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Klukowska A, Sidonio RF, Young G, Mancuso ME, Álvarez-Román MT, Bhatnagar N, Jansen M, Knaub S. Simoctocog alfa (Nuwiq ®) in children: early steps in life's journey for people with severe hemophilia A. Ther Adv Hematol 2024; 15:20406207241245511. [PMID: 38737006 PMCID: PMC11085023 DOI: 10.1177/20406207241245511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/20/2024] [Indexed: 05/14/2024] Open
Abstract
People with severe hemophilia A usually experience their first bleed early in life. In children with severe hemophilia A, primary prophylaxis is recommended to prevent recurrent and potentially life-threatening bleeds that significantly impact day-to-day life. Factor VIII (FVIII) prophylaxis is well-established in children and has been shown to reduce the development of hemophilic arthropathy. However, a major challenge of FVIII therapy is the development of neutralizing anti-FVIII antibodies (FVIII inhibitors). Simoctocog alfa (Nuwiq®) is a human cell line-derived recombinant FVIII (rFVIII) whose immunogenicity, efficacy, and safety have been studied in 167 children with severe hemophilia A across two prospective clinical trials and their long-term extensions. In 105 previously untreated children, the inhibitor rate of 16.2% for high-titer inhibitors (26.7% for all inhibitors) was lower than published rates for hamster cell line-derived rFVIII products. There was no inhibitor development in previously untreated children with non-null F8 mutations and in previously treated children. In a case series of 10 inhibitor patients, 8 (80%) underwent successful immune tolerance induction with simoctocog alfa with a median time to undetectable inhibitor of 3.5 months. In an analysis of 96 children who enrolled in the extension studies and received long-term simoctocog alfa prophylaxis for up to 5 years, median spontaneous, joint, and total annualized bleeding rates were 0.3, 0.4, and 1.8, respectively. No thromboembolisms were reported in any of the 167 children, and there were no treatment-related deaths. Optimal care of children should consider several factors, including minimization of inhibitor development risk, maintaining tolerance to FVIII, highly effective bleed prevention and treatment, safety, and impact on long-term outcomes such as bone and joint health. In this context we review the pediatric clinical data and ongoing studies with simoctocog alfa.
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Affiliation(s)
- Anna Klukowska
- Haemostasis Group of the Polish Society of Haematology and Transfusiology, 14 Indira Gandhi Street, Warsaw 02-776, Poland
| | - Robert F. Sidonio
- Hemophilia of Georgia Center for Bleeding and Clotting Disorders, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Guy Young
- Hemostasis and Thrombosis Center, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Humanitas University, Pieve Emanuele, Italy
| | | | - Neha Bhatnagar
- Oxford Haemophilia and Thrombosis Comprehensive Care Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Martina Jansen
- Clinical Research and Development, Octapharma Pharmazeutika Produktionsges m.b.H., Vienna, Austria
| | - Sigurd Knaub
- Clinical Research and Development, Octapharma AG, Lachen, Switzerland
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Ahuja S, Biss T, Maas Enriquez M, Mancuso ME, Steele M, Kenet G. A post hoc analysis of PROTECT VIII kids assessing long-term efficacy and safety of damoctocog alfa pegol in adolescents with severe haemophilia A. Eur J Haematol 2024; 112:756-764. [PMID: 38193596 DOI: 10.1111/ejh.14167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 01/10/2024]
Abstract
INTRODUCTION The safety and efficacy of the extended half-life factor VIII (FVIII) product damoctocog alfa pegol (BAY 94-9027, Jivi®) has been demonstrated in the PROTECT VIII Kids study (NCT01775618), where male previously-treated patients (PTPs) aged <12 years old with severe haemophilia A and ≥ 50 exposure days (EDs) were treated prophylactically. The PROTECT VIII Kids extension study assessed the long-term safety and efficacy of damoctocog alfa pegol in the same population. AIM To evaluate the long-term impact of damoctocog alfa pegol in a post hoc subgroup analysis of adolescent patients in the PROTECT VIII Kids study and its extension from 12th birthday onwards. METHODS The current analysis included PTPs aged ≥12 years old, who remained in the extension for ≥6 months following their 12th birthday. The observation period was defined as the time from 12th birthday to the end of the extension period; all data from this birthday were included whether in the main study or extension phase. The main efficacy variable was annualised bleeding rate (ABR) and the main safety variable was the frequency of inhibitor development. RESULTS This subgroup analysis comprised 25 patients. Median observation time after 12th birthday was 3.2 years. Median total/joint/spontaneous ABRs in the observation period were 1.7/0.7/0.3, respectively. Safety findings were consistent with those reported for the overall study population; no confirmed FVIII inhibitors or anti-drug antibodies were reported. CONCLUSIONS Damoctocog alfa pegol is efficacious with a favourable safety profile in adolescents with haemophilia A, supporting its long-term use in children and adolescents.
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Affiliation(s)
- Sanjay Ahuja
- Rainbow Hemostasis & Thrombosis Center, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Tina Biss
- Department of Haematology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Humanitas University, Pieve Emanuele, Milan, Italy
| | - MacGregor Steele
- Cumming School of Medicine, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Gili Kenet
- Israel National Hemophilia Center, Chaim Sheba Medical Center, Tel Hashomer, Israel & The Amalia Biron Thrombosis Research Institute, Tel Aviv University, Tel Aviv-Yafo, Israel
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Mehrizi TZ, Mirzaei M, Ardestani MS. Pegylation, a Successful Strategy to Address the Storage and Instability Problems of Blood Products: Review 2011-2021. Curr Pharm Biotechnol 2024; 25:247-267. [PMID: 37218184 DOI: 10.2174/1389201024666230522091958] [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: 08/02/2022] [Revised: 01/24/2023] [Accepted: 02/06/2023] [Indexed: 05/24/2023]
Abstract
Conjugation of polyethylene glycol (PEGylation) to blood proteins and cells has emerged as a successful approach to address some of the issues attributed to the storage of blood products, including their short half-life and instability. In this regard, this review study aims to compare the influence of different PEGylation strategies on the quality of several blood products like red blood cells (RBCs), platelets, plasma proteins, i.e., albumin, coagulation factor VIII, and antibodies. The results indicated that conjugating succinimidyl carbonate methoxyPEG (SCmPEG) to platelets could improve blood transfusion safety by preventing these cells from being attached to low-load hidden bacteria in blood products. Moreover, coating of 20 kD succinimidyl valerate (SVA)-mPEG to RBCs was able to extend the half-life and stability of these cells during storage, as well as immune camouflage their surface antigens to prevent alloimmunisation. As regards albumin products, PEGylation improved the albumin stability, especially during sterilization, and there was a relationship between the molecular weight (MW) of PEG molecules and the biological half-life of the conjugate. Although coating antibodies with short-chain PEG molecules could enhance their stabilities, these modified proteins were cleared from the blood faster. Also, branched PEG molecules enhanced the retention and shielding of the fragmented and bispecific antibodies. Overall, the results of this literature review indicate that PEGylation can be considered a useful tool for enhancing the stability and storage of blood components.
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Affiliation(s)
| | - Mehdi Mirzaei
- Iran Ministry of Health and Medical Education, Deputy Ministry for Education, Tehran, Iran
| | - Mehdi Shafiee Ardestani
- Department of Radiopharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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Kenet G, Young G, Chuansumrit A, Matsushita T, Yadav V, Zak M, Male C. The immunogenicity, safety, and efficacy of N8-GP in previously untreated patients with severe hemophilia A: pathfinder6 end-of-trial results. J Thromb Haemost 2023; 21:3109-3116. [PMID: 37597724 DOI: 10.1016/j.jtha.2023.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/05/2023] [Accepted: 07/06/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND The pathfinder6 (NCT02137850) international phase 3 trial examined immunogenicity, safety, and efficacy of the extended half-life factor VIII (FVIII) replacement product N8-GP (turoctocog alfa pegol; Esperoct) in previously untreated patients (PUPs) with hemophilia A. OBJECTIVES We present end-of trial results for extended PUP N8-GP treatment for up to a median (range) 2.5 (0.0; 7.4) years. PATIENTS/METHODS Longer-term N8-GP treatment in PUPs with hemophilia A was examined. The prophylaxis regimen was ∼60 IU/kg N8-GP i.v. twice weekly, or every 3 or 7 days. The primary endpoint was the incidence of FVIII inhibitors. RESULTS Overall, 81 patients received N8-GP and were included in this analysis. The inhibitor incidence was 30.0% (15.7% high-titer [>5 BU]) for the extension phase. Patients had a median (range) 2.9 (0.1; 7.2) years of prophylaxis following the pre-prophylaxis period. During prophylaxis, the median annualized bleeding rate (ABR) (interquartile range) was 1.4 (0.6; 3.5), 13% of patients experienced no bleeding episodes, and 55.1% of patients experienced no spontaneous bleeds. The proportion of patients without any spontaneous bleeding episodes increased after the first year of prophylaxis. The hemostatic success rate in the treatment of bleeding episodes was 87.6%. No additional safety concerns were observed in patients with previously reported observation of temporarily decreased incremental recovery (IR). CONCLUSION Long-term end-of-trial PUP N8-GP prophylaxis data indicate that PUPs respond well to long-term N8-GP treatment. The inhibitor incidence was consistent with previous results. Median ABR during prophylaxis was 1.4. There were no lasting clinical impacts or safety concerns for patients with an observation of temporarily decreased IR.
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Affiliation(s)
- Gili Kenet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel; The Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel.
| | - Guy Young
- Children's Hospital Los Angeles/University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Ampaiwan Chuansumrit
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Vandana Yadav
- Novo Nordisk Service Centre India Private Ltd, Bangalore, India
| | | | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Austria
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Oldenburg J, Benson G, Chowdary P, Halimeh S, Matsushita T, Nørland A, Wahid MN, Nemes L. Cases of less-than-expected FVIII activity in previously treated patients during post-marketing surveillance of N8-GP. Haemophilia 2023; 29:1475-1482. [PMID: 37729439 DOI: 10.1111/hae.14864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 09/22/2023]
Abstract
INTRODUCTION Turoctocog alfa pegol (N8-GP) is a glycoPEGylated, extended half-life (EHL), human recombinant factor VIII (FVIII) approved for the treatment and prevention of bleeding episodes in patients with haemophilia A. Since its launch in August 2019, > 800 patients have been treated worldwide. AIM To present data from identified post-marketing cases of less-than-expected FVIII activity in previously treated patients (PTPs) without inhibitors after switching to N8-GP. METHODS The post-marketing safety database was searched using keywords such as 'coagulation FVIII level decreased'. Identified cases reported prior to 13 October 2021 were included in this report. Cases in which patients had FVIII inhibitors were excluded. RESULTS Here we report 14 cases of less-than-expected FVIII activity. Details varied greatly amongst the cases. At presentation, FVIII activity ranged from 1% (15 min post-dose) to 51% (2 days post-dose). Seven patients experienced bleeding episodes after switching to N8-GP with heterogeneity in bleeding presentations. Six out of seven patients who were tested for anti-PEG IgG and/or IgM antibodies were positive. In all known cases, FVIII activity returned to the expected range when switched to an alternative FVIII replacement product. CONCLUSION In conclusion, the 14 reported cases of less-than-expected FVIII activity, without presence of detectable FVIII inhibitors, presented with heterogenous characteristics, and wide variations in FVIII activity and anti-PEG antibody titre. FVIII activity returned to the expected range after switching to alternative FVIII products. In line with WFH guidelines, monitoring of FVIII activity can ensure FVIII activity in the expected range. The safety surveillance of N8-GP continues.
