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Fedewa SA, Kempton CL. Race and ethnicity and the success of immune tolerance induction among people with severe haemophilia A in the United States. Haemophilia 2024; 30:628-637. [PMID: 38462837 DOI: 10.1111/hae.14980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/14/2024] [Accepted: 02/18/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Immune tolerance induction (ITI) is the only treatment to eradicate inhibitors in people with severe haemophilia A with inhibitors. Since the risk of inhibitor development is greater among Black and Hispanic persons, it has been hypothesized that race and ethnicity may influence ITI success. Limited studies have evaluated this hypothesis. AIM To examine the success of ITI according to race and ethnicity. METHODS Participants who entered the Community Counts (CC) Registry between 2013 and 2017, were aged ≥3 years at study entry, and received ITI were included (n = 559). The proportion of participants with successful ITI was examined with adjusted prevalence ratios (aPRs) and corresponding 95% confidence intervals (95% CIs). RESULTS Among 559 participants, 56.9%, 19.1%, 18.1% and 4.3% were Non-Hispanic (NH) White, NH Black, Hispanic and Asian, respectively, and 1.7% were coded as other or missing. Approximately 80% of Hispanic, NH Black and NH White participants had good/very good prognosis, defined as having a pre-ITI peak inhibitor of < 200 Bethesda Units per millilitre. Nearly 60% of participants (59.7%) achieved successful ITI, 20.7% and 19.5% experienced partially successful or failed ITI, respectively. Successful ITI was non-significantly lower in NH Black (54.2%; aPR = 0.95, 95% CI 0.62-1.44) and Hispanic (55.4%; aPR = 0.89, 95% CI 0.71-1.13) relative to NH White participants (62.6%). CONCLUSION In this study, 60% of participants in the CC Registry had successful ITI, consistent with previous studies. The proportion with successful ITI was generally comparable across racial and ethnic groups with similar prognosis. These findings do not support the hypothesis that ITI response varies according to race or ethnicity.
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Affiliation(s)
- Stacey A Fedewa
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
- Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christine L Kempton
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
- Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, Emory University School of Medicine, Atlanta, Georgia, USA
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Levy-Mendelovich S, Atia N, Budnik I, Barg AA, Avishai E, Cohen O, Brutman-Barazani T, Livnat T, Kenet G. Factor VIII inhibitors in hemophilia A treated with emicizumab: longitudinal follow-up of outcomes. Res Pract Thromb Haemost 2023; 7:100278. [PMID: 37538499 PMCID: PMC10394563 DOI: 10.1016/j.rpth.2023.100278] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/10/2023] [Accepted: 05/31/2023] [Indexed: 08/05/2023] Open
Abstract
Background Using emicizumab in lieu of immune tolerance induction (ITI) for patients with hemophilia A (HA) and factor (F)VIII inhibitors has been well described. However, decisions regarding ITI initiation, regimen, and preservation of tolerance remain to be elucidated. Objectives To study the course of FVIII inhibitors in patients with HA and a history of FVIII inhibitors receiving emicizumab prophylaxis. Methods Patients with HA, with and without FVIII inhibitors, initiating emicizumab prophylaxis were prospectively followed up in our center. All patients with current or previous inhibitors were included in this analysis. Plasma samples for FVIII inhibitor assays were obtained every 3 to 6 months or following FVIII exposure. Patients documented annual bleeding rate and any FVIII exposure days (EDs). Results Of 162 emicizumab-treated participants, 51 met the inclusion criteria. A decrease in annual bleeding rate was observed in all 51 participants followed up for a median of 3.3 years, with 31 breakthrough bleeding episodes reported in 22 of 51 participants. FVIII inhibitor level transiently increased following FVIII exposures in 5 of 15 failed ITI participants. Eight of 21 participants who did not undergo ITI were exposed to FVIII (1-2 EDs)), and 1 of these 8 participants demonstrated increased FVIII inhibitor levels after head trauma (following 1 ED). Among participants who underwent successful ITI, 8 of 15 patients were exposed to FVIII over a total of 13 EDs (1-2 ED(s) each) for traumatic breakthrough bleeds. In all these participants, inhibitor levels remained zero, indicating successful tolerance maintenance. Conclusion Our longitudinal follow-up of emicizumab-treated patients with HA and FVIII inhibitors shows that occasional exposure to FVIII may induce a transient anamnestic response. Nonetheless, no FVIII inhibitor recurrence was noted following FVIII exposures in patients who underwent successful ITI.
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Affiliation(s)
- Sarina Levy-Mendelovich
- National Hemophilia Center and Coagulation Unit, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Sheba Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Israel
| | - Nitzan Atia
- National Hemophilia Center and Coagulation Unit, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ivan Budnik
- Department of Internal Medicine, Division of Hematology/Oncology, University of Iowa, Iowa City, Iowa, USA
| | - Assaf Arie Barg
- National Hemophilia Center and Coagulation Unit, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Einat Avishai
- National Hemophilia Center and Coagulation Unit, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Omri Cohen
- National Hemophilia Center and Coagulation Unit, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Brutman-Barazani
- National Hemophilia Center and Coagulation Unit, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Livnat
- National Hemophilia Center and Coagulation Unit, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Hemophilia Center and Coagulation Unit, Sheba Medical Center, Tel Hashomer, Israel
- Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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3
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Camelo RM, Barbosa MM, Araújo MS, Muniz RL, Guerra AA, Godman B, Rezende SM, Acurcio FDA, Martin AP, Alvares-Teodoro J. Economic Evaluation of Immune Tolerance Induction in Children With Severe Hemophilia A and High-Responding Inhibitors: A Cost-Effectiveness Analysis of Prophylaxis With Emicizumab. Value Health Reg Issues 2023; 34:31-39. [PMID: 36463835 DOI: 10.1016/j.vhri.2022.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 09/20/2022] [Accepted: 10/19/2022] [Indexed: 12/02/2022]
Abstract
OBJECTIVE This study aimed to measure the cost-effectiveness of prophylaxis with emicizumab in PsHAhri on ITI in Brazil. METHODS A cost-effectiveness modeling analysis was used to estimate the costs per PsHAhri on ITI and the number of prevented bleedings from undertaking one intervention (prophylaxis with BpA) over another (prophylaxis with emicizumab), based on the Brazilian Ministry of Health perspective. Costs of ITI with recombinant FVIII, prophylaxis with BpA or emicizumab, and treated bleeding episodes with BpA costs were evaluated for PsHAhri who had ITI success or failure. This study was conducted with the perspective of the Brazilian Ministry of Health (payer). RESULTS During ITI, prophylaxis with BpA cost US $924 666/PsHAhri/ITI, whereas prophylaxis with emicizumab cost US $488 785/PsHAhri/ITI. During ITI, there was an average of 9.32 bleeding episodes/PsHAhri/ITI when BpA were used as prophylaxis and 0.67 bleeding/PsHAhri/ITI when emicizumab was used. By univariate deterministic sensitivity analysis, emicizumab remained dominant whichever variable was modified. CONCLUSION In this study, prophylaxis with emicizumab during ITI is a dominant option compared with prophylaxis with BpA during ITI.
