1
|
Affiliation(s)
- Cindy Leissinger
- From the Louisiana Center for Bleeding and Clotting Disorders, Department of Medicine, Tulane University School of Medicine, New Orleans
| |
Collapse
|
2
|
Escobar MA, Leissinger C, Young G. Hemophilia A: Strategies for Improving Long-Term Holistic Management, Adherence, and Quality of Life. J Adv Pract Oncol 2022; 13:7-20. [PMID: 35769336 PMCID: PMC9236157 DOI: 10.6004/jadpro.2022.13.4.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hemophilia A is a rare inherited bleeding disorder characterized by a deficiency in factor VIII. The evolution of currently approved prophylaxis therapy in hemophilia A will be reviewed, including the clinical value of prophylaxis, real-world experience with prophylaxis, and patient quality-of-life factors that must be considered when choosing treatment options for these patients.
Collapse
Affiliation(s)
- Miguel A Escobar
- University of Texas Health Science Center and Gulf States Hemophilia & Thrombophilia Center, Houston, Texas
| | - Cindy Leissinger
- Louisiana Center for Bleeding and Clotting Disorders New Orleans, Louisiana
| | - Guy Young
- Hemostasis & Thrombosis Center, Children's Hospital Los Angeles, and University of Southern California, Keck School of Medicine, Los Angeles, California
| |
Collapse
|
3
|
Escobar M, Mancuso ME, Hermans C, Leissinger C, Seifert W, Li Y, McKeand W, Oldenburg J. IDELVION: A Comprehensive Review of Clinical Trial and Real-World Data. J Clin Med 2022; 11:jcm11041071. [PMID: 35207344 PMCID: PMC8875492 DOI: 10.3390/jcm11041071] [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: 02/07/2022] [Accepted: 02/14/2022] [Indexed: 01/19/2023] Open
Abstract
Hemophilia B is a bleeding disorder caused by a deficiency of coagulation factor IX (FIX). Treatment with FIX replacement products can increase FIX activity levels to minimize or prevent bleeding events. However, frequent dosing with standard-acting FIX products can create a high treatment burden. Long-acting products have been developed to maintain bleed protection with extended dosing intervals. Recombinant factor IX–albumin fusion protein (rIX-FP) is a long-acting product indicated for the treatment and prophylaxis of bleeding events and perioperative management in adult and pediatric patients. This review outlines data from all previously treated patients in the Prophylaxis and On-Demand Treatment using Longer Half-Life rIX-FP (PROLONG-9FP) clinical trial program and summarizes real-world data evaluating the use of rIX-FP in routine clinical practice. In the PROLONG-9FP program, rIX-FP demonstrated effective hemostasis in all patients at dose regimens of up to 21 days in patients aged ≥ 18 years and up to 14 days in patients aged < 12 years. rIX-FP has a favorable pharmacokinetic profile and an excellent safety and tolerability profile. Extended dosing intervals with rIX-FP led to high levels of adherence and reduced consumption compared with other FIX therapies. Data from real-world practice are encouraging and reflect the results of the clinical trials.
Collapse
Affiliation(s)
- Miguel Escobar
- University of Texas Health Science Center, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-(713)-500-8360
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy;
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), 1200 Brussels, Belgium;
| | - Cindy Leissinger
- Tulane University School of Medicine, New Orleans, LA 70112, USA;
| | | | - Yanyan Li
- CSL Behring, King of Prussia, PA 19406, USA; (Y.L.); (W.M.)
| | | | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, 53127 Bonn, Germany;
| |
Collapse
|
4
|
Escobar M, Castaman G, Boix SB, Callaghan M, Moerloose P, Ducore J, Hermans C, Journeycake J, Leissinger C, Luck J, Mahlangu J, Miesbach W, Mitha IH, Négrier C, Quon D, Recht M, Schved JF, Shapiro AD, Sidonio R, Srivastava A, Stasyshyn O, Vilchevska KV, Wang M, Young G, Alexander WA, Al‐Sabbagh A, Bonzo D, Macie C, Wilkinson TA, Kessler C. Cover Image. Haemophilia 2021. [DOI: 10.1111/hae.14463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
5
|
Escobar M, Castaman G, Boix SB, Callaghan M, de Moerloose P, Ducore J, Hermans C, Journeycake J, Leissinger C, Luck J, Mahlangu J, Miesbach W, Mitha IH, Négrier C, Quon D, Recht M, Schved JF, Shapiro AD, Sidonio R, Srivastava A, Stasyshyn O, Vilchevska KV, Wang M, Young G, Alexander WA, Al-Sabbagh A, Bonzo D, Macie C, Wilkinson TA, Kessler C. The safety of activated eptacog beta in the management of bleeding episodes and perioperative haemostasis in adult and paediatric haemophilia patients with inhibitors. Haemophilia 2021; 27:921-931. [PMID: 34636112 PMCID: PMC9292935 DOI: 10.1111/hae.14419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 04/13/2021] [Revised: 08/31/2021] [Accepted: 09/06/2021] [Indexed: 01/19/2023]
Abstract
Introduction Haemophilia patients with inhibitors often require a bypassing agent (BPA) for bleeding episode management. Eptacog beta (EB) is a new FDA‐approved recombinant activated human factor VII BPA for the treatment and control of bleeding in haemophilia A or B patients with inhibitors (≥12 years of age). We describe here the EB safety profile from the three prospective Phase 3 clinical trials performed to date. Aim To assess EB safety, immunogenicity and thrombotic potential in children and adults who received EB for treatment of bleeding and perioperative care. Methods Using a randomized crossover design, 27 subjects in PERSEPT 1 (12‐54 years) and 25 subjects in PERSEPT 2 (1‐11 years) treated bleeding episodes with 75 or 225 μg/kg EB initially followed by 75 μg/kg dosing at predefined intervals as determined by clinical response. Twelve PERSEPT 3 subjects (2‐56 years) received an initial preoperative infusion of 75 μg/kg (minor procedures) or 200 μg/kg EB (major surgeries) with subsequent 75 μg/kg doses administered intraoperatively and post‐operatively as indicated. Descriptive statistics were used for data analyses. Results Sixty subjects who received 3388 EB doses in three trials were evaluated. EB was well tolerated, with no allergic, hypersensitivity, anaphylactic or thrombotic events reported and no neutralizing anti‐EB antibodies detected. A death occurred during PERSEPT 3 and was determined to be unlikely related to EB treatment by the data monitoring committee. Conclusion Results from all three Phase 3 trials establish an excellent safety profile of EB in haemophilia A or B patients with inhibitors for treatment of bleeding and perioperative use.
Collapse
Affiliation(s)
- Miguel Escobar
- Gulf States Hemophilia and Thrombophilia Center, Houston, Texas, USA
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | | | | | | | - Jonathan Ducore
- Hematology/Oncology Clinic, University of California at Davis, Sacramento, California, USA
| | - Cédric Hermans
- Cliniques Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Janna Journeycake
- Oklahoma Bleeding and Clotting Disorders Center at OU Health, Oklahoma City, Oklahoma, USA
| | - Cindy Leissinger
- Section of Hematology/Oncology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - James Luck
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Johnny Mahlangu
- Hemophilia Comprehensive Care Center, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | | | | | | | - Doris Quon
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, New York, USA.,Oregon Health & Science University, Portland, Oregon, USA
| | - Jean François Schved
- Haemophilia Treatment Centre, University Hospital Montpellier, Montpellier, France
| | - Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Robert Sidonio
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, Georgia, USA
| | | | | | | | - Michael Wang
- Hemophilia and Thrombosis Center, University of Colorado, Aurora, Colorado, USA
| | - Guy Young
- Children's Hospital Los Angeles, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | | | | | | | | | - Craig Kessler
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| |
Collapse
|
6
|
Escobar M, Luck J, Averianov Y, Ducore J, Fernández MFL, Giermasz A, Hart DP, Journeycake J, Kessler C, Leissinger C, Mahlangu J, Martinez LV, Miesbach W, Mitha IH, Quon D, Reding MT, Schved JF, Stasyshyn O, Vilchevska KV, Wang M, Windyga J, Alexander WA, Al-Sabbagh A, Bonzo D, Mitchell IS, Wilkinson TA, Hermans C. PERSEPT 3: A phase 3 clinical trial to evaluate the haemostatic efficacy of eptacog beta (recombinant human FVIIa) in perioperative care in subjects with haemophilia A or B with inhibitors. Haemophilia 2021; 27:911-920. [PMID: 34614267 PMCID: PMC9292306 DOI: 10.1111/hae.14418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 05/14/2021] [Revised: 08/17/2021] [Accepted: 09/06/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Surgical procedures in persons with haemophilia A or B with inhibitors (PwHABI) require the use of bypassing agents (BPA) and carry a high risk of complications. Historically, only two BPAs have been available; these are reported to have variable responses. AIM To prospectively evaluate the efficacy and safety of a new bypassing agent, human recombinant factor VIIa (eptacog beta) in elective surgical procedures in PwHABI in a phase 3 clinical trial, PERSEPT 3. METHODS Subjects were administered 200 µg/kg (major procedures) or 75 µg/kg eptacog beta (minor procedures) immediately prior to the initial surgical incision; subsequent 75 µg/kg doses were administered to achieve postoperative haemostasis and wound healing. Efficacy was assessed on a 4-point haemostatic scale during the intra- and postoperative periods. Anti-drug antibodies, thrombotic events and changes in clinical/laboratory parameters were monitored throughout the perioperative period. RESULTS Twelve subjects underwent six major and six minor procedures. The primary efficacy endpoint success proportion was 100% (95% CI: 47.8%-100%) for minor procedures and 66.7% (95% CI: 22.3%-95.7%) for major procedures; 81.8% (95% CI: 48.2%-97.7%) of the procedures were considered successful using eptacog beta. There was one death due to bleeding from a nonsurgical site; this was assessed as unlikely related to eptacog beta. No thrombotic events or anti-eptacog beta antibodies were reported. CONCLUSION Two eptacog beta dosing regimens in PwHABI undergoing major and minor surgical procedures were well-tolerated, and the majority of procedures were successful based on surgeon/investigator assessments. Eptacog beta offers clinicians a new potential therapeutic option for procedures in PwHABI.