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Affiliation(s)
- Johannes Oldenburg
- Institute for Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, Germany
| | - Gary Benson
- Department of Haematology, Belfast City Hospital, Belfast, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | | | - Tadashi Matsushita
- Nagoya University Hospital, Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | | | | | - Laszlo Nemes
- DepartmentMedical Center of the Hungarian Defence Forces, National Hemophilia Center and Hemostasis, Budapest, Hungary
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Nguyen NH, Jarvi NL, Balu-Iyer SV. Immunogenicity of Therapeutic Biological Modalities - Lessons from Hemophilia A Therapies. J Pharm Sci 2023; 112:2347-2370. [PMID: 37220828 DOI: 10.1016/j.xphs.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 05/25/2023]
Abstract
The introduction and development of biologics such as therapeutic proteins, gene-, and cell-based therapy have revolutionized the scope of treatment for many diseases. However, a significant portion of the patients develop unwanted immune reactions against these novel biological modalities, referred to as immunogenicity, and no longer benefit from the treatments. In the current review, using Hemophilia A (HA) therapy as an example, we will discuss the immunogenicity issue of multiple biological modalities. Currently, the number of therapeutic modalities that are approved or recently explored to treat HA, a hereditary bleeding disorder, is increasing rapidly. These include, but are not limited to, recombinant factor VIII proteins, PEGylated FVIII, FVIII Fc fusion protein, bispecific monoclonal antibodies, gene replacement therapy, gene editing therapy, and cell-based therapy. They offer the patients a broader range of more advanced and effective treatment options, yet immunogenicity remains the most critical complication in the management of this disorder. Recent advances in strategies to manage and mitigate immunogenicity will also be reviewed.
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Affiliation(s)
- Nhan H Nguyen
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA; Currently at Truvai Biosciences, Buffalo, NY, USA
| | - Nicole L Jarvi
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Sathy V Balu-Iyer
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.
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Gogia P, Tarantino M, Schramm W, Aledort L. New directions to develop therapies for people with hemophilia. Expert Rev Hematol 2023:1-17. [PMID: 36891589 DOI: 10.1080/17474086.2023.2184341] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
INTRODUCTION The past few decades have seen a tremendous advancement in the management of hemophilia. Whether it is improved methods to attenuate critical viruses, recombinant bioengineering with decreased immunogenicity, extended half-life replacement therapies to mitigate the burden of repeated infusion treatments, novel nonreplacement products to avoid the drawback of inhibitor development with its attractive subcutaneous administration and then the introduction of gene therapy, the management has trodden a long way. AREAS COVERED This expert review describes the progress in the treatment of hemophilia over the years. We discuss, in detail, the past and current therapies, their benefits, drawbacks, along with relevant studies leading to approval, efficacy and safety profile, ongoing trials, and future prospects. EXPERT OPINION The technological advances in the treatment of hemophilia with convenient modes of administration and innovative modalities offer a chance for a normal existence of the patients living with this disease. However, it is imperative for clinicians to be aware of the potential adverse effects and the need for further studies to establish causality or chance association of these events with novel agents. Thus, it is crucial for clinicians to engage patients and their families in informed decision-making and tailor individual concerns and necessities.
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Affiliation(s)
- Pooja Gogia
- Division of Hematology/Oncology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Michael Tarantino
- University of Illinois College of Medicine, and the Bleeding and Clotting Disorders Institute, Peoria, IL, USA
| | - Wolfgang Schramm
- Ludwig-Maximilians University (LMU) Rudolf Marx Stiftung Munich, München, Germany
| | - Louis Aledort
- Division of Hematology/Oncology, Icahn School of Medicine, New York, NY, USA
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Franchini M, Mannucci PM. The More Recent History of Hemophilia Treatment. Semin Thromb Hemost 2022; 48:904-910. [DOI: 10.1055/s-0042-1756188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractThe availability first in the 1970s of plasma-derived and then in the 1990s of recombinant clotting factor concentrates represented a milestone in hemophilia care, enabling not only treatment of episodic bleeding events but also implementation of prophylactic regimens. The treatment of hemophilia has recently reached new landmarks. The traditional clotting factor replacement therapy for hemophilia has been substituted over the last 10 years by novel treatments such as bioengineered factor VIII and IX molecules with extended half-life and non-factor treatments including the bispecific antibody emicizumab. This narrative review is dedicated to these newer therapies, which are contributing significantly to improving the long-term management of prophylaxis in hemophilia patients. Another section is focused on the current state of gene therapy, which is a promising definitive cure for severe hemophilia A and B.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Prezotti ANL, Frade-Guanaes JO, Yamaguti-Hayakawa GG, Ozelo MC. Immunogenicity of Current and New Therapies for Hemophilia A. Pharmaceuticals (Basel) 2022; 15:ph15080911. [PMID: 35893734 PMCID: PMC9331070 DOI: 10.3390/ph15080911] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023] Open
Abstract
Anti-drug antibody (ADA) development is a significant complication in the treatment of several conditions. For decades, the mainstay of hemophilia A treatment was the replacement of deficient coagulation factor VIII (FVIII) to restore hemostasis, control, and prevent bleeding events. Recently, new products have emerged for hemophilia A replacement therapy, including bioengineered FVIII molecules with enhanced pharmacokinetic profiles: the extended half-life (EHL) recombinant FVIII products. However, the main complication resulting from replacement treatment in hemophilia A is the development of anti-FVIII neutralizing alloantibodies, known as inhibitors, affecting approximately 25–30% of severe hemophilia A patients. Therefore, the immunogenicity of each FVIII product and the mechanisms that could help increase the tolerance to these products have become important research topics in hemophilia A. Furthermore, patients with inhibitors continue to require effective treatment for breakthrough bleedings and procedures, despite the availability of non-replacement therapy, such as emicizumab. Herein, we discuss the currently licensed treatments available for hemophilia A and the immunogenicity of new therapies, such as EHL-rFVIII products, compared to other products available.
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Affiliation(s)
- Alessandra N. L. Prezotti
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- HEMOES, Hematology and Hemotherapy Center Dr. Marcos Daniel Santos, Av. Marechal Campos, 1468, Maruípe, Vitória 29047-105, ES, Brazil
| | - Jéssica O. Frade-Guanaes
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
| | - Gabriela G. Yamaguti-Hayakawa
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
| | - Margareth C. Ozelo
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
- Correspondence: ; Tel.: +55-(19)-3521-8395
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Ozelo MC, Yamaguti‐Hayakawa GG. Impact of novel hemophilia therapies around the world. Res Pract Thromb Haemost 2022; 6:e12695. [PMID: 35434467 PMCID: PMC9004233 DOI: 10.1002/rth2.12695] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/02/2022] [Accepted: 03/22/2022] [Indexed: 12/22/2022] Open
Abstract
Hemophilia A and B are hereditary bleeding disorders, characterized by factor VIII or IX deficiencies, respectively. For many decades, prophylaxis with coagulation factor concentrates (replacement therapy) was the standard‐of‐care approach in hemophilia. Since the 1950s, when prophylaxis started, factor concentrates have been improved with virus inactivation and molecule modification to extend its half‐life. The past years have brought an intense revolution in hemophilia care, with the development of nonfactor therapy and gene therapy. Emicizumab is the first and only nonreplacement agent to be licensed for prophylaxis in people with hemophilia A, and real‐world data show similar efficacy and safety from the pivotal studies. Other nonreplacement agents and gene therapy have ongoing studies with promising results. Innovative approaches, like subcutaneous factor VIII and lipid nanoparticles, are in the preclinical phase. These novel agents, such as extended half‐life concentrates and emicizumab, have been available in resource‐constrained countries through the constant efforts of the World Federation of Haemophilia Humanitarian Aid Program. Despite the wide range of new approaches and therapies, the main challenge remains the same: to guarantee treatment for all. In this article, we discuss the evolution of hemophilia care, global access to hemophilia treatment, and the current and future strategies that are now under development. Finally, we summarize relevant new data on this topic presented at the ISTH 2021 virtual congress.
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Affiliation(s)
- Margareth C. Ozelo
- Hemocentro UNICAMP University of Campinas Campinas Brazil
- Department of Internal Medicine School of Medical Sciences University of Campinas UNICAMP Campinas Brazil
| | - Gabriela G. Yamaguti‐Hayakawa
- Hemocentro UNICAMP University of Campinas Campinas Brazil
- Department of Internal Medicine School of Medical Sciences University of Campinas UNICAMP Campinas Brazil
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Hermans C, Reding MT, Astermark J, Klamroth R, Mancuso ME. Clinical studies of extended-half-life recombinant FVIII products for prophylaxis in adults and children: a critical review from the physician's perspective. Crit Rev Oncol Hematol 2022; 174:103678. [DOI: 10.1016/j.critrevonc.2022.103678] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/01/2022] [Accepted: 04/01/2022] [Indexed: 11/27/2022] Open
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Müller J, Miesbach W, Prüller F, Siegemund T, Scholz U, Sachs UJ. An Update on Laboratory Diagnostics in Haemophilia A and B. Hamostaseologie 2022; 42:248-260. [PMID: 35104901 PMCID: PMC9388220 DOI: 10.1055/a-1665-6232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Haemophilia A (HA) and B (HB) are X-linked hereditary bleeding disorders caused by lack of activity of coagulation factors VIII (FVIII) or IX (FIX), respectively. Besides conventional products, modern replacement therapies include FVIII or FIX concentrates with an extended half-life (EHL-FVIII/FIX). Two main strategies for measuring plasma FVIII or FIX activity are applied: the one-stage clotting assay (OSCA) and the chromogenic substrate assay (CSA), both calibrated against plasma (FVIII/FIX) standards. Due to the structural modifications of EHL-FVIII/FIX, reagent-dependent assay discrepancies have been described when measuring the activity of these molecules. Assay discrepancies have also been observed in FVIII/FIX gene therapy approaches. On the other hand, nonfactor replacement by the bispecific antibody emicizumab, a FVIIIa-mimicking molecule, artificially shortens activated partial thromboplastin time–based clotting times, making standard OSCAs inapplicable for analysis of samples from patients treated with this drug. In this review, we aim to give an overview on both, the currently applied and future therapies in HA and HB with or without inhibitors and corresponding test systems suitable for accompanying diagnostics.
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Affiliation(s)
- Jens Müller
- Institute for Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
| | - Wolfgang Miesbach
- Department of Haemostaseology and Hemophilia Center, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Thomas Siegemund
- Division of Hemostaseology, Department of Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Ute Scholz
- Center of Hemostasis, MVZ Labor Leipzig, Leipzig, Germany
| | - Ulrich J Sachs
- Department of Thrombosis and Haemostasis, Giessen University Hospital, Giessen, Germany
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Zadeh Mehrizi T, Mousavi Hosseini K. An overview on the investigation of nanomaterials' effect on plasma components: immunoglobulins and coagulation factor VIII, 2010-2020 review. NANOSCALE ADVANCES 2021; 3:3730-3745. [PMID: 36133015 PMCID: PMC9419877 DOI: 10.1039/d1na00119a] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 05/16/2021] [Indexed: 05/04/2023]
Abstract
FVIII and immunoglobulins (Igs) are the most prominent plasma proteins, which play a vital role in plasma hemostasis. These proteins have been implemented frequently in protein therapy. Therefore, their maintenance, durability, and stability are highly essential. Herein, various approaches to improve protein functions have been investigated, such as using recombinant protein replacement. In comparison, advances in nanotechnology have provided adequate context to boost biomaterial utilization. In this regard, the applications of various nanoparticles such as polymeric nanomaterials (PEG and PLGA), metal nanoparticles, dendrimers, and lipid based nanomaterials (liposomes and lipid nanoparticles) in stability and the functional improvement of antibodies and coagulation factor VIII (FVIII) have been reviewed from 2010 to 2020. Reviewing related articles has shown that not only can nanomaterials adequately protect the structure of proteins, but have also improved proteins' functions in some cases. For example, the high rate of FVIII instability has been successfully enhanced by bio-PEGylation. Also, utilizing PEGylated liposomes, using the PEG-lip technique for coating nanostructures, leads to FIIIV half-life prolongation. Hence, PEGylation had most impact on the stability of FVIII. Likewise, PEG-coated liposome nano-carriers also presented such a good effect on stability improvements for FVIII due to their ability to tune the immune system by reducing FVIII immunogenicity. Similarly, Ig PEGylation and conjugation to magnetic nanoparticles resulted in increased half-life and better purification of Igs, respectively, without any loss in structural or functional features. Consequently, metal-organic frameworks and recent hybrid systems have been introduced as promising nanomaterials in biomedical applications. As far as we know, this is the first study in this field, which considers the applications of nanoparticles for improving the storage and stability of antibodies and coagulation FVIII.
