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Mancuso ME, McLaughlin P, Forsyth AL, Valentino LA. Joint health and pain in the changing hemophilia treatment landscape. Expert Rev Hematol 2024:1-14. [PMID: 38981851 DOI: 10.1080/17474086.2024.2378936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 07/08/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Hemophilia is an inherited bleeding disorder. Bleeding, and in particular joint hemorrhage results in chronic arthropathy and disability. Acute and chronic pain are frequent and limit activity and participation and result in decreased health-related quality of life. Remarkable progress has been made in the diagnosis and treatment of hemophilia but bleeding continues to prove recalcitrant to currently available treatments and joint disease remains problematic. Physiotherapy and pain management are mainstays of current multidisciplinary integrated care of people with hemophilia (PWH). The focus of this review is on preservation of joint health in the era of new and innovative therapies. AREAS COVERED A search of the PubMed Central was conducted on 1 February 2024 using the MeSH Major Topic terms identified as keywords for the manuscript. This review will highlight what is known and unknown about joint bleeding and arthropathy, including insights on pain as a related complication. EXPERT OPINION Recent advances in therapeutic interventions aimed at promoting healthy joints in PWH will be discussed, including both the pharmacological treatment landscape and related strategies to promote joint health.
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Affiliation(s)
- Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, Department of Cardiovascular Medicine, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Humanitas University, Pieve Emanuele, Milan, Italy
| | - Paul McLaughlin
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London, UK
- Research Department of Haematology, University College London, London, UK
| | - Angela L Forsyth
- Physical Therapy Collaborative, Optum Infusion Pharmacy, Eden Praire, MN, USA
| | - Leonard A Valentino
- Hemophilia and Thrombophilia Center, Rush University Medical Center, Chicago, IL, USA
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Chandran R, Tohit ERM, Stanslas J, Salim N, Mahmood TMT, Rajagopal M. Shifting Paradigms and Arising Concerns in Severe Hemophilia A Treatment. Semin Thromb Hemost 2024; 50:695-713. [PMID: 38224699 DOI: 10.1055/s-0043-1778103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
The management of hemophilia A has undergone a remarkable revolution, in line with technological advancement. In the recent past, the primary concern associated with Factor VIII (FVIII) concentrates was the risk of infections, which is now almost resolved by advanced blood screening and viral inactivation methods. Improving patients' compliance with prophylaxis has become a key focus, as it can lead to improved health outcomes and reduced health care costs in the long term. Recent bioengineering research is directed toward prolonging the recombinant FVIII (rFVIII) coagulant activity and synthesising higher FVIII yields. As an outcome, B-domain deleted, polyethylene glycolated, single-chain, Fc-fused rFVIII, and rFVIIIFc-von Willebrand Factor-XTEN are available for patients. Moreover, emicizumab, a bispecific antibody, is commercially available, whereas fitusiran and tissue factor pathway inhibitor are in clinical trial stages as alternative strategies for patients with inhibitors. With these advancements, noninfectious complications, such as inhibitor development, allergic reactions, and thrombosis, are emerging concerns requiring careful management. In addition, the recent approval of gene therapy is a major milestone toward a permanent cure for hemophilia A. The vast array of treatment options at our disposal today empowers patients and providers alike, to tailor therapeutic regimens to the unique needs of each individual. Despite significant progress in modern treatment options, these highly effective therapies are markedly more expensive than conventional replacement therapy, limiting their access for patients in developing countries.
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Affiliation(s)
- Rubhan Chandran
- Department of Pathology, Haematology Unit, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
- Faculty of Pharmaceutical Sciences, Department of Pharmaceutical Biology, UCSI University, Jalan Puncak Menara Gading, Taman Connaught, Cheras, Kuala Lumpur, Malaysia
| | - Eusni R Mohd Tohit
- Department of Pathology, Haematology Unit, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
| | - Johnson Stanslas
- Department of Medicine, Pharmacotherapeutics Unit, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Norazlinaliza Salim
- Centre of Foundation Studies for Agricultural Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
- Integrated Chemical Biophysics Research, Faculty of Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Tuan M T Mahmood
- Faculty of Pharmacy, The National University of Malaysia (UKM), Jalan Raja Muda Abdul Aziz, Kuala Lumpur, Malaysia
| | - Mogana Rajagopal
- Faculty of Pharmaceutical Sciences, Department of Pharmaceutical Biology, UCSI University, Jalan Puncak Menara Gading, Taman Connaught, Cheras, Kuala Lumpur, Malaysia
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Augustsson C, Strandberg K, Kjalke M. Minimal interference of concizumab with standard clinical coagulation laboratory assays - An in vitro study. Haemophilia 2024. [PMID: 38924198 DOI: 10.1111/hae.15070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/10/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Non-factor replacement therapies are emerging as prophylactic treatment options in haemophilia A or B (HA/HB) with and without inhibitors. Concizumab is an anti-tissue factor pathway inhibitor (TFPI) monoclonal antibody preventing factor (F)Xa inhibition and enhancing thrombin generation. Based on experience with other non-factor therapies and extended half-life products, there is a focus on potential interference with common clinical coagulation assays used to monitor patients treated with concizumab. AIM To evaluate the impact of concizumab on standard clinical coagulation assays. METHODS Plasma samples (normal, HA/HB with/without inhibitors) in the presence/absence of added concizumab (250-16,000 ng/mL) were analysed in clinical assays including activated partial thromboplastin time (aPTT), prothrombin time (PT), FVIII and FIX one-stage clot and chromogenic substrate assay, assays for detecting FVIII or FIX inhibitors and other assays for coagulation factors. RESULTS Concizumab did not impact PT assays, but resulted in a small shortening of aPTT (up to 5 s in haemophilia plasma and 0.4 s in normal plasma). Concizumab had no, or only a minor impact on FVIII and FIX activity assays or Bethesda inhibitor assays. FXI and FXII activity in normal plasma, as measured by single factor aPTT-based assay, was significantly increased in the presence of concizumab (+11% each). This was also the case for FVII and FX measured by PT-based assays using plasma with 25% of FVII or FX (+64% and +22%, respectively). CONCLUSION The presence of concizumab did not, or only slightly, influence the outcome of standard clinical coagulation assays relevant for HA and HB.
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Affiliation(s)
- Cecilia Augustsson
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation Laboratory Malmö, Regional Laboratories Region Skåne, Malmö, Sweden
| | - Karin Strandberg
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Coagulation Laboratory Malmö, Regional Laboratories Region Skåne, Malmö, Sweden
| | - Marianne Kjalke
- Rare Disease Research, Global Drug Discovery, Novo Nordisk A/S, Måløv, Denmark
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Dubut J, Goin V, Derray C, Huguenin Y, Fiore M. Targeting tissue factor pathway inhibitor with concizumab to improve hemostasis in patients with Glanzmann thrombasthenia: an in vitro study. J Thromb Haemost 2024:S1538-7836(24)00356-8. [PMID: 38880178 DOI: 10.1016/j.jtha.2024.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/27/2024] [Accepted: 05/30/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Glanzmann thrombasthenia (GT) is caused by an inherited defect of platelet αIIbβ3 integrin. Concizumab, a monoclonal antibody specific for tissue factor pathway inhibitor, abolishes its anticoagulant effect. OBJECTIVES To evaluate the in vitro ability of concizumab to improve hemostasis in GT. METHODS The effects of concizumab were evaluated in whole blood or platelet-rich plasma from GT patients (n = 5-9) using a thrombin generation assay, rotational thromboelastometry (ROTEM), a global fibrinolytic capacity assay, and a flow chamber assay (Total Thrombus formation Analysis System). Washed platelets (WPs) and 20 nM recombinant activated factor VII (rFVIIa) were included for comparison. RESULTS The lag time in the thrombin generation assay was significantly longer (+85%; P < .0001) in GT patients than in controls. WPs, rFVIIa, and concizumab each significantly improved thrombin generation profiles. The ROTEM clotting time (CT) was significantly longer in GT patients than in controls (677 seconds vs 523 seconds; P = .03). However, CT improved after adding WPs, rFVIIa, or concizumab. Under flow, occlusive thrombi were present in all healthy controls after 10 minutes, whereas platelet-fibrin depositions were not seen in GT patients. Subocclusive or occlusive thrombi formed when GT blood was mixed with WPs, rFVIIa, or concizumab. Clots in GT platelet-rich plasma were more susceptible to fibrinolysis and were improved by WPs, rFVIIa, or concizumab. CONCLUSION Concizumab enhanced thrombin generation, decreased the ROTEM CT, improved thrombus formation under flow, and reduced clot lysis. Our results demonstrate the potential of concizumab for subcutaneous prophylaxis in GT patients.
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Affiliation(s)
- Jade Dubut
- Department of Haematology, University Hospital of Bordeaux, Pessac, France; Institut National de la Santé et de la Recherche Médicale U1034, Biology of Cardiovascular Disease, Pessac, France
| | - Valérie Goin
- French Reference Centre for Inherited Platelet Disorders, University Hospital of Bordeaux, Pessac, France
| | - Cloé Derray
- Department of Haematology, University Hospital of Bordeaux, Pessac, France
| | - Yoann Huguenin
- Competence Centre for Inherited Bleeding Disorders, University Hospital of Bordeaux, Bordeaux, France
| | - Mathieu Fiore
- Department of Haematology, University Hospital of Bordeaux, Pessac, France; Institut National de la Santé et de la Recherche Médicale U1034, Biology of Cardiovascular Disease, Pessac, France; French Reference Centre for Inherited Platelet Disorders, University Hospital of Bordeaux, Pessac, France.
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Jewell MP, Ashour Z, Baird CH, Manco Johnson M, Warren BB, Wufsus AR, Pallini C, Dockal M, Kjalke M, Neeves KB. Concizumab improves clot formation in hemophilia A under flow. J Thromb Haemost 2024:S1538-7836(24)00306-4. [PMID: 38815755 DOI: 10.1016/j.jtha.2024.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 05/01/2024] [Accepted: 05/15/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Inhibition of tissue factor pathway inhibitor (TFPI) is an emerging therapeutic strategy for treatment of hemophilia. Concizumab is a monoclonal antibody that binds TFPI and blocks its inhibition of factor (F)Xa thereby extending the initiation of coagulation and compensating for lack of FVIII or FIX. OBJECTIVES The objective of this in vitro study was to evaluate how concizumab affects clot formation in hemophilia A under flow. METHODS Blood was collected from normal controls or people with hemophilia A. An anti-FVIII antibody was added to normal controls to simulate hemophilia A with inhibitory antibodies to FVIII. Whole blood and recombinant activated FVII (rFVIIa, 25 nM) or concizumab (200, 1000, and 4000 ng/mL) were perfused at 100 s-1 over a surface micropatterned with tissue factor (TF) and collagen-related peptide. Platelet and fibrin(ogen) accumulation were measured by confocal microscopy. Static thrombin generation in plasma was measured in response to rFVIIa and concizumab. RESULTS Concizumab (1000 and 4000 ng/mL) and rFVIIa both rescued (93%-101%) total platelet accumulation, but only partially rescued (53%-63%) fibrin(ogen) incorporation to normal control levels in simulated hemophilia A. Results using congenital hemophilia A blood confirmed effects of rFVIIa and concizumab. While these 2 agents had similar effect on clot formation under flow, concizumab enhanced thrombin generation in plasma under static conditions to a greater extent than rFVIIa. CONCLUSION TFPI inhibition by concizumab enhanced activation and aggregation of platelets and fibrin clot formation in hemophilia A to levels comparable with that of rFVIIa.
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Affiliation(s)
- Megan P Jewell
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Zaina Ashour
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christine H Baird
- Department of Pediatrics, Section of Hematology, Oncology, and Bone Marrow Transplant, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Hemophilia and Thrombosis Center, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Marilyn Manco Johnson
- Department of Pediatrics, Section of Hematology, Oncology, and Bone Marrow Transplant, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Hemophilia and Thrombosis Center, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Beth Boulden Warren
- Department of Pediatrics, Section of Hematology, Oncology, and Bone Marrow Transplant, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Hemophilia and Thrombosis Center, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Adam R Wufsus
- Rare Blood Disorders, Medical Affairs Rare Disease, Novo Nordisk Inc, Plainsboro, New Jersey, USA
| | - Chiara Pallini
- Rare Blood Disorders, Rare Disease Research, Novo Nordisk, Måløv, Denmark
| | - Michael Dockal
- Rare Blood Disorders, Rare Disease Research, Novo Nordisk, Måløv, Denmark
| | - Marianne Kjalke
- Rare Blood Disorders, Rare Disease Research, Novo Nordisk, Måløv, Denmark
| | - Keith B Neeves
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA; Department of Pediatrics, Section of Hematology, Oncology, and Bone Marrow Transplant, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Hemophilia and Thrombosis Center, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA.
