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Olasupo OO, Noronha N, Lowe MS, Ansel D, Bhatt M, Matino D. Non-clotting factor therapies for preventing bleeds in people with congenital hemophilia A or B. Cochrane Database Syst Rev 2024; 2:CD014544. [PMID: 38411279 PMCID: PMC10897951 DOI: 10.1002/14651858.cd014544.pub2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Management of congenital hemophilia A and B is by prophylactic or on-demand replacement therapy with clotting factor concentrates. The effects of newer non-clotting factor therapies such as emicizumab, concizumab, marstacimab, and fitusiran compared with existing standards of care are yet to be systematically reviewed. OBJECTIVES To assess the effects (clinical, economic, patient-reported, and adverse outcomes) of non-clotting factor therapies for preventing bleeding and bleeding-related complications in people with congenital hemophilia A or B compared with prophylaxis with clotting factor therapies, bypassing agents, placebo, or no prophylaxis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, electronic databases, conference proceedings, and reference lists of relevant articles and reviews. The date of the last search was 16 August 2023. SELECTION CRITERIA Randomized controlled trials (RCTs) evaluating people with congenital hemophilia A or B with and without inhibitors, who were treated with non-clotting factor therapies to prevent bleeds. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed studies for eligibility, assessed risk of bias, and extracted data for the primary outcomes (bleeding rates, health-related quality of life (HRQoL), adverse events) and secondary outcomes (joint health, pain scores, and economic outcomes). We assessed the mean difference (MD), risk ratio (RR), 95% confidence interval (CI) of effect estimates, and evaluated the certainty of the evidence using GRADE. MAIN RESULTS Six RCTs (including 397 males aged 12 to 75 years) were eligible for inclusion. Prophylaxis versus on-demand therapy in people with inhibitors Four trials (189 participants) compared emicizumab, fitusiran, and concizumab with on-demand therapy in people with inhibitors. Prophylaxis using emicizumab likely reduced annualized bleeding rates (ABR) for all bleeds (MD -22.80, 95% CI -37.39 to -8.21), treated bleeds (MD -20.40, 95% CI -35.19 to -5.61), and annualized spontaneous bleeds (MD -15.50, 95% CI -24.06 to -6.94), but did not significantly reduce annualized joint and target joint bleeding rates (AjBR and AtjBR) (1 trial; 53 participants; moderate-certainty evidence). Fitusiran also likely reduced ABR for all bleeds (MD -28.80, 95% CI -40.07 to -17.53), treated bleeds (MD -16.80, 95% CI -25.80 to -7.80), joint bleeds (MD -12.50, 95% CI -19.91 to -5.09), and spontaneous bleeds (MD -14.80, 95% CI -24.90 to -4.71; 1 trial; 57 participants; moderate-certainty evidence). No evidence was available on the effect of bleed prophylaxis using fitusiran versus on-demand therapy on AtjBR. Concizumab may reduce ABR for all bleeds (MD -12.31, 95% CI -19.17 to -5.45), treated bleeds (MD -10.10, 95% CI -17.74 to -2.46), joint bleeds (MD -9.55, 95% CI -13.55 to -5.55), and spontaneous bleeds (MD -11.96, 95% CI -19.89 to -4.03; 2 trials; 78 participants; very low-certainty evidence), but not target joint bleeds (MD -1.00, 95% CI -3.26 to 1.26). Emicizumab prophylaxis resulted in an 11.31-fold increase, fitusiran in a 12.5-fold increase, and concizumab in a 1.59-fold increase in the proportion of participants with no bleeds. HRQoL measured using the Haemophilia Quality of Life Questionnaire for Adults (Haem-A-QoL) physical and total health scores was improved with emicizumab, fitusiran, and concizumab prophylaxis (low-certainty evidence). Non-serious adverse events were higher with non-clotting factor therapies versus on-demand therapy, with injection site reactions being the most frequently reported adverse events. Transient antidrug antibodies were reported for fitusiran and concizumab. Prophylaxis versus on-demand therapy in people without inhibitors Two trials (208 participants) compared emicizumab and fitusiran with on-demand therapy in people without inhibitors. One trial assessed two doses of emicizumab (1.5 mg/kg weekly and 3.0 mg/kg bi-weekly). Fitusiran 80 mg monthly, emicizumab 1.5 mg/kg/week, and emicizumab 3.0 mg/kg bi-weekly all likely resulted in a large reduction in ABR for all bleeds, all treated bleeds, and joint bleeds. AtjBR was not reduced with either of the emicizumab dosing regimens. The effect of fitusiran prophylaxis on target joint bleeds was not assessed. Spontaneous bleeds were likely reduced with fitusiran (MD -20.21, 95% CI -32.12 to -8.30) and emicizumab 3.0 mg/kg bi-weekly (MD -15.30, 95% CI -30.46 to -0.14), but not with emicizumab 1.5 mg/kg/week (MD -14.60, 95% CI -29.78 to 0.58). The percentage of participants with zero bleeds was higher following emicizumab 1.5 mg/kg/week (50% versus 0%), emicizumab 3.0 mg/kg bi-weekly (40% versus 0%), and fitusiran prophylaxis (40% versus 5%) compared with on-demand therapy. Emicizumab 1.5 mg/kg/week did not improve Haem-A-QoL physical and total health scores, EQ-5D-5L VAS, or utility index scores (low-certainty evidence) when compared with on-demand therapy at 25 weeks. Emicizumab 3.0 mg/kg bi-weekly may improve HRQoL measured by the Haem-A-QoL physical health score (MD -15.97, 95% CI -29.14 to -2.80) and EQ-5D-5L VAS (MD 9.15, 95% CI 2.05 to 16.25; 1 trial; 43 participants; low-certainty evidence). Fitusiran may result in improved HRQoL shown as a reduction in Haem-A-QoL total score (MD -7.06, 95% CI -11.50 to -2.62) and physical health score (MD -19.75, 95% CI -25.76 to -11.94; 1 trial; 103 participants; low-certainty evidence). The risk of serious adverse events in participants without inhibitors also likely did not differ following prophylaxis with either emicizumab or fitusiran versus on-demand therapy (moderate-certainty evidence). Transient antidrug antibodies were reported in 4% (3/80) participants to fitusiran, with no observed effect on antithrombin lowering. A comparison of the different dosing regimens of emicizumab identified no differences in bleeding, safety, or patient-reported outcomes. No case of treatment-related cancer or mortality was reported in any study group. None of the included studies assessed our secondary outcomes of joint health, clinical joint function, and economic outcomes. None of the included studies evaluated marstacimab. AUTHORS' CONCLUSIONS Evidence from RCTs shows that prophylaxis using non-clotting factor therapies compared with on-demand treatment may reduce bleeding events, increase the percentage of individuals with zero bleeds, increase the incidence of non-serious adverse events, and improve HRQoL. Comparative assessments with other prophylaxis regimens, assessment of long-term joint outcomes, and assessment of economic outcomes will improve evidence-based decision-making for the use of these therapies in bleed prevention.
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Affiliation(s)
- Omotola O Olasupo
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Canada
| | - Noella Noronha
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Canada
| | - Megan S Lowe
- Department of Health Sciences, McMaster University, Hamilton, Canada
| | | | - Mihir Bhatt
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Davide Matino
- Department of Internal Medicine, McMaster University, Hamilton, Canada
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2
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Han JP, Lee Y, Lee JH, Chung HY, Lee GS, Nam YR, Choi M, Moon KS, Lee H, Lee H, Yeom SC. In vivo genome editing using 244- cis LNPs and low-dose AAV achieves therapeutic threshold in hemophilia A mice. Mol Ther Nucleic Acids 2023; 34:102050. [PMID: 37916225 PMCID: PMC10616378 DOI: 10.1016/j.omtn.2023.102050] [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] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023]
Abstract
Gene therapy and rebalancing therapy have emerged as promising approaches for treating hemophilia A, but there are limitations, such as temporary efficacy due to individual differences. Genome editing for hemophilia has shown long-term therapeutic potential in preclinical trials. However, a cautious approach is necessary because genome editing is irreversible. Therefore, we attempted to induce low-level human factor 8 (hF8) gene knockin (KI) using 244-cis lipid nanoparticles and low-dose adeno-associated virus to minimize side effects and achieve a therapeutic threshold in hemophilia A mice. We selected the serpin family C member 1, SerpinC1, locus as a target to enable a combined rebalancing strategy with hF8 KI to augment efficacy. This strategy improved blood coagulation activity and reduced hemophilic complications without adverse effects. Furthermore, hemophilic mice with genome editing exhibit enhanced survival for 40 weeks. Here, we demonstrate an effective, safe, and sustainable treatment for hemophilia A. This study provides valuable information to establish safe and long-term genome-editing-mediated treatment strategies for treating hemophilia and other protein-deficient genetic diseases.
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Affiliation(s)
- Jeong Pil Han
- Graduate School of International Agricultural Technology and Institute of Green BioScience and Technology, Seoul National University, Pyeongchang, Gangwon 25354, Korea
| | - Yeji Lee
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seodaemun-gu, Seoul 03760, Korea
| | - Jeong Hyeon Lee
- Graduate School of International Agricultural Technology and Institute of Green BioScience and Technology, Seoul National University, Pyeongchang, Gangwon 25354, Korea
| | - Hye Yoon Chung
- Graduate School of International Agricultural Technology and Institute of Green BioScience and Technology, Seoul National University, Pyeongchang, Gangwon 25354, Korea
| | - Geon Seong Lee
- Graduate School of International Agricultural Technology and Institute of Green BioScience and Technology, Seoul National University, Pyeongchang, Gangwon 25354, Korea
| | - Yu Ri Nam
- Deartment of Chemistry, Korea Advanced Institute of Science and Technology (KAIST), Yuseong-gu, Daejeon 34141, Korea
| | - Myeongjin Choi
- Department of Advanced Toxicology Research, Korea Institute of Toxicology, Yuseong-gu, Daejeon 34114, Korea
| | - Kyoung-Sik Moon
- Department of Advanced Toxicology Research, Korea Institute of Toxicology, Yuseong-gu, Daejeon 34114, Korea
| | - Haeshin Lee
- Deartment of Chemistry, Korea Advanced Institute of Science and Technology (KAIST), Yuseong-gu, Daejeon 34141, Korea
| | - Hyukjin Lee
- College of Pharmacy, Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seodaemun-gu, Seoul 03760, Korea
| | - Su Cheong Yeom
- Graduate School of International Agricultural Technology and Institute of Green BioScience and Technology, Seoul National University, Pyeongchang, Gangwon 25354, Korea
- WCU Biomodulation Major, Department of Agricultural Biotechnology, Seoul National University, Gwanank-gu, Seoul 08826, Korea
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3
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Donoso-Úbeda E, Pérez-Llanes R, Meroño-Gallut J, Ucero-Lozano R, Cuesta-Barriuso R. Foam roller-based self-induced myofascial therapy in patients with hemophilic knee arthropathy: a multicenter, single-blind, randomized clinical study. Eur J Phys Rehabil Med 2023; 59:763-771. [PMID: 37869759 PMCID: PMC10795767 DOI: 10.23736/s1973-9087.23.07944-3] [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: 02/24/2023] [Revised: 09/05/2023] [Accepted: 10/02/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Hemophilia is a congenital coagulopathy characterized by degenerative joint damage. Self-induced myofascial therapy aims to decrease pain and improve tissue mobility, functionality and proprioception. AIM The aim of this study was to evaluate the safety and efficacy of self-induced myofascial release in patients with hemophilic knee arthropathy. DESIGN This is a randomized clinical study. SETTING This study was carried out in different patient associations. POPULATION Fifty-two patients with hemophilia were included in the study. METHODS Patients were randomized to the experimental group (daily home protocol of foam roller-based self-induced myofascial therapy for 8 weeks) or the control group (no intervention). The variables were the frequency of hemarthrosis (self-reporting), pain intensity (visual analog scale), range of motion (goniometry) and muscle strength (dynamometry). All variables were evaluated at baseline, post-treatment and after a 10-week follow-up. RESULTS The patients included in the experimental group showed significant improvements in terms of a decrease in frequency of hemarthrosis (mean difference [MD]=-0.61; 95% confidence interval [CI]: -0.81; -0.41) and pain intensity (MD=-0.33; 95% CI: -0.48, -0.18), increased range of motion (MD=0.88; 95% CI: 0.39; 1.37), strength in quadriceps (MD=0.88; 95% CI: 0.39; 1.37). (MD=12.39; 95% CI: 3.44; 21.34) and hamstrings (MD=7.85; 95% CI: 0.60; 15.11). There were intergroup differences in the frequency of hemarthrosis (F=14.51; P<0.001), pain intensity (F=9.14; P<0.001) and range of motion (F=13.58; P<0.001). CONCLUSIONS Self-induced myofascial therapy can be an effective complementary technique in the treatment of patients with hemophilic arthropathy. Self-induced myofascial therapy can reduce the frequency of knee hemarthrosis in patients with hemophilia. This technique can improve pain intensity and range of motion in patients with hemophilic knee arthropathy. CLINICAL REHABILITATION IMPACT Hemophilic knee arthropathy is characterized by chronic pain, decreased range of motion, and periarticular muscle atrophy. Foam roller-based self-induced myofascial therapy can reduce the frequency of hemarthrosis and pain intensity and improve range of motion in patients with hemophilic arthropathy. Foam roller-based self-induced myofascial therapy is safe and effective in the treatment of patients with hemophilia. The inclusion of self-induced myofascial therapy exercises in the approach to degenerative joint pathologies may be an effective and safe treatment option.
