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Roberts JC, Escobar MA, Acharya S, Hwang NX, Wang M, Hale S, Brighton S, Kouides PA. Retrospective chart review of GI bleeding in people with von Willebrand disease. Haemophilia 2024; 30:970-980. [PMID: 38751022 DOI: 10.1111/hae.15034] [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: 05/19/2023] [Revised: 02/07/2024] [Accepted: 05/01/2024] [Indexed: 07/18/2024]
Abstract
INTRODUCTION Gastrointestinal (GI) bleeding events (BEs) in von Willebrand disease (VWD) are difficult to diagnose and often recurrent. Limited data from clinical trials has led to lack of consensus on treatment options. AIM Describe current treatments and outcomes for GI BEs in people with VWD. METHODS This retrospective, observational, multicentre chart review study was conducted from January 2018 through December 2019 and included patients with inherited VWD with ≥1 GI BE in the preceding 5 years. Baseline characteristics, number and aetiology of BEs, associated GI-specific morbidities/lesions, treatment and outcomes were analysed descriptively. RESULTS Sixty bleeds were reported in 20 patients with type 1 (20%), type 2 (50%) and type 3 (30%) VWD. During the 5-year study period, 31 (52%) BEs had one identified or suspected cause; multiple causes were reported in 11 (18%). Most GI BEs (72%) were treated with a combination of von Willebrand factor (VWF), antifibrinolytics and/or other haemostatic or non-haemostatic treatments. Time to resolution did not differ by VWF treatment use; however, BEs treated with non-VWF treatments tended to resolve later. In patients with GI-specific morbidities/lesions, 84% resolved with first-line treatment; time to resolution tended to be longer than in patients without such morbidities/lesions. Thirteen BEs occurred in patients receiving prophylaxis and 47 in patients receiving on-demand treatment; 18 BEs resulted in a switch to prophylaxis after bleed resolution. CONCLUSIONS This study confirms the unmet need for the management of recurrent GI BEs in people with VWD and the need for prospective data, especially on prophylaxis.
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Affiliation(s)
- Jonathan C Roberts
- Bleeding & Clotting Disorders Institute, Dills Family Foundation Center for Research at BCDI, Peoria, Illinois, USA
- Departments of Pediatrics and Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Miguel A Escobar
- University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Suchitra Acharya
- Northwell Health Hemostasis and Thrombosis Center, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA
| | - Nina X Hwang
- Center for Inherited Blood Disorders, CHOC Children's Hospital, Orange, California, USA
| | - Michael Wang
- Hemophilia and Thrombosis Center, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sarah Hale
- Takeda Pharmaceuticals U.S.A., Inc., Lexington, Massachusetts, USA
| | | | - Peter A Kouides
- Department of Medicine, Mary M. Gooley Hemophilia Center, Rochester, New York, USA
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2
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Cozzi MR, Del Ben F, Corso C, Steffan A. A comparative study of anti-ADAMTS-13 antibody dynamics in immune-mediated thrombotic thrombocytopenic purpura. Res Pract Thromb Haemost 2024; 8:102525. [PMID: 39221447 PMCID: PMC11364000 DOI: 10.1016/j.rpth.2024.102525] [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: 05/10/2024] [Revised: 06/19/2024] [Accepted: 07/16/2024] [Indexed: 09/04/2024] Open
Abstract
Background Thrombotic thrombocytopenic purpura, particularly its immune-mediated variant (iTTP), necessitates accurate diagnostic approaches for effective management. Objectives To compare a chemiluminescence immunoassay (CLIA) and an enzyme-linked immunosorbent assay (ELISA) for testing ADAMTS-13 activity and detecting anti-ADAMTS-13 autoantibodies (AAbs) in patients with iTTP. Methods This study involved 31 paired samples from 12 iTTP patients. ADAMTS-13 activity was measured using the HemosIL AcuStar (Instrumentation Laboratory, CLIA) and Technozym (Technoclone) activity assay (ELISA). The presence of AAbs was assessed using Technozym ADAMTS-13-INH assay (ELISA) and HemosIL AcuStar activity (CLIA) within a Bethesda assay following mixing with normal pool plasma. von Willebrand factor (VWF) multimers were analyzed using the HYDRASYS-2 SCAN system and the HYDRAGEL 5- or 11-VW Multimer kits (Sebia). VWF activity levels were measured with the HemosIL AcuStar VWF:GPIbR on the ACL AcuStar Analyzer (IL). Results For ADAMTS-13 activity, a strong linear relationship and no bias between CLIA and ELISA were confirmed (slope = 1.01 [0.91, 1.11], intercept = 0.00 [-0.47, 0]). However, significant discrepancies were found in AAb detection during remission phases with ADAMTS-13 activity between 10% and 50%, with CLIA and ELISA showing significant divergence (P < .001, Cohen's g = 0.34). Consistently, VWF multimers and activity levels exhibited significantly different values between remission samples with ADAMTS-13 activity below 50% and above 50%. In longitudinal analysis of patients with multiple iTTP relapses, positivity to CLIA appears to precede ELISA in predicting exacerbations. Conclusion While CLIA and ELISA might be interchangeable for assessing ADAMTS-13 activity, they are not equivalent for detecting AAbs, particularly in patients in clinical remission with ADAMTS-13 activity between 10% and 50%.
