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Walsh KS, Mrakotsky C, Carcao M, Chan AK, Nielsen PH, Holst H, Shapiro K. Nonacog beta pegol prophylaxis in children with hemophilia B: safety, efficacy, and neurodevelopmental outcomes for up to 8 years. Res Pract Thromb Haemost 2024; 8:102341. [PMID: 38516633 PMCID: PMC10955654 DOI: 10.1016/j.rpth.2024.102341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 03/23/2024] Open
Abstract
Background Nonacog beta pegol (N9-GP) is an extended half-life PEGylated factor (F)IX product with established efficacy and short-term safety in persons with hemophilia B (HB). Long-term safety has been evaluated for polyethylene glycol exposure but not N9-GP. Objectives To assess safety, neurodevelopmental, and efficacy outcomes of children with HB receiving N9-GP prophylaxis across 2 open-label, single-arm, phase 3 studies: paradigm5 (previously treated patients [PTPs]) and paradigm6 (previously untreated patients [PUPs]) in this interim analysis. Methods PTPs (aged ≤12 years) and PUPs (aged <6 years) with severe/moderate (≤2% FIX level) HB were recruited to N9-GP prophylaxis (40 IU/kg once weekly) in paradigm5 and paradigm6, respectively. Safety assessments included FIX inhibitor incidence, adverse events, neurocognitive and neurologic outcomes, polyethylene glycol concentration in plasma, and medical events of special interest. Efficacy endpoints included bleeds, N9-GP hemostatic effect, and FIX consumption. Results Overall, 25 patients in paradigm5 and 50 patients in paradigm6 received N9-GP and were followed for up to 8 and 6 years, respectively. No inhibitory antibodies were reported in PTPs; 4 of the 50 PUPs developed inhibitors. Extensive evaluation revealed no neurocognitive or neurologic concerns with N9-GP use in children during the study period. Across both studies, few adverse events were reported as possibly related to N9-GP. High hemostatic response rate, high treatment adherence, low annualized bleeding rates, and no new target joints were reported. Conclusion These data provide the longest follow-up for an extended half-life FIX and confirm the long-term efficacy of N9-GP prophylaxis in children with HB with no observed neurocognitive or neurologic safety concerns.
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Affiliation(s)
- Karin S. Walsh
- Center for Neuroscience and Behavioral Medicine, Children’s National Hospital and the George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Christine Mrakotsky
- Departments of Neurology & Psychiatry, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Manuel Carcao
- Division of Haematology/Oncology, Department of Paediatrics, the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anthony K.C. Chan
- Department of Paediatrics, McMaster Centre for Transfusion Research, McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Kevin Shapiro
- Cortica Healthcare and Children’s Hospital Los Angeles, Westlake Village, California, USA
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2
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Goedhart TMHJ, Janssen A, Mathôt RAA, Cnossen MH. The road to implementation of pharmacokinetic-guided dosing of factor replacement therapy in hemophilia and allied bleeding disorders. Identifying knowledge gaps by mapping barriers and facilitators. Blood Rev 2023; 61:101098. [PMID: 37321952 DOI: 10.1016/j.blre.2023.101098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 04/02/2023] [Accepted: 05/07/2023] [Indexed: 06/17/2023]
Abstract
Clinical guidelines and expert groups recommend the use of pharmacokinetic (PK)-guided dosing of factor replacement therapy for the treatment of bleeding disorders, especially for patients with hemophilia. Although PK-guided dosing is increasingly applied, it is generally not considered standard clinical practice. The aim of this scoping review is to map barriers and facilitators for the implementation of PK-guided dosing in clinical practice and to identify knowledge gaps. A literature search was performed and 110 articles were included that describe PK-guided dosing in patients with bleeding disorders, mostly hemophilia A. We defined two overarching themes, efficacy and feasibility, and discuss five topics within each theme. For each topic, barriers, facilitators and knowledge gaps were described. Although consensus was found with regard to some topics, contradicting reports were found for others, especially with respect to the efficacy of PK-guided dosing. These contradictions highlight the need for future research to elucidate current ambiguities.
