1
|
Mannucci PM. Pros and cons of the ISTH treatment guidelines for hemophilia. J Thromb Haemost 2024; 22:2413-2415. [PMID: 38908833 DOI: 10.1016/j.jtha.2024.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 05/31/2024] [Indexed: 06/24/2024]
Affiliation(s)
- Pier Mannuccio Mannucci
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.
| |
Collapse
|
2
|
Reyes Ruiz A, Bhale AS, Venkataraman K, Dimitrov JD, Lacroix-Desmazes S. Binding Promiscuity of Therapeutic Factor VIII. Thromb Haemost 2024. [PMID: 38950594 DOI: 10.1055/a-2358-0853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
The binding promiscuity of proteins defines their ability to indiscriminately bind multiple unrelated molecules. Binding promiscuity is implicated, at least in part, in the off-target reactivity, nonspecific biodistribution, immunogenicity, and/or short half-life of potentially efficacious protein drugs, thus affecting their clinical use. In this review, we discuss the current evidence for the binding promiscuity of factor VIII (FVIII), a protein used for the treatment of hemophilia A, which displays poor pharmacokinetics, and elevated immunogenicity. We summarize the different canonical and noncanonical interactions that FVIII may establish in the circulation and that could be responsible for its therapeutic liabilities. We also provide information suggesting that the FVIII light chain, and especially its C1 and C2 domains, could play an important role in the binding promiscuity. We believe that the knowledge accumulated over years of FVIII usage could be exploited for the development of strategies to predict protein binding promiscuity and therefore anticipate drug efficacy and toxicity. This would open a mutational space to reduce the binding promiscuity of emerging protein drugs while conserving their therapeutic potency.
Collapse
Affiliation(s)
- Alejandra Reyes Ruiz
- Centre de Recherche des Cordeliers, Institut National de la Santé et de la Recherche Médicale, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
| | - Aishwarya S Bhale
- Centre for Bio-Separation Technology (CBST), Vellore Institute of Technology (VIT), Vellore, Tamil Nadu, India
| | - Krishnan Venkataraman
- Centre for Bio-Separation Technology (CBST), Vellore Institute of Technology (VIT), Vellore, Tamil Nadu, India
| | - Jordan D Dimitrov
- Centre de Recherche des Cordeliers, Institut National de la Santé et de la Recherche Médicale, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
| | - Sébastien Lacroix-Desmazes
- Centre de Recherche des Cordeliers, Institut National de la Santé et de la Recherche Médicale, CNRS, Sorbonne Université, Université Paris Cité, Paris, France
| |
Collapse
|
3
|
Fischer K, Lassila R, Peyvandi F, Gatt A, Hollingsworth R, Lambert T, Kaczmarek R, Bettle A, Samji N, Rivard GÉ, Carcao M, Iorio A, Makris M. Inhibitor development according to concentrate in severe hemophilia: reporting on 1392 Previously Untreated Patients from Europe and Canada. Res Pract Thromb Haemost 2023; 7:102265. [PMID: 38193044 PMCID: PMC10772871 DOI: 10.1016/j.rpth.2023.102265] [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: 06/05/2023] [Revised: 09/01/2023] [Accepted: 10/09/2023] [Indexed: 01/10/2024] Open
Abstract
Background Clotting factor concentrates have been the mainstay of severe hemophilia treatment over the last 50 years. Differences in risk of neutralizing antibody (inhibitor) formation according to concentrate used remain clinically relevant. Objectives To assess inhibitor development according to type of clotting factor concentrate in previously untreated patients (PUPs) with severe hemophilia A and B. Methods The European Haemophilia Safety Surveillance (EUHASS) and Canadian Bleeding Disorders Registry (CBDR) have been monitoring adverse events overall and according to concentrate for 11 and 8 years, respectively. Inhibitors were reported quarterly, and PUPs completed 50 exposure days without inhibitor development annually. Cumulative inhibitor incidences and 95% confidence intervals (CIs) were compared without adjustment for other risk factors. Results Fifty-six European and 23 Canadian centers reported inhibitor development in 312 of 1219 (26%; CI, 23%-28%) PUPs with severe hemophilia A and 14 of 173 (8%; CI, 5%-13%) PUPs with severe hemophilia B. Inhibitor development was lower on plasma-derived factor (F)VIII (pdFVIII, 20%; CI, 14%-26%) than on standard half-life recombinant FVIII (SHL-rFVIII, 27%; CI, 24%-30% and odds ratio, 0.67; CI, 0.45%-0.98%; P = .04). Extended half-life recombinant FVIII (EHL-rFVIII, 22%; CI, 12%-36%) showed an intermediate inhibitor rate, while inhibitor rates for Advate (26%; CI, 22%-31%) and Kogenate/Helixate (30%; CI, 24%-36%) overlapped. For other SHL-rFVIII concentrates, inhibitor rates varied from 3% to 43%. Inhibitor development was similar for pdFIX (11%; CI, 3%-25%), SHL-rFIX (8%; CI, 3%-15%), and EHL-rFIX (7%; CI, 1%-22%). Conclusion While confirming expected rates of inhibitors in PUPs, inhibitor development was lower in pdFVIII than in SHL-rFVIII. Preliminary data suggest variation in inhibitor development among different SHL-rFVIII and EHL-rFVIII concentrates.
Collapse
Affiliation(s)
- Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Riitta Lassila
- Department of Hematology, Unit of Coagulation Disorders, Helsinki University Central Hospital, Helsinki, Finland
| | - Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | | | | | - Radek Kaczmarek
- Coagulation Products Safety Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada
- Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Nasrin Samji
- Department of Pediatrics, Division of Hematology-Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Georges-Étienne Rivard
- Department of Pediatrics, Division of Hematology-Oncology, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Manuel Carcao
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alfonso Iorio
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Toronto, Ontario, Canada
| | - Mike Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - EUHASS and CHESS participants
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
- Department of Hematology, Unit of Coagulation Disorders, Helsinki University Central Hospital, Helsinki, Finland
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Mater Dei Hospital, Tal-QRoqq, Msida, Malta
- MDSAS, Manchester, United Kingdom
- Hopital Bicetre, Paris, France
- Coagulation Products Safety Supply and Access Committee, World Federation of Hemophilia, Montreal, Quebec, Canada
- Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
- IWK Health Centre, Halifax, Nova Scotia, Canada
- Department of Pediatrics, Division of Hematology-Oncology, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, Division of Hematology-Oncology, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Toronto, Ontario, Canada
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| |
Collapse
|
4
|
Mohammed Ali IM, Hussein AA, Al-Musawi IMS, Hillawi SSH, Kadhim NS, Jasim AA. Epidemiological profile of hemophilia A in Karbala-Iraq. J Med Life 2023; 16:1611-1614. [PMID: 38406788 PMCID: PMC10893571 DOI: 10.25122/jml-2023-0218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/18/2023] [Indexed: 02/27/2024] Open
Abstract
Hemophilia is an X-linked congenital bleeding disorder caused by a deficiency of coagulation factor VIII (FVIII) (in hemophilia A) or factor IX (FIX) (in hemophilia B) and is one of the most important hereditary conditions in Iraq. The current study tried to provide a glimpse into the epidemiological and clinical status, as well as complications and treatment used for patients with hemophilia A in Karbala, Iraq. This retrospective research was carried out by reviewing the medical records of 90 male patients diagnosed with hemophilia A registered at the Hereditary Blood Disease Center in Karbala Teaching Hospital for children in Karbala, Iraq. The data was collected from May 10, 2023, until June 15, 2023, and included age, severity, type of bleeding, therapeutic approach, chronic viral infections including hepatitis B, hepatitis C, and human immunodeficiency virus (HIV). The median age of the patients was 15 years (18.86±14.42). In this study, one-third of patients' presentations started in the first year of life. The most common type was severe hemophilia A (factor VIII activity < 1%). Consequently, more than half of the patients were treated with factor VIII concentrate. Four patients had hepatitis C, while HIV was confirmed in one patient. The epidemiological or clinical parameters of hemophilia A patients in Karbala seem similar to those in other cities in Iraq. By considering this preliminary data, further comprehensive studies for patients with hemophilia and associated complications in other provinces or cities in Iraq are highly suggested to provide a clear perspective about the prevalence and epidemiological burdens.
Collapse
Affiliation(s)
| | - Ashwaq Ali Hussein
- Department of Pediatrics, College of Medicine, University of Kerbala, Karbala, Iraq
| | | | | | | | | |
Collapse
|
5
|
Pratt KP, Gunasekera D, Vir P, Tan S, Pierce GF, Olsen C, Butenas S, Mann KG. Anti-FVIII antibodies in Black and White hemophilia A subjects: do F8 haplotypes play a role? Blood Adv 2023; 7:4983-4998. [PMID: 36459498 PMCID: PMC10471934 DOI: 10.1182/bloodadvances.2021004909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 09/28/2022] [Accepted: 10/12/2022] [Indexed: 12/04/2022] Open
Abstract
The most common complication in hemophilia A (HA) treatment, affecting 25% to 30% of patients with severe HA, is the development of alloimmune inhibitors that foreclose the ability of infused factor VIII (FVIII) to participate in coagulation. Inhibitors confer significant pathology on affected individuals and present major complexities in their management. Inhibitors are more common in African American patients, and it has been hypothesized that this is a consequence of haplotype (H)-treatment product mismatch. F8 haplotypes H1 to H5 are defined by nonsynonymous single-nucleotide polymorphisms encoding sequence variations at FVIII residues 1241, 2238, and 484. Haplotypes H2 to H5 are more prevalent in individuals with Black African ancestry, whereas 80% to 90% of the White population has the H1 haplotype. This study used an established multiplex fluorescence immunoassay to determine anti-FVIII antibody titers in plasma from 394 individuals with HA (188 Black, 206 White), measuring their binding to recombinant full-length H1 and H2 and B-domain-deleted (BDD) H1/H2, H3/H5, and H4 FVIII proteins. Inhibitor titers were determined using a chromogenic assay and linear B-cell epitopes characterized using peptide microarrays. FVIII-reactive antibodies were readily detected in most individuals with HA, with higher titers in those with a current inhibitor, as expected. Neither total nor inhibitory antibody titers correlated with F8 haplotype mismatches, and peptides with D1241E and M2238V polymorphisms did not comprise linear B-cell epitopes. Interestingly, compared with the full-length FVIII products, the BDD-FVIII proteins were markedly more reactive with plasma antibodies. The stronger immunoreactivity of BDD-FVIII suggests that B-domain removal might expose novel B-cell epitopes, perhaps through conformational rearrangements of FVIII domains.
