1
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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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2
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Andreeva TA, Zharkov PA, Zozulya NI, Zorenko VY, Konstantinova VN, Lavrentieva IN, Davydkin IL, Petrov VY, Polyanskaya TY, Soldatenkov VE, Shutov SA. [Methodological recommendations for surgical care in patients with hemophilia A receiving prophylactic therapy with emicizumab]. Khirurgiia (Mosk) 2024:3-20. [PMID: 38591217 DOI: 10.17116/hirurgia20240323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Methodological recommendations for surgical care in patients with hemophilia A receiving prophylactic therapy with emicizumab. Recommendations of the expert group. Moscow, 2024.
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Affiliation(s)
- T A Andreeva
- GBUZ "City Polyclinic #37", City Hemophilia Treatment Center, St. Petersburg, Russian Federation
| | - P A Zharkov
- FGBU "National Medical Research Center of Pediatric Hematology, Oncology and Immunology named after Dmitry Rogachev", St. Petersburg, Russia
| | - N I Zozulya
- FGBU "National Medical Research Center of Hematology", Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - V Y Zorenko
- FGBU "National Medical Research Center of Hematology", Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - V N Konstantinova
- GBUZ "City Polyclinic #37", City Hemophilia Treatment Center, St. Petersburg, Russian Federation
| | - I N Lavrentieva
- GBUZ "Morozov Children's City Clinical Hospital of the Moscow City Health Department", Moscow, Russian Federation
| | - I L Davydkin
- FGBOU VO "Samara State Medical University", Ministry of Health of the Russian Federation, Samara, Russian Federation
| | - V Y Petrov
- GBUZ "Morozov Children's City Clinical Hospital of the Moscow City Health Department", Moscow, Russian Federation
| | - T Yu Polyanskaya
- FGBU "National Medical Research Center of Hematology", Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - V E Soldatenkov
- FGBU "Russian Research Institute of Hematology and Transfusiology FMBA", St. Petersburg, Russian Federation
| | - S A Shutov
- FGBU "National Medical Research Center of Hematology", Ministry of Health of the Russian Federation, Moscow, Russian Federation
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3
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Donners AAMT, van der Zwet K, Rademaker CMA, Egberts TCG, Schutgens REG, Fischer K. The efficacy of the entire-vial dosing of emicizumab: Real-world evidence on plasma concentrations, bleeds, and drug waste. Res Pract Thromb Haemost 2023; 7:100074. [PMID: 36915864 PMCID: PMC10005899 DOI: 10.1016/j.rpth.2023.100074] [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: 10/25/2022] [Revised: 12/14/2022] [Accepted: 12/27/2022] [Indexed: 02/10/2023] Open
Abstract
Background Prophylaxis with emicizumab provides effective bleeding protection in persons with hemophilia A (PwHA) but pressures healthcare budgets. The body weight-adjusted dosing at 7-, 14-, or 28-day intervals, according to the label, often mismatches the vial content. Entire-vial dosing resulted in therapeutic concentrations according to pharmacokinetic simulations and was introduced to avoid waste. Objectives The objective of this study was to evaluate the efficacy of entire-vial dosing of emicizumab by investigating real-world evidence of plasma concentrations, bleeds, and drug waste. Methods This is a single-center, observational study with PwHA receiving emicizumab in mg/kg doses according to label but dosing interval extrapolated to the nearest vial size. Patient characteristics and bleeds were compared 1 year before starting emicizumab and during emicizumab until January 2022. Concentrations were assessed at weeks 4, 12, and annually. The mean (95% CI) annualized bleed rates were compared by using negative binomial regression. Drug waste between label-based dosing and entire-vial dosing was compared. Results A total of 112 individuals (94% severe phenotype and 9% positive FVIII inhibitors) were followed for a median of 56 weeks (interquartile range [IQR] 52-68) before and 51 weeks (IQR 29-75) after starting emicizumab. The median emicizumab dose was 5.9 (IQR 5.5-6.2) mg/kg/4 wk with median concentrations of 63 (IQR 51-80) μg/mL. The annualized bleed rate of treated bleeds before emicizumab was 3.6 (95% CI 2.9-4.4) and was 0.8 (95% CI 0.6-1.1) during emicizumab (P < .001). Drug waste was reduced by 9%. Conclusion The entire-vial dosing of emicizumab is an attractive treatment option for PwHA leading to therapeutic plasma concentrations, good bleeding control, and drug waste avoidance.
