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Tonetto E, Cucci A, Follenzi A, Bernardi F, Pinotti M, Balestra D. DNA base editing corrects common hemophilia A mutations and restores factor VIII expression in in vitro and ex vivo models. J Thromb Haemost 2024; 22:2171-2183. [PMID: 38718928 DOI: 10.1016/j.jtha.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/22/2024] [Accepted: 04/22/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Replacement and nonreplacement therapies effectively control bleeding in hemophilia A (HA) but imply lifelong interventions. Authorized gene addition therapy could provide a cure but still poses questions on durability. FVIIIgene correction would definitively restore factor (F)VIII production, as shown in animal models through nuclease-mediated homologous recombination (HR). However, low efficiency and potential off-target double-strand break still limit HR translatability. OBJECTIVES To correct common model single point mutations leading to severe HA through the recently developed double-strand break/HR-independent base editing (BE) and prime editing (PE) approaches. METHODS Screening for efficacy of BE/PE systems in HEK293T cells transiently expressing FVIII variants and validation at DNA (sequencing) and protein (enzyme-linked immunosorbent assay; activated partial thromboplastin time) level in stable clones. Evaluation of rescue in engineered blood outgrowth endothelial cells by lentiviral-mediated delivery of BE. RESULTS Transient assays identified the best-performing BE/PE systems for each variant, with the highest rescue of FVIII expression (up to 25% of wild-type recombinant FVIII) for the p.R2166∗ and p.R2228Q mutations. In stable clones, we demonstrated that the mutation reversion on DNA (∼24%) was consistent with the rescue of FVIII secretion and activity of 20% to 30%. The lentiviral-mediated delivery of the selected BE systems was attempted in engineered blood outgrowth endothelial cells harboring the p.R2166∗ and p.R2228Q variants, which led to an appreciable and dose-dependent rescue of secreted functional FVIII. CONCLUSION Overall data provide the first proof-of-concept for effective BE/PE-mediated correction of HA-causing mutations, which encourage studies in mouse models to develop a personalized cure for large cohorts of patients through a single intervention.
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Affiliation(s)
- Elena Tonetto
- Department of Life Sciences and Biotechnology and Laboratorio per le Tecnologie delle Terapie Avanzate (LTTA), University of Ferrara, Ferrara, Italy
| | - Alessia Cucci
- Department of Health Sciences, School of Medicine, University of Piemonte Orientale, Novara, Italy
| | - Antonia Follenzi
- Department of Health Sciences, School of Medicine, University of Piemonte Orientale, Novara, Italy
| | - Francesco Bernardi
- Department of Life Sciences and Biotechnology and Laboratorio per le Tecnologie delle Terapie Avanzate (LTTA), University of Ferrara, Ferrara, Italy
| | - Mirko Pinotti
- Department of Life Sciences and Biotechnology and Laboratorio per le Tecnologie delle Terapie Avanzate (LTTA), University of Ferrara, Ferrara, Italy.
| | - Dario Balestra
- Department of Life Sciences and Biotechnology and Laboratorio per le Tecnologie delle Terapie Avanzate (LTTA), University of Ferrara, Ferrara, Italy
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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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Nummi V, Hiltunen L, Szanto T, Poikonen E, Lehtinen AE. Acquired haemophilia A in Finland: A nationwide study of incidence, treatment and outcomes. Haemophilia 2024. [PMID: 38941448 DOI: 10.1111/hae.15037] [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: 11/22/2023] [Revised: 04/10/2024] [Accepted: 04/10/2024] [Indexed: 06/30/2024]
Abstract
INTRODUCTION Acquired haemophilia A (AHA) is a bleeding disorder caused by autoantibody development against factor VIII (FVIII). Studies on AHA have mainly focused on patients treated at specialist centres. AIM To determine the incidence, clinical characteristics and outcomes of AHA in an unselected population-based patient cohort from Finland. METHODS This retrospective observational cohort comprised all cases diagnosed with AHA in Finland between 2006 and 2019. Patients were identified by the two central laboratories performing FVIII antibody testing in Finland, the Finnish Red Cross Blood Service and HUSLAB. Clinical details were collected from all hospitals and healthcare units where patients were treated. This study was performed in conjunction with the AHA in the Nordics study. RESULTS The median incidence of AHA was 0.65 per million per year (range 0.19-1.27). Fifty-five patients were identified, with a median age of 76 years and an even sex ratio (51% women). When diagnosed, all had bleeding symptoms with severe bleeds in 92%. First-line immunosuppressive treatment regimens included steroid monotherapy in 31% of cases, steroids and a cytotoxic agent in 51% and a rituximab-based regimen in 16%. Clinical remission was achieved in 71% of cases, and 15% had relapses. Mortality was 13% for bleeds and 9% for treatment-related infections. Overall survival was 64% for 1 year and 56% for 2 years after diagnosis. CONCLUSIONS In a nationwide population-based cohort study, we discovered a lower incidence of AHA than previously reported. Mortality among patients with AHA was high, calling for the consideration of updated treatment strategies.
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Affiliation(s)
- Vuokko Nummi
- Coagulation Disorders Unit, Department of Hematology, Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University, Helsinki, Finland
- Department of Cardiology, Helsinki University and Helsinki University Hospital, Heart and Lung Center, Helsinki, Finland
| | - Leena Hiltunen
- Department of Haemostasis, Finnish Red Cross Blood Service, Helsinki, Finland
- Hemostasis and Platelet Laboratory, Fimlab Laboratories Oy Ltd, Vantaa, Finland
| | - Timea Szanto
- Coagulation Disorders Unit, Department of Hematology, Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University, Helsinki, Finland
| | - Eira Poikonen
- Coagulation Disorders Unit, Department of Hematology, Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University, Helsinki, Finland
| | - Anna-Elina Lehtinen
- Coagulation Disorders Unit, Department of Hematology, Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University, Helsinki, Finland
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Giuffrida AC, Siboni SM, Baronciani L, Poli G, Gandini G, Peyvandi F. Emicizumab in Type 3 von Willebrand Disease: Report of a Case with an Alloantibody and Literature Review. Semin Thromb Hemost 2024. [PMID: 38936417 DOI: 10.1055/s-0044-1787662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Type 3 von Willebrand disease (VWD), the most severe form of VWD, is an inherited recessive bleeding disorder caused by the complete deficiency of von Willebrand factor (VWF). The reported prevalence is 1 per million but varies worldwide according to the frequency of consanguineous marriages. The clinical phenotype is characterized not only by mucocutaneous bleedings, but also by hemarthroses and muscle hematoma, as in patients with moderate hemophilia. Long-term prophylaxis with factor (F)VIII/VWF concentrates is recommended in patients with a history of severe and frequent bleeds. A rare complication of replacement therapy is the development of alloantibodies against VWF, with the consequences of an ineffective therapy and risk of anaphylactic reactions upon treatment. Emicizumab is the first bispecific monoclonal antibody that mimics FVIII coagulant activity and is approved for prophylaxis of bleeding in patients with inherited hemophilia A with or without inhibitors and recently also for acquired hemophilia. In this manuscript we report and discuss available data in the literature on the use of emicizumab in type 3 VWD and describe the case of a female patient with type 3 VWD with a history of alloantibodies against VWF and posttransfusion anaphylaxis, recently and successfully put on off-label prophylaxis with emicizumab.
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Affiliation(s)
- Anna C Giuffrida
- Transfusion Medicine Department, Hemophilia Center, Integrated University Hospital, Verona, Italy
| | - Simona M Siboni
- IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Luciano Baronciani
- IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Giovanni Poli
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Giorgio Gandini
- Transfusion Medicine Department, Hemophilia Center, Integrated University Hospital, Verona, Italy
| | - Flora Peyvandi
- IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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Hart C, Klamroth R, Sachs UJ, Greil R, Knoebl P, Oldenburg J, Miesbach W, Pfrepper C, Trautmann-Grill K, Pekrul I, Holstein K, Eichler H, Weigt C, Schipp D, Werwitzke S, Tiede A. Emicizumab versus immunosuppressive therapy for the management of acquired hemophilia A. J Thromb Haemost 2024:S1538-7836(24)00368-4. [PMID: 38936699 DOI: 10.1016/j.jtha.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 06/03/2024] [Accepted: 06/10/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Acquired hemophilia A (AHA) is an autoimmune bleeding disorder caused by neutralizing antibodies against coagulation factor VIII. Immunosuppressive therapy (IST) is standard of care to eradicate autoantibody production and protect from further bleeding but carries a risk of severe infection and mortality in frail patients with AHA. Recently, emicizumab has been studied for its potential to reduce the need for early and aggressive IST. OBJECTIVES To compare outcomes of 2 studies that used either IST (GTH-AH 01/2010; N = 101) or prophylaxis with emicizumab (GTH-AHA-EMI; N = 47) early after diagnosis of AHA. METHODS Baseline characteristics were balanced by propensity score matching. Primary endpoint was the rate of clinically relevant new bleeds during the first 12 weeks; secondary endpoints were adverse events and overall survival. RESULTS The negative binominal model-based bleeding rate was 68% lower with emicizumab as compared with IST (incident rate ratio, 0.325; 95% CI, 0.182-0.581). No difference was apparent in the overall frequency of infections (emicizumab 21%, IST 29%) during the first 12 weeks, but infections were less often fatal in emicizumab-treated patients (0%) compared with IST-treated patients (11%). Thromboembolic events occurred less often with emicizumab (2%) than with IST (7%). Overall survival after 24 weeks was better with emicizumab (90% vs 76%; hazard ratio, 0.44; 95%, CI, 0.24-0.81). CONCLUSION Using emicizumab instead of IST in the early phase after initial diagnosis of AHA reduced bleeding and fatal infections and improved overall survival.
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Affiliation(s)
- Christina Hart
- Department of Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Robert Klamroth
- Internal Medicine, Vivantes Clinic Friedrichshain, Berlin, Germany
| | - Ulrich J Sachs
- Institute for Clinical Immunology and Transfusion Medicine, Justus Liebig University, Giessen, Germany
| | - Richard Greil
- Medical Department III, Paracelsus Medical University Salzburg, Salzburg Cancer Research Institute-Center for Clinical Cancer and Immunology Trials, Cancer Cluster Salzburg, Salzburg, Austria
| | - Paul Knoebl
- Hematology and Hemostasis, Vienna Medical University, Vienna, Austria
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Wolfgang Miesbach
- Medical Clinic II, Institute of Transfusion Medicine, Goethe University, Frankfurt, Germany
| | - Christian Pfrepper
- Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
| | - Karolin Trautmann-Grill
- Medical Clinic I, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Isabell Pekrul
- Department of Transfusion Medicine, Cellular Therapeutics and Hemostaseology, Department of Anesthesiology, Hospital of Ludwig Maximilian University, Munich, Germany
| | - Katharina Holstein
- Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Eichler
- Institute for Clinical Hemostaseology and Transfusion Medicine, Saarland University and University Hospital, Homburg/Saar, Germany
| | | | | | - Sonja Werwitzke
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Andreas Tiede
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.
