (P.E.); (V.I.A.); (S.C.); (S.V.)
| | - Paschalis Evangelidis
- Hematology Unit-Hemophilia Centre, 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (N.E.); (N.K.); (P.E.); (V.I.A.); (S.C.); (S.V.)
| | - Vlasios I. Alevizopoulos
- Hematology Unit-Hemophilia Centre, 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (N.E.); (N.K.); (P.E.); (V.I.A.); (S.C.); (S.V.)
| | - Iasonas Dermitzakis
- Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Sofia Chissan
- Hematology Unit-Hemophilia Centre, 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (N.E.); (N.K.); (P.E.); (V.I.A.); (S.C.); (S.V.)
| | - Sofia Vakalopoulou
- Hematology Unit-Hemophilia Centre, 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (N.E.); (N.K.); (P.E.); (V.I.A.); (S.C.); (S.V.)
| | - Eleni Gavriilaki
- Hematology Unit-Hemophilia Centre, 2nd Propedeutic Department of Internal Medicine, Hippocration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (N.E.); (N.K.); (P.E.); (V.I.A.); (S.C.); (S.V.)
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Gupta N, Dutta A, Ahmed B, Ross CR, S C, Dolan G, John MJ, Radhakrishnan N, Aggarwal S, Seth T, Kaul V, Shah V. Expert Opinions on the Management of Hemophilia A in India: The Role of Emicizumab. Cureus 2024; 16:e58941. [PMID: 38725780 PMCID: PMC11081140 DOI: 10.7759/cureus.58941] [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: 04/21/2024] [Indexed: 05/12/2024] Open
Abstract
Hemophilia A (HA) is a genetic disorder of hemostasis associated with a deficiency or reduced activity of clotting factor VIII (FVIII). This disorder remains unacceptably underdiagnosed in India. Early diagnosis and appropriate management of HA can substantially prevent morbidity and mortality. Currently, HA is managed with regular replacement therapy using standard or extended half-life FVIII concentrates or non-factor drug products. The challenges associated with FVIII concentrates include plateauing of drug effect, issues with its administration and adherence to treatment, breakthrough bleeds, and the development of inhibiting antibodies against administered clotting factors. Emicizumab is a bispecific antibody, launched in India in April 2019, for managing patients with HA. To investigate the role of emicizumab in Indian patients with HA, opinions were sought from 13 eminent hematologists and experts from India on the effectiveness of emicizumab in preventing all bleeds, spontaneous bleeds, perioperative bleeds, and intracranial hemorrhage; resolving target joints; and reducing the rate of hospitalizations and fatality associated with HA in children and adults, with or without inhibitors. The benefits of emicizumab over traditional FVIII concentrates include the subcutaneous route of delivery, less frequent dosing, and a lack of inhibitor development, in addition to providing sustained hemostasis without in-depth monitoring. It is a safe and effective management option for all HA patients, especially for patients with certain archetypes, such as those with inhibitors, those with high annualized bleed rates, those living far away from hemophilia care centers, pediatric patients and infants with intravenous access challenges, and those with a history of life-threatening bleeding events.
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Affiliation(s)
- Naresh Gupta
- Medicine and Surgery, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
- Haematology & Haemophilia, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, IND
| | - Anupam Dutta
- General Medicine, Assam Medical College and Hospital, Dibrugarh, IND
| | - Bilal Ahmed
- Pathology, Transfusion Medicine & Hemophilia, Government Medical College, Srinagar, IND
| | - Cecil R Ross
- Hematology, St. John's Medical College and Hospital, Bangalore, IND
| | - Chandrakala S
- Clinical Haematology, King Edward Memorial Hospital, Mumbai, IND
| | - Gerard Dolan
- Haematology, St. Thomas' Haemophilia Comprehensive Care Centre, Bournemouth, GBR
| | - M J John
- Clinical Hematology, Hemato-Oncology & Bone Marrow Transplant, Christian Medical College & Hospital, Ludhiana, IND
| | - Nita Radhakrishnan
- Hematology and Oncology, Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida, IND
| | | | - Tulika Seth
- Hematology, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
| | - Varun Kaul
- Pediatrics, Guru Gobind Singh Medical College & Hospital, Faridkot, IND
| | - Vijay Shah
- Pediatrics, Nirmal Hospital Pvt. Ltd., Surat, IND
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7
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Español MG, Mistretta JN, Tarantino MD, Roberts JC. The Evolution of Hemophilia Therapeutics: An Illustrated Review. Res Pract Thromb Haemost 2024; 8:102308. [PMID: 38883215 PMCID: PMC11180375 DOI: 10.1016/j.rpth.2023.102308] [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: 03/18/2023] [Revised: 11/30/2023] [Accepted: 12/19/2023] [Indexed: 06/18/2024] Open
Abstract
Hemophilia is a rare genetic bleeding disorder historically associated with high morbidity and mortality. Some individuals with hemophilia suffer associated chronic joint disease, chronic pain, and other physical and mental health challenges. In the last 50 years, a better understanding of the pathophysiology of the disease has resulted in extraordinary therapeutic advances leading to enhanced quality of life and increased life expectancy. We present an illustrated review of the evolution of hemophilia treatment from the development of non-factor therapies to gene therapy.