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Affiliation(s)
- Maria Rita Cozzi
- Centro di Riferimento Oncologico (CRO) Aviano, National Cancer Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Immunopathology and Cancer Biomarkers Unit, Department of Cancer Research and Advanced Diagnostics, Aviano, Italy
| | - Fabio Del Ben
- Centro di Riferimento Oncologico (CRO) Aviano, National Cancer Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Immunopathology and Cancer Biomarkers Unit, Department of Cancer Research and Advanced Diagnostics, Aviano, Italy
| | - Chiara Corso
- Centro di Riferimento Oncologico (CRO) Aviano, National Cancer Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Immunopathology and Cancer Biomarkers Unit, Department of Cancer Research and Advanced Diagnostics, Aviano, Italy
| | - Agostino Steffan
- Centro di Riferimento Oncologico (CRO) Aviano, National Cancer Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Immunopathology and Cancer Biomarkers Unit, Department of Cancer Research and Advanced Diagnostics, Aviano, Italy
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Mert S, Kuhlmann C, Hagen CS, Kessler K, Balubaid M, Giunta RE, Wiggenhauser PS. Abdominoplasty in a Patient With Type 3 von Willebrand Disease: A Case Report. Ann Plast Surg 2024; 92:133-136. [PMID: 37962210 DOI: 10.1097/sap.0000000000003711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
ABSTRACT von Willebrand disease (vWD) is an inherited bleeding disorder that is characterized by a quantitative or qualitative deficiency of the von Willebrand factor (vWF). Type 3 is the most severe form of vWD with a near-complete absence of vWF and a significantly increased risk of excessive bleeding and hematoma during a surgical procedure. To date, no data on surgical and hemostatic management of a type 3 vWD patient undergoing body-contouring surgery has been published. We report the case of a 47-year-old woman with type 3 vWD requiring medically indicated abdominoplasty after massive weight loss due to bariatric surgery. The case was successfully managed with individualized bodyweight-adapted substitution of recombinant vWF vonicog alfa and tranexamic acid under close monitoring of vWF and factor VIII activity. For further risk stratification, we propose the multidisciplinary treatment of patients with severe vWF undergoing elective plastic surgery in specialized centers providing around-the-clock laboratory testing and access to a blood bank. In addition, strict hemostasis during surgery and early postoperative mobilization with fitted compression garments are recommended to further reduce the risk of bleeding and thromboembolic complications.
