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Nolan B, Recht M, Rendo P, Falk A, Foster M, Casiano S, Rauch A, Shapiro A. Prophylaxis with recombinant factor IX Fc fusion protein reduces the risk of bleeding and delays time to first spontaneous bleed event in previously untreated patients with haemophilia B: A post hoc analysis of the PUPs B-LONG study. Eur J Haematol 2024. [PMID: 38922990 DOI: 10.1111/ejh.14252] [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: 02/16/2024] [Revised: 05/23/2024] [Accepted: 06/04/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES Haemophilia B (HB), characterised by deficient factor IX (FIX), leads to spontaneous bleeds. Severe cases require prophylactic FIX replacement. This post hoc analysis assessed the first spontaneous bleeds among previously untreated patients (PUPs) with HB treated with recombinant FIX Fc fusion protein (rFIXFc) (NCT02234310) to identify factors influencing bleeds. METHODS Subjects included paediatric PUPs with HB (≤2 IU/dL endogenous FIX). Analyses described treatment patterns (on demand [OD] vs. prophylaxis) and prophylaxis type (started on vs. switched to prophylaxis). Kaplan-Meier analyses assessed the time to first spontaneous bleed, including median time to event and fitting models with predictors for treatment regimen and/or baseline age. RESULTS PUPs B-LONG enrolled 33 subjects. Baseline age did not influence the time to first spontaneous bleed for any rFIXFc regimen. Those who started on prophylaxis with rFIXFc (n = 11), compared with those treated OD (n = 22), had an extended time to first spontaneous bleed. Starting prophylaxis afforded a 93% reduced risk of first spontaneous bleed versus starting OD (hazard ratio [95% confidence interval]: 0.071 [0.009-0.592]) (p = .015). CONCLUSION rFIXFc prophylaxis, particularly starting early, reduced the risk of bleeding and delayed time to first spontaneous bleed compared with rFIXFc OD. Hence, initial treatment regimens impact bleed patterns in paediatric PUPs.
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Affiliation(s)
- Beatrice Nolan
- Haematology Department, Children's Health Ireland at Crumlin, Dublin, Republic of Ireland
| | - Michael Recht
- National Bleeding Disorders Foundation, New York City, New York, USA
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | | | | | | | - Antoine Rauch
- Department of Hematology and Transfusion, CHU Lille, Lille, France
| | - Amy Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
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Mizumachi K, Nakajima Y, Shimonishi N, Furukawa S, Ogiwara K, Takeyama M, Nogami K. Hybrid human-porcine factor VIII proteins partially escape the inhibitory effects of anti-factor VIII inhibitor alloantibodies having A2 or C2 domain specificity. Haemophilia 2024; 30:140-150. [PMID: 38058226 DOI: 10.1111/hae.14911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/29/2023] [Accepted: 11/28/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Porcine factor (pF)VIII has low cross-reactivity with anti-human (h)FVIII inhibitor alloantibodies. Clinical trials of pFVIII in congenital haemophilia A patients with inhibitor (PwHA-I) are in progress. Most polyclonal anti-hFVIII inhibitors recognize its A2 and/or C2 domain(s), and recombinant human-porcine hybrid (hp)FVIII proteins may escape neutralization by these inhibitors. AIM To evaluate the ability of hpFVIII to limit the anti-FVIII activity of inhibitor alloantibodies. METHODS Three hybrid proteins were created by substituting the hFVIII A2, C2 domain or both with the corresponding domains of pFVIII [termed hp(A2), hp(C2) and hp(A2/C2), respectively]. The reactivity of these hybrids was assessed by one-stage clotting assays (OSA), thrombin generation assays (TGA) and rotational thromboelastometry (ROTEM) by adding them to FVIII-deficient samples. RESULTS OSA demonstrated that the hybrid proteins avoided neutralization by anti-FVIII A2 or C2 monoclonal antibodies (mAb) and polyclonal inhibitor-antibodies (polyAb) from PwHA-I. In TGA, thrombin generation with hp(A2) and hp(A2/C2) was not attenuated in the presence of patient IgG recognizing anti-A2 domain. In contrast, that with hFVIII and hp(C2) was suppressed by this IgG to levels equivalent to those of FVIII-deficient plasma. With anti-A2/C2 polyAb, the activity of hp(A2/C2) was unaffected. ROTEM demonstrated that the addition of hp(A2) or hp(A2/C2) to anti-A2 polyAb shortened clot times/clot formation times, whilst hFVIII or hp(C2) were ineffective. Similarly with anti-A2/C2 polyAb, hp(A2/C2) restored coagulation potential to a greater extent than hp(A2) and hp(C2). CONCLUSION Hybrid FVIII proteins containing porcine FVIII A2 and/or C2 domain(s) could support effective therapy in PwHA-I by avoiding neutralization.
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Affiliation(s)
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Sidonio RF, Thompson AA, Peyvandi F, Stasyshyn O, Yeoh SL, Sosothikul D, Antmen AB, Maggiore C, Engl W, Ewenstein B, Tangada S. Immunogenicity, safety, and efficacy of rurioctocog alfa pegol in previously untreated patients with severe hemophilia A: interim results from a phase 3, prospective, multicenter, open-label study. Expert Rev Hematol 2023; 16:793-801. [PMID: 37646148 DOI: 10.1080/17474086.2023.2247160] [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: 01/19/2023] [Revised: 07/18/2023] [Accepted: 08/07/2023] [Indexed: 09/01/2023]
Abstract
AIM To determine the immunogenicity, safety, and efficacy of rurioctocog alfa pegol in previously untreated patients (PUPs) with severe hemophilia A (HA). METHODS This prospective, phase 3 study (NCT02615691) was conducted in PUPs, or patients with ≤2 exposure days (EDs) prior to screening, aged <6 years with severe HA. The primary endpoint was incidence of factor VIII (FVIII) inhibitor development. This protocol-specified interim analysis was conducted after 50 patients had completed ≥50 EDs without developing FVIII inhibitors or had developed a confirmed inhibitor at any time. RESULTS Of the enrolled patients, 59/80 (73.8%) received ≥1 dose of rurioctocog alfa pegol; 54 received prophylaxis, and 35 on-demand treatment. Incidence of inhibitor development was 0.19 (10/52). Total annualized bleeding rate (95% CIs) was 3.2 (2.0-5.0) for patients receiving prophylaxis and 3.2 (1.6-6.3) for on-demand treatment. Hemostatic efficacy of most bleedings was rated as 'excellent' or 'good' after 24 hours (122/131 [93.1%]) and at resolution (161/170 [94.7%]). Five patients received ≥1 dose of rurioctocog alfa pegol for immune tolerance induction (ITI) and 1 patient was defined as having ITI success. Thirteen patients experienced 14 treatment-related adverse events, including 10 cases of FVIII inhibitor development. CONCLUSION This is the first prospective study of rurioctocog alfa pegol for the treatment of PUPs with severe HA. TRIAL REGISTRATION This trial is registered at ClinicalTrials.gov (CT.gov identifier: NCT02615691).