Collapse
Affiliation(s)
| | - Devi Gunasekera
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Pooja Vir
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Glenn F. Pierce
- Independent Consultant, La Jolla, CA
- World Federation of Hemophilia, Montreal, QC, Canada
| | - Cara Olsen
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | | | - Kenneth G. Mann
- College of Medicine, University of Vermont, Burlington, VT
- Haematologic Technologies, Inc, Colchester, VT
| |
Collapse
|
6
|
Nguyen NH, Jarvi NL, Balu-Iyer SV. Immunogenicity of Therapeutic Biological Modalities - Lessons from Hemophilia A Therapies. J Pharm Sci 2023; 112:2347-2370. [PMID: 37220828 DOI: 10.1016/j.xphs.2023.05.014] [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: 02/10/2023] [Revised: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 05/25/2023]
Abstract
The introduction and development of biologics such as therapeutic proteins, gene-, and cell-based therapy have revolutionized the scope of treatment for many diseases. However, a significant portion of the patients develop unwanted immune reactions against these novel biological modalities, referred to as immunogenicity, and no longer benefit from the treatments. In the current review, using Hemophilia A (HA) therapy as an example, we will discuss the immunogenicity issue of multiple biological modalities. Currently, the number of therapeutic modalities that are approved or recently explored to treat HA, a hereditary bleeding disorder, is increasing rapidly. These include, but are not limited to, recombinant factor VIII proteins, PEGylated FVIII, FVIII Fc fusion protein, bispecific monoclonal antibodies, gene replacement therapy, gene editing therapy, and cell-based therapy. They offer the patients a broader range of more advanced and effective treatment options, yet immunogenicity remains the most critical complication in the management of this disorder. Recent advances in strategies to manage and mitigate immunogenicity will also be reviewed.
Collapse
Affiliation(s)
- Nhan H Nguyen
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA; Currently at Truvai Biosciences, Buffalo, NY, USA
| | - Nicole L Jarvi
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Sathy V Balu-Iyer
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.
| |
Collapse
|
7
|
Fischer K, Carcao M, Male C, Ranta S, Pergantou H, Kenet G, Kartal-Kaess M, Königs C, Carvalho M, Alvarez MT, Brakenhoff T, Chambost H, van den Berg HM. Different inhibitor incidence for individual factor VIII concentrates in 1076 previously untreated patients with severe hemophilia A: data from the PedNet cohort. J Thromb Haemost 2023; 21:700-703. [PMID: 36696215 DOI: 10.1016/j.jtha.2022.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/04/2022] [Accepted: 11/17/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Kathelijn Fischer
- Center for Benign Hematology Thrombosis and Hemostasis, Van Creveldkliniek, University Medical Center, Utrecht University, The Netherlands.
| | - Manuel Carcao
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Canada
| | - Christoph Male
- Department of Paediatrics, Medical University Hospital of Vienna, Vienna, Austria
| | - Susanna Ranta
- Pediatric Coagulation Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Helen Pergantou
- Haemophilia-Haemostasis Unit, St. Sophia Children's Hospital, Athens, Greece
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer & Amalia Biron Research Institute of Thrombosis & Hemostasis, Tel Aviv University, Israel
| | - Mutlu Kartal-Kaess
- Division of Pediatric Hematology & Oncology, Department of Pediatrics, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Königs
- University Hospital Frankfurt, Department of Paediatrics and Adolescent Medicine, Frankfurt, Germany
| | - Manuela Carvalho
- Centro de Referência de Coagulopatias Congénitas do Centro Hospitalar Universitário S. João, EPE, Porto, Portugal
| | | | | | - Hervé Chambost
- Centre de Traitement de l'Hémophilie, AP-HM, Aix Marseille Université, Marseille, France
| | | |
Collapse
|
8
|
Prezotti ANL, Frade-Guanaes JO, Yamaguti-Hayakawa GG, Ozelo MC. Immunogenicity of Current and New Therapies for Hemophilia A. Pharmaceuticals (Basel) 2022; 15:ph15080911. [PMID: 35893734 PMCID: PMC9331070 DOI: 10.3390/ph15080911] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023] Open
Abstract
Anti-drug antibody (ADA) development is a significant complication in the treatment of several conditions. For decades, the mainstay of hemophilia A treatment was the replacement of deficient coagulation factor VIII (FVIII) to restore hemostasis, control, and prevent bleeding events. Recently, new products have emerged for hemophilia A replacement therapy, including bioengineered FVIII molecules with enhanced pharmacokinetic profiles: the extended half-life (EHL) recombinant FVIII products. However, the main complication resulting from replacement treatment in hemophilia A is the development of anti-FVIII neutralizing alloantibodies, known as inhibitors, affecting approximately 25–30% of severe hemophilia A patients. Therefore, the immunogenicity of each FVIII product and the mechanisms that could help increase the tolerance to these products have become important research topics in hemophilia A. Furthermore, patients with inhibitors continue to require effective treatment for breakthrough bleedings and procedures, despite the availability of non-replacement therapy, such as emicizumab. Herein, we discuss the currently licensed treatments available for hemophilia A and the immunogenicity of new therapies, such as EHL-rFVIII products, compared to other products available.
Collapse
Affiliation(s)
- Alessandra N. L. Prezotti
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- HEMOES, Hematology and Hemotherapy Center Dr. Marcos Daniel Santos, Av. Marechal Campos, 1468, Maruípe, Vitória 29047-105, ES, Brazil
| | - Jéssica O. Frade-Guanaes
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
| | - Gabriela G. Yamaguti-Hayakawa
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
| | - Margareth C. Ozelo
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
- Correspondence: ; Tel.: +55-(19)-3521-8395
| |
Collapse
|
9
|
Kohar K, Prayogo SA, Wiyono L. The Impact of Recombinant Versus Plasma-Derived Factor VIII Concentrates on Inhibitor Development in Previously Untreated Patients With Hemophilia A: A 2021 Update of a Systematic Review and Meta-Analysis. Cureus 2022; 14:e26015. [PMID: 35859961 PMCID: PMC9288272 DOI: 10.7759/cureus.26015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 11/05/2022] Open
Abstract
Hemophilia A, the most common hereditary disorder, is caused by clotting factor deficiency. Challenges encountered in the current treatment of hemophilia A [factor VIII (FVIII) replacement therapy] due to inhibitor development have caused ineffective treatment as well as morbidity and mortality among patients. However, there are no studies comparing the two types of FVIII treatments in terms of inhibitor development rate. Therefore, we conducted this systematic review to devise a better treatment option with a lower risk of inhibitor development. The systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and by searching several databases. Data extraction on study characteristics and outcomes was conducted. Reviewers also conducted a risk of bias assessment on all studies. All eligible studies for quantitative analysis were then processed using RevMan 5.4.1 and the data was extrapolated into cumulative outcomes and expressed in forest and funnel plots. Nine studies were included in the meta-analysis, involving a total of 2,531 hemophilia A patients who were followed up from birth until death. A higher incidence of inhibitor development was found to be associated with recombinant FVIII (rFVIII) [odds ratio (OR)=1.57, 95% confidence interval (CI): 0.95-2.59; hazard ratio (HR)=1.89, 95% CI: 1.15-3.12]. The same trend was also found for high-responding inhibitors (OR=1.38, 95% CI: 0.70-2.70; HR=1.42, 95% CI: 0.84-2.39). rFVIII is associated with a higher risk of overall and high-responding inhibitor development compared to plasma-derived FVIII (pdFVIII).
Collapse
Affiliation(s)
- Kelvin Kohar
- Faculty of Medicine, Universitas Indonesia, Jakarta, IDN
| | | | | |
Collapse
|
10
|
Lauritzen B, Bjelke M, Björkdahl O, Bloem E, Keane K, Kjalke M, Rossen M, Lippert SL, Weldingh KN, Skydsgaard M, Kjellev S. A novel next-generation FVIIIa mimetic, Mim8, has a favorable safety profile and displays potent pharmacodynamic effects: Results from safety studies in cynomolgus monkeys. J Thromb Haemost 2022; 20:1312-1324. [PMID: 35191180 PMCID: PMC9314625 DOI: 10.1111/jth.15682] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Mim8 is a novel, next-generation factor VIIIa mimetic in development for subcutaneous prophylactic treatment of patients with hemophilia A with and without inhibitors. In vitro and in vivo models indicate that Mim8 has a distinct hemostatic potential. OBJECTIVES To test the nonclinical safety and pharmacodynamics of Mim8. METHODS The Mim8 nonclinical safety program in cynomolgus monkeys consisted of three studies of 4-26 weeks in duration with Mim8 doses ranging from 0.3-60 mg/kg/week intravenously or subcutaneously. After sacrifice, macroscopic and microscopic pathological examinations were performed. RESULTS Mim8 was well tolerated with no noteworthy clinical observations. No signs of excessive coagulation or pathological macroscopic or microscopic findings were observed at doses 0.3-3 mg/kg/week subcutaneous. Thrombosis-related findings were detected during histopathological examination in a small proportion of animals (16%) receiving doses ranging 6-20 mg/kg/week. Dose-dependent increases in factor X (FX) and factor IX (FIX) concentrations were observed. Shortening of activated partial thromboplastin time (APTT) and increased thrombin generation under ex vivo hemophilia A-like conditions were observed at all Mim8 dose levels. CONCLUSIONS Thrombosis-related findings observed at doses above 6 mg/kg/week Mim8 may have been exaggerated pharmacological reactions to a procoagulant compound in normocoagulant animals. Increases in FX and FIX concentrations could be because of a half-life prolongation due to binding to Mim8, but were limited at clinically relevant exposure levels. Subcutaneous administration of up to 3 mg/kg/week (several fold greater than expected clinical exposure) for 26 weeks resulted in relevant pharmacodynamic effects, observed in thrombin generation and APTT, with no signs of thrombi or excessive coagulation activation.
