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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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Yada K, Nogami K. Pharmacokinetic evaluation of efanesoctocog alfa: breakthrough factor VIII therapy for hemophilia A. Expert Opin Drug Metab Toxicol 2024:1-10. [PMID: 39323385 DOI: 10.1080/17425255.2024.2409931] [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: 06/09/2024] [Revised: 09/15/2024] [Accepted: 09/24/2024] [Indexed: 09/27/2024]
Abstract
INTRODUCTION Blood coagulation factor (F)VIII functions as a cofactor in the tenase complex responsible for phospholipid-dependent FIXa-mediated activation of FX in plasma. Congenital defect of FVIII causes severe bleeding disorder, hemophilia (H) A. Intravenous FVIII replacement therapy is the gold standard therapy in patients with HA (PwHA) but requirement for frequent dosing of FVIII owing to pharmacokinetics burdens PwHA a lot. Efanesoctocog alfa is a new class of recombinant FVIII and has the ability to overcome conceivable unmet needs in treatment for PwHA. AREAS COVERED Efanesoctocog alfa is a B domain-deleted single-chain fusion FVIII connected to the Fc-region of human immunoglobulin G1, D'D3-fragment of von Willebrand factor (VWF), and unstructured hydrophilic recombinant polypeptides (XTEN). Owing to its novel design, it can function independently of endogenous VWF and elicits 2 to 4 times longer half-life compared to other existing FVIII products. The prolonged half-life contributes to maintain high level of FVIII activity for most of the week and has led to excellent hemostatic effect by once-weekly administration in phase 3 clinical trials. EXPERT OPINION Efanesoctocog alfa with outstanding pharmacological properties, well tolerated in the clinical trials, is a promising FVIII therapy for PwHA. Future studies should include long-term safety, especially in previously untreated patients.
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Affiliation(s)
- Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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3
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Hart C, Klamroth R, Sachs UJ, Greil R, Knoebl P, Oldenburg J, Miesbach W, Pfrepper C, Trautmann-Grill K, Pekrul I, Holstein K, Eichler H, Weigt C, Schipp D, Werwitzke S, Tiede A. Emicizumab versus immunosuppressive therapy for the management of acquired hemophilia A. J Thromb Haemost 2024; 22:2692-2701. [PMID: 38936699 DOI: 10.1016/j.jtha.2024.06.010] [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: 03/29/2024] [Revised: 06/03/2024] [Accepted: 06/10/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Acquired hemophilia A (AHA) is an autoimmune bleeding disorder caused by neutralizing antibodies against coagulation factor VIII. Immunosuppressive therapy (IST) is standard of care to eradicate autoantibody production and protect from further bleeding but carries a risk of severe infection and mortality in frail patients with AHA. Recently, emicizumab has been studied for its potential to reduce the need for early and aggressive IST. OBJECTIVES To compare outcomes of 2 studies that used either IST (GTH-AH 01/2010; N = 101) or prophylaxis with emicizumab (GTH-AHA-EMI; N = 47) early after diagnosis of AHA. METHODS Baseline characteristics were balanced by propensity score matching. Primary endpoint was the rate of clinically relevant new bleeds during the first 12 weeks; secondary endpoints were adverse events and overall survival. RESULTS The negative binominal model-based bleeding rate was 68% lower with emicizumab as compared with IST (incident rate ratio, 0.325; 95% CI, 0.182-0.581). No difference was apparent in the overall frequency of infections (emicizumab 21%, IST 29%) during the first 12 weeks, but infections were less often fatal in emicizumab-treated patients (0%) compared with IST-treated patients (11%). Thromboembolic events occurred less often with emicizumab (2%) than with IST (7%). Overall survival after 24 weeks was better with emicizumab (90% vs 76%; hazard ratio, 0.44; 95%, CI, 0.24-0.81). CONCLUSION Using emicizumab instead of IST in the early phase after initial diagnosis of AHA reduced bleeding and fatal infections and improved overall survival.
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Affiliation(s)
- Christina Hart
- Department of Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Robert Klamroth
- Internal Medicine, Vivantes Clinic Friedrichshain, Berlin, Germany
| | - Ulrich J Sachs
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany
| | - Richard Greil
- Medical Department III, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Cancer Cluster Salzburg, Salzburg, Austria
| | - Paul Knoebl
- Hematology and Hemostasis, Vienna Medical University, Vienna, Austria
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Wolfgang Miesbach
- Medical Clinic II, Institute of Transfusion Medicine, Goethe University, Frankfurt, Germany
| | - Christian Pfrepper
- Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
| | - Karolin Trautmann-Grill
- Medical Clinic I, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Isabell Pekrul
- Department of Transfusion Medicine, Cellular Therapeutics and Hemostaseology, Department of Anesthesiology, Hospital of Ludwig Maximilian University, Munich, Germany
| | - Katharina Holstein
- Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Eichler
- Institute for Clinical Hemostaseology and Transfusion Medicine, Saarland University and University Hospital, Homburg/Saar, Germany
| | | | | | - Sonja Werwitzke
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Andreas Tiede
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.
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Scarlatescu E. The Effect of Increasing Factor X Levels on Emicizumab-Driven Coagulation Potential. Thromb Haemost 2024. [PMID: 39260396 DOI: 10.1055/a-2413-4453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Affiliation(s)
- Ecaterina Scarlatescu
- Department of Anesthesia and Intensive Care Medicine, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
- Department of Anesthesia and Intensive Care Medicine, Fundeni Clinical Institute, Bucharest, Romania
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Lemos F, Petraccia C, Fraga ML, Casuriaga AL, Lutz S, Gómez R, Giachetto G, Boggia B. Prophylaxis with emicizumab in children under 12 years old with haemophilia A without inhibitors in Uruguay: National experience. Haemophilia 2024; 30:1077-1079. [PMID: 38684449 DOI: 10.1111/hae.15024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Felipe Lemos
- Departamento de Medicina Transfusional, Centro de Referencia para la Hemofilia y otros Desórdenes Hemorrágicos Congénitos, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
- Clínica Pediátrica C, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Carlos Petraccia
- Departamento de Medicina Transfusional, Centro de Referencia para la Hemofilia y otros Desórdenes Hemorrágicos Congénitos, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - María Laura Fraga
- Departamento de Medicina Transfusional, Centro de Referencia para la Hemofilia y otros Desórdenes Hemorrágicos Congénitos, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - Ana Laura Casuriaga
- Clínica Pediátrica C, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Stefani Lutz
- Departamento de Medicina Transfusional, Centro de Referencia para la Hemofilia y otros Desórdenes Hemorrágicos Congénitos, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - Rosario Gómez
- Departamento de Medicina Transfusional, Centro de Referencia para la Hemofilia y otros Desórdenes Hemorrágicos Congénitos, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - Gustavo Giachetto
- Clínica Pediátrica C, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Beatriz Boggia
- Departamento de Medicina Transfusional, Centro de Referencia para la Hemofilia y otros Desórdenes Hemorrágicos Congénitos, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
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Onishi T, Shimo H, Harada S, Nogami K. The effects of emicizumab on in vitro coagulation and fibrinolysis parameters in patients with disseminated intravascular coagulation with and without addition of anti-FVIII antibody. Haemophilia 2024; 30:836-844. [PMID: 38523253 DOI: 10.1111/hae.14997] [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: 12/07/2023] [Revised: 03/02/2024] [Accepted: 03/09/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Emicizumab (Emi) is used as haemostatic prophylaxis for patients with haemophilia A (PwHA). Disseminated intravascular coagulation (DIC) is a condition characterized by persistent systemic activation of coagulation, but there is yet no information on coagulation and fibrinolysis potentials in Emi-treated PwHA with DIC. AIM To examine the effect of Emi on coagulation and fibrinolysis potentials in HA-model DIC plasmas. METHODS Plasma from a patient with sepsis-DIC (seven patients) was treated with anti-factor (F)VIII monoclonal antibody (HA-model DIC plasma) and incubated with Emi (50 µg/mL). The plasma was then assessed using clot-fibrinolysis waveform analysis (CFWA). Coagulation and fibrinolysis parameters were expressed as ratios relative to normal plasma (|min1|-ratio and |FL-min1|-ratio, respectively). PATIENTS AND RESULTS In case 1, coagulant potential was slightly high and fibrinolytic potential was extremely low, presenting a coagulant-dominant state (|min1|-ratio/|FL-min1|-ratio: 1.1/.38). In cases 2-5, fibrinolytic potential was not suppressed, but there were marked hypercoagulant potentials, indicating relative coagulant-dominant states. In case 6, coagulant and fibrinolytic potentials were increased but well balanced (|min1|-ratio/|FL-min1|-ratio: 1.38/1.28). In case 7, both potentials were severely deteriorated in not only CFWA but also the thrombin/plasmin generation assay. The addition of Emi into the HA-model DIC plasmas increased |min1|-ratio values in all cases, but the coagulant potentials did not exceed the initial ones (DIC plasma before treatment with anti-FVIII antibody). CONCLUSIONS The presence of Emi in the HA-model DIC plasma improved coagulation potentials, but did not increase coagulation potentials beyond those of DIC plasma in non-HA states.
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Affiliation(s)
- Tomoko Onishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Center of Postgraduate Training Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Hanako Shimo
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Suguru Harada
- Chugai Pharmaceutical Co., Ltd, Yokohama, Kanagawa, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Oda A, Takeyama M, Kitazawa T, Nogami K. The emicizumab-bridged ternary complex with activated factor IX and factor X evaluated by fluorescence resonance energy transfer. Thromb Res 2024; 237:108-111. [PMID: 38579512 DOI: 10.1016/j.thromres.2024.03.030] [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: 06/13/2023] [Revised: 03/20/2024] [Accepted: 03/28/2024] [Indexed: 04/07/2024]
Affiliation(s)
- Akihisa Oda
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Yada K, Fujitate N, Ogiwara K, Soeda T, Kitazawa T, Nogami K. Reduced plasma factor X is associated with a lack of response to recombinant activated factor VII in patients with hemophilia A and inhibitor, but does not impair emicizumab-driven hemostasis in vitro. Thromb Res 2024; 237:37-45. [PMID: 38547693 DOI: 10.1016/j.thromres.2024.03.023] [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: 10/29/2023] [Revised: 03/14/2024] [Accepted: 03/21/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND The hemostatic effect of recombinant (r) factor (F)VIIa after repetitive intermittent administration may be attenuated in patients with hemophilia A (PwHA) with inhibitors (PwHAwI) creating a clinically unresponsive status, although mechanism(s) remain to be clarified. In patients receiving prophylaxis treatment with emicizumab, concomitant rFVIIa is sometimes utilized in multiple doses for surgical procedures or breakthrough bleeding. AIM AND METHODS We identified 'unresponsiveness' to rFVIIa, based on global coagulation function monitored using rotational thromboelastometry (ROTEM) in 11 PwHAwI and 5 patients with acquired HA, and investigated possible mechanisms focusing on the association between plasma FX levels and rFVIIa-mediated interactions. RESULTS Our data demonstrated that FX antigen levels were lower in the rFVIIa-unresponsive group than in the rFVIIa-responsive group (0.46 ± 0.14 IU/mL vs. 0.87 ± 0.15 IU/mL, p < 0.01). This relationship was further examined by thrombin generation assays using a FX-deficient PwHAwI plasma model. The addition of FX with rFVIIa was associated with increased peak thrombin (PeakTh) generation. At low levels of FX (<0.5 IU/mL), rFVIIa failed to increase PeakTh to the normal range, consistent with clinical rFVIIa-unresponsiveness. In the presence of emicizumab (50 μg/mL), PeakTh was increased maximally to 80 % of normal, even at low levels of FX (0.28 IU/mL). CONCLUSIONS Unresponsiveness to rFVIIa was associated with reduced levels of FX in PwHAwI. Emicizumab exhibited in vitro coagulation potential in the presence of FX at concentrations that appeared to limit the clinical response to rFVIIa therapy.
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Affiliation(s)
- Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.
| | | | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Tetsuhiro Soeda
- Research Division, Chugai Pharmaceutical Co., Ltd., Yokohama, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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9
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Carcao M, Selvaratnam V, Blatny J. How much prophylaxis is enough in haemophilia? Haemophilia 2024; 30 Suppl 3:86-94. [PMID: 38523288 DOI: 10.1111/hae.14964] [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: 01/19/2024] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Prophylaxis has become standard of care for all persons with haemophilia (PWH) with a severe phenotype. However, 'standard prophylaxis' with either factor or non-factor therapies (currently only emicizumab available) is prohibitively expensive for much of the world. We sought to address the question of 'How much prophylaxis is enough?' and 'Can it be individualized?' and specifically 'Can emicizumab be individualized?'. METHODS We reviewed the literature on prophylaxis in haemophilia since its inception in the 1950s to the present, the development of more and less intense factor prophylaxis regimens and their outcomes and additionally the published outcomes of prophylaxis with low dose emicizumab. RESULTS What these experiences collectively show is that low dose emicizumab does result in significant benefits to patients whilst being much less expensive than a "one size fits all" emicizumab prophylaxis approach. We also took note that some non-factor therapies still in development are individualized given that high doses of these can potentially put patients at risk. CONCLUSIONS Prophylaxis is now clearly accepted as standard of care for PWH with a severe phenotype but now in a very short time a large assortment of different treatment options for prophylaxis have become/are becoming available and the haemophilia community will need to determine how to best use these recognizing that no 'one treatment fits all'.