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Wang L, Jiang H, Yin X, Liang T, Li G, Ding C, Yang M, Zhang L, Liu J, Xu Y. PHE1-based IgG-like antibody platform provides a novel strategy for enhanced T-cell immunotherapy. Front Immunol 2024; 15:1415834. [PMID: 38933272 PMCID: PMC11201533 DOI: 10.3389/fimmu.2024.1415834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024] Open
Abstract
Introduction Bispecific antibodies (BsAbs) can simultaneously target two epitopes of different antigenic targets, bringing possibilities for diversity in antibody drug design and are promising tools for the treatment of cancers and other diseases. T-cell engaging bsAb is an important application of the bispecific antibody, which could promote T cell-mediated tumor cell killing by targeting tumor-associated antigen (TAA) and CD3 at the same time. Methods This study comprised antibodies purification, Elisa assay for antigen binding, cytotoxicity assays, T cell activation by flow cytometry in vitro and xenogenic tumor model in vivo. Results We present a novel bsAb platform named PHE-Ig technique to promote cognate heavy chain (HC)-light chain (LC) pairing by replacing the CH1/CL regions of different monoclonal antibodies (mAbs) with the natural A and B chains of PHE1 fragment of Integrin β2 based on the knob-in-hole (KIH) technology. We had also verified that PHE-Ig technology can be effectively used as a platform to synthesize different desired bsAbs for T-cell immunotherapy. Especially, BCMA×CD3 PHE-Ig bsAbs exhibited robust anti-multiple myeloma (MM) activity in vitro and in vivo. Discussion Moreover, PHE1 domain was further shortened with D14G and R41S mutations, named PHE-S, and the PHE-S-based BCMA×CD3 bsAbs also showed anti BCMA+ tumor effect in vitro and in vivo, bringing more possibilities for the development and optimization of different bsAbs. To sum up, PHE1-based IgG-like antibody platform for bsAb construction provides a novel strategy for enhanced T-cell immunotherapy.
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Affiliation(s)
- Lingbin Wang
- Department of Biochemistry and Molecular Cell Biology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haojie Jiang
- Department of Biochemistry and Molecular Cell Biology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xuying Yin
- Department of Biochemistry and Molecular Cell Biology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tingting Liang
- Department of Biochemistry and Molecular Cell Biology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guoming Li
- Department of Biochemistry and Molecular Cell Biology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chen Ding
- Department of Biochemistry and Molecular Cell Biology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mina Yang
- Department of Biochemistry and Molecular Cell Biology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin Zhang
- Department of Biochemistry and Molecular Cell Biology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junling Liu
- Department of Biochemistry and Molecular Cell Biology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Synvida Biotechnology Co., Ltd, Shanghai, China
| | - Yanyan Xu
- Department of Biochemistry and Molecular Cell Biology, Key Laboratory of Cell Differentiation and Apoptosis of Chinese Ministry of Education, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Franchini M, Focosi D. Inhibitor eradication and treatment for acquired hemophilia A. Expert Rev Hematol 2024; 17:233-240. [PMID: 38708599 DOI: 10.1080/17474086.2024.2352505] [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: 01/08/2024] [Accepted: 05/03/2024] [Indexed: 05/07/2024]
Abstract
INTRODUCTION Acquired hemophilia A (AHA) is a rare hemorrhagic autoimmune disorder characterized by autoantibodies against coagulation factor VIII (FVIII). In approximately half of the cases AHA does not recognize any cause (idiopathic form), while in the other cases it may be triggered by autoimmune disorders, cancers, drugs, infections, or pregnancy. Besides treating the underlying disorder, specific AHA treatment includes management of bleeding, if necessary, and inhibitor eradication. AREAS COVERED This narrative review summarizes the main epidemiological, clinical, laboratory, and therapeutic characteristics of AHA. In particular, it is focused on the current therapeutic options for the inhibitor eradication, also showing the latest findings on the innovative therapies. A literature search strategy was performed, without temporal limits, through Medline and PubMed electronic databases. EXPERT OPINION Various first-line and second-line immunosuppressive agents are currently available for the management of AHA. Among the latter, the anti-CD20 monoclonal antibody rituximab has been the object of intense research during the last years from investigators as innovative promising eradicating therapy for AHA. Preliminary data from the studies support the use of this drug as a first-line option for newly diagnosed AHA cases.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
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Lévesque H, Viallard JF, Houivet E, Bonnotte B, Voisin S, Le Cam-Duchez V, Maillot F, Lambert M, Liozon E, Hervier B, Fain O, Guillet B, Schmidt J, Luca LE, Ebbo M, Ferreira-Maldent N, Babuty A, Sailler L, Duffau P, Barbay V, Audia S, Benichou J, Graveleau J, Benhamou Y. Cyclophosphamide vs rituximab for eradicating inhibitors in acquired hemophilia A: A randomized trial in 108 patients. Thromb Res 2024; 237:79-87. [PMID: 38555718 DOI: 10.1016/j.thromres.2024.03.012] [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: 11/07/2023] [Revised: 02/19/2024] [Accepted: 03/07/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a rare autoimmune disorder due to autoantibodies against Factor VIII, with a high mortality risk. Treatments aim to control bleeding and eradicate antibodies by immunosuppression. International recommendations rely on registers and international expert panels. METHODS CREHA, an open-label randomized trial, compared the efficacy and safety of cyclophosphamide and rituximab in association with steroids in patients with newly diagnosed AHA. Participants were treated with 1 mg/kg prednisone daily and randomly assigned to receive either 1.5-2 mg/kg/day cyclophosphamide orally for 6 weeks, or 375 mg/m2 rituximab once weekly for 4 weeks. The primary endpoint was complete remission over 18 months. Secondary endpoints included time to achieve complete remission, relapse occurrence, mortality, infections and bleeding, and severe adverse events. RESULTS Recruitment was interrupted because of new treatment recommendations after 108 patients included (58 cyclophosphamide, 50 rituximab). After 18 months, 39 cyclophosphamide patients (67.2 %) and 31 rituximab patients (62.0 %) were in complete remission (OR 1.26; 95 % CI, 0.57 to 2.78). In the poor prognosis group (FVIII < 1 IU/dL, inhibitor titer > 20 BU mL-1), significantly more remissions were observed with cyclophosphamide (22 patients, 78.6 %) than with rituximab (12 patients, 48.0 %; p = 0.02). Relapse rates, deaths, severe infections, and bleeding were similar in the 2 groups. In patients with severe infection, cumulative doses of steroids were significantly higher than in patients without infection (p = 0.03). CONCLUSION Cyclophosphamide and rituximab showed similar efficacy and safety. As first line, cyclophosphamide seems preferable, especially in poor prognosis patients, as administered orally and less expensive. FUNDING French Ministry of Health. CLINICALTRIALS gov number: NCT01808911.
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Affiliation(s)
- H Lévesque
- Normandie Univ, UNIROUEN, U 1096, CHU Rouen, Department of Internal Medicine, F-76000 Rouen, France.
| | - J F Viallard
- Service de Médecine Interne et Maladies Infectieuses Hôpital Haut-Lévêque, CHU Bordeaux, 5 avenue de Magellan, 33604 Pessac, France
| | - E Houivet
- Department of Biostatistics, CHU Rouen, F-76031 Rouen, France
| | - B Bonnotte
- Service de médecine interne et immunologie clinique, CHU Dijon-Bourgogne, Université de Dijon, F-21079 Dijon, France
| | - S Voisin
- Department of Internal Medicine, CHU Toulouse, F-31059 Toulouse. France
| | - V Le Cam-Duchez
- Normandie Univ, UNIROUEN, Hématologie biologique, F-76031 Rouen, France
| | - F Maillot
- Département de Médecine Interne et immunologie clinique, CHRU Tours, Université de Tours, F-37044 Tours, France
| | - M Lambert
- CHU Lille, Département de Médecine Interne et d'Immunologie Clinique, Centre National de Référence Maladies Systémiques et Auto-immunes Rares Nord et Nord-Ouest de France (CeRAINO), European Reerence Network on Rare Connective Tissue and Musculoskeletal Diseases Network (ReCONNECT), F-59000 Lille, France
| | - E Liozon
- Department of Internal Medicine, Dupuytren Hospital, F-87000 Limoges, France
| | - B Hervier
- Service de Médecine Interne, Hôpital Saint-Louis, APHP, 75010 Paris & INSERM UMR-S 976, Human Immunology, Pathophysiology, Immunotherapy, Saint-Louis Research Institute, F-75000 Paris, France
| | - O Fain
- Sorbonne Université, APHP, Service de Médecine Interne-DMU i3, Hôpital Saint-Antoine, Paris F-75000, France
| | - B Guillet
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR-S 1085, F-35000 Rennes, France
| | - J Schmidt
- Department of Internal Medicine, Amiens University Hospital, F-80000 Amiens, France
| | - L E Luca
- Department of Internal Medicine, Poitiers University Hospital, F-86000 Poitiers, France
| | - M Ebbo
- Service de Médecine Interne, Hôpital La Timone, CHU Marseille, Aix-Marseille Université, F-13000 Marseille, France
| | - N Ferreira-Maldent
- Département de Médecine Interne et immunologie clinique, CHRU Tours, Université de Tours, F-37044 Tours, France
| | - A Babuty
- Service d'Hématologie Biologique, CRC-MHC, CHU de Nantes, Nantes Cedex 1, France
| | - L Sailler
- Department of Internal Medicine, CHU Toulouse, F-31059 Toulouse. France
| | - P Duffau
- Service de Médecine Interne-Immunologie Clinique Hôpital Saint-André, CHU Bordeaux, 1 rue Jean Burguet, 33075 Bordeaux, France
| | - V Barbay
- Normandie Univ, UNIROUEN, Hématologie biologique, F-76031 Rouen, France
| | - S Audia
- Service de médecine interne et immunologie clinique, CHU Dijon-Bourgogne, Université de Dijon, F-21079 Dijon, France
| | - J Benichou
- Department of Biostatistics, CHU Rouen and CESP UMR 1018, University of Rouen and University Paris-Saclay, F-76031 Rouen, France
| | - J Graveleau
- Nantes Université, CHU Nantes, Service de Médecine Interne, Nantes, France
| | - Y Benhamou
- Normandie Univ, UNIROUEN, U 1096, CHU Rouen, Department of Internal Medicine, F-76000 Rouen, France
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Iarossi M, Hermans C. Emicizumab as first-line therapy in acquired hemophilia A. Res Pract Thromb Haemost 2024; 8:102438. [PMID: 38953052 PMCID: PMC11215093 DOI: 10.1016/j.rpth.2024.102438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/30/2024] [Accepted: 05/01/2024] [Indexed: 07/03/2024] Open
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune disease resulting from the development of autoantibodies directed against endogenous factor (F)VIII, leading to bleeding manifestations that can be life-threatening. The current standard hemostatic treatment involves the use of bypassing agents that circumvent FVIII (recombinant activated FVII, activated prothrombin complex concentrate, and recombinant porcine FVIII) that must be administered intravenously and possess a short half-life. These limitations and the risk of potentially fatal bleeding complications justify the early initiation of immunosuppressive treatment (IST) aimed at promptly eradicating the autoantibodies. IST is not without side effects, sometimes severe and possibly fatal, especially in persons with AHA who are generally older and have multiple comorbidities. Emicizumab, a bispecific antibody that mimics the action of FVIII, has emerged as an effective hemostatic therapy among persons with congenital hemophilia, whether complicated by the presence of anti-FVIII antibodies or not. Numerous arguments from recent clinical experiences suggest positioning emicizumab as a first-line treatment for AHA. This strategy has the potential to reduce bleeding complications and, importantly, the side effects associated with IST, which can be delayed and tailored to each patient.
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Affiliation(s)
- Michael Iarossi
- Division of Hematology, Hemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain, Brussels, Belgium
| | - Cedric Hermans
- Division of Hematology, Hemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain, Brussels, Belgium
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10
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Ahmed F, Kasianchyk M, Moreno A, Chang S, Maharaj S. Emicizumab for acquired hemophilia A: Report of two cases and dosing strategies. EJHAEM 2024; 5:387-391. [PMID: 38633111 PMCID: PMC11020103 DOI: 10.1002/jha2.878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 02/10/2024] [Accepted: 02/28/2024] [Indexed: 04/19/2024]
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder caused by autoantibodies against FVIII. Severe AHA is life-threatening. Currently, licensed hemostatic agents for the treatment of severe AHA have short half-lives and require intravenous administration, leading to a need for hospitalization, higher costs, and negative effects on quality of life. We present two cases of severe AHA with high inhibitor titers where emicizumab was safely and effectively used with intensive immunosuppression. These reports suggest in vivo efficacy even in high inhibitor environments. The optimal dosing regimen (accelerated vs. standard loading, maintenance frequency) is unknown and we discuss the current approaches.