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Affiliation(s)
- Ricardo Mesquita Camelo
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Maiara Silva Araújo
- Faculty of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Roberto Lúcio Muniz
- Faculty of Pharmacy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, Scotland, UK; Centre of Medical and Bio-allied Health Sciences Research, Ajman University, United Arab Emirates; School of Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, Pretoria, South Africa
| | | | | | - Antony P Martin
- Faculty of Health and Life Sciences, Liverpool, England, UK; QC Medica, York, England, UK
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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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Dou X, Zhang W, Poon MC, Zhang X, Wu R, Feng X, Yang L, Cheng P, Chen S, Wang Y, Zhou H, Huang M, Song Y, Jin C, Zhang D, Chen L, Liu W, Zhang L, Xue F, Yang R. Factor IX inhibitors in haemophilia B: A report of National Haemophilia Registry in China. Haemophilia 2023; 29:123-134. [PMID: 36163649 DOI: 10.1111/hae.14665] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 04/20/2022] [Revised: 08/25/2022] [Accepted: 09/12/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION The development of inhibitors against factor FIX (FIX) is the most serious complication of FIX replacement therapy in haemophilia B (HB) patients. Currently, only few cohorts of HB inhibitor patients have been reported worldwide. AIM This Chinese nationwide study of HB inhibitor patients explored their risk factors for FIX inhibitor development and experience on their management. METHODS We retrospectively analysed patient characteristics, F9 genotypes, treatment strategies and outcomes of HB inhibitor patients registered to the Chinese National Registry and Patient Organization Registry. RESULTS Forty-four unique HB inhibitor patients were identified in 4485 unique HB patients registered by year 2021 to the two Registries. Inhibitor diagnosis were usually delayed and the low prevalence (.98%) may suggest some inhibitor patients were not identified. Their median age at inhibitor diagnosis was 7.5 (IQR, 3.0-14.8) years. Most patients (95.5%) had high-titre inhibitors. Allergic/Anaphylactic reactions occurred in 59.1% patients. Large deletions and nonsense mutations were the most common F9 mutation types in our FIX inhibitor patients. Patients with large F9 gene deletions were more likely to develop inhibitors (p = .0002), while those with missense mutations had a low risk (p < .0001). Thirteen (29.5%) patients received immune tolerance induction (ITI) therapy using low-dose prothrombin complex concentrate regimens. Twelve completed ITI with three (25.0%) achieving success. Nephrotic syndrome developed in two (16.7%) patients during ITI. CONCLUSION This study reports the largest Chinese cohort of HB inhibitor patients. Large deletions were most significantly associated with inhibitor development. Low-dose ITI might be feasible for FIX inhibitor eradication.
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Affiliation(s)
- Xueqing Dou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China.,National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wenhui Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Man-Chiu Poon
- Departments of Medicine, Pediatrics and Oncology, Cumming School of Medicine, University of Calgary, and the Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Hospital, Alberta Health Services, Calgary, Alberta, Canada
| | - Xinsheng Zhang
- Shandong Hemophilia Treatment Center, Shandong Blood Center, Jinan, China
| | - Runhui Wu
- Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoqin Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Linhua Yang
- Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Peng Cheng
- Department of Hematology, Guangxi Medical University First Affiliated Hospital, Nanning, China
| | - Shu Chen
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Wang
- Shenzhen Children's Hospital, Shenzhen, China
| | - Hu Zhou
- The Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer hospital, Zhengzhou, China
| | - Meijuan Huang
- Fujian Medical University Union Hospital, Fujian Institute of Haematology, Fuzhou, China
| | | | - Chenghao Jin
- Department of Hematology, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Donglei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Lingling Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin, China
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Peyvandi F, Kavakli K, El‐Beshlawy A, Rangarajan S. Management of haemophilia A with inhibitors: A regional cross-talk. Haemophilia 2022; 28:950-961. [PMID: 35868021 PMCID: PMC9796719 DOI: 10.1111/hae.14638] [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: 02/25/2022] [Revised: 07/04/2022] [Accepted: 07/09/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The development of inhibitors with factor VIII (FVIII) replacement therapy is one of the most common and challenging complications of haemophilia A (HA) treatment, jeopardising treatment efficacy and predisposing patients to high risks of morbidity and mortality. The management of patients with inhibitors is particularly challenging in countries where resources are limited. AIM To provide a comprehensive summary of the management of HA with inhibitors while focusing on differences in practice between Western and non-Western countries and how resource scarcity can impact HA management, leading to suboptimal outcomes in patients with inhibitors. METHODS Summary of key evidence and regional expert opinion. RESULTS We address, particularly, the diagnosis of and testing for inhibitors, as well as the epidemiology of inhibitors, including incidence, prevalence and disease burden. Secondly, we provide an overview of the current treatment landscape in HA with inhibitors regarding the eradication of inhibitors with immune tolerance induction and the treatment and prevention of bleeding with bypassing agents, non-factor replacement agents and other experimental therapies. This is complemented with insights from the authors around the applicability of, and challenges associated with, such therapies in their settings of practice. CONCLUSIONS We conclude by proposing some key steps towards bridging the gaps in the management of HA with inhibitors in resource-limited countries, including: (1) the collection of quality data that can inform healthcare reforms and policies; (2) improving disease knowledge among healthcare practitioners and patients with the aim of standardising disease management across centres and (3) working towards promoting equal access to HA care and therapies for everyone.