Collapse
Affiliation(s)
| | - Mads Bjelke
- Global Drug DiscoveryNovo Nordisk A/SMåløvDenmark
| | | | - Esther Bloem
- Global Drug DiscoveryNovo Nordisk A/SMåløvDenmark
| | - Kevin Keane
- Global Drug DiscoveryNovo Nordisk A/SMåløvDenmark
| | | | - Marie Rossen
- Global Drug DiscoveryNovo Nordisk A/SMåløvDenmark
| | | | | | | | | |
Collapse
|
11
|
Haemophilia in France: Modelisation of the Clinical Pathway for Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19020646. [PMID: 35055467 PMCID: PMC8775796 DOI: 10.3390/ijerph19020646] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/02/2022] [Accepted: 01/04/2022] [Indexed: 11/24/2022]
Abstract
Process-of-care studies participate in improving the efficiency of the care pathway for patient with haemophilia (CPPH) and rationalize the multidisciplinary management of patients. Our objective is to establish a current overview of the different actors involved in the management of patients with haemophilia and to provide an accurate description of the patient trajectory. This is a qualitative exploratory research based on interviews of the principal health professionals of four haemophilia services, between November 2019 and February 2020, in France. Mapping of the CPPH processes within the different institutions and/or services, as well as the rupture zones, were identified. Treatment delivery and biological analyses were carried out exclusively in healthcare institutions. The main liberal health professionals solicited were nurses, physiotherapists and general practitioner. Obstacles and barriers within the specialized service, with other hospital services and external hospital or private services, community health care providers et community environment and individual one was complex and multiples. Our research identified potential concerns that need to be addressed to improve future studies to identify influential elements. Similarly, other qualitative studies will have to be conducted on the perceptions and literacy of patients with haemophilia to develop a global interactive mapping of their trajectories.
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Jardim LL, Santana MP, Chaves DG, van der Bom J, Rezende SM. Risk factors for antibody formation in children with hemophilia: methodological aspects and clinical characteristics of the HEMFIL cohort study. Blood Coagul Fibrinolysis 2021; 32:443-450. [PMID: 34127617 DOI: 10.1097/mbc.0000000000001057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Up to 35% of patients with hemophilia A and 5% with hemophilia B develop neutralizing antibodies which can inhibit the therapeutic activity of factor replacement (inhibitors). Despite the clinical relevance of antifactor VIII and IX neutralizing antibodies, there is still a major gap on the knowledge of risk factors for their development. Furthermore, most of the studies on risk factors for inhibitor development come from Caucasian and Afro-American populations. The HEMFIL is a Brazilian prospective cohort study of previously untreated children with hemophilia, which primary aim is to identify new risk factors related to inhibitor development. This manuscript aims at describing the study design and its methodology. After the diagnosis, children are followed up to 75 exposure days or to inhibitor development. Standardized forms and blood samples are collected to describe clinical characteristics and to perform the measurement of immunological and genetic biomarkers at three time points; Inclusion time (T0), at inhibitor development or at 75 exposure days without inhibitors (T1) and after immune tolerance induction for patients in whom it is indicated and performed (T2). Currently, 120 children have been included, of whom, 95 have completed the follow-up. For severe/moderately severe hemophilia A, the cumulative incidence of inhibitors at 75 exposure days was 35% (95% confidence interval, 26-46%). The inclusion of additional patients and a longer follow-up will allow the analysis of risk factors for inhibitor development.
Collapse
Affiliation(s)
- Letícia L Jardim
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marcio P Santana
- Hemocentro de Belo Horizonte, Fundação HEMOMINAS, Belo Horizonte, Brazil
| | - Daniel G Chaves
- Hemocentro de Belo Horizonte, Fundação HEMOMINAS, Belo Horizonte, Brazil
| | - Johanna van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
- Center for Clinical Transfusion Research, Sanquin, Leiden, The Netherlands
| | - Suely M Rezende
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| |
Collapse
|
14
|
Saultier P, Guillaume Y, Demiguel V, Berger C, Borel-Derlon A, Claeyssens S, Harroche A, Oudot C, Rafowicz A, Trossaert M, Wibaut B, Vinciguerra C, Boucekine M, Baumstarck K, Meunier S, Calvez T, Chambost H. Compliance with Early Long-Term Prophylaxis Guidelines for Severe Hemophilia A. J Pediatr 2021; 234:212-219.e3. [PMID: 33676933 DOI: 10.1016/j.jpeds.2021.02.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/10/2021] [Accepted: 02/26/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the applicability and compliance with guidelines for early initiation of long-term prophylaxis in infants with severe hemophilia A and to identify factors associated with guideline compliance. STUDY DESIGN This real-world, prospective, multicenter, population-based FranceCoag study included almost all French boys with severe hemophilia A, born between 2000 and 2009 (ie, after guideline implementation). RESULTS We included 333 boys in the study cohort. The cumulative incidence of long-term prophylaxis use was 61.2% at 3 years of age vs 9.5% in a historical cohort of 39 boys born in 1996 (ie, before guideline implementation). The guidelines were not applicable in 23.1% of patients due to an early intracranial bleeding or inhibitor development. Long-term prophylaxis was delayed in 10.8% of patients. In the multivariate analysis, 2 variables were significantly associated with "timely long-term prophylaxis" as compared with "delayed long-term prophylaxis": hemophilia treating center location in the southern regions of France (OR 23.6, 95% CI 1.9-286.7, P = .013 vs Paris area) and older age at long-term prophylaxis indication (OR 7.2 for each additional year, 95% CI 1.2-43.2, P = .031). Long-term prophylaxis anticipation was observed in 39.0% of patients. Earlier birth year (OR 0.5, 95% CI 0.3-0.8, P = .010 for birth years 2005-2009 vs 2000-2004) and age at first factor replacement (OR 1.9 for each additional year, 95% CI 1.2-3.0, P = .005) were significantly associated with "long-term prophylaxis guideline compliance" vs "long-term prophylaxis anticipation." CONCLUSIONS This study suggests that long-term prophylaxis guidelines are associated with increased long-term prophylaxis use. However, early initiation of long-term prophylaxis remains a challenge.
Collapse
Affiliation(s)
- Paul Saultier
- APHM, La Timone Children's Hospital, Department of Pediatric Hematology, Immunology and Oncology, Marseille, France; Aix Marseille Univ, INSERM, INRAe, C2VN, Marseille, France.