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Affiliation(s)
- Sinan Mert
- From the Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, LMU Munich, Munich, Germany
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4
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Franchini M, Focosi D. Targeting von Willebrand disease: the current status and future directions of management therapies. Expert Rev Hematol 2023; 16:871-878. [PMID: 37800892 DOI: 10.1080/17474086.2023.2268282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/04/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION von Willebrand disease (VWD) is the commonest inherited bleeding disorder, and is typically caused by deficits in the quantity or quality of von Willebrand factor (VWF). AREAS COVERED This review describes the main clinical, diagnostic, and therapeutic aspects of VWD, with particular attention to its management. In addition, standard and avant-garde replacement therapies based on the use of VWF are discussed. EXPERT OPINION The goal of treatment for VWD is to reverse the double hemostatic defect resulting from the abnormal or reduced expression of VWF and the concomitant factor VIII (FVIII) deficiency. Treatment consists of managing any bleeds and both short-term prophylaxis (i.e. for surgery or invasive procedures) and long-term prophylaxis. While desmopressin is suitable for most patients with type 1 VWD, VWF/FVIII concentrates are the treatment of choice for the other types of VWD. Beside plasma-derived VWF/FVIII concentrates, whose safety and efficacy have been demonstrated by several clinical trials, products containing only VWF, obtained by plasma fractionation and recombinant DNA technology, have become available and marketed more recently. The clinical use of these VWF-only products is particularly attractive in the setting of surgery and long-term prophylaxis, such as the prevention of recurrent gastrointestinal bleeding in cases of angiodysplasia.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
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5
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Bauer A, Friberg-Hietala S, Smania G, Wolfsegger M. Pharmacokinetic-Pharmacodynamic Comparison of Recombinant and Plasma-Derived von Willebrand Factor in Patients with von Willebrand Disease Type 3. J Blood Med 2023; 14:399-411. [PMID: 37332615 PMCID: PMC10276593 DOI: 10.2147/jbm.s395845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 05/26/2023] [Indexed: 06/20/2023] Open
Abstract
Background Recombinant von Willebrand factor (rVWF, vonicog alfa, Vonvendi/Veyvondi, Takeda Pharmaceuticals USA, Lexington, MA) and several plasma-derived VWF/factor VIII (pdVWF/FVIII) concentrates are available for treating bleeding episodes in patients with von Willebrand disease (VWD). Purpose To develop population pharmacokinetic (PK)/pharmacodynamic (PD) models that describe VWF:ristocetin cofactor (VWF:RCo) activity and its relationship with FVIII activity (FVIII:C) over time following intravenous administration of either rVWF or a pdVWF/FVIII concentrate (VWF:RCo/FVIII:C 2.4:1) in patients with VWD; to use the final PK/PD models for an in silico comparison of rVWF and pdVWF/FVIII. Methods The population PK model for rVWF was based on data from four clinical studies in which rVWF was administered to adult patients with VWD type 1, 2 or 3 (phase 1: NCT00816660; phase 3: NCT01410227 and NCT02283268) or severe hemophilia A (phase 1: EudraCT 2011-004314-42). The PK and PK/PD models for pdVWF/FVIII were based on data from the phase 1 study (NCT00816660) in patients with type 3 VWD who received either rVWF plus recombinant FVIII (rFVIII, octocog alfa, ADVATE®, Takeda Pharmaceuticals USA, Lexington, MA, USA) or pdVWF/FVIII. Results There was a marked difference in clearance following rVWF administration compared with pdVWF/FVIII in type 3 VWD, leading to a ~1.75 longer mean residence time (ie, persistence of VWF:RCo activity in the body) and half-life for rVWF versus pdVWF/FVIII. Simulations showed that following repeated administration of rVWF (50 IU/kg), a FVIII:C activity of >40 IU/dL can be maintained for the full 72 h dosing interval. Conclusion The slower elimination of VWF:RCo following rVWF administration results in a prolonged effect on FVIII turnover compared with pdVWF/FVIII administration.
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Affiliation(s)
- Alexander Bauer
- Statistical and Quantitative Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | | | | | - Martin Wolfsegger
- Statistical and Quantitative Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
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6
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Gritsch H, Schrenk G, Weinhappl N, Mellgård B, Ewenstein B, Turecek PL. Structure and Function of Recombinant versus Plasma-Derived von Willebrand Factor and Impact on Multimer Pharmacokinetics in von Willebrand Disease. J Blood Med 2022; 13:649-662. [PMID: 36405429 PMCID: PMC9673800 DOI: 10.2147/jbm.s377126] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 11/03/2022] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Recombinant von Willebrand factor (rVWF, vonicog alfa) is a purified VWF concentrate produced from Chinese hamster ovary cells. rVWF is not exposed to the VWF-cleaving protease ADAMTS13 and so is not subject to proteolytic degradation of large (L) and ultra-large (UL) VWF multimers by that enzyme. PURPOSE To compare the structure and function of rVWF with the human plasma-derived VWF [pdVWF] concentrates Haemate P®/Humate-P®, Voncento®, Wilate®/Eqwilate®, and Wilfactin®/Willfact®; to investigate the relationship between VWF multimeric pattern and VWF:ristocetin cofactor (VWF:RCo) activity through population pharmacokinetic (PK) modeling in patients with severe von Willebrand disease (VWD) treated with rVWF. METHODS Analyses included VWF:RCo activity, VWF:collagen-binding activity, VWF:platelet glycoprotein Ib receptor binding, factor VIII (FVIII) binding capacity, and VWF-mediated platelet adhesion under flow conditions. VWF multimeric structure was determined by agarose gel electrophoresis. Population PK models describing the activity-time profile of small, medium, and L/UL multimers following intravenous administration of rVWF in patients with severe VWD were developed. RESULTS Findings demonstrate that rVWF contains a non-degraded VWF multimer pattern including the UL multimers not present in pdVWF concentrates. rVWF displayed higher specific platelet-binding activity, and faster mediation of platelet adhesion to collagen under shear stress versus pdVWF concentrates. rVWF also demonstrated higher FVIII binding capacity than Haemate P®, Voncento® and Wilate®. Modeling provided evidence that VWF:RCo activity in patients with severe VWD treated with rVWF is associated with L/UL VWF multimers in the circulation. CONCLUSIONS Findings suggest that the L and UL multimers preserved in rVWF contribute to high biological activity and might be important for providing hemostatic efficacy.
