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Zhang F, Zhou X, Hua B, He X, Li Z, Xiao X, Wu X. Activated factor X delivered by adeno-associated virus significantly inhibited bleeding and alleviated hemophilic synovitis in hemophilic mice. Gene Ther 2024:10.1038/s41434-024-00479-5. [PMID: 39256611 DOI: 10.1038/s41434-024-00479-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 08/07/2024] [Accepted: 08/12/2024] [Indexed: 09/12/2024]
Abstract
In hemophilia, deficiency of factor VIII or IX prevents the activation of the common coagulation pathway, and inhibits the conversion of FX to activated FXa, which is required for thrombin generation. We hypothesized that the direct expressed FXa has the potential to activate the common pathway and restore coagulation in hemophilia patients. In this study, the cassettes that expressed FXa, FXaop and FXa-FVII were packaged into an engineered AAV capsid, AAV843, and were delivered into hemophilia A and B mice by intravenous injection. AAV-FXaop could be stably expressed in vivo and showed the best immediate and prolonged hemostatic effects, similar to those of commercial drugs (Xyntha and Benefix). AAV-FXaop also significantly inhibited bleeding in hemophilia A mice with inhibitors. In addition, FXa expression in joints significantly alleviated the occurrence of hemophilic synovitis. AAV-delivered FXa may be a novel target for treating hemophilic and hemophilic synovitis.
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Affiliation(s)
- Feixu Zhang
- School of Biotechnology, East China University of Science and Technology, Shanghai, China
| | - Xinyue Zhou
- School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Baolai Hua
- Department of Hematology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xinyi He
- School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Zhanao Li
- School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Xiao Xiao
- School of Biotechnology, East China University of Science and Technology, Shanghai, China
- School of Pharmacy, East China University of Science and Technology, Shanghai, China
| | - Xia Wu
- School of Pharmacy, East China University of Science and Technology, Shanghai, China.
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Nakajima Y, Osuna M, Mizumachi K, Shimonishi N, Furukawa S, Ogiwara K, Nogami K. Activated protein C resistance in the copresence of emicizumab and activated prothrombin complex concentrates. Res Pract Thromb Haemost 2024; 8:102479. [PMID: 39114481 PMCID: PMC11305313 DOI: 10.1016/j.rpth.2024.102479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 05/11/2024] [Accepted: 06/12/2024] [Indexed: 08/10/2024] Open
Abstract
Background Venous thromboembolic events have been reported in persons with hemophilia A who received emicizumab and activated prothrombin complex concentrate (APCC) concomitantly, but the relevant mechanism(s) remains unclear. We speculated that activated protein C (APC) and antithrombin (AT) resistance might be associated with these adverse events. Objectives To investigate APC and AT resistance in factor (F)VIII-deficient (FVIIIdef) plasma in the presence of emicizumab and APCC. Methods In pooled normal plasma or FVIIIdef plasma samples mixed with emicizumab (50 μg/mL) and FVIII-bypassing agents, including recombinant FVIIa (2.2 μg/mL), APCC (1.3 IU/mL), or plasma-derived FVIIa/FX (1.5 μg/mL), the suppression effect of AT (0-2.4 μM) and APC (0-16 nM) was assessed by tissue factor-triggered thrombin generation assay. The APC effects in FVIIIdef plasma with the copresence of emicizumab, FII (1.3 μM), and/or FIXa (280 pM) were also examined. Results The AT resistance in emicizumab and each bypassing agent was not observed. Moreover, APC dose-dependent suppression effect was observed in pooled normal plasma or FVIIIdef plasma mixed with emicizumab and recombinant FVIIa or plasma-derived FVIIa/FX. However, APC-catalyzed inactivation had little effect on thrombin generation assay potential in FVIIIdef plasma spiked with emicizumab and APCC. The addition of FIXa to emicizumab in FVIIIdef plasma could lead to partial APC resistance. Furthermore, FVIIIdef plasma spiked with emicizumab, FIXa, and FII was markedly resistant to APC-mediated inactivation. Conclusion FII and FIXa in APCCs were key clotting factors for APC resistance in FVIIIdef plasma supplemented with emicizumab and APCCs. The APC resistance in persons with hemophilia A receiving emicizumab and APCC may contribute to venous thromboembolic events.