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Affiliation(s)
- Robert F Sidonio
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, GA, USA
| | - Alexis A Thompson
- Division of Hematology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Universitàdegli Studi di Milano, Milan, Italy
| | | | - Seoh Leng Yeoh
- Department of Pediatrics, Hospital Pulau Pinang, George Town, Malaysia
| | - Darintr Sosothikul
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Integrative and Innovative Hematology/Oncology Research Unit, Faculty of Medicine, Chulalonkorn University, Bangkok, Thailand
| | - Ali Bulent Antmen
- Department of Pediatric Hematology and Oncology, Acibadem Adana Hospital, Adana, Turkey
| | | | - Werner Engl
- Pharmacometrics & Biostatistics, Baxalta Innovations GmbH, A Takeda Company, Vienna, Austria
| | - Bruce Ewenstein
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
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Tice JA, Walton SM, Sarker J, Moradi A, Chu JN, Herce-Hagiwara B, Fahim SM, Agboola F, Rind D, Pearson SD. The effectiveness and value of gene therapy for hemophilia: A Summary from the Institute for Clinical and Economic Review's California Technology Assessment Forum. J Manag Care Spec Pharm 2023; 29:576-581. [PMID: 37121251 PMCID: PMC10387967 DOI: 10.18553/jmcp.2023.29.5.576] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
DISCLOSURES: Dr Tice and Mr Sarker received ICER grants during the conduct of the study. Dr Moradi, Ms Herce-Hagiwara, Dr Faghim, Dr Agboola, Dr Rind, and Dr Pearson reports grants from Arnold Ventures, grants from Blue Cross Blue Shield of MA, grants from California Healthcare Foundation, grants from The Commonwealth Fund, grants from The Peterson Center on Healthcare, during the conduct of the study; other from Aetna, other from America's Health Insurance Plans, other from Anthem, other from AbbVie, other from Alnylam, other from AstraZeneca, other from Biogen, other from Blue Shield of CA, other from Cambia Health Services, other from CVS, other from Editas, other from Express Scripts, other from Genentech/Roche, other from GlaxoSmithKline, other from Harvard Pilgrim, other from Health Care Service Corporation, other from Health Partners, other from Johnson & Johnson (Janssen), other from Kaiser Permanente, other from LEO Pharma, other from Mallinckrodt, other from Merck, other from Novartis, other from National Pharmaceutical Council, other from Premera, other from Prime Therapeutics, other from Regeneron, other from Sanofi, other from Spark Therapeutics, other from United Healthcare, other from HealthFirst, other from Pfizer, other from Boehringer-Ingelheim, other from uniQure, other from Evolve Pharmacy Solutions, other from Humana, other from Sun Life, outside the submitted work.
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Affiliation(s)
- Jeffrey A Tice
- Division of General Internal Medicine, University of California San Francisco
| | - Surrey M Walton
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago
| | - Jyotirmoy Sarker
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago
| | - Ashton Moradi
- Institute for Clinical and Economic Review, Boston, MA
| | - Janet N Chu
- Division of General Internal Medicine, University of California San Francisco
| | | | | | | | - David Rind
- Institute for Clinical and Economic Review, Boston, MA
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5
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Peyvandi F, Kavakli K, El‐Beshlawy A, Rangarajan S. Management of haemophilia A with inhibitors: A regional cross-talk. Haemophilia 2022; 28:950-961. [PMID: 35868021 PMCID: PMC9796719 DOI: 10.1111/hae.14638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/04/2022] [Accepted: 07/09/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The development of inhibitors with factor VIII (FVIII) replacement therapy is one of the most common and challenging complications of haemophilia A (HA) treatment, jeopardising treatment efficacy and predisposing patients to high risks of morbidity and mortality. The management of patients with inhibitors is particularly challenging in countries where resources are limited. AIM To provide a comprehensive summary of the management of HA with inhibitors while focusing on differences in practice between Western and non-Western countries and how resource scarcity can impact HA management, leading to suboptimal outcomes in patients with inhibitors. METHODS Summary of key evidence and regional expert opinion. RESULTS We address, particularly, the diagnosis of and testing for inhibitors, as well as the epidemiology of inhibitors, including incidence, prevalence and disease burden. Secondly, we provide an overview of the current treatment landscape in HA with inhibitors regarding the eradication of inhibitors with immune tolerance induction and the treatment and prevention of bleeding with bypassing agents, non-factor replacement agents and other experimental therapies. This is complemented with insights from the authors around the applicability of, and challenges associated with, such therapies in their settings of practice. CONCLUSIONS We conclude by proposing some key steps towards bridging the gaps in the management of HA with inhibitors in resource-limited countries, including: (1) the collection of quality data that can inform healthcare reforms and policies; (2) improving disease knowledge among healthcare practitioners and patients with the aim of standardising disease management across centres and (3) working towards promoting equal access to HA care and therapies for everyone.
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Affiliation(s)
- Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly,Department of Pathophysiology and TransplantationUniversità degli Studi di MilanooMilanItaly
| | - Kaan Kavakli
- Department of Pediatric HematologyEge University Children's HospitalIzmirTurkey
| | - Amal El‐Beshlawy
- Department of Pediatric Hematology, Faculty of MedicineCairo UniversityCairoEgypt
| | - Savita Rangarajan
- Department of HaematologyUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK,Clinical Trials and Research UnitKJ Somaiya Super Specialty Hospital and Research CentreMumbaiIndia
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6
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Ferri Grazzi E, Sun SX, Burke T, O'Hara J. The Impact of Pharmacokinetic-Guided Prophylaxis on Clinical Outcomes and Healthcare Resource Utilization in Hemophilia A Patients: Real-World Evidence from the CHESS II Study. J Blood Med 2022; 13:505-516. [PMID: 36157322 PMCID: PMC9507282 DOI: 10.2147/jbm.s363028] [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: 02/23/2022] [Accepted: 08/30/2022] [Indexed: 11/23/2022] Open
Abstract
Background Using a pharmacokinetic (PK)-guided approach to personalize the dose and frequency of prophylactic treatment can help achieve and maintain targeted factor VIII (FVIII) trough levels in patients with hemophilia A. Objective Investigate clinical and healthcare resource use outcomes in patients with hemophilia A treated with or without PK-guided prophylaxis using data from the Cost of Haemophilia in Europe: A Socioeconomic Survey (CHESS) II database. Methods CHESS II was a cross-sectional, retrospective, burden-of-illness study incorporating data from eight European countries. Patients were eligible for this analysis if they were male, ≥18 years of age, and diagnosed with congenital hemophilia A of any severity. The clinical endpoints included annualized bleeding rate (ABR), presence and number of problem/target joints, and occurrence of joint surgeries. Healthcare resource utilization endpoints included the number of hematologist consultations and bleed-related hospitalizations or emergency department admissions. Data from November 2018 to October 2020 were included and were stratified according to treatment regimen and use of PK-guided dosing. Results Altogether, 281 patients on prophylaxis had available FVIII trough level data. Mean (SD) age was 35.7 (13.8) years. A specific FVIII trough level was targeted in 120 (42.7%) patients and 47 (39.2%) received PK-guided dosing. Patients receiving PK-guided dosing had a mean (SD) ABR of 2.8 (2.1) and target joint number of 0.5 (0.7), compared with 3.9 (2.7) and 0.9 (1.4), respectively, for patients receiving non-PK-guided treatment. The mean (SD) number of hematologist consultations was 7.1 (5.3) for patients receiving PK-guided dosing versus 10.7 (5.7) for those who were not. A higher proportion of patients in the non-PK-guided group required hospitalization during their lifetime compared with the PK-guided group. Conclusion This analysis of real-world data suggests that PK-guided dosing for prophylaxis has a beneficial impact on clinical and healthcare resource utilization outcomes in patients with hemophilia A.