Collapse
Affiliation(s)
- Miguel Escobar
- Gulf States Hemophilia and Thrombophilia Center, Houston, Texas, USA
| | - James Luck
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Yevhenii Averianov
- City Research and Development Center for Diagnostics and Treatment of Patients with Abnormal Hemostasis, Kyiv, Ukraine
| | - Jonathan Ducore
- Hematology/Oncology Clinic, University of California at Davis, Sacramento, California, USA
| | | | - Adam Giermasz
- Division of Hematology/Oncology, University of California at Davis, Sacramento, California, USA
| | - Daniel P Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - Janna Journeycake
- Oklahoma Center for Bleeding and Clotting Disorders, Oklahoma City, Oklahoma, USA
| | - Craig Kessler
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Cindy Leissinger
- Section of Hematology/Oncology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Johnny Mahlangu
- Hemophilia Comprehensive Care Center, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | | | | | | | - Doris Quon
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Mark T Reding
- Center for Bleeding and Clotting Disorders, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Jean-François Schved
- Haemophilia Treatment Centre, University Hospital Montpellier, Montpellier, France
| | | | | | - Michael Wang
- Hemophilia and Thrombosis Center, University of Colorado, Aurora, Colorado, USA
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | | | | | | | | | - Cédric Hermans
- Cliniques Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Janbain M, Enjolras N, Bordet JC, Bolbos R, Brevet M, Leissinger C, Dargaud Y. Hemostatic effect of tranexamic acid combined with factor VIII concentrate in prophylactic setting in severe hemophilia A: A preclinical study. J Thromb Haemost 2020; 18:584-592. [PMID: 31782901 DOI: 10.1111/jth.14694] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 09/27/2019] [Revised: 10/29/2019] [Accepted: 11/22/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hemophilia is characterized by a compromised hemostatic response with delayed development of a clot and the formation of clots that are vulnerable to fibrinolysis. We proposed to study, in vitro and in factor VIII knockout mice (FVIII-KO), whether hemostasis is improved with the addition of tranexamic acid (TXA) to low FVIII plasma concentrations. METHODS In vitro, blood samples from adults with severe hemophilia-A, spiked to final concentrations of 0-3-10 and 30IU.dL-1 of FVIII, were studied with and without TXA 0.1 mg/mL using thromboelastography in the presence of tPA (ROTEM-tPA), thrombin generation (TG) assay, and scanning electron microscopy. FVIII-KO mice received prophylaxis before trauma, to obtain circulating plasma FVIII at 3 IU.dL-1 or FVIII 3IU.dL-1 + TXA 0.1 mg/mL. After trauma-induced knee joint bleeding, magnetic resonance imaging, histological analysis, and tail clip assay were used to compare hemostastic efficacy of the two prophylactic strategies. RESULTS A dose-dependent improvement of TG was observed with recombinant FVIII (rFVIII) alone (P = .024). As expected, no effect of TXA on TG capacity was observed. Fibrin fiber diameters were significantly decreased with TXA + rFVIII compared to rFVIII, suggesting a stronger fibrin network. Surprisingly, ROTEM-tPA was normalized with TXA alone. In FVIII-KO mice, blood loss after tail clip was lower after prophylaxis with rFVIII + TXA compared to rFVIII, with no statistical significance (P = .15). However, MRI results and histological analysis of knee joints showed that the addition of TXA significantly decreased joint bleeding (P = .022). CONCLUSION Our results suggest a potential benefit of TXA when used in combination with FVIII in prophylactic settings.
Collapse
Affiliation(s)
- Maissa Janbain
- Tulane School of Medicine, Hematology, New Orleans, LA, USA
| | - Nathalie Enjolras
- EA4609 Unite de Recherche Hemostase et Cancer, Universite Lyon 1, Lyon, France
| | - Jean-Claude Bordet
- EA4609 Unite de Recherche Hemostase et Cancer, Universite Lyon 1, Lyon, France
| | - Radu Bolbos
- CERMEP, Centre d'Etude et de Recherche Multimodal Et Pluridisciplinaire Lyon, Lyon, France
| | - Marie Brevet
- Laboratoire d'anatomopathologie, GHE, Hospices Civils de Lyon, Bron, France
| | | | - Yesim Dargaud
- EA4609 Unite de Recherche Hemostase et Cancer, Universite Lyon 1, Lyon, France
- Unite d'Hemostase Clinique, Hopital Cardiologique Louis Pradel, Bron, France
| |
Collapse
|
9
|
Warren BB, Jacobson L, Kempton C, Buchanan GR, Recht M, Brown D, Leissinger C, Shapiro AD, Abshire TC, Manco-Johnson MJ. Factor VIII prophylaxis effects outweigh other hemostasis contributors in predicting severe haemophilia A joint outcomes. Haemophilia 2019; 25:867-875. [PMID: 31115111 PMCID: PMC7273872 DOI: 10.1111/hae.13778] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 07/19/2018] [Revised: 04/15/2019] [Accepted: 05/03/2019] [Indexed: 02/01/2023]
Abstract
INTRODUCTION The Joint Outcome Study (JOS) demonstrated that previously untreated children with severe haemophilia A treated with prophylactic factor VIII (FVIII) concentrate had superior joint outcomes at age 6 years compared to those children treated episodically for bleeding. However, variation in joint outcome within each treatment arm was not well explained. AIM In this study, we sought to better understand variation in joint outcomes at age 6 years in participants of the JOS. METHODS We evaluated the influence of FVIII half-life, treatment adherence, constitutional coagulant and anticoagulant proteins, and global assays on joint outcomes (number of joint bleeds, total number of bleeds, total MRI score and joint physical exam score). Logistic regression was used to evaluate the association of variables with joint failure status on MRI, defined as presence of subchondral cyst, surface erosion or joint-space narrowing. Each parameter was also correlated with each joint outcome using Spearman correlations. RESULTS Prophylaxis treatment arm and FVIII trough were each found to reduce risk of joint failure on univariate logistic regression analysis. When controlling for treatment arm, FVIII trough was no longer significant, likely because of the high level of covariation between these variables. We found no consistent correlation between any laboratory assay performed and any joint outcome parameter measured. CONCLUSION In the JOS, the effect of prescribed prophylactic FVIII infusions on joint outcome overshadowed the contribution of treatment adherence, FVIII half-life, global assays of coagulation and constitutional coagulation proteins. (ClinicalTrials.gov number, NCT00207597).
Collapse
Affiliation(s)
| | - Linda Jacobson
- University of Colorado Anschutz Medical Campus, Aurora,
CO
| | | | - George R. Buchanan
- University of Texas Southwestern Medical Center and
Children’s Medical Center at Dallas, TX
| | - Michael Recht
- Phoenix Children’s Hospital, Phoenix, AZ
- Oregon Health & Science University, Portland, OR
| | | | | | - Amy D. Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis,
IN
| | - Thomas C. Abshire
- Emory University School of Medicine, Atlanta, GA
- Blood Research Institute, BloodCenter of Wisconsin/Versiti,
Milwaukee, WI
| | | |
Collapse
|
10
|
Aledort L, Carpenter SL, Cuker A, Kulkarni R, Recht M, Young G, Leissinger C. Why plasma-derived factor VIII? Haemophilia 2019; 25:e183-e185. [PMID: 30866124 DOI: 10.1111/hae.13705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/12/2018] [Accepted: 01/24/2019] [Indexed: 06/09/2023]
Affiliation(s)
- Louis Aledort
- Department of Hematology-Oncology, Icahn School of Medicine, New York, New York
| | | | - Adam Cuker
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Michael Recht
- Oregon Health and Science University Hospital, Portland, Oregon
| | - Guy Young
- University of Southern California, Los Angeles, California
| | | |
Collapse
|
11
|
Carcao M, Lambert T, Leissinger C, Escuriola-Ettingshausen C, Santagostino E, Aledort L. Prophylaxis re-visited: The potential impact of novel factor and non-factor therapies on prophylaxis. Haemophilia 2018; 24:845-848. [DOI: 10.1111/hae.13558] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2018] [Indexed: 12/21/2022]
Affiliation(s)
- M. Carcao
- Division of Haematology/Oncology; Department of Paediatrics; Child Health Evaluative Sciences; Research Institute; Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - T. Lambert
- Haemophilia Care Centre; Bicêtre APHP University Hospital; Le Kremlin-Bicêtre France
| | - C. Leissinger
- Tulane University School of Medicine; New Orleans LA USA
| | | | - E. Santagostino
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico; University of Milan; Milan Italy
| | - L. Aledort
- Icahn School of Medicine; New York NY USA
| | | |
Collapse
|
12
|
Navalkele D, Boehme A, Albright K, Leissinger C, Schluter L, Freeman M, Drury S, Khoury RE, Beasley TM, Martin-Schild S. Factor VIII in Acute Cerebral Ischemia Pilot Study: Biomarker in Patients With Large Vessel Occlusion? Clin Appl Thromb Hemost 2018; 24:1249-1254. [PMID: 29895187 PMCID: PMC6714777 DOI: 10.1177/1076029618781045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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] [Indexed: 11/17/2022] Open
Abstract
We conducted a prospective serial laboratory cohort study to assess the correlation of factor VIII (FVIII) levels in response to thrombolysis in patients with large vessel occlusion (LVO) and acute ischemic stroke (AIS). Patients with AIS with anterior circulation LVO were eligible for enrollment if treated within 4.5 hours from last seen normal with intravenous tissue plasminogen activator (tPA). Patients (n = 29) had a mean age of 71 years and median National Institute of Health Stroke Scale of 14. Baseline pre-tPA FVIII was not significantly correlated with clot burden score (-0.147, P = .447) or vessel recanalization (-0.133, P = .499). Median FVIII decreased significantly from baseline to 6 hours post-tPA (282% to 161%, P = .002), but delta in FVIII level did not correlate with vessel recanalization (0.013, P = .948). There was no difference between median FVIII level at baseline and 90 days post-AIS. FVIII level decreased significantly after tPA, but baseline FVIII level and early change in FVIII level were not significant predictors of clot burden, vessel recanalization after thrombolysis, or symptomatic hemorrhage.
