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Dix C, McFadyen JD, Tran HA. Exploring the effects of Factor Xa inhibitors on thrombin generation in people with haemophilia. Thromb Res 2024; 237:148-153. [PMID: 38603817 DOI: 10.1016/j.thromres.2024.03.031] [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: 06/14/2023] [Revised: 02/29/2024] [Accepted: 03/28/2024] [Indexed: 04/13/2024]
Abstract
Optimal management of cardiovascular disease (CVD) in people with haemophilia (PWH) is a growing issue, given the continuing improvement in life expectancy among PWH. The evolving treatment paradigms targeting higher trough levels and the advent of non-factor replacement therapies (NFRT) means much of the 'protection' PWH were thought to have against CVD may be lost. There is a paucity of evidence regarding the safety of using anticoagulants in PWH. We designed a study assessing the thrombin generation (TG) of PWH of different severities and treatments, compared to non-haemophilia patients receiving a Factor Xa (FXa) inhibitor (apixaban or rivaroxaban), healthy controls, and assessing TG parameters of adding FXa inhibitor to the plasma of PWH receiving emicizumab prophylaxis. In total, 40 patients were included. TG was initiated with 5pM tissue factor (TF) using the calibrated automated thrombinoscope. Compared to those with mild haemophilia, patients receiving a FXa inhibitor had higher endogenous thrombin potential (ETP) (1278.42 vs 1831.36) and velocity index (40.71 vs 112.56), but both had a similar peak height (154.0 vs 262.63) and time to peak (both 5.83). People with severe haemophilia receiving emicizumab had significantly improved TG parameters compared to those not receiving emicizumab - ETP 1678.11 vs 809.96 and peak height 233.8 vs 92.05; however, when FXa inhibitor was added their TG parameters deteriorated to the severe haemophilia range (ETP 1179.60 and peak height 103.05). TG may provide additional useful information regarding the use of anticoagulants in PWH.
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Affiliation(s)
- Caroline Dix
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - James D McFadyen
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia; Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Huyen A Tran
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Victoria, Australia; Australian Centre for Blood Diseases, Central Clinical School, Monash University, Melbourne, Victoria, Australia.
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2
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Dix C, Dolan G, Hunt BJ. Reducing the risk of atherosclerotic cardiovascular disease in people with hemophilia: the importance of primary prevention. J Thromb Haemost 2024; 22:1304-1312. [PMID: 38309435 DOI: 10.1016/j.jtha.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/12/2024] [Accepted: 01/23/2024] [Indexed: 02/05/2024]
Abstract
Revolutionary advances in the treatment of hemophilia has led to a significant improvement in life expectancy. Associated with this has been an increase in age-related diseases especially atherosclerotic cardiovascular disease (CVD). While people with hemophilia (PWH) develop atherosclerosis at rates similar to those of the general population, rates of atherothrombosis and mortality related to CVD have been much lower, due to their hypocoagulable state. Changing treatment paradigms, aimed at reducing the risk of bleeding by improving hemostasis to levels approaching normality, has meant that the protection they are thought to have had may be lost. CVD risk factors are just as common in PWH as in the general population, but appear to be undertreated. In particular, primary prevention of CVD is vital in all individuals, but particularly in PWH as treatment of established CVD can be difficult. Active identification and management of CVD risk factors, such as obesity, physical inactivity, hypertension, and hypercholesterolemia, is required. In particular, statins have been shown to significantly reduce cardiovascular and all-cause mortality with few adverse events and no increased risk of bleeding in the general population, and their use needs urgent assessment in PWH. Further longitudinal research into preventing CVD in PWH, including accurate CVD risk assessment, is required to optimize prevention and management.
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Affiliation(s)
- Caroline Dix
- Haemophilia & Thrombosis Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Gerry Dolan
- Haemophilia & Thrombosis Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Beverley J Hunt
- Haemophilia & Thrombosis Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.
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3
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Jiménez-Yuste V, Oldenburg J, Tzeng E, Lim E, Sanabria F, Mahlangu J. Emicizumab is efficacious in people with hemophilia A with comorbidities aged ≥50 years: analysis of 4 phase III trials. Res Pract Thromb Haemost 2024; 8:102405. [PMID: 38783987 PMCID: PMC11112372 DOI: 10.1016/j.rpth.2024.102405] [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: 03/18/2024] [Revised: 04/02/2024] [Accepted: 04/04/2024] [Indexed: 05/25/2024] Open
Abstract
Background The treatment of older people with hemophilia A (HA) can be complicated by comorbidities. Objectives This post hoc analysis evaluates the efficacy and safety of emicizumab in people with HA aged ≥50 years with cardiovascular (CV) risk factors or HIV and/or hepatitis C virus (HCV) infection. Methods The HAVEN 1 (NCT02622321), HAVEN 3 (NCT02847637), HAVEN 4 (NCT03020160), and STASEY (NCT03191799) studies enrolled adults/adolescents with severe HA. Participants were categorized as having a comorbidity if they had any CV risk factors (including history of CV disease, hypertension, diabetes, hyperlipidemia, prior stroke, or obesity), HIV, and/or HCV infection. Efficacy and safety outcomes were compared by age (<50 vs ≥50 years). Results Of 504 participants at data cutoff, 408 were aged <50 years and 96 were aged ≥50 years. In people with HA aged <50 years, 26.7% had ≥1 CV risk factor and 29.4% had HIV and/or HCV infection. In people with HA aged ≥50 years, 72.9% had ≥1 CV risk factor and 74.0% had HIV and/or HCV infection. The mean (95% CI) annualized bleed rate for treated bleeds was 1.29 (0.07-6.06) for people with HA aged <50 years and 1.82 (0.19-6.93) for people with HA aged ≥50 years. No significant differences in annualized bleed rates were observed for those with comorbidities compared with those without. Safety outcomes were similar regardless of age. Conclusion This pooled analysis suggests that emicizumab efficacy and safety in people with HA aged ≥50 years with CV and HIV/HCV comorbidities were consistent with those in people with HA aged <50 years enrolled in the HAVEN 1, 3, and 4 and STASEY studies.
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Affiliation(s)
- Víctor Jiménez-Yuste
- Hematology Department, Hospital Universitario La Paz, IdiPAZ, Autónoma University, Madrid, Spain
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, Germany
| | - Eunice Tzeng
- Genentech, Inc., South San Francisco, California, USA
| | - Elise Lim
- Genentech, Inc., South San Francisco, California, USA
| | | | - Johnny Mahlangu
- Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
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4
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Camelo RM, Caram-Deelder C, Duarte BP, de Moura MCB, Costa NCDM, Costa IM, Vanderlei AM, Guimarães TMR, Gouw S, Rezende SM, van der Bom J. Cardiovascular Risk Scores among Asymptomatic Adults with Haemophilia. Arq Bras Cardiol 2023; 120:e20230004. [PMID: 37729292 PMCID: PMC10519352 DOI: 10.36660/abc.20230004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/12/2023] [Accepted: 07/17/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND The mortality rate of Brazilian people with haemophilia (PwH) is decreasing, but the relative incidence of deaths associated with cardiovascular disease (CVD) is increasing. OBJECTIVES We aimed to describe the CVD risk score of PwH according to Pooled Cohort Equations Risk (PCER) Calculator tool and its treatment recommendations. We also compared the PCER estimates with the respective Framingham Risk Score (FRS). METHODS This cross-sectional study included male PwH ≥ 40 years treated at the Comprehensive Haemophilia Treatment Centre of Pernambuco (Recife/Brazil). PwH with a previous CVD event or a low-density lipid cholesterol ≥ 5.0 mmol/L were excluded. Interviews, medical file reviews, and blood tests were performed. The PCER tool was used to estimate the CVD risk and compare it with the respective FRS. A p-value < 0.05 was accepted as statistically significant. RESULTS Thirty PwH were included. Median age was 51.5 [interquartile range-IQR; 46.0-59.5] years. The prevalence of obesity, systemic arterial hypertension, diabetes mellitus, hypertriglyceridaemia, hypercholesterolaemia, and hypoHDLaemia were 20%, 67%, 24%, 14%, 47%, and 23%, respectively. The median PCER score was 6.9% [IQR; 3.1-13.2], with 50% having a high risk (PCER ≥ 7.5%). Statin use was suggested for 54% of PwH. Blood pressure was poorly controlled in 47% of PwH. The agreement between PCER and FRS was 80% (κ = 0.60; p = 0.001). CONCLUSIONS Half of the male people with haemophilia aged 40 years or older had a 10-year high risk of developing CVD with strong recommendations to improve control of dyslipidaemia and blood pressure.
