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Doshi BS, Samelson-Jones BJ, Nichols TC, Merricks EP, Siner JL, French RA, Lee BJ, Arruda VR, Callan MB. AAV gene therapy in companion dogs with severe hemophilia: Real-world long-term data on immunogenicity, efficacy, and quality of life. Mol Ther Methods Clin Dev 2024; 32:101205. [PMID: 38374963 PMCID: PMC10875295 DOI: 10.1016/j.omtm.2024.101205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/30/2024] [Indexed: 02/21/2024]
Abstract
The hemophilias are the most common severe inherited bleeding disorders and are caused by deficiency of clotting factor (F) VIII (hemophilia A) or FIX (hemophilia B). The resultant bleeding predisposition significantly increases morbidity and mortality. The ability to improve the bleeding phenotype with modest increases in clotting factor levels has enabled the development and regulatory approval of adeno-associated viral (AAV) vector gene therapies for people with hemophilia A and B. The canine hemophilia model has proven to be one of the best predictors of therapeutic response in humans. Here, we report long-term follow-up of 12 companion dogs with severe hemophilia that were treated in a real-world setting with AAV gene therapy. Despite more baseline bleeding than in research dogs, companion dogs demonstrated a 94% decrease in bleeding rates and 61% improvement in quality of life over a median of 4.1 years (range 2.6-8.9). No new anti-transgene immune responses were detected; one dog with a pre-existing anti-FVIII inhibitor achieved immune tolerance with gene therapy. Two dogs expressing 1%-5% FVIII post gene therapy experienced fatal bleeding events. These data suggest AAV liver-directed gene therapy is efficacious in a real-world setting but should target expression >5% and closely monitor those with levels in the 1%-5% range.
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Affiliation(s)
- Bhavya S. Doshi
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Benjamin J. Samelson-Jones
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Timothy C. Nichols
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC 27516, USA
| | - Elizabeth P. Merricks
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC 27516, USA
| | - Joshua L. Siner
- Divisions of Hematology and Medical Oncology, Department of Medicine, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Robert A. French
- Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Ben J. Lee
- Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Valder R. Arruda
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Mary Beth Callan
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Van Gorder L, Doshi BS, Willis E, Nichols TC, Cook E, Everett JK, Merricks EP, Arruda VR, Bushman FD, Callan MB, Samelson-Jones BJ. Analysis of vector genome integrations in multicentric lymphoma after AAV gene therapy in a severe hemophilia A dog. Mol Ther Methods Clin Dev 2023; 31:101159. [PMID: 38094200 PMCID: PMC10716008 DOI: 10.1016/j.omtm.2023.101159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/12/2023] [Indexed: 02/01/2024]
Abstract
Adeno-associated viral (AAV) vectors have traditionally been viewed as predominantly nonintegrating, with limited concerns for oncogenesis. However, accumulating preclinical data have shown that AAV vectors integrate more often than previously appreciated, with the potential for genotoxicity. To understand the consequences of AAV vector integration, vigilance for rare genotoxic events after vector administration is essential. Here, we investigate the development of multicentric lymphoma in a privately owned dog, PC9, with severe hemophilia A that was treated with an AAV8 vector encapsidating a B domain-deleted canine coagulation F8 gene. PC9 developed an aggressive B cell lineage multicentric lymphoma 3.5 years after AAV treatment. Postmortem analysis of the liver, spleen, and lymph nodes showed the expected biodistribution of the AAV genome. Integration events were found both in PC9 and a second privately owned hemophilia A dog treated similarly with canine F8 gene transfer, which died of a bleeding event without evidence of malignancy. However, we found no evidence of expanded clones harboring a single integration event, indicating that AAV genome integrations were unlikely to have contributed to PC9's cancer. These findings suggest AAV integrations occur but are mostly not genotoxic and support the safety profile of AAV gene therapy.
