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Liu YL, Zhu XX, Niu LY, Gao Y, Gan H, Wu ZN, Li J, Feng SX, Dou GF, Gu RL, Meng ZY. The Pharmacokinetics and Pharmacodynamics of A Novel Recombinant Activated Human Factor VII, GEN-0828, in Hemophilia B Mice. J Pharm Sci 2023; 112:877-883. [PMID: 36565924 DOI: 10.1016/j.xphs.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
GEN-0828, a proposed clinical candidate for hemophilia and trauma hemorrhage treatment, is a novel recombinant activated human factor VII (rFVIIa). The purpose of this paper is to compare the pharmacokinetics and pharmacodynamics of GEN-0828 in hemophilia B mice with those of NovoSeven®, the only marketed rFVIIa product worldwide., GEN-0828 and NovoSeven® showed similar affinity bioactivity to recombinant tissue factor (rTF) in vitro. Pharmacodynamics data indicated a generally similar hemostatic efficacy (ED50) of GEN-0828 (10.91 KIU·kg-1) and NovoSeven® (18.91 KIU·kg-1) at the doses studied in hemophilia B mice, while GEN-0828 represented a lower initial effective dosage compared with that of NovoSeven® in terms of both blood loss and APTT. GEN-0828 exhibited linear pharmacokinetic profiles in hemophilia B mice at the 30-338 KIU·kg-1 dose range, the comparative pharmacokinetic study with NovoSeven® indicated better characteristics than NovoSeven® in terms of the appropriate higher maximal concentration (Cmax) and area under the plasma concentration-time curve (AUClast) and longer mean residence time (MRT). In conclusion, GEN-0828 was a promising new type of rFVIIa compound with favourable pharmacokinetic and pharmacodynamic profiles.
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Affiliation(s)
- Yu-Lu Liu
- Beijing Institute of Radiation Medicine, Beijing 100850, China; College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou 450046, China
| | - Xiao-Xia Zhu
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Li-Yun Niu
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Ya Gao
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Hui Gan
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Zhuo-Na Wu
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Jian Li
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Su-Xiang Feng
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou 450046, China; Co-construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of China, Henan University of Chinese Medicine, Zhengzhou 450046, China.
| | - Gui-Fang Dou
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Ruo-Lan Gu
- Beijing Institute of Radiation Medicine, Beijing 100850, China.
| | - Zhi-Yun Meng
- Beijing Institute of Radiation Medicine, Beijing 100850, China.
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2
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Schutgens REG, Urbanus RT. Glanzmann thrombasthenia complicated by frequent myeloproliferative neoplasm-related thromboembolism: thrombosis occurring regardless of αIIbβIII integrin deficiency. Clin Case Rep 2021; 9:e04757. [PMID: 34552732 PMCID: PMC8443414 DOI: 10.1002/ccr3.4757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/06/2021] [Accepted: 08/08/2021] [Indexed: 11/06/2022] Open
Abstract
A patient with Glanzmann Thrombasthenia developed recurrent venous thrombosis with a JAK2 positive myeloproliferative neoplasm. This indicates that the platelet aIIbβIII integrin has no role in venous thrombosis. We discuss the other potential mechanisms that are involved. In addition, we describe the successful use of dabigatran in this patient.
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Affiliation(s)
- Roger E. G. Schutgens
- Van CreveldkliniekUniversity Medical Centre Utrecht, University UtrechtThe Netherlands
| | - Rolf T. Urbanus
- Van CreveldkliniekUniversity Medical Centre Utrecht, University UtrechtThe Netherlands
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3
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Platelet transfusion for patients with platelet dysfunction: effectiveness, mechanisms, and unanswered questions. Curr Opin Hematol 2021; 27:378-385. [PMID: 32868672 DOI: 10.1097/moh.0000000000000608] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW In this review, we discuss current clinical guidelines and potential underlying mechanisms regarding platelet transfusion therapy in patients at risk of bleeding, comparing management of patients with thrombocytopenia versus those with qualitative platelet disorders. RECENT FINDINGS Platelet transfusion therapy is highly effective in managing bleeding in patients with hypoproliferative thrombocytopenia. Clinical trials have demonstrated that platelet transfusion can be used at a lower trigger threshold and reduced platelet doses, and may be used therapeutically rather than prophylactically in some situations, although additional data are needed. In patients with inherited platelet disorders such as Glanzmann's Thrombasthenia or those with RASGRP2 mutations, platelet transfusion may be ineffective because of competition between transfused and endogenous platelets at the site of vascular injury. Successful management of these patients may require transfusion of additional platelet units, or mechanism-driven combination therapy with other pro-hemostatic agents. In patients on antiplatelet therapy, timing of transfusion and inhibitor mechanism-of-action are key in determining therapeutic success. SUMMARY Expanding our understanding of the mechanisms by which transfused platelets exert their pro-hemostatic function in various bleeding disorders will improve the appropriate use of platelet transfusion.
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4
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Keshava S, Pendurthi UR, Esmon CT, Rao LVM. Therapeutic doses of recombinant factor VIIa in hemophilia generates thrombin in platelet-dependent and -independent mechanisms. J Thromb Haemost 2020; 18:1911-1921. [PMID: 32359012 PMCID: PMC7415704 DOI: 10.1111/jth.14881] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/09/2020] [Accepted: 04/14/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND In hemophilia bypass therapy, a platelet-dependent mechanism is believed to be primarily responsible for recombinant factor VIIa (rFVIIa)'s hemostatic effect. rFVIIa may also possibly interact with other cells through its binding to endothelial cell protein C receptor (EPCR) or cell surface phospholipids. OBJECTIVES We aim to investigate the relative contribution of platelet-dependent and platelet-independent mechanisms in rFVIIa-mediated thrombin generation in hemophilic conditions at the injury site. METHODS Platelets were depleted in acquired and genetic hemophilia mice using anti-platelet antibodies. The mice were subjected to the saphenous vein injury, and the hemostatic effect of pharmacological concentrations of rFVIIa was evaluated by measuring thrombin generation at the injury site. RESULTS Administration of anti-mouse CD42 antibodies to mice depleted platelets by more than 95%. As expected, hemophilia mice, compared with wild-type mice, generated only a small fraction of thrombin at the injury site. The depletion of platelets in hemophilia mice further reduced thrombin generation. However, when pharmacological doses of rFVIIa were administered to hemophilia mice, substantial amounts of thrombin were generated even in the platelet-depleted hemophilia mice. No differences in thrombin generation were detected among FVIII-/- , EPCR-deficient FVIII-/- , and EPCR-overexpressing FVIII-/- mice depleted of platelets or not. Evaluation of platelets by flow cytometry as well as immunoblot analysis showed no detectable expression of EPCR. CONCLUSIONS Our data suggest that pharmacological concentrations of rFVIIa generate thrombin in hemophilia in both platelet-dependent and platelet-independent mechanisms.
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Affiliation(s)
- Shiva Keshava
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Texas, USA
| | - Usha R Pendurthi
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Texas, USA
| | - Charles T. Esmon
- Coagulation Biology Laboratory, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - L. Vijaya Mohan Rao
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Texas, USA
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5
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Lee RH, Piatt R, Dhenge A, Lozano ML, Palma-Barqueros V, Rivera J, Bergmeier W. Impaired hemostatic activity of healthy transfused platelets in inherited and acquired platelet disorders: Mechanisms and implications. Sci Transl Med 2019; 11:eaay0203. [PMID: 31826978 PMCID: PMC10824274 DOI: 10.1126/scitranslmed.aay0203] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 10/11/2019] [Indexed: 12/21/2022]
Abstract
Platelet transfusions can fail to prevent bleeding in patients with inherited platelet function disorders (IPDs), such as Glanzmann's thrombasthenia (GT; integrin αIIbβ3 dysfunction), Bernard-Soulier syndrome [BSS; glycoprotein (GP) Ib/V/IX dysfunction], and the more recently identified nonsyndromic RASGRP2 variants. Here, we used IPD mouse models and real-time imaging of hemostatic plug formation to investigate whether dysfunctional platelets impair the hemostatic function of healthy donor [wild-type (WT)] platelets. In Rasgrp2-/- mice or mice with platelet-specific deficiency in the integrin adaptor protein TALIN1 ("GT-like"), WT platelet transfusion was ineffective unless the ratio between mutant and WT platelets was ~2:1. In contrast, thrombocytopenic mice or mice lacking the extracellular domain of GPIbα ("BSS-like") required very few transfused WT platelets to normalize hemostasis. Both Rasgrp2-/- and GT-like, but not BSS-like, platelets effectively localized to the injury site. Mechanistic studies identified at least two mechanisms of interference by dysfunctional platelets in IPDs: (i) delayed adhesion of WT donor platelets due to reduced access to GPIbα ligands exposed at sites of vascular injury and (ii) impaired consolidation of the hemostatic plug. We also investigated the hemostatic activity of transfused platelets in the setting of dual antiplatelet therapy (DAPT), an acquired platelet function disorder (APD). "DAPT" platelets did not prolong the time to initial hemostasis, but plugs were unstable and frequent rebleeding was observed. Thus, we propose that the endogenous platelet count and the ratio of transfused versus endogenous platelets should be considered when treating select IPD and APD patients with platelet transfusions.
