1
|
Rezende SM, Neumann I, Angchaisuksiri P, Awodu O, Boban A, Cuker A, Curtin JA, Fijnvandraat K, Gouw SC, Gualtierotti R, Makris M, Nahuelhual P, O'Connell N, Saxena R, Shima M, Wu R, Rosendaal FR. International Society on Thrombosis and Haemostasis clinical practice guideline for treatment of congenital hemophilia A and B based on the Grading of Recommendations Assessment, Development, and Evaluation methodology. J Thromb Haemost 2024; 22:2629-2652. [PMID: 39043543 DOI: 10.1016/j.jtha.2024.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 05/28/2024] [Accepted: 05/31/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Hemophilia is a rare congenital bleeding disorder that results from complete or partial deficiency of blood coagulation factor (F)VIII (hemophilia A) or FIX (hemophilia B) due to pathogenic variants in their coding genes. Hemophilia requires complex management. To date, there is no evidence-based clinical practice guideline on hemophilia treatment based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. OBJECTIVES This evidence-based clinical practice guideline from the International Society on Thrombosis and Haemostasis aims to provide an overview of evidence and support patients, caregivers, hematologists, pediatricians, other clinicians, researchers, and stakeholders in treatment decisions about congenital hemophilia A and B. METHODS The International Society on Thrombosis and Haemostasis formed a multidisciplinary guideline panel of physicians and patients with global representation, balanced to minimize potential bias from conflicts of interest. The panel prioritized a set of clinical questions and outcomes according to their importance for clinicians and patients. A methodological team supported the guideline development process, including searching for evidence and performing systematic reviews. The GRADE approach was used, including GRADE Evidence to Decision frameworks. The recommendations were subject to public comment. RESULTS The panel selected 13 questions, of which 11 addressed the treatment of hemophilia A and 2 the treatment of hemophilia B. Specifically, the panel addressed questions on prophylactic and episodic treatment with FVIII concentrates, bypassing agents, and nonfactor therapy (emicizumab) for hemophilia A (with and without inhibitors) as well as immune tolerance induction for hemophilia A. For hemophilia B, the panel addressed questions on prophylactic and episodic treatment of bleeding events with FIX concentrates. Agreement was reached for all 13 recommendations, of which 7 (54%) were based on evidence from randomized clinical trials, 3 (23%) on observational studies, and 3 (23%) on indirect comparisons. CONCLUSION Strong recommendations were issued for prophylactic over episodic treatment for severe and moderately severe hemophilia A and B. Only conditional recommendations were issued for the remaining questions. Future research should focus on direct treatment comparisons and the treatment of hemophilia B with and without inhibitors. Future updates of this guideline will provide an updated evidence synthesis on the current questions and focus on new FVIII and FIX concentrates, novel nonfactor therapies, and gene therapy for severe and nonsevere hemophilia A and B.
Collapse
Affiliation(s)
- Suely M Rezende
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Ignacio Neumann
- School of Medicine, Universidad San Sebastian, Santiago, Chile
| | - Pantep Angchaisuksiri
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Omolade Awodu
- Department of Hematology, School of Medicine, University of Benin, Benin City, Nigeria
| | - Ana Boban
- School of Medicine, University of Zagreb, Zagreb, Croatia; Department of Hematology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Julie A Curtin
- Department of Haematology, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Molecular Cellular Hemostasis, Sanquin Research and Landsteiner Laboratory, Amsterdam, the Netherlands
| | - Samantha C Gouw
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Molecular Cellular Hemostasis, Sanquin Research and Landsteiner Laboratory, Amsterdam, the Netherlands
| | - Roberta Gualtierotti
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy; Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michael Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Paula Nahuelhual
- Departamento de Evaluación de Tecnologías Sanitarias y Salud Basada en Evidencia, Ministerio de Salud, Santiago, Chile; Facultad de Medicina, Clínica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile
| | - Niamh O'Connell
- Department of Haematology, National Coagulation Centre, St. James's Hospital Dublin, Dublin, Ireland; Department of Haematology, School of Medicine, Trinity College, Dublin, Ireland
| | - Renu Saxena
- Department of Hematopathology, Medanta Hospital, Gurugram, India
| | - Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, Nara, Japan
| | - Runhui Wu
- Department of Hematology, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.
| |
Collapse
|
2
|
Dargaud Y, Leuci A, Ruiz AR, Lacroix-Desmazes S. Efanesoctocog alfa: the renaissance of Factor VIII replacement therapy. Haematologica 2024; 109:2436-2444. [PMID: 38356459 PMCID: PMC11290510 DOI: 10.3324/haematol.2023.284498] [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: 12/04/2023] [Accepted: 02/06/2024] [Indexed: 02/16/2024] Open
Abstract
Efanesoctocog alfa (Altuviiio,TM Sanofi-SOBI) is a B domain-deleted single-chain Factor VIII (FVIII) connected to D'D3 domain of von Willebrand Factor (vWF). Its ingenious design allows efanesoctocog alfa to operate independently of endogenous vWF and results in an outstanding 3-4 times longer half-life compared to standard and extended half-life (EHL) FVIII products. The prolonged half-life ensures sustained high levels of factor activity, maintaining normal to near-normal ranges for the majority of the week, facilitating the convenience of once-weekly administration. Efanesoctocog alfa received regulatory approval in 2023 for application in both adults and children with inherited hemophilia A in the United States and Japan. Its sanctioned use encompasses both prophylaxis and 'on demand' treatment for bleeding episodes. The European Medicines Agency (EMA) is currently undertaking a comprehensive review of Altuviiio. TM This comprehensive review focuses on the immunological profile of efanesoctocog alfa, a highly sophisticated new class of EHL FVIII molecule. The integration of the vWF D'D3 domain, XTEN polypeptides, and potential regulatory T-cell epitopes within various segments of efanesoctocog alfa collectively serves as a mitigating factor against the development of a neutralizing T-cell-mediated immune response. We hypothesize that such distinctive attribute may significantly reduce the risk of neutralizing antibodies, particularly in previously untreated patients. The discussion extends beyond regulatory approval to encompass the preclinical and clinical development of efanesoctocog alfa, including considerations for laboratory monitoring. The review also highlights areas that warrant further investigation to deepen our understanding of this groundbreaking therapeutic agent.