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Affiliation(s)
- Ricardo Mesquita Camelo
- Faculdade de MedicinaUniversidade Federal de Minas GeraisBelo HorizonteMGBrasilFaculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG – Brasil
- HEMOPERecifePEBrasilFundação de Hematologia e Hemoterapia de Pernambuco (HEMOPE), Recife, PE – Brasil
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenPaíses BaixosDepartment of Clinical Epidemiology, Leiden University Medical Center, Leiden – Países Baixos
| | - Camila Caram-Deelder
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenPaíses BaixosDepartment of Clinical Epidemiology, Leiden University Medical Center, Leiden – Países Baixos
- SanquinLUMCLeidenPaíses BaixosJon J van Rood Center for Clinical Transfusion Research, Sanquin/LUMC, Leiden – Países Baixos
| | - Bruna Pontes Duarte
- HEMOPERecifePEBrasilFundação de Hematologia e Hemoterapia de Pernambuco (HEMOPE), Recife, PE – Brasil
| | | | | | - Iris Maciel Costa
- HEMOPERecifePEBrasilFundação de Hematologia e Hemoterapia de Pernambuco (HEMOPE), Recife, PE – Brasil
| | - Ana Maria Vanderlei
- HEMOPERecifePEBrasilFundação de Hematologia e Hemoterapia de Pernambuco (HEMOPE), Recife, PE – Brasil
| | - Tania Maria Rocha Guimarães
- HEMOPERecifePEBrasilFundação de Hematologia e Hemoterapia de Pernambuco (HEMOPE), Recife, PE – Brasil
- Faculdade de Enfermagem Nossa Senhora das GraçasUniversidade de PernambucoRecifePEBrasilFaculdade de Enfermagem Nossa Senhora das Graças, Universidade de Pernambuco, Recife, PE – Brasil
| | - Samantha Gouw
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenPaíses BaixosDepartment of Clinical Epidemiology, Leiden University Medical Center, Leiden – Países Baixos
- Department of Pediatric HematologyEmma Children’s HospitalUniversity of AmsterdamAmsterdãPaíses BaixosDepartment of Pediatric Hematology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam,Amsterdã – Países Baixos
| | - Suely Meireles Rezende
- Faculdade de MedicinaUniversidade Federal de Minas GeraisBelo HorizonteMGBrasilFaculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG – Brasil
| | - Johanna van der Bom
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenPaíses BaixosDepartment of Clinical Epidemiology, Leiden University Medical Center, Leiden – Países Baixos
- SanquinLUMCLeidenPaíses BaixosJon J van Rood Center for Clinical Transfusion Research, Sanquin/LUMC, Leiden – Países Baixos
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Tripodi A, Mannucci PM, Peyvandi F. Hemophilia patients: are they naturally anticoagulated? Intern Emerg Med 2023; 18:1251-1254. [PMID: 37515677 DOI: 10.1007/s11739-023-03331-7] [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: 04/11/2023] [Accepted: 05/25/2023] [Indexed: 07/31/2023]
Abstract
Hemophilia is an X-linked bleeding disorder, characterized by low plasma levels of coagulation factor VIII (FVIII) (hemophilia A) or FIX (hemophilia B). Because of this, hemophilia patients (HP) were considered as naturally-anticoagulated and therefore protected from thrombosis. Over the last decades hemophilia care underwent striking changes by the introduction of prophylaxis with repeated injections of standard or modified coagulation factor products that maintain steady-state trough levels of the deficient factor. Meanwhile, new medications, not based on replacement therapy, were developed (i.e., emicizumab and others). However, emicizumab (the only licensed drug) can be used only for prophylaxis; during acute bleeding or surgery, HP require additional therapies, supplementing emicizumab with FVIII/IX concentrates or with bypassing agents (e.g., recombinant activated FVII or activated prothrombin complex concentrate). Owing to the new therapeutic strategies, the hemostatic competency of HP is now much better assured than in the past and therefore their life expectancy is considerably improved. Furthermore, the combined effects of the improved life-expectancy and of the steady-state hemostatic competence achieved by prophylaxis, make HP to be near(normal). They are, therefore, liable to be affected by the circumstantial risk factors of venous thromboembolism (VTE) that are common in the general population. Furthermore, HP undergo frequent surgery/invasive procedures (especially major orthopedic surgery) when they are treated with coagulation factor concentrates or bypassing agents that may increase the risk of post-operative VTE. Therefore, one wonders if HP should be considered for perioperative antithrombotic prophylaxis to prevent postoperative VTE.Clinical data on the value of antithrombotic prophylaxis in this setting are scanty. Indeed, data from an observational multicentre prospective study of 46 HP who underwent orthopedic surgery concluded that the prevalence of postoperative symptomatic VTE was similar to that estimated in the general population. Multicenter prospective trials are warranted to address the value of antithrombotic prophylaxis to avoid post-operative VTE in HP, especially during major surgery when regular prophylaxis is supplemented with additional coagulation factor products or bypassing agents. Until this information is available, HP undergoing major surgery whilst on antihemorrhagic prophylaxis supplemented with coagulation factor concentrates or bypassing agents, should at least receive intermittent pneumatic compression.
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Affiliation(s)
- Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy.
| | - Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Pace 9, 20122, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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6
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Schutgens RE, Jimenez-Yuste V, Escobar M, Falanga A, Gigante B, Klamroth R, Lassila R, Leebeek FW, Makris M, Owaidah T, Sholzberg M, Tiede A, Werring DJ, van der Worp HB, Windyga J, Castaman G. Antithrombotic Treatment in Patients With Hemophilia: an EHA-ISTH-EAHAD-ESO Clinical Practice Guidance. Hemasphere 2023; 7:e900. [PMID: 37304933 PMCID: PMC10256340 DOI: 10.1097/hs9.0000000000000900] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 06/13/2023] Open
Abstract
Cardiovascular disease is an emerging medical issue in patients with hemophilia (PWH) and its prevalence is increasing up to 15% in PWH in the United States. Atrial fibrillation, acute and chronic coronary syndromes, venous thromboembolism, and cerebral thrombosis are frequent thrombotic or prothrombotic situations, which require a careful approach to fine-tune the delicate balance between thrombosis and hemostasis in PWH when using both procoagulant and anticoagulant treatments. Generally, PWH could be considered as being naturally anticoagulated when clotting factors are <20 IU/dL, but specific recommendations in patients with very low levels according to the different clinical situations are lacking and mainly based on the anecdotal series. For PWH with baseline clotting factor levels >20 IU/dL in need for any form of antithrombotic therapy, usually treatment without additional clotting factor prophylaxis could be used, but careful monitoring for bleeding is recommended. For antiplatelet treatment, this threshold could be lower with single-antiplatelet agent, but again factor level should be at least 20 IU/dL for dual antiplatelet treatment. In this complex growing scenario, the European Hematology Association in collaboration with the International Society on Thrombosis and Haemostasis, the European Association for Hemophilia and Allied Disorders, the European Stroke Organization, and a representative of the European Society of Cardiology Working Group on Thrombosis has produced this current guidance document to provide clinical practice recommendations for health care providers who care for PWH.
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Affiliation(s)
- Roger E.G. Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Victor Jimenez-Yuste
- Hematology Department, La Paz University Hospital, Autonoma University, Madrid, Spain
| | - Miguel Escobar
- University of Texas Health Science Center at Houston, TX, USA
| | - Anna Falanga
- University of Milano Bicocca, School of Medicine, Monza, Italy
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Solna, Sweden
- Department of Clinical Science, Danderyd Hospital, Karolinska institutet, Stockholm, Sweden
| | - Robert Klamroth
- Department of Internal Medicine Angiology and Coagulation Disorders at the Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Germany
| | - Riitta Lassila
- Department of Hematology, Coagulation Disorders Unit, and Research Program Unit in Systems Oncology Oncosys, Medical Faculty, University of Helsinki, Finland
| | - Frank W.G. Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Michael Makris
- Haemophilia and Thrombosis Centre, University of Sheffield, United Kingdom
| | - Tarek Owaidah
- King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
| | - Michelle Sholzberg
- Division of Hematology-Oncology, Departments of Medicine, and Laboratory Medicine and Pathobiology, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Canada
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Germany
| | - David J. Werring
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom
| | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
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7
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DAVULCU EA, DEMİRCİ Z, SAYDAM G, ŞAHİN F. Multimorbidities and polypharmacy in ageing hemophilia patients. EGE TIP DERGISI 2023. [DOI: 10.19161/etd.1262533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
Aim: The aim of the study was to investigate whether multimorbidities, comorbidities, and therefore polypharmacy increase with age in hemophilia A and B patients followed in Ege University Adult Hemophilia and Thrombosis Center.
Materials and Methods: Adult hemophilia A and B patients were retrospectively evaluated. Patients'demographic data, medical information about hemophilic arthropathy, viral infections hepatitis C virus (HCV), body mass index (BMI), smoking and alcohol consumption, concomitant diseases, and all medications except factor replacement therapy were analyzed. Polypharmacy was defined as ≥5 drug use. Patients were compared by dividing into two groups: ≤55 years and >55 years.