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Affiliation(s)
- María G Español
- The Bleeding & Clotting Disorders Institute, Peoria, IL
- Department of Pediatrics, University of Illinois College of Medicine at Peoria, Peoria, IL
| | | | - Michael D Tarantino
- The Bleeding & Clotting Disorders Institute, Peoria, IL
- Department of Pediatrics and Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL
| | - Jonathan C Roberts
- The Bleeding & Clotting Disorders Institute, Peoria, IL
- Department of Pediatrics and Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL
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8
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Duboscq C, Sueldo E, Rosa C, Zirpoli M, Ceresetto J, Baques A, Arias M. High variability in Factor IX one-stage assay in samples spiked with nonacog beta pegol among different pairs of reagent/detection system. Int J Lab Hematol 2024; 46:128-134. [PMID: 37704365 DOI: 10.1111/ijlh.14171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 08/30/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION Haemophilia B (HB) is an X-linked hereditary bleeding disorder characterized by coagulation factor IX (FIX) deficiency. To improve the quality of life of patients and adherence to treatment, recombinant factor concentrates modified to extend their half-life have been developed, called extended half-life factors (EHL: extended half-life). Nonacog beta pegol (N9-GP) is a glycopegylated recombinant human FIX molecule that has a half-life of 93 h with a single dose and has shown a higher recovery percentage than other molecules. To diagnose and monitor the treatment of haemophiliac patients, FIX activity is determined with the one-stage clotting assay (OSA) and/or the chromogenic assay. The objective of this work, carried out in three centres, was to measure the recovery of N9-PG with 10 different activated partial thromboplastin time (APTT) reagents on three platforms, in samples spiked in vitro with N9-GP, at four different concentration levels. METHODS It was measured the recovery of N9-GP with 10 different APTT reagents (polyphenol, ellagic acid, silice dioxide, colloidal silica as APTT activator on three platforms, in sample spiked in vitro with N9-GP. RESULTS The results show heterogeneity in the activity of N9-GP measured by OSA with the different APTT reagents when the calibrations were performed with the specific calibrator of each coagulometer. A recovery percentage between 87% and 108% was obtained only with polyphenol and ellagic acid as activator in the three platforms evaluated. The other reagents studied overestimate or underestimate, with no clear profile. When a calibration curve was performed with a calibrator prepared from the N9-GP vial, all APTT reagents met the established recovery requirement. CONCLUSION APTT reagents with polyphenol or ellagic acid as activator would be the only ones appropriate when using the commercially available OSA with specific calibrator to monitor patients treated with N9-GP.
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Affiliation(s)
- C Duboscq
- Servicio Hematología, Hospital Británico, Buenos Aires, Argentina
| | - E Sueldo
- Laboratorio de Hematología Y Hemostasia, Hospital Dr. César Milstein, Buenos Aires, Argentina
| | - C Rosa
- Laboratorio Central Hospital, Hospital Universitario Austral, Buenos Aires, Argentina
| | - M Zirpoli
- Laboratorio Central Hospital, Hospital Universitario Austral, Buenos Aires, Argentina
| | - J Ceresetto
- Servicio Hematología, Hospital Británico, Buenos Aires, Argentina
| | - A Baques
- Servicio de Hemofilia, Dr. César Milstein, Buenos Aires, Argentina
| | - M Arias
- Laboratorio de Hematología Y Hemostasia, Hospital Dr. César Milstein, Buenos Aires, Argentina
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Shafaati Lambert M, Bruzelius M, Mahmoud Hourani Soutari N, Ranta S, Antovic JP. Laboratory response to paradigm change in hemophilia treatment. Clin Chem Lab Med 2023; 61:e248-e250. [PMID: 37319338 DOI: 10.1515/cclm-2023-0443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/24/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Marjan Shafaati Lambert
- Coagulation & Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Coagulation, Clinical Chemistry, Karolinska University Laboratory, Medical Diagnostics Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Bruzelius
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Nida Mahmoud Hourani Soutari
- Coagulation & Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Coagulation, Clinical Chemistry, Karolinska University Laboratory, Medical Diagnostics Karolinska, Karolinska University Hospital, Stockholm, Sweden
| | - Susanna Ranta
- Astrid Lindgren's Children's Hospital, Karolinska Univeristy Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Jovan P Antovic
- Coagulation & Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Coagulation, Clinical Chemistry, Karolinska University Laboratory, Medical Diagnostics Karolinska, Karolinska University Hospital, Stockholm, Sweden
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Bhatti MQ, Gonzalez-Fernandez E, Bhatia K, Divani AA, Di Napoli M, Hinduja A, Datta YH. Neurological Complications Associated with Hereditary Bleeding Disorders. Curr Neurol Neurosci Rep 2023; 23:751-767. [PMID: 37864642 DOI: 10.1007/s11910-023-01313-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW Hereditary bleeding disorders may have a wide variety of clinical presentations ranging from mild mucosal and joint bleeding to severe central nervous system (CNS) bleeding, of which intracranial hemorrhage (ICH) is the most dreaded complication. In this review, we will discuss the pathophysiology of specific hereditary bleeding disorders, namely, hemophilia A, hemophilia B, and von Willebrand disease (vWD); their clinical manifestations with a particular emphasis on neurological complications; a brief overview of management strategies pertaining to neurological complications; and a review of literature guiding treatment strategies. RECENT FINDINGS ICH is the most significant cause of morbidity and mortality in patients with hemophilia. Adequate control of bleeding with the administration of specific factors or blood products, identification of risk factors for bleeding, and maintaining optimal coagulant activity are essential for appropriately managing CNS bleeding complications in these patients. The administration of specific recombinant factors is tailored to a patient's pharmacokinetics and steady-state levels. During acute bleeding episodes, initial factor activity should be maintained between 80 and 100%. Availability of monoclonal antibody Emicizumab has revolutionized prophylactic therapies in patients with hemophilia. Management of ICH in patients with vWD involves using plasma-derived factor concentrates, recombinant von Willebrand factor, and supportive antifibrinolytic agents individualized to the type and severity of vWD. Hemophilia and vWD are the most common hereditary bleeding disorders that can predispose patients to life-threatening CNS complications-intracranial bleeds, intraspinal bleeding, and peripheral nerve syndromes. Early care coordination with a hematologist can help develop an effective prophylactic regimen to avoid life-threatening bleeding complications in these patients. Further research is needed to evaluate using emicizumab as an on-demand treatment option for acute bleeding episodes in patients with hemophilia.
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Affiliation(s)
| | | | - Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA.