Collapse
Affiliation(s)
- Yesim Dargaud
- French Reference Center for Haemophilia, Clinical Haemostasis Unit, Hopital Louis Pradel, Lyon, France; UR4609 Research Unit on Haemostasis and Thrombosis, University Claude Bernard Lyon 1, Lyon.
| | - Alexandre Leuci
- UR4609 Research Unit on Haemostasis and Thrombosis, University Claude Bernard Lyon 1, Lyon
| | - Alejandra Reyes Ruiz
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université de Paris, F-75006 Paris
| | - Sebastien Lacroix-Desmazes
- Institut National de la Santé et de la Recherche Médicale, Centre de Recherche des Cordeliers, CNRS, Sorbonne Université, Université de Paris, F-75006 Paris
| |
Collapse
|
3
|
Han JH, Dupervil B, Mahajerin A, Kulkarni R, Manco-Johnson M, Thornburg C. Clinical and treatment characteristics of infants and toddlers less than 2 years of age with hemophilia. Blood Adv 2024; 8:2707-2717. [PMID: 38547443 PMCID: PMC11170200 DOI: 10.1182/bloodadvances.2023012486] [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: 12/21/2023] [Accepted: 03/20/2024] [Indexed: 05/31/2024] Open
Abstract
ABSTRACT Infants and toddlers (ITs) with hemophilia have unique bleeding features. Factor prophylaxis has been shown to decrease the risk of intracranial hemorrhage (ICH), which supports recommendations to begin at a young age. Clinical and demographic characteristics were analyzed for 883 ITs ≤2 years old with hemophilia A and B, seen at US Hemophilia Treatment Centers and enrolled in the Community Counts Registry, a surveillance program of the Centers for Disease Control and Prevention. ICH in the first 2 years of life was seen in 68 of 883 (7.7%) ITs, of whom 8 of 68 (11.8%) were on continuous prophylaxis at the time of ICH. ITs in this study usually started prophylaxis within the first year of life (mean, 10.3 months), with earlier ages of prophylaxis initiation in later birth cohorts in ITs with hemophilia A. Compared with those without a family history (FH) of hemophilia, known positive FH of hemophilia was associated with earlier age of diagnosis (P ≤ .0001) and decreased rates of vaginal delivery (P = .0006). The use of factor VIII mimetics and extended half-life clotting factor prophylaxis increased with later birth cohorts for ITs with hemophilia A and B. The study highlights that ICH rates in ITs with hemophilia remains substantial and underscores the need for further research to identify modifiable risk factors to prevent ICH by earlier diagnosis and initiating prophylaxis early, even within the first month of life.
Collapse
Affiliation(s)
| | - Brandi Dupervil
- Division of Blood Disorders and Public Health Genomics, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Roshni Kulkarni
- Center for Bleeding and Clotting Disorders, Department of Pediatrics and Human Development, Michigan State University, East Lansing, MI
| | - Marilyn Manco-Johnson
- Hemophilia & Thrombosis Center, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Courtney Thornburg
- Hemophilia & Thrombosis Treatment Center, Rady Children’s Hospital San Diego, San Diego, CA
- Department of Pediatrics, University of California Health Sciences, La Jolla, CA
| |
Collapse
|
4
|
Klukowska A, Sidonio RF, Young G, Mancuso ME, Álvarez-Román MT, Bhatnagar N, Jansen M, Knaub S. Simoctocog alfa (Nuwiq ®) in children: early steps in life's journey for people with severe hemophilia A. Ther Adv Hematol 2024; 15:20406207241245511. [PMID: 38737006 PMCID: PMC11085023 DOI: 10.1177/20406207241245511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/20/2024] [Indexed: 05/14/2024] Open
Abstract
People with severe hemophilia A usually experience their first bleed early in life. In children with severe hemophilia A, primary prophylaxis is recommended to prevent recurrent and potentially life-threatening bleeds that significantly impact day-to-day life. Factor VIII (FVIII) prophylaxis is well-established in children and has been shown to reduce the development of hemophilic arthropathy. However, a major challenge of FVIII therapy is the development of neutralizing anti-FVIII antibodies (FVIII inhibitors). Simoctocog alfa (Nuwiq®) is a human cell line-derived recombinant FVIII (rFVIII) whose immunogenicity, efficacy, and safety have been studied in 167 children with severe hemophilia A across two prospective clinical trials and their long-term extensions. In 105 previously untreated children, the inhibitor rate of 16.2% for high-titer inhibitors (26.7% for all inhibitors) was lower than published rates for hamster cell line-derived rFVIII products. There was no inhibitor development in previously untreated children with non-null F8 mutations and in previously treated children. In a case series of 10 inhibitor patients, 8 (80%) underwent successful immune tolerance induction with simoctocog alfa with a median time to undetectable inhibitor of 3.5 months. In an analysis of 96 children who enrolled in the extension studies and received long-term simoctocog alfa prophylaxis for up to 5 years, median spontaneous, joint, and total annualized bleeding rates were 0.3, 0.4, and 1.8, respectively. No thromboembolisms were reported in any of the 167 children, and there were no treatment-related deaths. Optimal care of children should consider several factors, including minimization of inhibitor development risk, maintaining tolerance to FVIII, highly effective bleed prevention and treatment, safety, and impact on long-term outcomes such as bone and joint health. In this context we review the pediatric clinical data and ongoing studies with simoctocog alfa.
Collapse
Affiliation(s)
- Anna Klukowska
- Haemostasis Group of the Polish Society of Haematology and Transfusiology, 14 Indira Gandhi Street, Warsaw 02-776, Poland
| | - Robert F. Sidonio
- Hemophilia of Georgia Center for Bleeding and Clotting Disorders, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Guy Young
- Hemostasis and Thrombosis Center, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Humanitas University, Pieve Emanuele, Italy
| | | | - Neha Bhatnagar
- Oxford Haemophilia and Thrombosis Comprehensive Care Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Martina Jansen
- Clinical Research and Development, Octapharma Pharmazeutika Produktionsges m.b.H., Vienna, Austria
| | - Sigurd Knaub
- Clinical Research and Development, Octapharma AG, Lachen, Switzerland
| |
Collapse
|
5
|
Fischer K, Lassila R, Peyvandi F, Gatt A, Gouw SC, Hollingsworth R, Lambert T, Kaczmarek R, Carbonero D, Makris M. Inhibitor development according to concentrate after 50 exposure days in severe hemophilia: data from the European HAemophilia Safety Surveillance (EUHASS). Res Pract Thromb Haemost 2024; 8:102461. [PMID: 39026659 PMCID: PMC11255940 DOI: 10.1016/j.rpth.2024.102461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/30/2024] [Accepted: 05/20/2024] [Indexed: 07/20/2024] Open
Abstract
Background Patients with hemophilia have a life-long risk of developing neutralizing antibodies (inhibitors) against clotting factor concentrates. After the first 50 exposure days (EDs), ie, in previously treated patients (PTPs), data on inhibitor development are limited. Objectives To report inhibitor development according to factor (F)VIII or FIX concentrate use in PTPs with severe hemophilia A and B. Methods Inhibitor development in PTPs was collected since 2008 from 97 centers participating in European HAemophilia Safety Surveillance. Per concentrate, inhibitors were reported quarterly and the number of PTPs treated annually. Incidence rates (IRs)/1000 treatment years with 95% CIs were compared between concentrate types (plasma derived FVIII/FIX, standard half-life recombinant FVIII/FIX, and extended half-life recombinant (EHL-rFVIII/IX) concentrates using IR ratios with CI. Medians and IQRs were calculated for inhibitor characteristics. Results For severe haemophilia A, inhibitor rate was 66/65,200 treatment years, IR 1.00/1000 years (CI 0.80-1.30), occurring at median 13.5 years (2.7-31.5) and 150 EDs (80-773). IR on plasma-derived pdFVIII (IR, 1.13) and standard half-life recombinant FVIII (IR, 1.12) were similar, whereas IR on EHL-rFVIII was lower at 0.13 (incidence rate ratio, 0.12; 95% CI, <0.01-0.70; P < .01).For severe hemophilia B, inhibitor rate was 5/11,160 treatment years and IR was 0.45/1000 years (95% CI, 0.15-1.04), at median 3.7 years (95% CI, 2.1-42.4) and 260 EDs (95% CI, 130 to >1000). Data were insufficient to compare by type of FIX concentrates. Conclusion Low inhibitor rates were observed for PTPs with severe hemophilia A and B. Data suggested reduced inhibitor development on EHL-rFVIII, but no significant difference between plasma-derived FVIII and standard half-life recombinant FVIII. FIX inhibitor rates were too low for robust statistical analysis.