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Affiliation(s)
- Anouk A M T Donners
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Konrad van der Zwet
- Van Creveldkliniek, Center for Benign Haematology, Thrombosis and Haemostasis, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Carin M A Rademaker
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Toine C G Egberts
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, the Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, Center for Benign Haematology, Thrombosis and Haemostasis, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, Center for Benign Haematology, Thrombosis and Haemostasis, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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4
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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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5
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Zerra PE, Parker ET, Baldwin WH, Healey JF, Patel SR, McCoy JW, Cox C, Stowell SR, Meeks SL. Engineering a Therapeutic Protein to Enhance the Study of Anti-Drug Immunity. Biomedicines 2022; 10:1724. [PMID: 35885029 PMCID: PMC9313379 DOI: 10.3390/biomedicines10071724] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
The development of anti-drug antibodies represents a significant barrier to the utilization of protein-based therapies for a wide variety of diseases. While the rate of antibody formation can vary depending on the therapeutic employed and the target patient population receiving the drug, the antigen-specific immune response underlying the development of anti-drug antibodies often remains difficult to define. This is especially true for patients with hemophilia A who, following exposure, develop antibodies against the coagulation factor, factor VIII (FVIII). Models capable of studying this response in an antigen-specific manner have been lacking. To overcome this challenge, we engineered FVIII to contain a peptide (323-339) from the model antigen ovalbumin (OVA), a very common tool used to study antigen-specific immunity. FVIII with an OVA peptide (FVIII-OVA) retained clotting activity and possessed the ability to activate CD4 T cells specific to OVA323-339 in vitro. When compared to FVIII alone, FVIII-OVA also exhibited a similar level of immunogenicity, suggesting that the presence of OVA323-339 does not substantially alter the anti-FVIII immune response. Intriguingly, while little CD4 T cell response could be observed following exposure to FVIII-OVA alone, inclusion of anti-FVIII antibodies, recently shown to favorably modulate anti-FVIII immune responses, significantly enhanced CD4 T cell activation following FVIII-OVA exposure. These results demonstrate that model antigens can be incorporated into a therapeutic protein to study antigen-specific responses and more specifically that the CD4 T cell response to FVIII-OVA can be augmented by pre-existing anti-FVIII antibodies.
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Affiliation(s)
- Patricia E. Zerra
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University, Atlanta, GA 30322, USA; (P.E.Z.); (J.W.M.)
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; (E.T.P.); (W.H.B.); (J.F.H.); (S.R.P.); (C.C.)
| | - Ernest T. Parker
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; (E.T.P.); (W.H.B.); (J.F.H.); (S.R.P.); (C.C.)
| | - Wallace Hunter Baldwin
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; (E.T.P.); (W.H.B.); (J.F.H.); (S.R.P.); (C.C.)
| | - John F. Healey
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; (E.T.P.); (W.H.B.); (J.F.H.); (S.R.P.); (C.C.)
| | - Seema R. Patel
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; (E.T.P.); (W.H.B.); (J.F.H.); (S.R.P.); (C.C.)
| | - James W. McCoy
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University, Atlanta, GA 30322, USA; (P.E.Z.); (J.W.M.)
| | - Courtney Cox
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; (E.T.P.); (W.H.B.); (J.F.H.); (S.R.P.); (C.C.)
| | - Sean R. Stowell
- Joint Program in Transfusion Medicine, Department of Pathology, Harvard Medical School, Boston, MA 02115, USA
| | - Shannon L. Meeks
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; (E.T.P.); (W.H.B.); (J.F.H.); (S.R.P.); (C.C.)