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, L'Aquila, Italy
| | - Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Yvonne H Datta
- Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA
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11
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Bowyer AE, Hickey K, Kitchen S, Ezban M. A next generation FVIII mimetic bispecific antibody, Mim8, the impact on non-factor VIII related haemostasis assays. Haemophilia 2023; 29:1633-1637. [PMID: 37824563 DOI: 10.1111/hae.14884] [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: 07/06/2023] [Revised: 09/19/2023] [Accepted: 09/29/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION AND AIMS Mim8 is a next generation bispecific antibody developed for the treatment of haemophilia A (HA). Mim8 has an increased potency compared to first generation molecules. The impact on Mim8 on non-FVIII measuring haemostasis assays was assessed in plasma containing Mim8. METHODS Congenital severe HA plasma was spiked with increasing concentrations of Mim8 (0-20 μg/mL). 28 routine and specialist haemostasis assays were used to measure activities. These included tests for prothrombin time (PT), fibrinogen, thrombin, D-dimer, anti-Xa, heparin induced thrombocytopenia (HIT), clotting factors II-XII, factor XIII, von Willebrand factor (VWF), thrombophilia and DRVVT. RESULTS AND CONCLUSIONS Less than 10 % difference was calculated between plasma without Mim8 and plasma spiked to 15 μg/mL Mim8 in all assays except thrombin time (-10.5%), APTT-based factor IX, XI and XII, Werfen VWF:RCo (10.6%) and Siemens LA1 (-26.4%) and LA2 (-16.9%). At the expected therapeutic steady state levels of Mim8 (5-8 μg/mL), less than 10% difference was calculated for thrombin time and Werfen VWF:RCo. APTT-based assays of FIX, XI and XII are significantly elevated in the presence of Mim8 and should not be performed. A chromogenic FIX assay could be used to accurately measure FIX activity in the presence of Mim8. There was some interference in the DRVVT method we used so local assessment of other DRVVT methods is advised. Differences in all other tests would not be predicted to affect patient management.
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Affiliation(s)
| | - Kieron Hickey
- Department of Coagulation, Sheffield Teaching Hospitals NHS FT, Sheffield, UK
| | - Steve Kitchen
- Department of Coagulation, Sheffield Teaching Hospitals NHS FT, Sheffield, UK
| | - Mirella Ezban
- Rare Disease Research, Global Drug Discovery, Novo Nordisk, Måløv, Denmark
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12
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Matsumoto T, Wada H, Shiraki K, Suzuki K, Yamashita Y, Tawara I, Shimpo H, Shimaoka M. The Evaluation of Clot Waveform Analyses for Assessing Hypercoagulability in Patients Treated with Factor VIII Concentrate. J Clin Med 2023; 12:6320. [PMID: 37834964 PMCID: PMC10573981 DOI: 10.3390/jcm12196320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Regular prophylactic therapy has become an increasingly common treatment for severe hemophilia. Therefore, hypercoagulability-a potential risk factor of thrombosis-is a cause for concern in hemophilic patients treated with a high dose of FVIII concentrate. In clot waveform analysis (CWA)-thrombin time (TT), a small amount of thrombin activates clotting factor VIII (FVIII) instead of fibrinogen, resulting in FVIII measurements using CWA-TT with a small amount of thrombin. METHODS The coagulation ability of patients treated with FVIII concentrate or emicizumab was evaluated using activated partial thromboplastin time (APTT), TT and a small amount of tissue factor-induced FIX activation assay (sTF/FIXa) using CWA. RESULTS The FVIII activity based on CWA-TT was significantly greater than that based on the CWA-APTT or chromogenic assay. FVIII or FVIII-like activities based on the three assays in plasma without emicizumab were closely correlated; those in plasma with emicizumab based on CWA-TT and chromogenic assays were also closely correlated. CWA-APTT and CWA-TT showed different patterns in patients treated with FVIII concentrates compared to those treated with emicizumab. In particular, CWA-TT in patients treated with FVIII concentrate showed markedly higher peaks in platelet-rich plasma than in platelet-poor plasma. CWA-APTT showed lower coagulability in hemophilic patients treated with FVIII concentrate than in healthy volunteers, whereas CWA-sTF/FIXa did not. In contrast, CWA-TT showed hypercoagulability in hemophilic patients treated with FVIII concentrate. CONCLUSIONS CWA-TT can be used to evaluate the thrombin bursts that cause hypercoagulability in patients treated with emicizumab. Although routine APTT evaluations demonstrated low coagulation ability in patients treated with FVIII concentrate, CWA-TT showed hypercoagulability in these patients, suggesting that the evaluation of coagulation ability may be useful when using multiple assays.
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Affiliation(s)
- Takeshi Matsumoto
- Department of Transfusion Medicine and Cell Therapy, Mie University Hospital, Tsu 514-8507, Japan;
| | - Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan;
| | - Katsuya Shiraki
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan;
| | - Kei Suzuki
- The Emergency and Critical Care Center, Mie University Hospital, Tsu 514-8507, Japan;
| | - Yoshiki Yamashita
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu 514-8507, Japan; (Y.Y.); (I.T.)
| | - Isao Tawara
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu 514-8507, Japan; (Y.Y.); (I.T.)
| | - Hideto Shimpo
- Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan;
| | - Motomu Shimaoka
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu 514-8507, Japan;
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13
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Bowyer AE, Gosselin RC. Factor VIII and Factor IX Activity Measurements for Hemophilia Diagnosis and Related Treatments. Semin Thromb Hemost 2023; 49:609-620. [PMID: 36473488 PMCID: PMC10421651 DOI: 10.1055/s-0042-1758870] [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] [Indexed: 12/12/2022]
Abstract
Accurate measurement of clotting factors VIII (FVIII) or IX (FIX) is vital for comprehensive diagnosis and management of patients with hemophilia A or B. The one-stage activated partial thromboplastin time (aPTT)-based clotting assay is the most commonly used method worldwide for testing FVIII or FIX activities. Alternatively, FVIII and FIX chromogenic substrate assays, which assess the activation of factor X, are available in some specialized laboratories. The choice of reagent or methodology can strongly influence the resulting activity. Variation between one-stage FVIII or FIX activities has been reported in the measurement of some standard and extended half-life factor replacement therapies and gene therapy for hemophilia B using different aPTT reagents. Discrepancy between one-stage and chromogenic reagents has been demonstrated in some patients with mild hemophilia A or B, the measurement of some standard and extended half-life factor replacement therapies, and the transgene expression of hemophilia A and B patients who have received gene therapy. Finally, the measurement of bispecific antibody therapy in patients with hemophilia A has highlighted differences between chromogenic assays. It is imperative that hemostasis laboratories evaluate how suitable their routine assays are for the accurate measurement of the various hemophilia treatment therapies.