Collapse
Affiliation(s)
- Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utretch, the Netherlands
| | - Riitta Lassila
- Coagulation Disorders Unit, Division of Hematology Department of Medicine, Helsinki University Central Hospital, Finland Wihuri Research Institute, Helsinki, Finland
| | - Flora Peyvandi
- Angelo Bianchi Bonomi, Hemophilia and Thrombosis Centre, Fondazione Istituto Candiolo Centro Oncologico d'Eccellenza, Ca’ Granda Ospedale Maggiore Policlinico, Milan Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Samantha C. Gouw
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Public Health, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | | | - Thierry Lambert
- Reference Center for hemophilia and rare bleeding disorders, Hôpital Bicêtre, APHP, Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Radek Kaczmarek
- Coagulation Products Safety Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada
- Wells Center for pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Diana Carbonero
- European Association for Haemophilia and Allied Disorders, Brussels, Belgium
| | - Mike Makris
- School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| |
Collapse
|
6
|
Meeks SL, Zimowski KL. Haemophilia in the era of novel therapies: Where do inhibitors feature in the new landscape? Haemophilia 2024; 30 Suppl 3:95-102. [PMID: 38539060 DOI: 10.1111/hae.14982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION The advent of therapeutic recombinant factor VIII (FVIII) and factor IX (FIX) protein infusions revolutionized the care of persons with haemophilia in the 1990s. It kicked off an era with the increasing use of prophylactic factor infusions for patients and transformed conversations around the ideal trough activity levels as well as the ultimate goals in tailored, individualized care. Our knowledge surrounding the immunologic basis of inhibitor development and treatment derives from a time when patients were receiving frequent factor infusions and focused on immune tolerance induction following inhibitor development. DISCUSSION More recently, care was revolutionized again in haemophilia A with the approval of emicizumab, a bispecific antibody mimicking activated FVIII function, to prevent bleeding. The use of emicizumab prophylaxis has resulted in a significantly slower accumulation of factor exposure days and continued effective prophylaxis in the case of inhibitor development. While emicizumab is effective at reducing the frequency of bleeding events in patients with haemophilia A, management of breakthrough bleeds, trauma, and surgeries still requires additional treatment. Ensuring that FVIII is a therapeutic option, particularly for life-threatening bleeding events and major surgeries is critical to optimizing the care of persons with haemophilia A. Other novel non-factor concentrate therapies, including rebalancing agents, will dramatically change the landscape for persons with haemophilia B with inhibitors. CONCLUSION This review discusses the changing landscape regarding the timing of inhibitor development and management strategies after inhibitor development, stressing the importance of education across the community to continue to vigilantly monitor for inhibitors and be prepared to treat persons with inhibitors.
Collapse
Affiliation(s)
- Shannon L Meeks
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Karen L Zimowski
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| |
Collapse
|
7
|
Carcao M, Schiavulli M, Kulkarni R, Rendo P, Foster M, Santagostino E, Casiano S, Königs C. A post hoc analysis of previously untreated patients with severe hemophilia A who developed inhibitors in the PUPs A-LONG trial. Blood Adv 2024; 8:1494-1503. [PMID: 38266154 PMCID: PMC10951906 DOI: 10.1182/bloodadvances.2023011475] [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: 08/17/2023] [Revised: 01/10/2024] [Accepted: 01/14/2024] [Indexed: 01/26/2024] Open
Abstract
ABSTRACT Inhibitor development is a major therapeutic complication for people with hemophilia. The phase 3 PUPs A-LONG study evaluated the safety and efficacy of efmoroctocog alfa (a recombinant factor VIII Fc fusion protein, herein referred to as rFVIIIFc) in previously untreated patients (PUPs) with severe hemophilia A. Male PUPs <6 years old were enrolled and received rFVIIIFc; inhibitor development was the primary end point. Post hoc analyses, including patient treatment regimen patterns and timing of inhibitor development, descriptive and Kaplan-Meier analyses of time to first inhibitor-positive test by treatment regimen and by titer, and consumption, were performed to describe patients who developed inhibitors during PUPs A-LONG. We investigated patient characteristics (eg, demographics and genotype) and nongenetic risk factors (eg, intense factor exposure and central venous access device [CVAD] placement) that may predict inhibitor development and characteristics of inhibitor development (low-titer vs high-titer inhibitor). Baseline characteristics were similarly distributed for age, race, and ethnicity across both patients who were inhibitor-positive and those who were inhibitor-negative (all P > .05). High-risk F8 variants were associated with development of high-titer inhibitors (P = .028). High-titer inhibitor development was often preceded by the presence of a low-titer inhibitor. Patients whose low-titer inhibitor progressed to a high-titer inhibitor received a higher mean dose per infusion (98.4 IU/kg, n = 5) compared with those whose low-titer inhibitor resolved spontaneously (59.2 IU/kg, n = 7; P = .033) or persisted (45.0 IU/kg, n = 5; P = .047). There was no association between CVAD placement surgery and inhibitor development. Post hoc analyses suggest that F8 genotype and dose of factor are as important as inhibitor risk factors and require further investigation. This study was registered at ClinicalTrials.gov as #NCT02234323.
