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Manon-Jensen T, Tangada S, Bager C, Chowdary P, Klamroth R, von Drygalski A, Windyga J, Escobar M, Frederiksen P, Engl W, Ewenstein B, Karsdal M. Evaluation of collagen turnover biomarkers as an objective measure for efficacy of treatment with rurioctocog alfa pegol in patients with hemophilia A: a secondary analysis of a randomized controlled trial. J Thromb Haemost 2024; 22:90-100. [PMID: 37717853 DOI: 10.1016/j.jtha.2023.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Patients with hemophilia who have recurrent hemarthroses develop hemophilic arthropathy (HA). Regular prophylaxis with factor (F) VIII (FVIII) can reduce HA, but there is a need for objective outcome measures to evaluate treatment efficacy. OBJECTIVES Evaluate and assess collagen turnover biomarkers in patients with hemophilia A to determine the efficacy of rurioctocog alfa pegol treatment and understand their potential as tools for guiding treatment decisions and monitoring outcomes. METHODS Joint remodeling was assessed by analyzing serum levels of collagen remodeling products at baseline and months 3, 6, 9, and 12 in a 98 patient subset receiving pharmacokinetics-guided prophylaxis with rurioctocog alfa pegol, targeting FVIII trough levels of 1 to 3 International Units (IU)/dL or 8 to 12 IU/dL (PROPEL study, NCT0285960). RESULTS Basement membrane metabolism-related type 4 collagen remodeling products (C4M and PRO-C4) decreased after 3 months at all time points by up to 25% at 1 to 3 IU/dL (P = .049, P < .0001) and 8 to 12 IU/dL FVIII trough levels (P = .0002, P < .0001). Interstitial tissue metabolism-related type 3 (C3M) and 5 (PRO-C5) collagen remodeling products decreased after 3 months, by up to 19% at 1 to 3 IU/dL FVIII trough level (P = .0001, P = .009) and 23% at 8 to 12 IU/dL FVIII trough level (P = .0002, P = .001). An increase of up to 12% was seen for cartilage metabolism-related type 2 collagen product (PRO-C2, not C2M) after 6 months at both trough levels (P = .01, P = .005). When stratified by prior treatment, changes in C3M (P = .03) and C4M (P = .02) levels were observed between trough levels for prior on-demand treatment but not for prophylaxis prior to study entry. CONCLUSION Joint improvement measured by collagen remodeling biomarkers specific to the basement membrane, interstitial matrix, and cartilage was seen with pharmacokinetics-guided prophylaxis. These collagen remodeling biomarkers warrant further exploration as biomarkers to guide treatment toward improvement in HA.
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Affiliation(s)
| | - Srilatha Tangada
- Takeda Development Center Americas, Inc, Cambridge, Massachusetts, USA
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Robert Klamroth
- Vascular Medicine and Haemostaseology, Vivantes Klinikum im Friedrichschain, Berlin, Germany
| | - Annette von Drygalski
- Hemophilia and Thrombosis Treatment Center, UC San Diego Health, San Diego, California, USA
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Miguel Escobar
- University of Texas Health and Science Center at Houston, Houston, Texas, USA
| | | | - Werner Engl
- Baxalta Innovations GmbH, a Takeda company, Vienna, Austria
| | - Bruce Ewenstein
- Takeda Development Center Americas, Inc, Cambridge, Massachusetts, USA
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Kloosterman FR, Zwagemaker AF, Bay-Jensen AC, Cnossen MH, Kruip MJHA, Leebeek FWG, Hemke R, Maas M, Fijnvandraat K, Gouw SC, Coppens M. Poor correlation between biomarkers and MRI-detected joint damage in a cross-sectional study of persons with nonsevere hemophilia A (DYNAMO study). J Thromb Haemost 2023; 21:1813-1823. [PMID: 37019364 DOI: 10.1016/j.jtha.2023.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/05/2023] [Accepted: 03/14/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Persons with nonsevere hemophilia A (NSHA) experience less frequent joint bleeding than persons with severe hemophilia A, but may still develop joint damage. Biomarkers of cartilage and synovial remodeling can reflect ongoing pathologic processes that may precede or coincide with damage on joint imaging. If so, biomarkers may be an important diagnostic tool for joint damage in NSHA. OBJECTIVE To assess the correlation between biomarkers and MRI-detected joint damage in persons with NSHA. METHODS In a cross-sectional study, men with NSHA (factor VIII [FVIII], 2-35 IU/dL) were included. Participants underwent magnetic resonance imaging of elbows, knees, and ankles and blood and urine sampling for biomarker analysis on a single visit. The following biomarker(s) were analyzed in urine: CTX-II or serum: cartilage oligomeric matrix protein, chondroitin sulfate 846, vascular cell adhesion molecule 1, osteopontin (OPN), neo-epitope of MMP -mediated degradation of type II collagen, N-terminal propeptide of type II collagen, collagen type IV M, and propetide of type IV collagen. Spearman's rank correlations were calculated between these biomarkers and the total International Prophylaxis Study group (IPSG) score, soft-tissue subscore, and osteochondral subscore. RESULTS In total, 48 persons with NSHA were included. Median age was 43 years (range, 24-55 years) and median FVIII was 10 IU/dL (IQR, 4-16 IU/dL). The median IPSG score was 4 (IQR, 2-9). Median IPSG soft-tissue subscores were 3 (IQR, 2-4) and osteochondral subscores were 0 (IQR, 0-4). No strong correlations were found between the studied biomarkers, total IPSG score, subsequent soft-tissue, and osteochondral subscores. CONCLUSIONS In this study, selected biomarkers indicative of different aspects of hemophilic arthropathy showed no consistent correlation with IPSG scores. This suggests that systemically measured biomarkers are currently not suitable for identifying milder joint damage in NSHA, as observed on magnetic resonance imaging.