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Affiliation(s)
- Faiza Ahmed
- Hematology and Oncology, Department of Internal MedicineTexas Tech UniversityEl PasoTexasUSA
| | - Mariia Kasianchyk
- Hematology and Oncology, Department of Internal MedicineTexas Tech UniversityEl PasoTexasUSA
| | - Alejandro Moreno
- Hematology and Oncology, Department of Internal MedicineTexas Tech UniversityEl PasoTexasUSA
| | - Simone Chang
- Hematology and Oncology, Department of Internal MedicineTexas Tech UniversityEl PasoTexasUSA
| | - Satish Maharaj
- Hematology and Oncology, Department of Internal MedicineTexas Tech UniversityEl PasoTexasUSA
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11
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Gupta N, Dutta A, Ahmed B, Ross CR, S C, Dolan G, John MJ, Radhakrishnan N, Aggarwal S, Seth T, Kaul V, Shah V. Expert Opinions on the Management of Hemophilia A in India: The Role of Emicizumab. Cureus 2024; 16:e58941. [PMID: 38725780 PMCID: PMC11081140 DOI: 10.7759/cureus.58941] [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] [Accepted: 04/21/2024] [Indexed: 05/12/2024] Open
Abstract
Hemophilia A (HA) is a genetic disorder of hemostasis associated with a deficiency or reduced activity of clotting factor VIII (FVIII). This disorder remains unacceptably underdiagnosed in India. Early diagnosis and appropriate management of HA can substantially prevent morbidity and mortality. Currently, HA is managed with regular replacement therapy using standard or extended half-life FVIII concentrates or non-factor drug products. The challenges associated with FVIII concentrates include plateauing of drug effect, issues with its administration and adherence to treatment, breakthrough bleeds, and the development of inhibiting antibodies against administered clotting factors. Emicizumab is a bispecific antibody, launched in India in April 2019, for managing patients with HA. To investigate the role of emicizumab in Indian patients with HA, opinions were sought from 13 eminent hematologists and experts from India on the effectiveness of emicizumab in preventing all bleeds, spontaneous bleeds, perioperative bleeds, and intracranial hemorrhage; resolving target joints; and reducing the rate of hospitalizations and fatality associated with HA in children and adults, with or without inhibitors. The benefits of emicizumab over traditional FVIII concentrates include the subcutaneous route of delivery, less frequent dosing, and a lack of inhibitor development, in addition to providing sustained hemostasis without in-depth monitoring. It is a safe and effective management option for all HA patients, especially for patients with certain archetypes, such as those with inhibitors, those with high annualized bleed rates, those living far away from hemophilia care centers, pediatric patients and infants with intravenous access challenges, and those with a history of life-threatening bleeding events.
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Affiliation(s)
- Naresh Gupta
- Medicine and Surgery, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
- Haematology & Haemophilia, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, IND
| | - Anupam Dutta
- General Medicine, Assam Medical College and Hospital, Dibrugarh, IND
| | - Bilal Ahmed
- Pathology, Transfusion Medicine & Hemophilia, Government Medical College, Srinagar, IND
| | - Cecil R Ross
- Hematology, St. John's Medical College and Hospital, Bangalore, IND
| | - Chandrakala S
- Clinical Haematology, King Edward Memorial Hospital, Mumbai, IND
| | - Gerard Dolan
- Haematology, St. Thomas' Haemophilia Comprehensive Care Centre, Bournemouth, GBR
| | - M J John
- Clinical Hematology, Hemato-Oncology & Bone Marrow Transplant, Christian Medical College & Hospital, Ludhiana, IND
| | - Nita Radhakrishnan
- Hematology and Oncology, Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida, IND
| | | | - Tulika Seth
- Hematology, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
| | - Varun Kaul
- Pediatrics, Guru Gobind Singh Medical College & Hospital, Faridkot, IND
| | - Vijay Shah
- Pediatrics, Nirmal Hospital Pvt. Ltd., Surat, IND
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12
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Tiede A, Susen S, Lisman T. Acquired bleeding disorders. Haemophilia 2024; 30 Suppl 3:29-38. [PMID: 38562115 DOI: 10.1111/hae.14995] [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: 01/23/2024] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 04/04/2024]
Abstract
Acquired bleeding disorders can develop in previously healthy people irrespective of age or gender but are particularly common in patients with certain underlying conditions. Here, we review recent advances in the management of acquired haemophilia A (AHA), acquired von Willebrand syndrome (AVWS), and patients with hemostatic abnormalities due to chronic liver disease (CLD). Patients with AHA can now benefit from prophylaxis with emicizumab, a therapeutic antibody that mimics the function of activated coagulation factor VIII. The treatment of AVWS remains challenging in many situations and requires careful consideration of the underlying condition. Haemostatic abnormalities in CLD are often compensated by proportional reduction in pro and anti-haemostatic factors resulting in sustained or even increased thrombin generation. Consequently, bleeding in CLD is rarely caused by haemostatic failure and infusion of plasma or coagulation factor concentrates may not be effective.
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Affiliation(s)
- Andreas Tiede
- Department of Haematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Sophie Susen
- Hemostasis and Transfusion Department, University of Lille, Lille University Hospital, Lille, France
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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13
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Franchini M, Focosi D. Innovative Therapies for Acquired Hemophilia A. Semin Thromb Hemost 2024. [PMID: 38395066 DOI: 10.1055/s-0044-1779737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder which can be life-threatening. AHA is due to autoantibodies against coagulation factor VIII. Disease onset may be idiopathic (approximately half of the cases) or triggered by autoimmune disorders, cancers, drugs, infections, or pregnancy. Besides treating the underlying disorder, specific AHA treatments include management of bleeding and inhibitor eradication. Various first-line and second-line hemostatic and immunosuppressive agents are currently available for the management of AHA. Recently, the hemostatic drug emicizumab and the immunosuppressive drug rituximab have been the object of intense research from investigators as innovative promising therapies for AHA. This narrative review will be focused on the current status of the clinical use of these two off-label therapeutic agents in AHA.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantua, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
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14
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Yu L, Hong Y, Maishi N, Matsuda AY, Hida Y, Hasebe A, Kitagawa Y, Hida K. Oral bacterium Streptococcus mutans promotes tumor metastasis through thrombosis formation. Cancer Sci 2024; 115:648-659. [PMID: 38096871 PMCID: PMC10859626 DOI: 10.1111/cas.16010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/10/2023] [Accepted: 10/25/2023] [Indexed: 02/13/2024] Open
Abstract
Thrombosis is a well-known cardiovascular disease (CVD) complication that has caused death in many patients with cancer. Oral bacteria have been reported to contribute to systemic diseases, including CVDs, and tumor metastasis. However, whether oral bacteria-induced thrombosis induces tumor metastasis remains poorly understood. In this study, the cariogenic oral bacterium Streptococcus mutans was used to examine thrombosis in vitro and in vivo. Investigation of tumor metastasis to the lungs was undertaken by intravenous S. mutans implantation using a murine breast cancer metastasis model. The results indicated that platelet activation, aggregation, and coagulation were significantly altered in S. mutans-stimulated endothelial cells (ECs), with elevated neutrophil migration, thereby inducing thrombosis formation. Streptococcus mutans stimulation significantly enhances platelet and tumor cell adhesion to the inflamed ECs. Furthermore, S. mutans-induced pulmonary thrombosis promotes breast cancer cell metastasis to the lungs in vivo, which can be reduced by using aspirin, an antiplatelet drug. Our findings indicate that oral bacteria promote tumor metastasis through thrombosis formation. Oral health management is important to prevent CVDs, tumor metastasis, and their associated death.
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Affiliation(s)
- Li Yu
- Vascular Biology and Molecular Pathology, Faculty of Dental Medicine and Graduate School of Dental MedicineHokkaido UniversitySapporoJapan
| | - Yuying Hong
- Vascular Biology and Molecular Pathology, Faculty of Dental Medicine and Graduate School of Dental MedicineHokkaido UniversitySapporoJapan
- Oral Diagnosis and Medicine, Faculty of Dental Medicine and Graduate School of Dental MedicineHokkaido UniversitySapporoJapan
| | - Nako Maishi
- Vascular Biology and Molecular Pathology, Faculty of Dental Medicine and Graduate School of Dental MedicineHokkaido UniversitySapporoJapan
| | - Aya Yanagawa Matsuda
- Vascular Biology and Molecular Pathology, Faculty of Dental Medicine and Graduate School of Dental MedicineHokkaido UniversitySapporoJapan
| | - Yasuhiro Hida
- Advanced Robotic and Endoscopic Surgery, School of MedicineFujita Health UniversityToyoakeJapan
| | - Akira Hasebe
- Oral Molecular Microbiology, Faculty of Dental Medicine and Graduate School of Dental MedicineHokkaido UniversitySapporoJapan
| | - Yoshimasa Kitagawa
- Oral Diagnosis and Medicine, Faculty of Dental Medicine and Graduate School of Dental MedicineHokkaido UniversitySapporoJapan
| | - Kyoko Hida
- Vascular Biology and Molecular Pathology, Faculty of Dental Medicine and Graduate School of Dental MedicineHokkaido UniversitySapporoJapan
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15
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Sin CF, Li THS, Wong KP, Wong KW, Sin YT, Lam WK, Mak HC, Lau WP, Yeung KP, Leung FSK, Li CH. Characteristics and outcome of a territory-wide cohort study of patients with acquired hemophilia A in Hong Kong. Thromb Res 2024; 233:138-144. [PMID: 38043393 DOI: 10.1016/j.thromres.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 10/29/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION Acquired hemophilia A (AHA) is a rare bleeding disorder with destruction of factor VIII by autoantibodies. Comprehensive data for Chinese patients are lacking. Predictors of hospital stay have not been investigated. METHODS A territory-wide review of patients diagnosed with AHA from January 1, 2012, to December 31, 2021 was performed by retrieving patients' information from an electronic database system in Hong Kong. RESULTS Overall, 165 patients were included in this 10-year study, and the estimated incidence was 2.4 per million/year, which was higher than those reported from Caucasian cohorts. The median age of diagnosis was 80 years old. Patients had a long hospital stay (median: 25 days) and high mortality (55.2 %). The majority of deaths were caused by immunosuppression-related sepsis (49.5 %). Age was an independent predictor of overall survival (Hazard ratio: 1.065, 95 % CI: 1.037-1.093, p < 0.001), complete remission (CR) status (odd ratios (OR): 0.948, 95 % CI: 0.921-0.976, p < 0.001) and time to achieve CR (OR: 1.043, 95 % CI: 1.019-1.067, p < 0.001). Higher hemoglobin level on presentation was associated with shorter time to achieve CR (OR: 0.888, 95 % CI: 0.795-0.993, p = 0.037). Factor VIII level < 1 % normal, high inhibitor titer and intensive immunosuppressive regimen predicted long hospital stay. CONCLUSION We presented comprehensive data of Chinese patients with AHA which comprised predominantly frail elderly who required long hospital stay and had high sepsis-related mortality. This posed challenges in managing AHA in such patients. Individualized immunosuppressive therapy is needed to balance the benefits and risk of septic complications.