Collapse
Affiliation(s)
- Manuel Carcao
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | | | - Christoph Königs
- University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| |
Collapse
|
8
|
Abdelgawad HAH, Foster R, Otto M. Nothing short of a revolution: Novel extended half-life factor VIII replacement products and non-replacement agents reshape the treatment landscape in hemophilia A. Blood Rev 2024; 64:101164. [PMID: 38216442 DOI: 10.1016/j.blre.2023.101164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/14/2024]
Abstract
Hemophilia A, an X-linked genetic disorder, is characterized by a deficiency or dysfunction of clotting Factor VIII. The treatment landscape has substantially changed by introducing novel extended half-life factor VIII (EHL-FVIII) replacement therapies such as efanesoctocog Alfa and non-factor replacement therapy such as emicizumab. These agents signal a shift from treatments requiring multiple weekly infusions to advanced therapies with long half-lives, offering superior protection against bleeding and improving patient adherence and quality of life. While EHL-FVIII treatment might lead to inhibitor development in some patients, non-factor replacement therapy carries thrombotic risks. Therefore, ongoing research and the generation of robust clinical evidence remain vital to guide the selection of optimal and cost-effective first-line therapies for hemophilia A patients.
Collapse
Affiliation(s)
- Hussien Ahmed H Abdelgawad
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA; Department of Child Health, University of Arizona College of Medicine, Phoenix, AZ, USA.
| | - Rachel Foster
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Mario Otto
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA; Department of Child Health, University of Arizona College of Medicine, Phoenix, AZ, USA.
| |
Collapse
|
9
|
Valentino LA, Ozelo MC, Herzog RW, Key NS, Pishko AM, Ragni MV, Samelson-Jones BJ, Lillicrap D. A review of the rationale for gene therapy for hemophilia A with inhibitors: one-shot tolerance and treatment? J Thromb Haemost 2023; 21:3033-3044. [PMID: 37225021 DOI: 10.1016/j.jtha.2023.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/09/2023] [Accepted: 05/14/2023] [Indexed: 05/26/2023]
Abstract
The therapeutic landscape for people living with hemophilia A (PwHA) has changed dramatically in recent years, but many clinical challenges remain, including the development of inhibitory antibodies directed against factor VIII (FVIII) that occur in approximately 30% of people with severe hemophilia A. Emicizumab, an FVIII mimetic bispecific monoclonal antibody, provides safe and effective bleeding prophylaxis for many PwHA, but clinicians still explore therapeutic strategies that result in immunologic tolerance to FVIII to enable effective treatment with FVIII for problematic bleeding events. This immune tolerance induction (ITI) to FVIII is typically accomplished through repeated long-term exposure to FVIII using a variety of protocols. Meanwhile, gene therapy has recently emerged as a novel ITI option that provides an intrinsic, consistent source of FVIII. As gene therapy and other therapies now expand therapeutic options for PwHA, we review the persistent unmet medical needs with respect to FVIII inhibitors and effective ITI in PwHA, the immunology of FVIII tolerization, the latest research on tolerization strategies, and the role of liver-directed gene therapy to mediate FVIII ITI.
Collapse
Affiliation(s)
- Leonard A Valentino
- National Hemophilia Foundation, New York, New York, USA; Rush University, Chicago, Illinois, USA.
| | | | - Roland W Herzog
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nigel S Key
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | | | | | | | | |
Collapse
|
10
|
Kenet G, Young G, Chuansumrit A, Matsushita T, Yadav V, Zak M, Male C. The immunogenicity, safety, and efficacy of N8-GP in previously untreated patients with severe hemophilia A: pathfinder6 end-of-trial results. J Thromb Haemost 2023; 21:3109-3116. [PMID: 37597724 DOI: 10.1016/j.jtha.2023.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/05/2023] [Accepted: 07/06/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND The pathfinder6 (NCT02137850) international phase 3 trial examined immunogenicity, safety, and efficacy of the extended half-life factor VIII (FVIII) replacement product N8-GP (turoctocog alfa pegol; Esperoct) in previously untreated patients (PUPs) with hemophilia A. OBJECTIVES We present end-of trial results for extended PUP N8-GP treatment for up to a median (range) 2.5 (0.0; 7.4) years. PATIENTS/METHODS Longer-term N8-GP treatment in PUPs with hemophilia A was examined. The prophylaxis regimen was ∼60 IU/kg N8-GP i.v. twice weekly, or every 3 or 7 days. The primary endpoint was the incidence of FVIII inhibitors. RESULTS Overall, 81 patients received N8-GP and were included in this analysis. The inhibitor incidence was 30.0% (15.7% high-titer [>5 BU]) for the extension phase. Patients had a median (range) 2.9 (0.1; 7.2) years of prophylaxis following the pre-prophylaxis period. During prophylaxis, the median annualized bleeding rate (ABR) (interquartile range) was 1.4 (0.6; 3.5), 13% of patients experienced no bleeding episodes, and 55.1% of patients experienced no spontaneous bleeds. The proportion of patients without any spontaneous bleeding episodes increased after the first year of prophylaxis. The hemostatic success rate in the treatment of bleeding episodes was 87.6%. No additional safety concerns were observed in patients with previously reported observation of temporarily decreased incremental recovery (IR). CONCLUSION Long-term end-of-trial PUP N8-GP prophylaxis data indicate that PUPs respond well to long-term N8-GP treatment. The inhibitor incidence was consistent with previous results. Median ABR during prophylaxis was 1.4. There were no lasting clinical impacts or safety concerns for patients with an observation of temporarily decreased IR.
Collapse
Affiliation(s)
- Gili Kenet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel; The Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel.