| | - Yves Guillaume
- APHM, La Timone Children's Hospital, Department of Pediatric Hematology, Immunology and Oncology, Marseille, France
| | - Virginie Demiguel
- Santé Publique France, French National Public Health Agency, Saint-Maurice, France
| | - Claire Berger
- Saint-Etienne University Hospital, Hematology and Oncology Pediatric Unit, Saint Etienne, France
| | - Annie Borel-Derlon
- La Côte de Nacre University Hospital, Center for Bleeding Disorders, Caen, France
| | | | - Annie Harroche
- AP-HP, Necker University Hospital, Center for Bleeding Disorders, Paris, France
| | - Caroline Oudot
- Limoges University Hospital, Hematology and Oncology Pediatric Unit, Limoges, France
| | - Anne Rafowicz
- AP-HP, Bicêtre University Hospital, Center for Bleeding Disorders, Le Kremlin Bicêtre, France
| | - Marc Trossaert
- Nantes University Hospital, Center for Bleeding Disorders, Nantes, France
| | - Bénédicte Wibaut
- Lille 2 University Hospital, Center for Bleeding Disorders, Lille, France
| | - Christine Vinciguerra
- Hospices Civils de Lyon, Service d'Hématologie Biologique, Centre de Biologie et Pathologie Est, Bron, France; Université Claude Bernard Lyon 1, Univ Lyon, EA 4609 Hémostase et Cancer, Lyon, France
| | - Mohamed Boucekine
- Aix-Marseille Univ, EA 3279, Self-perceived Health Assessment Research Unit, School of Medicine, Marseille, France
| | - Karine Baumstarck
- Aix-Marseille Univ, EA 3279, Self-perceived Health Assessment Research Unit, School of Medicine, Marseille, France
| | - Sandrine Meunier
- Hospices Civils de Lyon, Lyon University Hospital, Center for Bleeding Disorders, Lyon, France
| | - Thierry Calvez
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Paris, France
| | - Hervé Chambost
- APHM, La Timone Children's Hospital, Department of Pediatric Hematology, Immunology and Oncology, Marseille, France; Aix Marseille Univ, INSERM, INRAe, C2VN, Marseille, France
| | | | | |
Collapse
|
15
|
Marchesini E, Morfini M, Valentino L. Recent Advances in the Treatment of Hemophilia: A Review. Biologics 2021; 15:221-235. [PMID: 34163136 PMCID: PMC8214539 DOI: 10.2147/btt.s252580] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/10/2021] [Indexed: 01/19/2023]
Abstract
Progress in hemophilia therapy has been remarkable in the first 20 years of the third millennium, but the innovation began with the description the fractionation of plasma in 1946. The first concentrates followed the discovery of FVIII in the cryoprecipitate of frozen plasma and FIX in the supernatant in the early 1960s, which led to the initial attempts at replacement therapy. Unfortunately, the lack of screening methods for viral pathogens resulted in people with hemophilia (PWH) receiving concentrates contaminated by hepatitis A virus, hepatitis C virus, and human immunodeficiency virus, as these concentrates were made from large industrial pools of plasma derived from thousands of donors. Fortunately, by 1985, viral screening methods and proper virucidal techniques were developed that made concentrates safe. Increasingly pure products followed the introduction of chromatography steps with monoclonal antibodies in the production process. The problem of immunogenicity of exogenously administered concentrates has not yet had a complete solution. The development of alloantibodies against FVIII in about 25-35% of PWH is the most serious adverse effect of replacement therapy. The next major advance followed the cloning of the F8 gene and later the F9 genes, which paved the way to produce concentrates of factors obtained by the recombinant DNA technology. The injected FVIII and FIX molecules had a relatively short circulating half-life in the plasma of people with hemophilia A and B, approximately 12 and 18 hours, respectively. The ability to prolong the plasma half-life and extend the interval between injections followed the application of methods to conjugate the factor molecule with the fragment crystallizable of IgG1 or albumin or by adding polyethylene glycol, which has led to an increase in the half-life of concentrates, especially for rFIX. The next frontier in hemophilia therapy is the application of durable and potentially curative therapies such as with gene addition therapy. Experiments in hemophilia B have demonstrated durable responses. Unfortunately, the results with gene therapy for hemophilia A have not been as remarkable and the durability must still be demonstrated. Nonetheless, the long-term safety, predictability, durability, and efficacy of gene therapy for hemophilia A and B remain an open question. At present, only healthy adult PWH have been enrolled in gene therapy clinical trials. The application of gene therapy to children and those with pre-existing antibodies against the delivery vector must also be studied before this therapy becomes widespread.
Collapse
Affiliation(s)
- Emanuela Marchesini
- Hemophilia Centre, SC Vascular and Emergency Department, University of Perugia, Perugia, Italy
| | - Massimo Morfini
- Italian Association of Haemophilia Centres (AICE), Naples, Italy
| | - Leonard Valentino
- National Hemophilia Foundation, New York, NY, USA
- Rush University, Chicago, IL, USA
| |
Collapse
|
16
|
Peyvandi F, Miri S, Garagiola I. Immune Responses to Plasma-Derived Versus Recombinant FVIII Products. Front Immunol 2021; 11:591878. [PMID: 33552050 PMCID: PMC7862552 DOI: 10.3389/fimmu.2020.591878] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 12/04/2020] [Indexed: 11/27/2022] Open
Abstract
The most severe side effect of hemophilia treatment is the inhibitor development occurring in 30% of patients, during the earliest stages of treatment with factor (F)VIII concentrates. These catastrophic immune responses rapidly inactivate the infused FVIII, rendering the treatment ineffective. This complication is associated with a substantial morbidity and mortality. The risk factors involved in the onset of the inhibitors are both genetic and environmental. The source of FVIII products, i.e. plasma-derived or recombinant FVIII products, is considered one of the most relevant factors for inhibitor development. Numerous studies in the literature report conflicting data on the different immunogenicity of the products. The SIPPET randomized trial showed an increased in the inhibitor rate in patients using recombinant FVIII products than those receiving plasma-derived products in the first exposure days. The SIPPET randomized trial showed an increase in the inhibitor rate in patients using recombinant FVIII products compared to those treated with plasma-derived products in the first days of exposure. The potential increase in the immunogenicity of recombinant products can be attributed to several factors such as: the different post-translational modification in different cell lines, the presence of protein aggregates, and the role played by the chaperon protein of FVIII, the von Willebrand factor, which modulates the uptake of FVIII by antigen presenting cells (APCs). Furthermore, the presence of non-neutralizing antibodies against FVIII has shown to be in increased inhibitor development as demonstrated in a sub-analysis of the SIPPET study. In addition, the presence of the specific subclasses of the immunoglobulins may also be an important biomarker to indicate whether the inhibitor will evolve into a persistent neutralizing antibody or a transient one that would disappear without any specific treatment. Recently, the availability of novel non-replacement therapies as well as emicizumab, administered by weekly subcutaneous infusion, have significantly changed the quality of life of patients with inhibitors showing a considerable reduction of the annual bleeding rate and in most patients the absence of bleeding. Although, these novel drugs improve patients' quality of life, they do not abolish the need to infuse FVIII during acute bleeding or surgery. Therefore, the issue of immunogenicity against FVIII still remains an important side effect of hemophilia treatment.
Collapse
Affiliation(s)
- Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Syna Miri
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Isabella Garagiola
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
17
|
Male C, Andersson NG, Rafowicz A, Liesner R, Kurnik K, Fischer K, Platokouki H, Santagostino E, Chambost H, Nolan B, Königs C, Kenet G, Ljung R, Van den Berg M. Inhibitor incidence in an unselected cohort of previously untreated patients with severe haemophilia B: a PedNet study. Haematologica 2021; 106:123-129. [PMID: 31919092 PMCID: PMC7776246 DOI: 10.3324/haematol.2019.239160] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/09/2020] [Indexed: 12/20/2022] Open
Abstract
The incidence of factor IX (FIX) inhibitors in severe hemophilia B (SHB) is not well defined. Frequencies of 3-5% have been reported but most studies to date have been small, including patients with different severities, and without prospective follow up for inhibitor incidence. The study objective was to investigate the inhibitor incidence in patients with SHB followed up for to 500 exposure days (ED), the frequency of allergic reactions, and the relationship with genotypes. Consecutive previously untreated patients (PUP) with SHB enrolled into the PedNet cohort were included. Detailed data was collected for the first 50 ED, followed by the annual collection of the inhibitor status and allergic re-actions. The presence of inhibitors was defined by at least two consecutive positive samples. Additionally, data on FIX gene mutation was collected. One hundred and fifty-four PUP with SHB were included; 75% were followed up until 75 ED, and 43% until 500 ED. Inhibitors developed in 14 patients (seven high-titer). The median number of ED at inhibitor manifestation was 11 (interquartile range [IQR]: 6.5-36.5). The cumulative inhibitor incidence was 9.3% (95% Confidence Interval [CI]: 4.4-14.1) at 75 ED, and 10.2% (95% CI: 5.1-15.3) at 500 ED. Allergic reactions occurred in four (28.6%) inhibitor patients. Missense mutations were most frequent (46.8%) overall but not associated with inhibitors. Nonsense mutations and deletions with large structural changes comprised all mutations among inhibitor patients and were associated with an inhibitor risk of 26.9% and 33.3%, respectively. In an unselected, well-defined cohort of PUP with SHB, the cumulative inhibitor incidence was 10.2% at 500 ED. Nonsense mutations and large deletions were strongly associated with the risk of inhibitor development. The ‘PedNet Registry’ is registered at clinicaltrials.gov; identifier: NCT02979119.
Collapse
Affiliation(s)
| | - Nadine G Andersson
- Centre for Thrombosis and Hemostasis, Skane University Hospital, Malmö, Sweden
| | | | - Ri Liesner
- Hemophilia Center, Dept. of Hematology, Great Ormond Street Hospital for Children, London
| | - Karin Kurnik
- Dr. V. Haunersches Kinderspital, University of Munich
| | | | - Helen Platokouki
- Haemophilia-Haemostasis Unit, St. Sophia Children Hospital, Athens
| | | | - Hervé Chambost
- APHM, La Timone Children Hospital, Center for Bleeding Disorders, Marseille
| | - Beatrice Nolan
- Department of Paediatric Hematology, Children Health Ireland at Crumlin, Dublin
| | - Christoph Königs
- J.W. Goethe University Hospital, Department of Pediatrics, Frankfurt
| | - Gili Kenet
- National Hemophilia Center, Ministry of Health, Sheba Medical Center, Tel Hashomer, Israel
| | - Rolf Ljung
- Department of Clinical Sciences, Department of Pediatrics, Lund University, Lund, Sweden
| | | |
Collapse
|
18
|
Keipert C, Drechsel-Bäuerle U, Oberle D, Müller-Olling M, Hilger A. Epidemiological Challenges in Rare Bleeding Disorders: FVIII Inhibitor Incidence in Haemophilia A Patients-A Known Issue of Unknown Origin. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 18:ijerph18010225. [PMID: 33396748 PMCID: PMC7795862 DOI: 10.3390/ijerph18010225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/17/2020] [Accepted: 12/22/2020] [Indexed: 01/10/2023]
Abstract
There is a broad range of factor products approved in Germany for haemophilia A treatment. Since the introduction of recombinant coagulation factor VIII (FVIII) products in the 1990s, there has been substantial debate whether there is a difference in inhibitor incidence between single FVIII products or product classes. Neither haemophilia registries nor clinical studies, including a randomised controlled clinical trial, provided a consistent and definite answer. The reasons were mainly related to methodological challenges in conducting controlled studies in a rare disease. In this analysis, the most relevant epidemiological challenges and main problems were examined, including study bias, potential overlap of individual studies and advanced development of therapy and methods in the course of time. Meta-analyses on two levels showed that therapies using recombinant products resulted in different event rates when compared to plasma-derived products. These results are accompanied by substantial study heterogeneity evidenced by Cochran's Q tests. Only three studies have been identified that meet the standards of current clinical guidance. To finally resolve this ongoing and disputable safety issue of replacement therapy, collaboration among registry owners, academia and regulators must be fostered.
