1
|
Male C, Ay C, Crevenna R, Eichinger S, Feistritzer C, Füller R, Haushofer A, Kurringer A, Neumeister P, Puchner S, Rettl T, Schindl T, Schuster G, Schwarz R, Sohm M, Streif W, Thom K, Wagner B, Wissmann E, Zwiauer K, Pabinger I. [Treatment of haemophilia in Austria]. Wien Klin Wochenschr 2024; 136:75-102. [PMID: 38743098 DOI: 10.1007/s00508-024-02370-0] [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] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
This guideline is intended to provide practical guidance for the diagnosis and treatment of haemophilia in Austria. Few randomized controlled interventional trials are available addressing the treatment of haemophilia, therefore recommendations are usually based on low level of evidence and represent expert consensus.This guideline is based on the WFH guideline, published in 2020, and adapted according to the national circumstances and experience.It includes recommendations and suggestions for diagnosis and follow-up visits and pharmacological therapies for treatment and prophylaxis. Further topics comprise special aspects in children and adults with severe haemophilia, outcome measurement, and management of trauma, special bleedings and interventions, including dental procedures, inhibitors, management of haemophilia carriers, and psychosocial aspects.
Collapse
Affiliation(s)
- Christoph Male
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - Cihan Ay
- Abteilung für Hämatologie und Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Wien, Österreich
| | - Richard Crevenna
- Universitätsklinik für Physikalische Medizin, Rehabilitation und Arbeitsmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Sabine Eichinger
- Abteilung für Hämatologie und Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Wien, Österreich
| | - Clemens Feistritzer
- Abteilung für Innere Medizin V - Hämatologie und Onkologie, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Robert Füller
- Österreichische Hämophilie Gesellschaft, Wien, Österreich
| | - Alexander Haushofer
- Institut für Medizinische und Chemische Labordiagnostik, Klinikum Wels-Grieskirchen, Wels-Grieskirchen, Österreich
| | - Andreas Kurringer
- Abteilung für Kinder- und Jugendheilkunde, Landeskrankenhaus Bregenz, Bregenz, Österreich
| | - Peter Neumeister
- Klinische Abteilung für Hämatologie, Medizinische Universität Graz, Graz, Österreich
| | - Stephan Puchner
- Klinische Abteilung für Orthopädie, Universitätsklinik für Orthopädie und Unfallchirurgie, Medizinische Universität Wien, Wien, Österreich
| | - Thomas Rettl
- Abteilung für Innere Medizin und Hämatologie und internistische Onkologie, Klinikum Klagenfurt, Klagenfurt, Österreich
| | - Thomas Schindl
- Österreichische Hämophilie Gesellschaft, Wien, Österreich
| | | | - Rudolf Schwarz
- Abteilung für Kinder- und Jugendheilkunde, Landesklinikum Amstetten, Universität Wien, Wien, Österreich
| | - Michael Sohm
- Universitätsklinik für Kinder- und Jugendheilkunde, Universitätsklinikum St. Pölten, St. Pölten, Österreich
| | - Werner Streif
- Department Kinder- und Jugendheilkunde, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Katharina Thom
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Barbara Wagner
- Universitätsklinik für Physikalische Medizin, Rehabilitation und Arbeitsmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Eva Wissmann
- Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Karl Zwiauer
- Universitätsklinik für Kinder- und Jugendheilkunde, Universitätsklinikum St. Pölten, St. Pölten, Österreich
| | - Ingrid Pabinger
- Abteilung für Hämatologie und Hämostaseologie, Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Wien, Österreich
| |
Collapse
|
2
|
van der Zwet K, de Kovel M, Motwani J, van Geet C, Nolan B, Glosli H, Escuriola Ettingshausen C, Königs C, Kenet G, Fischer K. Bleeding control improves after switching to emicizumab: Real-world experience of 177 children in the PedNet registry. Haemophilia 2024; 30:685-692. [PMID: 38578720 DOI: 10.1111/hae.15015] [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: 01/09/2024] [Revised: 03/20/2024] [Accepted: 03/31/2024] [Indexed: 04/07/2024]
Abstract