Collapse
Affiliation(s)
| | - Amelia Boehme
- 2 Department of Neurology, Columbia University, New York, NY, USA
| | - Karen Albright
- 3 Department of Neurology, The State University of New York, New York, NY, USA
| | | | - Laurie Schluter
- 1 Touro Infirmary and New Orleans East Hospital, New Orleans, LA, USA
| | | | | | - Ramy El Khoury
- 1 Touro Infirmary and New Orleans East Hospital, New Orleans, LA, USA
| | - T Mark Beasley
- 6 University of Alabama in Birmingham, Birmingham, AL, USA
| | | |
Collapse
|
13
|
Buckner T, Leavitt A, Ragni M, Kempton C, Eyster M, Cuker A, Lentz S, Ducore J, Leissinger C, Wang M, Key N. Prospective, multicenter study of postoperative deep-vein thrombosis in patients with haemophilia undergoing major orthopaedic surgery. Thromb Haemost 2017; 116:42-9. [DOI: 10.1160/th15-10-0802] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 03/15/2016] [Indexed: 11/05/2022]
Abstract
SummaryPerioperative clotting factor replacement is administered to reverse the inherent haemostatic defect in persons with haemophilia (PWH), potentially increasing their risk for developing venous thromboembolism (VTE) postoperatively. It was our objective to determine the prevalence of VTE in PWH undergoing total hip or knee arthroplasty (THA, TKA). Patients with haemophilia A or B who underwent THA or TKA were enrolled in this prospective, multicentre observational cohort study. Lower extremity venous duplex ultrasound was performed prior to surgery and 4–6 weeks after surgery. Eleven centres enrolled 51 subjects, 46 of whom completed the study. Six subjects (13.0 %) were treated with bypass agents perioperatively; the remaining 40 subjects received factor VIII or IX replacement. Intermittent pneumatic compression devices were utilised postoperatively in 23 subjects (50 %), and four subjects (8.7 %) also received low-molecular-weight heparin prophylaxis. One subject (2.2 %) with moderate haemophilia A was diagnosed with symptomatic distal deep-vein thrombosis (DVT) on day 6 following TKA. One subject (2.2 %) with severe haemophilia A was diagnosed with pulmonary embolism on day 9 following bilateral TKA. No subjects had asymptomatic DVT. Eighteen subjects (39.1 %) had major bleeding, and three subjects (6.5 %) experienced minor bleeding. The observed prevalence of ultrasound-detectable, asymptomatic DVT in PWH following TKA or THA in this study was low, but the incidence of symptomatic VTE (4.3 %, 95 % CI, 0.5–14.8 %) appeared similar to the estimated incidence in the general population without thromboprophylaxis.
Collapse
|
14
|
Kuter DJ, Konkle BA, Hamza TH, Uhl L, Assmann SF, Kiss JE, Kaufman RM, Key NS, Sachais BS, Hess JR, Ness P, McCrae KR, Leissinger C, Strauss RG, McFarland JG, Neufeld E, Bussel JB, Ortel TL. Clinical outcomes in a cohort of patients with heparin-induced thrombocytopenia. Am J Hematol 2017; 92:730-738. [PMID: 28388835 DOI: 10.1002/ajh.24759] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 04/03/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a thrombotic disorder usually prompting treatment with non-heparin anticoagulants. The benefits and risks of such treatments have not been fully assessed. METHODS We analyzed data for 442 patients having a positive heparin-platelet factor 4 antibody test and recent heparin exposure. The primary outcome was a composite endpoint (death, limb amputation/gangrene, or new thrombosis). Secondary outcomes included bleeding and the effect of anticoagulation. FINDINGS Seventy-one patients (16%) had HIT with thrombosis (HIT-T); 284 (64%) had HIT without thrombosis (isolated HIT); 87 (20%) did not have HIT. An intermediate or high "4T" score was found in 85%, 58%, and 8% of the three respective groups. Non-heparin anticoagulation was begun in 80%, 56%, and 45%. The composite endpoint occurred in 48%, 36%, and 17% (P = .01) of which 61%, 38%, and 40% were receiving non-heparin anticoagulation. Compared with the no HIT group, the composite endpoint was significantly more likely in HIT-T [HR 2.48 (1.35-4.55), P = .003)] and marginally more likely in isolated HIT [HR 1.66 (0.96-2.85), P = .071]. Importantly, risk increased (HR 1.77, P = .02) after platelet transfusion. Major bleeding occurred in 48%, 36%, and 16% of the three groups (P = .005). Non-heparin anticoagulation was not associated with a reduction in composite endpoint events in either HIT group. INTERPRETATION HIT patients have high risks of death, limb amputation/gangrene, thrombosis, and bleeding. Non-heparin anticoagulant treatment may not benefit all patients and should be considered only after careful assessment of the relative risks of thrombosis and bleeding in individual patients.
Collapse
Affiliation(s)
- David J. Kuter
- Massachusetts General Hospital; Boston Massachusetts USA
| | - Barbara A. Konkle
- Puget Sound Blood Center and University of Washington Medical Center; Seattle Washington USA
| | - Taye H. Hamza
- New England Research Institutes; Watertown Massachusetts USA
| | - Lynne Uhl
- Beth Israel Deaconess Medical Center; Boston Massachusetts USA
| | | | | | | | - Nigel S. Key
- University of North Carolina; Chapel Hill North Carolina USA
| | | | | | - Paul Ness
- Johns Hopkins University; Baltimore Maryland USA
| | | | - Cindy Leissinger
- Tulane University Hospital and Clinics; New Orleans Louisiana USA
| | | | | | | | | | | |
Collapse
|
15
|
Carcao MD, Avila L, Leissinger C, Blanchette VS, Aledort L. An International Prophylaxis Study Group (IPSG) survey of prophylaxis in inhibitor positive children/adults with severe haemophilia. Haemophilia 2017; 23:e444-e447. [DOI: 10.1111/hae.13222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2017] [Indexed: 01/11/2023]
Affiliation(s)
- M. D. Carcao
- Department of Paediatrics; Division of Haematology/Oncology and Research Institute; Hospital for Sick Children; University of Toronto; Toronto Canada
| | - L. Avila
- Department of Paediatrics; Division of Haematology/Oncology and Research Institute; Hospital for Sick Children; University of Toronto; Toronto Canada
| | - C. Leissinger
- Tulane University School of Medicine; New Orleans USA
| | - V. S. Blanchette
- Department of Paediatrics; Division of Haematology/Oncology and Research Institute; Hospital for Sick Children; University of Toronto; Toronto Canada
| | - L. Aledort
- Mount Sinai School of Medicine; New York NY USA
| | | |
Collapse
|
16
|
Carcao MD, Avila L, Leissinger C, Blanchette VS, Aledort L. An International Prophylaxis Study Group (IPSG) survey of prophylaxis in adults with severe haemophilia. Haemophilia 2017; 23:e447-e450. [DOI: 10.1111/hae.13238] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2017] [Indexed: 01/23/2023]
Affiliation(s)
- M. D. Carcao
- Department of Paediatrics; Division of Haematology/Oncology and Research Institute; Hospital for Sick Children; University of Toronto; Toronto Canada
| | - L. Avila
- Department of Paediatrics; Division of Haematology/Oncology and Research Institute; Hospital for Sick Children; University of Toronto; Toronto Canada
| | - C. Leissinger
- Tulane University School of Medicine; New Orleans USA
| | - V. S. Blanchette
- Department of Paediatrics; Division of Haematology/Oncology and Research Institute; Hospital for Sick Children; University of Toronto; Toronto Canada
| | - L. Aledort
- Mount Sinai School of Medicine; New York NY USA
| | | |
Collapse
|
17
|
Navalkele DD, Boehme A, Albright K, Leissinger C, El Khoury R, Freeman M, Schluter L, Martin-Schild S. Abstract TP129: Factor VIII in Acute Cerebral Ischemia Trial - Biomarker in Patients with Large Vessel Occlusion? Stroke 2017. [DOI: 10.1161/str.48.suppl_1.tp129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Baseline elevated Factor VIII (FVIII) level is a significant independent predictor of stroke occurrence and severity. We conducted a prospective serial laboratory cohort study to assess the correlation of FVIII levels in response to thrombolysis in patients with large vessel occlusion (LVO) and acute ischemic stroke (AIS).
Methods:
AIS patients with anterior circulation LVO were enrolled within 4.5 hours from last seen normal. Baseline and serial FVIII levels were obtained to determine whether FVIII serves as a surrogate marker of clot burden and if FVIII levels or changes predict (1) recanalization with intravenous tissue plasminogen activator (IV tPA) or (2) symptomatic intracranial hemorrhage (sICH) following tPA. Linear and logistic regression analyses were used to determine significant predictors.
Results:
Patients (n=29) had a mean age of 71years, median NIHSS of 15, 62% were of black race and 48% were female. Baseline pre -tPA FVIII was not significantly correlated with clot burden score (-0.15, p=0.45) or vessel recanalization (-0.13, p=0.50). Median FVIII decreased significantly from baseline to 6hrs post-tPA (282% to 161%, p=0.0024), but delta in FVIII level did not correlate with vessel recanalization (0.01, p=0.95). No patient had sICH. There was no difference between median FVIII level at baseline and 90 days post AIS.
Interpretation:
FVIII level decreased significantly after tPA, but baseline FVIII level and early change in FVIII level were not significant predictors of clot burden, vessel recanalization after treatment with IV tPA, or symptomatic hemorrhage. This trial provided no evidence to support the value of acute FVIII level as a biomarker in AIS due to LVO. The physiology behind the decrease in FVIII level after tPA remains unknown.
Collapse
Affiliation(s)
| | | | | | | | - Ramy El Khoury
- Cobalt Rehabilitation Hosp of New Orleans and AMG Physical Rehabilitation Hosp, New Orleans, LA
| | | | | | | |
Collapse
|
18
|
Klamroth R, Simpson M, von Depka-Prondzinski M, Gill JC, Morfini M, Powell JS, Santagostino E, Davis J, Huth-Kühne A, Leissinger C, Neumeister P, Bensen-Kennedy D, Feussner A, Limsakun T, Zhou M, Veldman A, St Ledger K, Blackman N, Pabinger I. Comparative pharmacokinetics of rVIII-SingleChain and octocog alfa (Advate(®) ) in patients with severe haemophilia A. Haemophilia 2016; 22:730-8. [PMID: 27434619 DOI: 10.1111/hae.12985] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND rVIII-SingleChain, a novel recombinant factor VIII (rFVIII), has been designed as a B-domain truncated construct with covalently bonded heavy and light chains, aiming to increase binding affinity to von Willebrand factor (VWF). Preclinical studies confirmed greater affinity for VWF, giving improved pharmacokinetic and pharmacodynamic properties compared with full-length rFVIII. AIM To investigate the pharmacokinetics of rVIII-SingleChain and compare them against those of full-length rFVIII. METHODS This study enrolled 27 patients with severe haemophilia A in the AFFINITY clinical trial programme. After a 4-day washout period, all patients received a single infusion of 50 IU kg(-1) octocog alfa (Advate(®) ); after a ≥4-day postinfusion washout period, they received a single infusion of 50 IU kg(-1) rVIII-SingleChain. Blood samples for pharmacokinetic assessments of each product were collected before infusion (predose) and at 0.5, 1, 4, 8, 10, 24, 32, 48 and 72 h postinfusion for both products. RESULTS rVIII-SingleChain had a longer mean half-life (t1/2 ) (14.5 vs. 13.3 h), lower mean clearance (CL) (2.64 vs. 3.68 mL h(-1) kg(-1) ), higher mean residence time (20.4 vs. 17.1 h) and larger mean AUCinf (2090 vs. 1550 IU?h dL(-1) ) than octocog alfa, respectively. The mean AUCinf after rVIII-SingleChain infusion was ~35% larger than after octocog alfa. A similar pattern was observed for AUC0-last . No serious adverse events or inhibitors were reported. CONCLUSIONS rVIII-SingleChain has a favourable pharmacokinetic profile compared with octocog alfa and was well tolerated. The prolonged t1/2 , larger AUC and reduced CL of rVIII-SingleChain may permit longer dosing intervals, thereby improving patient adherence to prophylactic treatment.