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6
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Quinn J, Delaney KA, Wong WY, Miesbach W, Bullinger M. Psychometric Validation of the Haemo-QOL-A in Participants with Hemophilia A Treated with Gene Therapy. Patient Relat Outcome Meas 2022; 13:169-180. [PMID: 35879931 PMCID: PMC9307866 DOI: 10.2147/prom.s357555] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose The hemophilia-specific health-related quality of life (HRQOL) questionnaire (Haemo-QOL-A) is validated for detecting QOL changes following standard therapy for hemophilia A, but has not been rigorously evaluated after gene therapy. This post hoc analysis evaluated the psychometric properties of Haemo-QOL-A in adult people with severe hemophilia A (PWSHA) receiving valoctocogene roxaparvovec (AAV5-hFVIII-SQ) in 2 clinical trials (phase 1/2, NCT02576795; phase 3, NCT03370913). Patients and Methods Adult PWSHA (factor VIII levels ≤1 IU/dL) received 1 AAV5-hFVIII-SQ infusion (6×1013 vg/kg). Participants were assessed using the Haemo-QOL-A and the EuroQOL (EQ)-5D-5L and visual analog scale (VAS) questionnaires pre- and post-infusion. Psychometric analyses included convergent and discriminant validity, internal consistency, and reliability. Clinically important difference (CID) was estimated using 3-point change in EQ-5D-5L VAS as anchor. Results Haemo-QOL-A data were analyzed from 7 (phase 1/2, 3-year follow-up) and 16 participants (phase 3, 26-week analysis). Change in Haemo-QOL-A Total Scores correlated with EQ-5D-5L VAS score change at 26 weeks (Pearson’s correlation 0.77). At 26 weeks, increased Haemo-QOL-A Physical Functioning was associated with decreased EQ-5D-5L Pain and Discomfort and decreased Anxiety and Depression (Spearman’s Rank correlations −0.73 and −0.62, respectively, P <0.01). Internal consistency analysis showed good reliability for all domains (Cronbach’s alpha >0.7) except Treatment Concern (Cronbach’s alpha = 0.31). Anchor-based CID estimates were met for Haemo-QOL-A Total Score (≥5.5) and domain scores (≥6) for Consequences of Bleeding, Physical Functioning, Role Functioning, and Worry. Conclusion Our preliminary results suggest that the Haemo‐QOL‐A is a valid, reliable instrument for HRQOL assessment in PWSHA undergoing gene therapy. Future research should be undertaken to confirm these findings in a larger number of participants.
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Affiliation(s)
- Jennifer Quinn
- BioMarin Pharmaceuticals UK Ltd, London, UK
- Correspondence: Jennifer Quinn, BioMarin Pharmaceuticals UK Ltd, 10 Bloomsbury Way, London, WC1A 2SL, UK, Tel +44 7976 129 039, Email
| | | | | | - Wolfgang Miesbach
- Medical Clinic 2, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Monika Bullinger
- Department of Medical Psychology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
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7
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Song J. Advances in laboratory assessment of thrombosis and hemostasis. Blood Res 2022; 57:93-100. [PMID: 35483933 PMCID: PMC9057656 DOI: 10.5045/br.2022.2022048] [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: 02/23/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/17/2022] Open
Abstract
Technologies in laboratory diagnostics are changing fast with progress in understanding and therapy of diseases. Unfortunately, new analyzers are often needed to be installed in a clinical laboratory to implement such techniques. The demand for new hardware is a bottleneck in improving the diagnostic services for many facilities with limited resources. In this regard, hemostasis laboratories take a slightly different position. Because many in vitro diagnostic tests target the functional aspects of hemostasis, further meaningful information can be obtained from the same analyzers as in current use. Automated coagulometers are good candidates for such further utilization. Clot waveform analysis is a leading example. Behind the simple values reported as clotting time, clotting curves exist that represent the process of fibrin clot formation. Clot waveform analysis examines the clotting curves and derives new parameters other than clotting times. The clot waveform parameters are now in active use in assessing the hemostatic potential of hemorrhagic patients. Clinical application of coagulometers can also be widened by modifying the reagent formulation. For example, the chromogenic factor VIII assay with bovine source reagent compositions has recently been introduced for hemophilia A patients on emicizumab prophylaxis. Also, new immunoturbidimetric functional assays for von Willebrand factor have been developed recently. Thus, new clinically relevant information can be mined from the automated coagulometers that are based on old technology.