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Schreuder M, Jourdi G, Veizaj D, Poole DA, Cheung KL, Poenou G, Verhoef D, Thomassen S, Janssen LFH, Stepanian A, Hackeng TM, Gaussem P, Reitsma PH, Geerke DP, Siguret V, Bos MHA. Minimally modified human blood coagulation factor X to bypass direct factor Xa inhibitors. J Thromb Haemost 2024:S1538-7836(24)00254-X. [PMID: 38729577 DOI: 10.1016/j.jtha.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 04/09/2024] [Accepted: 04/23/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Direct oral factor (F)Xa inhibitors are widely used as alternatives to conventional vitamin K antagonists in managing venous thromboembolism and nonvalvular atrial fibrillation. Unfortunately, bleeding-related adverse events remain a major concern in clinical practice. In case of bleeding or emergency surgery, rapid-onset reversal agents may be required to counteract the anticoagulant activity. OBJECTIVES The ability of FXa variants to bypass the direct oral FXa inhibitors was assessed. METHODS Human FXa variants were generated through substitution of phenylalanine 174 (F174) for either alanine, isoleucine, or serine. FXa variants were stably expressed in HEK293 cells and purified to homogeneity using ion-exchange chromatography. RESULTS F174-substituted human FX variants demonstrated efficacy in restoring thrombin generation in plasma containing direct FXa inhibitors (apixaban, rivaroxaban, edoxaban). Their ability to bypass the anticoagulant effects stems from a significantly reduced sensitivity for the direct FXa inhibitors due to a decrease in binding affinity determined using molecular dynamics simulations and free energy computation. Furthermore, F174 modification resulted in a partial loss of inhibition by tissue factor pathway inhibitor, enhancing the procoagulant effect of F174-substituted FX. Consequently, the F174A- and F174S-substituted FX variants effectively counteracted the effects of 2 widely used anticoagulants, apixaban and rivaroxaban, in plasma of atrial fibrillation and venous thromboembolism patients. CONCLUSION These human FX variants have the potential to serve as a rescue reversal strategy to overcome the effect of direct FXa inhibitors in case of life-threatening bleeding events or emergency surgical interventions.
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Affiliation(s)
- Mark Schreuder
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Georges Jourdi
- Assistance publique - Hôpitaux de Paris (AH-HP) Centre, Service d'hématologie biologique, Hôpital Cochin, Paris, France; Innovative Therapies in Haemostasis, Institut national de la santé et de la recherche médicale (INSERM) U1140, Université Paris Cité, Paris, France; Assistance publique - Hôpitaux de Paris (AH-HP) Nord, Service d'hématologie biologique, Hôpital Lariboisière, Paris, France
| | - Dejvid Veizaj
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - David A Poole
- Amsterdam Institute of Molecular and Life Sciences (AIMMS), Division of Molecular and Computational Toxicology, Department of Chemistry and Pharmaceutical Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ka Lei Cheung
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Géraldine Poenou
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands; Innovative Therapies in Haemostasis, Institut national de la santé et de la recherche médicale (INSERM) U1140, Université Paris Cité, Paris, France
| | - Daniël Verhoef
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands; VarmX B.V., Leiden, The Netherlands
| | - Stella Thomassen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Laura F H Janssen
- Amsterdam Institute of Molecular and Life Sciences (AIMMS), Division of Molecular and Computational Toxicology, Department of Chemistry and Pharmaceutical Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Alain Stepanian
- Assistance publique - Hôpitaux de Paris (AH-HP) Nord, Service d'hématologie biologique, Hôpital Lariboisière, Paris, France; EA3518 Institut Universitaire d'Hématologie, Hôpital Saint Louis, Paris-Diderot, Paris, France
| | - Tilman M Hackeng
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Pascale Gaussem
- Innovative Therapies in Haemostasis, Institut national de la santé et de la recherche médicale (INSERM) U1140, Université Paris Cité, Paris, France; Assistance publique - Hôpitaux de Paris (AP-HP) Centre, Service d'hématologie biologique, Hôpital Européen Georges Pompidou, Paris, France
| | - Pieter H Reitsma
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands; VarmX B.V., Leiden, The Netherlands
| | - Daan P Geerke
- Amsterdam Institute of Molecular and Life Sciences (AIMMS), Division of Molecular and Computational Toxicology, Department of Chemistry and Pharmaceutical Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Virginie Siguret
- Innovative Therapies in Haemostasis, Institut national de la santé et de la recherche médicale (INSERM) U1140, Université Paris Cité, Paris, France; Assistance publique - Hôpitaux de Paris (AH-HP) Nord, Service d'hématologie biologique, Hôpital Lariboisière, Paris, France
| | - Mettine H A Bos
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands.
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Mancuso ME, Croteau SE, Klamroth R. Benefits and risks of non-factor therapies: Redefining haemophilia treatment goals in the era of new technologies. Haemophilia 2024; 30 Suppl 3:39-44. [PMID: 38481077 DOI: 10.1111/hae.14976] [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: 01/09/2024] [Revised: 02/21/2024] [Accepted: 02/21/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION Over the last decades progress in haemophilia treatment has been remarkable and prophylaxis with clotting factor concentrates in haemophilia A and B has been established as the standard of care in individuals with haemophilia and a severe bleeding phenotype. Besides clotting factor products with prolonged half-life non-factor therapies were developed which enable prophylaxis via subcutaneous administration. Factor VIIIa mimetics like emicizumab facilitate the coagulation pathway and are used in routine clinical practice for indivdiduals with haemophilia A. Rebalancing therapeutic agents like fitusiran, concizumab, marstacimab and serpin PC block the anticoagulant pathway and clinical trials using these products in individuals with haemophilia A and B are ongoing. AIM AND METHODS A narrative review to asess the benefits and risks of non-factor therapies taking in to account re-defined haemophilia treatment goals. RESULTS Prophylaxis for prevention of bleeds using non-factor products by subcutaneous administration is effective and results in reductions of bleeding episodes in individuals with haemophilia A or B with and without inhibitors. The treatment with emicizumab showed tolerable safety both in clinical trials and long-term real-world observations with few thrombotic events. In some clinical trials with rebalancing therapies (fitusiran and concizumab) thrombotic events occurred. Monitoring of the haemostatic function of novel therapies especially with concomitant haemostatic treatment is not yet established. CONCLUSION With the advent of novel therapeutic agents including factor concentrates with ultra-long half-life and improved FVIIIa mimetics aimed at raising the bar of protection into the non-hemophilic range redefinition of haemophilia treatment goals is eagerly needed.
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Affiliation(s)
- Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Humanitas University, Pieve Emanuele, Milan, Italy
| | - Stacy E Croteau
- Boston Children's Hospital, Boston Hemophilia Center, Harvard Medical School, Boston, USA
| | - Robert Klamroth
- Department of Internal Medicine, Hemophilia Treatment Center, Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
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Olasupo OO, Noronha N, Lowe MS, Ansel D, Bhatt M, Matino D. Non-clotting factor therapies for preventing bleeds in people with congenital hemophilia A or B. Cochrane Database Syst Rev 2024; 2:CD014544. [PMID: 38411279 PMCID: PMC10897951 DOI: 10.1002/14651858.cd014544.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Management of congenital hemophilia A and B is by prophylactic or on-demand replacement therapy with clotting factor concentrates. The effects of newer non-clotting factor therapies such as emicizumab, concizumab, marstacimab, and fitusiran compared with existing standards of care are yet to be systematically reviewed. OBJECTIVES To assess the effects (clinical, economic, patient-reported, and adverse outcomes) of non-clotting factor therapies for preventing bleeding and bleeding-related complications in people with congenital hemophilia A or B compared with prophylaxis with clotting factor therapies, bypassing agents, placebo, or no prophylaxis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, electronic databases, conference proceedings, and reference lists of relevant articles and reviews. The date of the last search was 16 August 2023. SELECTION CRITERIA Randomized controlled trials (RCTs) evaluating people with congenital hemophilia A or B with and without inhibitors, who were treated with non-clotting factor therapies to prevent bleeds. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed studies for eligibility, assessed risk of bias, and extracted data for the primary outcomes (bleeding rates, health-related quality of life (HRQoL), adverse events) and secondary outcomes (joint health, pain scores, and economic outcomes). We assessed the mean difference (MD), risk ratio (RR), 95% confidence interval (CI) of effect estimates, and evaluated the certainty of the evidence using GRADE. MAIN RESULTS Six RCTs (including 397 males aged 12 to 75 years) were eligible for inclusion. Prophylaxis versus on-demand therapy in people with inhibitors Four trials (189 participants) compared emicizumab, fitusiran, and concizumab with on-demand therapy in people with inhibitors. Prophylaxis using emicizumab likely reduced annualized bleeding rates (ABR) for all bleeds (MD -22.80, 95% CI -37.39 to -8.21), treated bleeds (MD -20.40, 95% CI -35.19 to -5.61), and annualized spontaneous bleeds (MD -15.50, 95% CI -24.06 to -6.94), but did not significantly reduce annualized joint and target joint bleeding rates (AjBR and AtjBR) (1 trial; 53 participants; moderate-certainty evidence). Fitusiran also likely reduced ABR for all bleeds (MD -28.80, 95% CI -40.07 to -17.53), treated bleeds (MD -16.80, 95% CI -25.80 to -7.80), joint bleeds (MD -12.50, 95% CI -19.91 to -5.09), and spontaneous bleeds (MD -14.80, 95% CI -24.90 to -4.71; 1 trial; 57 participants; moderate-certainty evidence). No evidence was available on the effect of bleed prophylaxis using fitusiran versus on-demand therapy on AtjBR. Concizumab may reduce ABR for all bleeds (MD -12.31, 95% CI -19.17 to -5.45), treated bleeds (MD -10.10, 95% CI -17.74 to -2.46), joint bleeds (MD -9.55, 95% CI -13.55 to -5.55), and spontaneous bleeds (MD -11.96, 95% CI -19.89 to -4.03; 2 trials; 78 participants; very low-certainty evidence), but not target joint bleeds (MD -1.00, 95% CI -3.26 to 1.26). Emicizumab prophylaxis resulted in an 11.31-fold increase, fitusiran in a 12.5-fold increase, and concizumab in a 1.59-fold increase in the proportion of participants with no bleeds. HRQoL measured using the Haemophilia Quality of Life Questionnaire for Adults (Haem-A-QoL) physical and total health scores was improved with emicizumab, fitusiran, and concizumab prophylaxis (low-certainty evidence). Non-serious adverse events were higher with non-clotting factor therapies versus on-demand therapy, with injection site reactions being the most frequently reported adverse events. Transient antidrug antibodies were reported for fitusiran and concizumab. Prophylaxis versus on-demand therapy in people without inhibitors Two trials (208 participants) compared emicizumab and fitusiran with on-demand therapy in people without inhibitors. One trial assessed two doses of emicizumab (1.5 mg/kg weekly and 3.0 mg/kg bi-weekly). Fitusiran 80 mg monthly, emicizumab 1.5 mg/kg/week, and emicizumab 3.0 mg/kg bi-weekly all likely resulted in a large reduction in ABR for all bleeds, all treated bleeds, and joint bleeds. AtjBR was not reduced with either of the emicizumab dosing regimens. The effect of fitusiran prophylaxis on target joint bleeds was not assessed. Spontaneous bleeds were likely reduced with fitusiran (MD -20.21, 95% CI -32.12 to -8.30) and emicizumab 3.0 mg/kg bi-weekly (MD -15.30, 95% CI -30.46 to -0.14), but not with emicizumab 1.5 mg/kg/week (MD -14.60, 95% CI -29.78 to 0.58). The percentage of participants with zero bleeds was higher following emicizumab 1.5 mg/kg/week (50% versus 0%), emicizumab 3.0 mg/kg bi-weekly (40% versus 0%), and fitusiran prophylaxis (40% versus 5%) compared with on-demand therapy. Emicizumab 1.5 mg/kg/week did not improve Haem-A-QoL physical and total health scores, EQ-5D-5L VAS, or utility index scores (low-certainty evidence) when compared with on-demand therapy at 25 weeks. Emicizumab 3.0 mg/kg bi-weekly may improve HRQoL measured by the Haem-A-QoL physical health score (MD -15.97, 95% CI -29.14 to -2.80) and EQ-5D-5L VAS (MD 9.15, 95% CI 2.05 to 16.25; 1 trial; 43 participants; low-certainty evidence). Fitusiran may result in improved HRQoL shown as a reduction in Haem-A-QoL total score (MD -7.06, 95% CI -11.50 to -2.62) and physical health score (MD -19.75, 95% CI -25.76 to -11.94; 1 trial; 103 participants; low-certainty evidence). The risk of serious adverse events in participants without inhibitors also likely did not differ following prophylaxis with either emicizumab or fitusiran versus on-demand therapy (moderate-certainty evidence). Transient antidrug antibodies were reported in 4% (3/80) participants to fitusiran, with no observed effect on antithrombin lowering. A comparison of the different dosing regimens of emicizumab identified no differences in bleeding, safety, or patient-reported outcomes. No case of treatment-related cancer or mortality was reported in any study group. None of the included studies assessed our secondary outcomes of joint health, clinical joint function, and economic outcomes. None of the included studies evaluated marstacimab. AUTHORS' CONCLUSIONS Evidence from RCTs shows that prophylaxis using non-clotting factor therapies compared with on-demand treatment may reduce bleeding events, increase the percentage of individuals with zero bleeds, increase the incidence of non-serious adverse events, and improve HRQoL. Comparative assessments with other prophylaxis regimens, assessment of long-term joint outcomes, and assessment of economic outcomes will improve evidence-based decision-making for the use of these therapies in bleed prevention.