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Affiliation(s)
- Manuel Carcao
- Division of Haematology/Oncology; Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Jan Blatny
- Hospital Bory, Bratislava, Slovakia and Masaryk University, Brno, Czech Republic
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Jiménez-Yuste V, Oldenburg J, Tzeng E, Lim E, Sanabria F, Mahlangu J. Emicizumab is efficacious in people with hemophilia A with comorbidities aged ≥50 years: analysis of 4 phase III trials. Res Pract Thromb Haemost 2024; 8:102405. [PMID: 38783987 PMCID: PMC11112372 DOI: 10.1016/j.rpth.2024.102405] [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] [Received: 03/18/2024] [Revised: 04/02/2024] [Accepted: 04/04/2024] [Indexed: 05/25/2024] Open
Abstract
Background The treatment of older people with hemophilia A (HA) can be complicated by comorbidities. Objectives This post hoc analysis evaluates the efficacy and safety of emicizumab in people with HA aged ≥50 years with cardiovascular (CV) risk factors or HIV and/or hepatitis C virus (HCV) infection. Methods The HAVEN 1 (NCT02622321), HAVEN 3 (NCT02847637), HAVEN 4 (NCT03020160), and STASEY (NCT03191799) studies enrolled adults/adolescents with severe HA. Participants were categorized as having a comorbidity if they had any CV risk factors (including history of CV disease, hypertension, diabetes, hyperlipidemia, prior stroke, or obesity), HIV, and/or HCV infection. Efficacy and safety outcomes were compared by age (<50 vs ≥50 years). Results Of 504 participants at data cutoff, 408 were aged <50 years and 96 were aged ≥50 years. In people with HA aged <50 years, 26.7% had ≥1 CV risk factor and 29.4% had HIV and/or HCV infection. In people with HA aged ≥50 years, 72.9% had ≥1 CV risk factor and 74.0% had HIV and/or HCV infection. The mean (95% CI) annualized bleed rate for treated bleeds was 1.29 (0.07-6.06) for people with HA aged <50 years and 1.82 (0.19-6.93) for people with HA aged ≥50 years. No significant differences in annualized bleed rates were observed for those with comorbidities compared with those without. Safety outcomes were similar regardless of age. Conclusion This pooled analysis suggests that emicizumab efficacy and safety in people with HA aged ≥50 years with CV and HIV/HCV comorbidities were consistent with those in people with HA aged <50 years enrolled in the HAVEN 1, 3, and 4 and STASEY studies.
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Affiliation(s)
- Víctor Jiménez-Yuste
- Hematology Department, Hospital Universitario La Paz, IdiPAZ, Autónoma University, Madrid, Spain
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, Germany
| | - Eunice Tzeng
- Genentech, Inc., South San Francisco, California, USA
| | - Elise Lim
- Genentech, Inc., South San Francisco, California, USA
| | | | - Johnny Mahlangu
- Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
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Teranishi-Ikawa Y, Soeda T, Koga H, Yamaguchi K, Kato K, Esaki K, Asanuma K, Funaki M, Ichiki M, Ikuta Y, Ito S, Joyashiki E, Komatsu SI, Muto A, Nishimura K, Okuda M, Sanada H, Sato M, Shibahara N, Wakabayashi T, Yamaguchi K, Matsusaki A, Sampei Z, Shiraiwa H, Konishi H, Kawabe Y, Hattori K, Kitazawa T, Igawa T. A bispecific antibody NXT007 exerts a hemostatic activity in hemophilia A monkeys enough to keep a nonhemophilic state. J Thromb Haemost 2024; 22:430-440. [PMID: 37940048 DOI: 10.1016/j.jtha.2023.09.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/09/2023] [Accepted: 09/25/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Emicizumab, a factor (F) VIIIa-function mimetic bispecific antibody (BsAb) to FIXa and FX, has become an indispensable treatment option for people with hemophilia A (PwHA). However, a small proportion of PwHA still experience bleeds even under emicizumab prophylaxis, as observed in the long-term outcomes of clinical studies. A more potent BsAb may be desirable for such patients. OBJECTIVES To identify a potent BsAb to FIXa and FX, NXT007, surpassing emicizumab by in vitro and in vivo evaluation. METHODS New pairs of light chains for emicizumab's heavy chains were screened from phage libraries, and subsequent antibody optimization was performed. For in vitro evaluation, thrombin generation assays were performed with hemophilia A plasma. In vivo hemostatic activity was evaluated in a nonhuman primate model of acquired hemophilia A. RESULTS NXT007 exhibited an in vitro thrombin generation activity comparable to the international standard activity of FVIII (100 IU/dL), much higher than emicizumab, when triggered by tissue factor. NXT007 also demonstrated a potent in vivo hemostatic activity at approximately 30-fold lower plasma concentrations than emicizumab's historical data. In terms of dose shift between NXT007 and emicizumab, the in vitro and in vivo results were concordant. Regarding pharmacokinetics, NXT007 showed lower in vivo clearance than those shown by typical monoclonal antibodies, suggesting that the Fc engineering to enhance FcRn binding worked well. CONCLUSION NXT007, a potent BsAb, was successfully created. Nonclinical results suggest that NXT007 would have a potential to keep a nonhemophilic range of coagulation potential in PwHA or to realize more convenient dosing regimens than emicizumab.
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Affiliation(s)
| | - Tetsuhiro Soeda
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Hikaru Koga
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan.
| | - Kazuki Yamaguchi
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Kazuki Kato
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Keiko Esaki
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Kentaro Asanuma
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Miho Funaki
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Mina Ichiki
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Yuri Ikuta
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Shunsuke Ito
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Eri Joyashiki
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | | | - Atsushi Muto
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Kei Nishimura
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Momoko Okuda
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Hisakazu Sanada
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Motohiko Sato
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Norihito Shibahara
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | | | - Koji Yamaguchi
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Akiko Matsusaki
- Translational Research Division, Chugai Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Zenjiro Sampei
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Hirotake Shiraiwa
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Hiroko Konishi
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Yoshiki Kawabe
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Kunihiro Hattori
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Takehisa Kitazawa
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan
| | - Tomoyuki Igawa
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Kanagawa, Japan; Translational Research Division, Chugai Pharmaceutical Co., Ltd., Tokyo, Japan
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12
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Castaman G, Peyvandi F, Kremer Hovinga JA, Schutgens RE, Robson S, Moreno K, Jiménez-Yuste V. Surgical Experience from the STASEY Study of Emicizumab Prophylaxis in People with Hemophilia A with Factor VIII Inhibitors. TH OPEN 2024; 8:e42-e54. [PMID: 38222041 PMCID: PMC10786707 DOI: 10.1055/s-0043-1777766] [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] [Received: 05/16/2023] [Accepted: 10/28/2023] [Indexed: 01/16/2024] Open
Abstract
Background Guidelines surrounding emicizumab prophylaxis and perioperative treatment for people with hemophilia A (PwHA) with factor (F)VIII inhibitors undergoing surgeries are limited. The phase IIIb multicenter, single-arm STASEY study evaluated safety and tolerability of emicizumab prophylaxis in PwHA aged ≥12 years with FVIII inhibitors. This analysis assesses surgeries during study conduct, associated hemophilia medications, and postoperative bleeds (treated and untreated). Methods PwHA with FVIII inhibitors received emicizumab 3.0 mg/kg/week for 4 weeks, then 1.5 mg/kg/week until 2 years. Surgeries were managed and documented by treating physicians. Bleeds and treatments were recorded by physicians and participants. Results Forty-six participants had ≥1 on-study surgery, 37 underwent 56 minor surgeries, and 13 underwent 22 major surgeries. Four participants underwent both minor and major surgeries. Of 18 (81.8%) and 4 (18.2%) major surgeries managed with/without additional hemostatic medication, 33.3 and 25.0% were associated with a treated postoperative bleed, respectively. Of 24 (42.9%) and 32 (57.1%) minor surgeries managed with/without additional hemostatic medication, 15.6 and 25.0% were associated with a treated postoperative bleed, respectively. Recombinant activated FVII was the most common medication for prophylaxis and bleed treatment. There were no thrombotic microangiopathies (TMAs). One hypertrophic clot, considered unrelated to emicizumab, occurred following tooth extraction. Conclusion In this challenging population with a high bleeding risk, major surgeries were performed in PwHA receiving emicizumab with/without additional hemostatic medication. Postoperative bleeds occurred following 59.1% of major surgeries; 53.8% were treated. No arterial/venous thrombotic events or TMAs occurred due to concomitant emicizumab and bypassing agents. Trial registration This trial is registered at ClinicalTrials.gov (NCT03191799).
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Affiliation(s)
- Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Flora Peyvandi
- IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Johanna A. Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roger E.G. Schutgens
- Center for Benign Haematology, Thrombosis and Haemostasis Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Susan Robson
- PD Data Science, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Katya Moreno
- Global Product Development/Medical Affairs, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Víctor Jiménez-Yuste
- Department of Hematology, Hospital Universitario La Paz, Autónoma University, Madrid, Spain
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13
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Grabowska K, Grzelak M, Zhao LY, Płuciennik E, Pasieka Z, Kciuk M, Gielecińska A, Smakosz AK, Kałuzińska-Kołat Ż, Kołat D. Emicizumab as a Promising Form of Therapy for Type A Hemophilia - A Review of Current Knowledge from Clinical Trials. Curr Protein Pept Sci 2024; 25:719-737. [PMID: 38797909 DOI: 10.2174/0113892037294674240509094418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/05/2024] [Accepted: 04/16/2024] [Indexed: 05/29/2024]
Abstract
Hemophilia is a plasma bleeding disorder characterized by a deficiency of certain blood clotting factors. The most common forms of this disease, i.e., type A and type B, affect approximately 400,000 people worldwide. Without appropriate treatment ensuring the proper coagulation cascade, this disease may lead to serious disability. Minimizing patient discomfort is possible via replacement therapy, consisting of the substitution of a missing coagulation factor via intravenous administration. Frequent medication and the risk related to factor inhibitors are significant disadvantages, necessitating the improvement of current therapies or the development of novel ones. This review examines the humanized bispecific antibody Emicizumab which ensures hemostasis by mimicking the action of the coagulation factor VIII, a deficiency of which causes type A hemophilia. The paper outlines the topic and then summarizes available clinical trials on Emicizumab in type A hemophilia. Several interventional clinical trials have found Emicizumab to be effective in decreasing bleeding episodes and raising patient satisfaction among various hemophilia A populations. Current Emicizumab-related trials are forecast to be completed between 2024 and 2030, and in addition to congenital hemophilia A, the trials cover acquired hemophilia A and patients playing sports. Providing a more comprehensive understanding of Emicizumab may revolutionize the management of hemophilia type A and improve quality of life. Conclusively, Emicizumab is a gentler therapy owing to subcutaneous delivery and fewer injections, which reduces injection-site reactions and makes therapy less burdensome, ultimately decreasing hospital visits and indirect costs.
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Affiliation(s)
- Katarzyna Grabowska
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
| | - Michalina Grzelak
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
| | - Lin-Yong Zhao
- Department of General Surgery & Laboratory of Gastric Cancer, State Key Laboratory of Biotherapy/Collaborative Innovation Center of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Gastric Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Elżbieta Płuciennik
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
| | - Zbigniew Pasieka
- Department of Biomedicine and Experimental Surgery, Medical University of Lodz, Narutowicza 60, 90-136, Lodz, Poland
| | - Mateusz Kciuk
- Department of Molecular Biotechnology and Genetics, University of Lodz, Banacha 12/16, 90-237, Lodz, Poland
| | - Adrianna Gielecińska
- Department of Molecular Biotechnology and Genetics, University of Lodz, Banacha 12/16, 90-237, Lodz, Poland
- Doctoral School of Exact and Natural Sciences, University of Lodz, Banacha 12/16, 90-237, Lodz, Poland
| | - Aleksander K Smakosz
- Department of Pharmaceutical Biology and Biotechnology, Wroclaw Medical University, 50-367, Wroclaw, Poland
| | - Żaneta Kałuzińska-Kołat
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
- Department of Biomedicine and Experimental Surgery, Medical University of Lodz, Narutowicza 60, 90-136, Lodz, Poland
| | - Damian Kołat
- Department of Functional Genomics, Medical University of Lodz, Żeligowskiego 7/9, 90-752, Lodz, Poland
- Department of Biomedicine and Experimental Surgery, Medical University of Lodz, Narutowicza 60, 90-136, Lodz, Poland
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14
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Atsou S, Schellenberg C, Lagrange J, Lacolley P, Lenting PJ, Denis CV, Christophe OD, Regnault V. Thrombin generation on vascular cells in the presence of factor VIII and/or emicizumab. J Thromb Haemost 2024; 22:112-125. [PMID: 37776978 DOI: 10.1016/j.jtha.2023.09.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/18/2023] [Accepted: 09/16/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND The effect of factor VIII (FVIII) or emicizumab on thrombin generation is usually assessed in assays using synthetic phospholipids. Here, we assessed thrombin generation at the surface of human arterial cells (aortic endothelial cells [hAECs] and aortic vascular smooth muscle cells [hVSMCs]). OBJECTIVES To explore the capacity of hAECs (resting or stimulated) and hVSMCs to support thrombin generation by FVIII or emicizumab. METHODS Primary hVSMCs and hAECs were analyzed for tissue factor (TF)-activity and antigen, phosphatidylserine (PS)-exposure, tissue factor pathway inhibitor (TFPI)-content and thrombomodulin expression. Cells were incubated with FVIII-deficient plasma spiked with FVIII, emicizumab, activated prothrombin complex concentrate (APCC) or combinations thereof. RESULTS TF activity and PS-exposure were present on both hVSMCs and hAECs. In contrast, thrombomodulin and TFPI were expressed on hAECs, while virtually lacking on hVSMCs, confirming the procoagulant nature of hVSMCs. Tumor necrosis factor α-mediated stimulation of hAECs increased not only TF antigen, TF activity, and PS-exposure but also TFPI and thrombomodulin expression. As expected, FVIII and emicizumab promoted thrombin generation on nonstimulated hAECs and hVSMCs, with more thrombin being generated on hVSMCs. Unexpectedly, FVIII and emicizumab increased thrombin generation to a lesser extent on stimulated hAECs compared with nonstimulated hAECs. Finally, adding emicizumab to FVIII did not further increase thrombin generation, whereas the addition of emicizumab to APCC resulted in exaggerated thrombin generation. CONCLUSION Tumor necrosis factor stimulation of hAECs increases both pro- and anticoagulant activity. Unexpectedly, the increased anticoagulant activity is sufficient to limit both FVIII- and emicizumab-induced thrombin generation. This protective effect disappears when emicizumab is combined with APCC.