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Affiliation(s)
- Chun-Fung Sin
- Department of Pathology, University of Hong Kong, Hong Kong Special Administrative Region.
| | - Ting Hon Stanford Li
- Department of Pathology, Queen Elizabeth Hospital, Hong Kong Special Administrative Region
| | - Ka-Ping Wong
- Department of Pathology, University of Hong Kong, Hong Kong Special Administrative Region
| | - Ka-Wai Wong
- Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong Special Administrative Region
| | - Yuen-Ting Sin
- Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong Special Administrative Region
| | - Wing Kit Lam
- Department of Clinical Pathology, Tuen Mun Hospital, Hong Kong Special Administrative Region
| | - Hiu-Chun Mak
- Department of Pathology, Pamela Youde Nethersole Eastern Hospital, Hong Kong Special Administrative Region
| | - Wai-Pun Lau
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong Special Administrative Region
| | - Ka-Pik Yeung
- Department of Pathology, Princes Margaret Hospital, Hong Kong Special Administrative Region
| | - Fung Shan Kate Leung
- Department of Pathology, Princes Margaret Hospital, Hong Kong Special Administrative Region
| | - Chung-Hin Li
- Department of Anatomical and Cellular Pathology, Princes of Wales Hospital, Hong Kong Special Administrative Region
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16
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Ocaña Gómez MÁ, Esquivel Negrín J, Ríos De Paz M, De Dios García MD. Utilization of emicizumab in the treatment of a case of acquired hemophilia A. FARMACIA HOSPITALARIA 2024; 48:45-47. [PMID: 37468348 DOI: 10.1016/j.farma.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 07/21/2023] Open
Affiliation(s)
- María Ángeles Ocaña Gómez
- Servicio de Farmacia, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España.
| | - Jorge Esquivel Negrín
- Servicio de Farmacia, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - Mario Ríos De Paz
- Servicio de Hematología, Unidad de Coagulopatías, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
| | - María Dolores De Dios García
- Servicio de Hematología, Unidad de Coagulopatías, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, España
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17
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Ocaña Gómez MÁ, Esquivel Negrín J, Ríos De Paz M, De Dios García MD. [Translated article] Utilization of emicizumab in the treatment of a case of acquired haemophilia A. FARMACIA HOSPITALARIA 2024; 48:T45-T47. [PMID: 37884400 DOI: 10.1016/j.farma.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/12/2023] [Accepted: 06/13/2023] [Indexed: 10/28/2023] Open
Affiliation(s)
- María Ángeles Ocaña Gómez
- Servicio de Farmacia, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain.
| | - Jorge Esquivel Negrín
- Servicio de Farmacia, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain.
| | - Mario Ríos De Paz
- Servicio de Hematología, Unidad de Coagulopatías, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - María Dolores De Dios García
- Servicio de Hematología, Unidad de Coagulopatías, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
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18
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Wang P, Zhou R, Xue F, Zhou H, Bai J, Wang X, Ma Y, Song Z, Chen Y, Liu X, Fu R, Sun T, Ju M, Dai X, Dong H, Yang R, Liu W, Zhang L. Single-dose rituximab plus glucocorticoid versus cyclophosphamide plus glucocorticoid in patients with newly diagnosed acquired hemophilia A: A multicenter, open-label, randomized noninferiority trial. Am J Hematol 2024; 99:28-37. [PMID: 37851608 DOI: 10.1002/ajh.27128] [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: 09/18/2023] [Accepted: 09/26/2023] [Indexed: 10/20/2023]
Abstract
Acquired hemophilia A (AHA) is a rare but serious bleeding disorder. Randomized controlled trial (RCT) comparing the efficacy of immunosuppression therapy for AHA lacks. We conducted the first multicenter RCT aiming to establish whether the single-dose rituximab combination regimen was noninferior to the cyclophosphamide combination regimen. From 2017 to 2022, 63 patients with newly diagnosed AHA from five centers were randomly assigned 1:1 to receive glucocorticoid (methylprednisolone 0.8 mg/kg per day for the first 3 weeks and then tapered) plus single-dose rituximab (375 mg/m2 ; n = 31) or plus cyclophosphamide (2 mg/kg per day until inhibitor becomes negative, for a maximum of 5 weeks; n = 32). The primary outcome was complete remission (CR, defined as FVIII activity ≥50 IU/dL, FVIII inhibitor undetectable, immunosuppression tapered and no bleeding for 24 h without bypassing agents) rate measured within 8 weeks. The noninferiority margin was an absolute difference of 20%. Twenty-four (77.4%) patients in the rituximab group and 22 (68.8%) patients in the cyclophosphamide group achieved CR, which showed the noninferiority of the single-dose rituximab-based regimen (absolute difference = -8.67%, lower limit of the 95% confidence interval = -13.11%; Pnoninferiority = 0.005). No difference was found in the incidence of treatment-related adverse events. Single-dose rituximab plus glucocorticoid regimen showed similar efficacy and safety, without a reported risk of secondary malignancies or reproductive toxicity seen in cyclophosphamide, it might be recommended as a first-line therapy for AHA, especially in China where there is a young age trend in AHA patients. This trial was registered at ClinicalTrials.gov as #NCT03384277.
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Affiliation(s)
- PanJing Wang
- 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, China
| | - Rongfu Zhou
- Department of Hematology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 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, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, 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
| | - Jie Bai
- Department of Hematology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xianghua Wang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yueshen Ma
- Office of Biostatistics, Center for Information and Resources of 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, China
| | - Zhen Song
- Center for Information and Resources of 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, 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, CAMS 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, CAMS 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, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, 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, CAMS 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, CAMS 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, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Huan Dong
- 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, 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, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - 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, CAMS 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, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
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19
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Poston J, Kruse-Jarres R. The role of emicizumab in acquired hemophilia A. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:24-30. [PMID: 38066880 PMCID: PMC10727101 DOI: 10.1182/hematology.2023000462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Acquired hemophilia is a rare bleeding disorder that predominantly affects older people with potential underlying comorbidities, including cardiovascular and thrombotic risk factors. The current standard therapies with hemostatic agents for acute bleeding and immunosuppression often require inpatient management, are not approved for routine bleeding prophylaxis, and contribute to the high mortality in this population. Emicizumab is a factor VIII (FVIII) mimetic approved for bleeding prophylaxis in congenital hemophilia A with and without FVIII inhibitors. Given subcutaneously, it may allow easier outpatient bleeding prophylaxis and reduce intensity of immunosuppression. This article summarizes the currently available data on the efficacy and safety of emicizumab in acquired hemophilia A.
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Affiliation(s)
- Jacqueline Poston
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Rebecca Kruse-Jarres
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
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20
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Tiede A. Immunotherapy of acquired hemophilia A. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:19-23. [PMID: 38066859 PMCID: PMC10727022 DOI: 10.1182/hematology.2023000461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Acquired hemophilia A (AHA) is an autoimmune disorder characterized by the formation of autoantibodies that neutralize the function of coagulation factor VIII. Immunosuppressive therapy (IST) with glucocorticoids, cyclophosphamide, rituximab, or combinations thereof is the standard of care to suppress autoantibody formation and induce remission of AHA. About 80% of patients achieve remission over the course of a few weeks to several months. However, patients with AHA are often elderly and frail and have adverse events from IST. Therefore, guidelines suggest an individualized approach using caution in elderly and frail patients. Prophylaxis with emicizumab may reduce the need for early and aggressive IST in the future.
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Affiliation(s)
- Andreas Tiede
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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21
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Pfrepper C, Klamroth R, Oldenburg J, Holstein K, Eichler H, Hart C, Moehnle P, Schilling K, Trautmann-Grill K, Alrifai M, Ay C, Miesbach W, Knoebl P, Tiede A. Emicizumab for the Treatment of Acquired Hemophilia A: Consensus Recommendations from the GTH-AHA Working Group. Hamostaseologie 2023. [PMID: 38049124 DOI: 10.1055/a-2197-9738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a severe bleeding disorder caused by autoantibodies against coagulation factor VIII (FVIII). Standard treatment consists of bleeding control with bypassing agents and immunosuppressive therapy. Emicizumab is a bispecific antibody that mimics the function of activated FVIII irrespective of the presence of neutralizing antibodies. Recently, the GTH-AHA-EMI study demonstrated that emicizumab prevents bleeds and allows to postpone immunosuppression, which may influence future treatment strategies. AIM To provide clinical practice recommendations on the use of emicizumab in AHA. METHODS A Delphi procedure was conducted among 33 experts from 16 German and Austrian hemophilia care centers. Statements were scored on a scale of 1 to 9, and agreement was defined as a score of ≥7. Consensus was defined as ≥75% agreement among participants, and strong consensus as ≥95% agreement. RESULTS Strong consensus was reached that emicizumab is effective for bleed prophylaxis and should be considered from the time of diagnosis (100% consensus). A fast-loading regimen of 6 mg/kg on day 1 and 3 mg/kg on day 2 should be used if rapid bleeding prophylaxis is required (94%). Maintenance doses of 1.5 mg/kg once weekly should be given (91%). Immunosuppression should be offered to patients on emicizumab if they are eligible based on physical status (97%). Emicizumab should be discontinued when remission of AHA is achieved (97%). CONCLUSION These GTH consensus recommendations provide guidance to physicians on the use of emicizumab in AHA and follow the results of clinical trials that have shown emicizumab is effective in preventing bleeding in AHA.
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Affiliation(s)
- Christian Pfrepper
- Division of Hemostaseology, Department of Hematology, Cellular Therapy, Hemostaseology and Infectiology, University Hospital Leipzig, Leipzig, Germany
| | - Robert Klamroth
- Department of Internal Medicine, Vascular Medicine and Coagulation Disorders, Vivantes Clinic Friedrichshain, Berlin, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Katharina Holstein
- Department of Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Eichler
- Clinical Hemostaseology and Transfusion Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Christina Hart
- Department of Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Patrick Moehnle
- Division of Transfusion Medicine, Cell Therapeutics and Hemostaseology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Kristina Schilling
- Department of Hematology and Oncology, University Hospital Jena, Jena, Germany
| | | | - Mohammed Alrifai
- Department of Thrombosis and Hemostasis, University Hospital Giessen and Marburg GmbH, Giessen Germany
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | | | - Paul Knoebl
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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22
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Tran MH, Mathur G, Barnhard S, Schwartz J. Historic and emerging trends in transfusion medicine: Maintaining relevance as a specialty. Transfusion 2023; 63:2341-2350. [PMID: 37921092 DOI: 10.1111/trf.17588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/05/2023] [Accepted: 10/08/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Minh-Ha Tran
- Department of Pathology and Laboratory Medicine, Irvine School of Medicine, University of California, Irvine, California, USA
| | - Gagan Mathur
- Department of Pathology and Laboratory Medicine, Irvine School of Medicine, University of California, Irvine, California, USA
| | - Sarah Barnhard
- Department of Pathology and Laboratory Medicine, Davis School of Medicine, University of California, Sacramento, California, USA
| | - Joseph Schwartz
- Department of Pathology, Moffitt Cancer Center, Tampa, Florida, USA
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23
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Moonla C, Polprasert C, Krittikarux S, Cheerasiri N, Akkawat B, Rojnuckarin P, Uaprasert N. Adjunctive daratumumab can induce rapid remission in acquired haemophilia A with poor prognostic markers. Haemophilia 2023; 29:1649-1652. [PMID: 37665794 DOI: 10.1111/hae.14850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/28/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023]
Affiliation(s)
- Chatphatai Moonla
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Chantana Polprasert
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - San Krittikarux
- Department of Medicine, Sakaeo Crown Prince Hospital, Sakaeo, Thailand
| | - Nuanrat Cheerasiri
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Benjaporn Akkawat
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Ponlapat Rojnuckarin
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Noppacharn Uaprasert
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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24
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Tiede A, Hart C, Knöbl P, Greil R, Oldenburg J, Sachs UJ, Miesbach W, Pfrepper C, Trautmann-Grill K, Holstein K, Pilch J, Möhnle P, Schindler C, Weigt C, Schipp D, May M, Dobbelstein C, Pelzer FJ, Werwitzke S, Klamroth R. Emicizumab prophylaxis in patients with acquired haemophilia A (GTH-AHA-EMI): an open-label, single-arm, multicentre, phase 2 study. Lancet Haematol 2023; 10:e913-e921. [PMID: 37858328 DOI: 10.1016/s2352-3026(23)00280-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Acquired haemophilia A is caused by neutralising autoantibodies against coagulation factor VIII, leading to severe bleeding. Standard treatment involves immunosuppressive therapy, which is associated with adverse events and mortality in the frail population of patients with acquired haemophilia A. This study investigated whether emicizumab, a factor VIIIa mimetic antibody, protects patients with acquired haemophilia A from bleeding and allows deferral of immunosuppression during the first 12 weeks after diagnosis. METHODS We report final results of an open-label, single-arm, phase 2 clinical trial. Adult patients with acquired haemophilia A from 16 haemophilia treatment centres in Germany and Austria were eligible if they had not previously received immunosuppression. Patients received emicizumab subcutaneously (6 and 3 mg/kg on days 1 and 2, 1·5 mg/kg weekly until week 12), but no immunosuppression. Follow-up was until week 24. The primary endpoint was the number of clinically relevant bleeds per patient-week until week 12. Emicizumab was considered effective if the mean bleeding rate was significantly below 0·15 bleeds per patient-week, the rate observed in a previous study of patients with acquired haemophilia A treated with bypassing agents and immunosuppression but no emicizumab. The study is registered with clinicaltrials.gov, NCT04188639 and is complete. FINDINGS Of 49 patients screened from March 25, 2021, to June 10, 2022, 47 were enrolled (23 women, 24 men). Median age was 76 years (IQR 66-80), 46 (98%) of 47 patients were White, median factor VIII activity was 1·4 IU/dL (0·3-5·6), and median inhibitor concentration was 11·4 Bethesda units per mL (3·9-42·7). Mean breakthrough bleeding rate was 0·04 bleeds per patient-week (upper 97·5% CI 0·06). 33 (70%) of 47 patients had no bleeding events, seven patients (15%) had one bleed, six patients (13%) had two bleeds, and one patient (2%) had three bleeds. Adverse events of grade 3 or worse included COVID-19 (n=2), acute kidney injury (n=2), and stroke (n=1). Four of 47 patients died, including two deaths related to bleeding, one from COVID-19, and one from cardiac arrest (none were judged as related to emicizumab). INTERPRETATION This study suggests that emicizumab prophylaxis prevents bleeding in patients with acquired haemophilia A and that immunosuppressive therapy can be deferred while patients are receiving this treatment. The low number of thromboembolic events, severe infections, and fatalities observed in this study are promising. FUNDING This study was supported by funding from Hoffman-La Roche.