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Affiliation(s)
- Enrico Ferri Grazzi
- Health Economics and Outcomes Research, HCD Economics Ltd, Daresbury, Warrington, UK
| | - Shawn X Sun
- Global Evidence and Outcomes, Takeda Development Center Americas, Inc, Cambridge, MA, USA
| | - Tom Burke
- Health Economics and Outcomes Research, HCD Economics Ltd, Daresbury, Warrington, UK.,Department of Health and Social Care, University of Chester, Chester, UK
| | - Jamie O'Hara
- Health Economics and Outcomes Research, HCD Economics Ltd, Daresbury, Warrington, UK.,Department of Health and Social Care, University of Chester, Chester, UK
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7
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Valérie C, Laurie F, Julie F, Clément C, Claude N, Carlos EK. PHAREO study: Perceived and observed accessibility to therapeutic drugs used for treating patients with inherited bleeding disorders. J Clin Pharm Ther 2022; 47:1667-1675. [PMID: 35726381 DOI: 10.1111/jcpt.13718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/19/2022] [Accepted: 05/29/2022] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The dispensing of clotting factor concentrates in hospital pharmacies imposes accessibility constraints on patients and their caregivers, thereby increasing the disease burden. Very few studies have addressed these issues so far in terms of individual perceptions and actual difficulties. The PHAREO study aims to report patient's perception of treatment accessibility and evaluate spatial accessibility. METHODS The PHAREO study is an observational survey based on a questionnaire specifically designed for the study purpose in collaboration with patients' representatives in the second demographic and economic French region. RESULTS AND DISCUSSION We collected 293 responses (participation rate of 64.1%) which show that 89.8% of respondents were either very or rather satisfied with regard to access to treatment. However, respondents reported difficulties in accessing the hospital pharmacy. The data also showed that 79.2% of respondents tended to over-estimate travel time which was reported above their acceptable threshold for 39.2% of them. The main determinants of dissatisfaction were parental burden (OR 2.5 [1.3; 4.8], p = 0.008) and waiting time at the hospital pharmacy (OR 1.5 [1.1;2.0], p = 0.016, per 10 min increase). WHAT IS NEW AND CONCLUSION The PHAREO study provides subjective and objective data regarding satisfaction levels of persons with haemophilia and other coagulation deficiencies, with a high representativeness rate for patients on prophylaxis (87.5%). Both respondents and hospital pharmacists pled for an evolution of the current dispensing circuit to improve access to treatment and reduce the burden for patients. Currently, the community pharmacists are apart from the dispensing circuit. The authors propose improvements in the pathway of care for patients and their caregivers by including the community pharmacists alongside the hospital pharmacists in a centralized coordination scheme.
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Affiliation(s)
- Chamouard Valérie
- Centre de Référence de l'Hémophilie et autres déficits constitutionnels en protéines de la coagulation, Hôpital Louis Pradel, Groupement Hospitalier Est, Bron, France.,Service pharmaceutique, Hôpital Louis Pradel, Groupement Hospitalier Est, Bron, France
| | - Fraticelli Laurie
- RESCUe-RESUVal, Centre Hospitalier Lucien Hussel, Montée Docteur Maurice Chapuis, Vienne, France.,Laboratoire Parcours Santé Systémique (P2S) UR 4129, Université de Lyon 1, Lyon, France
| | - Freyssenge Julie
- RESCUe-RESUVal, Centre Hospitalier Lucien Hussel, Montée Docteur Maurice Chapuis, Vienne, France.,Research On Healthcare Performance (RESHAPE), INSERM, Lyon, France
| | - Claustre Clément
- RESCUe-RESUVal, Centre Hospitalier Lucien Hussel, Montée Docteur Maurice Chapuis, Vienne, France
| | - Négrier Claude
- Centre de Référence de l'Hémophilie et autres déficits constitutionnels en protéines de la coagulation, Hôpital Louis Pradel, Groupement Hospitalier Est, Bron, France
| | - El Khoury Carlos
- RESCUe-RESUVal, Centre Hospitalier Lucien Hussel, Montée Docteur Maurice Chapuis, Vienne, France.,Clinical Research Unit, Médipôle Hôpital Mutualiste, Villeurbanne, France
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8
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A multicentre real-world data study to assess the bleeding rate and management of patients with haemophilia A and factor VIII inhibitors in Argentina. Blood Coagul Fibrinolysis 2021; 32:564-571. [PMID: 34776503 DOI: 10.1097/mbc.0000000000001077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The development of inhibitors against factor VIII (FVIII) concentrates is a severe complication of treatment for patients with haemophilia. We investigated annualized bleeding rates (ABRs) in patients in Argentina with haemophilia A with inhibitors and analysed potential differences between treatment strategies. This multicentre, retrospective, real-world data, cohort design study comprised ambulatory paediatric and adult patients with congenital haemophilia A and FVIII inhibitors treated according to standard clinical practice, with 12-months follow-up. Of 69 included patients, 39 (56.5%) received on-demand treatment, 13 (18.8%) received prophylactic treatment, and 17 (24.6%) received immune tolerance induction (ITI) therapy. The mean overall ABR was 7.68 ± 8.18, with similar rates for on-demand (8.59 ± 9.69), prophylaxis (5.54 ± 4.71), and ITI (7.24 ± 6.23) subgroups. In the negative binomial regression model, prophylactic treatment [incidence rate ratio (IRR) 0.41, 95% confidence interval (CI): 0.21-0.79, P < 0.01] and ITI (IRR 0.47, 95% CI: 0.27-0.81, P < 0.01) therapy were significantly associated with a decrease in the ABR compared with on-demand treatment. Age (IRR 0.96, 95% CI: 0.94-0.97, P < 0.01), number of target joints (IRR 1.21, 95% CI: 1.11-1.31, P < 0.001), and history of recurring bleeding (IRR 2.3, 95% CI: 1.19-4.57, P = 0.012) were significantly and independently associated with ABR. The ABR in standard clinical practice was lower than that reported in controlled clinical trials. Patients undergoing prophylaxis and ITI therapy showed reduced ABRs compared with on-demand treatment, after controlling for bleeding predictor variables.