| | - Guy Young
- Children's Hospital Los Angeles/University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Ampaiwan Chuansumrit
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Vandana Yadav
- Novo Nordisk Service Centre India Private Ltd, Bangalore, India
| | | | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Austria
| |
Collapse
|
11
|
Sherman A, Bertolini TB, Arisa S, Herzog RW, Kaczmarek R. Factor IX administration in the skin primes inhibitor formation and sensitizes hemophilia B mice to systemic factor IX administration. Res Pract Thromb Haemost 2023; 7:102248. [PMID: 38193070 PMCID: PMC10772885 DOI: 10.1016/j.rpth.2023.102248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/02/2023] [Accepted: 10/23/2023] [Indexed: 01/10/2024] Open
Abstract
Background Factor IX inhibitor formation is the most serious complication of replacement therapy for the bleeding disorder hemophilia B, exacerbated by severe allergic reactions occurring in up to 60% of patients with inhibitors. Low success rates of immune tolerance induction therapy in hemophilia B necessitate the search for novel immune tolerance therapies. Skin-associated lymphoid tissues have been successfully targeted in allergen-specific immunotherapy. Objectives We aimed to develop a prophylactic immune tolerance protocol based on intradermal administration of FIX that would prevent inhibitor formation and/or anaphylaxis in response to replacement therapy. Methods We measured FIX inhibitor, anti-FIX immunoglobulin G1, and immunoglobulin E titers using the Bethesda assay and enzyme-linked immunosorbent assay after 4 weeks of twice-weekly intradermal FIX or FIX-Fc administration followed by 5 to 6 weeks of weekly systemic FIX injections in C3H/HeJ hemophilia B mice. We also measured skin antigen-presenting, follicular helper T, and germinal center B cell frequencies in skin-draining lymph nodes after a single or repeat intradermal FIX administration. Results Intradermal administration enhanced FIX inhibitor formation in response to systemic administration. We further found that intradermal administration alone triggers inhibitor formation, even at a low dose of 0.4 IU/kg, which is 100-fold lower than the intravenous dose of 40 IU/kg typically required to induce inhibitor development in hemophilia B mice. Also, intradermal administration triggered germinal center formation in skin-draining lymph nodes and sensitized mice to systemic administration. Factor IX-Fc fusion protein did not modulate inhibitor formation. Conclusion Intradermal FIX administration is highly immunogenic, suggesting that the skin compartment is not amenable to immune tolerance induction or therapeutic delivery of clotting factors.
Collapse
Affiliation(s)
- Alexandra Sherman
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Thais B. Bertolini
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sreevani Arisa
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Roland W. Herzog
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Radoslaw Kaczmarek
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
12
|
Mathias M, Abraham A, Belletrutti MJ, Carcao M, Carvalho M, Chambost H, Chan AKC, Dubey L, Ducore J, Gattens M, Gresele P, Gruel Y, Guillet B, Jiménez-Yuste V, Kitanovski L, Klukowska A, Lohade S, Mancuso ME, Oldenburg J, Pollio B, Sigaud M, Vilchevska K, Wu JKM, Jansen M, Belyanskaya L, Walter O, Knaub S, Neufeld EJ. Simoctocog alfa (Nuwiq®) in previously untreated patients with severe haemophilia A-Final efficacy and safety results from the NuProtect study. Eur J Haematol 2023; 111:544-552. [PMID: 37439123 DOI: 10.1111/ejh.14040] [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: 03/17/2023] [Revised: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 07/14/2023]
Abstract
INTRODUCTION Simoctocog alfa (Nuwiq®) is a 4th generation recombinant FVIII with proven efficacy for the prevention and treatment of bleeding episodes (BEs) in previously treated patients with severe haemophilia A. The NuProtect study assessed the immunogenicity, efficacy and safety of simoctocog alfa in 108 previously untreated patients (PUPs). The incidence of high-titre inhibitors was 16.2% and no patients with non-null F8 mutations developed inhibitors. AIM To report the efficacy and safety results from the NuProtect study. METHODS PUPs received simoctocog alfa for prophylaxis, treatment of BEs, or as surgical prophylaxis. The efficacy of prophylaxis (during inhibitor-free periods) was assessed using annualised bleeding rates (ABRs). The efficacy in treating BEs and in surgical prophylaxis was assessed using a 4-point scale. Adverse events were recorded throughout the study. RESULTS Of 108 PUPs treated with simoctocog alfa, 103 received at least one prophylactic dose and 50 received continuous prophylaxis for at least 24 weeks. In patients on continuous prophylaxis, the median ABR was 0 (mean 0.5) for spontaneous BEs and 2.5 (mean 3.6) for all BEs. In 85 patients who had BEs, efficacy of BE treatment was excellent or good for 92.9% (747/804) of rated BEs; 92.3% of BEs were treated with 1 or 2 infusions. The efficacy of surgical prophylaxis was excellent or good for 94.7% (18/19) of rated procedures. There were no safety concerns and no thromboembolic events. CONCLUSION Simoctocog alfa was efficacious and well tolerated as prophylaxis, surgical prophylaxis and for the treatment of BEs in PUPs with severe haemophilia A.
Collapse
Affiliation(s)
- Mary Mathias
- Haemophilia Comprehensive Care Centre, Great Ormond Street Hospital for Children NHS Trust Haemophilia Centre, NIHR GOSH BRC, London, UK
| | - Aby Abraham
- Department of Hematology, Christian Medical College, Vellore, India
| | - Mark J Belletrutti
- Department of Pediatrics, Division of Hematology/Oncology/BMT, University of British Columbia and British Columbia Children's Hospital, Vancouver, Canada
| | - Manuel Carcao
- Department of Paediatrics, Division of Haematology/Oncology and Child Health Evaluative Sciences, Research Institute Hospital for Sick Children, Toronto, Canada
| | - Manuela Carvalho
- Congenital Coagulopathies Reference Centre, São João University Hospital Centre, Porto, Portugal
| | - Hervé Chambost
- AP-HM, Department of Pediatric Hematology Oncology, Children Hospital La Timone, Aix Marseille Univ INSERM, INRA, C2VN, Marseille, France
| | - Anthony K C Chan
- Department of Pediatrics, McMaster Centre of Transfusion Research, McMaster University, Hamilton, Canada
| | - Leonid Dubey
- Department of Paediatrics, Western Ukrainian Specialized Children's Medical Centre, Lviv, Ukraine
| | - Jonathan Ducore
- Department of Pediatrics, University of California Davis Medical Center, Sacramento, California, USA
| | - Michael Gattens
- Department of Paediatric Haematology and Oncology, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Paolo Gresele
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Yves Gruel
- Centre Régional de Traitement de l'Hémophilie, Hôpital Trousseau, Tours, France
| | - Benoit Guillet
- Haemophilia Treatment Centre, Univ Rennes, CHU Rennes, INSERM, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France
| | - Victor Jiménez-Yuste
- Servicio de Hematología, Hospital Univeristario La Paz, Autónoma, University of Madrid, Madrid, Spain
| | - Lidija Kitanovski
- Department of Haematooncology, Division of Paediatrics, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Anna Klukowska
- Haemostasis Group of the Polish Society of Haematology and Transfusiology, Warsaw, Poland
| | - Sunil Lohade
- Department of Hematology, Sahyadri Speciality Hospital, Pune, India
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Berardino Pollio
- Regional Reference Centre for Inherited Bleeding and Thrombotic Disorders, Regina Margherita Children Hospital, Turin, Italy
| | - Marianne Sigaud
- Centre Régional de Traitement de I'Hémophilie, University Hospital of Nantes, Nantes, France
| | - Kateryna Vilchevska
- Department of Hematology, OHMATDYT - National Specialized Children's Hospital, Kiev, Ukraine
| | - John K M Wu
- Department of Pediatrics, Division of Hematology/Oncology/BMT, University of British Columbia and British Columbia Children's Hospital, Vancouver, Canada
| | - Martina Jansen
- Octapharma Pharmazeutika Produktionsges m.b.H, Vienna, Austria
| | | | | | | | - Ellis J Neufeld
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| |
Collapse
|
13
|
Nguyen NH, Jarvi NL, Balu-Iyer SV. Immunogenicity of Therapeutic Biological Modalities - Lessons from Hemophilia A Therapies. J Pharm Sci 2023; 112:2347-2370. [PMID: 37220828 DOI: 10.1016/j.xphs.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 05/25/2023]
Abstract
The introduction and development of biologics such as therapeutic proteins, gene-, and cell-based therapy have revolutionized the scope of treatment for many diseases. However, a significant portion of the patients develop unwanted immune reactions against these novel biological modalities, referred to as immunogenicity, and no longer benefit from the treatments. In the current review, using Hemophilia A (HA) therapy as an example, we will discuss the immunogenicity issue of multiple biological modalities. Currently, the number of therapeutic modalities that are approved or recently explored to treat HA, a hereditary bleeding disorder, is increasing rapidly. These include, but are not limited to, recombinant factor VIII proteins, PEGylated FVIII, FVIII Fc fusion protein, bispecific monoclonal antibodies, gene replacement therapy, gene editing therapy, and cell-based therapy. They offer the patients a broader range of more advanced and effective treatment options, yet immunogenicity remains the most critical complication in the management of this disorder. Recent advances in strategies to manage and mitigate immunogenicity will also be reviewed.