Results: A total of 230 patients were evaluated (189 hemophilia A, 41 hemophilia B). There were 191 patients in ≤55 years (83%), and 39 patients in >55 years age groups (17%). The most common diseases in hemophilia patients were hypertension (19.5%), diabetes mellitus (10%), and gastroesophageal reflux disease-chronic gastritis (5.2%). The most common drugs that patients use
regularly were non-steroidal anti-inflammatory drugs (14.3%), proton pump inhibitors (12.1%), and oral antidiabetics (9.5%). The number of diseases not related to hemophilia (multimorbidity) and
polypharmacy in hemophilia patients aged >55 years was significantly higher than those aged
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Affiliation(s)
- Eren Arslan DAVULCU
- University of Health Sciences Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Hematology Clinic, İstanbul, Türkiye
| | - Zühal DEMİRCİ
- Ege University Faculty of Medicine, Department of Internal Medicine, Hematology, İzmir, Türkiye
| | - Güray SAYDAM
- Ege University Faculty of Medicine, Department of Internal Medicine, Hematology, İzmir, Türkiye
| | - Fahri ŞAHİN
- Ege University Faculty of Medicine, Department of Internal Medicine, Hematology, İzmir, Türkiye
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Di Minno G, Castaman G, De Cristofaro R, Brunetti-Pierri N, Pastore L, Castaldo G, Trama U, Di Minno M. Progress, and prospects in the therapeutic armamentarium of persons with congenital hemophilia. Defining the place for liver-directed gene therapy. Blood Rev 2023; 58:101011. [PMID: 36031462 DOI: 10.1016/j.blre.2022.101011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 02/07/2023]
Abstract
In persons with congenital severe hemophilia A (HA) living in high-income countries, twice weekly intravenous infusions of extended half-life (EHL) factor VIII (FVIII) products, or weekly/biweekly/monthly subcutaneous injections of emicizumab are the gold standard home treatments to grant days without hurdles and limitations. Once weekly/twice monthly infusions of EHL Factor IX (FIX) products achieve the same target in severe hemophilia B (HB). Gene therapy, which is likely to be licensed for clinical use within 1-2 years, embodies a shift beyond these standards. At an individual patient level, a single functional gene transfer leads to a > 10-yr almost full correction of the hemostatic defect in HB and to a sustained (3-6-yrs) expression of FVIII sufficient to discontinue exogenous clotting factor administrations. At the doses employed, the limited liver toxicity of systemically infused recombinant adeno-associated virus (rAAV) vectors is documented by long-term (12-15 yrs) follow-ups, and pre-existing high-titer neutralizing antibodies to the AAV5 vector are no longer an exclusion criterion for effective transgene expression with this vector. A safe durable treatment that converts a challenging illness to a phenotypically curable disease, allows persons to feel virtually free from the fears and the obligations of hemophilia for years/decades. Along with patient organizations and health care professionals, communicating to government authorities and reimbursement agencies the liberating potential of this substantial innovation, and disseminating across the Centers updated information on benefits and risks of this strategy, will align expectations of different stakeholders and establish the notion of a potentially lifelong cure of hemophilia.
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Affiliation(s)
- Giovanni Di Minno
- Hub Center for Hemorrhagic and Thrombotic Disorders, Dep. of Clinical Medicine and Surgery, School of Medicine, Federico II University, Naples, Italy.
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy.
| | - Raimondo De Cristofaro
- Center for Hemorrhagic and Thrombotic Diseases, Foundation University Hospital A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy.
| | - Nicola Brunetti-Pierri
- Telethon Institute of Genetics and Medicine, Pozzuoli, Italy; Dept of Translational Medicine, School of Medicine, Università degli Studi di Napoli "Federico II", Italy.
| | - Lucio Pastore
- CEINGE-Biotecnologie Avanzate, and Department of Molecular Medicine and Medical Biotechnology, School of Medicine, University of Naples Federico II, 80131 Naples, Italy.
| | - Giuseppe Castaldo
- CEINGE-Biotecnologie Avanzate, and Department of Molecular Medicine and Medical Biotechnology, School of Medicine, University of Naples Federico II, 80131 Naples, Italy.
| | - Ugo Trama
- Coordination of the Regional Health System, General Directorate for Health Protection, Naples, Italy.
| | - Matteo Di Minno
- Hub Center for Hemorrhagic and Thrombotic Disorders, Dep. of Clinical Medicine and Surgery, School of Medicine, Federico II University, Naples, Italy.
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9
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Schnohr C, Ekholm O, Poulsen LH, Lehrmann L, Andersen T, Funding E, Holm KB, Bjorner JB. Health and quality of life of patients with haemophilia: A national study of 124 Danish men. Haemophilia 2023; 29:538-544. [PMID: 36729615 DOI: 10.1111/hae.14751] [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: 09/13/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 02/03/2023]
Abstract
PURPOSE In the past decades, haemophilia treatment has greatly improved the health of persons with haemophilia (PWH). This study compares PWH to the general population on social conditions and health. METHODS In December 2021, all Danes with moderate or severe haemophilia A or B, or von Willebrands disease type 3 were invited to participate in an online self-report survey concerning sociodemographic factors, self-rated health, teeth status, chronic health conditions, symptoms and loneliness. This study compares responses from the 124 adult male PWH with responses from a male general population sample (N = 4849). Analyses used logistic regression, controlling for age and highest completed education. RESULTS Fewer PWH were in the oldest age group (65-84 years). Controlling for age, no significant differences were found regarding cohabitation status or education. Fewer PWH were employed (OR = .48, [.33-.71])-particularly in the 45-64 age group. PWH were less likely to report good health (OR = .49, [.31-.77]). The odds of joint disease was much higher (OR = 13.00, [8.37-20.28]). Also, hypertension (OR = 2.25, [1.13-5.65]) and previous stroke (OR = 2.51, [1.44-3.50]) were more frequent. PWH were more likely to report pain in the arms/hands/legs/hips (OR = 2.94, [1.92-4.52]), but less likely to report pain in the head/neck/shoulder (OR = .66, [.45-.96]). CONCLUSION The disease burden of haemophilia has improved so PWH resembles the general population in areas such as marriage and education. However, even for young PWH, the disease still imposes a significant burden from hemophilia arthropathy and pain in extremities and joints. Middle-aged PWH also have poorer levels of employment than same-aged peers.
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Affiliation(s)
- Christina Schnohr
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ola Ekholm
- National Institute of Public Health, Copenhagen, Denmark
| | | | | | | | - Eva Funding
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Jakob Bue Bjorner
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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10
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Ter-Zakarian A, Al Banaa K, Barnes R, von Drygalski A. Hypertension in haemophilia: A meta-analysis. Haemophilia 2023; 29:352-356. [PMID: 36413602 DOI: 10.1111/hae.14686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 09/14/2022] [Accepted: 10/15/2022] [Indexed: 11/24/2022]
Affiliation(s)
- Anna Ter-Zakarian
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, California, USA
| | - Kadhim Al Banaa
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, California, USA
| | - Richard Barnes
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, California, USA
| | - Annette von Drygalski
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, California, USA.,Department of Molecular Medicine, The Scripps Research Institute, La Jolla, California, USA
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11
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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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12
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KİLİNCER BOZGUL SM, ATİLLA FD, AK G, TÜRK UÖ, BARUTCUOĞLU B, SAYDAM G, ŞAHİN F. Evaluation of cardiovascular disease risk factors, inflammatory markers and subclinical atherosclerosis in patients with hemophilia. EGE TIP DERGISI 2022. [DOI: 10.19161/etd.1208982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aim: To assess and compare the risk factors of cardiovascular disease (CVD) between patients with hemophilia (PwH) and healthy controls in a single center cohort in Turkey.
Material and Methods: Anthropometric parameters including height, weight, and body mass index were recorded. Fasting glucose, HbA1c, high sensitive C-Reactive Protein (hs-CRP), adiponectin, lipid parameters (total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides) were assessed. International Physical Activity Questionnaires (IPAQ) and carotid intima media thickness (CIMT) measurements were performed. The data from PwH (n=80) and healthy controls (n=36) were compared. Independent associates of CIMT value were analyzed.
Results: Hypertension, diabetes mellitus, metabolic syndrome and smoking frequencies were remarkable in PwH. Family history of CVD was significantly more frequent ( p=0.005) and when considered with IPAQ scores; PwH was much more sedentary than controls (p<0.001). Total cholesterol, LDL-cholesterol were significantly higher in the control group (p =0.003,=0.003) while hs-CRP levels were higher in PwH (p=0.009). Age and IPAQ score were significant independent predictors of CIMT (p=0.004 and 0.003, respectively).
Conclusion: As a result of aging; PwH exposure to the same CVD risk factors as the general population. Screening for CVD risk factors in PwH other than hemophilia evaluation will be essential.
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Affiliation(s)
| | - Fatoş Dilan ATİLLA
- Bakircay University, Ciğli Education and Research Hospital, Department of Internal Medicine, Division of Hematology
| | - Güneş AK
- Ege University, Faculty of Medicine, Department of Clinical Biochemistry
| | | | - Burcu BARUTCUOĞLU
- Ege University, Faculty of Medicine, Department of Clinical Biochemistry
| | - Güray SAYDAM
- Ege University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Ege Adult Hemophilia and Thrombosis Center,
| | - Fahri ŞAHİN
- Ege University, Faculty of Medicine, Department of Internal Medicine, Division of Hematology, Ege Adult Hemophilia and Thrombosis Center,
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13
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Novais T, Prudent C, Cransac A, Gervais F, Jouglen J, Gigan M, Cahoreau V, Chamouard V. Polypharmacy and medication regimen complexity in older patients with hemophilia or von willebrand disease: the M'HEMORRH-AGE study. Int J Clin Pharm 2022; 44:922-929. [PMID: 35704151 DOI: 10.1007/s11096-022-01401-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: 10/18/2021] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND In older patients, multiple chronic conditions lead topolypharmacy which is associated with a higher risk of adverse drug events. Nowadays, the medication exposure of older patients with bleeding disorders has been poorly explored. AIM The aim of this study was to assess the prevalence of polypharmacy and the medication regimen complexity in older community-dwelling patients with hemophilia or von Willebrand Disease (VWD). METHOD The M'HEMORRH-AGE study (Medication in AGEd patients with HEMORRHagic disease) is a multicenter prospective observational study. Community-dwelling patients over 65 years with hemophilia or VWD were included in the study. The rate of polypharmacy (use of 5 to 9 drugs daily) and excessive polypharmacy (use of 10 or more medications daily) was assessed. The complexity of prescribed medication regimens was assessed using the Medication Regimen Complexity Index (MRCI). RESULTS Overall, 142 older community-dwelling patients with hemophilia (n = 89) or VWD (n = 53) were included (mean age: 72.8 (5.8) years). Prevalence of polypharmacy and excessive polypharmacy were 40.8% and 17.6%, respectively. The mean MRCI score was 16.9 (6.1). The mean MRCI score related to bleeding disorders medications was 6.9 (1.1). There was no significant difference between older hemophilia patients and VWD patients. CONCLUSION The M'HEMORRH-AGE study showed that more than half of older community-dwelling patients were affected by polypharmacy. In addition, the high medication regimen complexity in this older population suggests that interventions focusing on medication review and deprescribing should be conducted to reduce polypharmacy with its negative health-related outcomes.