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Affiliation(s)
- Herbert Gritsch
- Pharmaceutical Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | - Gerald Schrenk
- Pharmaceutical Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | - Nina Weinhappl
- Pharmaceutical Sciences, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | - Björn Mellgård
- Rare Genetics and Hematology, Research & Development, Takeda Development Center Americas, Inc, Cambridge, MA, USA
| | - Bruce Ewenstein
- Rare Genetics and Hematology, Research & Development, Takeda Development Center Americas, Inc, Cambridge, MA, USA
| | - Peter L Turecek
- Department of Pharmaceutical Sciences, Division of Pharmacology, University of Vienna, Vienna, Austria
- Plasma Derived Therapies, Research & Development, Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
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7
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Manz XD, Bogaard HJ, Aman J. Regulation of VWF (Von Willebrand Factor) in Inflammatory Thrombosis. Arterioscler Thromb Vasc Biol 2022; 42:1307-1320. [PMID: 36172866 DOI: 10.1161/atvbaha.122.318179] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Increasing evidence indicates that inflammation promotes thrombosis via a VWF (von Willebrand factor)-mediated mechanism. VWF plays an essential role in maintaining the balance between blood coagulation and bleeding, and inflammation can lead to aberrant regulation. VWF is regulated on a transcriptional and (post-)translational level, and its secretion into the circulation captures platelets upon endothelial activation. The significant progress that has been made in understanding transcriptional and translational regulation of VWF is described in this review. First, we describe how VWF is regulated at the transcriptional and post-translational level with a specific focus on the influence of inflammatory and immune responses. Next, we describe how changes in regulation are linked with various cardiovascular diseases. Recent insights from clinical diseases provide evidence for direct molecular links between inflammation and thrombosis, including atherosclerosis, chronic thromboembolic pulmonary hypertension, and COVID-19. Finally, we will briefly describe clinical implications for antithrombotic treatment.
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Affiliation(s)
- Xue D Manz
- Department of Pulmonary Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam Cardiovascular Sciences (ACS), the Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam Cardiovascular Sciences (ACS), the Netherlands
| | - Jurjan Aman
- Department of Pulmonary Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam Cardiovascular Sciences (ACS), the Netherlands
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8
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Ogweno G. Challenges in Platelet Functions in HIV/AIDS Management. Infect Dis (Lond) 2022. [DOI: 10.5772/intechopen.105731] [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] [Indexed: 11/08/2022] Open
Abstract
The interest in platelet functions in HIV/AIDS is due to the high incidence of microvascular thrombosis in these individuals. A lot of laboratory data have been generated regarding platelet functions in this population. The tests demonstrate platelet hyperactivity but decreased aggregation, though results are inconsistent depending on the study design. Antiretroviral treatments currently in use display complex interactions. Many studies on platelet functions in these patients have been for research purposes, but none have found utility in guiding drug treatment of thrombosis.