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Affiliation(s)
- Elena Donoso-Úbeda
- Department of Physiotherapy, UCAM Catholic University of Murcia, Murcia, Spain
- InHeFis Research Group, Instituto Asturiano de Investigación Sanitaria, Oviedo, Spain
| | - Raúl Pérez-Llanes
- Department of Physiotherapy, UCAM Catholic University of Murcia, Murcia, Spain
- InHeFis Research Group, Instituto Asturiano de Investigación Sanitaria, Oviedo, Spain
| | - Javier Meroño-Gallut
- InHeFis Research Group, Instituto Asturiano de Investigación Sanitaria, Oviedo, Spain
- Service of Physiotherapy, Tu Bienestar 360°, San Javier, Spain
| | - Roberto Ucero-Lozano
- InHeFis Research Group, Instituto Asturiano de Investigación Sanitaria, Oviedo, Spain
- Department of Physiotherapy, European University of Madrid, Madrid, Spain
| | - Rubén Cuesta-Barriuso
- InHeFis Research Group, Instituto Asturiano de Investigación Sanitaria, Oviedo, Spain -
- Department of Surgery and Medical-Surgical Specialties, University of Oviedo, Oviedo, Spain
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Liu Y, Li D, Yu D, Liang Q, Chen G, Li F, Gao L, Li Z, Xie T, Wu L, Mao A, Wu L, Liang D. Comprehensive Analysis of Hemophilia A (CAHEA): Towards Full Characterization of the F8 Gene Variants by Long-Read Sequencing. Thromb Haemost 2023; 123:1151-1164. [PMID: 37285902 PMCID: PMC10686748 DOI: 10.1055/a-2107-0702] [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: 03/01/2023] [Accepted: 05/15/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Hemophilia A (HA) is the most frequently occurring X-linked bleeding disorder caused by heterogeneous variants in the F8 gene, one of the largest genes known. Conventional molecular analysis of F8 requires a combination of assays, usually including long-range polymerase chain reaction (LR-PCR) or inverse-PCR for inversions, Sanger sequencing or next-generation sequencing for single-nucleotide variants (SNVs) and indels, and multiplex ligation-dependent probe amplification for large deletions or duplications. MATERIALS AND METHODS This study aimed to develop a LR-PCR and long-read sequencing-based assay termed comprehensive analysis of hemophilia A (CAHEA) for full characterization of F8 variants. The performance of CAHEA was evaluated in 272 samples from 131 HA pedigrees with a wide spectrum of F8 variants by comparing to conventional molecular assays. RESULTS CAHEA identified F8 variants in all the 131 pedigrees, including 35 intron 22-related gene rearrangements, 3 intron 1 inversion (Inv1), 85 SNVs and indels, 1 large insertion, and 7 large deletions. The accuracy of CAHEA was also confirmed in another set of 14 HA pedigrees. Compared with the conventional methods combined altogether, CAHEA assay demonstrated 100% sensitivity and specificity for identifying various types of F8 variants and had the advantages of directly determining the break regions/points of large inversions, insertions, and deletions, which enabled analyzing the mechanisms of recombination at the junction sites and pathogenicity of the variants. CONCLUSION CAHEA represents a comprehensive assay toward full characterization of F8 variants including intron 22 and intron 1 inversions, SNVs/indels, and large insertions and deletions, greatly improving the genetic screening and diagnosis for HA.
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Affiliation(s)
- Yingdi Liu
- Center for Medical Genetics and Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, Hunan, China
| | - Dongzhi Li
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Dongyi Yu
- Center for Medical Genetics and Prenatal Diagnosis, Shandong Provincial Maternal and Child Health Care Hospital, Shandong Medicine and Health Key Laboratory of Birth Defect Prevention and Genetic Medicine, Key Laboratory of Birth Regulation and Control Technology of National Health Commission of China, Jinan, Shandong, China
| | - Qiaowei Liang
- Department of Medical Genetics, Hunan Jiahui Genetics Hospital, Changsha, Hunan, China
| | - Guilan Chen
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Fucheng Li
- Prenatal Diagnostic Center, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Lu Gao
- Center for Medical Genetics and Prenatal Diagnosis, Shandong Provincial Maternal and Child Health Care Hospital, Shandong Medicine and Health Key Laboratory of Birth Defect Prevention and Genetic Medicine, Key Laboratory of Birth Regulation and Control Technology of National Health Commission of China, Jinan, Shandong, China
| | - Zhuo Li
- Center for Medical Genetics and Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, Hunan, China
| | | | - Le Wu
- Berry Genomics Corporation, Beijing, China
| | - Aiping Mao
- Berry Genomics Corporation, Beijing, China
| | - Lingqian Wu
- Center for Medical Genetics and Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, Hunan, China
- Department of Medical Genetics, Hunan Jiahui Genetics Hospital, Changsha, Hunan, China
| | - Desheng Liang
- Center for Medical Genetics and Hunan Key Laboratory of Medical Genetics, School of Life Sciences, Central South University, Changsha, Hunan, China
- Department of Medical Genetics, Hunan Jiahui Genetics Hospital, Changsha, Hunan, China
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Chopra P, Singh M, Singh A, Masi A, Yurkofsky J, Zaita B, Kaur G. Perioperative Management of Spontaneous Intracranial Hemorrhage in a Patient With Hemophilia A in a Resource Limited Country. Cureus 2023; 15:e43485. [PMID: 37711951 PMCID: PMC10499499 DOI: 10.7759/cureus.43485] [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] [Accepted: 08/13/2023] [Indexed: 09/16/2023] Open
Abstract
Intracranial hemorrhage (ICH) is a serious complication of hemophilia A with high morbidity and mortality. The management of such cases is complicated by nonspecific and often delayed presentation, increased frequency of rebleeding, low awareness regarding clotting factor replacement, and debate regarding the efficacy of surgical interventions. We report a case of an 18-year-old male patient with hemophilia A, who first presented to the emergency department in India in a comatose state. Neuroimaging revealed subdural hematoma with midline shift and uncal herniation. The patient was successfully managed with perioperative cryoprecipitate and factor VIII replacement, tiered intracranial pressure lowering strategies, and early decompressive craniectomy with clot evacuation. In India, there are no standardized guidelines for screening and routine care for hereditary diseases like hemophilia. In a resource-deficient country, management was complicated by the limited availability of factor VIII in the emergent setting, as well as the inability to obtain serial factor levels in the postoperative period. We hope that this article helps to guide the management of ICH and hemophilia in resource-limited countries.
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Affiliation(s)
- Puneet Chopra
- Critical Care, Satguru Partap Singh (SPS) Hospital, Ludhiana, IND
| | - Manraj Singh
- Basic Biomedical Sciences, Dayanand Medical College and Hospital, Ludhiana, IND
| | | | - Athena Masi
- Basic Biomedical Sciences, Touro College of Osteopathic Medicine, Middletown, USA
| | - Judith Yurkofsky
- Basic Biomedical Sciences, Touro College of Osteopathic Medicine, Middletown, USA
| | - Brittany Zaita
- Basic Biomedical Sciences, Touro College of Osteopathic Medicine, Middletown, USA
| | - Gurjinder Kaur
- Basic Biomedical Sciences, Touro College of Osteopathic Medicine, Middletown, USA
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Munawar Ali R, Abid M, Zafar S, Ali MS, Nadeem R, Ahmed R, Borhany M. Management of Severe Hemophilia A: Low-Dose Prophylaxis vs. On-Demand Treatment. Cureus 2023; 15:e41410. [PMID: 37546069 PMCID: PMC10402932 DOI: 10.7759/cureus.41410] [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] [Accepted: 06/30/2023] [Indexed: 08/08/2023] Open
Abstract
INTRODUCTION Prophylactic clotting factor infusion regimens to prevent bleeding and joint deformity has become the standard of care in severe hemophilia A patients. AIM To assess low-dose factor prophylaxis in our population as an alternative approach to managing severe hemophilia A. METHODS A prospective cohort study that included 68 hemophilia A patients divided into two groups, i.e., Prophylaxis and on-demand. The two groups were compared for annualized bleeding rate (ABR), hospitalization, units of factor VIII (FVIII) infused, or plasma products transfused, i.e., fresh frozen plasma (FFP) and cryoprecipitate (CP), and development of FVIII inhibitors. RESULTS Of the 68 patients recruited in this study, 25 (36.7%) were in the prophylaxis group, and 43(63.3%) were in the on-demand group. The on-demand group presented a higher median-IQR ABR [8(20-3) vs. 5(10-1.5), p-value 0.024], several hospitalizations (39.7% vs. 0, p-value 0.001), and inhibitor development (9.3% vs. 0, p-value 0.289) compared to the prophylaxis group. The prophylaxis approach demonstrated a significant negative correlation of ABR with FVIII prophylaxis (r=-0484, p=value=0.014). Moreover, no hospitalizations or inhibitor development was observed in the prophylaxis group. The estimated annual consumption of FVIII was 328 IU/kg/year in the on-demand group and 1662.6 IU/kg/year in the prophylaxis group. However, a highly significant difference in plasma product utilization was observed between the two groups, i.e., p-value <0.001 and 0.038 for FFP and CP, respectively. CONCLUSION Low-dose factor prophylaxis resulted in improved outcomes compared to on-demand treatment in terms of ABR, joint bleeding, hospitalization, and the development of inhibitors. This treatment approach should be adopted as an economically feasible alternative to high-dose Prophylaxis in resource-constrained countries.
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Affiliation(s)
- Rabeea Munawar Ali
- Hematology, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
| | - Madiha Abid
- Hematology, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
| | - Sidra Zafar
- Research and Development, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
| | - Muhammad Shujat Ali
- Hematology, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
| | - Rukhshanda Nadeem
- Physical Medicine and Rehabilitation, Hemophilia Welfare Society, Karachi, PAK
| | - Raheel Ahmed
- Hematology, Haemophilia Welfare Society, Karachi, PAK
| | - Munira Borhany
- Hematology, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
- Hematology, Haemophilia Welfare Society, Karachi, PAK
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7
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MacNeill M, Mansory EM, Lazo-Langner A, Phua CW. Acquired Hemophilia A Masquerading as Bleeding on Anticoagulation: A Case Report Including Key Laboratory Considerations. Cureus 2023; 15:e41029. [PMID: 37519483 PMCID: PMC10373513 DOI: 10.7759/cureus.41029] [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] [Accepted: 06/26/2023] [Indexed: 08/01/2023] Open
Abstract
We report a case of a patient with recurrent hematomas while on anticoagulation for a pulmonary embolism and a prolonged hospital stay due to a delayed diagnosis for acquired hemophilia A. Acquired hemophilia A is a rare autoimmune bleeding disorder with autoantibodies directed against coagulation factor VIII (FVIII), leading to an acquired FVIII deficiency. A prolonged isolated activated partial thromboplastin time (aPTT) in a bleeding patient warrants workup for acquired hemophilia A. This is specifically challenging in patients with thrombosis on anticoagulation and can lead to significant delays in diagnosis and associated morbidities. The case highlights the need for further awareness of this disease, potential laboratory pitfalls when conducting and interpreting coagulation assays, and the management considerations in a patient with a simultaneous thrombotic and hemorrhagic condition.
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Affiliation(s)
- Michael MacNeill
- Medicine, Schulich School of Medicine & Dentistry, Western University, London, CAN
| | | | | | - Chai W Phua
- Hematology, Schulich School of Medicine & Dentistry, Western University, London, CAN
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8
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Zhang H, Li Y, Lv X, Mao Y, Sun Y, Xu T. A novel F8 variant in a Chinese hemophilia A family and involvement of X-chromosome inactivation: A case report. Medicine (Baltimore) 2023; 102:e33665. [PMID: 37145012 PMCID: PMC10158889 DOI: 10.1097/md.0000000000033665] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/11/2023] [Indexed: 05/06/2023] Open
Abstract
RATIONALE Hemophilia A (HA) is an X-linked recessive bleeding disorder, which shows factor VIII (FVIII) deficiency caused by genetic variant in F8 gene. PATIENT CONCERNS Males with F8 variants are affected, whereas female carriers with a wide range of FVIII levels are usually asymptomatic, it is possible that different X-chromosome inactivation (XCI) may effect the FVIII activity. DIAGNOSES We identified a novel variant F8: c.6193T > G in a Chinese HA proband, it was inherited from the mother and grandmother with different FVIII levels. INTERVENTIONS We performed Androgen receptor gene (AR) assays and RT-PCR. OUTCOMES AR assays revealed that the X chromosome with the F8 variant was severely skewed inactivated in the grandmother with higher FVIII levels, but not in the mother with lower FVIII levels. Further, RT-PCR of mRNA confirmed that only the wild allele of F8 was expressed in the grandmother, with lower expression in the wild allele of the mother. LESSONS Our findings suggest that F8: c.6193T > G could be the cause of HA and that XCI affected the FVIII plasma levels in female carriers.
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Affiliation(s)
- Honghong Zhang
- Department of Pediatrics, Hangzhou Children’s Hospital, Hangzhou, Zhejiang, China
| | - Yinjie Li
- Department of Pediatrics, Hangzhou Children’s Hospital, Hangzhou, Zhejiang, China
| | - Xiaojuan Lv
- Department of Pediatrics, Hangzhou Children’s Hospital, Hangzhou, Zhejiang, China
| | - Yuchan Mao
- Key Laboratory of Reproductive Genetics, Ministry of Education (Zhejiang University), Hangzhou, Zhejiang, China
| | - Yixi Sun
- Key Laboratory of Reproductive Genetics, Ministry of Education (Zhejiang University), Hangzhou, Zhejiang, China
- Department of Reproductive Genetics, Women’s Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Ting Xu
- Department of Pediatrics, Hangzhou Children’s Hospital, Hangzhou, Zhejiang, China
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9
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Yabut J, Lima G, Vankina R, Kumar S, Meng J. Acquired Hemophilia A and ST-Elevation Myocardial Infarction (STEMI): A Rare Presentation and Management Dilemma. Cureus 2023; 15:e38549. [PMID: 37288205 PMCID: PMC10241663 DOI: 10.7759/cureus.38549] [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] [Accepted: 05/03/2023] [Indexed: 06/09/2023] Open
Abstract
Thrombotic events are a rare complication of recombinant activated factor VII (rFVIIa) therapy in patients with hemophilia. We present a case of a 71-year-old male who developed ST-elevation myocardial infarction after receiving rFVIIa replacement therapy for acquired hemophilia A.