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Affiliation(s)
- Tahereh Zadeh Mehrizi
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine Tehran Iran +989338606292
| | - Kamran Mousavi Hosseini
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine Tehran Iran +989338606292
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14
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Mancuso ME, Biss T, Fischer K, Maas Enriquez M, Steele M, Wang M, Tseneklidou-Stoeter D, Ahuja S, Kenet G. PROTECT VIII kids extension study: Long-term safety and efficacy of BAY 94-9027 (damoctocog alfa pegol) in children with severe haemophilia A. Haemophilia 2021; 27:434-444. [PMID: 33724632 PMCID: PMC8251516 DOI: 10.1111/hae.14294] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/05/2021] [Accepted: 02/25/2021] [Indexed: 01/26/2023]
Abstract
Introduction BAY 94‐9027 (damoctocog alfa pegol; an extended half‐life PEGylated recombinant factor VIII [FVIII]) demonstrated efficacy and safety in previously treated paediatric patients (PTPs) aged <12 years with severe haemophilia A in the PROTECT VIII Kids study (NCT01775618). Aim To evaluate the long‐term safety of BAY 94‐9027 in PTPs aged <12 years at enrolment. Methods In the PROTECT VIII Kids study, boys <12 years with severe haemophilia A were enrolled in two age cohorts (6–<12 years and <6 years) and treated prophylactically twice weekly, every 5 days or every 7 days, with BAY 94‐9027 for ≥50 exposure days (EDs). Patients who had completed ≥50 EDs and ≥6 months in the main study or 12‐week safety expansion study were eligible to participate in the extension. Primary safety variable was frequency of inhibitor development; main efficacy variable was annualised bleeding rate (ABR). Results Of 73 PTPs from the main/expansion studies, 59 (81%) entered the extension phase for a median (range) duration of 5.0 (0.4–5.9) years. Overall, 39 patients completed ≥5 years of treatment. No patients developed FVIII inhibitors/anti‐PEG antibodies, and two patients aged <6 years discontinued. Median ABR for total bleeds was 1.5 (<6 years) and 1.9 (6–<12 years). Total ABR improved in the extension vs. the main study. In the last 12 months of treatment, median spontaneous ABR was 0.0 in both age groups. Conclusions BAY 94‐9027 showed long‐term safety and efficacy for the prevention and treatment of bleeds in younger and older paediatric patients with severe haemophilia A.
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Affiliation(s)
- Maria Elisa Mancuso
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Tina Biss
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - MacGregor Steele
- Cumming School of Medicine, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | | | | | - Sanjay Ahuja
- Rainbow Hemostasis & Thrombosis Center, University Hospitals Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Gili Kenet
- Israel National Hemophilia Center, Chaim Sheba Medical Center, Tel Hashomer, Israel & The Amalia Biron Thrombosis Research Institute, Tel Aviv University, Tel Aviv, Israel
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15
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Napolitano M, Olsen AA, Nøhr AM, Eichler H. Recombinant FVIII Products (Turoctocog Alfa and Turoctocog Alfa Pegol) Stable Up to 40°C. J Blood Med 2021; 12:9-20. [PMID: 33536803 PMCID: PMC7847773 DOI: 10.2147/jbm.s284060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/26/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE The stability under high-temperature conditions of factor VIII (FVIII) concentrates for replacement therapy is of critical importance to patients, particularly those who reside in, or travel to, regions with high ambient temperatures. Concerns about product stability may limit or prevent access to treatment for patients and may limit their ability to live a close-to-normal life. This study evaluated the effect of hot and humid storage conditions on the long-term stability of the recombinant FVIII products, turoctocog alfa and turoctocog alfa pegol. METHODS Turoctocog alfa samples were assessed for stability at 30°C for 9 months or 40°C for 3 months following storage at 5°C for 21 or 27 months, respectively, while turoctocog alfa pegol samples were assessed at 30°C for 12 months or 40°C for 3 months following storage at 5°C for 18 or 27 months, respectively. In addition, turoctocog alfa and turoctocog alfa pegol dry powders were evaluated for stability at 5°C/ambient humidity (AH) for 30 months, 30°C/75% relative humidity (RH) for 12 months and 40°C/75% RH for 6 months. Both studies utilized a range of product strengths. Key stability assessments included oxidized forms, potency, water content and high molecular weight protein (HMWP). RESULTS Both turoctocog alfa and turoctocog alfa pegol remained stable following storage at 40°C/75% RH for 3 months, and at single temperatures (5°C/AH, 30 and 40°C/75% RH), without any major increase in HMWP or any impairment of potency or water content. CONCLUSION Turoctocog alfa and turoctocog alfa pegol offer stability at 40°C for up to 3 months without jeopardizing the quality of each product. These stability characteristics may offer patients flexibility with product storage and daily use.
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Affiliation(s)
- Mariasanta Napolitano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo Reference Regional Center for Thrombosis and Hemostasis, Hematology Unit, Palermo, Italy
| | | | - Anne Mette Nøhr
- Novo Nordisk A/S, Biopharm Manufacturing Development, Gentofte, Denmark
| | - Hermann Eichler
- Saarland University and Saarland University Hospital, Institute of Clinical Haemostaseology and Transfusion Medicine, Homburg (Saar), Germany
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16
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Klamroth R, Hampton K, Saulyte Trakymienė S, Korsholm L, Carcao M. Illustrative Cases from the Pathfinder Clinical Trials of Patients with Hemophilia A Treated with Turoctocog Alfa Pegol (N8-GP). Patient Prefer Adherence 2021; 15:2443-2454. [PMID: 34764641 PMCID: PMC8575374 DOI: 10.2147/ppa.s326282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/12/2021] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To illustrate the benefits of the extended half-life (EHL) recombinant factor VIII product N8-GP (Esperoct®, turoctocog alfa pegol) by describing individual cases of patients with severe hemophilia A treated with N8-GP in the pathfinder clinical trial program. PATIENTS AND METHODS This manuscript presents selected patient cases from the pivotal pathfinder clinical trial program, which included a number of clinical studies in adults (pathfinder 2 and 3) and children (pathfinder 5); overall results published previously. Clinical data and outcomes described in this manuscript are more detailed and derived from several interesting patient cases (five adults from pathfinder 2 and two children from pathfinder 5), who received N8-GP as prophylaxis (PPX) for their severe hemophilia A. Three of the five adults described here also underwent multiple major surgeries (for which they moved from pathfinder 2 into pathfinder 3 and later returned to pathfinder 2). New analyses on pediatric joint health from pathfinder 5 are also summarized here. Outcomes assessed included bleeding complications, improvements in quality of life, intraoperative hemostatic response, blood loss during surgery, number of blood transfusions, and annualized bleeding rates. For the pediatric patients, target joint resolution, adverse events, and annualized joint bleeding rate were also assessed, all by the treating physician. RESULTS Considerable improvements in treatment adherence, bleeding rates, and overall physical activity levels were demonstrated in two adult cases from the pathfinder 2 trial. N8-GP demonstrated good or excellent hemostatic coverage in three adult patients undergoing multiple major surgeries. The benefits of N8-GP for joint health and in support of children and adolescents with evolving active lifestyles were reported for several pediatric cases. CONCLUSION These patient cases highlight the benefits of EHL products, such as N8-GP, for patients with severe hemophilia A. They include more challenging scenarios relating to improvements in previously poor adherence to PPX, children with active sporting lifestyles, and patients requiring multiple major surgeries.
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Affiliation(s)
- Robert Klamroth
- Department of Internal Medicine, Hemophilia Treatment Centre, Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Correspondence: Robert Klamroth Department of Internal Medicine, Hemophilia Treatment Centre, Vivantes Klinikum im Friedrichshain, Berlin, GermanyTel +49 30 130 231575Fax +49 30 130 232130 Email
| | - Kingsley Hampton
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | - Sonata Saulyte Trakymienė
- Clinic of Children’s Diseases, Faculty of Medicine, Vilnius University, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | | | - Manuel Carcao
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
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17
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Di Minno MND, Di Minno A, Calcaterra I, Cimino E, Dell'Aquila F, Franchini M. Enhanced Half-Life Recombinant Factor VIII Concentrates for Hemophilia A: Insights from Pivotal and Extension Studies. Semin Thromb Hemost 2020; 47:32-42. [PMID: 33348412 DOI: 10.1055/s-0040-1718887] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The development of enhanced half-life recombinant factor VIII (EHL-rFVIII) concentrates has improved the management of hemophilia. Furthermore, the chance of maintaining higher trough levels has allowed higher protection from bleeding and, in turn, improved safely performance for certain types of physical activity. The first technology used to improve the pharmacokinetic profile of factor VIII (FVIII) was fusion with the Fc domain of immunoglobulin G. More recently, conjugation to hydrophilic polymers of polyethylene glycol (PEG) has been demonstrated to prolong plasma half-life of FVIII by means of a reduction in clearance of the molecule due to steric hindrance by PEG covering the protein. Here we report results of a systematic review of pivotal studies on EHL-rFVIII concentrates. Significant heterogeneity is observed among different studies on EHL-rFVIII concentrates, and direct comparisons should be avoided. The annualized bleeding rate has ranged between 1.2 and 1.9 in different EHL-rFVIII concentrates, with a progressive further decrease during extension phases of pivotal studies. Zero bleeding was reported by 40 to 45% of patients. Overall, the emerging treatment options seem to be highly effective and safe, associated with a decreased dosing interval to twice weekly or less, which reduces, but does not entirely eliminate, the burden of treatment. Overall, further information is needed from real-life settings to permit differentiation between EHL-FVIII concentrates and for individualizing treatment.
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Affiliation(s)
| | - Alessandro Di Minno
- Dipartimento di Farmacia, Università degli Studi di Napoli "Federico II," Napoli, Italy
| | - Ilenia Calcaterra
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Ernesto Cimino
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | | | - Massimo Franchini
- Department of Haematology and Transfusion Medicine, "Carlo Poma" Hospital, Mantua, Italy
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18
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Møss J, Clausen WHO, Ezban M. Measuring factor VIII activity in samples from patients treated with N8-GP (Esperoct ® ; turoctocog alfa pegol) during the pathfinder clinical trials programme. Haemophilia 2020; 27:e389-e392. [PMID: 33314455 DOI: 10.1111/hae.14173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/27/2020] [Accepted: 09/21/2020] [Indexed: 11/30/2022]
Abstract
FVIII activity in samples taken at various time points from 21 patients treated with N8-GP (Esperoct® ; turoctocog alfa pegol) during the pathfinder clinical trial programme was assessed and compared using different assay methods. FVIII activity measurements in samples from patients treated with N8-GP were similar using chromogenic assays, regardless of calibration method or kit/analyser combination. FVIII activity measurements using one-stage aPTT-based assays were slightly lower when calibrated using normal human plasma (NHP) compared with a product-specific standard; this difference may be partially attributable to differences in the aPTT reagent/analyser combinations used to perform the measurements. Overall, these results confirm the accuracy of FVIII activity measurements using N8-GP-treated patient samples and routine clinical laboratory methods with NHP calibration.