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Affiliation(s)
- Teddy Novais
- Pharmaceutical Unit, Charpennes Hospital, University Hospital of Lyon, 27 rue Gabriel Péri, FR-69100 Villeurbanne, Lyon, France.
- Research on Healthcare Performance (RESHAPE), University Lyon 1, INSERM U1290, Lyon, France.
| | | | - Amélie Cransac
- Pharmaceutical Unit, F. University Hospital of Dijon, Dijon, France
- LNC-UMR1231, University of Burgundy and Franche Comté, Dijon, France
| | - Frederic Gervais
- Pharmaceutical Unit, Charpennes Hospital, University Hospital of Lyon, 27 rue Gabriel Péri, FR-69100 Villeurbanne, Lyon, France
| | - Julien Jouglen
- Pharmaceutical Unit, University Hospital of Toulouse, Toulouse, France
- PERMEDES Group « Plateforme d'Echange et de Recherche sur les MEdicaments DErivés du Sang », Société française de pharmacie clinique, Toulouse, France
| | - Mickael Gigan
- Pharmaceutical Unit, Pellegrin Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Véronique Cahoreau
- PERMEDES Group « Plateforme d'Echange et de Recherche sur les MEdicaments DErivés du Sang », Société française de pharmacie clinique, Toulouse, France
- Pharmaceutical Unit, Pellegrin Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Valérie Chamouard
- PERMEDES Group « Plateforme d'Echange et de Recherche sur les MEdicaments DErivés du Sang », Société française de pharmacie clinique, Toulouse, France
- Pharmaceutical Unit, Louis Pradel Hospital, University Hospital of Lyon, Lyon, France
- Hemophilia and Thrombosis Center, University Hospital of Lyon, Lyon, France
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14
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Vithanage T, Ratnamalala V, Wickramaratne C, Katulanda G, Rodrigo CH. Prevalence of cardiovascular diseases and risk factors in adult patients with haemophilia: a cross-sectional study in a tertiary care hospital clinic in Sri Lanka. BMC Cardiovasc Disord 2022; 22:343. [PMID: 35907807 PMCID: PMC9339172 DOI: 10.1186/s12872-022-02789-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 07/25/2022] [Indexed: 11/24/2022] Open
Abstract
Background Management of cardiovascular disease (CVD) in patients with haemophilia is extremely challenging. Therefore, knowing the prevalence of CVD and risk factors in this population is imperative. Methods All consented patients ≥ 18 years of age attending the haemophilia clinic at a tertiary care centre were recruited to the study. Data were collected using a pretested, investigator administered questionnaire. Seated blood pressure, anthropometric measurements and blood samples were obtained using standard techniques. Lipid profile and fasting plasma glucose were estimated. Prevalence of risk factors for CVD was compared with those of age matched males in the general population. P values < 0.05 were considered significant. Results Of the total 109 participants, 92 (84.4%) had haemophilia A. The median age of the study group was 36 years. Three (2.8%) had at least one cardiovascular disease. There were 10 (9.2%), 30 (27.5%), 13 (11.9%) and 4 (3.7%) participants with diabetes, hypertension, current smoking and obesity (Body Mass Index (BMI) ≥ 30 kg/m2) respectively. 32 (29.4%) and 37 (33.9%) participants had waist circumference ≥ 90 cm and waist hip ratio ≥ 0.9 respectively. 38 (34.9%) had total cholesterol ≥ 200 mg/dl, 43 (39.5%) had low density lipoprotein (LDL) cholesterol ≥ 130 mg/dl, 25 (22.9%) had triglycerides (TG) ≥ 150 mg/dl and 58 (53.2%) had High density lipoprotein (HDL) cholesterol < 40 mg/dl. Diabetes was significantly associated with factor levels below 5% (p = 0.038). BMI, waist circumference and dyslipidaemia in the study were significantly higher compared to the general population. Conclusion The study signifies an increased prevalence of risk factors for CVD among patients with haemophilia and the need for preventive measures.
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Affiliation(s)
| | | | | | - Gaya Katulanda
- Chemical Pathology Unit, National Hospital of Sri Lanka, Colombo, Sri Lanka
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15
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Barnes RFW, Pandey B, Sun HL, Jackson S, Kruse-Jarres R, Quon DV, von Drygalski A. Diabetes, hepatitis C and human immunodeficiency virus influence hypertension risk differently in cohorts of haemophilia patients, veterans and the general population. Haemophilia 2022; 28:e228-e236. [PMID: 35877992 DOI: 10.1111/hae.14637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/16/2022] [Accepted: 07/09/2022] [Indexed: 01/15/2023]
Abstract
INTRODUCTION The reasons for the high prevalence of hypertension in persons with haemophilia (PWH) are poorly understood. AIM To examine the roles of diabetes, Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV) in the etiology of hypertension for PWH. METHODS Retrospective cross-sectional design. Adult PWH (n = 691) were divided into two groups: (A) free of diabetes, HCV and HIV; (B) with diabetes and/or HCV positivity and/or HIV positivity. Each group was matched by race and age with random samples from the general population of the US (National Health and Nutrition Examination Surveys, NHANES) and outpatients at the Veterans Affairs Medical Center (VAMC) in San Diego. Generalized additive models (GAMs) were fitted for graphical analysis of hypertension risk over the lifespan. RESULTS In Group A, PWH had the highest prevalence of hypertension compared to NHANES and VAMC, especially in young adults. In Group B, diabetes increased the risk of hypertension for all three cohorts (PWH, NHANES and VAMC), especially for PWH. In PWH, hypertension risk was also increased by HIV, in NHANES by HCV, and in VAMC by HCV and HIV. CONCLUSION Diabetes conferred the greatest risk of hypertension for all three cohorts. However, curves of hypertension in relation to age revealed that diabetes, HCV and HIV modulated hypertension risk differently in PWH. PWH experienced a disproportionally high risk increase with diabetes. Therefore, haemophilia care should include screening for hypertension and diabetes at a young age.
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Affiliation(s)
- Richard F W Barnes
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Braj Pandey
- Department of Medicine, University of California San Diego, San Diego, California, USA.,Department of Primary Care, Veterans Affairs Medical Center, San Diego, California, USA
| | | | | | - Rebecca Kruse-Jarres
- Washington Center for Bleeding Disorders at Bloodworks Northwest, Seattle, Washington, USA
| | - Doris V Quon
- Orthopaedic Institute for Children, Los Angeles, California, USA
| | - Annette von Drygalski
- Department of Medicine, University of California San Diego, San Diego, California, USA
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16
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Ter-Zakarian A, Barnes RFW, Kruse-Jarres R, Quon DV, Jackson S, Sun HL, Drygalski AV. Blood pressure in persons with haemophilia with a focus on haemophilia-specific risk factors. Haemophilia 2022; 28:977-985. [PMID: 35768896 DOI: 10.1111/hae.14614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/26/2022] [Accepted: 06/12/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Persons with haemophilia (PWH) have a higher prevalence of hypertension compared to the general population, which cannot be explained entirely by the usual cardiovascular risk factors. Neutralizing antibodies (inhibitors) against clotting factors might have some relation to cardiovascular disease in PWH. However, whether inhibitors facilitate hypertension is unknown. AIM We investigated the relationship between hypertension/blood pressure and inhibitors in PWH. Additional goals were to determine the relationships with haemophilia type, race, and viral status. METHODS Records were extracted retrospectively for PWH (age ≥18 years) between 2003 and 2014 from four Hemophilia Treatment Centers in North America and included demographics, weight, height, haemophilia type/severity, HCV and HIV infection status, hypertension, use of anti-hypertensive medications, and inhibitor status. We fitted semiparametric generalized additive models (GAMs) to describe adjusted curves of blood pressure (BP) against age. RESULTS Among 691 PWH, 534 had haemophilia A and 157 had haemophilia B, with a median age of 39 years (range 18 to 79). Forty-four PWH (6.5%) had a history of inhibitors, without evidence for a higher prevalence of hypertension or higher BP. A higher prevalence of hypertension and higher BP were noted for haemophilia A (vs. haemophilia B), coinfection with HCV/HIV (vs. uninfected), or moderate haemophilia (vs. severe haemophilia). CONCLUSION While there was no signal to suggest that a history of inhibitors is associated with hypertension, differences based on haemophilia type, severity, and viral infection status were identified, encouraging prospective investigations to better delineate haemophilia-specific risk factors for hypertension.