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Affiliation(s)
- Jevin Yabut
- Medicine, University of Connecticut, Farmington, USA
| | - Gian Lima
- Internal Medicine, University of Connecticut, Farmington, USA
| | - Ritika Vankina
- Hematology and Oncology, University of Connecticut, Farmington, USA
| | - Swarup Kumar
- Hematology and Oncology, University of Connecticut, Farmington, USA
| | - Joyce Meng
- Cardiology, University of Connecticut, Farmington, USA
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10
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Hemşinlioğlu C, Aslan ES, Taştan C, Çakırsoy D, Turan RD, Seyis U, Elek M, Karakuş GS, Günaydın ÖS, Abanuz S, Kançağı DD, Yurtsever B, Yalçın K, Kasap M, Ovalı E. In Vitro FVIII Encoding Transgenic Mesenchymal Stem Cells Maintain A Successful Coagulation in FVIII- Deficient Plasma Mimicking Hemophilia A. Turk J Haematol 2023. [PMID: 37022209 DOI: 10.4274/tjh.galenos.2023.2022.0318] [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] [Indexed: 04/07/2023] Open
Abstract
Objective Hemophilia A is an X-linked recessive bleeding disorder caused by deficiency of plasma coagulation factor VIII (FVIII), and accounts for about 80-85% of patients with hemophilia. Plasma-derived therapies or recombinant factor VIII concentrates and also FVIII mimicking antibodies are used to prevent and treat the bleeding symptoms. Recently, EMA granted a conditional marketing approval for the first gene therapy of Hemophilia A. Aim of this study was to determine the effectiveness of coagulation in correcting FVIII deficiency with FVIII secreting transgenic mesenchymal stem cells (MSC). Materials and Methods A lentiviral vector encoding B-domain-deleted Factor VIII cDNA sequence with CD45 R0 truncated (CD45R0t) surface marker was designed to develop a transgenic FVIII expressing primary cell line by transducing MSC. Efficacy and functionality of secreted FVIII from MSCs was assessed with anti- FVIII ELISA, CD45R0t flow cytometry, FVIII Western Blot and Mixing Test analysis in vitro. Results Results of this study showed that the transgenic MSCs maintain a persistent FVIII secretion. There was no significant difference in FVIII secretion over time, suggesting stable FVIII expression from the MSCs. Functionality of FVIII protein secreted in MSC supernatant was demonstrated by using Mixing Test in coagulation analysis. In the Mixing Test analysis, FVIIIdeficient human plasma products were mixed either with saline control or FVIII-secreted MSC supernatant. Mean FVIII levels of saline control group were 0.41±0.03 IU/dL whereas mean FVIII levels were 25.41±33.38 IU/dL (p<0.01) in FVIII-secreting MSC supernatant mixed group. Mean activated partial thromboplastin time (aPTT) of saline control group was 92.69±11.38 seconds whereas in FVIII-secreting MSC supernatant mixed group, mean aPTT levels were decreased to 38.60±13.38 seconds (p<0.001). Conclusion Findings of this in vitro study shows a promising new method applicable to treat Hemophilia A. Accordingly, a FVIII secreting transgenic mesenchymal stem cell study will be initiated in FVIII knock-out animal model.
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Affiliation(s)
- Cansu Hemşinlioğlu
- Acıbadem Labcell Cellular Therapy Laboratory, İstanbul, Türkiye
- Molecular Biology and Medical Genetics Department, Biruni University, İstanbul, Türkiye
| | - Elif Sibel Aslan
- Molecular Biology and Medical Genetics Department, Biruni University, İstanbul, Türkiye
| | - Cihan Taştan
- Acıbadem Labcell Cellular Therapy Laboratory, İstanbul, Türkiye
- Molecular Biology and Genetics Department, Üsküdar University, İstanbul, Türkiye
- Transgenic Cell Technologies and Epigenetic Application and Research Center (TRGENMER), Uskudar University, İstanbul, Türkiye
| | - Didem Çakırsoy
- Acıbadem Labcell Cellular Therapy Laboratory, İstanbul, Türkiye
- Medicine Department, Institute of Karolinska, Stockholm, Sweden
| | - Raife Dilek Turan
- Acıbadem Labcell Cellular Therapy Laboratory, İstanbul, Türkiye
- Biotechnology Department, Yeditepe University, İstanbul, Türkiye
- Cell and Gene Therapy Center of Excellence, Yeditepe University, İstanbul, Türkiye
| | - Utku Seyis
- Acıbadem Labcell Cellular Therapy Laboratory, İstanbul, Türkiye
| | - Muhammer Elek
- Acıbadem Labcell Cellular Therapy Laboratory, İstanbul, Türkiye
- Biotechnology Department, Yeditepe University, İstanbul, Türkiye
| | | | | | - Selen Abanuz
- Acıbadem Labcell Cellular Therapy Laboratory, İstanbul, Türkiye
- Medical Biochemistry Department, Acibadem Mehmet Ali Aydinlar University, İstanbul, Türkiye
| | | | - Bulut Yurtsever
- Acıbadem Labcell Cellular Therapy Laboratory, İstanbul, Türkiye
| | - Koray Yalçın
- Acıbadem Labcell Cellular Therapy Laboratory, İstanbul, Türkiye
- Medical Park Goztepe Hospital, Pediatric Bone Marrow Transplantation Unit, İstanbul, Türkiye
- Medical Biotechnology Department, Acıbadem Mehmet Ali Aydinlar University, İstanbul, Türkiye
| | - Murat Kasap
- Department of Medical Biology, Medical School of Kocaeli University, Kocaeli, Türkiye
| | - Ercüment Ovalı
- Acıbadem Labcell Cellular Therapy Laboratory, İstanbul, Türkiye
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11
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Bukkems LH, Goedhart TM, Zwaan CM, Cnossen MH, Mathôt RA. Limited sampling strategies for individualized BAX 855 prophylaxis in severe hemophilia A: in silico evaluation. Blood Coagul Fibrinolysis 2023; 34:171-178. [PMID: 37038844 PMCID: PMC10101132 DOI: 10.1097/mbc.0000000000001204] [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: 09/05/2022] [Revised: 12/29/2022] [Accepted: 01/05/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Limited sampling strategies (LSS) lower the burden of pharmacokinetic (PK)-guided dosing, but an extensive evaluation of LSS for BAX 855 (Adynovi) is currently lacking. This study aimed to develop a LSS for BAX 855 and combine this with a LSS of a standard half-life (SHL) factor VIII (FVIII) concentrate in a clinical setting. METHODS Individual PK parameters of BAX 855 were estimated for 10 000 virtual patients with severe hemophilia A using Monte Carlo simulations. Several LSS consisting of 2-6 samples were examined based on patient burden, bias and accuracy of clearance, elimination half-life, volume of distribution and trough levels at 72 h (C72). Analyses were performed separately for adults and children <12 years. RESULTS The preferred LSS for BAX 855 consisted of three sampling points at 15-30 min, 48 h and 72 h for both adults (mean accuracy C72: 14.0% vs. 10.8% using six samples) and children (mean accuracy C72: 14.9% vs. 11.4% using six samples). The best strategy with two samples (peak, 48 h) resulted in an adequate, but lower accuracy than strategies with ≥3 samples (mean accuracy C72: 22.3%). The optimal combination of the LSS of SHL FVIII and BAX 855 led to six samples during four clinical visits. CONCLUSION This in silico study has identified that two to three samples are necessary to estimate the individual PK of BAX-855 adequately. These samples can be collected in one or two clinical visits. When combining PK profiling of SHL FVIII and BAX 855, six samples during four clinical visits are needed.
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Affiliation(s)
- Laura H. Bukkems
- Department of Clinical Pharmacology – Hospital Pharmacy, Amsterdam University Medical Centers, Amsterdam
| | - Tine M.H.J. Goedhart
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - C. Michel Zwaan
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - 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
- Department of Clinical Pharmacology – Hospital Pharmacy, Amsterdam University Medical Centers, Amsterdam
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12
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Chen H, Yang S. Acute coronary syndrome management in hemophiliacs: How to maintain balance?: A review. Medicine (Baltimore) 2023; 102:e33298. [PMID: 36930106 PMCID: PMC10019142 DOI: 10.1097/md.0000000000033298] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/24/2023] [Indexed: 03/18/2023] Open
Abstract
To analyze existing literature and understand how to balance the minimization of bleeding risk and ensuring adequate anticoagulation during coronary intervention treatment and long-term postoperative anticoagulation in hemophilia patients during the perioperative period, in order to provide guidance for healthcare professionals in developing effective treatment plans. This narrative review will analyze existing studies, case reports, and clinical guidelines to determine the most effective strategies for managing acute coronary syndrome in hemophilia patients. When evaluating the literature, factors such as patient age, medical history, and severity of the condition will be considered. The current management guidelines for acute coronary syndrome in hemophilia patients are not based on systematic evaluation and mainly rely on expert opinions. This article provides a comprehensive analysis of existing literature and recommends coagulation factor replacement therapy before anticoagulation and intervention treatment, as well as personalized anticoagulation treatment during the postoperative period for better management of hemophilia patients with acute coronary syndrome. These recommendations can help healthcare professionals develop more effective treatment plans for hemophilia patients.
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Affiliation(s)
- Hao Chen
- Internal Medicine Resident, Department of Cardiology, The First Affiliated Hospital of Yangtze University, Jingzhou, China
| | - Shaning Yang
- Department of Cardiology, The First Affiliated Hospital of Yangtze University, Jingzhou, China
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13
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Li W, Hobson EC, Bunch CM, Miller JB, Nehme J, Kwaan HC, Walsh MM, McCurdy MT, Aversa JG, Thomas AV, Zackariya N, Thomas SJ, Smith SA, Cook BC, Boyd B, Stegemann JP, Deng CX. Resonant Acoustic Rheometry to Measure Coagulation Kinetics in Hemophilia A and Healthy Plasma: A Novel Viscoelastic Method. Semin Thromb Hemost 2023; 49:201-208. [PMID: 36318959 PMCID: PMC9898113 DOI: 10.1055/s-0042-1757896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Compared with conventional coagulation tests and factor-specific assays, viscoelastic hemostatic assays (VHAs) can provide a more thorough evaluation of clot formation and lysis but have several limitations including clot deformation. In this proof-of-concept study, we test a noncontact technique, termed resonant acoustic rheometry (RAR), for measuring the kinetics of human plasma coagulation. Specifically, RAR utilizes a dual-mode ultrasound technique to induce and detect surface oscillation of blood samples without direct physical contact and measures the resonant frequency of the surface oscillation over time, which is reflective of the viscoelasticity of the sample. Analysis of RAR results of normal plasma allowed defining a set of parameters for quantifying coagulation. RAR detected a flat-line tracing of resonant frequency in hemophilia A plasma that was corrected with the addition of tissue factor. Our RAR results captured the kinetics of plasma coagulation and the newly defined RAR parameters correlated with increasing tissue factor concentration in both healthy and hemophilia A plasma. These findings demonstrate the feasibility of RAR as a novel approach for VHA, providing the foundation for future studies to compare RAR parameters to conventional coagulation tests, factor-specific assays, and VHA parameters.
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Affiliation(s)
- Weiping Li
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Eric C. Hobson
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Connor M. Bunch
- Department of Emergency Medicine and Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Joseph B. Miller
- Department of Emergency Medicine and Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Jimmy Nehme
- Department of Emergency Medicine and Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Hau C. Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark M. Walsh
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, Indiana
| | - Michael T. McCurdy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - John G. Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Anthony V. Thomas
- Indiana University School of Medicine South Bend Campus, Notre Dame, Indiana
| | - Nuha Zackariya
- Indiana University School of Medicine South Bend Campus, Notre Dame, Indiana
| | - Samuel J. Thomas
- Department of Emergency Medicine, St. Joseph Regional Medical Center, Mishawaka, Indiana
| | - Stephanie A. Smith
- Department of Biological Chemistry, Michigan Medicine, Ann Arbor, Michigan
| | - Bernard C. Cook
- Department of Pathology, Henry Ford Hospital, Detroit, Michigan
| | - Bryan Boyd
- Department of Pathology, Henry Ford Hospital, Detroit, Michigan
| | - Jan P. Stegemann
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
| | - Cheri X. Deng
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan
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14
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Ljung R, Chan AKC, Glosli H, Afonja O, Becker B, Tseneklidou-Stoeter D, Mancuso ME, Saulyte-Trakymiene S, Kenet G. BAY 81-8973 Efficacy and Safety in Previously Untreated and Minimally Treated Children with Severe Hemophilia A: The LEOPOLD Kids Trial. Thromb Haemost 2023; 123:27-39. [PMID: 36626898 PMCID: PMC9831689 DOI: 10.1055/s-0042-1757876] [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] [Indexed: 01/12/2023]
Abstract
INTRODUCTION BAY 81-8973, a full-length recombinant factor VIII for hemophilia A treatment, has been extensively evaluated in previously treated patients in the LEOPOLD (Long-Term Efficacy Open-Label Program in Severe Hemophilia A Disease) clinical trials. AIM To assess BAY 81-8973 efficacy and safety when used for bleed prophylaxis and treatment in previously untreated/minimally treated patients (PUPs/MTPs). METHODS In this phase III, multicenter, open-label, uncontrolled study, PUPs/MTPs (<6 years old) with severe hemophilia A received BAY 81-8973 (15-50 IU/kg) at least once weekly as prophylaxis. Primary efficacy endpoint was the annualized bleeding rate (ABR) within 48 hours after prophylaxis infusion. Adverse events and immunogenicity were assessed. Patients who developed inhibitors were offered immune tolerance induction (ITI) treatment in an optional extension phase. RESULTS Fifty-two patients were enrolled, with 43 patients (mean age: 13.6 months) treated. Median (interquartile range) ABR for all bleeds within 48 hours of prophylaxis infusion was 0.0 (0.0-1.8) among patients without inhibitors (n = 20) and 0.0 (0.0-2.2) among all patients. As expected, inhibitors were the most frequent treatment-related adverse event (high titer: 17 [39.5%] patients; low titer: 6 [13.9%] patients). Six of 12 patients who underwent ITI treatment in the extension phase (high titer [n = 5], low titer [n = 1]) achieved a negative inhibitor titer. CONCLUSION BAY 81-8973 was effective for bleed prevention and treatment in PUPs/MTPs. The observed inhibitor rate was strongly influenced by a cluster of inhibitor cases, and consequently, slightly higher than in other PUP/MTP studies. Overall, the BAY 81-8973 benefit-risk profile remains unchanged and supported by ongoing safety surveillance. Immune tolerance can be achieved with BAY 81-8973.
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Affiliation(s)
- Rolf Ljung
- Department of Clinical Sciences Lund-Pediatrics, Lund University, Lund, Sweden,Address for correspondence Rolf Ljung, MD, PhD Department of Clinical Sciences Lund-PediatricsLund UniversitySweden
| | - Anthony K. C. Chan
- McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Heidi Glosli
- Centre for Rare Disorders and Department of Pediatric Research, Oslo University Hospital, Oslo, Norway
| | | | | | | | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Sonata Saulyte-Trakymiene
- Clinic of Children's Diseases, Faculty of Medicine, Vilnius University Hospital Santaros Klinikos, Vilnius University, Vilnius, Lithuania
| | - Gili Kenet
- Sheba Medical Center, The Israeli National Hemophilia Center, The Amalia Biron Thrombosis Research Institute and The Sackler Medical School, Tel Aviv University, Tel-Hashomer, Israel
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15
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Cüre O, Ilkkilic K. The development of ankylosing spondylitis in a patient with familial hemophilia. Int J Rheum Dis 2023; 26:954-956. [PMID: 36599812 DOI: 10.1111/1756-185x.14553] [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: 10/02/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 01/06/2023]
Abstract
Hemophilia is a rare inherited disease which causes bleeding due to Factor VIII or Factor IX deficiency. It is usually X-linked recessive and typically affects males. Arthropathy occurs as a result of cartilage damage and chronic synovitis due to recurrent intra-articular bleeding in hemophilic patients and is mostly seen in the knee, shoulder, hip and ankle joints. There are many other diseases that cause chronic synovitis ankylosing spondylitis (AS), which is a subtype of spondyloarthropathies that cause chronic low back pain, more common in men younger than 45 years of age. In addition to axial involvement, peripheral arthritis, uveitis, enthesitis and dactylitis can be seen. Although the etiology is not fully known, genetic and environmental factors are responsible for the pathogenesis. In this study, we aimed to present congenital hemophilia and AS coexistence in a 22-year-old male patient.
