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Josset L, Leuci A, Janbain M, De-Wreede A, Desage S, Lienhart A, Bin V, Lambert D, Delavenne X, Dargaud Y. Multicenter evaluation of the haemostatic activity of emicizumab in patients with severe haemophilia A. J Thromb Haemost 2024:S1538-7836(24)00181-8. [PMID: 38583717 DOI: 10.1016/j.jtha.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 02/19/2024] [Accepted: 03/25/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Emicizumab has been approved for the prophylaxis of patients with hemophilia A with or without inhibitors. However, spontaneous and trauma-induced breakthrough bleeds have been reported in patients on emicizumab prophylaxis and no laboratory assay is validated to evaluate the hemostatic activity of emicizumab . OBJECTIVES The thrombin generation assay (TGA) could be a surrogate marker of the hemostatic efficacy of emicizumab. The correlation between TGA and the methods used to measure emicizumab blood concentration was evaluated in this study. METHODS TGA was modified by the use of a trigger reagent combining a very low concentration of tissue factor (TF) and activated factor XI (FXIa). Emicizumab quantification was performed by three methods, the modified one-step factor VIII (FVIII) assay, and two methods based on liquid chromatography and mass spectrometry (LC-MS). RESULTS Using TF/FXIa-triggered TGA and platelet-poor plasma, a relationship was observed between the area under the thrombin generation curve (ETP) and the clinical response of patients to emicizumab. The ultrastructure of fibrin clots was consistent with ETP results and showed that emicizumab had a hemostatic activity equivalent to 20-30 IU/dL of factor VIII. Finally, pharmacokinetic/pharmacodynamic analyses showed no correlation between ETP and LC-MS nor with modified one-stage FVIII assay, but a statistically significant correlation between the LC-MS methods and the time to peak results of TGA. CONCLUSION Using a modified TGA, this study showed that patients who experienced breakthrough bleeds while on emicizumab had a lower thrombin generating capacity compared to others with good clinical response to emicizumab.
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Affiliation(s)
- Laurie Josset
- UR4609 - Hémostase et Thrombose, Université Claude Bernard Lyon I, Lyon, France; INSERM, UMR 1059, Dysfonction Vasculaire et de l'Hémostase, Université de Lyon, Saint-Etienne, France
| | - Alexandre Leuci
- UR4609 - Hémostase et Thrombose, Université Claude Bernard Lyon I, Lyon, France
| | - Maissaa Janbain
- Deming Department of Internal Medicine, Section of Hematology and Medical Oncology, Tulane School of Medicine, New Orleans, LA, USA
| | - Anaëlle De-Wreede
- Laboratoire d'Hémostase, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France
| | - Stephanie Desage
- Unite d'Hémostase Clinique, Hôpital Cardiologique, Hospices Civils de Lyon, Lyon, France
| | - Anne Lienhart
- Unite d'Hémostase Clinique, Hôpital Cardiologique, Hospices Civils de Lyon, Lyon, France
| | - Valérie Bin
- INSERM, UMR 1059, Dysfonction Vasculaire et de l'Hémostase, Université de Lyon, Saint-Etienne, France
| | | | - Xavier Delavenne
- INSERM, UMR 1059, Dysfonction Vasculaire et de l'Hémostase, Université de Lyon, Saint-Etienne, France
| | - Yesim Dargaud
- UR4609 - Hémostase et Thrombose, Université Claude Bernard Lyon I, Lyon, France; Unite d'Hémostase Clinique, Hôpital Cardiologique, Hospices Civils de Lyon, Lyon, France.