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Affiliation(s)
- Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly,Department of Pathophysiology and TransplantationUniversità degli Studi di MilanooMilanItaly
| | - Kaan Kavakli
- Department of Pediatric HematologyEge University Children's HospitalIzmirTurkey
| | - Amal El‐Beshlawy
- Department of Pediatric Hematology, Faculty of MedicineCairo UniversityCairoEgypt
| | - Savita Rangarajan
- Department of HaematologyUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK,Clinical Trials and Research UnitKJ Somaiya Super Specialty Hospital and Research CentreMumbaiIndia
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7
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Camelo RM, Dias MM, Caram-Deelder C, Gouw S, de Magalhães LP, Zuccherato LW, Jardim LL, de Oliveira AG, de Albuquerque Ribeiro R, Franco VKB, do Rosário Ferraz Roberti M, de Araújo Callado FMR, Etto LY, de Cerqueira MAF, Cerqueira MH, Lorenzato CS, de Souza IS, Serafim ÉSS, Garcia AA, Anegawa TH, Neves DCF, Tan DM, van der Bom J, Rezende SM. Time between inhibitor detection and start of immune tolerance induction: Association with outcome in the BrazIT study. J Thromb Haemost 2022; 20:2526-2537. [PMID: 36102352 DOI: 10.1111/jth.15878] [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: 05/13/2022] [Revised: 08/26/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Immune tolerance induction (ITI) is the treatment of choice for eradication of anti-factor VIII (FVIII) neutralizing alloantibodies (inhibitors) in people with inherited hemophilia A and high-responding inhibitor (PwHA-HRi). The association between ITI outcome and time elapsed between inhibitor detection and start of ITI (∆tinhi-ITI ) is debatable. OBJECTIVE The aim of this study was to evaluate this association among a large cohort of severe PwHA-HRi. METHODS Severe (factor VIII activity level <1%) PwHA-HRi on ITI (n = 142) were enrolled in 15 hemophilia treatment centers. PwHA-HRi were treated according to the Brazilian ITI Protocol. ITI outcomes were defined as success (i.e., recovered responsiveness to exogenous FVIII) and failure (i.e., no responsiveness to exogenous FVIII and requirement of bypassing agents to control bleeding). RESULTS Median ages at inhibitor detection and at ITI start were 3.2 years (interquartile range [IQR], 1.6-8.1) and 6.9 years [IQR, 2.6-20.1), respectively. PwHA-HRi were stratified according to ∆tinhi-ITI quartiles: first (0.0-0.6 year), second (>0.6-1.7 year), third (>1.7-9.2 years), and fourth quartile (>9.2-24.5 years). The overall success rate was 65.5% (93/142), with no difference among first, second, third, and fourth quartiles (62.9%, 69.4%, 58.3%, and 71.4%, respectively) even after adjusting the analyses for potential confounders. CONCLUSION In conclusion, delayed ITI start is not associated with failure of ITI in PwHA-HRi. Therefore, ITI should be offered for these patients, regardless of the time elapsed between the detection of inhibitor and the ITI start.
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Affiliation(s)
- Ricardo Mesquita Camelo
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Maíse Moreira Dias
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Camila Caram-Deelder
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Center of Clinical Transfusion Research, Sanquin Research, Leiden, The Netherlands
| | - Samantha Gouw
- Amsterdam UMC, University of Amsterdam, Department of Pediatric Hematology, Amsterdam, the Netherlands
| | | | | | - Letícia Lemos Jardim
- Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Rosângela de Albuquerque Ribeiro
- Centro de Hematologia e Hemoterapia do Ceará (HEMOCE), Fortaleza, Brazil
- Hospital Universitário Walter Cantídeo, Universidade Federal do Ceará, Fortaleza, Brazil
| | | | | | | | - Leina Yukari Etto
- Hemocentro da Paraíba (HEMOÍBA), João Pessoa, Brazil
- Department of Internal Medicine, Center of Medical Sciences, Universidade Federal da Paraíba, João Pessoa, Brazil
| | | | | | | | - Ieda Solange de Souza
- Department of Clinical Haematology, Centro de Hematologia e Hemoterapia do Pará (HEMOPA), Belém, Brazil
- Universitary Hospital João de Barros Barreto, Universidade Federal do Pará, Belém, Brazil
| | | | - Andrea Aparecida Garcia
- Centro de Sangue de São José do Rio Preto, São José do Rio Preto, Brazil
- Fundação Faculdade Regional de Medicina de São José do Rio Preto, São José do Rio Preto, Brazil
| | - Tânia Hissa Anegawa
- Centro de Hematologia Regional de Londrina (HEMEPAR Londrina), Londrina, Brazil
- Faculty of Medicine, Universidade Estadual de Londrina, Londrina, Brazil
| | - Daniele Campos Fontes Neves
- Fundação Hemocentro de Rondônia (FHEMERON), Porto Velho, Brazil
- Department of Medicine, Universidade de Rondônia, Porto Velho, Brazil
| | - Doralice Marvulle Tan
- Department of Paediatric Onco-haematology, Faculdade de Medicina de Marília, Marília, Brazil
| | - Johanna van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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8
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Sun J, Li Z, Li G, Huang K, Ai D, Liu G, Yao W, Xie X, Gu H, Zhen Y, Chen Z, Wu R. Low-dose immune tolerance induction in children with severe hemophilia A with high-titer inhibitors: Type of factor 8 mutation and outcomes. Res Pract Thromb Haemost 2022; 6:e12824. [PMID: 36313984 PMCID: PMC9606347 DOI: 10.1002/rth2.12824] [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: 07/02/2022] [Revised: 08/30/2022] [Accepted: 09/08/2022] [Indexed: 11/12/2022] Open
Abstract
Background No studies evaluated the role of F8 mutations in outcomes for low-dose immune tolerance induction (ITI) in people with severe hemophilia A (SHA) with high-titer inhibitors. Objectives To explore the association between F8 mutation types and low-dose ITI outcomes in children with SHA with high-titer inhibitors. Methods Children SHA with high-titer inhibitors who received low-dose ITI therapy at least for 1 year were included in this study. Based on the risk of inhibitor development, F8 mutations were classified into a high-risk group and a non-high-risk group. Rapid tolerance and the final ITI outcomes were assessed at the 12th and 24th month of treatment, respectively, and the predictor of outcomes was analyzed. Results Of 104 children included, 101 had F8 mutations identified. The children with non-high-risk mutations presented a higher rate of rapid tolerance than those with high-risk mutations (61.0% vs. 29.2%; p = 0.006). Among 72 children beyond 24 months of ITI, 55 children (76.4%) achieved success, 3 (4.2%) achieved partial success, and 14 (19.4%) failed. The children in the non-high-risk group showed a higher success rate (86.8% vs. 43.8%; p = 0.001) and a shorter time to success (mean time, 9.3 months vs. 13.2 months; p = 0.04) compared to those in the high-risk group. In multivariable logistic regression, F8 mutations were an independent predictor of ITI success (non-high-risk group vs. high-risk group, adjusted odds ratio [OR], 20.3; 95% confidence interval [CI], 3.5-117.8), as was the interval from inhibitor diagnosis to ITI start (adjusted OR, 0.95; 95% CI, 0.90-0.99). They remained the significant predictors when success time was taken into account in a Cox model. Conclusions Types of F8 mutation were a key predictor of outcomes for low-dose ITI in children with SHA with high-titer inhibitors. It can help to stratify the prognosis and guide clinical decisions.