INTRODUCTION Despite the rapid uptake of emicizumab in the paediatric haemophilia A (HA) population, real-world data on the safety and efficacy is limited. AIM To report on bleeding and safety in paediatric patients receiving emicizumab prophylaxis. METHODS Data were extracted from the multicentre prospective observational PedNet Registry (NCT02979119). Children with haemophilia A, and ≥50 FVIII exposures or inhibitors present receiving emicizumab maintenance therapy were analysed. Data were summarized as medians with interquartile range (IQR, P25-P75). Mean (95% confidence interval (CI)), annualized (joint) bleeding rate (A(J)BR) during emicizumab and ≤2 years before emicizumab prophylaxis were modelled and compared using negative binomial regression. RESULTS Total of 177 patients started emicizumab at median 8.6 years (IQR 4.8-13.1), most had no FVIII inhibitors (64%). Follow up before emicizumab was median: 1.68 years (IQR: 1.24-1.90) and during emicizumab: 1.32 years (IQR: .94-2.11). In patients without inhibitors, mean ABR reduced after starting emicizumab from 2.41 (CI 1.98-2.95) to 1.11 (CI .90-1.36, p < .001), while AJBR reduced from.74 (CI .56-.98) to.31 (CI .21-.46, p < .001). Concordantly, in patients with inhibitors, mean ABR reduced from 5.08 (CI 4.08-6.38) to .75 (CI .56-1.01, p < .001), while AJBR reduced from 1.90 (CI 1.42-2.58) to .34 (CI .21-.56, p < .001). Five emicizumab-related adverse events were reported (3% of the cohort), including one patient with antidrug antibodies. CONCLUSION This study showed improved bleeding control compared to previous treatment and a favourable safety profile during emicizumab therapy in paediatric haemophilia A patients.
Collapse
Affiliation(s)
- Konrad van der Zwet
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Jayashree Motwani
- Department of Paediatric Haematology, Birmingham Children's Hospital, Birmingham, UK
| | - Chris van Geet
- Department of Pediatrics, University of Leuven, Leuven, Belgium
| | | | - Heidi Glosli
- Centre for Rare Disorders Oslo University Hospital, Oslo, Norway
| | | | - Christoph Königs
- Department of Pediatrics and Adolescents Medicine, Clinical and Molecular Haemostasis, University Hospital Frankfurt, Frankfurt, Germany
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
- The Amalia Biron Thrombosis Research Institute, Tel Aviv University, Tel Aviv, Israel
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
3
|
Cohen CT, Tarango C, Powers JM. Emicizumab use in infancy: A survey of United States Pediatric Hemophilia Treatment Center Medical Directors. Haemophilia 2024; 30:848-851. [PMID: 38421188 DOI: 10.1111/hae.14959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 01/30/2024] [Accepted: 01/30/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Clay T Cohen
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| | - Cristina Tarango
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jacquelyn M Powers
- Division of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, Texas, USA
| |
Collapse
|
4
|
Abshire TC. A treatment bridge for infants with hemophilia. Blood 2024; 143:1317-1318. [PMID: 38573607 DOI: 10.1182/blood.2023023576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Affiliation(s)
- Thomas C Abshire
- Versiti Blood Research Institute and Medical College of Wisconsin
| |
Collapse
|
5
|
Mancuso ME, Croteau SE, Klamroth R. Benefits and risks of non-factor therapies: Redefining haemophilia treatment goals in the era of new technologies. Haemophilia 2024; 30 Suppl 3:39-44. [PMID: 38481077 DOI: 10.1111/hae.14976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/21/2024] [Accepted: 02/21/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION Over the last decades progress in haemophilia treatment has been remarkable and prophylaxis with clotting factor concentrates in haemophilia A and B has been established as the standard of care in individuals with haemophilia and a severe bleeding phenotype. Besides clotting factor products with prolonged half-life non-factor therapies were developed which enable prophylaxis via subcutaneous administration. Factor VIIIa mimetics like emicizumab facilitate the coagulation pathway and are used in routine clinical practice for indivdiduals with haemophilia A. Rebalancing therapeutic agents like fitusiran, concizumab, marstacimab and serpin PC block the anticoagulant pathway and clinical trials using these products in individuals with haemophilia A and B are ongoing. AIM AND METHODS A narrative review to asess the benefits and risks of non-factor therapies taking in to account re-defined haemophilia treatment goals. RESULTS Prophylaxis for prevention of bleeds using non-factor products by subcutaneous administration is effective and results in reductions of bleeding episodes in individuals with haemophilia A or B with and without inhibitors. The treatment with emicizumab showed tolerable safety both in clinical trials and long-term real-world observations with few thrombotic events. In some clinical trials with rebalancing therapies (fitusiran and concizumab) thrombotic events occurred. Monitoring of the haemostatic function of novel therapies especially with concomitant haemostatic treatment is not yet established. CONCLUSION With the advent of novel therapeutic agents including factor concentrates with ultra-long half-life and improved FVIIIa mimetics aimed at raising the bar of protection into the non-hemophilic range redefinition of haemophilia treatment goals is eagerly needed.