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Affiliation(s)
- Sénadé Atsou
- Université Paris-Saclay, INSERM, Hémostase Inflammation Thrombose HITh U1176, 94276, Le KremLin-Bicêtre, France
| | - Célia Schellenberg
- Université de Lorraine, INSERM, Défaillance Cardiovasculaire Aigüe et Chronique DCAC U1116, 54505 Vandoeuvre-les-Nancy, France
| | - Jeremy Lagrange
- Université de Lorraine, INSERM, Défaillance Cardiovasculaire Aigüe et Chronique DCAC U1116, 54505 Vandoeuvre-les-Nancy, France
| | - Patrick Lacolley
- Université de Lorraine, INSERM, Défaillance Cardiovasculaire Aigüe et Chronique DCAC U1116, 54505 Vandoeuvre-les-Nancy, France
| | - Peter J Lenting
- Université Paris-Saclay, INSERM, Hémostase Inflammation Thrombose HITh U1176, 94276, Le KremLin-Bicêtre, France.
| | - Cécile V Denis
- Université Paris-Saclay, INSERM, Hémostase Inflammation Thrombose HITh U1176, 94276, Le KremLin-Bicêtre, France. https://twitter.com/InsermU1176
| | - Olivier D Christophe
- Université Paris-Saclay, INSERM, Hémostase Inflammation Thrombose HITh U1176, 94276, Le KremLin-Bicêtre, France
| | - Véronique Regnault
- Université de Lorraine, INSERM, Défaillance Cardiovasculaire Aigüe et Chronique DCAC U1116, 54505 Vandoeuvre-les-Nancy, France
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15
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Nogami K, Fujii T, Sawada A, Nagao A, Nagae C, Nojima M, Suzuki N, Nosaka D, Shimura T, Sugao Y, Amano K. Association of physical activity with bleeding events and safety in patients with haemophilia A starting emicizumab prophylaxis: an interim analysis of the TSUBASA study. Int J Hematol 2024; 119:14-23. [PMID: 38100026 PMCID: PMC10769904 DOI: 10.1007/s12185-023-03679-8] [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: 05/30/2023] [Revised: 10/31/2023] [Accepted: 11/12/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Little information exists on the relationship between bleeding outcomes and physical activity in patients with haemophilia A (PwHA). AIM This interim analysis of the TSUBASA study (UMIN-CTR ID: UMIN000037448) evaluated the association of physical activity with bleeding and safety in PwHA starting emicizumab. METHODS PwHA without factor VIII inhibitors were recruited. Physical activity and bleed data were obtained using an electronic patient-reported outcome application and wearable activity tracker. Adverse events (AEs) were documented. RESULTS At data cut-off (31-May-2021), 107 PwHA were enrolled, with a median (range) age of 35 (0-73) years. Physical activity data were obtained for 74 participants. Of these, 47 (63.5%) recorded a total of 396 exercise events. The most common exercise events were walking (32.4%), cycling (14.9%), and football (5.4%). Two (0.5%) exercise events in the same individual were associated with bleeding (running, weight training). The safety analysis population consisted of 106 participants treated with emicizumab (median observation period: 241.5 days). Twenty-one (19.8%) participants experienced a total of 39 AEs. Five (4.7%) experienced a serious AE, none of which was emicizumab-related, and three (2.8%) experienced an adverse drug reaction. CONCLUSIONS PwHA receiving emicizumab in the TSUBASA study experienced minimal bleeding associated with physical activity. TRIAL REGISTRATION Trial registration: UMIN-CTR ID: UMIN000037448.
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Affiliation(s)
- Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Teruhisa Fujii
- Division of Transfusion Medicine/Hemophilia Treatment Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Akihiro Sawada
- Department of Respiratory Medicine and Hematology, Hyogo College of Medicine, Hyogo, Japan
| | - Azusa Nagao
- Department of Blood Coagulation, Ogikubo Hospital, Tokyo, Japan
| | - Chiai Nagae
- Department of Pediatrics, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masanori Nojima
- Center for Translational Research/Division of Advanced Medicine Promotion, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Nobuaki Suzuki
- Department of Transfusion Medicine, Nagoya University Hospital, Aichi, Japan
| | | | | | | | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
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16
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Tiede A, Hart C, Knöbl P, Greil R, Oldenburg J, Sachs UJ, Miesbach W, Pfrepper C, Trautmann-Grill K, Holstein K, Pilch J, Möhnle P, Schindler C, Weigt C, Schipp D, May M, Dobbelstein C, Pelzer FJ, Werwitzke S, Klamroth R. Emicizumab prophylaxis in patients with acquired haemophilia A (GTH-AHA-EMI): an open-label, single-arm, multicentre, phase 2 study. Lancet Haematol 2023; 10:e913-e921. [PMID: 37858328 DOI: 10.1016/s2352-3026(23)00280-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Acquired haemophilia A is caused by neutralising autoantibodies against coagulation factor VIII, leading to severe bleeding. Standard treatment involves immunosuppressive therapy, which is associated with adverse events and mortality in the frail population of patients with acquired haemophilia A. This study investigated whether emicizumab, a factor VIIIa mimetic antibody, protects patients with acquired haemophilia A from bleeding and allows deferral of immunosuppression during the first 12 weeks after diagnosis. METHODS We report final results of an open-label, single-arm, phase 2 clinical trial. Adult patients with acquired haemophilia A from 16 haemophilia treatment centres in Germany and Austria were eligible if they had not previously received immunosuppression. Patients received emicizumab subcutaneously (6 and 3 mg/kg on days 1 and 2, 1·5 mg/kg weekly until week 12), but no immunosuppression. Follow-up was until week 24. The primary endpoint was the number of clinically relevant bleeds per patient-week until week 12. Emicizumab was considered effective if the mean bleeding rate was significantly below 0·15 bleeds per patient-week, the rate observed in a previous study of patients with acquired haemophilia A treated with bypassing agents and immunosuppression but no emicizumab. The study is registered with clinicaltrials.gov, NCT04188639 and is complete. FINDINGS Of 49 patients screened from March 25, 2021, to June 10, 2022, 47 were enrolled (23 women, 24 men). Median age was 76 years (IQR 66-80), 46 (98%) of 47 patients were White, median factor VIII activity was 1·4 IU/dL (0·3-5·6), and median inhibitor concentration was 11·4 Bethesda units per mL (3·9-42·7). Mean breakthrough bleeding rate was 0·04 bleeds per patient-week (upper 97·5% CI 0·06). 33 (70%) of 47 patients had no bleeding events, seven patients (15%) had one bleed, six patients (13%) had two bleeds, and one patient (2%) had three bleeds. Adverse events of grade 3 or worse included COVID-19 (n=2), acute kidney injury (n=2), and stroke (n=1). Four of 47 patients died, including two deaths related to bleeding, one from COVID-19, and one from cardiac arrest (none were judged as related to emicizumab). INTERPRETATION This study suggests that emicizumab prophylaxis prevents bleeding in patients with acquired haemophilia A and that immunosuppressive therapy can be deferred while patients are receiving this treatment. The low number of thromboembolic events, severe infections, and fatalities observed in this study are promising. FUNDING This study was supported by funding from Hoffman-La Roche.
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Affiliation(s)
- Andreas Tiede
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.
| | - Christina Hart
- Department of Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Paul Knöbl
- Department of Medicine 1, Division of Hematology and Hemostasis, Medical University of Vienna, Vienna, Austria
| | - Richard Greil
- Medical Department III, Paracelsus Medical University Salzburg, Salzburg, Austria; Salzburg Cancer Research Institute-CCCIT Salzburg, Austria; Cancer Cluster Salzburg, Salzburg, Austria
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Ulrich J Sachs
- Department of Thrombosis and Haemostasis, Giessen University Hospital, Giessen, Germany
| | | | - Christian Pfrepper
- Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
| | | | - Katharina Holstein
- Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Pilch
- Clinical Hemostaseology and Transfusion Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Patrick Möhnle
- Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | | | | | | | - Marcus May
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Christiane Dobbelstein
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Fabius J Pelzer
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Sonja Werwitzke
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Robert Klamroth
- Internal Medicine, Vascular Medicine and Coagulation Disorders, Vivantes Clinic Friedrichshain, Berlin, Germany
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17
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Onishi T, Harada S, Shimo H, Tashiro Y, Soeda T, Nogami K. The in vitro effect of anticoagulant agents on coagulation and fibrinolysis in the presence of emicizumab in the plasmas from patients with haemophilia A. Haemophilia 2023; 29:1529-1538. [PMID: 37766492 DOI: 10.1111/hae.14877] [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: 07/05/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION Emicizumab is used as hemostatic prophylaxis for patients with hemophilia A (PwHA), irrespective of the presence of inhibitors. Although bacterial infection can lead to a procoagulant state, there is limited information on coagulation and fibrinolysis potentials in emicizumab-treated PwHA and on the use of anticoagulants in such cases. AIM We examined whether anticoagulants affect the coagulation and fibrinolysis potentials in plasma from PwHA spiked with emicizumab. METHODS Plasma from PwHA was in vitro supplemented with emicizumab (50 μg/mL; emi-plasma) and anticoagulants (recombinant thrombomodulin (rTM), nafamostat mesylate (NM), unfractionated heparin (UFH), or low-molecular-weight heparin (LMH)). PwHA plasma spiked with rFVIII (1 IU/mL) was used as a reference (ref-plasma). The coagulation and fibrinolysis potentials in plasma was measured by thrombin and plasmin generation assay (T/P-GA) and clot-fibrinolysis waveform analysis (CFWA). RESULTS In T/P-GA and CFWA, coagulation potentials (maximum coagulation velocity; |min1|, and peak thrombin; Th-Peak) in plasma rose with increasing concentrations of emicizumab and rFVIII, but fibrinolytic potentials (peak plasmin; Plm-Peak, and maximum fibrinolytic velocity; |FL-min1|) remained unchanged. Adding rTM, NM, and UFH to emi-plasma suppressed coagulation and fibrinolysis potentials, similar to ref-plasma. Regarding the heparin, UFH and LMH inhibited the improved coagulation in emi-plasma. UFH inhibited fibrinolysis as well, but LMH did not. CONCLUSIONS Anticoagulants could exhibit the inhibitory effects on the coagulation and fibrinolysis potentials in plasma from PwHA spiked with emicizumab, similar to those in normal plasma.
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Affiliation(s)
- Tomoko Onishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Suguru Harada
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | - Hanako Shimo
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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18
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Di Minno G, Spadarella G, Maldonato NM, De Lucia N, Castaman G, De Cristofaro R, Santoro C, Peyvandi F, Borrelli A, Lupi A, Follino M, Guerrino G, Morisco F, Di Minno M. Awareness of individual goals, preferences, and priorities of persons with severe congenital haemophilia A for a tailored shared decision-making approach to liver-directed gene therapy. A practical guideline. Blood Rev 2023; 62:101118. [PMID: 37544828 DOI: 10.1016/j.blre.2023.101118] [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: 06/05/2023] [Revised: 07/26/2023] [Accepted: 07/30/2023] [Indexed: 08/08/2023]
Abstract
In clinical medicine, shared decision making (SDM) is a well-recognized strategy to enhance engagement of both patients and clinicians in medical decisions. The success of liver-directed gene therapy (GT) to transform severe congenital haemophilia A (HA) from an incurable to a curable disease has launched a shift beyond current standards of treatment. However, GT acceptance remains low in the community of HA persons. We argue for both persons with haemophilia (PWH) and specialists in HA care including clinicians, as needing SDM-oriented educational programs devoted to GT. Here, we provide an ad hoc outline to implement education to SDM and tailor clinician information on GT to individual PWHs. Based on routine key components of SDM: patient priorities; recommendations based on individual risk reduction; adverse effects; drug-drug interactions; alternatives to GT; and ongoing re-assessment of the objectives as risk factors (and individual priorities) change, this approach is finalized to exploit efficacious communication.
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Affiliation(s)
| | - Gaia Spadarella
- Dipartimento di Scienze Mediche Traslazionali, Naples, Italy.
| | - Nelson Mauro Maldonato
- Dipartimento di Neuroscienze e di Scienze Riproduttive e Odontostomatologiche, "Federico II" University, Naples, Italy
| | - Natascia De Lucia
- Dipartimento di Neuroscienze e di Scienze Riproduttive e Odontostomatologiche, "Federico II" University, Naples, Italy.
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy.
| | - Raimondo De Cristofaro
- Section of Haemorrhagic and Thrombotic Diseases, Department of Medicine and Translational Surgery, Sacred Heart University, Rome, Italy..
| | - Cristina Santoro
- Ematologia, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Rome, Italy.
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy; Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy.
| | - Anna Borrelli
- Direzione Sanitaria, AOU "Federico II" Napoli, Italy
| | - Angelo Lupi
- Federazione delle Associazioni Emofilici (FedEmo), Milan, Italy.
| | | | | | | | - Matteo Di Minno
- Dipartimento di Medicina Clinica e Chirurgia, Naples, Italy.
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19
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Shim J, Chen J, Carrasco-Triguero M, Fischer SK. Overcoming Soluble Target Interference in Measurement of Total Bispecific Therapeutic Antibody Concentrations. AAPS J 2023; 25:82. [PMID: 37594571 DOI: 10.1208/s12248-023-00848-9] [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: 05/19/2023] [Accepted: 08/04/2023] [Indexed: 08/19/2023] Open
Abstract
The measurement of therapeutic drug concentrations is used to assess drug exposure and the relationship between therapeutic pharmacokinetics (PK) and pharmacodynamics (PD), which help determine the optimal dose for patients. Ligand binding assays (LBAs) are often the method of choice for evaluation of drug concentration and use either the therapeutic target protein or antibodies to the therapeutic as capture and/or detection reagents. Due to the bivalency of antibody therapeutics, heterogeneous states of the drug/target complex can exist in the presence of soluble targets which can complicate measurement of unbound drug. In the case of bispecific antibodies, measurement of drug can be even more complicated and depend upon the levels of both targets to each arm. Measuring the total drug allows for PKPD modeling prediction of human dose projections in addition to overcoming challenges associated with measuring free drug for bispecific antibodies. Here, we present a study in which a sandwich ELISA format was used to measure total anti-KLK5/KLK7 antibody concentrations. This assay utilized a non-blocking anti-idiotype (ID) antibody to one arm of the antibody for capture and an antibody to target bound to the other arm of the antibody for detection. Our qualified assay showed acceptable precision, accuracy, dilutional linearity, and reproducibility and enabled detection of a total bispecific antibody at high levels of two targets. To confirm that our assay was detecting total drug, a subset of samples was evaluated in a generic total LC-MS/MS assay.