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Reding MT, Álvarez-Román MT, Castaman G, Janbain M, Matsushita T, Meijer K, Schmidt K, Oldenburg J. Interim analyses of the multinational real-world prospective cohort HEM-POWR study evaluating the effectiveness and safety of damoctocog alfa pegol in patients with hemophilia A. Eur J Haematol 2024; 112:286-295. [PMID: 37876046 DOI: 10.1111/ejh.14114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/26/2023] [Accepted: 09/28/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVES To assess effectiveness and safety of damoctocog alfa pegol in interim analyses of the ongoing real-world hemophilia A HEM-POWR study. METHODS HEM-POWR (NCT03932201) is a multinational Phase 4 prospective observational study. The primary objective was annualized bleeding rate (ABR) in previously treated patients (PTPs) with hemophilia A. Secondary objectives included adverse events and number of affected joints. RESULTS At data cut-off (August 17, 2022), the safety analysis set included 268 patients and the full analysis set (FAS) included 161 patients. The most common dosing regimen during observation period was prophylaxis (FAS = 158/161, 98.1%) every 3-4 days (twice weekly; FAS = 78/158, 49.4%) and a median (min, max) infusion dose of 37.5 (10, 72) IU/kg. PTPs receiving prophylactic damoctocog alfa pegol have fewer infusions compared with prior treatment. Median total ABR (Q1, Q3) was 0.0 (0.0, 1.8) and mean total ABR (SD) was 2.4 (8.2). The proportion of patients with no affected joints increased between initial visit and follow-up. No FVIII inhibitors, treatment-related adverse events, or deaths were reported. CONCLUSIONS Damoctocog alfa pegol shows effectiveness and acceptable safety, as well as consistent utilization, in real-world PTPs with hemophilia A, including in patients with non-severe hemophilia and those with a history of inhibitors. Please see video for a summary of this study.
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Affiliation(s)
- Mark T Reding
- Center for Bleeding and Clotting Disorders, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | | | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Maissaa Janbain
- Deming Department of Internal Medicine, Section of Hematology and Medical Oncology, Tulane School of Medicine, New Orleans, Louisiana, USA
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, Groningen, Netherlands
| | | | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
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Wilson HP, Pierre A, Paysse AL, Kumar N, Cooley BC, Rudra P, Dorsey AW, Polania-Villanueva D, Chatterjee S, Janbain M, Velez MC, Majumder R. Protein S antibody as an adjunct therapy for hemophilia B. Blood Adv 2024; 8:441-452. [PMID: 37773781 PMCID: PMC10827407 DOI: 10.1182/bloodadvances.2023010819] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023] Open
Abstract
ABSTRACT Hemophilia B (HB) is caused by an inherited deficiency of plasma coagulation factor IX (FIX). Approximately 60% of pediatric patients with HB possess a severe form of FIX deficiency (<1% FIX activity). Treatment typically requires replacement therapy through the administration of FIX. However, exogenous FIX has a limited functional half-life, and the natural anticoagulant protein S (PS) inhibits activated FIX (FIXa). PS ultimately limits thrombin formation, which limits plasma coagulation. This regulation of FIXa activity by PS led us to test whether inhibiting PS would extend the functional half-life of FIX and thereby prolong FIX-based HB therapy. We assayed clotting times and thrombin generation to measure the efficacy of a PS antibody for increasing FIX activity in commercially obtained plasma and plasma from pediatric patients with HB. We included 11 pediatric patients who lacked additional comorbidities and coagulopathies. In vivo, we assessed thrombus formation in HB mice in the presence of the FIXa ± PS antibody. We found an accelerated rate of clotting in the presence of PS antibody. Similarly, the peak thrombin formed was significantly greater in the presence of the PS antibody, even in plasma from patients with severe HB. Furthermore, HB mice injected with PS antibody and FIX had a 4.5-fold higher accumulation of fibrin at the thrombus induction site compared with mice injected with FIX alone. Our findings imply that a PS antibody would be a valuable adjunct to increase the effectiveness of FIX replacement therapy in pediatric patients who have mild, moderate, and severe HB.