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Affiliation(s)
- Osman Cüre
- Recep Tayyip Erdogan University Medical Faculty Internal Medicine Rheumatology, Rize, Turkey
| | - Kadir Ilkkilic
- Recep Tayyip Erdogan University Medical Faculty Internal Medicine Hematology, Rize, Turkey
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16
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Bukkems LH, Versloot O, Cnossen MH, Jönsson S, Karlsson MO, Mathôt RA, Fischer K. Association between Sports Participation, Factor VIII Levels and Bleeding in Hemophilia A. Thromb Haemost 2022; 123:317-325. [PMID: 36402130 PMCID: PMC9981275 DOI: 10.1055/a-1983-0594] [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] [Indexed: 11/21/2022]
Abstract
BACKGROUND Little is known on how sports participation affects bleeding risk in hemophilia. This study aimed to examine associations between sports participation, factor VIII (FVIII) levels and bleeding in persons with hemophilia A. METHODS In this observational, prospective, single-center study, persons with hemophilia A who regularly participated in sports were followed for 12 months. The associations of patient characteristics, FVIII levels, and type/frequency of sports participation with bleeding were analyzed by repeated time-to-event modelling. RESULTS One hundred and twelve persons (median age: 24 years [interquartile range:16-34], 49% severe, 49% on prophylaxis) were included. During follow-up, 70 bleeds of which 20 sports-induced were observed. FVIII levels were inversely correlated with the bleeding hazard; a 50% reduction of the baseline bleeding hazard was observed at FVIII levels of 3.1 and a 90% reduction at 28.0 IU/dL. The bleeding hazard did not correlate with sports participation. In addition, severe hemophilia, prestudy annual bleeding rate, and presence of arthropathy showed a positive association with the bleeding hazard. CONCLUSION This analysis showed that FVIII levels were an important determinant of the bleeding hazard, but sports participation was not. This observation most likely reflects the presence of adequate FVIII levels during sports participation in our study. Persons with severe hemophilia A exhibited a higher bleeding hazard at a similar FVIII levels than nonsevere, suggesting that the time spent at lower FVIII levels impacts overall bleeding hazard. These data may be used to counsel persons with hemophilia regarding sports participation and the necessity of adequate prophylaxis.
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Affiliation(s)
- Laura H. Bukkems
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Noord-Holland, The Netherlands
| | - Olav Versloot
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands,Department of Physiotherapy, Institute of Movement Studies, University of Applied Science, Utrecht, The Netherlands
| | - Marjon H. Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus University Medical Center - Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands
| | - Siv Jönsson
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | | | - Ron A.A. Mathôt
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Noord-Holland, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands,Address for correspondence Kathelijn Fischer, MD, PhD, MSc Van Creveldkliniek, PO Box 85500, 3508 GA, UtrechtThe Netherlands
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17
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Ketteler C, Hoffmann I, Davidson S, Chen D, Tiede A, Richter N. Impact of different factor VIII inhibitor kinetic profiles on the inhibitor titer quantification using the modified Nijmegen–Bethesda assay. Res Pract Thromb Haemost 2022; 6:e12799. [PMID: 36518189 PMCID: PMC9743337 DOI: 10.1002/rth2.12799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 12/14/2022] Open
Abstract
Background Coagulation factor VIII (FVIII) inhibitor titer quantification is vital for optimizing care in people with hemophilia A. Objectives This study analyzed the impact of the different kinetic profiles of four FVIII monoclonal antibodies on inhibitor titer quantification using the modified Nijmegen–Bethesda assay. Methods Concentration‐related and time‐related profiles of FVIII antibodies (4A4, BO2C11, 2‐54, ESH‐8) were evaluated in vitro. FVIII residual activity was measured using a one‐stage clotting assay and chromogenic substrate assay. Profiles of the FVIII antibodies were compared with the theoretical kinetic model: the ideal log (residual activity)‐linear (inhibitor concentration) relationship. Different theoretical kinetic model–dependent and –independent criteria to calculate FVIII inhibitor titer were compared. Results Factor VIII monoclonal antibodies had different concentration‐related and time‐related profiles, ideal for comparative analysis using the modified Nijmegen–Bethesda assay. The kinetic profile of 4A4 was similar to the theoretical kinetic model, while BO2C11 showed a steeper curve, and 2‐54 and ESH‐8 a flatter curve, than the model. In the modified Nijmegen–Bethesda assay, conversion of measured FVIII residual activities for different inhibitor dilutions into FVIII inhibitor titer is based on the theoretical kinetic model. Therefore, titer calculations for FVIII inhibitors that deviate from the model are prone to underestimation or overestimation. Calculating a theoretical dilution at 50% FVIII residual activity by sigmoidal regression reflecting different kinetic inhibition profiles can provide a more accurate titer result. Conclusion Kinetic profiles of FVIII antibodies can deviate from the theoretical kinetic model in the modified Nijmegen–Bethesda assay, leading to differences in FVIII inhibitor titer quantification.
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Affiliation(s)
| | | | | | - David Chen
- Genentech, Inc.South San FranciscoCaliforniaUSA
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell TransplantationHannover Medical SchoolHannoverGermany
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Abstract
Total hip arthroplasty (THA) has been an effective tool of advanced hemophiliac hip arthritis. There are only limited data of bilateral synchronous THA for end-stage arthropathy in hemophilia A patients. The aim of this retrospective study was to analyze clinical outcome and complication rate of bilateral THA for hemophilia A patients with end-stage arthropathy of hip and review the operative strategy. From August 2012 to July 2016, 48 hips of 24 patients with hemophilia A patients underwent THA by a single experienced chief orthopedic surgeon. Clinical and radiological evaluations were included of operation time, blood loss, the quantity of blood transfusion, clotting factor consumption, duration of hospitalization, modified Harris hip score, complication rate, and radiographic assessment. All the 24 patients successfully completed the operation, followed up for 5 to 8 years, and the mean time was 6.5 years. The average operation time was 140 minutes (range, 120-180 minutes). The average total blood loss was 225 mL (range, 150-400 mL). The mean red blood cell transfusion amount was 2.4 U (range, 0-6 U). the mean hospitalization time was 24 days (range, 16-46 days). The mean amount of clotting factor VIII used in the perioperative period for management of hemophilia A was 30,600 U (range, 18,000-52,000 U). Average modified Harris hip score increased from 46.6 (range 28-70) points preoperatively to 90.2 (range 75-98) points at final follow-up, complications were few. With excellent operative techniques and hematological management, bilateral synchronous THA for end-stage arthropathy in hemophilia A patients can provide satisfactory outcomes.
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Affiliation(s)
- Bang Jian He
- Department of Orthopedics, The First Affiliated Hospital of Zhejiang Traditional Chinese Medicine University, Hangzhou, China
| | - Qiang Mao
- Department of Orthopedics, The First Affiliated Hospital of Zhejiang Traditional Chinese Medicine University, Hangzhou, China
| | - Ju Li
- Department of Orthopedics, The First Affiliated Hospital of Zhejiang Traditional Chinese Medicine University, Hangzhou, China
| | - Shuai Jie Lv
- Department of Orthopedics, The First Affiliated Hospital of Zhejiang Traditional Chinese Medicine University, Hangzhou, China
| | - Peijian Tong
- Department of Orthopedics, The First Affiliated Hospital of Zhejiang Traditional Chinese Medicine University, Hangzhou, China
| | - Hong Ting Jin
- Department of Orthopedics, The First Affiliated Hospital of Zhejiang Traditional Chinese Medicine University, Hangzhou, China
- * Correspondence: Hong Ting Jing, Department of Orthopedic Surgery, the First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54, Youdian Road, Hangzhou 310006, China (e-mail: )
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19
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Kertész G, Kállay K, Kassa C, Zombori M, Bodó I, Kiss C, Szegedi I, Kriván G. Case Report: A Child With Hemophilia A Serves as Donor for Hematopoietic Stem Cell Transplantation to Cure His Brother's Severe Aplastic Anemia. Pathol Oncol Res 2022; 28:1610171. [PMID: 35755418 PMCID: PMC9214756 DOI: 10.3389/pore.2022.1610171] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 05/17/2022] [Indexed: 11/13/2022]
Abstract
The first-line treatment of severe aplastic anemia is allogeneic hematopoietic stem cell transplantation with a matched sibling donor. However, co-morbidities of the identical donor can make donation difficult. We present a transplantation where in parallel with the patient's conditioning treatment, the preparation of the donor with severe hemophilia A required a special management with perioperative factor VIII substitution. Donation was successful without complications, and 18 months after transplantation, the patient and his donor are well without any long-term sequelae. To our knowledge, this is the first reported succesfull transplantation with hemophilic child serving as a bone marrow donor. The procedure did not mean a significant risk to donor health, so donors with hemophilia should not be excluded from donation.
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Affiliation(s)
- Gabriella Kertész
- Department of Pediatric Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest, National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Krisztián Kállay
- Department of Pediatric Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest, National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Csaba Kassa
- Department of Pediatric Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest, National Institute of Hematology and Infectious Diseases, Budapest, Hungary.,Department of Infectious Diseases, Semmelweis University, Budapest, Hungary
| | - Marianna Zombori
- Kemény Pál Pediatric Onco-Hematologic Department, Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Imre Bodó
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Csongor Kiss
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - István Szegedi
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gergely Kriván
- Department of Pediatric Hematology and Stem Cell Transplantation, Central Hospital of Southern Pest, National Institute of Hematology and Infectious Diseases, Budapest, Hungary.,Department of Infectious Diseases, Semmelweis University, Budapest, Hungary
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Abstract
OBJECTIVES The objective of our study was to assess the current knowledge, the oral health status, and the pro-health needs of patients with hemophilia. MATERIALS AND METHODS The study included 77 patients with known hemophilia. The study included the assessment of dental indicators related to caries incidence (decayed, missing, and filled teeth [DMFT] and decayed, missing, and filled permanent teeth or surfaces [DMFS]), caries treatment (treatment index), oral hygiene status (Approximal Plaque Index [API] and simplified oral hygiene index [OHI-S]), and periodontal status (bleeding on probing [BoP]). A questionnaire addressed symptoms of hemorrhagic diathesis and health-promoting habits. The influence of routine management ("on-demand" vs. prophylactic therapy), type of hemophilia (A, B), and severity of clotting factor deficiency (mild, moderate, or severe) on oral health was assessed. STATISTICAL ANALYSIS The tests used in the study were Shapiro-Wilk, Mann-Whitney, Kruskal-Wallis, and Dunn's tests. The level of significance was set at p < 0.05. RESULTS Patients with hemophilia showed a higher prevalence of caries compared with patients without hemorrhagic diathesis (DMFT 14 and 9, and DMFS 30 and 15, respectively), and they also presented a higher bleeding index value during probing and worse effectiveness of hygienic interdental procedures. The type of therapy and secondary prophylaxis used and the type and severity of hemophilia did not affect the oral health status. CONCLUSIONS Patients with hemophilia have an increased risk of developing dental caries. Undertaking educational activities related to the prevention of oral diseases is necessary to improve oral health.
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Affiliation(s)
- Sylwia Czajkowska
- Department of Conservative Dentistry and Endodontics, Poznan University of Medical Sciences, Poznan, Poland,Address for correspondence Sylwia Czajkowska, DMD Department of Conservative Dentistry and Endodontics, Poznan University of Medical SciencesBukowska 70, Poznań 60-356Poland
| | - Joanna Rupa-Matysek
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznan, Poland
| | - Anna Surdacka
- Department of Conservative Dentistry and Endodontics, Poznan University of Medical Sciences, Poznan, Poland
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21
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Liu G, Huang K, Li G, Zhen Y, Li Z, Chen Z, Wu R. Real-world experience of emicizumab prophylaxis in young children with hemophilia A: retrospective data from China. Front Pediatr 2022; 10:992267. [PMID: 36340724 PMCID: PMC9627604 DOI: 10.3389/fped.2022.992267] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/26/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND As a new non-factor therapy for hemophilia A (HA), real-world study of emicizumab is still scarce. This study aimed to investigate the real-world use of emicizumab in Chinese boys with HA. METHODS Patients with moderate or severe HA were enrolled at Beijing Children's Hospital. They take emicizumab weekly (3 mg/kg) for a month and then went into a maintenance period with a different dosing regimen. After obtaining platelet-poor plasma at end of the loading period and during the maintenance period, coagulation ability and FVIII inhibitor were determined using human and bovine chromogenic Bethesda assay. Patients' bleeding rates were calculated through patients' records from 24 weeks before to at least 6 months after the switch (to emicizumab). RESULT In total, 13 pediatric patients with HA (severe: moderate = 11:2) were enrolled in this study. The patients' age was 3.51 (0.73-6.65) years. Eight had FVIII inhibitors at enrollment and one of them developed FVIII inhibitors again during the switch. The coagulation level of the maintenance period was 19.6 (13.5-32.8) IU/dL (N = 10). The median dose of each emicizumab injection was 2.7 (1.3-3.8) mg/kg and the monthly consumption of emicizumab was 5.2 (3.2-6.8) mg/kg/month. After switching to emicizumab, reduced annualized bleeding rate (ABR) [0.5 (0-4) vs. 4 (0-18), P < 0.01], annualized joint bleeding rate (AJBR) [0 (0-1.1) vs. 1.0 (0-12), P < 0.01], and annualized spontaneous bleeding rate (ASBR) [0 (0-1) vs. 2.0 (0-18), P < 0.01] were observed. In patients with or without FVIII inhibitor, similar ABR [0.33 (0-4) vs. 0.5 (0-3), P = 0.78], AJBR [0 (0-1.1) vs. 0 (0-0.5), P = 0.63], and ASBR [0 (0-1) vs. 0 (0-1.5), P = 0.73] were also noticed. Five inhibitor-positive patients (at enrollment) all had their inhibitor titer reduced. In addition, all target joints vanished after switching to emicizumab. CONCLUSION Emicizumab could reduce bleeds in pediatric patients with/without FVIII inhibitors and eliminate target joints.