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Affiliation(s)
- Jie Sun
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina,Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Zekun Li
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina,Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Gang Li
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Kun Huang
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina,Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Di Ai
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina,Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Guoqing Liu
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Wanru Yao
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Xingjuan Xie
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina,Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Hao Gu
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina,Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Yingzi Zhen
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Zhenping Chen
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Runhui Wu
- Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
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9
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Liang Q, Vlaar EC, Catalano F, Pijnenburg JM, Stok M, van Helsdingen Y, Vulto AG, Unger WW, van der Ploeg AT, Pijnappel WP, van Til NP. Lentiviral gene therapy prevents anti-human acid α-glucosidase antibody formation in murine Pompe disease. Mol Ther Methods Clin Dev 2022; 25:520-532. [PMID: 35662813 PMCID: PMC9127119 DOI: 10.1016/j.omtm.2022.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 04/29/2022] [Indexed: 01/20/2023]
Abstract
Enzyme replacement therapy (ERT) is the current standard treatment for Pompe disease, a lysosomal storage disorder caused by deficiency of the lysosomal enzyme acid alpha-glucosidase (GAA). ERT has shown to be lifesaving in patients with classic infantile Pompe disease. However, a major drawback is the development of neutralizing antibodies against ERT. Hematopoietic stem and progenitor cell-mediated lentiviral gene therapy (HSPC-LVGT) provides a novel, potential lifelong therapy with a single intervention and may induce immune tolerance. Here, we investigated whether ERT can be safely applied as additional or alternative therapy following HSPC-LVGT in a murine model of Pompe disease. We found that lentiviral expression at subtherapeutic dose was sufficient to induce tolerance to the transgene product, as well as to subsequently administered ERT. Immune tolerance was established within 4–6 weeks after gene therapy. The mice tolerated ERT doses up to 100 mg/kg, allowing ERT to eliminate glycogen accumulation in cardiac and skeletal muscle and normalizing locomotor function. The presence of HSPC-derived cells expressing GAA in the thymus suggested the establishment of central immune tolerance. These findings demonstrate that lentiviral gene therapy in murine Pompe disease induced robust and long-term immune tolerance to GAA either expressed by a transgene or supplied as ERT.
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Affiliation(s)
- Qiushi Liang
- Department of Hematology and Research Laboratory of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
- Molecular Stem Cell Biology, Department of Clinical Genetics, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Department of Pediatrics, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
| | - Eva C. Vlaar
- Molecular Stem Cell Biology, Department of Clinical Genetics, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Department of Pediatrics, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
| | - Fabio Catalano
- Molecular Stem Cell Biology, Department of Clinical Genetics, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Department of Pediatrics, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
| | - Joon M. Pijnenburg
- Molecular Stem Cell Biology, Department of Clinical Genetics, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Department of Pediatrics, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
| | - Merel Stok
- Molecular Stem Cell Biology, Department of Clinical Genetics, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Department of Pediatrics, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Department of Hematology, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
| | - Yvette van Helsdingen
- Department of Hematology, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
| | - Arnold G. Vulto
- Hospital Pharmacy, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
| | - Wendy W.J. Unger
- Laboratory of Pediatrics, Erasmus MC University Medical Center-Sophia Children’s Hospital, 3015GE Rotterdam, the Netherlands
| | - Ans T. van der Ploeg
- Department of Pediatrics, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
| | - W.W.M. Pim Pijnappel
- Molecular Stem Cell Biology, Department of Clinical Genetics, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Department of Pediatrics, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Center for Lysosomal and Metabolic Diseases, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
- Corresponding author W.W.M. Pim Pijnappel, PhD, Erasmus University Medical Center, 3015GE Rotterdam, the Netherlands.
| | - Niek P. van Til
- Department of Hematology, Erasmus MC University Medical Center, 3015GE Rotterdam, the Netherlands
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10
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Li Z, Liu G, Yao W, Chen Z, Li G, Cheng X, Zhen Y, Ai D, Huang K, Sun J, Poon MC, Wu R. Eradication of FIX inhibitor in haemophilia B children using low-dose immune tolerance induction with rituximab-based immunosuppressive agent(s) in China. Haemophilia 2022; 28:625-632. [PMID: 35503087 DOI: 10.1111/hae.14577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/10/2022] [Accepted: 04/13/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Development of haemophilia B inhibitors (HBI) results in the ineffectiveness of FIX replacement therapy. Inhibitor eradication by immune tolerance induction (ITI) is therefore necessary. In HBI, ITI even at high FIX dose is less effective and has a higher risk of severe complications. AIM To characterize clinical features and outcome of ITI on HBI. METHODS This retrospective study was conducted in Haemophilia Paediatric Comprehensive Care Centre of China. We used low-dose ITI (25-50 FIX IU/kg/three-times-weekly to every-other-day) with domestic prothrombin complex concentrate (PCC), combined with two successive immunosuppressive (IS) regimens. RESULTS Sixteen HBI children, representing 5.7% of all and 14.4% of our severe registered HB patients, were enroled. Seven cases reported allergic reactions (ARs) proximal to inhibitor development. The historic peak inhibitor titre was median 54.2 (range 4.7-512) BU, and 15 (93.8%) had high-titre inhibitors. Twelve patients adherent to ITI were analysable. Of the nine ITI patients who received rituximab/prednisone (IS Regimen-1), four achieved tolerization in 1.4-43.3 months. Two subsequently relapsed but re-tolerized after a second course of IS Regimen-1. During ITI, the median treated bleed was .39/month (82.7% reduction from before ITI), and the incidence of AR and nephrotic syndrome (NS) complications was each at 22% (2/9). Three ITI patients received modified 'Beutel' protocol (IS Regimen-2) using multiple-IS-drugs, and two had rapid tolerization (.8 and 1.8 months). CONCLUSIONS Inhibitor eradication could be achieved by low-dose ITI protocol using PCC combined with IS. Larger studies are needed to confirm if ITI with IS Regimen-2 is more effective with less complications.