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Affiliation(s)
- Hope P. Wilson
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
- Department of Pediatric Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Aliyah Pierre
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Ashley L. Paysse
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Narender Kumar
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Brian C. Cooley
- Department of Biochemistry and Biophysics, University of North Carolina, Chapel Hill, NC
| | | | - Adrianne W. Dorsey
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Diana Polania-Villanueva
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Sabyasachi Chatterjee
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
| | - Maissaa Janbain
- Department of Hematology & Medical Oncology, Tulane University, New Orleans, LA
| | - Maria C. Velez
- Department of Pediatric Hematology and Oncology, Children's Hospital of New Orleans, New Orleans, LA
| | - Rinku Majumder
- Department of Biochemistry and Molecular Biology, Louisiana State University Health Sciences Center, New Orleans, LA
- Department of Interdisciplinary Oncology, Louisiana State University Health Sciences Center, New Orleans, LA
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Tarantino MD, Hardesty B, Metjian A, Ortel TL, Chen J, Badejo K, Ma A, Cuker A, Rajasekhar A, Friedman KD, Janbain M. Real-world safety and effectiveness of recombinant porcine sequence factor VIII in acquired haemophilia A: A non-interventional, post-authorization safety study. Haemophilia 2023; 29:1259-1268. [PMID: 37584309 DOI: 10.1111/hae.14832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 06/29/2023] [Accepted: 07/07/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Recombinant porcine factor VIII (rpFVIII, susoctocog alfa) is indicated for the treatment of bleeding episodes in adults with acquired haemophilia A (AHA). AIM To provide long-term real-world safety and effectiveness data for rpFVIII in the management of AHA bleeding episodes. METHODS US PASS (NCT02610127) was a multicentre, uncontrolled, open-label, post-marketing safety surveillance study conducted in adults with AHA. Data were collected retrospectively or prospectively for 180 days after rpFVIII treatment. The primary outcome was the incidence of treatment-related serious adverse events (SAEs). Secondary outcomes included haemostatic effectiveness of rpFVIII and rpFVIII utilization. RESULTS Fifty-three patients were enrolled from December 2015 to June 2019 (prospective, n = 30; retrospective, n = 23). Six patients experienced seven treatment-related SAEs (incidence 12.0%). The most common treatment-related SAE was FVIII inhibition (inhibiting antibodies to rpFVIII; incidence 8.0%, 95% CI: 2.2-19.2). Five patients reported seven thromboembolic events; one was an SAE and possibly related to rpFVIII. Of bleeding events treated with rpFVIII, 80.3% (57/71) of bleeds resolved with rpFVIII. The median (range) dose of rpFVIII per infusion was 50 (10-300) units/kg, with a median (range) of 6.0 (1-140) infusions and a median (range) time from bleed onset to bleed resolution of 14.0 (2.0-132.7) days. CONCLUSION In this real-world study of rpFVIII for AHA, no new safety signals were identified compared with previous clinical trial findings. Eighty percent of bleeds resolved with rpFVIII treatment.
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Affiliation(s)
| | - Brandon Hardesty
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Ara Metjian
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Jie Chen
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Kayode Badejo
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Alice Ma
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anita Rajasekhar
- Department of Hematology/Oncology, University of Florida Health, Gainesville, Florida, USA
| | - Kenneth D Friedman
- Medical College of Wisconsin and Versiti/Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
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Janbain M, Kouides P. Managing Pregnant Women with Hemophilia and von Willebrand Disease: How Do We Provide Optimum Care and Prevent Complications? Int J Womens Health 2022; 14:1307-1313. [PMID: 36119805 PMCID: PMC9480585 DOI: 10.2147/ijwh.s273043] [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: 04/15/2022] [Accepted: 08/25/2022] [Indexed: 11/30/2022] Open
Abstract
The challenge of pregnancy can be significant to the point of being life-threatening in a woman with a bleeding disorder. Additionally there can be a risk to the fetus and the neonate. A hemostatic defect can affect the course of the pregnancy, but the impact is most feared around delivery in the immediate and the extended post partum period, requiring rapid identification and prompt referral to a hematologist for assistance in management. Identifying the type of congenital bleeding disorder and knowing its inheritance pattern is crucial during counseling prior to conception and in preparation for delivery. A comprehensive approach by a specialized and experienced team in a tertiary care center with access to adequate laboratory monitoring and therapies can facilitate the process. The multidisciplinary team should include a hematologist, an obstetrician, a pediatric hematologist, an anesthesiologist, and in select cases a clinical geneticist and a maternal fetal medicine specialist. In this review article, we will detail the diagnostic path and management of pregnancy and delivery in women with some inherited bleeding disorders, in particular those affected by hemophilia A (HA), hemophilia B (HB), and von Willebrand disease (VWD).