Collapse
Affiliation(s)
- R Klamroth
- Department for Internal Medicine, Vascular Medicine and Haemostaseology, Vivantes Klinikum, Berlin Friedrichshain, Germany
| | - M Simpson
- Rush University Medical Center, Chicago, IL, USA
| | | | - J C Gill
- Medical College of Wisconsin and Blood Center of Wisconsin, Milwaukee, WI, USA
| | - M Morfini
- Ospedaliero Universitaria Careggi, Firenze, Italy
| | - J S Powell
- Hemophilia Treatment Center, UC Davis, Sacramento, CA, USA
| | - E Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Fondazione Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - J Davis
- University of Miami Hemophilia Treatment Center, Miami, FL, USA
| | - A Huth-Kühne
- Hämophiliezentrum und Gerinnungsambulanz SRH Kurpfalzkrankenhaus, Heidelberg, Germany
| | - C Leissinger
- Louisiana Center for Bleeding and Clotting Disorders, New Orleans, LA, USA
| | - P Neumeister
- Klinische Abteilung für Hämatologie, Medizinische Universität of Graz, Graz, Austria
| | | | - A Feussner
- Clinical R&D, CSL Behring, Marburg, Germany
| | - T Limsakun
- Clinical R&D, CSL Behring, King of Prussia, PA, USA
| | - M Zhou
- Clinical R&D, CSL Behring, King of Prussia, PA, USA
| | - A Veldman
- Clinical R&D, CSL Behring, Marburg, Germany
| | - K St Ledger
- Clinical R&D, CSL Behring, King of Prussia, PA, USA
| | - N Blackman
- Clinical R&D, CSL Behring, King of Prussia, PA, USA
| | - I Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
19
|
Affiliation(s)
- Daniel De Kee
- Department of Mechanical and Industrial Engineering; University of Toronto; Toronto ON Canada
| | - David Rice
- Department of Biomedical Engineering; Tulane University; New Orleans LA USA
| | | | - Bin Meng
- Department of Chemical and Biomolecular Engineering; Tulane University; New Orleans LA USA
| |
Collapse
|
20
|
Samai AA, Boehme AK, Shaban A, George AJ, Dowell L, Monlezun DJ, Leissinger C, Schluter L, El Khoury R, Martin-Schild S. A Model for Predicting Persistent Elevation of Factor VIII among Patients with Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2015; 25:428-35. [PMID: 26777556 DOI: 10.1016/j.jstrokecerebrovasdis.2015.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 10/12/2015] [Accepted: 10/20/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND AND PURPOSE Elevated levels of coagulation factor VIII (FVIII) may persist independent of the acute-phase response; however, this relationship has not been investigated relative to acute ischemic stroke (AIS). We examined the frequency and predictors of persistently elevated FVIII in AIS patients. METHODS AIS patients admitted between July 2008 and May 2014 with elevated baseline FVIII levels and repeat FVIII levels drawn for more than 7 days postdischarge were included. The patients were dichotomized by repeat FVIII level for univariate analysis at 150% and 200% activity thresholds. An adjusted model was developed to predict the likelihood of persistently elevated FVIII levels. RESULTS Among 1616 AIS cases, 98 patients with elevated baseline FVIII had repeat FVIII levels. Persistent FVIII elevation was found in more than 75% of patients. At the 150% threshold, the prediction score ranged from 0 to 7 and included black race, female sex, prior stroke, hyperlipidemia, smoking, baseline FVIII > 200%, and baseline von Willebrand factor (vWF) level greater than 200%. At the 200% threshold, the prediction score ranged from 0-5 and included female sex, prior stroke, diabetes mellitus, baseline FVIII level greater 200%, and baseline vWF level greater than 200%. For each 1-point increase in score, the odds of persistent FVIII at both the 150% threshold (odds ratio [OR] = 10.4, 95% confidence interval [CI] 1.63-66.9, P = .0134) and 200% threshold (OR = 10.2, 95% CI 1.82-57.5, P = .0083) increased 10 times. CONCLUSION Because an elevated FVIII level confers increased stroke risk, our model for anticipating a persistently elevated FVIII level may identify patients at high risk for recurrent stroke. FVIII may be a target for secondary stroke prevention.
Collapse
Affiliation(s)
- Alyana A Samai
- Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana; Department of Epidemiology, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Amelia K Boehme
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama; Department of Neurology, Columbia University, New York, New York
| | - Amir Shaban
- Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Alexander J George
- Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Lauren Dowell
- Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Dominique J Monlezun
- Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Cindy Leissinger
- Section of Hematology/Oncology, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
| | - Laurie Schluter
- Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Ramy El Khoury
- Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana
| | - Sheryl Martin-Schild
- Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana.
| |
Collapse
|
21
|
Miller CH, Rice AS, Boylan B, Payne AB, Kelly FM, Escobar MA, Gill J, Leissinger C, Soucie JM. Characteristics of hemophilia patients with factor VIII inhibitors detected by prospective screening. Am J Hematol 2015; 90:871-6. [PMID: 26147783 PMCID: PMC4642843 DOI: 10.1002/ajh.24104] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 06/03/2015] [Accepted: 07/01/2015] [Indexed: 11/11/2022]
Abstract
Characteristics of inhibitors identified by prospective screening may differ from those detected clinically. In a prospective study at 17 hemophilia centers with central inhibitor measurement by Nijmegen-Bethesda assay, 23 (2.8%) of 824 hemophilia A patients had new inhibitors detected: nine high-titer inhibitors (HTI: 7 ≥ 5.0 NBU plus 2 of 2.6 and 3.4 NBU at immune tolerance induction initiation) and 14 low-titer inhibitors (LTI: 0.5-1.9 NBU). HTI occurred at an earlier age (median 2 years, range 1-18, vs. median 11 years, range 2-61, P = 0.016). Both HTI (22%) and LTI (43%) occurred in non-severe patients. All HTI, but only 64% of LTI, were found to be FVIII-specific by chromogenic Bethesda assay or fluorescence immunoassay (FLI), indicating a high rate of false-positive LTI. Repeat specimens confirmed all HTI, 7/9 LTI, and 7/7 FVIII-specific LTI. FLI results were similar between HTI and FVIII-specific LTI; all included IgG1 and IgG4 subclasses. A comparable prospective study conducted from 1975 to 1979 at 13 U.S. centers found 31 (2.4%) new inhibitors among 1,306 patients. In both studies, one-third of inhibitors occurred in non-severe patients and one-quarter after 150 exposure days (ED). Significant differences were seen in the age at which inhibitors occurred (median 16 years in the older study vs. 5 years currently, P = 0.024) and in ED before inhibitor development, 10% in the older study and 43% currently study occurring within 20 ED, suggesting a temporal change in inhibitor development. Prospective screening detects inhibitors in patients of all severities, ages, and ED. Some LTI, however, are false positives.
Collapse
Affiliation(s)
- Connie H. Miller
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anne S. Rice
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Brian Boylan
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Amanda B. Payne
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Fiona M. Kelly
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Joan Gill
- Comprehensive Center for Bleeding Disorders, Blood Center of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cindy Leissinger
- Louisiana Center for Bleeding and Clotting Disorders, New Orleans, Louisiana
| | - J. Michael Soucie
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | |
Collapse
|
22
|
Samai AA, Boehme AK, Shaban A, George A, Monlezun DJ, Dowell L, Leissinger C, Schluter L, El Khoury R, Martin-Schild S. Abstract T P190: A Model for Predicting Persistent Elevation of Factor VIII Among Patients with Acute Ischemic Stroke (AIS). Stroke 2015. [DOI: 10.1161/str.46.suppl_1.tp190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Recent studies have demonstrated that elevated levels of coagulation factor VIII (FVIII), a risk factor for stroke, may persist independent of the acute-phase response; however, this relationship has not yet been investigated in the context of acute ischemic stroke (AIS). We sought to determine 1) the proportion of AIS patients with acutely elevated serum FVIII levels who had persistently elevated FVIII levels in the outpatient setting and 2) the characteristics at baseline predictive of persistently elevated FVIII levels.
Methods:
From our stroke registry, patients diagnosed with AIS between 07/2008-05/2014 were included if the initial FVIII level was elevated and a repeat FVIII level was obtained. A score was developed to predict which patients are at the greatest odds of remaining persistently elevated at both the 150% and 200% thresholds.
Results:
Among 1,616 AIS cases, 106 patients had initially elevated FVIII levels and repeat FVIII levels obtained. A total of 82.7% of patients had persistent elevation at the 150% threshold and 75.7% had persistent elevation at the 200% threshold. Time from initial FVIII measurement to second FVIII measurement was not different between the two groups (p=0.054). According to the models developed, for every one-point increase in the score, an individual is at ten-fold increased odds to have persistently elevated FVIII at both the 150% threshold (OR=10.43, 95% CI 1.63-66.9, p=0.0134) and 200% threshold (OR=10.2, 95% CI 1.82-57.5, p=0.0083).
Conclusions:
Persistent elevation in FVIII is common and in most AIS patients likely represents a constitutional risk factor. Persistent elevation in FVIII can be predicted by baseline characteristics in the setting of AIS, potentially proving useful in identifying patients at high risk for developing subsequent stroke.
Collapse
Affiliation(s)
| | | | - Amir Shaban
- Neurology, Tulane Univ Sch of Medicine, New Orleans, LA
| | | | | | - Lauren Dowell
- Neurology, Tulane Univ Sch of Medicine, New Orleans, LA
| | | | | | | | | |
Collapse
|
23
|
Samai AA, Boehme AK, Monlezun DJ, George A, Dowell L, Leissinger C, Schluter L, El Khoury R, Martin-Schild S. Abstract T P187: How High Is Too High? An Analysis of the Upper Threshold for Serum FVIII in Ischemic Stroke. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.tp187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Elevated factor VIII (FVIII) is an independent risk factor for thromboembolic events and acute ischemic stroke (AIS). Laboratory reference ranges categorize levels >150% and >200% activity as elevated and severely elevated, respectively. We sought to identify the upper limit of FVIII activity with the most clinical relevance for outcomes after AIS.