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Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Mitsumasa Osuna
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Jiménez-Yuste V, Álvarez-Román MT, Berrueco R, Bonanad S, Calvo-Villas JM, González-González R, Porras JRG, Núñez-Vázquez RJ, Rodríguez-López M. Management of Urgent Bleeding in Patients with Hemophilia A: Focus on the Use of Emicizumab. TH OPEN 2024; 8:e194-e201. [PMID: 38633730 PMCID: PMC11023713 DOI: 10.1055/s-0044-1785525] [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: 12/11/2023] [Accepted: 02/23/2024] [Indexed: 04/19/2024] Open
Abstract
Management of patients with hemophilia A (HA) requires the knowledge and experience of specialized health care professionals. However, these patients may need to be attended in emergencies, outside the referral hospital, where health care professionals do not know about hemophilia and/or new innovative treatments. This study aimed to develop a simple and practical algorithm that could be used in emergency situations by nonspecialized treaters in HA and bleeding with or without factor VIII (FVIII) inhibitors under emicizumab prophylaxis. A group of experts agreed on a simple algorithm, easy to operate, adapted from previous international guidelines, and based on their clinical experience. The proposed algorithm starts with identifying the patient, confirming the diagnosis of HA, prophylaxis with emicizumab, and/or use of other treatments. After stabilizing the patient and stratifying the bleeding risk, the patient is managed according to the presence/absence of FVIII inhibitors. Patients without FVIII inhibitors should receive FVIII concentrate. Dose and follow-up depend on bleeding localization and severity. Patients with FVIII inhibitors should preferably receive recombinant activated factor VII as bypass agent. A basic coagulation assay, FVIII assessment, and FVIII inhibitors detection assays are necessary in an emergency. However, these tests should be interpreted with caution and appropriately chosen, as emicizumab may alter the results. The management of patients with HA is challenging in emergency situations, especially if they are treated with new agents. Nonspecialized in coagulopathies health care professionals have limited understanding of the disease, highlighting the need for an algorithm to assist them in making informed decisions.
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Affiliation(s)
- Víctor Jiménez-Yuste
- Hematology Department, La Paz University Hospital-IdiPaz, Universidad Autónoma, Madrid, Spain
| | - María T. Álvarez-Román
- Hematology Department, La Paz University Hospital-IdiPaz, Universidad Autónoma, Madrid, Spain
| | - Rubén Berrueco
- Pediatric Hematology Unit, Hospital Sant Joan de Deu, Barcelona, Spain
| | - Santiago Bonanad
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | | | | | - Ramiro J. Núñez-Vázquez
- Hematology Department, Hospital Universitario Virgen del Rocío, Instituto deBiomedicina de Sevilla (IBIS), Sevilla, Spain
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Pipe SW, Dunn AL, Young G. Efficacy and safety evaluation of eptacog beta (coagulation factor VIIa [recombinant]-jncw) for the treatment of hemophilia A and B with inhibitors. Expert Rev Hematol 2023; 16:715-729. [PMID: 37602448 DOI: 10.1080/17474086.2023.2248385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/26/2023] [Accepted: 08/11/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION Bypassing agents (BPAs) are used to treat acute bleeding episodes, manage bleeding during perioperative care, and prophylactically minimize bleed occurrence in persons with hemophilia A or B with inhibitors (PwHABI). However, the effectiveness of BPAs that have been prescribed for the last several decades can be variable, motivating the development of a new recombinant activated factor VII, eptacog beta. AREAS COVERED This review covers key eptacog beta findings from phase 1b and phase 3 (PERSEPT) clinical trials, which formed the basis for its regulatory approval to treat PwHABI ages 12 and older. Descriptions of eptacog beta structure and glycosylation profile, mechanism of action, preclinical study results, and cost analyses are also presented. EXPERT OPINION PwHABI have had only two options for bleed treatment for the past several decades. With its distinct glycosylation profile, eptacog beta offers a novel therapy aiming to improve upon BPAs currently in use, providing an option with more than one dosing regimen and a rapid response that allows most bleeds to be treated with just one dose. This has become particularly important given the use of subcutaneous medications (e.g., emicizumab) for prophylaxis of bleeding. Clinicians should consider eptacog beta as a BPA for all PwHABI.
