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Miesbach W, Konkle B, Chowdary P, Kaczmarek R, Leebeek F, Mahlangu J, Makris M, Pipe SW, Srivastava A, Voorberg J, Pierce GF, Peyvandi F. Recommendations for a minimum data set for monitoring gene therapy in hemophilia: communication from the ISTH SSC Working Group on Gene Therapy. J Thromb Haemost 2024; 22:1510-1515. [PMID: 38242208 DOI: 10.1016/j.jtha.2023.12.039] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/14/2023] [Accepted: 12/29/2023] [Indexed: 01/21/2024]
Abstract
Independent data collection is crucial in addressing the challenges associated with gene therapy for hemophilia, which is a promising treatment option but requires careful monitoring and management of short-term and potential long-term safety concerns. The International Society on Thrombosis and Haemostasis has identified a minimum efficacy and safety data set included in the World Federation of Hemophilia Gene Therapy Registry that should be collected on a national basis at specific time points for each patient who has been treated with the gene therapy products. This Gene Therapy Minimum Data Set (GT-MDS) was developed to facilitate data collection and to ensure capturing the most relevant data and most known and unknown safety and efficacy parameters recently cited by the European Medicine Agencies. The concept of assembling a minimum data set is not about creating a new data set but rather about identifying a subset of critical and essential topics that should always be included. The GT-MDS is structured into 3 sections and comprises an abridged list of 6 topics during routine gene therapy follow-up, keeping the number of data points low but allowing for rapid and independent data evaluation. The World Federation of Hemophilia Gene Therapy Registry data set, developed by the World Federation of Hemophilia, the International Society on Thrombosis and Haemostasis, and other organizations, including industry partners in 2020, is comprehensive. The GT-MDS reports the minimum relevant information that should not be lost and is mandatory to be collected for all patients who undergo gene therapy. Therefore, the implementation of the gene therapy registry and the minimum data set empowers and enhances data collection at a global level.
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Affiliation(s)
- Wolfgang Miesbach
- Medical Clinic 2, University Hospital Frankfurt, Frankfurt, Germany.
| | - Barbara Konkle
- Bloodworks Northwest, Seattle, Washington, USA; University of Washington - Medicine, Seattle, Washington, USA
| | - Pratima Chowdary
- Royal Free Hospital, Katharine Dormandy Haemophilia and Thrombosis Centre, London, United Kingdom of Great Britain and Northern Ireland
| | - Radoslaw Kaczmarek
- Herman B Wells Center for Pediatric Research Indiana University School of Medicine, Indianapolis, Indiana, USA; Ludwik Hirszfeld Polish Academy of Sciences, Institute of Immunology and Experimental Therapy, Wroclaw, Poland
| | - Frank Leebeek
- Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Michael Makris
- Royal Hallamshire Hospital, Sheffield Haemophilia and Thrombosis Centre, Sheffield, United Kingdom of Great Britain and Northern Ireland
| | | | | | | | | | - Flora Peyvandi
- Universita degli Studi di Milano, Milano, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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2
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Lentz SR, Chowdary P, Gil L, Lopez-Jaime FJ, Mahlangu J, Matytsina I, Nielsen AL, Windyga J. FRONTIER1: a partially randomized phase 2 study assessing the safety, pharmacokinetics, and pharmacodynamics of Mim8, a factor VIIIa mimetic. J Thromb Haemost 2024; 22:990-1000. [PMID: 38142846 DOI: 10.1016/j.jtha.2023.12.016] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 12/26/2023]
Abstract
BACKGROUND Mim8 (denecimig) is a factor VIII (FVIII) mimetic bispecific antibody in development for the treatment of hemophilia. Data from the phase 1 part of FRONTIER1 (EudraCT: 2019-000465-20, NCT04204408, and NN7769-4513) suggested that Mim8 was well tolerated in healthy participants and exhibited pharmacokinetic (PK) properties consistent with dose proportionality. OBJECTIVES The partially randomized, phase 2, multiple ascending dose (MAD) part of FRONTIER1 aimed to evaluate the safety, PK, pharmacodynamics (PD), and exploratory efficacy of Mim8 in participants with hemophilia A with or without FVIII inhibitors. METHODS The MAD part of FRONTIER1 consisted of 42 participants, assigned to 5 cohorts, with participants in cohorts 3 and 4 randomized 1:1 to dosing weekly or every 4 weeks, respectively. Four of the 42 participants (9.5%) had FVIII inhibitors prior to study enrolment. The primary endpoint was treatment-emergent adverse events (TEAEs). PK and PD were evaluated by Mim8 plasma concentration and thrombin generation, respectively. Exploratory efficacy was assessed via the number of treated bleeds. Safety and PD parameters were also evaluated from an exploratory cohort treated with emicizumab. RESULTS Mim8 was well tolerated, with 1 serious TEAE (anxiety-related chest pain) deemed unrelated to Mim8. There was no dose dependency on the number, causality, type, or severity of TEAEs. PK/PD properties supported weekly to monthly dosing approaches, and few participants experienced treated bleeds beyond the lowest dose cohort (1 in cohorts 2 and 3, and 3 in cohort 5). CONCLUSION These data support the continued clinical development of Mim8, and FRONTIER1 has proceeded onto an extension phase.
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Affiliation(s)
- Steven R Lentz
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA.
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznań University of Medical Sciences, Poznań, Poland
| | | | - Johnny Mahlangu
- University of the Witwatersrand, National Health Laboratory Service, and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | | | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
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Chowdary P, Ofori-Asenso R, Nissen F, Grazzi EF, Aizenas M, Moreno K, Burke T, Nolan B, O'Hara J, Khair K. Disease Burden, Clinical Outcomes, and Quality of Life in People with Hemophilia A without Inhibitors in Europe: Analyses from CHESS II/CHESS PAEDs. TH Open 2024; 8:e181-e193. [PMID: 38628421 PMCID: PMC11018388 DOI: 10.1055/s-0044-1785524] [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: 11/22/2023] [Accepted: 03/04/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction Limited data relating to treatment burden, quality of life, and mental health burden of hemophilia A (HA) are currently available. Aim To provide a comprehensive overview of unmet needs in people with HA (PwHA) using data generated from the Cost of Haemophilia in Europe: a Socioeconomic Survey-II (CHESS II) and CHESS in the pediatric population (CHESS PAEDs) studies. Methods CHESS II and CHESS PAEDs are cross-sectional surveys of European males with HA or hemophilia B (HB) aged ≥18 and ≤17 years, respectively. Participants with FVIII inhibitors, mild HA, or HB were excluded from this analysis, plus those aged 18 to 19 years. Annualized bleeding rates (ABRs), target joints, and other patient-reported outcomes were evaluated. Results Overall, 468 and 691 PwHA with available data for the outcomes of interest were stratified by hemophilia severity and treatment regimen in CHESS II and CHESS PAEDs, respectively. In these studies, 173 (37.0%) and 468 (67.7%) participants received FVIII prophylaxis, respectively; no participants received the FVIII mimetic emicizumab or gene therapy. ABRs of 2.38 to 4.88 were reported across disease severity and treatment subgroups in both studies. Target joints were present in 35.7 and 16.6% of participants in CHESS II and CHESS PAEDS; 43.8 and 23.0% had problem joints. Chronic pain was reported by a large proportion of PwHA (73.9% in CHESS II; 58.8% in CHESS PAEDs). Participants also reported low EQ-5D scores (compared with people without HA), anxiety, depression, and negative impacts on their lifestyles due to HA. Conclusions These analyses suggest significant physical, social, and mental burdens of HA, irrespective of disease severity. Optimization of prophylactic treatment could help reduce the burden of HA on patients.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Richard Ofori-Asenso
- Real-World Data Enabling Platform, Roche Products Ltd, Welwyn Garden City, United Kingdom
| | - Francis Nissen
- Department of Real-World Data, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Enrico F. Grazzi
- Health Economics and Outcomes Research, HCD Economics, Daresbury, United Kingdom
| | - Martynas Aizenas
- Department of Access Strategy, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Katya Moreno
- Department of Product Development and Medical Affairs, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Tom Burke
- Health Economics and Outcomes Research, HCD Economics, Daresbury, United Kingdom
- Department of Health and Social Care, University of Chester, Chester, United Kingdom
| | - Beatrice Nolan
- Department of Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Jamie O'Hara
- Health Economics and Outcomes Research, HCD Economics, Daresbury, United Kingdom
- Department of Health and Social Care, University of Chester, Chester, United Kingdom
| | - Kate Khair
- Department of Research, Haemnet, London, United Kingdom
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Kaczmarek R, Miesbach W, Ozelo MC, Chowdary P. Current and emerging gene therapies for haemophilia A and B. Haemophilia 2024; 30 Suppl 3:12-20. [PMID: 38528615 DOI: 10.1111/hae.14984] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/19/2024] [Accepted: 02/26/2024] [Indexed: 03/27/2024]
Abstract
INTRODUCTION After decades of stumbling clinical development, the first gene therapies for haemophilia A and B have been commercialized and have normalized factor (F)VIII and factor (F)IX levels in some individuals in the long term. Several other clinical programs testing adeno-associated viral (AAV) vector gene therapy are at various stages of clinical testing. DISCUSSION Multiyear follow-up in phase 1/2 and 3 studies showed long-term and sometimes curative but widely variable and unpredictable efficacy. Liver toxicities, mostly low-grade, occur in the 1st year in at least some individuals in all haemophilia A and B trials and are poorly understood. Wide variability and unpredictability of outcome and slow decline of FVIII levels are a major disadvantage because immune responses to AAV vectors preclude repeat dosing, which otherwise could improve suboptimal or restore declining expression, while overexpression may predispose to thrombosis. Long-term safety outcomes will need lifelong monitoring because AAV vectors infused at high doses integrate into chromosomes at rates that raise questions about potential oncogenicity and necessitate vigilance. Alternative gene transfer systems employing gene editing and/or non-viral vectors are under development and promise to overcome some limitations of the current state of the art for both haemophilia A and B. CONCLUSIONS AAV gene therapies for haemophilia have now become new treatment options but not universal cures. AAV is a powerful but imperfect gene transfer platform. Biobetter FVIII transgenes may help solve some problems plaguing gene therapy for haemophilia A. Addressing variability and unpredictability of efficacy, and delivery of gene therapy to ineligible patient subgroups may require different gene transfer systems, most of which are not ready for clinical translation yet but bring innovations needed to overcome the current limitations of gene therapy.
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Affiliation(s)
- Radoslaw Kaczmarek
- Wells Centre for Paediatric Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Wolfgang Miesbach
- Department of Haemostasis/Haemophilia Centre, Laboratory for Coagulation Disorders, University Hospital Frankfurt, Frankfurt, Germany
| | - Margareth C Ozelo
- Hemocentro UNICAMP, Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, SP, Brazil
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
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Miesbach W, Boban A, Chowdary P, Coppens M, Crato M, Jimenez-Yuste V, Klamroth R, Makris M, Mulders G, Peyvandi F. Administration of gene therapy for haemophilia - The hub and spoke model and its regional differences and challenges. Haemophilia 2024. [PMID: 38500258 DOI: 10.1111/hae.14985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 03/20/2024]
Affiliation(s)
- Wolfgang Miesbach
- Medical Clinic 2, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Ana Boban
- Haemophilia Centre, Department of Haematology, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Michiel Coppens
- Hemophilia Treatment Center, Department of Vascular Medicine, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Miguel Crato
- European Haemopilia Consortium, Brussels, Belgium
| | - Victor Jimenez-Yuste
- Hematology Department, Hospital Universitario La Paz-IdiPaz, Autonoma University, Madrid, Spain
| | - Robert Klamroth
- Department for Internal Medicine and Vascular Medicine, Haemophilia Treatment Center, Vivantes Hospital im Friedrichshain, Berlin, Germany
| | - Mike Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Greta Mulders
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Miesbach W, Boban A, Chowdary P, Coppens M, Crato M, Jimenez-Yuste V, Klamroth R, Makris M, Mulders G, Peyvandi F. EAHAD haemophilia gene therapy clinical outcome database (EAHAD-GTD). Haemophilia 2024. [PMID: 38462796 DOI: 10.1111/hae.14981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/12/2024]
Affiliation(s)
- Wolfgang Miesbach
- Medical Clinic 2, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Ana Boban
- Department of Haematology, Haemophilia Centre, University Hospital Centre Zagreb, Zagreb, Croatia
- Haemophilia Centre, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Michiel Coppens
- Department of Vascular Medicine, Hemophilia Treatment Center, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, The Netherlands
| | - Miguel Crato
- European Haemopilia Consortium, Brussels, Belgium
| | - Victor Jimenez-Yuste
- Hematology Department, Hospital Universitario La Paz-IdiPaz, Autonoma University, Madrid, Spain
| | - Robert Klamroth
- Department for Internal Medicine and Vascular Medicine, Haemophilia Treatment Center, Vivantes Hospital im Friedrichshain, Berlin, Germany
| | - Mike Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Greta Mulders
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Mahlangu J, Jiménez-Yuste V, Ventriglia G, Niggli M, Barlera S, Hermans C, Lehle M, Chowdary P, Jew L, Windyga J, Frenzel L, Schmitt C, Castaman G, Pipe SW. Long-term outcomes with emicizumab in hemophilia A without inhibitors: results from the HAVEN 3 and 4 studies. Res Pract Thromb Haemost 2024; 8:102364. [PMID: 38559572 PMCID: PMC10978536 DOI: 10.1016/j.rpth.2024.102364] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/14/2024] [Indexed: 04/04/2024] Open
Abstract
Background Emicizumab, a bispecific monoclonal antibody, bridges activated factor (F) IX and FX, mimicking the function of missing or deficient activated FVIII in people with hemophilia A (HA). Objectives To evaluate the long-term efficacy and safety of emicizumab prophylaxis in people with HA without FVIII inhibitors in the HAVEN 3 and 4 studies. Methods HAVEN 3 and 4 were phase 3 open-label studies. Participants received emicizumab maintenance doses of 1.5 mg/kg every week or 3 mg/kg every 2 weeks (HAVEN 3), or 6 mg/kg every 4 weeks (HAVEN 4). Long-term efficacy and safety were assessed. Results A total of 151 and 40 individuals without FVIII inhibitors received emicizumab in HAVEN 3 and 4, respectively. At the last patient, last visit dates (May 12, 2022 [HAVEN 3] and June 29, 2022 [HAVEN 4]), the median (range) duration of emicizumab exposure across the 2 studies was 248.1 (6.1-287.1) weeks. The mean (95% CI) annualized bleed rate for treated bleeds was 2.0 (0.23-7.15) for weeks 1 to 24, decreasing to 0.9 (0.01-5.28) by weeks 217 to 240. Overall, 188 (98.4%) participants experienced ≥1 adverse event (AE), with 185 treatment-related AEs in 71 (37.2%) participants. Forty-four (23.0%) participants reported a serious AE. Two thromboembolic events were reported, which were deemed unrelated to emicizumab by the investigator. No thrombotic microangiopathies were reported. Conclusion With nearly 5 years of emicizumab exposure across the HAVEN 3 and 4 studies in people with HA without inhibitors, these data indicate continued bleed control with no new safety signals observed during long-term follow-up.