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Affiliation(s)
- Omotola O Olasupo
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Canada
| | - Noella Noronha
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Canada
| | - Megan S Lowe
- Department of Health Sciences, McMaster University, Hamilton, Canada
| | | | - Mihir Bhatt
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Davide Matino
- Department of Internal Medicine, McMaster University, Hamilton, Canada
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9
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Wilson HP, Pierre A, Paysse AL, Kumar N, Cooley BC, Rudra P, Dorsey AW, Polania-Villanueva D, Chatterjee S, Janbain M, Velez MC, Majumder R. Protein S antibody as an adjunct therapy for hemophilia B. Blood Adv 2024; 8:441-452. [PMID: 37773781 PMCID: PMC10827407 DOI: 10.1182/bloodadvances.2023010819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023] Open
Abstract
ABSTRACT Hemophilia B (HB) is caused by an inherited deficiency of plasma coagulation factor IX (FIX). Approximately 60% of pediatric patients with HB possess a severe form of FIX deficiency (<1% FIX activity). Treatment typically requires replacement therapy through the administration of FIX. However, exogenous FIX has a limited functional half-life, and the natural anticoagulant protein S (PS) inhibits activated FIX (FIXa). PS ultimately limits thrombin formation, which limits plasma coagulation. This regulation of FIXa activity by PS led us to test whether inhibiting PS would extend the functional half-life of FIX and thereby prolong FIX-based HB therapy. We assayed clotting times and thrombin generation to measure the efficacy of a PS antibody for increasing FIX activity in commercially obtained plasma and plasma from pediatric patients with HB. We included 11 pediatric patients who lacked additional comorbidities and coagulopathies. In vivo, we assessed thrombus formation in HB mice in the presence of the FIXa ± PS antibody. We found an accelerated rate of clotting in the presence of PS antibody. Similarly, the peak thrombin formed was significantly greater in the presence of the PS antibody, even in plasma from patients with severe HB. Furthermore, HB mice injected with PS antibody and FIX had a 4.5-fold higher accumulation of fibrin at the thrombus induction site compared with mice injected with FIX alone. Our findings imply that a PS antibody would be a valuable adjunct to increase the effectiveness of FIX replacement therapy in pediatric patients who have mild, moderate, and severe HB.
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Affiliation(s)
- Hope P. Wilson
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
- Department of Pediatric Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Aliyah Pierre
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Ashley L. Paysse
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Narender Kumar
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Brian C. Cooley
- Department of Biochemistry and Biophysics, University of North Carolina, Chapel Hill, NC
| | | | - Adrianne W. Dorsey
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Diana Polania-Villanueva
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Sabyasachi Chatterjee
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Maissaa Janbain
- Department of Hematology & Medical Oncology, Tulane University, New Orleans, LA
| | - Maria C. Velez
- Department of Pediatric Hematology and Oncology, Children's Hospital of New Orleans, New Orleans, LA
| | - Rinku Majumder
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
- Department of Interdisciplinary Oncology, Louisiana State University Health Sciences Center, New Orleans, LA
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10
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Hou PX, Yang RC. [Recent advances in the replacement therapy for Hemophilia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:1052-1056. [PMID: 38503535 PMCID: PMC10834880 DOI: 10.3760/cma.j.issn.0253-2727.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Indexed: 03/21/2024]
Affiliation(s)
- P X Hou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China Tianjin Institutes of Health Science, Tianjin 301600, China
| | - R C Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China Tianjin Institutes of Health Science, Tianjin 301600, China
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11
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Pruthi RK, Chen D. The Use of Bypassing Treatment Strategies in Hemophilia and Their Effect on Laboratory Testing. Semin Thromb Hemost 2023; 49:651-660. [PMID: 37146647 DOI: 10.1055/s-0043-1768660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Factor VIII and IX inhibitors in congenital hemophilia A and B, respectively, neutralize the infused coagulation factor concentrate rendering them ineffective. Bypassing agents (BPAs) that circumvent the block imposed by the inhibitors are used for the prevention and management of bleeding. Activated prothrombin complex concentrate was the original BPA, recombinant activated factor VII was then introduced, and more recently nonfactor agents that target the procoagulant and anticoagulant systems have been developed and are in clinical use (e.g., emicizumab, a bispecific antibody for hemophilia A). Other BPAs are in clinical trials (e.g., fitusiran targets antithrombin, concizumab and marstacimab target tissue factor pathway inhibitor, and SerpinPC targets activated protein C). The BPAs have a varied effect on coagulation assays, and as more patients are exposed to these agents, it is important to be aware of the effects. Herein, we present an overview of the effect of BPAs on routine and specialized coagulation assays including thrombin generation and viscoelastic assays.
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Affiliation(s)
- Rajiv K Pruthi
- Division of Hematology, Department of Internal Medicine, Comprehensive Hemophilia Center, Rochester, Minnesota
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Special Coagulation Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Dong Chen
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Special Coagulation Laboratory, Mayo Clinic, Rochester, Minnesota
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12
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Bowyer AE, Gosselin RC. Factor VIII and Factor IX Activity Measurements for Hemophilia Diagnosis and Related Treatments. Semin Thromb Hemost 2023; 49:609-620. [PMID: 36473488 PMCID: PMC10421651 DOI: 10.1055/s-0042-1758870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Accurate measurement of clotting factors VIII (FVIII) or IX (FIX) is vital for comprehensive diagnosis and management of patients with hemophilia A or B. The one-stage activated partial thromboplastin time (aPTT)-based clotting assay is the most commonly used method worldwide for testing FVIII or FIX activities. Alternatively, FVIII and FIX chromogenic substrate assays, which assess the activation of factor X, are available in some specialized laboratories. The choice of reagent or methodology can strongly influence the resulting activity. Variation between one-stage FVIII or FIX activities has been reported in the measurement of some standard and extended half-life factor replacement therapies and gene therapy for hemophilia B using different aPTT reagents. Discrepancy between one-stage and chromogenic reagents has been demonstrated in some patients with mild hemophilia A or B, the measurement of some standard and extended half-life factor replacement therapies, and the transgene expression of hemophilia A and B patients who have received gene therapy. Finally, the measurement of bispecific antibody therapy in patients with hemophilia A has highlighted differences between chromogenic assays. It is imperative that hemostasis laboratories evaluate how suitable their routine assays are for the accurate measurement of the various hemophilia treatment therapies.
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Affiliation(s)
- Annette E. Bowyer
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Robert C. Gosselin
- Hemostasis and Thrombosis Center, University of California, Davis Health System, Sacramento, California
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13
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Matsushita T, Shapiro A, Abraham A, Angchaisuksiri P, Castaman G, Cepo K, d'Oiron R, Frei-Jones M, Goh AS, Haaning J, Hald Jacobsen S, Mahlangu J, Mathias M, Nogami K, Skovgaard Rasmussen J, Stasyshyn O, Tran H, Vilchevska K, Villarreal Martinez L, Windyga J, You CW, Zozulya N, Zulfikar B, Jiménez-Yuste V. Phase 3 Trial of Concizumab in Hemophilia with Inhibitors. N Engl J Med 2023; 389:783-794. [PMID: 37646676 DOI: 10.1056/nejmoa2216455] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Concizumab is an anti-tissue factor pathway inhibitor monoclonal antibody designed to achieve hemostasis in all hemophilia types, with subcutaneous administration. A previous trial of concizumab (explorer4) established proof of concept in patients with hemophilia A or B with inhibitors. METHODS We conducted the explorer7 trial to assess the safety and efficacy of concizumab in patients with hemophilia A or B with inhibitors. Patients were randomly assigned in a 1:2 ratio to receive no prophylaxis for at least 24 weeks (group 1) or concizumab prophylaxis for at least 32 weeks (group 2) or were nonrandomly assigned to receive concizumab prophylaxis for at least 24 weeks (groups 3 and 4). After a treatment pause due to nonfatal thromboembolic events in three patients receiving concizumab, including one from the explorer7 trial, concizumab therapy was restarted with a loading dose of 1.0 mg per kilogram of body weight, followed by 0.2 mg per kilogram daily (potentially adjusted on the basis of concizumab plasma concentration as measured at week 4). The primary end-point analysis compared treated spontaneous and traumatic bleeding episodes in group 1 and group 2. Safety, patient-reported outcomes, and pharmacokinetics and pharmacodynamics were also assessed. RESULTS Of 133 enrolled patients, 19 were randomly assigned to group 1 and 33 to group 2; the remaining 81 were assigned to groups 3 and 4. The estimated mean annualized bleeding rate in group 1 was 11.8 episodes (95% confidence interval [CI], 7.0 to 19.9), as compared with 1.7 episodes (95% CI, 1.0 to 2.9) in group 2 (rate ratio, 0.14 [95% CI, 0.07 to 0.29]; P<0.001). The overall median annualized bleeding rate for patients receiving concizumab (groups 2, 3, and 4) was 0 episodes. No thromboembolic events were reported after concizumab therapy was restarted. The plasma concentrations of concizumab remained stable over time. CONCLUSIONS Among patients with hemophilia A or B with inhibitors, the annualized bleeding rate was lower with concizumab prophylaxis than with no prophylaxis. (Funded by Novo Nordisk; explorer7 ClinicalTrials.gov number, NCT04083781.).
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Affiliation(s)
- Tadashi Matsushita
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Amy Shapiro
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Aby Abraham
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Pantep Angchaisuksiri
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Giancarlo Castaman
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Katarina Cepo
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Roseline d'Oiron
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Melissa Frei-Jones
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Ai-Sim Goh
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Jesper Haaning
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Sanja Hald Jacobsen
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Johnny Mahlangu
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Mary Mathias
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Keiji Nogami
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Josephine Skovgaard Rasmussen
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Oleksandra Stasyshyn
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Huyen Tran
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Kateryna Vilchevska
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Laura Villarreal Martinez
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Jerzy Windyga
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Chur Woo You
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Nadezhda Zozulya
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Bulent Zulfikar
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
| | - Victor Jiménez-Yuste
- From the Department of Transfusion Medicine, Nagoya University Hospital, Nagoya (T.M.), and Nara Medical University, Kashiwara (K.N.) - both in Japan; Indiana Hemophilia and Thrombosis Center, Indianapolis (A.S.); the Department of Hematology, Christian Medical College, Vellore, India (A.A.); the Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy (P.A.); the Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (G.C.); Novo Nordisk, Søborg, Denmark (K.C., J.H., S.H.J., J.S.R.); the Reference Center for Hemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital Assistance Publique-Hôpitaux de Paris, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, France (R.O.); the Department of Pediatrics, University of Texas Health Long School of Medicine, San Antonio (M.F.-J.); the Department of Medicine, Hospital Pulau Pinang, Georgetown, Malaysia (A.-S.G.); the Department of Molecular Medicine and Haematology, University of the Witwatersrand, National Health Laboratory Service, Johannesburg (J.M.); Great Ormond Street Hospital for Children NHS Foundation Trust, London (M.M.); the Institute of Blood Pathology and Transfusion Medicine, Lviv (O.S.), and National Specialized Children's Hospital Okhmatdyt, Kyiv (K.V.) - both in Ukraine; the Ronald Sawers Haemophilia Centre,Alfred Hospital, and the Australian Centre for Blood Diseases, Monash University - both in Melbourne, VIC, Australia (H.T.); Dr. José Eleuterio González Monterrey University Hospital, Monterrey, México (L.V.M.); the Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland (J.W.); the Department of Pediatrics, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, South Korea (C.W.Y.); the National Research Center for Hematology of the Ministry of Health of the Russian Federation, Moscow (N.Z.); the Division of Pediatric Hematology-Oncology, Istanbul University Oncology Institute, Istanbul, Turkey (B.Z.); and the Hematology Department, La Paz University Hospital, Hospital La Paz Institute for Health Research, Universidad Autónoma Madrid, Madrid (V.J.-Y.)
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14
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Castaman G, Coppens M, Pipe SW. Etranacogene dezaparvovec for the treatment of adult patients with severe and moderately severe hemophilia B. Expert Rev Hematol 2023; 16:919-932. [PMID: 37882214 DOI: 10.1080/17474086.2023.2276206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/24/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Etranacogene dezaparvovec is the first gene therapy approved for treatment of adults with severe and moderately severe hemophilia B. AREAS COVERED This review describes the results of the clinical trial program of AMT-060 and etranacogene dezaparvovec, outlining the pharmacokinetic, clinical efficacy and safety data. With the entry of etranacogene dezaparvovec into the market, this review summarizes the treatment landscape in hemophilia B and discusses the current unknowns in the field. EXPERT OPINION Gene therapy appears to be a feasible option for adults with severe and moderately severe hemophilia B. Etranacogene dezaparvovec enables most patients to reach stable factor IX (FIX) levels after a single intravenous infusion, eliminating the need for regular prophylaxis; thus, drastically reducing treatment burden and avoiding variable bleeding risk owing to fluctuating FIX activity levels. Efficacy of etranacogene dezaparvovec has been demonstrated even in the presence of preexisting neutralizing antibodies (up to a titer of 1:678), with a relative low risk of transaminitis and its associated potential loss of transgene expression. However, long-term data are required to ascertain the durability of FIX levels achieved and safety. The cost-effectiveness and adoption of innovative payment models for reimbursement are key in choosing gene therapy over existing treatments.
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Affiliation(s)
- Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Michiel Coppens
- Vascular Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, The Netherlands
| | - Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan Medical School, Ann Arbor, MI, USA
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Yoneyama K, Schmitt C, Portron A, Kiialainen A, Kotani N, Jaminion F, Retout S, Adamkewicz JI. Clinical pharmacology of emicizumab for the treatment of hemophilia A. Expert Rev Clin Pharmacol 2023; 16:775-790. [PMID: 37529848 DOI: 10.1080/17512433.2023.2243213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/22/2023] [Accepted: 07/28/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Emicizumab is a humanized bispecific antibody approved for the routine prophylaxis of bleeding episodes in patients with hemophilia A (PwHA) regardless of the presence of factor VIII (FVIII) inhibitors. It mimics the cofactor function of missing activated FVIII by bridging activated factor IX and factor X, thereby restoring hemostasis. AREAS COVERED This review covers the clinical pharmacology of emicizumab and the translation of its pharmacokinetics (PK) and pharmacodynamics (PD) to clinical efficacy and safety. The PK of emicizumab is linear, with an approximately 1-month half-life. Once-weekly to every-4-week subcutaneous (SC) administrations maintain effective trough concentrations throughout the dosing intervals, associated with a coagulation potential analogous to that in patients with mild hemophilia A. In combination with activated prothrombin complex concentrate, and to a lesser extent with recombinant activated factor VII, emicizumab exerts a synergistic effect, whereas combination with FVIII may result in a non-additive coagulation potential at normal FVIII activity. EXPERT OPINION The translation of emicizumab PK/PD into clinical effects was demonstrated in several phase III studies, which showed remarkable bleed control and a favorable safety profile in PwHA. These emicizumab attributes, together with the convenience of use (infrequent SC injections), offer a novel paradigm for the management of PwHA.