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Affiliation(s)
- Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Amy L Dunn
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Guy Young
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Muniz RL, Camelo RM, Araújo MS, Barbosa MM, Guerra AA, Acurcio FDA, Alvares-Teodoro J. Efficacy/effectiveness and safety of emicizumab prophylaxis of people with hemophilia A: a systematic review and meta-analysis. Expert Rev Hematol 2023; 16:1087-1097. [PMID: 38066708 DOI: 10.1080/17474086.2023.2293096] [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: 08/26/2023] [Accepted: 11/27/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Emicizumab is a monoclonal antibody approved for prophylaxis against bleeds for people with hemophilia A (PwHA). A systematic review was conducted evaluating the efficacy/effectiveness and the safety of emicizumab as prophylaxis for PwHA compared to prophylaxis with factor VIII (FVIII) or bypassing agents (BPA), respectively in patients without and with inhibitors. RESEARCH DESIGN AND METHODS Database-directed search strategies were performed in Aug/26/2022 and updated in Mar/16/2023. Studies evaluating the prophylaxis with emicizumab versus prophylaxis with FVIII or BPA in PwHA without or with inhibitors, respectively, were selected by two independent reviewers. Data were extracted by two independent reviewers. Annualized bleeding rates for total treated bleeding events (ABR-all) were evaluated by meta-analysis. The quality of studies and certainty of evidence were assessed. RESULTS A total of 11 studies were included. The standard mean differences for ABR-all were -0.6 (95%CI -1.0 to -0.2, p-value = 0.0002), among PwHA without inhibitors, and -1.7 (95%CI -2.4 to -0.9, p-value <0.00001), among PwHA with inhibitors. However, there was moderate heterogeneity in both meta-analyses. The most frequent adverse event was injection site reaction. CONCLUSIONS Emicizumab prophylaxis was superior in reducing the ABR-all when compared with prophylaxis with FVIII or BPA.
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Affiliation(s)
- Roberto Lúcio Muniz
- Faculty of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Maiara Silva Araújo
- Faculty of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Gogia P, Tarantino M, Schramm W, Aledort L. New directions to develop therapies for people with hemophilia. Expert Rev Hematol 2023:1-17. [PMID: 36891589 DOI: 10.1080/17474086.2023.2184341] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
INTRODUCTION The past few decades have seen a tremendous advancement in the management of hemophilia. Whether it is improved methods to attenuate critical viruses, recombinant bioengineering with decreased immunogenicity, extended half-life replacement therapies to mitigate the burden of repeated infusion treatments, novel nonreplacement products to avoid the drawback of inhibitor development with its attractive subcutaneous administration and then the introduction of gene therapy, the management has trodden a long way. AREAS COVERED This expert review describes the progress in the treatment of hemophilia over the years. We discuss, in detail, the past and current therapies, their benefits, drawbacks, along with relevant studies leading to approval, efficacy and safety profile, ongoing trials, and future prospects. EXPERT OPINION The technological advances in the treatment of hemophilia with convenient modes of administration and innovative modalities offer a chance for a normal existence of the patients living with this disease. However, it is imperative for clinicians to be aware of the potential adverse effects and the need for further studies to establish causality or chance association of these events with novel agents. Thus, it is crucial for clinicians to engage patients and their families in informed decision-making and tailor individual concerns and necessities.