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Affiliation(s)
- Anna Ter-Zakarian
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, California, USA
| | - Richard F W Barnes
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, California, USA
| | - Rebecca Kruse-Jarres
- Washington Center for Bleeding Disorders and University of Washington, Seattle, Washington, USA
| | - Doris V Quon
- Orthopaedic Hemophilia Treatment Center, Orthopaedic Institute for Children, Los Angeles, California, USA
| | - Shannon Jackson
- Department of Medicine, Division of Hematology, University of British Columbia, Vancouver, California, USA
| | - Haowei Linda Sun
- Department of Medicine, Division of Hematology, University of Alberta, Edmonton, California, USA
| | - Annette von Drygalski
- Department of Medicine, Division of Hematology/Oncology, University of California San Diego, San Diego, California, USA
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17
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Acute coronary syndrome in patients with hemophilia: a delicate balancing act. J Thromb Thrombolysis 2022; 54:323-329. [PMID: 35543796 DOI: 10.1007/s11239-022-02664-y] [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] [Accepted: 04/24/2022] [Indexed: 10/18/2022]
Abstract
Therapeutic advances have resulted in increased life expectancy in patients with hemophilia. Consequently, the prevalence of coronary artery disease in this population is increasing. Little is known about the optimal management of acute coronary syndrome in these patients. Current guidelines for the management of this condition are based mainly on expert opinion and generally recommend administration of the clotting factor prior to the anticoagulant, antiplatelet, and interventional therapies. We report a case that illustrates the potential harm that may come from this approach: evolution of non-ST-segment elevation acute coronary syndrome into ST-elevation acute coronary syndrome during the administration of recombinant clotting factor. We review available literature and describe the refined informatics-based guidelines for managing acute coronary syndrome in patients with hemophilia we developed in response to the presented clinical case. We propose adopting this novel informatics-based approach, which aids in the identification and early treatment of these patients, operationalizes timely involvement of hematology experts, and gathers data for further study.
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18
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Badescu MC, Badulescu OV, Butnariu LI, Floria M, Ciocoiu M, Costache II, Popescu D, Bratoiu I, Buliga-Finis ON, Rezus C. Current Therapeutic Approach to Atrial Fibrillation in Patients with Congenital Hemophilia. J Pers Med 2022; 12:519. [PMID: 35455634 PMCID: PMC9029474 DOI: 10.3390/jpm12040519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 11/21/2022] Open
Abstract
Cardiovascular disease in hemophiliacs has an increasing prevalence due to the aging of this population. Hemophiliacs are perceived as having a high bleeding risk due to the coagulation factor VIII/IX deficiency, but it is currently acknowledged that they also have an important ischemic risk. The treatment of atrial fibrillation (AF) is particularly challenging since it usually requires anticoagulant treatment. The CHA2DS2-VASc score is used to estimate the risk of stroke and peripheral embolism, and along with the severity of hemophilia, guide the therapeutic strategy. Our work provides the most complete, structured, and updated analysis of the current therapeutic approach of AF in hemophiliacs, emphasizing that there is a growing interest in therapeutic strategies that allow for short-term anticoagulant therapy. Catheter ablation and left atrial appendage occlusion have proven to be efficient and safe procedures in hemophiliacs, if appropriate replacement therapy can be provided.
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Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Oana Viola Badulescu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (O.V.B.); (M.C.)
- Hematology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Lacramioara Ionela Butnariu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mariana Floria
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- Internal Medicine Clinic, “Dr. Iacob Czihac” Emergency Military Clinical Hospital Iasi, 700483 Iasi, Romania
| | - Manuela Ciocoiu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (O.V.B.); (M.C.)
| | - Irina-Iuliana Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
| | - Ioana Bratoiu
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Oana Nicoleta Buliga-Finis
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
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19
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Walker GE, Merlin S, Zanolini D, Vandoni A, Volpe A, Gaidano G, Valente G, Olivero M, Follenzi A. Factor VIII as a potential player in cancer pathophysiology. J Thromb Haemost 2022; 20:648-660. [PMID: 34847278 PMCID: PMC9306727 DOI: 10.1111/jth.15611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 11/29/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Trousseau sign was the first demonstration of a close relationship between cancer and thrombosis. Currently, venous thromboembolism (VTE) is five to six times more likely to occur in cancer patients, whereas there is a greater risk of cancer diagnoses following thromboses. In considering novel players, factor VIII (FVIII), an essential coagulation cofactor with emerging extracoagulative functions, has been identified as an independent VTE risk factor in cancer; however, the basis of this increase is unknown. OBJECTIVE To investigate the possible direct expression and secretion of FVIII by cancer cells. METHODS Bladder cancer, with a high VTE risk, and normal bladder tissue and epithelium, were used to investigate FVIII. Factor VIII protein and secretion were examined in bladder cancer cell lines. Expanding to other cancers, the Cancer Cell line Encyclopedia database was used to analyze FVIII, tissue factor, FV, FVII, FIX, FX, and von Willebrand factor (VWF) mRNA in 811 cell lines subdivided according to origin. Factor VIII protein synthesis, secretion, and bioactivity were investigated in a profile of cancer cell lines of differing origins. RESULTS AND CONCLUSIONS Although expressed in the normal bladder epithelium, FVIII mRNA and protein were higher in matched bladder neoplasms, with synthesis and secretion of bioactive FVIII evident in bladder cancer cells. This can be extended to other cancer cell lines, with a pattern reflecting the tumor origin, and that is independent of VWF and other relevant players in the coagulation cascade. Here, evidence is provided of a possible independent role for FVIII in cancer-related pathophysiology.
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Affiliation(s)
- Gillian E. Walker
- Department of Health SciencesUniversità del Piemonte OrientaleNovaraItaly
| | - Simone Merlin
- Department of Health SciencesUniversità del Piemonte OrientaleNovaraItaly
| | - Diego Zanolini
- Department of Health SciencesUniversità del Piemonte OrientaleNovaraItaly
| | - Andrea Vandoni
- Department of Translational MedicineUniversità del Piemonte OrientaleNovaraItaly
| | - Alessandro Volpe
- Department of Translational MedicineUniversità del Piemonte OrientaleNovaraItaly
| | - Gianluca Gaidano
- Department of Translational MedicineUniversità del Piemonte OrientaleNovaraItaly
| | - Guido Valente
- Department of Translational MedicineUniversità del Piemonte OrientaleNovaraItaly
| | - Martina Olivero
- Department of OncologyUniversity of TorinoTorinoItaly
- Candiolo Cancer Institute‐FPOIRCCSCandiolo, TorinoItaly
| | - Antonia Follenzi
- Department of Health SciencesUniversità del Piemonte OrientaleNovaraItaly
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20
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Abou-Ismail MY, Connell NT. How to manage bleeding disorders in aging patients needing surgery. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:529-535. [PMID: 34889441 PMCID: PMC8791143 DOI: 10.1182/hematology.2021000288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
With improvements in medical care, the life expectancy of patients with bleeding disorders is approaching that of the general population. A growing population of older adult patients with bleeding disorders is at risk of age-related comorbidities and in need of various elective and emergent age-related procedures. The increased risk of thrombosis and volume overload in older adults complicates perioperative hemostatic management. Furthermore, antithrombotic treatment such as antiplatelet or anticoagulant therapy, which is frequently required for various cardiovascular interventions, requires a meticulous individualized approach. Evidence-based guidelines for the management of aging patients with bleeding disorders are lacking, largely due to the underrepresentation of older adult patients in clinical trials as well as the rarity of many such bleeding disorders. We discuss the current guidelines and recommendations in the perioperative hemostatic management of older adult patients with hemophilia and von Willebrand disease as well as other rare bleeding disorders. The optimal management of these patients is often complex and requires a thorough multidisciplinary and individualized approach involving hematologists, surgeons, anesthesiologists, and the specialists treating the underlying disorder.
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Affiliation(s)
- Mouhamed Yazan Abou-Ismail
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Nathan T Connell
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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21
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Reduced cardiovascular morbidity in patients with hemophilia: results of a 5-year multinational prospective study. Blood Adv 2021; 6:902-908. [PMID: 34879394 PMCID: PMC8945305 DOI: 10.1182/bloodadvances.2021005260] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 11/08/2021] [Indexed: 11/20/2022] Open
Abstract
In this prospective study, PWH have a lower-than-predicted incidence of CVD. The QRISK-2011 risk predictor is not valid for PWH.
Hemophilia is a congenital bleeding disorder caused by low levels of clotting factor VIII or IX. The life expectancy of people with hemophilia (PWH) has increased with the availability of clotting factor concentrates. At the same time, the incidence of cardiovascular disease (CVD) has increased; in retrospective studies, there are conflicting data regarding if, despite this increase, the incidence is still lower than in the general population. We prospectively compared the incidence of CVD in PWH vs the predicted incidence. This prospective, multicenter, observational study included adult PWH (aged >30 years) from The Netherlands and United Kingdom. They were followed up for a 5-year period, and CVD incidence was compared with a predicted event rate based on the QRISK2-2011 CVD risk model. The primary end point was the observed fatal and nonfatal CVD incidence after 5 years compared with the estimated events and in relation to severity of hemophilia. The study included 709 patients, of whom 687 (96.9%) completed 5 years’ follow-up or reached an end point. For 108 patients, the QRISK score could not be calculated at inclusion. For the remaining 579, fewer CVD events were observed than predicted: 9 vs 24 (relative risk, 0.38; 95% confidence interval, 0.18-0.80; P = .01), corresponding with an absolute risk reduction of 2.4%. Severe hemophilia treated on demand had the highest risk reduction. There was no statistically significant relation between severity of hemophilia and incidence of CVD. In hemophilia, a lower-than-predicted CVD incidence was found, supporting the theory that hemophilia protects against CVD. The study is registered at www.clinicaltrials.gov as #NCT01303900.