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Affiliation(s)
- Robert H Lee
- Department of Biochemistry and Biophysics, University of North Carolina, Chapel Hill, NC 27599, USA.
- UNC Blood Research Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Raymond Piatt
- Department of Biochemistry and Biophysics, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Ankita Dhenge
- Department of Biochemistry and Biophysics, University of North Carolina, Chapel Hill, NC 27599, USA
- UNC Blood Research Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - María L Lozano
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CB15/00055-CIBERER, Murcia 30003, Spain
| | - Verónica Palma-Barqueros
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CB15/00055-CIBERER, Murcia 30003, Spain
| | - José Rivera
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CB15/00055-CIBERER, Murcia 30003, Spain
| | - Wolfgang Bergmeier
- Department of Biochemistry and Biophysics, University of North Carolina, Chapel Hill, NC 27599, USA.
- UNC Blood Research Center, University of North Carolina, Chapel Hill, NC 27599, USA
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6
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Lee SM, Kim KN, Kim SY. Perioperative Hemostatic Management of a Pediatric Patient with Glanzmann Thrombasthenia Undergoing Osteoplastic Craniotomy and Hematoma Removal: A Case Report. Acta Haematol 2019; 142:244-248. [PMID: 31085914 DOI: 10.1159/000499362] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 03/04/2019] [Indexed: 11/19/2022]
Abstract
Glanzmann thrombasthenia is an uncommon hereditary disease that involves an abnormal platelet function leading to complicated hemostatic problems. In situations of anticipated hemorrhage, irradiated apheresed platelets are the first line of treatment. In addition, a combination of recombinant factor VIIa and an antifibrinolytic agent such as tranexamic acid can be utilized to minimize bleeding. Here we are present stable management of a pediatric patient with Glanzmann thrombasthenia admitted for traumatic epidural hematoma removal. Due to the condition of the operation site, some blood loss was unavoidable. However, hemostasis was successfully controlled, and the patient was discharged without additional complications.
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Affiliation(s)
- Sung Min Lee
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Seoul, Republic of Korea
| | - Kyu Nam Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Seoul, Republic of Korea,
| | - Soo Yeon Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, Seoul, Republic of Korea
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7
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Factor VIIa. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00063-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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8
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Inherited platelet disorders : Management of the bleeding risk. Transfus Clin Biol 2018; 25:228-235. [PMID: 30077511 DOI: 10.1016/j.tracli.2018.07.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 01/19/2023]
Abstract
Inherited platelet disorders are rare bleeding syndromes due to either platelet function abnormalities or thrombocytopenia which may be associated with functional defects. The haemorrhagic symptoms observed in these patients are mostly muco-cutaneous and of highly variable severity. Although 30 to 50% of the platelet disorders are still of unknown origin, the precise diagnosis of these pathologies by specialized laboratories together with haemorrhagic scores enables an assessment of the risk of bleeding in each patient. Depending on the diagnostic elements collected, an appropriate medical procedure can be proposed for each situation: scheduled or emergency surgical interventions and pregnancy follow-up. The pathologies most at risk correspond to Glanzmann's thrombasthenia, Bernard-Soulier syndrome, severe thrombocytopenia (<40,000 platelets/μL) and signalling protein abnormalities affecting the activation of GPIIb-IIIa, a membrane glycoprotein essential for platelet aggregation. For these particular patients, in whom the risk of bleeding can be increased by a factor of 40, management protocols during surgical procedures are generally based on the use of conventional platelet concentrates, for both prophylaxis and the control of active bleeding. The perinatal period in women with platelet disorders and their new-born also require special attention. Indeed, beyond unpredictable delivery haemorrhages, bleeding requiring a blood transfusion is observed after delivery in more than 50% of women with Glanzmann's thrombastenia or Bernard-Soulier syndrome.
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9
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Lee A, Poon MC. Inherited platelet functional disorders: General principles and practical aspects of management. Transfus Apher Sci 2018; 57:494-501. [PMID: 30031712 DOI: 10.1016/j.transci.2018.07.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Platelets are a critical component for effecting hemostasis and wound healing. Disorders affecting any platelet pathway mediating adhesion, activation, aggregation and procoagulant surface exposure can result in a bleeding diathesis. Specific diagnosis even with advanced techniques which are unavailable to most centers is often difficult. Inherited platelet function disorders therefore represent a heterogeneous and complex collection of disorders with a spectrum of bleeding severity, from relatively mild (and easily missed or misdiagnosed) to severe bleeding phenotype with salient diagnostic features. We advocate the use of bleeding assessment tools to help identification of patients and more importantly for assessment of individual patient bleeding phenotype to guide management decisions for treating and preventing bleeding. The complex management of these patients is best coordinated in a multidisciplinary comprehensive care clinic setting expert in managing bleeding disorders and associated complications, with particular attention to the physical and psychosocial health of patients and their families. Depending on the bleeding phenotype, the location and severity of bleeding, and the nature of an invasive procedure, available treatment modalities range from conservative measures using local pressure, topical thrombin, fibrin sealant, antifibrinolytics etc. to the use of systemic haemostatics such as desmopressin (DDAVP), platelets and recombinant human activated factor VII (rFVIIa). This review will provide opinions on the practical aspects and general management of inherited platelet function disorders, with discussion on the mechanism of action, and the pros and cons of various hemostatic agents. Finally, the prospect of curative treatment for patients with severe bleeding phenotype refractory to available treatments and with poor quality of life will be briefly discussed.
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Affiliation(s)
- Adrienne Lee
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada; Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Canada.
| | - Man-Chiu Poon
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Pediatric, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Canada; Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Canada.
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10
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Fiore M, d'Oiron R, Pillois X, Alessi MC. Anti-α IIb β 3 immunization in Glanzmann thrombasthenia: review of literature and treatment recommendations. Br J Haematol 2018; 181:173-182. [PMID: 29611179 DOI: 10.1111/bjh.15087] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Glanzmann thrombasthenia (GT) is caused by inherited defects of the αIIb β3 platelet glycoprotein. This bleeding disorder can be treated with platelet transfusion therapy, but some patients will be immunized and begin to form anti-human leucocyte antigen (HLA) and/or anti-αIIb β3 antibodies. These antibodies can bind and interfere with the function of the transfused platelets, rendering treatment ineffective. However, platelet transfusion refractoriness attributable to HLA antibodies may be managed by the selection of compatible donors, although they are not always readily available, particularly in an emergency. Thus, anti-αIIb β3 antibodies represent one of the most severe complications in GT. Both genetic and environmental factors may contribute to the risk of anti-αIIb β3 development, but the underlying pathogenic mechanisms are still unknown. This review will summarize the current knowledge of the risk factors for development of anti-αIIb β3 antibodies in patients with GT and discuss how these findings may influence the clinical management of patients.