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Affiliation(s)
- Lucas Van Gorder
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Hematology, Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Bhavya S. Doshi
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Hematology, Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Elinor Willis
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Timothy C. Nichols
- Department of Pathology and Laboratory Medicine and the UNC Blood Research Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Emma Cook
- Department of Microbiology Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - John K. Everett
- Department of Microbiology Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Elizabeth P. Merricks
- Department of Pathology and Laboratory Medicine and the UNC Blood Research Center, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Valder R. Arruda
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Hematology, Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Frederic D. Bushman
- Department of Microbiology Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Mary Beth Callan
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Benjamin J. Samelson-Jones
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Hematology, Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Cao W, Trask AR, Bignotti AI, George LA, Doshi BS, Sabatino DE, Yada N, Zheng L, Camire RM, Zheng XL. Coagulation factor VIII regulates von Willebrand factor homeostasis invivo. J Thromb Haemost 2023; 21:3477-3489. [PMID: 37726033 PMCID: PMC10842601 DOI: 10.1016/j.jtha.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/02/2023] [Accepted: 09/06/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Coagulation factor VIII (FVIII) and von Willebrand factor (VWF) circulate as a noncovalent complex, but each has its distinct functions. Binding of FVIII to VWF results in a prolongation of FVIII's half-life in circulation and modulates FVIII's immunogenicity during hemophilia therapy. However, the biological effect of FVIII and VWF interaction on VWF homeostasis is not fully understood. OBJECTIVES To determine the effect of FVIII in VWF proteolysis and homeostasis in vivo. METHODS Mouse models, recombinant FVIII infusion, and patients with hemophilia A on a high dose FVIII for immune tolerance induction therapy or emicizumab for bleeding symptoms were included to address this question. RESULTS An intravenous infusion of a recombinant B-domain less FVIII (BDD-FVIII) (40 and 160 μg/kg) into wild-type mice significantly reduced plasma VWF multimer sizes and its antigen levels; an infusion of a high but not low dose of BDD-FVIII into Adamts13+/- and Adamts13-/- mice also significantly reduced the size of VWF multimers. However, plasma levels of VWF antigen remained unchanged following administration of any dose BDD-FVIII into Adamts13-/- mice, suggesting partial ADAMTS-13 dependency in FVIII-augmented VWF degradation. Moreover, persistent expression of BDD-FVIII at ∼50 to 250 U/dL via AAV8 vector in hemophilia A mice also resulted in a significant reduction of plasma VWF multimer sizes and antigen levels. Finally, the sizes of plasma VWF multimers were significantly reduced in patients with hemophilia A who received a dose of recombinant or plasma-derived FVIII for immune tolerance induction therapy. CONCLUSION Our results demonstrate the pivotal role of FVIII as a cofactor regulating VWF proteolysis and homeostasis under various (patho)physiological conditions.
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Affiliation(s)
- Wenjing Cao
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA; Institute of Reproductive Medicine and Developmental Sciences, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Aria R Trask
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Antonia I Bignotti
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Lindsey A George
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bhavya S Doshi
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Denise E Sabatino
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Noritaka Yada
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Liang Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA; Institute of Reproductive Medicine and Developmental Sciences, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Rodney M Camire
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - X Long Zheng
- Department of Pathology and Laboratory Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA; Institute of Reproductive Medicine and Developmental Sciences, The University of Kansas Medical Center, Kansas City, Kansas, USA.
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Abstract
In acquired hemophilia A (AHA), autoantibodies to coagulation factor VIII (FVIII) neutralize FVIII activity leading to a potentially severe bleeding diathesis that carries a high rate of morbidity and mortality. This disorder is rare and occurs mainly in adults over 60 years of age or in the postpartum period. The diagnosis should be suspected in patients with new-onset bleeding without a personal or family history of bleeding and can be confirmed via specific assays for FVIII inhibitors. Treatment involves both hemostatic therapies to decrease bleeding and immune modulation strategies to re-establish immune tolerance to FVIII. There are limited data on treatment for refractory disease, based mostly on small case series. Registry studies have informed consensus guidelines for optimal hemostatic therapies and initial immunosuppressive therapies. Additional studies are needed to evaluate novel hemostatic agents and develop biomarkers to risk-stratify treatment while limiting adverse events.