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Affiliation(s)
- Tine M H J Goedhart
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - A Janssen
- Department of Clinical Pharmacology - Hospital Pharmacy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Ron A A Mathôt
- Department of Clinical Pharmacology - Hospital Pharmacy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Zanon E, De Cristofaro R, Franchini M, Morfini M, Pasut G, Molinari AC, Santoro C, Santoro RC, Coppola A, Rocino A. Bioequivalence of recombinant factor VIII products: a position paper from the Italian Association of Hemophilia Centers. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2023; 21:441-451. [PMID: 36795340 PMCID: PMC10497389 DOI: 10.2450/2023.0235-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2023]
Abstract
Over the last three decades, the continuous evolution of recombinant factor VIII (rFVIII) concentrates for replacement treatment of hemophilia A, including recent extended half-life products, implies that patients may switch from one product to another, technologically more advanced, with the aim of improving treatment efficacy, safety, management and, ultimately, quality of life. In this scenario, the issues of bioequivalence of rFVIII products and the clinical implications of their interchangeability are keenly debated, in particular when economic reasons or purchasing systems influence product availability and choices. Although sharing the same Anatomical Therapeutic Chemical (ATC) level, rFVIII concentrates, as other biological products, show relevant differences in terms of molecular structure, source and manufacturing process, which make them unique products, recognized as new active substances by regulatory agencies. Moreover, data from clinical trials with both standard and extended half-life products clearly document the large inter-patient variability of pharmacokinetic profiles after administering the same dose of the same product; in cross-over evaluations, even when mean values are comparable, some patients show better patterns with one product or with the comparator one. Pharmacokinetic assessment thus reflects the response to a specific product in the individual patient, with his genetic determinants, only partially identified, affecting the behavior of exogenous FVIII. These concepts, consistent with the currently recommended approach of personalization of prophylaxis, are discussed in this position paper endorsed by the Italian Association of Hemophilia Centers (AICE), highlighting that ATC or other available classifications do not completely consider differences between drugs and innovations and that substitutions of rFVIII products will not invariably ensure the previously achieved clinical outcomes or generate benefits for all patients.
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Affiliation(s)
- Ezio Zanon
- Hemophilia Center, General Medicine, Padua University Hospital, Padua, Italy
| | - Raimondo De Cristofaro
- Center for Hemorrhagic and Thrombotic Diseases, IRCCS A. Gemelli University Hospital Foundation, Rome, Italy
| | - Massimo Franchini
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy
| | | | - Gianfranco Pasut
- Department of Pharmaceutical and Pharmacological Sciences, University of Padua, Padua, Italy
| | - Angelo Claudio Molinari
- Regional Reference Center for Hemorrhagic Diseases, Thrombosis and Hemostasis Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Rita C. Santoro
- Centre for Hemorrhagic and Thrombotic Disorders, Pugliese Ciaccio Hospital, Catanzaro, Italy
| | - Antonio Coppola
- Regional Reference Center for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | - Angiola Rocino
- Hematology Unit, Hemophilia and Thrombosis Center, S.M. di Loreto Nuovo Hospital, ASL Napoli 1 Centro, Naples, Italy
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4
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Goren R, Pullenayegum E, Blanchette VS, Dover S, Carcao M, Israels SJ, Chan A, Rivard GE, Steele M, Cloutier S, Klaassen RJ, Sinha R, Price VE, Laferriere N, Paradis E, Wu JK, Feldman BM. Patterns of joint damage in severe haemophilia A treated with prophylaxis. Haemophilia 2021; 27:666-673. [PMID: 34015166 DOI: 10.1111/hae.14345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 04/19/2021] [Accepted: 05/03/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The primary objective of this study was to assess whether there are different patterns (classes) of joint health in young boys with severe haemophilia A (SHA) prescribed primary tailored prophylaxis. We also assessed whether age at first index joint bleed, blood group, FVIII gene abnormality variant, factor VIII trough level, first-year bleeding rate and adherence to the prescribed prophylaxis regimen significantly predicted joint damage trajectory, and thus class membership. METHODS Using data collected prospectively as part of the Canadian Hemophilia Primary Prophylaxis Study (CHPS), we implemented a latent class growth mixture model technique to determine how many joint damage classes existed within the cohort. We used a multinomial logistic regression to predict the odds of class membership based on the above predictors. We fitted a survival model to assess whether there were differences in the rate of dose escalation across the groups. RESULTS We identified three distinct classes of trajectory: persistently low, moderately increasing and rapidly increasing joint scores. By multinomial regression, we found that only age at first index joint bleed predicted rapidly increasing joint scores. The rapidly increasing joint score class group moved through dose escalation significantly faster than the other two groups. CONCLUSIONS Using tailored prophylaxis, boys with SHA follow one of three joint health trajectories. By using knowledge of disease trajectories, clinicians may be able to adjust treatment according to a subject's predicted long-term joint health and institute cost-effective programmes of prophylaxis targeted at the individual subject level.