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Affiliation(s)
- Pooja Gogia
- Division of Hematology/Oncology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Michael Tarantino
- University of Illinois College of Medicine, and the Bleeding and Clotting Disorders Institute, Peoria, IL, USA
| | - Wolfgang Schramm
- Ludwig-Maximilians University (LMU) Rudolf Marx Stiftung Munich, München, Germany
| | - Louis Aledort
- Division of Hematology/Oncology, Icahn School of Medicine, New York, NY, USA
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Camelo RM, Barbosa MM, Araújo MS, Muniz RL, Guerra AA, Godman B, Rezende SM, Acurcio FDA, Martin AP, Alvares-Teodoro J. Economic Evaluation of Immune Tolerance Induction in Children With Severe Hemophilia A and High-Responding Inhibitors: A Cost-Effectiveness Analysis of Prophylaxis With Emicizumab. Value Health Reg Issues 2023; 34:31-39. [PMID: 36463835 DOI: 10.1016/j.vhri.2022.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/20/2022] [Accepted: 10/19/2022] [Indexed: 12/02/2022]
Abstract
OBJECTIVE This study aimed to measure the cost-effectiveness of prophylaxis with emicizumab in PsHAhri on ITI in Brazil. METHODS A cost-effectiveness modeling analysis was used to estimate the costs per PsHAhri on ITI and the number of prevented bleedings from undertaking one intervention (prophylaxis with BpA) over another (prophylaxis with emicizumab), based on the Brazilian Ministry of Health perspective. Costs of ITI with recombinant FVIII, prophylaxis with BpA or emicizumab, and treated bleeding episodes with BpA costs were evaluated for PsHAhri who had ITI success or failure. This study was conducted with the perspective of the Brazilian Ministry of Health (payer). RESULTS During ITI, prophylaxis with BpA cost US $924 666/PsHAhri/ITI, whereas prophylaxis with emicizumab cost US $488 785/PsHAhri/ITI. During ITI, there was an average of 9.32 bleeding episodes/PsHAhri/ITI when BpA were used as prophylaxis and 0.67 bleeding/PsHAhri/ITI when emicizumab was used. By univariate deterministic sensitivity analysis, emicizumab remained dominant whichever variable was modified. CONCLUSION In this study, prophylaxis with emicizumab during ITI is a dominant option compared with prophylaxis with BpA during ITI.
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Affiliation(s)
- Ricardo Mesquita Camelo
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Maiara Silva Araújo
- Faculty of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Roberto Lúcio Muniz
- Faculty of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, Scotland, UK; Centre of Medical and Bio-allied Health Sciences Research, Ajman University, United Arab Emirates; School of Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, Pretoria, South Africa
| | | | | | - Antony P Martin
- Faculty of Health and Life Sciences, Liverpool, England, UK; QC Medica, York, England, UK
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Liu YL, Zhu XX, Niu LY, Gao Y, Gan H, Wu ZN, Li J, Feng SX, Dou GF, Gu RL, Meng ZY. The Pharmacokinetics and Pharmacodynamics of A Novel Recombinant Activated Human Factor VII, GEN-0828, in Hemophilia B Mice. J Pharm Sci 2023; 112:877-883. [PMID: 36565924 DOI: 10.1016/j.xphs.2022.12.013] [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: 09/06/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
GEN-0828, a proposed clinical candidate for hemophilia and trauma hemorrhage treatment, is a novel recombinant activated human factor VII (rFVIIa). The purpose of this paper is to compare the pharmacokinetics and pharmacodynamics of GEN-0828 in hemophilia B mice with those of NovoSeven®, the only marketed rFVIIa product worldwide., GEN-0828 and NovoSeven® showed similar affinity bioactivity to recombinant tissue factor (rTF) in vitro. Pharmacodynamics data indicated a generally similar hemostatic efficacy (ED50) of GEN-0828 (10.91 KIU·kg-1) and NovoSeven® (18.91 KIU·kg-1) at the doses studied in hemophilia B mice, while GEN-0828 represented a lower initial effective dosage compared with that of NovoSeven® in terms of both blood loss and APTT. GEN-0828 exhibited linear pharmacokinetic profiles in hemophilia B mice at the 30-338 KIU·kg-1 dose range, the comparative pharmacokinetic study with NovoSeven® indicated better characteristics than NovoSeven® in terms of the appropriate higher maximal concentration (Cmax) and area under the plasma concentration-time curve (AUClast) and longer mean residence time (MRT). In conclusion, GEN-0828 was a promising new type of rFVIIa compound with favourable pharmacokinetic and pharmacodynamic profiles.