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19
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Matsushita T, Mangles S. An overview of the pathfinder clinical trials program: Long-term efficacy and safety of N8-GP in patients with hemophilia A. J Thromb Haemost 2020; 18 Suppl 1:26-33. [PMID: 32558236 PMCID: PMC7540506 DOI: 10.1111/jth.14958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/31/2020] [Indexed: 12/11/2022]
Abstract
N8-GP (turoctocog alfa pegol, Esperoct® ; Novo Nordisk A/S, Bagsvaerd, Denmark) is a state-of-the-art, extended half-life factor VIII (FVIII) molecule used for prophylactic and on-demand treatment of patients with hemophilia A. The pathfinder clinical trial program, which began with the pathfinder1 trial in 2010, was developed to assess the long-term efficacy and safety of N8-GP in children, adolescents, and adults. The pivotal pathfinder2 (adolescents and adults) and pathfinder5 (children) trials were completed in late 2018, and comprehensive analyses of the end-of-trial results are published together with this article as part of an N8-GP Supplement. Furthermore, results from the pathfinder3 trial, which was designed to evaluate the safety and efficacy of N8-GP during major surgery, have also recently been finalized. Here, we provide an overview of the pathfinder clinical development program and summarize key data from the completed pathfinder trials. We also provide perspectives on the future of extended half-life FVIII molecules in the treatment of patients with hemophilia A and describe currently ongoing pathfinder trials.
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Affiliation(s)
| | - Sarah Mangles
- Haemophilia, Haemostasis and Thrombosis CentreHampshire Hospitals NHS Foundation TrustBasingstokeUK
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20
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Šaulytė Trakymienė S, Economou M, Kenet G, Landorph A, Shen C, Kearney S. Long-term safety and efficacy of N8-GP in previously treated pediatric patients with hemophilia A: Final results from pathfinder5. J Thromb Haemost 2020; 18 Suppl 1:15-25. [PMID: 32940955 PMCID: PMC7540298 DOI: 10.1111/jth.15036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/13/2020] [Accepted: 07/20/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND N8-GP (turoctocog alfa pegol; Esperoct® , Novo Nordisk A/S, Bagsvaerd, Denmark) is a glycoPEGylated, extended half-life human recombinant factor VIII (FVIII). OBJECTIVE Here, we report end-of-trial safety and efficacy results from the completed N8-GP pathfinder5 trial. METHODS pathfinder5 (NCT01731600) was a multi-national, open-label, single-arm, non-randomized, non-controlled trial in previously treated male patients aged <12 years old with severe hemophilia A that comprised a main and an extension phase. During the main phase, patients received twice-weekly N8-GP 60 IU/kg for 50 exposure days (~26 weeks). During the extension phase, patients received the same regimen until the end of trial (first patient in main phase, 20 February 2013; trial end, 28 September 2018). RESULTS Sixty-eight patients were exposed to N8-GP for a median time of ~4.9 years on regimen. Of the 63 patients who started in the extension phase, 62 completed the trial. No FVIII inhibitors (≥0.6 BU) or other safety concerns were detected. The overall estimated annualized bleeding rate was 1.08 (median 0.81), and nearly 20% of patients had no bleeds during the entire trial. The proportion of patients with no annual bleeds increased with time, with 56% of patients experiencing no bleeds and 86% experiencing no spontaneous bleeds during the fourth year of exposure. All baseline target joints of patients who participated in both phases of this trial were resolved in slightly over 2 years. CONCLUSION Overall, data from the completed pathfinder5 trial show that long-term (median 4.9 years) N8-GP treatment was efficacious and well tolerated in previously treated pediatric patients with severe hemophilia A.
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Affiliation(s)
- Sonata Šaulytė Trakymienė
- Center for Pediatric Oncology and HematologyChildren's HospitalVilnius University Hospital Santaros KlinikosVilniusLithuania
| | - Marina Economou
- 1st Department of PediatricsHippokration General HospitalAristotle University of ThessalonikiThessalonikiGreece
| | - Gili Kenet
- Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
- The Israeli National Hemophilia Center and Thrombosis UnitSheba Medical CenterTel HashomerIsrael
- The Amalia Biron Research Institute of Thrombosis and HemostasisSheba Medical CenterTel HashomerIsrael
| | | | | | - Susan Kearney
- Center for Bleeding and Clotting DisordersChildren's Hospital MinnesotaMinneapolisMNUSA
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21
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Giangrande P, Abdul Karim F, Nemes L, You CW, Landorph A, Geybels MS, Curry N. Long-term safety and efficacy of N8-GP in previously treated adults and adolescents with hemophilia A: Final results from pathfinder2. J Thromb Haemost 2020; 18 Suppl 1:5-14. [PMID: 32544297 PMCID: PMC7540590 DOI: 10.1111/jth.14959] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/04/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND N8-GP (turoctocog alfa pegol; Esperoct® , Novo Nordisk A/S, Bagsvaerd, Denmark) is a glycoPEGylated human recombinant factor VIII with a half-life of ~1.6-fold of standard FVIII products. pathfinder2 (NCT01480180) was a multi-national, open-label trial of N8-GP in previously treated adolescent and adult patients with severe hemophilia A. OBJECTIVE We report end-of-trial efficacy and safety of N8-GP from pathfinder2. METHODS pathfinder2 main phase and extension phase part 1 results have been previously reported. During extension phase part 2, patients could switch from N8-GP prophylaxis 50 IU/kg every fourth day (Q4D) or 75 IU/kg once weekly (Q7D), depending on bleeding status. Extension phase part 2 collected long-term safety and efficacy data for all regimens until trial end (first patient in main phase, 30 January 2012; trial end, 10 December 2018). RESULTS Overall, 186 patients were exposed to N8-GP for up to 6.6 years (median 5.4 years). The estimated annualized bleeding rate (ABR) was 2.14 (median 0.84) for the Q4D prophylaxis arm and 1.31 (median 1.67) for the Q7D prophylaxis arm. Nearly 30% of patients experienced zero bleeds throughout the entire duration of the trial, the hemostatic response was 83.2% across all treatment arms, and patient-reported outcomes were maintained or slightly improved. No safety concerns were detected. CONCLUSION Data from the completed pathfinder2 trial, one of the largest and longest-running clinical trials to investigate treatment of severe hemophilia A, demonstrate the efficacy and safety of N8-GP in previously treated adolescent and adult patients.
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Affiliation(s)
- Paul Giangrande
- Department of Clinical and Laboratory SciencesUniversity of OxfordOxfordUK
| | | | - Laszlo Nemes
- National Hemophilia Center and Hemostasis DepartmentMedical Center of the Hungarian Defence ForcesBudapestHungary
| | - Chur Woo You
- Pediatric DepartmentEulji University HospitalDaejeonKorea
| | | | | | - Nicola Curry
- Oxford Haemophilia and Thrombosis Centre and Oxford National Institute for Health Research Biomedical Research CentreChurchill HospitalOxfordUK
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22
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Firrman J, Wang Q, Wu W, Dong B, Cao W, Moore AR, Roberts S, Konkle BA, Miao C, Liu L, Li D, Xiao W. Identification of Key Coagulation Activity Determining Elements in Canine Factor VIII. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2020; 17:328-336. [PMID: 32071925 PMCID: PMC7013134 DOI: 10.1016/j.omtm.2019.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/24/2019] [Indexed: 11/29/2022]
Abstract
It is well known that canine factor VIII (cFVIII) has a higher specific activity than does human FVIII (hFVIII), and it has been previously demonstrated that cFVIII light chain is able to enhance hFVIII activity. The goal of this study was to first determine which amino acids in cFVIII light chain were responsible for enhancing hFVIII activity, and second to use these amino acids to develop a hFVIII variant with enhanced functional activity. We systemically screened segments of cFVIII light chain by testing an array of human-canine light chain hybrids and found that canine amino acids 1857-2147 were key to this enhancement. Each canine amino acid within this span was screened individually using a negative selection method, which led to the identification of 12 aa (JF12) in the FVIII light chain that could enhance activity. Substitution of the corresponding 12 aa into hFVIII (hFVIIIJF12BDD) elevated the specific activity profile in vitro. Furthermore, hFVIIIJF12BDD expressed an in vivo-displayed increased coagulation activity compared to wild-type, while maintaining normal secretion efficiency. In conclusion, we identified the amino acids in cFVIII that are the key determinants for higher specific activity and may be the basis for future development of therapeutic treatments for hemophilia A.
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Affiliation(s)
- Jenni Firrman
- Department of Microbiology and Immunology, Temple University School of Medicine, Philadelphia, PA, USA.,Dairy and Functional Foods Research Unit, Agricultural Research Service, Eastern Regional Research Center, Wyndmoor, PA, USA
| | - Qizhao Wang
- Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Philadelphia, PA, USA
| | - Wenman Wu
- Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Philadelphia, PA, USA
| | - Biao Dong
- Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Philadelphia, PA, USA
| | - Wenjing Cao
- Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Philadelphia, PA, USA
| | - Andrea Rossi Moore
- Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Philadelphia, PA, USA
| | - Sean Roberts
- Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Philadelphia, PA, USA
| | - Barbara A Konkle
- Bloodworks Northwest, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Carol Miao
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - LinShu Liu
- Dairy and Functional Foods Research Unit, Agricultural Research Service, Eastern Regional Research Center, Wyndmoor, PA, USA
| | - Dong Li
- Shanghai Tongji Hospital, Tongji University, Shanghai, P.R. China
| | - Weidong Xiao
- Department of Microbiology and Immunology, Temple University School of Medicine, Philadelphia, PA, USA.,Dairy and Functional Foods Research Unit, Agricultural Research Service, Eastern Regional Research Center, Wyndmoor, PA, USA.,Sol Sherry Thrombosis Research Center, Temple University School of Medicine, Philadelphia, PA, USA
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Abstract
INTRODUCTION A number of new FVIII/IX concentrates enriched the portfolio of products available for the treatment of hemophilia A/B patients. Due to the large inter-patient variability, accurate tailoring of the therapy became essential to improve patients' adherence, clinical outcomes, and cost/effectiveness ratio. Recently, non-replacement therapies have taken the limelight and succeeded in decreasing the bleedings of patients. AREAS COVERED The PK characteristics, efficacy, and safety of the new rFVIII and rFIX concentrates and of non-replacement therapy, are reported in detail in the published clinical trials. EXPERT OPINION Outstanding improvements of rFIX concentrates' pharmacokinetics and pharmacodynamics have allowed to reduce the bleedings in hemophilia B patients, in order to increase their adherence to prophylaxis and quality of life. Less significant are the effects of pegylation or Fc fusion on the pharmacokinetics of the new rFVIII concentrates. The new non-replacement therapy is achieving the favor of many treaters and patients, in particular those with Factor VIII inhibitors. Great attention must be paid to the dangerous synergy of APCC and emicizumab, responsible for some fatal events during the clinical trials and compassionate use of this drug. So far, replacement therapy should be the standard of care for hemophilia patients without inhibitors or difficulties in venous access.