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Affiliation(s)
- Rachel Goren
- Institute of Health Policy, Management & Evaluation, The Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Eleanor Pullenayegum
- Institute of Health Policy, Management & Evaluation, The Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Victor S Blanchette
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.,Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Saunya Dover
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Manuel Carcao
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.,Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sara J Israels
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - Anthony Chan
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Georges E Rivard
- Division of Hematology/Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | - MacGregor Steele
- Section of Pediatric Hematology, Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, AB, Canada
| | - Stéphanie Cloutier
- Centre de l'hémophilie de l'est du Québec, Hôpital de l'Enfant-Jésus, Université Laval, Québec, QC, Canada
| | - Robert J Klaassen
- Division of Pediatric Hematology/Oncology, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Roona Sinha
- Saskatchewan Bleeding Disorders Program, Royal University Hospital, Saskatoon, SK, Canada
| | - Victoria E Price
- Division of Pediatric Hematology/Oncology, IWK Health Centre, Halifax, NS, Canada
| | - Nicole Laferriere
- Division of Hematology/Oncology, Thunder Bay Regional Cancer Care, Thunder Bay, ON, Canada
| | | | - John K Wu
- Division of Hematology/Oncology/BMT, Department of Pediatrics, UBC & BC Children's Hospital, Vancouver, BC, Canada
| | - Brian M Feldman
- Institute of Health Policy, Management & Evaluation, The Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Rheumatology, The Hospital for Sick Children, Toronto, ON, Canada
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5
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Hermans C, Dolan G. Pharmacokinetics in routine haemophilia clinical practice: rationale and modalities-a practical review. Ther Adv Hematol 2020; 11:2040620720966888. [PMID: 33194165 PMCID: PMC7594230 DOI: 10.1177/2040620720966888] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 09/24/2020] [Indexed: 01/19/2023] Open
Abstract
Prophylactic therapy with exogenous clotting factor concentrates in haemophilia A
and B aims to achieve levels of circulating FVIII or FIX that are adequate for
the prevention or reduction of spontaneous joint bleeding. Historically, a
minimum trough level of at least 1% of the normal levels of circulating clotting
factor has been targeted using standardised protocols. However, clearance of
clotting factor varies between products and patients, and other pharmacokinetic
(PK) parameters such as the frequency and magnitude of peaks may be important
for ensuring optimal coverage. Thus, it is increasingly recognised that an
individualised, PK-based approach to prophylaxis is necessary to achieve optimal
protection. This review focuses on the clinical implications of using PK-guided,
individualised prophylaxis in haemophilia to improve patient outcomes and
considers practical methods of establishing patients’ PK parameters. The most
useful PK parameters will depend on the aim of the specific treatment (e.g.
preventing activity-related and traumatic bleeds or addressing subclinical
bleeding). In clinical practice, lengthy and frequent post-infusion sampling for
PK analysis is costly and a significant burden for patients. However, a Bayesian
analysis allows for the estimation of different PK parameters (e.g. half-life,
factor concentrations over time, etc.) with only a minimum number of samples
(e.g. 4, 24 and 48 h for haemophilia A), by using the patient’s data to adjust a
relevant population PK value towards the actual value. Numerous tools are
available to aid in the practical use of Bayesian PK-guided dosing in the
clinic, including the Web-based Application for the Population Pharmacokinetic
Service hosted by McMaster University, Canada. The PK data can be used to
determine the appropriate prophylaxis regimen for the individual patient, which
can be monitored by assessment of the trough level at each clinic visit. Collection of PK data and subsequent PK-guided dosing should become standard
practice when determining treatment strategies for people with haemophilia.