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Affiliation(s)
- Yu-Lu Liu
- Beijing Institute of Radiation Medicine, Beijing 100850, China; College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou 450046, China
| | - Xiao-Xia Zhu
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Li-Yun Niu
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Ya Gao
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Hui Gan
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Zhuo-Na Wu
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Jian Li
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Su-Xiang Feng
- College of Pharmacy, Henan University of Chinese Medicine, Zhengzhou 450046, China; Co-construction Collaborative Innovation Center for Chinese Medicine and Respiratory Diseases by Henan & Education Ministry of China, Henan University of Chinese Medicine, Zhengzhou 450046, China.
| | - Gui-Fang Dou
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Ruo-Lan Gu
- Beijing Institute of Radiation Medicine, Beijing 100850, China.
| | - Zhi-Yun Meng
- Beijing Institute of Radiation Medicine, Beijing 100850, China.
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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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10
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Hassan E, Motwani J. Breakthrough bleeding episodes in pediatric severe hemophilia a patients with and without inhibitors receiving emicizumab prophylaxis: a single-center retrospective review. Pediatr Hematol Oncol 2022; 39:418-426. [PMID: 35170384 DOI: 10.1080/08880018.2021.2004269] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Emicizumab has been widely used for prophylaxis in patients with hemophilia A (HA) of all ages, with or without factor VIII inhibitors. Data on emicizumab efficacy are certainly significant; however, protection against bleeding is not absolute, and the breakthrough bleeding risk can be approximately equivalent to that of patients with mild HA. This single-center retrospective review aimed to present the rate and management of breakthrough bleeding events in pediatric HA patients with and without inhibitors who are on emicizumab prophylaxis. Fifty-one pediatric patients on emicizumab prophylaxis that were followed up at Birmingham Children's Hospital between March 1, 2018, and May 15, 2021, were included in the current study. Our results showed that 56.8% (29/51) experienced no bleeding events, and 80.3% (41/51) had no major treated bleeds during the follow-up period. A total of 29.4% (15/51) had minor bleeds that resolved spontaneously or with antifibrinolytics. Overall, 19.6% (10/51) of the patients received additional FVIII to prevent or treat breakthrough bleeding. One patient had a major bleeding event in the form of hematuria. However, it resolved without treatment. Both major and minor bleeding episodes occurred in 7.8% (4/51) of patients. None of the patients with inhibitors (5/51) developed breakthrough bleeding. Only a few, mostly minor, breakthrough bleeding episodes were reported in our cohort. The balance between bleeding control and the risk of inhibitor development after episodic factor administration should be considered. Therefore, careful decisions should be made in managing bleeding events.Supplemental data for this article is available online at.
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Affiliation(s)
- Eman Hassan
- Department of Pediatric Hematology, Birmingham Children's Hospital, Birmingham, UK.,Department of Pediatrics, Hematology and Oncology Unit, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Jayashree Motwani
- Department of Pediatric Hematology, Birmingham Children's Hospital, Birmingham, UK
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11
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Holstein K, Le Quellec S, Klamroth R, Batorova A, Holme PA, Jiménez-Yuste V, Astermark J. Immune tolerance induction in the era of emicizumab - still the first choice for patients with haemophilia A and inhibitors? Haemophilia 2021; 28:215-222. [PMID: 34918839 DOI: 10.1111/hae.14470] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/12/2021] [Accepted: 11/29/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The development of inhibitory antibodies is a severe complication of clotting factor replacement therapy in patients with severe haemophilia A (HA). Current World Federation of Hemophilia (WFH) guidelines for haemophilia care indicate that eradication of inhibitors is best achieved through immune tolerance induction (ITI) therapy. AIM The European Collaborative Haemophilia Network conducted a survey to determine whether ITI is still used in the routine management of patients with HA, and whether the availability of emicizumab prophylaxis has influenced treatment decisions. METHODS The survey was conducted in late 2020/early 2021 in 18 centres representing 17 countries in the Europe/Middle East region treating a total of 4955 patients, and included sections specific to patient and centre demographics, treatment protocols (both ITI and prophylactic), inhibitor development and initiation of ITI, treatment success, and the incidence of adverse events. RESULTS While our results indicate that ITI can still be considered a mainstay of treatment for patients with HA with inhibitors, less than daily dosing of ITI in combination with emicizumab prophylaxis is becoming commonplace across the spectrum of disease severity, with initiation being guided by bleeding patterns. The most frequently cited reasons for not initiating emicizumab prophylaxis were availability or reimbursement issues. CONCLUSION ITI remains a mainstay for haemophilia treatment of patients with HA with inhibitors, but emicizumab has become a preferred first-line approach to protect against bleeds and represents an alternative to burdensome ITI in certain patient groups.