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Affiliation(s)
- Jeongsup Shim
- BioAnalytical Sciences, Development Sciences, Genentech, Inc., 1 DNA Way, South San Francisco, California, 94080, USA.
| | - Jessica Chen
- BioAnalytical Sciences, Development Sciences, Genentech, Inc., 1 DNA Way, South San Francisco, California, 94080, USA
| | - Montserrat Carrasco-Triguero
- BioAnalytical Sciences, Development Sciences, Genentech, Inc., 1 DNA Way, South San Francisco, California, 94080, USA
| | - Saloumeh K Fischer
- BioAnalytical Sciences, Development Sciences, Genentech, Inc., 1 DNA Way, South San Francisco, California, 94080, USA
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20
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Yoneyama K, Schmitt C, Portron A, Kiialainen A, Kotani N, Jaminion F, Retout S, Adamkewicz JI. Clinical pharmacology of emicizumab for the treatment of hemophilia A. Expert Rev Clin Pharmacol 2023; 16:775-790. [PMID: 37529848 DOI: 10.1080/17512433.2023.2243213] [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: 04/14/2023] [Revised: 06/22/2023] [Accepted: 07/28/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Emicizumab is a humanized bispecific antibody approved for the routine prophylaxis of bleeding episodes in patients with hemophilia A (PwHA) regardless of the presence of factor VIII (FVIII) inhibitors. It mimics the cofactor function of missing activated FVIII by bridging activated factor IX and factor X, thereby restoring hemostasis. AREAS COVERED This review covers the clinical pharmacology of emicizumab and the translation of its pharmacokinetics (PK) and pharmacodynamics (PD) to clinical efficacy and safety. The PK of emicizumab is linear, with an approximately 1-month half-life. Once-weekly to every-4-week subcutaneous (SC) administrations maintain effective trough concentrations throughout the dosing intervals, associated with a coagulation potential analogous to that in patients with mild hemophilia A. In combination with activated prothrombin complex concentrate, and to a lesser extent with recombinant activated factor VII, emicizumab exerts a synergistic effect, whereas combination with FVIII may result in a non-additive coagulation potential at normal FVIII activity. EXPERT OPINION The translation of emicizumab PK/PD into clinical effects was demonstrated in several phase III studies, which showed remarkable bleed control and a favorable safety profile in PwHA. These emicizumab attributes, together with the convenience of use (infrequent SC injections), offer a novel paradigm for the management of PwHA.
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21
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Matsumoto N, Abe H, Kawasaki R, Tashiro Y, Noguchi-Sasaki M, Harada S, Yoneyama K, Niino T, Soeda T, Yoshimura Y. Characterization of Anti-Emicizumab Antibodies Using Repository Samples Obtained in Clinical Studies of Emicizumab Conducted in Japan. TH OPEN 2023; 7:e241-e243. [PMID: 37645671 PMCID: PMC10462426 DOI: 10.1055/a-2122-7887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Affiliation(s)
| | - Hiroto Abe
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | | | | | | | - Suguru Harada
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | | | - Tomomi Niino
- Chugai Pharmaceutical Co., Ltd., Chuo-ku, Tokyo, Japan
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22
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Schutgens RE, Jimenez-Yuste V, Escobar M, Falanga A, Gigante B, Klamroth R, Lassila R, Leebeek FW, Makris M, Owaidah T, Sholzberg M, Tiede A, Werring DJ, van der Worp HB, Windyga J, Castaman G. Antithrombotic Treatment in Patients With Hemophilia: an EHA-ISTH-EAHAD-ESO Clinical Practice Guidance. Hemasphere 2023; 7:e900. [PMID: 37304933 PMCID: PMC10256340 DOI: 10.1097/hs9.0000000000000900] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 06/13/2023] Open
Abstract
Cardiovascular disease is an emerging medical issue in patients with hemophilia (PWH) and its prevalence is increasing up to 15% in PWH in the United States. Atrial fibrillation, acute and chronic coronary syndromes, venous thromboembolism, and cerebral thrombosis are frequent thrombotic or prothrombotic situations, which require a careful approach to fine-tune the delicate balance between thrombosis and hemostasis in PWH when using both procoagulant and anticoagulant treatments. Generally, PWH could be considered as being naturally anticoagulated when clotting factors are <20 IU/dL, but specific recommendations in patients with very low levels according to the different clinical situations are lacking and mainly based on the anecdotal series. For PWH with baseline clotting factor levels >20 IU/dL in need for any form of antithrombotic therapy, usually treatment without additional clotting factor prophylaxis could be used, but careful monitoring for bleeding is recommended. For antiplatelet treatment, this threshold could be lower with single-antiplatelet agent, but again factor level should be at least 20 IU/dL for dual antiplatelet treatment. In this complex growing scenario, the European Hematology Association in collaboration with the International Society on Thrombosis and Haemostasis, the European Association for Hemophilia and Allied Disorders, the European Stroke Organization, and a representative of the European Society of Cardiology Working Group on Thrombosis has produced this current guidance document to provide clinical practice recommendations for health care providers who care for PWH.
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Affiliation(s)
- Roger E.G. Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Victor Jimenez-Yuste
- Hematology Department, La Paz University Hospital, Autonoma University, Madrid, Spain
| | - Miguel Escobar
- University of Texas Health Science Center at Houston, TX, USA
| | - Anna Falanga
- University of Milano Bicocca, School of Medicine, Monza, Italy
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Solna, Sweden
- Department of Clinical Science, Danderyd Hospital, Karolinska institutet, Stockholm, Sweden
| | - Robert Klamroth
- Department of Internal Medicine Angiology and Coagulation Disorders at the Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Germany
| | - Riitta Lassila
- Department of Hematology, Coagulation Disorders Unit, and Research Program Unit in Systems Oncology Oncosys, Medical Faculty, University of Helsinki, Finland
| | - Frank W.G. Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Michael Makris
- Haemophilia and Thrombosis Centre, University of Sheffield, United Kingdom
| | - Tarek Owaidah
- King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
| | - Michelle Sholzberg
- Division of Hematology-Oncology, Departments of Medicine, and Laboratory Medicine and Pathobiology, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Canada
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Germany
| | - David J. Werring
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom
| | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
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El Maamari J, Amid A, Pelland-Marcotte MC, Tole S. Between Scylla and Charybdis: thrombosis in children with hemophilia. Front Pediatr 2023; 11:1173549. [PMID: 37287631 PMCID: PMC10242037 DOI: 10.3389/fped.2023.1173549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/27/2023] [Indexed: 06/09/2023] Open
Abstract
Thromboembolism is an infrequent complication in children with hemophilia that has been traditionally associated with the presence of a central venous access device. Novel rebalancing agents have shown promising results as prophylactic therapies to minimize the risk of bleeding but both thromboembolism and thrombotic microangiopathy have been reported as complications. The management of thrombosis in children with hemophilia is particularly challenging given the inherent risk of bleeding. In this paper, we present clinical vignettes to review the literature, highlight challenges, and describe our approach to managing thromboembolism in children with hemophilia.
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Affiliation(s)
- Jad El Maamari
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, BC Children’s Hospital, Vancouver, BC, Canada
| | - Ali Amid
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, BC Children’s Hospital, Vancouver, BC, Canada
| | - Marie-Claude Pelland-Marcotte
- Division of Pediatric Hematology-Oncology, CHU deQuébec—Centre Mère-Enfant Soleil, Quebec City, QC, Canada
- Research Center of the CHU de Québec, Axe Reproduction, Santé de la Mère et de l’Enfant, Quebec City, Canada
| | - Soumitra Tole
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Department of Pediatrics, Division of Hematology/Oncology, London Health Sciences Centre, London, ON, Canada
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24
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Awane M, Wakui M, Ozaki Y, Kondo Y, Oka S, Fujimori Y, Yatabe Y, Arai T, Yamada Y, Hori S, Obara H, Hasegawa Y, Matsushita H. Clot waveform analysis for perioperative hemostatic monitoring in a hemophilia A patient on emicizumab undergoing liver transplantation. Clin Chim Acta 2023; 544:117339. [PMID: 37076096 DOI: 10.1016/j.cca.2023.117339] [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: 12/23/2022] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 04/21/2023]
Abstract
How to optimize perioperative factor VIII (FVIII) replacement through hemostatic monitoring is critically important to manage hemophilia A patients. The bispecific antibody emicizumab binds activated FIX (FIXa) and FX to functionally mimic FVIIIa. While being used for hemostatic control in hemophilia A, this therapeutic antibody inconveniently interferes with coagulation tests using human FIXa and FX, such as activated partial thromboplastin time (APTT) and FVIII activity measurement based on one-stage clotting assays. Clot waveform analysis (CWA) extends the interpretation of measurement curves for coagulation time to provide global information. We performed APTT-CWA to monitor perioperative hemostasis in a hemophilia A patient on emicizumab undergoing liver transplantation. Plasma samples were treated with anti-idiotype monoclonal antibodies against emicizumab to enable accurate coagulation assays. Kinetics of maximum coagulation velocity and acceleration mimicked that of FVIII activity. These CWA parameters better correlated with FVIII activity than APTT. The plateaus of them were observed at FVIII activity of 100% or more, supporting the protocol for perioperative FVIII replacement. Thus, CWA may measure coagulation potential in hemophilia A patients undergoing liver transplantation, aiding in optimizing perioperative hemostasis.
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Affiliation(s)
- Mai Awane
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Masatoshi Wakui
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan.
| | - Yuko Ozaki
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Yoshino Kondo
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Shusaku Oka
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Yuta Fujimori
- Office of Clinical Laboratory Technology, Keio University Hospital, Tokyo, Japan
| | - Yoko Yatabe
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Tomoko Arai
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Yohei Yamada
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Shutaro Hori
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hideaki Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiromichi Matsushita
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
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25
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Bowyer AE, Kitchen S, Ezban M. The effect of a next generation factor VIII mimetic bispecific antibody (Mim8) on assays of factor VIII activity and thrombin generation. J Thromb Haemost 2023; 21:480-487. [PMID: 36696203 DOI: 10.1016/j.jtha.2022.12.023] [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: 08/26/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Mim8 is a next generation bispecific antibody developed for the prophylactic treatment of hemophilia A. The sensitivity of activated plasma thromboplastin time (APTT), assays measuring factor VIII activity (FVIII:C) and thrombin generation to plasma containing Mim8 was assessed. METHODS Congenital severe hemophilia A plasma was spiked with Mim8 at 0 μg/mL to 20 μg/mL. APTT was measured with 4 reagents, one-stage FVIII with 9 reagents, and chromogenic FVIII with 6 assays. Thrombin generation was assessed in a low tissue factor system. RESULTS At 1-μg/mL Mim8, the APTT was shortened to within normal limits and one-stage FVIII:C was >1.00 IU/mL with all APTT reagents. Modified one-stage assays calibrated with Mim8 reference material calibrated recovered within 20% of the target Mim8 concentration with most APTT reagents. Factor VIII:C of bovine only chromogenic assays was <0.04 IU/mL at all Mim8 concentrations. Factor VIII:C of human only chromogenic assay was >4.00 IU/mL at 20-μg/mL Mim8. Factor VIII:C of hybrid bovine FX, human FIXa chromogenic assays ranged from 0.076 to >3.00 IU/mL at 20-μg/mL Mim8. Normal thrombin generation was restored at 5-μg/mL Mim8. CONCLUSIONS APTT-based assays are sensitive to Mim8 and should not be performed in the presence of the drug. Chromogenic assays containing human proteins or hybrid human/bovine proteins demonstrated variable sensitivity to Mim8. Bovine only chromogenic assays were largely insensitive to the presence of Mim8. Thrombin generation normalized at increased Mim8 concentrations. Modified one-stage and chromogenic assays could be used to quantify the Mim8 concentration in plasma.
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Affiliation(s)
| | - Steve Kitchen
- Department of Coagulation, Sheffield Teaching Hospitals NHS FT, Sheffield, UK
| | - Mirella Ezban
- Rare Disease Research, Global Drug Discovery, Novo Nordisk, Denmark
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26
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Di Minno G, Castaman G, De Cristofaro R, Brunetti-Pierri N, Pastore L, Castaldo G, Trama U, Di Minno M. Progress, and prospects in the therapeutic armamentarium of persons with congenital hemophilia. Defining the place for liver-directed gene therapy. Blood Rev 2023; 58:101011. [PMID: 36031462 DOI: 10.1016/j.blre.2022.101011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 02/07/2023]
Abstract
In persons with congenital severe hemophilia A (HA) living in high-income countries, twice weekly intravenous infusions of extended half-life (EHL) factor VIII (FVIII) products, or weekly/biweekly/monthly subcutaneous injections of emicizumab are the gold standard home treatments to grant days without hurdles and limitations. Once weekly/twice monthly infusions of EHL Factor IX (FIX) products achieve the same target in severe hemophilia B (HB). Gene therapy, which is likely to be licensed for clinical use within 1-2 years, embodies a shift beyond these standards. At an individual patient level, a single functional gene transfer leads to a > 10-yr almost full correction of the hemostatic defect in HB and to a sustained (3-6-yrs) expression of FVIII sufficient to discontinue exogenous clotting factor administrations. At the doses employed, the limited liver toxicity of systemically infused recombinant adeno-associated virus (rAAV) vectors is documented by long-term (12-15 yrs) follow-ups, and pre-existing high-titer neutralizing antibodies to the AAV5 vector are no longer an exclusion criterion for effective transgene expression with this vector. A safe durable treatment that converts a challenging illness to a phenotypically curable disease, allows persons to feel virtually free from the fears and the obligations of hemophilia for years/decades. Along with patient organizations and health care professionals, communicating to government authorities and reimbursement agencies the liberating potential of this substantial innovation, and disseminating across the Centers updated information on benefits and risks of this strategy, will align expectations of different stakeholders and establish the notion of a potentially lifelong cure of hemophilia.