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9
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Agboola F, Rind DM, Walton SM, Herron-Smith S, Quach D, Pearson SD. The effectiveness and value of emicizumab and valoctocogene roxaparvovec for the management of hemophilia A without inhibitors. J Manag Care Spec Pharm 2021; 27:667-673. [PMID: 33908280 PMCID: PMC10390946 DOI: 10.18553/jmcp.2021.27.5.667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
DISCLOSURES: Funding for this summary was contributed by Arnold Ventures, California Health Care Foundation, The Donaghue Foundation, Harvard Pilgrim Health Care, and Kaiser Foundation Health Plan to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from AbbVie, Aetna, America's Health Insurance Plans, Anthem, Alnylam, AstraZeneca, Biogen, Blue Shield of CA, Boehringer-Ingelheim, Cambia Health Services, CVS, Editas, Evolve Pharmacy, Express Scripts, Genentech/Roche, GlaxoSmithKline, Harvard Pilgrim, Health Care Service Corporation, HealthFirst, Health Partners, Humana, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Pfizer, Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, uniQure, and United Healthcare. Agboola, Rind, Herron-Smith, and Pearson are employed by ICER. Walton and Quach, through the University of Illinois at Chicago, received funding from ICER for development of the economic model described in this report.
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Affiliation(s)
| | - David M Rind
- Institute for Clinical and Economic Review, Boston, MA
| | - Surrey M Walton
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago
| | | | - Danny Quach
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago
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10
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Deguchi H, Morla S, Griffin JH. Novel blood coagulation molecules: Skeletal muscle myosin and cardiac myosin. J Thromb Haemost 2021; 19:7-19. [PMID: 32920971 PMCID: PMC7819347 DOI: 10.1111/jth.15097] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/03/2020] [Accepted: 09/03/2020] [Indexed: 12/21/2022]
Abstract
Essentials Striated muscle myosins can promote prothrombin activation by FXa or FVa inactivation by APC. Cardiac myosin and skeletal muscle myosin are pro-hemostatic in murine tail cut bleeding models. Infused cardiac myosin exacerbates myocardial injury caused by myocardial ischemia reperfusion. Skeletal muscle myosin isoforms that circulate in human plasma can be grouped into 3 phenotypes. ABSTRACT: Two striated muscle myosins, namely skeletal muscle myosin (SkM) and cardiac myosin (CM), may potentially contribute to physiologic mechanisms for regulation of thrombosis and hemostasis. Thrombin is generated from activation of prothrombin by the prothrombinase (IIase) complex comprising factor Xa, factor Va, and Ca++ ions located on surfaces where these factors are assembled. We discovered that SkM and CM, which are abundant motor proteins in skeletal and cardiac muscles, can provide a surface for thrombin generation by the prothrombinase complex without any apparent requirement for phosphatidylserine or lipids. These myosins can also provide a surface that supports the inactivation of factor Va by activated protein C/protein S, resulting in negative feedback downregulation of thrombin generation. Although the physiologic significance of these reactions remains to be established for humans, substantive insights may be gleaned from murine studies. In mice, exogenously infused SkM and CM can promote hemostasis as they are capable of reducing tail cut bleeding. In a murine myocardial ischemia-reperfusion injury model, exogenously infused CM exacerbates myocardial infarction damage. Studies of human plasmas show that SkM antigen isoforms of different MWs circulate in human plasma, and they can be used to identify three plasma SkM phenotypes. A pilot clinical study showed that one SkM isoform pattern appeared to be linked to isolated pulmonary embolism. These discoveries enable multiple preclinical and clinical studies of SkM and CM, which should provide novel mechanistic insights with potential translational relevance for the roles of CM and SkM in the pathobiology of hemostasis and thrombosis.
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Affiliation(s)
- Hiroshi Deguchi
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - Shravan Morla
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
| | - John H Griffin
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, USA
- Division of Hematology, Department of Medicine, University of California, San Diego, CA, USA
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11
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Blatný J, Kardos M, Miljic P, Bilić E, Benedik-Dolničar M, Faganel-Kotnik B, Konstantinov D, Kovalova Z, Ovesná P. Incidence of inhibitor development in PUPs with severe Haemophilia A in the CEE region between 2005 and 2015. Thromb Res 2020; 198:196-203. [PMID: 33360154 DOI: 10.1016/j.thromres.2020.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/05/2020] [Accepted: 12/09/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION This study analyses real-world data on 144 previously untreated patients (PUPs) with severe Haemophilia A, from seven countries in Central and Eastern Europe (CEE: Bulgaria, Croatia, Czech Republic, Hungary, Latvia, Serbia, and Slovenia), over a period of 11 years. It analyses the risk factors associated with development of inhibitors to factor VIII concentrates. METHODS Cox proportional hazard models were used to estimate the hazard risk of factors possibly influencing the development of inhibitors. Patients were followed for up to 100 exposure days (EDs). RESULTS Cumulative inhibitor incidence at the time of 100 EDs was 18.7%, slightly lower than the 25-35% incidence reported in most studies. Of PUPs who developed inhibitors, a majority (56%) developed them within the first 20 EDs and 88% by the 50th ED. FVIII class (recombinant or plasma-derived) did not influence the inhibitors' incidence rate (p = 0.64). We found a significant protective effect of prophylaxis compared to on-demand treatment (p = 0.003). PUPs who had an intensive peak treatment during the first 50 EDs were at significantly higher risk for inhibitor development (HR (95% CI) 5.3 (2.3-12.5), p < 0.001). CONCLUSION Inhibitors are and will continue to be the most significant complication of haemophilia treatment with factor concentrates. This is particularly true for haemophilia A. In our cohort, we were able to show that the treatment regimen used during first 50EDs influenced significantly the inhibitor risk, but the class of the factor concentrate did not play an important role. Real world data will remain one of the important resources for improving our knowledge of haemophilia.