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Affiliation(s)
- Katharina Holstein
- II. Medical Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sandra Le Quellec
- Unité d'hémostase Clinique - Hôpital Cardiologique Louis Pradel - Hospices Civils de Lyon, Lyon, France
| | - Robert Klamroth
- Department for Internal Medicine - vascular medicine and coagulation disorders at the Vivantes Hospital im Friedrichshain, Berlin, Germany
| | - Angelika Batorova
- National Hemophilia Centre, Dept. of Hematology and Transfusion Medicine, Faculty of Medicine of Comenius University and University Hospital, Bratislava, Slovakia
| | - Pål Andre Holme
- Department of Haematology, Oslo University Hospital and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Victor Jiménez-Yuste
- Servicio de Hematología, Hospital Universitario La Paz, Paseo de la Castellana, Autónoma University, Madrid, Spain
| | - Jan Astermark
- Department for Translational Medicine, Lund University and Department for Hematology Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
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12
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Factor-mimetic and rebalancing therapies in hemophilia A and B: the end of factor concentrates? Hematology 2021; 2021:219-225. [DOI: 10.1182/hematology.2021000253] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Abstract
Hemophilia A (HA) and B are inherited bleeding disorders caused by a deficiency of factor VIII or factor IX, respectively. The current standard of care is the administration of recombinant or purified factor. However, this treatment strategy still results in a high economic and personal burden to patients, which is further exacerbated by the development of inhibitors—alloantibodies to factor. The treatment landscape is changing, with nonfactor therapeutics playing an increasing role in what we consider to be the standard of care. Emicizumab, a bispecific antibody that mimics the function of factor VIIIa, is the first such nonfactor therapy to gain US Food and Drug Administration approval and is rapidly changing the paradigm for HA treatment. Other therapies on the horizon seek to target anticoagulant proteins in the coagulation cascade, thus “rebalancing” a hemorrhagic tendency by introducing a thrombotic tendency. This intricate hemostatic balancing act promises great things for patients in need of more treatment options, but are these other therapies going to replace factor therapy? In light of the many challenges facing these therapies, should they be viewed as a replacement of our current standard of care? This review discusses the background, rationale, and potential of nonfactor therapies as well as the anticipated pitfalls and limitations. This is done in the context of a review of our current understanding of the many aspects of the coagulation system.
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Hassan E, Lancashire J, Motwani J. Patients on emicizumab prophylaxis with previously tolerized inhibitors: Is there a risk of inhibitors recurrence? Haemophilia 2021; 28:e36-e38. [PMID: 34821004 DOI: 10.1111/hae.14466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/09/2021] [Accepted: 11/15/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Eman Hassan
- Department of Paediatric Haematology, Birmingham Children's Hospital, Birmingham, UK.,Haematology and Oncology Unit, Faculty of Medicine, Alexandria University, Department of Paediatrics, Alexandria, Egypt
| | - Jonathan Lancashire
- Department of Paediatric Haematology, Birmingham Children's Hospital, Birmingham, UK
| | - Jayashree Motwani
- Department of Paediatric Haematology, Birmingham Children's Hospital, Birmingham, UK
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