Collapse
Affiliation(s)
- Christine Keipert
- German Haemophilia Registry, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany
- Correspondence:
| | - Ursula Drechsel-Bäuerle
- Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (U.D.-B.); (D.O.)
| | - Doris Oberle
- Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (U.D.-B.); (D.O.)
| | - Mirco Müller-Olling
- Hematology and Transfusion Medicine, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (M.M.-O.); (A.H.)
| | - Anneliese Hilger
- Hematology and Transfusion Medicine, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (M.M.-O.); (A.H.)
| |
Collapse
|
19
|
Drillaud N, Babuty A, Rugeri L, Fouassier M, Lienhart A, Béné M, Lefranc C, Ternisien C, Chamouard V, Sigaud M, Pennetier M, Trossaërt M, Meunier S. Management of previously untreated patients with severe haemophilia A preferentially treated with recombinant factor VIII products: Two French centres' real‐life experience. Haemophilia 2020; 26:e349-e352. [DOI: 10.1111/hae.14132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/30/2020] [Accepted: 07/30/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - Antoine Babuty
- Haemophilia Treatment Center University Hospital Nantes France
| | - Lucia Rugeri
- Haemophilia Treatment Center University Hospital Lyon France
| | - Marc Fouassier
- Haemophilia Treatment Center University Hospital Nantes France
| | - Anne Lienhart
- Haemophilia Treatment Center University Hospital Lyon France
| | - Marie‐C Béné
- Haemophilia Treatment Center University Hospital Nantes France
| | - Carole Lefranc
- Haemophilia Treatment Center University Hospital Lyon France
| | | | | | - Marianne Sigaud
- Haemophilia Treatment Center University Hospital Nantes France
| | | | - Marc Trossaërt
- Haemophilia Treatment Center University Hospital Nantes France
| | | |
Collapse
|
20
|
Chen CY, Tran DM, Cavedon A, Cai X, Rajendran R, Lyle MJ, Martini PGV, Miao CH. Treatment of Hemophilia A Using Factor VIII Messenger RNA Lipid Nanoparticles. MOLECULAR THERAPY. NUCLEIC ACIDS 2020; 20:534-544. [PMID: 32330871 PMCID: PMC7178004 DOI: 10.1016/j.omtn.2020.03.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 03/23/2020] [Accepted: 03/30/2020] [Indexed: 12/17/2022]
Abstract
Hemophilia A (HemA) patients are currently treated with costly and inconvenient replacement therapy of short-lived factor VIII (FVIII) protein. Development of lipid nanoparticle (LNP)-encapsulated mRNA encoding FVIII can change this paradigm. LNP technology constitutes a biocompatible and scalable system to efficiently package and deliver mRNA to the target site. Mice intravenously infused with the luciferase mRNA LNPs showed luminescence signals predominantly in the liver 4 h after injection. Repeated injections of LNPs did not induce elevation of liver transaminases. We next injected LNPs carrying mRNAs encoding different variants of human FVIII (F8 LNPs) into HemA mice. A single injection of B domain-deleted F8 LNPs using different dosing regimens achieved a wide range of therapeutic activities rapidly, which can be beneficial for various usages in hemophilia treatment. The expression slowly declined yet remained above therapeutic levels up to 5–7 days post-injection. Furthermore, routine repeated injections of F8 LNPs in immunodeficient mice produced consistent expression of FVIII over time. In conclusion, F8 LNP treatment produced rapid and prolonged duration of FVIII expression that could be applied to prophylactic treatment and potentially various other treatment options. Our study showed potential for a safe and effective platform of new mRNA therapies for HemA.
Collapse
Affiliation(s)
- Chun-Yu Chen
- Seattle Children's Research Institute, Seattle, WA, USA
| | | | | | - Xiaohe Cai
- Seattle Children's Research Institute, Seattle, WA, USA
| | | | - Meghan J Lyle
- Seattle Children's Research Institute, Seattle, WA, USA
| | | | - Carol H Miao
- Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA.
| |
Collapse
|
21
|
Lillicrap D, Fijnvandraat K, Young G, Mancuso ME. Patients with hemophilia A and inhibitors: prevention and evolving treatment paradigms. Expert Rev Hematol 2020; 13:313-321. [PMID: 32186928 DOI: 10.1080/17474086.2020.1739518] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: Novel non-replacement therapies (e.g. emicizumab) have improved the management of patients with hemophilia A with and without inhibitors while introducing new challenges and increasing the complexity of clinical decision-making.Areas covered: Use of emicizumab can substantially delay initial exposure to FVIII thereby altering the natural history of inhibitor development, but it remains unclear whether later exposure to FVIII might modify the incidence of inhibitor development. Moreover, decisions regarding initiation of immune tolerance induction (ITI) therapy in patients with newly diagnosed inhibitors have become more complicated since emicizumab was introduced. Using emicizumab in lieu of ITI has implications such as precluding the use of FVIII for breakthrough bleeds and surgery, and possibly impacting on patients' future ability to receive gene therapy. Although bypassing agents are the mainstay of managing acute bleeds and surgery in inhibitor patients, their concomitant use with novel therapies can be difficult to manage/monitor. Evidence from the HAVEN clinical trials program suggests that minor surgeries in inhibitor patients can be performed with emicizumab alone, whereas major surgeries require the use of perioperative bypassing agents.Expert opinion: Until the long-term effects of non-replacement therapies become known, patients who develop inhibitors should continue to receive ITI.
Collapse
Affiliation(s)
- David Lillicrap
- Department of Pathology & Molecular Medicine, Queen's University, Kingston, Canada
| | - Karin Fijnvandraat
- Emma Children's Hospital, Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Guy Young
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Maria Elisa Mancuso
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| |
Collapse
|
22
|
Zakas PM, Healey JF, Smith IW, Lillicrap D, Lollar P. Sedimentation Velocity Analytical Ultracentrifugation of Oxidized Recombinant Full-Length Factor VIII. Front Immunol 2020; 11:150. [PMID: 32117290 PMCID: PMC7020254 DOI: 10.3389/fimmu.2020.00150] [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: 11/24/2019] [Accepted: 01/20/2020] [Indexed: 11/17/2022] Open
Abstract
Anti-drug antibodies to coagulation factor VIII (fVIII), often termed inhibitors, present the greatest economical and treatment related obstacle in the management of hemophilia A. Although several genetic and environmental risk factors associated with inhibitor development have been identified, the precise mechanisms responsible for the immune response to exogenous fVIII therapies remain undefined. Clinical trials suggest there is an increased immunogenic potential of recombinant fVIII compared to plasma-derived products. Additional biochemical and immunological studies have demonstrated that changes in recombinant fVIII production and formulation can alter fVIII structure and immunogenicity. Recently, one study demonstrated increased immunogenicity of the recombinant fVIII product Helixate in hemophilia A mice following oxidation with hypochlorite (ClO−). It is widely reported that protein aggregates within drug products can induce adverse immune reactions in patients. Several studies have therefore investigated the prevalence of molecular aggregates in commercial recombinant products with and without use-relevant stress and agitation. To investigate the potential link between oxidation-induced immunogenicity and molecular aggregation, we analyzed the recombinant fVIII product, Helixate, via sedimentation velocity analytical ultracentrifugation following oxidation with ClO−. At 80 μM ClO−, a concentration that reduced the specific-activity by 67%, no detectable increase in large molecular aggregates (s > 12 S) was observed when compared to non-oxidized fVIII. This lack of aggregates was demonstrated both in commercial excipient as well as a HEPES buffered saline formulation. These data suggest that oxidation induced immunogenicity is independent of aggregate-mediated immune response. Therefore, our data support multiple, independent mechanisms underlying fVIII immunogenicity.
Collapse
Affiliation(s)
- Philip M Zakas
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - John F Healey
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Ian W Smith
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Pete Lollar
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| |
Collapse
|
23
|
Burnouf T, Faber JC, Radosevic M, Goubran H, Seghatchian J. Plasma fractionation in countries with limited infrastructure and low-/medium income: How to move forward? Transfus Apher Sci 2020; 59:102715. [DOI: 10.1016/j.transci.2019.102715] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
24
|
Lacroix-Desmazes S, Voorberg J, Lillicrap D, Scott DW, Pratt KP. Tolerating Factor VIII: Recent Progress. Front Immunol 2020; 10:2991. [PMID: 31998296 PMCID: PMC6965068 DOI: 10.3389/fimmu.2019.02991] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 12/05/2019] [Indexed: 02/02/2023] Open
Abstract
Development of neutralizing antibodies against biotherapeutic agents administered to prevent or treat various clinical conditions is a longstanding and growing problem faced by patients, medical providers and pharmaceutical companies. The hemophilia A community has deep experience with attempting to manage such deleterious immune responses, as the lifesaving protein drug factor VIII (FVIII) has been in use for decades. Hemophilia A is a bleeding disorder caused by genetic mutations that result in absent or dysfunctional FVIII. Prophylactic treatment consists of regular intravenous FVIII infusions. Unfortunately, 1/4 to 1/3 of patients develop neutralizing anti-FVIII antibodies, referred to clinically as “inhibitors,” which result in a serious bleeding diathesis. Until recently, the only therapeutic option for these patients was “Immune Tolerance Induction,” consisting of intensive FVIII administration, which is extraordinarily expensive and fails in ~30% of cases. There has been tremendous recent progress in developing novel potential clinical alternatives for the treatment of hemophilia A, ranging from encouraging results of gene therapy trials, to use of other hemostatic agents (either promoting coagulation or slowing down anti-coagulant or fibrinolytic pathways) to “bypass” the need for FVIII or supplement FVIII replacement therapy. Although these approaches are promising, there is widespread agreement that preventing or reversing inhibitors remains a high priority. Risk profiles of novel therapies are still unknown or incomplete, and FVIII will likely continue to be considered the optimal hemostatic agent to support surgery and manage trauma, or to combine with other therapies. We describe here recent exciting studies, most still pre-clinical, that address FVIII immunogenicity and suggest novel interventions to prevent or reverse inhibitor development. Studies of FVIII uptake, processing and presentation on antigen-presenting cells, epitope mapping, and the roles of complement, heme, von Willebrand factor, glycans, and the microbiome in FVIII immunogenicity are elucidating mechanisms of primary and secondary immune responses and suggesting additional novel targets. Promising tolerogenic therapies include development of FVIII-Fc fusion proteins, nanoparticle-based therapies, oral tolerance, and engineering of regulatory or cytotoxic T cells to render them FVIII-specific. Importantly, these studies are highly applicable to other scenarios where establishing immune tolerance to a defined antigen is a clinical priority.