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Affiliation(s)
- Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Adult Haematology, St-Luc University Hospital, Université catholique de Louvain (UCLouvain), Avenue Hippocrate 10, Brussels, 1200, Belgium
| | - Gerry Dolan
- Haemophilia and Thrombosis Centre, St Thomas' Hospital, London, UK
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Escobar M, Santagostino E, Mancuso ME, Coppens M, Balasa V, Taylor JA, Iorio A, Negrier C. Switching patients in the age of long-acting recombinant products? Expert Rev Hematol 2020; 12:1-13. [PMID: 31282771 DOI: 10.1080/17474086.2018.1564032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Introduction: Prophylaxis with factor replacement therapy is the gold standard for the treatment of hemophilia, but this often requires frequent infusions. A number of long-acting factor products have been developed to reduce the burden on patients. Areas covered: This is an overview of information presented at two symposia held at the World Federation of Hemophilia and International Society on Thrombosis and Haemostasis - Scientific and Standardization Committee annual meetings. The pharmacokinetic, safety and efficacy data for long-acting recombinant products are reviewed, with a focus on recombinant factor IX albumin fusion protein (rIX-FP) and rVIII-SingleChain. This overview also provides a guide for managing a patient's switch to long-acting products. Expert opinion: Long-acting products may allow patients to maintain or decrease bleeding rates whilst increasing their dosing interval, which may in turn reduce the burden on patients and caregivers. When switching patients to long-acting products health-care professionals should provide balanced and thorough education to the patient, whilst supporting their emotional well-being. Regimens should address patients' needs and goals but should also be guided by clinical phenotype and pharmacokinetic assessment. Follow-up should assess safety concerns, bleeding rates, joint health and the impact of the regimen on patients' lifestyle.
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Affiliation(s)
- Miguel Escobar
- a Department of Internal Medicine and Pediatrics, Division of Hematology , University of Texas Health Science Center and the Gulf States Hemophilia and Thrombophilia Center , Houston , TX , USA
| | - Elena Santagostino
- b Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico , Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre , Milan , Italy
| | - Maria Elisa Mancuso
- b Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico , Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre , Milan , Italy
| | - Michiel Coppens
- c Department of Vascular Medicine , Amsterdam Cardiovascular Sciences, Amsterdam UMC , Amsterdam , the Netherlands
| | - Vinod Balasa
- d Division Chief and Medical Director, Hematology/Oncology , Valley Children's Hospital , Madera , CA , USA
| | - Jason A Taylor
- e Division of Hematology and Medical Oncology , The Hemophilia Center, Knight Cancer Institute, Oregon Health & Science University and Portland VA Medical Center , Portland , OR , USA
| | - Alfonso Iorio
- f Department of Health Research Methods, Evidence and Impact , McMaster University , Hamilton , ON , Canada
| | - Claude Negrier
- g National Reference Centre for Haemophilia, Louis Pradel Hospital , University Claude Bernard Lyon I , Lyon , France
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7
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Tegenge MA, Mahmood I, Forshee R. Clinical Pharmacology Review of Plasma-derived and Recombinant Protein Products: CBER Experience and Perspectives on Model-Informed Drug Development. Haemophilia 2019; 25:e240-e246. [PMID: 31131515 DOI: 10.1111/hae.13767] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/01/2019] [Accepted: 04/10/2019] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Clinical pharmacology studies are one of the major types of regulatory data submitted for review of therapeutic proteins regulated by the Center for Biologics Evaluation and Research (CBER). AIM The primary objective of the current study is to provide an overview of the role of clinical pharmacology including pharmacokinetics (PK), pharmacodynamics (PD) and exposure-response analysis at CBER. Furthermore, we aim to provide a baseline estimate for the use of quantitative clinical pharmacology studies prior to implementation of FDA's model-informed drug development (MIDD) pilot programme. METHODS We survey original Biologics License Applications (BLAs) for plasma-derived and related recombinant therapeutic protein products approved by CBER/FDA (2008-2017). RESULTS There were 37 original BLAs that met our inclusion criteria, and 34 of these products (92%) contained human PK data as part of the biological licensing. The products were broadly classified as coagulation factors (54%), IgG and related proteins (24%), and other therapeutic proteins (22%). Coagulation factor VIII and IX products constitute 32% of the BLAs and indicated for treatment of haemophilia A and B, respectively. Twelve products (35%) used model-based approaches (population PK/PD and exposure-response). Over the past 5 years (2013 to 2017), there is a trend for increased application of MIDD approaches as compared to the previous cohort years (2008 to 2012). CONCLUSION In conclusion, clinical pharmacology has played a major role in regulatory review of plasma-derived products, and we expect that the application of quantitative methods will further evolve for these products under the FDA MIDD programme.