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Affiliation(s)
- Guoqing Liu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Kun Huang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Gang Li
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yingzi Zhen
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhengping Li
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhenping Chen
- Hematologic Disease Laboratory, Hematology Center, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Healt, Beijingh, China
| | - Runhui Wu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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Saiyarsarai P, Robabpour Derakhshan A, Khedmati J, Eshghi P, Seyedifar M. A comparison between on-demand usage of rFVIIa vs prophylaxis use of emicizumab in high titer inhibitory hemophilia A patients in Iran: A cost-utility analysis. Medicine (Baltimore) 2021; 100:e27303. [PMID: 34622828 PMCID: PMC8500655 DOI: 10.1097/md.0000000000027303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/02/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Hemophilia A (HA) is an inherited X-linked bleeding disease with costly treatment, especially for high titer inhibitory patients. Emicizumab, a new humanized bispecific antibody, has been approved for use to prevent or reduce the frequency of bleeding episodes in HA patients with inhibitors. This study evaluated the cost-utility of emicizumab prophylaxis (EP) in comparison with recombinant factor VII activated on-demand treatment in HA patients with inhibitors. METHODS A life-time Markov model with payer and societal perspectives was developed in different age groups with different annual bleeding rates (ABR). Efficacy of treatments were extracted from HAVEN trials. Utilities were retrieved from published evidence. Costs were calculated based on Iran food and drug administration official website, national tariff book for medical services and hospital data. One-way deterministic sensitivity analysis was performed. RESULTS EP was dominant choice in comparison with on-demand administration of recombinant factor VII activated in all age groups with ABR 20 and 25, and it remained dominant in patients with age 2 and age 12 at start point with ABR 16 and 17. The reported incremental cost-effectiveness ratio for the group with ABR 18 at the age 20, was 12,936 United States Dollars which is lower than the acceptable threshold of cost-effectiveness in Iran (1-3 gross domestic product per capita) and EP can be considered as cost-effective choice in this scenario. CONCLUSION EP was found to be a dominant and cost-effective choice for Iranian HA patients with factor VIII inhibitors with ABR 18 and above with considerable cost saving.
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Affiliation(s)
- Parisa Saiyarsarai
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Pharmaceutical Management and Economics Research Center (PMERC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Atefeh Robabpour Derakhshan
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Jamaleddin Khedmati
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Peyman Eshghi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Meysam Seyedifar
- Pharmaceutical Management and Economics Research Center (PMERC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
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23
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Wang LY, Shen Y, Zeng HQ, Zhang Y, Lou SF, Deng JC, Luo Y. Feasibility of therapeutic plasma exchange-based combination therapy in the treatment of acquired hemophilia A: A retrospective 6 case series. Medicine (Baltimore) 2021; 100:e26587. [PMID: 34398013 PMCID: PMC8294921 DOI: 10.1097/md.0000000000026587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 06/17/2021] [Indexed: 01/04/2023] Open
Abstract
Poor availability and a lack of affordability of bypassing agents (recombinant activated factor VII and activated prothrombin complex concentrate) in west China prompted us to investigate an alternative cost-effective combination therapy. We aimed to explore the feasibility of therapeutic plasma exchange (TPE)-based combination therapy in the treatment of acquired hemophilia A (AHA).We retrospectively investigated the clinical features of AHA in 6 patients who were treated with a combination of TPE, corticosteroids, and rituximab in our department for 9 years between January, 2011 and December, 2019.We examined 1 male and 5 female patients. The median age at diagnosis of AHA was 51 years (18-66 years). In all patients, FVIII activity levels were low (median: 1.5%; 1-3%), FVIII inhibitor titers were high (median: 24.5 BU/mL; 13.2-48.6 BU/mL), and activated partial thromboplastin time was markedly prolonged (median: 99.4 s; 60.9-110.1 s). They underwent 2 to 8 cycles of plasma exchange and were given varying combinations of dexamethasone, methylprednisolone, prednisone, and rituximab. After TPE bleeding gradually stopped, and activated partial thromboplastin time decreased. After 3 months of treatment, FVIII inhibitors completely disappeared.TPE when combined with corticosteroids and rituximab, as adjunctive immunosuppressive agents, may be an effective and reliable treatment for AHA. When there is no alternative, intensive first-line treatment including TPE may be lifesaving.
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24
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Regino CA, Alvarez JC, Buriticá LM, Pulido NU, Yepes VT, Torres JD. Idiopathic Acquired Hemophilia A, a Rare Cause of Bleeding: A Case Report and Literature Review. Am J Case Rep 2021; 22:e929401. [PMID: 33594037 PMCID: PMC7899955 DOI: 10.12659/ajcr.929401] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/05/2021] [Accepted: 12/22/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acquired hemophilia is a bleeding disorder mediated by an autoimmune process, in which antibodies against clotting factors are developed. This is a rarely suspected complex condition in which the initial manifestations are spontaneous bleeding in the skin, soft tissues, and mucosa in patients with no known history of bleeding disorders. Most of the cases are idiopathic (50%), but it can be associated with autoimmune diseases, malignancy, pregnancy, and medications. The most frequent type is mediated by inhibitors against factor VIII, followed by coagulation factor IX and XI. It is a disease with high morbidity and mortality rates without adequate treatment. Diagnosis is based on the detection of low concentrations of clotting factors and the presence of an inhibitor. CASE REPORT We present 2 cases of patients with spontaneous bleeding in whom the diagnosis of idiopathic acquired hemophilia A was made, an extensive malignancy study was performed that was negative, and the presence of autoimmunity markers (positive antinuclear antibodies (ANA)) was observed, without any another sign of autoimmune disease. They received immunosuppressive therapy with bleeding control and inhibitor eradication. CONCLUSIONS Acquired hemophilia A is a rare but potentially lethal disease, representing a medical challenge from its diagnosis to its treatment. An early recognition and treatment are fundamental because delays are associated with adverse outcomes. Optimal management includes the workup and treatment for an underlying disease, use of "bypass" agents when active bleeding presents, and inhibitor titer eradication through immunosuppressants drugs. With the present cases, we highlight the importance of considering acquired hemophilia A in older patients with similar symptoms, to achieve early diagnosis and treatment.
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Affiliation(s)
| | - José C. Alvarez
- Department of Internal Medicine, University of Antioquia, Medellín, Colombia
| | | | - Natalí Uribe Pulido
- Department of Internal Medicine, University of Antioquia, Medellín, Colombia
| | | | - José D. Torres
- Department of Hematology, University of Antioquia, Medellín, Colombia
- Hematology Unit, Thrombosis Group, San Vicente Foundation University Hospital, Medellín, Colombia
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25
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Abstract
RATIONALE Hemophilia A (HA) is an X-linked recessive disorder caused by clotting factor VIII (FVIII) deficiency. There is limited data on the use of replacement therapy in cardiac surgery. Since no international guideline for anticoagulation in such patient exists, careful thought should be taken to design an individualized anticoagulation strategy. PATIENT CONCERNS We report a 54-year-old male with severe HA with FVIII activity of 0.8% when he was first diagnosed, who underwent successful mitral valve repair and coronary artery bypass graft with FVIII replacement perioperatively. DIAGNOSES Transthoracic echocardiography and coronary angiography confirmed the HA patient with the diagnosis of severe mitral valve regurgitation and left anterior descending artery stenosis. INTERVENTIONS Before surgery, a bolus of 1000 IU FVIII was injected, which obtained an FVIII of 80%. After induction, a 3750 IU bolus of FVIII was injected and subsequent FVIII level reached 135%. Mitral valve repair and coronary artery bypass graft with FVIII replacement were performed. After the surgery, a repeat FVIII activity level was 50.6%. The 400 mL of autologous blood and 700 mL of cardiopulmonary bypass (CPB) machine blood was returned to the patient as well as 4 units of fresh frozen plasma with an additional bolus of 1000 IU FVIII. 100 mg aspirin per day alone was given after surgery. OUTCOMES The patient recovered uneventfully and 1-year follow-up showed no complications. LESSONS The anticoagulant or antiplatelet regimen of HA patient following surgery should be individualized based on the evaluation of the risk factors for bleeding and thrombosis and the lowest FVIII activity ever recorded after FVIII replacement therapy.
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Affiliation(s)
| | | | | | | | - Yanyan Yang
- Department of pharmacy, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Majid Z, Tahir F, Qadar LT, Shaikh MY, Mahmood Shah SM. Hemophilia A with a Rare Presentation of Hemarthrosis and Arthropathy Involving Multiple Joints in a Young Male Child. Cureus 2019; 11:e4524. [PMID: 31259133 PMCID: PMC6590732 DOI: 10.7759/cureus.4524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Hemophilia A is an X-linked hereditary bleeding disorder that is rarely encountered by most physicians and surgeons in their practice. Patients with mild hemophilia A tend to bleed profusely after surgery or trauma whereas a severe variant may manifest as spontaneous bleeding after minor trauma, mainly into the joints and muscles. However, seldom do we find a case where the patient experiences bleeding into multiple joints at the same time. In the South Asian population, the incidence of hemarthrosis in hemophilic patients holds scarce literature, making this an under-reported entity.
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Affiliation(s)
- Zainab Majid
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Faryal Tahir
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Laila Tul Qadar
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Mahnoor Y Shaikh
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
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Stephen SE, Loong JLX, Hoong CK, Lim SM, Botross NP. Acquired Hemophilia of Unknown Etiology in an Elderly Man: Case Report. Am J Case Rep 2018; 19:858-863. [PMID: 30033442 PMCID: PMC6066981 DOI: 10.12659/ajcr.909228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/17/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND Acquired hemophilia is a rare but potentially dangerous bleeding disorder caused by autoantibodies against coagulation factors. It affects 1 to 1.5 per 1 million people each year. While 50% of cases could be idiopathic, other causes include malignancies, diabetes, pregnancy, infection, and autoimmune disorders. CASE REPORT We report a case of a 90-year-old male who developed a spontaneous hematoma on the dorsum of his right hand, with no prior history of trauma or any other mucosal bleeding. His activated partial thromboplastin time (aPTT) was found to be prolonged (>180 seconds) with a very low level of factor VIII (0.1%). CONCLUSIONS As workups did not identify the source, including malignancy and autoimmune diseases, of his acquired hemophilia, it is believed to be idiopathic. He was started on intravenous recombinant factor VIIa (NovoSeven) to control the bleeding in combination with an immunosuppressive therapy of cyclophosphamide and prednisolone. In approximately 10% of patients with acquired hemophilia, underlying malignancy, such as squamous cell cancer, chronic lymphocytic leukemia, non-Hodgkin lymphoma, and multiple myeloma can present and commonly develop in elderly patients. Therefore, patients diagnosed with idiopathic acquired hemophilia should be given long-term follow up.
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Affiliation(s)
| | | | - Chan Kwok Hoong
- Jeffrey Cheah School of Medicine, Monash University, Johor Bahru, Malaysia
| | - Soo Min Lim
- Department of Hematology, Hospital Sultanah Aminah, Johor Bahru, Malaysia
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28
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Abstract
RATIONALE Hemophilic arthropathy (HA) is a crucial morbidity and a major cause of joint pain and disability in patients with hemophilia A. Surgical methods, such as total joint arthroplasty, are of vital importance for end-stage HA treatment, but the feasibility and effects of multi-joint replacement surgery remain debatable. PATIENT CONCERNS A 24-year-old patient with advanced HA presented multiple joint pain. Physical examination revealed joint tenderness, swelling, and limited activity. Radiographs revealed bilateral knee joints and left elbow joint damage with joint space narrowing, articular facet erosion, and bone deformation. DIAGNOSES The patient was diagnosed with hemophilic arthropathy with multi-joint lesions. INTERVENTIONS The key points of this case include arthropathy in multiple joints and the management of simultaneous total multi-joint arthroplasty. We performed bilateral total knee arthroplasty and total left elbow arthroplasty simultaneously after adequate preparations. Special attention was paid to factor VIII infusion, hemorrhage control, and other safety precautions perioperatively. OUTCOMES After the surgery, no complications, such as infection or aseptic loosening, occurred, and the joints functioned well at follow-up. LESSONS The surgical outcome and safety of multi-joint replacement for HA are attested. Simultaneous multi-joint arthroplasty can ameliorate the quality of life for patients with hemophilia A.
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Affiliation(s)
- Wei Zhu
- Department of Orthopedics, Peking Union Medical College Hospital
| | - Xuxia He
- Department of Clinical Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tsinghua University, Beijing, China
| | - Zenan Xia
- Department of Orthopedics, Peking Union Medical College Hospital
| | - Jiliang Zhai
- Department of Orthopedics, Peking Union Medical College Hospital
| | - Xisheng Weng
- Department of Orthopedics, Peking Union Medical College Hospital
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Zupančić-Šalek S, Vodanović M, Pulanić D, Skorić B, Matytsina I, Klovaite J. A case report of acute inferior myocardial infarction in a patient with severe hemophilia A after recombinant factor VIII infusion. Medicine (Baltimore) 2017; 96:e9075. [PMID: 29384900 PMCID: PMC6392801 DOI: 10.1097/md.0000000000009075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE The extent of protective effects of hemophilia against thrombotic events such as myocardial infarction (MI) and other acute coronary syndromes remains to be determined, as major risk factors for cardiovascular disease exist despite factor VIII (FVIII) deficiency. We present a case report of a 41-year-old male with severe hemophilia A and several cardiovascular risk factors. PATIENT CONCERNS This morbidly obese patient developed chest pressure, followed by chest pain and difficulty in breathing shortly after receiving on-demand treatment with intravenous recombinant FVIII (rFVIII) (turoctocog alfa) dosed per body weight. DIAGNOSES An electrocardiogram revealed a diagnosis of inferior ST-segment elevation MI. INTERVENTIONS The patient underwent an urgent coronary angiography using a radial artery approach. During the next 12 months, he received dual antiplatelet treatment, acetylsalicylic acid 100 mg, and clopidogrel 75 mg daily. His treatment for severe hemophilia A was changed to plasma-derived FVIII replacement therapy. OUTCOMES During this 12-month period, he experienced several small bleeds in his elbows. CONCLUSIONS The temporal relationship between rFVIII infusion and onset of the MI suggests a possible association; however, apart from obesity, the patient also had other major risk factors for arterial thrombosis, such as hypertension and smoking. Furthermore, atherosclerotic disease and underlying atherosclerotic changes could not be excluded with certainty. This case highlights the importance of studies assessing the impact of excess body weight on rFVIII dosing.