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Affiliation(s)
- Allyson M Pishko
- Department of Medicine, Division of Hematology/Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Bhavya S Doshi
- Department of Pediatrics, Division of Hematology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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5
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Doshi BS, Rana J, Castaman G, Shaheen MA, Kaczmarek R, Butterfield JS, Meeks SL, Leissinger C, Biswas M, Arruda VR. B cell-activating factor modulates the factor VIII immune response in hemophilia A. J Clin Invest 2021; 131:142906. [PMID: 33651716 PMCID: PMC8262462 DOI: 10.1172/jci142906] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 02/23/2021] [Indexed: 01/19/2023] Open
Abstract
Inhibitors of factor VIII (FVIII) remain the most challenging complication of FVIII protein replacement therapy in hemophilia A (HA). Understanding the mechanisms that guide FVIII-specific B cell development could help identify therapeutic targets. The B cell-activating factor (BAFF) cytokine family is a key regulator of B cell differentiation in normal homeostasis and immune disorders. Thus, we used patient samples and mouse models to investigate the potential role of BAFF in modulating FVIII inhibitors. BAFF levels were elevated in pediatric and adult HA inhibitor patients and decreased to levels similar to those of noninhibitor controls after successful immune tolerance induction (ITI). Moreover, elevations in BAFF levels were seen in patients who failed to achieve FVIII tolerance with anti-CD20 antibody-mediated B cell depletion. In naive HA mice, prophylactic anti-BAFF antibody therapy prior to FVIII immunization prevented inhibitor formation and this tolerance was maintained despite FVIII exposure after immune reconstitution. In preimmunized HA mice, combination therapy with anti-CD20 and anti-BAFF antibodies dramatically reduced FVIII inhibitors via inhibition of FVIII-specific plasma cells. Our data suggest that BAFF may regulate the generation and maintenance of FVIII inhibitors and/or anti-FVIII B cells. Finally, anti-CD20/anti-BAFF combination therapy may be clinically useful for ITI.
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Affiliation(s)
- Bhavya S Doshi
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Divison of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jyoti Rana
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Mostafa A Shaheen
- Divison of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Radoslaw Kaczmarek
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John Ss Butterfield
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shannon L Meeks
- Department of Pediatrics, Aflac Cancer Center and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Cindy Leissinger
- Section of Hematology/Oncology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Moanaro Biswas
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Valder R Arruda
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Divison of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Raymond G. Perelman Center for Cellular and Molecular Therapies, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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6
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Doshi BS, Ellison AM. Diagnosis and Management of Pediatric Venous Thromboembolism: New Therapies on the Horizon. Pediatr Emerg Care 2021; 37:273-279. [PMID: 33903287 DOI: 10.1097/pec.0000000000002431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The incidence of venous thromboembolism (VTE) is increasing in pediatric patients. Prompt recognition and evaluation of VTE in young patients could prevent significant morbidity or mortality. In contrast to VTE in adults, current treatment guidelines are largely based on expert opinion as limited randomized controlled trial data exist about the appropriate management in pediatric patients with traditional anticoagulants. However, recently approved direct-acting oral anticoagulants in adults are also being investigated in pediatric VTE and these data could inform future evidence-based treatment principles. Thus, healthcare providers must be well informed about the management of pediatric VTE and the data from these trials to date. This continuing medical education article will provide a summary of management of pediatric VTE with particular emphasis on emerging direct-acting oral anticoagulants.
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7
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Doshi BS, Witmer CM. Recurrence of a high-titre factor VIII inhibitor in a haemophilia A patient on emicizumab prophylaxis. Haemophilia 2021; 27:e551-e553. [PMID: 33866659 DOI: 10.1111/hae.14311] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Bhavya S Doshi
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
| | - Char M Witmer
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
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8
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Arruda VR, Doshi BS. Gene Therapy for Hemophilia: Facts and Quandaries in the 21st Century. Mediterr J Hematol Infect Dis 2020; 12:e2020069. [PMID: 32952980 PMCID: PMC7485465 DOI: 10.4084/mjhid.2020.069] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/19/2020] [Indexed: 01/19/2023] Open
Abstract
Therapy for hemophilia has evolved in the last 40 years from plasma-based concentrates to recombinant proteins and, more recently, to non-factor therapeutics. Along this same timeline, research in adeno-associated viral (AAV) based gene therapy vectors has provided the framework for early phase clinical trials initially for hemophilia B (HB) and now for hemophilia A. Successive lessons learned from early HB trials have paved the way for current advanced phase trials. Nevertheless, questions linger regarding 1) the optimal balance of vector dose to transgene expression, 2) amount and durability of transgene expression required, and 3) long-term safety. Some trials have demonstrated unique findings not seen previously regarding transient elevation of liver enzymes, immunogenicity of the vector capsid, and loss of transgene expression. This review will provide an update on the clinical AAV gene therapy trials in hemophilia and address the questions above. A thoughtful and rationally approached expansion of gene therapy to the clinics would certainly be a welcome addition to the arsenal of options for hemophilia therapy. Further, the global impact of gene therapy could be vastly improved by expanding eligibility to different patient populations and to developing nations. With the advances made to date, it is possible to envision a shift from the early goal of simply increasing life expectancy to a significant improvement in quality of life by reduction in spontaneous bleeding episodes and disease complications.