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Affiliation(s)
- Mathieu Fiore
- Laboratory of Haematology, Reference Centre for Platelet Disorders, University Hospital of Bordeaux, Pessac, France
| | - Roseline d'Oiron
- Centre for Haemophilia and Rare Congenital Disorders, University Hospital Paris-Sud, AP-HP, Bicêtre Hospital, Kremlin-Bicêtre, France
| | - Xavier Pillois
- Laboratory of Haematology, Reference Centre for Platelet Disorders, University Hospital of Bordeaux, Pessac, France.,Cardiovascular Adaptation to Ischaemia, Inserm U1034, Pessac, France
| | - Marie-Christine Alessi
- Laboratory of Haematology, University Hospital of La Timone, French Reference Centre for Rare Platelet Disorders, Marseille, France
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11
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Saultier P, Szepetowski S, Canault M, Falaise C, Poggi M, Suchon P, Barlogis V, Michel G, Loyau S, Jandrot-Perrus M, Bordet JC, Alessi MC, Chambost H. Long-term management of leukocyte adhesion deficiency type III without hematopoietic stem cell transplantation. Haematologica 2018; 103:e264-e267. [PMID: 29472353 DOI: 10.3324/haematol.2017.186304] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Paul Saultier
- APHM, La Timone Children's Hospital, Department of pediatric hematology and oncology, Marseille, France .,Aix Marseille Univ, INSERM, INRA, C2VN, France
| | - Sarah Szepetowski
- APHM, La Timone Children's Hospital, Department of pediatric hematology and oncology, Marseille, France
| | | | - Céline Falaise
- APHM, La Timone Children's Hospital, Department of pediatric hematology and oncology, Marseille, France.,APHM, CHU Timone, Laboratory of Hematology, Marseille, France.,APHM, CHU Timone, French national reference center for inherited platelet disorders (CRPP), Marseille, France
| | | | - Pierre Suchon
- Aix Marseille Univ, INSERM, INRA, C2VN, France.,APHM, CHU Timone, Laboratory of Hematology, Marseille, France
| | - Vincent Barlogis
- APHM, La Timone Children's Hospital, Department of pediatric hematology and oncology, Marseille, France.,APHM, La Timone Children's Hospital, French national reference center for primary immune deficiencies (CEREDIH), Marseille, France
| | - Gérard Michel
- APHM, La Timone Children's Hospital, Department of pediatric hematology and oncology, Marseille, France.,APHM, La Timone Children's Hospital, French national reference center for primary immune deficiencies (CEREDIH), Marseille, France
| | - Stéphane Loyau
- Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Univ Paris Diderot, Sorbonne Paris Cité, France
| | - Martine Jandrot-Perrus
- Laboratory of Vascular Translational Science, U1148 Institut National de la Santé et de la Recherche Médicale (INSERM), Univ Paris Diderot, Sorbonne Paris Cité, France
| | - Jean-Claude Bordet
- HCL, Hôpital Cardiologique Louis Pradel, Unité d'Hémostase Biologique, Bron, France.,EAM 4609 Hémostase et cancer, Université Claude Bernard Lyon 1, France
| | - Marie-Christine Alessi
- Aix Marseille Univ, INSERM, INRA, C2VN, France.,APHM, CHU Timone, Laboratory of Hematology, Marseille, France.,APHM, CHU Timone, French national reference center for inherited platelet disorders (CRPP), Marseille, France
| | - Hervé Chambost
- APHM, La Timone Children's Hospital, Department of pediatric hematology and oncology, Marseille, France.,Aix Marseille Univ, INSERM, INRA, C2VN, France
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12
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Loon JEV, Jaegere PPTD, Vliet HHDMV, Maat MPMD, de Groot PG, Simoons ML, Leebeek FWG. The in vitro effect of the new antithrombotic drug candidate ALX-0081 on blood samples of patients undergoing percutaneous coronary intervention. Thromb Haemost 2017; 106:165-71. [DOI: 10.1160/th10-12-0804] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 04/05/2011] [Indexed: 11/05/2022]
Abstract
SummaryCompound ALX-0081 is a bivalent humanised Nanobody® that binds the A1-domain of von Willebrand factor (VWF) with high affinity. Consequently, it can block the interaction between VWF and its platelet-receptor- glycoprotein Ib, which leads inevitably to formation of arterial thrombi. It was the objective of this study to assess the in vitro effects of ALX-0081 on platelet adhesion and aggregation in coronary artery disease (CAD) patients to determine the optimal concentration of ALX-0081 and the effect of co-medication. We included nine CAD patients, who were scheduled for elective percutaneous coronary intervention (PCI), and 11 healthy volunteers. At admission all patients received aspirin, clopidogrel and heparin. Blood was drawn 24 hours (h) before and 1 h after start of the PCI procedure and was subsequently spiked with different concentrations of ALX-0081 or buffer. The efficacy of ALX-0081 was assessed by in vitro experiments: flow chamber experiments, ristocetin-induced platelet aggregation (RIPA), and the platelet function analyser (PFA-100TM). VWF levels in CAD patients were significantly higher than in healthy controls. During PCI VWF levels did not rise. In all in vitro experiments, ALX-0081 led to complete inhibition of platelet adhesion and aggregation. However, the required effective concentration was higher in patients than in controls and was related to plasma VWF levels. In conclusion, ALX-0081 is able to completely inhibit in vitro platelet adhesion and aggregation in CAD patients scheduled for elective PCI. The efficacy of ALX-0081 is not influenced by PCI or co-medication. However, due to higher VWF levels in CAD patients a higher effective concentration of ALX-0081 was required than in healthy individuals.
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13
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Recht M, Rajpurkar M, Chitlur M, d'Oiron R, Zotz R, Di Minno G, Cooper DL, Poon MC. Independent adjudicator assessments of platelet refractoriness and rFVIIa efficacy in bleeding episodes and surgeries from the multinational Glanzmann's thrombasthenia registry. Am J Hematol 2017; 92:646-652. [PMID: 28370369 DOI: 10.1002/ajh.24741] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 03/22/2017] [Accepted: 03/23/2017] [Indexed: 11/07/2022]
Abstract
Glanzmann's thrombasthenia (GT) is a rare congenital bleeding disorder associated with decreased platelet aggregation due to qualitative/quantitative deficiencies of the fibrinogen receptor. Severe bleeding episodes and perioperative bleeding are typically managed with platelet transfusions, although patients can develop anti-platelet antibodies or experience clinical refractoriness. The GT Registry (GTR) was established to collect efficacy/safety data on hemostatic treatments for GT, including recombinant factor VIIa (rFVIIa). At the request of the United States Food and Drug Administration, three hematology experts evaluated platelet refractoriness, antibody status, and rFVIIa efficacy data on a case-by-case basis to support a potential indication for rFVIIa in GT. Adjudication included 195 patients with 810 events (619 severe bleeding episodes, 192 surgeries), and a consensus algorithm was developed to describe adjudicators' coding of refractoriness and antibody status based on treatment patterns over time. Most rFVIIa-treated events were in patients without refractoriness or antibodies. Adjudicators rated most rFVIIa-treated bleeding episodes as successful (251/266, 94.4%; rFVIIa only, 101/109, 92.7%; rFVIIa ± platelets ± other agents, 150/157, 95.5%); efficacy was consistent in patients with platelet refractoriness ± antibodies (75/79, 94.9%), antibodies only (10/10, 100.0%), and neither/unknown (166/177, 93.8%). Adjudicators also rated most rFVIIa-treated surgeries as successful (159/160, 99.4%; rFVIIa only, 65/66, 98.5%; rFVIIa ± platelets ± other agents, 94/94, 100.0%); efficacy was consistent in patients with platelet refractoriness ± antibodies (69/70, 98.6%), antibodies only (24/24, 100.0%), and neither/unknown (66/66, 100.0%). Unblinding the adjudicators to investigator efficacy ratings changed few assessments. Doses of rFVIIa were narrowly distributed, regardless of other hemostatic agents used.