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22
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Faghmous I, Nissen F, Kuebler P, Flores C, Patel AM, Pipe SW. Estimating the risk of thrombotic events in people with congenital hemophilia A using US claims data. J Comp Eff Res 2021; 10:1323-1336. [PMID: 34676773 DOI: 10.2217/cer-2021-0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Compare thrombotic risk in people with congenital hemophilia A (PwcHA) to the general non-hemophilia A (HA) population. Patients & methods: US claims databases were analyzed to identify PwcHA. Incidence rates of myocardial infarction, pulmonary embolism, ischemic stroke, deep vein thrombosis and device-related thrombosis were compared with a matched cohort without HA. Results: Over 3490 PwcHA were identified and 16,380 individuals matched. PwcHA had a similar incidence of myocardial infarction and pulmonary embolism compared with the non-HA population, but a slightly higher incidence of ischemic stroke and deep vein thrombosis. The incidence of device-related thrombosis was significantly higher in PwcHA. Conclusion: This analysis suggests that PwcHA are not protected against thrombosis, and provides context to evaluate thrombotic risk of HA treatments.
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Affiliation(s)
- Imi Faghmous
- Real-World Data Oncology-Hematology, F. Hoffmann-La Roche Ltd, Grenzacherstrasse 124, Basel, 4070, Switzerland
- Current affiliation: Health, Medicine & Life Sciences, University of Maastricht, Minderbroedersberg 4-6, 6211, LK Maastricht, The Netherlands
| | - Francis Nissen
- Real-World Data Oncology-Hematology, F. Hoffmann-La Roche Ltd, Grenzacherstrasse 124, Basel, 4070, Switzerland
| | - Peter Kuebler
- PHC Safety Interface, Genentech, Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Carlos Flores
- Evidence Strategy, Genesis Research Hoboken, 111 River St Ste 1120, Hoboken, NJ 07030, USA
| | - Anisha M Patel
- US Medical Affairs, Genentech, Inc., 1 DNA Way, South San Francisco, CA 94080, USA
| | - Steven W Pipe
- Pediatrics and Pathology, University of Michigan, D4202 MPB, 1500 E Medical Center Drive, Ann Arbor, MI 48109-5718, USA
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23
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Badescu MC, Ciocoiu M, Rezus E, Badulescu OV, Tanase DM, Ouatu A, Dima N, Ganceanu-Rusu AR, Popescu D, Seritean Isac PN, Genes TM, Rezus C. Current Therapeutic Approach to Acute Myocardial Infarction in Patients with Congenital Hemophilia. Life (Basel) 2021; 11:1072. [PMID: 34685443 PMCID: PMC8537181 DOI: 10.3390/life11101072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/07/2021] [Accepted: 10/09/2021] [Indexed: 12/22/2022] Open
Abstract
Advances in the treatment of hemophilia have made the life expectancy of hemophiliacs similar to that of the general population. Physicians have begun to face age-related diseases not previously encountered in individuals with hemophilia. Treatment of acute myocardial infarction (AMI) is particularly challenging because the therapeutic strategies influence both the patient's thrombotic and hemorrhagic risk. As progress has been made in the treatment of AMI over the last decade, we performed an in-depth analysis of the available literature, highlighting the latest advances in the therapy of AMI in hemophiliacs. It is generally accepted that after the optimal substitution therapy has been provided, patients with hemophilia should be treated in the same way as those in the general population. New-generation stents that allow short dual antiplatelet therapy and potent P2Y12 receptor inhibitors have begun to be successfully used. At a time when specific recommendations and relevant data are scarce, our study provides up-to-date information to physicians involved in the treatment of AMI in hemophiliacs.
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Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.M.T.); (A.O.); (N.D.); (A.R.G.-R.); (D.P.); (P.N.S.I.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Manuela Ciocoiu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
| | - Elena Rezus
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
- I Rheumatology Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
| | - Oana Viola Badulescu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- Hematology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Daniela Maria Tanase
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.M.T.); (A.O.); (N.D.); (A.R.G.-R.); (D.P.); (P.N.S.I.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Anca Ouatu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.M.T.); (A.O.); (N.D.); (A.R.G.-R.); (D.P.); (P.N.S.I.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Nicoleta Dima
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.M.T.); (A.O.); (N.D.); (A.R.G.-R.); (D.P.); (P.N.S.I.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Ana Roxana Ganceanu-Rusu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.M.T.); (A.O.); (N.D.); (A.R.G.-R.); (D.P.); (P.N.S.I.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
| | - Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.M.T.); (A.O.); (N.D.); (A.R.G.-R.); (D.P.); (P.N.S.I.); (C.R.)
| | - Petronela Nicoleta Seritean Isac
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.M.T.); (A.O.); (N.D.); (A.R.G.-R.); (D.P.); (P.N.S.I.); (C.R.)
| | - Tudor-Marcel Genes
- Department of Neurology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania;
- Neurological Rehabilitation Clinic, Clinical Rehabilitation Hospital, 14 Pantelimon Halipa Street, 700661 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania; (M.C.B.); (D.M.T.); (A.O.); (N.D.); (A.R.G.-R.); (D.P.); (P.N.S.I.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 1 Independence Boulevard, 700111 Iasi, Romania
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Misgav M, Brutman-Barazani T, Budnik I, Avishai E, Schapiro J, Bashari D, Barg AA, Lubetsky A, Livnat T, Kenet G. Emicizumab prophylaxis in haemophilia patients older than 50 years with cardiovascular risk factors: Real-world data. Haemophilia 2021; 27:253-260. [PMID: 33595174 DOI: 10.1111/hae.14261] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/06/2021] [Accepted: 01/09/2021] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Emicizumab (Hemlibra™) is approved for prophylaxis of Haemophilia A (HA) patients with and without inhibitors. However, real-world data on emicizumab use in the elderly HA patients with concomitant cardiovascular risk factors are lacking. AIM To evaluate the safety and efficacy of emicizumab in a real-world cohort of elderly HA patients. METHODS A prospective longitudinal observational study on HA patients over 50 years old treated, followed and monitored during emicizumab prophylaxis was conducted. We documented any bleeding or adverse events and collected plasma samples for emicizumab levels, aPTT and thrombin generation (TG). RESULTS Seventeen HA patients (2 with inhibitor), whose median age was 62.4 years (range: 51.5-77.1) composed the cohort, including 9/17 with multiple cardiovascular risk factors (high risk group). Seven patients had chronic HIV infection. The median follow-up of our cohort was 400 days (range 89-805, IQR 211-479 days). The median annualized bleeding rate (ABR) significantly decreased for all patients. Among patients who displayed significant bleeding tendencies, emicizumab steady state levels as well as TG were lower as compared with the group. The ABR of four patients concomitantly treated by antiplatelet agents was significantly higher compared with the rest of the cohort. Neither thrombosis nor thrombotic microangiopathy (TMA) was encountered. CONCLUSIONS Emicizumab prophylaxis for HA patients older than 50 years including those with cardiovascular risk factors was well tolerated. As lower emicizumab and TG levels were observed among bleeding patients, we suggest that monitoring laboratory assays could be of value within this age group.
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Affiliation(s)
- Mudi Misgav
- National Hemophilia Center, Sheba Medical center, Tel Hashomer, Israel.,Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Brutman-Barazani
- National Hemophilia Center, Sheba Medical center, Tel Hashomer, Israel.,Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ivan Budnik
- Department of Pathophysiology, First Moscow State Medical University (Sechenov University)
| | - Einat Avishai
- National Hemophilia Center, Sheba Medical center, Tel Hashomer, Israel.,Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Schapiro
- National Hemophilia Center, Sheba Medical center, Tel Hashomer, Israel.,Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dalia Bashari
- National Hemophilia Center, Sheba Medical center, Tel Hashomer, Israel.,Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assaf A Barg
- National Hemophilia Center, Sheba Medical center, Tel Hashomer, Israel.,Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aaron Lubetsky
- National Hemophilia Center, Sheba Medical center, Tel Hashomer, Israel.,Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Livnat
- National Hemophilia Center, Sheba Medical center, Tel Hashomer, Israel.,Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical center, Tel Hashomer, Israel.,Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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25
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Hay CRM, Nissen F, Pipe SW. Mortality in congenital hemophilia A - a systematic literature review. J Thromb Haemost 2021; 19 Suppl 1:6-20. [PMID: 33331043 PMCID: PMC7839505 DOI: 10.1111/jth.15189] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/14/2020] [Accepted: 11/02/2020] [Indexed: 12/20/2022]
Abstract
Against a background of a rapidly evolving treatment landscape, a contemporary, evidence-based consolidated understanding of mortality in people with congenital hemophilia A (PwcHA) is lacking. This systematic literature review examines the available data on mortality and causes of death in PwcHA to enable a better understanding of fatalities in PwcHA and evaluate the impact of new treatment paradigms on mortality. A systematic literature review of observational studies was conducted by searching Medline, Embase, and clinical trials registries for articles published from January 2010 to March 2020, using the search terms: hemophilia A (HA), mortality, cause of death. Interventional studies, studies not reporting fatalities, and those reporting only on hemophilia B, acquired HA, or mixed other coagulopathies were excluded. Overall, 7818 unique records were identified and 17 were analyzed. Of these, six reported mortality rates and five reported mortality ratios. Mortality generally decreased over time, despite a spike associated with human immunodeficiency virus (HIV)/hepatitis C virus (HCV) infection in the 1980s and 1990s. Mortality was strongly correlated with age and hemophilia severity. People with hemophilia had a raised mortality risk compared with the general population, particularly in severe hemophilia, and when infected with HIV or HCV. Causes of death varied across populations, countries, and time in 15 identified studies; however, incomplete and heterogeneous reporting limits evidence. Hemorrhage, HIV, HCV, and hepatic disease were the leading causes of death. A unified approach to reporting mortality and cause of death is needed to understand mortality in PwcHA as treatments continue to advance.