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Affiliation(s)
- Andreas Tiede
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany.
| | - Christina Hart
- Department of Hematology and Oncology, University Hospital Regensburg, Regensburg, Germany
| | - Paul Knöbl
- Department of Medicine 1, Division of Hematology and Hemostasis, Medical University of Vienna, Vienna, Austria
| | - Richard Greil
- Medical Department III, Paracelsus Medical University Salzburg, Salzburg, Austria; Salzburg Cancer Research Institute-CCCIT Salzburg, Austria; Cancer Cluster Salzburg, Salzburg, Austria
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Ulrich J Sachs
- Department of Thrombosis and Haemostasis, Giessen University Hospital, Giessen, Germany
| | | | - Christian Pfrepper
- Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
| | | | - Katharina Holstein
- Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Pilch
- Clinical Hemostaseology and Transfusion Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Patrick Möhnle
- Division of Transfusion Medicine, Cell Therapeutics and Haemostaseology, University Hospital, Ludwig Maximilian University, Munich, Germany
| | | | | | | | - Marcus May
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Christiane Dobbelstein
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Fabius J Pelzer
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Sonja Werwitzke
- Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Robert Klamroth
- Internal Medicine, Vascular Medicine and Coagulation Disorders, Vivantes Clinic Friedrichshain, Berlin, Germany
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25
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Valke LLFG, Verhagen MJA, Mulders BTPM, Polenewen R, Blijlevens NMA, Jansen JH, Mansouritorghabeh H, Elsheikh E, Reipert BM, Turecek PL, O'Donnell JS, Rijpma SR, Schols SEM, van Heerde WL, Meijer D. The Nijmegen ultra-sensitive Bethesda Assay detects very low-titer factor VIII inhibitors in patients with congenital and acquired hemophilia A. Thromb Res 2023; 231:112-120. [PMID: 37844518 DOI: 10.1016/j.thromres.2023.10.007] [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: 07/19/2023] [Revised: 09/23/2023] [Accepted: 10/04/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND An inhibitor can develop in congenital hemophilia A (HA) patients against exogenous infused factor (F)VIII, whereas in acquired HA (AHA) inhibitors initially develop against endogenous FVIII. Inhibitors can be detected with the Nijmegen Bethesda Assay (NBA), which has an international cut-off level of 0.60 Nijmegen Bethesda Units/mL (NBU/mL). Thereby, very low-titer inhibitors may remain undetected. AIM To describe the design and validation of the Nijmegen ultra-sensitive Bethesda Assay (NusBA) for the detection of very low-titer inhibitors. METHODS The NusBA is a modification of the NBA in which the ratio of patient plasma to normal pooled plasma is changed from 1:1 to 9:1. Analytical validation was performed according to the CLSI EP10 guideline in order to determine trueness and reproducibility. Clinical validation was performed in two cohorts of congenital HA patients (82 adults) with pharmacokinetic data and four AHA patients. The limit of quantitation (LOQ) was determined by measuring plasma samples spiked with inhibitor levels in the low range (0.05-0.80 NBU/mL). RESULTS The LOQ for the NusBA was 0.10 NusBU/mL, with a coefficient of variation of 24.2 %. Seven (8.5 %) congenital HA patients had a positive NusBA result, of which only one was detected with the NBA. There was no correlation between NusBA and FVIII half-life. In three of the AHA patients the NusBA remained positive, when the NBA became negative. DISCUSSION The NusBA is able to detect very low-titer FVIII inhibitors of ≥0.10 NBU/mL. Thereby, it may have added value in early inhibitor detection and therapy adjustments in patients with congenital HA and AHA.
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Affiliation(s)
- Lars L F G Valke
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - Marieke J A Verhagen
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands; Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bart T P M Mulders
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Robert Polenewen
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Joop H Jansen
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hassan Mansouritorghabeh
- Central Diagnostic Laboratories, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Einas Elsheikh
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Ireland
| | | | - Peter L Turecek
- Baxalta Innovations GmbH, A Member of the Takeda Group of Companies, Vienna, Austria
| | - James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Ireland; National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Sanna R Rijpma
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - Waander L van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands; Enzyre BV, Novio Tech Campus, Nijmegen, the Netherlands.
| | - Danielle Meijer
- Laboratory of Hematology, Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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26
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Ragni MV. Rapidly loading emicizumab without immunosuppression in acquired haemophilia. Lancet Haematol 2023; 10:e870-e871. [PMID: 37858327 DOI: 10.1016/s2352-3026(23)00303-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Margaret V Ragni
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh Medical Center, and Hemophilia Center of Western PA, Pittsburgh, PA, USA.
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27
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De Pablo-Moreno JA, Miguel-Batuecas A, Rodríguez-Merchán EC, Liras A. Treatment of congenital coagulopathies, from biologic to biotechnological drugs: The relevance of gene editing (CRISPR/Cas). Thromb Res 2023; 231:99-111. [PMID: 37839151 DOI: 10.1016/j.thromres.2023.10.001] [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: 07/17/2023] [Revised: 09/09/2023] [Accepted: 10/02/2023] [Indexed: 10/17/2023]
Abstract
Congenital coagulopathies have, throughout the history of medicine, been a focus of scientific study and of great interest as they constitute an alteration of one of the most important and conserved pathways of evolution. The first therapeutic strategies developed to address them were aimed at restoring the blood components lost during hemorrhage by administering whole blood or plasma. Later on, the use of cryoprecipitates was a significant breakthrough as it made it possible to decrease the volumes of blood infused. In the 1970' and 80', clotting factor concentrates became the treatment and, from the 1990's to the present day, recombinant factors -with increasingly longer half-lives- have taken over as the treatment of choice for certain coagulopathies in a seamless yet momentous transition from biological to biotechnological drugs. The beginning of this century, however, saw the emergence of new advanced (gene and cell) treatments, which are currently transforming the therapeutic landscape. The possibility to use cells and viruses as well as specific or bispecific antibodies as medicines is likely to spark a revolution in the world of pharmacology where therapies will be individualized and have long-term effects. Specifically, attention is nowadays focused on the development of gene editing strategies, chiefly those based on CRISPR/Cas technology. Rare coagulopathies such as hemophilia A and B, or even ultra-rare ones such as factor V deficiency, could be among those deriving the greatest benefit from these new developments.
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Affiliation(s)
- Juan A De Pablo-Moreno
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, Spain
| | - Andrea Miguel-Batuecas
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, Spain
| | - E Carlos Rodríguez-Merchán
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Autonomous University of Madrid), Spain
| | - Antonio Liras
- Department of Genetic, Physiology and Microbiology, Biology School, Complutense University of Madrid, Spain.
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28
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Kim JM, Stern RM, Maron BA. Bleeding and Myocardial Infarction in Acquired Factor VIII Deficiency. Circulation 2023; 148:1127-1133. [PMID: 37782697 DOI: 10.1161/circulationaha.123.063904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Affiliation(s)
- Joseph M Kim
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA (J.M.K.)
- Harvard Medical School, Boston, MA (J.M.K., R.M.S., B.A.M.)
| | - Robert M Stern
- Harvard Medical School, Boston, MA (J.M.K., R.M.S., B.A.M.)
- Divisions of Hematology (R.M.S.), Brigham and Women's Hospital, Boston, MA
| | - Bradley A Maron
- Harvard Medical School, Boston, MA (J.M.K., R.M.S., B.A.M.)
- Cardiovascular Medicine (B.A.M.), Brigham and Women's Hospital, Boston, MA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD and the University of Maryland-Institute for Health Computing, Bethesda, MD (B.A.M.)
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29
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Marino R. Acquired Hemophilia A: Bleeding Pattern and Hemostatic Therapeutic Strategies. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1739. [PMID: 37893457 PMCID: PMC10608116 DOI: 10.3390/medicina59101739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/20/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023]
Abstract
Acquired Hemophilia A (AHA) is a rare autoimmune disorder characterized by the onset of a sudden and unexpected bleeding episode in a patient with no personal or family history of bleeding diathesis, and with a typical laboratory feature, i.e., a prolonged activated partial thromboplastin time that is not otherwise explained. This bleeding disorder is caused by autoantibodies directed against the coagulation factor VIII (FVIII). AHA is idiopathic in 50% of cases and is secondary to well-defined diseases in the remaining 50%. AHA affects elderly patients although it has also been observed in the post-partum period. Bleeding manifestations are heterogeneous, ranging from mild to life-threatening bleeds involving limbs and organs. Severe bleeding with a significant decrease in hemoglobin levels must be promptly and adequately treated in order to avoid a worsening of the hemorrhages and their complications. According to international recommendations, the bypass agents (i.e., activated prothrombin complex concentrate and activated recombinant factor VII) and the replacement therapy with recombinant porcine FVIII are considered as the first-line therapy for bleeding control, due to their proven clinical efficacy. Plasma-derived or recombinant FVIII concentrates could be used as second-line treatments. Emicizumab may represent a valid and interesting therapeutic option for prophylaxis of bleeding recurrences.