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Affiliation(s)
- Michael Recht
- Oregon Health & Science University; Portland Oregon USA
| | - Madhvi Rajpurkar
- Children's Hospital of Michigan, Wayne State University; Detroit Michigan USA
| | - Meera Chitlur
- Children's Hospital of Michigan, Wayne State University; Detroit Michigan USA
| | - Roseline d'Oiron
- Centre for Haemophilia and Rare Congenital Bleeding Disorders, University Hospitals Paris-Sud, AP-HP, Bicêtre Hospital; Le Kremlin-Bicêtre France
| | - Rainer Zotz
- Department of Hemostasis; Hemotherapy and Transfusion Medicine, Heinrich Heine University Medical Center, Dusseldorf, Germany and Center for Laboratory Medicine, Blood Coagulation and Transfusion Medicine (LBT); Dusseldorf Germany
| | | | - David L. Cooper
- Clinical Development, Medical and Regulatory Affairs, Novo Nordisk Inc.; Plainsboro New Jersey, USA
| | - Man-Chiu Poon
- University of Calgary and Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program; Calgary Alberta Canada
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14
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Poon MC, Di Minno G, Zotz R, d’Oiron R. Glanzmann’s thrombasthenia: strategies for identification and management. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1341306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Man-Chiu Poon
- Cumming School of Medicine, University of Calgary, Calgary, Canada
- Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, Canada
| | - Giovanni Di Minno
- Department of Clinical Medicine and Surgery, Regional Reference Center for Coagulation Disorders, Federico II University, Naples, Italy
| | - Rainer Zotz
- Institute for Laboratory Medicine, Blood Coagulation and Transfusion Medicine (LBT), Düsseldorf, Germany
- Department of Haemostasis, Haemotherapy and Transfusion Medicine, Heinrich Heine University Medical Centre, D-40225 Düsseldorf, Germany
| | - Roseline d’Oiron
- Centre for Haemophilia and Rare Congenital Bleeding Disorders, University Hospitals Paris-Sud, Le Kremlin-Bicêtre, France
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15
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Martin AC, Houssany-Pissot S, Zlotnik D, Taylor G, Godier A. [Management of the bleeding risk associated with antiplatelet agents]. Rev Med Interne 2017; 38:467-473. [PMID: 28528236 DOI: 10.1016/j.revmed.2017.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 01/09/2017] [Accepted: 01/23/2017] [Indexed: 10/19/2022]
Abstract
Like all antithrombotic drugs, antiplatelet agents expose to a risk of bleeding complications. Clinical research has extensively focused on the efficacy of these drugs to reduce ischemic events. The bleeding risk associated with them was solely considered as an inevitable and acceptable complication. When two new potent P2Y12-receptor inhibitors, prasugrel and ticagrelor, were marketed, the risk of major bleeding increased. These new agents have modified the balance between the absolute risk reduction in ischemic events and the absolute risk increase in bleeding events. This paper is an update on the bleeding risk assessment associated with antiplatelet agents. It discusses the place of platelet function monitoring, and the optimal management of bleeding complications. It addresses the challenging issue of reversal of antiplatelet therapy, focusing especially on ticagrelor, which pharmacodynamics complicate bleeding management.
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Affiliation(s)
- A-C Martin
- Service de cardiologie, hôpital d'instruction des armées Percy, 92140 Clamart, France; Inserm UMRS 1140, faculté de pharmacie, université Paris Descartes, 75006 Paris, France.
| | - S Houssany-Pissot
- Service de cardiologie, hôpital d'instruction des armées Percy, 92140 Clamart, France
| | - D Zlotnik
- Inserm UMRS 1140, faculté de pharmacie, université Paris Descartes, 75006 Paris, France
| | - G Taylor
- Service d'anesthésie réanimation, fondation Adolphe-de-Rothschild, 75019 Paris, France
| | - A Godier
- Inserm UMRS 1140, faculté de pharmacie, université Paris Descartes, 75006 Paris, France; Service d'anesthésie réanimation, fondation Adolphe-de-Rothschild, 75019 Paris, France
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16
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Nurden AT. Should studies on Glanzmann thrombasthenia not be telling us more about cardiovascular disease and other major illnesses? Blood Rev 2017; 31:287-299. [PMID: 28395882 DOI: 10.1016/j.blre.2017.03.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 03/23/2017] [Indexed: 12/17/2022]
Abstract
Glanzmann thrombasthenia (GT) is a rare inherited bleeding disorder caused by loss of αIIbβ3 integrin function in platelets. Most genetic variants of β3 also affect the widely expressed αvβ3 integrin. With brief mention of mouse models, I now look at the consequences of disease-causing ITGA2B and ITGB3 mutations on the non-hemostatic functions of platelets and other cells. Reports of arterial thrombosis in GT patients are rare, but other aspects of cardiovascular disease do occur including deep vein thrombosis and congenital heart defects. Thrombophilic and other risk factors for thrombosis and lessons from heterozygotes and variant forms of GT are discussed. Assessed for GT patients are reports of leukemia and cancer, loss of fertility, bone pathology, inflammation and wound repair, infections, kidney disease, autism and respiratory disease. This survey shows an urgent need for a concerted international effort to better determine how loss of αIIbβ3 and αvβ3 influences health and disease.
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Affiliation(s)
- Alan T Nurden
- Institut de Rhythmologie et de Modélisation Cardiaque, Plateforme Technologique d'Innovation Biomédicale, Hôpital Xavier Arnozan, Pessac, France.
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17
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Successful management of perioperative hemostasis in a patient with Glanzmann thrombasthenia who underwent a right total mastectomy. Int J Hematol 2016; 105:221-225. [PMID: 27696190 DOI: 10.1007/s12185-016-2096-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 09/20/2016] [Accepted: 09/26/2016] [Indexed: 10/20/2022]
Abstract
Perioperative hemostatic management is a challenge in patients with Glanzmann thrombasthenia (GT). The standard means of preventing surgical bleeding in GT patients is platelet transfusion. However, GT patients often possess alloantibodies against GPIIb/IIIa and/or HLA, which cause resistance to platelet transfusion. HLA-matched platelet transfusion, plasmapheresis, or recombinant human-activated factor VII (rFVIIa) are alternative interventions in such cases. Monitoring of hemostasis is also critical in the management of GT patients who undergo surgery. Here, we report the case of a 56-year-old female GT patient with anti-HLA antibodies, who underwent a right total mastectomy without significant blood loss under HLA-matched platelet transfusion. Bleeding at the surgical site, which occurred on the 18th postoperative day, was successfully treated by immediate bolus administration of rFVIIa and subsequent HLA-matched platelet transfusion. The perioperative hemostatic state was monitored in combination with bleeding time, platelet aggregation assay, and flow cytometric analysis of GPIIb/IIIa expression. Although a flow cytometric analysis is not a functional assay, it enabled the estimation of transfused platelet counts, and helped to inform the decision regarding whether to perform the surgery. Thus, perioperative hemostasis was successfully managed in our GT patient by HLA-matched platelet transfusion, rFVIIa administration, and the close monitoring of hemostasis.
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Abstract
Glanzmann's thrombasthenia (GT) and congenital factor VII deficiency (FVII CD) are rare autosomal recessive bleeding disorders: GT is the most frequent congenital platelet function disorder, and FVII CD is the most common factor-deficiency disease after haemophilia. The frequency of these disorders in the general population ranges from 1:500,000 to 1:2,000,000. Because GT and FVII CD are both rare, registries are the only approach possible to allow the collection and analysis of sufficient observational data. Recombinant activated factor VII (rFVIIa, eptacog alfa activated) is indicated for the treatment of acute bleeding episodes and for surgery coverage in patients with GT who are refractory to platelets and have antiplatelet or anti-human leukocyte antigen (HLA) antibodies, and for the prevention and treatment of bleeding in patients with FVII CD. This article summarises published data on the mechanism of action and use of rFVIIa in these disorders from two international, prospective, observational registries: the Glanzmann's Thrombasthenia Registry (GTR) for GT; and the Seven Treatment Evaluation Registry (STER) for FVII CD. Haemostatic effectiveness rates with rFVIIa were high across all patients with GT and those with FVII CD, and treatment with rFVIIa in the GTR and STER registries was well tolerated. The GTR and the STER are the largest collections of data in GT and FVII CD, respectively, and have expanded our knowledge of the management of these two rare bleeding disorders.
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19
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New Insights Into the Treatment of Glanzmann Thrombasthenia. Transfus Med Rev 2016; 30:92-9. [PMID: 26968829 DOI: 10.1016/j.tmrv.2016.01.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 01/12/2016] [Accepted: 01/12/2016] [Indexed: 11/21/2022]
Abstract
Glanzmann thrombasthenia (GT) is a rare inherited autosomal recessive bleeding disorder of platelet function caused by a quantitative or qualitative defect of platelet membrane glycoprotein IIb/IIIa (integrin αIIbβ3), a fibrinogen receptor required for platelet aggregation. Bleeds in GT are variable and may be severe and unpredictable. Bleeding not responsive to local and adjunctive measures, as well as surgical procedures, is treated with platelets, recombinant activated factor VII (rFVIIa), or antifibrinolytics, alone or in combination. Although platelets are the standard treatment for GT, their use is associated with the risk of blood-borne infection transmission and may also cause the development of platelet antibodies (to human leukocyte antigens and/or αIIbβ3), potentially resulting in platelet refractoriness. Currently, where rFVIIa is approved for use in GT, this is mostly for patients with platelet antibodies and/or a history of platelet refractoriness. However, data from the prospective Glanzmann's Thrombasthenia Registry (829 bleeds and 206 procedures in 218 GT patients) show that rFVIIa was frequently used in nonsurgical and surgical bleeds, with high efficacy rates, irrespective of platelet antibodies/refractoriness status. The mechanisms underpinning rFVIIa effectiveness in GT have been studied. At therapeutic concentrations, rFVIIa binds to activated platelets and directly activates FX to FXa, resulting in a burst of thrombin generation. Thrombin converts fibrinogen to fibrin and also enhances GT platelet adhesion and aggregation mediated by the newly converted (polymeric) fibrin, leading to primary hemostasis at the wound site. In addition, thrombin improves the final clot structure and activates thrombin-activatable fibrinolysis inhibitor to decrease clot lysis.