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Affiliation(s)
- Fabienne R Kloosterman
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Pediatric Hematology, Amsterdam, the Netherlands
| | - Anne-Fleur Zwagemaker
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Pediatric Hematology, Amsterdam, the Netherlands
| | - Anne C Bay-Jensen
- Immunoscience, Nordic Bioscience, Biomarkers and Research, Herlev, Denmark
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus MC, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Robert Hemke
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Mario Maas
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Karin Fijnvandraat
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Pediatric Hematology, Amsterdam, the Netherlands; Department of Molecular Cellular Hemostasis, Sanquin Research and Landsteiner Laboratory, Amsterdam, the Netherlands
| | - Samantha C Gouw
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Pediatric Hematology, Amsterdam, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands.
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Minno MNDD, Martinoli C, Pasta G, la Corte-Rodriguez HD, Samy I, Stephensen D, Timmer MA, Winburn I. How to assess, detect, and manage joint involvement in the era of transformational therapies: Role of point-of-care ultrasound. Haemophilia 2023; 29:1-10. [PMID: 36163646 DOI: 10.1111/hae.14657] [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: 11/05/2021] [Revised: 08/11/2022] [Accepted: 08/28/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patients with haemophilia experience recurring hemarthroses, mainly involving knees, elbows and ankles, which lead to haemophilic arthropathy, the major chronic complication of haemophilia. With new approaches to haemophilia treatment leading to fewer joint bleeds and, in some cases, no bleeding events, assessing whether current outcome assessment tools provide adequate sensitivity and specificity for management and care of patients with haemophilia is needed. METHODS An overview of current imaging tools for monitoring joint health, novel osteochondral damage and synovial proliferation biomarkers, and the relationship between assessments for functionality and imaging modalities is provided. Usefulness and sensitivity of point-of-care ultrasound (POCUS) to complement other assessments and use of ultrasound to monitor haemophilic arthropathy are also examined. RESULTS This review provides rationale for haemophilia teams to move beyond traditional outcomes in joint imaging, as well as guidance and evidence on assessment of joint health for potential new treatment modalities, such as gene therapy. The role of POCUS in the existing paradigm for haemophilia care and management along with the use of ultrasound as a complement to other outcome assessment tools are also discussed. Finally, the clinical effects of subclinical bleeding on joint function are described, to motivate screening for synovial proliferation. CONCLUSION POCUS can facilitate the early detection of joint damage and can monitor disease progression while providing insights into the efficacy of treatment regimens, and should be considered as an essential assessment tool for managing the care of patients with haemophilia.
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Affiliation(s)
| | - Carlo Martinoli
- Department of Health Science - DISSAL, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | | | - David Stephensen
- Kent Haemophilia & Thrombosis Centre, Canterbury, United Kingdom and Royal London Hospital, London, UK
| | - Merel A Timmer
- Van Creveldkliniek, UMC Utrecht, Utrecht, The Netherlands
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Pain in Hemophilia: Unexplored Role of Oxidative Stress. Antioxidants (Basel) 2022; 11:antiox11061113. [PMID: 35740010 PMCID: PMC9220316 DOI: 10.3390/antiox11061113] [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] [Received: 04/29/2022] [Revised: 05/26/2022] [Accepted: 05/29/2022] [Indexed: 02/04/2023] Open
Abstract
Hemophilia is the most common X-linked bleeding diathesis caused by the genetic deficiency of coagulation factors VIII or IX. Despite treatment advances and improvements in clinical management to prevent bleeding, management of acute and chronic pain remains to be established. Repeated bleeding of the joints leads to arthropathy, causing pain in hemophilia. However, mechanisms underlying the pathogenesis of pain in hemophilia remain underexamined. Herein, we describe the novel perspectives on the role for oxidative stress in the periphery and the central nervous system that may contribute to pain in hemophilia. Specifically, we cross examine preclinical and clinical studies that address the contribution of oxidative stress in hemophilia and related diseases that affect synovial tissue to induce acute and potentially chronic pain. This understanding would help provide potential treatable targets using antioxidants to ameliorate pain in hemophilia.
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