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9
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Kim S, Park YS. Recombinant von Willebrand Factor for Pediatric Patient with von Willebrand Disease: First Report in Korea. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2021. [DOI: 10.15264/cpho.2021.28.1.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Seoin Kim
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Young Shil Park
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
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10
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Abstract
The management of von Willebrand disease (VWD) is based upon the dual correction of the primary hemostasis defect, due to the inherited deficiency of von Willebrand factor (VWF), and of the secondary defect of factor VIII coagulant activity (FVIII:C), due to the loss of binding and stabilization by VWF of this intrinsic coagulation factor in flowing blood. The traditional therapeutic weapons (the synthetic derivative of the antidiuretic hormone desmopressin and plasma-derived VWF/FVIII concentrates) are able to transiently correct both the defects. With the goal of tackling the primary deficiency in the disease, that is, VWF, but at the same time exploiting the normal capacity of patients to produce FVIII, the novel approach of replacing only VWF was implemented in the last 10 years. Following the manufacturing of a concentrate fractionated from human plasma and of one obtained by recombinant DNA technology, clinical studies have shown that VWF-only products correct not only the primary VWF deficiency but also the secondary FVIII:C deficiency. The demonstrated efficacy of these products in various clinical situations and, ultimately, in such a hemostasis-challenging context as surgery testifies to the effectiveness and safety of this approach. It remains to be seen whether VWF-only products are efficacious and safe in still-unexplored situations, such as use in children; the long-term use for prophylaxis; and in recurrent gastrointestinal (GI) bleeding due to angiodysplasia, a major therapeutic problem in VWD.
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11
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Mannucci PM. New therapies for von Willebrand disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:590-595. [PMID: 31808884 PMCID: PMC6913470 DOI: 10.1182/hematology.2019000368] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
The management of von Willebrand disease (VWD) is based upon the dual correction of the primary hemostasis defect, due to the inherited deficiency of von Willebrand factor (VWF), and of the secondary defect of factor VIII coagulant activity (FVIII:C), due to the loss of binding and stabilization by VWF of this intrinsic coagulation factor in flowing blood. The traditional therapeutic weapons (the synthetic derivative of the antidiuretic hormone desmopressin and plasma-derived VWF/FVIII concentrates) are able to transiently correct both the defects. With the goal of tackling the primary deficiency in the disease, that is, VWF, but at the same time exploiting the normal capacity of patients to produce FVIII, the novel approach of replacing only VWF was implemented in the last 10 years. Following the manufacturing of a concentrate fractionated from human plasma and of one obtained by recombinant DNA technology, clinical studies have shown that VWF-only products correct not only the primary VWF deficiency but also the secondary FVIII:C deficiency. The demonstrated efficacy of these products in various clinical situations and, ultimately, in such a hemostasis-challenging context as surgery testifies to the effectiveness and safety of this approach. It remains to be seen whether VWF-only products are efficacious and safe in still-unexplored situations, such as use in children; the long-term use for prophylaxis; and in recurrent gastrointestinal (GI) bleeding due to angiodysplasia, a major therapeutic problem in VWD.
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Affiliation(s)
- Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Maggiore Policlinico Hospital Foundation, Milan, Italy
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12
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Peyvandi F, Mamaev A, Wang J, Stasyshyn O, Timofeeva M, Curry N, Cid AR, Yee TT, Kavakli K, Castaman G, Sytkowski A. Phase 3 study of recombinant von Willebrand factor in patients with severe von Willebrand disease who are undergoing elective surgery. J Thromb Haemost 2019; 17:52-62. [PMID: 30362288 PMCID: PMC7379610 DOI: 10.1111/jth.14313] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Indexed: 01/28/2023]
Abstract
Essentials Recombinant von Willebrand factor (rVWF) is effective in von Willebrand disease (VWD). A phase 3 study of rVWF, with/without recombinant factor VIII (rFVIII) before surgery in VWD. Overall rVWF's efficacy was rated excellent/good; rVWF was administered alone in most patients. rVWF was well-tolerated and hemostasis was achieved in patients with severe VWD undergoing surgery. SUMMARY: Background Recombinant von Willebrand factor (rVWF) has demonstrated efficacy for on-demand treatment of bleeding in severe von Willebrand disease (VWD), warranting evaluation in the surgical setting. Objectives This study (NCT02283268) evaluated the hemostatic efficacy/safety profile of rVWF, with/without recombinant factor VIII (rFVIII), in patients with severe VWD undergoing surgery. Patients/Methods Patients received rVWF 40-60 IU kg-1 , VWF ristocetin cofactor activity was measured 12-24 h before surgery. If endogenous FVIII activity (FVIII:C) target levels were achieved 3 h before surgery, rVWF was administered alone 1 h before surgery; rVWF was co-administered with rFVIII if target endogenous FVIII levels were not achieved. rVWF was infused postoperatively to maintain target trough levels. Overall and intraoperative hemostatic efficacy, the pharmacodynamics of rVWF administration and the incidence of adverse events (AEs) were assessed. Results All patients treated with rVWF for major (n = 10), minor (n = 4) and oral (n = 1) surgery had overall and intraoperative hemostatic efficacy ratings of excellent (73.3% and 86.7%) or good (26.7% and 13.3%). Most rVWF infusions (89.4%) were administered alone, resulting in hemostatically effective levels of endogenous FVIII within 6 h, which were sustained for 72-96 h; 70% (n = 7/10) of major surgeries were performed without rFVIII co-administration. Six patients reported 12 treatment-emergent AEs. Two patients each had one serious AE: diverticulitis (not treatment related) and deep vein thrombosis (sponsor-assessed as possibly treatment related). No severe allergic reactions or inhibitory antibodies were reported. Conclusions These data support the efficacy and safety profile of rVWF in patients with severe VWD undergoing elective surgery.