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Affiliation(s)
- Zekun Li
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Guoqing Liu
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Wanru Yao
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Zhenping Chen
- Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Gang Li
- Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Cheng
- Pharmacology Department, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yingzi Zhen
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Di Ai
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Kun Huang
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jie Sun
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Man-Chiu Poon
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Oncology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Hospital, Alberta Health Services, Calgary, Alberta, Canada
| | - Runhui Wu
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
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11
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Starosta RT, Hou YCC, Leestma K, Singh P, Viehl L, Manwaring L, Granadillo JL, Schroeder MC, Colombo JN, Whitehead H, Dickson PI, Hulbert ML, Nguyen HT. Infantile-onset Pompe disease complicated by sickle cell anemia: Case report and management considerations. Front Pediatr 2022; 10:944178. [PMID: 36245745 PMCID: PMC9555291 DOI: 10.3389/fped.2022.944178] [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: 05/14/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Infantile-onset Pompe disease (IOPD) is a rare, severe disorder of lysosomal storage of glycogen that leads to progressive cardiac and skeletal myopathy. IOPD is a fatal disease in childhood unless treated with enzyme replacement therapy (ERT) from an early age. Sickle cell anemia (SCA) is a relatively common hemoglobinopathy caused by a specific variant in the hemoglobin beta-chain. Here we report a case of a male newborn of African ancestry diagnosed and treated for IOPD and SCA. Molecular testing confirmed two GAA variants, NM_000152.5: c.842G>C, p.(Arg281Pro) and NM_000152.5: c.2560C>T, p.(Arg854*) in trans, and homozygosity for the HBB variant causative of SCA, consistent with his diagnosis. An acute neonatal presentation of hypotonia and cardiomyopathy required ERT with alglucosidase alfa infusions preceded by immune tolerance induction (ITI), as well as chronic red blood cell transfusions and penicillin V potassium prophylaxis for treatment of IOPD and SCA. Clinical course was further complicated by multiple respiratory infections. We review the current guidelines and interventions taken to optimize his care and the pitfalls of those guidelines when treating patients with concomitant conditions. To the best of our knowledge, no other case reports of the concomitance of these two disorders was found. This report emphasizes the importance of newborn screening, early intervention, and treatment considerations for this complex patient presentation of IOPD and SCA.
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Affiliation(s)
- Rodrigo Tzovenos Starosta
- Division of Clinical Genetics and Genomics, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Ying-Chen Claire Hou
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, United States
| | - Katelyn Leestma
- Division of Clinical Genetics and Genomics, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Prapti Singh
- Division of Clinical Genetics and Genomics, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Luke Viehl
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Linda Manwaring
- Division of Clinical Genetics and Genomics, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Jorge Luis Granadillo
- Division of Clinical Genetics and Genomics, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Molly C Schroeder
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, United States
| | - Jamie N Colombo
- Division of Pediatric Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Halana Whitehead
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Patricia Irene Dickson
- Division of Clinical Genetics and Genomics, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Monica L Hulbert
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Hoanh Thi Nguyen
- Division of Clinical Genetics and Genomics, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
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12
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Holstein K, Le Quellec S, Klamroth R, Batorova A, Holme PA, Jiménez-Yuste V, Astermark J. Immune tolerance induction in the era of emicizumab - still the first choice for patients with haemophilia A and inhibitors? Haemophilia 2021; 28:215-222. [PMID: 34918839 DOI: 10.1111/hae.14470] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/12/2021] [Accepted: 11/29/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The development of inhibitory antibodies is a severe complication of clotting factor replacement therapy in patients with severe haemophilia A (HA). Current World Federation of Hemophilia (WFH) guidelines for haemophilia care indicate that eradication of inhibitors is best achieved through immune tolerance induction (ITI) therapy. AIM The European Collaborative Haemophilia Network conducted a survey to determine whether ITI is still used in the routine management of patients with HA, and whether the availability of emicizumab prophylaxis has influenced treatment decisions. METHODS The survey was conducted in late 2020/early 2021 in 18 centres representing 17 countries in the Europe/Middle East region treating a total of 4955 patients, and included sections specific to patient and centre demographics, treatment protocols (both ITI and prophylactic), inhibitor development and initiation of ITI, treatment success, and the incidence of adverse events. RESULTS While our results indicate that ITI can still be considered a mainstay of treatment for patients with HA with inhibitors, less than daily dosing of ITI in combination with emicizumab prophylaxis is becoming commonplace across the spectrum of disease severity, with initiation being guided by bleeding patterns. The most frequently cited reasons for not initiating emicizumab prophylaxis were availability or reimbursement issues. CONCLUSION ITI remains a mainstay for haemophilia treatment of patients with HA with inhibitors, but emicizumab has become a preferred first-line approach to protect against bleeds and represents an alternative to burdensome ITI in certain patient groups.