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Affiliation(s)
- Johnny Mahlangu
- Faculty of Health Sciences, University of the Witwatersrand, National Health Laboratory Service, Johannesburg, South Africa
| | - Víctor Jiménez-Yuste
- Jefe de Servicio de Hematología, La Paz University Hospital-IdiPaz, Autónoma University, Madrid, Spain
| | - Giuliana Ventriglia
- Oncology and Hematology Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Markus Niggli
- Product Development Data Sciences, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Simona Barlera
- Department of Biometrics, Parexel International, Milan, Italy
| | - Cédric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Catholic University of Louvain, Brussels, Belgium
| | - Michaela Lehle
- Oncology and Hematology Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Unit, Royal Free London, London, United Kingdom
| | - Lyle Jew
- Product Development Safety, Genentech, Inc. South San Francisco, California, USA
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Laurent Frenzel
- Department of Hematology, Necker-Enfants Malades Hospital, Paris, France
| | - Christophe Schmitt
- Department of Clinical Pharmacology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Steven W. Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
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Koopman SF, Goedhart TMHJ, Bukkems LH, Mulders TM, Leebeek FWG, Fijnvandraat K, Coppens M, Mathias M, Collins PW, Tait RC, Bagot CN, Curry N, Payne J, Chowdary P, Cnossen MH, Mathôt RAA. A new population pharmacokinetic model for recombinant factor IX-Fc fusion concentrate including young children with haemophilia B. Br J Clin Pharmacol 2024; 90:220-231. [PMID: 37567779 DOI: 10.1111/bcp.15881] [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: 05/25/2023] [Revised: 07/24/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
AIMS Recombinant factor IX Fc fusion protein (rFIX-Fc) is an extended half-life factor concentrate administered to haemophilia B patients. So far, a population pharmacokinetic (PK) model has only been published for patients aged ≥12 years. The aim was to externally evaluate the predictive performance of the published rFIX-Fc population PK model for patients of all ages and develop a model that describes rFIX-Fc PK using real-world data. METHODS We collected prospective and retrospective data from patients with haemophilia B treated with rFIX-Fc and included in the OPTI-CLOT TARGET study (NTR7523) or United Kindom (UK)-EHL Outcomes Registry (NCT02938156). Predictive performance was assessed by comparing predicted with observed FIX activity levels. A new population PK model was constructed using nonlinear mixed-effects modelling. RESULTS Real-world data were obtained from 37 patients (median age: 16 years, range 2-71) of whom 14 were aged <12 years. Observed FIX activity levels were significantly higher than levels predicted using the published model, with a median prediction error of -48.8%. The new model showed a lower median prediction error (3.4%) and better described rFIX-Fc PK, especially for children aged <12 years. In the new model, an increase in age was correlated with a decrease in clearance (P < .01). CONCLUSIONS The published population PK model significantly underpredicted FIX activity levels. The new model better describes rFIX-Fc PK, especially for children aged <12 years. This study underlines the necessity to strive for representative population PK models, thereby avoiding extrapolation outside the studied population.
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Affiliation(s)
- Sjoerd F Koopman
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Tine M H J Goedhart
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Laura H Bukkems
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Trevor M Mulders
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Karin Fijnvandraat
- Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Pediatric Hematology, Amsterdam, The Netherlands
| | - Michiel Coppens
- Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, The Netherlands
| | - Mary Mathias
- Haemophilia Comprehensive Care Centre, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Peter W Collins
- Arthur Bloom Haemophilia Centre, School of Medicine, Cardiff University Hospital, Cardiff, UK
| | - R Campbell Tait
- Department of Haematology, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Nicola Curry
- Oxford Haemophilia and Thrombosis Centre and Oxford NIHR BRC, Nuffield Orthopaedic Hospital, Oxford, UK
| | - Jeanette Payne
- Department of Paediatric Haematology, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Miesbach W, Halimeh S, Platokouki H, Podolak-Dawidziak M, Zdziarska J, Korczowski B, Chowdary P, Austin S, Millar C, Alamelu J, Rogosch T, Pabinger I. An open-label, multi-centre, post-marketing study to assess the efficacy and safety of a plasma-derived VWF/FVIII concentrate in patients with von Willebrand disease. Haemophilia 2024; 30:236-240. [PMID: 38030954 DOI: 10.1111/hae.14868] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Wolfgang Miesbach
- Haemophilia Centre, Medical Clinic II, Institute of Transfusion Medicine, Goethe University Hospital, Frankfurt am Main, Germany
| | | | | | - Maria Podolak-Dawidziak
- Department of Haematology, Blood Neoplasms and Bone Marrow Transplantation, Medical University of Wroclaw, Wroclaw, Poland
| | - Joanna Zdziarska
- Department of Haematology, University Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Bartosz Korczowski
- Department of Pediatrics, Institute of Medical Sciences, Medical College, University of Rzeszow, Rzeszow, Poland
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Steve Austin
- St George's Healthcare NHS Trust Haemophilia Centre, London, UK
| | - Carolyn Millar
- Imperial College, London, UK and Imperial College Healthcare NHS Trust, London, UK
| | - Jayanthi Alamelu
- Children's Haemophilia Centre, Evelina London Children's Hospital, London, UK
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Manon-Jensen T, Tangada S, Bager C, Chowdary P, Klamroth R, von Drygalski A, Windyga J, Escobar M, Frederiksen P, Engl W, Ewenstein B, Karsdal M. Evaluation of collagen turnover biomarkers as an objective measure for efficacy of treatment with rurioctocog alfa pegol in patients with hemophilia A: a secondary analysis of a randomized controlled trial. J Thromb Haemost 2024; 22:90-100. [PMID: 37717853 DOI: 10.1016/j.jtha.2023.08.035] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Patients with hemophilia who have recurrent hemarthroses develop hemophilic arthropathy (HA). Regular prophylaxis with factor (F) VIII (FVIII) can reduce HA, but there is a need for objective outcome measures to evaluate treatment efficacy. OBJECTIVES Evaluate and assess collagen turnover biomarkers in patients with hemophilia A to determine the efficacy of rurioctocog alfa pegol treatment and understand their potential as tools for guiding treatment decisions and monitoring outcomes. METHODS Joint remodeling was assessed by analyzing serum levels of collagen remodeling products at baseline and months 3, 6, 9, and 12 in a 98 patient subset receiving pharmacokinetics-guided prophylaxis with rurioctocog alfa pegol, targeting FVIII trough levels of 1 to 3 International Units (IU)/dL or 8 to 12 IU/dL (PROPEL study, NCT0285960). RESULTS Basement membrane metabolism-related type 4 collagen remodeling products (C4M and PRO-C4) decreased after 3 months at all time points by up to 25% at 1 to 3 IU/dL (P = .049, P < .0001) and 8 to 12 IU/dL FVIII trough levels (P = .0002, P < .0001). Interstitial tissue metabolism-related type 3 (C3M) and 5 (PRO-C5) collagen remodeling products decreased after 3 months, by up to 19% at 1 to 3 IU/dL FVIII trough level (P = .0001, P = .009) and 23% at 8 to 12 IU/dL FVIII trough level (P = .0002, P = .001). An increase of up to 12% was seen for cartilage metabolism-related type 2 collagen product (PRO-C2, not C2M) after 6 months at both trough levels (P = .01, P = .005). When stratified by prior treatment, changes in C3M (P = .03) and C4M (P = .02) levels were observed between trough levels for prior on-demand treatment but not for prophylaxis prior to study entry. CONCLUSION Joint improvement measured by collagen remodeling biomarkers specific to the basement membrane, interstitial matrix, and cartilage was seen with pharmacokinetics-guided prophylaxis. These collagen remodeling biomarkers warrant further exploration as biomarkers to guide treatment toward improvement in HA.
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Affiliation(s)
| | - Srilatha Tangada
- Takeda Development Center Americas, Inc, Cambridge, Massachusetts, USA
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Robert Klamroth
- Vascular Medicine and Haemostaseology, Vivantes Klinikum im Friedrichschain, Berlin, Germany
| | - Annette von Drygalski
- Hemophilia and Thrombosis Treatment Center, UC San Diego Health, San Diego, California, USA
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Miguel Escobar
- University of Texas Health and Science Center at Houston, Houston, Texas, USA
| | | | - Werner Engl
- Baxalta Innovations GmbH, a Takeda company, Vienna, Austria
| | - Bruce Ewenstein
- Takeda Development Center Americas, Inc, Cambridge, Massachusetts, USA
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11
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McLaughlin P, Hurley M, Chowdary P, Khair K, Smith C, Stephensen D. Using theory of change to co-create a programme theory for a telerehabilitation intervention for pain management in people with haemophilia. Orphanet J Rare Dis 2023; 18:376. [PMID: 38041200 PMCID: PMC10693140 DOI: 10.1186/s13023-023-02988-9] [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: 08/18/2023] [Accepted: 11/18/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Improved approaches for chronic pain management are a clinical and research priority for people with haemophilia (PWH). Involving people with lived experience in the design of a complex rehabilitation intervention strengthens the credibility and plausibility of the intervention, particularly in relation to rare disorders. Here we describe using a 'Theory of Change' (ToC) dialogue-based stakeholder process to create a programme theory for a telerehabilitation intervention. METHODS An online workshop was convened and stakeholders received a briefing document in advance. Five stakeholders took part (3 PWH and 2 physiotherapists). At the workshop the group first agreed the overall aim of the intervention. Discussions then identified the resources, activities, barriers and enablers needed to achieve this outcome. All discussions were recorded and annotated by the workshop moderator. Behaviour change techniques were mapped for inclusion in the theory. RESULTS A programme theory and narrative report were produced. All stakeholders reviewed these for clarity and to ensure a true reflection of the workshop discussions. Agreement was based on how meaningful, well-defined, do-able, plausible, credible, and testable each component was. Stakeholders highlighted the importance of issues unique to PWH. Key components included the need for physiotherapists to be knowledgeable of the condition, a range of exercises that were inclusive of all abilities, and the need for people to feel safe and supported whilst taking part. CONCLUSIONS Co-developed theory based approaches to intervention design offer an inclusive and transparent way to develop novel and meaningful interventions for people with complex health conditions. The ToC is wholly transparent in its design and content. Together with the identified behaviour change techniques, the theory informs the protocol for a feasibility study evaluating a telerehabilitation intervention. Importantly, it allows the opportunity to revise, adapt and improve the programme theory for further implementation and evaluation.
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Affiliation(s)
- Paul McLaughlin
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK.
- Department of Academic Haematology, University College, London, UK.
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
- Department of Academic Haematology, University College, London, UK
| | | | | | - David Stephensen
- School of Medicine, Health and Social Care, Canterbury Christchurch University, Canterbury, Kent, UK
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12
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Kamel KS, McLaughlin P, Chowdary P. Bone marrow oedema syndrome as a cause of chronic knee pain in a person with severe Haemophilia A. Haemophilia 2023; 29:1668-1670. [PMID: 37842756 DOI: 10.1111/hae.14889] [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: 09/06/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 10/17/2023]
Affiliation(s)
| | - Paul McLaughlin
- Katharine Dormandy Haemophilia Centre, Royal Free Hospital, London, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre, Royal Free Hospital, London, UK
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13
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Oldenburg J, Benson G, Chowdary P, Halimeh S, Matsushita T, Nørland A, Wahid MN, Nemes L. Cases of less-than-expected FVIII activity in previously treated patients during post-marketing surveillance of N8-GP. Haemophilia 2023; 29:1475-1482. [PMID: 37729439 DOI: 10.1111/hae.14864] [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: 02/10/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 09/22/2023]
Abstract
INTRODUCTION Turoctocog alfa pegol (N8-GP) is a glycoPEGylated, extended half-life (EHL), human recombinant factor VIII (FVIII) approved for the treatment and prevention of bleeding episodes in patients with haemophilia A. Since its launch in August 2019, > 800 patients have been treated worldwide. AIM To present data from identified post-marketing cases of less-than-expected FVIII activity in previously treated patients (PTPs) without inhibitors after switching to N8-GP. METHODS The post-marketing safety database was searched using keywords such as 'coagulation FVIII level decreased'. Identified cases reported prior to 13 October 2021 were included in this report. Cases in which patients had FVIII inhibitors were excluded. RESULTS Here we report 14 cases of less-than-expected FVIII activity. Details varied greatly amongst the cases. At presentation, FVIII activity ranged from 1% (15 min post-dose) to 51% (2 days post-dose). Seven patients experienced bleeding episodes after switching to N8-GP with heterogeneity in bleeding presentations. Six out of seven patients who were tested for anti-PEG IgG and/or IgM antibodies were positive. In all known cases, FVIII activity returned to the expected range when switched to an alternative FVIII replacement product. CONCLUSION In conclusion, the 14 reported cases of less-than-expected FVIII activity, without presence of detectable FVIII inhibitors, presented with heterogenous characteristics, and wide variations in FVIII activity and anti-PEG antibody titre. FVIII activity returned to the expected range after switching to alternative FVIII products. In line with WFH guidelines, monitoring of FVIII activity can ensure FVIII activity in the expected range. The safety surveillance of N8-GP continues.