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Affiliation(s)
- Annette E. Bowyer
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Robert C. Gosselin
- Hemostasis and Thrombosis Center, University of California, Davis Health System, Sacramento, California
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14
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Bannow BS, Konkle BA. How I approach bleeding in hospitalized patients. Blood 2023; 142:761-768. [PMID: 36652635 PMCID: PMC10562531 DOI: 10.1182/blood.2021014766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 01/05/2023] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Excessive bleeding is relatively common in adult inpatients, whether as the primary reason for admission or as a development during the hospital stay. Common causes include structural issues, medication effects, and systemic illnesses; occasionally, unexpected bleeding can develop as a result of an undiagnosed or newly acquired bleeding disorder. The first step in caring for the inpatient who is bleeding is to determine whether the bleeding symptom is truly new or whether the patient has a history of abnormal bleeding. Patients with a history of abnormal bleeding may warrant evaluation for inherited bleeding disorders, such as platelet function disorders, von Willebrand disease, hemophilia, or rare factor deficiencies. Patients with no history of bleeding, for whom other causes, such as liver dysfunction, medication effect, disseminated intravascular coagulation, or certain vitamin deficiencies have been ruled out may require evaluation for acquired coagulopathies, such as acquired hemophilia or acquired von Willebrand disease. Here, we present 3 cases to discuss the diagnosis and management of the 2 most common acquired bleeding disorders as well as a patient with a congenital bleeding disorder with a historical diagnosis.
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Affiliation(s)
- Bethany Samuelson Bannow
- Division of Hematology/Medical Oncology, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Barbara A Konkle
- Division of Hematology, Department of Medicine, Washington Center for Bleeding Disorders, University of Washington, Seattle, WA
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15
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Gualtierotti R, Pasca S, Ciavarella A, Arcudi S, Giachi A, Garagiola I, Suffritti C, Siboni SM, Peyvandi F. Updates on Novel Non-Replacement Drugs for Hemophilia. Pharmaceuticals (Basel) 2022; 15:1183. [PMID: 36297295 PMCID: PMC9611302 DOI: 10.3390/ph15101183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/27/2022] Open
Abstract
Over the last decade, the world of hemophilia has experienced an unprecedented therapeutic advance, thanks to the progress in bioengineering technologies, leading to the introduction of drugs with novel mechanisms of action based on restoring thrombin generation or coagulation factor VIII mimicking. Apart from the bispecific monoclonal antibody emicizumab, already approved for patients with severe hemophilia A with and without inhibitors, novel non-replacement drugs designed to reduce the treatment burden of patients with hemophilia A or B with or without inhibitors are undergoing evaluation in clinical trials. Thanks to their innovative mechanism of action and subcutaneous administration, these drugs promise to provide effective bleeding protection together with improved adherence and improve health-related quality of life for patients with hemophilia. On the other hand, rare thromboembolic events have been reported with some of these drugs and warrant continuous post-marketing surveillance and investigation of predisposing factors, although the overall safety profile of most of these drugs is good. Finally, new challenges need to be faced in the clinical and laboratory monitoring of the hemostatic status in patients treated with these innovative therapies. In this review, we provide an update on the available data on novel non-replacement drugs currently undergoing evaluation in clinical trials for patients with hemophilia.
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Affiliation(s)
- Roberta Gualtierotti
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
| | - Samantha Pasca
- Biomedical Sciences Department (DSB)/Medicine Department (DIMED) Padua University Hospital, 35131 Padua, Italy
| | - Alessandro Ciavarella
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20133 Milan, Italy
| | - Sara Arcudi
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
| | - Andrea Giachi
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
| | - Isabella Garagiola
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
| | - Chiara Suffritti
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
| | - Simona Maria Siboni
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
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16
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Nummi V, Lehtinen AE, Iorio A, Szanto T, Lassila R. Switching from standard to extended half-life FVIII prophylaxis in haemophilia A: Comparison of factor product use, bleed rates and pharmacokinetics. Haemophilia 2022; 28:e237-e244. [PMID: 35939628 DOI: 10.1111/hae.14649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/16/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Majority of haemophilia A patients in our comprehensive care centre have switched from standard half-life (SHL) to extended half-life (EHL) FVIII products in a short time. AIM We compared the clinical and laboratory outcomes between SHL and EHL FVIII prophylaxis in product switchers. METHODS This is a retrospective inception cohort of all adult haemophilia A patients switched to EHL (rFVIIIFc or rFVIII-PEG) prophylaxis in our centre. Dosing, product utilization, annualized bleed rates (ABR), treatment regimen and pharmacokinetics by Web Accessible Population Pharmacokinetic Service (WAPPS)-Hemo were compared between SHL and EHL. RESULTS We included 38 patients, whose median age was 38 years (range 17-75). Median FVIII dose was 23 IU/kg for SHL versus 25 IU/kg for EHL. After switching, weekly infusions decreased by 29% from median 2.8 (every 2.5 days) to 2.0 (every 3.5 days) (P = <.001) and factor consumption for prophylaxis by 17% from 60 to 50 IU/kg/week (P = <.001). Weekly infusions decreased in 71% and FVIII utilization in 55% of patients. ABR remained low (1.0 for SHL and .5 for EHL, respectively). In pharmacokinetics, the half-life of FVIII increased from median 13 to 21 h after switching. Times above .01 and .03 IU/ml improved from 85 to 131 h and from 65 to 106 h. Half-lives of the SHL products and von Willebrand factor levels predicted half-lives with the EHL products. CONCLUSIONS Our cohort study confirms the successful experience of switching to EHL FVIII products, with decreased infusion frequency, factor consumption and excellent clinical efficacy.