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Affiliation(s)
- Silva Zupančić-Šalek
- Unit for Haemostasis, Thrombosis and Benign Diseases of Haematopoietic System, Division of Hematology, Department of Internal Medicine, University Hospital Centre Zagreb
- Medical School University of Zagreb, Zagreb
- Faculty of Medicine Osijek, J.J. Strossmayer University of Osijek, Osijek
| | - Marijo Vodanović
- Unit for Haemostasis, Thrombosis and Benign Diseases of Haematopoietic System, Division of Hematology, Department of Internal Medicine, University Hospital Centre Zagreb
| | - Dražen Pulanić
- Unit for Haemostasis, Thrombosis and Benign Diseases of Haematopoietic System, Division of Hematology, Department of Internal Medicine, University Hospital Centre Zagreb
- Medical School University of Zagreb, Zagreb
- Faculty of Medicine Osijek, J.J. Strossmayer University of Osijek, Osijek
| | - Boško Skorić
- Medical School University of Zagreb, Zagreb
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Zagreb, Croatia
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He JP, Feng JX. Two-incision laparoscopic appendectomy for a severe hemophilia A child patient with coagulation factor VII deficiency: Case report and review of literature. Medicine (Baltimore) 2017; 96:e8197. [PMID: 29019885 PMCID: PMC5662308 DOI: 10.1097/md.0000000000008197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE The main complication of patients with severe hemophilia is recurrent bleeding events that usually affected musculoskeletal contractures. And replacement therapy methods were continuously improved to minimize adverse impacts brought by those complications. However, only several cases reported about the appendectomy for hemophilia A. We report a case of acute appendicitis treated by two-incision laparoscopy in a boy with hemophilia A and coagulation factor VII deficiency for the first time. PATIENT CONCERNS An 8y7m-old Chinese boy presented with half a day of right sided abdominal pain, fever, nausea, and vomiting. DIAGNOSES He received a computed tomography (CT) scan which revealed an enlarged appendix, thickened wall and appendiceal fecalith, and had received a conservative anti-bacterial treatment for his acute appendicitis but failed. He was diagnosed with hemophilia A and coagulation factor VII deficiency. INTERVENTIONS Two-incision laparoscopic appendectomy was made in success with a careful management of perioperative period. We monitored the clotting factor FVIII level and gave him a replacement therapy. OUTCOMES The patient had an uneventful recovery. LESSONS It is important to exclude intraabdominal or retroperitoneal hemorrhage in patients suffering from hemophilia and acute abdominal pain. Pre-operative evaluation of validity of the FVIII replacement therapy is another effective strategy to assess the safety and feasibility of applying an operation procedure. The two-incision laparoscopic appendectomy is an effective treatment for this kind of patients for its minimal trauma and fast recovery characteristics. Our report shows that laparoscopic appendectomy is feasible in a child suffering from hemophilia after adequate blood clotting factor replacement treatment.
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Abstract
Hemophilic arthropathy is the most common chronic complication in patients with hemophilia. The pathogenesis of hemophilic arthropathy involves the inflammatory processes associated with rheumatoid arthritis (RA). Determining the severity and/or progression of joint damage is crucial when evaluating the effect of treatment modalities. Identifying reliable biomarkers in the peripheral blood of patients with hemophilic arthropathy may be beneficial in clinical practice. Circulating soluble vascular cell adhesion molecule-1 (sVCAM-1), E-selectin, and P-selectin levels are elevated in patients with RA. Our study investigated whether these soluble adhesion molecules can be used as biological indicators in the course of joint damage in patients with hemophilia A.Patients with hemophilia A (mild, moderate, and severe) were enrolled. The plasma levels of sVCAM-1, E-selectin, and P-selectin in patients with hemophilia A and control were measured using specific enzyme-linked immunosorbent assay kits. Joint damages were evaluated using Pettersson scores.No statistically significant differences were observed in E-selectin and P-selectin levels between patients and controls. The sVCAM-1 level was significantly higher in patients with hemophilia A than in controls. The differences remained significant in patients with severe hemophilia A but not in patients with mild or moderate hemophilia A. The degree of hemophilic arthropathy was evaluated using Pettersson scores, and a score higher than 5 indicated marked arthropathy. Patients with more than 1 joint with marked arthropathy showed significantly higher sVCAM-1 levels.sVCAM-1 levels in patients with hemophilia A are associated with the severity of hemophilic arthropathy.
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Affiliation(s)
| | - Shyh-Shin Chiou
- Department of Pediatrics
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital
- Department of Pediatrics, School of Medicine, College of Medicine
- Special Hematologic Disease Service Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yu-Sheng Zeng
- Department of Pediatrics
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital
- Special Hematologic Disease Service Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Shih-Pien Tsai
- Department of Nursing
- Special Hematologic Disease Service Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chun-Shih Chen
- Special Hematologic Disease Service Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Yu-Mei Liao
- Department of Pediatrics
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital
- Special Hematologic Disease Service Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Pei-Chin Lin
- Department of Pediatrics
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Kaohsiung Medical University Hospital
- Department of Pediatrics, School of Medicine, College of Medicine
- Graduate Institute of Clinical Medicine, Kaohsiung Medical University
- Special Hematologic Disease Service Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Abstract
BACKGROUND Acquired haemophilia A is a rare bleeding disorder caused by the development of specific autoantibodies against coagulation factor VIII. Rituximab may be an alternative approach to the treatment of acquired haemophilia by eradicating FVIII autoantibodies. OBJECTIVES To assess and summarise the efficacy and adverse effects of rituximab for treating people with acquired haemophilia A. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's trials registers, comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and conference proceedings.Date of last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's trials registers: 01 March 2016. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of rituximab for people with acquired hemophilia A, with no restrictions on gender, age or ethnicity. DATA COLLECTION AND ANALYSIS No trials matching the selection criteria were eligible for inclusion. MAIN RESULTS No trials matching the selection criteria were eligible for inclusion. AUTHORS' CONCLUSIONS No randomised clinical trials of rituximab for acquired hemophilia A were found. Thus, based on the highest quality of evidence, we are not able to draw any conclusions or make any recommendations on rituximab for eradicating inhibitors in people with acquired haemophilia A. Given that undertaking randomised controlled trials in this field is a complex task, the authors suggest that, while planning such trials, clinicians treating the disease continue to base their choices on alternative, lower quality sources of evidence. The authors plan, for a future update of this review, to appraise and incorporate any randomised controlled trials, as well as other high-quality non-randomised studies.
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Affiliation(s)
- Yan Zeng
- General Hospital of Chengdu Military RegionDepartment of Hematology270#, Rongdu Da DaoChengduChina610083
| | - Ruiqing Zhou
- Guangzhou First People's Hospital, Guangzhou Medical UniversityDepartment of HematologyPanfu RoadGuangzhouChina510180
| | - Xin Duan
- West China Hospital, Sichuan UniversityDepartment of Orthopaedics SurgeryNo. 37 GuoXueXiang StreetChengduChina610041
| | - Dan Long
- West China Hospital, Sichuan UniversityKey Laboratory of Transplant Engineering and ImmunologyNo. 37, Guo Xue XiangChengduChina610041
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Kavakli K, Yang R, Rusen L, Beckmann H, Tseneklidou-Stoeter D, Maas Enriquez M. Prophylaxis vs. on-demand treatment with BAY 81-8973, a full-length plasma protein-free recombinant factor VIII product: results from a randomized trial (LEOPOLD II). J Thromb Haemost 2015; 13:360-9. [PMID: 25546368 PMCID: PMC4671268 DOI: 10.1111/jth.12828] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 12/19/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND BAY 81-8973 is a new full-length human recombinant factor VIII product manufactured with technologies to improve consistency in glycosylation and expression to optimize clinical performance. OBJECTIVES To demonstrate superiority of prophylaxis vs. on demand therapy with BAY 81-8973 in patients with severe hemophilia A. PATIENTS/METHODS In this multinational,randomized, open-label crossover study (LEOPOLD II;ClinicalTrials.gov identifier: NCT01233258), males aged 12–65 years with severe hemophilia A were randomized to twice-weekly prophylaxis (20-30 IU kg(-1)), 3-times-weekly prophylaxis (30-40 IU kg(-1)), or on-demand treatment with BAY 81-8973. Potency labeling for BAY 81-8973 was based on the chromogenic substrate assay or adjusted to the one-stage assay. Primary efficacy endpoint was annualized number of all bleeds (ABR). Adverse events (AEs)and immunogenicity were also assessed. RESULTS Eighty patients (on demand, n = 21; twice-weekly prophylaxis, n = 28; 3-times-weekly prophylaxis, n = 31) were treated and analyzed. Mean ± SD ABR was significantly lower with prophylaxis (twice-weekly, 5.7 ± 7.2; 3-times-weekly, 4.3 ± 6.5; combined, 4.9 ± 6.8) vs. on-demand treatment (57.7 ± 24.6; P < 0.0001, ANOVA). Median ABR was reduced by 97% with prophylaxis (twice-weekly, 4.0;3-times-weekly, 2.0; combined, 2.0) vs. on-demand treatment (60.0). Median ABR was higher with twice-weekly vs. 3-times-weekly prophylaxis during the first 6-month treatment period (4.1 vs. 2.0) but was comparable in the second 6-month period (1.1 vs. 2.0). Few patients reported treatment-related AEs (4%); no treatment-related serious AEs or inhibitors were reported. CONCLUSIONS Twice weekly or 3-times-weekly prophylaxis with BAY 81-8973 reduced median ABR by 97% compared with on-demand therapy, confirming the superiority of prophylaxis. Treatment with BAY 81-8973 was well tolerated.
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Affiliation(s)
- K Kavakli
- Ege University Children’s Hospital, Izmir, Turkey.
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Abstract
BACKGROUND Patients with well-managed rare chronic diseases such as hemophilia maintain a stable health state and health-related quality of life (HrQoL) that may be affected by acute events. Longitudinal HrQoL assessments analyzed using multivariate multilevel (MVML) modelling can determine the impact of such events on individuals (within-person effect) and identify factors influencing within-population differences (between-person effect). OBJECTIVES To demonstrate the application of MVML modelling in a longitudinal study of HrQoL in hemophilia A. METHODS/DESIGN/PARTICIPANTS Using data on 136 adults and 125 children from a two-year observational cohort study of burden of illness in US hemophilia A patients, MVML modelling determined the effect of time-invariant (sociodemographic and clinical characteristics) and time-varying factors (bleeding frequency, emergency room visits, and missed work/school days) on within-person and between-person HrQoL changes. HrQoL was assessed using the SF-12 health survey (adults) and PedsQL inventory (children) at baseline, then every 6 months. RESULTS In children, within-person (p < 0.0001) and between-person (p < 0.0001) psychosocial functioning was reduced by each additional bleed and missed day (within-person: p = 0.0089; between-person: p = 0.0060). Within-person physical functioning was reduced by each additional bleed (p < 0.0001), emergency room (ER) visit (p = 0.0284), and missed day (p = 0.0473). Between-persons, additional missed days (p < 0.0001) significantly decreased physical functioning. In adults, each additional missed day reduced SF-12 Health Survey mental (p = 0.0025) and physical (p = 0.0093) component summary scores. Each additional bleed also decreased physical component summary (PCS) significantly (p = 0.0093). CONCLUSIONS This study demonstrated the applicability of MVML modelling in identifying time-invariant and time-varying factors influencing HrQoL in a rare chronic disease population. Small but significant within-person and between-person changes in HrQoL with each additional acute event experienced were identified, which if frequent, could have a large cumulative impact. The results suggest that MVML modelling may be applied to future studies of longitudinal change in HrQoL in other rare chronic disease populations.
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Sundaram J, Keshava S, Gopalakrishnan R, Esmon CT, Pendurthi UR, Rao LVM. Factor VIIa binding to endothelial cell protein C receptor protects vascular barrier integrity in vivo. J Thromb Haemost 2014; 12:690-700. [PMID: 24977291 PMCID: PMC4085578 DOI: 10.1111/jth.12532] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recent studies have shown that factor VIIa binds to endothelial cell protein C receptor(EPCR), a cellular receptor for protein C and activated protein C. At present, the physiologic significance of FVIIa interaction with EPCR in vivo remains unclear. OBJECTIVE To investigate whether exogenously administered FVIIa, by binding to EPCR, induces a barrier protective effect in vivo. METHODS Lipopolysaccharide(LPS)-induced vascular leakage in the lung and kidney,and vascular endothelial growth factor (VEGF)-induced vascular leakage in the skin, were used to evaluate the FVIIa-induced barrier protective effect. Wild-type, EPCR-deficient, EPCR-overexpressing and hemophilia A mice were used in the studies. RESULTS Administration ofFVIIa reduced LPS-induced vascular leakage in the lung and kidney; the FVIIa-induced barrier protective effect was attenuated in EPCR-deficient mice. The extent of VEGF-induced vascular leakage in the skin was highly dependent on EPCR expression levels. Therapeutic concentrations of FVIIa attenuated VEGF-induced vascular leakage in control mice but not in EPCR-deficient mice.Blockade of FVIIa binding to EPCR with a blocking mAb completely attenuated the FVIIa-induced barrier protective effect. Similarly, administration of protease activated receptor 1 antagonist blocked the FVIIa induced barrier protective effect. Hemophilic mice showed increased vascular permeability, and administration of therapeutic concentrations of FVIIa improved barrier integrity in these mice. CONCLUSIONS This is the first study to demonstrate that FVIIa binding to EPCR leads to a barrier protective effect in vivo. This finding may have clinical relevance, as it indicates additional advantages of using FVIIa in treating hemophilic patients.
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Paroskie A, Oso O, Almassi B, DeBaun MR, Sidonio RF Jr. Both hemophilia health care providers and hemophilia a carriers report that carriers have excessive bleeding. J Pediatr Hematol Oncol 2014; 36:e224-30. [PMID: 24309601 DOI: 10.1097/MPH.0000000000000022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Hemophilia A, the result of reduced factor VIII activity, is an X-linked recessive bleeding disorder. Previous reports of hemophilia A carriers suggest an increased bleeding tendency. Our objective was to determine the attitudes and understanding of the hemophilia A carrier bleeding phenotype, and opinions regarding timing of carrier testing from the perspective of both medical providers and affected patients. Data from this survey were used as preliminary data for an ongoing prospective study. MATERIALS AND METHODS An electronic survey was distributed to physicians and nurses employed at Hemophilia Treatment Centers, and hemophilia A carriers who were members of Hemophilia Federation of America. The questions focused on the clinical understanding of bleeding symptoms and management of hemophilia A carriers, and the timing and intensity of carrier testing. RESULTS Our survey indicates that 51% (36/51) of providers compared with 78% (36/46) of carriers believe that hemophilia A carriers with normal factor VIII activity have an increased bleeding tendency (P<0.001); 72% (33/36) of hemophilia A carriers report a high frequency of bleeding symptoms. Regarding carrier testing, 72% (50/69) of medical providers recommend testing after 14 years of age, conversely 65% (29/45) of hemophilia A carriers prefer testing to be done before this age (P<0.001). DISCUSSION Hemophilia A carriers self-report a higher frequency of bleeding than previously acknowledged, and have a preference for earlier testing to confirm carrier status.