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Affiliation(s)
- Johannes Oldenburg
- Institute for Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, Germany
| | - Gary Benson
- Department of Haematology, Belfast City Hospital, Belfast, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | | | - Tadashi Matsushita
- Nagoya University Hospital, Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | | | | | - Laszlo Nemes
- DepartmentMedical Center of the Hungarian Defence Forces, National Hemophilia Center and Hemostasis, Budapest, Hungary
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14
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Chowdary P, Agarwal B, Peralta MR, Bhagani S, Lee S, Goldring J, Lipman M, Waqif E, Phillips M, Philippou H, Foley JH, Mutch NJ, Ariëns RAS, Stringer KA, Ricciardi F, Watissée M, Hughes D, Nathwani A, Riddell A, Patch D, Buckley J, De Neef M, Dimber R, Diaz-Garcia C, Patel H, Nandani A, Dissanayake U, Chadwick N, Alkhatip AAAMM, Watkinson P, Raith E, Singh S, Wolff T, Jha R, Brill SE, Bakhai A, Evans A, Gilani F, Gomez K. Nebulized Recombinant Tissue Plasminogen Activator (rt-PA) for Acute COVID-19-Induced Respiratory Failure: An Exploratory Proof-of-Concept Trial. J Clin Med 2023; 12:5848. [PMID: 37762789 PMCID: PMC10531875 DOI: 10.3390/jcm12185848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/31/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
Acute lung injury in COVID-19 results in diffuse alveolar damage with disruption of the alveolar-capillary barrier, coagulation activation, alveolar fibrin deposition and pulmonary capillary thrombi. Nebulized recombinant tissue plasminogen activator (rt-PA) has the potential to facilitate localized thrombolysis in the alveolar compartment and improve oxygenation. In this proof-of-concept safety study, adults with COVID-19-induced respiratory failure and a <300 mmHg PaO2/FiO2 (P/F) ratio requiring invasive mechanical ventilation (IMV) or non-invasive respiratory support (NIRS) received nebulized rt-PA in two cohorts (C1 and C2), alongside standard of care, between 23 April-30 July 2020 and 21 January-19 February 2021, respectively. Matched historical controls (MHC; n = 18) were used in C1 to explore efficacy. Safety co-primary endpoints were treatment-related bleeds and <1.0-1.5 g/L fibrinogen reduction. A variable dosing strategy with clinical efficacy endpoint and minimal safety concerns was determined in C1 for use in C2; patients were stratified by ventilation type to receive 40-60 mg rt-PA daily for ≤14 days. Nine patients in C1 (IMV, 6/9; NIRS, 3/9) and 26 in C2 (IMV, 12/26; NIRS, 14/26) received nebulized rt-PA for a mean (SD) of 6.7 (4.6) and 9.1(4.6) days, respectively. Four bleeds (one severe, three mild) in three patients were considered treatment related. There were no significant fibrinogen reductions. Greater improvements in mean P/F ratio from baseline to study end were observed in C1 compared with MHC (C1; 154 to 299 vs. MHC; 154 to 212). In C2, there was no difference in the baseline P/F ratio of NIRS and IMV patients. However, a larger improvement in the P/F ratio occurred in NIRS patients (NIRS; 126 to 240 vs. IMV; 120 to 188) and fewer treatment days were required (NIRS; 7.86 vs. IMV; 10.5). Nebulized rt-PA appears to be well-tolerated, with a trend towards improved oxygenation, particularly in the NIRS group. Randomized clinical trials are required to demonstrate the clinical effect significance and magnitude.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Banwari Agarwal
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Maria Rita Peralta
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Sanjay Bhagani
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Simon Lee
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - James Goldring
- Respiratory Medicine, Royal Free London NHS Foundation Trust, London NW1 2BU, UK
| | - Marc Lipman
- Respiratory Medicine, Royal Free London NHS Foundation Trust, London NW1 2BU, UK
- UCL Respiratory, University College London, London WC1E 6JF, UK;
| | - Emal Waqif
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Mark Phillips
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Helen Philippou
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
| | | | - Nicola J. Mutch
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences & Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen AB25 2ZD, UK
| | - Robert A. S. Ariëns
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
| | - Kathleen A. Stringer
- Department of Clinical Pharmacy, College of Pharmacy University of Michigan, Ann Arbor, MI 48109, USA
- Division of Pulmonary and Critical Care Medicine, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Federico Ricciardi
- Department of Statistical Science, University College London, London WC1E 6BT, UK
| | | | - Derralynn Hughes
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Amit Nathwani
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
| | - Anne Riddell
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London WC1H 9AX, UK
| | - David Patch
- Department of Hepatology, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Jim Buckley
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Mark De Neef
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Rahul Dimber
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Cecilia Diaz-Garcia
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Honey Patel
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Aarti Nandani
- Clinical Trials Pharmacy, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Upuli Dissanayake
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Nick Chadwick
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Ahmed A. A. M. M. Alkhatip
- Department of Anaesthesia, Birmingham Children’s Hospital, Birmingham B4 6NH, UK
- Department of Anaesthesia, Faculty of Medicine, Beni-Suef University Hospital, Beni-Suef University, Beni-Suef 2721562, Egypt
| | - Peter Watkinson
- NIHR Biomedical Research Centre Oxford, Oxford University Hospitals NHS Trust, University of Oxford, Oxford OX3 9DU, UK
| | - Eamon Raith
- Bloomsbury Institute for Intensive Care Medicine, Department of Experimental and Translational Medicine, University College London, London WC1E 6JF, UK
- Discipline of Acute Care Medicine, School of Medicine, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Suveer Singh
- Department of Respiratory and Critical Care Medicine, Chelsea & Westminster Hospital, London SW10 9NH, UK
- Department of Adult Intensive Care, Royal Brompton Hospital, London SW3 6NP, UK
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK
| | - Tony Wolff
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Rajeev Jha
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
| | - Simon E. Brill
- UCL Respiratory, University College London, London WC1E 6JF, UK;
| | - Ameet Bakhai
- Department of Intensive Care and Anaesthesia, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Department of Cardiology, Royal Free London NHS Foundation Trust, London NW3 2PS, UK
| | - Alison Evans
- University College London (UCL)/University College London Hospitals NHS Trust (UCLH) Joint Research Office, London WC1E 6BT, UK; (A.E.)
| | - Farhat Gilani
- University College London (UCL)/University College London Hospitals NHS Trust (UCLH) Joint Research Office, London WC1E 6BT, UK; (A.E.)
| | - Keith Gomez
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London NW3 2QG, UK
- Cancer Institute, University College London, London WC1E 6DD, UK
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Escuriola-Ettingshausen C, Klamroth R, Escobar M, Stasyshyn O, Tangada S, Engl W, Honauer I, Lee HY, Chowdary P, Windyga J. Targeting an elevated FVIII level using personalized rurioctocog alfa pegol prophylaxis in specific patient populations with hemophilia A: post hoc subanalysis of the randomized, phase 3 PROPEL study. Ther Adv Hematol 2023; 14:20406207231178596. [PMID: 37465396 PMCID: PMC10350756 DOI: 10.1177/20406207231178596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 05/11/2023] [Indexed: 07/20/2023] Open
Abstract
Background The phase 3, prospective PROPEL study demonstrated that pharmacokinetic (PK)-guided prophylaxis targeting elevated factor VIII (FVIII) troughs in patients with hemophilia A resulted in lower annualized bleeding rates (ABRs) and a higher proportion of patients experiencing zero bleeds in the second 6 months of treatment when targeting a FVIII trough of 8-12% versus 1-3%. Objective To investigate the benefit of PK-guided prophylaxis with rurioctocog alfa pegol targeting two FVIII trough levels in specific patient subgroups in a post hoc analysis using data from PROPEL. Design This is a post hoc analysis of data from the PROPEL study. The design and primary outcomes of the prospective, randomized PROPEL study (NCT02585960) have been reported previously. Methods This post hoc analysis reports data stratified by FVIII half-life (t1/2), hemophilic arthropathy status, number of target joints at screening, previous treatment regimen, and ABR range in the 12 months before study entry. Results Targeting an elevated FVIII trough of 8-12% was associated with higher average FVIII levels over time, regardless of FVIII t1/2 at baseline. The decrease in total ABR between the 8-12% and 1-3% arms was greatest in patients with a FVIII t1/2 of 6 to <12 h (0.7 versus 3.5); a higher number of target joints, that is, at least four target joints, at baseline (0.2 versus 1.6); the presence of arthropathy (0.1 versus 1.7); and those previously treated on-demand (0.3 versus 1.8). Conclusion These results support the feasibility of targeting elevated FVIII levels using personalized rurioctocog alfa pegol prophylaxis. These benefits may be especially important in patients with a short FVIII t1/2 and those receiving standard prophylaxis with frequent breakthrough bleeds, arthropathy, and target joints. Registration ClinicalTrials.gov Identifier: NCT02585960; https://clinicaltrials.gov/ct2/show/NCT02585960.
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Affiliation(s)
| | | | - Miguel Escobar
- The University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Srilatha Tangada
- Takeda Development Center Americas, Inc., 650 East Kendall Street, Cambridge, MA 02142, USA
| | - Werner Engl
- Baxalta Innovations GmbH, a Takeda Company, Vienna, Austria
| | - Ivan Honauer
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | - Hye-Youn Lee
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
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16
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Chowdary P, Nissen F, Burke T, Aizenas M, Czirok T, Dhillon H, O'Hara J. The humanistic and economic burden of problem joints for children and adults with moderate or severe haemophilia A: Analysis of the CHESS population studies. Haemophilia 2023; 29:753-760. [PMID: 36897517 DOI: 10.1111/hae.14766] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 01/31/2023] [Accepted: 02/13/2023] [Indexed: 03/11/2023]
Abstract
INTRODUCTION Adequate prophylactic treatment and physical activity improve joint health and clinical outcomes for people with haemophilia A (HA). However, non-clinical joint-related burden of moderate (MHA) and severe (SHA) HA has not been well characterised. AIM To quantify the joint health-related humanistic and economic burden of MHA and SHA in Europe. METHODS A retrospective analysis of the cross-sectional CHESS population studies using a patient-centric measure of joint health (problem joints, PJs: chronic joint pain and/or limited range of movement due to compromised joint integrity with or without persistent bleeding) was conducted. Descriptive statistics summarised health-related quality of life (HRQoL), work productivity/activity impairment and costs by number of PJs (0, 1 or ≥2) and HA severity. RESULTS A total of 1171 patients were included from CHESS-II (n = 468) and CHESS-PAEDs (n = 703). In both studies, 41 and 59% of patients had MHA and SHA, respectively. Prevalence of ≥2 PJs was similar with MHA and SHA (CHESS-II: 23 and 26%; CHESS-PAEDs: 4 and 3%, respectively). HRQoL was worse with an increasing number of PJs (CHESS-II: .81 vs. .66 with 0 and ≥2 PJs, respectively, for MHA; .79 vs. .51 for SHA; CHESS-PAEDs: .64 vs. .26 and .72 vs. .14). Total costs increased with increasing PJs regardless of severity in CHESS-II (€2923 vs. €22,536 with 0 and ≥2 PJs, respectively, for MHA; €11,022 vs. €27,098 for SHA) and CHESS-PAEDs (€6222 vs. €11,043 for MHA; €4457 vs. €14,039 for SHA). CONCLUSION Presence of PJs was associated with a substantial humanistic and economic burden on patients with MHA or SHA across the lifespan.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | | | - Tom Burke
- HCD Economics, Daresbury, UK.,University of Chester, Chester, UK
| | | | | | | | - Jamie O'Hara
- HCD Economics, Daresbury, UK.,University of Chester, Chester, UK
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17
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Négrier C, Mahlangu J, Lehle M, Chowdary P, Catalani O, Bernardi RJ, Jiménez-Yuste V, Beckermann BM, Schmitt C, Ventriglia G, Windyga J, d'Oiron R, Moorehead P, Koparkar S, Teodoro V, Shapiro AD, Oldenburg J, Hermans C. Emicizumab in people with moderate or mild haemophilia A (HAVEN 6): a multicentre, open-label, single-arm, phase 3 study. Lancet Haematol 2023; 10:e168-e177. [PMID: 36716761 DOI: 10.1016/s2352-3026(22)00377-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Clinical trial data are scarce for the use of prophylaxis in people with non-severe haemophilia A. The HAVEN 6 study aims to assess safety and efficacy of emicizumab prophylaxis in people with non-severe haemophilia A without factor VIII (FVIII) inhibitors. METHODS HAVEN 6 is a multicentre, open-label, single-arm, phase 3 study taking place in 22 specialty clinics and hospitals in Europe, North America, and South Africa. Eligible participants were people of all ages weighing at least 3 kg with a diagnosis of moderate (FVIII activity ≥1%-≤5%) or mild (FVIII >5%-<40%) haemophilia A without FVIII inhibitors requiring prophylaxis as assessed by the treating physician. Participants received subcutaneous emicizumab 3 mg/kg of bodyweight once weekly for 4 weeks, followed by the participant's choice of maintenance dose: 1·5 mg/kg once weekly, 3 mg/kg every 2 weeks, or 6 mg/kg every 4 weeks. Safety was the primary objective of the study. Safety endpoints included adverse events, serious adverse events, and adverse events of special interest including thromboembolic events and thrombotic microangiopathies. The primary efficacy endpoint was the annualised bleed rate for treated bleeds. Analyses were done for participants who received at least one dose of emicizumab. This study is registered with ClinicalTrials.gov, number NCT04158648, and is active but not recruiting. FINDINGS Between Feb 10, 2020, and Aug 31, 2021, we assigned 73 people to treatment. 72 participants received at least one dose of emicizumab (51 moderate [71%]; 21 mild [29%]; 69 male [96%]; three female [4%]; and 61 White [85%]). Median age was 23·5 years (IQR 12·0-36·0); median follow-up was 55·6 weeks (IQR 52·3-61·6) weeks. At baseline, 24 participants (33%) had target joints and 37 (51%) were receiving FVIII prophylaxis. 60 participants (83%) had at least one adverse event; the most common adverse events were headache (in 12 participants [17%]), injection-site reaction (12 [17%]), and arthralgia (11 [15%]). 15 (21%) had at least one emicizumab-related adverse event; no adverse events led to treatment withdrawal, modification, or interruption. Eight participants (11%) reported ten serious adverse events in total, none emicizumab-related. There were no deaths or thrombotic microangiopathies. One participant had grade 1 thrombosed haemorrhoids (classified as a thromboembolic event), unrelated to emicizumab. The annualised bleed rate was 0·9 (95% CI 0·55-1·52) for treated bleeds. 48 participants (67%) had no treated bleeds. All-bleed annualised bleed rates were 10·1 (95% CI 6·93-14·76) from 24 weeks pre-study and 2·3 (1·67-3·12) on-study after a median follow-up of 55·6 weeks. INTERPRETATION These data show efficacy and a favourable safety profile of emicizumab in people with non-severe haemophilia A without FVIII inhibitors who warrant prophylaxis, confirming emicizumab as a valuable treatment option in this population. FUNDING F Hoffmann-La Roche.
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Affiliation(s)
| | - Johnny Mahlangu
- University of the Witwatersrand and NHLS, Johannesburg, South Africa
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London, London, UK
| | | | | | | | | | | | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Roseline d'Oiron
- Bicêtre Hospital AP-HP, University of Paris-Saclay and UMR_S1176 INSERM, Le Kremlin-Bicêtre, Paris, France
| | - Paul Moorehead
- Memorial University of Newfoundland, St John's, NL, Canada
| | | | | | - Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, IN, USA
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University of Bonn, Bonn, Germany
| | - Cedric Hermans
- University Clinic of Saint Luke, Catholic University of Louvain, Brussels, Belgium
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Burke T, Rodriguez-Santana I, Chowdary P, Curtis R, Khair K, Laffan M, Mclaughlin P, Noone D, O'Mahony B, Pasi J, Skinner M, O'Hara J. Humanistic burden of problem joints for children and adults with haemophilia. Haemophilia 2023; 29:608-618. [PMID: 36574369 DOI: 10.1111/hae.14731] [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: 05/10/2022] [Revised: 11/25/2022] [Accepted: 12/14/2022] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The "problem joint" (PJ) concept was developed to address patient-centric needs for a more holistic assessment of joint morbidity for people with haemophilia (PwH). AIM To quantify the humanistic burden of PJs in PwH to further support validation of the PJ outcome measure. METHODS Multivariable regression models evaluated the relationship between PJs and health-related quality of life (HRQoL, EQ-5D-5L) and overall work productivity loss (WPL) using data from the 'Cost of HaEmophilia: a Socioeconomic Survey' population studies (adults: CHESS II, CHESS US+; children/adolescents: CHESS-Paeds). Covariates included were haemophilia severity, age, comorbidities and education. RESULTS The CHESS II sample included 292 and 134 PwH for HRQoL and WPL analyses, mean age 38.6 years (39% ≥1 PJ, 61% none). CHESS US+ included 345 and 239 PwH for HRQoL and WPL, mean age 35 years (43% ≥1 PJ, 57% none). CHESS-Paeds included 198 PwH aged 4-17 (HRQoL only), mean age 11.5 years (19% ≥1 PJ, 81% none). In CHESS II and CHESS US+, presence of PJs was associated with worse HRQoL (Both p < .001). Few CHESS-Paeds participants had PJs, with no significant correlation with HRQoL. In CHESS II, upper body PJs were significantly correlated to WPL (p < .05). In CHESS US+, having ≥1 PJ or upper and lower body PJs were significantly correlated to WPL (vs. none; both p < .05). CONCLUSION This study has shown a meaningful burden of PJs on PwH, which should be considered in clinical and health policy assessments of joint health.