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16
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Shima M. Current status and future prospects of activated recombinant coagulation factor VIIa, NovoSeven®, in the treatment of haemophilia and rare bleeding disorders. Ann Hematol 2023:10.1007/s00277-023-05287-2. [PMID: 37391649 DOI: 10.1007/s00277-023-05287-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 05/19/2023] [Indexed: 07/02/2023]
Abstract
rFVIIa, a human recombinant activated coagulation factor VII, has been used worldwide for more than two decades for the treatment of bleeding episodes and prevention of bleeding in patients undergoing surgery/invasive procedures with congenital haemophilia A or B with inhibitors (CHwI A or B), acquired haemophilia (AH), congenital factor VII deficiency and Glanzmann thrombasthenia (GT), refractory to platelet transfusion. The approved dosage, administration and indication of rFVIIa in the US, Europe and Japan differ, depending on the needs of the patient population and regulatory practices. This review presents an overview of the current status and future prospects, including that from a Japanese perspective, of using rFVIIa in the treatment of approved indications. The efficacy and safety of rFVIIa in the approved indications has been demonstrated in several randomised and observational studies and data from registries. The overall incidence of thrombosis across all approved indications in a retrospective safety assessment of clinical trials and registries, prelicensure studies and postmarketing surveillance studies of rFVIIa use was 0.17%. Specifically, the risk of thrombotic events was 0.11% for CHwI, 1.77% for AH, 0.82% for congenital factor VII deficiency and 0.19% for GT. Emerging non-factor therapies such as emicizumab have changed the treatment landscape of haemophilia A, including preventing bleeding in patients with CHwI. However, rFVIIa will continue to play a significant role in the treatment of such patients, particularly during breakthrough bleeding or surgical procedures.
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Affiliation(s)
- Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, 840 Shijo‑cho, Kashihara City, Nara, 634-8522, Japan.
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Abstract
Concizumab (Alhemo™), a subcutaneously administered humanised monoclonal IgG4 antibody against tissue factor pathway inhibitor (TFPI), binds to the Kunitz-2 domain of TFPI and prevents TFPI from binding to activated Factor X. Concizumab is being developed by Novo Nordisk for the treatment of hemophilia A and B with and without inhibitors. In March 2023, concizumab was approved in Canada for the treatment of adolescent and adult patients (12 years of age or older) with hemophilia B who have FIX inhibitors and require routine prophylaxis to prevent or reduce the frequency of bleeding episodes. This article summarizes the milestones in the development of concizumab leading to this first approval for the treatment of hemophilia B.
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Affiliation(s)
- Susan J Keam
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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18
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Young G. Nonfactor Therapies for Hemophilia. Hemasphere 2023; 7:e911. [PMID: 37292115 PMCID: PMC10247213 DOI: 10.1097/hs9.0000000000000911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/09/2023] [Indexed: 06/10/2023] Open
Affiliation(s)
- Guy Young
- Cancer and Blood Disorders Institute, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, 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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Brod M, Bushnell DM, Neergaard JS, Waldman LT, Busk AK. Understanding treatment burden in hemophilia: development and validation of the Hemophilia Treatment Experience Measure (Hemo-TEM). J Patient Rep Outcomes 2023; 7:17. [PMID: 36821002 PMCID: PMC9950311 DOI: 10.1186/s41687-023-00550-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 01/16/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND To capture the broad range of treatment burden issues experienced by adolescent and adult people with hemophilia (PWH), the Hemophilia Treatment Experience Measure (Hemo-TEM) was developed. We describe the development of this new hemophilia-specific patient-reported outcome (PRO) measure including concept elicitation, cognitive debriefing, and psychometric validation. RESULTS Concept elicitation interviews were conducted with 5 clinical experts and 30 adult PWH in the United States (US). The qualitative analysis of these interviews and a review of the literature informed the PRO measure development. The project team reviewed concept endorsement rates and generated a 27-item preliminary version of the Hemo-TEM. Cognitive debriefing interviews were conducted to ensure participant understanding and item relevance in samples of (adolescent (n = 20) and adult (n = 14)) PWH in the US. The refined, validation-ready version of the Hemo-TEM included 30 items. Lastly, data from 3 clinical trials comprised the 4 analysis sets used for the psychometric validation with a sample size of N = 88. Item reduction dropped 4 items resulting in a final 26-item measure. Factor analysis generated 5 domains in the Hemo-TEM [injection difficulties (3 items), physical impact (6 items), treatment bother (7 items), interference with daily life (4 items), and emotional impact (6 items)] and a total score. All scores were reliable [internally consistent (0.84-0.88)]. For convergent validity, with the exception of one domain, all hypothesized associations were met. Preliminary sensitivity to change effect sizes were between - 0.30 and - 0.70. Meaningful change thresholds ranged from 6 points (physical impact and emotional impact) to 10 points (treatment bother) with 8 points for the Hemo-TEM total score. CONCLUSIONS Findings from the concept elicitation, cognitive debriefing, and psychometric validation phases provide evidence that the Hemo-TEM is a well-designed, valid, and reliable measure of the burden of hemophilia treatment, including treatment impact on adolescent and adult PWH.
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Affiliation(s)
- Meryl Brod
- The Brod Group, 219 Julia Ave, Mill Valley, CA, USA.
| | | | | | - Laura Tesler Waldman
- grid.430475.10000 0004 0591 7571The Brod Group, 219 Julia Ave, Mill Valley, CA USA
| | - Anne Kirstine Busk
- grid.425956.90000 0004 0391 2646Novo Nordisk A/S, Vandtaarnsvej 112, Søborg Denmark
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Liu W, Xue F, Fu R, Ding B, Li M, Sun T, Chen Y, Liu X, Ju M, Dai X, Wu Q, Zhou Z, Yu J, Wang X, Zhu Q, Zhou H, Yang R, Zhang L. Preclinical studies of a factor X activator and a phase 1 trial for hemophilia patients with inhibitors. J Thromb Haemost 2023; 21:1453-1465. [PMID: 36796484 DOI: 10.1016/j.jtha.2023.01.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 01/10/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Bleeding episodes in hemophiliacs with inhibitors are difficult to control. Staidson protein-0601 (STSP-0601), a specific factor (F)X activator purified from the venom of Daboia russelii siamensis, has been developed. OBJECTIVES We aimed to investigate the efficacy and safety of STSP-0601 in preclinical and clinical studies. METHODS In vitro and in vivo preclinical studies were performed. A phase 1, first-in-human, multicenter, and open-label trial was conducted. The clinical study was divided into parts A and B. Hemophiliacs with inhibitors were eligible for this study. Patients received a single intravenous injection of STSP-0601 (0.01 U/kg, 0.04 U/kg, 0.08 U/kg, 0.16 U/kg, 0.32 U/kg, or 0.48 U/kg) in part A or a maximum of 6 4-hourly injections (0.16 U/kg) in part B. The primary endpoint for each part was the number of adverse events (AEs) from baseline to 168 hours after administration. This study was registered at clinicaltrials.gov (NCT-04747964 and NCT-05027230). RESULTS Preclinical studies showed that STSP-0601 could specifically activate FX in a dose-dependent manner. In the clinical study, 16 patients in part A and 7 patients in part B were enrolled. Eight (22.2%) AEs in part A and 18 (75.0%) AEs in part B were reported to be related to STSP-0601. Neither severe AEs nor dose-limiting toxicity events were reported. There were no thromboembolic event. The antidrug antibody of STSP-0601 was not detected. CONCLUSION Preclinical and clinical studies showed that STSP-0601 had a good ability to activate FX and had a good safety profile. STSP-0601 could be used as a hemostatic treatment in hemophiliacs with inhibitors.
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Affiliation(s)
- Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Rongfeng Fu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Bingjie Ding
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, China
| | - Mengjuan Li
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, China
| | - Ting Sun
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Yunfei Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Xiaofan Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Mankai Ju
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Xinyue Dai
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Quanrui Wu
- Staidson (Beijing) Biopharmaceuticals Co, Ltd, Beijing, China
| | - Zan Zhou
- Staidson (Beijing) Biopharmaceuticals Co, Ltd, Beijing, China
| | - Jiaojiao Yu
- Staidson (Beijing) Biopharmaceuticals Co, Ltd, Beijing, China
| | - Xiaomin Wang
- Staidson (Beijing) Biopharmaceuticals Co, Ltd, Beijing, China
| | - Qing Zhu
- Staidson (Beijing) Biopharmaceuticals Co, Ltd, Beijing, China
| | - Hu Zhou
- Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Hemostasis and Thrombosis Diagnostic Engineering Research Center of Henan Province, Zhengzhou, China.
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China.
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, Chinese Academy of Medical Sciences Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China.
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22
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Young G. The dosing conundrum of emicizumab: To waste product or not? Res Pract Thromb Haemost 2023; 7:100087. [PMID: 36908771 PMCID: PMC9999193 DOI: 10.1016/j.rpth.2023.100087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 01/24/2023] [Indexed: 02/17/2023] Open
Affiliation(s)
- Guy Young
- Cancer and Blood Disorders Institute, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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23
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Affiliation(s)
- Cindy Leissinger
- From the Louisiana Center for Bleeding and Clotting Disorders, Department of Medicine, Tulane University School of Medicine, New Orleans
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24
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Blazquez-Ramos N, Romero-Garrido JA, Gonzalez Del Valle L, Collada-Sanchez VL, Alvarez-Roman MT, Jimenez-Yuste V, Martin-Salces M, De la Corte-Rodriguez H, Herrero-Ambrosio A, Benedi-Gonzalez J, Rodriguez-Merchan EC. Development of a telematic pharmaceutical care app (Haemoassist) for multidisciplinary follow-up of patients with congenital coagulopathies. Expert Rev Hematol 2023; 16:213-226. [PMID: 36563352 DOI: 10.1080/17474086.2023.2162497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Guidelines for congenital coagulopathies recommend that patients record treatment administrations and bleeding episodes to help healthcare professionals monitor the disease. RESEARCH DESIGN AND METHODS We studied over two years which patient profiles (age, treatment regimen, treatment compliance) were most likely to accept the use of an app to collect this information. We validated the quality of patient-reported data by comparing it with data obtained from hospital electronic records, pharmacy dispensing records and patient interview, collected in an access database used as a reference. Patient and professional opinions were solicited through open-ended interviews. RESULTS The app was used by 52% of 315 patients studied. Younger patients were the most frequent users. Patients with better treatment compliance used the app more, although data collection was incomplete for most patients. The best rated by patients were the reminders of days of administration and the minimum stock alerts at home. Healthcare professionals rated the app positively. CONCLUSIONS Healthcare professionals valued the app as useful for managing treatment of congenital coagulopathies. Patients need support and time to use the app and improve the quality of the data entered. Patients who used the app rated it positively. The treatment compliance improved.
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Affiliation(s)
- Nuria Blazquez-Ramos
- Department of Pharmacy, La Paz University Hospital, Madrid, Spain.,IdiPAZ, La Paz University Hospital Health Research Institute, Madrid, Spain
| | - José A Romero-Garrido
- Department of Pharmacy, La Paz University Hospital, Madrid, Spain.,IdiPAZ, La Paz University Hospital Health Research Institute, Madrid, Spain.,Department of Pharmacology, Complutense University of Madrid, Madrid, Spain
| | - Luis Gonzalez Del Valle
- Department of Pharmacy, La Paz University Hospital, Madrid, Spain.,IdiPAZ, La Paz University Hospital Health Research Institute, Madrid, Spain
| | | | - María Teresa Alvarez-Roman
- IdiPAZ, La Paz University Hospital Health Research Institute, Madrid, Spain.,Department of Hematology, La Paz University Hospital, Madrid, Spain
| | - Victor Jimenez-Yuste
- IdiPAZ, La Paz University Hospital Health Research Institute, Madrid, Spain.,Department of Hematology, La Paz University Hospital, Madrid, Spain
| | - Monica Martin-Salces
- IdiPAZ, La Paz University Hospital Health Research Institute, Madrid, Spain.,Department of Hematology, La Paz University Hospital, Madrid, Spain
| | - Hortensia De la Corte-Rodriguez
- IdiPAZ, La Paz University Hospital Health Research Institute, Madrid, Spain.,Department of Physical Medicine and Rehabilitation, La Paz University Hospital, Madrid, Spain
| | - Alicia Herrero-Ambrosio
- Department of Pharmacy, La Paz University Hospital, Madrid, Spain.,IdiPAZ, La Paz University Hospital Health Research Institute, Madrid, Spain
| | | | - E Carlos Rodriguez-Merchan
- IdiPAZ, La Paz University Hospital Health Research Institute, Madrid, Spain.,Department of Orthopedic Surgery, La Paz University Hospital, Madrid, Spain
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25
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Mahlangu JN, Lamas JL, Morales JC, Malan DR, Šalek SZ, Wang M, Boggio LN, Hegemann I, Mital A, Cardinal M, Zhu T, Sun P, Arkin S. A phase 1b/2 clinical study of marstacimab, targeting human tissue factor pathway inhibitor, in haemophilia. Br J Haematol 2023; 200:229-239. [PMID: 35999026 DOI: 10.1111/bjh.18420] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 07/29/2022] [Accepted: 08/09/2022] [Indexed: 02/06/2023]
Abstract
A phase 1b/2, three-month study of marstacimab, a human monoclonal antibody targeting tissue factor pathway inhibitor (TFPI), was conducted in participants with haemophilia A or B, with or without inhibitors. Participants assigned to four cohorts received escalating weekly doses based on inhibitor status (without inhibitors: 300 mg, a single 300-mg loading dose with subsequent 150-mg doses, or 450 mg; with inhibitors: 300 mg). Safety outcomes were treatment-emergent adverse events (TEAEs), injection site reactions, clinical and laboratory parameter changes. Efficacy was assessed by annualised bleeding rates (ABRs). Pharmacokinetics and pharmacodynamics (PD) were also evaluated. Among 26 treated participants [haemophilia A without inhibitor, n = 16 (61.5%); haemophilia A with inhibitor, n = 7 (26.9%); haemophilia B, n = 3 (11.5%)], 24 completed the study. Overall, 80.8% experienced TEAEs. ABR during treatment was significantly reduced versus an external on-demand control group (p < 0.0001) and versus pretreatment ABR (p < 0.0001), with significant reductions observed across all dose cohorts. Marstacimab exposure generally increased in a dose-related manner, with steady-state concentration reached by day 57. Changes in pharmacodynamic biomarkers occurred across all dose cohorts. Marstacimab was safe and well tolerated. Clinically meaningful reductions in ABR and treatment-related changes for all PD biomarkers indicated effective targeting of TFPI. (Clinicaltrials.gov identifier, NCT02974855).