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Affiliation(s)
- Massimo Morfini
- Italian Association of Hemophilia Centres (AICE) , Milan, Italy
| | - Emanuela Marchesini
- Hemophilia Centre - SC Vascular and Emergency Department, University of Perugia , Perugia, Italy
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24
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Escobar M, Santagostino E, Mancuso ME, Coppens M, Balasa V, Taylor JA, Iorio A, Negrier C. Switching patients in the age of long-acting recombinant products? Expert Rev Hematol 2020; 12:1-13. [PMID: 31282771 DOI: 10.1080/17474086.2018.1564032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Introduction: Prophylaxis with factor replacement therapy is the gold standard for the treatment of hemophilia, but this often requires frequent infusions. A number of long-acting factor products have been developed to reduce the burden on patients. Areas covered: This is an overview of information presented at two symposia held at the World Federation of Hemophilia and International Society on Thrombosis and Haemostasis - Scientific and Standardization Committee annual meetings. The pharmacokinetic, safety and efficacy data for long-acting recombinant products are reviewed, with a focus on recombinant factor IX albumin fusion protein (rIX-FP) and rVIII-SingleChain. This overview also provides a guide for managing a patient's switch to long-acting products. Expert opinion: Long-acting products may allow patients to maintain or decrease bleeding rates whilst increasing their dosing interval, which may in turn reduce the burden on patients and caregivers. When switching patients to long-acting products health-care professionals should provide balanced and thorough education to the patient, whilst supporting their emotional well-being. Regimens should address patients' needs and goals but should also be guided by clinical phenotype and pharmacokinetic assessment. Follow-up should assess safety concerns, bleeding rates, joint health and the impact of the regimen on patients' lifestyle.
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Affiliation(s)
- Miguel Escobar
- a Department of Internal Medicine and Pediatrics, Division of Hematology , University of Texas Health Science Center and the Gulf States Hemophilia and Thrombophilia Center , Houston , TX , USA
| | - Elena Santagostino
- b Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico , Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre , Milan , Italy
| | - Maria Elisa Mancuso
- b Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico , Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre , Milan , Italy
| | - Michiel Coppens
- c Department of Vascular Medicine , Amsterdam Cardiovascular Sciences, Amsterdam UMC , Amsterdam , the Netherlands
| | - Vinod Balasa
- d Division Chief and Medical Director, Hematology/Oncology , Valley Children's Hospital , Madera , CA , USA
| | - Jason A Taylor
- e Division of Hematology and Medical Oncology , The Hemophilia Center, Knight Cancer Institute, Oregon Health & Science University and Portland VA Medical Center , Portland , OR , USA
| | - Alfonso Iorio
- f Department of Health Research Methods, Evidence and Impact , McMaster University , Hamilton , ON , Canada
| | - Claude Negrier
- g National Reference Centre for Haemophilia, Louis Pradel Hospital , University Claude Bernard Lyon I , Lyon , France
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Tosetto A, Neff A, Lentz SR, Santagostino E, Nemes L, Sathar J, Meijer K, Chowdary P, Shen C, Landorph A, Hampton K. Turoctocog alfa pegol provides effective management for major and minor surgical procedures in patients across all age groups with severe haemophilia A: Full data set from the pathfinder 3 and 5 phase III trials. Haemophilia 2020; 26:450-458. [PMID: 32293786 PMCID: PMC7317207 DOI: 10.1111/hae.13980] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/24/2020] [Accepted: 03/09/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Turoctocog alfa pegol is a glycoPEGylated recombinant factor VIII (FVIII) with an extended half-life developed for prophylaxis, treatment of bleeds and perioperative management in patients with haemophilia A. AIM Evaluate the efficacy and safety of turoctocog alfa pegol treatment for major and minor surgeries in the pathfinder 3 and 5 phase III trials. METHODS Adults/adolescents aged ≥12 years with severe haemophilia A (FVIII <1%) received perioperative turoctocog alfa pegol treatment planned to achieve FVIII activity levels >80% during major surgery (pathfinder 3). The primary end point was haemostatic efficacy during surgery; secondary end points were blood loss, haemostatic effect postsurgery, consumption, transfusions, safety and health economics. Children (0-11 years) undergoing minor surgeries received 20-75 IU/kg turoctocog alfa pegol at Investigator's discretion (pathfinder 5). RESULTS pathfinder 3 included 35 patients undergoing 49 major surgeries. Haemostasis was successful in 47/49 (95.9%) surgeries; two had moderate haemostatic responses. Median (mean) blood loss during major surgery was 75 (322.6) mL. Four bleeds were reported postsurgery; three were successfully treated with turoctocog alfa pegol (one was not evaluated). On the day of surgery, overall mean (median) dose was 75.5 (74.5) IU/kg and mean (median) number of doses was 1.7 (2.0). Five procedures required 11 transfusions on the day of surgery or days 1-6. No safety concerns or inhibitors were identified. Forty-five minor surgeries in 23 children were performed without complications. CONCLUSION Turoctocog alfa pegol was effective for perioperative haemostatic management of major and minor surgeries in patients across age groups with severe haemophilia A.
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Affiliation(s)
- Alberto Tosetto
- Hematology Department, Haemophilia and Thrombosis Center, San Bortolo Hospital, Vicenza, Italy
| | - Anne Neff
- Department of Hematology/Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Steven R Lentz
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Elena Santagostino
- Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Haemophilia and Thrombosis Center, Milan, Italy
| | - Laszlo Nemes
- National Haemophilia Centre and Haemostasis Department, Medical Centre of Hungarian Defence Forces, Budapest, Hungary
| | - Jameela Sathar
- Department of Haematology, Ampang Hospital, Selangor, Malaysia
| | - Karina Meijer
- Department of Haematology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | | | | | - Kingsley Hampton
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
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Santagostino E, Kenet G, Fischer K, Biss T, Ahuja S, Steele M. PROTECT VIII Kids: BAY 94-9027 (PEGylated Recombinant Factor VIII) safety and efficacy in previously treated children with severe haemophilia A. Haemophilia 2020; 26:e55-e65. [PMID: 32212300 PMCID: PMC7317355 DOI: 10.1111/hae.13963] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/11/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION BAY 94-9027, a site-specifically PEGylated, B-domain-deleted recombinant factor VIII (FVIII) with extended half-life, demonstrated efficacy for bleed prevention and treatment in previously treated adolescents and adults with severe haemophilia A. AIM To assess BAY 94-9027 in children with severe haemophilia A. METHODS In the two-part PROTECT VIII Kids study, boys <12 years with <1% FVIII and >50 exposure days (EDs) to FVIII were enrolled in two cohorts (<6 years; 6-<12 years) and treated with BAY 94-9027 prophylaxis twice-weekly, every 5 days, or every 7 days at physician discretion for ≥50 EDs (Part 1) or twice-weekly for 12-weeks (Part 2). Annualized bleeding rate (ABR) was a primary efficacy endpoint; FVIII inhibitor development was the primary safety variable. RESULTS At study completion, 25 patients had been treated twice-weekly, 28 in the every-5-day group, and 8 in the every-7-day group. Median ABR for all bleeds was 2.9 (Part 1) and 2.4 (Part 2) and similar in younger and older patients; median ABR for joint bleeds was 0 for both cohorts. In the last 90 days' treatment, median ABR was 0 for younger and older patients (Part 1). Of 149 reported bleeds, 93% were treated with ≤2 infusions. Twelve patients, the majority <6 years (n = 11), discontinued due to apparent loss of efficacy or hypersensitivity. No FVIII inhibitors developed. CONCLUSIONS In PROTECT VIII Kids, which allowed tailoring of prophylaxis to individual clinical response, BAY 94-9027 was efficacious for bleed prevention and treatment in previously treated children with severe haemophilia A.
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Affiliation(s)
- Elena Santagostino
- Foundation IRCCS Ca' Granda, Maggiore Hospital Policlinico, A. Bianchi Bonomi, Hemophilia and Thrombosis Center, Milan, Italy
| | - Gili Kenet
- Chaim Sheba Medical Center, Israel National Hemophilia Center, Tel Hashomer, Israel
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tina Biss
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Sanjay Ahuja
- UH Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - MacGregor Steele
- Cumming School of Medicine, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
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Plasma Polyethylene Glycol (PEG) Levels Reach Steady State Following Repeated Treatment with N8-GP (Turoctocog Alfa Pegol; Esperoct ®). Drugs R D 2020; 20:75-82. [PMID: 32152818 PMCID: PMC7221073 DOI: 10.1007/s40268-020-00297-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background Extended half-life (EHL) factor VIII (FVIII)-replacement therapies enable patients with haemophilia A to maintain higher activity levels with fewer injections. N8-GP (turoctocog alfa pegol; Esperoct®) is an EHL product derived from conjugation of polyethylene glycol (PEG) to a recombinant FVIII protein. Upon activation, PEG is released from the active protein and excreted in urine and faeces. While PEG levels are expected to reach steady state with repeated dosing, there has been some discussion regarding whether abnormal accumulation of PEG in plasma and tissues may occur. Objective Our objective was to examine plasma PEG concentrations in rats and humans repeatedly treated with N8-GP for periods of up to 5 years. Methods PEG levels were measured using liquid chromatography-tandem mass spectrometry in plasma samples from rats treated with N8-GP as part of a 52-week toxicity study. Human plasma samples from children, adolescents and adults treated with N8-GP as part of the pathfinder programme were also examined (NCT01731600; NCT01480180). These data were compared with steady-state PEG levels predicted by pharmacokinetic modelling of single-dose rat data. Results PEG levels reached steady state in plasma in both rats and humans after repeated dosing. The timing and degree of PEG increase to steady state were in line with or below model predictions, confirming the utility of the pharmacokinetic model and indicating that rat data can be used to estimate human plasma PEG levels. Conclusion Steady-state PEG levels were reached in plasma from rats and humans repeatedly treated with N8-GP. No unexpected increase in PEG was observed.
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Moncalvo F, Martinez Espinoza MI, Cellesi F. Nanosized Delivery Systems for Therapeutic Proteins: Clinically Validated Technologies and Advanced Development Strategies. Front Bioeng Biotechnol 2020; 8:89. [PMID: 32117952 PMCID: PMC7033645 DOI: 10.3389/fbioe.2020.00089] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 01/30/2020] [Indexed: 12/18/2022] Open
Abstract
The impact of protein therapeutics in healthcare is steadily increasing, due to advancements in the field of biotechnology and a deeper understanding of several pathologies. However, their safety and efficacy are often limited by instability, short half-life and immunogenicity. Nanodelivery systems are currently being investigated for overcoming these limitations and include covalent attachment of biocompatible polymers (PEG and other synthetic or naturally derived macromolecules) as well as protein nanoencapsulation in colloidal systems (liposomes and other lipid or polymeric nanocarriers). Such strategies have the potential to develop next-generation protein therapeutics. Herein, we review recent research progresses on these nanodelivery approaches, as well as future directions and challenges.
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Affiliation(s)
| | | | - Francesco Cellesi
- Dipartimento di Chimica, Materiali e Ingegneria Chimica “G. Natta”, Politecnico di Milano, Milan, Italy
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Mannucci PM. Hemophilia therapy: the future has begun. Haematologica 2020; 105:545-553. [PMID: 32060150 PMCID: PMC7049365 DOI: 10.3324/haematol.2019.232132] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 01/20/2020] [Indexed: 02/06/2023] Open
Abstract
The success story of hemophilia care first began in the 1970s, when the availability of plasma-derived concentrates of coagulation factor VIII (FVIII) and factor IX (FIX) provided efficacious treatment of bleeding in patients with hemophilia A and B. This positive scenario was consolidated in terms of greater safety and availability in the 1990s, when the first recombinant coagulation factors were produced. This meant that, instead of only treating episodic bleeding events, prophylaxis regimens could be implemented as a preventive measure. Following the demonstration of its superiority in the frame of two randomized clinical trials, prophylaxis became evidence-based standard of care. In high-income countries, these achievements have led to a patients’ life expectancy being extended to close to that of the general male population. Alongside this, the last decade has witnessed further spectacular therapeutic progress, such as the availability of coagulation factors with a longer plasma half-life that allow for wider intervals between treatment. Moreover, new therapeutic products based on new mechanisms other than the replacement of the deficient factor, have become available (emicizumab) or are at an advanced stage of development. This review celebrates the success story of hemophilia care, while also discussing current limitations, issues and as yet unmet needs. The prospects of cure by means of gene therapy are also outlined.