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Affiliation(s)
| | | | - Pratima Chowdary
- Katherine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | - Randall Curtis
- Hematology Utilization Group Study (HUGS), Walnut Creek, USA
| | - Kate Khair
- HCD Economics, Daresbury, UK.,Haemnet, London, UK
| | - Michael Laffan
- Centre for Haematology, Imperial College London, London, UK
| | - Paul Mclaughlin
- Katherine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | - Declan Noone
- HCD Economics, Daresbury, UK.,European Haemophilia Consortium, Brussels, Belgium
| | | | - John Pasi
- Royal London Haemophilia Centre, Barts and the London School of Medicine and Dentistry, London, UK
| | - Mark Skinner
- McMaster University, Hamilton, Canada.,Institute for Policy Advancement Ltd, Washington, DC
| | - Jamie O'Hara
- HCD Economics, Daresbury, UK.,University of Chester, Chester, UK
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19
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Wall C, Xiang H, Palmer B, Chalmers E, Chowdary P, Collins PW, Fletcher S, Hall GW, Hart DP, Mathias M, Sartain P, Shapiro S, Stephensen D, Talks K, Hay CRM. Emicizumab prophylaxis in haemophilia A with inhibitors: Three years follow-up from the UK Haemophilia Centre Doctors' Organisation (UKHCDO). Haemophilia 2023; 29:743-752. [PMID: 36811304 DOI: 10.1111/hae.14762] [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: 11/07/2022] [Revised: 01/20/2023] [Accepted: 01/29/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION The UK National Haemophilia Database (NHD) collects data from all UK persons with haemophilia A with inhibitors (PwHA-I). It is well-placed to investigate patient selection, clinical outcomes, drug safety and other issues not addressed in clinical trials of emicizumab. AIMS To determine safety, bleeding outcomes and early effects on joint health of emicizumab prophylaxis in a large, unselected cohort using national registry and patient reported Haemtrack (HT) data between 01 January 2018 and 30 September 2021. METHODS Prospectively collected bleeding outcomes were analysed in people with ≥6 months emicizumab HT data and compared with previous treatment if available. Change in paired Haemophilia Joint Health Scores (HJHS) were analysed in a subgroup. Adverse events (AEs) reports were collected and adjudicated centrally. RESULTS This analysis includes 117 PwHA-I. Mean annualised bleeding rate (ABR) was .32 (95% CI, .18; .39) over a median 42 months treatment with emicizumab. Within-person comparison (n = 74) demonstrated an 89% reduction in ABR after switching to emicizumab and an increase in zero treated bleed rate from 45 to 88% (p < .01). In a subgroup of 37 people, total HJHS improved in 36%, remained stable in 46% and deteriorated in 18%, with a median (IQR) within-person change of -2.0 (-9, 1.5) (p = .04). Three arterial thrombotic events were reported, two possibly drug related. Other AEs were generally non-severe and usually limited to early treatment, included cutaneous reactions (3.6%), headaches (1.4%), nausea (2.8%) and arthralgia (1.4%). CONCLUSIONS Emicizumab prophylaxis is associated with sustained low bleeding rates and was generally well-tolerated in people with haemophilia A and inhibitors.
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Affiliation(s)
| | - Hua Xiang
- National Haemophilia Database, Manchester, UK
| | - Ben Palmer
- National Haemophilia Database, Manchester, UK
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | | | | | | | - Daniel P Hart
- The Royal London Hospital, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Paul Sartain
- Patient Representative, The Haemophilia Society, UK
| | | | | | - Kate Talks
- Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Charles R M Hay
- Manchester Royal Infirmary, Manchester, UK.,National Haemophilia Database, Manchester, UK
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20
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von Drygalski A, Chowdary P, Kulkarni R, Susen S, Konkle BA, Oldenburg J, Matino D, Klamroth R, Weyand AC, Jimenez-Yuste V, Nogami K, Poloskey S, Winding B, Willemze A, Knobe K. Efanesoctocog Alfa Prophylaxis for Patients with Severe Hemophilia A. N Engl J Med 2023; 388:310-318. [PMID: 36720133 DOI: 10.1056/nejmoa2209226] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [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: 01/26/2023]
Abstract
BACKGROUND Efanesoctocog alfa provides high sustained factor VIII activity by overcoming the von Willebrand factor-imposed half-life ceiling. The efficacy, safety, and pharmacokinetics of efanesoctocog alfa for prophylaxis and treatment of bleeding episodes in previously treated patients with severe hemophilia A are unclear. METHODS We conducted a phase 3 study involving patients 12 years of age or older with severe hemophilia A. In group A, patients received once-weekly prophylaxis with efanesoctocog alfa (50 IU per kilogram of body weight) for 52 weeks. In group B, patients received on-demand treatment with efanesoctocog alfa for 26 weeks, followed by once-weekly prophylaxis with efanesoctocog alfa for 26 weeks. The primary end point was the mean annualized bleeding rate in group A; the key secondary end point was an intrapatient comparison of the annualized bleeding rate during prophylaxis in group A with the rate during prestudy factor VIII prophylaxis. Additional end points included treatment of bleeding episodes, safety, pharmacokinetics, and changes in physical health, pain, and joint health. RESULTS In group A (133 patients), the median annualized bleeding rate was 0 (interquartile range, 0 to 1.04), and the estimated mean annualized bleeding rate was 0.71 (95% confidence interval [CI], 0.52 to 0.97). The mean annualized bleeding rate decreased from 2.96 (95% CI, 2.00 to 4.37) to 0.69 (95% CI, 0.43 to 1.11), a finding that showed superiority over prestudy factor VIII prophylaxis (P<0.001). A total of 26 patients were enrolled in group B. In the overall population, nearly all bleeding episodes (97%) resolved with one injection of efanesoctocog alfa. Weekly prophylaxis with efanesoctocog alfa provided mean factor VIII activity of more than 40 IU per deciliter for the majority of the week and of 15 IU per deciliter at day 7. Prophylaxis with efanesoctocog alfa for 52 weeks (group A) improved physical health (P<0.001), pain intensity (P = 0.03), and joint health (P = 0.01). In the overall study population, efanesoctocog alfa had an acceptable side-effect profile, and the development of inhibitors to factor VIII was not detected. CONCLUSIONS In patients with severe hemophilia A, once-weekly efanesoctocog alfa provided superior bleeding prevention to prestudy prophylaxis, normal to near-normal factor VIII activity, and improvements in physical health, pain, and joint health. (Funded by Sanofi and Sobi; XTEND-1 ClinicalTrials.gov number, NCT04161495.).
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Affiliation(s)
- Annette von Drygalski
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
| | - Pratima Chowdary
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
| | - Roshni Kulkarni
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
| | - Sophie Susen
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
| | - Barbara A Konkle
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
| | - Johannes Oldenburg
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
| | - Davide Matino
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
| | - Robert Klamroth
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
| | - Angela C Weyand
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
| | - Victor Jimenez-Yuste
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
| | - Keiji Nogami
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
| | - Stacey Poloskey
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
| | - Bent Winding
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
| | - Annemieke Willemze
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
| | - Karin Knobe
- From the Division of Hematology and Oncology, Department of Medicine, University of California, San Diego, San Diego (A.D.); the Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London (P.C.); Michigan State University, East Lansing (R. Kulkarni); Centre Hospitalier Universitaire de Lille, Université de Lille, Lille (S.S.), and Sanofi, Chilly-Mazarin (K.K.) - both in France; the Washington Center for Bleeding Disorders and the University of Washington - both in Seattle (B.A.K.); the Institute of Experimental Hematology and Transfusion Medicine, Universitätsklinikum Bonn, Bonn (J.O.), and Vivantes Klinikum im Friedrichshain, Berlin (R. Klamroth) - both in Germany; the Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada (D.M.); the Division of Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor (A.C.W.); Hospital Universitario La Paz, Autónoma University, Madrid (V.J.-Y.); Nara Medical University, Nara, Japan (K.N.); Sanofi, Cambridge, MA (S.P.); Sobi, Stockholm (B.W.); and Sanofi, Amsterdam (A.W.)
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21
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McLaughlin P, Hurley M, Chowdary P, Stephensen D, Khair K. The experiences and beliefs of people with severe haemophilia and healthcare professionals on pain management, and their views of using exercise as an aspect of intervention: a qualitative study. Disabil Rehabil 2022; 44:8420-8428. [PMID: 34951552 DOI: 10.1080/09638288.2021.2018054] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE To explore the experiences, views and beliefs of people with severe haemophilia and healthcare professionals (HCPs) on approaches for pain management, as well as their views on exercise being used as an aspect of management. METHODS Taking a qualitative inquiry approach using focus groups and semi-structured interviews, participants included people with severe haemophilia living with chronic pain and haemophilia HCPs. Data were analysed using reflexive thematic analysis. RESULTS Fourteen men with haemophilia with a median age of 47 (range 23-73) and six haemophilia HCPs agreed to participate. Of the people with haemophilia, 11 attended two focus groups and three were interviewed over telephone. Healthcare professionals were interviewed face-to-face. Two themes were conceptualised from the data: (i) haemophilia management and pain management is discordant (imbalance between good haemophilia care but poor pain management, historical medico-social influences on pain management, the need for trust); (ii) uncertain about exercise but clear on what matters (conflicting views on exercise, the need for proof of safety, personalised care). CONCLUSIONS Options for effective pain management remain limited and what is used is heavily influenced by beliefs and experience. Exercise as a treatment option in pain management is conceptually acceptable for people with haemophilia. Effective pain management requires understanding of individual beliefs and fears, and a personalised approach supported by knowledgeable, trusted clinicians.Implications for rehabilitationMusculoskeletal joint pain and its relationship with bleeding in people with haemophilia continues to be a management challenge.Current pain management strategies are of limited effectiveness with little evidence of an approach that reflects the multi-modal pain experience.Whilst exercise and rehabilitation approaches are conceptually possible for people with severe haemophilia, barriers remain regarding perception of overall safety and effectiveness.People with severe haemophilia may consider exercise as part of a pain management strategy if it is individualised, and they are supported to do it by clinicians who understand them and their haemophilia.
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Affiliation(s)
- P McLaughlin
- St George's University of London and Kingston University, London, UK.,Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - M Hurley
- St George's University of London and Kingston University, London, UK
| | - P Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - D Stephensen
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - K Khair
- Centre for Outcomes and Experience Research in Child Health, Illness and Disability (ORCHID) Research Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK.,Haemnet, London, UK
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22
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McLaughlin P, Hurley M, Chowdary P, Stephensen D, Khair K. How does a lifetime of painful experiences influence sensations and beliefs about pain in adults with severe haemophilia? A qualitative study. Disabil Rehabil 2022; 44:8412-8419. [PMID: 34951551 DOI: 10.1080/09638288.2021.2018053] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 01/19/2023]
Abstract
PURPOSE To explore the life experiences of pain in people with severe haemophilia and understand how such experiences influence beliefs and sensation of pain in adulthood. METHODS A qualitative inquiry approach using focus groups and semi-structured individual interviews was used. Participants included people with severe haemophilia living with chronic pain. Data were analysed using reflexive thematic analysis. RESULTS Fourteen men with a median age of 47 (range 23-73) agreed to take part. Eleven participated in two focus groups and three were interviewed over telephone. Two themes were conceptualised from the data: (i) haemophilia and pain - an evolving life biography (the personal narrative, historical, social, and medical context, continuous adaptation of activity choices, surveillance of pain and its meaning); (ii) "My normal isn't normal" - identity and self-agency (pain as a feature of life and identify with severe haemophilia, loss of enjoyable activities balanced against staying active, barriers to participation). CONCLUSIONS Pain is a constantly evolving, lifetime feature for many adults with haemophilia and it is viewed as part of their identity with their condition. Healthcare professionals working in haemophilia should try to better understand the influence of an individuals lived experience with their haemophilia on beliefs and behaviours of pain.Implications for rehabilitationSevere haemophilia is a rare bleeding disorder that results in musculoskeletal joint disease.Adults with severe haemophilia have experienced multiple episodes of bleeding related musculoskeletal pain since childhood.Pain beliefs and behaviours in adulthood appear to be influenced by a lifetime of painful experiences associated with haemophilia.In order to better support people with haemophilia and chronic pain, healthcare professionals in haemophilia need to better understand how an individuals lived experience of pain helps inform their beliefs about it.
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Affiliation(s)
- P McLaughlin
- Faculty of Health, Social Care and Education, St George's University of London and Kingston University, London, UK.,Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - M Hurley
- Faculty of Health, Social Care and Education, St George's University of London and Kingston University, London, UK
| | - P Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - D Stephensen
- East Kent Hospitals University NHS Foundation Trust, Canterbury, UK
| | - K Khair
- Centre for Outcomes and Experience Research in Child Health, Illness and Disability (ORCHID) Research Unit, Great Ormond Street Hospital for Children NHS Trust, London, UK.,Haemnet, London, UK
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23
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Uster DW, Chowdary P, Riddell A, Garcia C, Aradom E, Musarara M, Wicha SG. Dosing for Personalized Prophylaxis in Hemophilia A Highly Varies on the Underlying Population Pharmacokinetic Models. Ther Drug Monit 2022; 44:665-673. [PMID: 35358115 DOI: 10.1097/ftd.0000000000000983] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/21/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Model-informed personalized prophylaxis with factor VIII (FVIII) replacement therapy aimed at higher trough levels is becoming indispensable for patients with severe hemophilia A. This study aimed to identify the most suitable population pharmacokinetic (PK) models for personalized prophylaxis using various FVIII products and 2 clinical assays and to implement the most suitable one in open-access software. METHODS Twelve published population PK models were systematically compared to predict the time above target (TaT) for a reference dosing occasion. External validation was performed using a 5-point PK data from 39 adult patients with hemophilia A with FVIII measured by chromogenic substrate (CSA) and 1-stage assays (OSAs) using NONMEM under 3 different conditions: a priori (with all FVIII samples blinded), a posteriori (with 1 trough sample), and general model fit (with all FVIII samples including the reference dosing occasion provided). RESULTS On average, the baseline covariate models overpredicted TaT (a priori; bias -3.8 hours to 49.6 hours). When additionally including 1 previous trough FVIII sample before the reference dosing occasion (a posteriori), only 50% of the models improved in bias (-1.0 hours to 36.5 hours) and imprecision (22.4 hours and 60.7 hours). Using all the time points (general model fit), the models accurately predicted (individual TaT less than ±12 hours compared with the reference) 62%-90% and 33%-74% of the patients using CSA and OSA data, respectively. Across all scenarios, predictions using CSA data were more accurate than those using the OSA data. CONCLUSIONS One model performed best across the population (bias: -3.8 hours a priori, -1.0 hours a posteriori , and 0.6 hours general model fit ) and acceptably predicted 44% (a priori) to 90% ( general model fit ) of the patients. To allow the community-based evaluation of patient-individual FVIII dosing, this model was implemented in the open-access model-informed precision dosing software "TDMx."