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Affiliation(s)
- Jan Blatný
- Department of Paediatric Haematology, University Hospital and Masaryk University Brno, Czech Republic.
| | - Mária Kardos
- Department of Paediatrics, Mohács Hospital, Mohács, Hungary
| | - Predrag Miljic
- Clinic of Hematology, Clinical Center of Serbia, Belgrade, Serbia
| | - Ernest Bilić
- Department of Pediatrics, University Hospital Centre Zagreb, School of Medicine, Zagreb, Croatia
| | - Majda Benedik-Dolničar
- Unit for Haematology and Oncology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Barbara Faganel-Kotnik
- Unit for Haematology and Oncology, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Dobrin Konstantinov
- Pediatric Hematology & Oncology Department, University Hospital "Tsaritsa Johanna-ISUL", Sofia, Bulgaria
| | - Zhanna Kovalova
- Department of Hematology and Oncology, Children's Clinical University Hospital, Riga, Latvia
| | - Petra Ovesná
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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12
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Lugin ML, Lee RT, Kwon YJ. Synthetically Engineered Adeno-Associated Virus for Efficient, Safe, and Versatile Gene Therapy Applications. ACS NANO 2020; 14:14262-14283. [PMID: 33073995 DOI: 10.1021/acsnano.0c03850] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Gene therapy directly targets mutations causing disease, allowing for a specific treatment at a molecular level. Adeno-associated virus (AAV) has been of increasing interest as a gene delivery vehicle, as AAV vectors are safe, effective, and capable of eliciting a relatively contained immune response. With the recent FDA approval of two AAV drugs for treating rare genetic diseases, AAV vectors are now on the market and are being further explored for other therapies. While showing promise in immune privileged tissue, the use of AAV for systemic delivery is still limited due to the high prevalence of neutralizing antibodies (nAbs). To avoid nAb-mediated inactivation, engineered AAV vectors with modified protein capsids, materials tethered to the capsid surface, or fully encapsulated in a second, larger carrier have been explored. Many of these engineered AAVs have added benefits, including avoided immune response, overcoming the genome size limit, targeted and stimuli-responsive delivery, and multimodal therapy of two or more therapeutic modalities in one platform. Native and engineered AAV vectors have been tested to treat a broad range of diseases, including spinal muscular atrophy, retinal diseases, cancers, and tissue damage. This review will cover the benefits of AAV as a promising gene vector by itself, the progress and advantages of engineered AAV vectors, particularly synthetically engineered ones, and the current state of their clinical translation in therapy.
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13
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Kim HK, Peral C, Rubio-Rodríguez D, Rubio-Terrés C. Cost of patients with hemophilia A treated with standard half-life or extended half-life FVIII in Spain. Expert Rev Pharmacoecon Outcomes Res 2020; 21:315-320. [PMID: 32597317 DOI: 10.1080/14737167.2020.1789457] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND In a real-world analysis (RWA) conducted in the United States (US), median international units (IUs) of extended half-life (EHL) recombinant coagulation factor VIII (rFVIII) dispensed were 10% to 45% greater than standard half-life (SHL) rFVIII. The mean IUs of each rFVIII dispensed quarterly were obtained from two databases (N = 776). METHODS A probabilistic model in a 1-year time horizon was used in order to analyze the cost comparison of SHL and EHL rFVIII products in Spain. In this analysis, mean IUs were those of the RWA, and frequency of use and prices for each rFVIII were obtained from sales estimates based on Spanish sources (IQVIA; €, 2019). RESULTS Data showed an average annual savings per patient of €11,227 for SHL rFVIII versus EHL rFVIII products, with a savings probability of 75.5%. The results were stable in the sensitivity analyses. Not switching treatment from SHL to EHL rFVIII resulted in greater savings per patient (€53,078), with a savings probability of 99.9%. Considering the frequency of rFVIII dispensation in the US, annual savings per patient would increase to €16,350 in Spain, with a savings probability of 79.9%. CONCLUSIONS According to this model, use of SHL rFVIII versus EHL rFVIII products could lead to savings for the Spanish National Health System.
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Affiliation(s)
| | - Carmen Peral
- Pfizer, S.L.U., Health Economics & Outcomes Research Department, Madrid, Spain
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14
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Linari S, Castaman G. Concomitant Use of rFVIIa and Emicizumab in People with Hemophilia A with Inhibitors: Current Perspectives and Emerging Clinical Evidence. Ther Clin Risk Manag 2020; 16:461-469. [PMID: 32547043 PMCID: PMC7251291 DOI: 10.2147/tcrm.s205310] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/23/2020] [Indexed: 01/19/2023] Open
Abstract
Emicizumab, a humanized, bi-specific, monoclonal antibody subcutaneously administered, mimicking the function of FVIIIa, represents a milestone in treatment of patients affected by hemophilia A complicated with inhibitors. The HAVEN 1 and 2 studies have clearly established its superiority compared to bypassing agents for routine prophylaxis in preventing or reducing bleeding episodes in adult and pediatric patients with inhibitors. However, its protection against bleeding is only partial, and concomitant use of a bypassing agent may be required with potential prothrombotic risk. The emicizumab Phase III trials (HAVEN 1, 2 and 4) have shown that the traditional bypassing agents, activated prothrombin complex concentrates or recombinant activated factor VII (rFVIIa), may be necessary for the treatment of breakthrough bleeds or surgery management. A post hoc analysis in particular has shown that the concomitant use of emicizumab and rFVIIa is safe and no thrombotic events have been described. The review describes the state of the art of the concomitant use of emicizumab and rFVIIa for treating acute bleeding and surgeries, its efficacy and safety and the lack of thrombotic events associated with this treatment modality. Data still derive mainly from HAVEN trials; however, the availability of emicizumab in clinical practice is progressively increasing the number of patients treated and no adverse events directly attributed to this agent have occurred. The availability of guidelines for the use and dosing of rFVIIa during emicizumab prophylaxis is useful in clinical practice for managing suspected or ongoing bleeding, emergency situations and elective invasive procedures. In the next years, careful prospective post-licensure surveillance to monitor safety of rFVIIa use during prophylaxis with emicizumab is highly recommended.