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Affiliation(s)
- F. Peyvandi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoAngelo Bianchi Bonomi Hemophilia and Thrombosis CenterMilanItaly
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | - A. Mamaev
- Regional State Budgetary Healthcare Institution “Regional Clinical Hospital”BarnaulAltai RegionRussian Federation
| | - J.‐D. Wang
- Center for Rare Diseases and Hemophilia CenterTaichung Veterans General HospitalTaichungTaiwan
| | - O. Stasyshyn
- SI Institute of Blood Pathology and Transfusion Medicine of NAMS of UkraineLvivUkraine
| | - M. Timofeeva
- Federal State Budgetary Research Institution “Kirov Scientific and Research Institute of Hematology and Blood Transfusion of Federal Medico‐Biological Agency of Russia”KirovRussian Federation
| | - N. Curry
- The Oxford Haemophilia and Thrombosis CentreChurchill Hospital and NIHR BRC, Blood ThemeOxfordUK
| | - A. R. Cid
- Hospital Universitario y Politécnico La Fe Hemostasia y TrombosisValenciaSpain
| | - T. T. Yee
- Royal Free London NHS Foundation TrustKatharine Dormandy Haemophilia and Thrombosis CentreLondonUK
| | - K. Kavakli
- Ege Universitesi Tip Fakultesi Hematoloji Bilim DaliBornova, IzmirTurkey
| | - G. Castaman
- Center for Bleeding Disorders and Coagulation Department of OncologyCareggi University HospitalFlorenceItaly
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13
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Rowlands GW, Good BC, Deutsch S, Manning KB. Characterizing the HeartMate II Left Ventricular Assist Device Outflow Using Particle Image Velocimetry. J Biomech Eng 2018; 140:2677750. [DOI: 10.1115/1.4039822] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Indexed: 11/08/2022]
Abstract
Ventricular assist devices (VADs) are implanted in patients with a diseased ventricle to maintain peripheral perfusion as a bridge-to-transplant or as destination therapy. However, some patients with continuous flow VADs (e.g., HeartMate II (HMII)) have experienced gastrointestinal (GI) bleeding, in part caused by the proteolytic cleavage or mechanical destruction of von Willebrand factor (vWF), a clotting glycoprotein. in vitro studies were performed to measure the flow located within the HMII outlet cannula under both steady and physiological conditions using particle image velocimetry (PIV). Under steady flow, a mock flow loop was used with the HMII producing a flow rate of 3.2 L/min. The physiological experiment included a pulsatile pump operated at 105 BPM with a ventricle filling volume of 50 mL and in conjunction with the HMII producing a total flow rate of 5.0 L/min. Velocity fields, Reynolds normal stresses (RNSs), and Reynolds shear stresses (RSSs) were analyzed to quantify the outlet flow's potential contribution to vWF degradation. Under both flow conditions, the HMII generated principal Reynolds stresses that are, at times, orders of magnitude higher than those needed to unfurl vWF, potentially impacting its physiological function. Under steady flow, principal RNSs were calculated to be approximately 500 Pa in the outlet cannula. Elevated Reynolds stresses were observed throughout every phase of the cardiac cycle under physiological flow with principal RNSs approaching 1500 Pa during peak systole. Prolonged exposure to these conditions may lead to acquired von Willebrand syndrome (AvWS), which is accompanied by uncontrollable bleeding episodes.