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Affiliation(s)
- Vuokko Nummi
- Department of Hematology, Coagulation Disorders Unit, Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, Helsinki University, Helsinki, Finland
| | - Anna-Elina Lehtinen
- Department of Hematology, Coagulation Disorders Unit, Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, Helsinki University, Helsinki, Finland
| | - Alfonso Iorio
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Timea Szanto
- Department of Hematology, Coagulation Disorders Unit, Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, Helsinki University, Helsinki, Finland
| | - Riitta Lassila
- Department of Hematology, Coagulation Disorders Unit, Comprehensive Cancer Center, Helsinki University Hospital, Helsinki, Finland.,Research Program in Systems Oncology, Faculty of Medicine, Helsinki University, Helsinki, Finland
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17
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Hart DP, Matino D, Astermark J, Dolan G, d’Oiron R, Hermans C, Jiménez-Yuste V, Linares A, Matsushita T, McRae S, Ozelo MC, Platton S, Stafford D, Sidonio RF, Tiede A. International consensus recommendations on the management of people with haemophilia B. Ther Adv Hematol 2022; 13:20406207221085202. [PMID: 35392437 PMCID: PMC8980430 DOI: 10.1177/20406207221085202] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/17/2022] [Indexed: 01/19/2023] Open
Abstract
Haemophilia B is a rare X-linked genetic deficiency of coagulation factor IX (FIX) that, if untreated, can cause recurrent and disabling bleeding, potentially leading to severe arthropathy and/or life-threatening haemorrhage. Recent decades have brought significant improvements in haemophilia B management, including the advent of recombinant FIX and extended half-life FIX. This therapeutic landscape continues to evolve with several non-factor replacement therapies and gene therapies under investigation. Given the rarity of haemophilia B, the evidence base and clinical experience on which to establish clinical guidelines are relatively sparse and are further challenged by features that are distinct from haemophilia A, precluding extrapolation of existing haemophilia A guidelines. Due to the paucity of formal haemophilia B-specific clinical guidance, an international Author Group was convened to develop a clinical practice framework. The group comprised 15 haematology specialists from Europe, Australia, Japan, Latin America and North America, covering adult and paediatric haematology, laboratory medicine and biomedical science. A hybrid approach combining a systematic review of haemophilia B literature with discussion of clinical experience utilized a modified Delphi format to develop a comprehensive set of clinical recommendations. This approach resulted in 29 recommendations for the clinical management of haemophilia B across five topics, including product treatment choice, therapeutic agent laboratory monitoring, pharmacokinetics considerations, inhibitor management and preparing for gene therapy. It is anticipated that this clinical practice framework will complement existing guidelines in the management of people with haemophilia B in routine clinical practice and could be adapted and applied across different regions and countries.
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Affiliation(s)
- Daniel P. Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Whitechapel Road, London E1 2AD, UK
| | - Davide Matino
- Department of Medicine, McMaster University and The Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Jan Astermark
- Institution of Translational Medicine and Department of Hematology, Oncology and Radiation Physics, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Gerard Dolan
- Centre for Haemostasis and Thrombosis, St Thomas’ Hospital, London, UK
| | - Roseline d’Oiron
- Centre for Haemophilia and Constitutional Bleeding Disorders, Hôpital Bicêtre AP-HP Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Cédric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | | | - Adriana Linares
- Grupo de Oncohematología Pediátrica, Universidad Nacional de Colombia, Bogotá, Colombia
- Programa de Hemofilia, Clínica Infantil Colsubsidio, Bogotá, Colombia
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Simon McRae
- Launceston General Hospital, Launceston, TAS, Australia
| | | | - Sean Platton
- The Royal London Hospital Haemophilia Centre, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Darrel Stafford
- Department of Biology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Robert F. Sidonio
- Aflac Cancer and Blood Disorders, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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18
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Lowe AE, Jones R, Kitchen S, Geisen U, Rozsnyai G, Jilma P, Quehenberger P. Multicenter performance evaluation and reference range determination of a new one-stage factor VIII assay. J Clin Lab Anal 2022; 36:e24294. [PMID: 35274775 PMCID: PMC8993620 DOI: 10.1002/jcla.24294] [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: 09/30/2021] [Revised: 01/18/2022] [Accepted: 02/04/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction We conducted a multicenter evaluation of a new one‐stage factor VIII (FVIII) assay (Roche Diagnostics), intended for the quantitative assessment of FVIII activity. We evaluated the analytical performance of the FVIII assay on the cobas t 711 analyzer. Methods Experiments performed at three laboratories used 3.2% citrated residual or commercially purchased plasma samples. Five human plasma pools and two controls were used to determine assay within‐run and within‐laboratory precision, and total reproducibility; coefficients of variation (CVs) and/or standard deviations (SDs) were calculated. Lot‐to‐lot variability and method comparison (vs Coagulation FVIII Deficient Plasma/Dade Actin FS Activated PTT reagent/Standard Human Plasma Calibrator on the Sysmex CS‐5100 analyzer; Siemens Healthineers) were evaluated by Passing–Bablok and Deming regression, respectively, and Pearson's r calculated. Assay‐specific reference range was determined using 199 fresh plasma samples from healthy adults, not receiving anticoagulants. Results Across sites, SDs for repeatability were 0.016–0.046 for samples with ≤1.0 international units (IU)/dL FVIII activity; CVs were 0.9%–3.8% for samples with >1.0 IU/dl activity. Among samples with mean FVIII activity 0.344–133 IU/dl, good intermediate precision (SD 0.020 for samples with 0.344 IU/dl activity; CV 1.8%–4.7%) and good total reproducibility (CV 2.0%–13.3%) were observed. The FVIII assay showed excellent lot‐to‐lot variability (Pearson's r = .999) and good correlation with the comparator assay (Pearson's r = .993–.996). The reference range for FVIII activity was 82.2−218.0 IU/dl. Conclusion The one‐stage FVIII assay demonstrated robust analytical performance on the cobas t 711 analyzer, supporting its use in routine laboratory practice.