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Affiliation(s)
- Katharina Holstein
- II. Medical Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sandra Le Quellec
- Unité d'hémostase Clinique - Hôpital Cardiologique Louis Pradel - Hospices Civils de Lyon, Lyon, France
| | - Robert Klamroth
- Department for Internal Medicine - vascular medicine and coagulation disorders at the Vivantes Hospital im Friedrichshain, Berlin, Germany
| | - Angelika Batorova
- National Hemophilia Centre, Dept. of Hematology and Transfusion Medicine, Faculty of Medicine of Comenius University and University Hospital, Bratislava, Slovakia
| | - Pål Andre Holme
- Department of Haematology, Oslo University Hospital and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Victor Jiménez-Yuste
- Servicio de Hematología, Hospital Universitario La Paz, Paseo de la Castellana, Autónoma University, Madrid, Spain
| | - Jan Astermark
- Department for Translational Medicine, Lund University and Department for Hematology Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
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13
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de Las Heras J, Cano A, Vinuesa A, Montes M, Unceta Suarez M, Arza A, Jiménez S, Vera E, Del Hoyo M, Gendive M, Aguirre L, Muñoz G, Fernández J, Ruiz-Espinoza C, Fernández MÁ, Galdeano JM, Rodríguez I, Román L, Rodríguez-Serna A, Loureiro B, Astigarraga I. Importance of Timely Treatment Initiation in Infantile-Onset Pompe Disease, a Single-Centre Experience. Children (Basel) 2021; 8:1026. [PMID: 34828739 DOI: 10.3390/children8111026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/04/2021] [Accepted: 11/06/2021] [Indexed: 01/10/2023]
Abstract
Classic infantile Pompe disease (IPD) is a rare lysosomal storage disorder characterized by severe hypertrophic cardiomyopathy and profound muscle weakness. Without treatment, death occurs within the first 2 years of life. Although enzyme replacement therapy (ERT) with alglucosidase alfa has improved survival, treatment outcome is not good in many cases and is largely dependent on age at initiation. The objective of the study was (a) to analyse the different stages in the diagnosis and specific treatment initiation procedure in IPD patients, and (b) to compare clinical and biochemical outcomes depending on age at ERT initiation (<1 month of age vs. <3 months of age). Here, we show satisfactory clinical and biochemical outcomes in two IPD patients after early treatment initiation before 3 months of life with immunomodulatory therapy in the ERT-naïve setting, with a high ERT dose from the beginning. Despite the overall good evolution, the patient who initiated treatment <1 month of life presented even better outcomes than the patient who started treatment <3 months of life, with an earlier normalization of hypertrophic cardiomyopathy, along with CK normalization, highlighting the importance of early treatment initiation in this progressive disease before irreversible muscle damage has occurred.
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14
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Escuriola Ettingshausen C, Sidonio RF. Design of an international investigator-initiated study on MOdern Treatment of Inhibitor-positiVe pATiEnts with haemophilia A (MOTIVATE). Ther Adv Hematol 2021; 12:20406207211032452. [PMID: 34589194 PMCID: PMC8474305 DOI: 10.1177/20406207211032452] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/25/2021] [Indexed: 02/01/2023] Open
Abstract
Background: Inhibitor development is the most serious treatment-related complication of
replacement coagulation factor VIII (FVIII) therapy for patients with
haemophilia A. Immune tolerance induction (ITI), which involves intensive
and prolonged treatment with plasma-derived or recombinant FVIII, is the
only clinically proven strategy for eradication of inhibitors. The
bispecific antibody emicizumab is approved for use in patients with and
without inhibitors to prevent bleeding but does not eliminate inhibitors.
MOTIVATE (www.motivate-study.com) aims to capture different approaches
to the treatment and management of patients with haemophilia A and
inhibitors, document current ITI approaches from real-world clinical
experience, and evaluate the efficacy and safety of ITI, emicizumab
prophylaxis and ITI with emicizumab prophylaxis. Methods: The investigator-initiated MOTIVATE study [ClinicalTrials.gov identifier:
NCT04023019; EudraCT 2019-003427-38] will investigate in real-life clinical
practice the management of patients with haemophilia A of any severity who
have developed inhibitors to FVIII. All treatment is at the investigator’s
discretion. The following treatment approaches will be evaluated: Group 1 –
ITI with Nuwiq®, octanate® or wilate® and
aPCC/rFVIIa if needed to treat bleeding episodes (BEs) or during surgery or
for prophylaxis; Group 2 – ITI with Nuwiq®, octanate®
or wilate® and emicizumab prophylaxis and aPCC/rFVIIa if needed
to treat BEs or during surgery; Group 3 – routine prophylaxis with
emicizumab, aPCC or rFVIIa without ITI and aPCC/rFVIIa if needed to treat
BEs or during surgery. Patients will not be randomised to a treatment group
and may change groups during the study. Conclusions: It is planned to enrol 120 patients who will be followed for up to 5 years.
Optional sub-studies will explore factors that may influence ITI results as
well as the impact of different treatment approaches on important aspects of
patient health, including joint and bone health and the risk of thrombotic
events.
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Affiliation(s)
| | - Robert F Sidonio
- Hemophilia of Georgia Center for Bleeding and Clotting Disorders, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
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15
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Hart DP, Alamelu J, Bhatnagar N, Biss T, Collins PW, Hall G, Hay C, Liesner R, Makris M, Mathias M, Motwani J, Palmer B, Payne J, Percy C, Richards M, Riddell A, Talks K, Tunstall O, Chalmers E. Immune tolerance induction in severe haemophilia A: A UKHCDO inhibitor and paediatric working party consensus update. Haemophilia 2021; 27:932-937. [PMID: 34403546 DOI: 10.1111/hae.14381] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 07/14/2021] [Accepted: 07/14/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION In good risk patients (historic inhibitor peak < 200BU), the International Immune Tolerance Study demonstrated equal efficacy to induce tolerance between high (200iu/kg/day) and low dose (50iu/kg ×3 times/week) immune tolerance induction (ITI) regimens. However, the trial stopped early on account of the excessive bleed rate in the low dose ITI arm. METHODS United Kingdom Haemophilia Centre Doctors' Organization (UKHCDO) Paediatric and Inhibitor working parties considered available ITI data alongside the bi-phenotypic antibody emicizumab (Hemlibra®) efficacy and safety data to develop a consensus guideline for the future UK ITI guideline. RESULTS This revision of UKHCDO ITI guidance incorporates the recommendation to use emicizumab as a prophylaxis haemostatic agent to reduce bleeding rates and to facilitate low dose and reduced frequency of FVIII CFC for ITI in the majority of children. CONCLUSION This consensus protocol will facilitate future evaluation of ITI outcomes in the evolving landscape of haemophilia therapeutics and ITI strategies.