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20
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Lisman T, de Groot PG. The role of cell surfaces and cellular receptors in the mode of action of recombinant factor VIIa. Blood Rev 2015; 29:223-9. [DOI: 10.1016/j.blre.2014.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 12/08/2014] [Indexed: 11/27/2022]
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21
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Platelet glycoprotein VI binds to polymerized fibrin and promotes thrombin generation. Blood 2015; 126:683-91. [PMID: 25977585 DOI: 10.1182/blood-2015-02-629717] [Citation(s) in RCA: 169] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 04/27/2015] [Indexed: 11/20/2022] Open
Abstract
Fibrin, the coagulation end product, consolidates the platelet plug at sites of vascular injury and supports the recruitment of circulating platelets. In addition to integrin αIIbβ3, another as-yet-unidentified receptor is thought to mediate platelet interaction with fibrin. Platelet glycoprotein VI (GPVI) interacts with collagen and several other adhesive macromolecules. We evaluated the hypothesis that GPVI could be a functional platelet receptor for fibrin. Calibrated thrombin assays using platelet-rich plasma (PRP) showed that tissue factor-triggered thrombin generation was impaired in GPVI-deficient patients and reduced by the anti-GPVI Fab 9O12. Assays on reconstituted PRP and PRP from fibrinogen-deficient patients revealed a fibrinogen-dependent enhancement of thrombin generation, which relied on functional GPVI. The effect of GPVI was found to depend on fibrin polymerization. A binding assay showed a specific interaction between GPVI-Fc and fibrin, inhibited by the Fab 9O12. This Fab also reduced platelet adhesion to fibrin at low (300 s(-1)) and high (1500 s(-1)) wall shear rates. Platelets adherent to fibrin displayed shape change, exposure of procoagulant phospholipids, and the formation of small clots. When hirudinated blood was perfused at 1500 s(-1) over preformed fibrin-rich clots, the Fab 9O12 decreased the recruitment of platelets by up to 85%. This study identifies GPVI as a platelet receptor for polymerized fibrin with 2 major functions: (1) amplification of thrombin generation and (2) recruitment of circulating platelets to clots. These so-far-unrecognized properties of GPVI confer on it a key role in thrombus growth and stabilization.
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22
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Enhanced Pharmacokinetics of Factor VIIa as a Monomeric Fc Fusion. Thromb Res 2015; 135:970-6. [DOI: 10.1016/j.thromres.2014.12.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 12/22/2014] [Accepted: 12/23/2014] [Indexed: 11/17/2022]
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23
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Rajpurkar M, Chitlur M, Recht M, Cooper DL. Use of recombinant activated factor VII in patients with Glanzmann's thrombasthenia: a review of the literature. Haemophilia 2014; 20:464-71. [DOI: 10.1111/hae.12473] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2014] [Indexed: 11/28/2022]
Affiliation(s)
- M. Rajpurkar
- Division of Hematology/Oncology; Carman and Ann Adams Department of Pediatrics; Children's Hospital of Michigan; Detroit MI USA
- Wayne State University; Detroit MI USA
| | - M. Chitlur
- Division of Hematology/Oncology; Carman and Ann Adams Department of Pediatrics; Children's Hospital of Michigan; Detroit MI USA
| | - M. Recht
- The Hemophilia Center at Oregon Health & Science University; Portland OR USA
| | - D. L. Cooper
- Clinical; Medical and Regulatory Affairs; Novo Nordisk Inc.; Plainsboro NJ USA
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24
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Nurden AT, Pillois X, Nurden P. Understanding the genetic basis of Glanzmann thrombasthenia: implications for treatment. Expert Rev Hematol 2014; 5:487-503. [PMID: 23146053 DOI: 10.1586/ehm.12.46] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Alan T Nurden
- Plateforme Technologique et d'Innovation Biomédicale, Hôpital Xavier Arnozan, Pessac, France.
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25
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Nurden AT, Pillois X, Wilcox DA. Glanzmann thrombasthenia: state of the art and future directions. Semin Thromb Hemost 2013; 39:642-55. [PMID: 23929305 DOI: 10.1055/s-0033-1353393] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Glanzmann thrombasthenia (GT) is the principal inherited disease of platelets and the most commonly encountered disorder of an integrin. GT is characterized by spontaneous mucocutaneous bleeding and an exaggerated response to trauma caused by platelets that fail to aggregate when stimulated by physiologic agonists. GT is caused by quantitative or qualitative deficiencies of αIIbβ3, an integrin coded by the ITGA2B and ITGB3 genes and which by binding fibrinogen and other adhesive proteins joins platelets together in the aggregate. Widespread genotyping has revealed that mutations spread across both genes, yet the reason for the extensive variation in both the severity and intensity of bleeding between affected individuals remains poorly understood. Furthermore, although genetic defects of ITGB3 affect other tissues with β3 present as αvβ3 (the vitronectin receptor), the bleeding phenotype continues to dominate. Here, we look in detail at mutations that affect (i) the β-propeller region of the αIIb head domain and (ii) the membrane proximal disulfide-rich epidermal growth factor (EGF) domains of β3 and which often result in spontaneous integrin activation. We also examine deep vein thrombosis as an unexpected complication of GT and look at curative procedures for the diseases, including allogeneic stem cell transfer and the potential for gene therapy.
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Affiliation(s)
- Alan T Nurden
- Plateforme Technologique et d'Innovation Biomédicale, Hôpital Xavier Arnozan, Pessac, France.
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26
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Factor VIIa. Platelets 2013. [DOI: 10.1016/b978-0-12-387837-3.00061-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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27
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Deep Vein Thrombosis, Raynaud's Phenomenon, and Prinzmetal Angina in a Patient with Glanzmann Thrombasthenia. Case Rep Hematol 2012; 2012:156290. [PMID: 23346430 PMCID: PMC3549378 DOI: 10.1155/2012/156290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 12/19/2012] [Indexed: 11/17/2022] Open
Abstract
Patients with Glanzmann thrombasthenia fail to form large platelet thrombi due to mutations that affect the biosynthesis and/or function of the αIIbβ3 integrin. The result is a moderate to severe bleeding syndrome. We now report unusual vascular behaviour in a 55-year-old woman with classic type I disease (with no platelet αIIbβ3 expression) and a homozygous ITGA2B missense mutation (E324K) affecting the terminal β-propeller domain of αIIb. While exhibiting classic bleeding symptoms as a child, in later life this woman first developed deep vein thrombosis after a long air flight then showed vascular problems characteristic of Raynaud's phenomenon, and finally this year she presented with chest pains suggestive of coronary heart disease. Yet while coronary angiography first showed a stenosis, this was not seen on a second examination when she was diagnosed with coronary spastic angina and Prinzmetal phenomenon. It is significant that the absence of platelet aggregation with physiologic agonists had not prevented any of the above cardiovascular or vascular diseases.
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28
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Abstract
Inherited diseases of the megakaryocyte lineage give rise to bleeding when platelets fail to fulfill their hemostatic function upon vessel injury. Platelet defects extend from the absence or malfunctioning of adhesion (GPIb-IX-V, Bernard-Soulier syndrome) or aggregation receptors (integrin αIIbβ3, Glanzmann thrombasthenia) to defects of primary receptors for soluble agonists, secretion from storage organelles, activation pathways and the generation of procoagulant activity. In disorders such as the Chediak-Higashi, Hermansky-Pudlak, Wiskott-Aldrich and Scott syndromes the molecular lesion extends to other cells. In familial thrombocytopenia (FT), platelets are produced in insufficient numbers to assure hemostasis. Some FT affect platelet morphology and give rise to the 'giant platelet' syndromes (e.g. MYH9-related diseases) with changes in megakaryocyte maturation within the bone marrow and premature release of platelets. Diseases of platelet production may also affect other cells and in some cases interfere with development and/or functioning of major organs. Diagnosis of platelet disorders requires platelet function testing, studies often aided by the quantitative analysis of receptors by flow cytometry and fluorescence and electron microscopy. New generation DNA-based procedures including whole exome sequencing offer an exciting new perspective. Transfusion of platelets remains the most common treatment of severe bleeding, management with desmopressin is often used for mild disorders. Substitute therapies are available including rFVIIa and the potential use of thrombopoietin analogues for FT. Stem cell or bone marrow transplantation has been successful for several diseases while gene therapy shows promise in the Wiskott-Aldrich syndrome.