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Affiliation(s)
- Giovanni Di Minno
- Hub Center for Hemorrhagic and Thrombotic Disorders, Dep. of Clinical Medicine and Surgery, School of Medicine, Federico II University, Naples, Italy.
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy.
| | - Raimondo De Cristofaro
- Center for Hemorrhagic and Thrombotic Diseases, Foundation University Hospital A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy.
| | - Nicola Brunetti-Pierri
- Telethon Institute of Genetics and Medicine, Pozzuoli, Italy; Dept of Translational Medicine, School of Medicine, Università degli Studi di Napoli "Federico II", Italy.
| | - Lucio Pastore
- CEINGE-Biotecnologie Avanzate, and Department of Molecular Medicine and Medical Biotechnology, School of Medicine, University of Naples Federico II, 80131 Naples, Italy.
| | - Giuseppe Castaldo
- CEINGE-Biotecnologie Avanzate, and Department of Molecular Medicine and Medical Biotechnology, School of Medicine, University of Naples Federico II, 80131 Naples, Italy.
| | - Ugo Trama
- Coordination of the Regional Health System, General Directorate for Health Protection, Naples, Italy.
| | - Matteo Di Minno
- Hub Center for Hemorrhagic and Thrombotic Disorders, Dep. of Clinical Medicine and Surgery, School of Medicine, Federico II University, Naples, Italy.
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27
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Yamaguchi T, Shinozawa K, Nagatoishi S, Mitsuhashi A, Bingo M, Inaba H, Amano K, Tsumoto K, Kinai E. In vitro validation of chromogenic substrate assay for evaluation of surrogate FVIII-activity of emicizumab. Thromb Res 2023; 222:131-139. [PMID: 36657269 DOI: 10.1016/j.thromres.2023.01.007] [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: 10/17/2022] [Revised: 12/09/2022] [Accepted: 01/05/2023] [Indexed: 01/15/2023]
Abstract
[Introduction] Emicizumab, a bispecific antibody mimicking activated factor VIII (FVIII), is increasingly used in prophylaxis against bleeding in hemophilia A. Human factor-based chromogenic substrate assay (hCSA) shows concentration-dependency between emicizumab and reported FVIII activity. However, the assay measurement settings have not been optimized for emicizumab, and the reported FVIII activity cannot be directly referred as surrogate FVIII activity. [Materials and Methods] For in vitro validation of hCSA-reported surrogate FVIII activity, we compared the equation curves for emicizumab concentration with surrogate FVIII activity using spiked plasma in the thrombin generation assay (TGA), hCSA, and clot waveform analysis (CWA). Then, we generated conversion equations for hCSA-reported surrogate FVIII value to that of TGA. We also assessed the additive effect of rFVIII onto 340 nM (i.e., 50 μg/mL) emicizumab using the same assays. [Results] With 1:20 diluted plasma, halving hCSA-reported surrogate FVIII activity can be approximated to that in TGA triggered by the extrinsic pathway reagent (27.3 IU/dL vs. 13.9 IU/dL) under therapeutic emicizumab concentration. Both in TGA and hCSA, the additive effect of added FVIII on therapeutic emicizumab concentration (340 nM) was maintained at low levels of FVIII but gradually decreased at higher levels. [Conclusions] Surrogate FVIII activity can be estimated simply by halving hCSA-reported FVIII value, and the additive effect of FVIII on emicizumab diminishes at high concentrations. Based on our in vitro study, a clinical study is currently being conducted to compare individual variation of surrogate FVIII activity in hCSA and TGA.
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Affiliation(s)
- Tomoko Yamaguchi
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Keiko Shinozawa
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Satoru Nagatoishi
- The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Ayano Mitsuhashi
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan; Research Resident Fellowship, Japan Foundation for AIDS Prevention, Tokyo, Japan
| | - Masato Bingo
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Hiroshi Inaba
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Kohei Tsumoto
- The Institute of Medical Science, The University of Tokyo, Tokyo, Japan; Department of Bioengineering, Graduate School of Engineering, The University of Tokyo, Tokyo, Japan
| | - Ei Kinai
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan.
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28
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Pipe SW, Trzaskoma B, Minhas M, Lehle M, Ko RH, Gao L, Mahlangu J, Kempton CL, Kessler CM, Kruse-Jarres R. Efficacy of emicizumab is maintained throughout dosing intervals for bleed prophylaxis. Res Pract Thromb Haemost 2023; 7:100077. [PMID: 36908770 PMCID: PMC9992752 DOI: 10.1016/j.rpth.2023.100077] [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: 08/18/2022] [Revised: 12/05/2022] [Accepted: 12/29/2022] [Indexed: 02/09/2023] Open
Abstract
Background Across the HAVEN clinical trial program, the efficacy of emicizumab has been demonstrated in children, adolescents, and adults with hemophilia A, with or without factor VIII inhibitors. After the 4-week loading dose period, emicizumab concentrations are expected to remain at levels that provide bleed protection throughout the entire dosing interval, regardless of the chosen maintenance dosing regimen, ie, weekly, every 2 weeks, or every 4 weeks. Objectives The objective of this study was to examine the timing of treated bleeds within the dosing intervals for emicizumab administered during the HAVEN 1 to 4 studies. Methods In this post hoc analysis, we pooled data from all the participants of the HAVEN 1 to 4 studies and analyzed the timing of treated bleeds in relation to the emicizumab dose. Results A total of 392 participants were included in this analysis, with a median (range) age of 28.0 years (1.1-77.0 years). Target joints were identified in 237 of 392 (60.5%) participants before the study entry. Overall, 211 of 392 (53.8%) participants experienced 907 treated bleeding events. The total mean (SD) annualized bleeding rate across the 4 studies was 1.6 (5.9). There was no evidence that bleeding events clustered on any 1 particular day in any dosing schedule from HAVEN 1 to 4 (P > .05 for all 3 treatment regimens). Conclusion Data from the HAVEN 1 to 4 trials show consistent bleed prevention within the dosing interval, regardless of the dosing regimen chosen. These findings provide further evidence of the sustained efficacy of emicizumab across all approved dosing regimens to reduce bleeding in people with hemophilia A.
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Affiliation(s)
- Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ben Trzaskoma
- US Medical Affairs, Genentech Inc, South San Francisco, California, USA
| | - Miranda Minhas
- US Medical Affairs, Genentech Inc, South San Francisco, California, USA
| | - Michaela Lehle
- Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Richard H Ko
- US Medical Affairs, Genentech Inc, South San Francisco, California, USA
| | - Ling Gao
- Analystat Corporation, Point Roberts, Washington, USA
| | - Johnny Mahlangu
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | - Christine L Kempton
- Department of Hematology and Medical Oncology and Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Craig M Kessler
- The Division of Coagulation, Georgetown University School of Medicine, Washington, DC, USA
| | - Rebecca Kruse-Jarres
- Division of Hematology, University of Washington and Washington Center for Bleeding Disorders, Seattle, Washington, USA
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29
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Nogami K, Shima M. Current and future therapies for haemophilia-Beyond factor replacement therapies. Br J Haematol 2023; 200:23-34. [PMID: 35869698 DOI: 10.1111/bjh.18379] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 12/01/2022]
Abstract
Some non-factor products that work by facilitating the coagulation pathway (emicizumab) and blocking the anticoagulant pathway (fitusiran, concizumab and marstacimab) for patients with haemophilia (H) have been developed, and clinical trials using these products are currently ongoing. Prophylaxis using non-factor products by subcutaneous administration provides marked reductions of bleeding episodes in patients with HA or HB, regardless of the presence of inhibitor. Emicizumab has already been approved globally. Emicizumab alters the phenotype of patients with HA from severe to mild by maintaining trough levels of equivalent factor VIII activity (15-20 iu/dl). Phase 3 clinical trials and long-term observations assessing emicizumab revealed tolerable safety and efficacy. However, thrombotic events have occurred in patients receiving these non-factor products. Furthermore, monitoring of the haemostatic function of these products with concomitant therapy is also required in clinical practice. These products have promising haemostatic efficiency, but wider clinical experience is needed to provide optimal therapeutic strategies in the future.
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Affiliation(s)
- Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,Thrombosis and Hemostasis Research Centre, Nara Medical University, Kashihara, Nara, Japan
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30
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Mak S, Marszal A, Matscheko N, Rant U. Kinetic analysis of ternary and binary binding modes of the bispecific antibody emicizumab. MAbs 2023; 15:2149053. [PMID: 36453702 PMCID: PMC9724730 DOI: 10.1080/19420862.2022.2149053] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The binding properties of bispecific antibodies (bsAb) are crucial for their function, especially when two antigens are targeted on the same cell surface. Dynamic interactions between each of the antibody's arms and its cognate target cause the formation and decay of a biologically functional ternary complex. How association and dissociation processes work cooperatively, and how they influence the avidity of the ternary complex, is still poorly understood. Here, we present a biosensor assay for the simultaneous measurement of the binding kinetics of the therapeutic bsAb emicizumab (Hemlibra®) and its two targets, the blood coagulation factors IX and X (FIX, FX). We describe an automated workflow to characterize binary and ternary-binding modes, utilizing a Y-shaped DNA nanostructure to immobilize the antigens on a sensor and to emulate conditions on a cell or platelet surface by presenting the antigens with optimal accessibility for the bsAb flown over the sensor as analyte. We find that emicizumab binds FX much stronger than FIX (Kd = 0.05 µM vs. 5 µM, t1/2 = 20 s vs. 1 s) with profound consequences on the avidity of the ternary complex, which is dominated by FX's binding properties and a hand-off mechanism from FX to FIX. Moreover, formation and decay of the ternary complex depend on the bsAb concentration during the association phase. Emicizumab's in-vivo mode of action and the catalytic activation of FX can be rationalized from the analyzed binding kinetics. The assay and workflow are well suited for the screening of bispecific binders in drug discovery and provide valuable new kinetic information.Abbreviations: bsAb: bispecific antibody; FVIII/FIX/FX: coagulation factors VIII/IX/X; SPR: surface plasmon resonance; kon: association rate constant; koff: dissociation rate constant; KD: equilibrium dissociation constant; t1/2: dissociation half-life.
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Affiliation(s)
| | | | - Nena Matscheko
- Dynamic Biosensors GmbH, Munich, Germany,CONTACT Nena Matscheko
| | - Ulrich Rant
- Dynamic Biosensors GmbH, Munich, Germany,Ulrich Rant Dynamic Biosensors GmbH, Munich, Germany
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Jiménez‐Yuste V, Peyvandi F, Klamroth R, Castaman G, Shanmukhaiah C, Rangarajan S, García Chavez J, Martinez R, Kenet G, Alzahrani H, Robson S, Schmitt C, Kiialainen A, Meier O, Ozelo M. Safety and efficacy of long-term emicizumab prophylaxis in hemophilia A with factor VIII inhibitors: A phase 3b, multicenter, single-arm study (STASEY). Res Pract Thromb Haemost 2022; 6:e12837. [PMID: 36397934 PMCID: PMC9663319 DOI: 10.1002/rth2.12837] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/07/2022] [Accepted: 10/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background The bispecific monoclonal antibody emicizumab bridges activated factor IX and factor X, mimicking the cofactor function of activated factor VIII (FVIII), restoring hemostasis. Objectives The Phase 3b STASEY study was designed to assess the safety of emicizumab prophylaxis in people with hemophilia A (HA) with FVIII inhibitors. Methods People with HA received 3 mg/kg emicizumab once weekly (QW) for 4 weeks followed by 1.5 mg/kg QW for 2 years. The primary objective was the safety of emicizumab prophylaxis, including incidence and severity of adverse events (AEs) and AEs of special interest (thrombotic events [TEs] and thrombotic microangiopathies). Secondary objectives included efficacy (annualized bleed rates [ABRs]). Results Overall, 195 participants were enrolled; 193 received emicizumab. The median (range) duration of exposure was 103.1 (1.1-108.3) weeks. Seven (3.6%) participants discontinued emicizumab. The most common AEs were arthralgia (n = 33, 17.1%) and nasopharyngitis (n = 30, 15.5%). The most common treatment-related AE was injection-site reaction (n = 19, 9.8%). Two fatalities were reported (polytrauma with fatal head injuries and abdominal compartment syndrome); both were deemed unrelated to emicizumab by study investigators. Two TEs occurred (myocardial infarction and localized clot following tooth extraction), also deemed unrelated to emicizumab. The negative binomial regression model-based ABR (95% confidence interval) for treated bleeds was 0.5 (0.27-0.89). Overall, 161 participants (82.6%) had zero treated bleeds. Conclusions The safety profile of emicizumab prophylaxis was confirmed in a large population of people with HA with FVIII inhibitors and no new safety signals occurred. The majority of participants had zero treated bleeds.