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Affiliation(s)
- Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Klamroth R, Feistritzer C, Friedrich U, Lentz SR, Reichwald K, Zak M, Chowdary P. Pharmacokinetics, immunogenicity, safety, and preliminary efficacy of subcutaneous turoctocog alfa pegol in previously treated patients with severe hemophilia A (alleviate 1). J Thromb Haemost 2020; 18:341-351. [PMID: 31618804 PMCID: PMC7027501 DOI: 10.1111/jth.14660] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 10/08/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND The current standard of care for patients with hemophilia A is regular prophylaxis with factor VIII (FVIII) administered intravenously. Interest in subcutaneous (s.c.) administration, to potentially increase convenience, reduce the treatment burden and improve compliance, is increasing. OBJECTIVES Evaluate the pharmacokinetics (PK), immunogenicity, safety, and preliminary efficacy of s.c. administration of turoctocog alfa pegol (s.c. N8-GP) in adult or adolescent previously treated patients (PTPs) with severe hemophilia A (alleviate 1; NCT02994407). PATIENTS/METHODS In part A, 24 PTPs received a single dose of s.c. N8-GP (12.5, 25, 50, or 100 IU/kg) with 6 patients per cohort. PK modelling of data from part A supported a suitable dose for part B. Part B comprised a multiple dose trial in 26 PTPs; patients <60 kg received 2000 IU and patients ≥60 kg received 4000 IU s.c. N8-GP daily for 3 months. RESULTS Single-dose s.c. N8-GP supported dose linearity. Daily prophylaxis with s.c. N8-GP appeared well tolerated and efficacious, achieving a mean trough FVIII activity close to 10% at steady state. Five patients developed anti-N8-GP binding antibodies after 42 to 91 exposure days, one of whom developed an inhibitor to FVIII. Anti-N8-GP antibody appearance was associated with a decline in FVIII plasma activity in four of the five patients. Five patients reported a total of nine treatment-requiring bleeding episodes during prophylaxis. CONCLUSIONS Subcutaneous administration of N8-GP is associated with a high incidence of antibodies in PTPs with severe hemophilia A. Further clinical development of s.c. N8-GP has been suspended.
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Affiliation(s)
- Robert Klamroth
- Department of Internal MedicineHemophilia Treatment CentreVivantes Klinikum im FriedrichshainBerlinGermany
| | - Clemens Feistritzer
- Internal Medicine V—Hematology and OncologyMedical University of InnsbruckInnsbruckAustria
| | | | - Steven R. Lentz
- The University of Iowa Carver College of MedicineIowa CityIAUSA
| | | | | | - Pratima Chowdary
- KD Haemophilia and Thrombosis CentreRoyal Free London NHS Foundation TrustLondonUK
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31
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Mannucci PM. Benefits and limitations of extended plasma half-life factor VIII products in hemophilia A. Expert Opin Investig Drugs 2020; 29:303-309. [DOI: 10.1080/13543784.2020.1723547] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Pier Mannuccio Mannucci
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Carcao M, Zunino L, Young NL, Dover S, Bouskill V, Hilliard P, Price VE, Blanchette VS. Measuring the impact of changing from standard half-life (SHL) to extended half-life (EHL) FVIII prophylaxis on health-related quality of life (HRQoL) in boys with moderate/severe haemophilia A: Lessons learned with the CHO-KLAT tool. Haemophilia 2019; 26:73-78. [PMID: 31865620 DOI: 10.1111/hae.13905] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 11/07/2019] [Accepted: 11/25/2019] [Indexed: 01/17/2023]
Abstract
INTRODUCTION In many countries, there is a shift from standard half-life (SHL) to extended half-life (EHL) clotting factor concentrates (CFCs). AIM To describe the experience of switching from SHL to an EHL FVIII CFC and the impact of this on frequency of infusions, factor consumption, bleeding rates and HRQoL using the Canadian Hemophilia Kids' Life Assessment Tool (CHO-KLAT). METHODS A retrospective chart review was conducted at a single haemophilia treatment centre in 2018 that included boys (ages: 4-18 years) with moderate/severe haemophilia A, without inhibitors, who switched from a SHL to an EHL FVIII CFC in the previous 2 years and for whom HRQoL data were available. RESULTS The study cohort comprised 38 boys [mean (SD) age: 11.0 (3.4) years] with moderate (n = 5)/severe (n = 33) haemophilia A. The switch was associated with a 33% reduction in the number of weekly infusions from a median of 3.5 to 2.3 (P < .0001) and a 17% reduction in median FVIII consumption from 103 IU/kg/wk to 85.5 IU/kg/wk (P = .004). There was no significant change in annualized joint bleed rates or in CHO-KLAT scores. CONCLUSIONS Despite documenting several benefits of switching to EHL FVIII (less infusions, lower factor consumption with no increase in bleeding), our study did not demonstrate any improvement in HRQoL. We conclude that either the current CHO-KLAT tool is not optimized to measure burden of treatment administration in boys with low bleed rates switching from SHL to EHL FVIII CFCs or that a reduction of 1.2 infusions/week does not result in a meaningful change in HRQoL.
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Affiliation(s)
- Manuel Carcao
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON.,Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Laura Zunino
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON
| | - Nancy L Young
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,School of Rural and Northern Health, Laurentian University, Sudbury, ON, Canada
| | - Saunya Dover
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON
| | - Vanessa Bouskill
- Department of Nursing, The Hospital for Sick Children, Toronto, ON, Canada
| | - Pamela Hilliard
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON
| | - Victoria E Price
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, IWK Health Centre, Dalhousie University, Halifax, NS, Canada
| | - Victor S Blanchette
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, ON.,Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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Chowdary P. Extended half-life recombinant products in haemophilia clinical practice - Expectations, opportunities and challenges. Thromb Res 2019; 196:609-617. [PMID: 31883700 DOI: 10.1016/j.thromres.2019.12.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/03/2019] [Accepted: 12/18/2019] [Indexed: 02/06/2023]
Abstract
Extended half-life (EHL) products have shown robust efficacy in clinical trials, whilst allowing for less intense treatment regimens when compared with standard half-life products. Regimen optimisation with EHL products could lead to further improvements in bleeding rates, quality of life and reductions in treatment burden. Patients now expect good efficacy, a lower treatment burden and equivalent safety when compared with standard half-life products. As our knowledge base grows these expectations have evolved and targeting an annualised bleeding rate of zero has become a more realistic clinical goal. Personalised prophylaxis can help patients achieve these goals. However, a number of challenges still remain, including cost, challenges in predicting outcomes for patients and differences in patients' and clinicians' expectations. When switching a patient, comprehensive patient care can reduce the impact of these issues. This review presents in brief the protein therapeutics with an extended half-life, including key trial results, challenges of chronic care that impact on patients' outcomes and how the modified proteins might help address some of these issues. In addition, practical steps for managing the switch to EHL products are presented.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK.
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Ezban M, Hansen M, Kjalke M. An overview of turoctocog alfa pegol (N8-GP; ESPEROCT ® ) assay performance: Implications for postadministration monitoring. Haemophilia 2019; 26:156-163. [PMID: 31809565 PMCID: PMC7028088 DOI: 10.1111/hae.13897] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 10/21/2019] [Accepted: 11/11/2019] [Indexed: 01/22/2023]
Abstract
Factor replacement therapy with factor VIII (FVIII) concentrates is the current standard of care for patients with haemophilia A. Postadministration monitoring of FVIII activity during on‐demand or prophylactic treatment is important, for example to guide a suitable dosing regimen. While the use of two‐stage chromogenic substrate (CS) assays is increasing, activated partial thromboplastin time (APTT)‐based one‐stage clotting (OSC) assays are most commonly used to measure FVIII activity in clinical laboratories. Substantial variations in activity measurements have been observed in association with some OSC assay reagents when assessing extended half‐life FVIII molecules. Certain silica‐based APTT reagents have previously been shown to underestimate FVIII activity with the polyethylene glycol (PEG)‐conjugated product turoctocog alfa pegol (N8‐GP [ESPEROCT®]; Novo Nordisk A/S). As a wide range of assay reagents are used in clinical laboratories worldwide, it is essential to establish which can be used to accurately measure activity with modified FVIII concentrates. Here, we describe the approach taken by Novo Nordisk to determine the suitability and accuracy of assays and reagents to measure FVIII activity in samples that contain N8‐GP. While accurate activity measurements were possible with all tested CS assays and most of the OSC APTT reagents tested, three APTT reagents that contain silica as a contact activator were found to underestimate N8‐GP recovery (APTT‐SP, TriniCLOT™, STA® PTT‐Automate). The data demonstrate the importance of characterizing the accuracy of each FVIII activity assay. Any limitations should be communicated to treating physicians and the clinical laboratories that test samples containing N8‐GP.
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Aledort L, Mannucci PM, Schramm W, Tarantino M. Factor VIII replacement is still the standard of care in haemophilia A. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2019; 17:479-486. [PMID: 31846611 PMCID: PMC6917528 DOI: 10.2450/2019.0211-19] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/10/2019] [Indexed: 12/13/2022]
Abstract
Prophylactic factor VIII (FVIII) has dramatically improved haemophilia A treatment, preventing joint bleeding and halting the deterioration of joint status. FVIII products with an extended plasma half-life further improve patients' quality of life and increase therapeutic adherence. New licensed classes of non-replacement products include prophylactic emicizumab, which is administered subcutaneously up to every 4 weeks. However, this drug is not suitable for acute bleeding episodes or management of major surgery, and long-term data on the impact of emicizumab on joint health, FVIII inhibitor development and thrombotic risk are awaited. Prophylaxis with FVIII replacement remains the standard of care in haemophilia A, with the aim of achieving a level of haemostasis control that allows patients to meet their lifestyle goals.
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Affiliation(s)
- Louis Aledort
- Division of Hematology/Oncology, Icahn School of Medicine, Mount Sinai, New York, NY, United States of America
| | - Pier Mannuccio Mannucci
- Scientific Direction, IRCCS Foundation Ca’ Granda Maggiore Policlinico Hospital, Milan, Italy
| | - Wolfgang Schramm
- Department of Transfusion Medicine and Haemostasis, University Hospital of Munich, Munich, Germany
| | - Michael Tarantino
- University of Illinois College of Medicine, and the Bleeding and Clotting Disorders Institute, Peoria, IL, United States of America
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Hegemann I, Koch K, Clausen WHO, Ezban M, Brand-Staufer B. Evaluation of N8-GP Activity Using a One-Stage Clotting Assay: A Single-Center Experience. Acta Haematol 2019; 143:504-508. [PMID: 31639805 DOI: 10.1159/000503377] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 09/16/2019] [Indexed: 01/30/2023]
Abstract
N8-GP (ESPEROCT®; turoctocog alfa pegol; Novo Nordisk A/S, Bagsvaerd, Denmark) is an extended half-life recombinant factor VIII (FVIII) molecule. FVIII-deficient plasma spiked with N8-GP can be accurately measured using many activated partial thromboplastin time (aPTT)-based one-stage clotting assay reagents with normal human plasma calibrators. To date, there are few data on the measurement accuracy of samples from patients treated with N8-GP. Here, we measure patient samples during routine treatment monitoring. Three previously treated patients with severe hemophilia A (HA) without inhibitors (baseline FVIII activity <0.01 IU/mL) received 50 IU/kg N8-GP every fourth day or twice weekly over 5 years as part of the pathfinder2 trial. Patient samples were monitored using the Pathromtin® SL aPTT reagent (Siemens Healthcare GmbH, Erlangen, Germany), a BCS® XP System analyzer (Siemens), and Standard Human Plasma (Siemens) or product-specific calibrators. Patient age ranged from 36 to 62 years. Overall, measurements performed using product-specific or Standard Human Plasma calibrators were in good agreement, with ratios randomly distributed around 1.0. Peak ratios tended to be closer to 1.0 than trough samples. Pathromtin® SL with Standard Human Plasma calibrator consistently and accurately measured FVIII activity in samples from severe HA patients receiving N8-GP prophylaxis.