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Affiliation(s)
- Valder R. Arruda
- Divsion of Hematology, Children’s Hospital of Philadelphia, Philadelphia PA USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA USA
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Children’s Hospital of Philadelphia, Philadelphia PA USA
| | - Bhavya S. Doshi
- Divsion of Hematology, Children’s Hospital of Philadelphia, Philadelphia PA USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA USA
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9
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Doshi BS, Raffini LJ, George LA. Combined anti-CD20 and mTOR inhibition with factor VIII for immune tolerance induction in hemophilia A patients with refractory inhibitors. J Thromb Haemost 2020; 18:848-852. [PMID: 31985872 PMCID: PMC7888210 DOI: 10.1111/jth.14740] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/31/2019] [Accepted: 01/14/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hemophilia A (HA) inhibitor patients that fail traditional immune tolerance induction (ITI) have increased morbidity and mortality. Preclinical studies support factor VIII (FVIII) tolerance induction with a combined approach of anti-CD20 mediated transient B cell depletion and rapamycin mediated regulatory T cell (Treg) induction. METHODS Two refractory HA inhibitor patients were treated with rituximab, rapamycin, and FVIII ITI. Their clinical course, anti-FVIII immunoglobulins, cytokines, and select lymphocytes were followed. RESULTS One patient achieved complete and the other partial FVIII tolerance; both had marked annualized bleeding rate improvement. FVIII-specific immunoglobulins, but not total Treg counts, correlated with tolerance induction. IL-6 and IL-21 correlation with complete tolerance induction may support that down-regulation of T effectors and IgG4 production, respectively, contribute to the pathogenesis of tolerance induction. CONCLUSIONS This regimen may be considered to induce FVIII tolerance in HA patients with refractory inhibitors. Further characterization of the FVIII-specific immune response is necessary to clarify the mechanism of immune tolerance.
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Affiliation(s)
- Bhavya S. Doshi
- Division of Hematology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
| | - Leslie J. Raffini
- Division of Hematology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
| | - Lindsey A. George
- Division of Hematology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Raymond G. Perelman Center for Cellular and Molecular Therapeutics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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10
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Doshi BS, Rogers RS, Whitworth HB, Stabnick EA, Britton J, Butler RB, Obstfeld AE, Witmer CM. Utility of repeat testing in the evaluation for von Willebrand disease in pediatric patients. J Thromb Haemost 2019; 17:1838-1847. [PMID: 31350816 DOI: 10.1111/jth.14591] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/23/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Von Willebrand disease (VWD) is the most common inherited bleeding disorder and is caused by quantitative and qualitative defects in von Willebrand factor (VWF). The laboratory diagnosis of VWD in pediatric patients is complicated by VWF interassay and intra-assay variability, stress-induced elevations in VWF levels, and a lack of significant bleeding history with which to correlate test results. OBJECTIVE Guidelines recommend repeat testing in patients with a high suspicion of VWD and unclear laboratory assay results; however, no studies have evaluated the utility of repeat VWF testing in pediatric patients. METHODS This retrospective single-center cohort study aimed to determine clinical variables associated with requiring more than one test to diagnose VWD and to establish a cutoff VWF value above which further testing is not informative. RESULTS Of 811 patients evaluated for a suspected bleeding disorder, 22.2% were diagnosed with VWD, with ~70% diagnosed on the first test. Patients with VWD were younger (5.8 vs. 8.5 years, P = .002) and more likely to have a family history of VWD (38% vs. 22%, P < .001) than those without VWD. Univariate analysis failed to identify any clinical variables that correlated with needing multiple tests for a VWD diagnosis. A cutoff of 100 IU/dL for VWF antigen or activity on the first test yielded negative predictive values >95%. CONCLUSIONS We demonstrate that the majority of pediatric patients had diagnostic VWF values on the first set of testing. Pediatric patients without a family history of VWD and VWF levels >100 IU/dL may not need further testing to rule out the diagnosis of VWD.