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Affiliation(s)
- David W Uster
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany ; and
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, United Kingdom
| | - Anne Riddell
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, United Kingdom
| | - Cecilia Garcia
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, United Kingdom
| | - Elsa Aradom
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, United Kingdom
| | - Molly Musarara
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, United Kingdom
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany ; and
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24
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Sudusinghe D, Riddell A, Gandhi T, Chowdary P, Davenport A. Increased risk of dialysis circuit clotting in hemodialysis patients with COVID-19 is associated with elevated FVIII, fibrinogen and D-dimers. Hemodial Int 2022; 27:38-44. [PMID: 36081392 PMCID: PMC9537782 DOI: 10.1111/hdi.13046] [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: 03/01/2022] [Revised: 08/09/2022] [Accepted: 08/23/2022] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Severe COVID-19 infections increase the risk of thrombotic events and Intensive Care Units reported increased extracorporeal circuit clotting (ECC) in COVID-19 patients with acute kidney injury. We wished to determine whether hemodialysis (HD) patients with COVID-19 also have increased risk of circuit clotting. METHODS We reviewed coagulation studies and HD records, 4 weeks before and after COVID-19 polymerase chain reaction detection in HD patients between April 2020 and June 2021. FINDINGS Sixty-eight (33.5%) of 203 HD patients with COVID-19, 65% male, mean age 64.9 ± 15.3 years, experienced some circuit clotting, and no clotting recorded prior to positive test results. In those who experienced ECC, prothrombin, activated partial thromboplastin or thrombin times were not different, whereas median factor VIII (273 [168-419] vs. 166 [139-225] IU/dl, p < 0.001), D-dimers (2654 [1381-6019] vs. 1351 [786-2334] ng/ml, p < 0.05), and fibrinogen (5.6 ± 1.4 vs. 4.9 ± 1.4 g/L, p < 0.05) were greater. Antithrombin (94 [83-112] vs. 89 [84-103] IU/dl), protein C (102 [80-130] vs. 86 [76-106] IU/dl), protein S (65 [61-75] vs. 65 [52-79] IU/dl) and platelet counts (193 [138-243] vs. 174 [138-229] × 109 /L) did not differ. On multivariable logistic analysis, circuit clotting was associated with log factor VIII (odds ratio [OR] 14.8 (95% confidence limits [95% CL] 1.12-19.6), p = 0.041), fibrinogen (OR 1.57 [95% CL 1.14-21.7], p = 0.006) and log D dimer (OR 4.8 [95% CL 1.16-12.5], p = 0.028). DISCUSSION Extracorporeal circuit clotting was increased within 4 weeks of testing positive for COVID-19. Clotting was associated with increased factor VIII, fibrinogen and D-dimer, suggesting that the risk of circuit clotting was related to the inflammatory response to COVID-19.
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Affiliation(s)
- Dinesha Sudusinghe
- Department of Physiology, Faculty of Medical SciencesUniversity of Sri JayewardenepuraNugegodaSri Lanka
| | - Anne Riddell
- Haemophilia and Thrombosis Laboratory (Health Services Laboratories)Royal Free HospitalLondonUK,Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
| | - Tejas Gandhi
- Haemophilia and Thrombosis Laboratory (Health Services Laboratories)Royal Free HospitalLondonUK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK,Research Department of HaematologyCancer Institute UCLLondonUK
| | - Andrew Davenport
- Department of Renal Medicine, Royal Free Hospital, Faculty of Medical SciencesUniversity College LondonLondonUK
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25
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Chow BJ, Chowdary P, Khurram MA, Mohamed IH. O061 A single-centre retrospective study in a large tertiary renal centre on the management of infected arteriovenous grafts. Br J Surg 2022. [DOI: 10.1093/bjs/znac242.061] [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: 11/05/2022]
Abstract
Abstract
Introduction
Prosthetic arteriovenous grafts (AVGs) are often used as tertiary vascular access for haemodialysis in patients with exhausted autogenous options. AVGs are associated with an increased risk of infection which can lead to excess morbidity and life-threatening complications. Infected AVGs are challenging to manage, and the current evidence remains unclear on optimal strategy with arguments for conservative management, salvaging with revision or surgical excision (subtotal or total). This study sought to evaluate the management of infected AVGs by examining the clinical outcomes of patients with infected AVGs managed in our institution.
Methods
We conducted a single-centre retrospective study of all AVG infections managed (conservative management via antibiotics; graft revision; surgical excision) between June 2016 to May 2021. Primary outcome was mortality at 1 year. Secondary outcome was functional vascular access at 6 months and 1 year. Data were extracted from electronic patient records, radiology imaging and reporting.
Results
34 patients were included in our study (14.7% conservatively managed; 14.7% revision; 70.6% surgical excision) with a mean age of 60.4 ± 14.4 years (67.6% males). Average time from AVG placement to presentation was 11.8 months. 1 year mortality was 14.7%. Functional vascular access at 6 months in the three groups was 60%, 60% and 10% and 1-year functional vascular access was 60%, 75% and 42% respectively.
Conclusion
Surgically excised infected AVGs are associated with poor 6-month and 1-year vascular access outcomes. The findings suggest that conservative management and/or revision are more prudent given their higher probability of subsequent functional access.
Take-home message
Provision of a definite vascular access within the first year of graft infection is highly challenging. As such, conservative management and graft revision present as superior options to manage infected arteriovenous grafts.
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Affiliation(s)
- BJ Chow
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London
| | - P Chowdary
- Department of Renal and Transplantation, Royal London Hospital, Bart's Health NHS Trust
| | - MA Khurram
- Department of Renal and Transplantation, Royal London Hospital, Bart's Health NHS Trust
| | - IH Mohamed
- Department of Renal and Transplantation, Royal London Hospital, Bart's Health NHS Trust
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26
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Chowdary P, Shapiro S, Makris M, Evans G, Boyce S, Talks K, Dolan G, Reiss U, Phillips M, Riddell A, Peralta MR, Quaye M, Patch DW, Tuddenham E, Dane A, Watissée M, Long A, Nathwani A. Phase 1-2 Trial of AAVS3 Gene Therapy in Patients with Hemophilia B. N Engl J Med 2022; 387:237-247. [PMID: 35857660 DOI: 10.1056/nejmoa2119913] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [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: 12/19/2022]
Abstract
BACKGROUND FLT180a (verbrinacogene setparvovec) is a liver-directed adeno-associated virus (AAV) gene therapy that uses a synthetic capsid and a gain-of-function protein to normalize factor IX levels in patients with hemophilia B. METHODS In this multicenter, open-label, phase 1-2 trial, we assessed the safety and efficacy of varying doses of FLT180a in patients with severe or moderately severe hemophilia B (factor IX level, ≤2% of normal value). All the patients received glucocorticoids with or without tacrolimus for immunosuppression to decrease the risk of vector-related immune responses. After 26 weeks, patients were enrolled in a long-term follow-up study. The primary end points were safety and efficacy, as assessed by factor IX levels at week 26. RESULTS Ten patients received one of four FLT180a doses of vector genomes (vg) per kilogram of body weight: 3.84×1011 vg, 6.40×1011 vg, 8.32×1011 vg, or 1.28×1012 vg. After receiving the infusion, all the patients had dose-dependent increases in factor IX levels. At a median follow-up of 27.2 months (range, 19.1 to 42.4), sustained factor IX activity was observed in all the patients except one, who resumed factor IX prophylaxis. As of the data-cutoff date (September 20, 2021), five patients had normal factor IX levels (range, 51 to 78%), three patients had levels from 23 to 43%, and one had a level of 260%. Of the reported adverse events, approximately 10% were related to FLT180a and 24% to immunosuppression. Increases in liver aminotransferase levels were the most common FLT180a-related adverse events. Late increases in aminotransferase levels occurred in patients who had received prolonged tacrolimus beyond the glucocorticoid taper. A serious adverse event of arteriovenous fistula thrombosis occurred in the patient with high factor IX levels. CONCLUSIONS Sustained factor IX levels in the normal range were observed with low doses of FLT180a but necessitated immunosuppression with glucocorticoids with or without tacrolimus. (Funded by Freeline Therapeutics; ClinicalTrials.gov numbers, NCT03369444 and NCT03641703; EudraCT numbers, 2017-000852-24 and 2017-005080-40.).
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Affiliation(s)
- Pratima Chowdary
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Susan Shapiro
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Mike Makris
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Gillian Evans
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Sara Boyce
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Kate Talks
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Gerard Dolan
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Ulrike Reiss
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Mark Phillips
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Anne Riddell
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Maria R Peralta
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Michelle Quaye
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - David W Patch
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Edward Tuddenham
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Allison Dane
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Marie Watissée
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Alison Long
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
| | - Amit Nathwani
- From the Katharine Dormandy Haemophilia and Thrombosis Centre (P.C., M.P., A.R., M.R.P., E.T., A.N.), Health Services Laboratory, Sonic Healthcare (A.R.), and the Department of Hepatology and Liver Transplantation (D.W.P.), Royal Free Hospital, University College London (P.C., M.P., M.Q., A.N.), Guy's and St. Thomas' Hospital (G.D.), and Wstats (M.W.), London, Oxford University Hospitals Foundation Trust, Oxford NIHR Biomedical Research Centre, and Oxford University, Oxford (S.S.), the University of Sheffield, Sheffield (M.M.), East Kent Hospitals NHS University Foundation Trust, Canterbury (G.E.), University Hospital Southampton, Southampton (S.B.), Newcastle upon Tyne Hospitals NHS Trust, Newcastle (K.T.), and Freeline Therapeutics, Stevenage (A.D., A.N.) - all in the United Kingdom; St. Jude Children's Research Hospital, Memphis, TN (U.R.); and Freeline Therapeutics, New York (A.L.)
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Chowdary P, Holmström M, Mahlangu J, Ozelo MC, Pabinger I, Pasi KJ, Ragni M, Shapiro A, Barnowski C, Lethagen S. Managing surgery in hemophilia with recombinant factor VIII Fc and factor IX Fc: Data on safety and effectiveness from phase 3 pivotal studies. Res Pract Thromb Haemost 2022; 6:e12760. [PMID: 35910942 PMCID: PMC9326287 DOI: 10.1002/rth2.12760] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 05/09/2022] [Accepted: 05/19/2022] [Indexed: 01/19/2023] Open
Abstract
Background Surgical procedures impose hemostatic risk to people with hemophilia, which may be minimized by optimal factor (F) replacement therapy. Methods This analysis evaluates the efficacy and safety of extended half-life factor replacement recombinant FVIII and FIX Fc fusion proteins (rFVIIIFc and rFIXFc) during surgery in phase 3 pivotal (A-LONG/Kids A-LONG and B-LONG/Kids B-LONG) and extension (ASPIRE and B-YOND) studies. Dosing regimens were determined by investigators. Injection frequency, dosing, blood loss, transfusions, and hemostatic response were assessed. Results Forty-five major (n = 31 subjects) and 90 minor (n = 70 subjects) procedures were performed in hemophilia A; 35 major (n = 22) and 62 minor (n = 37) procedures were performed in hemophilia B. Unilateral knee arthroplasty was the most common major orthopedic procedure (hemophilia A: n = 15/34; hemophilia B: n = 8/24). On the day of surgery, median total dose in adults/adolescents was 81 IU/kg for rFVIIIFc and 144 IU/kg for rFIXFc; most major procedures required ≤2 injections (including loading dose). Through days 1-14, most major procedures had ≤1 injection/day. Hemostasis was rated excellent (rFVIIIFc: n = 39/42; rFIXFc: n = 29/33) or good (n = 3/42; n = 4/33) in evaluable major surgeries, with blood loss comparable with subjects without hemophilia. Most minor procedures in adults/adolescents required one injection on the day of surgery, including median loading dose of 51 IU/kg (rFVIIIFc) and 80 IU/kg (rFIXFc). No major treatment-related safety concerns were identified. No subjects developed inhibitors or serious vascular thromboembolic events. Conclusions rFVIIIFc and rFIXFc were efficacious and well tolerated for the management of perioperative hemostasis across a wide spectrum of major and minor surgeries in hemophilia.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free HospitalLondonUK
| | - Margareta Holmström
- Coagulation Unit, Department of Hematology, Department of Medicine, Karolinska Institute SolnaKarolinska University HospitalStockholmSweden
- Department of Health, Medicine and Caring SciencesLinköping UniversityLinköpingSweden
| | - Johnny N. Mahlangu
- Hemophilia Comprehensive Care Centre, Department of Molecular Medicine and Haematology, Faculty of Health SciencesUniversity of the Witwatersrand and National Health Laboratory ServiceJohannesburgSouth Africa
| | | | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine IMedical University of ViennaViennaAustria
| | - K. John Pasi
- Royal London Hospital Haemophilia CentreBarts and The London School of Medicine and DentistryLondonUK
| | - Margaret V. Ragni
- Division of Hematology/Oncology, and Hemophilia Center of Western PA, Department of MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Amy Shapiro
- Indiana Hemophilia and Thrombosis CenterIndianapolisIndianaUSA
| | | | - Stefan Lethagen
- Swedish Orphan Biovitrum ABStockholmSweden
- Copenhagen UniversityCopenhagenDenmark
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28
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Abstract
NEW FINDINGS What is the topic of this review? Overview of the coagulation abnormalities, including elevated D-dimers widely reported with COVID-19, often labelled as COVID coagulopathy. What advances does it highlight? The review highlights the changes in bronchoalveolar haemostasis due to apoptosis of alveolar cells, which contributes to acute lung injury and acute respiratory distress syndrome; the pathophysiological mechanisms, including endothelial dysfunction and damage responsible for thrombosis of pulmonary microcirculation and potential contribution to the hypoxaemia of COVID-19 acute lung injury; and changes in coagulation proteins responsible for the hypercoagulability and increased risk of thrombosis in other venous and arterial beds. The rationale for anticoagulation and fibrinolytic therapies is detailed, and potential confounders that might have led to less than expected improvement in the various randomised controlled trials are considered. ABSTRACT Coronavirus disease 19 (COVID-19) causes acute lung injury with diffuse alveolar damage, alveolar-capillary barrier disruption, thrombin generation and alveolar fibrin deposition. Clinically, hypoxaemia is associated with preserved lung compliance early in the disease, suggesting the lack of excessive fluid accumulation typical of other lung injuries. Notably, autopsy studies demonstrate infection of the endothelium with extensive capillary thrombosis distinct from the embolic thrombi in pulmonary arteries. The inflammatory thrombosis in pulmonary vasculature secondary to endothelial infection and dysfunction appears to contribute to hypoxaemia. This is associated with elevated D-dimers and acquired hypercoagulability with an increased risk of deep vein thrombosis. Hypercoagulability is secondary to elevated plasma tissue factor levels, von Willebrand factor, fibrinogen, reduced ADAMTS-13 with platelet activation and inhibition of fibrinolysis. Multi-platform randomised controlled studies of systemic therapeutic anticoagulation with unfractionated and low molecular mass heparins demonstrated a survival benefit over standard care with full-dose anticoagulation in patients with non-severe disease who require supplemental oxygen, but not in severe disease requiring ventilatory support. Late intervention and the heterogeneous nature of enrolled patients can potentially explain the apparent lack of benefit in severe disease. Improvement in oxygenation has been demonstrated with intravenous fibrinolytics in small studies. Inhaled anticoagulants, thrombolytic agents and non-specific proteolytic drugs in clinical trials for decreasing alveolar fibrin deposition might benefit early disease. Essentially, COVID-19 is a multi-system disorder with pulmonary vascular inflammatory thrombosis that requires an interdisciplinary approach to combination therapies addressing both inflammation and intravascular thrombosis or alveolar fibrin deposits to improve outcomes.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK.,Cancer Institute, University College London, London, UK
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29
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Pipe SW, Reddy KR, Chowdary P. Gene therapy: Practical aspects of implementation. Haemophilia 2022; 28 Suppl 4:44-52. [PMID: 35521727 PMCID: PMC9324089 DOI: 10.1111/hae.14545] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 01/10/2022] [Revised: 02/27/2022] [Accepted: 02/28/2022] [Indexed: 12/17/2022]
Abstract
The first wave of gene therapies for haemophilia submitted for regulatory review utilize a liver-directed approach in which a functional gene copy of factor VIII (FVIII) or factor IX (FIX) is packaged inside a recombinant adeno-associated viral vector (rAAV). Following a single treatment event, these particles are taken up into liver cells, where the rAAV uncoats and delivers the DNA to the nucleus of the cell, where genetic elements that accompany the gene allow for efficient expression and secretion of FVIII or FIX protein into the plasma. An immune response to the vector capsid has been manifest by elevations in common liver enzymes that must be diligently followed postinfusion for weeks and months afterward and if signs of toxicity appear, will trigger a course of immunosuppression. Despite this, the studies have shown that this works in the great majority of individuals and the immunosuppression course is either avoided or short-lived for many. Optimal outcomes in the haemophilia population will be dependent on proper screening assessment and maintenance of liver health prior to consideration of gene therapy, close short-term follow up and implementation of immunomodulatory strategies to identify and manage liver toxicity and preserve durable transgene expression. This review proposes best practices to assist clinical teams with overcoming the challenges this platform of therapy poses to the traditional clinical care models and infrastructure within the haemophilia treatment centres (HTCs) who will be coordinating the patient's journey through this potentially transformative therapy.