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Affiliation(s)
- Jaewoo Song
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea
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8
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Doshi BS, Rana J, Castaman G, Shaheen MA, Kaczmarek R, Butterfield JS, Meeks SL, Leissinger C, Biswas M, Arruda VR. B cell-activating factor modulates the factor VIII immune response in hemophilia A. J Clin Invest 2021; 131:142906. [PMID: 33651716 PMCID: PMC8262462 DOI: 10.1172/jci142906] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 02/23/2021] [Indexed: 01/19/2023] Open
Abstract
Inhibitors of factor VIII (FVIII) remain the most challenging complication of FVIII protein replacement therapy in hemophilia A (HA). Understanding the mechanisms that guide FVIII-specific B cell development could help identify therapeutic targets. The B cell-activating factor (BAFF) cytokine family is a key regulator of B cell differentiation in normal homeostasis and immune disorders. Thus, we used patient samples and mouse models to investigate the potential role of BAFF in modulating FVIII inhibitors. BAFF levels were elevated in pediatric and adult HA inhibitor patients and decreased to levels similar to those of noninhibitor controls after successful immune tolerance induction (ITI). Moreover, elevations in BAFF levels were seen in patients who failed to achieve FVIII tolerance with anti-CD20 antibody-mediated B cell depletion. In naive HA mice, prophylactic anti-BAFF antibody therapy prior to FVIII immunization prevented inhibitor formation and this tolerance was maintained despite FVIII exposure after immune reconstitution. In preimmunized HA mice, combination therapy with anti-CD20 and anti-BAFF antibodies dramatically reduced FVIII inhibitors via inhibition of FVIII-specific plasma cells. Our data suggest that BAFF may regulate the generation and maintenance of FVIII inhibitors and/or anti-FVIII B cells. Finally, anti-CD20/anti-BAFF combination therapy may be clinically useful for ITI.
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Affiliation(s)
- Bhavya S Doshi
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Divison of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jyoti Rana
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Mostafa A Shaheen
- Divison of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Radoslaw Kaczmarek
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John Ss Butterfield
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shannon L Meeks
- Department of Pediatrics, Aflac Cancer Center and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Cindy Leissinger
- Section of Hematology/Oncology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Moanaro Biswas
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Valder R Arruda
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Divison of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Raymond G. Perelman Center for Cellular and Molecular Therapies, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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9
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Jiménez‐Yuste V, Rodríguez‐Merchán EC, Matsushita T, Holme PA. Concomitant use of bypassing agents with emicizumab for people with haemophilia A and inhibitors undergoing surgery. Haemophilia 2021; 27:519-530. [PMID: 33988293 PMCID: PMC8359827 DOI: 10.1111/hae.14322] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Surgery in people with haemophilia and factor VIII inhibitors is typically managed with perioperative administration of haemostatic agents to prevent or control the occurrence of bleeding events. Practical experience of surgery in patients with inhibitors who are receiving treatment with emicizumab is growing; however, the novelty of the situation means that standardised guidelines are lacking with regard to the concomitant administration of haemostatic agents, including dose and laboratory monitoring. AIM To review approaches to haemostatic management during major and minor invasive procedures in patients with haemophilia A and inhibitors, and to provide recommendations for controlling bleeding events. METHODS A search was conducted, limited to the past 4 years (January 2016-April 2020), pertaining to published evidence of surgery for patients receiving emicizumab. Publications identified from the search were manually reviewed to determine studies and case reports relevant for inclusion. RESULTS Identified literature and practical experience of the authors were used to build a consensus of practical recommendations for the concomitant administration of haemostatic agents during the perioperative period for elective surgery in patients with inhibitors who are receiving emicizumab. CONCLUSIONS The current evidence base indicates that surgery can be successfully performed in patients with inhibitors who are receiving emicizumab and that bypassing agents can be used concomitantly. Data from prospective studies are required to further support recommendations for haemostatic management of surgery in patients receiving emicizumab.