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Affiliation(s)
- Million A Tegenge
- Office of Biostatistics & Epidemiology, Center for Biologics Evaluation and Research, Food & Drug Administration, Silver Spring, Maryland
| | - Iftekhar Mahmood
- Division of Clinical Evaluation and Pharmacology/Toxicology, Office of Tissue and Advanced Therapies (OTAT), Center for Biologics Evaluation and Research, Food & Drug Administration, Silver Spring, Maryland
| | - Richard Forshee
- Office of Biostatistics & Epidemiology, Center for Biologics Evaluation and Research, Food & Drug Administration, Silver Spring, Maryland
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8
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Surgical Risk on Patients with Coagulopathies: Guidelines on Hemophiliac Patients for Oro-Maxillofacial Surgery. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16081386. [PMID: 30999657 PMCID: PMC6518229 DOI: 10.3390/ijerph16081386] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/29/2019] [Accepted: 04/10/2019] [Indexed: 12/14/2022]
Abstract
Background: Haemophilia is a disease of genetic origin, which causes a defect in blood coagulation. Under normal conditions, in the case of leakage from the blood vessels, the blood forms a clot that reduces or blocks the bleeding. This process involves the activation of several plasma proteins in a cascade-like species. Two of these proteins, produced in the liver, factor VIII and factor IX, are deficient or present a functional defect in people with haemophilia. Because of this deficit, the haemophiliacs easily suffer external and internal bleeding. Surgical treatment of these patients is to be observed, and often their treatment is delayed due to unclear guidelines and risks in treating these patients. The aim is to provide clear guidelines in the case of surgical treatment of these patients. Methods: In this study, we have considered all the guidelines that refer to the gold-maxillofacial surgery, focusing on the literature of the last 10 years. Results: Surely, this collection of guidelines will favor the choice of the clinician towards safer and predictable protocols. This study does not want to create a guideline but evaluates the literature of the last 10 years, and highlights the latest for the treatment of these patients., with the aim of informing the pathology and at the same time making the surgical maneuvers safer. Conclusions: Despite the research of literature has produced few results, it was nevertheless possible to draw up a guideline thanks to additional information extrapolated from textbooks and other scientific articles. According to the guidelines, it is possible to proceed to the treatment of these patients, if with appropriate therapy in a safe and risk-free manner.
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Lambert T, Benson G, Dolan G, Hermans C, Jiménez-Yuste V, Ljung R, Morfini M, Zupančić-Šalek S, Santagostino E. Practical aspects of extended half-life products for the treatment of haemophilia. Ther Adv Hematol 2018; 9:295-308. [PMID: 30210757 DOI: 10.1177/2040620718796429] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/16/2018] [Indexed: 11/15/2022] Open
Abstract
Haemophilia A and haemophilia B are congenital X-linked bleeding disorders caused by deficiency of coagulation factor VIII (FVIII) and IX (FIX), respectively. The preferred treatment option for patients with haemophilia is replacement therapy. For patients with severe disease, prophylactic replacement of coagulation factor is the treatment of choice; this has been shown to reduce arthropathy significantly, reduce the frequency of bleeds and improve patients' quality of life. Prophylaxis with standard recombinant factor requires regular intravenous infusion at least two (FIX) to three (FVIII) times a week. Recombinant FVIII and FIX products with an extended half-life are in development, or have been recently licensed. With reported mean half-life extensions of 1.5-1.8 times that of standard products for FVIII and 3-5 times that of standard products for FIX, these products have the potential to address many of the unmet needs of patients currently treated with standard factor concentrates. For example, they may encourage patients to switch from on-demand treatment to prophylaxis and improve the quality of life of patients receiving prophylaxis. Indeed, extended half-life products have the potential to reduce the burden of frequent intravenous injections, reducing the need for central venous lines in children, promote adherence, improve outcomes, potentially allow for more active lifestyles and, depending on the dosing regimen, increase factor trough levels. Members of the Zürich Haemophilia Forum convened for their 19th meeting to discuss the practicalities of incorporating new treatments into the management of people with haemophilia. This review of extended half-life products considers their introduction in haemophilia treatment, including the appropriate dose and schedule of infusions, laboratory monitoring, patient selection, safety considerations, and the economic aspects of care.