Collapse
Affiliation(s)
- Nhan H Nguyen
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA; Currently at Truvai Biosciences, Buffalo, NY, USA
| | - Nicole L Jarvi
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Sathy V Balu-Iyer
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.
| |
Collapse
|
14
|
Konkle BA, Oldenburg J, Pasi J, Kulkarni R, Nolan B, Mahlangu J, Young G, Brown SA, Pabinger I, Shapiro A, Négrier C, Blanchette V, Ragni MV, Dumont J, Lethagen S. Prophylaxis with a recombinant factor VIII Fc in hemophilia A: long-term follow-up on joint health, efficacy, and safety from phase 3 studies in children and adults. Res Pract Thromb Haemost 2023; 7:102180. [PMID: 37753224 PMCID: PMC10518483 DOI: 10.1016/j.rpth.2023.102180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 06/28/2023] [Accepted: 07/13/2023] [Indexed: 09/28/2023] Open
Abstract
Background Recurrent joint bleeds are a major cause of morbidity in severe hemophilia. Prophylaxis with efmoroctocog alfa (a recombinant factor VIII Fc fusion protein, [rFVIIIFc]) has demonstrated benefits beyond bleed control, including joint health maintenance. Objectives To assess long-term efficacy and safety of rFVIIIFc prophylaxis in severe hemophilia A in phase 3 pivotal (A-LONG/Kids A-LONG) and extension (ASPIRE) studies. Methods Longitudinal analysis included pooled data from A-LONG/Kids A-LONG and ASPIRE. Subgroup analyses investigated outcomes in modified Hemophilia Joint Health Score or Hemophilia Joint Health Score and target joints in subjects with 4 to 5 years follow-up on individualized prophylaxis (IP), and those with the highest annualized bleeding rate (ABR) quartile during Year 1 of IP. Results Overall, rFVIIIFc consumption remained stable and low ABRs were maintained, with a median treatment duration of 4.2/3.4 years in subjects from A-LONG/Kids A-LONG, respectively. Median overall ABR also remained low (1.0-2.0) in subjects on IP for 4 to 5 years. Sustained improvements in modified Hemophilia Joint Health Score or Hemophilia Joint Health Score were demonstrated over a median follow-up of 3.7 years. In subjects from A-LONG/Kids A-LONG, 99.6% (n = 234)/100% (n = 9) of evaluable baseline target joints were resolved, with no recurrence in 95%/100% of target joints. In IP subjects within the highest ABR quartile in Year 1, continued improvements were observed over a median follow-up of 4.3 years in ABR and joint health, without increased factor consumption. No inhibitors or treatment-related serious adverse events were reported. Conclusion Previously treated subjects of all ages receiving long-term prophylaxis with rFVIIIFc had sustained clinical benefits, including improved joint health and low ABR.
Collapse
Affiliation(s)
- Barbara A. Konkle
- Washington Center for Bleeding Disorders, Seattle, Washington, USA
- Division of Hematology, University of Washington, Seattle, Washington, USA
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine University Clinic Bonn, Bonn, Germany
| | - John Pasi
- Royal London Haemophilia Centre, Barts and the London School of Medicine and Dentistry, London, UK
| | - Roshni Kulkarni
- Department of Pediatrics and Human Development, Michigan State University, East Lansing, Michigan, USA
| | | | - Johnny Mahlangu
- Hemophilia Comprehensive Care Centre, Department of Molecular Medicine and Hematology, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | - Guy Young
- Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Simon A. Brown
- Queensland Children’s Hospital, Brisbane, QLD, Australia
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Amy Shapiro
- Indiana Hemophilia & Thrombosis Center, Indianapolis, Indiana, USA
| | - Claude Négrier
- Division of Hematology, University Claude Bernard Lyon I, Lyon, France
| | - Victor Blanchette
- Department of Pediatrics and Child Health Evaluative Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Margaret V. Ragni
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Stefan Lethagen
- Swedish Orphan Biovitrum AB, Stockholm, Sweden
- Copenhagen University, Copenhagen, Denmark
| |
Collapse
|
15
|
Mathias M, Abashidze M, Abraham A, Belletrutti MJ, Carcao M, Chambost H, Chan AKC, Dubey L, Ducore J, Lambert T, Kavardakova N, Lohade S, Turea V, Wu JKM, Klukowska A. Long-term immunogenicity, efficacy and tolerability of simoctocog alfa in patients with severe haemophilia A who had completed the NuProtect study in previously untreated patients. Haemophilia 2023. [PMID: 37335546 DOI: 10.1111/hae.14796] [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: 02/03/2023] [Revised: 04/13/2023] [Accepted: 04/29/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND The NuProtect study reported data on the immunogenicity, efficacy and tolerability of simoctocog alfa (Nuwiq® ) in 108 previously untreated patients with severe haemophilia A planned to be treated for ≥100 exposure days or up to 5 years. The NuProtect-Extension study collected long-term prophylaxis data in children with severe haemophilia A. METHODS Patients who completed the NuProtect study according to the protocol were eligible for the NuProtect-Extension study, a prospective, multinational, non-controlled, Phase 3b study. RESULTS Of 48 patients who entered the extension study, 47 (median age 2.8 years) received prophylaxis with simoctocog alfa for a median of 24 months, with 82%-88% on a twice-weekly or less regimen. No patient developed FVIII inhibitors during the extension study. The median (IQR) annualized bleeding rate (ABR) during prophylaxis was 0 (0-0.5) for spontaneous bleeding episodes (BEs) and 1.00 (0-1.95) for all BEs. ABRs estimated using a negative binomial model were .28 (95% CI: .15, .53) for spontaneous and 1.62 (95% CI: 1.09, 2.42) for all BEs. During the median follow-up of 24 months, 34 (72%) patients had zero spontaneous BEs and 46 (98%) had zero spontaneous joint BEs. Efficacy in treating BEs was excellent or good for 78.2% of rated BEs, and efficacy of surgical prophylaxis was excellent for two rated surgeries. No treatment-related adverse events were reported. CONCLUSION No FVIII inhibitors developed during long-term prophylaxis in the NuProtect-Extension study. Prophylaxis with simoctocog alfa was efficacious and well-tolerated, and is therefore an attractive long-term option for children with severe haemophilia A.