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Affiliation(s)
- Silvia Linari
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
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15
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Subcutaneous concizumab prophylaxis in hemophilia A and hemophilia A/B with inhibitors: phase 2 trial results. Blood 2020; 134:1973-1982. [PMID: 31444162 DOI: 10.1182/blood.2019001542] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 08/06/2019] [Indexed: 11/20/2022] Open
Abstract
Results from the main parts (24 weeks) of 2 concizumab phase 2 trials are presented: explorer4 in hemophilia A (HA) or B (HB) with inhibitors (HAwI/HBwI) and explorer5 in HA. The trials aimed to evaluate the efficacy of daily subcutaneous concizumab prophylaxis (evaluated as annualized bleeding rate [ABR] at last dose level), with secondary objectives being safety and immunogenicity (assessed as number of adverse events [AEs] and antidrug antibodies [ADAs]). Patients received 0.15 mg/kg concizumab, with potential dose escalation to 0.20 and 0.25 mg/kg (if ≥3 spontaneous bleeding episodes within 12 weeks of concizumab treatment). Relevant pharmacokinetic/pharmacodynamic (PK/PD) parameters were assessed. Thirty-six HA, 9 HAwI, and 8 HBwI patients were exposed to concizumab. Most inhibitor patients (15 of 17; 88.2%) did not escalate the dose; all patients chose to continue to the extension phase of the trials. Clinical proof of concept for prevention of bleeding episodes was demonstrated in both trials. Estimated ABRs in HAwI and HBwI were lower vs HA: 3.0 (95% confidence interval [CI], 1.7; 5.3) and 5.9 (95% CI, 4.2; 8.5) vs 7.0 (95% CI, 4.6; 10.7), respectively. PK/PD results were as expected, with no difference between hemophilia subtypes for concizumab exposure, free tissue factor pathway inhibitor, thrombin generation, prothrombin fragment 1+2, and d-dimers. Concizumab was safe and well tolerated (no severe AEs, AE-related withdrawals, or thromboembolic events). Three patients had (very low to medium titer) ADA+ tests in each trial, with no observed clinical effect. These results support further development of concizumab as a daily prophylactic treatment in all hemophilia patients. These trials were registered at www.clinicaltrials.gov as #NCT03196284 and #NCT03196297.
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16
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Ar MC, Balkan C, Kavaklı K. Extended Half-Life Coagulation Factors: A New Era in the Management of Hemophilia Patients. Turk J Haematol 2019; 36:141-154. [PMID: 31088040 PMCID: PMC6682782 DOI: 10.4274/tjh.galenos.2019.2018.0393] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Despite effective factor replacement and various treatment schedules, there remain several challenges and unmet needs in the prophylactic treatment of hemophilia limiting its adoption and thereby posing an increased risk of spontaneous bleeding. In this regard, extended half-life (EHL) recombinant factor VIII (rFVIII) and factor IX (rFIX) products promise optimal prophylaxis by decreasing the dose frequency, increasing the compliance, and improving the quality of life without compromising safety and efficacy. EHL products might lead to higher trough levels without increasing infusion frequency, or could facilitate the ability to maintain trough levels while reducing infusion frequency. This paper aims to provide a comprehensive review of the rationale for developing EHL coagulation factors and their utility in the management of hemophilia, with special emphasis on optimal techniques for half-life extension and criteria for defining EHL coagulation factors, as well as indications, efficacy, and safety issues of the currently available EHL-rFVIII and EHL-rFIX products. Potential impacts of these factors on quality of life, health economics, and immune tolerance treatment will also be discussed alongside the challenges in pharmacokinetic-driven prophylaxis and difficulties in monitoring the EHL products with laboratory assays.
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Affiliation(s)
- Muhlis Cem Ar
- İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine Department of Internal Medicine, Division of Hematology, İstanbul, Turkey
| | - Can Balkan
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Hemato-Oncology, İzmir, Turkey
| | - Kaan Kavaklı
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Hemato-Oncology, İzmir, Turkey
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17
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Eichler H, Angchaisuksiri P, Kavakli K, Knoebl P, Windyga J, Jiménez-Yuste V, Harder Delff P, Chowdary P. Concizumab restores thrombin generation potential in patients with haemophilia: Pharmacokinetic/pharmacodynamic modelling results of concizumab phase 1/1b data. Haemophilia 2018; 25:60-66. [PMID: 30408848 PMCID: PMC7379180 DOI: 10.1111/hae.13627] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/04/2018] [Accepted: 10/04/2018] [Indexed: 01/18/2023]
Abstract
Introduction Concizumab enhances thrombin generation (TG) potential in haemophilia patients by inhibiting tissue factor pathway inhibitor (TFPI). In EXPLORER3 (phase 1b), a dose‐dependent pharmacokinetic/pharmacodynamic (PK/PD) relationship was confirmed between concizumab dose, free TFPI and TG potential. Aim Determine the association between concizumab exposure, PD markers (free TFPI; peak TG) and bleeding episodes to establish the minimum concizumab concentration for achieving sufficient efficacy. Methods Free TFPI predictions were generated using an estimated concizumab‐free TFPI exposure‐response (Emax) model based on concizumab phase 1/1b data for which simultaneously collected concizumab and free TFPI samples were available. Concizumab concentration at the time of a bleed was predicted using a PK model, based on available data for concizumab doses >50 μg/kg to ≤9 mg/kg. Peak TG vs concizumab concentration analyses and an Emax model were constructed based on EXPLORER3 observations. Results The Emax model showed a tight PK/PD relationship between concizumab exposure and free TFPI; free TFPI decreased with increasing concizumab concentration. A strong correlation between concizumab concentration and peak TG was observed; concizumab >100 ng/mL re‐established TG potential to within the normal reference range. Estimated EC50 values for the identified concizumab‐free TFPI and concizumab‐TG potential models were very similar, supporting free TFPI as an important biomarker. A correlation between bleeding episode frequency and concizumab concentration was indicated; patients with a concizumab concentration >100 ng/mL experienced less frequent bleeding. The PK model predicted that once‐daily dosing would minimize within‐patient concizumab PK variability. Conclusion Concizumab phase 2 trials will target an exposure ≥100 ng/mL, with a once‐daily regimen.