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Affiliation(s)
- Renato Marino
- Hemophilia and Thrombosis Centre, University Hospital of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
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30
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Tarantino MD, Hardesty B, Metjian A, Ortel TL, Chen J, Badejo K, Ma A, Cuker A, Rajasekhar A, Friedman KD, Janbain M. Real-world safety and effectiveness of recombinant porcine sequence factor VIII in acquired haemophilia A: A non-interventional, post-authorization safety study. Haemophilia 2023; 29:1259-1268. [PMID: 37584309 DOI: 10.1111/hae.14832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 06/29/2023] [Accepted: 07/07/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Recombinant porcine factor VIII (rpFVIII, susoctocog alfa) is indicated for the treatment of bleeding episodes in adults with acquired haemophilia A (AHA). AIM To provide long-term real-world safety and effectiveness data for rpFVIII in the management of AHA bleeding episodes. METHODS US PASS (NCT02610127) was a multicentre, uncontrolled, open-label, post-marketing safety surveillance study conducted in adults with AHA. Data were collected retrospectively or prospectively for 180 days after rpFVIII treatment. The primary outcome was the incidence of treatment-related serious adverse events (SAEs). Secondary outcomes included haemostatic effectiveness of rpFVIII and rpFVIII utilization. RESULTS Fifty-three patients were enrolled from December 2015 to June 2019 (prospective, n = 30; retrospective, n = 23). Six patients experienced seven treatment-related SAEs (incidence 12.0%). The most common treatment-related SAE was FVIII inhibition (inhibiting antibodies to rpFVIII; incidence 8.0%, 95% CI: 2.2-19.2). Five patients reported seven thromboembolic events; one was an SAE and possibly related to rpFVIII. Of bleeding events treated with rpFVIII, 80.3% (57/71) of bleeds resolved with rpFVIII. The median (range) dose of rpFVIII per infusion was 50 (10-300) units/kg, with a median (range) of 6.0 (1-140) infusions and a median (range) time from bleed onset to bleed resolution of 14.0 (2.0-132.7) days. CONCLUSION In this real-world study of rpFVIII for AHA, no new safety signals were identified compared with previous clinical trial findings. Eighty percent of bleeds resolved with rpFVIII treatment.
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Affiliation(s)
| | - Brandon Hardesty
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Ara Metjian
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Jie Chen
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Kayode Badejo
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Alice Ma
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anita Rajasekhar
- Department of Hematology/Oncology, University of Florida Health, Gainesville, Florida, USA
| | - Kenneth D Friedman
- Medical College of Wisconsin and Versiti/Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
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31
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Bannow BS, Konkle BA. How I approach bleeding in hospitalized patients. Blood 2023; 142:761-768. [PMID: 36652635 PMCID: PMC10562531 DOI: 10.1182/blood.2021014766] [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: 08/04/2022] [Revised: 01/05/2023] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Excessive bleeding is relatively common in adult inpatients, whether as the primary reason for admission or as a development during the hospital stay. Common causes include structural issues, medication effects, and systemic illnesses; occasionally, unexpected bleeding can develop as a result of an undiagnosed or newly acquired bleeding disorder. The first step in caring for the inpatient who is bleeding is to determine whether the bleeding symptom is truly new or whether the patient has a history of abnormal bleeding. Patients with a history of abnormal bleeding may warrant evaluation for inherited bleeding disorders, such as platelet function disorders, von Willebrand disease, hemophilia, or rare factor deficiencies. Patients with no history of bleeding, for whom other causes, such as liver dysfunction, medication effect, disseminated intravascular coagulation, or certain vitamin deficiencies have been ruled out may require evaluation for acquired coagulopathies, such as acquired hemophilia or acquired von Willebrand disease. Here, we present 3 cases to discuss the diagnosis and management of the 2 most common acquired bleeding disorders as well as a patient with a congenital bleeding disorder with a historical diagnosis.
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Affiliation(s)
- Bethany Samuelson Bannow
- Division of Hematology/Medical Oncology, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Barbara A Konkle
- Division of Hematology, Department of Medicine, Washington Center for Bleeding Disorders, University of Washington, Seattle, WA
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32
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Chao TC, Wang SH, Chen YC, Li TY. Successful transfemoral prosthesis in a patient with haemophilia A and factor VIII inhibitors: A case report. J Int Med Res 2023; 51:3000605231195446. [PMID: 37646621 PMCID: PMC10469231 DOI: 10.1177/03000605231195446] [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: 06/20/2023] [Accepted: 08/01/2023] [Indexed: 09/01/2023] Open
Abstract
Haemophilia A patients who develop factor VIII inhibitors pose a challenge with respect to bleeding and orthopaedic management. This is particularly relevant in cases requiring amputation. We present here a case of a patient with severe haemophilia A and inhibitors who had a history of multiple surgeries due to periprosthetic joint infection and a non-healing wound which led to above-knee amputation. Following the implementation of appropriate and suitable transfemoral prosthesis and emicizumab therapy, the patient experienced a significant improvement in mobility and quality of life without any adverse events or bleeding episodes. Additional studies are required to more fully understand treatment options for lower limb amputations in the haemophilia population.
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Affiliation(s)
- Ta-Chung Chao
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Sheng-Hao Wang
- Department of Orthopaedics, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Haemophilia Care and Research Center, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yeu-Chin Chen
- Division of Haematology/Oncology, Department of Internal Medicine, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Haemophilia Care and Research Center, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tsung-Ying Li
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Haemophilia Care and Research Center, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Simman R, Oostra D, Sullivan P, Wilson M, Khatib J, Jackson SE. Wounds resulting from non-malignant haematological disease: a case series. J Wound Care 2023; 32:S6-S18. [PMID: 37405961 DOI: 10.12968/jowc.2023.32.sup7.s6] [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: 07/07/2023]
Abstract
A proactive and systemic approach is imperative to preventing wounds due to disorders of non-malignant haematologic disease. Here, the authors provide several examples of patients with either a known history or acute diagnosis of a coagulation disorder with the aim of reviewing potential cutaneous injuries as well as diagnosis and treatment. A description of the wound and treatment course along with recommendations where appropriate are presented. The article serves as a general review for health professionals who may encounter patients with this disorder and who are involved in treatment decisions. After reviewing the article, the practitioner will be able to identify cutaneous injuries that may be secondary to an underlying haematological disorder, review the diagnosis and treatment recommended, and understand the need for a multidisciplinary approach to patient care.
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Affiliation(s)
- Richard Simman
- University of Toledo, College of Medicine and Life Science, Department of Surgery, Toledo, Ohio, US
- Jobst Vascular Institute, ProMedica Health Network, Toledo, Ohio, US
| | - Drew Oostra
- Jobst Vascular Institute, ProMedica Health Network, Toledo, Ohio, US
- University of Toledo, College of Medicine and Life Sciences, Department of Hematology and Oncology, Toledo, Ohio, US
| | - Patrick Sullivan
- Jobst Vascular Institute, ProMedica Health Network, Toledo, Ohio, US
| | - Michael Wilson
- Department of Pharmacology and Toxicology, Boonshoft School of Medicine, Wright State University, Dayton Ohio, US
| | - Jude Khatib
- Department of Pharmacology and Toxicology, Boonshoft School of Medicine, Wright State University, Dayton Ohio, US
| | - Sarah E Jackson
- University of Toledo, College of Medicine and Life Science, Department of Internal Medicine, Toledo, Ohio, US
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Billerhart M, Hunjadi M, Hawlin V, Grünwald-Gruber C, Maresch D, Mayrhofer P, Kunert R. Recombinant Human CD19 in CHO-K1 Cells: Glycosylation Patterns as a Quality Attribute of High Yield Processes. Int J Mol Sci 2023; 24:10891. [PMID: 37446069 PMCID: PMC10341778 DOI: 10.3390/ijms241310891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/22/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
CD19 is an essential protein in personalized CD19-targeting chimeric antigen receptor (CAR)-T cell-based cancer immunotherapies and CAR-T cell functionality evaluation. However, the recombinant expression of this "difficult to-express" (DTE) protein is challenging, and therefore, commercial access to the protein is limited. We have previously described the successful stable expression of our soluble CD19-AD2 fusion protein of the CD19 extracellular part fused with human serum albumin domain 2 (AD2) in CHO-K1 cells. The function, stability, and secretion rate of DTE proteins can be improved by culture conditions, such as reduced temperature and a shorter residence time. Moreover, glycosylation, as one of the most important post-translational modifications, represents a critical quality attribute potentially affecting CAR-T cell effector function and thus impacting therapy's success. In this study, we increased the production rate of CD19-AD2 by 3.5-fold through applying hypothermic culture conditions. We efficiently improved the purification of our his-tagged CD19-AD2 fusion protein via a Ni-NTA-based affinity column using a stepwise increase in the imidazole concentration. The binding affinity to commercially available anti-CD19 antibodies was evaluated via Bio-Layer Interferometry (BLI). Furthermore, we revealed glycosylation patterns via Electrospray Ionization Mass Spectrometry (ESI-MS), and five highly sialylated and multi-antennary N-glycosylation sites were identified. In summary, we optimized the CD19-AD2 production and purification process and were the first to characterize five highly complex N-glycosylation sites.
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Affiliation(s)
- Magdalena Billerhart
- Institute of Animal Cell Technology and Systems Biology, Department of Biotechnology, University of Natural Resources and Life Sciences, Muthgasse 18, 1190 Vienna, Austria; (M.B.); (M.H.)
| | - Monika Hunjadi
- Institute of Animal Cell Technology and Systems Biology, Department of Biotechnology, University of Natural Resources and Life Sciences, Muthgasse 18, 1190 Vienna, Austria; (M.B.); (M.H.)
| | - Vanessa Hawlin
- Institute of Animal Cell Technology and Systems Biology, Department of Biotechnology, University of Natural Resources and Life Sciences, Muthgasse 18, 1190 Vienna, Austria; (M.B.); (M.H.)
| | - Clemens Grünwald-Gruber
- BOKU Core Facility Mass Spectrometry, University of Natural Resources and Life Sciences, Muthgasse 11, 1190 Vienna, Austria; (C.G.-G.)
| | - Daniel Maresch
- BOKU Core Facility Mass Spectrometry, University of Natural Resources and Life Sciences, Muthgasse 11, 1190 Vienna, Austria; (C.G.-G.)
| | - Patrick Mayrhofer
- Institute of Animal Cell Technology and Systems Biology, Department of Biotechnology, University of Natural Resources and Life Sciences, Muthgasse 18, 1190 Vienna, Austria; (M.B.); (M.H.)
| | - Renate Kunert
- Institute of Animal Cell Technology and Systems Biology, Department of Biotechnology, University of Natural Resources and Life Sciences, Muthgasse 18, 1190 Vienna, Austria; (M.B.); (M.H.)
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MacNeill M, Mansory EM, Lazo-Langner A, Phua CW. Acquired Hemophilia A Masquerading as Bleeding on Anticoagulation: A Case Report Including Key Laboratory Considerations. Cureus 2023; 15:e41029. [PMID: 37519483 PMCID: PMC10373513 DOI: 10.7759/cureus.41029] [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] [Accepted: 06/26/2023] [Indexed: 08/01/2023] Open
Abstract
We report a case of a patient with recurrent hematomas while on anticoagulation for a pulmonary embolism and a prolonged hospital stay due to a delayed diagnosis for acquired hemophilia A. Acquired hemophilia A is a rare autoimmune bleeding disorder with autoantibodies directed against coagulation factor VIII (FVIII), leading to an acquired FVIII deficiency. A prolonged isolated activated partial thromboplastin time (aPTT) in a bleeding patient warrants workup for acquired hemophilia A. This is specifically challenging in patients with thrombosis on anticoagulation and can lead to significant delays in diagnosis and associated morbidities. The case highlights the need for further awareness of this disease, potential laboratory pitfalls when conducting and interpreting coagulation assays, and the management considerations in a patient with a simultaneous thrombotic and hemorrhagic condition.