Methods:
From our stroke registry, patients admitted with AIS between 07/2008 to 10/2013 were included if FVIII levels were measured during admission. Logistic regression, was used to assess differences in baseline, in-hospital, and outcome variables in patients with FVIII elevation as compared to those with normal levels. The primary outcome was poor modified Rankin Scale (mRS) score on discharge, defined as mRS>2. Serial dichotomized FVIII levels using a 5-point incremental analysis of levels were analyzed with respect to poor outcome. The threshold yielding the largest area under the curve (AUC) was determined.
Results:
Among 1,453 cases in our registry, inclusion criteria were met for 267 patients. In our sample, in a comparison of normal FVIII levels vs. elevation >150%, and elevation >200%, patients differed significantly according to race (p=0.0017), history of diabetes (p=0.0001), and history of congestive heart failure (p=0.0401). FVIII elevation threshold of 150% was the best predictor of poor mRS on discharge (OR 3.7, 95% CI 1.77-8.05, p=0.0006) with an AUC of 0.618.
Conclusions:
FVIII elevation greater than 150% is the most clinically useful threshold for the prediction of poor clinical outcomes in the setting of AIS based on data from our center.
Collapse
Affiliation(s)
| | | | | | | | - Lauren Dowell
- Neurology, Tulane Univ Sch of Medicine, New Orleans, LA
| | | | | | | | | |
Collapse
|
24
|
Samai AA, Boehme AK, George A, Monlezun DJ, Dowell L, Leissinger C, Schluter L, El Khoury R, Martin-Schild S. Abstract W P154: Von Willebrand Factor Elevation Threshold for Poor Clinical Outcomes in Patients with Ischemic Stroke. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.wp154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Elevation in von Willebrand factor (vWF) is an independent risk factor for thromboembolic events and acute ischemic stroke (AIS). Laboratory reference ranges categorize levels >150% activity as abnormal. Our prior research demonstrated worse outcomes with severe (>200%) elevation in vWF. We sought to determine the most clinically relevant threshold value for vWF with respect to patient outcome in AIS.
Methods:
From our stroke registry, patients admitted with AIS between 07/2008-10/2013 were included if vWF levels were measured during admission. Logistic regression was used to assess differences in baseline, in-hospital, and outcome variables in patients with vWF elevation as compared to those with normal levels. Optimal threshold levels were determined by assessing dichotomized vWF levels using a 5-point incremental analysis of levels with respect to outcome, and subsequent determination of the threshold yielding the largest area under the curve (AUC). The outcome was poor modified Rankin Scale (mRS) score on discharge, defined as mRS>2.
Results:
Among 1,453 cases in our registry, inclusion criteria were met for 99 patients. Compared to patients with normal vWF, elevated vWF was associated with age, female gender, and diabetes. vWF elevation threshold of 200% was the best predictor of poor mRS on discharge (OR 2.88, 95% CI 1.32-6.29, p=0.0079) with an AUC of 0.629.
Conclusions:
Despite a laboratory cut-off of 150% as a normal value, elevation of vWF >200% is the most clinically useful threshold for the prediction of poor clinical outcome in the setting of AIS based on data from our center.
Collapse
Affiliation(s)
| | | | | | | | - Lauren Dowell
- Neurology, Tulane Univ Sch of Medicine, New Orleans, LA
| | | | | | | | | |
Collapse
|
25
|
Young G, Teitel J, d'Oiron R, Leissinger C, Berntorp E. Evaluation of algorithms for the treatment of problem bleeding episodes in patients with hemophilia having inhibitors. Clin Appl Thromb Hemost 2014; 21:10-8. [PMID: 25343956 DOI: 10.1177/1076029614554993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The correlation between real-world clinical decisions and adherence to published treatment algorithms for problem bleeding episodes in patients with severe hemophilia and inhibitors and the resultant impact on clinical outcomes were assessed. Nine cases documenting treatment for problem bleeding episodes in patients with severe hemophilia and inhibitors were retrospectively reviewed. Adherence to treatment algorithms was rated on a scale of 1 to 5, 1 being no adherence and 5 being very high adherence. Adherence ratings >3 were assigned to 7 cases in which high adherence was associated with ≤4 days to achieve hemostatic control; hospitalization for ≤7 days was noted in 6 of these cases. In cases rated ≤3 (n = 2), time to hemostatic control ranged from 5 to 8 days and hospitalization duration ranged from 10 to 16 days. These findings suggest that adherence to treatment algorithms may be beneficial in treating problem bleeding events in patients with hemophilia and inhibitors.
Collapse
Affiliation(s)
- Guy Young
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Jerome Teitel
- Division of Hematology and Oncology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Roseline d'Oiron
- Haemophilia Centre, APHP Bicêtre Hospital, University Paris XI, Le Kremlin-Bicêtre, France
| | - Cindy Leissinger
- Louisiana Center for Bleeding and Clotting Disorders, Tulane University School of Medicine, New Orleans, LA, USA
| | - Erik Berntorp
- Malmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Lund University, Lund, Sweden
| |
Collapse
|
26
|
Leissinger C, Josephson CD, Granger S, Konkle BA, Kruse-Jarres R, Ragni MV, Journeycake JM, Valentino L, Key NS, Gill JC, McCrae KR, Neufeld EJ, Manno C, Raffini L, Saxena K, Torres M, Marder V, Bennett CM, Assmann SF. Rituximab for treatment of inhibitors in haemophilia A. A Phase II study. Thromb Haemost 2014; 112:445-58. [PMID: 24919980 DOI: 10.1160/th14-01-0078] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 03/22/2014] [Indexed: 01/19/2023]
Abstract
The development of antibodies against infused factor VIII (FVIII) in patients with haemophilia A is a serious complication leading to poorly controlled bleeding and increased morbidity. No treatment has been proven to reduce high titre antibodies in patients who fail immune tolerance induction or are not candidates for it. The Rituximab for the Treatment of Inhibitors in Congenital Hemophilia A (RICH) study was a phase II trial to assess whether rituximab can reduce anamnestic FVIII antibody (inhibitor) titres. Male subjects with severe congenital haemophilia A and an inhibitor titre ≥5 Bethesda Units/ml (BU) following a FVIII challenge infusion received rituximab 375 mg/m² weekly for weeks 1 through 4. Post-rituximab inhibitor titres were measured monthly from week 6 through week 22 to assess treatment response. Of 16 subjects who received at least one dose of rituximab, three (18.8%) met the criteria for a major response, defined as a fall in inhibitor titre to <5 BU, persisting after FVIII re-challenge. One subject had a minor response, defined as a fall in inhibitor titre to <5 BU, increasing to 5-10 BU after FVIII re-challenge, but <50% of the original peak inhibitor titre. Rituximab is useful in lowering inhibitor levels in patients, but its effect as a solo treatment strategy is modest. Future studies are indicated to determine the role of rituximab as an adjunctive therapy in immune tolerisation strategies.
Collapse
Affiliation(s)
| | | | - S Granger
- Suzanne Granger, MS, New England Research Institutes, Inc., 480 Pleasant St., Watertown, MA 02472, USA, Tel.: +1 617 972 3319, Fax: +1 617 926 8246, E-mail:
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Tarsia J, Chang TR, Aysenne A, Boehme AK, Sartor AE, Albright KC, Yalvac EA, Kruse-Jarres R, Leissinger C, Martin-Schild S. Elevated Plasma Factor VIII in Patients with Ischemic Stroke: Does it have any Association with Hypertensive Heart Disease? J Neurol Disord Stroke 2013; 1:1027. [PMID: 25750937 PMCID: PMC4350327] [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] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Elevated factor VIII (FVIII) has been linked with higher risk of vascular events. We aimed to determine the relationship between FVIII and hypertension in patients with acute ischemic stroke. METHODS FVIII levels and transthoracic echocardiogram reports were reviewed in patients with acute ischemic stroke who presented to our stroke center between July 2008 and September 2011. Presenting systolic and diastolic blood pressure, history of hypertention, left ventricular hypertrophy, diastolic dysfunction, and depressed left ventricular function (ejection fraction <50%) were compared in patients with normal and elevated FVIII levels. RESULTS No differences in presenting blood pressure or frequency of hypertension history were found based on FVIII level. Patients with elevated FVIII had demonstrated a statistically significant higher frequency of diastolic dysfunction (64.8 vs. 43.6%, p=0.042) and a trend towards higher frequency of left ventricular hypertrophy (18.5 vs 5.1%, p=0.073). Median FVIII was significantly higher in patients with left ventricular hypertrophy (194.4 vs 152.9%, p=0.042) and diastolic dysfunction (180.5 vs 149.3%, p=0.031) than patients without these findings. CONCLUSIONS Among patients with acute ischemic stroke, FVIII levels were higher when there was evidence of hypertensive heart disease. Synthesis of FVIII may be augmented by the ongoing presence of shear stress and could contribute to the higher risk of vaso-occlusive events in patients with elevated FVIII.