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Affiliation(s)
- Grant W. Rowlands
- Department of Biomedical Engineering, The Pennsylvania State University, 205 Hallowell Building, University Park, PA 16802
| | - Bryan C. Good
- Department of Biomedical Engineering, The Pennsylvania State University, 205 Hallowell Building, University Park, PA 16802
| | - Steven Deutsch
- Department of Biomedical Engineering, The Pennsylvania State University, 205 Hallowell Building, University Park, PA 16802
| | - Keefe B. Manning
- Professor Department of Biomedical Engineering, The Pennsylvania State University, 205 Hallowell Building, University Park, PA 16802
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA 17033 e-mail:
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Warlo EMK, Pettersen AÅR, Arnesen H, Seljeflot I. vWF/ADAMTS13 is associated with on-aspirin residual platelet reactivity and clinical outcome in patients with stable coronary artery disease. Thromb J 2017; 15:28. [PMID: 29200971 PMCID: PMC5700557 DOI: 10.1186/s12959-017-0151-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 11/09/2017] [Indexed: 01/08/2023] Open
Abstract
Background The mechanisms behind residual platelet reactivity (RPR) despite aspirin treatment are not established. It has been shown that coronary artery disease (CAD) patients with high on-aspirin RPR have elevated levels of von Willebrand factor (vWF). ADAMTS13 is a metalloprotease cleaving ultra large vWF multimers into less active fragments. Our aim was to investigate whether ADAMTS13 and vWF/ADAMTS13 ratio were associated with high RPR, and further with clinical endpoints after 2 years. Methods Stable aspirin-treated CAD patients (n = 999) from the ASCET trial. RPR was assessed by PFA-100. ADAMTS13 antigen and activity were analysed using chromogenic assays. Endpoints were a composite of acute myocardial infarction, stroke and death. Results The number of patients with high RPR was 258 (25.8%). Their serum thromboxane B2 (TxB2) levels were low, indicating inhibition of COX-1. They had significantly lower levels of ADAMTS13 antigen compared to patients with low RPR (517 vs 544 ng/mL, p = 0.001) and significantly lower ADAMTS13 activity (0.99 vs 1.04 IU/mL, p = 0.020). The differences were more pronounced when relating RPR to ratios of vWF/ADAMTS13 antigen and vWF/ADAMTS13 activity (p < 0.001, both). We found an inverse correlation between vWF and ADAMTS13 antigen (r = −0.14, p < 0.001) and ADAMTS13 activity (r = −0.11, p < 0.001). No correlations between TxB2 and ADAMTS13 antigen or activity, were observed, implying that ADAMTS13 is not involved in TxB2 production. Patients who experienced endpoints (n = 73) had higher vWF level (113 vs 105%, p = 0.032) and vWF/ADAMTS13 antigen ratio (0.23 vs 0.20, p = 0.012) compared to patients without. When dichotomizing vWF/ADAMTS13 antigen at median level we observed that patients above median had higher risk for suffering endpoints, with an adjusted OR of 1.86 (95% CI 1.45, 2.82). Conclusion These results indicate that ADAMTS13 is of importance for RPR, and that it in combination with vWF also is associated with clinical endpoints in stable CAD patients on aspirin. Trial registration Clinicaltrials.gov NCT00222261. Registered 13.09.2005. Retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s12959-017-0151-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ellen M K Warlo
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Ullevaal, Pb 4956 Nydalen, 0424 Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway.,Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Alf-Åge R Pettersen
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Ullevaal, Pb 4956 Nydalen, 0424 Oslo, Norway.,Center for Heart Failure Research, University of Oslo, Oslo, Norway.,Department of Medicine, Vestre Viken HF, Ringerike Hospital, Hønefoss, Norway
| | - Harald Arnesen
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Ullevaal, Pb 4956 Nydalen, 0424 Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway.,Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Ingebjørg Seljeflot
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Ullevaal, Pb 4956 Nydalen, 0424 Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway.,Center for Heart Failure Research, University of Oslo, Oslo, Norway
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Cibor D, Owczarek D, Butenas S, Salapa K, Mach T, Undas A. Levels and activities of von Willebrand factor and metalloproteinase with thrombospondin type-1 motif, number 13 in inflammatory bowel diseases. World J Gastroenterol 2017; 23:4796-4805. [PMID: 28765701 PMCID: PMC5514645 DOI: 10.3748/wjg.v23.i26.4796] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 04/07/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the levels of von Willebrand factor (VWF) and metalloproteinase with thrombospondin type-1 motif, number 13 (ADAMTS13) in inflammatory bowel disease (IBD) and correlate them with the disease activity.
