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Jewell MP, Ashour Z, Baird CH, Manco Johnson M, Warren BB, Wufsus AR, Pallini C, Dockal M, Kjalke M, Neeves KB. Concizumab improves clot formation in hemophilia A under flow. J Thromb Haemost 2024; 22:2438-2448. [PMID: 38815755 PMCID: PMC11343664 DOI: 10.1016/j.jtha.2024.05.020] [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: 11/02/2023] [Revised: 05/01/2024] [Accepted: 05/15/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Inhibition of tissue factor pathway inhibitor (TFPI) is an emerging therapeutic strategy for treatment of hemophilia. Concizumab is a monoclonal antibody that binds TFPI and blocks its inhibition of factor (F)Xa thereby extending the initiation of coagulation and compensating for lack of FVIII or FIX. OBJECTIVES The objective of this in vitro study was to evaluate how concizumab affects clot formation in hemophilia A under flow. METHODS Blood was collected from normal controls or people with hemophilia A. An anti-FVIII antibody was added to normal controls to simulate hemophilia A with inhibitory antibodies to FVIII. Whole blood and recombinant activated FVII (rFVIIa, 25 nM) or concizumab (200, 1000, and 4000 ng/mL) were perfused at 100 s-1 over a surface micropatterned with tissue factor (TF) and collagen-related peptide. Platelet and fibrin(ogen) accumulation were measured by confocal microscopy. Static thrombin generation in plasma was measured in response to rFVIIa and concizumab. RESULTS Concizumab (1000 and 4000 ng/mL) and rFVIIa both rescued (93%-101%) total platelet accumulation, but only partially rescued (53%-63%) fibrin(ogen) incorporation to normal control levels in simulated hemophilia A. Results using congenital hemophilia A blood confirmed effects of rFVIIa and concizumab. While these 2 agents had similar effect on clot formation under flow, concizumab enhanced thrombin generation in plasma under static conditions to a greater extent than rFVIIa. CONCLUSION TFPI inhibition by concizumab enhanced activation and aggregation of platelets and fibrin clot formation in hemophilia A to levels comparable with that of rFVIIa.
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Affiliation(s)
- Megan P Jewell
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Zaina Ashour
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christine H Baird
- Department of Pediatrics, Section of Hematology, Oncology, and Bone Marrow Transplant, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Hemophilia and Thrombosis Center, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Marilyn Manco Johnson
- Department of Pediatrics, Section of Hematology, Oncology, and Bone Marrow Transplant, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Hemophilia and Thrombosis Center, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Beth Boulden Warren
- Department of Pediatrics, Section of Hematology, Oncology, and Bone Marrow Transplant, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Hemophilia and Thrombosis Center, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Adam R Wufsus
- Rare Blood Disorders, Medical Affairs Rare Disease, Novo Nordisk Inc, Plainsboro, New Jersey, USA
| | - Chiara Pallini
- Rare Blood Disorders, Rare Disease Research, Novo Nordisk, Måløv, Denmark
| | - Michael Dockal
- Rare Blood Disorders, Rare Disease Research, Novo Nordisk, Måløv, Denmark
| | - Marianne Kjalke
- Rare Blood Disorders, Rare Disease Research, Novo Nordisk, Måløv, Denmark
| | - Keith B Neeves
- Department of Bioengineering, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA; Department of Pediatrics, Section of Hematology, Oncology, and Bone Marrow Transplant, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA; Hemophilia and Thrombosis Center, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA.
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Bingo M, Fukutake K, Togo K, Xu L, Alvir JMJ, Winburn I, Karumori T. Real-World Amount of Clotting Factor Products and Non-Factor Products Dispensed and Annual Medical Expenditures for Japanese Patients with Haemophilia A. Drugs Real World Outcomes 2024:10.1007/s40801-024-00420-7. [PMID: 39127822 DOI: 10.1007/s40801-024-00420-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Treatment for haemophilia A has expanded from plasma-derived factor VIII (pdFVIII) and standard half-life (SHL) recombinant FVIII (rFVIII) to extended half-life (EHL) rFVIII and non-factor products that mimic FVIII activity. OBJECTIVE To determine amounts of clotting factor concentrates (CFCs) and emicizumab dispensed and associated healthcare expenditures in Japanese patients with haemophilia A. METHODS This retrospective, non-interventional, observational study analysed data from 2016 to 2020 from a large-scale, hospital-based administrative database. Patients had haemophilia A without inhibitors and ≥ 2 prescriptions of the same CFC or emicizumab. RESULTS In total, 974 patients with haemophilia A (median age, 30.0 years; median follow-up, 3.7 years) were included. Outpatient use of EHL rFVIII and emicizumab increased, although pdFVIII/SHL rFVIII were still used over the study. Median annual total healthcare expenditures/patient increased from ¥9,200,230 in 2016 to ¥19,748,221 in 2020. Overall, the median annual drug expenditure/patient increased from ¥8,723,120 in 2016 to ¥18,051,689 in 2020. Drug expenditure was highest with emicizumab, with an increase in median annual expenditure/patient from 2018 (n = 4, ¥26,030,206) to 2020 (n = 107, ¥45,430,408). Overall, 233 patients (23.9%) switched from an SHL to an EHL product. Although amounts of FVIII prescribed increased in the 3 months after switching, overall, there was no noticeable difference before and after switching. Median total healthcare and FVIII product expenditures increased following switching. CONCLUSIONS Prescribing of EHL products increased over the study and healthcare expenditures increased for patients who switched from SHL to EHL rFVIII products.
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Affiliation(s)
| | | | - Kanae Togo
- Pfizer Japan Inc., Shinjuku Bunka Quint Bldg., 3-22-7, Yoyogi, Shibuya-ku, Tokyo, Japan
| | - Linghua Xu
- Pfizer Japan Inc., Shinjuku Bunka Quint Bldg., 3-22-7, Yoyogi, Shibuya-ku, Tokyo, Japan
| | | | | | - Toshiyuki Karumori
- Pfizer Japan Inc., Shinjuku Bunka Quint Bldg., 3-22-7, Yoyogi, Shibuya-ku, Tokyo, Japan.
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Prudente TP, Camelo RM, Guimarães RA, Roberti MDRF. Emicizumab prophylaxis in people with hemophilia A and inhibitors: a systematic review and meta-analysis. SAO PAULO MED J 2024; 142:e2023102. [PMID: 38747872 PMCID: PMC11087007 DOI: 10.1590/1516-3180.2023.0102.r1.20022024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/06/2023] [Accepted: 02/20/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Until recently, the treatment of people with hemophilia A and inhibitors (PwHAi) was based on the use of bypassing agents (BPA). However, the advent of emicizumab as prophylaxis has demonstrated promising results. OBJECTIVES We aimed to compare the bleeding endpoints between PwHAi on BPA and those on emicizumab prophylaxis. DESIGN AND SETTING Systematic review of interventions and meta-analysis conducted at the Universidade Federal de Goiás, Goiânia, Goiás, Brazil. METHODS The CENTRAL, MEDLINE, Scopus, and LILACS databases were searched on February 21, 2023. Two authors conducted the literature search, publication selection, and data extraction. The selected publications evaluated the bleeding endpoints between PwHAi on emicizumab prophylaxis and those on BPA prophylaxis. The risk of bias was evaluated according to the Joanna Briggs Institute criteria. A meta-analysis was performed to determine the annualized bleeding rate (ABR) for treated bleeds. RESULTS Five publications (56 PwHAi) were selected from the 543 retrieved records. Overall, bleeding endpoints were lower during emicizumab prophylaxis than during BPA prophylaxis. All the publications had at least one risk of bias. The only common parameter for the meta-analysis was the ABR for treated bleeds. During emicizumab prophylaxis, the ABR for treated bleeds was lower than during BPA prophylaxis (standard mean difference: -1.58; 95% confidence interval -2.50, -0.66, P = 0.0008; I2 = 68.4%, P = 0.0031). CONCLUSION Emicizumab was superior to BPA in bleeding prophylaxis in PwHAi. However, both the small population size and potential risk of bias should be considered when evaluating these results. SYSTEMATIC REVIEW REGISTRATION CRD42021278726, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278726.
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Affiliation(s)
- Tiago Paiva Prudente
- Medical student, Faculty of Medicine, Universidade Federal de Goiás (UFG), Goiânia (GO), Brazil
| | - Ricardo Mesquita Camelo
- MD, PhD. Physician, Postdoctoral associate, Faculty of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil
| | - Rafael Alves Guimarães
- RN, PhD. Epidemiologist, Professor, Faculty of Nursing, Universidade Federal de Goiás (UFG), Goiânia (GO), Brazil
| | - Maria do Rosário Ferraz Roberti
- MD, PhD. Physician, Professor, Faculty of Medicine, Universidade Federal de Goiás (UFG), Goiânia (GO), Brazil; Physician, Secretaria de Saúde do Estado de Goiás (SES/GERAT), Goiânia (GO), Brazil
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Nakajima Y, Osuna M, Mizumachi K, Shimonishi N, Furukawa S, Ogiwara K, Nogami K. Activated protein C resistance in the copresence of emicizumab and activated prothrombin complex concentrates. Res Pract Thromb Haemost 2024; 8:102479. [PMID: 39114481 PMCID: PMC11305313 DOI: 10.1016/j.rpth.2024.102479] [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: 03/23/2024] [Revised: 05/11/2024] [Accepted: 06/12/2024] [Indexed: 08/10/2024] Open
Abstract
Background Venous thromboembolic events have been reported in persons with hemophilia A who received emicizumab and activated prothrombin complex concentrate (APCC) concomitantly, but the relevant mechanism(s) remains unclear. We speculated that activated protein C (APC) and antithrombin (AT) resistance might be associated with these adverse events. Objectives To investigate APC and AT resistance in factor (F)VIII-deficient (FVIIIdef) plasma in the presence of emicizumab and APCC. Methods In pooled normal plasma or FVIIIdef plasma samples mixed with emicizumab (50 μg/mL) and FVIII-bypassing agents, including recombinant FVIIa (2.2 μg/mL), APCC (1.3 IU/mL), or plasma-derived FVIIa/FX (1.5 μg/mL), the suppression effect of AT (0-2.4 μM) and APC (0-16 nM) was assessed by tissue factor-triggered thrombin generation assay. The APC effects in FVIIIdef plasma with the copresence of emicizumab, FII (1.3 μM), and/or FIXa (280 pM) were also examined. Results The AT resistance in emicizumab and each bypassing agent was not observed. Moreover, APC dose-dependent suppression effect was observed in pooled normal plasma or FVIIIdef plasma mixed with emicizumab and recombinant FVIIa or plasma-derived FVIIa/FX. However, APC-catalyzed inactivation had little effect on thrombin generation assay potential in FVIIIdef plasma spiked with emicizumab and APCC. The addition of FIXa to emicizumab in FVIIIdef plasma could lead to partial APC resistance. Furthermore, FVIIIdef plasma spiked with emicizumab, FIXa, and FII was markedly resistant to APC-mediated inactivation. Conclusion FII and FIXa in APCCs were key clotting factors for APC resistance in FVIIIdef plasma supplemented with emicizumab and APCCs. The APC resistance in persons with hemophilia A receiving emicizumab and APCC may contribute to venous thromboembolic events.
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Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Mitsumasa Osuna
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Alcedo Andrade PE, Mannucci PM, Kessler CM. Emicizumab: the hemophilia A game-changer. Haematologica 2024; 109:1334-1347. [PMID: 37916312 PMCID: PMC11063855 DOI: 10.3324/haematol.2022.282099] [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: 08/14/2023] [Accepted: 10/26/2023] [Indexed: 11/03/2023] Open
Abstract
In hemophilia, the unmet needs regarding adherence to prophylaxis and lack of effective long-term prophylaxis regimens, especially in patients with inhibitors, led to the production of emicizumab, the first non-factor medicine for subcutaneous administration in patients with severe and moderate hemophilia A with or without factor VIII inhibitors. This review describes the research steps behind the development of this game-changing medication as well as its success in the prophylaxis of bleeding episodes, as witnessed by the results of pivotal clinical trials but also by real-life use in the frame of a still expanding global market. We also discuss potential and actual adverse events and the nuances related to clinical use, such as laboratory monitoring, development of neutralizing antidrug antibodies, risk of thrombosis/hypercoagulability and role in the management of surgical operations. The potential of emicizumab to prevent bleeding in other congenital and acquired coagulation disorders is also outlined.
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Affiliation(s)
- Pedro E Alcedo Andrade
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC,
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi, Hemophilia and Thrombosis Center, Milan
| | - Craig M Kessler
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, District of Columbia.