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Affiliation(s)
- Inga Hegemann
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Karin Koch
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
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Shah A, Solms A, Wiegmann S, Ahsman M, Berntorp E, Tiede A, Iorio A, Mancuso ME, Zhivkov T, Lissitchkov T. Direct comparison of two extended-half-life recombinant FVIII products: a randomized, crossover pharmacokinetic study in patients with severe hemophilia A. Ann Hematol 2019; 98:2035-2044. [PMID: 31236667 PMCID: PMC6700041 DOI: 10.1007/s00277-019-03747-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/15/2019] [Indexed: 11/25/2022]
Abstract
BAY 94-9027 is an extended-half-life, recombinant factor VIII (rFVIII) product conjugated with a 60-kDa branched polyethylene glycol (PEG) molecule indicated for use in previously treated patients (aged ≥ 12 years) with hemophilia A. This randomized, open-label, two-way crossover study compared the pharmacokinetics (PK) of BAY 94-9027 and rFVIII Fc fusion protein (rFVIIIFc) in patients with hemophilia A. Patients aged 18-65 years with FVIII < 1% and ≥ 150 exposure days to FVIII were randomized to receive intravenous single-dose BAY 94-9027 60 IU/kg followed by rFVIIIFc 60 IU/kg or vice versa, with ≥ 7-day wash-out between doses. FVIII activity was measured by one-stage assay. PK parameters, including area under the curve from time 0 to the last data point (AUClast, primary parameter), half-life, and clearance were calculated. Eighteen patients were randomized and treated. No adverse events were observed. In the analysis set excluding one outlier, geometric mean (coefficient of variation [%CV, 95% confidence interval {CI}]) AUClast was significantly higher for BAY 94-9027 versus rFVIIIFc (2940 [37.8, 2440-3550] IU h/dL versus 2360 [31.8, 2010-2770] IU h/dL, p = 0.0001). A population PK model was developed to simulate time to reach FVIII threshold levels; median time to 1 IU/dL was approximately 13 h longer for BAY 94-9027 versus rFVIIIFc after a single infusion of 60 IU/kg. In conclusion, BAY 94-9027 had a superior PK profile versus rFVIIIFc. ClinicalTrials.gov : NCT03364998.
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Affiliation(s)
| | | | | | | | - Erik Berntorp
- Centre for Thrombosis and Haemostasis, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence and Impact, and Department of Medicine, McMaster University, Hamilton, Canada
| | - Maria Elisa Mancuso
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Tiefenbacher S, Clausen WHO, Hansen M, Lützhøft R, Ezban M. A field study evaluating the activity of N8-GP in spiked plasma samples at clinical haemostasis laboratories. Haemophilia 2019; 25:893-901. [PMID: 31294905 PMCID: PMC6852407 DOI: 10.1111/hae.13813] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/15/2019] [Accepted: 06/12/2019] [Indexed: 12/17/2022]
Abstract
AIM N8-GP (turoctocog alfa pegol) is a glycoPEGylated, extended half-life human recombinant factor VIII (FVIII) shown to be an efficacious treatment for patients with haemophilia A. Accurate monitoring of replacement therapy helps ensure proper dosing, leading to better patient care. The objective of this field study was to evaluate the accuracy and intra- and inter-laboratory variabilities of N8-GP and rAHF (Advate® ) FVIII activity (FVIII:C) measurements in clinical laboratories using their routine methods and reagents. METHODS Laboratories measured plasma samples spiked with 0.03, 0.2, 0.6 and 0.9 IU/mL N8-GP or rAHF. Samples were blinded, and laboratories were instructed to perform evaluations using their routine FVIII activity assays and calibrators. RESULTS Of the 67 participating laboratories from 25 countries, 60 used a one-stage assay, 36 used a chromogenic assay, and 29 used both one-stage and chromogenic assays. Participating laboratories used nine different activated partial thromboplastin time (aPTT) reagents, the most common being SynthASil® and Actin® FS. Most aPTT reagents recovered N8-GP close to target. Three silica-based aPTT reagents (APTT-SP, TriniCLOT™ and STA® PTT-Automate) underestimated N8-GP, recovering 40%-83% of target concentration. For chromogenic assays, N8-GP and rAHF recoveries were comparable at all concentrations, with overall mean recoveries for both products close to 130%. Assay variability was similar for both assay types and both products; inter-laboratory variability was greater than intra-laboratory variability and highest at 0.03 IU/mL. CONCLUSIONS Most clinical laboratories accurately measured N8-GP and rAHF when using their in-house one-stage or chromogenic FVIII:C assays. However, three silica-based aPTT reagents underestimated N8-GP recovery.
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Affiliation(s)
- Stefan Tiefenbacher
- Laboratory Corporation of America Holdings, Colorado Coagulation, Englewood, Colorado, USA
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Carcao MD, Chelle P, Clarke E, Kim L, Tiseo L, Morfini M, Hossain T, Rand ML, Brown C, Edginton AN, Lillicrap D, Iorio A, Blanchette VS. Comparative pharmacokinetics of two extended half-life FVIII concentrates (Eloctate and Adynovate) in adolescents with hemophilia A: Is there a difference? J Thromb Haemost 2019; 17:1085-1096. [PMID: 31038793 DOI: 10.1111/jth.14469] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/09/2019] [Accepted: 04/19/2019] [Indexed: 01/19/2023]
Abstract
Essentials The PK parameters of Eloctate vs Adynovate were compared using one-stage and chromogenic assays in 25 boys (12-18 years). The FVIII levels were taken at 3, 24, 48, and 72 hours following a dose of either FVIII; levels analyzed by WAPPS PK program. The PK profiles (half-life, clearance, and time to 5%, 3%, and 1%) were not statistically different for the two EHL FVIIIs. The significant interpatient variability in PK is mainly related to VWF levels (and blood group). BACKGROUND A head-to-head comparison of the pharmokinetcs (PK) of extended half-life (EHL) factor VIII (FVIII) concentrates in the same subjects has not been reported. Recently, boys (ages 12-18 years) with hemophilia A in Canada were required to switch from Eloctate to Adynovate. OBJECTIVES Compare the PK profiles of Eloctate vs Adynovate in the same boys. METHODS Boys switching from Eloctate to Adynovate prophylaxis had FVIII levels sampled at 3, 24, 48, and 72 hours following a regular prophylactic infusion of Eloctate and then 1-3 months later, of Adynovate. Testing was done by one-stage assay (OSA) and chromogenic assay (CA). The PK parameters were determined with the Web Accessible Population Pharmacokinetic Service (WAPPS)-Hemo PK tool. RESULTS Twenty-five boys (mean age 15.3 years; range: 12.1-18.4; 9 O blood group) underwent switching. Mean (range) terminal half-lives with the OSA were 16.1 hours (10.4 to 23.4; Eloctate) and 16.7 hours (11.0 to 23.6; Adynovate) (NS). With the CA, these were 18.0 hours (12.0 to 25.5; Eloctate) and 16.0 hours (10.3 to 22.9; Adynovate) (P = 0.001). There were no significant differences between the two EHL-FVIIIs in clearance, area under the concentration vs time curve (AUC), Vss, or time for FVIII levels to drop to 5%, 3%, and 1%. At the 72-h time point, mean observed FVIII levels following a mean dose of 39.3 IU/kg of Eloctate were 4.4% (OSA) and 4.4% (CA). For Adynovate, these were 5.1% (OSA) and 5.3% (CA) following similar doses. There was considerable interpatient variation in PK, mainly explained by differences in blood group/von Willebrand factor (VWF) levels. CONCLUSIONS Eloctate and Adynovate have almost identical PK parameters. When switching from one to another no prophylaxis regimen change is needed.
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Affiliation(s)
- Manuel D Carcao
- Division of Haematology/Oncology, Department of Paediatrics and Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Pierre Chelle
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Emily Clarke
- Department of Nursing, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Lussia Kim
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Laura Tiseo
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Taneya Hossain
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - Margaret L Rand
- Division of Haematology/Oncology, Department of Paediatrics and Translational Medicine, Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Departments of Laboratory Medicine & Pathobiology and Biochemistry, University of Toronto, Toronto, ON, Canada
| | - Christine Brown
- Department of Pathology & Molecular Medicine, Queen's University, Kingston, ON, Canada
| | | | - David Lillicrap
- Department of Pathology & Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Alfonso Iorio
- McMaster-Bayer Endowed Research Chair for Clinical Epidemiology of Congenital Bleeding Disorders, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Victor S Blanchette
- Division of Haematology/Oncology, Department of Paediatrics and Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Chowdary P, Carcao M, Holme PA, Jiménez‐Yuste V, Lentz SR, Møss J, Poulsen LH, Shen C, Tosetto A, Wheeler A, Santagostino E. Fixed doses of N8-GP prophylaxis maintain moderate-to-mild factor VIII levels in the majority of patients with severe hemophilia A. Res Pract Thromb Haemost 2019; 3:542-554. [PMID: 31294338 PMCID: PMC6611478 DOI: 10.1002/rth2.12220] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/11/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND N8-GP is an extended half-life recombinant factor VIII developed for prophylaxis and treatment of bleeds in patients with hemophilia A. OBJECTIVE To assess pharmacokinetic (PK) characteristics of N8-GP in previously treated patients with severe hemophilia A, model the time spent at hemophilia thresholds of ≥1 and ≤5 IU/dL (moderate) or >5 IU/dL (mild) FVIII levels during N8-GP prophylaxis, and investigate the relationship between N8-GP half-life and von Willebrand factor (vWF). METHODS PK assessments were obtained from patients with severe hemophilia A (FVIII < 1 IU/dL) participating in 4 clinical trials: pathfinder 1 (20-60 years); pathfinder 2 (12-17 and ≥18 years); pathfinder 5 (0-11 years), and pathfinder 7 (25-71 years). All PK profiles were assessed after washout and considered single-dose PK profiles. Pre- and postdose FVIII activity at steady state was measured at all visits. RESULTS From 69 patients, 108 PK profiles of N8-GP 50 IU/kg were assessed. Adults/adolescents received 50 IU/kg every 4 days, achieving mean trough levels of 3.0 IU/dL (95% confidence interval, 2.6-3.5, adults) and 2.7 IU/dL (1.8-4.0, adolescents). Children received 60 IU/kg twice weekly, leading to mean trough levels of 1.2 IU/dL (0.8-1.6, 0- to 5-year-olds) and 2.0 IU/dL (1.5-2.7, 6- to 11-year-olds). PK modeling predicted children dosed every 3 days and adults/adolescents dosed every 3 to 4 days would maintain FVIII levels >5 and >1 IU/dL for >80% and 100% of the time, respectively. N8-GP half-life correlated linearly with von Willebrand factor levels in adults/adolescents, less in children. CONCLUSIONS Prophylaxis with fixed intervals (Q4D/twice weekly) and fixed weight-based dosing (50/60 IU/kg) ensured >1 IU/dL FVIII trough levels in both adults and children.