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Affiliation(s)
- Steven W Pipe
- Departments of Paediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - K Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
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Woollacott I, Morgan G, Chowdary P, O'Hara J, Franks B, van Overbeeke E, Dunn N, Michelsen S, Huys I, Martin A, Cawson M, Brownrigg J, Winburn I, Thomson J. Examining patient and professional perspectives in the UK for gene therapy in haemophilia. Haemophilia 2022; 28:588-609. [PMID: 35438818 PMCID: PMC9546085 DOI: 10.1111/hae.14572] [Citation(s) in RCA: 4] [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: 07/14/2021] [Revised: 04/01/2022] [Accepted: 04/08/2022] [Indexed: 11/30/2022]
Abstract
Introduction With the development of gene therapy for people with haemophilia (PWH), it is important to understand how people impacted by haemophilia (PIH) and clinicians prioritise haemophilia treatment attributes to support informed treatment decisions. Objective To examine the treatment attribute preferences of PIH and clinical experts in the United Kingdom (UK) and to develop a profile of gene therapy characteristics fit for use in future discrete choice experiments (DCEs). Methods Semi‐structured interviews were conducted with PIH (n = 14) and clinical experts (n = 6) who ranked pre‐defined treatment attributes by importance. Framework analysis was conducted to identify key themes and treatment attributes; points were allocated based on the rankings. Synthesis of results by a multidisciplinary group informed development of a profile of gene therapy characteristics for use in future research. Results Key themes identified by PIH and clinical experts included patient relevant features and the importance of ‘informed decision making'. The six top‐ranked treatment attributes were ‘effect on factor level’ (79 points), ‘uncertainty regarding long‐term risks’ (57 points), ‘impact on daily life’ (41 points), ‘frequency of monitoring’ (33 points), ‘impact on ability to participate in physical activity’ (29 points), and ‘uncertainty regarding long‐term benefits’ (28 points). The final treatment characteristics were categorised as therapeutic option, treatment effectiveness, safety concerns, impact on self‐management and quality of life (role limitations). Conclusion We identified several gene therapy characteristics important to PIH and clinicians in the UK. These characteristics will be used in a future DCE to further investigate patient preferences for gene therapy.
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Affiliation(s)
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Jamie O'Hara
- HCD Economics, Daresbury, UK.,Faculty of Health and Social Care, University of Chester, Chester, UK
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31
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Bowyer A, Gray E, Lowe A, Murphy P, Platton S, Riddell A, Chowdary P, Lester W, Jenkins PV. Laboratory coagulation tests and recombinant porcine factor VIII: A United Kingdom Haemophilia Centre Doctors’ Organisation guideline. Haemophilia 2022; 28:515-519. [DOI: 10.1111/hae.14536] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/18/2022] [Accepted: 02/25/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Annette Bowyer
- Department of Coagulation Royal Hallamshire Hospital Sheffield UK
| | - Elaine Gray
- Haemostasis Section National Institute for Biological Standards and Control Potters Bar UK
| | - Anna Lowe
- UK National External Quality Assurance Scheme for Blood Coagulation Sheffield UK
| | - Paul Murphy
- Department of Haematology Newcastle Upon Tyne Hospitals Newcastle upon Tyne UK
| | - Sean Platton
- The Royal London Hospital Haemophilia Centre Barts Health NHS Trust London UK
| | - Anne Riddell
- Katharine Dormandy Haemophilia Centre Royal Free Hospital London UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre Royal Free Hospital London UK
| | - Will Lester
- Haemophilia Unit University Hospitals Birmingham Birmingham UK
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32
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Miesbach W, Baghaei F, Boban A, Chowdary P, Coppens M, Hart DP, Jimenez-Yuste V, Klamroth R, Makris M, Noone D, Peyvandi F. Gene therapy of hemophilia: Hub centres should be haemophilia centres: A joint publication of EAHAD and EHC. Haemophilia 2022; 28:e86-e88. [PMID: 35263819 DOI: 10.1111/hae.14546] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/22/2022] [Accepted: 02/27/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Wolfgang Miesbach
- Medical Clinic, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Fariba Baghaei
- Coagulation Centre, Department of Medicine, Section of Hematology and Coagulation, Sahlgrenska University Hospital and Department of Internal Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ana Boban
- Haemophilia Centre, Department of Haematology, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Michiel Coppens
- Department of Vascular Medicine, Hemophilia Treatment Center, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Daniel P Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine & Dentistry, QMUL, London, UK
| | - Victor Jimenez-Yuste
- Hematology Department, Hospital Universitario La Paz, Autonoma University, Madrid, Spain
| | - Robert Klamroth
- Department for Internal Medicine and Vascular Medicine, Haemophilia Treatment Center, Vivantes Hospital im Friedrichshain, Berlin, Germany
| | - Mike Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Declan Noone
- European Haemopilia Consortium, Brussels, Belgium
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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33
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Guffon N, Chowdary P, Teles EL, Hughes D, Hennermann JB, Huot-Marchand P, Faudot-Vernier E, Lacombe O, Fiquet A, Richard MP, Abitbol JL, Tallandier M, Hendriksz CJ. Oral treatment for mucopolysaccharidosis VI: Outcomes of the first phase IIa study with odiparcil. J Inherit Metab Dis 2022; 45:340-352. [PMID: 34910312 DOI: 10.1002/jimd.12467] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 12/07/2021] [Accepted: 12/13/2021] [Indexed: 11/10/2022]
Abstract
Mucopolysaccharidosis (MPS) disorders are a group of rare, progressive lysosomal storage diseases characterized by the accumulation of glycosaminoglycans (GAGs) and classified according to the deficient enzyme. Enzyme replacement therapy (ERT) of MPS VI has limited effects on ophthalmic, cardiovascular, and skeletal systems. Odiparcil is an orally available small molecule that results in the synthesis of odiparcil-linked GAGs facilitating their excretion and reducing cellular and tissue GAG accumulation. Improve MPS treatment was a Phase 2a study of the safety, pharmacokinetics/pharmacodynamics, and efficacy of two doses of odiparcil in patients with MPS VI. The core study was a 26-week, randomized, double-blind, placebo-controlled trial in patients receiving ERT and an open-label, noncomparative, single-dose cohort not receiving ERT. Patients aged ≥ 16 years receiving ERT were randomized to odiparcil 250 or 500 mg twice daily or placebo. Patients without ERT received odiparcil 500 mg twice daily. Of 20 patients enrolled, 13 (65.0%) completed the study. Odiparcil increased total urine GAGs (uGAGs), chondroitin sulfate, and dermatan sulfate concentrations. A linear increase in uGAG levels and odiparcil exposure occurred with increased odiparcil dose. Odiparcil demonstrated a good safety and tolerability profile. Individual analyses found more improvements in pain, corneal clouding, cardiac, vascular, and respiratory functions in the odiparcil groups vs placebo. This study confirmed the mechanism of action and established the safety of odiparcil with clinical beneficial effects after only a short treatment duration in an advanced stage of disease. Further assessment of odiparcil in younger patients is needed.
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Affiliation(s)
- Nathalie Guffon
- Centre de Référence des Maladies Héréditaires du Métabolisme, Hospices Civils de Lyon, Lyon, France
| | | | | | | | - Julia B Hennermann
- Villa Metabolica, Department of Pediatric and Adolescent Medicine, University Medical Center Mainz, Mainz, Germany
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34
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Riddell A, Chowdary P, Davenport A. The effect of SARS-Co-V2 infection on prothrombotic and anticoagulant factors in dialysis patients. Artif Organs 2022; 46:1328-1333. [PMID: 35167146 PMCID: PMC9111238 DOI: 10.1111/aor.14206] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 11/14/2021] [Revised: 01/11/2022] [Accepted: 02/01/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Patients with COVID-19 infection are at increased risk of thrombosis. We wished to determine whether this was is due to an increase in prothrombotic or reduction in anticoagulant factors, and whether heparin would be an appropriate anticoagulant. METHODS We measured routine coagulation and prothrombtic factors in dialysis patients after a positive COVID-19 test between March 2020 -April 2021. RESULTS Routine coagulation tests were measured in 227 dialysis patients, 148 males (65.2%), median age 67.5 (53.8-77.0) years. The international normalised ratio was prolonged in 11.5%, activated partial thromboplastin time in 48.5%, thrombin time in 57%. Factor VIII was increased in 59.1%, fibrinogen in 73.8%, and D-dimer 95.5%. Protein C was reduced in 15.3%, protein S in 28%, and antithrombin (AT) in 12.1%. Two patients were Lupus anticoagulant positive , and two Factor VLeiden positive. Factor VIII levels increased with clinical disease; outpatients 159 (136-179) IU/dL, hospitalised but not ventilated 228 (167-311) IU, ventilated 432 (368-488) IU/dL (p<0.01). Overall 75% had an AT level ≥ 88 IU/dL (reference range 79-106), but only 11.7% of non-hospitalised patientscompared to 45% of those who died, p<0.01, Fibrinogen,D-dimers, proteins S or C did not differ with clinical disease severity, whether patients required hospital admission or not and between survivors and those who died. CONCLUSION COVID-19 dialysis patients have increased levels of fibrinogen and D-Dimers, but only factor VIII levels in the clotting profile increased with clinical disease severity increasing systemic hypercoagulability. AT concentrations are maintained and as such should not compromise anticoagulation with heparins.
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Affiliation(s)
- Anne Riddell
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia & Thrombosis Centre, Royal Free Hospital.,Research Department of Haematology, Cancer Institute UCL
| | - Andrew Davenport
- UCL Department of Nephrology, Royal Free Hospital, Faculty of Medical Sciences, University College London, London, UK
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St-Louis J, Chowdary P, Dolan G, Goodyear D, Strike K, Pollard D, Teitel J. Multidisciplinary Team Care of Patients with Hemophilic Arthropathy: A Qualitative Assessment of Contemporary Practice in the UK and Canada. Clin Appl Thromb Hemost 2022; 28:10760296211070002. [PMID: 35060765 PMCID: PMC8796082 DOI: 10.1177/10760296211070002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 12/02/2022] Open
Abstract
We used a structured interview to explore approaches to comprehensive hemophilia and arthropathy care among 24 healthcare professionals (HCPs) from multidisciplinary teams (MDTs) in Canada and the UK. Represented MDTs typically comprise a hematologist, nurse, physiotherapist, and sometimes an orthopedic surgeon; pediatric (and some adult) MDTs also include a social worker/psychologist. HCPs emphasized the centrality of a team approach, facilitated through MDT meetings and involvement of all MDT members in patient care. In both countries, nurses and physiotherapists play critical, multifaceted roles. Respondents agreed that MDTs are crucial for successful transitioning, which can be facilitated by close collaboration between pediatric and adult MDTs, even when they are not co-located. Physiotherapists are instrumental in providing non-pharmacological pain relief. Hematologists or physiotherapists typically make orthopedic referrals, with the nurse, physiotherapist and hematologist working together in patient preparation for (and follow-up after) surgery. MDT best practices include a non-hierarchical team approach, ensuring that all MDT members know all patients, and regular MDT meetings. Together, these real-life insights from the MDT perspective emphasize the value of the MDT approach in comprehensive hemophilia care.
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Affiliation(s)
| | | | - Gerry Dolan
- Guy's and St Thomas’ NHS Foundation Trust, London, UK
| | | | - Karen Strike
- Hamilton Niagara Regional Hemophilia Treatment Centre, McMaster Children's Hospital, McMaster University, Hamilton, Canada
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Perera A, Chowdary P, Johnson J, Lamb L, Drebes A, Mir N, Sood T. A 10-fold and greater increase in D-dimer at admission in COVID-19 patients is highly predictive of pulmonary embolism in a retrospective cohort study. Ther Adv Hematol 2022; 12:20406207211048364. [PMID: 34987740 PMCID: PMC8721362 DOI: 10.1177/20406207211048364] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 02/05/2021] [Accepted: 09/03/2021] [Indexed: 01/08/2023] Open
Abstract
Background: COVID-19 patients present with both elevated D-dimer and a higher incidence of pulmonary embolism (PE). This single-centre retrospective observational study investigated the prevalence of early PE in COVID-19 patients and its relation to D-dimer at presentation. Methods: The study included 1038 COVID-19-positive patients, with 1222 emergency department (ED) attendances over 11 weeks (16 March to 31 May 2020). Computed tomography pulmonary angiogram (CTPA) for PE was performed in 123 patients within 48 h of ED presentation, of whom 118 had D-dimer results. The remaining 875 attendances had D-dimer performed. Results: CTPA performed in 11.8% of patients within 48 h of ED presentation confirmed PE in 37.4% (46/123). Thrombosis was observed at all levels of pulmonary vasculature with and without right ventricular strain. In the CTPA cohort, patients with PE had significantly higher D-dimer, prothrombin time, C-reactive protein, troponin, total bilirubin, neutrophils, white cell count and lower albumin compared with non-PE patients. However, there was no difference in the median duration of inpatient stay or mortality. A receiver operator curve analysis demonstrated that D-dimer could discriminate between PE and non-PE COVID-19 patients (area under the curve of 0.79, p < 0.0001). Furthermore, 43% (n = 62/145) of patients with D-dimer >5000 ng/ml had CTPA with PE confirmed in 61% (n = 38/62), that is, 26% of >5000 ng/ml cohort. The sensitivity and specificity were related to D-dimer level; cutoffs of 2000, 3000, 4000, and 5000 ng/ml, respectively, had a sensitivity of 93%, 90%, 90% and 86%, and a specificity of 38%, 54%, 59% and 68%, and if implemented, an additional 229, 141, 106 and 83 CTPAs would be required. Conclusion: Our data suggested an increased PE prevalence in COVID-19 patients attending ED with an elevated D-dimer, and patients with levels >5000 ng/ml might benefit from CTPA to exclude concomitant PE.
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Affiliation(s)
- Adrian Perera
- Emergency Department, Royal Free London NHS Foundation Trust, London, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London, UK
| | - James Johnson
- Emergency Department, Royal Free London NHS Foundation Trust, London, UK
| | - Lucy Lamb
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London, UK
| | - Anja Drebes
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London, UK
| | - Naheed Mir
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Tara Sood
- Consultant Emergency Medicine, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK, NW3 2QG
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Chowdary P, Hampton K, Jiménez-Yuste V, Young G, Benchikh El Fegoun S, Cooper A, Scalfaro E, Tiede A. Predictive Modeling Identifies Total Bleeds at 12-Weeks Postswitch to N8-GP Prophylaxis as a Predictor of Treatment Response. Thromb Haemost 2021; 122:913-925. [PMID: 34865209 PMCID: PMC9251711 DOI: 10.1055/s-0041-1739514] [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: 11/29/2022]
Abstract
Background
Predicting annualized bleeding rate (ABR) during factor VIII (FVIII) prophylaxis for severe hemophilia A (SHA) is important for long-term outcomes. This study used supervised machine learning-based predictive modeling to identify predictors of long-term ABR during prophylaxis with an extended half-life FVIII.