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Yada K, Fujitate N, Ogiwara K, Soeda T, Kitazawa T, Nogami K. Reduced plasma factor X is associated with a lack of response to recombinant activated factor VII in patients with hemophilia A and inhibitor, but does not impair emicizumab-driven hemostasis in vitro. Thromb Res 2024; 237:37-45. [PMID: 38547693 DOI: 10.1016/j.thromres.2024.03.023] [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: 10/29/2023] [Revised: 03/14/2024] [Accepted: 03/21/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND The hemostatic effect of recombinant (r) factor (F)VIIa after repetitive intermittent administration may be attenuated in patients with hemophilia A (PwHA) with inhibitors (PwHAwI) creating a clinically unresponsive status, although mechanism(s) remain to be clarified. In patients receiving prophylaxis treatment with emicizumab, concomitant rFVIIa is sometimes utilized in multiple doses for surgical procedures or breakthrough bleeding. AIM AND METHODS We identified 'unresponsiveness' to rFVIIa, based on global coagulation function monitored using rotational thromboelastometry (ROTEM) in 11 PwHAwI and 5 patients with acquired HA, and investigated possible mechanisms focusing on the association between plasma FX levels and rFVIIa-mediated interactions. RESULTS Our data demonstrated that FX antigen levels were lower in the rFVIIa-unresponsive group than in the rFVIIa-responsive group (0.46 ± 0.14 IU/mL vs. 0.87 ± 0.15 IU/mL, p < 0.01). This relationship was further examined by thrombin generation assays using a FX-deficient PwHAwI plasma model. The addition of FX with rFVIIa was associated with increased peak thrombin (PeakTh) generation. At low levels of FX (<0.5 IU/mL), rFVIIa failed to increase PeakTh to the normal range, consistent with clinical rFVIIa-unresponsiveness. In the presence of emicizumab (50 μg/mL), PeakTh was increased maximally to 80 % of normal, even at low levels of FX (0.28 IU/mL). CONCLUSIONS Unresponsiveness to rFVIIa was associated with reduced levels of FX in PwHAwI. Emicizumab exhibited in vitro coagulation potential in the presence of FX at concentrations that appeared to limit the clinical response to rFVIIa therapy.
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Affiliation(s)
- Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.
| | | | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Tetsuhiro Soeda
- Research Division, Chugai Pharmaceutical Co., Ltd., Yokohama, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Olasupo OO, Noronha N, Lowe MS, Ansel D, Bhatt M, Matino D. Non-clotting factor therapies for preventing bleeds in people with congenital hemophilia A or B. Cochrane Database Syst Rev 2024; 2:CD014544. [PMID: 38411279 PMCID: PMC10897951 DOI: 10.1002/14651858.cd014544.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Management of congenital hemophilia A and B is by prophylactic or on-demand replacement therapy with clotting factor concentrates. The effects of newer non-clotting factor therapies such as emicizumab, concizumab, marstacimab, and fitusiran compared with existing standards of care are yet to be systematically reviewed. OBJECTIVES To assess the effects (clinical, economic, patient-reported, and adverse outcomes) of non-clotting factor therapies for preventing bleeding and bleeding-related complications in people with congenital hemophilia A or B compared with prophylaxis with clotting factor therapies, bypassing agents, placebo, or no prophylaxis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, electronic databases, conference proceedings, and reference lists of relevant articles and reviews. The date of the last search was 16 August 2023. SELECTION CRITERIA Randomized controlled trials (RCTs) evaluating people with congenital hemophilia A or B with and without inhibitors, who were treated with non-clotting factor therapies to prevent bleeds. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed studies for eligibility, assessed risk of bias, and extracted data for the primary outcomes (bleeding rates, health-related quality of life (HRQoL), adverse events) and secondary outcomes (joint health, pain scores, and economic outcomes). We assessed the mean difference (MD), risk ratio (RR), 95% confidence interval (CI) of effect estimates, and evaluated the certainty of the evidence using GRADE. MAIN RESULTS Six RCTs (including 397 males aged 12 to 75 years) were eligible for inclusion. Prophylaxis versus on-demand therapy in people with inhibitors Four trials (189 participants) compared emicizumab, fitusiran, and concizumab with on-demand therapy in people with inhibitors. Prophylaxis using emicizumab likely reduced annualized bleeding rates (ABR) for all bleeds (MD -22.80, 95% CI -37.39 to -8.21), treated bleeds (MD -20.40, 95% CI -35.19 to -5.61), and annualized spontaneous bleeds (MD -15.50, 95% CI -24.06 to -6.94), but did not significantly reduce annualized joint and target joint bleeding rates (AjBR and AtjBR) (1 trial; 53 participants; moderate-certainty evidence). Fitusiran also likely reduced ABR for all bleeds (MD -28.80, 95% CI -40.07 to -17.53), treated bleeds (MD -16.80, 95% CI -25.80 to -7.80), joint bleeds (MD -12.50, 95% CI -19.91 to -5.09), and spontaneous bleeds (MD -14.80, 95% CI -24.90 to -4.71; 1 trial; 57 participants; moderate-certainty evidence). No evidence was available on the effect of bleed prophylaxis using fitusiran versus on-demand therapy on AtjBR. Concizumab may reduce ABR for all bleeds (MD -12.31, 95% CI -19.17 to -5.45), treated bleeds (MD -10.10, 95% CI -17.74 to -2.46), joint bleeds (MD -9.55, 95% CI -13.55 to -5.55), and spontaneous bleeds (MD -11.96, 95% CI -19.89 to -4.03; 2 trials; 78 participants; very low-certainty evidence), but not target joint bleeds (MD -1.00, 95% CI -3.26 to 1.26). Emicizumab prophylaxis resulted in an 11.31-fold increase, fitusiran in a 12.5-fold increase, and concizumab in a 1.59-fold increase in the proportion of participants with no bleeds. HRQoL measured using the Haemophilia Quality of Life Questionnaire for Adults (Haem-A-QoL) physical and total health scores was improved with emicizumab, fitusiran, and concizumab prophylaxis (low-certainty evidence). Non-serious adverse events were higher with non-clotting factor therapies versus on-demand therapy, with injection site reactions being the most frequently reported adverse events. Transient antidrug antibodies were reported for fitusiran and concizumab. Prophylaxis versus on-demand therapy in people without inhibitors Two trials (208 participants) compared emicizumab and fitusiran with on-demand therapy in people without inhibitors. One trial assessed two doses of emicizumab (1.5 mg/kg weekly and 3.0 mg/kg bi-weekly). Fitusiran 80 mg monthly, emicizumab 1.5 mg/kg/week, and emicizumab 3.0 mg/kg bi-weekly all likely resulted in a large reduction in ABR for all bleeds, all treated bleeds, and joint bleeds. AtjBR was not reduced with either of the emicizumab dosing regimens. The effect of fitusiran prophylaxis on target joint bleeds was not assessed. Spontaneous bleeds were likely reduced with fitusiran (MD -20.21, 95% CI -32.12 to -8.30) and emicizumab 3.0 mg/kg bi-weekly (MD -15.30, 95% CI -30.46 to -0.14), but not with emicizumab 1.5 mg/kg/week (MD -14.60, 95% CI -29.78 to 0.58). The percentage of participants with zero bleeds was higher following emicizumab 1.5 mg/kg/week (50% versus 0%), emicizumab 3.0 mg/kg bi-weekly (40% versus 0%), and fitusiran prophylaxis (40% versus 5%) compared with on-demand therapy. Emicizumab 1.5 mg/kg/week did not improve Haem-A-QoL physical and total health scores, EQ-5D-5L VAS, or utility index scores (low-certainty evidence) when compared with on-demand therapy at 25 weeks. Emicizumab 3.0 mg/kg bi-weekly may improve HRQoL measured by the Haem-A-QoL physical health score (MD -15.97, 95% CI -29.14 to -2.80) and EQ-5D-5L VAS (MD 9.15, 95% CI 2.05 to 16.25; 1 trial; 43 participants; low-certainty evidence). Fitusiran may result in improved HRQoL shown as a reduction in Haem-A-QoL total score (MD -7.06, 95% CI -11.50 to -2.62) and physical health score (MD -19.75, 95% CI -25.76 to -11.94; 1 trial; 103 participants; low-certainty evidence). The risk of serious adverse events in participants without inhibitors also likely did not differ following prophylaxis with either emicizumab or fitusiran versus on-demand therapy (moderate-certainty evidence). Transient antidrug antibodies were reported in 4% (3/80) participants to fitusiran, with no observed effect on antithrombin lowering. A comparison of the different dosing regimens of emicizumab identified no differences in bleeding, safety, or patient-reported outcomes. No case of treatment-related cancer or mortality was reported in any study group. None of the included studies assessed our secondary outcomes of joint health, clinical joint function, and economic outcomes. None of the included studies evaluated marstacimab. AUTHORS' CONCLUSIONS Evidence from RCTs shows that prophylaxis using non-clotting factor therapies compared with on-demand treatment may reduce bleeding events, increase the percentage of individuals with zero bleeds, increase the incidence of non-serious adverse events, and improve HRQoL. Comparative assessments with other prophylaxis regimens, assessment of long-term joint outcomes, and assessment of economic outcomes will improve evidence-based decision-making for the use of these therapies in bleed prevention.
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Affiliation(s)
- Omotola O Olasupo
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Canada
| | - Noella Noronha
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Canada
| | - Megan S Lowe
- Department of Health Sciences, McMaster University, Hamilton, Canada
| | | | - Mihir Bhatt
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Davide Matino
- Department of Internal Medicine, McMaster University, Hamilton, Canada
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Yada K, Ogiwara K, Shimonishi N, Nakajima Y, Soeda T, Kitazawa T, Nogami K. Emicizumab-mediated hemostatic function assessed by thrombin generation assay in an in vitro model of factor VIII-depleted thrombophilia plasma. Int J Hematol 2024; 119:109-118. [PMID: 38112996 DOI: 10.1007/s12185-023-03683-y] [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: 06/01/2023] [Revised: 11/09/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023]
Abstract
Patients with hemophilia A (PwHA) may have concurrent deficiency of representative anticoagulant proteins, protein (P)C, PS, and antithrombin (AT), which reduces bleeding frequency. However, emicizumab-driven hemostasis in PwHA with such thrombophilic potential remains unclarified. This study investigated the influence of natural anticoagulants on emicizumab-driven coagulation in HA model plasma. Various concentrations of PS and AT were added to PS-deficient plasma and AT-deficient plasma in the presence of anti-FVIII antibody (FVIIIAb; 10BU/mL). PC-deficient plasma was mixed with normal plasma at various concentrations in the presence of FVIIIAb. Emicizumab (50 µg/mL) was added to these thrombophilic HA model plasmas, prior to tissue factor/ellagic acid-triggered thrombin generation assays. Co-presence of emicizumab increased peak thrombin values (PeakTh) dependent on PS, AT, and PC concentrations. Maximum coagulation potentials in the PS-reduced HA model plasmas remained normal in the presence of emicizumab. PeakTh were close to normal in the presence of 50%AT irrespective of emicizumab, but were higher than normal in the presence of 25%AT. Addition of recombinant FVIIa (corresponding to an administered dose of 90 μg/kg) enhanced coagulation potential to normal levels. Our findings provide novel information on hemostatic regulation in emicizumab-treated PwHA with a possible thrombophilic disposition.
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Affiliation(s)
- Koji Yada
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan.
- Division of Hemophilia, National Hospital Organization Osaka National Hospital, Osaka, Japan.
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Japan
| | - Tetsuhiro Soeda
- Research Division, Chugai Pharmaceutical Co., Ltd, Kamakura, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
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Nakajima Y, Ogiwara K, Inaba K, Kitazawa T, Nogami K. NXT007-mediated hemostatic potential is suppressed by activated protein C-catalyzed inactivation of activated factor V. Res Pract Thromb Haemost 2024; 8:102271. [PMID: 38115953 PMCID: PMC10727940 DOI: 10.1016/j.rpth.2023.102271] [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: 08/03/2023] [Revised: 10/16/2023] [Accepted: 11/09/2023] [Indexed: 12/21/2023] Open
Abstract
Background Activated protein C (APC) inactivates activated factor (F) V (FVa) and FVIIIa. NXT007, an emicizumab-based engineered therapeutic bispecific antibody, enhances the coagulation potential of FVIII-deficient plasma (FVIIIdef-plasma) to near normal levels. However, little is known about the effect of APC-induced inactivation in NXT007-mediated hemostatic function. Objectives To investigate the contribution of APC-mediated reactions to NXT007-driven hemostasis. Methods In pooled normal plasma (PNP) or FVIIIdef-plasma spiked with NXT007 (10 μg/mL), effects of APC (0-16 nM) were measured using a thrombin generation assay (TGA). The direct effects of APC on cofactor activity of NXT007 or FVIIIa in a FXa generation assay were also measured. The FVdef-plasma and FV Leiden plasma (FVLeiden plasma) were preincubated with 2 anti-FVIII monoclonal antibodies (termed FVIII-depleted), and the APC effect in the presence of NXT007 in FVIII-depleted FVdef-plasma with the addition of exogenous FV (7.5-30 nM) or FVIII-depleted FVLeiden plasma was investigated. Results The APC dose-dependent suppression effect in TGA of FVIIIdef-plasma spiked with NXT007 was similar to that of PNP. FXa generation with NXT007 was not impaired by the addition of APC, suggesting that the APC-induced reaction in TGA with NXT007 was attributed to the direct inactivation of FVa. The addition of APC to FVIII-depleted FVdef-plasma, along with NXT007 and various FV concentrations, showed a similar attenuation to PNP. The NXT007-driven thrombin generation in FVIII-depleted FVLeiden plasma was suppressed by APC, similar to the reaction in native FVLeiden plasma. Conclusion NXT007 did not impair APC-mediated downregulation of FVa in FVIIIdef-plasmas, regardless of the presence of FV mutation with APC resistance.