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Affiliation(s)
- Anna E Lowe
- Sheffield Haemophilia and Thrombosis Centre, Sheffield, UK
| | - Robert Jones
- Sheffield Haemophilia and Thrombosis Centre, Sheffield, UK
| | - Steve Kitchen
- Sheffield Haemophilia and Thrombosis Centre, Sheffield, UK
| | - Ulrich Geisen
- Institute for Clinical Chemistry and Laboratory Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Petra Jilma
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
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19
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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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20
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Kitchen S, Bowyer A, Lowe A, Jennings I, Walker ID. External quality assessment for one-stage and chromogenic factor IX assays in samples containing Alprolix (rFIXFc) or Idelvion (rIX-FP) and evidence that UK National External Quality Assessment Scheme for blood coagulation samples are commutable with patient samples. Int J Lab Hematol 2022; 44:619-625. [PMID: 35040275 DOI: 10.1111/ijlh.13795] [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: 06/23/2021] [Revised: 12/02/2021] [Accepted: 12/10/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION There may be clinically relevant differences between results of different FIX assays in samples containing extended half life FIX concentrates requiring regular surveillance of assay results through proficiency testing exercises. Control materials used in proficiency testing must be commutable, that is have the same inter-assay properties as those demonstrated by authentic clinical samples when measured by different analytical methods. METHODS We assessed relationships between results with different FIX assays and commutability of UK National External Quality Assessment Scheme (NEQAS) materials containing rIX-FP (Idelvion) or rFIXFc (Alprolix) by comparing results obtained using widely used one-stage and chromogenic assays during a proficiency testing exercise with results obtained when analysing a series of individual patient samples using the same assay systems. NEQAS samples prepared by addition of either Idelvion or Alprolix to FIX deficient plasma were sent to 76 haemophilia centres in Europe. A total of 18 Idelvion and 22 Alprolix patient samples were assayed in a single centre. Two chromogenic and two one-stage assays were compared. RESULTS The pattern of results obtained for NEQAS samples and patient samples was similar. In all cases, the NEQAS sample data point was within the scatter of patient sample data in plots of patient sample results showing one-stage assay results using Synthasil or Actin FS plotted against chromogenic assay results with Biophen or Rox chromogenic FIX kits. CONCLUSION This indicates that the NEQAS samples containing Idelvion or Alprolix were commutable and therefore suitable for use in proficiency testing exercises.
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Affiliation(s)
- Steve Kitchen
- Sheffield Haemophilia and Thrombosis Centre, Sheffield, UK.,UK National External Quality Assessment Scheme for Blood Coagulation, Sheffield, UK
| | - Annette Bowyer
- Sheffield Haemophilia and Thrombosis Centre, Sheffield, UK
| | - Anna Lowe
- UK National External Quality Assessment Scheme for Blood Coagulation, Sheffield, UK
| | - Ian Jennings
- UK National External Quality Assessment Scheme for Blood Coagulation, Sheffield, UK
| | - Isobel D Walker
- UK National External Quality Assessment Scheme for Blood Coagulation, Sheffield, UK
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21
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Ectopic Expression of FVIII in HPCs and MSCs Derived from hiPSCs with Site-Specific Integration of ITGA2B Promoter-Driven BDDF8 Gene in Hemophilia A. Int J Mol Sci 2022; 23:ijms23020623. [PMID: 35054807 PMCID: PMC8775870 DOI: 10.3390/ijms23020623] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 12/27/2021] [Accepted: 01/04/2022] [Indexed: 02/01/2023] Open
Abstract
Hemophilia A (HA) is caused by mutations in the coagulation factor VIII (FVIII) gene (F8). Gene therapy is a hopeful cure for HA; however, FVIII inhibitors formation hinders its clinical application. Given that platelets promote coagulation via locally releasing α-granule, FVIII ectopically expressed in platelets has been attempted, with promising results for HA treatment. The B-domain-deleted F8 (BDDF8), driven by a truncated ITGA2B promoter, was targeted at the ribosomal DNA (rDNA) locus of HA patient-specific induced pluripotent stem cells (HA-iPSCs). The F8-modified, human induced pluripotent stem cells (2bF8-iPSCs) were differentiated into induced hematopoietic progenitor cells (iHPCs), induced megakaryocytes (iMKs), and mesenchymal stem cells (iMSCs), and the FVIII expression was detected. The ITGA2B promoter-driven BDDF8 was site-specifically integrated into the rDNA locus of HA-iPSCs. The 2bF8-iPSCs were efficiently differentiated into 2bF8-iHPCs, 2bF8-iMKs, and 2bF8-iMSCs. FVIII was 10.31 ng/106 cells in lysates of 2bF8-iHPCs, compared to 1.56 ng/106 cells in HA-iHPCs, and FVIII was 3.64 ng/106 cells in 2bF8-iMSCs lysates, while 1.31 ng/106 cells in iMSCs with CMV-driven BDDF8. Our results demonstrated a high expression of FVIII in iHPCs and iMSCs derived from hiPSCs with site-specific integration of ITGA2B promoter-driven BDDF8, indicating potential clinical prospects of this platelet-targeted strategy for HA gene therapy.
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22
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Kato K, Hatayama Y, Shimohiro H, Ichikawa H, Fukuda T. Differences in the Composition of Activated Partial Thromboplastin Time (APTT) Reagents Affect Clot Waveform Analysis. Yonago Acta Med 2022. [DOI: 10.33160/yam.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Konami Kato
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
| | - Yuki Hatayama
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
| | - Hisashi Shimohiro
- Department of Pathobiological Science and Technology, School of Health Sciences, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Hitomi Ichikawa
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
| | - Tetsuya Fukuda
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
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23
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Kato K, Hatayama Y, Shimohiro H, Ichikawa H, Fukuda T. Differences in the Composition of Activated Partial Thromboplastin Time (APTT) Reagents Affect Clot Waveform Analysis. Yonago Acta Med 2022; 65:226-230. [DOI: 10.33160/yam.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/08/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Konami Kato
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
| | - Yuki Hatayama
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
| | - Hisashi Shimohiro
- Department of Pathobiological Science and Technology, School of Health Sciences, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Hitomi Ichikawa
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
| | - Tetsuya Fukuda
- Division of Clinical Laboratory, Tottori University Hospital, Yonago 683-8504, Japan and
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24
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Thomas VM, Abou-Ismail MY, Lim MY. Off-label use of emicizumab in persons with acquired haemophilia A and von Willebrand disease: A scoping review of the literature. Haemophilia 2021; 28:4-17. [PMID: 34820989 DOI: 10.1111/hae.14450] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/08/2021] [Accepted: 10/16/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Since the approval of emicizumab, a bispecific, factor VIII-mimetic antibody, for use in persons with congenital haemophilia A in 2018, there have been increasing case reports and case series of off-label use of emicizumab in other bleeding disorders, including acquired haemophilia A (AHA) and von Willebrand disease (VWD). AIM We conducted a scoping review on the use of emicizumab in AHA and VWD, focusing on the clinical presentation and outcomes. METHODS We conducted a comprehensive search in PubMed, EMBASE and Scopus up to July 15, 2021. The following criteria were applied to the studies identified in the initial search: patients had a diagnosis of AHA or VWD; and the study reported on the clinical outcome of emicizumab use. RESULTS Seventeen studies were included in the final review for a total of 41 patients (33 AHA, eight type 3 VWD). The majority of AHA patients and all type 3 VWD patients were started on emicizumab for active/recurrent bleeds. The dosing regimen of emicizumab used varied significantly in AHA patients. All patients had a clinical response to emicizumab use. One AHA patient developed a stroke on emicizumab use in association with concomitant recombinant FVIIa use for surgery. Data on adverse events from emicizumab use were not specifically reported in 24.4% of patients (four AHA, six type 3 VWD). CONCLUSION Based on published case reports and case series, emicizumab appears to be an effective haemostatic therapy for AHA and VWD. Larger confirmatory clinical trials are needed to confirm these findings.