Methods
Data were from 166 SHA patients who received N8-GP prophylaxis (50 IU/kg every 4 days) in the pathfinder 2 study. Predictive models were developed to identify variables associated with an ABR of ≤1 versus >1 during the trial's main phase (median follow-up of 469 days). Model performance was assessed using area under the receiver operator characteristic curve (AUROC). Pre-N8-GP prophylaxis models learned from data collected at baseline; post-N8-GP prophylaxis models learned from data collected up to 12-weeks postswitch to N8-GP, and predicted ABR at the end of the outcome period (final year of treatment in the main phase).
Results
The predictive model using baseline variables had moderate performance (AUROC = 0.64) for predicting observed ABR. The most performant model used data collected at 12-weeks postswitch (AUROC = 0.79) with cumulative bleed count up to 12 weeks as the most informative variable, followed by baseline von Willebrand factor and mean FVIII at 30 minutes postdose. Univariate cumulative bleed count at 12 weeks performed equally well to the 12-weeks postswitch model (AUROC = 0.75). Pharmacokinetic measures were indicative, but not essential, to predict ABR.
Conclusion
Cumulative bleed count up to 12-weeks postswitch was as informative as the 12-week post-switch predictive model for predicting long-term ABR, supporting alterations in prophylaxis based on treatment response.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, United Kingdom
| | - Kingsley Hampton
- Department of Cardiovascular Science, University of Sheffield, Sheffield, United Kingdom
| | - Victor Jiménez-Yuste
- Department of Hematology, La Paz University Hospital-IdiPaz, Autónoma University, Madrid, Spain
| | - Guy Young
- Hemostasis and Thrombosis Center, Cancer and Blood Disorders Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, United Sates
| | | | - Aidan Cooper
- Predictive Analytics, Real World Solutions, IQVIA, London, United Kingdom
| | | | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hanover, Germany
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Hampton K, Tiede A, Shivamurthy S, Chowdary P. Clinical outcomes after joint surgery in patients on turoctocog alfa pegol (N8-GP) prophylaxis: A post hoc analysis. Haemophilia 2021; 28:158-165. [PMID: 34811856 DOI: 10.1111/hae.14460] [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: 06/23/2021] [Revised: 10/26/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Joint damage in haemophilia often requires surgical correction. However, the surgery effect on bleeding rates and other clinical joint outcomes can be unclear. AIM To investigate the effects of joint surgery on joint annualized bleeding rates (JABRs) and physical health outcomes in patients with haemophilia A undergoing N8-GP prophylaxis. METHODS Patients in the pathfinder 2 trial received N8-GP prophylaxis, enrolling in the pathfinder 3 trial for indicated surgery. Patients returned to pathfinder 2 post-surgery, continuing N8-GP prophylaxis until end-of-trial. JABRs were calculated from bleeding across all joints for pre-surgery (immediately before surgery) and post-surgery (to pathfinder 2 study end) periods. Joint-health-related outcomes were derived from patient records. RESULTS Data (41 joint surgeries; n = 30) were analysed statistically using datamining and descriptively. Pre-surgery mean JABR was higher in patients who later were operated than in 146 non-operated patients (p = .004). In operated patients, mean JABR decreased from 1.33 pre-surgery to .37 post-surgery (p = .011). In all but three patients, JABR improved or remained the same post-surgery. In the three patients whose JABR remained at one (all with multiple joint arthropathy), post-surgery bleeds were mostly at non-operated sites. Two of the three patients whose JABR increased post-surgery had undergone surgery for reasons unlikely to improve JABR. Mobility parameters often improved in patients whose JABR remained at zero. CONCLUSION Patients with haemophilia treated with N8-GP prophylaxis benefit from surgeries. However, this analysis could not differentiate the relative contributions of surgical interventions and prophylactic treatment to the improvement of JABR.
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Affiliation(s)
- Kingsley Hampton
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | - Andreas Tiede
- Department of Haematology, Haemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hanover, Germany
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
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Tiede A, Hampton K, Jiménez-Yuste V, Young G, Benchikh El Fegoun S, Chowdary P. Post-hoc analysis on the long-term response to fixed-dose prophylaxis with N8-GP in patients with haemophilia A. Haemophilia 2021; 28:27-35. [PMID: 34562332 DOI: 10.1111/hae.14409] [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: 06/18/2021] [Revised: 08/20/2021] [Accepted: 08/30/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Challenges with personalised prophylaxis in haemophilia remain, including designing unique dosing schedules that require continual adjustments and monitoring using complex sampling procedures. AIM To assess long-term efficacy and pharmacokinetic outcomes with fixed-dose N8-GP prophylaxis. METHODS Descriptive analyses were performed on data from the pathfinder 2 and pathfinder 5 trials of patients with severe haemophilia A. Bleed frequency and reoccurrence were assessed in relation to several clinical criteria of interest. Bleed risk relative to time since last dose was assessed using calculated annualised bleeding rate (ABR). Long-term ABR and mean factor VIII (FVIII) trough levels were assessed in patients who received consistent N8-GP prophylaxis every 4 days (Q4D). RESULTS During pathfinder 2, 117/136 patients with study-drug exposure of ≥600 days experienced bleeding episodes; 8.6% of bleeds were reoccurring bleeds; bleed reoccurrence decreased over time. For patients who received consistent Q4D prophylaxis across the trial (n = 61), mean ABR decreased from 3.5 bleeds/year (Year 1) to 1.6 bleeds/year (Year 6); mean FVIII trough levels stabilised at approximately 5% (Year 6). Across patients who received prophylaxis at some point during pathfinder 2 (n = 177), 125/126 (99%) reoccurring bleeds were joint bleeds. For patients receiving Q4D prophylaxis, bleeding risk generally increased as the time since the last prophylaxis dose increased. A similar reduction in ABR and stabilisation of trough level was observed in pathfinder 5. CONCLUSION Long-term exposure (> 5 years) to fixed-dose N8-GP prophylaxis resulted in a protective haemostatic effect, with reduction in bleed frequency and reoccurrence, and stabilisation of FVIII trough level over time.
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Affiliation(s)
- Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hanover, Germany
| | - Kingsley Hampton
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | - Victor Jiménez-Yuste
- Department of Hematology, La Paz University Hospital-IdiPaz, Autónoma University, Madrid, Spain
| | - Guy Young
- Hemostasis and Thrombosis Center, Cancer and Blood Disorders Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
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Miesbach W, Chowdary P, Coppens M, Hart DP, Jimenez-Yuste V, Klamroth R, Makris M, Noone D, Peyvandi F. Delivery of AAV-based gene therapy through haemophilia centres-A need for re-evaluation of infrastructure and comprehensive care: A Joint publication of EAHAD and EHC. Haemophilia 2021; 27:967-973. [PMID: 34553460 DOI: 10.1111/hae.14420] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [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: 07/29/2021] [Revised: 09/10/2021] [Accepted: 09/10/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Adeno-associated virus (AAV)-based gene therapy for haemophilia presents a challenge to the existing structure of haemophilia centres and requires a rethink of current collaboration and information exchange with the aim of ensuring a system that is fit-for-purpose for advanced therapies to maximise benefits and minimise risks. In Europe, a certification process based on the number of patients and facilities is offered to the haemophilia centres by European Haemophilia Network (EUHANET). AIM AND METHODS This joint European Association for Haemophilia and Allied Disorders (EAHAD) and European Haemophilia Consortium (EHC) publication describes criteria for centres participating in gene therapy care that require a reassessment of the infrastructure of comprehensive care and provides an outlook on how these criteria can be implemented in the future work of haemophilia centres. RESULTS The core definition of a haemophilia treatment centre remains, but additional roles could be implemented. A modifiable 'hub-and-spoke' model addresses all aspects associated with gene therapy, including preparation and administration of the gene therapy product, determination of coagulation and immunological parameters, joint score and function, and liver health. This will also include the strategy on how to follow-up patients for a long-term safety and efficacy surveillance. CONCLUSION We propose a modifiable, networked 'hub and spoke' model with a long term safety and efficacy surveillance system. This approach will be progressively developed with the goal of making haemophilia centres better qualified to deliver gene therapy and to make gene therapy accessible to all persons with haemophilia, irrespective of their country or centre of origin.
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Affiliation(s)
- Wolfgang Miesbach
- Medical Clinic 2, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Michiel Coppens
- Department of Vascular Medicine, Haemophilia Treatment Centre, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Daniel P Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - Victor Jimenez-Yuste
- Hematology Department, Hospital Universitario La Paz, Autonoma University, Madrid, Spain
| | - Robert Klamroth
- Department for Internal Medicine and Vascular Medicine, Haemophilia Treatment Centre, Vivantes Hospital im Friedrichshain, Berlin, Germany
| | - Michael Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Declan Noone
- European Haemophilia Consortium, Brussels, Belgium
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre and Fondazione Luigi Villa, Milan, Italy.,Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy
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Chowdary P. Nonfactor Therapies: New Approaches to Prophylactic Treatment of Haemophilia. Hamostaseologie 2021; 41:247-256. [PMID: 34187062 DOI: 10.1055/a-1424-7900] [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: 10/21/2022] Open
Abstract
For several decades, the treatment of haemophilia has relied on factor replacement therapy, which restores haemostasis by replacing the missing coagulation factor. In recent years, novel alternative therapies for the treatment of haemophilia in patients with and without inhibitors have been developed. These emergent therapies promote haemostasis by mimicking coagulation factors or inhibiting natural anticoagulants. They provide a less invasive route of administration (i.e. subcutaneous) and some offer reduced frequency of dosing (i.e. every 2 weeks, monthly) compared with the majority of factor replacement therapies, and thus have the potential to simplify treatment, increase adherence and subsequently improve outcomes for patients. Their introduction has transformed the care of haemophilia patients with inhibitors to factor VIII, with similar expectation for haemophilia B patients with inhibitors. However, these therapies also come with several new challenges including their limitation to prophylactic treatment, the observed increased incidence of thrombosis, or their impact on the natural history of the disease and potential disruption of existing treatment guidelines like the use of immune tolerance induction. Moreover, questions remain regarding the long-term impact of non-replacement therapies on joint health as well as the optimal strategy to manage breakthrough bleeds in patients with inhibitors.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free London NHS Foundation Trust, London, United Kingdom
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Pasi KJ, Lissitchkov T, Mamonov V, Mant T, Timofeeva M, Bagot C, Chowdary P, Georgiev P, Gercheva‐Kyuchukova L, Madigan K, Van Nguyen H, Yu Q, Mei B, Benson CC, Ragni MV. Targeting of antithrombin in hemophilia A or B with investigational siRNA therapeutic fitusiran-Results of the phase 1 inhibitor cohort. J Thromb Haemost 2021; 19:1436-1446. [PMID: 33587824 PMCID: PMC8251589 DOI: 10.1111/jth.15270] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [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] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 01/19/2021] [Accepted: 02/09/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Fitusiran, an investigational small interfering RNA therapy, reduces antithrombin production to rebalance hemostasis in people with hemophilia A or B, with or without inhibitors. OBJECTIVES To evaluate the safety and efficacy of fitusiran treatment for people with moderate/severe hemophilia A or B with inhibitors. PATIENTS/METHODS In this open-label phase 1, part D study, 17 males with hemophilia A or B with inhibitors received three once-monthly subcutaneous injections of fitusiran 50 mg (n = 6) or 80 mg (n = 11); followed for up to 112 days. Endpoints included safety (primary), pharmacokinetics/pharmacodynamics (secondary), annualized bleeding rate, and patient-reported outcomes (exploratory). RESULTS The most common adverse event was injection site erythema (n = 8). No thrombotic events were reported. At nadir, mean (standard error of the mean [SEM]) antithrombin activity decreased from baseline by 82.0% (2.2) and 87.4% (0.7) in the 50 mg and 80 mg groups, respectively. Antithrombin reduction was associated with increased thrombin generation. 11/17 (64.7%) participants had no bleeds during the observation period (mean [standard deviation] 69.4 [16.3] days). Mean (SEM) changes from baseline in Haemophilia Quality of Life Questionnaire for Adults total (-9.2 [2.9]) and physical health (-12.3 [3.9]) domain scores suggested clinically meaningful improvement. CONCLUSIONS Monthly fitusiran was generally well tolerated, lowered antithrombin levels from baseline, and resulted in improved thrombin generation. These preliminary results suggest that monthly fitusiran treatment may reduce bleeding episodes and improve quality of life in participants with hemophilia A or B with inhibitors.
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Affiliation(s)
- K. John Pasi
- Royal London Haemophilia CentreBarts and The London School of Medicine and DentistryLondonUK
| | - Toshko Lissitchkov
- Clinic of HaematologyNational Specialized Hospital for Active Treatment of Haematologic DiseasesSofiaBulgaria
| | | | - Tim Mant
- IqviaReadingUK
- Guy's and St Thomas' NHS Foundation Trust and Kings College LondonLondonUK
| | - Margarita Timofeeva
- Federal State Budget Institution of Science “Kirov Scientific Research Institute of Hematology and Blood Transfusion of the Federal Medical‐Biological Agency"KirovRussia
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis CentreRoyal Free London NHS Foundation TrustLondonUK
| | - Pencho Georgiev
- University Multiprofile Hospital for Active Treatment “Sveti Georgi” and Medical University PlovdivPlovdivBulgaria
| | | | | | | | | | | | | | - Margaret V. Ragni
- Department of MedicineUniversity of PittsburghPittsburghPAUSA
- Hemophilia Center of Western PennsylvaniaPittsburghPAUSA
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Chowdary P, Shetty S, Whittaker C, Prasad M, Mohamed I, Khurram M. 769 Analysing the Change – Outcomes and Benefits of Clinic-Based Removal of Renal Transplant Stents Using A Disposable Cystoscope. Br J Surg 2021. [DOI: 10.1093/bjs/znab134.485] [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: 11/13/2022]
Abstract
Abstract
Introduction
Literature is chock-full of data regarding the “when” of ureteric stent removal after renal transplantation. We have attempted to address the “who”, “where” and “how” components.
Method
The Isiris disposable scope was used to remove renal allograft stents from 383 patients in the Transplant Clinic from June 2018 to April 2020. An advanced nurse practitioner was trained in the procedure. The learning curve, incidence of complications, benefits and cost implications were studied, and compared with the cohort having stent removal with a traditional flexible cystoscope in theatres.
Results
There were 14 failures necessitating theatre removal. The transplant-to-stent-removal interval was significantly lower in the clinic cohort with a mean of 38.80 days (95%CI 37.26–40.34) to 46.55 days in theatres (95%CI 43.47–49.62). 11 patients had urgent bedside stent removal. The service was delivered independently by the nurse for 5.3% of the patients in June 2018 and progressed to over 80% by April 2019. Estimated net gain was £919/patient.
Conclusions
Moving transplant ureteric stent removals from a resource intensive all-day process in theatres to a one-stop event in the clinic is a safe and economical model that can streamline flow in patient pathway and inculcate new skills in other members of the multidisciplinary team.