Collapse
Affiliation(s)
- Joseph Tarsia
- Stroke Program, Department of Neurology, Tulane University Medical School, USA
| | - Tiffany R. Chang
- Stroke Program, Department of Neurology, Tulane University Medical School, USA
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, USA
| | - Aimee Aysenne
- Stroke Program, Department of Neurology, Tulane University Medical School, USA
| | - Amelia K Boehme
- Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (COERE), School of Medicine, University of Alabama at Birmingham, USA
| | - Alton E. Sartor
- Stroke Program, Department of Neurology, Tulane University Medical School, USA
| | - Karen C. Albright
- Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (COERE), School of Medicine, University of Alabama at Birmingham, USA
- Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities (CERED) Minority Health & Health Disparities Research Center (MHRC), School of Medicine, University of Alabama at Birmingham, 35294
- Memorial Herman Hospital, USA
| | - Ethan Arda Yalvac
- Stroke Program, Department of Neurology, University of Texas in Houston, USA
| | | | - Cindy Leissinger
- Stroke Program, Department of Neurology, Tulane University Medical School, USA
| | | |
Collapse
|
28
|
Leissinger C, Carcao M, Gill JC, Journeycake J, Singleton T, Valentino L. Desmopressin (DDAVP) in the management of patients with congenital bleeding disorders. Haemophilia 2013; 20:158-67. [DOI: 10.1111/hae.12254] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2013] [Indexed: 11/29/2022]
Affiliation(s)
- C. Leissinger
- Section of Hematology and Medical Oncology; Tulane University; New Orleans LA USA
| | - M. Carcao
- Division of Haematology/Oncology; The Hospital for Sick Children; University of Toronto; Toronto ON Canada
| | - J. C. Gill
- Pediatric Hematology, Medicine and Epidemiology; The Medical College of Wisconsin and the Blood Center of Wisconsin; Milwaukee WI USA
| | - J. Journeycake
- Pediatrics; University of Texas Southwestern Medical Center; USA
- Bleeding Disorders and Thrombosis Program; Children's Medical Center; Dallas TX USA
| | - T. Singleton
- Section of Pediatric Hematology/Oncology; Tulane University; New Orleans LA USA
| | - L. Valentino
- Section of Pediatric Hematology/Oncology; Rush Hemophilia & Thrombophilia Center; Rush University Medical Center; Chicago IL USA
| |
Collapse
|
29
|
Gringeri A, Leissinger C, Cortesi PA, Jo H, Fusco F, Riva S, Antmen B, Berntorp E, Biasoli C, Carpenter S, Kavakli K, Morfini M, Négrier C, Rocino A, Schramm W, Windyga J, Zülfikar B, Mantovani LG. Health-related quality of life in patients with haemophilia and inhibitors on prophylaxis with anti-inhibitor complex concentrate: results from the Pro-FEIBA study. Haemophilia 2013; 19:736-43. [DOI: 10.1111/hae.12178] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2013] [Indexed: 11/30/2022]
Affiliation(s)
- A. Gringeri
- Department of Clinical Sciences and Community Health; Università degli Studi di Milano; Milan; Italy
| | - C. Leissinger
- Louisiana Center for Bleeding and Clotting Disorders; Tulane University Medical Center; New Orleans; LA; USA
| | - P. A. Cortesi
- Research Centre on Public Health; University of Milano-Bicocca; Monza; Italy
| | - H. Jo
- Quintiles; Rockville; MD; USA
| | | | - S. Riva
- IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy and Institute of Communication and Health; University of Svizzera Italiana; Lugano; Switzerland
| | | | - E. Berntorp
- Malmö University Hospital, Malmö Center for Thrombosis and Hemostasis; Lund University; Malmö; Sweden
| | - C. Biasoli
- Hemophilia Center; Bufalini Hospital; Cesena; Italy
| | - S. Carpenter
- University of Missouri-Kansas City School of Medicine; Kansas City; MO; USA
| | - K. Kavakli
- University of Ege; Children's Hospital; Izmir; Turkey
| | - M. Morfini
- Azienda University Hospital Careggi; Florence; Italy
| | - C. Négrier
- Hemophilia Treatment Center; Edouard Herriot Hospital; University Claude Bernard; Lyon; France
| | - A. Rocino
- Hemophilia and Thrombosis Center; San Giovanni Bosco Hospital; Naples; Italy
| | - W. Schramm
- Ludwig-Maximilians University; Munich; Germany
| | - J. Windyga
- Institute of Hematology and Transfusion Medicine; Warsaw; Poland
| | | | - L. G. Mantovani
- CIRFF/Center of Pharmacoeconomics; Federico II University of Naples; Naples; Italy
| |
Collapse
|
30
|
Chang TR, Albright KC, Boehme AK, Dorsey A, Sartor EA, Kruse-Jarres R, Leissinger C, Martin-Schild S. Factor VIII in the setting of acute ischemic stroke among patients with suspected hypercoagulable state. Clin Appl Thromb Hemost 2013; 20:124-8. [PMID: 23677913 DOI: 10.1177/1076029613488936] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Elevation of factor VIII is associated with higher risk of large vessel arterial occlusions including stroke. METHODS Factor VIII levels were examined in consecutive patients with acute ischemic stroke (AIS) presenting to a single center between July 2008 and May 2012. Factor VIII levels exceeding the laboratory reference range were considered elevated (>150%). RESULTS Factor VIII level was elevated in 72.4% (84 of 116) of the patients. Elevated factor VIII level was more frequent in blacks, diabetics, and patients who were anemic. Patients with elevated factor VIII had higher median baseline National Institute of Health Stroke Scale (NIHSS; 5 vs 2, P = .0295) and twice the frequency of neuroworsening (21.4% vs 9.4%), but discharge NIHSS and modified Rankin Scale were similar in the groups. CONCLUSIONS High factor VIII level was found in the majority of tested patients with AIS. Several baseline differences were found between patients with normal and high factor VIII levels, but no differences were identified in outcome.
Collapse
Affiliation(s)
- Tiffany R Chang
- 1Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, LA, USA
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Dorsey AM, Boehme AK, Schluter L, Albright KC, Chang TR, Beasley TM, Kruse-Jarres R, Leissinger C, Martin-Schild S. Abstract TP170: Persistently Elevated Factor VIII In Acute Ischemic Stroke Is Associated With Higher CRP, Lower Baseline NIHSS, And Longer Length Of Hospital Stay. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.atp170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
We sought to determine the proportion of patients with elevated factor VIII (FVIII) levels whose FVIII levels remain elevated after the acute phase of stroke, and the patient characteristics that predict sustained elevation of FVIII levels.
Background:
Factor VIII plays a major role in the fluid phase of blood coagulation. Elevated FVIII has been shown to increase risk of venous and arterial thrombosis. The importance of screening for elevated FVIII after a first thrombotic event especially acute ischemic stroke (AIS) has not been adequately investigated.
Design/Methods:
We reviewed FVIII levels taken at baseline and follow-up in patients with AIS treated at our stroke center from July 2008 to June 2012. Elevated FVIII was defined as >150%. Baseline demographics, laboratory data, clinical course, outcomes, and time to follow-up were collected in patients with elevated FVIII at baseline and data was compared in patients who had normalized FVIII with patients whose FVIII remained elevated at least 7 days later.
Results:
Repeat FVIII levels were available for 34/111 patients with elevated FVIII level with AIS. FVIII remained elevated in 68% after a median interval of 110 days. Factors associated with persistent elevation included higher baseline FVIII level (239 vs 185%, p=0.015), elevated CRP (73.3 vs 12.5%, p=0.008), lower baseline NIHSS (4 vs 8, p=0.046), and longer length of hospital stay (8 vs. 3, p=0.0063). Normalization of FVIII was associated with tPA use (54.5% vs 13%, p=0.016). No relationship was found between persistently elevated FVIII and baseline demographics, clinical course and outcomes.
Conclusion:
Persistently elevated FVIII after AIS may be predicted by higher baseline levels and elevations in CRP. Despite worse baseline stroke severity, patient with normalization of FVIII had similar outcomes as those with persistent elevation, which may be explained by the higher use of tPA in the normalized group. The relevance of elevated FVIII in stroke is not well understood. Our preliminary results suggest elevations persist in the majority and may not merely represent an acute phase reactant.
Collapse
|
32
|
Gelhorn H, Merikle E, Krishnan S, Nemes L, Leissinger C, Valentino L. Physician preferences for medication attributes for the prophylactic treatment of patients with severe haemophilia A with inhibitors to factor VIII. Haemophilia 2012; 19:119-25. [PMID: 23005041 DOI: 10.1111/hae.12011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2012] [Indexed: 11/30/2022]
Abstract
Prophylaxis may be beneficial for patients with severe haemophilia A who have developed inhibitors to factor VIII. The aim of this study was to determine physicians' preferences for medication attributes in the prophylactic treatment of this patient population. Haematologists from Europe (EU) and the United States (US) participated in a discrete choice exercise to explore their preferences for medication attributes (efficacy, cost, scientific evidence, dosing frequency and administration time) associated with prophylaxis for severe haemophilia A in patients with inhibitors to factor VIII. Physicians' preferences for medication attributes were assessed through completion of 25 trade-off tasks that included a choice between two hypothetical medications each comprised of one randomized level of each medication attribute. Participants also completed a sociodemographic questionnaire. Data were analysed using a random effects logit model. Participants (N = 36: US = 19; EU = 17) were 80.6% men, had a mean of 19.8 years (SD ± 8.1) [range 6-35] of practice experience. The physicians treated an average of 5.7 (± 5.5) patients with severe haemophilia A and inhibitors per month and reported treating 36.2% of these patients prophylactically. The most important medication attributes for prophylactic treatment were efficacy [Relative Importance (RI) = 35.0%] and scientific evidence (RI = 34.1%), whereas treatment cost (12.0%), dosing frequency (10.8%) and administration time (8.2%) were less important. Results were similar across the EU and US. Efficacy and scientific evidence are the primary considerations for physicians' choice of prophylactic medications for use in this patient population.
Collapse
Affiliation(s)
- H Gelhorn
- United BioSource Corporation, Bethesda, MD, USA.
| | | | | | | | | | | |
Collapse
|
33
|
Abstract
Joint bleeding is the hallmark of severe haemophilia and the major cause of disability in patients with this coagulopathy. Repeated bleeding into the same joint can lead to chronic synovitis and progressive arthropathy. Radiosynovectomy is one option for the treatment of chronic haemophilic synovitis, but concerns about the risks of exposure to ionizing radiation have divided clinicians as to the safety and appropriate use of the procedure. This article presents two differing viewpoints, one from a pair of orthopaedic surgeons who collectively have performed more than 300 radiosynovectomies in patients with haemophilia. They maintain that radiosynovectomy is a simple, effective, safe and low-cost technique children and adults with chronic haemophilic synovitis. The other perspective is from an experienced haemophilia treater who directs a major US haemophilia treatment centre. She believes that unresolved questions about the safety of radiation exposure in children argue against the use of radiosynovectomy in paediatric patients with haemophilia.
Collapse
Affiliation(s)
- M Silva
- Los Angeles Orthopaedic Hospital, UCLA/Orthopaedic Hospital, Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90007, USA.
| | | | | |
Collapse
|
34
|
Chang T, Albright K, Kruse-Jarres R, Leissinger C, Martin-Schild S. Elevated Factor VIII Is Common in the Acute Phase of Ischemic Stroke and Is Associated with African American Race and Poor Outcomes (S43.007). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.s43.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
35
|
Thornburg CD, Carpenter S, Zappa S, Munn J, Leissinger C. Current prescription of prophylactic factor infusions and perceived adherence for children and adolescents with haemophilia: a survey of haemophilia healthcare professionals in the United States. Haemophilia 2012; 18:568-74. [PMID: 22335526 DOI: 10.1111/j.1365-2516.2012.02756.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The primary goal of prophylaxis in patients with severe haemophilia is to convert the phenotype from severe to moderate and to prevent the development of chronic arthropathy. Prior studies have demonstrated that prophylaxis decreases episodes of joint bleeds and chronic arthropathy. Effectiveness depends on prescription of prophylaxis and adherence to the prescribed regimen. The aim of this study was to determine if prescription of prophylaxis for children with haemophilia and perceptions of adherence to prophylaxis have changed since publication of the Joint Outcome Study (JOS). A questionnaire was sent, in electronic and written formats, to health professionals who provide care to children with haemophilia at US haemophilia treatment centres (HTCs). The response rate was 56 of 128 (44%) of the targeted HTCs. There were a few missing data and denominators are provided. All responses agreed with the results of the JOS and 30/55 (55%) reported the JOS increased their prescription of prophylaxis. Nineteen of 56 (34%) physicians or HTC staff reported that they had not prescribed prophylaxis within the last year due to concerns about adherence, and 19/56 (34%) reported they had stopped prophylaxis due to concerns about adherence within the last year. Predicted adherence decreased with increasing age. Prescription of prophylaxis appears to be increasing since publication of the JOS. Strategies to improve adherence may increase the likelihood of physician prescription of prophylaxis and make prophylaxis easier to implement for individual patients, thereby improving the clinical outcome of children and adults with haemophilia.