METHODS Consecutive patients with IBD aged 18 years or older were enrolled in the study. Forty-seven patients with ulcerative colitis (UC), 38 with Crohn’s disease (CD), and 50 healthy controls were included. The white blood cell count, haematocrit, platelet count, fibrinogen, partial activated thromboplastin time, C-reactive protein, albumin, VWF antigen level (VWF:Ag), VWF ristocetin cofactor activity (VWF:RCo), VWF collagen-binding activity (VWF:CB), and ADAMTS13 antigen level (ADAMTS13:Ag) and activity (ADAMTS13act) were measured. The following ratios were assessed: VWF:RCo/VWF:Ag, VWF:CB/VWF:Ag, VWF:Ag/ADAMTS13act, and ADAMTS13act/ADAMTS13:Ag.
RESULTS Compared to controls, the odds ratio (OR) of an elevated VWF: Ag > 150% was 8.7 (95%CI: 2.7-28.1) in the UC group and 16.2 (95%CI: 4.8-54.0) in the CD group. VWF:CB was lower in UC patients, and active CD was associated with a higher VWF: RCo (+38%). The ORs of VWF:CB/VWF:Ag < 0.7 (a marker of acquired von Willebrand syndrome) in the UC and CD groups were 11.9 (95%CI: 4.4-32.4) and 13.3 (95%CI: 4.6-38.1), respectively. Active UC was associated with lower ADAMTS13:Ag (-23%) and ADAMTS13act (-20%) compared to UC in remission. Patients with active CD had a 15% lower ADAMTS13act than controls. The activity of UC, but not that of CD, was inversely correlated with ADAMTS13:Ag (r = -0.76) and ADAMTS13act (r = -0.81).
CONCLUSION Complex VWF-ADAMTS13-mediated mechanisms disturb haemostasis in IBD. A reduced WVF:CB is a risk factor for bleeding, while a lower ADAMTS13 level combined with an elevated VWF:Ag could predispose one to thrombosis.
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Franchini M, Mannucci PM. Von Willebrand factor (Vonvendi®): the first recombinant product licensed for the treatment of von Willebrand disease. Expert Rev Hematol 2016; 9:825-30. [DOI: 10.1080/17474086.2016.1214070] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Acquired intracoronary ADAMTS13 deficiency and VWF retention at sites of critical coronary stenosis in patients with STEMI. Blood 2016; 127:2934-6. [DOI: 10.1182/blood-2015-12-688010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Hemostatic efficacy, safety, and pharmacokinetics of a recombinant von Willebrand factor in severe von Willebrand disease. Blood 2015; 126:2038-46. [PMID: 26239086 DOI: 10.1182/blood-2015-02-629873] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 06/25/2015] [Indexed: 01/09/2023] Open
Abstract
This phase 3 trial evaluated the safety and hemostatic efficacy of a recombinant von Willebrand factor (rVWF) for treatment of bleeds in severe von Willebrand disease (VWD). rVWF was initially administered together with recombinant factor VIII (rFVIII) and subsequently alone, as long as hemostatic factor VIII activity (FVIII : C) levels were maintained. Pharmacokinetics (PK) were evaluated in a randomized cross-over design (rVWF vs rVWF:rFVIII at 50 IU VWF:ristocetin cofactor activity [RCo]/kg). Bleed control for all treated bleeds (N = 192 bleeds in 22 subjects) was rated good or excellent (96.9% excellent; 119 of 122 minor, 59 of 61 moderate, and 6 of 7 major bleeds) on a 4-point scale (4 = none to 1 = excellent). A single infusion was effective in 81.8% of bleeds. Treatment success, defined as the number of subjects with a mean efficacy rating of <2.5, was 100%. The PK profile of rVWF was not influenced by rFVIII (mean VWF:RCo terminal half-life: 21.9 hours for rVWF and 19.6 hours for rVWF:rFVIII). FVIII : C levels increased rapidly after rVWF alone, with hemostatic levels achieved within 6 hours and sustained through 72 hours after infusion. Eight adverse events (AEs; 6 nonserious AEs in 4 subjects and 2 serious AEs [chest discomfort and increased heart rate, without cardiac symptomatology] concurrently in 1 subject) were associated with rVWF. There were no thrombotic events or severe allergic reactions. No VWF or FVIII inhibitors, anti-VWF binding antibodies, or antibodies against host cell proteins were detected. These results show that rVWF was safe and effective in treating bleeds in VWD patients and stabilizes endogenous FVIII : C, which may eliminate the need for rFVIII after the first infusion. This trial was registered at www.clinicaltrials.gov as #NCT01410227.
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