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Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keito Inaba
- Research Division, Chugai Pharmaceutical Co, Ltd, Yokohama, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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10
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Novembrino C, Boscolo-Anzoletti M, Galbiati E, Shinohara S, Peyvandi F. Effect of emicizumab-neutralizing antibodies on activated partial thromboplastin time-based clotting time test results in patients treated with emicizumab. Res Pract Thromb Haemost 2023; 7:102260. [PMID: 38193066 PMCID: PMC10772886 DOI: 10.1016/j.rpth.2023.102260] [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: 03/22/2023] [Revised: 10/17/2023] [Accepted: 10/27/2023] [Indexed: 01/10/2024] Open
Abstract
Background Emicizumab is a bispecific humanized monoclonal antibody that shortens the activated partial thromboplastin time (aPTT), making aPTT-based tests unreliable. Objectives To evaluate the efficacy of a mixture of 2 anti-idiotype monoclonal antibodies (anti-emi) in neutralizing emicizumab in samples from persons with hemophilia A treated with emicizumab. Methods Fifty samples from persons with hemophilia A treated with emicizumab were analyzed for aPTT and factor VIII procoagulant activity; FVIII inhibitor titer was measured using Nijmegen-Bethesda assay in 50 plasma samples of additional patients (positive for FVIII inhibitor) treated with emicizumab. FVIII procoagulant activity and inhibitor titer were measured using 1-stage (Actin FS, Siemens) and chromogenic assays with bovine regents (Factor VIII Chromogenic Assay, Siemens). Emicizumab concentration was measured by modified a 1-stage assay calibrated with a drug-specific calibrator (r2 Diagnostics Inc). All the tests were performed on Sysmex CS-2400 (Sysmex) before and after the addition of anti-emi (Chugai Pharmaceutical). Results Emicizumab concentrations measured after neutralization were <1.6 μg/mL in all samples. FVIII levels were >480 IU/dL with an aPTT of <30.8 seconds in all samples before neutralization and were <1 IU/dL with an aPTT of >70 seconds after adding anti-emi. FVIII inhibitor resulted in a false negative result in 44 of 50 samples measured with the 1-stage assay before neutralization. A good correlation (r = 0.98) was found between inhibitor titer measured using the chromogenic (insensitive to emicizumab) and 1-stage assays after neutralization. Conclusion The anti-emi antibodies were shown to completely neutralize emicizumab, making samples pretreated with anti-emi analyzable with the 1-stage assay.
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Affiliation(s)
- Cristina Novembrino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Boscolo-Anzoletti
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Eleonora Galbiati
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sho Shinohara
- Sysmex Corporation, Kobe, Japan
- Hyphen BioMed, Neuville-sur-Oise, France
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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11
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Takeyama M, Matsumoto N, Abe H, Harada S, Ogiwara K, Furukawa S, Shimonishi N, Nakajima Y, Yada K, Soeda T, Nogami K. Coagulant potentials of emicizumab in the plasmas from infant and toddler patients with hemophilia A. Pediatr Blood Cancer 2023; 70:e30590. [PMID: 37467119 DOI: 10.1002/pbc.30590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Emicizumab significantly reduces bleedings in patients with hemophilia A (PwHA). A clinical study (HAVEN 7; NCT04431726) for PwHA aged less than or equal to 12 months is ongoing, but emicizumab-driven coagulation potential in PwHA in early childhood remains to be clarified. AIM To investigate the in vitro or in vivo coagulation potential of emicizumab in plasmas obtained from infant and toddler PwHA. METHODS Twenty-seven plasma samples from 14 infant/toddler PwHA (aged 0-42 months, median 19 months) who received emicizumab (n = 9), factor (F)VIII products (n = 8), or no treatment (n = 10) were obtained. FVIII activity in FVIII-treated plasmas was cancelled by the addition of anti-FVIII monoclonal antibody (mAb). Emicizumab-treated plasmas (in vivo) and emicizumab-spiked plasmas (in vitro) were analyzed. Emicizumab-untreated plasma or emicizumab-treated plasma supplemented with two anti-emicizumab mAbs were used as references. Adjusted maximum coagulation velocity (Ad|min1|) by clot waveform analysis and peak thrombin (Peak-Th) by thrombin generation assay was assessed. RESULTS Ad|min1| values in 24 samples were improved by the presence of emicizumab. Values did not improve in the three remaining samples (aged 1, 23, and 31 months). Although the presence of emicizumab showed an age-dependent increase in Peak-Th in 20 samples, this increase was not observed in seven samples (aged 0, 1, 1, 2, 8, 19, and 36 months). Emicizumab-dependent increases in both Ad|min1| and Peak-Th were shown in 18 samples, and increases in either parameter were shown in eight samples. One sample (from patient aged 1 month) showed no increase in both, however. CONCLUSION Emicizumab could improve coagulant potential in plasmas from infant/toddler patients with hemophilia A.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | - Hiroto Abe
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | - Suguru Harada
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Division of Hemophilia, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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12
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Hu Z, Cohen S, Swanson SJ. The immunogenicity of human-origin therapeutic antibodies are associated with V gene usage. Front Immunol 2023; 14:1237754. [PMID: 37720227 PMCID: PMC10502710 DOI: 10.3389/fimmu.2023.1237754] [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: 06/09/2023] [Accepted: 08/18/2023] [Indexed: 09/19/2023] Open
Abstract
Therapeutic antibodies can elicit unwanted immune responses in a subset of patients, which leads to the production of anti-drug antibodies (ADA). Some of these ADAs have been reported to effect the pharmacokinetics, efficacy and/or safety of the therapeutic antibodies. The sequence diversity of antibodies are generated by VDJ recombination and mutagenesis. While the antibody generation process can create a large candidate pool for identifying high-affinity antibodies, it also could produce sequences that are foreign to the human immune system. However, it is not clear how VDJ recombination and mutagenesis impact the clinical ADA rate of therapeutic antibodies. In this study, we identified a positive correlation between the clinical ADA rate and the number of introduced mutations in the antibody sequences. We also found that the use of rare V alleles in human-origin antibody therapeutics is associated with higher risk of immunogenicity. The results suggest that antibody engineering projects should start with frameworks that contain commonly used V alleles and prioritize antibody candidates with low number of mutations to reduce the risk of immunogenicity.
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13
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Persson P, Amstrup AB, Coester HV, Matytsina I, Bas S. Mim8, a novel factor VIIIa mimetic bispecific antibody, shows favorable safety and pharmacokinetics in healthy adults. Res Pract Thromb Haemost 2023; 7:102181. [PMID: 37745159 PMCID: PMC10514552 DOI: 10.1016/j.rpth.2023.102181] [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: 03/15/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 09/26/2023] Open
Abstract
Background Mim8 (denecimig) is a novel activated coagulation factor VIII-mimetic bispecific antibody that assembles with activated coagulation FIX and FX on the platelet membrane surface. Objectives The FRONTIER1 (NCT04204408, NN7769-4513) single ascending dose and the 4882 pharmacokinetic (PK) studies (NCT05127473, NN7769-4882) examined the safety, tolerability, PK, and pharmacodynamics (PD) of Mim8 in healthy adult males. Methods The FRONTIER1 single ascending dose study consisted of 6 cohorts, each with 6 participants who received a single subcutaneous (s.c.) dose of Mim8 and 2 participants who received a placebo. The 4882 PK study had 11 arms, each with 6 participants who received a single s.c. dose of Mim8. The primary endpoint for both studies was treatment-emergent adverse events. Other safety assessments included relative changes in D-dimer, prothrombin fragments 1 and 2, fibrinogen, and platelets. The PK and PD were assessed using Mim8 plasma concentration and activated partial thromboplastin clotting time and thrombin generation, respectively. Results Mim8 was well tolerated, and there were no severe treatment-emergent adverse events. The PK properties of Mim8 in both studies were consistent with dose-proportionality. The terminal half-life of Mim8 after a single dose was approximately 1 month, and maximum plasma concentration was reached after 10 days. Conclusion The PK and PD profiles suggest that Mim8 is suitable as a long-acting FVIIIa-mimetic bispecific antibody for hemophilia A prophylaxis.
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Affiliation(s)
| | | | | | | | - Selcuk Bas
- Charité Research Organization, Campus Charité Mitte, Berlin, Germany
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14
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Yoneyama K, Schmitt C, Portron A, Kiialainen A, Kotani N, Jaminion F, Retout S, Adamkewicz JI. Clinical pharmacology of emicizumab for the treatment of hemophilia A. Expert Rev Clin Pharmacol 2023; 16:775-790. [PMID: 37529848 DOI: 10.1080/17512433.2023.2243213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/22/2023] [Accepted: 07/28/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Emicizumab is a humanized bispecific antibody approved for the routine prophylaxis of bleeding episodes in patients with hemophilia A (PwHA) regardless of the presence of factor VIII (FVIII) inhibitors. It mimics the cofactor function of missing activated FVIII by bridging activated factor IX and factor X, thereby restoring hemostasis. AREAS COVERED This review covers the clinical pharmacology of emicizumab and the translation of its pharmacokinetics (PK) and pharmacodynamics (PD) to clinical efficacy and safety. The PK of emicizumab is linear, with an approximately 1-month half-life. Once-weekly to every-4-week subcutaneous (SC) administrations maintain effective trough concentrations throughout the dosing intervals, associated with a coagulation potential analogous to that in patients with mild hemophilia A. In combination with activated prothrombin complex concentrate, and to a lesser extent with recombinant activated factor VII, emicizumab exerts a synergistic effect, whereas combination with FVIII may result in a non-additive coagulation potential at normal FVIII activity. EXPERT OPINION The translation of emicizumab PK/PD into clinical effects was demonstrated in several phase III studies, which showed remarkable bleed control and a favorable safety profile in PwHA. These emicizumab attributes, together with the convenience of use (infrequent SC injections), offer a novel paradigm for the management of PwHA.
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15
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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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16
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Furukawa S, Ogiwara K, Yada K, Takeyama M, Niino T, Shima M, Keiji N. Decrease in in vivo coagulant potential of emicizumab in a patient with hemophilia A and inhibitor complicated with infectious mononucleosis. Blood Coagul Fibrinolysis 2023; 34:122-128. [PMID: 36719809 DOI: 10.1097/mbc.0000000000001177] [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: 02/01/2023]
Abstract
Emicizumab prophylaxis significantly reduces bleeding episodes in patients with hemophilia A (PwHA). There is little information on coagulant potentials in emicizumab-treated PwHA with infection, however. We encountered an emicizumab-treated PwHA with inhibitor, complicated with Epstein-Barr virus-associated infectious mononucleosis (IM) in phase 1/2 study (ACE001JP/ACE002JP). Although it was a typical clinical course of IM, activated partial thromboplastin time was mildly prolonged but rotational thromboelastometry revealed severely impaired coagulant potential. The blood concentration of emicizumab decreased moderately in the low concentration range, resulting in an increased risk of bleeding and possibly leading to severe ileocecal bleeds requiring coil embolization. The blood concentrations of factors IX/X little decreased and antiemicizumab antibodies did not develop, however. After the influence by IM resolved, his coagulant potentials gradually recovered with the recovery of emicizumab concentration, and parameters by global coagulation assays improved. An IM case for emicizumab-treated PwHA may need to monitor using global coagulation assays.
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Affiliation(s)
- Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara
- Department of Haemophilia, National Hospital Organization Osaka National Hospital, Osaka
| | | | | | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara
| | - Nogami Keiji
- Department of Pediatrics, Nara Medical University, Kashihara, Nara
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17
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Mannucci PM. Hemophilia treatment innovation: 50 years of progress and more to come. J Thromb Haemost 2023; 21:403-412. [PMID: 36858789 DOI: 10.1016/j.jtha.2022.12.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/01/2022] [Accepted: 12/28/2022] [Indexed: 03/02/2023]
Abstract
With the goal of emphasizing the striking advances that materialized in hemophilia care particularly in the last 10 years, the progress of knowledge that started from the 1970s will first be sketched as background. Subsequently, the unmet needs pertaining to therapeutic adherence and thus to prophylaxis effectiveness led to the availability of factor VIII and IX products with an extended plasma half-life as well as to emicizumab, the first nonfactor medicine for subcutaneous administration in patients with hemophilia A with or without inhibitor. The issue of a still lacking cure for the disease is approached by means of gene therapy, the first products of which were approved in 2022 for adults with both hemophilia types. Finally, views will be offered on further progress that is expected in the next few years and how patients and their care providers may make personalized choices among the wide array of therapeutic options.