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Coyle TE, Reding MT, Lin JC, Michaels LA, Shah A, Powell J. Phase I study of BAY 94-9027, a PEGylated B-domain-deleted recombinant factor VIII with an extended half-life, in subjects with hemophilia A. J Thromb Haemost 2014; 12:488-96. [PMID: 24843882 PMCID: PMC4265842 DOI: 10.1111/jth.12506] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND BAY 94-9027 is a B-domain-deleted recombinant factor VIII (rFVIII) with site-specific attachment of poly(ethylene glycol) that has shown an extended half-life in animal models of hemophilia. OBJECTIVES To assess the pharmacokinetics and safety of BAY 94-9027 after single and repeated administration in subjects with severe hemophilia A. PATIENTS/METHODS This 8-week, prospective, multicenter, open-label, phase I trial was conducted in 14 subjects aged 21–58 years with FVIII of < 1%, ≥ 150 days of exposure to FVIII, and no history of FVIII inhibitors. After a ≥ 3-day washout, subjects received a single dose of sucrose-formulated rFVIII (rFVIII-FS) (cohort 1 [n = 7], 25 IU kg−1; cohort 2 [n = 7], 50 IU kg−1) for a 48-h pharmacokinetic (PK) study. After another ≥ 3-day washout, cohort 1 received twice-weekly BAY 94-9027 at 25 IU kg−1 (16 doses), and cohort 2 received once-weekly BAY 94-9027 at 60 IU kg−1 (nine doses). A 168-h PK study was performed after the first and last BAY 94-9027 doses. RESULTS BAY 94-9027 showed equivalent recovery and an improved PK profile vs. rFVIII-FS, with a half-life of ~ 19 h (vs. ~ 13.0 h for rFVIII-FS). BAY 94-9027 was well tolerated, and no immunogenicity was observed. CONCLUSIONS This phase I study demonstrates that BAY 94-9027 has an extended half-life in subjects with hemophilia A and, after multiple dosing, was well tolerated with no immunogenicity during the 8-week trial. A phase III study in a larger number of subjects is underway to fully characterize how this prolonged half-life will permit less frequent prophylaxis dosing for patients with hemophilia.
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Peters RT, Toby G, Lu Q, Liu T, Kulman JD, Low SC, Bitonti AJ, Pierce GF. Biochemical and functional characterization of a recombinant monomeric factor VIII-Fc fusion protein. J Thromb Haemost 2013; 11:132-41. [PMID: 23205847 PMCID: PMC3588154 DOI: 10.1111/jth.12076] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 11/06/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hemophilia A results from a deficiency in factor VIII activity. Current treatment regimens require frequent dosing, owing to the short half-life of FVIII. A recombinant FVIII-Fc fusion protein (rFVIIIFc) was molecularly engineered to increase the half-life of FVIII, by 1.5-2-fold, in several preclinical animal models and humans. OBJECTIVE To perform a biochemical and functional in vitro characterization of rFVIIIFc, with existing FVIII products as comparators. METHODS rFVIIIFc was examined by utilizing a series of structural and analytic assays, including mass spectrometry following lysyl endopeptidase or thrombin digestion. rFVIIIFc activity was determined in both one-stage clotting (activated partial thromboplastin time) and chromogenic activity assays, in the context of the FXase complex with purified components, and in both in vitro and ex vivo rotational thromboelastometry (ROTEM) assays performed in whole blood. RESULTS rFVIIIFc contained the predicted primary structure and post-translational modifications, with an FVIII moiety that was similar to other recombinant FVIII products. The von Willebrand factor-binding and specific activity of rFVIIIFc were also found to be similar to those of other recombinant FVIII molecules. Both chromogenic and one-stage assays of rFVIIIFc gave similar results. Ex vivo ROTEM studies demonstrated that circulating rFVIIIFc activity was prolonged in mice with hemophilia A in comparison with B-domain-deleted or full-length FVIII. Clot parameters at early time points were similar to those for FVIII, whereas rFVIIIFc showed prolonged improvement of clot formation. CONCLUSIONS rFVIIIFc maintains normal FVIII interactions with other proteins necessary for its activity, with prolonged in vivo activity, owing to fusion with the Fc region of IgG(1) .
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Affiliation(s)
- R T Peters
- Biogen Idec Hemophilia, Waltham, MA 02451, USA.
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Kuether EL, Schroeder JA, Fahs SA, Cooley BC, Chen Y, Montgomery RR, Wilcox DA, Shi Q. Lentivirus-mediated platelet gene therapy of murine hemophilia A with pre-existing anti-factor VIII immunity. J Thromb Haemost 2012; 10:1570-80. [PMID: 22632092 PMCID: PMC3419807 DOI: 10.1111/j.1538-7836.2012.04791.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [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] [Indexed: 01/01/2023]
Abstract
BACKGROUND The development of inhibitory antibodies, referred to as inhibitors, against exogenous factor VIII in a significant subset of patients with hemophilia A remains a persistent challenge to the efficacy of protein replacement therapy. Our previous studies using the transgenic approach provided proof-of-principle that platelet-specific expression could be successful in treating hemophilia A in the presence of inhibitory antibodies. OBJECTIVE To investigate a clinically translatable approach for platelet gene therapy of hemophilia A with pre-existing inhibitors. METHODS Platelet FVIII expression in preimmunized FVIII(null) mice was introduced by transplantation of lentivirus-transduced bone marrow or enriched hematopoietic stem cells. FVIII expression was determined with a chromogenic assay. The transgene copy number per cell was quantitated with real-time PCR. Inhibitor titer was measured with the Bethesda assay. Phenotypic correction was assessed by the tail clipping assay and an electrolytically induced venous injury model. Integration sites were analyzed with linear amplification-mediated PCR. RESULTS Therapeutic levels of platelet FVIII expression were sustained in the long term without evoking an anti-FVIII memory response in the transduced preimmunized recipients. The tail clip survival test and the electrolytic injury model confirmed that hemostasis was improved in the treated animals. Sequential bone marrow transplants showed sustained platelet FVIII expression resulting in phenotypic correction in preimmunized secondary and tertiary recipients. CONCLUSIONS Lentivirus-mediated platelet-specific gene transfer improves hemostasis in mice with hemophilia A with pre-existing inhibitors, indicating that this approach may be a promising strategy for gene therapy of hemophilia A even in the high-risk setting of pre-existing inhibitory antibodies.
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Affiliation(s)
- E L Kuether
- Department of Pediatrics, Medical College of Wisconsin, Blood Research Institute, BloodCenter of Wisconsin, Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI 53226, USA
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Valentino LA, Mamonov V, Hellmann A, Quon DV, Chybicka A, Schroth P, Patrone L, Wong WY. A randomized comparison of two prophylaxis regimens and a paired comparison of on-demand and prophylaxis treatments in hemophilia A management. J Thromb Haemost 2012; 10:359-67. [PMID: 22212248 PMCID: PMC3488301 DOI: 10.1111/j.1538-7836.2011.04611.x] [Citation(s) in RCA: 208] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 12/20/2011] [Indexed: 12/03/2022]
Abstract
BACKGROUND Prophylaxis with factor (F)VIII is considered the optimal treatment for managing hemophilia A patients without inhibitors. OBJECTIVES To compare the efficacy of two prophylaxis regimens (primary outcome) and of on-demand and prophylaxis treatments (secondary outcome), and to continue the evaluation of immunogenicity and overall safety of the ADVATE Antihemophilic Factor (Recombinant), Plasma/Albumin Free Method (rAHF-PFM). PATIENTS/METHODS Previously on-demand-treated patients aged 7-59 years (n = 66) with FVIII levels ≤ 2% received 6 months of on-demand treatment and then were randomized to 12 months of either standard (20-40 IU kg(-1) every other day) or pharmacokinetic (PK)-tailored (20-80 IU kg(-1) every third day) prophylaxis, both regimens intended to maintain FVIII trough levels at or above 1%. Efficacy was evaluated in terms of annualized bleeding rates (ABRs). As subjects were first treated on-demand and then on prophylaxis, statistical comparisons between these treatments were paired. RESULTS Twenty-two (33.3%) subjects on prophylaxis experienced no bleeding episodes, whereas none treated on-demand were free from an episode of bleeding. ABRs for the two prophylaxis regimens were comparable, whereas differences between on-demand and either prophylaxis were statistically significant (P < 0.0001): median (interquartile range [IQR]) ABRs were 43.9 (21.9), 1.0 (3.5), 2.0 (6.9) and 1.1 (4.9) during on-demand treatment, standard, PK-tailored and any prophylaxis, respectively. There were no differences in FVIII consumption or adverse event rates between prophylaxis regimens. No subject developed FVIII inhibitors. CONCLUSIONS The present study demonstrates comparable safety and effectiveness for two prophylaxis regimens and that prophylaxis significantly reduces bleeding compared with on-demand treatment. PK-tailored prophylaxis offers an alternative to standard prophylaxis for the prevention of bleeding.
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Affiliation(s)
- L A Valentino
- Hemophilia and Thrombophilia Center, Rush University Medical Center, Chicago, IL, USA.
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Selvaraj SR, Scheller AN, Miao HZ, Kaufman RJ, Pipe SW. Bioengineering of coagulation factor VIII for efficient expression through elimination of a dispensable disulfide loop. J Thromb Haemost 2012; 10:107-15. [PMID: 22044596 PMCID: PMC3290727 DOI: 10.1111/j.1538-7836.2011.04545.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [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] [Indexed: 01/03/2023]
Abstract
BACKGROUND Heterologous expression of factor VIII (FVIII) is about two to three orders of magnitude lower than similarly sized proteins. Bioengineering strategies aimed at different structural and biochemical attributes of FVIII have been successful in enhancing its expression levels. OBJECTIVE Disulfide bonds are vital to the proper folding, secretion and stability of most secretory proteins. In an effort to explore additional targeted bioengineering approaches, the role of disulfide bonds in FVIII secretion and function was probed in this study. METHODS AND RESULTS Single and paired cysteine mutants were generated by substituting with serine or glycine residues and analyzed by transient transfection into COS-1 and CHO cells. Seven of the eight disulfide bonds in FVIII were found to be indispensable for proper secretion and function. However, elimination of the disulfide bond formed by C1899 and C1903 within the conserved A3 domain improved the secretion of FVIII. The addition of the C1899G/C1903G mutations to a previously described FVIII variant, 226/N6, with high secretion efficiency increased its secretion by 2.2-fold. Finally, the addition of the A1-domain mutation, F309S, in conjunction with the disulfide mutation had an additive effect, resulting in a net improvement in secretion of between 35 and 45-fold higher than wild-type FVIII in CHO cells. CONCLUSION Such combined targeted bioengineering strategies may facilitate more efficient production of recombinant FVIII and contribute toward low-cost factor replacement therapy for hemophilia A.
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Affiliation(s)
- S R Selvaraj
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical Center, Ann Arbor, MI 48109, USA
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Abstract
Several genes that modify risk of factor VIII (FVIII) inhibitors in haemophilia A patients have been identified. Aside from the underlying mutations that cause haemophilia A, inhibitor risk appears to be modified by polymorphisms in various cytokines and immunomodulators including IL10, TNFα and CTLA4. HLA haplotypes have not been strong determinants of inhibitor risk. We sought to confirm previous observations on FVIII inhibitor risk-modifying genes and to test new candidate genes encoding various otherTH1/TH2 cytokines. We also sought to determine whether normal FVIII gene polymorphisms affect inhibitor risk in caucasians. We studied 915 caucasian, severe haemophilia A patients (282 inhibitor cases and 633 non-inhibitor controls). Genes were analysed using 368 tagging single nucleotide polymorphisms starting 20 kb 5' and ending 10 kb 3' of each gene's coding sequence; four other polymorphisms (factor V Leiden & prothrombin 20210 polymorphisms and two in HFE) were also evaluated. Haplotypes that increased inhibitor risk were found in IL10 (OR = 1.33, P = 0.04), IL12 (OR = 1.31, P = 0.04) and IL1α (OR = 2.16, P = 0.034). Protective haplotypes were seen in IL2 (OR = .69, P = 0.008) and IL1β (OR = 0.75, P = 0.02). One rare haplotype in the FVIII gene increased the risk of inhibitor development by nearly fourfold (OR = 3.8, P = 0.004). We replicate previous findings for IL10; identify new associations with IL1, IL2 and IL12; and identify a rare FVIII haplotype in caucasians that is associated with increased inhibitor risk.
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Affiliation(s)
- J N Lozier
- Department of Laboratory Medicine, National Institutes of Health Clinical Center, Bethesda, MD, USA.
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Ogata K, Selvaraj SR, Miao HZ, Pipe SW. Most factor VIII B domain missense mutations are unlikely to be causative mutations for severe hemophilia A: implications for genotyping. J Thromb Haemost 2011; 9:1183-90. [PMID: 21645226 PMCID: PMC3111924 DOI: 10.1111/j.1538-7836.2011.04268.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [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] [Indexed: 12/20/2022]
Abstract
UNLABELLED BACKGROUND & OBJECTIVE The factor VIII (FVIII) B domain shares very little amino acid homology with other known proteins and is not directly necessary for procoagulant activity. Despite this, missense mutations within the B domain have been reported in patients with hemophilia A. Given that the B domain is dispensable for secretion and function of FVIII, we hypothesized that these mutations should not be causative of hemophilia A in these patients. METHODS Plasmid vectors containing B domain missense mutations that were reported to be associated with moderate/severe hemophilia A (T751S, D826E, V993L, H1047Y, T1353A, N1441K, L1462P, E1579D, A1591S, P1641L and S1669L) were analyzed for their effect on synthesis and secretion compared with FVIII wild-type (WT) following transient transfection into COS-1 and CHO cells in vitro. Further, H1047Y, N1441K and E1579D mutants were expressed in vivo in a hemophilia A mouse model by hydrodynamic tail-vein injection. RESULTS FVIII activity and antigen levels for all mutants expressed into the conditioned media of COS-1 and CHO cells were similar to FVIII WT. Also, plasma expression of these mutants was similar to FVIII WT in hemophilia A mice. An in vivo tail clip bleeding assay also demonstrated that blood loss from hemophilia A mice expressing FVIII WT, H1047Y, N1441K and E1579D was similar. CONCLUSIONS We conclude that most missense mutations within the FVIII B domain would be unlikely to lead to severe hemophilia A and that the majority of such missense mutations represent polymorphisms or non-pathologic mutations.