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Affiliation(s)
| | | | - Steven W. Pipe
- Departments of Pediatrics and PathologyUniversity of MichiganAnn ArborMIUSA
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26
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Nezami A, Tarhani F, Elahi S. Evaluation of Ischemic Heart Disease Factors in Hemophilia Patients in Khorramabad. Cardiovasc Hematol Disord Drug Targets 2020; 20:284-288. [PMID: 33256585 DOI: 10.2174/1871529x20666201130105100] [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] [Received: 12/23/2019] [Revised: 07/07/2020] [Accepted: 07/07/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Evaluation of risk factors associated with coronary artery disease and cardiac health in hemophilia patients is necessary to prevent the onset of ischemic heart disease. In this study, we evaluated the cardiovascular status of hemophilic patients in Lorestan province for the early onset of ischemic heart disease. METHODS In this cross-sectional descriptive study, a total of 80 patients presenting severe hemophilia, a detailed questionnaire-based investigation was conducted to analyze the prevalence of cardiovascular risk factors in severe hemophilic patients. In patients with hemophilia, body mass index (BMI), blood pressure, diabetes, LDL, cholesterol and HDL, the risk of cardiovascular death was estimated using a predictive risk predictor algorithm of Europe SCORE. RESULTS The mean age of the patients was 25 years, where all the patients were non-diabetic. Echocardiography did not show any wall motion abnormality and changes in the T wave and dysrhythmia were also not seen by ECG. 7 patients had high blood pressure, 11 had abnormal HDL, and 1 had abnormal LDL. In this study, serum LDL and HDL levels were not significantly correlated with age and BMI. Conversely, age and BMI were significantly associated with hypertension. Hypertension was observed in people over the age of 25 years and in overweighed individuals. 78.8% had normal BMI and 21.3% were overweighed. There was no significant correlation between serum LDL, serum HDL, and blood pressure and sex. The levels of abnormal LDL and HDL were higher in men than in women. CONCLUSION ECG findings from our study did not report any significant cardiac abnormalities among hemophilic patients. Cardiovascular risk factors were not significantly correlated in these patients.
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Affiliation(s)
- Alireza Nezami
- Department of Pediatric, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Fariba Tarhani
- Department of Pediatric, Faculty of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Sina Elahi
- Student Research Committee, Lorestan University of Medical Sciences, Khorramabad, Iran
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27
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Lim MY, Wei G, Presson AP, Bray P, Rodgers GM. High prevalence of overweight/obesity in adult persons with hemophilia in Utah and a review of the literature. Blood Coagul Fibrinolysis 2020; 31:522-529. [PMID: 32941196 PMCID: PMC8687737 DOI: 10.1097/mbc.0000000000000957] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: The objectives of this study were firstly to determine the prevalence of overweight/obesity in adult persons with hemophilia in Utah, and to explore the association between age, disease severity and race with body mass index (BMI), and secondly to provide recent data on the prevalence of overweight/obesity in the hemophilia population via a review of the literature. We conducted a retrospective cross section study of adult persons with hemophilia who were seen at a Utah hemophilia treatment center from 1 January 2017 to 31 December 2019. The electronic database PubMed was searched for studies with observation periods from 1 January 2012 to 31 December 2019. The age-adjusted prevalence for overweight/obesity in the adult Utah hemophilia population was higher than the overall Utah population and the general US population. After adjusting for race and age, mild hemophilia was associated with a 7.7% higher BMI (95% confidence interval, 0.023-15.98%, P < 0.05). Review of the literature demonstrated high levels of overweight/obesity in hemophilia communities globally with considerable heterogeneity between studies. Despite increasing awareness, prevalence of overweight/obesity in the hemophilia population remains high in comparison with the general population. There is a critical need to address this issue acutely at hemophilia treatment centers due to the considerable burden of obesity.
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Affiliation(s)
- Ming Y. Lim
- Department of Medicine, Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, UT
| | - Guo Wei
- Departments of Population Health Sciences and Internal Medicine, Division of Biostatistics, University of Utah, Salt Lake City, Utah
| | - Angela P. Presson
- Department of Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Paul Bray
- Department of Medicine, Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, UT
| | - George M. Rodgers
- Department of Medicine, Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, UT
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28
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Inhibitors and mortality in persons with nonsevere hemophilia A in the United States. Blood Adv 2020; 4:4739-4747. [PMID: 33007074 DOI: 10.1182/bloodadvances.2020002626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/02/2020] [Indexed: 11/20/2022] Open
Abstract
Although persons with nonsevere hemophilia A (NSHA) account for about one-half of the hemophilia A population, epidemiological data in this subset of individuals are scarce. We set out to describe the clinical characteristics of persons with NSHA with inhibitors, and to determine mortality rates, predictors of mortality, and primary causes of death in persons with NSHA in the United States over a 9-year period (2010-2018). We queried the American Thrombosis and Hemostasis Network dataset (ATHNdataset) for information on demographics, inhibitor status, and date and cause of death. A total of 6624 persons with NSHA (86.0% men; 14.0% women) were observed for an average of 8.5 years; total 56 119 person-years . The prevalence of inhibitors was 2.6% (n = 171), occurring at a median age of 13 years. At the end of follow-up, 136 persons died at a median age of 63 years; an age-adjusted mortality rate of 3.3 deaths per 1000 person-years. Three deaths occurred in inhibitor participants. Presence of inhibitors was not associated with increased mortality risk (hazard ratio [HR], 0.7, 95% confidence interval [CI], 0.2-2.3). Factors independently associated with increased risk of death (HR, 95% CI) were the following: age (10-year increase) (2.1, 2.0-2.4); male (2.6, 1.0-6.4); hepatitis C (2.2, 1.5-3.1); and HIV (3.6, 2.2-6.0). The most common primary cause of death was malignancy (n = 27, 20.0%). In persons with NSHA, the development of inhibitors occurred at an early age and was not associated with increased mortality.
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Kempton CL, Makris M, Holme PA. Management of comorbidities in haemophilia. Haemophilia 2020; 27 Suppl 3:37-45. [PMID: 32476243 DOI: 10.1111/hae.14013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/07/2020] [Indexed: 02/06/2023]
Abstract
With the introduction of clotting factor concentrates in the early 1970s, significant improvements in quality of life and life expectancy of persons with haemophilia (PWH) were realized. Unfortunately, as a result of transmission of HIV and hepatitis C virus (HCV) by contaminated concentrates in the 1980s, many of these gains were lost. Now with four decades of PWH unexposed to contaminated factor products and current treatments capable of suppressing and eliminating HIV and HCV, respectively, the survival rate is once again increasing. In addition to the usual comorbidities associated with advanced age in the general population, several specific issues occur in patients with bleeding disorders. This manuscript explores the incidence and management of the comorbidities of the ageing PWH with a focus on cardiovascular disease and osteoporosis.
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Affiliation(s)
- Christine L Kempton
- Department of Hematology and Medical Oncology and Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Makris
- Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Pål Andre Holme
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Mahlangu J, Lopez Fernandez MF, Santagostino E, Lalezari S, Tseneklidou-Stoeter D, Beckmann H, Church N. BAY 81-8973 demonstrated efficacy, safety and joint status improvement in patients with severe haemophilia A in the LEOPOLD I extension for ≤2 years. Eur J Haematol 2020; 104:594-601. [PMID: 32112434 PMCID: PMC7383510 DOI: 10.1111/ejh.13402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVES BAY 81-8973 (Kovaltry® ), a full-length, unmodified, recombinant human factor VIII, provided excellent bleeding control for patients with haemophilia A in the pivotal 1-year LEOPOLD I trial. The LEOPOLD I extension evaluated long-term efficacy and safety of BAY 81-8973 prophylaxis. METHODS After completing LEOPOLD I, patients continued receiving 20-50 IU/kg BAY 81-8973 two- or three-times weekly in the extension. Outcomes included annualised bleeding rate (ABR) and haemostasis during surgery. RESULTS Fifty-five patients aged 12-65 years participated in the extension. Median (range) exposure days during the 2-year total study period was 309 (115-355). No patient switched regimens. Median (Q1; Q3) ABR for all bleeds was 2.0 (1.0; 6.1) during the pivotal study, 2.0 (0.0; 5.2) during the extension, and 2.0 (0.5; 5.5) combined. The proportion of joint bleeds affecting target joints decreased (pivotal study: 90.9%, extension: 60.0%). Haemostasis was assessed as excellent/good in all five major surgeries. One serious adverse event (myocardial infarction) occurred in a patient with cardiovascular risk factors. No patients developed inhibitors. CONCLUSIONS BAY 81-8973 prophylaxis efficacy outcomes in the pivotal study were maintained or, in the case of joint protection, improved during the extension, with a safety and tolerability profile consistent with previous experience.