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Affiliation(s)
- Thierry Lambert
- Haemophilia Care Centre, Bicêtre AP-HP Hospital and Faculté de Médecine Paris XI, 78 rue du general leclerc, 94270 Le Kremlin Bicetre, France
| | - Gary Benson
- Haemophilia and Thrombosis Centre, Belfast City Hospital, Belfast, Northern Ireland, UK
| | - Gerry Dolan
- Centre for Haemostasis and Thrombosis, St Thomas's Hospital, London, UK
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | - Rolf Ljung
- Department of Clinical Sciences: Paediatrics, Lund University, Lund, SwedenMalmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden
| | | | - Silva Zupančić-Šalek
- Division of Haematology, University Hospital Centre Zagreb, Zagreb, Croatia Medical School University of Zagreb, Zagreb, Croatia Faculty of Medicine Osijek, JJ Strossmayer University of Osijek, Osijek, Croatia
| | - Elena Santagostino
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Maggiore Hospital Policlinic, Milan, Italy
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10
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Escobar MA, Brewer A, Caviglia H, Forsyth A, Jimenez-Yuste V, Laudenbach L, Lobet S, McLaughlin P, Oyesiku JOO, Rodriguez-Merchan EC, Shapiro A, Solimeno LP. Recommendations on multidisciplinary management of elective surgery in people with haemophilia. Haemophilia 2018; 24:693-702. [PMID: 29944195 DOI: 10.1111/hae.13549] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2018] [Indexed: 12/23/2022]
Abstract
Planning and undertaking elective surgery in people with haemophilia (PWH) is most effective with the involvement of a specialist and experienced multidisciplinary team (MDT) at a haemophilia treatment centre. However, despite extensive best practice guidelines for surgery in PWH, there may exist a gap between guidelines and practical application. For this consensus review, an expert multidisciplinary panel comprising surgeons, haematologists, nurses, physiotherapists and a dental expert was assembled to develop practical approaches to implement the principles of multidisciplinary management of elective surgery for PWH. Careful preoperative planning is paramount for successful elective surgery, including dental examinations, physical assessment and prehabilitation, laboratory testing and the development of haemostasis and pain management plans. A coordinator may be appointed from the MDT to ensure that critical tasks are performed and milestones met to enable surgery to proceed. At all stages, the patient and their parent/caregiver, where appropriate, should be consulted to ensure that their expectations and functional goals are realistic and can be achieved. The planning phase should ensure that surgery proceeds without incident, but the surgical team should be ready to handle unanticipated events. Similarly, the broader MDT must be made aware of events in surgery that may require postoperative plans to be changed. Postoperative rehabilitation should begin soon after surgery, with attention paid to management of haemostasis and pain. Surgery in patients with inhibitors requires even more careful preparation and should only be undertaken by an MDT experienced in this area, at a specialized haemophilia treatment centre with a comprehensive care model.