Collapse
Affiliation(s)
- Mary Mathias
- Haemophilia Comprehensive Care Centre, Great Ormond Street Hospital for Children NHS Foundation Trust, NIHR GOSH BRC, London, UK
| | - Marina Abashidze
- JSC Institute of Haematology and Transfusiology, Tbilisi, Georgia
| | - Aby Abraham
- Department of Hematology, Christian Medical College, Vellore, India
| | - Mark J Belletrutti
- Department of Pediatrics, Division of Hematology/Oncology/BMT, University of British Columbia and British Columbia Children's Hospital, Vancouver, Canada
| | - Manuel Carcao
- Department of Paediatrics, Division of Haematology/Oncology and Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Hervé Chambost
- Department of Pediatric Hematology Oncology, Children Hospital La Timone, APHM and Inserm, UMR 1062, Aix Marseille University, Marseille, France
| | - Anthony K C Chan
- Department of Pediatrics, McMaster Centre of Transfusion Research, McMaster University, Hamilton, ON, Canada
| | - Leonid Dubey
- Department of Pediatrics, Western Ukrainian Specialized Children's Medical Centre, Lviv, Ukraine
| | - Jonathan Ducore
- Department of Pediatrics, University of California Davis Medical Center, Sacramento, USA
| | - Thierry Lambert
- Centre de Référence pour le Traitement des Hémophiles, Hôpital Universitaire Bicêtre APHP, Le Kremlin Bicêtre, France
| | | | - Sunil Lohade
- Department of Hematology, Sahyadri Speciality Hospital, Pune, India
| | - Valentin Turea
- Scientific Research Institute of Mother and Child Health Care, Chişinău, Moldova
| | - John K M Wu
- Department of Pediatrics, Division of Hematology/Oncology/BMT, University of British Columbia and British Columbia Children's Hospital, Vancouver, Canada
| | - Anna Klukowska
- Haemostasis Group of the Polish Society of Haematology and Transfusiology, Warsaw, Poland
| |
Collapse
|
16
|
Ji Y, Liu D, Zhu H, Bao L, Chang R, Gao X, Yin J. Unstructured Polypeptides as a Versatile Drug Delivery Technology. Acta Biomater 2023; 164:74-93. [PMID: 37075961 DOI: 10.1016/j.actbio.2023.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/23/2023] [Accepted: 04/13/2023] [Indexed: 04/21/2023]
Abstract
Although polyethylene glycol (PEG), or "PEGylation" has become a widely applied approach for improving the efficiency of drug delivery, the immunogenicity and non-biodegradability of this synthetic polymer have prompted an evident need for alternatives. To overcome these caveats and to mimic PEG -or other natural or synthetic polymers- for the purpose of drug half-life extension, unstructured polypeptides are designed. Due to their tunable length, biodegradability, low immunogenicity and easy production, unstructured polypeptides have the potential to replace PEG as the preferred technology for therapeutic protein/peptide delivery. This review provides an overview of the evolution of unstructured polypeptides, starting from natural polypeptides to engineered polypeptides and discusses their characteristics. Then, it is described that unstructured polypeptides have been successfully applied to numerous drugs, including peptides, proteins, antibody fragments, and nanocarriers, for half-life extension. Innovative applications of unstructured peptides as releasable masks, multimolecular adaptors and intracellular delivery carriers are also discussed. Finally, challenges and future perspectives of this promising field are briefly presented. STATEMENT OF SIGNIFICANCE: : Polypeptide fusion technology simulating PEGylation has become an important topic for the development of long-circulating peptide or protein drugs without reduced activity, complex processes, and kidney injury caused by PEG modification. Here we provide a detailed and in-depth review of the recent advances in unstructured polypeptides. In addition to the application of enhanced pharmacokinetic performance, emphasis is placed on polypeptides as scaffolders for the delivery of multiple drugs, and on the preparation of reasonably designed polypeptides to manipulate the performance of proteins and peptides. This review will provide insight into future application of polypeptides in peptide or protein drug development and the design of novel functional polypeptides.
Collapse
Affiliation(s)
- Yue Ji
- Jiangsu Key Laboratory of Druggability of Biopharmaceuticals and State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing 210009, China
| | - Dingkang Liu
- Jiangsu Key Laboratory of Druggability of Biopharmaceuticals and State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing 210009, China
| | - Haichao Zhu
- Jiangsu Key Laboratory of Druggability of Biopharmaceuticals and State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing 210009, China
| | - Lichen Bao
- Jiangsu Key Laboratory of Neurodegeneration, Nanjing Medical University, Nanjing 210009, China
| | - Ruilong Chang
- Jiangsu Key Laboratory of Druggability of Biopharmaceuticals and State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing 210009, China
| | - Xiangdong Gao
- Jiangsu Key Laboratory of Druggability of Biopharmaceuticals and State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing 210009, China.
| | - Jun Yin
- Jiangsu Key Laboratory of Druggability of Biopharmaceuticals and State Key Laboratory of Natural Medicines, School of Life Science and Technology, China Pharmaceutical University, Nanjing 210009, China.