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Affiliation(s)
- Johnny Mahlangu
- Hemophilia Comprehensive Care Center, Faculty of Health Sciences, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, and National Health Laboratory Service, Johannesburg, South Africa
| | | | - Elena Santagostino
- Foundation IRCCS Ca' Granda, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Maggiore Hospital Policlinico, Milan, Italy
| | - Shadan Lalezari
- Israel National Haemophilia Center, Chaim Sheba Medical Center, Tel Hashomer, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv-Yafo, Israel
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31
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Wang M, Peltier S, Baumann K, Sidonio RF, Witkop M, Cooper DL, Waters EK, Kahan S. Awareness, Care and Treatment In Obesity maNagement to inform Haemophilia Obesity Patient Empowerment (ACTION-TO-HOPE): Results of a survey of US haemophilia treatment centre professionals. Haemophilia 2020; 26 Suppl 1:20-30. [DOI: 10.1111/hae.13919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Michael Wang
- University of Colorado Anschutz Medical Campus; Aurora CO USA
| | - Skye Peltier
- University of Minnesota Medical Center; Minneapolis MN USA
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32
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Zong Y, Maanja M, Chaireti R, Schlegel TT, Ugander M, Antovic JP. Substantial prevalence of subclinical cardiovascular diseases in patients with hemophilia A evaluated by advanced electrocardiography. J Electrocardiol 2020; 58:171-175. [DOI: 10.1016/j.jelectrocard.2019.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/05/2019] [Accepted: 12/11/2019] [Indexed: 12/11/2022]
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33
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Chiasakul T, De Jesus E, Tong J, Chen Y, Crowther M, Garcia D, Chai‐Adisaksopha C, Messé SR, Cuker A. Inherited Thrombophilia and the Risk of Arterial Ischemic Stroke: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2019; 8:e012877. [PMID: 31549567 PMCID: PMC6806047 DOI: 10.1161/jaha.119.012877] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 09/04/2019] [Indexed: 01/01/2023]
Abstract
Background Inherited thrombophilias are well-established predisposing factors for venous thromboembolism, but their role in arterial thrombosis, such as arterial ischemic stroke, remains uncertain. We aimed to evaluate the association between inherited thrombophilia (factor V Leiden, prothrombin G20210A mutation, protein C deficiency, protein S deficiency, and antithrombin deficiency) and risk of arterial ischemic stroke in adults. Methods and Results We searched PubMed, EMBASE, and Cochrane Library Databases from inception to December 31, 2018. We included case-control or cohort studies of adults reporting the prevalence of inherited thrombophilias in those with arterial ischemic stroke and subjects without arterial ischemic stroke. Two reviewers (T.C., E.D.) independently searched the literature and extracted data. Pooled odds ratios (ORs) and 95% CIs were calculated using random-effects model. We identified 68 eligible studies, which collectively enrolled 11 916 stroke patients and 96 057 controls. The number of studies reporting factor V Leiden, prothrombin G20210A mutation, protein C deficiency, protein S deficiency, and antithrombin deficiency were 56, 45, 15, 17, and 12, respectively. Compared with controls, patients with arterial ischemic stroke were significantly more likely to have the following inherited thrombophilias: factor V Leiden (OR, 1.25; 95% CI, 1.08-1.44; I2=0%), prothrombin G20210A mutation (OR, 1.48; 95% CI, 1.22-1.80; I2=0%), protein C deficiency (OR, 2.13; 95% CI, 1.16-3.90; I2=0%), and protein S deficiency (OR, 2.26; 95% CI, 1.34-3.80; I2=8.8%). Statistical significance was not reached for antithrombin deficiency (OR, 1.25; 95% CI, 0.58-2.67; I2=8.8%). Conclusions Inherited thrombophilias (factor V Leiden, prothrombin G20210A mutation, protein C deficiency, and protein S deficiency) are associated with an increased risk of arterial ischemic stroke in adults. The implications of these findings with respect to clinical management of patients with ischemic stroke require further investigation.
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Affiliation(s)
- Thita Chiasakul
- Division of HematologyDepartment of MedicineFaculty of MedicineChulalongkorn University and King Chulalongkorn Memorial HospitalThai Red Cross SocietyBangkokThailand
| | | | - Jiayi Tong
- Department of Biostatistics and EpidemiologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Yong Chen
- Department of Biostatistics and EpidemiologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Mark Crowther
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - David Garcia
- Department of MedicineUniversity of Washington School of MedicineSeattleWA
| | | | - Steven R. Messé
- Department of NeurologyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Adam Cuker
- Department of MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Department of Pathology and Laboratory MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPA
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Aging with Hemophilia: The Challenge of Appropriate Drug Prescription. Mediterr J Hematol Infect Dis 2019; 11:e2019056. [PMID: 31528322 PMCID: PMC6736229 DOI: 10.4084/mjhid.2019.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 07/13/2019] [Indexed: 12/31/2022] Open
Abstract
In high-income countries persons with severe hemophilia (PWH) A and B are aging, like their age-matched peers without hemophilia from the general population. Aging is associated not only with the comorbidities stemming from their inherited bleeding disorder (arthropathy, chronic viral infections such as hepatitis and AIDS) but also with the multiple chronic ailments associated with aging (cancer, cardiovascular disease, COPD). Multimorbidity is inevitably associated with polypharmacy, i.e., the chronic daily intake of at least five drugs, and with the related risk of severe adverse events associated with the use of inappropriate drugs and drug-drug interactions. Information on the pattern of drug prescription and usage by PWH is relatively scanty, but on the whole, the available data indicate that the rate of polypharmacy, as well as the risk of drug-drug interaction, is relatively low in PWH and better than that in their age peers without hemophilia followed by general practitioners. It is believed that this advantage results from the collaborative coordination on drug prescribing exerted, through their integration with practitioners and organ specialists, by specialized hemophilia treatment centers in the frame of comprehensive care programs. However, the available cross-sectional data were mainly obtained in relatively young PWH, so that there is a need to obtain more accurate data from the ongoing prospective studies that are being carried out in more and more progressively aging PWH.
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Factor VIII: Long-established role in haemophilia A and emerging evidence beyond haemostasis. Blood Rev 2019; 35:43-50. [DOI: 10.1016/j.blre.2019.03.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/01/2019] [Accepted: 03/01/2019] [Indexed: 12/20/2022]
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36
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Feng B, Xiao K, Gao P, Liu Y, Zhang B, Ren Y, Weng X. Comparison of 90-Day Complication Rates and Cost Between Single and Multiple Joint Procedures for End-Stage Arthropathy in Patients with Hemophilia. JB JS Open Access 2018; 3:e0026. [PMID: 30882056 PMCID: PMC6400505 DOI: 10.2106/jbjs.oa.18.00026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Multiple joint procedures during a single anesthetic episode have been proposed for patients with hemophilia as a way to reduce cost. The postoperative 90-day complication rate and the cost distribution between multiple joint procedures and single joint procedures for patients with hemophilia have not been well studied. Methods Between January 1996 and December 2016, 124 patients underwent 177 surgical procedures (total knee arthroplasty, total hip arthroplasty, and ankle arthrodesis) for the treatment of hemophilic end-stage arthropathy. Forty-eight patients (39%) underwent multiple joint procedures during 1 hospitalization, and 76 patients (61%) underwent single joint procedures. The medical records were retrospectively reviewed. The patients were evaluated for complications within 90 days postoperatively and the cost during hospitalization. Risk factors related to complications were further analyzed. Results Twenty-seven of the 124 patients experienced 29 complications within 90 days postoperatively, representing a complication rate of 16.4% for all procedures. The patients who had undergone multiple joint procedures had a higher rate of surgical complications than those who had undergone a single joint procedure (14.6% vs. 3.9%; p = 0.039). The patients who had had multiple joint procedures had similar rates of hematological complications (8.3% vs. 9.2%; p = 0.867) and total complications (31.3% vs. 18.4%; p = 0.100) compared with those who had had a single joint procedure. There was no difference between the patients who had had multiple joint procedures and those who had had a single joint procedure with regard to the cost of the coagulation factor (p = 0.212). Conclusions The performance of multiple joint procedures during a single anesthetic episode is a safe approach for patients with hemophilia with end-stage arthropathy, with no substantial increase in the 90-day complication rate in comparison with that following a single joint procedure. The performance of multiple joint procedures under a single anesthetic episode can save cost and is more cost-effective when managing patients with hemophilia who have end-stage arthropathy. Level of Evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Bin Feng
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, China
| | - Ke Xiao
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, China
| | - Peng Gao
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, China
| | - Yong Liu
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, China
| | - Baozhong Zhang
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, China
| | - Yi Ren
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, China
| | - Xisheng Weng
- Department of Orthopaedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, China
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