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Affiliation(s)
- Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.
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18
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Ogiwara K, Furukawa S, Shinohara S, Tabuchi Y, Arai N, Noguchi-Sasaki M, Soeda T, Shima M, Nogami K. Anti-idiotype monoclonal antibodies against emicizumab enable accurate procoagulant and anticoagulant assays, irrespective of the test base, in the presence of emicizumab. Haemophilia 2023; 29:329-335. [PMID: 36137299 DOI: 10.1111/hae.14662] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/15/2022] [Accepted: 09/06/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Emicizumab markedly shortens the activated partial thromboplastin time (aPTT), resulting in inaccurate measurements of procoagulant and anticoagulant factor activities. We have recently reported that mixtures of two different anti-idiotype monoclonal antibodies against emicizumab (anti-emicizumab-mAbs) allow measurement of factor (F)VIII activity (FVIII:C) and FVIII inhibitor in emicizumab-containing plasmas. It is unknown whether anti-emicizumab mAbs can work for other aPTT-based procoagulant and anticoagulant assays. AIM To investigate whether anti-emicizumab mAbs were measured by all of the aPTT-based assays tested. METHODS Two anti-emicizumab-mAbs (300 μg/mL each) were preincubated with emicizumab (200 μg/mL)-spiked FVIII-deficient plasma; we then measured FVIII:C, FIX:C, FXI:C, FXII:C, protein (P)C:C, PS:C, global PC-FV (aPTT-based), and prothrombin time (PT), diluted Russel's viper venom time (dRVVT), chromogenic-based FVIII:C, FIX:C and PC:C (non-aPTT-based). Emicizumab (100 μg/mL)-spiked haemophilia (H)A plasmas from patients (n = 23) were also measured. RESULTS Emicizumab shortened the clotting time in all aPTT-based assays, resulting in high levels of FVIII:C, FIX:C, FXI:C and FXII:C; low levels of PC:C and PS:C; and false-positive results for activated PC resistance. The addition of anti-emicizumab-mAbs to emicizumab-added plasma restored all factors to the initial levels without emicizumab. Chromogenic FVIII:C measurement by human FIXa/FX was affected by emicizumab, but anti-emicizumab mAbs cancelled this effect. PT-based assays and dRVVT, chromogenic FIX:C and PC:C assays showed no effect with emicizumab. Twenty-three plasma samples from HA patients also showed similar patterns. CONCLUSION Anti-emicizumab mAbs in vitro could cancel the effect of emicizumab, irrespective of the test base, resulting in accurate measurements of procoagulant and anticoagulant factor activity.
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Affiliation(s)
- Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Sho Shinohara
- Reagent Engineering, Sysmex Corporation, Kobe, Japan
| | - Yuka Tabuchi
- System Engineering, Sysmex Corporation, Kobe, Japan
| | - Nobuo Arai
- Reagent Engineering, Sysmex Corporation, Kobe, Japan
| | | | - Tetsuhiro Soeda
- Chugai Pharmaceutical Co., Research Division, Gotemba, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Center of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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19
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Shapiro AD, Hardesty BM, Peyvandi F, Iorio A. Prevalence of selected bleeding and thrombotic events in persons with hemophilia versus the general population: A scoping review. Res Pract Thromb Haemost 2023; 7:100007. [PMID: 36891522 PMCID: PMC9986102 DOI: 10.1016/j.rpth.2022.100007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 10/12/2022] [Accepted: 11/06/2022] [Indexed: 01/13/2023] Open
Abstract
Life expectancy for persons with hemophilia has increased over recent decades due to advances in treatment practice and patient care. Those with hemophilia are now more likely to be affected by conditions associated with aging, such as myocardial infarction, hemorrhagic/ischemic stroke, deep vein thrombosis, pulmonary embolism, and intracranial hemorrhage. Here, we describe the results of a literature search designed to summarize current data on the prevalence of the above selected bleeding and thrombotic events in persons with hemophilia vs the general population. A total of 912 articles published between 2005 and 2022 were identified in a search of BIOSIS Previews, Embase, and MEDLINE databases conducted in July 2022. Case studies, conference abstracts, review articles, studies focusing on hemophilia treatments or surgical outcomes, and studies examining patients with inhibitors only were excluded. After screening, 83 relevant publications were identified. The prevalence of bleeding events was consistently higher in hemophilia populations vs reference populations (hemorrhagic stroke, 1.4%-5.31% vs 0.2%-0.97%; intracranial hemorrhage, 1.1%-10.8% vs 0.04%-0.4%). Serious bleeding events showed a high rate of mortality with standardized mortality ratios for intracranial hemorrhage ranging from 3.5 to 14.88. Although 9 studies reported lower prevalence of arterial thrombosis (myocardial infarction/stroke) in hemophilia vs general populations, 5 studies reported higher or comparable prevalence in hemophilia. Prospective studies are therefore needed to understand the prevalence of bleeding and thrombotic events in hemophilia populations, particularly with the observed increases in life expectancy and availability of novel treatments.
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Affiliation(s)
- Amy D Shapiro
- Indiana Haemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | | | - Flora Peyvandi
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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20
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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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21
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Takeyama M, Furukawa S, Onishi T, Noguchi-Sasaki M, Shima M, Nogami K. Heterogeneous coagulant potential of emicizumab in neonatal factor VIII-deficient plasma. Pediatr Blood Cancer 2022; 69:e29731. [PMID: 35441786 DOI: 10.1002/pbc.29731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/01/2022] [Accepted: 03/27/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Emicizumab prophylaxis reduces bleeding in hemophilia A (HA) patients. However, there are few data on emicizumab treatment in neonates with HA (neonate-HA), and the procoagulant effects of emicizumab in these patients are unknown. AIM To investigate the coagulation activity of emicizumab in vitro in a plasma model of neonate-HA. METHODS Plasmas from 84 neonates with non-HA were enrolled. However, due to the limited plasma volumes in some cases, 50 plasmas were assigned to two different assay groups. To prepare the neonate-HA model, plasma was first preincubated with an antifactor (F) VIII A2 monoclonal antibody (mAb). After further incubation with emicizumab, global coagulation activity was measured: adjusted maximum coagulation velocity (Ad|min1|) in clot waveform analysis (CWA) and peak thrombin in thrombin generation assay (TGA). RESULTS Because the addition of anti-FVIII mAb to 22 of 43 samples showed little decrease in Ad|min1|, the remaining 21 samples were analyzed by CWA. The addition of emicizumab increased Ad|min1| in 18 of the 19 cases (effective group) but not in the remaining 3 cases (noneffective group). Similarly, TGA found that emicizumab (effective group) improved peak thrombin in seven of the nine samples tested, but two cases did not respond (noneffective group). Although the effective group had lower levels of FX, there was no significant difference between the effective and noneffective groups in terms of FIX, protein S, protein C, antithrombin, and fibrinogen. CONCLUSIONS The in vitro coagulant potentials of emicizumab in the neonate-HA model were more heterogeneous than those recorded in the adult-HA model.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Nara, Japan
| | - Tomoko Onishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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22
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Shima M, Takedani H, Kitsukawa K, Taki M, Ishiguro A, Nagao A, Yamaguchi-Suita H, Kyogoku Y, Yoshida S, Nogami K. AOZORA: long-term safety and joint health in paediatric persons with haemophilia A without factor VIII inhibitors receiving emicizumab - protocol for a multicentre, open-label, phase IV clinical study. BMJ Open 2022; 12:e059667. [PMID: 35697445 PMCID: PMC9196178 DOI: 10.1136/bmjopen-2021-059667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Persons with haemophilia A (PwHA) commonly experience regular bleeding into joints, which may result in joint damage and complications such as degenerative arthritis. Emicizumab has previously demonstrated efficacy in reducing the occurrence of joint bleeds and target joints, along with having a favourable safety profile; however, data on the long-term effects on joint health are lacking. The AOZORA study will evaluate the long-term safety and joint health of paediatric PwHA without factor (F)VIII inhibitors taking emicizumab; here, we report the details of the study protocol and baseline data. METHODS AND ANALYSIS AOZORA is a multicentre, open-label, phase IV clinical study in Japan that aims to enrol approximately 30 PwHA aged <12 years without FVIII inhibitors. The primary endpoints include a long-term safety evaluation of adverse events, laboratory test abnormalities and FVIII inhibitor development; and a long-term joint health assessment using MRI and the Hemophilia Joint Health Score. Exploratory endpoints include characterising participants' physical activities and the number of activity-related bleeds requiring coagulation factor treatment. Currently, 30 participants have been enrolled, including 20 emicizumab-naïve participants and 10 who transferred from HOHOEMI, a previous study in paediatric PwHA. ETHICS AND DISSEMINATION The AOZORA study was approved by the Institutional Review Boards of Nara Medical University and the St Marianna University Group. The study will be conducted in compliance with the Declaration of Helsinki, the standards stipulated in paragraph 3 of Article 14 and Article 80-2 of the Pharmaceuticals, Medical Devices and Other Therapeutic Products Act, the Ministerial Ordinance on Good Clinical Practice and the Ministerial Ordinance on Good Post-marketing Study Practice. Data will be published in peer-reviewed journals and presented at Global congresses. TRIAL REGISTRATION NUMBER JapicCTI-194701.
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Affiliation(s)
- Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Hideyuki Takedani
- Department of Joint Surgery, IMSUT Hospital, The University of Tokyo, Tokyo, Japan
| | - Kaoru Kitsukawa
- Department of Radiology, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Masashi Taki
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Akira Ishiguro
- Division of Hematology, National Center for Child Health and Development, Tokyo, Japan
| | - Azusa Nagao
- Department of Blood Coagulation, Ogikubo Hospital, Tokyo, Japan
| | | | - Yui Kyogoku
- Medical Affairs Division, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Seitaro Yoshida
- Clinical Development Division, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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23
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Utilization of Emicizumab in Acquired Hemophilia A: A Case Report. Transfus Apher Sci 2022; 61:103457. [DOI: 10.1016/j.transci.2022.103457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/30/2022] [Accepted: 05/09/2022] [Indexed: 11/21/2022]
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24
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Yaoi H, Shida Y, Ogiwara K, Kitazawa T, Shima M, Nogami K. Emicizumab enhances thrombus formation in vitro under high shear flow conditions in whole blood from patients with type 1 and type 3 von Willebrand disease. Haemophilia 2022; 28:694-701. [PMID: 35478475 DOI: 10.1111/hae.14581] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/30/2022] [Accepted: 04/19/2022] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Type 1 and type 3 von Willebrand disease (VWD) are caused by partial and complete, quantitative deficiency of von Willebrand factor (VWF), respectively, and factor (F)VIII/VWF complex concentrates are used for haemostatic treatment. Emicizumab, mimics activated FVIII, reduces bleeding in haemophilia A patients. The effects of emicizumab on haemostasis in both types of VWD remain to be fully established, however. AIM To examine the effects of emicizumab on thrombogenesis in type 1 and type 3 VWD. PATIENTS/METHODS Perfusion chamber experiments under high shear conditions (2500 s-1 ) combined with immunostaining were performed using whole blood samples from patients with type 1 (VWF:Ag 25 U/dl) and type 3 VWD (<1.0 U/dl). RESULTS The addition of FVIII (1 U/ml) to type 1 blood did not affect thrombus formation, whilst supplementation with VWF (1.6 U/ml) or FVIII/VWF (1 U/ml/1.6 U/ml) enhanced thrombogenesis to a similar extent. FVIII/VWF promoted thrombus formation significantly more than VWF alone, however, in type 3 blood. Emicizumab (100 μg/ml) augmented thrombus formation in type 3 blood compared to FVIII, and this potency seemed to be somewhat greater than that of VWF. Surface coverage of formed thrombus in type 3 VWD was less than that in type 1 VWD, but thrombus height was comparable in both. The addition of emicizumab to type 3 blood enhanced thrombin generation and fibrin formation compared to control IgG. CONCLUSION Emicizumab promoted mechanisms of thrombus formation in vitro in type 3 and type 1 VWD, suggesting the possibility of alternative therapeutic protocols in these patients.