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Affiliation(s)
- Bhavya S Doshi
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel S Rogers
- Biostatistical and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hilary B Whitworth
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Emily A Stabnick
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jessica Britton
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Regina B Butler
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Amrom E Obstfeld
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Char M Witmer
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
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12
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Abstract
Recent phase I/II adeno-associated viral vector-mediated gene therapy clinical trials have reported remarkable success in ameliorating disease phenotype in hemophilia A and B. These trials, which highlight the challenges overcome through decades of preclinical and first in human clinical studies, have generated considerable excitement for patients and caregivers alike. Optimization of vector and transgene expression has significantly improved the ability to achieve therapeutic factor levels in these subjects. Long-term follow-up studies will guide standardization of the approach with respect to the combination of serotype, promoter, dose, and manufacturing processes and inform safety for inclusion of young patients. Certain limitations preclude universal applicability of gene therapy, including transient liver transaminase elevations due to the immune responses to vector capsids or as yet undefined mechanisms, underlying liver disease from iatrogenic viral hepatitis, and neutralizing antibodies to clotting factors. Integrating vectors show promising preclinical results, but manufacturing and safety concerns still remain. The prospect of gene editing for correction of the underlying mutation is on the horizon with considerable potential. Herein, we review the advances and limitations that have resulted in these recent successful clinical trials and outline avenues that will allow for broader applicability of gene therapy.
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Affiliation(s)
- Bhavya S Doshi
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Valder R Arruda
- Department of Pediatrics, The Children's Hospital of Philadelphia, 3501 Civic Center Blvd, 5056 Colket Translational Research Center, Philadelphia, PA 19104, USA
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13
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Zielonka B, Cohen AR, Smith-Whitley K, Doshi BS. Iliopsoas hematoma in a patient with sickle cell disease. Pediatr Blood Cancer 2018. [PMID: 29528178 DOI: 10.1002/pbc.27040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although musculoskeletal pain in patients with sickle cell disease (SCD) is most frequently the result of vaso-occlusive episodes, clinicians often consider other etiologies including osteomyelitis, avascular necrosis, and trauma. In this study, we report the case of a young female with SCD with hip and back pain secondary to a nontraumatic iliopsoas periosteal hematoma with evidence of adjacent bone infarction. The pathophysiology, diagnostic considerations, and management of periosteal hematomas in SCD are reviewed. This case highlights the need for recognition of unusual causes of musculoskeletal pain in SCD.
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Affiliation(s)
- Benjamin Zielonka
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alan R Cohen
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kim Smith-Whitley
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bhavya S Doshi
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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14
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Abstract
Several new therapies for hemophilia have emerged in recent years. These strategies range from extended half-life factor replacement products and non-factor options with improved pharmacokinetic profiles to gene therapy aiming for phenotypic cure. While these products have the potential to change hemophilia care dramatically, several challenges and questions remain regarding broader applicability, long-term safety, and which option to pursue for each patient. Here, we review these emerging therapies with a focus on controversies and unanswered questions in each category.
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Affiliation(s)
- Valder R Arruda
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Raymond G. Perelman Center for Cellular and Molecular Therapeutics, Philadelphia, PA, USA
| | - Bhavya S Doshi
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Benjamin J Samelson-Jones
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Doshi BS, Abramowsky C, Briones M, Bunting ST. Concomitant a novel ALAS2 mutation and GATA1 mutation in a newborn: a case report and review of the literature. Am J Blood Res 2014; 4:41-45. [PMID: 25232504 PMCID: PMC4165116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 08/06/2014] [Indexed: 06/03/2023]
Abstract
GATA-1, an X-linked gene, encodes a transcription factor that plays a role in erythropoiesis and megakaryopoiesis. GATA-1 mutations have been associated with various diseases, such as X-linked thrombocytopenia. ALAS2 is an X-linked erythroid-specific isoenzyme expressed during erythropoiesis. Mutations of ALAS2 were associated with X-linked sideroblastic anemia. We report a case of newborn twin boy with anemia and thrombocytopenia at birth. A bone marrow biopsy at 4 months of age showed marked dyserythropoiesis, dysmegakaryopoiesis, and rare ringed sideroblasts. Gene sequencing study showed a previously reported mutation in GATA-1 at c.622G>A location (G208R) and a novel ALAS2 mutation at c.1436G>A location (R479Q).