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Affiliation(s)
| | - Flora Peyvandi
- IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterMilanItaly
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - Robert Klamroth
- Comprehensive Care Haemophilia Treatment Centre, Vivantes KlinikumBerlinGermany
| | | | | | - Savita Rangarajan
- Clinical Trials & Research UnitK J Somaiya Superspeciality Hospital & Research CentreMumbaiIndia
- Faculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Jaime García Chavez
- Unidad de Investigación en Enfermedades Hematologicas, Hospital de Especialidades CMN La Raza, IMSSMexico CityMexico
| | - Raul Martinez
- UMAE Hospital De Especialidades CMNSXXIMexico CityMexico
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical CenterTel HashomerIsrael
- The Amalia Biron Research Institute of Thrombosis & HemostasisSackler Medical SchoolTel Aviv UniversityTel AvivIsrael
| | - Hazaa Alzahrani
- King Faisal Specialist Hospital and Research CentreRiyadhSaudi Arabia
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Kang J, Sun T, Zhang Y. Immunotherapeutic progress and application of bispecific antibody in cancer. Front Immunol 2022; 13:1020003. [PMID: 36341333 PMCID: PMC9630604 DOI: 10.3389/fimmu.2022.1020003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/05/2022] [Indexed: 08/19/2023] Open
Abstract
Bispecific antibodies (bsAbs) are artificial antibodies with two distinct antigen-binding sites that can bind to different antigens or different epitopes on the same antigen. Based on a variety of technology platforms currently developed, bsAbs can exhibit different formats and mechanisms of action. The upgrading of antibody technology has promoted the development of bsAbs, which has been effectively used in the treatment of tumors. So far, 7 bsAbs have been approved for marketing in the world, and more than 200 bsAbs are in clinical and preclinical research stages. Here, we summarize the development process of bsAbs, application in tumor treatment and look forward to the challenges in future development.
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Affiliation(s)
- Jingyue Kang
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Tonglin Sun
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Division of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Zhang
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Division of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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Anandani G, Patel T, Parmar R. The Implication of New Developments in Hemophilia Treatment on Its Laboratory Evaluation. Cureus 2022; 14:e30212. [DOI: 10.7759/cureus.30212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 11/07/2022] Open
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Mazurkiewicz Ł, Czernikiewicz K, Rupa-Matysek J, Gil L. Emicizumab: a novel drug in hemophilia A prophylaxis - a narrative review. Expert Rev Hematol 2022; 15:933-942. [PMID: 36191306 DOI: 10.1080/17474086.2022.2131526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Hemophilia A is a genetically conditioned disease leading to hemostatic disorders due to factor VIII (FVIII) deficiency. The treatment of hemophilia has evolved throughout the past years and has significantly changed. One of the newest drugs for prophylactic treatment is the humanized bispecific IgG antibody - emicizumab, which binds with factor IXa and factor X, bridging those factors and thus mimicking the activity of factor VIII. AREAS COVERED The literature search was made via PubMed database, with the emphasis on clinical trials and case reports, describing the off-label emicizumab use. This review presents an extensive summary and considers advantages and disadvantages (side-effects) of emicizumab, describing additional clinical situations, where emicizumab has been successfully used. In our review we cover information about the mechanisms of action, indications, efficacy and discuss some chosen case reports about off-label emicizumab use. EXPERT OPINION Its convenient administration method (subcutaneous) and frequency of injections (from once a week to once a month) makes it a more comfortable treatment, limiting injection-site reactions, hospital stays, costs of prophylaxis, and significantly increasing patients' quality of life. Adverse effects are scarce and rarely serious - the most common ones are reactions at the injection-site and upper respiratory tract infections.
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Affiliation(s)
- Łukasz Mazurkiewicz
- Department of Hematology and Bone Marrow Transplantation, Poznań University of Medical Sciences, Poznań, Poland
| | - Krystian Czernikiewicz
- Department of Hematology and Bone Marrow Transplantation, Poznań University of Medical Sciences, Poznań, Poland
| | - Joanna Rupa-Matysek
- Department of Hematology and Bone Marrow Transplantation, Poznań University of Medical Sciences, Poznań, Poland
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznań University of Medical Sciences, Poznań, Poland
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Surgical outcomes in people with hemophilia A taking emicizumab prophylaxis: experience from the HAVEN 1-4 studies. Blood Adv 2022; 6:6140-6150. [PMID: 35939785 PMCID: PMC9768240 DOI: 10.1182/bloodadvances.2022007458] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/21/2022] [Accepted: 07/21/2022] [Indexed: 12/30/2022] Open
Abstract
Many people with hemophilia A (PwHA) undergo surgery in their lifetime, often because of complications of their disease. Emicizumab is the first bispecific monoclonal antibody prophylactic therapy for PwHA, and its efficacy and safety have been previously demonstrated; however, there is a need to build an evidence base on the management of PwHA on emicizumab undergoing surgery. Data from the HAVEN 1-4 phase 3 clinical trials were pooled to provide a summary of all minor and major surgeries in PwHA with or without factor VIII (FVIII) inhibitors who were receiving emicizumab prophylaxis. Overall, 233 surgeries were carried out during the HAVEN 1-4 trials: 215 minor surgeries (including minor dental and joint procedures, central venous access device placement or removal, and endoscopies) in 115 PwHA (64 with FVIII inhibitors) and 18 major surgeries (including arthroplasty and synovectomy) in 18 PwHA (10 with FVIII inhibitors). Perioperative hemostatic support was at the discretion of the treating physician. Overall, the median (interquartile range [IQR]) age was 33.5 (13.0-49.0) years and the median (IQR) emicizumab exposure time before surgery was 278.0 (177.0-431.0) days. Among the 215 minor surgeries, 141 (65.6%) were managed without additional prophylactic factor concentrate, and of those, 121 (85.8%) were not associated with a postoperative bleed. The majority (15 of 18 [83.3%]) of major surgeries were managed with additional prophylactic factor concentrate. Twelve (80.0%) of these 15 surgeries were associated with no intraoperative or postoperative bleeds. The data demonstrate that minor and major surgeries can be performed safely in PwHA receiving emicizumab prophylaxis. These trials are registered at www.clinicaltrials.gov as #NCT02622321, #NCT02795767, #NCT02847637, and #NCT03020160.
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Optimization and evaluation of a two-stage chromogenic assay procedure for measurement of emicizumab plasma levels. PLoS One 2022; 17:e0271330. [PMID: 35834493 PMCID: PMC9282532 DOI: 10.1371/journal.pone.0271330] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/29/2022] [Indexed: 11/19/2022] Open
Abstract
Emicizumab mimics the hemostatic activity of activated factor VIII (FVIIIa) within the tenase complex. Despite functional similarities between FVIIIa and emicizumab, conventional laboratory methods designed for monitoring of FVIII activity are inappropriate for the measurement of emicizumab. At present, a modified one stage (FVIII) assay (mOSA) is mainly used for emicizumab monitoring. Two-stage chromogenic FVIII assays based on human factors can be used, although limited performance due to lack of corresponding optimization might be observed. Furthermore, the presence of FVIII or anticoagulants in the patient sample may falsify assay results. To address these issues, we optimized and evaluated a two-stage chromogenic assay (emi-tenase) for measurement of emicizumab in plasma samples. Heat inactivation of samples was established to abolish the influence of endogenous or substituted FVIII. The lower limit of quantification (LLoQ) was found to be 2 μg/ml in a manual assay format and 9.5 μg/ml on an automated coagulation analyzer. Intra- and inter-assay coefficients of variation (CV) did not exceed 20%. Analysis of 17 patient plasma samples with severe haemophilia A under emicizumab treatment showed good correlation of results between the emi-tenase assay and the mOSA (Cohens Kappa coefficient = 0.9). Taken together, the emi-tenase assay allows specific measurement of emicizumab plasma levels over a broad concentration range (10 μg/ml to 100 μg/ml). The assay can be applied on an automated coagulation analyzer, demonstrating its applicability within a routine laboratory setting.
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Segués A, Huang S, Sijts A, Berraondo P, Zaiss DM. Opportunities and challenges of bi-specific antibodies. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2022; 369:45-70. [PMID: 35777864 DOI: 10.1016/bs.ircmb.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The recent clinical approval of different Bi-specific antibodies (BsAbs) has revealed the great therapeutic potential of this novel class of biologicals. For example, the bispecific T-cell engager (BiTE), Blinatumomab, demonstrated the unique capacity of BsAbs to link T-cells with tumor cells, inducing targeted tumor cell removal. Additionally, Amivantamab, recognizing the EGFR and cMet in cis, revealed a substantial improvement of therapeutic efficacy by concomitantly targeting two tumor antigens. Cis-targeting BsAbs furthermore allow discerning cell populations which concurrently express two antigens, for which each antigen expression pattern in itself might not be selective. In this way, BsAbs harbor the great prospect of being more specific and showing fewer side effects than monoclonal antibodies. Nevertheless, BsAbs have also faced major obstacles, for instance, in ensuring reliable assembly and clinical-grade purification. In this review, we summarize the different available antibody platforms currently used for the generation of IgG-like and non-IgG-like BsAbs and explain which approaches have been used to assemble those BsAbs which are currently approved for clinical application. By focusing on the example of regulatory T-cells (Tregs) and the different, ongoing approaches to develop BsAbs specifically targeting Tregs within the tumor microenvironment, our review highlights the huge potential as well as the pitfalls BsAb face in order to emerge as one of the most effective therapeutic biologicals targeting desired cell populations in a highly selective way. Such BsAb may improve treatment efficacy and reduce side effects, thereby opening novel treatment opportunities for a range of different diseases, such as cancer or autoimmune diseases.
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Affiliation(s)
- Aina Segués
- Institute of Immunology and Infection Research, School of Biological Sciences, University of Edinburgh, Edinburgh, United Kingdom; Faculty of Veterinary Medicine, Department of Infectious Diseases and Immunology, Utrecht University, Utrecht, The Netherlands
| | - Shuyu Huang
- Institute of Immunology and Infection Research, School of Biological Sciences, University of Edinburgh, Edinburgh, United Kingdom; Faculty of Veterinary Medicine, Department of Infectious Diseases and Immunology, Utrecht University, Utrecht, The Netherlands
| | - Alice Sijts
- Faculty of Veterinary Medicine, Department of Infectious Diseases and Immunology, Utrecht University, Utrecht, The Netherlands
| | - Pedro Berraondo
- Program of Immunology and Immunotherapy, Cima Universidad de Navarra, Pamplona, Spain; Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Madrid, Spain; Navarra Institute for Health Research (IDISNA), Pamplona, Spain
| | - Dietmar M Zaiss
- Institute of Immunology and Infection Research, School of Biological Sciences, University of Edinburgh, Edinburgh, United Kingdom; Department of Immune Medicine, University Regensburg, Regensburg, Germany; Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg, Germany; Institute of Pathology, University Regensburg, Regensburg, Germany.
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Takeyama M, Furukawa S, Onishi T, Noguchi-Sasaki M, Shima M, Nogami K. Heterogeneous coagulant potential of emicizumab in neonatal factor VIII-deficient plasma. Pediatr Blood Cancer 2022; 69:e29731. [PMID: 35441786 DOI: 10.1002/pbc.29731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/01/2022] [Accepted: 03/27/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Emicizumab prophylaxis reduces bleeding in hemophilia A (HA) patients. However, there are few data on emicizumab treatment in neonates with HA (neonate-HA), and the procoagulant effects of emicizumab in these patients are unknown. AIM To investigate the coagulation activity of emicizumab in vitro in a plasma model of neonate-HA. METHODS Plasmas from 84 neonates with non-HA were enrolled. However, due to the limited plasma volumes in some cases, 50 plasmas were assigned to two different assay groups. To prepare the neonate-HA model, plasma was first preincubated with an antifactor (F) VIII A2 monoclonal antibody (mAb). After further incubation with emicizumab, global coagulation activity was measured: adjusted maximum coagulation velocity (Ad|min1|) in clot waveform analysis (CWA) and peak thrombin in thrombin generation assay (TGA). RESULTS Because the addition of anti-FVIII mAb to 22 of 43 samples showed little decrease in Ad|min1|, the remaining 21 samples were analyzed by CWA. The addition of emicizumab increased Ad|min1| in 18 of the 19 cases (effective group) but not in the remaining 3 cases (noneffective group). Similarly, TGA found that emicizumab (effective group) improved peak thrombin in seven of the nine samples tested, but two cases did not respond (noneffective group). Although the effective group had lower levels of FX, there was no significant difference between the effective and noneffective groups in terms of FIX, protein S, protein C, antithrombin, and fibrinogen. CONCLUSIONS The in vitro coagulant potentials of emicizumab in the neonate-HA model were more heterogeneous than those recorded in the adult-HA model.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Nara, Japan
| | - Tomoko Onishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Shima M, Takedani H, Kitsukawa K, Taki M, Ishiguro A, Nagao A, Yamaguchi-Suita H, Kyogoku Y, Yoshida S, Nogami K. AOZORA: long-term safety and joint health in paediatric persons with haemophilia A without factor VIII inhibitors receiving emicizumab - protocol for a multicentre, open-label, phase IV clinical study. BMJ Open 2022; 12:e059667. [PMID: 35697445 PMCID: PMC9196178 DOI: 10.1136/bmjopen-2021-059667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Persons with haemophilia A (PwHA) commonly experience regular bleeding into joints, which may result in joint damage and complications such as degenerative arthritis. Emicizumab has previously demonstrated efficacy in reducing the occurrence of joint bleeds and target joints, along with having a favourable safety profile; however, data on the long-term effects on joint health are lacking. The AOZORA study will evaluate the long-term safety and joint health of paediatric PwHA without factor (F)VIII inhibitors taking emicizumab; here, we report the details of the study protocol and baseline data. METHODS AND ANALYSIS AOZORA is a multicentre, open-label, phase IV clinical study in Japan that aims to enrol approximately 30 PwHA aged <12 years without FVIII inhibitors. The primary endpoints include a long-term safety evaluation of adverse events, laboratory test abnormalities and FVIII inhibitor development; and a long-term joint health assessment using MRI and the Hemophilia Joint Health Score. Exploratory endpoints include characterising participants' physical activities and the number of activity-related bleeds requiring coagulation factor treatment. Currently, 30 participants have been enrolled, including 20 emicizumab-naïve participants and 10 who transferred from HOHOEMI, a previous study in paediatric PwHA. ETHICS AND DISSEMINATION The AOZORA study was approved by the Institutional Review Boards of Nara Medical University and the St Marianna University Group. The study will be conducted in compliance with the Declaration of Helsinki, the standards stipulated in paragraph 3 of Article 14 and Article 80-2 of the Pharmaceuticals, Medical Devices and Other Therapeutic Products Act, the Ministerial Ordinance on Good Clinical Practice and the Ministerial Ordinance on Good Post-marketing Study Practice. Data will be published in peer-reviewed journals and presented at Global congresses. TRIAL REGISTRATION NUMBER JapicCTI-194701.