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Affiliation(s)
- Hiroaki Yaoi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Yasuaki Shida
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Takehisa Kitazawa
- Research Division, Chugai Pharmaceutical Co., Gotemba, Shizuoka, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,Thrombosis and Hemostasis Research Center, Nara Medical University, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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25
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Matsushita T, Suzuki N, Nagao A, Nagae C, Yamaguchi-Suita H, Kyogoku Y, Ioka A, Nogami K. AKATSUKI study: a prospective, multicentre, phase IV study evaluating the safety of emicizumab under and immediately after immune tolerance induction therapy in persons with congenital haemophilia A with factor VIII inhibitors. BMJ Open 2022; 12:e057018. [PMID: 35288393 PMCID: PMC8921931 DOI: 10.1136/bmjopen-2021-057018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION For persons with haemophilia A with factor (F) VIII inhibitors (PwHAwI), immune tolerance induction (ITI) therapy is indicated for inhibitor eradication; however, since PwHAwI on ITI were excluded from the emicizumab clinical development programme, there are limited safety data for emicizumab treatment under/immediately after ITI in PwHAwI. Accordingly, there is a need to collect safety and efficacy data on this concomitant treatment strategy. The AKATSUKI study aims to evaluate the safety of emicizumab under/immediately after ITI in PwHAwI; here we report details of the study protocol. METHODS AND ANALYSIS AKATSUKI is an open-label, non-randomised, interventional, multicentre study. Twenty participants with congenital HA with FVIII inhibitors will be enrolled from 17 sites across Japan. Emicizumab will be administered subcutaneously, with an initial loading dose of 3 mg/kg once per week (QW) for the first 4 weeks, followed by a maintenance dose of 1.5 mg/kg QW, 3 mg/kg once every 2 weeks or 6 mg/kg once every 4 weeks. For ITI therapy, 50 IU/kg FVIII will be administered three times per week. For extended half-life FVIII, a dosing frequency of twice per week will be permitted. The primary endpoint is a comprehensive safety evaluation of adverse events (mainly thromboembolic events) and abnormal laboratory values over time. Secondary endpoints are the number of bleeds requiring coagulation factor treatment, the number of participants achieving a partially successful ITI response, FVIII inhibitor titres under/immediately after ITI, quality of life and time to achieve a negative FVIII inhibitor result (<0.6 BU/mL) and partial success in PwHAwI starting ITI after study enrolment. CONCLUSIONS AKATSUKI will evaluate the safety of emicizumab administered under/immediately after ITI, providing reference data to inform treatment strategies in PwHAwI. ETHICS AND DISSEMINATION The results of this study will be published in a peer-reviewed international journal and presented at national and/or international medical scientific conferences; the major findings of this study will be published on the jRCT registry website (https://jrct.niph.go.jp). TRIAL REGISTRATION NUMBER jRCTs041200037.
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Affiliation(s)
| | | | | | - Chiai Nagae
- St Marianna University School of Medicine, Kawasaki, Japan
| | | | | | - Akiko Ioka
- Chugai Pharmaceutical Co Ltd, Tokyo, Japan
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26
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Yang R, Wang S, Wang X, Sun J, Chuansumrit A, Zhou J, Schmitt C, Hsu W, Xu J, Li L, Chang T, Zhao X. Prophylactic emicizumab for hemophilia A in the Asia-Pacific region: A randomized study (HAVEN 5). Res Pract Thromb Haemost 2022; 6:e12670. [PMID: 35284778 PMCID: PMC8902287 DOI: 10.1002/rth2.12670] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 01/18/2022] [Accepted: 01/24/2022] [Indexed: 12/31/2022] Open
Abstract
Background Emicizumab is a subcutaneously administered humanized, bispecific, monoclonal antibody approved for prophylaxis in people with hemophilia A. Methods HAVEN 5 (NCT03315455) is a randomized, open-label, phase 3 study of individuals aged ≥12 years with severe hemophilia A without factor VIII (FVIII) inhibitors, or hemophilia A of any severity with FVIII inhibitors, across the Asia-Pacific region. Participants were randomly assigned (2:2:1) to receive emicizumab 1.5 mg/kg once weekly (arm A), emicizumab 6 mg/kg every 4 weeks (arm B), or no prophylaxis (arm C). The primary end point was annualized bleeding rate (ABR) for treated bleeds; ABRs were compared between people receiving emicizumab prophylaxis versus those with no prophylaxis. Secondary end points included ABR for treated target joint bleeds. Safety was also evaluated. Results From April 26, 2018, to January 4, 2019, 70 of 76 screened participants were enrolled and randomized (arm A, n = 29; arm B, n = 27; arm C, n = 14). ABRs (95% confidence interval) for treated bleeds and treated target joint bleeds, respectively, were: arm A, 1.0 (0.53-1.85) and 0.4 (0.18-1.09); arm B, 1.0 (0.50-1.84) and 0.3 (0.12-0.85); arm C, 27.0 (13.29-54.91) and 8.6 (3.15-23.42). The most common adverse event, upper respiratory tract infection, was reported for 14 of 56 (25.0%; emicizumab) and 2 of 14 (14.3%; no prophylaxis) participants. No thrombotic events, thrombotic microangiopathies, or deaths were reported. Conclusion Emicizumab 1.5 mg/kg once weekly and 6 mg/kg every 4 weeks demonstrated bleed control in this study population, was well tolerated, and could improve use of prophylaxis in people with hemophilia A.
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Affiliation(s)
- Renchi Yang
- Institute of Haematology & Blood Diseases HospitalChinese Academy of Medical SciencesTianjinChina
| | - Shujie Wang
- Peking Union Medical College HospitalBeijingChina
| | - Xuefeng Wang
- Ruijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Jing Sun
- Nanfang HospitalSouthern Medical UniversityGuangzhouChina
| | | | - Jianfeng Zhou
- Tongji HospitalTongji Medical CollegeHuazhong University of Science & TechnologyWuhanChina
| | | | - Wanling Hsu
- Product Development OncologyRoche (China) Holding LtdShanghaiChina
| | - Jeffrey Xu
- Product Development OncologyRoche (China) Holding LtdShanghaiChina
| | - Lindong Li
- Product Development OncologyRoche (China) Holding LtdShanghaiChina
| | - Tiffany Chang
- Genentech, Inc.South San FranciscoCaliforniaUSA
- Present address:
Spark Therapeutics, Inc.PhiladelphiaPennsylvaniaUSA
| | - Xielan Zhao
- Xiangya Hospital of Centre‐South UniversityChangshaChina
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27
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Nakajima Y, Mizumachi K, Shimonishi N, Furukawa S, Yada K, Ogiwara K, Takeyama M, Shima M, Nogami K. Comparisons of global coagulation potential and bleeding episodes in emicizumab-treated hemophilia A patients and mild hemophilia A patients. Int J Hematol 2022; 115:489-498. [PMID: 35043383 DOI: 10.1007/s12185-021-03276-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 12/18/2022]
Abstract
Emicizumab reduces bleeding events in patients with severe hemophilia A (HA). The coagulation potential of emicizumab at a clinical dose appears to correspond to about 15 IU/dL of factor VIII activity (FVIII:C), the equivalent of converting from a severe to mild phenotype. However, the clinical and laboratory characteristics of HA patients receiving emicizumab (Emi-PwHA) compared with patients with mild HA (PwMHA) remain to be determined. We reviewed clinical data from Emi-PwHA (n = 63) and PwMHA (n = 15) and evaluated comprehensive coagulation function using Ca2+-triggered rotational thromboelastometry (ROTEM) and ellagic acid/tissue factor-triggered clot waveform analysis (modified CWA). The median FVIII:C in PwMHA was 13.0 (IQR 8.5-17.0) IU/dL. Bleeding patterns in both groups were similar and classified into three categories: (1) spontaneous bleeding, post-traumatic, (2) bleeding within 1-2 days, and (3) delayed bleeding after 1-2 weeks. The coagulation potential in Emi-PwHA with and without breakthrough bleeds was comparable. Furthermore, coagulation function in Emi-PwHA was equivalent to PwMHA, although time between treatment and hospitalization for breakthrough bleeds in PwMHA appeared to be longer than those in Emi-PwHA. The coagulation potential and bleeding patterns appeared to be similar in Emi-PwHA and PwMHA, indicating that emicizumab-driven coagulation potential reflected mild HA.
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Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Japan.
| | - Kuniyoshi Mizumachi
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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28
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Donners AAMT, Rademaker CMA, Bevers LAH, Huitema ADR, Schutgens REG, Egberts TCG, Fischer K. Pharmacokinetics and Associated Efficacy of Emicizumab in Humans: A Systematic Review. Clin Pharmacokinet 2021; 60:1395-1406. [PMID: 34389928 PMCID: PMC8585815 DOI: 10.1007/s40262-021-01042-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Emicizumab is an effective new treatment option for people with hemophilia A (PwHA). The approved dosing regimens are based on body weight, without the necessity for laboratory monitoring. This assumes a clear dose-concentration-response relationship, with acceptable variability due to factors other than body weight. To investigate this assumption, a systematic review on the pharmacokinetics (PK) and associated efficacy of emicizumab in humans was conducted. METHODS The EMBASE, Pubmed and CENTRAL databases were systematically searched to November 2020 to identify studies on the PK data of emicizumab in humans. Data on the study, population, PK and efficacy (annualized bleeding rate of treated [joint] bleeds) were extracted and synthesized, and exposure effects modeling was performed using non-linear least squares regression in a maximum effect (Emax) model. RESULTS The 15 included studies reported on data for 140 volunteers and 467 PwHA, including children (0 to <12 years) and adolescents and adults (≥12 years), both with and without factor VIII (FVIII) inhibitors. Emicizumab demonstrated dose-linear PK. The interindividual variability of trough concentrations was moderate (32%) and was similar across various subgroups, such as FVIII inhibitor status, age group and dosing interval. The control of bleeds did not further improve above emicizumab concentrations of 30 µg/mL, potentially enabling lower dosing in a substantial proportion of PwHA. CONCLUSION This review supports body weight-based dosing, although individualized monitoring of emicizumab concentrations may allow for more cost-effective dosing.
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Affiliation(s)
- Anouk A M T Donners
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands.
| | - Carin M A Rademaker
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands
| | - Lisanne A H Bevers
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands
- Department of Pharmacy and Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Toine C G Egberts
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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29
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Hassan E, Jonathan L, Jayashree M. Real-world experience on the tolerability and safety of emicizumab prophylaxis in paediatric patients with severe haemophilia A with and without FVIII inhibitors. Haemophilia 2021; 27:e698-e703. [PMID: 34628693 DOI: 10.1111/hae.14432] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/27/2021] [Accepted: 09/27/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Emicizumab is a bispecific monoclonal antibody that bridges activated factor (F) IX and FX, and maintains haemostasis in patients with haemophilia A (PwHA). As a novel agent, many questions remain unanswered about the loss of emicizumab efficacy due to anti-drug antibody (ADA) development, the incidence of inhibitor recurrence in previously tolerized patients, and the risk of de novo inhibitor development. AIM To present real-world experience regarding tolerability, side effects, and outcomes of adverse events of emicizumab prophylaxis in paediatric PwHA. METHODS Data on tolerability, compliance, adverse events, and laboratory results of paediatric patients receiving emicizumab prophylaxis, treated at the Haemophilia Comprehensive Care Centre, at Birmingham Children's Hospital between March 2018 and June 2021, were collected. RESULTS Our results showed that out of 52 patients, four experienced minor adverse events, two developed headaches, one developed abdominal pain and nausea, and one developed injection site reactions. Moreover, four patients experienced major adverse events, including severe headaches, major bleeding events, development of ADAs, and recurrence of inhibitors. Emicizumab prophylaxis was discontinued in three patients (5.7% of the cohort) due to adverse events. In addition, emicizumab was discontinued in one patient because of poor compliance. No adverse events were reported in previously untreated/minimally treated patients, represented by four patients in our cohort. CONCLUSIONS The real-world experience of emicizumab prophylaxis in our cohort showed that emicizumab was safe and well tolerated in paediatric PwHA with and without inhibitors. Long-term assessment is crucial to monitor major adverse events, recurrence of inhibitors, and development of ADAs.
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Affiliation(s)
- Eman Hassan
- Department of Paediatrics, NHS Foundation Trust, Paediatric Haematology, Haematology and Oncology Unit, Birmingham Children's Hospital, Birmingham, UK
| | - Lancashire Jonathan
- Department of Paediatric Haematology, NHS Foundation Trust, Birmingham Children's Hospital, Birmingham, UK
| | - Motwani Jayashree
- Department of Paediatric Haematology, NHS Foundation Trust, Birmingham Children's Hospital, Birmingham, UK
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30
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Population Pharmacokinetic Analysis and Exploratory Exposure-Bleeding Rate Relationship of Emicizumab in Adult and Pediatric Persons with Hemophilia A. Clin Pharmacokinet 2021; 59:1611-1625. [PMID: 32504271 PMCID: PMC7717049 DOI: 10.1007/s40262-020-00904-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Emicizumab is a bispecific monoclonal antibody developed for routine prophylaxis of bleeding in people with hemophilia A (PwHA). This work characterizes the pharmacokinetics of emicizumab in adult and pediatric PwHA, identifies factors contributing to its between-person variabilities, compares the pharmacokinetics following different dosing regimens, and makes a descriptive assessment of the exposure–bleeding events relationship. Methods A population pharmacokinetic model was developed, using a database of 389 PwHA from five clinical studies. Potential baseline covariate effects were assessed, including body size, age, race, presence of factor VIII inhibitors, and albumin levels. Using the population pharmacokinetic model, the estimated individual average exposures over the administration period were compared across categories of annualized bleeding rate. Results A linear one-compartment model with first-order absorption and elimination processes and no lag time best described the emicizumab pharmacokinetics. Body weight, albumin levels, age, and black race were statistically correlated with primary pharmacokinetic parameters, but only body weight had an important influence on exposure. Dosing regimens of 1.5 mg/kg weekly, 3 mg/kg every 2 weeks, or 6 mg/kg every 4 weeks provided similar average concentrations at steady state. A trend for lower exposure was observed in the small proportion of PwHA having an annualized bleeding rate > 4 (11.9%), suggesting that reducing exposure to lower levels may potentially increase the bleeding risk. Conclusions Emicizumab pharmacokinetics in PwHA was described with dose-independent parameters. Body weight was an important predictor of emicizumab pharmacokinetics. All three dosing regimens are predicted to achieve similar exposure associated with clinically meaningful prevention of bleeding. Electronic supplementary material The online version of this article (10.1007/s40262-020-00904-z) contains supplementary material, which is available to authorized users.