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Affiliation(s)
- A T Nurden
- Centre de Référence des Pathologies Plaquettaires, Plateforme Technologique et d'Innovation Biomédicale, Hôpital Xavier Arnozan, Pessac, France.
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29
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Abstract
For patients affected by severe inherited platelet dysfunctions, e.g. Glanzmann thrombasthenia (GT) or Bernard-Soulier syndrome (BSS), platelet transfusion is frequently needed for controlling spontaneous bleeding, and is always needed when trauma occurs or surgery is performed. For the mild-to-moderate bleeding entities, e.g. storage pool disease, thrombaxane A2 receptor defect, platelet transfusion is usually unnecessary. Transfusion of platelets should be used selectively and sparingly because of the substantial risk of alloimmunization against HLA antigens and/or platelet glycoproteins (GP) αIIb, β(3), or αIIbβ(3) in GT, and GPI-IX-V in BSS, which may lead to refractoriness to therapy. To reduce the risk, HLA-matched single donors of platelets should be used. If such donors are unavailable, leucocyte-depleted blood components should be used. Therapy other than platelet transfusion includes: (i) Prevention (vaccination against hepatitis B, avoidance of non-steroidal anti-inflammatory drugs, preservation of dental hygiene, correction of iron deficiency and prenatal diagnosis). (ii) Topical measures (compression with gauze soaked with tranexamic acid, fibrin sealants, splints for dental extractions and packing for nose bleeds). (iii) Antifibrinolytic agents that are useful for minor surgery and as adjuncts for other treatment modalities. (iv) Desmopressin that increases plasma levels of von Willebrand factor and factor VIII giving rise to increased platelet adhesiveness and aggregation associated with shortened bleeding time. (v) Recombinant factor VIIa (rFVIIa). GT patients have been treated for bleeding episodes by rFVIIa with partial success. The mechanism by which rFVIIa arrests bleeding is probably related to increased thrombin generation by a tissue factor-independent process, enhanced platelet adhesion and restoration of platelet aggregation. (vi) Female hormones. Excessive bleeding during menarche in patients with GT or BSS can be controlled by high doses of oestrogen followed by high doses of oral oestrogen-progestin. Menorrhagia later in life can be managed by continuous oral contraceptives. Depo-medroxyprogesterone acetate administered every 3 months is an alternative when combined oral contraceptives are contraindicated.
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Affiliation(s)
- U Seligsohn
- Amalia Biron Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculity of Medicine, Tel Aviv University, Israel.
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Krishnamoorthy S, Kumar S, Kekre N. Hematuria: an uncommon presentation of Glanzmann's thrombasthenia-lessons learnt. Indian J Urol 2011; 26:115-7. [PMID: 20535297 PMCID: PMC2878421 DOI: 10.4103/0970-1591.60456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 55-year-old man with Glanzmann's thrombasthenia had recurrent episodes of gross painless hematuria for the past 30 years. His last episode of hematuria occurred a month ago, associated with pain in the right loin and was diagnosed to have a right mid-ureteric calculus. Under adequate platelet cover, he underwent right ureteroscopy. Postoperatively, he had persistent significant hematuria that did not improve despite repeated platelet transfusions. Factor VIIa was also transfused, without much benefit. A ureteroscopy was done, which identified bleeding from within the renal pelvis. CT angiogram confirmed the rupture of an artery supplying the interpole segment of the right kidney. Bleeding settled after angioembolization. Indiscriminate use of platelet transfusions would result in a state of platelet refractoriness. It is also important to suspect an iatrogenic cause for any complication that occurs after a surgical procedure, even if there could be an underlying medical etiology that can be attributed to the development of such complication.
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32
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Nurden P, Youlouz-Marfak I, Siberchicot F, Kostrzewa E, Andia I, Anitua E, Nurden AT. Use of autologous platelet-rich clots for the prevention of local injury bleeding in patients with severe inherited mucocutaneous bleeding disorders. Haemophilia 2011; 17:620-4. [PMID: 21323803 DOI: 10.1111/j.1365-2516.2010.02480.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Stopping or preventing local bleeding in patients with inherited bleeding disorders linked to abnormal platelet function is traditionally treated by transfusion of blood cell products or recombinant factor VIIa. We now report the use in such patients of autologous platelet-rich clots as an aid to preventing bleeding and to facilitating tissue regeneration at superficial sites. Two patients with von Willebrand's disease (VWD) type 2B and one patient with type I Glanzmann thrombasthenia were treated after tooth extraction and dental surgery. A fourth patient with platelet-type VWD underwent a skin biopsy. Whereas all four patients had a lifelong history of bleeding complications, the application of an autologous platelet-rich clot immediately after surgery combined with tranexamic acid intake to slow fibrinolysis prevented blood loss and resulted in rapid and normal healing. This new procedure is simple, safe and inexpensive; it provides extra security for patients with a bleeding risk undergoing dentistry or superficial surgery.
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Affiliation(s)
- P Nurden
- Centre de Référence des Pathologies Plaquettaires, Hôpital Xavier Arnozan, Pessac, France.
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33
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Zinke RA, Ornstein DL, Holmes CE. Factor VIII/von Willebrand factor concentrate for treatment of life threatening epistaxis in Glanzmann's thrombasthenia. Haemophilia 2010; 16:701-704. [PMID: 20331758 DOI: 10.1111/j.1365-2516.2010.02222.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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35
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P-selectin-dependent platelet aggregation and apoptosis may explain the decrease in platelet count during Helicobacter pylori infection. Blood 2010; 115:4247-53. [PMID: 20097880 DOI: 10.1182/blood-2009-09-241166] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
P-selectin expression has been shown in Helicobacter pylori-infected persons, an infection that has been clinically associated with platelet-related diseases, such as idiopathic thrombocytopenic purpura. However, the role of P-selectin expression during H pylori infection remains unclear. In this study, we hypothesized that P-selectin expression was associated with platelet aggregation during H pylori infection. Using flow cytometry, we examined the levels of adhesion between H pylori and platelets as well as the levels of P-selectin expression and platelet phosphatidylserine (PS) expression during H pylori infection. Significantly high levels of adhesion between pro-aggregatory bacteria and platelets were observed. We identified that H pylori IgG is required for bacteria to induce P-selectin expression and that a significant release of P-selectin is essential for H pylori to induce aggregation. In addition, cellular apoptotic signs, such as membrane blebbing, were observed in platelet aggregates. PS expression was also detected in platelets during infection with both pro-aggrogatory and nonaggregatory strains of H pylori. These results suggest that the decrease in platelet counts seen during H pylori infection is the result of P-selection-dependent platelet aggregation and PS expression induced by the bacteria.
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36
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Surgical treatment of cecal cancer in a patient with Glanzmann's thrombasthenia: report of a case. Surg Today 2009; 39:1002-5. [PMID: 19882326 DOI: 10.1007/s00595-009-3962-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Accepted: 02/24/2009] [Indexed: 10/20/2022]
Abstract
Glanzmann's thrombasthenia (GT) is a rare inherited platelet disorder with no specific treatment. Prophylactic and therapeutic platelet transfusions work only as supportive treatments. To date, there has been no report of surgical treatment for malignant disease in GT patients. We herein report the case of a 43-year-old woman presenting with cecal cancer with accompanying GT. The patient underwent a laparotomic procedure under general anesthesia for resection of the tumor. A good perioperative course was achieved by the transfusion of ABO-identical and antihistocompatibility locus antigen-matched platelets, without causing any accidental bleeding.