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Affiliation(s)
- Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Hideyuki Takedani
- Department of Joint Surgery, IMSUT Hospital, The University of Tokyo, Tokyo, Japan
| | - Kaoru Kitsukawa
- Department of Radiology, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Masashi Taki
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Akira Ishiguro
- Division of Hematology, National Center for Child Health and Development, Tokyo, Japan
| | - Azusa Nagao
- Department of Blood Coagulation, Ogikubo Hospital, Tokyo, Japan
| | | | - Yui Kyogoku
- Medical Affairs Division, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Seitaro Yoshida
- Clinical Development Division, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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Xu R, Kalluri AL, Sun LR, Lawrence CE, Lee JK, Kannan S, Cohen AR. The neurosurgical management of Severe Hemophilia A and Moyamoya (SHAM): challenges, strategies, and literature review. Childs Nerv Syst 2022; 38:1077-1084. [PMID: 35262754 DOI: 10.1007/s00381-022-05489-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/03/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Severe Hemophilia A and Moyamoya arteriopathy (SHAM syndrome) is a rare genetic disorder caused by deletion of portions of the cytogenic band Xq28. A case of SHAM syndrome requiring bilateral cerebral revascularization is described with an emphasis on perioperative management. CASE REPORT A 5-year-old boy with severe hemophilia A complicated by factor VIII inhibition presented with right-sided weakness. Imaging revealed multiple strokes and vascular changes consistent with Moyamoya disease. The patient underwent two-staged indirect cerebral bypass revascularizations, first on the left side and several months later on the right. Perioperative management required balancing the administration of agents to prevent coagulopathy and perioperative hemorrhage while mitigating the risk of thromboembolic events associated with bypass surgery. Despite a multidisciplinary effort by the neurosurgery, hematology, critical care, and anesthesiology teams, the post-operative course after both surgeries was complicated by stroke. Fortunately, the patient recovered rapidly to his preoperative functional baseline. CONCLUSION We describe a rare case of SHAM syndrome in a pediatric patient who required bilateral revascularizations and discuss strategies for managing the perioperative risk of hemorrhage and stroke. We also review existing literature on SHAM syndrome.
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Affiliation(s)
- Risheng Xu
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Anita L Kalluri
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Lisa R Sun
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Courtney E Lawrence
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Jennifer K Lee
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Sujatha Kannan
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Alan R Cohen
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA.
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Lauritzen B, Bjelke M, Björkdahl O, Bloem E, Keane K, Kjalke M, Rossen M, Lippert SL, Weldingh KN, Skydsgaard M, Kjellev S. A novel next-generation FVIIIa mimetic, Mim8, has a favorable safety profile and displays potent pharmacodynamic effects: Results from safety studies in cynomolgus monkeys. J Thromb Haemost 2022; 20:1312-1324. [PMID: 35191180 PMCID: PMC9314625 DOI: 10.1111/jth.15682] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Mim8 is a novel, next-generation factor VIIIa mimetic in development for subcutaneous prophylactic treatment of patients with hemophilia A with and without inhibitors. In vitro and in vivo models indicate that Mim8 has a distinct hemostatic potential. OBJECTIVES To test the nonclinical safety and pharmacodynamics of Mim8. METHODS The Mim8 nonclinical safety program in cynomolgus monkeys consisted of three studies of 4-26 weeks in duration with Mim8 doses ranging from 0.3-60 mg/kg/week intravenously or subcutaneously. After sacrifice, macroscopic and microscopic pathological examinations were performed. RESULTS Mim8 was well tolerated with no noteworthy clinical observations. No signs of excessive coagulation or pathological macroscopic or microscopic findings were observed at doses 0.3-3 mg/kg/week subcutaneous. Thrombosis-related findings were detected during histopathological examination in a small proportion of animals (16%) receiving doses ranging 6-20 mg/kg/week. Dose-dependent increases in factor X (FX) and factor IX (FIX) concentrations were observed. Shortening of activated partial thromboplastin time (APTT) and increased thrombin generation under ex vivo hemophilia A-like conditions were observed at all Mim8 dose levels. CONCLUSIONS Thrombosis-related findings observed at doses above 6 mg/kg/week Mim8 may have been exaggerated pharmacological reactions to a procoagulant compound in normocoagulant animals. Increases in FX and FIX concentrations could be because of a half-life prolongation due to binding to Mim8, but were limited at clinically relevant exposure levels. Subcutaneous administration of up to 3 mg/kg/week (several fold greater than expected clinical exposure) for 26 weeks resulted in relevant pharmacodynamic effects, observed in thrombin generation and APTT, with no signs of thrombi or excessive coagulation activation.
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Affiliation(s)
| | - Mads Bjelke
- Global Drug DiscoveryNovo Nordisk A/SMåløvDenmark
| | | | - Esther Bloem
- Global Drug DiscoveryNovo Nordisk A/SMåløvDenmark
| | - Kevin Keane
- Global Drug DiscoveryNovo Nordisk A/SMåløvDenmark
| | | | - Marie Rossen
- Global Drug DiscoveryNovo Nordisk A/SMåløvDenmark
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Escobar M, Dunn A, Quon D, Trzaskoma B, Lee L, Ko RH, Carpenter SL. A phase IV, multicentre, open-label study of emicizumab prophylaxis in people with haemophilia A with or without FVIII inhibitors undergoing minor surgical procedures. Haemophilia 2022; 28:e105-e108. [PMID: 35510949 PMCID: PMC9544354 DOI: 10.1111/hae.14574] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/17/2022] [Accepted: 04/09/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Miguel Escobar
- University of Texas Health Science Center, Houston, Texas, USA
| | - Amy Dunn
- Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Doris Quon
- Orthopedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Ben Trzaskoma
- Genentech, Inc., South San Francisco, California, USA
| | - Lucy Lee
- Genentech, Inc., South San Francisco, California, USA
| | - Richard H Ko
- Genentech, Inc., South San Francisco, California, USA
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Hatayama Y, Motokura T, Hosoda Y, Suzuki S, Namba H, Kato K, Kojima N, Horie T, Iwamoto T, Yamashita N, Ichikawa H, Fukuda T. Regression Analysis to Estimate the Factor VIII Activity of Patients with Hemophilia A Without Inhibitor who Received Emicizumab Therapy. Clin Appl Thromb Hemost 2022; 28:10760296221082992. [PMID: 35225012 PMCID: PMC8894944 DOI: 10.1177/10760296221082992] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Emicizumab, a bispecific monoclonal antibody for hemophilia A (HA), has strong pharmacodynamic effects in several coagulation assays resulting in dosing difficulties with Factor VIII (FVIII) concentrates during bleeding emergencies. MATERIALS AND METHODS Single and multiple regression models were studied to estimate FVIII activity using 27 archived plasma samples from three patients with HA without inhibitor under emicizumab treatment. Explanatory variables were FVIII chromogenic assay (CSA), Ad|min1|, Ad|min2|, the number of seconds of APTT, and the FVIII one-stage assay (OSA), which were measured without idiotype antibodies. The response variable was FVIII OSA measured with idiotype antibodies. RESULTS In the simple linear model, the FVIII CSA regression coefficient was 1.04 and the intercept was -14.55 (r2 = 0.95; p < 0.001). In the multiple regression model, FVIII OSA and FVIII CSA were selected based on the Akaike Information Criterion, with regression coefficients of 1.74 and 1.15, respectively, and an intercept of -92.03 (r2 = 0.96, p < 0.001). CONCLUSIONS The regression models can estimate the FVIII:C levels in patients with HA receiving emicizumab and would be useful in a bleeding emergency and/or surgery.
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Affiliation(s)
- Yuki Hatayama
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan.,Division of Clinical Laboratory Medicine, Department of Multidisciplinary Internal Medicine, School of Medicine, 34827Tottori University Faculty of Medicine, Yonago, Tottori, Japan
| | - Toru Motokura
- Division of Clinical Laboratory Medicine, Department of Multidisciplinary Internal Medicine, School of Medicine, 34827Tottori University Faculty of Medicine, Yonago, Tottori, Japan.,Department of Hematology, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Yuzuru Hosoda
- Department of Hematology, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Sayaka Suzuki
- Department of Hematology, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Hiroya Namba
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Konami Kato
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Nao Kojima
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Takuya Horie
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Takuya Iwamoto
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Noriko Yamashita
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Hitomi Ichikawa
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan
| | - Tetsuya Fukuda
- Division of Clinical Laboratory, 68353Tottori University Hospital, Yonago, Tottori, Japan.,Department of Hematology, 68353Tottori University Hospital, Yonago, Tottori, Japan
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Shanmukhaiah C, Jijina F, Kannan S, Pai NG, Kulkarni B, Khuba SV, Shaikh M, Joshi A, Phatale R, Apte S. Efficacy of emicizumab in von Willebrand disease (VWD) patients with and without alloantibodies to von Willebrand factor (VWF): Report of two cases and review of literature. Haemophilia 2022; 28:286-291. [PMID: 35014121 DOI: 10.1111/hae.14491] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 12/28/2021] [Accepted: 12/28/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION von Willebrand disease (VWD) is the common bleeding disorder with a clinically relevant bleeding prevalence of 1:10,000. von Willebrand disease patients lack both von Willebrand factor (VWF) and factor VIII (FVIII), which are critical for normal haemostasis. The conventional treatment for VWD includes desmopressin and replacement therapy with plasma derived FVIII with VWF concentrates or recombinant VWF. Development of alloantibodies is a rare occurrence, there is a paucity in the literature of treatment modalities in these patients. Not many reports are available in literature on the efficacy of emicizumab in VWD patients with or without alloantibodies to VWF. AIM To do systematic review of literature on emicizumab in VWD and report our experience of emicizumab in two patients of VWD METHODS: We used electronic search engines till May 2021 in 'Google scholar' and 'PubMed', to collect the case reports or case series on use of emicizumab for management of VWD. Two of our severe VWD patients were successfully treated with emicizumab. A systematic review was performed and the results discussed. RESULTS The electronic search revealed six case reports using emicizumab for treatment of VWD. Two were in vitro studies and four in patients with VWD type 3 disease. In vitro studies and in VWD patients on emicizumab, showed improvement in thrombin generation and fibrin formation. Among four patients, three had alloantibodies to VWD and one was negative. All these patients were treated with emicizumab for 6-12 m. After starting emicizumab, none of them had spontaneous bleeding requiring treatment. During treatment with emicizumab, one patient had trauma-associated soft tissue hematoma, which was treated with rFVIIa and another patient had bleeding following dental exfoliation treated with Humate P. We treated two of our VWD patients one with and one without inhibitors with emicizumab after failure of other therapies. Both the patients showed marked improvement and continued to remain well and free of bleeding episodes. None of the patients had any thrombosis or thrombotic microangiopathy (TMA) during treatment with emicizumab. CONCLUSION In conclusion, this review supports the safety and efficacy of emicizumab in type 3 VWD patients with or without alloantibodies. Further large studies are required to confirm the safety and efficacy of emicizumab in VWD.
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Affiliation(s)
- Chandrakala Shanmukhaiah
- Department of Clinical Haematology, Seth G.S. Medical College and KEM Hospital Parel, Mumbai, India
| | - Farah Jijina
- Department of Clinical Haematology, Seth G.S. Medical College and KEM Hospital Parel, Mumbai, India
| | - S Kannan
- Department of Haematology, Sahyadri Specialty Hospitals, Pune, India
| | - Nanda G Pai
- Department of Dentistry, Seth G.S. Medical College and KEM Hospital Parel, Mumbai, India
| | - Bipin Kulkarni
- ICMR- National Institute of Immunohaematology, 13th floor, MS building, KEM Hospital Campus, Parel, Mumbai, India
| | - Santosh V Khuba
- Department of Clinical Haematology, Seth G.S. Medical College and KEM Hospital Parel, Mumbai, India
| | - Madiha Shaikh
- Department of Clinical Haematology, Seth G.S. Medical College and KEM Hospital Parel, Mumbai, India
| | - Aditi Joshi
- Department of Haematology, Sahyadri Specialty Hospitals, Pune, India
| | - Rajesh Phatale
- Department of Haematology, Sahyadri Specialty Hospitals, Pune, India
| | - Shashikant Apte
- Department of Haematology, Sahyadri Specialty Hospitals, Pune, India
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Zhao H, Luo F, Xue J, Li S, Xu RH. Emerging immunological strategies: recent advances and future directions. Front Med 2021; 15:805-828. [PMID: 34874513 DOI: 10.1007/s11684-021-0886-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 07/31/2021] [Indexed: 12/12/2022]
Abstract
Immunotherapy plays a compelling role in cancer treatment and has already made remarkable progress. However, many patients receiving immune checkpoint inhibitors fail to achieve clinical benefits, and the response rates vary among tumor types. New approaches that promote anti-tumor immunity have recently been developed, such as small molecules, bispecific antibodies, chimeric antigen receptor T cell products, and cancer vaccines. Small molecule drugs include agonists and inhibitors that can reach the intracellular or extracellular targets of immune cells participating in innate or adaptive immune pathways. Bispecific antibodies, which bind two different antigens or one antigen with two different epitopes, are of great interest. Chimeric antigen receptor T cell products and cancer vaccines have also been investigated. This review explores the recent progress and challenges of different forms of immunotherapy agents and provides an insight into future immunotherapeutic strategies.
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Affiliation(s)
- Hongyun Zhao
- Department of Clinical Research, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China
| | - Fan Luo
- Department of Experimental Research, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China
| | - Jinhui Xue
- Department of Clinical Research, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China
| | - Su Li
- Department of Clinical Research, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China
| | - Rui-Hua Xu
- Department of Medical Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, China.