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Affiliation(s)
- Daniel P Hart
- Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | | | - Neha Bhatnagar
- Oxford Haemophilia Centre, Oxford University Trust, Oxford, UK
| | - Tina Biss
- Newcastle Haemophilia Comprehensive Care Centre, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Peter W Collins
- Cardiff Haemophilia Centre, University of Wales, Cardiff, Wales, UK
| | - Georgina Hall
- Oxford Haemophilia Centre, Oxford University Trust, Oxford, UK
| | - Charles Hay
- Manchester Haemophilia Centre, Manchester, UK.,National Haemophilia Database, United Kingdom Haemophilia centre doctors' organisation (UKHCDO), Manchester, UK
| | - Ri Liesner
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Michael Makris
- Sheffield Haemophilia & Thrombosis Centre, Royal Hallamshire hospital, Sheffield, UK
| | - Mary Mathias
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Ben Palmer
- National Haemophilia Database, United Kingdom Haemophilia centre doctors' organisation (UKHCDO), Manchester, UK
| | - Jeanette Payne
- Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Charles Percy
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Anne Riddell
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital NHS Foundation Trust, London, UK
| | - Kate Talks
- Newcastle Haemophilia Comprehensive Care Centre, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Oliver Tunstall
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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16
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Young G. Management of children with hemophilia A: How emicizumab has changed the landscape. J Thromb Haemost 2021; 19:1629-1637. [PMID: 33872458 DOI: 10.1111/jth.15342] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 12/27/2022]
Abstract
The key to having a good quality of life for an adult with hemophilia rests largely on how he or she was managed as children. With effective prophylaxis, young men can begin their adult life with excellent joint function and few, if any, other sequelae from their disease. Unfortunately, this outcome is not always (nor often) attained because of the limitations of the mainstay of treatment, which is factor replacement therapy. In resource-rich countries with an adequate supply of factor concentrates, the treatment burden and formation of inhibitors limit the potential for an ideal outcome, whereas in much of the world, factor concentrates are too expensive to even be an option. The novel agent, emicizumab, which has become available in numerous countries around the world, is reshaping how one approaches the treatment of children with hemophilia A. This Forum Article, based on a State-of-the-Art lecture given at the 2020 International Society on Thrombosis and Haemostasis Virtual Meeting, presents an approach including clinically applicable algorithms for treating children with hemophilia A in the new era with emicizumab.
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Affiliation(s)
- Guy Young
- Hemostasis and Thrombosis Center, Cancer and Blood Diseases Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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17
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Li Z, Chen Z, Liu G, Cheng X, Yao W, Huang K, Li G, Zhen Y, Wu X, Cai S, Poon M, Wu R. Low-dose immune tolerance induction alone or with immunosuppressants according to prognostic risk factors in Chinese children with hemophilia A inhibitors. Res Pract Thromb Haemost 2021; 5:e12562. [PMID: 34278191 PMCID: PMC8279128 DOI: 10.1002/rth2.12562] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/28/2021] [Accepted: 05/18/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND In developing countries, children with hemophilia A (HA) with high-titer inhibitor and poor immune tolerance induction (ITI) prognostic risk(s) cannot afford the recommended high- or intermediate-dose ITI. OBJECTIVES To determine the efficacy of low-dose ITI (plasma-derived factor VIII [FVIII]/von Willebrand factor at 50 FVIII IU/kg every other day) by itself (ITI-alone) or combined with immunosuppressants rituximab and prednisone (ITI-IS) in children with HA with high-titer inhibitor. METHODS All enrolled patients had pre-ITI inhibitor ≥10 BU. We used ITI-alone if inhibitor titer was <40 BU pre-ITI and during ITI, and ITI-IS if titer was ≥100 BU (historic) or ≥40 BU (pre- or during ITI) or if the patient was nonresponsive on ITI-alone. RESULTS Fifty-six children were analyzable, with median historic peak inhibitor titer 48.0 BU and followed for median 31.4 months. Overall, 35 (62.5%) achieved phase 2 success with negative inhibitor and normal FVIII recovery. The phase 2 success rate was 95% for the 20 patients receiving ITI-alone. For the 36 patients receiving ITI-IS, the phase 2 success rate was 44.4%, but would increase to 63.6% if the 14 patients with historic peak inhibitor titer ≥100 BU (and having phase 2 success rate of only 14.3%) were excluded. One patient developed repeated infection after IS treatment. Relapse occurred in 11.4% (4/35) patients with phase 2 success associated with rapid ITI dose reduction or irregular post-ITI FVIII prophylaxis. Our strategy reduced the cost from high-dose ITI by 74% to 90%. CONCLUSION The use of low-dose ITI with or without immunosuppressants according to ITI prognostic risk(s) is a clinically and economically feasible strategy for eradicating inhibitors in children with HA, particularly for those with historic peak inhibitor titer <100 BU.
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Affiliation(s)
- Zekun Li
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Zhenping Chen
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Guoqing Liu
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Xiaoling Cheng
- Department of Pharmacy, Beijing Children’s Hospital, National Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Wanru Yao
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Kun Huang
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Gang Li
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Yingzi Zhen
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Xinyi Wu
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Siyu Cai
- Center for Clinical Epidemiology and Evidence‐based MedicineCapital Medical UniversityBeijingChina
| | - Man‐Chiu Poon
- Departments of Medicine, Pediatrics and OncologySouthern Alberta Rare Blood and Bleeding Disorders Comprehensive Care ProgramFoothills HospitalAlberta Health ServicesUniversity of Calgary Cumming School of MedicineCalgaryABCanada
| | - Runhui Wu
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
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18
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Astermark J, Holstein K, Abajas YL, Kearney S, Croteau SE, Liesner R, Funding E, Kempton CL, Acharya S, Lethagen S, LeBeau P, Bowen J, Berntorp E, Shapiro AD. The B-Natural study-The outcome of immune tolerance induction therapy in patients with severe haemophilia B. Haemophilia 2021; 27:802-813. [PMID: 34118102 DOI: 10.1111/hae.14357] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/14/2021] [Accepted: 05/31/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Inhibitors develop less frequently in haemophilia B (HB) than haemophilia A (HA). However, when present, the success of tolerization by immune tolerance induction (ITI) therapy is lower and the risk of complications higher. AIM To evaluate the use and outcome of ITI in patients with HB and inhibitors. METHODS Subjects include singletons or siblings with a current/history of inhibitors enrolled in B-Natural-an observational study designed to increase understanding of clinical management of patients with HB. Patients were followed for 6 months and information on demographics, medical and social history, and treatment were recorded. RESULTS Twenty-nine patients with severe HB and inhibitors were enrolled in 24 centres. Twenty-two underwent one or more courses of ITI with or without immune suppression. Eight patients (36.4%) were successfully tolerized after the first course of ITI. One of these successes (12.5%) experienced allergic manifestations, whereas the corresponding number for the 10 treatment failures was five (50%). One of seven (14.2%) patients with large deletions and three of eight (37.5%) with nonsense mutations were tolerized at the first attempt, and all patients experiencing nephrosis either failed or were on-going. At study end, 11 (50%) were considered successfully tolerized after one or more ITI courses, three were unsuccessful, and eight were still undergoing treatment. CONCLUSION Our data underscore the possibilities and difficulties of achieving tolerization in patients with HB with inhibitors. The type of mutation and complications appear to correlate with ITI outcome, but more accurate definitions of successful ITI are warranted.