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Affiliation(s)
- Michael MacNeill
- Medicine, Schulich School of Medicine & Dentistry, Western University, London, CAN
| | | | | | - Chai W Phua
- Hematology, Schulich School of Medicine & Dentistry, Western University, London, CAN
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Amu-Hernández LA, Marzo-Alonso C, Tugues-Peiró A, Vicente-Pascual EP, Monteagudo-Aguilar P. A Case Report of Idiopathic Acquired Hemophilia Type A. Cureus 2023; 15:e38634. [PMID: 37284359 PMCID: PMC10241219 DOI: 10.7759/cureus.38634] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 06/08/2023] Open
Abstract
Acquired hemophilia A (AHA) is a rare hemorrhagic coagulopathy caused by the presence of autoantibodies that inhibit the activity of factor VIII (FVIII). Its diagnosis requires a high index of suspicion. It should be suspected in the presence of extensive hematomas or intense mucosal bleeding in patients with no history of previous trauma or hemorrhagic symptoms. We present two clinical cases of AHA, with different presentations and therapeutic management based on immunosuppression and hemostatic control through bypass agents such as activated recombinant FVII (rFVIIa; Novoseven®) and activated prothrombin complex concentrate (aPCC; Feiba®). The first case was an idiopathic AHA that presented with extensive subcutaneous hematomas with inhibitor titer >40 Bethesda units/ml (BU/mL), prolonged activated partial thromboplastin time (aPTT), and FVIII of 0.8%. In contrast, the second case involved a patient with a history of autoimmune disease, who presented with epistaxis and inhibitor titer of 10.8 BU/ml and FVIII of 5.3%.
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Affiliation(s)
- Liz A Amu-Hernández
- Hematology and Hemostasis, Arnau de Vilanova University Hospital, Lleida, ESP
| | | | - Albert Tugues-Peiró
- Thrombosis and Hemostasis Unit, Arnau de Vilanova University Hospital, Lleida, ESP
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Nardi MA. Hemophilia A: Emicizumab monitoring and impact on coagulation testing. Adv Clin Chem 2023; 113:273-315. [PMID: 36858648 DOI: 10.1016/bs.acc.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Hemophilia A is an X-linked recessive bleeding disorder characterized by absent or ineffective coagulation factor VIII, a condition that could result in a severe and potentially life-threatening bleed. Although the current standard of care involves prophylactic replacement therapy of factor VIII, the development of neutralizing anti-factor VIII alloantibody inhibitors often complicates such therapeutic treatment. Emicizumab (Hemlibra®), a novel recombinant therapeutic agent for patients with hemophilia A, is a humanized asymmetric bispecific IgG4 monoclonal antibody designed to mimic activated factor VIII by bridging factor IXa and factor X thus effecting hemostasis. Importantly, this drug eliminates the need for factor VIII and complications associated with inhibitor generation. Emicizumab has been approved for use in several countries including the United States and Japan for prophylaxis of bleeding episodes in hemophilia A with and without FVIII inhibitors. Therapy is also approved in the European Union for routine prophylaxis of bleeds in hemophilia A with inhibitors or severe hemophilia A without inhibitors. Unfortunately, emicizumab therapy presents unique challenges for routine and specialty coagulation tests currently used to monitor hemophilia A. In this review, hemophilia A is presented, the biochemistry of factor VIII is discussed, and the impact of the therapeutic agent emicizumab is highlighted.
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Affiliation(s)
- Michael A Nardi
- Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, United States; Department of Pathology, New York University Grossman School of Medicine, New York, NY, United States.
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Abbattista M, Ciavarella A, Noone D, Peyvandi F. Hemorrhagic and thrombotic adverse events associated with emicizumab and extended half-life factor VIII replacement drugs: EudraVigilance data of 2021. J Thromb Haemost 2023; 21:546-552. [PMID: 36710195 DOI: 10.1016/j.jtha.2023.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Safety concerns for an increased risk of thrombotic complications in patients with hemophilia A have been pointed out, particularly during nonreplacement treatment with emicizumab and concomitant bypassing agents. Surveillance with the Roche Global Database reporting adverse events for emicizumab has been discontinued on May 2021. OBJECTIVES The objective of this study was to evaluate the reporting rate of hemorrhagic and thrombotic adverse drug reactions (ADRs) associated with nonreplacement (emicizumab) and replacement extended half-life (EHL) factor VIII (FVIII) products as retrieved from the EudraVigilance database. METHODS Total ADR reported during treatment with emicizumab or EHL FVIII products from January 1 to December 31, 2021, were collected. The proportional reporting ratio and the reporting odds ratio (ROR) with their 95% CIs were calculated to express the hemorrhagic and thrombotic ADR reporting frequency ratio between emicizumab and EHL FVIII products. RESULTS Overall, 406 and 376 ADRs were reported for emicizumab and for EHL FVIII products, respectively. Hemorrhagic and thrombotic ADRs were 232 and 24 for emicizumab and 275 and 9 for the EHL FVIII products. Approximately 25% of thrombotic ADRs were reported concomitantly with eptacog alfa. ROR of 0.49 (95% CI, 0.36-0.66) for hemorrhagic and of 2.56 (95% CI, 1.18-5.59) for thrombotic ADRs were obtained for emicizumab compared with EHL FVIII products. CONCLUSION The analysis of 2021 EudraVigilance reports shows a lower reporting rate of hemorrhagic ADR vs a higher reporting rate of thrombotic ADR for emicizumab than for EHL FVIII products. These signals stress the importance of monitoring novel drugs in hemophilia, particularly when administered in association with bypassing agents.
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Affiliation(s)
- Maria Abbattista
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, UOC Medicina Generale, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy. https://twitter.com/AbbattistaMaria
| | - Alessandro Ciavarella
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Declan Noone
- European Haemophilia Consortium, Brussels, Belgium
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, UOC Medicina Generale, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
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Shima M, Amano K, Ogawa Y, Yoneyama K, Ozaki R, Kobayashi R, Sakaida E, Saito M, Okamura T, Ito T, Hattori N, Higasa S, Suzuki N, Seki Y, Nogami K. A prospective, multicenter, open-label phase III study of emicizumab prophylaxis in patients with acquired hemophilia A. J Thromb Haemost 2023; 21:534-545. [PMID: 36696195 DOI: 10.1016/j.jtha.2022.10.004] [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: 06/09/2022] [Revised: 09/09/2022] [Accepted: 10/05/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Emicizumab is a bispecific antibody that mimics the cofactor function of activated factor (F) VIII. It prevents bleeds in patients with congenital hemophilia A regardless of the inhibitor status; however, no prospective clinical studies have been conducted for emicizumab in patients with acquired hemophilia A (PwAHA). OBJECTIVES To describe the primary analysis results from a prospective, multicenter, open-label phase III study evaluating the efficacy, safety, and pharmacokinetics of emicizumab in PwAHA (AGEHA; JapicCTI-205151). METHODS Emicizumab was administered subcutaneously at 6 mg/kg on day 1 and 3 mg/kg on day 2, followed by 1.5 mg/kg once weekly from day 8 onward. Predefined criteria for the completion of dosing included FVIII activity of >50 IU/dL. RESULTS By the cutoff date (April 23, 2021), 12 patients on immunosuppressive therapy were enrolled, and 11 of them (91.7%) completed emicizumab treatment. The mean trough plasma emicizumab concentration rapidly reached a steady state (1 week), achieving the efficacious level that was established in patients with congenital hemophilia A (>30 μg/mL). Before first emicizumab administration, 7 patients (58.3%) experienced 77 major bleeds. During emicizumab treatment, no major bleeds occurred in any patient. Neither death due to bleeding or infection nor any study treatment-related serious adverse event was reported. One asymptomatic, nonserious deep vein thrombosis was discovered with no laboratory findings indicating any trend toward hypercoagulation. CONCLUSION These results suggest that emicizumab prophylaxis with the tested dosing regimen and completion criteria may have a favorable benefit-risk profile in PwAHA.
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Affiliation(s)
- Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, Kashihara, Japan; Department of Pediatrics, Nara Medical University, Kashihara, Japan.
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yoshiyuki Ogawa
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | | | | | | | - Emiko Sakaida
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Makoto Saito
- Blood Disorders Center, Aiiku Hospital, Sapporo, Japan
| | - Takashi Okamura
- Department of Hematology, St. Mary's Hospital, Kurume, Japan
| | - Toshihiro Ito
- Department of Infectious Diseases, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Norimichi Hattori
- Division of Hematology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Satoshi Higasa
- Department of Hematology, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Nobuaki Suzuki
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Yoshinobu Seki
- Department of Hematology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minami-uonuma, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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Wei L, Tian Y, Chen X, Guo X, Chen C, Zheng Y, Xu J, Ye X. Data mining and analysis for emicizumab adverse event signals based on the Food and Drug Administration Adverse Event Reporting System database. Int J Clin Pharm 2023:10.1007/s11096-022-01514-4. [PMID: 36848023 DOI: 10.1007/s11096-022-01514-4] [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: 05/10/2022] [Accepted: 10/23/2022] [Indexed: 03/01/2023]
Abstract
BACKGROUND Emicizumab is the latest treatment for patients with hemophilia A. Its safety in real-world data is limited, and regulatory agencies and clinical researchers have raised concerns about the risk of adverse events. AIM This study aimed to detect potential adverse event signals of emicizumab using the FDA Adverse Event Reporting System (FAERS) database. METHOD Data in FAERS from the fourth quarter of 2017 to the second quarter of 2021 were searched. Cases of adverse events were extracted using the Preferred Term in the Medical Dictionary for Regulatory Activities (version 24.0). Disproportionality analysis was performed using the reporting odds ratio (ROR) and information component (IC) methods based on statistical shrinkage transformation. RESULTS A total of 5,598,717 patients were included, of which 1,244 took emicizumab. A total of 703 emicizumab-related adverse event signals were mined, and 101 positive signals were detected. Haemarthrosis (ROR/ROR975/ROR025 = 155.62/184.34/131.38, IC/IC975/IC025 = 7.28/7.48/7.01), haemorrhage (ROR/ROR975/ROR025 = 71.01/81.18/62.12, IC/IC975/IC025 = 6.15/6.31/5.94), muscle haemorrhage (ROR/ROR975/ROR025 = 53.38/75.83/37.58, IC/IC975/IC025 = 5.74/6.16/5.15), traumatic haemorrhage (ROR/ROR975/ROR025 = 27.78/46.29/16.67, IC/IC975/IC025 = 4.80/5.40/3.92), haematoma (ROR/ROR975/ROR025 = 18.15/26.35/12.51, IC/IC975/IC025 = 4.18/4.63/3.55), device-related thrombosis (ROR/ROR975/ROR025 = 21.27/37.57/12.04, IC/IC975/IC025 = 4.41/5.08/3.43), and activated partial thromboplastin time prolonged (ROR/ROR975/ROR025 = 20.68/36.51/11.71, IC/IC975/IC025 = 4.37/5.04/3.39) had the strongest signal intensities. Haemorrhage, haemarthrosis, arthralgia, fall, and injection site pain were reported more frequently. CONCLUSION This study found that mild arthralgia and injection site reaction were associated with emicizumab. Attention should also be paid to other serious adverse events related to emicizumab, such as acute myocardial infarction and sepsis, to ensure patient safety.
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Affiliation(s)
- Lianhui Wei
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, 200433, China
| | - Ye Tian
- Dapartment of Anesthesiology, The Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiao Chen
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, 200433, China
| | - Xiaojing Guo
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, 200433, China
| | - Chenxin Chen
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, 200433, China
| | - Yi Zheng
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, 200433, China
| | - Jinfang Xu
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, 200433, China
| | - Xiaofei Ye
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, 200433, China.