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31
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Yoneyama K, Schmitt C, Chang T, Dhalluin C, Nagami S, Petry C, Levy GG. A Model-Based Framework to Inform the Dose Selection and Study Design of Emicizumab for Pediatric Patients With Hemophilia A. J Clin Pharmacol 2021; 62:232-244. [PMID: 34545950 PMCID: PMC9298840 DOI: 10.1002/jcph.1968] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/10/2021] [Indexed: 12/13/2022]
Abstract
Emicizumab is a bispecific antibody mimicking the cofactor function of activated coagulation factor VIII to prevent bleeds in patients with hemophilia A. The dose selection for the first-in-child phase III study of emicizumab was addressed by pediatric pharmacokinetic prediction using an adult/adolescent population pharmacokinetic model developed in phase I-I/II studies. The model was modified to incorporate functions describing the age-dependent increase in body weight (BW) with or without clearance maturation to account for the differences in emicizumab pharmacokinetics between adults/adolescents and children. A minimal dose anticipated to achieve in children the same target efficacious exposure as for adults/adolescents was identified when considering BW and clearance maturation. It was the same BW-based dose as for adults/adolescents and was selected for the starting dose for the pediatric study. Whether considering clearance maturation or not in addition to BW led to uncertainty in the pediatric pharmacokinetic prediction and dose selection, which informed implementation of a dose-adapting scheme in the study design. Exposure matching to adults/adolescents was ultimately achieved in children with the starting dose, indicating that consideration of clearance maturation in addition to BW provided adequate pediatric pharmacokinetic predictions for emicizumab. This pharmacokinetic finding in conjunction with exposure-response information served as a basis for the efficacy demonstrated in children, avoiding a time-consuming process for exploring an optimal pediatric dose of emicizumab. This experience indicates that a model-based framework helped optimize the pediatric dose selection and study design, thereby streamlining the development process with extrapolation, of emicizumab for children.
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Affiliation(s)
| | | | - Tiffany Chang
- Genentech, Inc., South San Francisco, California, USA
| | | | | | | | - Gallia G Levy
- Genentech, Inc., South San Francisco, California, USA
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Hansenne A, Hermans C. Emicizumab in acquired haemophilia A: about two clinical cases and literature review. Ther Adv Hematol 2021; 12:20406207211038193. [PMID: 34471508 PMCID: PMC8404634 DOI: 10.1177/20406207211038193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 07/19/2021] [Indexed: 01/31/2023] Open
Abstract
Acquired haemophilia A (AHA) is a rare and severe haemorrhagic autoimmune disease caused by autoantibodies directed against factor VIII (FVIII). Treatment is based on two principles, including haemostatic control to compensate FVIII inhibition and eradication of inhibiting antibodies using immunosuppressive therapy. Rapid recognition and proper management are essential to avoid excess morbidity and mortality. Effective and safe treatments can be challenging, given that AHA patients are often elderly, with multiple comorbidities. Emicizumab, a bispecific antibody that mimics the action of FVIII, has proven effective in managing patients with congenital haemophilia, with or without inhibitors. Likewise, its mode of action suggests theoretical efficacy in AHA patients. We herein describe two AHA cases with comorbidities that were treated effectively using emicizumab combined with immunosuppressive therapy. We have also reviewed the current literature regarding the promising use of emicizumab in this indication.
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Affiliation(s)
- Amandine Hansenne
- Division of Haematology, Hemostasis-Thrombosis Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Cedric Hermans
- Division of Haematology, Hemostasis-Thrombosis Unit, Cliniques universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), 10 avenue Hippocrate, 1200 Brussels, Belgium
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Jonsson F, Schmitt C, Petry C, Mercier F, Frey N, Retout S. Exposure-Bleeding Count Modeling of Emicizumab for the Prophylaxis of Bleeding in Persons with Hemophilia A with/Without Inhibitors Against Factor VIII. Clin Pharmacokinet 2021; 60:931-941. [PMID: 33709296 PMCID: PMC8249270 DOI: 10.1007/s40262-021-01006-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Emicizumab is a monoclonal antibody that bridges activated coagulation factor IX and factor X to restore effective hemostasis in persons with hemophilia A. It is indicated for routine prophylaxis of bleeding episodes in persons with hemophilia A. The aim of the present study is to describe the exposure-response relationship between emicizumab concentrations and bleeding frequency, and to confirm adequate bleeding control of the investigated dosing regimens 1.5 mg/kg once weekly, 3 mg/kg every 2 weeks, and 6 mg/kg every 4 weeks. METHODS Treated bleeding events were pooled from 445 persons with hemophilia A with and without inhibitors against factor VIII, participating in six clinical studies. Emicizumab concentrations were predicted using a previously developed population pharmacokinetic model. A count model was used to quantify the exposure-response relationship. These models were used to illustrate the relationship between emicizumab concentrations and cumulative count of bleeding over 1 year (annualized bleeding rate). RESULTS The final exposure-response model, based on a generalized Poisson distribution and an inhibitory Emax relationship, adequately describes the relationship between daily emicizumab concentrations and daily bleed frequency. A significant effect of factor VIII prophylaxis among persons with hemophilia A without inhibitors was found. Annualized bleeding rate simulations show that the three emicizumab dosing regimens maintain the concentrations close to the plateau of the effect. At the average steady-state concentration across all regimens (53.5 µg/mL), the predicted mean annualized bleeding rate is 1.28, corresponding to a 94.0% reduction from baseline. CONCLUSIONS These results confirm that average emicizumab concentrations achieved with all three emicizumab dosing regimens provide adequate bleeding control.
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Affiliation(s)
| | - Christophe Schmitt
- Clinical Pharmacology, Roche Pharma Research and Early Development, Roche Innovation Center, Basel, Switzerland
| | - Claire Petry
- Clinical Pharmacology, Roche Pharma Research and Early Development, Roche Innovation Center, Basel, Switzerland
| | - Francois Mercier
- Clinical Pharmacology, Roche Pharma Research and Early Development, Roche Innovation Center, Basel, Switzerland
| | - Nicolas Frey
- Clinical Pharmacology, Roche Pharma Research and Early Development, Roche Innovation Center, Basel, Switzerland
| | - Sylvie Retout
- Clinical Pharmacology, Roche Pharma Research and Early Development, Roche Innovation Center, Basel, Switzerland
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Abstract
INTRODUCTION Emicizumab is a bispecific antibody exerting cofactor function of FVIIIa irrespective of the presence of FVIII inhibitors. Long-term data of phase 1/2 and phase 3 studies have been accumulated. Various questions such as indicated patients, ITI, application to PUPs, hemostatic treatment including surgeries, and emicizumab-related morbidity remain to be solved. AREAS COVERED The review describes the mode of action, data from pre-/post-marketing and ongoing clinical studies according to PubMed search and our own works. EXPERT OPINION For patients with a persistent inhibitor, emicizumab is a definite therapeutic option, although the possibility of BPAs-associated thromboembolic/TMA events raises concerns. The use of ITI together with emicizumab prophylaxis is being examined in clinical trials. For non-inhibitor, especially pediatric patients, emicizumab prophylaxis can be an option. Outcome assessment 'beyond ABR' such as joint health, physical/mental activity, QOL is required. Furthermore, continuous data collection for emicizumab-related adverse events and morbidity would be recommended.
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Affiliation(s)
- Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, Kashihara-shi, Japan
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Young adult outcomes of childhood prophylaxis for severe hemophilia A: results of the Joint Outcome Continuation Study. Blood Adv 2021; 4:2451-2459. [PMID: 32492157 DOI: 10.1182/bloodadvances.2019001311] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 04/10/2020] [Indexed: 11/20/2022] Open
Abstract
The Joint Outcome Study (JOS), a randomized controlled trial, demonstrated that children with severe hemophilia A (HA) initiating prophylactic factor VIII (FVIII) prior to age 2.5 years had reduced joint damage at age 6 years compared with those treated with episodic FVIII for bleeding. The Joint Outcome Continuation Study (JOS-C) evaluated early vs delayed prophylaxis effects on long-term joint health, following JOS participants to age 18 years in an observational, partially retrospective study. Index joint magnetic resonance imaging (MRI) scores of osteochondral (OC) damage (primary outcome), joint physical examination scores, and annualized rates of joint/other bleeding episodes (secondary outcomes) were collected. Thirty-seven of 65 JOS participants enrolled in JOS-C, including 15 randomized to prophylaxis at mean age 1.3 years ("early prophylaxis"); 18 initially randomized to episodic treatment, starting "delayed prophylaxis" at mean age 7.5 years; and 4 with high-titer inhibitors. At JOS-C exit, MRI OC damage was found in 77% of those on delayed and 35% of those on early prophylaxis for an odds ratio of OC damage, in the delayed vs early prophylaxis group, of 6.3 (95% confidence interval, 1.3, 29.9; P = .02). Annualized bleeding rates were higher with delayed prophylaxis (mean plus or minus standard deviation, 10.6 ± 6.6 vs 3.5 ± 2.1; P < .001), including when only comparing time periods on prophylaxis (6.2 ± 5.3 vs 3.3 ± 1.9; P < .05). In severe HA, early initiation of prophylaxis provided continued protection against joint damage throughout childhood compared with delayed initiation, but early prophylaxis was not sufficient to fully prevent damage. This trial was registered at www.clinicaltrials.gov as #NCT01000844.
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Bukkems LH, Fischer K, Kremer-Hovinga I, Donners AAM, Fijnvandraat K, Schutgens REG, Cnossen MH, Mathôt RAA. Emicizumab Dosing in Children and Adults with Hemophilia A: Simulating a User-Friendly and Cost-Efficient Regimen. Thromb Haemost 2021; 122:208-215. [PMID: 33946119 DOI: 10.1055/a-1499-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND When emicizumab is dosed according to label, clinicians are obligated to discard or overdose medication due to discrepancies between calculated dose and vial content. The aim of this study was to compose a cost-efficient emicizumab maintenance dosing regimen using Monte Carlo simulation based on vial size, patient-friendly intervals, and patient characteristics, while striving for similar plasma concentrations as observed in clinical trials. METHODS Monte Carlo simulations were used to investigate alternative dosing regimens in patients weighing 3 to 150 kg. Simulated regimens were targeted to achieve median emicizumab plasma concentrations at a steady state (C av,ss) of 40 to 60 (90% range: 25-95) µg/mL. The cost-efficiency of the alternative dosing regimen was calculated in mg and costs saved per patient per year. RESULTS The developed alternative dosing regimen achieved similar emicizumab C av,ss levels compared with the registered dosing regimen with a median deviation of less than 2 µg/mL in 78% of the body-weight categories. A dose of 60 mg every 3 weeks was advised for children weighing 12 to 16 kg, while adults weighing 76 to 85 kg can receive 120 mg emicizumab every week. Compared with the registered weekly dosing of 1.5 mg/kg, alternative dosing saved €35,434 per year in children weighing between 12 and 16 kg. For patients weighing 76 to 85 kg, the median saving was €29,529 (range: €0-€59,057). CONCLUSION This alternative maintenance dosing scheme-applicable in patients with hemophilia A receiving emicizumab prophylaxis-reduces financial costs, avoids medication spillage, and is patient-friendly without loss of efficacy.
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Affiliation(s)
- Laura H Bukkems
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, The Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Idske Kremer-Hovinga
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Anouk A M Donners
- Department of Clinical Pharmacy, Division of Laboratory, Pharmacy, and Biomedical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karin Fijnvandraat
- Pediatric Hematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, Center for Benign Hematology, Thrombosis and Hemostasis, UMC Utrecht, Utrecht, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus University Medical Center - Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, The Netherlands
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Key Features Defining the Disposition of Bispecific Antibodies and Their Efficacy In Vivo. Ther Drug Monit 2021; 42:57-63. [PMID: 31283557 DOI: 10.1097/ftd.0000000000000668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Bispecific antibodies (BsAbs) are novel drugs, with only a few approved for clinical use. BsAbs are versatile molecules that come in many different forms and are designed and produced via genetic engineering. Although BsAbs share several pharmacokinetic (PK) and pharmacodynamic (PD) properties with monoclonal antibodies, they have their own unique characteristics based on their overall structure and specificities. BsAbs are generally more complex to investigate and develop than monoclonal antibodies, because they recognize at least 2 different antigens. Understanding their relative affinities to each target is crucial for determining their mechanism of action and efficacy. Moreover, the presence or absence of an Fc region determines, in part, their in vivo stability, distribution, and half-life. This study summarizes several PK and PD aspects that are specific for BsAbs and are important for the success of these new drugs. We emphasize previous PK/PD studies that have been fundamental for the correct prediction of appropriate dosages and schedules of these new drugs in clinical trials or for defining which drugs may take advantage of individualized and standardized drug monitoring for improved efficacy and safety.