Collapse
Affiliation(s)
- Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Humanitas University, Pieve Emanuele, Milan, Italy
| | - Stacy E Croteau
- Boston Children's Hospital, Boston Hemophilia Center, Harvard Medical School, Boston, USA
| | - Robert Klamroth
- Department of Internal Medicine, Hemophilia Treatment Center, Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
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
|
8
|
Kiialainen A, Adamkewicz JI, Petry C, Oldenburg J, Pipe SW, Young G, Mahlangu J, Lehle M, Niggli M, Castaman G, Jiménez-Yuste V, Shima M, Négrier C, Schmitt C. Pharmacokinetics and coagulation biomarkers in children and adults with hemophilia A receiving emicizumab prophylaxis every 1, 2, or 4 weeks. Res Pract Thromb Haemost 2024; 8:102306. [PMID: 38282901 PMCID: PMC10818085 DOI: 10.1016/j.rpth.2023.102306] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 10/25/2023] [Accepted: 11/28/2023] [Indexed: 01/30/2024] Open
Abstract
Background Emicizumab is a bispecific antibody that bridges activated factor (F)IX and FX, mimicking the function of missing activated FVIII and thus improving hemostasis in people with hemophilia A. The efficacy and safety of emicizumab were demonstrated in 4 phase III clinical trials (HAVEN 1-4). Objectives Here, we describe pharmacokinetics (PKs), pharmacodynamics (PDs), and exploratory safety biomarkers in HAVEN 1 to 4. Methods Participants received emicizumab at a loading dose of 3 mg/kg weekly for 4 weeks, followed by maintenance doses of 1.5 mg/kg weekly, 3 mg/kg every 2 weeks, or 6 mg/kg every 4 weeks. PKs, PDs, and safety biomarkers were assessed in samples collected at regular intervals during the trials. Results Emicizumab plasma trough concentrations increased during the loading dose period, reaching a mean of 52.9 μg/mL (SD, 13.6 μg/mL) at week 5, and were sustained at 42.1 to 52.3 μg/mL thereafter with maintenance dosing. Activated partial thromboplastin time shortened following the first emicizumab dose. Mean FVIII-like activity and thrombin generation peak height increased to 25.2 IU/dL (SD, 6.9 IU/dL) and 115.2 nM (SD, 42.5 nM) at week 5, with levels sustained at 17 to 23 IU/dL and >116 nM thereafter, respectively. Emicizumab did not notably affect FIX or FX plasma antigen levels, prothrombin time, or concentrations of exploratory safety markers of coagulation activation (D-dimer, prothrombin fragment 1 + 2, and fibrinogen). Conclusion In HAVEN 1 to 4, emicizumab demonstrated sustained PKs and PDs and improved coagulation parameters without affecting safety biomarkers.
Collapse
Affiliation(s)
| | | | | | | | | | - Guy Young
- Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Johnny Mahlangu
- University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | | | | | | | - Víctor Jiménez-Yuste
- Department of Hematology, La Paz University Hospital-IdiPAZ, Autónoma University, Madrid, Spain
| | | | | | | |
Collapse
|