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Affiliation(s)
- P Chowdary
- The Royal London Hospital, London, United Kingdom
| | - S Shetty
- The Royal London Hospital, London, United Kingdom
| | - C Whittaker
- The Royal London Hospital, London, United Kingdom
| | - M Prasad
- The Royal London Hospital, London, United Kingdom
| | - I Mohamed
- The Royal London Hospital, London, United Kingdom
| | - M Khurram
- The Royal London Hospital, London, United Kingdom
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Khair K, Chalmers E, Flannery T, Griffiths A, Rowley F, Tobaruela G, Chowdary P. Expert opinion on the UK standard of care for haemophilia patients with inhibitors: a modified Delphi consensus study. Ther Adv Hematol 2021; 12:20406207211007058. [PMID: 33995986 PMCID: PMC8111519 DOI: 10.1177/20406207211007058] [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: 02/08/2021] [Accepted: 03/03/2021] [Indexed: 11/22/2022] Open
Abstract
Background and Aims: Despite advances in haemophilia care, inhibitor development remains a significant complication. Although viable treatment options exist, there is some divergence of opinion in the appropriate standard approach to care and goals of treatment. The aim of this study was to assess consensus on United Kingdom (UK) standard of care for child and adult haemophilia patients with inhibitors. Methods: A modified Delphi study was conducted using a two-round online survey. A haemophilia expert steering committee and published literature informed the Round 1 questionnaire. Invited participants included haematologists, haemophilia nurses and physiotherapists who had treated at least one haemophilia patient with inhibitors in the past 5 years. Consensus for 6-point Likert scale questions was pre-defined as ⩾70% participants selecting 1–2 (disagreement) or 5–6 (agreement). Results: In all, 46.7% and 35.9% questions achieved consensus in Rounds 1 (n = 41) and 2 (n = 34), respectively. Consensus was reached on the importance of improving quality of life (QoL) and reaching clinical goals such as bleed prevention, eradication of inhibitors and pain management. There was agreement on criteria constituting adequate/inadequate responses to immune tolerance induction (ITI) and the appropriate factor VIII dose to address suboptimal ITI response. Opinions varied on treatment aims for adults and children/adolescents, when to offer prophylaxis with bypassing agents and expectations of prophylaxis. Consensus was also lacking on appropriate treatment for mild/moderate patients with inhibitors. Conclusion: UK healthcare professionals appear to be aligned on the clinical goals and role of ITI when managing haemophilia patients with inhibitors, although novel treatment developments may require reassessment of these goals. Lack of consensus on prophylaxis with bypassing agents and management of mild/moderate cases identifies a need for further research to establish more comprehensive, evidence-based treatment guidance, particularly for those patients who are unable/prefer not to receive non-factor therapies.
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Affiliation(s)
- Kate Khair
- Centre for Outcomes and Experience Research in Children's Health Illness and Disability (ORCHID), NIHR Biomedical Research Centre Great Ormond Street Hospital for Children, London, UK
| | - Elizabeth Chalmers
- Paediatric Haemophilia Comprehensive Care Centre, Royal Hospital for Sick Children, Glasgow, UK
| | - Thuvia Flannery
- Leeds Haemophilia Centre, St James' University Hospital, Leeds, UK
| | | | | | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, Pond Street, London, NW3 2QG, UK
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45
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Preijers T, Liesner R, Hazendonk HCAM, Chowdary P, Driessens MHE, Hart DP, Laros-van Gorkom BAP, van der Meer FJM, Meijer K, Fijnvandraat K, Leebeek FWG, Mathôt RAA, Cnossen MH. Validation of a perioperative population factor VIII pharmacokinetic model with a large cohort of pediatric hemophilia a patients. Br J Clin Pharmacol 2021; 87:4408-4420. [PMID: 33884664 PMCID: PMC8596686 DOI: 10.1111/bcp.14864] [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: 12/20/2020] [Revised: 04/04/2021] [Accepted: 04/06/2021] [Indexed: 11/30/2022] Open
Abstract
AIMS Population pharmacokinetic (PK) models are increasingly applied to perform individualized dosing of factor VIII (FVIII) concentrates in haemophilia A patients. To guarantee accurate performance of a population PK model in dose individualization, validation studies are of importance. However, external validation of population PK models requires independent data sets and is, therefore, seldomly performed. Therefore, this study aimed to validate a previously published population PK model for FVIII concentrates administrated perioperatively. METHODS A previously published population PK model for FVIII concentrate during surgery was validated using independent data from 87 children with severe haemophilia A with a median (range) age of 2.6 years (0.03-15.2) and body weight of 14 kg (4-57). First, the predictive performance of the previous model was evaluated with MAP Bayesian analysis using NONMEM v7.4. Subsequently, the model parameters were (re)estimated using a combined dataset consisting of the previous modelling data and the data available for the external validation. RESULTS The previous model underpredicted the measured FVIII levels with a median of 0.17 IU mL-1 . Combining the new, independent and original data, a dataset comprising 206 patients with a mean age of 7.8 years (0.03-77.6) and body weight of 30 kg (4-111) was obtained. Population PK modelling provided estimates for CL, V1, V2, and Q: 171 mL h-1 68 kg-1 , 2930 mL 68 kg-1 , 1810 mL 68 kg-1 , and 172 mL h-1 68 kg-1 , respectively. This model adequately described all collected FVIII levels, with a slight median overprediction of 0.02 IU mL-1 . CONCLUSIONS This study emphasizes the importance of external validation of population PK models using real-life data.
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Affiliation(s)
- Tim Preijers
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Ri Liesner
- Great Ormond Street Haemophilia Centre, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Hendrika C A M Hazendonk
- Department of Pediatric Hematology, Erasmus University Medical Center, Sophia Children's Hospital Rotterdam, Rotterdam, the Netherlands
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | - Dan P Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | | | - Felix J M van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Karina Meijer
- University of Groningen, Department of Hematology, University Medical Center Groningen, Groningen, the Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus University Medical Center, Sophia Children's Hospital Rotterdam, Rotterdam, the Netherlands
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46
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Gooding R, Thachil J, Alamelu J, Motwani J, Chowdary P. Asymptomatic Joint Bleeding and Joint Health in Hemophilia: A Review of Variables, Methods, and Biomarkers. J Blood Med 2021; 12:209-220. [PMID: 33833602 PMCID: PMC8023018 DOI: 10.2147/jbm.s304597] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/19/2021] [Indexed: 12/14/2022] Open
Abstract
Joint health is a key contributor to quality of life in patients with hemophilia. However, variables that impact long-term joint outcomes have not been comprehensively defined. A systematic literature search identified publications relating to joint health in patients with hemophilia. Studies clearly show that early, sustained prophylaxis with factor replacements improves long-term joint outcomes. However, a subset of patients appear to develop arthropathy despite maintaining excellent bleeding outcomes, which suggests possible recurrent asymptomatic bleeding into the joints in these patients. Furthermore, limited data are available on how long-acting factor VIII and factor IX replacement therapies could impact long-term joint outcomes. Many variables were identified as potential indicators that a patient may develop hemophilic arthropathy, including genetic mutations, endogenous factor VIII and IX levels, bone health, and physical activity levels. Tools for the diagnosis and monitoring of hemophilic arthropathy are critical to detect early joint damage, so that management can be adjusted accordingly. Imaging techniques, particularly magnetic resonance imaging, can detect synovial changes, a strong predictor for the future development of hemophilic arthropathy. In addition, several biomarkers associated with cartilage and bone formation, vascularization, and angiogenesis could potentially identify the onset and progression of early joint damage. Since the development of hemophilic arthropathy is complex, a comprehensive therapeutic approach is necessary for the effective prevention of arthropathy in patients with hemophilia.
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Affiliation(s)
- Richard Gooding
- Leicester Haemophilia Centre, Haemostasis & Thrombosis Unit, Leicester Royal Infirmary, Leicester, UK
| | - Jecko Thachil
- Haematology Department, Manchester Royal Infirmary, Manchester, UK
| | - Jayanthi Alamelu
- Haemophilia Department, Evelina Children's Hospital - St Thomas' Hospital, London, UK
| | - Jayashree Motwani
- Haemophilia Comprehensive Care Centre, Birmingham Children's Hospital, Birmingham, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre, Royal Free Hospital, London, UK
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47
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Cohen OC, Bertelli M, Manmathan G, Little C, Riddell A, Pollard D, Aradom E, Mussara M, Harrington C, Kanagasabapathy P, De Silva R, Martin B, Peralta R, Gomez K, Yee T, Chowdary P, Rakhit RD. Challenges of antithrombotic therapy in the management of cardiovascular disease in patients with inherited bleeding disorders: A single-centre experience. Haemophilia 2021; 27:425-433. [PMID: 33749973 DOI: 10.1111/hae.14296] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 09/29/2020] [Revised: 03/03/2021] [Accepted: 03/03/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Cardiovascular events in patients with inherited bleeding disorders are challenging to manage. The risk of bleeding secondary to antithrombotic treatment must be balanced against the risk of thrombosis secondary to haemostatic therapy. METHODS Patients with inherited bleeding disorders with coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI) or atrial fibrillation (AF) from a single centre (2010-2018) are included. RESULTS A total of 11 patients undergoing CABG (n = 3), PCI (n = 5) or with AF (n = 3) and a diagnosis of haemophilia A (n = 8), haemophilia B (n = 1), factor XI deficiency (n = 1) and von Willebrand disease (n = 1) managed by a multidisciplinary team are reported. In patients undergoing CABG, factor levels were normalized for 7-10 days with trough levels of 70-80% with severe patients continuing high-dose factor prophylaxis (trough 20-30%) three weeks post-operatively with daily aspirin. In a patient with mild haemophilia A and an inhibitor, recombinant factor VIIa dosing was monitored with thromboelastometry. For PCI, a 3rd-generation drug-eluting stent with one month of dual antiplatelet therapy in addition to high-dose prophylaxis as needed was preferred. Patients with AF and severe haemophilia did not receive antithrombotic treatment, and a thrombin generation assay was used to guide heparin dosing in mild haemophilia. CONCLUSION Our experience demonstrates the importance of interdisciplinary communication to identify strategies that decrease the risk of bleeding and thrombosis. The use of extended, increased intensity prophylaxis facilitated antiplatelet therapy. Global assays may help balance the intensity of haemostatic and antithrombotic treatment.
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Affiliation(s)
- Oliver C Cohen
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Michele Bertelli
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | | | - Callum Little
- Department of Cardiology, Royal Free Hospital, London, UK
| | - Anne Riddell
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Debra Pollard
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Elsa Aradom
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Molly Mussara
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Chris Harrington
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | | | - Ravi De Silva
- Department of Cardio-Thoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Bruce Martin
- Heart Hospital, University College London NHS Trust, London, UK
| | - Rita Peralta
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Keith Gomez
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Thynn Yee
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Roby D Rakhit
- Department of Cardiology, Royal Free Hospital, London, UK
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48
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Gandhi T, Lawler P, Foxton E, Chowdary P, Riddell A. Clinical utility of sample preheat treatment in a modified Nijmegen-Bethesda assay (mNBA) for inhibitor monitoring in congenital and acquired haemophilia A: A single-centre four-year experience. Haemophilia 2020; 26:e300-e307. [PMID: 32892451 DOI: 10.1111/hae.14090] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Laboratory monitoring for factor VIII inhibitors ideally requires samples with the lowest possible factor VIII (FVIII) level, potentially challenging in patients with congenital haemophilia A (CHA) receiving regular prophylaxis and acquired haemophilia A (AHA) patients with endogenous FVIII. Inactivation of FVIII by preheating (preheat treatment, PHT) of patient plasma has been suggested to facilitate monitoring. AIM To evaluate the clinical utility of PHT prior to inhibitor analysis by modified Nijmegen-Bethesda assay (mNBA) in patients with CHA and AHA. METHODS Inhibitor screening by mNBA under standard conditions and with PHT at 56°C for 30, 60 and 90 minutes was evaluated. FVIII inhibitor results between 2007 and 2010 without PHT (720 results from 222 CHA and AHA patients), and between 2011 and 2014 post-PHT (1102 results from 302 patients) were available for analysis. RESULTS Of total 1822 results available, 61% were from severe HA patients, 22% from mild and moderate HA and 16% from AHA. Pre-PHT, 74% of samples were analysed by the mNBA, and the remaining 26% were not tested as FVIII levels were >20 IU/dL as per local protocol. Postintroduction of PHT (90 and 60 minutes), 96% of samples received were analysed for an inhibitor. Post-PHT in patients with AHA (n = 26), 69% of samples tested with factor VIII levels >20 IU/dL were found to have detectable inhibitor. CONCLUSION FVIII inhibitor testing using PHT at 56°C for 60 minutes facilitates inhibitor surveillance of CHA on prophylaxis. Potentially, 30 minutes at 56°C might be equally efficacious. In AHA receiving immunosuppression, monitoring of inhibitor titre after initial factor VIII response might enable personalized immunosuppression.
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Affiliation(s)
- Tejas Gandhi
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London, UK
| | - Pura Lawler
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London, UK
| | - Eleanor Foxton
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia & Thrombosis Centre, Royal Free Hospital, London, UK
| | - Anne Riddell
- Haemophilia & Thrombosis Laboratory (Health Services Laboratories), Royal Free Hospital, London, UK
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49
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Chowdary P. N8-GP: A new extended half-life recombinant factor VIII product for hemophilia A. J Thromb Haemost 2020; 18 Suppl 1:3-4. [PMID: 32940956 DOI: 10.1111/jth.14966] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/31/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
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50
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Whyte CS, Morrow GB, Mitchell JL, Chowdary P, Mutch NJ. Fibrinolytic abnormalities in acute respiratory distress syndrome (ARDS) and versatility of thrombolytic drugs to treat COVID-19. J Thromb Haemost 2020; 18:1548-1555. [PMID: 32329246 PMCID: PMC7264738 DOI: 10.1111/jth.14872] [Citation(s) in RCA: 195] [Impact Index Per Article: 48.8] [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] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 01/10/2023]
Abstract
The global pandemic of coronavirus disease 2019 (COVID-19) is associated with the development of acute respiratory distress syndrome (ARDS), which requires ventilation in critically ill patients. The pathophysiology of ARDS results from acute inflammation within the alveolar space and prevention of normal gas exchange. The increase in proinflammatory cytokines within the lung leads to recruitment of leukocytes, further propagating the local inflammatory response. A consistent finding in ARDS is the deposition of fibrin in the air spaces and lung parenchyma. COVID-19 patients show elevated D-dimers and fibrinogen. Fibrin deposits are found in the lungs of patients due to the dysregulation of the coagulation and fibrinolytic systems. Tissue factor (TF) is exposed on damaged alveolar endothelial cells and on the surface of leukocytes promoting fibrin deposition, while significantly elevated levels of plasminogen activator inhibitor 1 (PAI-1) from lung epithelium and endothelial cells create a hypofibrinolytic state. Prophylaxis treatment of COVID-19 patients with low molecular weight heparin (LMWH) is important to limit coagulopathy. However, to degrade pre-existing fibrin in the lung it is essential to promote local fibrinolysis. In this review, we discuss the repurposing of fibrinolytic drugs, namely tissue-type plasminogen activator (tPA), to treat COVID-19 associated ARDS. tPA is an approved intravenous thrombolytic treatment, and the nebulizer form has been shown to be effective in plastic bronchitis and is currently in Phase II clinical trial. Nebulizer plasminogen activators may provide a targeted approach in COVID-19 patients to degrade fibrin and improving oxygenation in critically ill patients.
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Affiliation(s)
- Claire S Whyte
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Aberdeen, UK
| | - Gael B Morrow
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Aberdeen, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Joanne L Mitchell
- Institute of Cardiovascular and Metabolic Sciences, School of Biological Sciences, University of Reading, Reading, UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre Royal Free Hospital, London, UK
| | - Nicola J Mutch
- Aberdeen Cardiovascular & Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Aberdeen, UK
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