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37
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Lison S, Spannagl M, Heindl B. Perioperative haemostatic management of Glanzmann thrombasthenia for abdominal surgery. Blood Coagul Fibrinolysis 2009; 20:371-3. [DOI: 10.1097/mbc.0b013e32832b280e] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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38
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Hers I, Mumford A. Understanding the therapeutic action of recombinant factor VIIa in platelet disorders. Platelets 2008; 19:571-81. [PMID: 19012175 DOI: 10.1080/09537100802406653] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Recombinant factor VIIa (rFVIIa) is a pro-haemostatic agent that is effective in the treatment of bleeding in haemophilia complicated by inhibitors and some other haemorrhagic disorders. The rFVIIa product promotes haemostasis in these settings by enabling the rapid generation of thrombin on the surface of activated platelets which increases fibrin deposition. rFVIIa also has therapeutic activity in bleeding in platelet function disorders such as Glanzmann's thrombasthenia and thrombocytopenia. This suggests that rFVIIa also has a pro-haemostatic effect on platelets and this may contribute to the overall therapeutic action of this agent. The effects of high-concentration FVIIa on platelets have been studied in detail in experiments using ex vivo model systems of haemostasis under static and flow conditions. These experiments show that FVIIa potentiates multiple functional markers of platelet activation and this effect requires direct binding of FVIIa to the activated platelet membrane and the generation of thrombin. The mechanism of this potentiating effect of FVIIa on platelet activation is complex and is likely to require multiple platelet activation receptors and signalling pathways. These include the GPIb-IX-V glycoprotein complex and the thrombin protease activated receptors. The proposed mechanism of action of high-concentration FVIIa has important implications for the therapeutic activity of rFVIIa in vivo. This review summarizes the clinical and experimental evidence supporting a potentiating effect of FVIIa on platelet activation and discusses the likely mechanism of action.
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Affiliation(s)
- Ingeborg Hers
- Department of Biochemistry, School of Medical Sciences, University of Bristol, University Walk, Bristol BS8 1TD, UK
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Weeterings C, Lisman T, de Groot PG. Tissue factor-independent effects of recombinant factor VIIa on hemostasis. Semin Hematol 2008; 45:S12-5. [PMID: 18544417 DOI: 10.1053/j.seminhematol.2008.03.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The molecular mechanisms responsible for the hemostatic efficacy of recombinant activated factor VII (rFVIIa; NovoSeven, Novo Nordisk, Bagsvaerd, Denmark) in platelet-related bleeding disorders remain unclear. The general concept is that rFVIIa locally enhances thrombin generation at the site of injury, where tissue factor (TF) has become exposed. However, a growing amount of evidence shows that rFVIIa is also able to exert its activity in a manner independent of TF. Using an in vitro flow model, we recently showed that TF-independent thrombin generation is responsible for increased platelet deposition onto injured vessels following rFVIIa administration. Furthermore, it has been shown that rFVIIa can restore platelet aggregation in Glanzmann's thrombasthenia (GT) patients via TF-independent thrombin generation. However, the mechanism behind TF-independent thrombin generation remains to be elucidated. It is postulated that, in vivo, both the TF-dependent and TF-independent thrombin generation induced by rFVIIa contribute to the control of hemorrhage in patients with platelet-related bleeding disorders and, perhaps, other causes of hemorrhagic diatheses.
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Affiliation(s)
- Cees Weeterings
- Department of Clinical Chemistry and Hematology, University Medical Center, Utrecht, The Netherlands
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Dargaud Y, Bordet JC, Lienhart A, Negrier C. Use of the Thrombin Generation Test to Evaluate Response to Treatment With Recombinant Activated Factor VII. Semin Hematol 2008; 45:S72-3. [DOI: 10.1053/j.seminhematol.2008.03.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tanaka KA, Taketomi T, Szlam F, Calatzis A, Levy JH. Improved Clot Formation by Combined Administration of Activated Factor VII (NovoSeven®) and Fibrinogen (Haemocomplettan® P). Anesth Analg 2008; 106:732-8, table of contents. [DOI: 10.1213/ane.0b013e318163fc76] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Girona E, Borrás-Blasco J, Conesa-García V, Navarro-Ruiz A, Solís J, García-Sepulcre MF, Oliver-García I. Successful treatment of severe gastrointestinal bleeding secondary to Crohn disease with recombinant factor VIIa. South Med J 2007; 100:601-4. [PMID: 17591314 DOI: 10.1097/smj.0b013e31804859a4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A 58-year-old man diagnosed with ileocolonic Crohn disease was admitted to the emergency room with massive lower gastrointestinal hemorrhage and hypovolemic shock. Treatment was started with methylprednisolone, metronidazole and omeprazole. Within the next 24 hours, he received a total of 9 U of red blood cell concentrate and 2 U of fresh frozen plasma. Because of persistence of bleeding, hypovolemic shock and life-threatening situation, we started therapy with rFVIIa. One dose of 120 microg/kg and another dose of 120 microg/kg three hours after the first dose were administered as compassionate use, with resolution of bleeding in the next 12 hours. On day 4 the patient was stabilized. We performed a total colonoscopy and intubation of the ileocecal valve that showed patchy deep ulcerations in the rectum with bleeding inflammatory pseudopolyps. Acute gastrointestinal bleeding is an unusual complication in Crohn disease. In this case, the use of recombinant activated factor VIIa controlled the massive gastrointestinal bleeding secondary to Crohn disease and without clinically significant adverse effect. There are few case reports documenting the use of recombinant activated factor VIIa for this type of off-label indication. Clinical trials should be carried out to define the dosage and dose interval schedule of rFVIIa in the treatment of uncontrolled massive gastrointestinal bleeding secondary to Crohn disease.
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Affiliation(s)
- Eva Girona
- Gastroenterology Section, Critical Care Unit, Hospital General Universitario de Elche, Spain
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43
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Poon MC. The Evidence for the Use of Recombinant Human Activated Factor VII in the Treatment of Bleeding Patients With Quantitative and Qualitative Platelet Disorders. Transfus Med Rev 2007; 21:223-36. [PMID: 17572261 DOI: 10.1016/j.tmrv.2007.03.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
There are increasing reports suggesting that high-dose recombinant human activated factor VII (rFVIIa) is effective in the treatment and prevention of bleeding in patients with quantitative and qualitative platelet disorders. These clinical observations are supported by evidence that FVIIa binds weakly to activated platelet surface and at high concentration improves thrombin generation. In experimental models, this improved thrombin generation enhances platelet adhesion in thrombocytopenic conditions and enhances adhesion and aggregation of platelets lacking glycoprotein IIbIIIa (integrin alpha(IIb)beta(3)), characteristic of the qualitative platelet disorder Glanzmann thrombasthenia (GT). There is a need for clinical trials to confirm the safety and efficacy of rFVIIa in patients with various quantitative and qualitative platelet defects, either by itself or in combination with other hemostatic agents such as platelet transfusion. Pending the availability of such data, rFVIIa may be considered in severe bleeding in thrombocytopenia and GT patients with platelet antibodies and refractory to platelet transfusions and other standard treatments. An international survey suggests that rFVIIa at about 90 microg/kg every 2 hours for 3 or more doses could be used for GT patients with severe bleeding, but confirmation by larger studies is needed. For GT patients undergoing surgery and for treatment and prevention of bleeding in thrombocytopenic patients, the optimal rFVIIa regimen remains to be defined.
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Affiliation(s)
- Man-Chiu Poon
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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44
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Poon MC. Factor VIIa. Platelets 2007. [DOI: 10.1016/b978-012369367-9/50830-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Inherited deficiencies of platelet surface glycoproteins, such as Glanzmann thrombasthenia (GT), occasionally result in severe bleeding episodes. Platelet transfusion is considered standard therapy for securing hemostasis in subjects with GT when local measures and antifibrinolytic agents are inadequate. We describe 4 case studies which suggest that recombinant activated factor VII may be an effective alternative to platelet transfusion in preventing or controlling bleeding, including surgical bleeding, in patients with GT.
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Affiliation(s)
- Leonard A Valentino
- Hemophilia and Thrombophilia Center, Rush University Medical Center and Rush Children's Hospital, 1653 West Congress Parkway, Chicago, IL 60612-3833, USA.