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Affiliation(s)
| | | | - Hongzhi Z Miao
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Steven W Pipe
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical Center, Ann Arbor, MI, USA
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Ramezani A, Zweier-Renn LA, Hawley RG. Factor VIII delivered by haematopoietic stem cell-derived B cells corrects the phenotype of haemophilia A mice. Thromb Haemost 2011; 105:676-87. [PMID: 21264447 PMCID: PMC3117307 DOI: 10.1160/th10-11-0725] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [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: 11/14/2010] [Accepted: 01/06/2011] [Indexed: 01/27/2023]
Abstract
The main impediments to clinical application of haematopoietic stem cell (HSC) gene therapy for treatment of haemophilia A are the bone marrow transplant-related risks and the potential for insertional mutagenesis caused by retroviral vectors. To circumvent these limitations, we have adapted a non-myeloablative conditioning regimen and directed factor VIII (FVIII) protein synthesis to B lineage cells using an insulated lentiviral vector containing an immunoglobulin heavy chain enhancer-promoter. Transplantation of lentiviral vector-modified HSCs resulted in therapeutic levels of FVIII in the circulation of all transplanted mice for the duration of the study (six months). Immunostaining of spleen cells showed that the majority of FVIII was synthesised by B220+ B cells and CD138+ plasma cells. Subsequent challenge with recombinant FVIII elicited at most a minor anti-FVIII antibody response, demonstrating induction of immune hyporesponsiveness. All transplant recipients exhibited clot formation and survived tail clipping, indicating correction of their haemophilic phenotype. Therapeutic levels of FVIII could be transferred to secondary recipients by bone marrow transplantation, confirming gene transfer into long-term repopulating HSCs. Moreover, short-term therapeutic FVIII levels could also be achieved in secondary recipients by adoptive transfer of HSC-derived splenic B cells. Our findings support pursuit of B cell-directed protein delivery as a potential clinical approach to treat haemophilia A and other disorders correctable by systemically distributed proteins.
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Affiliation(s)
- Ali Ramezani
- Department of Anatomy and Regenerative Biology The George Washington University, Washington, DC
| | - Lynnsey A. Zweier-Renn
- Department of Anatomy and Regenerative Biology The George Washington University, Washington, DC
- Graduate Program in Biochemistry and Molecular Genetics, The George Washington University, Washington, DC
| | - Robert G. Hawley
- Department of Anatomy and Regenerative Biology The George Washington University, Washington, DC
- Graduate Program in Biochemistry and Molecular Genetics, The George Washington University, Washington, DC
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James EA, van Haren SD, Ettinger RA, Fijnvandraat K, Liberman JA, Kwok WW, Voorberg J, Pratt KP. T-cell responses in two unrelated hemophilia A inhibitor subjects include an epitope at the factor VIII R593C missense site. J Thromb Haemost 2011; 9:689-99. [PMID: 21251204 PMCID: PMC4323178 DOI: 10.1111/j.1538-7836.2011.04202.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [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] [Indexed: 11/29/2022]
Abstract
BACKGROUND Development of neutralizing anti-factor (F)VIII antibodies ('inhibitors') is a serious clinical problem in hemophilia A. Increased inhibitor risk has been associated with certain FVIII missense substitutions, including R593C in the A2 domain. OBJECTIVES The aim of the present study was to identify T-cell epitopes in FVIII and characterize T-cell responses in two unrelated hemophilia A subjects sharing F8-R593C and HLA-DRB1*1101 genotypes. We hypothesized that the hemophilic substitution site coincides with an important T-cell epitope. PATIENTS/METHODS The binding affinities of peptides for recombinant HLA-DR proteins were measured and compared with epitope prediction results. CD4+ T cells were stimulated using peptides and stained with fluorescent, peptide-loaded tetramers. RESULTS The inhibitor subjects, but not HLA-matched controls, had high-avidity HLA-DRB1*1101-restricted T-cell responses against FVIII(589-608), which contains the hemophilic missense site. Antigen-specific T cells secreted Th1 and Th2 cytokines and proliferated in response to FVIII and FVIII(592-603). FVIII(589-608) bound with physiologically relevant (micromolar) IC(50) values to recombinant DR0101, DR1101 and DR1501 proteins. CONCLUSIONS Hemophilia A patients with R593C missense substitutions and these HLA haplotypes had an increased incidence of inhibitors in our cohorts, supporting a paradigm in which presentation of FVIII epitopes containing the wild-type R593 influences inhibitor risk in this hemophilia A sub-population.
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Affiliation(s)
- E A James
- Benaroya Research Institute, Seattle, WA, USA
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Kempton CL, Soucie JM, Miller CH, Hooper C, Escobar MA, Cohen AJ, Key NS, Thompson AR, Abshire TC. In non-severe hemophilia A the risk of inhibitor after intensive factor treatment is greater in older patients: a case-control study. J Thromb Haemost 2010; 8:2224-31. [PMID: 20704648 PMCID: PMC3612936 DOI: 10.1111/j.1538-7836.2010.04013.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [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] [Indexed: 11/30/2022]
Abstract
BACKGROUND Twenty-five percent of new anti-factor VIII (FVIII) antibodies (inhibitors) that complicate hemophilia A occur in those with mild and moderate disease. Although intensive FVIII treatment has long been considered a risk factor for inhibitor development in those with non-severe disease, its strength of association and the influence of other factors have remained undefined. OBJECTIVE To evaluate risk factors for inhibitor development in patients with non-severe hemophilia A. METHODS Information on clinical and demographic variables and FVIII genotype was collected on 36 subjects with mild or moderate hemophilia A and an inhibitor and 62 controls also with mild or moderate hemophilia A but without an inhibitor. RESULTS Treatment with FVIII for six or more consecutive days during the prior year was more strongly associated with inhibitor development in those ≥30years of age compared with those <30years of age [adjusted odds ratio (OR) 12.62; 95% confidence interval (CI), 2.76-57.81 vs. OR 2.54; 95% CI, 0.61-10.68]. Having previously received <50days of FVIII was also not statistically associated with inhibitor development on univariate or multivariate analysis. CONCLUSIONS These findings suggest that inhibitor development in mild and moderate hemophilia A varies with age, but does not vary significantly with lifetime FVIII exposure days: two features distinct from severe hemophilia A.
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Affiliation(s)
- C L Kempton
- Aflac Cancer Center and Blood Disorders Service and Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, USA.
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Doering CB, Archer D, Spencer HT. Delivery of nucleic acid therapeutics by genetically engineered hematopoietic stem cells. Adv Drug Deliv Rev 2010; 62:1204-12. [PMID: 20869414 PMCID: PMC2991563 DOI: 10.1016/j.addr.2010.09.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 08/17/2010] [Accepted: 09/08/2010] [Indexed: 01/02/2023]
Abstract
Several populations of adult human stem cells have been identified, but only a few of these are in routine clinical use. The hematopoietic stem cell (HSC) is arguably the most well characterized and the most routinely transplanted adult stem cell. Although details regarding several aspects of this cell's phenotype are not well understood, transplant of HSCs has advanced to become the standard of care for the treatment of a range of monogenic diseases and several types of cancer. It has also proven to be an excellent target for genetic manipulation, and clinical trials have already demonstrated the usefulness of targeting this cell as a means of delivering nucleic acid therapeutics for the treatment of several previously incurable diseases. It is anticipated that additional clinical trials will soon follow, such as genetically engineering HSCs with vectors to treat monogenic diseases such as hemophilia A. In addition to the direct targeting of HSCs, induced pluripotent stem (iPS) cells have the potential to replace virtually any engineered stem cell therapeutic, including HSCs. We now know that for the broad use of genetically modified HSCs for the treatment of non-lethal diseases, e.g. hemophilia A, we must be able to regulate the introduction of nucleic acid sequences into these target cells. We can begin to refine transduction protocols to provide safer approaches to genetically manipulate HSCs and strategies are being developed to improve the overall safety of gene transfer. This review focuses on recent advances in the systemic delivery of nucleic acid therapeutics using genetically modified stem cells, specifically focusing on i) the use of retroviral vectors to genetically modify HSCs, ii) the expression of fVIII from hematopoietic stem cells for the treatment of hemophilia A, and iii) the use of genetically engineered hematopoietic cells generated from iPS cells as treatment for disorders of hematopoiesis.
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Affiliation(s)
- Christopher B Doering
- Aflac Cancer Center and Blood Disorders Service, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
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Björkman S, Blanchette VS, Fischer K, Oh M, Spotts G, Schroth P, Fritsch S, Patrone L, Ewenstein BM, Collins PW. Comparative pharmacokinetics of plasma- and albumin-free recombinant factor VIII in children and adults: the influence of blood sampling schedule on observed age-related differences and implications for dose tailoring. J Thromb Haemost 2010; 8:730-6. [PMID: 20398185 PMCID: PMC2855866 DOI: 10.1111/j.1538-7836.2010.03757.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Accepted: 01/08/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND Dose tailoring of coagulation factors requires reliably estimated and reproducible pharmacokinetics (PK) in the individual patient. OBJECTIVES To investigate the contribution of both biological and methodological factors to the observed variability of factor VIII (FVIII) PK, with the focus on differences between children and adults, and to examine the implications for dosing. PATIENTS Data from 52 1-6-year-old and 100 10-65-year-old patients with hemophilia A (FVIII < or = 2 IU dL(-1)) in three clinical studies were included. RESULTS In vivo recovery was lower, weight-adjusted clearance was higher and FVIII half-life was on average shorter in children than in adults. However, a reduced blood sampling schedule for children was estimated to account for up to one half of the total observed differences. Intrapatient variance in PK was smaller than interpatient variance in 10-65-year-olds. Age and ratio of actual to ideal weight only showed weak relationships with PK parameters. Variance in PK caused large variance in the calculated dose required to maintain a target FVIII trough level during prophylactic treatment. CONCLUSION Differences in blood sampling schedules should be taken into account when results from different PK studies are compared. However, even with this consideration, PK cannot be predicted from observable patient characteristics but must be determined for the individual. Because the influence of reducing the blood sampling was minor in comparison to the true variance between patients, a reduced blood sampling protocol can be used. Low intrapatient variability supports the use of PK measurements for dose tailoring of FVIII.
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Affiliation(s)
- S Björkman
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden.
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Porada CD, Sanada C, Long CR, Wood JA, Desai J, Frederick N, Millsap L, Bormann C, Menges SL, Hanna C, Flores-Foxworth G, Shin T, Westhusin ME, Liu W, Glimp H, Zanjani ED, Lozier JN, Pliska V, Stranzinger G, Joerg H, Kraemer DC, Almeida-Porada G. Clinical and molecular characterization of a re-established line of sheep exhibiting hemophilia A. J Thromb Haemost 2010; 8:276-85. [PMID: 19943872 PMCID: PMC2826196 DOI: 10.1111/j.1538-7836.2009.03697.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Large animal models that accurately mimic human hemophilia A (HA) are in great demand for developing and testing novel therapies to treat HA. OBJECTIVES To re-establish a line of sheep exhibiting a spontaneous bleeding disorder closely mimicking severe human HA, fully characterize their clinical presentation, and define the molecular basis for disease. PATIENTS/METHODS Sequential reproductive manipulations were performed with cryopreserved semen from a deceased affected ram. The resultant animals were examined for hematologic parameters, clinical symptoms, and responsiveness to human FVIII (hFVIII). The full coding region of sheep FVIII mRNA was sequenced to identify the genetic lesion. RESULTS AND CONCLUSIONS The combined reproductive technologies yielded 36 carriers and 8 affected animals. The latter had almost non-existent levels of FVIII:C and extremely prolonged aPTT, with otherwise normal hematologic parameters. These animals exhibited bleeding from the umbilical cord, prolonged tail and nail cuticle bleeding time, and multiple episodes of severe spontaneous bleeding, including hemarthroses, muscle hematomas and hematuria, all of which responded to hFVIII. Inhibitors of hFVIII were detected in four treated animals, further establishing the preclinical value of this model. Sequencing identified a premature stop codon and frame-shift in exon 14, providing a molecular explanation for HA. Given the decades of experience using sheep to study both normal physiology and a wide array of diseases and the high homology between human and sheep FVIII, this new model will enable a better understanding of HA and facilitate the development and testing of novel treatments that can directly translate to HA patients.
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Affiliation(s)
- C D Porada
- Department of Animal Biotechnology, University of Nevada, Reno, NV 89557-0104, USA
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Peng A, Gaitonde P, Kosloski MP, Miclea RD, Varma P, Balu-Iyer SV. Effect of route of administration of human recombinant factor VIII on its immunogenicity in Hemophilia A mice. J Pharm Sci 2009; 98:4480-4. [PMID: 19499565 PMCID: PMC2796435 DOI: 10.1002/jps.21765] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [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] [Indexed: 11/06/2022]
Abstract
Factor VIII is a multi-domain glycoprotein and is an essential cofactor in the blood coagulation cascade. Its deficiency or dysfunction causes Hemophilia A, a bleeding disorder. Replacement using exogenous recombinant Factor VIII (FVIII) is the first line of therapy for Hemophilia A. Immunogenicity, the development of binding (total) and neutralizing (inhibitory) antibody against administered protein is a clinical complication of the therapy. There are several product related factors such as presence of aggregates, route and frequency of administration and glycosylation have been shown to contribute to immunogenicity. The effect of route of administration of FVIII on antibody development in Hemophilia A is not completely understood. Here we investigated the effect of route of administration (s.c. or i.v.) on immunogenicity in Hemophilia A mice. The total and inhibitory titers were determined using ELISA and modified Bethesda Assay respectively. The results indicated that s.c. is more immunogenic compared to i.v. route in terms of total antibody titer development (binding antibodies) but no significant differences in inhibitory titer levels could be established.
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Affiliation(s)
| | | | | | | | | | - Sathy V. Balu-Iyer
- Corresponding Author: Formerly Sathyamangalam V. Balasubramanian, Ph.D., Department of Pharmaceutical Sciences, 521 Hochstetter Hall, University at Buffalo, State University of New York Amherst, NY 14260, Telephone: (716) 645-2842 (x245), Fax: (716) 645-3693,
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