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Affiliation(s)
- Vinay Mathew Thomas
- Department of Internal Medicine, Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, Utah, USA
| | - Mouhamed Yazan Abou-Ismail
- Department of Internal Medicine, Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, Utah, USA
| | - Ming Y Lim
- Department of Internal Medicine, Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City, Utah, USA
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25
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Ketteler C, Hoffmann I, Davidson S, Tiede A, Richter N. Monitoring of different factor VIII replacement products using a factor VIII one-stage clotting assay on cobas t 511/711 analysers. Haemophilia 2021; 27:e704-e712. [PMID: 34590394 PMCID: PMC9291471 DOI: 10.1111/hae.14416] [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: 04/07/2021] [Revised: 08/04/2021] [Accepted: 09/06/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Recombinant coagulation factor VIII (FVIII) products are the standard of care for patients with haemophilia A. The development of modified FVIII products has provided benefit for patients but presented challenges for monitoring FVIII activity. AIM This single-centre study evaluated the Roche FVIII one-stage clotting assay (OSA) in measuring FVIII activity in plasma samples spiked with seven FVIII products at clinically relevant concentrations. METHODS FVIII-deficient plasma samples were spiked with two batches of recombinant FVIII products (octocog alfa, moroctocog alfa, simoctocog alfa, efmoroctocog alfa, damoctocog alfa pegol, rurioctocog alfa pegol, lonoctocog alfa) at 1-120 IU/dL FVIII activity, according to their labelled potency. Measurement was conducted on the cobas t 511/711 analysers using the Roche FVIII OSA and the Technoclone TECHNOCHROM FVIII:C chromogenic substrate assay (CSA). RESULTS Using the OSA, FVIII activity was close to labelled potency for most analysed FVIII products including a recombinant FVIII Fc fusion protein. PEGylated FVIII product, damoctocog alfa pegol, was marginally above and single-chain product, lonoctocog alfa, below the predefined acceptance criteria: for FVIII activity < 25 IU/dL: ± 5 IU/dL; for FVIII activity ≥ 25 IU/dL: ± 20% (relative). The different principles of OSA and CSA led to discrepancies in the estimation of all analysed FVIII products. Additionally, in vitro recovery was increased at lower levels of FVIII activity using the OSA, whereas recovery was more consistent using the CSA. CONCLUSION These data allow the interpretation of FVIII activity results for different FVIII products using the Roche FVIII OSA on the cobas t 511/711 analysers.
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Affiliation(s)
| | | | - Simon Davidson
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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26
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Ovanesov MV, Jackson JW, Golding B, Lee TK. Considerations on activity assay discrepancies in factor VIII and factor IX products. J Thromb Haemost 2021; 19:2102-2111. [PMID: 34145730 DOI: 10.1111/jth.15425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/28/2021] [Accepted: 06/15/2021] [Indexed: 12/13/2022]
Abstract
New modified coagulation factor VIII (FVIII) and factor IX (FIX) products have been designed to improve the treatment of individuals with hemophilia A and B by increasing the interval between dosing. Although these FVIII and FIX molecules have been structurally modified to improve the circulation time, the changes have also influenced their behavior in functional assays in comparison with traditional plasma-derived or recombinant coagulation factors. The assignment of potencies for these products can be problematic because discordance in factor activity values between the commonly used one-stage clotting and chromogenic substrate assays is often observed. Discrepancies in potency assay values also exist when different assay kits and reagents are used in the same assay type. Ideally, all FVIII and FIX products should be calibrated against the World Health Organization (WHO) International Standards (IS) because the assignment of potencies in international units (IU) helps maintain treatment tradition and meaningful references for manufacturers, patients, and clinicians. The discrepant measurements, attributed to the modified structural and functional properties of these products, are manifested in their lack of commutability with the WHO IS for FVIII or FIX. Herein, we discuss the considerations upon which an assay is chosen for potency assignment and postadministration monitoring of a new factor product, which include the validity of the assay calibrated with the IS, the meaning of the potency values in IU, standards of care for patients, clinical relevance between the assigned potency value and recovery value from clinical laboratories, and patient safety.
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Affiliation(s)
- Mikhail V Ovanesov
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Joseph W Jackson
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Basil Golding
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Timothy K Lee
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
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27
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Abstract
Haemophilia is an inherited bleeding disorder in which the haemostatic defect results from deficiency of coagulation factor VIII (FVIII) in haemophilia A or factor IX (FIX) in haemophilia B. Traditional treatments for haemophilia have largely worked by directly replacing the missing coagulation factor, but face challenges due to the short half-life of FVIII and FIX, the need for frequent intravenous access and development of neutralising antibodies to coagulation factors (inhibitors). Recent advances in haemophilia therapy have worked to eliminate these challenges. Half-life extension of factor concentrates has lengthened the time needed between infusions, enhancing quality of life. Subcutaneous administration of therapeutics utilising alternative mechanisms to overcome inhibitors have expanded the options to prevent bleeding. Finally, initial successes with gene therapy offer a cautious hope for durable cure. In the present review, we will discuss currently available treatments, as well as highlight therapeutics in various stages of clinical development for the treatment of haemophilia A and B. In this review, we present therapies that are currently clinically available and highlight therapeutics that are in various stages of clinical development for the treatment of haemophilia A and B.