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Altman R, Scazziota A, DE Lourdes Herrera M, Gonzalez C. Recombinant factor VIIa reverses the inhibitory effect of aspirin or aspirin plus clopidogrel on in vitro thrombin generation. J Thromb Haemost 2006; 4:2022-7. [PMID: 16961610 DOI: 10.1111/j.1538-7836.2006.02088.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Antiplatelet drugs constitute the therapy of choice for acute coronary syndromes, but bleeding can be a side-effect requiring treatment. Restoration of normal platelet activity is also mandatory before urgent surgery. This study investigated: (a) whether a regimen of aspirin or clopidogrel plus aspirin significantly inhibited platelet thrombin generation (TG); and (b) the reversal of this inhibition by recombinant activated factor VII (rFVIIa). METHODS AND RESULTS TG was evaluated by the lag time, time to peak, peak of TG, and area under the curve after 35 min of assay (AUC(0 --> 35 min)). These measures were examined by the calibrated automated thrombography method in 22 healthy volunteers, 22 volunteers after a 100 mg day(-1) aspirin intake (200 mg first day) for 5-7 days, and 22 healthy volunteers after aspirin 100 mg day(-1) (200 mg first day) plus clopidogrel 75 mg day(-1) (300 mg first day) for 4-7 days. The TG parameters were measured under basal conditions and after platelet stimulation by sodium arachidonate (AA), adenosine 5'-diphosphate (ADP), collagen and rFVIIa in normal non-aspirinated as well as in vivo aspirinated platelet-rich plasma (PRP) or aspirin plus clopidogrel PRP. Lag time was shorter (P < 0.05), and peak of TG and AUC(0 --> 35 min) were significantly greater (P < 0.01 for both), in PRP activated with ADP, collagen, AA or FVIIa than in non-activated PRP from normal subjects. Both non-activated PRP and activated PRP prepared from platelets obtained from volunteers after aspirin intake showed significant prolongation of the time parameters but there was less effect on peak of TG and AUC(0 --> 35 min). For most parameters, aspirin plus clopidogrel administration showed to be more effective compared with the effect obtained by aspirin alone. When rFVIIa was added to ASA-PRP or ASA + Clop PRP, lag time (P < 0.001 for all) and time to peak (P < 0.001-0.017) were significantly shortened, indicating that rFVIIa reverses the inhibitory effect of these anti-aggregating agents. CONCLUSION Platelets activated by AA, ADP, collagen or FVIIa triggered TG. This effect was inhibited by aspirin plus clopidogrel, suggesting an additional benefit of this drug combination for preventing thrombosis. rFVIIa reverses the inhibitory effect of aspirin or aspirin plus clopidogrel, and could be useful for bleeding complications or when acute surgery is needed during treatment with these antiplatelet drugs.
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Affiliation(s)
- R Altman
- Centro de Trombosis de Buenos Aires, Buenos Aires, Argentina.
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Inagaki M, Mori T, Tsunematsu Y, Ambo H, Kawai Y. Use of recombinant activated factor VII to control bleeding in a young child with qualitative platelet disorder: a case report. Blood Coagul Fibrinolysis 2006; 17:317-22. [PMID: 16651876 DOI: 10.1097/01.mbc.0000224853.50248.6f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Defects of platelet adhesion, aggregation, secretion, or procoagulant activities can lead to bleeding diathesis of variable severity. We used recombinant activated factor VII (rFVIIa) in the treatment of uncontrolled epistaxis in a patient with a qualitative platelet disorder. We aimed to assess the efficacy of a single rFVIIa dose (100 microg/kg) in the control of mild and severe refractory epistaxis, and evaluate the influence of rFVIIa on markers of platelet adhesion and aggregation during a period of hematological stability (i.e. non-bleeding, no medication). The efficacy study showed mild episodes of epistaxis could be successfully managed using a single rFVIIa (100 microg/kg) dose; however, severe bleedings were not well controlled, and platelet transfusion was required to achieve hemostasis. Hematological investigations showed ADP-induced and collagen-induced platelet aggregation increases from 20 to 34% and 16 to 30%, respectively, following rFVIIa administration. There were no differences between pre-dose and post-dose concentrations of membrane glycoproteins. rFVIIa may therefore induce platelet aggregation by activating a glycoprotein-independent aggregation pathway. rFVIIa may have a role in managing mild bleeding episodes not controlled using conventional measures in patients with a qualitative platelet disorder. Further research is needed to determine the mechanism of action, efficacy, and safety of rFVIIa in this population.
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Abstract
PURPOSE OF REVIEW To overview inherited syndromes that affect platelets and to discuss current data on the molecular origin and management of these rare diseases. RECENT FINDINGS An increasing number of genes responsible for inherited thrombocytopenias have been identified and these now extend to glycosylation defects. Although Glanzmann thrombasthenia remains the predominant disorder of platelet function, knowledge is increasing of pathologies concerning primary receptors for adhesion and signalling, the activation and secretory pathways, and even the development of procoagulant activity. SUMMARY These syndromes affect cell adhesion, cell activation, and cell-to-cell contact interactions fundamental in cell biology. Studies on the pathophysiology of alphaIIbbeta3 in platelets have helped unravel the molecular mechanisms of integrin function, and the information gained has resulted in improved antithrombotic therapy. The establishment of national registries and the use of state-of-the-art genomic and proteomic technologies will accelerate progress and help to define how mutations affecting a much larger range of proteins contribute alone or in combination to defining specific platelet phenotypes.
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Affiliation(s)
- Alan T Nurden
- Centre de Référence des Pathologies Plaquettaires, Institut Fédératif de Recherche n 4, CHU Bordeaux, Pessac, France.
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Altman R, Scazziota AS, Herrera MDL, Gonzalez C. Thrombin generation by activated factor VII on platelet activated by different agonists. Extending the cell-based model of hemostasis. Thromb J 2006; 4:5. [PMID: 16630353 PMCID: PMC1459108 DOI: 10.1186/1477-9560-4-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2006] [Accepted: 04/21/2006] [Indexed: 01/25/2023] Open
Abstract
Background Platelet activation is crucial in normal hemostasis. Using a clotting system free of external tissue factor, we investigated whether activated Factor VII in combination with platelet agonists increased thrombin generation (TG) in vitro. Methods and results TG was quantified by time parameters: lag time (LT) and time to peak (TTP), and by amount of TG: peak of TG (PTG) and area under thrombin formation curve after 35 minutes (AUC→35min) in plasma from 29 healthy volunteers using the calibrated automated thrombography (CAT) technique. TG parameters were measured at basal conditions and after platelet stimulation by sodium arachidonate (AA), ADP, and collagen (Col). In addition, the effects of recombinant activated FVII (rFVIIa) alone or combined with the other platelet agonists on TG parameters were investigated. We found that LT and TTP were significantly decreased (p < 0.05) and PTG and AUC→35min were significantly increased (p < 0.05) in platelet rich plasma activated with AA, ADP, Col, and rFVIIa compared to non-activated platelet rich plasma from normal subjects (p = 0.01). Furthermore platelet rich plasma activated by the combined effects of rFVIIa plus AA, ADP or Col had significantly reduced LT and TTP and increased AUC→35min (but not PTG) when compared to platelet rich plasma activated with agonists in the absence of rFVIIa. Conclusion Platelets activated by AA, ADP, Col or rFVIIa triggered TG. This effect was increased by combining rFVIIa with other agonists. Our intrinsic coagulation system produced a burst in TG independent of external tissue factor activity an apparent hemostatic effect with little thrombotic capacity. Thus we suggest a modification in the cell-based model of hemostasis.
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Affiliation(s)
- Raul Altman
- Centro de Trombosis de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Claudio Gonzalez
- Department of Pharmacology, School of Medicine, University of Buenos Aires, Argentina
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Livnat T, Zivelin A, Martinowitz U, Salomon O, Seligsohn U. Prerequisites for recombinant factor VIIa-induced thrombin generation in plasmas deficient in factors VIII, IX or XI. J Thromb Haemost 2006; 4:192-200. [PMID: 16409469 DOI: 10.1111/j.1538-7836.2005.01683.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) used for the treatment of hemophilia A or B patients with an inhibitor is hemostatically effective because it induces thrombin generation (TG), despite grossly impaired FVIII- and FIX-dependent amplification of FX activation. Tissue factor (TF) and or activated platelets were shown to be essential for the rFVIIa activity. OBJECTIVE To evaluate the relative effects of TF and phospholipids on rFVIIa-induced TG in FVIII-, FIX- and FXI-deficient plasmas. METHODS Phospholipids had an independent effect that was augmented by TF. The contribution of blood-borne TF in FVIII-, FIX- and FXI-deficient plasma to rFVIIa-induced TG was demonstrated by removing microparticles and use of anti-TF antibodies. RESULTS At increasing concentrations of rFVIIa, the dependence of rFVIIa-induced TG on TF declined, but the presence of phospholipids was essential. rFVIIa was also shown to activate purified FIX and FX in the presence of phospholipids and absence of TF. rFVIIa-induced TG was dramatically augmented in FVIII- or FIX-deficient plasma in which the level of FVIII or FIX was increased to 1 or 2 U dL(-1). CONCLUSIONS The data indicate that rFVIIa-induced TG is affected by TF, phospholipids, rFVIIa concentration, and the presence of FVIII and FIX.
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Affiliation(s)
- T Livnat
- The Amalia Biron Research Institute of Thrombosis and Hemostasis, Chaim Sheba Medical Centre, Tel Hashomer, Israel
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