Collapse
Affiliation(s)
| | - Jan Voorberg
- Sanquin Research and Landsteiner Laboratory, Department of Molecular and Cellular Hemostasis, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - David W Scott
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Kathleen P Pratt
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| |
Collapse
|
25
|
Diego VP, Luu BW, Hofmann M, Dinh LV, Almeida M, Powell JS, Rajalingam R, Peralta JM, Kumar S, Curran JE, Sauna ZE, Kellerman R, Park Y, Key NS, Escobar MA, Huynh H, Verhagen AM, Williams-Blangero S, Lehmann PV, Maraskovsky E, Blangero J, Howard TE. Quantitative HLA-class-II/factor VIII (FVIII) peptidomic variation in dendritic cells correlates with the immunogenic potential of therapeutic FVIII proteins in hemophilia A. J Thromb Haemost 2020; 18:201-216. [PMID: 31556206 DOI: 10.1111/jth.14647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/23/2019] [Accepted: 09/23/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Plasma-derived (pd) or recombinant (r) therapeutic factor VIII proteins (FVIIIs) are infused to arrest/prevent bleeding in patients with hemophilia A (PWHA). However, FVIIIs are neutralized if anti-FVIII-antibodies (inhibitors) develop. Accumulating evidence suggests that pdFVIIIs with von Willebrand factor (VWF) are less immunogenic than rFVIIIs and that distinct rFVIIIs are differentially immunogenic. Since inhibitor development is T-helper-cell-dependent, human leukocyte antigen (HLA)-class-II (HLAcII) molecules constitute an important early determinant. OBJECTIVES Use dendritic cell (DC)-protein processing/presentation assays with mass-spectrometric and peptide-proteomic analyses to quantify the DP-bound, DQ-bound, and DR-bound FVIII-derived peptides in individual HLAcII repertoires and compare the immunogenic potential of six distinct FVIIIs based on their measured peptide counts. PATIENTS/METHODS Monocyte-derived DCs from normal donors and/or PWHA were cultured with either: Mix-rFVIII, a VWF-free equimolar mixture of a full-length (FL)-rFVIII [Advate® (Takeda)] and four distinct B-domain-deleted (BDD)-rFVIIIs [Xyntha® (Pfizer), NovoEight® (Novo-Nordisk), Nuwiq® (Octapharma), and Afstyla® (CSL Behring GmBH)]; a pdFVIII + pdVWF [Beriate® (CSL Behring GmBH)]; Advate ± pdVWF; Afstyla ± pdVWF; and Xyntha + pdVWF. RESULTS We showed that (i) Beriate had a significantly lower immunogenic potential than Advate ± pdVWF, Afstyla - pdVWF, and Mix-rFVIII; (ii) distinct FVIIIs differed significantly in their immunogenic potential in that, in addition to (i), Afstyla + pdVWF had a significantly lower immunogenic potential than Beriate, while the immunogenic potential of Beriate was not significantly different from that of Xyntha + pdVWF; and (iii) rFVIIIs with pdVWF had significantly lower immunogenic potentials than the same rFVIIIs without pdVWF. CONCLUSIONS Our results provide HLAcII peptidomic level explanations for several important clinical observations/issues including the differential immunogenicity of distinct FVIIIs and the role of HLAcII genetics in inhibitor development.
Collapse
Affiliation(s)
- Vincent P Diego
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
| | - Bernadette W Luu
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
- Haplogenics Corporation, Brownsville, Texas
| | | | | | - Marcio Almeida
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
| | | | - Raja Rajalingam
- Immunogenetics and Transplantation Laboratory, Department of Surgery, School of Medicine, University of California at San Francisco, California
| | - Juan M Peralta
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
| | - Satish Kumar
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
| | - Joanne E Curran
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
| | - Zuben E Sauna
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapeutics, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Roberta Kellerman
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, North Carolina
| | - Yara Park
- Department of Laboratory Medicine and Pathology, University of North Carolina at Chapel Hill, North Carolina
| | - Nigel S Key
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, North Carolina
- Department of Laboratory Medicine and Pathology, University of North Carolina at Chapel Hill, North Carolina
| | - Miguel A Escobar
- Division of Hematology, Department of Medicine, McGovern School of Medicine, University of Texas Health Sciences Center at Houston, Texas
| | - Huy Huynh
- CSL Limited Research, Bio21 Institute, Melbourne, Australia
| | | | - Sarah Williams-Blangero
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
| | - Paul V Lehmann
- Department of Pathology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Cellular Technology Ltd, Shaker Heights, Ohio
| | | | - John Blangero
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
| | - Tom E Howard
- South Texas Diabetes and Obesity Institute, University of Texas Rio Grande Valley, Brownsville, Texas
- Department of Human Genetics, School of Medicine, University of Texas Rio Grande Valley, Brownsville, Texas
- Haplogenics Corporation, Brownsville, Texas
- Department of Pathology and Lab Medicine, VA Valley Coastal Bend Healthcare Center, Harlingen, Texas
| |
Collapse
|
26
|
Timing of inhibitor development in more than 1000 previously untreated patients with severe hemophilia A. Blood 2019; 134:317-320. [DOI: 10.1182/blood.2019000658] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
27
|
De Cristofaro R, Sacco M, Lancellotti S, Berruti F, Garagiola I, Valsecchi C, Basso M, Di Stasio E, Peyvandi F. Molecular Aggregation of Marketed Recombinant FVIII Products: Biochemical Evidence and Functional Effects. TH OPEN 2019; 3:e123-e131. [PMID: 31249992 PMCID: PMC6524925 DOI: 10.1055/s-0039-1688413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 03/08/2019] [Indexed: 12/12/2022] Open
Abstract
Background Recombinant (rec-) coagulation factor VIII concentrates available for hemophilia A (HA) treatment differ in cell line production and structure, which could affect their pharmacodynamics and immunogenicity. Clinical trials showed that previously untreated patients with severe HA present higher rates of inhibitor development if treated with rec-FVIII products and that differences do exist as to inhibitor's formation among different rec-FVIII products. This finding could arise from several causes, such as absence of von Willebrand factor, different glycosylation profiles, or processes of molecular aggregation of the recombinant FVIII molecules. Objectives/Methods In this study, using size exclusion high-performance liquid chromatography (SE-HPLC), dynamic light scattering (DLS) spectroscopy, and functional biochemical assays, we investigated the purity grade, FX activating ability, and aggregation status of three recombinant marketed products (Advate [Baxalta], Refacto AF [Pfizer], and Kogenate [Bayer]). Results The overall analysis of the results obtained with SE-HPLC and DLS spectroscopy showed that the three recombinant FVIII concentrates contain low but significant amounts of molecular aggregates. This phenomenon was less evident for the Advate product. Molecular aggregation negatively affects the in vitro pharmacodynamics of the concentrates with higher aggregates' content. Conclusions This study shows that the three pharmaceutical formulations of recombinant FVIII contain variable amounts of molecular aggregates after their reconstitution at therapeutic concentrations. This phenomenon negatively affects the in vitro potency of the products with higher aggregates' content and might be invoked as a contributing cause of their increased risk to induce the formation of FVIII inhibitors.