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Affiliation(s)
- Johnny N Mahlangu
- University of the Witwatersrand, Johannesburg, South Africa.,National Health Laboratory Service, Johannesburg, South Africa.,Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | | | | | - Daniel R Malan
- Phoenix Pharma, Mount Croix, Port Elizabeth, South Africa
| | | | - Michael Wang
- University of Colorado Hemophilia and Thrombosis Center, Aurora, Colorado, USA
| | - Lisa N Boggio
- Rush Hemophilia and Thrombophilia Center, Chicago, Illinois, USA
| | - Inga Hegemann
- Haemophilia Comprehensive Care Center, University Hospital, Zurich, Switzerland
| | | | | | - Tong Zhu
- Pfizer Worldwide Research and Development, Cambridge, Massachusetts, USA
| | - Pengling Sun
- Pfizer Worldwide Research and Development, Cambridge, Massachusetts, USA
| | - Steven Arkin
- Pfizer Worldwide Research and Development, Cambridge, Massachusetts, USA
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26
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Ogiwara K, Furukawa S, Shinohara S, Tabuchi Y, Arai N, Noguchi-Sasaki M, Soeda T, Shima M, Nogami K. Anti-idiotype monoclonal antibodies against emicizumab enable accurate procoagulant and anticoagulant assays, irrespective of the test base, in the presence of emicizumab. Haemophilia 2023; 29:329-335. [PMID: 36137299 DOI: 10.1111/hae.14662] [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] [Received: 05/17/2022] [Revised: 08/15/2022] [Accepted: 09/06/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Emicizumab markedly shortens the activated partial thromboplastin time (aPTT), resulting in inaccurate measurements of procoagulant and anticoagulant factor activities. We have recently reported that mixtures of two different anti-idiotype monoclonal antibodies against emicizumab (anti-emicizumab-mAbs) allow measurement of factor (F)VIII activity (FVIII:C) and FVIII inhibitor in emicizumab-containing plasmas. It is unknown whether anti-emicizumab mAbs can work for other aPTT-based procoagulant and anticoagulant assays. AIM To investigate whether anti-emicizumab mAbs were measured by all of the aPTT-based assays tested. METHODS Two anti-emicizumab-mAbs (300 μg/mL each) were preincubated with emicizumab (200 μg/mL)-spiked FVIII-deficient plasma; we then measured FVIII:C, FIX:C, FXI:C, FXII:C, protein (P)C:C, PS:C, global PC-FV (aPTT-based), and prothrombin time (PT), diluted Russel's viper venom time (dRVVT), chromogenic-based FVIII:C, FIX:C and PC:C (non-aPTT-based). Emicizumab (100 μg/mL)-spiked haemophilia (H)A plasmas from patients (n = 23) were also measured. RESULTS Emicizumab shortened the clotting time in all aPTT-based assays, resulting in high levels of FVIII:C, FIX:C, FXI:C and FXII:C; low levels of PC:C and PS:C; and false-positive results for activated PC resistance. The addition of anti-emicizumab-mAbs to emicizumab-added plasma restored all factors to the initial levels without emicizumab. Chromogenic FVIII:C measurement by human FIXa/FX was affected by emicizumab, but anti-emicizumab mAbs cancelled this effect. PT-based assays and dRVVT, chromogenic FIX:C and PC:C assays showed no effect with emicizumab. Twenty-three plasma samples from HA patients also showed similar patterns. CONCLUSION Anti-emicizumab mAbs in vitro could cancel the effect of emicizumab, irrespective of the test base, resulting in accurate measurements of procoagulant and anticoagulant factor activity.
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Affiliation(s)
- Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Sho Shinohara
- Reagent Engineering, Sysmex Corporation, Kobe, Japan
| | - Yuka Tabuchi
- System Engineering, Sysmex Corporation, Kobe, Japan
| | - Nobuo Arai
- Reagent Engineering, Sysmex Corporation, Kobe, Japan
| | | | - Tetsuhiro Soeda
- Chugai Pharmaceutical Co., Research Division, Gotemba, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Center of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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27
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Shapiro AD, Hardesty BM, Peyvandi F, Iorio A. Prevalence of selected bleeding and thrombotic events in persons with hemophilia versus the general population: A scoping review. Res Pract Thromb Haemost 2023; 7:100007. [PMID: 36891522 PMCID: PMC9986102 DOI: 10.1016/j.rpth.2022.100007] [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: 05/05/2022] [Revised: 10/12/2022] [Accepted: 11/06/2022] [Indexed: 01/13/2023] Open
Abstract
Life expectancy for persons with hemophilia has increased over recent decades due to advances in treatment practice and patient care. Those with hemophilia are now more likely to be affected by conditions associated with aging, such as myocardial infarction, hemorrhagic/ischemic stroke, deep vein thrombosis, pulmonary embolism, and intracranial hemorrhage. Here, we describe the results of a literature search designed to summarize current data on the prevalence of the above selected bleeding and thrombotic events in persons with hemophilia vs the general population. A total of 912 articles published between 2005 and 2022 were identified in a search of BIOSIS Previews, Embase, and MEDLINE databases conducted in July 2022. Case studies, conference abstracts, review articles, studies focusing on hemophilia treatments or surgical outcomes, and studies examining patients with inhibitors only were excluded. After screening, 83 relevant publications were identified. The prevalence of bleeding events was consistently higher in hemophilia populations vs reference populations (hemorrhagic stroke, 1.4%-5.31% vs 0.2%-0.97%; intracranial hemorrhage, 1.1%-10.8% vs 0.04%-0.4%). Serious bleeding events showed a high rate of mortality with standardized mortality ratios for intracranial hemorrhage ranging from 3.5 to 14.88. Although 9 studies reported lower prevalence of arterial thrombosis (myocardial infarction/stroke) in hemophilia vs general populations, 5 studies reported higher or comparable prevalence in hemophilia. Prospective studies are therefore needed to understand the prevalence of bleeding and thrombotic events in hemophilia populations, particularly with the observed increases in life expectancy and availability of novel treatments.
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Affiliation(s)
- Amy D Shapiro
- Indiana Haemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | | | - Flora Peyvandi
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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28
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Nogami K, Shima M. Current and future therapies for haemophilia-Beyond factor replacement therapies. Br J Haematol 2023; 200:23-34. [PMID: 35869698 DOI: 10.1111/bjh.18379] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 12/01/2022]
Abstract
Some non-factor products that work by facilitating the coagulation pathway (emicizumab) and blocking the anticoagulant pathway (fitusiran, concizumab and marstacimab) for patients with haemophilia (H) have been developed, and clinical trials using these products are currently ongoing. Prophylaxis using non-factor products by subcutaneous administration provides marked reductions of bleeding episodes in patients with HA or HB, regardless of the presence of inhibitor. Emicizumab has already been approved globally. Emicizumab alters the phenotype of patients with HA from severe to mild by maintaining trough levels of equivalent factor VIII activity (15-20 iu/dl). Phase 3 clinical trials and long-term observations assessing emicizumab revealed tolerable safety and efficacy. However, thrombotic events have occurred in patients receiving these non-factor products. Furthermore, monitoring of the haemostatic function of these products with concomitant therapy is also required in clinical practice. These products have promising haemostatic efficiency, but wider clinical experience is needed to provide optimal therapeutic strategies in the future.
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Affiliation(s)
- Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,Thrombosis and Hemostasis Research Centre, Nara Medical University, Kashihara, Nara, Japan
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29
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Mahlangu J, Luis Lamas J, Cristobal Morales J, Malan DR, Teeter J, Charnigo RJ, Hwang E, Arkin S. Long-term safety and efficacy of the anti-tissue factor pathway inhibitor marstacimab in participants with severe haemophilia: Phase II study results. Br J Haematol 2023; 200:240-248. [PMID: 36220152 PMCID: PMC10092220 DOI: 10.1111/bjh.18495] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 08/31/2022] [Accepted: 09/20/2022] [Indexed: 01/14/2023]
Abstract
Marstacimab, an investigational human monoclonal antibody targeting tissue factor pathway inhibitor, demonstrated safety and efficacy in preventing bleeding episodes in patients with haemophilia. This multicentre, open-label study investigated safety, tolerability, and efficacy of long-term weekly prophylactic marstacimab treatment in participants with severe haemophilia A and B, with or without inhibitors. Adult participants were enrolled from a previous phase Ib/II study or de novo and assigned to one of two subcutaneous (SC) marstacimab doses: once-weekly 300 mg or a 300-mg loading dose followed by once-weekly 150-mg doses, for up to 365 days. Study end-points included safety assessments and annualised bleeding rates (ABRs). Of 20 enrolled participants, 18 completed the study. Overall, 70% of participants had treatment-emergent adverse events, including injection site reactions, injection site haematoma, and haemarthrosis. No treatment-related serious adverse events or thrombotic events occurred. Across all dose cohorts, mean and median on-study ABRs ranged from 0 to 3.6 and 0 to 2.5 bleeding episodes/participant/year respectively, demonstrating comparable efficacy to that observed in the short-term parent study. No treatment-induced anti-drug antibodies were detected. Once-weekly SC marstacimab prophylaxis was well tolerated, with an acceptable safety profile, and maintained long-term efficacy up to 365 days. (Clinicaltrials.gov identifier, NCT03363321).
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Affiliation(s)
- Johnny Mahlangu
- Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | | | | | | | | | | | | | - Steven Arkin
- Rare Diseases Research Unit, Pfizer Worldwide R&D, Cambridge, Massachusetts, USA
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30
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Manco-Johnson MJ. Long-term prophylaxis: what are our options and how to define success? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:579-585. [PMID: 36485126 PMCID: PMC9820516 DOI: 10.1182/hematology.2022000397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Currently, we are at an enviable place in hemophilia treatment. Although full prophylaxis with standard half-life recombinant or plasma-derived factor concentrates has been definitively shown to be inadequate for full protection against bleeding and arthropathy, a number of novel therapies with improved hemostatic enhancement are clinically available or in promising clinical trials. In order to compare outcomes among a number of very efficacious therapies, it is necessary to have sensitive tools employed in long-term follow-up for several years for participants with no or minimal joint disease. The tool kit must be comprehensive, with outcomes of bleeding, factor level restoration or hemostatic capacity, joint structure, joint function, pain, quality of life, and patient satisfaction. This article reviews the history of prophylaxis, the promise of emerging therapies, and the sensitive tools used to assess long-term efficacy for joint structure and function.
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Affiliation(s)
- Marilyn Jean Manco-Johnson
- Correspondence Marilyn Jean Manco-Johnson, University of Colorado Anschutz Medical Center, 13199 E Montview Blvd, Ste 100, Aurora CO, 80045; e-mail:
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31
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Luo L, Zheng Q, Chen Z, Huang M, Fu L, Hu J, Shi Q, Chen Y. Hemophilia a patients with inhibitors: Mechanistic insights and novel therapeutic implications. Front Immunol 2022; 13:1019275. [PMID: 36569839 PMCID: PMC9774473 DOI: 10.3389/fimmu.2022.1019275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 11/09/2022] [Indexed: 12/14/2022] Open
Abstract
The development of coagulation factor VIII (FVIII) inhibitory antibodies is a serious complication in hemophilia A (HA) patients after FVIII replacement therapy. Inhibitors render regular prophylaxis ineffective and increase the risk of morbidity and mortality. Immune tolerance induction (ITI) regimens have become the only clinically proven therapy for eradicating these inhibitors. However, this is a lengthy and costly strategy. For HA patients with high titer inhibitors, bypassing or new hemostatic agents must be used in clinical prophylaxis due to the ineffective ITI regimens. Since multiple genetic and environmental factors are involved in the pathogenesis of inhibitor generation, understanding the mechanisms by which inhibitors develop could help identify critical targets that can be exploited to prevent or eradicate inhibitors. In this review, we provide a comprehensive overview of the recent advances related to mechanistic insights into anti-FVIII antibody development and discuss novel therapeutic approaches for HA patients with inhibitors.