Collapse
Affiliation(s)
- C D Thornburg
- Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA.
| | | | | | | | | |
Collapse
|
36
|
Leissinger C, Gringeri A, Antmen B, Berntorp E, Biasoli C, Carpenter S, Cortesi P, Jo H, Kavakli K, Lassila R, Morfini M, Négrier C, Rocino A, Schramm W, Serban M, Uscatescu MV, Windyga J, Zülfikar B, Mantovani L. Anti-inhibitor coagulant complex prophylaxis in hemophilia with inhibitors. N Engl J Med 2011; 365:1684-92. [PMID: 22047559 DOI: 10.1056/nejmoa1104435] [Citation(s) in RCA: 175] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Patients with severe hemophilia A and factor VIII inhibitors are at increased risk for serious bleeding complications and progression to end-stage joint disease. Effective strategies to prevent bleeding in such patients have not yet been established. METHODS We enrolled patients with hemophilia A who were older than 2 years of age, had high-titer inhibitors, and used concentrates known as bypassing agents for bleeding in a prospective, randomized, crossover study comparing 6 months of anti-inhibitor coagulant complex (AICC), infused prophylactically at a target dose of 85 U per kilogram of body weight (±15%) on 3 nonconsecutive days per week, with 6 months of on-demand therapy (AICC at a target dose of 85 U per kilogram [±15%] used for bleeding episodes). The two treatment periods were separated by a 3-month washout period, during which patients received on-demand therapy for bleeding. The primary outcome was the number of bleeding episodes during each 6-month treatment period. RESULTS Thirty-four patients underwent randomization; 26 patients completed both treatment periods and could be evaluated per protocol for the efficacy analysis. As compared with on-demand therapy, prophylaxis was associated with a 62% reduction in all bleeding episodes (P<0.001), a 61% reduction in hemarthroses (P<0.001), and a 72% reduction in target-joint bleeding (≥3 hemarthroses in a single joint during a 6-month treatment period) (P<0.001). Thirty-three randomly assigned patients received at least one infusion of the study drug and were evaluated for safety. One patient had an allergic reaction to the study drug. CONCLUSIONS AICC prophylaxis at the dosage evaluated significantly and safely decreased the frequency of joint and other bleeding events in patients with severe hemophilia A and factor VIII inhibitors. (Funded by Baxter BioScience; Pro-FEIBA ClinicalTrials.gov number, NCT00221195.).
Collapse
Affiliation(s)
- Cindy Leissinger
- Louisiana Center for Bleeding and Clotting Disorders, Tulane University, New Orleans, LA, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Singleton T, Kruse-Jarres R, Leissinger C. Emergency Department Care for Patients with Hemophilia and Von Willebrand Disease. J Emerg Med 2010; 39:158-65. [DOI: 10.1016/j.jemermed.2007.12.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2006] [Revised: 12/14/2007] [Accepted: 12/23/2007] [Indexed: 11/15/2022]
|
38
|
Slichter SJ, Kaufman RM, Assmann SF, McCullough J, Triulzi DJ, Strauss RG, Gernsheimer TB, Ness PM, Brecher ME, Josephson CD, Konkle BA, Woodson RD, Ortel TL, Hillyer CD, Skerrett DL, McCrae KR, Sloan SR, Uhl L, George JN, Aquino VM, Manno CS, McFarland JG, Hess JR, Leissinger C, Granger S. Dose of prophylactic platelet transfusions and prevention of hemorrhage. N Engl J Med 2010; 362:600-13. [PMID: 20164484 PMCID: PMC2951321 DOI: 10.1056/nejmoa0904084] [Citation(s) in RCA: 436] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We conducted a trial of prophylactic platelet transfusions to evaluate the effect of platelet dose on bleeding in patients with hypoproliferative thrombocytopenia. METHODS We randomly assigned hospitalized patients undergoing hematopoietic stem-cell transplantation or chemotherapy for hematologic cancers or solid tumors to receive prophylactic platelet transfusions at a low dose, a medium dose, or a high dose (1.1x10(11), 2.2x10(11), or 4.4x10(11) platelets per square meter of body-surface area, respectively), when morning platelet counts were 10,000 per cubic millimeter or lower. Clinical signs of bleeding were assessed daily. The primary end point was bleeding of grade 2 or higher (as defined on the basis of World Health Organization criteria). RESULTS In the 1272 patients who received at least one platelet transfusion, the primary end point was observed in 71%, 69%, and 70% of the patients in the low-dose group, the medium-dose group, and the high-dose group, respectively (differences were not significant). The incidences of higher grades of bleeding, and other adverse events, were similar among the three groups. The median number of platelets transfused was significantly lower in the low-dose group (9.25x10(11)) than in the medium-dose group (11.25x10(11)) or the high-dose group (19.63x10(11)) (P=0.002 for low vs. medium, P<0.001 for high vs. low and high vs. medium), but the median number of platelet transfusions given was significantly higher in the low-dose group (five, vs. three in the medium-dose and three in the high-dose group; P<0.001 for low vs. medium and low vs. high). Bleeding occurred on 25% of the study days on which morning platelet counts were 5000 per cubic millimeter or lower, as compared with 17% of study days on which platelet counts were 6000 to 80,000 per cubic millimeter (P<0.001). CONCLUSIONS Low doses of platelets administered as a prophylactic transfusion led to a decreased number of platelets transfused per patient but an increased number of transfusions given. At doses between 1.1x10(11) and 4.4x10(11) platelets per square meter, the number of platelets in the prophylactic transfusion had no effect on the incidence of bleeding. (ClinicalTrials.gov number, NCT00128713.)
Collapse
|
39
|
Kruse-Jarres R, Barnett B, Leissinger C. Immune tolerance induction for the eradication of inhibitors in patients with hemophilia A. Expert Opin Biol Ther 2008; 8:1885-96. [DOI: 10.1517/14712590802515537] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
40
|
Teitel J, Berntorp E, Collins P, D'Oiron R, Ewenstein B, Gomperts E, Goudemand J, Gringeri A, Key N, Leissinger C, Monahan P, Young G. A systematic approach to controlling problem bleeds in patients with severe congenital haemophilia A and high-titre inhibitors. Haemophilia 2007; 13:256-63. [PMID: 17498074 DOI: 10.1111/j.1365-2516.2007.01449.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
UNLABELLED The presence of inhibitory antibodies to clotting factors complicates the treatment of bleeding in haemophilia patients. For patients with high-titre inhibitors, bypassing agents are essential to haemostatic management. To determine optimal treatment practices, an international panel of physicians convened to develop a systematic treatment approach for problem bleeds (i.e. bleeds that are unresponsive to initial therapy with a single agent within a reasonable amount of time) in haemophilia patients with inhibitors. AIM The goal of this panel was to develop a consensus algorithm that would aid physicians in considering a variety of treatment approaches to optimize patient care by preventing extensive therapy with inadequate treatments that may lead to suboptimal patient outcomes and unnecessary costs. METHODS Consensus opinions were analyzed for clinical preferences at different time periods, depending on patient response to treatment. Decision-making points were defined based on the type of bleed: every 8-12 h for the first 24 h, then every 24 h thereafter for limb-threatening bleeds; every 2-4 h for 2-7 days for life-threatening bleeds. RESULTS The resultant consensus guidelines provide a generalized methodology to guide the treatment of problem bleeds in patients with severe haemophilia A and inhibitors, and emphasize changing treatment at the first sign of an inadequate haemostatic response. The treatment algorithms apply to both paediatric and adult patients, although the differences between the two groups were reviewed. CONCLUSION These guidelines are focused on optimising the timing of treatment decisions, which may lead to faster responses and improved outcomes.
Collapse
Affiliation(s)
- J Teitel
- St Michael's Hospital, Toronto, ON, Canada.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Manco-Johnson MJ, Abshire TC, Shapiro AD, Riske B, Hacker MR, Kilcoyne R, Ingram JD, Manco-Johnson ML, Funk S, Jacobson L, Valentino LA, Hoots WK, Buchanan GR, DiMichele D, Recht M, Brown D, Leissinger C, Bleak S, Cohen A, Mathew P, Matsunaga A, Medeiros D, Nugent D, Thomas GA, Thompson AA, McRedmond K, Soucie JM, Austin H, Evatt BL. Prophylaxis versus episodic treatment to prevent joint disease in boys with severe hemophilia. N Engl J Med 2007; 357:535-44. [PMID: 17687129 DOI: 10.1056/nejmoa067659] [Citation(s) in RCA: 1389] [Impact Index Per Article: 81.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Effective ways to prevent arthropathy in severe hemophilia are unknown. METHODS We randomly assigned young boys with severe hemophilia A to regular infusions of recombinant factor VIII (prophylaxis) or to an enhanced episodic infusion schedule of at least three doses totaling a minimum of 80 IU of factor VIII per kilogram of body weight at the time of a joint hemorrhage. The primary outcome was the incidence of bone or cartilage damage as detected in index joints (ankles, knees, and elbows) by radiography or magnetic resonance imaging (MRI). RESULTS Sixty-five boys younger than 30 months of age were randomly assigned to prophylaxis (32 boys) or enhanced episodic therapy (33 boys). When the boys reached 6 years of age, 93% of those in the prophylaxis group and 55% of those in the episodic-therapy group were considered to have normal index-joint structure on MRI (P=0.006). The relative risk of MRI-detected joint damage with episodic therapy as compared with prophylaxis was 6.1 (95% confidence interval, 1.5 to 24.4). The mean annual numbers of joint and total hemorrhages were higher at study exit in the episodic-therapy group than in the prophylaxis group (P<0.001 for both comparisons). High titers of inhibitors of factor VIII developed in two boys who received prophylaxis; three boys in the episodic-therapy group had a life-threatening hemorrhage. Hospitalizations and infections associated with central-catheter placement did not differ significantly between the two groups. CONCLUSIONS Prophylaxis with recombinant factor VIII can prevent joint damage and decrease the frequency of joint and other hemorrhages in young boys with severe hemophilia A. (ClinicalTrials.gov number, NCT00207597 [ClinicalTrials.gov].).