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Affiliation(s)
- Maissaa Janbain
- Deming Department of Internal Medicine, Section of Hematology and Medical Oncology, Tulane School of Medicine, New Orleans, LA, USA
| | - Peter Kouides
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Sanabria M, Álvarez Román MT, Castaman G, Janbain M, Matsushita T, Meijer K, Oldenburg J, Friedl S, Reding MT. Design of the HEM-POWR study: a prospective, observational study of real-world treatment with damoctocog alfa pegol in patients with haemophilia A. BMJ Open 2021; 11:e044997. [PMID: 34475142 PMCID: PMC8413870 DOI: 10.1136/bmjopen-2020-044997] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Haemophilia A is a rare bleeding disorder caused by defects in coagulation factor VIII (FVIII). Damoctocog alfa pegol (BAY 94-9027, Jivi, Bayer, Germany) is a site-specifically PEGylated, extended-half-life, recombinant FVIII, approved for use in previously treated patients (PTPs) aged ≥12 years with haemophilia A. However, a real-world evidence regarding routine clinical use of damoctocog alfa pegol is limited. METHODS AND ANALYSIS HEM-POWR is a multinational, multicentre, non-interventional, prospective, postmarketing cohort study evaluating the effectiveness and safety of real-world treatment with damoctocog alfa pegol. Estimated enrolment is ≥200 PTPs with haemophilia A, receiving damoctocog alfa pegol (on-demand, prophylaxis or intermittent prophylaxis (as per local label)), observed for 36 months. Primary outcomes are total bleeding events and annualised bleeding rate; secondary outcomes include long-term safety, joint health, pharmacokinetics, patient-reported outcomes (PROs) from validated questionnaires and perioperative haemostasis. Where applicable, reasons for switching to damoctocog alfa pegol, choice of treatment regimen and dose will also be captured. Exploratory and descriptive statistical analyses will be performed, and will be stratified by parameters including, but not limited to, prophylaxis regimen and haemophilia severity. Patients can record bleeds and consumption in electronic (e) Diaries, ePROs, and can access non-promotional study information (videos explaining study procedures) via an online patient portal. Optionally, patients can enrol in the LIFE-ACTIVE substudy designed to investigate the relationship between activity (measured by the ActiGraph CP Insight watch) and effectiveness parameters collected from HEM-POWR. ETHICS AND DISSEMINATION Study approval was obtained by local independent ethics committees and authorities in participating study centres across Europe, the Americas and Asia. Informed consent from patients or their legal representative is a requirement for participation. The study results will be submitted for publication in a peer-reviewed scientific journal and presented at scientific conferences. TRIAL REGISTRATION NUMBERS NCT03932201, EUPAS26416. PROTOCOL VERSION AND DATE V.1.2, 27 September 2019.