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Affiliation(s)
- Liping Luo
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Qiaoyun Zheng
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Zhenyu Chen
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China,Medical Technology and Engineering College of Fujian Medical University, Fuzhou, Fujian, China
| | - Meijuan Huang
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Lin Fu
- Department of Hematology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jianda Hu
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Qizhen Shi
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States,Blood Research Institute, Versiti, Milwaukee, WI, United States,Children’s Research Institute, Children’s Wisconsin, Milwaukee, WI, United States,Midwest Athletes Against Childhood Cancer (MACC) Fund Research Center, Milwaukee, WI, United States,*Correspondence: Yingyu Chen, ; Qizhen Shi,
| | - Yingyu Chen
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China,*Correspondence: Yingyu Chen, ; Qizhen Shi,
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32
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Valke LLFG, Rijpma S, Meijer D, Schols SEM, van Heerde WL. Thrombin generation assays to personalize treatment in bleeding and thrombotic diseases. Front Cardiovasc Med 2022; 9:1033416. [PMID: 36440026 PMCID: PMC9684194 DOI: 10.3389/fcvm.2022.1033416] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/26/2022] [Indexed: 07/30/2023] Open
Abstract
Treatment of bleeding and thrombotic disorders is highly standardized and based on evidence-based medicine guidelines. These evidence-based treatment schemes are well accepted but may lead to either insufficient treatment or over-dosing, because the individuals' hemostatic properties are not taken into account. This can potentially introduce bleeding or thrombotic complications in individual patients. With the incorporation of pharmacokinetic (PK) and pharmacodynamic (PK-PD) parameters, based on global assays such as thrombin generation assays (TGAs), a more personalized approach can be applied to treat either bleeding or thrombotic disorders. In this review, we will discuss the recent literature about the technical aspects of TGAs and the relation to diagnosis and management of bleeding and thrombotic disorders. In patients with bleeding disorders, such as hemophilia A or factor VII deficiency, TGAs can be used to identify patients with a more severe bleeding phenotype and also in the management with non-replacement therapy and/or bypassing therapy. These assays have also a role in patients with venous thrombo-embolism, but the usage of TGAs in patients with arterial thrombosis is less clear. However, there is a potential role for TGAs in the monitoring of (long-term) antithrombotic therapy, for example with the use of direct oral anticoagulants. Finally this review will discuss controversies, limitations and knowledge gaps in relation to the introduction of TGAs to personalize medicine in daily medical practice.
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Affiliation(s)
- Lars L. F. G. Valke
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
| | - Sanna Rijpma
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Danielle Meijer
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia E. M. Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
| | - Waander L. van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
- Enzyre BV, Novio Tech Campus, Nijmegen, Netherlands
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Peyvandi F, Kavakli K, El‐Beshlawy A, Rangarajan S. Management of haemophilia A with inhibitors: A regional cross-talk. Haemophilia 2022; 28:950-961. [PMID: 35868021 PMCID: PMC9796719 DOI: 10.1111/hae.14638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/04/2022] [Accepted: 07/09/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The development of inhibitors with factor VIII (FVIII) replacement therapy is one of the most common and challenging complications of haemophilia A (HA) treatment, jeopardising treatment efficacy and predisposing patients to high risks of morbidity and mortality. The management of patients with inhibitors is particularly challenging in countries where resources are limited. AIM To provide a comprehensive summary of the management of HA with inhibitors while focusing on differences in practice between Western and non-Western countries and how resource scarcity can impact HA management, leading to suboptimal outcomes in patients with inhibitors. METHODS Summary of key evidence and regional expert opinion. RESULTS We address, particularly, the diagnosis of and testing for inhibitors, as well as the epidemiology of inhibitors, including incidence, prevalence and disease burden. Secondly, we provide an overview of the current treatment landscape in HA with inhibitors regarding the eradication of inhibitors with immune tolerance induction and the treatment and prevention of bleeding with bypassing agents, non-factor replacement agents and other experimental therapies. This is complemented with insights from the authors around the applicability of, and challenges associated with, such therapies in their settings of practice. CONCLUSIONS We conclude by proposing some key steps towards bridging the gaps in the management of HA with inhibitors in resource-limited countries, including: (1) the collection of quality data that can inform healthcare reforms and policies; (2) improving disease knowledge among healthcare practitioners and patients with the aim of standardising disease management across centres and (3) working towards promoting equal access to HA care and therapies for everyone.
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Affiliation(s)
- Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly,Department of Pathophysiology and TransplantationUniversità degli Studi di MilanooMilanItaly
| | - Kaan Kavakli
- Department of Pediatric HematologyEge University Children's HospitalIzmirTurkey
| | - Amal El‐Beshlawy
- Department of Pediatric Hematology, Faculty of MedicineCairo UniversityCairoEgypt
| | - Savita Rangarajan
- Department of HaematologyUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK,Clinical Trials and Research UnitKJ Somaiya Super Specialty Hospital and Research CentreMumbaiIndia
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Guzzardo GM, Sidonio R, Callaghan MU, Regling K. Early stage clinical trials for the treatment of hemophilia A. Expert Opin Investig Drugs 2022; 31:1169-1186. [PMID: 36265129 DOI: 10.1080/13543784.2022.2138742] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Hemophilia A is a severe bleeding disorder affecting about 1 in 5,000 males. The gold standard for prophylaxis and treatment of acute bleeding has been factor (F) VIII concentrate. A multitude of treatment modalities are now available and under clinical investigation. AREAS COVERED This review discusses ongoing/recently completed early-phase clinical trials registered on ClinicalTrials.gov in patients with hemophilia A through April 2022. These new pipeline therapies are focused on addressing the safety and efficacy of new factor-related products, non-factor related products, and gene therapy options for hemophilia. EXPERT OPINION Current standard of care effectively prevents and treats acute bleeding and has significantly improved the quality of life in hemophilia. The biggest challenges in the improvement of care are treatment-related burden and the burden of cost in developing countries. New drugs under development are likely to enter practice by the end of this decade and address many of the unmet needs particularly of those with severe disease. Data is limited in unique populations (e.g. congenital/inherited FVIII inhibitors, non-severe hemophilia A, women/girls with hemophilia and children) which are important areas for future research; additional clinical trials and long-term outcome data are necessary prior to incorporating these new therapies in our treatment arsenal.
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Affiliation(s)
- Gianna M Guzzardo
- Pediatric Hematology Oncology, Children's Hospital of Michigan, Detroit, MI, USA
| | - Robert Sidonio
- Pediatric Hematology Oncology, Emory University and Aflac Cancer and Blood Disorders, Atlanta, GA, USA
| | - Michael U Callaghan
- Agios Pharmaceuticals, Cambridge, MA, USA.,Department of Pediatrics, Central Michigan University School of Medicine, Mount Pleasant, MI, USA
| | - Katherine Regling
- Pediatric Hematology Oncology, Children's Hospital of Michigan, Detroit, MI, USA.,Department of Pediatrics, Central Michigan University School of Medicine, Mount Pleasant, MI, USA
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Anandani G, Patel T, Parmar R. The Implication of New Developments in Hemophilia Treatment on Its Laboratory Evaluation. Cureus 2022; 14:e30212. [DOI: 10.7759/cureus.30212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 11/07/2022] Open
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Gualtierotti R, Pasca S, Ciavarella A, Arcudi S, Giachi A, Garagiola I, Suffritti C, Siboni SM, Peyvandi F. Updates on Novel Non-Replacement Drugs for Hemophilia. Pharmaceuticals (Basel) 2022; 15:1183. [PMID: 36297295 PMCID: PMC9611302 DOI: 10.3390/ph15101183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/27/2022] Open
Abstract
Over the last decade, the world of hemophilia has experienced an unprecedented therapeutic advance, thanks to the progress in bioengineering technologies, leading to the introduction of drugs with novel mechanisms of action based on restoring thrombin generation or coagulation factor VIII mimicking. Apart from the bispecific monoclonal antibody emicizumab, already approved for patients with severe hemophilia A with and without inhibitors, novel non-replacement drugs designed to reduce the treatment burden of patients with hemophilia A or B with or without inhibitors are undergoing evaluation in clinical trials. Thanks to their innovative mechanism of action and subcutaneous administration, these drugs promise to provide effective bleeding protection together with improved adherence and improve health-related quality of life for patients with hemophilia. On the other hand, rare thromboembolic events have been reported with some of these drugs and warrant continuous post-marketing surveillance and investigation of predisposing factors, although the overall safety profile of most of these drugs is good. Finally, new challenges need to be faced in the clinical and laboratory monitoring of the hemostatic status in patients treated with these innovative therapies. In this review, we provide an update on the available data on novel non-replacement drugs currently undergoing evaluation in clinical trials for patients with hemophilia.
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Affiliation(s)
- Roberta Gualtierotti
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
| | - Samantha Pasca
- Biomedical Sciences Department (DSB)/Medicine Department (DIMED) Padua University Hospital, 35131 Padua, Italy
| | - Alessandro Ciavarella
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20133 Milan, Italy
| | - Sara Arcudi
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
| | - Andrea Giachi
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
| | - Isabella Garagiola
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
| | - Chiara Suffritti
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
| | - Simona Maria Siboni
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico di Milano, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20122 Milan, Italy
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Swan D, Mahlangu J, Thachil J. Non‐factor therapies for bleeding disorders: A primer for the general haematologist. EJHAEM 2022; 3:584-595. [PMID: 36051064 PMCID: PMC9422036 DOI: 10.1002/jha2.442] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 11/09/2022]
Abstract
Management of patients with severe bleeding disorders, particularly haemophilia A and B, and to a lesser extent, von Willebrand disease, has come on leaps and bounds over the past decade. Until recently, patients relied upon the administration of factor concentrates to prevent or treat bleeding episodes. Factor administration requires intravenous access and, in up to one‐third of patients, leads to the development of neutralising antibodies, or inhibitors, which are associated with more frequent bleeding episodes and higher morbidity. Novel non‐factor therapies may offer a solution to these unmet needs. In this review, we discuss the factor mimetics, particularly emicizumab, and the rebalancing agents, which inhibit antithrombin, tissue factor pathway inhibitor and activated protein C, and novel treatments to enhance von Willebrand factor levels. We review the available trial data, unanswered questions and challenges associated with these new treatment modalities. Finally, we provide practical management algorithms to aid the general haematologist when faced with a patient receiving emicizumab who requires surgery or may develop bleeding.
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Affiliation(s)
- Dawn Swan
- National University Ireland Galway Republic of Ireland
| | - Johnny Mahlangu
- Department of Molecular Medicine and Haematology School of Pathology Faculty of Health Sciences University of the Witwatersrand and NHLS Johannesburg South Africa
| | - Jecko Thachil
- Department of Haematology Manchester University Hospitals NHS Foundation Trust Manchester UK
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Kavaklı K, Antmen B, Okan V, Şahin F, Aytaç S, Balkan C, Berber E, Kaya Z, Küpesiz A, Zülfikar B. Gene therapy in haemophilia: literature review and regional perspectives for Turkey. Ther Adv Hematol 2022; 13:20406207221104591. [PMID: 35898436 PMCID: PMC9310332 DOI: 10.1177/20406207221104591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/16/2022] [Indexed: 01/19/2023] Open
Abstract
Haemophilia is an X-linked lifelong congenital bleeding disorder that is caused by insufficient levels of factor VIII (FVIII; haemophilia A) or factor IX (FIX; haemophilia B) and characterized by spontaneous and trauma-related bleeding episodes. The cornerstone of the treatment, factor replacement, constitutes several difficulties, including frequent injections due to the short half-life of recombinant factors, intravenous administration and the risk of inhibitor development. While extended half-life factors and subcutaneous novel molecules enhanced the quality of life, initial successes with gene therapy offer a significant hope for cure. Although adeno-associated viral (AAV)-based gene therapy is one of the most emerging approaches for treatment of haemophilia, there are still challenges in vector immunogenicity, potency and efficacy, genotoxicity and persistence. As the approval for the first gene therapy product is coming closer, eligibility criteria for patient selection, multidisciplinary approach for optimal delivery and follow-up and development of new pricing policies and reimbursement models should be concerned. Therefore, this review addresses the unmet needs of current haemophilia treatment and explains the rationale and principles of gene therapy. Limitations and challenges are discussed from a global and national perspective and recommendations are provided to adopt the gene therapies faster and more sufficient for the haemophilia patients in developing countries like Turkey.