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Affiliation(s)
- Hermann Eichler
- Institute of Clinical Hemostaseology and Transfusion Medicine, Saarland University and University Hospital, Homburg/Saar, Germany
| | - Pantep Angchaisuksiri
- Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kaan Kavakli
- Department of Hematology, Ege University Children's Hospital, Izmir, Turkey
| | - Paul Knoebl
- Clinical Division of Hematology and Hemostasis, Medical University of Vienna, Vienna, Austria
| | - Jerzy Windyga
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
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18
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Eichler H, Angchaisuksiri P, Kavakli K, Knoebl P, Windyga J, Jiménez-Yuste V, Hyseni A, Friedrich U, Chowdary P. A randomized trial of safety, pharmacokinetics and pharmacodynamics of concizumab in people with hemophilia A. J Thromb Haemost 2018; 16:2184-2195. [PMID: 30137664 DOI: 10.1111/jth.14272] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Indexed: 01/22/2023]
Abstract
Essentials explorer™3 was a double-blinded, multiple-dose escalation trial of subcutaneous concizumab. A pharmacodynamic relationship for unbound TFPI and thrombin generation was confirmed. No serious adverse events and no anti-drug antibodies were observed. explorer™3 data support further clinical development of concizumab in people with hemophilia. SUMMARY: Background Concizumab is a humanized mAb targeting tissue factor pathway inhibitor (TFPI), leading to enhanced thrombin generation (TG) potential. explorer™3 (NCT02490787) was a phase 1b, double-blind, multiple-dose escalation trial of subcutaneous concizumab in people with severe hemophilia A without inhibitors. Objectives The primary objective was to evaluate safety. Assessments of pharmacokinetics, pharmacodynamics and subcutaneous concizumab immunogenicity were secondary objectives. Patients/Methods Adverse events (AEs), clinical assessments and bleeding episodes were recorded. Plasma concizumab levels and unbound TFPI levels were measured with ELISAs; residual TFPI activity was measured with a chromogenic assay. Standardized assays were used to assess TG, D-dimer and prothrombin fragment 1 + 2 (F1 + 2 ) levels. explorer™3 was completed after investigation of three dose cohorts (0.25, 0.5 and 0.8 mg kg-1 , once every 4 days) had been completed. Twenty-four patients received 12 doses of concizumab or placebo in a 3 : 1 randomization over a 42-day period. Results No serious AEs and no anti-drug antibodies were observed. Fifty-four mild and two moderate AEs were observed in 19 patients. Concizumab exposure increased with dose in a non-linear manner, confirming target-mediated drug disposition. D-dimer and F1 + 2 levels were increased mostly in the highest dose cohort, in line with previous observations. The level of unbound TFPI decreased in a dose-dependent manner, and was accompanied by a residual TFPI activity decrease and an increase in peak TG. Although the trial was not powered to evaluate efficacy, a trend towards lower bleeding rates was observed in patients in the highest dose cohort. Conclusion explorer™3 data support further clinical development of concizumab for use in people with hemophilia, with or without inhibitors.
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Affiliation(s)
- H Eichler
- Institute of Clinical Hemostaseology and Transfusion Medicine, Saarland University and University Hospital, Homburg/Saar, Germany
| | - P Angchaisuksiri
- Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - K Kavakli
- Department of Hematology, Ege University Children's Hospital, Izmir, Turkey
| | - P Knoebl
- Department of Medicine 1, Division of Hematology and Hemostasis, Medical University of Vienna, Vienna, Austria
| | - J Windyga
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - V Jiménez-Yuste
- Hematology Department, La Paz University Hospital, Madrid, Spain
| | - A Hyseni
- Research and Development, Novo Nordisk A/S, Copenhagen, Denmark
| | - U Friedrich
- Research and Development, Novo Nordisk A/S, Copenhagen, Denmark
| | - P Chowdary
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
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Nederlof A, Mathôt RAA, Leebeek FWG, Fijnvandraat K, Fischer K, Cnossen MH. Positioning extended half-life concentrates for future use: a practical proposal. Haemophilia 2018; 24:e369-e372. [PMID: 30144218 DOI: 10.1111/hae.13588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Angelique Nederlof
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Division of Clinical Pharmacology, Department of Hospital Pharmacy, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Haematology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Karin Fijnvandraat
- Department of Paediatric Haematology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Marjon H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
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Castaman G, Linari S. Prophylactic versus on-demand treatments for hemophilia: advantages and drawbacks. Expert Rev Hematol 2018; 11:567-576. [PMID: 29886751 DOI: 10.1080/17474086.2018.1486704] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Early long-term prophylaxis is the standard of care to prevent joint bleeding and chronic arthropathy in patients with severe hemophilia. Areas covered: Despite the obvious prophylaxis advantages upon the clinical outcomes, there are still several drawbacks to be addressed for the optimal patients' compliance. Frequency of treatment due to short half-life of conventional FVIII and FIX concentrates, difficult venous access, adherence to the prescribed therapy and costs may represent significant critical issues. The development of inhibitors also makes replacement therapy ineffective, preventing patients from receiving long-term prophylaxis. This paper will review these drawbacks and the tools to overcome these limitations, mainly thanks to the use of extended half-life products and the development of novel non-conventional therapeutic approaches. Expert commentary: The use of extended half-life products may help in reducing the burden of the frequent intravenous administration and in better tailoring an individualized prophylaxis. The development of novel therapeutic approaches, like the bi-specific antibody mimicking the coagulation function of FVIII or inhibition of anticoagulant proteins may facilitate prophylaxis treatment not only in patients with inhibitors, but also in severe hemophilia patients without inhibitors. Exciting opportunities are emerging for improving prophylaxis in hemophilia.
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Affiliation(s)
- Giancarlo Castaman
- a Center for Bleeding Disorders and Coagulation, Department of Oncology , Careggi University Hospital , Florence , Italy
| | - Silvia Linari
- a Center for Bleeding Disorders and Coagulation, Department of Oncology , Careggi University Hospital , Florence , Italy
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21
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Graf L. Extended Half-Life Factor VIII and Factor IX Preparations. Transfus Med Hemother 2018; 45:86-91. [PMID: 29765290 DOI: 10.1159/000488060] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 03/01/2018] [Indexed: 01/06/2023] Open
Abstract
In the last couple of years, several extended half-life factor VIII and factor IX preparations were intensively studied and gained approval. In order to extend half-lives, techniques like fusion to protein conjugates (Fc part of IgG1 or albumin), chemical modification (PEGylation), and protein sequence modification are implemented. With these techniques, it is possible to extend half-lives of factor IX products 4- to 6- fold, while half-life extension of factor VIII products is limited to 1.5- to 2-fold due to their interaction with von Willebrand factor. Nevertheless, both extended half-life factor VIII and IX products have improved and facilitated prophylactic factor replacement therapy in hemophilia A and B, respectively. Extended half-life factor concentrates pose challenges to coagulation laboratories because accurate therapy monitoring is not possible with all factor activity assays currently used.
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Affiliation(s)
- Lukas Graf
- Center for Laboratory Medicine, Hemophilia and Hemostasis Center, St. Gallen, Switzerland
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22
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McEneny-King A, Chelle P, Henrard S, Hermans C, Iorio A, Edginton AN. Modeling of Body Weight Metrics for Effective and Cost-Efficient Conventional Factor VIII Dosing in Hemophilia A Prophylaxis. Pharmaceutics 2017; 9:pharmaceutics9040047. [PMID: 29039750 PMCID: PMC5750653 DOI: 10.3390/pharmaceutics9040047] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 01/21/2023] Open
Abstract
The total body weight-based dosing strategy currently used in the prophylactic treatment of hemophilia A may not be appropriate for all populations. The assumptions that guide weight-based dosing are not valid in overweight and obese populations, resulting in overdosing and ineffective resource utilization. We explored different weight metrics including lean body weight, ideal body weight, and adjusted body weight to determine an alternative dosing strategy that is both safe and resource-efficient in normal and overweight/obese adult patients. Using a validated population pharmacokinetic model, we simulated a variety of dosing regimens using different doses, weight metrics, and frequencies; we also investigated the implications of assuming various levels of endogenous factor production. Ideal body weight performed the best across all of the regimens explored, maintaining safety while moderating resource consumption for overweight and obese patients.