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Affiliation(s)
- Hannah Fassel
- Tufts University School of Medicine, Boston, MA, USA
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28
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Ryoo SH, Kwon D, Lee JH, Seo KS, Kim HJ, Karm MH. An anesthetic management of head and neck cancer reconstructive surgery in a patient having hemophilia A: a case report. J Dent Anesth Pain Med 2021; 21:261-268. [PMID: 34136648 PMCID: PMC8187023 DOI: 10.17245/jdapm.2021.21.3.261] [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: 04/27/2021] [Revised: 05/18/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022] Open
Abstract
Hemophilia A is a hemorrhagic disease caused by coagulation factor VIII deficiency. In head and neck cancer surgery, especially during a reconstructive one, complications can occur. These include hematomas due to bleeding which can then lead to flap ischemia, necrosis, and impaired wound healing. There are fewer cases of reconstructive surgery in patients with hemophilia A. Here in we report, a reconstructive surgery that involved mass resection, partial glossectomy (right), selective neck dissection (right, Levels I, II, III, IV), and reconstruction at the lateral arm free flap (left) in a 25-year-old man with hemophilia A. The surgery was successfully performed without any complications after pretreatment with Factor VIII concentrate, which has not been reported earlier.
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Affiliation(s)
- Seung-Hwa Ryoo
- Department of Dental Anesthesiology, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Dohyun Kwon
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Jong-Ho Lee
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Kwang-Suk Seo
- Department of Dental Anesthesiology, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Hyun Jeong Kim
- Department of Dental Anesthesiology, School of Dentistry, Seoul National University, Seoul, Republic of Korea
| | - Myong-Hwan Karm
- Department of Dental Anesthesiology, School of Dentistry, Seoul National University, Seoul, Republic of Korea
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29
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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: 84] [Impact Index Per Article: 28.0] [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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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: 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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31
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Wada H, Shiraki K, Matsumoto T, Ohishi K, Shimpo H, Sakano Y, Nishii H, Shimaoka M. The Evaluation of APTT Reagents in Reference Plasma, Recombinant FVIII Products; Kovaltry® and Jivi® Using CWA, Including sTF/7FIX Assay. Clin Appl Thromb Hemost 2021; 27:1076029620976913. [PMID: 33606948 PMCID: PMC7900842 DOI: 10.1177/1076029620976913] [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] [Indexed: 11/17/2022] Open
Abstract
The FVIII activity in patients treated with several extended half-life FVIII (EHL-FVIII) agents different when various activated partial thromboplastin time (APTT) reagents were used. The present study examined the difference in clot waveform analysis (CWA) findings and FVIII activity when various APTT reagents and CWA were used. The CWA including FVIII activity was measured using 12 APTT reagents, and the FIX activation based on a small amount of tissue factor assay (sTF/FIX) were examined in reference plasma (RP), EHL-FVIII (Jivi®) and Kovaltry®. The 3 APTT reagents were associated with high variation in the peak time and height in the CWA when analyzing low concentrations of FVIII. The peak time and height could not be measured with one APTT reagent, and there were marked differences in the CWA findings between Jivi® and Kovaltry® among APTT reagents. Several APTT reagents showed a markedly lower FVIII activity with Jivi® than with Kovaltry®. In the FVIII assay, the peak time measured with sTF/FIX did not differ markedly between Jivi® and Kovaltry®; however, the FVIII activity in Jivi® (as measured by the peak height) tended to be higher than in Kovaltry®. The CWA findings for monitoring Jivi® varied for monitoring Jivi® depending on the APTT reagents used, and sTF/FIX assay may be able to measure the EHL-FVIII.
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Affiliation(s)
- Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan.,Associated Department with Mie Graduate School of Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Katsuya Shiraki
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan.,Associated Department with Mie Graduate School of Medicine, Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Takeshi Matsumoto
- Department of Transfusion Medicine and Cell Therapy, Mie University Hospital, Tsu, Japan
| | - Kohshi Ohishi
- Department of Transfusion Medicine and Cell Therapy, Mie University Hospital, Tsu, Japan
| | - Hideto Shimpo
- Mie Prefectural General Medical Center, Yokkaichi, Japan
| | - Yumi Sakano
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of medicine, Tsu, Japan
| | - Hiroko Nishii
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of medicine, Tsu, Japan
| | - Motomu Shimaoka
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of medicine, Tsu, Japan
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32
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Müller J, Goldmann G, Marquardt N, Pötzsch B, Oldenburg J. Extended Half-Life Factor VIII/Factor IX Products: Assay Discrepancies and Implications for Hemophilia Management. Hamostaseologie 2020; 40:S15-S20. [PMID: 33187006 DOI: 10.1055/a-1282-2251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Due to structural differences between extended half-life (EHL) factor VIII (FVIII) or FIX products and equivalent plasma wild-type molecules used for assay calibration, reagent-dependent discrepancies during monitoring of FVIII- and FIX-replacement therapies with EHL products have been described. To assess the performance of available one-stage clotting and chromogenic substrate assays on the Siemens Atellica COAG 360 analyzer, an in vitro study using spiked plasma samples was performed. The described results confirm previously described findings and allowed allocation of each EHL product to an appropriate assay. In addition, corresponding EHL product-specific analytes were defined within the order entry system of the University Hospital Bonn. The requirement of product-specific FVIII and FIX assays complicates patient monitoring and demonstrates the need for both continuous education and communication between treating physicians and the coagulation laboratory.
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Affiliation(s)
- Jens Müller
- University Hospital Bonn, Institute of Experimental Haematology and Transfusion Medicine, Bonn, Germany
| | - Georg Goldmann
- University Hospital Bonn, Institute of Experimental Haematology and Transfusion Medicine, Bonn, Germany
| | - Natascha Marquardt
- University Hospital Bonn, Institute of Experimental Haematology and Transfusion Medicine, Bonn, Germany
| | - Bernd Pötzsch
- University Hospital Bonn, Institute of Experimental Haematology and Transfusion Medicine, Bonn, Germany
| | - Johannes Oldenburg
- University Hospital Bonn, Institute of Experimental Haematology and Transfusion Medicine, Bonn, Germany
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