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Gelbenegger G, Traby L, Rahimi N, Knöbl P. Management of acquired haemophilia A in severe Covid-19: Haemostatic bridging with emicizumab to keep the balance between bleeding and thrombosis. Br J Clin Pharmacol 2023; 89:908-913. [PMID: 36369653 PMCID: PMC9877795 DOI: 10.1111/bcp.15598] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/05/2022] [Accepted: 11/06/2022] [Indexed: 11/15/2022] Open
Abstract
Acquired haemophilia A (AHA) is an autoimmune bleeding disorder caused by autoantibodies blocking coagulation factor VIII (FVIII). Haemostatic management of AHA and concomitant thrombotic risk is difficult. We cover the management of a 75-year-old male with severe Covid-19, a prothrombotic disease, and de novo AHA with severe muscle bleeding, a disease requiring highly thrombogenic haemostatic therapy and immunosuppression-a challenging combination. FVIII activity was measured using human and bovine reagents to differentiate between endo- and exogenous FVIII activity. For haemostatic control, recombinant human activated FVII was given, followed by emicizumab, as a less thrombogenic long-term haemostatic agent. Steroids were used as initial immunosuppressive therapy. Later, rituximab was used for inhibitor eradication. No thromboembolic events occurred, and bleeding was effectively controlled. Emicizumab achieved haemostatic balance in a patient under haemorrhagic and thrombogenic conditions. Individual risk assessment is needed to guide treatment decisions in patients threatened by simultaneous bleeding and thrombosis.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical PharmacologyMedical University of ViennaViennaAustria
| | - Ludwig Traby
- Department of Medicine I, Division of Infectious Diseases and Tropical MedicineMedical University of ViennaViennaAustria
| | - Nina Rahimi
- Department of Medicine I, Division of Infectious Diseases and Tropical MedicineMedical University of ViennaViennaAustria
| | - Paul Knöbl
- Department of Medicine I, Division of Hematology and HemostasisMedical University of ViennaViennaAustria
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Acquired Hemophilia A: An Update on the Etiopathogenesis, Diagnosis, and Treatment. Diagnostics (Basel) 2023; 13:diagnostics13030420. [PMID: 36766524 PMCID: PMC9914651 DOI: 10.3390/diagnostics13030420] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/10/2023] [Accepted: 01/20/2023] [Indexed: 01/25/2023] Open
Abstract
Acquired haemophilia A (AHA) is a rare bleeding disorder caused by inhibitory autoantibodies against coagulation factor VIII (FVIII). AHA is a disease that most commonly affects the elderly but has also been observed in children and in the postpartum period. AHA is idiopathic in 50% of cases and is associated with autoimmune diseases, malignancies, and infections in the remaining 50%. Recently, cases of association between AHA, COVID-19 vaccination, and infection have been reported in the literature. For diagnoses, determining FVIII levels is crucial to distinguish the different causes of aPTT prolongation. Treatment of AHA is based on bypassing agents (recombinant factor VIIa, activated prothrombin complex concentrate) and porcine FVIII to control the bleeding and immunosuppressive therapy (corticosteroids, rituximab, cyclophosphamide) to suppress autoantibody production. It is important to start a prophylactic regimen to prevent further bleeding episodes until the inhibitor is negative. Recently, the series of cases reported in the literature suggest that emicizumab may provide effective and safe haemorrhage prophylaxis in the outpatient setting.
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Chen EC, Gibson W, Temoczko P, Connell NT, Handin R, Parnes AD. Emicizumab for the treatment of acquired hemophilia A: Retrospective review of a single-institution experience. Haemophilia 2023; 29:84-89. [PMID: 36163651 DOI: 10.1111/hae.14664] [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: 05/17/2022] [Revised: 08/15/2022] [Accepted: 09/06/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Acquired haemophilia A (AHA) is a rare and potentially life-threatening bleeding disorder arising from autoantibodies that inhibit coagulation factor VIII (FVIII). Treatment entails achieving haemostasis with bypassing agents or factor replacement, and eradication of the inhibitor with immunosuppressive therapy (IST). Due to the rarity of AHA, there are few prospective data to guide management. METHODS We present a retrospective report of 11 AHA patients treated with emicizumab, a FVIII-mimetic bispecific antibody, administered at 3 mg/kg weekly for 4 weeks in conjunction with rituximab-based immunosuppressive therapy. The chromogenic FVIII inhibitor assay was used to assess for inhibitor eradication. RESULTS The median follow-up was 13.9 months. The median number of days of additional haemostatic therapy or red blood cell transfusions after initiating emicizumab was 2 (range 0-15). The median was 0 days (range 0-8) for patients who did not require vascular embolization to achieve haemostasis. Eight patients achieved a complete remission (defined as recovery of FVIII activity to > 50% with a negative inhibitor test in the absence of haemostatic and IST); two patients achieved a partial remission (FVIII activity > 50% but with detectable inhibitor); one patient experienced refractory disease. One patient experienced rebleeding and two patients experienced inhibitor recurrence. No thrombotic, thrombotic microangiopathic or infectious complications occurred. CONCLUSION Our observations suggest emicizumab can facilitate haemostasis for AHA patients and be combined with safer, lower-intensity immunosuppressive therapies to achieve remission.
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Affiliation(s)
- Evan C Chen
- Dana Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - William Gibson
- Dana Farber Cancer Institute, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Paula Temoczko
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nathan T Connell
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Handin
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Aric D Parnes
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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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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45
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Lindahl R, Nummi V, Lehtinen A, Szanto T, Hiltunen L, Olsson A, Glenthoej A, Chaireti R, Vaide I, Funding E, Zetterberg E. Acquired Haemophilia A in four north European countries: survey of 181 patients. Br J Haematol 2022; 201:326-333. [PMID: 36541135 DOI: 10.1111/bjh.18611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
Acquired haemophilia A (AHA) is a rare bleeding disorder caused by acquired antibodies against coagulation factor VIII. In the Nordic countries, treatment and outcomes have not been studied in recent times. To collect retrospective data on patients diagnosed with AHA in the Nordic countries between 2006 and 2018 and compare demographic data and clinical outcomes with previously published reports, data were collected by six haemophilia centres: three Swedish, one Finnish, one Danish and one Estonian. The study included 181 patients. Median age at diagnosis was 76 (range 5-99) years, with even gender distribution. Type and severity of bleeding was comparable to that in the large European Acquired Haemophilia Registry study (EACH2). Bleedings were primarily treated with activated prothrombin complex concentrate (aPCC) with a high success rate (91%). For immunosuppressive therapy, corticosteroid monotherapy was used most frequently and this may be the cause of the overall lower clinical remission rate compared to the EACH2 study (57% vs. 72%). Survey data on 181 patients collected from four north European countries showed similar demographic and clinical features as in previous studies on AHA. aPCC was used more frequently than in the EACH2 study and the overall remission rate was lower.
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Affiliation(s)
- Rickard Lindahl
- Department of Haematology, Oncology and Radiation Physics, Coagulation Unit Skåne University Hospital Malmö and Lund University Lund Sweden
| | - Vuokko Nummi
- Coagulation Disorders Unit, Department of Haematology Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University Helsinki Finland
| | - Anna‐Elina Lehtinen
- Coagulation Disorders Unit, Department of Haematology Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University Helsinki Finland
| | - Timea Szanto
- Coagulation Disorders Unit, Department of Haematology Helsinki University Hospital Comprehensive Cancer Centre, Helsinki University Helsinki Finland
| | - Leena Hiltunen
- Department of Haemostasis Finnish Red Cross Blood Service Helsinki Finland
| | - Anna Olsson
- Department of Medicine Region Västra Götaland, Sahlgrenska University Hospital Gothenburg Sweden
| | - Andreas Glenthoej
- Department of Haematology Rigshospitalet Copenhagen Denmark
- Department of Clinical Medicine Copenhagen University Copenhagen Denmark
| | - Roza Chaireti
- Department of Haematology Karolinska University Hospital Stockholm Sweden
| | - Ines Vaide
- Department of Haematology and Oncology Institute of Clinical Medicine, University of Tartu Tartu Estonia
| | - Eva Funding
- Department of Haematology Rigshospitalet Copenhagen Denmark
- Department of Clinical Medicine Copenhagen University Copenhagen Denmark
| | - Eva Zetterberg
- Department of Haematology, Oncology and Radiation Physics, Coagulation Unit Skåne University Hospital Malmö and Lund University Lund Sweden
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46
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Lechtman S, Gilardin L, Taurel M, Jeandel P, Martis N. Emicizumab en traitement de sauvetage d’une hémophilie A acquise résistante au traitement conventionnel. Rev Med Interne 2022. [DOI: 10.1016/j.revmed.2022.10.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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47
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Mingot-Castellano ME, Rodríguez-Martorell FJ, Nuñez-Vázquez RJ, Marco P. Acquired Haemophilia A: A Review of What We Know. J Blood Med 2022; 13:691-710. [PMID: 36447782 PMCID: PMC9701517 DOI: 10.2147/jbm.s342077] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/10/2022] [Indexed: 08/31/2023] Open
Abstract
Autoantibodies against plasma coagulation factors could be developed by some individuals inducing severe and sometimes fatal bleedings. This clinical entity is called acquired haemophilia. It should be suspected in subjects with acute abnormal bleedings, without personal or familiar history of congenital bleeding disorders with an unexplained prolonged aPTT. It is rare disease, although its incidence may be underestimated due to the low knowledge about it by many specialists, the frequent use of anticoagulant or antiplatelet therapies in the affected population that can mask the diagnosis and, sometimes, a so withering effect that avoid its confirmation. Mortality ranges between 9% and 33% depending on the series in the first 2 months after diagnosis. This mortality is attributed in up to 40% of the cases to infections in the context of immunosuppressive treatments used to eliminate the inhibitor. Factor VIII levels below 1% and high inhibitor titers are conditions of worse response rates. Advanced age, patient's ECOG, and underlying conditions are key prognostic factors for response to treatment and patient survival. To reduce morbidity and mortality in these patients, it is important to have clinical knowledge and access to guidelines to achieve an early diagnosis and to optimize the haemostatic and immunosuppressive treatment. This review aims to contribute to the dissemination of basic concepts on the epidemiology etiopathogenesis, diagnosis, treatment and management of these patients, as well as risk factors to get remission and the longest overall survival to allow individualized care. Especial awareness will be proposed in patients with some underlying conditions like cancer, autoimmune diseases, children, pregnancy or drugs.
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Affiliation(s)
- María Eva Mingot-Castellano
- Hematology Department, Hospital Universitario Virgen del Rocío. Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | | | - Ramiro José Nuñez-Vázquez
- Hematology Department, Hospital Universitario Virgen del Rocío. Instituto de Biomedicina de Sevilla (IBIS), Sevilla, Spain
| | - Pascual Marco
- General Medicine Department, Universidad Miguel Hernández, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
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48
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Safer steps on a narrow path. Blood 2022; 140:1923-1924. [PMID: 36326794 DOI: 10.1182/blood.2022017947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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49
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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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50
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Abstract
PURPOSE OF REVIEW The particular fields within patient blood management (PBM) and patient safety reviewed here include novel insights into bleeding therapy, autologous cell salvage, and perioperative anemia therapy. RECENT FINDING World Health Organization has published that implementation of PBM is important but has not yet been performed in all hospitals. Two antibodies that mimic the function of FVIII, Emicizumab, and Mim8 have been developed. Tranexamic acid (TXA) has been investigated further in patients with hip surgery and shows reduction of bleeding. Thrombocytopenia in patients undergoing cardiac surgery is a particular concern that has been investigated in another trial. The use of autologous cell salvage was updated in form of a review and meta-analysis. And last but not least, intravenous iron in preoperative anemia therapy can reduce the number of transfusions, but especially iron carboxymaltose can cause hypophosphatemia. SUMMARY PBM should be further implemented in more hospitals. Emicizumab and Mim8 are indicated in acquired hemophilia or hemophilia A with inhibitors. TXA was confirmed to reduce bleeding. Autologous cell salvage is state of the art to reduce transfusion requirements in major cardiac and noncardiac surgery. Serum phosphate concentrations should be monitored after administration of intravenous iron compounds.
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