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Peyvandi F, Garagiola I, Mannucci PM. Post-authorization pharmacovigilance for hemophilia in Europe and the USA: Independence and transparency are keys. Blood Rev 2021; 49:100828. [PMID: 33810898 DOI: 10.1016/j.blre.2021.100828] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 01/19/2023]
Abstract
The regulatory process is currently designed to ensure drug safety during the pre-marketing process. Due to limitations of the pivotal studies owing to their short duration and small number of highly selected cases, some adverse drug reactions (ADRs) are not detected, particularly the rarest and those which appear a long time after exposure. Thus it is essential to foster pharmacovigilance run totally independently from marketing authorization holders in order to attain transparent surveillance. This challenge is relevant for hemophilia drugs, after recent advances offered innovative replacement and non-replacement medicines that warrant monitoring due to the occurrence of predicted but also unexpected and rare ADRs. This article contains an overview of pharmacovigilance systems in the European Union and USA, describing the main ADRs related to traditional and recently available hemophilia medications and suggests how to involve stakeholders other than marketing authorization holders for an independent and transparent pharmacovigilance targeted to detect not only early ADRs but also those emerging post-marketing.
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Affiliation(s)
- Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy; Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy.
| | - Isabella Garagiola
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
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Yu JK, Iorio A, Chelle P, Edginton AN. Pharmacokinetic implications of dosing emicizumab based on vial size: A simulation study. Haemophilia 2021; 27:358-365. [PMID: 33650745 DOI: 10.1111/hae.14292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/15/2021] [Accepted: 02/22/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Emicizumab is dosed as mg/kg and, according to the label, any unused drug left in the vial(s) must be discarded, thereby wasting expensive resources. The aim of this study was to use population pharmacokinetics to illustrate the implications of changing the dosing interval to avoid wastage. METHODS We used a previously published emicizumab PopPK model after extending its validation to children. We simulated PK parameters for labelled dosing regimens and for regimens using full vials with infusion frequency varied to keep the steady-state drug concentration unchanged. Cost and drug savings were calculated. RESULTS The model evaluation was successful. When rounding up, the average individual below 53, 47 and 39 has a time-to-trough increase of up to 5.7, 7.9 and 5.8 days for the QW, Q2 W and Q4 W regimen, respectively. This resulted in an annual cost reduction of up to $173,136, $75,747 and $61,319 USD per patient. At higher body weights, rounding down the dose to the nearest vial resulted in negligible changes in the steady state concentration and cost savings of up to $93,781, $46,891 and $23,446 USD per patient, respectively. CONCLUSION Individuals with a lower body weight may benefit from increasing dose intervals and rounding up dose up to the nearest vial, and individuals with a higher body weight from maintaining the injection frequency and rounding dose down to the nearest vial without significant change in emicizumab levels. Administering the entire vial may result in a reduction of vials used annually and potential cost savings.
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Affiliation(s)
- Jacky K Yu
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Alfonso Iorio
- McMaster-Bayer Endowed Research Chair for Clinical Epidemiology of Congenital Bleeding Disorders, Department of Medicine; and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Pierre Chelle
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
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Takeyama M, Furukawa S, Yada K, Ogiwara K, Shimonishi N, Nakajima Y, Mizumachi K, Noguchi-Sasaki M, Shima M, Nogami K. Ex Vivo Prediction of Comprehensive Coagulation Potential Using Simulated Blood Concentrations of Emicizumab in Patients with Acquired Hemophilia A. Thromb Haemost 2021; 121:1289-1298. [PMID: 33641138 DOI: 10.1055/s-0041-1725009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Emicizumab prophylaxis improves coagulation function in congenital hemophilia A, regardless of inhibitor presence. We recently reported that emicizumab enhanced the coagulant potentials, ex vivo, in plasmas from patients with acquired hemophilia A (PwAHAs) at diagnosis. However, coagulant effects of emicizumab in PwAHAs during the clinical course remain unclear. AIM To assess ex vivo coagulant effects of emicizumab in PwAHAs during the clinical course. METHODS/RESULTS Blood samples were obtained from 14 PwAHAs on (median) days 0 and 6 during a severe-bleeding phase, and days 27 and 59 during a reduced-bleeding phase with elevated endogenous factor VIII (FVIII) and decreased inhibitor titers. If administered a single dose of 3 or 6 mg/kg, or two doses at 6 mg/kg followed by 3 mg/kg, estimated plasma emicizumab concentrations (10/5/2.5, 20/10/5, and 30/15/7.5 µg/mL on days 0-7/30/60, respectively) could be used to represent potential changes, based on the half-life (T 1/2: ∼30 days). Emicizumab concentrations that covered maximum plasma concentrations of each dosage were used for spiking on day 0. Ex vivo addition of estimated emicizumab to PwAHA's plasma containing endogenous FVIII and/or inhibitor, without and with recombinant (r)FVIIa administration during immunosuppressive therapy, increased the calculated Ad|min1| values, assessed by clot waveform analysis, and their coagulant potentials were below normal levels. Rotational thromboelastometry revealed that ex vivo emicizumab addition resulted in the further improvement of coagulant potentials in whole bloods when combined with rFVIIa administration. CONCLUSION Based on ex vivo and in vitro data, emicizumab has the potential to be effective in clinical situations for PwAHAs.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Course of Hemophilia Education, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | | | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Wang CP, Young G, Thornburg CD. Safety evaluation of emicizumab prophylaxis in individuals with haemophilia A. Expert Opin Drug Saf 2021; 20:387-396. [PMID: 33612049 DOI: 10.1080/14740338.2021.1893303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Emicizumab is a bispecific-humanized monoclonal antibody that improves hemostasis by bridging activated factor IX and factor X to substitute for the function of missing activated FVIII. It is an alternative to prophylaxis with factor VIII replacement and is associated with improved outcomes in individuals with hemophilia A with and without inhibitors. AREAS COVERED Emicizumab is efficacious in reducing bleeding events when compared to on-demand treatment and factor-based prophylaxis. Except for the few thrombotic microangiopathy and thrombotic event cases mainly seen in the HAVEN 1 trial, emicizumab has an overall excellent safety profile with minimal side effects. EXPERT OPINION Knowledge gaps include the efficacy and safety of emicizumab in younger age groups and those with mild or moderate hemophilia A. Future directions for research include exploring the risk of inhibitor recurrence in patients with a history of high titer inhibitor who have been successfully tolerized, who switch from factor prophylaxis to emicizumab, as well as conducting 'real world studies' to evaluate the patient's perception of emicizumab in regard to ease and tolerability in order to optimize individualized treatment plans.
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Affiliation(s)
- Cassandra P Wang
- Department of Pediatrics, University of California-San Diego School of Medicine, La Jolla, CA, USA
| | - Guy Young
- Division of Pediatric Hematology/Oncology, Children's Hospital Los Angeles/University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Courtney D Thornburg
- Division of Pediatric Hematology/Oncology, Rady Children's Hospital San Diego/University of California, San Diego, CA, USA
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Nakajima Y, Tonegawa H, Noguchi-Sasaki M, Nogami K. Predicted coagulation potential using an in vitro simulated model of emicizumab prophylaxis and immune tolerance induction therapy in hemophilia A patients with inhibitor. Int J Hematol 2021; 113:789-796. [PMID: 33635530 DOI: 10.1007/s12185-021-03108-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/05/2021] [Accepted: 02/18/2021] [Indexed: 11/29/2022]
Abstract
Emicizumab reduces bleeding in hemophilia A patients with inhibitor (HA-inh). A combination of immune tolerance induction therapy (ITI) and emicizumab prophylaxis may provide additional benefits, but coagulation potential during this treatment remains unknown. We assessed coagulation potentials in simulated ITI models in vitro using modified-clot waveform analysis. Factor (F)VIII-deficient plasma preincubated with anti-A2 and anti-C2 monoclonal antibodies was reacted with emicizumab (50 µg/mL) (emicizumab-HA-plasma), then spiking bypassing agents (BPAs): activated prothrombin complex concentrates (aPCC 1.3 IU/mL; 50 IU/kg), recombinant factor (rF)VIIa (2.2 µg/mL; 90 µg/kg), and FVIIa/FX (1.5 µg/mL; 60 µg/kg), and/or FVIII (100, 200 IU/dL). Coagulation potentials in emicizumab-HA-plasma (10 BU/mL) remained within the normal range when BPA and FVIII were both present. In emicizumab-HA-plasma (1 BU/mL) with BPA and FVIII (200 IU/dL), they were near or beyond the normal range, but those with a half concentration of rFVIIa based on the half-life in blood were within the normal range. In samples without inhibitor, coagulation potentials with combined BPA and FVIII were far beyond the normal range but with FVIII (100 IU/dL) and rFVIIa at half concentration they remained within the normal range. These results may provide information on the feasibility of concurrent ITI under emicizumab prophylaxis.
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Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Hitoshi Tonegawa
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
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Carcao M, Mancuso ME, Young G, Jiménez-Yuste V. Key questions in the new hemophilia era: update on concomitant use of FVIII and emicizumab in hemophilia A patients with inhibitors. Expert Rev Hematol 2021; 14:143-148. [PMID: 33499681 DOI: 10.1080/17474086.2021.1875817] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Introduction: Immune tolerance induction (ITI) is the primary therapeutic strategy and only proven method to eradicate inhibitors to coagulation factor VIII (FVIII) in hemophilia A. Emicizumab, a humanized bispecific monoclonal antibody that mimics the function of activated FVIII, has expanded options to treat hemophilia A. The availability of emicizumab necessitates a revisit of recommendations for managing patients with inhibitors.Areas covered: Current evidence is reviewed about the concomitant use of emicizumab and FVIII concentrates during and after ITI. Areas where data are lacking are highlighted and ongoing studies designed to address these issues are described.Expert opinion: Inhibitor eradication remains a desirable goal. All patients with inhibitors should be offered at least one attempt at ITI. Emicizumab monotherapy is an option for inhibitor patients who are not candidates for ITI. Evidence is emerging about the use of emicizumab during ITI to prevent bleeds. Studies are currently addressing the safety, efficacy, and feasibility of concomitant emicizumab and FVIII in ITI. As evidence regarding the risk of inhibitor recurrence and need for continued FVIII to maintain immune tolerance post-ITI is limited, the role of emicizumab alone or in combination with FVIII after ITI is the subject of an upcoming study.
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Affiliation(s)
- Manuel Carcao
- Division of Haematology/Oncology and Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Guy Young
- Children's Hospital Los Angeles, Los Angeles, University of Southern California Keck School of Medicine, CA, USA
| | - Víctor Jiménez-Yuste
- Haematology Department, Hospital Universitario La Paz, Autónoma University, Madrid, Spain
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44
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Shima M, Nagao A, Taki M, Matsushita T, Oshida K, Amano K, Nagami S, Okada N, Maisawa S, Nogami K. Long-term safety and efficacy of emicizumab for up to 5.8 years and patients' perceptions of symptoms and daily life: A phase 1/2 study in patients with severe haemophilia A. Haemophilia 2020; 27:81-89. [PMID: 33236410 PMCID: PMC7894561 DOI: 10.1111/hae.14205] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/21/2020] [Accepted: 11/03/2020] [Indexed: 02/06/2023]
Abstract
Introduction Safety and efficacy results of the phase 1 study and phase 1/2 extension study of the bispecific antibody emicizumab in patients with severe haemophilia A with or without factor VIII inhibitors for up to 2.8 years were reported previously. Aim To evaluate further longer‐term data including patients’ perceptions at study completion. Methods Emicizumab was administered subcutaneously once weekly at maintenance doses of 0.3, 1 or 3 mg/kg with potential up‐titration. All patients were later switched to the approved maintenance dose of 1.5 mg/kg. Results Eighteen patients received emicizumab for up to 5.8 years. Most adverse events were mild and unrelated to emicizumab. Annualized bleeding rates (ABRs) for bleeds treated with coagulation factors decreased from pre‐emicizumab rates or remained zero in all patients. The median ABRs were low at 1.25, 0.83 and 0.22 during the 0.3, 1 and 3 mg/kg dosing periods, respectively. Of 8 patients who decreased their doses from 3 to 1.5 mg/kg, ABRs decreased in 4, remained at zero in 2, and increased in 2. Total time spent with symptoms associated with treated bleeds decreased in all patients except 2. All patients answered ‘improved’ for bleeding severity and time until bleeding stops, except 1 answering ‘slightly improved’. Most patients answered ‘improved’ or ‘slightly improved’’ for daily life and feelings; in particular, all patients except 1 answered ‘improved’ or ‘slightly improved’ for anxiety. Conclusions Long‐term emicizumab prophylaxis for up to 5.8 years was safe and efficacious, and may improve patients’ daily lives and feelings, regardless of inhibitor status.