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Affiliation(s)
- Kaan Kavaklı
- Division of Hematology, Department of Pediatrics, Ege University Faculty of Medicine, Bornova, 35100 İzmir, Turkey
| | - Bülent Antmen
- Division of Hematology, Department of Pediatrics, Acıbadem Adana Hospital, Adana, Turkey
| | - Vahap Okan
- Division of Hematology, Department of Internal Diseases, Gaziantep University Faculty of Medicine, Gaziantep, Turkey
| | - Fahri Şahin
- Division of Hematology, Department of Internal Diseases, Ege Adult Hemophilia and Thrombosis Center, Ege University Faculty of Medicine, İzmir, Turkey
| | - Selin Aytaç
- Division of Hematology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Can Balkan
- Division of Hematology, Department of Pediatrics, Ege University Faculty of Medicine, İzmir, Turkey
| | - Ergül Berber
- Department of Molecular Biology and Genetics, İstanbul Arel University, İstanbul, Turkey
| | - Zühre Kaya
- Division of Hematology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Alphan Küpesiz
- Division of Hematology, Department of Pediatrics, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Bülent Zülfikar
- Division of Hematology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey
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Mast AE, Ruf W. Regulation of coagulation by tissue factor pathway inhibitor: Implications for hemophilia therapy. J Thromb Haemost 2022; 20:1290-1300. [PMID: 35279938 PMCID: PMC9314982 DOI: 10.1111/jth.15697] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/08/2022] [Accepted: 03/07/2022] [Indexed: 11/27/2022]
Abstract
Tissue factor pathway inhibitor (TFPI) is an alternatively spliced anticoagulant protein that primarily dampens the initiation phase of coagulation before thrombin is generated. As such, TFPI's actions are localized to cells expressing TF and to sites of injury, where it is an important regulator of bleeding in hemophilia. The major splice isoforms TFPIα and TFPIβ localize to different sites within and surrounding the vasculature. Both forms directly inhibit factor Xa (FXa) via their Kunitz 2 domain and inhibit TF-FVIIa via their Kunitz 1 domain in a tight complex primarily localized to cells. By forming complexes localized to distinct cellular microenvironments and engaging additional cell surface receptors, TFPI alters cellular trafficking and signaling pathways driven by coagulation proteases of the TF pathway. TFPIα, which circulates in complex with FV and protein S, also serves an inhibitor of FXa independent of the TF initiation complex and prevents the formation of an active prothrombinase. This regulation of thrombin generation in the context of vessel injury is effectively blocked by antibodies to Kunitz 2 domain of TFPI and exploited as a therapy to restore efficient hemostasis in hemophilia.
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Affiliation(s)
- Alan E. Mast
- Versiti Blood Research InstituteMilwaukeeWisconsinUSA
| | - Wolfram Ruf
- Center for Thrombosis and HemostasisJohannes Gutenberg University Medical CenterMainzGermany
- Department of Immunology and MicrobiologyScripps ResearchLa JollaCaliforniaUSA
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Mancuso ME, Apte S, Hermans C. Managing invasive procedures in haemophilia patients with limited resources, extended half-life concentrates or non-replacement therapies in 2022. Haemophilia 2022; 28 Suppl 4:93-102. [PMID: 35521735 DOI: 10.1111/hae.14551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 01/15/2023]
Abstract
New treatment possibilities and modalities are now available globally for patients with haemophilia requiring surgery or invasive procedures. The first is the appropriate application of low-dose protocols of clotting factor concentrates (CFC) achieving adequate perioperative haemostasis in resources constraint environments. The increasing availability of CFC through humanitarian aid programs allows more invasive surgeries to be performed for which efficacy and safety data should be more widely collected and reported. Second, extended half-life CFC that are increasingly available in many countries represent valuable alternatives to standard half-life products in surgical patients allowing reduced number of infusions and lower consumption, in particular for extended half-life factor IX. Third, in the era of recently introduced nonfactor prophylaxis, some minor surgical procedures can now be performed without additional haemostatic treatment, others with few low-dose administrations of CFC or bypassing agents. Additional factor VIII/IX or recombinant activated factor VII has proven to be safe and effective in association with emicizumab for major surgeries and it was effectively given at low doses in association with fitusiran (including activated prothrombin complex concentrate). No thrombotic complications have been reported in the surgical setting so far. A multidisciplinary team/facility remains crucial to manage major surgery in patients on prophylaxis with these new agents.
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Affiliation(s)
- Maria Elisa Mancuso
- Center for Thrombosis and Haemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Cedric Hermans
- Division of Haematology, Haemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain (UCLouvain), Brussels, Belgium
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Alexander WA, Jensen I, Hathway J, Srivastava K, Cyr P, Sidonio RF, Batt K. Bleeding in patients with hemophilia who have inhibitors: Modeling US medical system utilization and cost avoidance between recombinant factor VIIa products with different clinical dosing requirements. J Manag Care Spec Pharm 2022; 28:518-527. [PMID: 35343812 DOI: 10.18553/jmcp.2022.21197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND: A mainstay of treatment in patients with hemophilia with inhibitors (PWIs) is the use of a recombinant factor VIIa (rFVIIa) bypassing agent. A new rFVIIa product may allow reduced rFVIIa utilization for on-demand treatment of bleeding episodes (BEs). OBJECTIVE: A decision analytic health economic model was developed to compare the utilization and consequent need for bleed-related clinical encounters of 2 rFVIIa products, with the International Nomenclature Name of eptacog alfa (EA) and eptacog beta (EB). METHODS: This study uses recent, peer-reviewed, and published data from clinical trials with similar endpoints for 1 million insured male lives in the United States. rFVIIa product utilization was modeled in hemophilia (A and B) PWI for on-demand treatment of BEs with rFVIIa treatment. Estimated annual BE rates were modeled to include prophylaxis and on-demand management. The clinical encounter avoidance estimates are based on refractory bleeding through 24 hours. RESULTS: In a cohort of 1 million insured, 5-6 patients with hemophilia A or B with inhibitors annually receive on-demand treatment for a total of 59 mild/moderate BEs. The model suggests that EB requires less unit utilization per BE (13,125 μg and 17,850 μg for the 75μg/kg and 225μg/kg dose regimens, respectively) than EA 90 μg/kg dosing (20,178μg), with wholesale acquisition costs expanding the difference. Further, both EB initial dose regimens would permit decreased total nonmedication health plan spending for the acute treatment of BEs by reducing the need for clinical encounters arising from BEs that fail to respond within 24 hours. CONCLUSIONS: With reduced infusion requirements, the model consistently shows that EB could generate lower insured-cohort drug utilization, as well as reduce costly clinical encounters by keeping mild and moderate BEs amenable to home bypassing agent management. DISCLOSURES: The article was funded by HEMA Biologic, LLC. The authors approved all content and results in this article without being subject to sponsor censorship. Mr Jensen, Mr Cyr, and Ms Hathway are employees of PRECISIONheor, which provides consulting services to the pharmaceutical industry, including HEMA Biologics, LLC. Dr Batt is an advisor to PRECISIONheor. Dr Alexander is a former employee of HEMA Biologics, LLC, and provides consulting services to the pharmaceutical industry.
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Affiliation(s)
| | | | | | | | | | - Robert F Sidonio
- Department of Pediatrics - Hematology, School of Medicine, Emory University, Atlanta, GA
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Hart DP, Matino D, Astermark J, Dolan G, d’Oiron R, Hermans C, Jiménez-Yuste V, Linares A, Matsushita T, McRae S, Ozelo MC, Platton S, Stafford D, Sidonio RF, Tiede A. International consensus recommendations on the management of people with haemophilia B. Ther Adv Hematol 2022; 13:20406207221085202. [PMID: 35392437 PMCID: PMC8980430 DOI: 10.1177/20406207221085202] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/17/2022] [Indexed: 01/19/2023] Open
Abstract
Haemophilia B is a rare X-linked genetic deficiency of coagulation factor IX (FIX) that, if untreated, can cause recurrent and disabling bleeding, potentially leading to severe arthropathy and/or life-threatening haemorrhage. Recent decades have brought significant improvements in haemophilia B management, including the advent of recombinant FIX and extended half-life FIX. This therapeutic landscape continues to evolve with several non-factor replacement therapies and gene therapies under investigation. Given the rarity of haemophilia B, the evidence base and clinical experience on which to establish clinical guidelines are relatively sparse and are further challenged by features that are distinct from haemophilia A, precluding extrapolation of existing haemophilia A guidelines. Due to the paucity of formal haemophilia B-specific clinical guidance, an international Author Group was convened to develop a clinical practice framework. The group comprised 15 haematology specialists from Europe, Australia, Japan, Latin America and North America, covering adult and paediatric haematology, laboratory medicine and biomedical science. A hybrid approach combining a systematic review of haemophilia B literature with discussion of clinical experience utilized a modified Delphi format to develop a comprehensive set of clinical recommendations. This approach resulted in 29 recommendations for the clinical management of haemophilia B across five topics, including product treatment choice, therapeutic agent laboratory monitoring, pharmacokinetics considerations, inhibitor management and preparing for gene therapy. It is anticipated that this clinical practice framework will complement existing guidelines in the management of people with haemophilia B in routine clinical practice and could be adapted and applied across different regions and countries.
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Affiliation(s)
- Daniel P. Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Whitechapel Road, London E1 2AD, UK
| | - Davide Matino
- Department of Medicine, McMaster University and The Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Jan Astermark
- Institution of Translational Medicine and Department of Hematology, Oncology and Radiation Physics, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Gerard Dolan
- Centre for Haemostasis and Thrombosis, St Thomas’ Hospital, London, UK
| | - Roseline d’Oiron
- Centre for Haemophilia and Constitutional Bleeding Disorders, Hôpital Bicêtre AP-HP Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Cédric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | | | - Adriana Linares
- Grupo de Oncohematología Pediátrica, Universidad Nacional de Colombia, Bogotá, Colombia
- Programa de Hemofilia, Clínica Infantil Colsubsidio, Bogotá, Colombia
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Simon McRae
- Launceston General Hospital, Launceston, TAS, Australia
| | | | - Sean Platton
- The Royal London Hospital Haemophilia Centre, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Darrel Stafford
- Department of Biology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Robert F. Sidonio
- Aflac Cancer and Blood Disorders, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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Pasca S. Concizumab as a Subcutaneous Prophylactic Treatment Option for Patients with Hemophilia A or B: A Review of the Evidence and Patient’s Perspectives. J Blood Med 2022; 13:191-199. [PMID: 35465188 PMCID: PMC9020573 DOI: 10.2147/jbm.s242219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/03/2022] [Indexed: 11/30/2022] Open
Abstract
Concizumab is a monoclonal, humanized IgG4 antibody specific for the Kunitz-2 domain of Tissue Factor Pathway Inhibitor (TFPI). Preclinical studies in vitro or on animal models and in vivo have demonstrated the ability of concizumab to restore thrombin generation, promoting the establishment of a procoagulant action; all these results were subsequently confirmed in the studies of EXPLORER program. Concizumab may represent a new opportunity for the treatment of persons with hemophilia, so there is much anticipation for the results of the ongoing trials still. This review retraces all the studies on concizumab published to date, with a brief discussion about the patient’ perspectives.
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Affiliation(s)
- Samantha Pasca
- Medicine Department (DIMED) – Padua University Hospital, Padua, Italy
- Biomedical Sciences Department (DSB) - Padua University Hospital, Padua, Italy
- Correspondence: Samantha Pasca, Medicine Department (DIMED) – Padua University Hospital, Padua, Italy, Tel +39-339-6552395, Email
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Verhagen MJA, Valke LLFG, Schols SEM. Thrombin generation for monitoring hemostatic therapy in hemophilia A: A narrative review. J Thromb Haemost 2022; 20:794-805. [PMID: 35034413 PMCID: PMC9305107 DOI: 10.1111/jth.15640] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/17/2021] [Accepted: 01/10/2022] [Indexed: 11/29/2022]
Abstract
Patients with severe hemophilia A (HA) have an increased risk of spontaneous and trauma-related bleeding because of a congenital absence of factor VIII (FVIII). Most severe HA patients use prophylactic FVIII concentrate, the effect of which can be monitored with FVIII activity level measurement. However, FVIII activity level is less valuable in predicting the potential clinical bleeding risk. Some patients still experience breakthrough bleeds despite adequate FVIII trough levels, whereas others do not bleed with trough levels below threshold. This difference may be caused by inter-individual differences in pro- and anticoagulant factors, the so-called hemostatic balance. Thrombin generation assays (TGAs) measure the hemostatic balance as a whole. Thereby, the TGAs may be a better tool in the guidance and monitoring of treatment in HA patients. In addition, TGAs offer the opportunity to determine the response to bypassing agents and treatment with non-factor replacement therapy, in which FVIII activity assays are not suitable for monitoring. This review summarizes the current knowledge about monitoring different HA treatment modalities by TGA, as a single treatment option and when used in a concomitant fashion.
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Affiliation(s)
- Marieke J. A. Verhagen
- Department of HematologyRadboud University Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐MaastrichtNijmegenThe Netherlands
| | - Lars L. F. G. Valke
- Department of HematologyRadboud University Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐MaastrichtNijmegenThe Netherlands
| | - Saskia E. M. Schols
- Department of HematologyRadboud University Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐MaastrichtNijmegenThe Netherlands
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Batorova A, Boban A, Brinza M, Lissitchkov T, Nemes L, Zupan Preložnik I, Smejkal P, Zozulya N, Windyga J. Expert opinion on current and future prophylaxis therapies aimed at improving protection for people with hemophilia A. J Med Life 2022; 15:570-578. [PMID: 35646171 PMCID: PMC9126455 DOI: 10.25122/jml-2022-0103] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/28/2022] [Indexed: 11/17/2022] Open
Abstract
The next frontier in hemophilia A management has arrived. However, questions remain regarding the broader applicability of new and emerging hemophilia A therapies, such as the long-term safety and efficacy of non-factor therapies and optimal regimens for individual patients. With an ever-evolving clinical landscape, it is imperative for physicians to understand how available and future hemophilia A therapies could potentially be integrated into real-life clinical practice to improve patient outcomes. Against this background, nine hemophilia experts from Central European countries participated in a pre-advisory board meeting survey. The survey comprised 11 multiple-choice questions about current treatment practices and future factor and non-factor replacement therapies. The survey questions were developed to reflect current unmet needs in hemophilia management reflected in the literature. The experts also took part in a follow-up advisory board meeting to discuss the most important unmet needs for hemophilia management as well as the pre-meeting survey results. All experts highlighted the challenge of maintaining optimal trough levels with prophylaxis as their most pressing concern. Targeting trough levels of ≥30-50 IU/L or even higher to achieve less bleeding was highlighted as their preferred strategy. However, the experts had an equal opinion on how this could be achieved (i.e., more efficacious non-factor therapies or factor therapy offering broader personalization possibilities such as targeting trough levels to individual pharmacokinetic data). In summary, our study favors personalized prophylaxis to individual pharmacokinetic data rather than a "one-size-fits-all" approach to hemophilia A management to maintain optimal trough levels for individual patients.