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Affiliation(s)
- Pratima Chowdary
- Katherine Dormandy Haemophilia Centre and Thrombosis UnitRoyal Free HospitalLondonUK
| | - Manuel Carcao
- Division of Haematology/Oncology and Child Health Evaluative SciencesResearch InstituteHospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Pål A. Holme
- Department of HaematologyInstitute of Clinical MedicineUniversity of OsloOslo University HospitalOsloNorway
| | - Victor Jiménez‐Yuste
- Hospital Universitario La PazUnidad De CoagulopatíasServicio De HematologíaAutonoma UniversityMadridSpain
| | - Steven R. Lentz
- Division of Hematology, Oncology, and Blood & Marrow TransplantationDepartment of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityIAUSA
| | | | - Lone H. Poulsen
- Hemophilia CenterDepartment of HematologyAarhus University HospitalAarhusDenmark
| | | | - Alberto Tosetto
- Hemophilia and Thrombosis CenterHematology DepartmentSan Bortolo HospitalVicenzaItaly
| | - Allison Wheeler
- School of Medicine, Pathology, Microbiologyand Immunology, Vanderbilt UniversityNashvilleTNUSA
| | - Elena Santagostino
- Foundation IRCCS Cà Granda, Maggiore Hospital PolyclinicAngelo Bianchi Bonomi Hemophilia and Thrombosis CentreMilanItaly
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41
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Yu JK, Iorio A, Edginton AN. Using pharmacokinetics for tailoring prophylaxis in people with hemophilia switching between clotting factor products: A scoping review. Res Pract Thromb Haemost 2019; 3:528-541. [PMID: 31294337 PMCID: PMC6611373 DOI: 10.1002/rth2.12204] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/28/2019] [Accepted: 03/21/2019] [Indexed: 01/19/2023] Open
Abstract
The objective of this scoping review is to summarize the current use of pharmacokinetics for tailoring prophylaxis in hemophilia patients switching between clotting factor products. Patients with hemophilia may require switching of clotting factor concentrates due to a variety of factors, but there have been perceived risks associated with switching, such as inhibitor development or suboptimal protection due to inadequate dosing while titrating treatment. Studies that look at patients switching from one clotting factor concentrate to another are categorized in terms of their primary and/or secondary objectives, notably biosimilarity and comparative pharmacokinetic studies and inhibitor development studies. Research on how best to switch concentrates with respect to dosing regimen are lacking, and currently a trial‐and‐error approach is used for dosing the new factor concentrate. In the future, studies looking at the predictability of pharmacokinetics (PK) of a new factor concentrate based on individual PK knowledge of the original factor concentrate may offer clinical benefit by providing a safer switching approach and protocol.
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Affiliation(s)
- Jacky K Yu
- School of Pharmacy University of Waterloo Waterloo Ontario Canada
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact McMaster University Hamilton Ontario Canada.,McMaster-Bayer Research Chair in Clinical Epidemiology of Congenital Bleeding Disorders Department of Medicine McMaster University Hamilton Ontario Canada
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Kearney S, Raffini LJ, Pham TP, Lee XY, von Mackensen S, Landorph A, Takedani H, Oldenburg J. Health-related quality-of-life and treatment satisfaction of individuals with hemophilia A treated with turoctocog alfa pegol (N8-GP): a new recombinant extended half-life FVIII. Patient Prefer Adherence 2019; 13:497-513. [PMID: 31040652 PMCID: PMC6460998 DOI: 10.2147/ppa.s196103] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Prophylactic treatment regimens lead to improvements in health-related quality-of-life (HRQoL) among individuals with hemophilia. Turoctocog alfa pegol (N8-GP) provides the benefit of extending the duration of protection from bleeding and reducing the number of injections, which is expected to impact HRQoL and treatment satisfaction (TS). AIM To investigate the HRQoL and TS of patients with severe hemophilia A from two phase III trials evaluating the safety and efficacy of N8-GP. METHODS HRQoL was assessed using the Haemo-QoL (reported by children and their parents) and Haem-A-QoL (reported by adults). TS was assessed using Hemo-Sat. Domain and total scores for all questionnaires ranged from 0 to 100, with lower scores indicating a better HRQoL or TS. A negative change in score indicates an improvement in HRQoL/TS. RESULTS Mean changes in HRQoL scores were reported for 14 children aged 4-7 years, 21 children aged 8-11 years, 10 adolescents aged 13-16 years, and 163 adults (17 years and above). Mean changes in children/adolescents-reported Haemo-QoL total score were -14.0 for ages 4-7 years, -3.6 for ages 8-11 years, and -0.1 for ages 13-16 years. Mean changes in parent-reported Haemo-QoL total scores were -11.5 for 4-7 years, -8.6 for ages 8-11 years, and -4.0 for 13-16 years. Adults' mean change in Haem-A-QoL total score was -3.1 for those receiving on-demand treatment and -2.3 for those receiving prophylaxis treatment. High levels of TS with N8-GP were reported by parents of children/adolescents and the adults at the end of the trial. CONCLUSION While most patients reported a relatively good baseline HRQoL when entering the respective trials, the HRQoL of patients was either maintained or further improved when treated with N8-GP. Adults and parents of children and adolescents reported a high level of treatment satisfaction with N8-GP.
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Affiliation(s)
- Susan Kearney
- Center for Bleeding and Clotting Disorders, Children's Hospital Minnesota, Minneapolis, MN, USA
| | - Leslie J Raffini
- Division of Hematology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Tan P Pham
- Mapi (an Icon plc company), Boston, MA, USA
| | - Xin Ying Lee
- Global Biopharm Patient Access, Biopharm Operations, Novo Nordisk A/S, Copenhagen, Denmark
| | - Sylvia von Mackensen
- Department of Medical Psychology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany,
| | - Andrea Landorph
- Medical & Science, Biopharm Operations, Novo Nordisk A/S, Copenhagen, Denmark
| | - Hideyuki Takedani
- Department of Joint Surgery, Research Hospital of the Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
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Mahlangu JN. Updates in clinical trial data of extended half-life recombinant factor IX products for the treatment of haemophilia B. Ther Adv Hematol 2018; 9:335-346. [PMID: 30364483 PMCID: PMC6196631 DOI: 10.1177/2040620718802606] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/03/2018] [Indexed: 12/23/2022] Open
Abstract
Whilst the global prevalence of haemophilia B is less than that of haemophilia A, rapid and remarkable innovations have been made in the development of haemophilia B therapies in the last decade. The most recent developments are the evolution of extended half-life haemophilia B replacement therapies which are designed to reduce the treatment burden associated with prophylactic infusion of factor IX (FIX) to prevent bleeding in haemophilia B participants. Clinical development programmes have culminated in the completion of three phase III studies on extended half-life (EHL) recombinant FIX (rFIX) products and subsequent approval and registration of these in many countries around the world. Current data from the three EHL rFIX clinical studies indicate that these products have acceptable safety profiles with no allergic reactions, thromboembolic phenomena or neutralizing antibodies when given to previously treated adolescent and adults for the prevention of bleeds, for the treatment of bleeds and in the perisurgical haemostasis use. Studies in previously untreated paediatric participants are currently ongoing. The EHL rFIX products have the potential impact to reduce the treatment burden associated with prophylactic infusion of replacement FIX, to treat and prevent bleeds in participants with haemophilia B and to improve the participant's health-related quality of life. The impact of EHL rFIX is likely to be modified by current development of other haemophilia B therapy such as antitissue factor pathway inhibitors and haemophilia B gene therapy. In this review, we aim to provide an update on the safety and efficacy data from the three EHL rFIX clinical studies and to consider their roles in the face of novel haemophilia B therapy currently evolving.
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Affiliation(s)
- Johnny N. Mahlangu
- Haemophilia Comprehensive Care Centre, Charlotte Maxeke Johannesburg Academic Hospital, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, 7 York Road, Parktown, Johannesburg 2193, South Africa
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Abstract
The unprecedented emergence of novel therapeutics for both hemophilia A and B during the last half decade has been accompanied by the promise of even more extraordinary progress in ameliorative and curative strategies for both disorders. Paradoxically, the speed of innovation has created new dilemmas for persons with hemophilia and their physicians with respect to optimizing individual choices from the expanding menu of standard and novel therapies and approaches to symptom or risk reduction, and ultimately, to normalizing the hemophilia phenotype. Among the most disruptive new approaches, challenges remain in the form of the adverse reactions that have been observed with nonfactor therapies, as well as in the uncertain long-term safety profile of potentially curative gene therapy. Together, these challenges have generated uncertainty as to how to adopt novel therapies and treatment strategies across a diverse patient population, creating speed bumps on the hemophilia innovation highway. It is from this perspective that this article discusses the current state of gene therapy and bleeding prophylaxis for hemophilia A and B, as well as prevention and treatment of the factor VIII inhibitor phenotype in hemophilia A. It further posits that these speed bumps may provide important clues to the mechanistic understanding of both symptom manifestation and resilience within the hemophilia phenotype, as well as opportunities to reconsider and reconfigure the current paradigms for symptom prediction and individualized therapeutic decision making.
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Affiliation(s)
- Donna M DiMichele
- Division of Blood Diseases and Resources, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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45
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Shah A, Coyle T, Lalezari S, Fischer K, Kohlstaedde B, Delesen H, Radke S, Michaels LA. BAY 94-9027, a PEGylated recombinant factor VIII, exhibits a prolonged half-life and higher area under the curve in patients with severe haemophilia A: Comprehensive pharmacokinetic assessment from clinical studies. Haemophilia 2018; 24:733-740. [DOI: 10.1111/hae.13561] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2018] [Indexed: 11/28/2022]
Affiliation(s)
| | - T. Coyle
- TriHealth Cancer Institute; Cincinnati OH USA
| | - S. Lalezari
- Israel National Hemophilia Center; Chaim Sheba Medical Center; Tel-Hashomer, and Sackler School of Medicine; Tel-Aviv University; Israel
| | - K. Fischer
- Van Creveldkliniek; University Medical Center Utrecht; Utrecht University; Utrecht The Netherlands
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46
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Graf L. Extended Half-Life Factor VIII and Factor IX Preparations. Transfus Med Hemother 2018; 45:86-91. [PMID: 29765290 DOI: 10.1159/000488060] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 03/01/2018] [Indexed: 01/06/2023] Open
Abstract
In the last couple of years, several extended half-life factor VIII and factor IX preparations were intensively studied and gained approval. In order to extend half-lives, techniques like fusion to protein conjugates (Fc part of IgG1 or albumin), chemical modification (PEGylation), and protein sequence modification are implemented. With these techniques, it is possible to extend half-lives of factor IX products 4- to 6- fold, while half-life extension of factor VIII products is limited to 1.5- to 2-fold due to their interaction with von Willebrand factor. Nevertheless, both extended half-life factor VIII and IX products have improved and facilitated prophylactic factor replacement therapy in hemophilia A and B, respectively. Extended half-life factor concentrates pose challenges to coagulation laboratories because accurate therapy monitoring is not possible with all factor activity assays currently used.
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Affiliation(s)
- Lukas Graf
- Center for Laboratory Medicine, Hemophilia and Hemostasis Center, St. Gallen, Switzerland
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47
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Zhang W, Mao JH. [Advances of hemophilia A treatment]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 39:83-86. [PMID: 29551046 PMCID: PMC7343114 DOI: 10.3760/cma.j.issn.0253-2727.2018.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | - J H Mao
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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