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Affiliation(s)
- M A Escobar
- McGovern Medical School and the Gulf States Hemophilia and Thrombophilia Center, University of Texas Health Science Center, Houston, TX, USA
| | - A Brewer
- Department of Oral and Maxillofacial Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - H Caviglia
- Orthopedics and Traumatology Department, "Juan A. Fernandez" Hospital, Buenos Aires, Argentina
| | - A Forsyth
- REBUILD Program/Diplomat Specialty Infusion Group, Cincinnati, OH, USA
| | - V Jimenez-Yuste
- Department of Haematology, La Paz University Hospital - IdiPaz, Madrid, Spain
| | - L Laudenbach
- London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | - S Lobet
- Haemostasis and Thrombosis Unit, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - P McLaughlin
- Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, London, UK
| | - J O O Oyesiku
- Haemophilia, Haemostasis and Thrombosis Centre, Basingstoke & North Hampshire Hospital, Basingstoke, UK
| | - E C Rodriguez-Merchan
- Department of Orthopaedic Surgery, La Paz University Hospital - IdiPaz, Madrid, Spain
| | - A Shapiro
- Indiana Hemophilia & Thrombosis Center, Indianapolis, IN, USA
| | - L P Solimeno
- IRCCS Cà Granda Foundation, Maggiore Hospital of Milan, Milan, Italy
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Castaman G, Linari S. Pharmacokinetic drug evaluation of recombinant factor VIII for the treatment of hemophilia A. Expert Opin Drug Metab Toxicol 2017; 14:143-151. [PMID: 29257899 DOI: 10.1080/17425255.2018.1420161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The prevention of bleeding by prophylactic factor replacement is the recommended approach for the treatment of severe hemophilia. Prophylaxis should be individualized to provide the best clinical benefit to each patient. Therefore, a pharmacokinetic approach is crucial. Areas covered: This review aims to concisely describe the basic principles of pharmacokinetics of FVIII, the role of population pharmacokinetic, the available different recombinant FVIII concentrates and the new extended half-life FVIII molecules with possible improvement in hemophilia A treatment. Expert opinion: Pharmacokinetic is a useful tool to predict the outcome of replacement therapy, even though a large inter-individual variability exists, becauseof several factors: age, weight, von Willebrand factor level, blood group, active bleed, presence of inhibitors to FVIII, FVIII concentrate. Among the different recombinant FVIII concentrates pharmacokinetic differences are minor and clinically not significant. The extended half-life FVIII products brings only moderate advances, as half life extension is limited to 1.5-1.8-fold in comparison to that of native FVIII. Thus, infusions could be done every fourth, rarely fifth day to ensure a safe through level and a significant benefit can be offered only to patients treated every other day or three times weekly.
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Affiliation(s)
- Giancarlo Castaman
- a Center for Bleeding Disorders, Department of Oncology , Careggi University Hospital , Florence , Italy
| | - Silvia Linari
- a Center for Bleeding Disorders, Department of Oncology , Careggi University Hospital , Florence , Italy
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Holme PA, Tjønnfjord GE, Batorova A. Continuous infusion of coagulation factor concentrates during intensive treatment. Haemophilia 2017; 24:24-32. [PMID: 28873263 DOI: 10.1111/hae.13331] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2017] [Indexed: 01/12/2023]
Abstract
In clinical management of bleeds and surgical procedures in patients suffering from bleeding disorders either repetitive bolus injections (BI) or continuous infusion (CI) can be used for coagulation factor replacement. Continuous infusion seems to be an attractive route of administration and may be considered if replacement therapy is required for more than 3 days. The strongest argument favouring continuous infusion is its superiority in providing the patient with a safe and constant level of the deficient coagulation factor by balancing input with clearance. Furthermore, several studies have shown that coagulation factor consumption may be reduced by CI compared to repetitive bolus injections (BI) since unnecessary peaks of factor level are avoided. Concerns have been raised whether continuous infusion of coagulation concentrates is associated with an increased risk of developing inhibitors. However, available data have so far not shown an increased risk for inhibitor development in severe haemophilia patients with more than 50 exposure days of coagulation factor concentrates. Further, previously reported complications when using CI such as phlebitis at the infusion site and pump failure are nowadays very seldom seen when small amounts of heparin are added to the infusion bag, and increased quality of the pumps are available. Over the last decades, numerous reports have confirmed CI to be a safe and effective mode of coagulation factor replacement even in the most challenging surgical procedures, such as total joint arthroplasties.
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Affiliation(s)
- P A Holme
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - G E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - A Batorova
- Faculty of Medicine of Comenius University, Department of Haematology and Transfusion Medicine, National Haemophilia Centre, University Hospital, Bratislava, Slovakia
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