Therapy for haemophilia: recent advances and goals for the future

The diagnosis and treatment strategy of occipital skull mass in hemophilic patients: a rare case report and literature review

Background

Cranial hemophilic pseudotumor (cHPT) is a very rare disease, which is easy to misdiagnose. It is also difficult to manage such patients. We reported the first case of occipital cHPT.

Case presentation

Here, we presented a rare case of an occipital bone mass in a 3-year-old boy who was diagnosed with hemophilia A. The mass was misdiagnosed as an aneurysmal bone cyst by pathological examination. After resection, the patient underwent one-stage cranioplasty. However, the patient was admitted again for hematoma caused by an invasive procedure. A second surgery and one-stage cranioplasty were performed at the same time. A follow-up 3 months after discharging showed the patient was uneventful, and the titanium mesh was well fixed.

Conclusion

The diagnosis of cHPT requires the combining of history, radiological examination, and pathological examination. Resection is the best choice for symptomatic cHPT. Replacement treatment and less invasive treatment can make perioperative management safer. One-stage cranioplasty for resection of an occipital cHPT can improve the quality of life.

Advancement in the treatment of haemophilia

Poor understanding of the pathophysiological mechanisms involved in Haemophilia is a major obstacle in accessing effective haemophilia disease management. Haemophilia is a life-frightening bleeding problem in which there are repeated bleeding episodes. Various approaches have been used, involves clotting factor replacement therapy for effective bleeding control in Haemophilia. Current advancements in the management of patients with haemophilia include altered pharmacokinetics clotting factor concentrates for better prophylaxis and management of haemophilia. This review sums up the prophylactic treatment, novel production techniques, other treatment techniques and the present position of gene therapy in the treatment of haemophilia.

Bilateral cranial hemophilic pseudotumor

Hemophilic pseudotumor is a rare but well-known complication of hemophilia manifesting as recurrent hemorrhage and progressive enlargement of hematoma. A patient with severe hemophilia has 1% to 2% chance to develop pseudotumor. The chronic pressure of osseous hemorrhage usually results in bone destruction or resorption. Cranial hemophilic pseudotumors are extremely rare, with only 7 reported cases associated with mild or moderate factor VIII or IX deficiency. A 42-year-old man with a mild factor VIII deficiency developed a pseudotumor of the bilateral skull. Computed tomography and magnetic resonance imaging revealed an extra-axial lesion with bone destruction, and signal changes are consistent with chronic hemorrhage. With adequate factor-deficient replacement therapy, surgical removal was performed. Histologic examination disclosed old blood coagulum. No recurrence was observed in 3 years of follow-up. Cranial hemophilic pseudotumor is extremely rare, and with adequate factor-deficient replacement therapy, surgical management is a safe and effective way for cranial hemophilic pseudotumor treatment.

Feasibility of Using Thrombin Generation Assay (TGA) for Monitoring Bypassing Agent Therapy in Patients With Hemophilia Having Inhibitors

Background:

Monitoring bypassing agent therapy and observing concordance with clinical hemostasis is crucial in vital hemorrhages and major surgeries in patients with hemophilia having inhibitor.

Objective:

We aimed to investigate the value of the thrombin generation assay (TGA) and thromboelastography (TEG) for monitoring hemostasis in patients with hemophilia having inhibitor, during supplementation therapy with bypassing agents.

Patients and Methods:

The study group consisted of 7 patients with hemophilia having factor VIII inhibitor. All patients were male. The median age of the participants was 10 years. Age range was 6 to 32 years. The median inhibitor level was 10 Bethesda units (BU), with a range of 5 to 32 BU. A total of 17 bleeding episodes were evaluated. Both TEG and TGA tests were assessed in addition to clinical responses. Assessments were made prior to bypass agent therapy such as recombinant factor VIIa (rFVIIa) or activated prothrombin complex concentrate (aPCC) for bleeding episodes, during the first hour and 24 hours after either intervention in patients.

Results:

No relation between clinical response and TGA or TEG parameters was found in patients. There was no difference between clinical responses after rFVIIa and aPCC treatments. However, after aPCC treatment, endogenous thrombin potential and peak thrombin levels and also TEG R, K, and alpha angle degrees were significantly higher.

Conclusions:

In conclusion, we found that the clinical effectiveness of bypass therapy in hemophilia cannot be assessed by TGA and TEG.

Cost and effectiveness of treatments for mild-to-moderate bleeding episodes in haemophilia patients with inhibitors in Korea

First-line treatment for mild-to-moderate bleeding episodes in patients with haemophilia and inhibitors in Korea is currently activated prothrombin complex concentrate (aPCC) with recombinant activated factor VII (rFVIIa) as second-line therapy or as a last resort. The aim of this study was to estimate the cost and effectiveness of aPCC vs. rFVIIa for treating mild-to-moderate bleeds in inhibitor patients from the Korean reimbursement authorities' perspective. Clinical outcomes and resource utilization data (number of doses, average dose, number of outpatient visits, inpatient stays, ambulance transport and concomitant medications) were collected from an observational study involving four Korean paediatric haemophilia centres. Cost-effectiveness was modelled using a decision analysis approach and sensitivity analyses undertaken. rFVIIa was a more effective haemostatic therapy (87.1% efficacy in bleed resolution) than aPCC (64.0%). rFVIIa effected more rapid haemostasis, resolving bleeding in a mean of 6.6 h vs. 25.2 h for aPCC. Fewer rFVIIa doses were required per bleed vs. aPCC (means 1.7 and 2.3). Mean total direct medical costs from bleed initiation to cessation were estimated at Korean Won (KRW)12 460 thousand (US$12 311) for rFVIIa given as first-line therapy and KRW18 304 thousand (US$18 085) for aPCC given as first-line therapy. Sensitivity analyses confirmed the cost-effectiveness of rFVIIa vs. aPCC given as first-line therapy. In Korea, use of rFVIIa as first-line therapy for treatment of mild-to-moderate bleeding episodes in inhibitor patients is both clinically effective and cost-effective compared with initial aPCC treatment. rFVIIa should be considered as the first-line treatment for mild-to-moderate bleeding episodes in patients with haemophilia and inhibitors in Korea.