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Affiliation(s)
- Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Azusa Nagao
- Department of Blood Coagulation, Ogikubo Hospital, Tokyo, Japan
| | - Masashi Taki
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Japan
| | | | - Koichi Oshida
- Department of Pediatrics, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | | | | | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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45
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Wang X, Fu RY, Li C, Chen CY, Firrman J, Konkle BA, Zhang J, Li L, Xiao W, Poncz M, Miao CH. Enhancing therapeutic efficacy of in vivo platelet-targeted gene therapy in hemophilia A mice. Blood Adv 2020; 4:5722-5734. [PMID: 33216891 PMCID: PMC7686911 DOI: 10.1182/bloodadvances.2020002479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/15/2020] [Indexed: 11/20/2022] Open
Abstract
Our previous studies demonstrated that intraosseous (IO) infusion of lentiviral vectors (LVs) carrying a modified B domain-deleted factor VIII (FVIII) transgene driven by a megakaryocyte-specific promoter (GP1Bα promoter; G-F8/N6-LV) successfully transduced hematopoietic stem cells (HSCs) to produce FVIII stored in the platelet α-granules. Platelet FVIII corrected the bleeding phenotype with limited efficacy in hemophilia A (HemA) mice with and without preexisting anti-FVIII inhibitors. The present study sought to further enhance the therapeutic efficacy of this treatment protocol by increasing both the efficiency of LV transduction and the functional activity of platelet FVIII. A combined drug regimen of dexamethasone and anti-CD8α monoclonal antibody enhanced the percentage of transduced bone marrow and HSCs over time. In G-F8/N6-LV-treated HemA mice, significant improvement in phenotypic correction was observed on day 84. To improve platelet FVIII functionality, genes encoding FVIII variant F8X10K12 with increased expression or F8N6K12RH with increased functional activity compared with F8/N6 were incorporated into LVs. Treatment with G-F8X10K12-LV in HemA mice produced a higher level of platelet FVIII but induced anti-FVIII inhibitors. After treatment with combined drugs and IO infusion of G-F8/N6K12RH-LV, HemA mice showed significant phenotypic correction without anti-FVIII inhibitor formation. These results indicate that new human FVIII variant F8/N6K12RH combined with immune suppression could significantly enhance the therapeutic efficacy of in vivo platelet-targeted gene therapy for murine HemA via IO delivery. This protocol provides a safe and effective treatment for hemophilia that may be translatable to and particularly beneficial for patients with preexisting inhibitory antibodies to FVIII.
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Affiliation(s)
- Xuefeng Wang
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA
| | - Richard Y Fu
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA
| | - Chong Li
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA
| | - Chun-Yu Chen
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA
| | - Jenni Firrman
- Department of Pediatrics, Indiana University, Indianapolis, IN
| | | | - Junping Zhang
- Department of Pediatrics, Indiana University, Indianapolis, IN
| | - Lei Li
- Department of Chemistry, Georgia State University, Atlanta, GA; and
| | - Weidong Xiao
- Department of Pediatrics, Indiana University, Indianapolis, IN
| | - Mortimer Poncz
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Carol H Miao
- Center for Immunity and Immunotherapies, Seattle Children's Research Institute, Seattle, WA
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46
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Yaoi H, Shida Y, Kitazawa T, Shima M, Nogami K. Activated factor VIII-mimicking effect by emicizumab on thrombus formation in type 2N von Willebrand disease under high shear flow conditions. Thromb Res 2020; 198:7-16. [PMID: 33248318 DOI: 10.1016/j.thromres.2020.11.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/24/2020] [Accepted: 11/19/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Type 2N von Willebrand disease (2NVWD) is characterized by a mild to moderate reduction in plasma levels of factor (F)VIII associated with defective binding of von Willebrand factor (VWF) to FVIII and accelerated proteolysis and clearance of FVIII. The clinical phenotype in 2NVWD is often indistinguishable from mild/moderate hemophilia (H)A. Emicizumab is a bispecific antibody to FIX/FIXa and FX/FXa that mimics FVIIIa cofactor function, and emicizumab prophylaxis significantly reduces bleeding events in patients with severe HA. AIM We investigated the potential benefits of emicizumab in the hemostatic management of 2NVWD. PATIENTS/METHODS Perfusion chamber experiments were performed using whole blood from three 2NVWD patients with different clinical phenotypes (bleeding scores: 0, 6 and 20; mutations: p.R816W, p.R816W, and p.R365X/p.T791M, respectively). Furthermore, the impact of specific FVIII-VWF interactions on thrombus formation was investigated. RESULTS Defective thrombus formation that correlated with bleeding phenotype was evident in these 2NVWD patients. Emicizumab improved surface coverage and thrombus height in all cases. Multi-color immunostaining of thrombi further demonstrated that emicizumab enhanced thrombin generation and fibrin formation. The addition of FVIII alone to 2NVWD whole blood did not augment thrombus formation, while supplementation with FVIII/VWF complex enhanced platelet-fibrin interactions. Furthermore, an anti-FVIII monoclonal antibody known to interrupt the release of FVIIIa from VWF depressed these effects. CONCLUSIONS Emicizumab-induced enhancing effects of thrombus formation, independent on VWF, might be useful as an alternative therapy for 2NVWD patients. The extent of FVIII-VWF interaction should be optimal to deliver and release FVIII/FVIIIa on the activated platelet surface.
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Affiliation(s)
- Hiroaki Yaoi
- Dept. Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Yasuaki Shida
- Dept. Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Takehisa Kitazawa
- Chugai Pharmaceutical Co., Research Division, Gotemba, Shizuoka, Japan
| | - Midori Shima
- Dept. Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Dept. Pediatrics, Nara Medical University, Kashihara, Nara, Japan.
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47
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Cefalo MG, Ronco F, Di Felice G, Rinelli M, Oriana V, Massoud M, Merli P, Luciani M. Effectiveness of emicizumab in preventing life-threatening bleeding complications in type 3 von Willebrand disease with inhibitors: A paediatric report. Haemophilia 2020; 27:e495-e497. [PMID: 33216432 DOI: 10.1111/hae.14209] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/13/2020] [Accepted: 11/03/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Maria Giuseppina Cefalo
- Bambino Gesù Pediatric Hospital, Roma, Italy.,Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | - Francesca Ronco
- Bambino Gesù Pediatric Hospital, Roma, Italy.,Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | - Giovina Di Felice
- Bambino Gesù Pediatric Hospital, Roma, Italy.,Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | - Martina Rinelli
- Bambino Gesù Pediatric Hospital, Roma, Italy.,Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | - Vincenzo Oriana
- Bambino Gesù Pediatric Hospital, Roma, Italy.,Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | - Michela Massoud
- Bambino Gesù Pediatric Hospital, Roma, Italy.,Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | - Pietro Merli
- Bambino Gesù Pediatric Hospital, Roma, Italy.,Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
| | - Matteo Luciani
- Bambino Gesù Pediatric Hospital, Roma, Italy.,Azienda Ospedaliera Bianchi-Melacrino-Morelli, Reggio Calabria, Italy
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48
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Schmitt C, Adamkewicz JI, Xu J, Petry C, Catalani O, Young G, Negrier C, Callaghan MU, Levy GG. Pharmacokinetics and Pharmacodynamics of Emicizumab in Persons with Hemophilia A with Factor VIII Inhibitors: HAVEN 1 Study. Thromb Haemost 2020; 121:351-360. [PMID: 33086400 PMCID: PMC7895541 DOI: 10.1055/s-0040-1717114] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Emicizumab, a bispecific monoclonal antibody, bridges activated factor IX (FIXa) and FX, replacing the function of missing FVIIIa to restore effective hemostasis in persons with hemophilia A (PwHA). Here we assess pharmacokinetic (PK) and pharmacodynamic (PD) biomarkers in PwHA with FVIII inhibitors in the Phase III HAVEN 1 study (NCT02622321). Blood samples from 112 PwHA receiving 1.5 mg/kg once-weekly subcutaneous emicizumab were analyzed at central laboratories. Emicizumab concentrations for PK analysis were measured via validated immunoassay. PD effects were assessed using FVIII chromogenic activity assay containing human factors (Hyphen Biophen FVIII:C), and by FXIa-triggered thrombin generation (TG). Activated partial thromboplastin time (aPTT), prothrombin time (PT), antigen levels of FIX and FX, fibrinogen, D-dimer, and prothrombin fragment 1.2 (PF1.2) levels were determined. Emicizumab trough concentrations ≥ 50 µg/mL were maintained throughout the study. FVIII-like activity and TG (peak height) correlated with emicizumab concentrations and remained above 20 U/dL and 100 nM, respectively, with a weekly maintenance dose, theoretically converting persons with severe hemophilia A to a mild disease phenotype. aPTT was normalized at subtherapeutic concentrations of emicizumab. Plasma concentrations of target antigens FIX and FX were not significantly affected by emicizumab treatment; nor were fibrinogen, PT (international normalized ratio), D-dimer, or PF1.2. The PK profile of once-weekly emicizumab in HAVEN 1 provides sustained therapeutic plasma levels, consistent with population PK models. Both the PK profile and the PD and safety biomarkers are consistent with the established efficacy of emicizumab prophylaxis in PwHA with FVIII inhibitors.
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Affiliation(s)
- Christophe Schmitt
- Department of Clinical Pharmacology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Joanne I Adamkewicz
- Department of Oncology Biomarker Development, Genentech, Inc., South San Francisco, California, United States
| | - Jin Xu
- Department of Clinical Research, Genentech, Inc., South San Francisco, California, United States
| | - Claire Petry
- Department of Clinical Pharmacology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Olivier Catalani
- Department of Pharma-Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Guy Young
- Hemostasis and Thrombosis Program, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, United States
| | - Claude Negrier
- Hematology Department, Louis Pradel Hospital, University Claude Bernard, Lyon, France
| | - Michael U Callaghan
- Division of Hematology/Oncology, Children's Hospital of Michigan, Detroit, Michigan, United States
| | - Gallia G Levy
- Department of Pharma Development, Genentech, Inc., South San Francisco, California, United States
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49
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Yaoi H, Shida Y, Kitazawa T, Shima M, Nogami K. Emicizumab Augments Thrombus Formation in Whole Blood from Patients with Hemophilia A under High Shear Flow Conditions. Thromb Haemost 2020; 121:279-286. [PMID: 32906155 DOI: 10.1055/s-0040-1716542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Emicizumab is a bispecific antibody to factor (F) IXa and FX that mimics the FVIIIa cofactor function. Emicizumab prophylaxis markedly decreases bleeding episodes in patients with hemophilia A (PwHAs), irrespective of the presence of FVIII inhibitors. However, thrombotic microangiopathy (TMA) was reported when repeated high doses of activated prothrombin complex concentrates (aPCC) were concomitantly used with emicizumab. Although bypassing agents (BPAs) are vital in the hemostatic treatment for PwHAs with inhibitors, the mechanism of emicizumab-related TMA remains unclear. AIM To assess the risk of excessive thrombus formation associated with BPAs and emicizumab under high shear conditions. METHODS Perfusion flow-chamber experiments under high shear conditions were performed using whole blood from PwHAs in the presence of emicizumab without or together with FVIII or BPAs ex vivo. RESULTS Emicizumab (100 μg/mL) added ex vivo to whole blood from PwHAs improved defective thrombus formation in a similar manner to that observed with the addition of recombinant FVIII at the early phase, while FVIII continued to be important at the later stages. aPCC (1.2 U/mL equivalent to 100 U/kg) or recombinant FVIIa (1.1 µg/mL; equivalent to 90 µg/kg) together with emicizumab further promoted platelet interactions and fibrin formation ex vivo but did not induce excessive thrombus formation. CONCLUSION Emicizumab enhanced thrombin generation at local sites and improved defective hemostasis in whole blood from PwHAs under high shear conditions. Simple concomitant use of BPAs with emicizumab did not mediate excessive thrombus formation and remains an option for hemostatic management of emicizumab-treated PwHAs with inhibitors.
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Affiliation(s)
- Hiroaki Yaoi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Yasuaki Shida
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Takehisa Kitazawa
- Research Division, Chugai Pharmaceutical Co., Kamakura, Kanagawa, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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50
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Ogiwara K, Nogami K, Matsumoto N, Noguchi-Sasaki M, Hirata M, Soeda T, Shima M. A modified thrombin generation assay to evaluate the plasma coagulation potential in the presence of emicizumab, the bispecific antibody to factors IXa/X. Int J Hematol 2020; 112:621-630. [DOI: 10.1007/s12185-020-02959-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/18/2020] [Accepted: 07/21/2020] [Indexed: 11/25/2022]
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