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Affiliation(s)
| | - Pierre Chelle
- School of Pharmacy, University of Waterloo, Waterloo, ON N2L 3G1, Canada.
| | - Severine Henrard
- Louvain Drug Research Institute, Clinical Pharmacy Research Group and Institute of Health and Society (IRSS), Université catholique de Louvain, 1348 Brussels, Belgium.
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques universitaires Saint-Luc, Université catholique de Louvain, 1348 Brussels, Belgium.
| | - Alfonso Iorio
- Department of Health Evidence, Research Methods and Impact, McMaster University, Hamilton, ON L8S 4L8, Canada.
- Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada.
| | - Andrea N Edginton
- School of Pharmacy, University of Waterloo, Waterloo, ON N2L 3G1, Canada.
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Bertamino M, Riccardi F, Banov L, Svahn J, Molinari AC. Hemophilia Care in the Pediatric Age. J Clin Med 2017; 6:E54. [PMID: 28534860 PMCID: PMC5447945 DOI: 10.3390/jcm6050054] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/12/2017] [Accepted: 05/16/2017] [Indexed: 01/19/2023] Open
Abstract
Hemophilia is the most common of the severe bleeding disorders and if not properly managed since early infancy can lead to chronic disease and lifelong disabilities. However, it enjoys the most efficacious and safe treatment among the most prevalent monogenic disorders. Hemophilia should be considered in the neonatal period in the case of unusual bleeding or in the case of positive family history. Later, hemophilia should be suspected mainly in males because of abnormal bruising/bleeding or unusual bleeding following invasive procedures-for example, tonsillectomy or circumcision. Prophylactic treatment that is started early with clotting-factor concentrates has been shown to prevent hemophilic arthropathy and is, therefore, the gold standard of care for hemophilia A and B in most countries with adequate resources. Central venous access catheters and arterovenous fistulas play an important role in the management of hemophilia children requiring repeated and/or urgent administration of coagulation factor concentrates. During childhood and adolescence, personalized treatment strategies that suit the patient and his lifestyle are essential to ensure optimal outcomes. Physical activity is important and can contribute to better coordination, endurance, flexibility and strength. The present article focuses also on questions frequently posed to pediatric hematologists like vaccinations, day-care/school access and dental care.
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Affiliation(s)
- Marta Bertamino
- Thrombosis and Hemostasis Unit, Regional Reference Center for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
| | - Francesca Riccardi
- Hematology Unit, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
| | - Laura Banov
- Thrombosis and Hemostasis Unit, Regional Reference Center for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
| | - Johanna Svahn
- Thrombosis and Hemostasis Unit, Regional Reference Center for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
| | - Angelo Claudio Molinari
- Thrombosis and Hemostasis Unit, Regional Reference Center for Hemorrhagic Diseases, Giannina Gaslini Children's Hospital, 16147 Genova, Italy.
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Amiral J, Seghatchian J. Blood derived products in pediatrics: New laboratory tools for optimizing potency assignment and reducing side effects. Transfus Apher Sci 2017; 56:107-117. [PMID: 28343935 DOI: 10.1016/j.transci.2017.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Neonates and children can develop rare bleeding disorders due to congenital/acquired coagulation Factor deficiencies, or allo-immune/autoimmune complications, or can undergo surgeries at high haemorrhagic risk. They then need specialized transfusion of blood components/products, or purified blood extracted products or recombinant proteins. Blood-derived therapies conventionally used for management of affected infants with genetic/acquired deficiencies, bleeding problems (coagulation Factor reduced or missing) or thrombotic disorders (reduced or missing anticoagulant proteins) pose some additional risks. These remedial therapies can cause tolerance when used very early in life and, sometimes needed, repeatedly. The introduction of recombinant proteins has allowed manufacturers to produce large amounts of the proteins usually present at very low concentration in blood. This has also changed the risk pattern of plasma-extracted products, especially in terms of continual reduction of viral transmission. Many efforts have been made over these past decades to reduce the risks associated with the use of all these products in terms of viral and bacterial safety, as well as immune disorders but they are not the objective of this article. Other associated side effects are the presence of undesired activities in blood products, which can produce thrombotic events or adverse reactions. The progressive introduction of blood derived products has greatly improved the prognosis and quality of life of affected patients. This concerns whole blood, but also blood cell concentrates, mainly platelets and red blood cells, plasma, while the blood extracted products are increasingly replaced by recombinant proteins. All these therapeutic products, i.e. blood extracted drugs, improve health and quality of life for hemophiliac's A or B, or patients with auto/allo-immune thrombocytopenias or with rare bleeding disorders, and those with thrombotic events occurring in childhood, which are mainly due to Protein C or Protein S deficiencies (congenital or acquired). Progress in analytical methods and biotechnology allow better control of the manufacturing processes for all blood derived or plasma extracted products and recombinant proteins, and contribute to improved manufacturing processes to minimize the occurrence of side effects. These adverse events can be due to the aging of the blood cell concentrate with release of their granule content, and generation of EVs, which can produce anaphylactic reactions and risk of thrombosis, but also to the presence of activated coagulation Factors in purified products, such as Factor Xia as recently identified in immunoglobulin concentrates. Characterization and measurement of contaminant products is of special usefulness during product preparation and for optimization of manufacturing processes for purified extracted products, but also for recombinant proteins. The pharmaceutical industry introduces these new methods for validating manufacturing processes, or for quality control assessments. The objective is first to warrant the full quality and safety of the lots produced, and assure the highest efficacy with the lowest risks when used in patients. For cell concentrates and fresh blood, storage conditions are critical and measurement of analytes such as EVs or Annexin V allows evaluation of quality of each individual transfused pouch. In addition to all the rules around viral and bacterial transmission risk, and immune tolerance, our available laboratory methods contribute to reducing the side effects of blood cell concentrates and derived plasma products, as well as those of the therapeutic recombinant proteins.
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Affiliation(s)
- Jean Amiral
- SH-Consulting, Andrésy, France; Scientific and Technical Advisor for Hyphen BioMed, Sysmex Group, Neuville sur Oise, France.
| | - Jerard Seghatchian
- International Consultancy in Blood Components Quality/Safety Improvement, Audit/Inspection and DDR Strategies, London, UK.
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