Cranial hemophilic pseudotumor associated with factor IX deficiency: case report

BACKGROUND

Hemophilic pseudotumor is an unusual complication occurring in only 1% to 2% of patients with severe factor VIII or IX deficiency, and manifests as a progressive enlargement of hematoma by recurrent hemorrhage, often resulting in bone destruction or resorption due to the chronic pressure of osseous hemorrhage. Cranial hemophilic pseudotumors are extremely rare, with only 4 previous cases associated with mild or moderate factor XIII deficiency.

CASE DESCRIPTION

A 24-year-old man with moderate deficiency of factor IX developed a cranial pseudotumor as a swelling in the frontal scalp. Blood coagulation profile revealed extended activated partial thromboplastin time (58.2 seconds). Factor IX analysis showed 3% of normal activity. Computed tomography and magnetic resonance imaging demonstrated an extra-axial lesion with bone destruction, enhanced rim, and signal changes consistent with chronic hemorrhage. Surgical removal was performed. Histologic examination disclosed old blood coagulum.

CONCLUSIONS

This case of cranial hemophilic pseudotumor in a patient with moderate factor IX deficiency suggests that cranial pseudotumor should be considered in the differential diagnosis of cranial lesion in a patient with hemophilia, and adequate replacement therapy in the perioperative period is essential to achieve safe surgical removal.

In vivo models of haemophilia - status on current knowledge of clinical phenotypes and therapeutic interventions

Animal models have contributed immensely to the understanding of and the improvement in treatment of haemophilia A and B. First, establishment of haemophilic dog colonies provided an invaluable opportunity to investigate the diseases and later, the advances in gene technologies resulting in small haemophilic animal models were a milestone in the preclinical research making it possible to address some of the many unanswered questions. This review provides an overview of animal models used in the study of haemophilia as well as a short overview of the contributions resulting from studies in these models.

A systematic approach to controlling problem bleeds in patients with severe congenital haemophilia A and high-titre inhibitors

The presence of inhibitory antibodies to clotting factors complicates the treatment of bleeding in haemophilia patients. For patients with high-titre inhibitors, bypassing agents are essential to haemostatic management. To determine optimal treatment practices, an international panel of physicians convened to develop a systematic treatment approach for problem bleeds (i.e. bleeds that are unresponsive to initial therapy with a single agent within a reasonable amount of time) in haemophilia patients with inhibitors.

AIM

The goal of this panel was to develop a consensus algorithm that would aid physicians in considering a variety of treatment approaches to optimize patient care by preventing extensive therapy with inadequate treatments that may lead to suboptimal patient outcomes and unnecessary costs.

METHODS

Consensus opinions were analyzed for clinical preferences at different time periods, depending on patient response to treatment. Decision-making points were defined based on the type of bleed: every 8-12 h for the first 24 h, then every 24 h thereafter for limb-threatening bleeds; every 2-4 h for 2-7 days for life-threatening bleeds.

RESULTS

The resultant consensus guidelines provide a generalized methodology to guide the treatment of problem bleeds in patients with severe haemophilia A and inhibitors, and emphasize changing treatment at the first sign of an inadequate haemostatic response. The treatment algorithms apply to both paediatric and adult patients, although the differences between the two groups were reviewed.

CONCLUSION

These guidelines are focused on optimising the timing of treatment decisions, which may lead to faster responses and improved outcomes.

Individualization of bypassing agent treatment for haemophilic patients with inhibitors utilizing thromboelastography

The treatment of bleeding for haemophilic patients with inhibitors relies on the use of the bypassing agents, recombinant factor VIIa and factor eight inhibitor bypass activity (FEIBA). While both therapies are effective in the majority of bleeding episodes, there is a significant amount of interindividual variability when it comes to the response to therapy. As of yet, there is no reliable laboratory parameter that can predict the response to therapy in the same manner that factor VIII and factor IX levels predict response in non-inhibitor patients. Developing such a laboratory parameter is vital in order to maximize the clinical efficacy of these agents. Thromboelastography (TEG) is a device, which assesses clot formation over time in whole blood and has several characteristics which suggest it may be an effective way to monitor bypass agent therapy. We studied the ability of TEG to individualize the treatment regimens of three patients with high titre inhibitors assessing the response to recombinant factor VIIa, FEIBA, and when both were used sequentially. The TEG allowed for individualization of treatment for each of the three patients and resulted in more effective, convenient and less expensive treatment regimens. We thus believe that TEG is a promising device for monitoring of bypass agent therapy and should be studied further.