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Affiliation(s)
- Victor Jiménez‐Yuste
- Department of HematologyLa Paz University Hospital‐IdiPaz, Autónoma UniversityMadridSpain
| | | | | | - Pål Andrè Holme
- Department of HematologyOslo University HospitalOsloNorway
- Institute of Clinical MedicineUniversity of OsloOsloNorway
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10
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Hermans C, Giangrande PLF, O'Mahony B, de Kleijn P, Bedford M, Batorova A, Blatný J, Jansone K. European principles of inhibitor management in patients with haemophilia: implications of new treatment options. Orphanet J Rare Dis 2020; 15:219. [PMID: 32831110 PMCID: PMC7444030 DOI: 10.1186/s13023-020-01511-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 08/13/2020] [Indexed: 12/22/2022] Open
Affiliation(s)
- C Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium.
| | - P L F Giangrande
- European Haemophilia Consortium, Brussels, Belgium.,University of Oxford, Oxford, UK
| | - B O'Mahony
- European Haemophilia Consortium, Brussels, Belgium.,Trinity College, Dublin, Ireland
| | - P de Kleijn
- Department of Rehabilitation, Nursing Science and Sports, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M Bedford
- Canterbury Christ Church University, Kent, UK
| | - A Batorova
- National Hemophilia Center, Dept. of Hematology and Transfusion Medicine, School of Medicine of Comenius University and University Hospital, Bratislava, Slovakia
| | - J Blatný
- Children's University Hospital and Masaryk University, Brno, Czech Republic
| | - K Jansone
- European Haemophilia Consortium, Brussels, Belgium
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11
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Gelbenegger G, Schoergenhofer C, Knoebl P, Jilma B. Bridging the Missing Link with Emicizumab: A Bispecific Antibody for Treatment of Hemophilia A. Thromb Haemost 2020; 120:1357-1370. [PMID: 32717759 PMCID: PMC7649063 DOI: 10.1055/s-0040-1714279] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hemophilia A, characterized by absent or ineffective coagulation factor VIII (FVIII), is a serious bleeding disorder that entails severe and potentially life-threatening bleeding events. Current standard therapy still involves replacement of FVIII, but is often complicated by the occurrence of neutralizing alloantibodies (inhibitors). Management of patients with inhibitors is challenging and necessitates immune tolerance induction for inhibitor eradication and the use of bypassing agents (activated prothrombin complex concentrates or recombinant activated factor VII), which are expensive and not always effective. Emicizumab is the first humanized bispecific monoclonal therapeutic antibody designed to replace the hemostatic function of activated FVIII by bridging activated factor IX and factor X (FX) to activate FX and allow the coagulation cascade to continue. In the majority of hemophilic patients with and without inhibitors, emicizumab reduced the annualized bleeding rate to almost zero in several clinical trials and demonstrated a good safety profile. However, the concurrent use of emicizumab and activated prothrombin complex concentrate imposes a high risk of thrombotic microangiopathy and thromboembolic events on patients and should be avoided. Yet, the management of breakthrough bleeds and surgery remains challenging with only limited evidence-based recommendations being available. This review summarizes published clinical trials and preliminary reports of emicizumab and discusses the clinical implications of emicizumab in treatment of hemophilia A.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Paul Knoebl
- Division of Hematology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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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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Coppola A, Tagliaferri A, Rivolta GF, Quintavalle G, Franchini M. Confronting COVID-19: Issues in Hemophilia and Congenital Bleeding Disorders. Semin Thromb Hemost 2020; 46:819-822. [PMID: 32512586 PMCID: PMC7645823 DOI: 10.1055/s-0040-1712961] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Antonio Coppola
- Regional Reference Center for Inherited Bleeding Disorders University, Hospital of Parma, Parma, Italy
| | - Annarita Tagliaferri
- Regional Reference Center for Inherited Bleeding Disorders University, Hospital of Parma, Parma, Italy
| | - Gianna Franca Rivolta
- Regional Reference Center for Inherited Bleeding Disorders University, Hospital of Parma, Parma, Italy
| | - Gabriele Quintavalle
- Regional Reference Center for Inherited Bleeding Disorders University, Hospital of Parma, Parma, Italy
| | - Massimo Franchini
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantova, Italy
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Franchini M, Liumbruno GM. "The times they are a-changin", ... or maybe not? BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2019; 17:401-402. [PMID: 31846604 PMCID: PMC6917533 DOI: 10.2450/2019.0259-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Massimo Franchini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Haematology and Transfusion Medicine, “Carlo Poma” Hospital, Mantua, Italy
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