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Affiliation(s)
- Bhavya S Doshi
- Department of Pediatrics, Emory University School of MedicineAtlanta, GA 30322, USA
| | - Carlos Abramowsky
- Department of Pathology, Emory University School of MedicineAtlanta, GA 30322, USA
| | - Michael Briones
- Children’s Healthcare of Atlanta, Aflac Cancer and Blood Disorders CenterAtlanta, GA 30322, USA
| | - Silvia T Bunting
- Department of Pathology, Children’s Healthcare of Atlanta, Emory UniversityAtlanta, GA, 30322, USA
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Doshi BS, Gangadharan B, Doering CB, Meeks SL. Potentiation of thrombin generation in hemophilia A plasma by coagulation factor VIII and characterization of antibody-specific inhibition. PLoS One 2012; 7:e48172. [PMID: 23144741 PMCID: PMC3483154 DOI: 10.1371/journal.pone.0048172] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 09/20/2012] [Indexed: 11/18/2022] Open
Abstract
Development of inhibitory antibodies to coagulation factor VIII (fVIII) is the primary obstacle to the treatment of hemophilia A in the developed world. This adverse reaction occurs in 20-30% of persons with severe hemophilia A treated with fVIII-replacement products and is characterized by the development of a humoral and neutralizing immune response to fVIII. Patients with inhibitory anti-fVIII antibodies are treated with bypassing agents including recombinant factor VIIa (rfVIIa). However, some patients display poor hemostatic response to bypass therapy and improved treatment options are needed. Recently, we demonstrated that fVIII inhibitors display widely variable kinetics of inhibition that correlate with their respective target epitopes. Thus, it was hypothesized that for antibodies that display slow rates of inhibition, supplementation of rfVIIa with fVIII would result in improved thrombin generation and be predictive of clinical responses to this novel treatment regimen. In order to test this hypothesis, 10 murine monoclonal antibodies (MAbs) with non-overlapping epitopes spanning fVIII, differential inhibition titers, and inhibition kinetics were studied using a thrombin generation assay. Of the 3 MAbs with high inhibitory titers, only the one with fast and complete (classically defined as "type I") kinetics displayed significant inhibition of thrombin generation with no improvement upon supplementation of rfVIIa with fVIII. The other two MAbs that displayed incomplete (classically defined as "type II") inhibition did not suppress the potentiation of thrombin generation by fVIII. All antibodies that did not completely inhibit fVIII activity demonstrated potentiation of thrombin generation by the addition of fVIII as compared to rfVIIa alone. In conclusion, fVIII alone or in combination with rfVIIa corrects the thrombin generation defect produced by the majority of anti-fVIII MAbs better than single agent rfVIIa. Therefore, combined fVIII/rfVIIa therapy may provide better hemostatic control than current therapy in some patients with anti-fVIII inhibitors.
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Affiliation(s)
- Bhavya S. Doshi
- Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Bagirath Gangadharan
- Aflac Cancer Center and Blood Disorders Service, Children’s Healthcare of Atlanta and Emory University, Atlanta, Georgia, United States of America
| | - Christopher B. Doering
- Aflac Cancer Center and Blood Disorders Service, Children’s Healthcare of Atlanta and Emory University, Atlanta, Georgia, United States of America
| | - Shannon L. Meeks
- Aflac Cancer Center and Blood Disorders Service, Children’s Healthcare of Atlanta and Emory University, Atlanta, Georgia, United States of America
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18
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Doshi BS, Vijayaraghavan KC, Ajit D, Chauhan BL, Amdekar YK, Kulkarni RD. Dose of digoxin and age of child. Indian J Pediatr 1987; 54:245-9. [PMID: 3583379 DOI: 10.1007/bf02750818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Chauhan BL, Doshi BS, Kulkarni RD. Diurnal variation in the pharmacokinetics of intravenous theophylline and etophylline in healthy subjects. Eur J Clin Pharmacol 1986; 30:635-6. [PMID: 3758152 DOI: 10.1007/bf00542428] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Chaudhari GN, Tipnis HP, Doshi BS, Kulkarni RD. Bioequivalence studies in humans of indomethacin capsules marketed in India. Eur J Clin Pharmacol 1984; 26:261-4. [PMID: 6723767 DOI: 10.1007/bf00630296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Two, separate 6 X 6 Latin square cross-over bioequivalence studies were performed in adult male volunteers using 10 different indomethacin capsule preparations marketed in India together with the pure drug powder as the standard. The products were evaluated with respect to plasma level at various times up to 8 h following administration of a 50 mg (2 X 25 mg) dose. Plasma samples were analysed by a fluorimetric method. Various pharmacokinetic parameters were calculated according to a two compartment model. Statistical evaluation of the data employed analysis of variance for a cross-over design (ANOVA) and Duncan's multiple range test to ascertain the significance of differences between the products. Of the 10 products studied, two were found to be bioinequivalent .
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Doshi BS, Rout SJ, Kulkarni RD. Absorption & urinary & salivary excretion of lithium after oral administration. Indian J Med Res 1983; 78:708-12. [PMID: 6423533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Doshi BS. Chronopharmacology and optimisation of dosage schedule. Indian J Physiol Pharmacol 1981; 25:253-258. [PMID: 7298150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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