Collapse
Affiliation(s)
- Raimondo De Cristofaro
- Haemorrhagic and Thrombotic Diseases Service, Area of Hematology, Fondazione Policlinico Universitario "A. Gemelli," IRCCS, Rome, Italy.,Institute di Internal Medicine and Geriatrics, Catholic University School of Medicine, Rome, Italy
| | - Monica Sacco
- Institute di Internal Medicine and Geriatrics, Catholic University School of Medicine, Rome, Italy
| | - Stefano Lancellotti
- Haemorrhagic and Thrombotic Diseases Service, Area of Hematology, Fondazione Policlinico Universitario "A. Gemelli," IRCCS, Rome, Italy
| | - Federico Berruti
- Institute di Internal Medicine and Geriatrics, Catholic University School of Medicine, Rome, Italy
| | - Isabella Garagiola
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Luigi Villa Foundation, Milan, Italy
| | - Carla Valsecchi
- Institute di Internal Medicine and Geriatrics, Catholic University School of Medicine, Rome, Italy
| | - Maria Basso
- Haemorrhagic and Thrombotic Diseases Service, Area of Hematology, Fondazione Policlinico Universitario "A. Gemelli," IRCCS, Rome, Italy
| | - Enrico Di Stasio
- Institute of Biochemistry and Clinical Biochemistry, Università degli Studi di Milano, Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Luigi Villa Foundation, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
28
|
Schep SJ, Boes M, Schutgens RE, van Vulpen LF. An update on the ‘danger theory’ in inhibitor development in hemophilia A. Expert Rev Hematol 2019; 12:335-344. [DOI: 10.1080/17474086.2019.1604213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Sarah J. Schep
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marianne Boes
- Department of Pediatrics, Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger E.G. Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lize F.D. van Vulpen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
29
|
Goubran H, Goubran M, Seghatchian J, Burnouf T. New monoclonal/bi-specific antibodies: Reshaping transfusion medicine beyond replacement. Transfus Apher Sci 2019; 58:208-211. [DOI: 10.1016/j.transci.2019.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
30
|
Morfini M, Rapisarda CAP. Safety of recombinant coagulation factors in treating hemophilia. Expert Opin Drug Saf 2019; 18:75-85. [PMID: 30681006 DOI: 10.1080/14740338.2019.1574743] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION During the last decade, new FVIII/IX concentrates have been developed for the treatment of patients affected by hemophilia A/B. Significant progress has been achieved regarding their half-life, but the old issue of immunogenicity and new concerns about safety need to be addressed. AREAS COVERED After the implementation of virucidal methods, both plasma-derived and recombinant clotting factor concentrates achieved a very safe profile. The development of anti-FVIII antibodies is the major adverse event of replacement therapy with both FVIII concentrates. Furthermore, the new extended half-life concentrates, protein fused or pegylated, raised some concerns about their side effects. EXPERT OPINION The treatment of hemophilia A with inhibitors by induction of immunotolerance and using by-passing concentrates, improved the quality of life of patients but did not allow them to have a life expectancy like that of patients without inhibitors. The new humanized monoclonal antibody (MAb) ACE910, mimicking FVIII function, seems to be able to reduce the bleedings of hemophilia A patients with inhibitors. The post-marketing surveillance will clarify if the adverse events observed during the phase III clinical trials and compassionate use were due to the association with a Prothrombin activated complex concentrate or to the prothrombotic effect of the drug itself.
Collapse
Affiliation(s)
- Massimo Morfini
- a Italian Association of Haemophilia Centres (AICE) Florence , Italy
| | | |
Collapse
|
31
|
Repessé Y, Costa C, Palla R, Moshai EF, Borel-Derlon A, D'Oiron R, Rothschild C, El-Beshlawy A, Elalfy M, Ramanan V, Eshghi P, Oldenburg J, Pavlova A, Rosendaal FR, Peyvandi F, Kaveri SV, Lacroix-Desmazes S. Role of factor VIII-binding capacity of endogenous von Willebrand factor in the development of factor VIII inhibitors in patients with severe hemophilia A. Haematologica 2019; 104:e369-e372. [PMID: 30705098 DOI: 10.3324/haematol.2018.212001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Yohann Repessé
- CHU de Caen, Hematology Laboratory, Caen, France.,INSERM, U1237, GIP Cyceron, Caen, France.,Normandie Université, UNI-CAEN, UFR Santé, Caen, France
| | - Catherine Costa
- Service de Génétique et Biologie Moléculaires, APHP, Groupe Hospitalier Cochin Broca, Hôtel-Dieu, Site Cochin, Paris, France
| | - Roberta Palla
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Elika Farrokhi Moshai
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, USPC, Université Paris Descartes, Université Paris Diderot, Paris, France
| | - Annie Borel-Derlon
- CHU de Caen, Hematology Laboratory, Caen, France.,INSERM, U1237, GIP Cyceron, Caen, France.,Normandie Université, UNI-CAEN, UFR Santé, Caen, France
| | - Roseline D'Oiron
- Centres de Traitement de l'Hémophilie, APHP, Le Kremlin-Bicêtre, France
| | - Chantal Rothschild
- Centres de Traitement de l'Hémophilie, APHP, Hôpital Necker, Paris, France
| | - Amal El-Beshlawy
- Pediatric Hematology Department, Cairo University Pediatric Hospital, Cairo, Egypt
| | - Mohsen Elalfy
- Faculty of Medicine, Ain Shams Center, University - Department of Pediatrics, Cairo, Egypt
| | - Vijay Ramanan
- Jehangir Clinical Development Center, Department of Hematology, Jehangir Hospital Premises, Pune, India
| | - Peyman Eshghi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Anna Pavlova
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Srinivas V Kaveri
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, USPC, Université Paris Descartes, Université Paris Diderot, Paris, France
| | - Sébastien Lacroix-Desmazes
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, USPC, Université Paris Descartes, Université Paris Diderot, Paris, France
| |
Collapse
|
32
|
Jardim LL, van der Bom J, Brommonschenkel CC, Gouw SC, Rezende SM. Inhibitor incidence in haemophilia A under exclusive use of a third-generation recombinant factor VIII concentrate: results of the HEMFIL Cohort Study. Br J Haematol 2018; 186:152-155. [PMID: 30556277 DOI: 10.1111/bjh.15728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Letícia L Jardim
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.,Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Johanna van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Samantha C Gouw
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Suely M Rezende
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | |
Collapse
|
33
|
Doncarli A, Demiguel V, Guseva Canu I, Goulet V, Bayart S, Calvez T, Castet S, Dalibard V, Demay Y, Frotscher B, Goudemand J, Lambert T, Milien V, Oudot C, Sannié T, Chambost H. FranceCoag: a 22-year prospective follow-up of the national French cohort of patients with inherited bleeding disorders. Eur J Epidemiol 2018; 34:521-532. [DOI: 10.1007/s10654-018-0468-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/20/2018] [Indexed: 10/27/2022]
|
34
|
Neufeld EJ, Sidonio RF, O'Day K, Runken MC, Meyer K, Spears J. Cost analysis of plasma-derived factor VIII/von Willebrand factor versus recombinant factor VIII for treatment of previously untreated patients with severe hemophilia A in the United States. J Med Econ 2018; 21:762-769. [PMID: 29681200 DOI: 10.1080/13696998.2018.1468335] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Inhibitor development to factor VIII (FVIII) hemophilia therapy results in increased complications and substantial economic costs. The SIPPET study, the first randomized controlled trial to compare the immunogenicity of plasma-derived FVIII (pdFVIII)/von Willebrand factor (VWF) and recombinant-DNA-derived FVIII (rFVIII), demonstrated higher inhibitor rates in previously untreated patients (PUPs) treated with rFVIII than in PUPs treated with pdFVIII/VWF. OBJECTIVE To quantify the economic impact of treating PUPs with pdFVIII/VWF vs rFVIII. METHODS An Excel-based clinical and economic model was developed from a US healthcare payer perspective and run over a 5-year period. The analysis utilized a cohort approach to model patient treatment and outcomes over a monthly cycle to quantify differences in costs of FVIII, bypassing agents, and hospitalizations for serious bleeds. Rates of high-titer inhibitor development were obtained from the SIPPET study. Patients developing high-titer inhibitors were treated with immune tolerance induction (ITI). Patients who developed low-titer inhibitors and those who did not develop inhibitors continued their usual FVIII treatment. Patients who were successfully treated with ITI returned to FVIII treatment, while unsuccessfully treated patients received bypassing agents. Total costs per treated patient were estimated and a one-way sensitivity analysis was conducted to quantify the impact of parameter uncertainty on the model outcomes. RESULTS Total cumulative costs per patient over 5 years were $834,621 for pdFVIII/VWF patients and $1,237,163 for rFVIII patients, representing a total saving of $402,542 per patient over the 5-year period, for an average annual saving of $80,508 per patient. CONCLUSIONS Based on data from the SIPPET study, this analysis found that initiating FVIII treatment in severe hemophilia A PUPs with pdFVIII/VWF has the potential to offer substantial cost savings to healthcare payers, amounting to a one-third reduction in costs.
Collapse
Affiliation(s)
| | - Robert F Sidonio
- b Emory University and Aflac Cancer and Blood Disorders , Atlanta , GA , USA
| | | | | | | | | |
Collapse
|
35
|
Garagiola I, Palla R, Peyvandi F. Risk factors for inhibitor development in severe hemophilia A. Thromb Res 2018; 168:20-27. [DOI: 10.1016/j.thromres.2018.05.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 05/11/2018] [Accepted: 05/24/2018] [Indexed: 12/21/2022]
|
36
|
Lai JD, Swystun LL, Cartier D, Nesbitt K, Zhang C, Hough C, Dennis JW, Lillicrap D. N-linked glycosylation modulates the immunogenicity of recombinant human factor VIII in hemophilia A mice. Haematologica 2018; 103:1925-1936. [PMID: 30002126 PMCID: PMC6278987 DOI: 10.3324/haematol.2018.188219] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 07/09/2018] [Indexed: 12/18/2022] Open
Abstract
Immune responses to factor VIII remain the greatest complication in the treatment of severe hemophilia A. Recent epidemiological evidence has highlighted that recombinant factor VIII produced in baby hamster kidney cells is more immunogenic than factor VIII produced in Chinese hamster ovary cells. Glycosylation differences have been hypothesized to influence the immunogenicity of these synthetic concentrates. In two hemophilia A mouse models, baby hamster kidney cell-derived factor VIII elicited a stronger immune response compared to Chinese hamster ovary cell-derived factor VIII. Furthermore, factor VIII produced in baby hamster kidney cells exhibited accelerated clearance from circulation independent of von Willebrand factor. Lectin and mass spectrometry analysis of total N-linked glycans revealed differences in high-mannose glycans, sialylation, and the occupancy of glycan sites. Factor VIII desialylation did not influence binding to murine splenocytes or dendritic cells, nor surface co-stimulatory molecule expression. We did, however, observe increased levels of immunoglobulin M specific to baby hamster kidney-derived factor VIII in naïve hemophilia A mice. De-N-glycosylation enhanced immunoglobulin M binding, suggesting that N-glycan occupancy masks epitopes. Elevated levels of immunoglobulin M and immunoglobulin G specific to baby hamster kidney-derived factor VIII were also observed in healthy individuals, and de-N-glycosylation increased immunoglobulin G binding. Collectively, our data suggest that factor VIII produced in baby hamster kidney cells is more immunogenic than that produced in Chinese hamster ovary cells, and that incomplete occupancy of N-linked glycosylation sites leads to the formation of immunoglobulin M- and immunoglobulin G-factor VIII immune complexes that contribute to the enhanced clearance and immunogenicity in these mouse models of hemophilia A.