| |
Collapse
|
17
|
Astermark J, Blatný J, Königs C, Hermans C, Jiménez-Yuste V, Hart DP. Considerations for shared decision management in previously untreated patients with hemophilia A or B. Ther Adv Hematol 2023; 14:20406207231165857. [PMID: 37113810 PMCID: PMC10126613 DOI: 10.1177/20406207231165857] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 01/04/2023] [Indexed: 04/29/2023] Open
Abstract
Recent advances in therapeutics are now providing a wide range of options for adults and children living with hemophilia. Although therapeutic choices are also increasing for the youngest individuals with severe disease, challenges remain about early management decisions, as supporting data are currently limited. Parents and healthcare professionals are tasked with helping children achieve an inclusive quality of life and maintain good joint health into adulthood. Primary prophylaxis is the gold standard to optimize outcomes and is recommended to start before 2 years of age. A range of topics need to be discussed with parents to aid their understanding of the decisions they can make and how these will affect the management of their child/children. For those with a family history of hemophilia, prenatal considerations include the possibility of genetic counseling, prenatal investigations, and planning for delivery, together with monitoring of the mother and neonate, as well as diagnosis of the newborn and treatment of any birth-associated bleeding. Subsequent considerations, which are also applicable to families where infant bleeding has resulted in a new diagnosis of sporadic hemophilia, involve explaining bleed recognition and treatment options, practical aspects of initiating/continuing prophylaxis, dealing with bleeds, and ongoing aspects of treatment, including possible inhibitor development. Over time, optimizing treatment efficacy, in which individualizing therapy around activities can play a role, and long-term considerations, including retaining joint health and tolerance maintenance, become increasingly important. The evolving treatment landscape is creating a need for continually updated guidance. Multidisciplinary teams and peers from patient organizations can help provide relevant information. Easily accessible, multidisciplinary comprehensive care remains a foundation to care. Equipping parents early with the knowledge to facilitate truly informed decision-making will help achieve the best possible longer-term health equity and quality of life for the child and family living with hemophilia. Plain language summary Points to be taken into account to help families make decisions to best care for children born with hemophilia Medical advances are providing a range of treatment options for adults and children with hemophilia. There is, however, relatively limited information about managing newborns with the condition. Doctors and nurses can help parents to understand the choices for infants born with hemophilia. We describe the various points doctors and nurses should ideally discuss with families to enable informed decision-making. We focus on infants who require early treatment to prevent spontaneous or traumatic bleeding (prophylaxis), which is recommended to start before 2 years of age. Families with a history of hemophilia may benefit from discussions before pregnancy, including how an affected child would be treated to protect against bleeds. When mothers are pregnant, doctors can explain investigations that can provide information about their unborn child, plan for the birth, and monitor mother and baby to minimize bleed risks at delivery. Testing will confirm whether the baby is affected by hemophilia. Not all infants with hemophilia will be born to families with a history of the condition. Identification of hemophilia for the first time in a family (which is 'sporadic hemophilia') occurs in previously undiagnosed infants who have bleeds requiring medical advice and possibly hospital treatment. Before any mothers and babies with hemophilia are discharged from hospital, doctors and nurses will explain to parents how to recognize bleeding and available treatment options can be discussed. Over time, ongoing discussions will help parents to make informed treatment decisions:• When and how to start, then continue, prophylaxis.• How to deal with bleeds (reinforcing previous discussions about bleed recognition and treatment) and other ongoing aspects of treatment. ○ For instance, children may develop neutralizing antibodies (inhibitors) to treatment they are receiving, requiring a change to the planned approach.• Ensuring treatment remains effective as their child grows, considering the varied needs and activities of their child.
Collapse
Affiliation(s)
| | - Jan Blatný
- Department of Pediatric Hematology, University
Hospital Brno and Masaryk University, Brno, Czech Republic
| | - Christoph Königs
- Clinical and Molecular Hemostasis, Department
of Pediatrics, University Hospital Frankfurt, Goethe University, Frankfurt,
Germany
| | - Cédric Hermans
- Hemostasis and Thrombosis Unit, Division of
Hematology, Cliniques Universitaires Saint-Luc, Université catholique de
Louvain (UCLouvain), Brussels, Belgium
| | - Victor Jiménez-Yuste
- Hematology Department, Hospital Universitario
La Paz, Autónoma University, Madrid, Spain
| | | |
Collapse
|
18
|
Franchini M, Mannucci PM. The More Recent History of Hemophilia Treatment. Semin Thromb Hemost 2022; 48:904-910. [DOI: 10.1055/s-0042-1756188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractThe availability first in the 1970s of plasma-derived and then in the 1990s of recombinant clotting factor concentrates represented a milestone in hemophilia care, enabling not only treatment of episodic bleeding events but also implementation of prophylactic regimens. The treatment of hemophilia has recently reached new landmarks. The traditional clotting factor replacement therapy for hemophilia has been substituted over the last 10 years by novel treatments such as bioengineered factor VIII and IX molecules with extended half-life and non-factor treatments including the bispecific antibody emicizumab. This narrative review is dedicated to these newer therapies, which are contributing significantly to improving the long-term management of prophylaxis in hemophilia patients. Another section is focused on the current state of gene therapy, which is a promising definitive cure for severe hemophilia A and B.
Collapse
Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico and University of Milan, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| |
Collapse
|
19
|
Prezotti ANL, Frade-Guanaes JO, Yamaguti-Hayakawa GG, Ozelo MC. Immunogenicity of Current and New Therapies for Hemophilia A. Pharmaceuticals (Basel) 2022; 15:ph15080911. [PMID: 35893734 PMCID: PMC9331070 DOI: 10.3390/ph15080911] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023] Open
Abstract
Anti-drug antibody (ADA) development is a significant complication in the treatment of several conditions. For decades, the mainstay of hemophilia A treatment was the replacement of deficient coagulation factor VIII (FVIII) to restore hemostasis, control, and prevent bleeding events. Recently, new products have emerged for hemophilia A replacement therapy, including bioengineered FVIII molecules with enhanced pharmacokinetic profiles: the extended half-life (EHL) recombinant FVIII products. However, the main complication resulting from replacement treatment in hemophilia A is the development of anti-FVIII neutralizing alloantibodies, known as inhibitors, affecting approximately 25–30% of severe hemophilia A patients. Therefore, the immunogenicity of each FVIII product and the mechanisms that could help increase the tolerance to these products have become important research topics in hemophilia A. Furthermore, patients with inhibitors continue to require effective treatment for breakthrough bleedings and procedures, despite the availability of non-replacement therapy, such as emicizumab. Herein, we discuss the currently licensed treatments available for hemophilia A and the immunogenicity of new therapies, such as EHL-rFVIII products, compared to other products available.
Collapse
Affiliation(s)
- Alessandra N. L. Prezotti
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- HEMOES, Hematology and Hemotherapy Center Dr. Marcos Daniel Santos, Av. Marechal Campos, 1468, Maruípe, Vitória 29047-105, ES, Brazil
| | - Jéssica O. Frade-Guanaes
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
| | - Gabriela G. Yamaguti-Hayakawa
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
| | - Margareth C. Ozelo
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
- Correspondence: ; Tel.: +55-(19)-3521-8395
| |
Collapse
|