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Kaneda M, Kawasaki R, Matsumoto N, Abe H, Tashiro Y, Inokuchi Y, Yasuno H, Sasaki‐Noguchi M, Soeda T, Yoshimura Y, Oka T. Detailed analysis of anti-emicizumab antibody decreasing drug efficacy, using plasma samples from a patient with hemophilia A. J Thromb Haemost 2021; 19:2938-2946. [PMID: 34418287 PMCID: PMC9292660 DOI: 10.1111/jth.15506] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/19/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Emicizumab is a humanized bispecific monoclonal antibody that bridges activated factor IX (FIXa) and factor X (FX) to mimic the function of factor VIII (FVIII). It suppresses the bleeding tendency in hemophilia A patients with or without FVIII inhibitors. A case of an adult FVIII inhibitor-positive hemophilia A patient in whom treatment with emicizumab was discontinued owing to the repeated bleeding events and prolonged activated partial thromboplastin time. OBJECTIVE To analyze the mechanisms of decreased efficacy of emicizumab. METHODS Residual plasma samples were used to measure the following: emicizumab concentration in plasma, measured by enzyme-linked immunosorbent assay; titer of anti-drug antibody (ADA) against emicizumab, measured by electrochemiluminescence; and neutralizing activity against emicizumab, measured by Bethesda method modified by using emicizumab-spiked FVIII-deficient plasma. RESULTS At week 31, emicizumab concentration was 15.0 μg/ml, and ADAs were measured as positive. Emicizumab concentration continued to decrease until emicizumab discontinuation point at week 49, and after week 50, emicizumab concentrations were below the limitation of quantification. The ADA titer increased transiently from week 31, even past the emicizumab discontinuation point at week 49. The ADA titer then gradually decreased until the last sampling point at week 93. Neutralizing activity against emicizumab was detected after emicizumab discontinuation. Epitope analysis showed that the ADAs recognize the anti-FIXa and anti-FX Fab arms of emicizumab, but not the Fc region. CONCLUSION The appearance of ADAs with emicizumab-neutralizing activity and potential to accelerate emicizumab clearance decreased the efficacy of emicizumab.
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Affiliation(s)
- Makoto Kaneda
- Department of PediatricsSapporo Tokushukai HospitalSapporoJapan
| | - Ryohei Kawasaki
- Medical Affairs DivisionProduct Research DepartmentChugai Pharmaceutical Co., Ltd.KamakuraJapan
| | - Naoki Matsumoto
- Medical Affairs DivisionProduct Research DepartmentChugai Pharmaceutical Co., Ltd.KamakuraJapan
| | - Hiroto Abe
- Medical Affairs DivisionProduct Research DepartmentChugai Pharmaceutical Co., Ltd.KamakuraJapan
| | - Yoshihito Tashiro
- Medical Affairs DivisionProduct Research DepartmentChugai Pharmaceutical Co., Ltd.KamakuraJapan
| | - Yuta Inokuchi
- Medical Affairs DivisionProduct Research DepartmentChugai Pharmaceutical Co., Ltd.KamakuraJapan
| | - Hideyuki Yasuno
- Medical Affairs DivisionProduct Research DepartmentChugai Pharmaceutical Co., Ltd.KamakuraJapan
| | - Mariko Sasaki‐Noguchi
- Medical Affairs DivisionProduct Research DepartmentChugai Pharmaceutical Co., Ltd.KamakuraJapan
| | - Tetsuhiro Soeda
- Medical Affairs DivisionProduct Research DepartmentChugai Pharmaceutical Co., Ltd.KamakuraJapan
| | - Yasushi Yoshimura
- Medical Affairs DivisionProduct Research DepartmentChugai Pharmaceutical Co., Ltd.KamakuraJapan
| | - Toshiaki Oka
- Department of PediatricsSapporo Tokushukai HospitalSapporoJapan
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Faghmous I, Nissen F, Kuebler P, Flores C, Patel AM, Pipe SW. Estimating the risk of thrombotic events in people with congenital hemophilia A using US claims data. J Comp Eff Res 2021; 10:1323-1336. [PMID: 34676773 DOI: 10.2217/cer-2021-0120] [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: 11/21/2022] Open
Abstract
Aim: Compare thrombotic risk in people with congenital hemophilia A (PwcHA) to the general non-hemophilia A (HA) population. Patients & methods: US claims databases were analyzed to identify PwcHA. Incidence rates of myocardial infarction, pulmonary embolism, ischemic stroke, deep vein thrombosis and device-related thrombosis were compared with a matched cohort without HA. Results: Over 3490 PwcHA were identified and 16,380 individuals matched. PwcHA had a similar incidence of myocardial infarction and pulmonary embolism compared with the non-HA population, but a slightly higher incidence of ischemic stroke and deep vein thrombosis. The incidence of device-related thrombosis was significantly higher in PwcHA. Conclusion: This analysis suggests that PwcHA are not protected against thrombosis, and provides context to evaluate thrombotic risk of HA treatments.
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Affiliation(s)
- Imi Faghmous
- Real-World Data Oncology-Hematology, F. Hoffmann-La Roche Ltd, Grenzacherstrasse 124, Basel, 4070, Switzerland
- Current affiliation: Health, Medicine & Life Sciences, University of Maastricht, Minderbroedersberg 4-6, 6211, LK Maastricht, The Netherlands
| | - Francis Nissen
- Real-World Data Oncology-Hematology, F. Hoffmann-La Roche Ltd, Grenzacherstrasse 124, Basel, 4070, Switzerland
| | - Peter Kuebler
- PHC Safety Interface, Genentech, Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Carlos Flores
- Evidence Strategy, Genesis Research Hoboken, 111 River St Ste 1120, Hoboken, NJ 07030, USA
| | - Anisha M Patel
- US Medical Affairs, Genentech, Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Steven W Pipe
- Pediatrics and Pathology, University of Michigan, D4202 MPB, 1500 E Medical Center Drive, Ann Arbor, MI 48109-5718, USA
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48
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Tanaka KA, Henderson R, Thangaraju K, Morita Y, Mazzeffi MA, Strauss E, Katneni U, Buehler PW. In vitro effects of emicizumab on activated clotting time in blood samples from cardiac surgical patients. Haemophilia 2021; 28:183-190. [PMID: 34735039 DOI: 10.1111/hae.14452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/15/2021] [Accepted: 10/22/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Heparin management in hemophilia A (HA) patients with a factor VIII (FVIII) inhibitor can be challenging due to severe activated clotting time (ACT) prolongations. It is important to better understand the impact of emicizumab, a FVIII mimetic on ACT, and tissue factor (TF)-based coagulation assays. METHODS Whole blood from 18 patients undergoing cardiopulmonary bypass (CPB) were mixed in vitro with pooled normal plasma, FVIII-deficient or FVIII-inhibitor plasma to affect functional FVIII levels. ACTs and heparin concentration by protamine titration were measured in whole blood mixture with/without emicizumab (50-100 μg/ml). Thrombin generation and plasmin generation were measured in the patient's plasma mixed with normal plasma or FVIII-inhibitor plasma to assess the impact of emicizumab under low TF activation. RESULTS FVIII inhibitors prolonged ACTs by 2.2-fold compared to those in normal plasma mixture at baseline. During CPB, ACTs in normal plasma mixture, and FVIII-deficient mixture were in 400s, but ACTs reached 900s in FVIII-inhibitor mixture. Emicizumab shortened ACTs by up to 100s in normal plasma mixture, and FVIII-deficient mixtures. ACTs remained over 600s in FVIII-inhibitor mixture, despite adding emicizumab at 100 μg/ml. Heparin concentration measured by TF-based protamine titration was unaffected. Emicizumab enhanced thrombin peak in the presence of FVIII inhibitors, whereas plasmin generation was mainly affected by thrombin generation, and systemic use of ɛ-aminocaproic acid. CONCLUSIONS FVIII inhibitors extensively prolong ACTs in heparinized whole blood, and clinical levels of emicizumab partially reverse ACT values. Protamine titration should be considered for optimal heparin monitoring in emicizumab-treated patients with FVIII inhibitors.
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Affiliation(s)
- Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Reney Henderson
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kiruphagaran Thangaraju
- Departments of Pathology and Pediatrics, Center for Blood Oxygen Transport, University of Maryland, Baltimore, Maryland, USA
| | - Yoshihisa Morita
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Michael A Mazzeffi
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Erik Strauss
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Upendra Katneni
- Departments of Pathology and Pediatrics, Center for Blood Oxygen Transport, University of Maryland, Baltimore, Maryland, USA
| | - Paul W Buehler
- Departments of Pathology and Pediatrics, Center for Blood Oxygen Transport, University of Maryland, Baltimore, Maryland, USA
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Østergaard H, Lund J, Greisen PJ, Kjellev S, Henriksen A, Lorenzen N, Johansson E, Røder G, Rasch MG, Johnsen LB, Egebjerg T, Lund S, Rahbek-Nielsen H, Gandhi PS, Lamberth K, Loftager M, Andersen LM, Bonde AC, Stavenuiter F, Madsen DE, Li X, Holm TL, Ley CD, Thygesen P, Zhu H, Zhou R, Thorn K, Yang Z, Hermit MB, Bjelke JR, Hansen BG, Hilden I. A factor VIIIa-mimetic bispecific antibody, Mim8, ameliorates bleeding upon severe vascular challenge in hemophilia A mice. Blood 2021; 138:1258-1268. [PMID: 34077951 PMCID: PMC8499050 DOI: 10.1182/blood.2020010331] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/11/2021] [Indexed: 11/29/2022] Open
Abstract
Hemophilia A is a bleeding disorder resulting from deficient factor VIII (FVIII), which normally functions as a cofactor to activated factor IX (FIXa) that facilitates activation of factor X (FX). To mimic this property in a bispecific antibody format, a screening was conducted to identify functional pairs of anti-FIXa and anti-FX antibodies, followed by optimization of functional and biophysical properties. The resulting bispecific antibody (Mim8) assembled efficiently with FIXa and FX on membranes, and supported activation with an apparent equilibrium dissociation constant of 16 nM. Binding affinity with FIXa and FX in solution was much lower, with equilibrium dissociation constant values for FIXa and FX of 2.3 and 1.5 µM, respectively. In addition, the activity of Mim8 was dependent on stimulatory activity contributed by the anti-FIXa arm, which enhanced the proteolytic activity of FIXa by 4 orders of magnitude. In hemophilia A plasma and whole blood, Mim8 normalized thrombin generation and clot formation, with potencies 13 and 18 times higher than a sequence-identical analogue of emicizumab. A similar potency difference was observed in a tail vein transection model in hemophilia A mice, whereas reduction of bleeding in a severe tail-clip model was observed only for Mim8. Furthermore, the pharmacokinetic parameters of Mim8 were investigated and a half-life of 14 days shown in cynomolgus monkeys. In conclusion, Mim8 is an activated FVIII mimetic with a potent and efficacious hemostatic effect based on preclinical data.
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Affiliation(s)
| | | | - Per J Greisen
- Global Research Technologies, Novo Nordisk A/S, Maaloev, Denmark; and
| | | | - Anette Henriksen
- Global Research Technologies, Novo Nordisk A/S, Maaloev, Denmark; and
| | - Nikolai Lorenzen
- Global Research Technologies, Novo Nordisk A/S, Maaloev, Denmark; and
| | - Eva Johansson
- Global Research Technologies, Novo Nordisk A/S, Maaloev, Denmark; and
| | - Gustav Røder
- Global Research Technologies, Novo Nordisk A/S, Maaloev, Denmark; and
| | - Morten G Rasch
- Global Research Technologies, Novo Nordisk A/S, Maaloev, Denmark; and
| | - Laust B Johnsen
- Global Research Technologies, Novo Nordisk A/S, Maaloev, Denmark; and
| | - Thomas Egebjerg
- Global Research Technologies, Novo Nordisk A/S, Maaloev, Denmark; and
| | - Søren Lund
- Global Research Technologies, Novo Nordisk A/S, Maaloev, Denmark; and
| | | | - Prafull S Gandhi
- Global Research Technologies, Novo Nordisk A/S, Maaloev, Denmark; and
| | - Kasper Lamberth
- Global Research Technologies, Novo Nordisk A/S, Maaloev, Denmark; and
| | | | | | | | | | | | - Xun Li
- Discovery Technology China, Novo Nordisk A/S, Beijing, China
| | | | | | | | - Haisun Zhu
- Discovery Technology China, Novo Nordisk A/S, Beijing, China
| | - Rong Zhou
- Discovery Technology China, Novo Nordisk A/S, Beijing, China
| | | | - Zhiru Yang
- Discovery Technology China, Novo Nordisk A/S, Beijing, China
| | | | - Jais R Bjelke
- Global Research Technologies, Novo Nordisk A/S, Maaloev, Denmark; and
| | - Bjarne G Hansen
- Global Research Technologies, Novo Nordisk A/S, Maaloev, Denmark; and
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50
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Kizilocak H, Young G. Emerging drugs for hemophilia A: insights into phase II and III clinical trials. Expert Opin Emerg Drugs 2021; 26:337-350. [PMID: 34601977 DOI: 10.1080/14728214.2021.1988073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Hemophilia is a lifelong, genetic-bleeding disorder, which inadequately treated results in permanent joint damage. It is characterized by spontaneous and trauma-related bleeding episodes. In the last 50 years, treatment has seen dramatic improvements which have improved the quality of life of persons with hemophilia. AREAS COVERED This review will provide a summary of current pharmacological approaches for hemophilia A as well as discuss novel agents which are either approved recently or in phase II-III clinical trials, plasma-derived and recombinant factor VIII (FVIII) products, extended half-life FVIII products, bypassing agents and non-replacement therapies. EXPERT OPINION Novel therapies are already changing the way that hemophilia A is managed, and as more new therapies get approved, there will be a revolution in the management of this serious condition. Clinicians will have both the opportunities as well as the challenges of incorporating such new technologies into clinical practice.
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Affiliation(s)
- Hande Kizilocak
- Children's Hospital Los Angeles, Hemostasis and Thrombosis Center, Cancer and Blood Disease Institute, Los Angeles, CA, USA
| | - Guy Young
- Children's Hospital Los Angeles, Hemostasis and Thrombosis Center, Cancer and Blood Disease Institute, Los Angeles, CA, USA.,Department of Hematology and Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
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