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Affiliation(s)
| | | | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, University Hospital Careggi, Firenze, Italy
| | - Maissaa Janbain
- Center for Bleeding and Clotting Disorders, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Tadashi Matsushita
- Department of Blood Transfusion Service, Nagoya University Hospital, Nagoya, Japan
| | - Karina Meijer
- Faculty of Medical Sciences, University Medical Centre Groningen, Groningen, Netherlands
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Hospital Bonn, Bonn, Germany
| | - Sabine Friedl
- Department of Oncology and Heamatology, Bayer AG, Berlin, Germany
| | - M T Reding
- Center for Bleeding and Clotting Disorders, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
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Jabbar AY, Baydoun H, Janbain M, Ferdinand KC. Current concepts in the management of stable ischemic heart disease and acute coronary syndrome in patients with hemophilia. Ann Transl Med 2018; 6:299. [PMID: 30211187 DOI: 10.21037/atm.2018.05.29] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Coronary artery disease (CAD), including stable ischemic heart disease (SIHD) and acute coronary syndrome (ACS), remains the leading cause of death in the US and one of the primary modalities used in the treatment of CAD is percutaneous coronary intervention (PCI). Despite the potential benefits of PCI in high risk CAD patients, the risk of hemorrhage presents a dilemma in the treatment of patients with hemophilia A and B. In an attempt to provide guidance on the management of SIHD and ACS in patients with hemophilia, we present the case of a patient with moderate hemophilia B and ACS who subsequently underwent PCI followed by a review of the associated literature.
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Affiliation(s)
- Ahmad Y Jabbar
- Department of Medicine, Tulane School of Medicine, Tulane Heart and Vascular Institute, New Orleans, LA, USA
| | - Hassan Baydoun
- Department of Medicine, Tulane School of Medicine, Tulane Heart and Vascular Institute, New Orleans, LA, USA
| | - Maissaa Janbain
- Department of Medicine, Tulane School of Medicine, Tulane Heart and Vascular Institute, New Orleans, LA, USA
| | - Keith C Ferdinand
- Department of Medicine, Tulane School of Medicine, Tulane Heart and Vascular Institute, New Orleans, LA, USA
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Dargaud Y, Lienhart A, Janbain M, Le Quellec S, Enjolras N, Negrier C. Use of thrombin generation assay to personalize treatment of breakthrough bleeds in a patient with hemophilia and inhibitors receiving prophylaxis with emicizumab. Haematologica 2018; 103:e181-e183. [PMID: 29472355 DOI: 10.3324/haematol.2017.185330] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Yesim Dargaud
- Unite d'Hemostase Clinique, Hopital Cardiologique Louis Pradel, Lyon, France .,EA 4609-Hémostase et Cancer, UFR Laennec, Universite Claude Bernard Lyon I, France
| | - Anne Lienhart
- Unite d'Hemostase Clinique, Hopital Cardiologique Louis Pradel, Lyon, France
| | - Maissaa Janbain
- Tulane School of Medicine, Louisiana Center for Bleeding and Clotting Disorders, New Orleans, LA, USA
| | - Sandra Le Quellec
- Unite d'Hemostase Clinique, Hopital Cardiologique Louis Pradel, Lyon, France.,EA 4609-Hémostase et Cancer, UFR Laennec, Universite Claude Bernard Lyon I, France
| | - Nathalie Enjolras
- EA 4609-Hémostase et Cancer, UFR Laennec, Universite Claude Bernard Lyon I, France
| | - Claude Negrier
- Unite d'Hemostase Clinique, Hopital Cardiologique Louis Pradel, Lyon, France.,EA 4609-Hémostase et Cancer, UFR Laennec, Universite Claude Bernard Lyon I, France
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Abstract
BACKGROUND People with hemophilia A or B with inhibitors are at high risk of bleeding complications. Infusion of bypassing agents, such as recombinant activated FVII (rFVIIa) and plasma-derived activated prothrombin complex concentrate, are suggested as alternative therapies to factor VIII (haemophilia A) or IX (haemophilia B) for individuals who no longer respond to these treatments because they develop inhibitory antibodies. The ultimate goal of treatment is to preserve the individual's joints, otherwise destroyed by recurrent bleeds. OBJECTIVES To assess the effects of bypassing agent prophylaxis to prevent bleeding in people with hemophilia A or B and inhibitors. SEARCH METHODS We