Collapse
|
42
|
Di Paola J, Aledort L, Britton H, Carcao M, Grabowski E, Hutter J, Journeycake J, Kempton C, Leissinger C. Application of current knowledge to the management of bleeding events during immune tolerance induction. Haemophilia 2006; 12:591-7. [PMID: 17083508 DOI: 10.1111/j.1365-2516.2006.01343.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The development of inhibitors to factor VIII is the most serious adverse event associated with the treatment of haemophilia A, predisposing patients to uncontrollable haemorrhage, disability and premature death. Eradication of inhibitors via immune tolerance induction (ITI) is effective in the majority of patients, but may require months to years to achieve success. In the interim, the treatment and prevention of acute bleeding episodes are primary foci of care. Regrettably, there is a paucity of information regarding management of bleeding episodes in inhibitor patients undergoing tolerization. Until specific data from ongoing clinical trials are available to provide more guidance in this patient group, it is reasonable and useful to rely on the broader base of medical literature pertaining to patients not being tolerized to deduce strategies for controlling acute and perioperative bleeding episodes in inhibitor patients during ITI.
Collapse
Affiliation(s)
- J Di Paola
- Department of Pediatrics, University of Iowa, Iowa City, IA 52242, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Abstract
Managing hemophilia becomes particularly difficult in patients with inhibitory antibodies, especially in those requiring surgery or with refractory bleeding events. Equally challenging are those patients who develop autoantibodies against factor VIII (FVIII) in the absence of a prior history of FVIII deficiency (acquired hemophilia). Physicians seeking both short- and long-term treatment strategies for bleeding events must often rely on FVIII-bypassing agents such as activated prothrombin complex concentrate (e.g., factor eight bypassing activity [FEIBA VH, Baxter BioScience, Westlake Village, CA]) or recombinant factor VIIa (rFVIIa [NovoSeven, NovoNordisk, Bagsvaerd, Denmark]). Surgical procedures in patients with inhibitors present a considerable challenge, from both a risk-benefit and a cost-benefit aspect. Hemostasis is difficult to achieve in these patients and new treatment options are being explored. Similarly challenging are refractory bleeds, the management of which is likely to benefit from a systematic treatment approach.
Collapse
|
44
|
Leissinger C, Nuss R, Wulff K, Giambartolomei S, Raith C, Urbancik W, Spotts G. Pilot introduction study of a needleless transfer device (BAXJECT) for reconstitution of Factor VIII concentrates for infusion. J Thromb Haemost 2003. [DOI: 10.1111/j.1538-7836.2003.tb03528.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
45
|
Hoots WK, Leissinger C, Stabler S, Schwartz BA, White G, Dasani H, Massion C, Negrier C, Schindel F, Schulman S. Continuous intravenous infusion of a plasma-derived factor IX concentrate (Mononine) in haemophilia B. Haemophilia 2003; 9:164-72. [PMID: 12614367 DOI: 10.1046/j.1365-2516.2003.00721.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This prospective, multicentre, open-label study evaluated the efficacy and safety of a plasma-derived factor IX concentrate [Mononine, Coagulation Factor IX (Human) Monoclonal Antibody Purified] administered by continuous intravenous (CIV) infusion to patients with haemophilia B. Admission criteria included documented diagnosis of haemophilia B (mild, moderate, or severe). Twenty-eight patients (25 surgery, two trauma, one severe spontaneous haemorrhage) were enrolled to receive a therapeutic bolus dose followed by CIV infusion of factor IX (FIX) to maintain FIX:C plasma levels of 0.4-1.0 IU mL(-1) (i.e. 40-100%). A median intravenous bolus dose of 54.2 IU kg(-1) FIX was administered to a subset of 13 non-emergency patients 7-21 days prior to CIV infusion to determine pharmacokinetic parameters in order to guide the dosing for CIV. For treatment, a bolus injection (median FIX dose; 89.6 IU kg(-1)) (range, 12.4-108.3), followed by a median total CIV infusion dose of 396.4 IU kg(-1) (range, 44.9-785.5) was administered at a median rate of 3.84 IU kg(-1) h(-1) (range, 1.74-7.33) for 107.17 h (range, 31.75-144). Twenty-four patients completed 72-120 h of FIX CIV infusion. Overall, 'excellent' (i.e. achievement of normal haemostasis) efficacy was reported in 23 of 24 (96%) evaluable patients, and 'good' (i.e. slight oozing) efficacy was reported in one (4%) patient. Median FIX:C was 72-86% for all patients receiving FIX by CIV on all days. Nine patients reported 13 adverse events that were possibly related to study medication but were not deemed serious by the investigator and were mainly because of local irritation at the infusion site. FIX CIV infusion therapy is safe and effective in the treatment of haemophilia B patients undergoing surgery, exposed to trauma, or experiencing severe spontaneous haemorrhage.
Collapse
Affiliation(s)
- W K Hoots
- University of Texas, Houston Health Science Center, Houston, TX 77030, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Abstract
Blood-borne hepatitis is a well-known complication in patients with bleeding disorders. A recently discovered parentally transmitted virus, hepatitis G [GB virus C (GBV-C)] has an increased prevalence in patients with haemophilia. Clotting factor concentrates derived from pools of human plasma currently undergo viral inactivation techniques known to be effective against hepatitis B, C and HIV; however, the effectiveness of current purification and viral inactivation techniques against newly discovered viruses such as GBV-C is unknown. A total of 37 vials of clotting factor concentrates manufactured in the USA from 1981 to 1995 were tested for the presence of GBV-C virus. All samples that did not undergo a specific viral inactivation step were positive for GBV-C. Viral inactivation techniques that did not uniformly remove GBV-C included vapour heat treatment and dry heat treatments for less than 144 h. All samples treated by pasteurization, solvent detergent or dry heat for 144 h, were negative for the presence of GBV-C.
Collapse
Affiliation(s)
- E Alonso-Rubiano
- Department of Pediatric Gastroenterology, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | | | | | | | | |
Collapse
|
47
|
Abstract
Chronic proliferative synovitis secondary to haemathroses is a major complication in patients with severe haemophilia. Current management strategies include prophylactic infusions of the missing coagulation factor, corticosteroids, synoviorthesis and/or synovectomy with variable degrees of benefit. In addition, patients with coagulation factor inhibitors are not amenable to the invasive therapeutic modalities. The gross and microscopic findings of the synovitis in haemophilic arthritis are remarkably similar to those seen in patients with rheumatoid arthritis, although the pathophysiology of these two conditions are quite different. Haemophilic arthropathy, in the later stages, resembles degenerative rather than inflammatory joint disease. Oral D-penicillamine, a drug effective in the proliferative synovitis of rheumatoid arthritis, was evaluated in 16 patients. Ten patients had an unequivocal response, while three had a reduction in palpable synovium and three had no response. Thus 81% of the patients had a beneficial response. Minor reversible drug side-effects occurred in two patients (proteinuria in one and a rash in the second). The results of this study suggest that D-penicillamine is an effective and safe drug for the treatment of haemophilic chronic synovitis.
Collapse
Affiliation(s)
- J J Corrigan
- Mountain States Regional Hemophilia Center at the University of Arizona Health Sciences Center, Tucson, AZ 70112, USA
| | | | | | | |
Collapse
|
48
|
Brown SA, Aledort LM, Astermark J, Berntorp E, van den Berg M, Blanchette V, Donfield S, Gringeri A, Hilgartner M, Kulkarni R, Leissinger C, Negrier C, Nuss R, Petterson H, Petrini P, Poulios N, Schramm W. Unresolved issues in prophylaxis. Haemophilia 2002; 8:817-21. [PMID: 12410654 DOI: 10.1046/j.1365-2516.2002.00685.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- S A Brown
- Katharine Dormandy Haemophilia Centre & Haemostasis Unit, Royal Free Hospital, London, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Kreuz W, Leissinger C, Oldenburg J, Lusher J, Kelleher J, Gorina E, Kellermann E, Larson P. Inhibitor development and FVIII gene mutation analysis in a pediatric cohort treated with sucrose formulated, full-length recombinant Factor VIII. Haemophilia 2002. [DOI: 10.1046/j.1365-2516.2002.d01-2_4.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
50
|
Goedert JJ, Eyster ME, Lederman MM, Mandalaki T, De Moerloose P, White GC, Angiolillo AL, Luban NLC, Sherman KE, Manco-Johnson M, Preiss L, Leissinger C, Kessler CM, Cohen AR, DiMichele D, Hilgartner MW, Aledort LM, Kroner BL, Rosenberg PS, Hatzakis A. End-stage liver disease in persons with hemophilia and transfusion-associated infections. Blood 2002; 100:1584-9. [PMID: 12176875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
Abstract
Many persons with hemophilia were infected with hepatitis C and B viruses (HCV, HBV) and HIV, but the consequences of these transfusion-acquired infections are poorly defined. We estimated the risk of HCV-related end-stage liver disease (ESLD) and the associations of age, HBV, and HIV with that risk. All 1816 HCV-seropositive hemophilic patients at 16 centers were followed for up to 16 years. Of these, 624 were HIV(-) and 1192 were HIV-coinfected; 135 had persistent HBV surface antigenemia, 1374 had resolved HBV infection, and 287 were HBV-uninfected. ESLD was defined as bleeding esophageal varices, hepatic encephalopathy, persistent ascites, or death excluding nonhepatic causes of these conditions. Competing risk models were used to estimate the annual hazard rate and cumulative incidence of ESLD. Proportional hazards models were used to estimate relative hazards of ESLD with covariates. ESLD developed in 127 of the HCV/HIV-coinfected participants, with an estimated 16-year cumulative incidence of 14.0% (95% confidence interval [CI], 11.6%-16.4%). Without HIV, 10 HCV-infected participants developed ESLD, for a significantly lower cumulative incidence of 2.6% (95% CI, 1.0%-4.3%, P <.0001). ESLD risk increased steeply with age in both groups. With HIV, ESLD risk was increased 8.1-fold (95% CI, 1.9-35.2) with HBV surface antigenemia, 2.1-fold (95% CI, 1.3-3.3) with fewer than 0.2 x 10(9)/L (200/microL) CD4(+) lymphocytes, and 1.04-fold (95% CI, 1.03-1.06) per year of age. Thus, HIV is associated with a markedly increased risk of HCV-related ESLD for persons with hemophilia, particularly with HBV infection, low CD4(+) lymphocytes, or older age.
Collapse
Affiliation(s)
- James J Goedert
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|