Collapse
Affiliation(s)
- Jesse D Lai
- Department of Pathology & Molecular Medicine, Queen's University, Kingston
| | - Laura L Swystun
- Department of Pathology & Molecular Medicine, Queen's University, Kingston
| | - Dominique Cartier
- Department of Pathology & Molecular Medicine, Queen's University, Kingston
| | - Kate Nesbitt
- Department of Pathology & Molecular Medicine, Queen's University, Kingston
| | - Cunjie Zhang
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, ON, Canada
| | - Christine Hough
- Department of Pathology & Molecular Medicine, Queen's University, Kingston
| | - James W Dennis
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, ON, Canada
| | - David Lillicrap
- Department of Pathology & Molecular Medicine, Queen's University, Kingston
| |
Collapse
|
37
|
Bitter progress in the treatment of haemophilia A in low-income countries. LANCET HAEMATOLOGY 2018; 5:e239. [DOI: 10.1016/s2352-3026(18)30062-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 04/17/2018] [Accepted: 04/17/2018] [Indexed: 11/24/2022]
|
38
|
Burnouf T. Principles of haemophilia care: The Asia-Pacific perspective. Haemophilia 2018; 24:e245-e246. [PMID: 29790630 DOI: 10.1111/hae.13523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2018] [Indexed: 01/04/2023]
Affiliation(s)
- T Burnouf
- Taipei Medical University, College of Biomedical Engineering, Taipei, Taiwan
| |
Collapse
|
39
|
Affiliation(s)
- J.-C. Faber
- Hemophilia Association Luxembourg; LuxConsulTrans; Luxembourg Luxembourg
| |
Collapse
|
40
|
Peyvandi F, Garagiola I. Product type and other environmental risk factors for inhibitor development in severe hemophilia A. Res Pract Thromb Haemost 2018; 2:220-227. [PMID: 30046724 PMCID: PMC6055565 DOI: 10.1002/rth2.12094] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/28/2018] [Indexed: 12/15/2022] Open
Abstract
The development of FVIII inhibitory antibodies is currently the most challenging complication of treatment, affecting ~30% of severe hemophilia A patients. These inhibitors inactivate FVIII, rendering the treatment ineffective, causing disability and increasing morbidity and mortality. Inhibitor development results from a complex multicausal immune response involving both genetic and environmental risk factors. One of the most important modifiable risk factors is the source of FVIII products, eg, plasma-derived or recombinant FVIII. Other environmental risk factors, such as age at first treatment, regimen, and intensity of treatment, could contribute to inhibitor development. Severe bleeds, surgery, concomitant infections, or vaccinations may all be events initiating danger signaling resulting in an immune reaction towards administered FVIII. All in all, the etiology of inhibitor development still remains unclear. The risk factors have been stratified into genetic and environmental, but there are no definitive data to determine the impact of each of them.
Collapse
Affiliation(s)
- Flora Peyvandi
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoFondazione Luigi VillaMilanItaly
| | - Isabella Garagiola
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoFondazione Luigi VillaMilanItaly
| |
Collapse
|
41
|
Lebreton A, Castet S, Falaise C, Rugeri L, Schved JF, Wibaut B. After the SIPPET study: Position paper of the CoMETH, the French society of haemophilia. Haemophilia 2018; 24:e55-e57. [PMID: 29316084 DOI: 10.1111/hae.13400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2017] [Indexed: 06/07/2023]
Affiliation(s)
- A Lebreton
- Centre de Traitement de l'Hémophilie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - S Castet
- Centre de Traitement de l'Hémophilie, CHU Bordeaux, Bordeaux, France
| | - C Falaise
- Centre de Traitement de l'Hémophilie, Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | - L Rugeri
- Centre de Traitement de l'Hémophilie, Hospices Civils de Lyon, Lyon, France
| | - J-F Schved
- Centre de Traitement de l'Hémophilie, CHU Montpellier, Montpellier, France
| | - B Wibaut
- Centre de Traitement de l'Hémophilie, CHU Lille, Lille, France
| |
Collapse
|
42
|
Healey JF, Parker ET, Lollar P. Identification of aggregates in therapeutic formulations of recombinant full-length factor VIII products by sedimentation velocity analytical ultracentrifugation. J Thromb Haemost 2018; 16:303-315. [PMID: 29197156 PMCID: PMC5809250 DOI: 10.1111/jth.13917] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Indexed: 01/27/2023]
Abstract
Essentials Factor VIII inhibitors are the most serious complication in patients with hemophilia A. Aggregates in biopharmaceutical products are an immunogenic risk factor. Aggregates were identified in recombinant full-length factor VIII products. Aggregates in recombinant factor VIII products are identified by analytical ultracentrifugation. SUMMARY Background The development of inhibitory anti-factor VIII antibodies is the most serious complication in the management of patients with hemophilia A. Studies have suggested that recombinant full-length FVIII is more immunogenic than plasma-derived FVIII, and that, among recombinant FVIII products, Kogenate is more immunogenic than Advate. Aggregates in biopharmaceutical products are considered a risk factor for the development of anti-drug antibodies. Objective To evaluate recombinant full-length FVIII products for the presence of aggregates. Methods Advate, Helixate and Kogenate were reconstituted to their therapeutic formulations, and subjected to sedimentation velocity (SV) analytical ultracentrifugation (AUC). Additionally, Advate and Kogenate were concentrated and subjected to buffer exchange by ultrafiltration to remove viscous cosolvents for the purpose of measuring s20,w values and molecular weights. Results The major component of all three products was a population of ~7.5 S heterodimers with a weight-average molecular weight of ~230 kDa. Helixate and Kogenate contained aggregates ranging from 12 S to at least 100 S, representing ≈ 20% of the protein mass. Aggregates greater than 12 S represented < 3% of the protein mass in Advate. An approximately 10.5 S aggregate, possibly representing a dimer of heterodimers, was identified in buffer-exchanged Advate and Kogenate. SV AUC analysis of a plasma-derived FVIII product was confounded by the presence of von Willebrand factor in molar excess over FVIII. Conclusions Aggregate formation has been identified in recombinant full-length FVIII products, and is more extensive in Helixate and Kogenate than in Advate. SV AUC is an important method for characterizing FVIII products.
Collapse
Affiliation(s)
- J. F. Healey
- Department of PediatricsAflac Cancer and Blood Disorders CenterChildren's Healthcare of AtlantaEmory UniversityAtlantaGAUSA
| | - E. T. Parker
- Department of PediatricsAflac Cancer and Blood Disorders CenterChildren's Healthcare of AtlantaEmory UniversityAtlantaGAUSA
| | - P. Lollar
- Department of PediatricsAflac Cancer and Blood Disorders CenterChildren's Healthcare of AtlantaEmory UniversityAtlantaGAUSA
| |
Collapse
|
43
|
Santagostino E, Young G, Carcao M, Mannucci PM, Halimeh S, Austin S. A contemporary look at FVIII inhibitor development: still a great influence on the evolution of hemophilia therapies. Expert Rev Hematol 2018; 11:87-97. [PMID: 29258406 DOI: 10.1080/17474086.2018.1419862] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The development of inhibitors against factor VIII (FVIII) replacement therapy remains the most important challenge for clinicians in the treatment of hemophilia patients. This review focusses on risk factors and management of FVIII inhibitors, particularly in light of SIPPET study findings and subsequent analyses. Areas covered: A brief history and evolution of hemophilia therapies is provided, including an overview of conventional and new (including investigational) therapeutic approaches for the treatment of hemophilia. The SIPPET study, the first randomized clinical trial to demonstrate a lower incidence of inhibitors in previously untreated patients treated with plasma-derived FVIII products compared with recombinant FVIII products, has generated much debate. We review the SIPPET trial and reactions, in addition to preliminary observations from a single center's experience, the cost impact of inhibitors, recent findings from SIPPET subanalyses, and inhibitor development in previously-treated patients. Expert commentary: Despite recent advances in potential new treatment options for hemophilia, conventional factor replacement concentrates currently remain the cornerstone of treatment. It is paramount that clinicians familiarize themselves with the findings from the SIPPET trial and substudies, in order to better inform their patients and families on inhibitor risk factors and to aid the treatment decision-making process.
Collapse
Affiliation(s)
- Elena Santagostino
- a Angelo Bianchi Bonomi Hemophilia and Thrombosis Center , University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan , Italy
| | - Guy Young
- b Hemostasis and Thrombosis Center, Children's Hospital Los Angeles , University of Southern California Keck School of Medicine , Los Angeles , CA , USA
| | - Manuel Carcao
- c Division of Hematology/Oncology; Department of Pediatrics and Child Health Evaluative Sciences , Research Institute Hospital for Sick Children , Toronto , ON , Canada
| | - Pier Mannuccio Mannucci
- d Scientific Direction , IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan , Milan , Italy
| | - Susan Halimeh
- e Gerinnungszentrum Rhein-Ruhr (GZRR) , Duisburg , Germany
| | - Steve Austin
- f St. George's Healthcare NHS Trust Haemophilia Centre , London , UK
| |
Collapse
|