searched for relevant studies from the Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, comprising of references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also searched trial registries (16 February 2017) and bibliographic references of retrieved studies were reviewed for potential articles to be included in the review.Date of the last search of the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register: 12 December 2016. SELECTION CRITERIA We included randomized and quasi-randomized controlled studies (cross-over or parallel design) evaluating the effect of prophylaxis treatment with bypassing agents compared with on-demand treatment, or studies evaluating the effects of high-dose compared with low-dose prophylaxis in males of any age with hemophilia with inhibitors. DATA COLLECTION AND ANALYSIS Two authors independently selected studies and extracted data and assessed the risk of bias according to standard Cochrane criteria. They assessed the quality of the evidence using the GRADE criteria. MAIN RESULTS We included four randomized studies (duration 7 to 15 months) involving 116 males. Risk of bias was judged to be high in two studies due to the open-label study design and in one study due to attrition bias.Two studies compared on-demand treatment to prophylaxis with bypassing agents. In one study (34 males) prophylaxis significantly reduced mean overall bleeding rates, MD - 7.27 (95% CI -9.92 to -4.62) (low quality evidence), mean number of overall bleeding events per month, MD -1.10 (95% CI -1.54 to -0.66), mean number of hemarthrosis, MD -6.60 (95% CI -9.32 to -3.88) (low quality evidence) and mean number of joints that had hemarthrosis, MD -0.90 (95% CI -1.36 to -0.44). The meta-analysis did not conclusively demonstrate significant benefit of prophylaxis on health-related quality of life as measured by Haem-A-QoL score, EQ-5D total score and utility score, EQ-5D VAS and SF-36 physical summary and mental summary score (low quality evidence for all health-related quality of life analyses).The remaining two studies compared dose regimens. The results from one study (22 males) did not conclusively demonstrate benefit or harm of high-dose versus low-dose recombinant activated factor VIIa (rFVIIa) as a prophylaxis for overall bleeding rate, MD -0.82 (95% CI -2.27 to 0.63) (moderate quality evidence), target joint bleeding rate, MD -3.20 (95% CI -7.23 to 0.83) (moderate quality evidence) and serious adverse events, RR 9.00 (95% CI, 0.54 to 149.50) (moderate quality evidence).The overall quality of evidence was moderate to low due to imprecision from limited information provided by studies with small sample sizes and incomplete outcome data in one study. AUTHORS' CONCLUSIONS The evidence suggests that prophylaxis with bypassing agents may be effective in reducing bleeding in males with hemophilia with inhibitors. However, there is a lack of evidence for the superiority of one agent over the other or for the optimum dosage regimen. Further studies are needed to evaluate the benefits and harms of prophylaxis treatment on health-related quality of life, as well as the effects of dose of bypassing agents on the outcomes.
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Affiliation(s)
| | - Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Mindy L Simpson
- Rush University Medical CenterSection of Pediatric Hematology/Oncology1653 W Congress ParkwayChicagoUSAIL 60612
| | - Maissaa Janbain
- Tulane University School of MedicineDepartment of Hematology & Medical Oncology1430 Tulane AvenueNew OrleansLouisianaUSALA 70112
| | - Barbara A Konkle
- 921 Terry AvenueBloodworks North WestSeattleWashingtonUSAWA 98104
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Janbain M, Pipe S. What is the role of an extended half-life product in immune tolerance induction in a patient with severe hemophilia A and high-titer inhibitors? Hematology Am Soc Hematol Educ Program 2016; 2016:648-649. [PMID: 27913541 PMCID: PMC6142440 DOI: 10.1182/asheducation-2016.1.648] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
A 10-year-old boy presents with a history of severe hemophilia A and high-titer inhibitor that had failed high-dose immune tolerance induction (ITI) with a recombinant factor VIII (rFVIII) product and a plasma-derived FVIII product. You are asked by his mother whether he should be tried on ITI with an extended half-life product, in particular, consideration of a rFVIIIFc concentrate.