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Affiliation(s)
- Angelika Batorova
- Department of Hematology and Transfusion Medicine, National Hemophilia Center, Faculty of Medicine of Comenius University and University Hospital, Bratislava, Slovakia
| | - Ana Boban
- Haemophilia Centre, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Melen Brinza
- Centre of Hematology and Bone Marrow Transplant, European Haemophilia Comprehensive Care Centre, Fundeni Clinical Institute, Bucharest, Romania
| | | | - Laszlo Nemes
- National Haemophilia Centre and Haemostasis Department, Medical Centre of Hungarian Defence Forces, Budapest, Hungary
| | - Irena Zupan Preložnik
- Department of Haematology, University Medical Centre Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Petr Smejkal
- Department of Clinical Haematology, University Hospital Brno, Brno, Czech Republic,Department of Laboratory Methods, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland,Corresponding Author: Jerzy Windyga, Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland. E-mail:
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46
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Long-term efficacy and safety of subcutaneous concizumab prophylaxis in hemophilia A and hemophilia A/B with inhibitors. Blood Adv 2022; 6:3422-3432. [PMID: 35290453 PMCID: PMC9198939 DOI: 10.1182/bloodadvances.2021006403] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/28/2022] [Indexed: 11/20/2022] Open
Abstract
Despite current treatments, there remains an unmet need for patients with hemophilia. The main parts of two phase 2 trials established clinical proof-of-concept for once-daily, subcutaneous concizumab prophylaxis in patients with hemophilia A/B with inhibitors (HAwI/HBwI; explorer4) and severe hemophilia A without inhibitors (HA; explorer5,). Here, we present results from extension parts of these trials, included to evaluate longer-term safety and efficacy. Both trials included main (≥24 weeks) and extension parts (52-102 weeks), with patients receiving 0.15 mg/kg concizumab with potential dose escalation to 0.20 or 0.25 mg/kg if they experienced ≥3 treated spontaneous bleeds within 12 weeks. Endpoints included annualized bleeding rate (ABR), adverse events (AEs), and anti-drug antibody (ADA) occurrence. Thromboembolic events were AEs of special interest. Thirty-six patients with HA, 15 with HAwI and 10 with HBwI were exposed to concizumab. Estimated ABRs during the main+extension parts at last dose level were 4.8 (95% confidence interval [CI]: 3.2-7.2) and 6.4 (95% CI: 4.1-9.9) in explorer4 and explorer5, respectively (spontaneous ABRs were 1.8 [95% CI: 1.2-2.6] and 2.1 [95% CI: 1.3-3.3]). Most AEs were mild, with no deaths, events leading to withdrawal or thromboembolic events. ADAs developed in 25% of patients and were low titer and transient with no observed clinical effect in most cases. Results of the main+extension parts of these trials were consistent with the main parts. Ongoing phase 3 trials will further evaluate concizumab as a once-daily, subcutaneous treatment across hemophilia subtypes. Trials registered at www.clinicaltrials.gov (NCT03196284; NCT03196297).
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47
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Peterson JA, Gupta S, Martinez ND, Hardesty B, Maroney SA, Mast AE. Factor V east Texas variant causes bleeding in a three-generation family. J Thromb Haemost 2022; 20:565-573. [PMID: 34847292 PMCID: PMC8885967 DOI: 10.1111/jth.15612] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/11/2021] [Accepted: 11/29/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND The factor V east Texas bleeding disorder (FVETBD) is caused by increased plasma tissue factor pathway inhibitor-α (TFPIα) concentration. The underlying cause is a variant in F5 causing alternative splicing within exon 13 and producing FV-short, which tightly binds the C-terminus of TFPIα, prolonging its circulatory half-life. OBJECTIVES To diagnose a family presenting with variable bleeding and laboratory phenotypes. PATIENTS/METHODS Samples were obtained from 17 family members for F5 exon 13 sequencing. Plasma/platelet TFPI and platelet FV were measured by ELISA and/or western blot. Plasma thrombin generation potential was evaluated using calibrated automated thrombography. RESULTS The FVET variant was identified in all family members with bleeding symptoms and associated with elevated plasma TFPIα (4.5- to 13.4-fold) and total TFPI (2- to 3-fold). However, TFPIα and FV-short were not elevated in platelets. TF-initiated thrombin generation in patient plasma was diminished but was restored by a monoclonal anti-TFPI antibody or factor VIIa. TFPIα localized within vascular extracellular matrix in an oral lesion biopsy from an affected family member. CONCLUSIONS Factor V east Texas bleeding disorder was diagnosed in an extended family. The variant was autosomal dominant and highly penetrant. Elevated plasma TFPIα, rather than platelet TFPIα, was likely the primary cause of bleeding. Plasma FV-short did not deplete TFPIα from extracellular matrix. In vitro thrombin generation was restored with an anti-TFPI antibody or factor VIIa suggesting effective therapies may be available. Increased awareness of, and testing for, bleeding disorders associated with F5 exon 13 variants and elevated plasma TFPI are needed.
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Affiliation(s)
| | - Sweta Gupta
- Indiana Hemophilia & Thrombosis Center, Indianapolis, IN USA 46260
| | | | - Brandon Hardesty
- Indiana Hemophilia & Thrombosis Center, Indianapolis, IN USA 46260
| | | | - Alan E. Mast
- Versiti, Blood Research Institute, Milwaukee, WI 53226
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI 53226
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Bonde AC, Lund J, Hansen JJ, Winther JR, Nielsen PF, Zahn S, Tiainen P, Olsen OH, Petersen HH, Bjelke JR. The functional role of the autolysis loop in the regulation of factor X upon hemostatic response. J Thromb Haemost 2022; 20:589-599. [PMID: 34927362 DOI: 10.1111/jth.15624] [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: 11/03/2021] [Accepted: 12/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The regulation of factor X (FX) is critical to maintain the balance between blood coagulation and fluidity. OBJECTIVES To functionally characterize the role of the FX autolysis loop in the regulation of the zymogen and active form of FX. METHODS We introduced novel N-linked glycosylations on the surface-exposed loop spanning residues 143-150 (chymotrypsin numbering) of FX. The activity and inhibition of recombinant FX variants was quantified in pure component assays. The in vitro thrombin generation potential of the FX variants was evaluated in FX-depleted plasma. RESULTS The factor VIIa (FVIIa)-mediated activation and prothrombin activation was reduced, presumably through steric hinderance. Prothrombin activation was, however, recovered in presence of cofactor factor Va (FVa) despite a reduced prothrombinase assembly. The introduced N-glycans exhibited position-specific effects on the interaction with two FXa inhibitors: tissue factor pathway inhibitor (TFPI) and antithrombin (ATIII). Ki for the inhibition by full-length TFPI of these FXa variants was increased by 7- to 1150-fold, whereas ATIII inhibition in the presence of the heparin-analog Fondaparinux was modestly increased by 2- to 15-fold compared with wild-type. When supplemented in zymogen form, the FX variants exhibited reduced thrombin generation activity relative to wild-type FX, whereas enhanced procoagulant activity was measured for activated FXa variants. CONCLUSION The autolysis loop participates in all aspects of FX regulation. In plasma-based assays, a modest decrease in FX activation rate appeared to knock down the procoagulant response even when down regulation of FXa activity by inhibitors was reduced.
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Affiliation(s)
- Amalie Carnbring Bonde
- Global Research, Novo Nordisk A/S, Måløv, Denmark
- Section for Biomolecular Sciences, Department of Biology, University of Copenhagen, Copenhagen N, Denmark
| | - Jacob Lund
- Global Research, Novo Nordisk A/S, Måløv, Denmark
| | | | - Jakob Rahr Winther
- Section for Biomolecular Sciences, Department of Biology, University of Copenhagen, Copenhagen N, Denmark
| | | | - Stefan Zahn
- Global Research, Novo Nordisk A/S, Måløv, Denmark
| | | | - Ole Hvilsted Olsen
- Novo Nordisk Foundation Centre for Basic Metabolic Research, University of Copenhagen, Copenhagen N, Denmark
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Regling K, Callaghan MU, Sidonio R. Managing Severe Hemophilia A in Children: Pharmacotherapeutic Options. Pediatric Health Med Ther 2022; 13:27-35. [PMID: 35210899 PMCID: PMC8857990 DOI: 10.2147/phmt.s293246] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/27/2021] [Indexed: 12/22/2022] Open
Abstract
Hemophilia A is the most common severe inherited bleeding disorder in males. Initial treatment strategies focused on the use of factor concentrates to prevent joint bleeding and the development of long-term crippling arthropathy. The current standard of care has evolved from regular replacement of factor VIII concentrates which has significantly improved the quality of life for those with severe disease to include and consider novel therapies that augment or bypass the hemostatic pathway (ie, emicizumab, Mim8). Other pipeline therapies that suppress specific natural anticoagulant pathways (ie, antithrombin, TFPI) to reestablish hemostatic balance are under Phase 3 trial investigation. These novel therapeutics have allowed providers more variety in dosing regimens and ease of administration while also maintaining effective bleeding prevention. The possibility of "curative" gene therapy is under exploration, with ongoing clinical trials in adult males.
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Affiliation(s)
- Katherine Regling
- Pediatric Hematology Oncology, Children’s Hospital of Michigan, Detroit, MI, USA
- Central Michigan University School of Medicine, Mount Pleasant, MI, USA
| | - Michael U Callaghan
- Pediatric Hematology Oncology, Children’s Hospital of Michigan, Detroit, MI, USA
- Central Michigan University School of Medicine, Mount Pleasant, MI, USA
- Agios Pharmaceuticals, Cambridge, MA, USA
| | - Robert Sidonio
- Emory University and Aflac Cancer and Blood Disorders, Atlanta, GA, USA
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50
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Han JP, Kim M, Choi BS, Lee JH, Lee GS, Jeong M, Lee Y, Kim EA, Oh HK, Go N, Lee H, Lee KJ, Kim UG, Lee JY, Kim S, Chang J, Lee H, Song DW, Yeom SC. In vivo delivery of CRISPR-Cas9 using lipid nanoparticles enables antithrombin gene editing for sustainable hemophilia A and B therapy. SCIENCE ADVANCES 2022; 8:eabj6901. [PMID: 35061543 PMCID: PMC8782450 DOI: 10.1126/sciadv.abj6901] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 11/30/2021] [Indexed: 05/24/2023]
Abstract
Hemophilia is a hereditary disease that remains incurable. Although innovative treatments such as gene therapy or bispecific antibody therapy have been introduced, substantial unmet needs still exist with respect to achieving long-lasting therapeutic effects and treatment options for inhibitor patients. Antithrombin (AT), an endogenous negative regulator of thrombin generation, is a potent genome editing target for sustainable treatment of patients with hemophilia A and B. In this study, we developed and optimized lipid nanoparticles (LNPs) to deliver Cas9 mRNA along with single guide RNA that targeted AT in the mouse liver. The LNP-mediated CRISPR-Cas9 delivery resulted in the inhibition of AT that led to improvement in thrombin generation. Bleeding-associated phenotypes were recovered in both hemophilia A and B mice. No active off-targets, liver-induced toxicity, and substantial anti-Cas9 immune responses were detected, indicating that the LNP-mediated CRISPR-Cas9 delivery was a safe and efficient approach for hemophilia therapy.
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Affiliation(s)
- Jeong Pil Han
- Graduate School of International Agricultural Technology and Institute of Green BioScience and Technology, Seoul National University, Pyeongchang, Gangwon 25354, Korea
| | - MinJeong Kim
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Woman’s University, Seodaemun-gu, Seoul 03760, Korea
| | | | - Jeong Hyeon Lee
- Graduate School of International Agricultural Technology and Institute of Green BioScience and Technology, Seoul National University, Pyeongchang, Gangwon 25354, Korea
| | - Geon Seong Lee
- Graduate School of International Agricultural Technology and Institute of Green BioScience and Technology, Seoul National University, Pyeongchang, Gangwon 25354, Korea
| | - Michaela Jeong
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Woman’s University, Seodaemun-gu, Seoul 03760, Korea
| | - Yeji Lee
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Woman’s University, Seodaemun-gu, Seoul 03760, Korea
| | - Eun-Ah Kim
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Woman’s University, Seodaemun-gu, Seoul 03760, Korea
| | | | - Nanyeong Go
- Toolgen Inc., Geumcheon-gu, Seoul 08501, Korea
| | - Hyerim Lee
- Toolgen Inc., Geumcheon-gu, Seoul 08501, Korea
| | - Kyu Jun Lee
- Toolgen Inc., Geumcheon-gu, Seoul 08501, Korea
| | - Un Gi Kim
- Toolgen Inc., Geumcheon-gu, Seoul 08501, Korea
| | | | | | - Jun Chang
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Woman’s University, Seodaemun-gu, Seoul 03760, Korea
| | - Hyukjin Lee
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Woman’s University, Seodaemun-gu, Seoul 03760, Korea
| | | | - Su Cheong Yeom
- Graduate School of International Agricultural Technology and Institute of Green BioScience and Technology, Seoul National University, Pyeongchang, Gangwon 25354, Korea
- WCU Biomodulation Major, Department of Agricultural Biotechnology, Seoul National University, Gwanank-gu, Seoul 08826, Korea
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