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Affiliation(s)
- Maissaa Janbain
- Section of Hematology and Medical Oncology, Department of Internal Medicine, Tulane School of Medicine, New Orleans, LA
| | - Steven Pipe
- Division of Pediatric Hematology and Oncology, University of Michigan, Ann Arbor, MI
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Abstract
Acquired hemophilia A is a rare autoimmune disorder caused by an autoantibody (inhibitor) to factor VIII (FVIII) that interferes with its coagulant function and predisposes to severe, potentially life-threatening hemorrhage. Disease management focuses on controlling bleeding, primarily with the use of bypassing therapy and recombinant porcine FVIII, and permanently eradicating the autoantibody using various immunosuppressants. Treatment challenges include delayed diagnosis, difficulty achieving hemostasis and durable remissions, and complications associated with the use of hemostatic and immunosuppressive therapy in a primarily older patient population.
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Affiliation(s)
- Maissaa Janbain
- Louisiana Center for Bleeding and Clotting Disorders, Tulane University Medical Center, New Orleans, LA, USA
| | - Cindy A Leissinger
- Louisiana Center for Bleeding and Clotting Disorders, Tulane University Medical Center, New Orleans, LA, USA
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12
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Janbain M, Nugent DJ, Powell JS, St-Louis J, Frame VB, Leissinger CA. Use of Factor XIII (FXIII) concentrate in patients with congenital FXIII deficiency undergoing surgical procedures. Transfusion 2014; 55:45-50. [PMID: 25070582 DOI: 10.1111/trf.12784] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 05/22/2014] [Accepted: 05/23/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with congenital Factor XIII (FXIII) deficiency have impaired fibrin stabilization and are at high risk for surgical bleeding. Data regarding the use of FXIII concentrates before and during surgery are lacking. The objective of this study was to report the use of plasma-derived FXIII concentrate (Corifact in the United States; Fibrogammin P in other countries) in patients with congenital FXIII deficiency undergoing surgical procedures. STUDY DESIGN AND METHODS FXIII concentrate at preoperative doses ranging from 25 to 40 U/kg was administered to six patients with congenital FXIII deficiency undergoing major or minor surgeries. RESULTS FXIII concentrate was administered immediately before surgery for five surgical cases; three of these patients achieved excellent hemostasis during and after surgery, while two had intraoperative bleeding. In one surgical case, a regular prophylactic dose of FXIII concentrate was administered to the patient 1 week before minor surgery. FXIII concentrate provided rapid replacement of FXIII activity. In all but one of the patients given a dose of FXIII designed to increase FXIII levels more than 50%, there was satisfactory intraoperative and postoperative hemostasis. One patient undergoing aortic valve replacement on cardiopulmonary bypass (CPB) was the exception. Intraoperative bleeding in this patient was associated with lower-than-expected blood levels of FXIII. CONCLUSION Preoperative plasma-derived FXIII concentrate allowed for sufficient hemostasis in most patients with FXIII deficiencies. Additional doses were necessary to achieve hemostasis in one patient who underwent a CPB procedure.
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Affiliation(s)
- Maissaa Janbain
- Tulane University School of Medicine, New Orleans, Louisiana, Canada
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Saba N, Saba J, Janbain M, Bitar C, Lipsky A, Blaya M. Cancer of the Indiana Pouch: a case report and review of the literature. Clin Genitourin Cancer 2013; 11:e30-4. [PMID: 24075928 DOI: 10.1016/j.clgc.2013.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 06/01/2013] [Accepted: 07/31/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Nakhle Saba
- Section of Hematology and Medical Oncology, Department of Medicine, Tulane University, New Orleans, LA
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Saba NS, Dang D, Saba J, Cao C, Janbain M, Maalouf B, Safah H. Bortezomib in Plasmablastic Lymphoma: A Case Report and Review of the Literature. ACTA ACUST UNITED AC 2013; 36:287-91. [DOI: 10.1159/000350325] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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