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Affiliation(s)
- Jan Astermark
- Department of Translational Medicine, Lund University, Malmö, Sweden.,Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
| | - Katharina Holstein
- Medical Department, Hemophilia Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yasmina L Abajas
- Hemophilia and Thrombosis Centre, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Susan Kearney
- Children's Minnesota Centre for Bleeding and Clotting Disorders, Minneapolis, Minnesota, USA
| | - Stacy E Croteau
- Boston Children's Hospital, Boston Haemophilia Centre, Boston, Massachusetts, USA
| | - Riana Liesner
- Great Ormond Street Hospital for Children, NHS Trust supported by NIHR, GOSH, BRC, London, UK
| | - Eva Funding
- Department of Haematology, Institute of Clinical Medicine, University Hospital Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christine L Kempton
- Emory University School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Suchitra Acharya
- Northwell Haemostasis and Thrombosis Centre, New York, New York, USA
| | | | | | - Joel Bowen
- Indiana Haemophilia and Thrombosis Centre, Indianapolis, Indiana, USA
| | - Erik Berntorp
- Department of Translational Medicine, Clinical Coagulation Research, Lund University, Malmö, Sweden
| | - Amy D Shapiro
- Indiana Haemophilia and Thrombosis Centre, Indianapolis, Indiana, USA
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19
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Capdevila L, Borgel D, Lasne D, Lacroix-Desmazes S, Desvages M, Delignat S, Bally C, Frenzel L, Harroche A. Reappearance of inhibitor in a tolerized patient with severe haemophilia A during FVIII-free emicizumab therapy. Haemophilia 2021; 27:e581-e584. [PMID: 34004050 DOI: 10.1111/hae.14334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/17/2021] [Accepted: 04/29/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Ladislas Capdevila
- Laboratoire d'Hématologie Biologique, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Delphine Borgel
- Laboratoire d'Hématologie Biologique, AP-HP, Hôpital Necker Enfants Malades, Paris, France.,HITh, UMR_S 1176 INSERM, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Dominique Lasne
- Laboratoire d'Hématologie Biologique, AP-HP, Hôpital Necker Enfants Malades, Paris, France.,HITh, UMR_S 1176 INSERM, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | - Maximilien Desvages
- Laboratoire d'Hématologie Biologique, AP-HP, Hôpital Necker Enfants Malades, Paris, France.,HITh, UMR_S 1176 INSERM, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Sandrine Delignat
- INSERM, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
| | - Cécile Bally
- Centre de Traitement de l'Hémophilie, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Laurent Frenzel
- Centre de Traitement de l'Hémophilie, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Annie Harroche
- Centre de Traitement de l'Hémophilie, AP-HP, Hôpital Necker Enfants Malades, Paris, France
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20
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Dou X, Liu W, Poon MC, Zhang X, Wu J, Zeng X, Wu R, Hu Q, Li C, Wang X, Song X, Chen L, Zhang L, Xue F, Yang R. Patients with haemophilia A with inhibitors in China: a national real-world analysis and follow-up. Br J Haematol 2021; 192:900-908. [PMID: 33534930 DOI: 10.1111/bjh.17322] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/21/2020] [Indexed: 12/25/2022]
Abstract
The development of alloantibodies (inhibitors) against coagulation factor VIII (FVIII) is the most serious complication of FVIII replacement therapy in patients with haemophilia A (HA). We carried out a nationwide study focussing on patients with HA with inhibitors in China to evaluate the condition and management of this population. The study retrospectively analysed patient characteristics, clinical history, manifestation, treatment strategy as well as individual haemophilia care of 493 patients with inhibitors (466 with severe HA and 27 with non-severe HA) registered all over China. The median (interquartile range) age at diagnosis of FVIII inhibitors was 13 (5-28) years in patients with severe HA and 24 (10·5-39·5) years in patients with non-severe HA. Most patients (85%) had high-titre inhibitors. Prothrombin complex concentrate and recombinant activated coagulation factor VII were used respectively in 76·2% and 29·2% of patients for acute bleeding. Only 22·3% of patients underwent immune tolerance induction (ITI) treatment, of whom 64·9% achieved negative inhibitor titre. In patients who did not undergo ITI, the inhibitors turned negative in 17·7%, and patients with low peak inhibitor titre were more likely to acquire negative titre spontaneously (odds ratio 11·524, 95% confidence interval 5·222-25·432; P = 0·000). We recorded that 3·2% of the patients died from haemophilia-related life-threatening bleeding.
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Affiliation(s)
- Xueqing Dou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Wei Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Man-Chiu Poon
- Departments of Medicine, Pediatrics and Oncology, University of Calgary, Cumming School of Medicine and Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Medical Centre, Alberta Health Services, Calgary, AB, Canada
| | | | - Jingsheng Wu
- First Affiliated Hospital, Chinese University of Science and Technology, Hefei, China
| | - Xiaojing Zeng
- The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Runhui Wu
- Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Qun Hu
- Department of Pediatric Hematology, Tongji Hospital of Tongji Medical College, Huazhong University of Sciences and Technology, Wuhan, China
| | - Chengping Li
- First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xiaomin Wang
- Xinjiang Uygur Autonomous Region People's Hospital, Urumchi, China
| | - Xuewen Song
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Lingling Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Lei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Feng Xue
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin Laboratory of Blood Disease Gene Therapy, CAMS Key Laboratory of Gene Therapy for Blood Diseases, CAMS Center for Stem Cell Medicine, PUMC Department of Stem Cell and Regenerative Medicine, Tianjin, China
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21
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Carcao M, Mancuso ME, Young G, Jiménez-Yuste V. Key questions in the new hemophilia era: update on concomitant use of FVIII and emicizumab in hemophilia A patients with inhibitors. Expert Rev Hematol 2021; 14:143-148. [PMID: 33499681 DOI: 10.1080/17474086.2021.1875817] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Introduction: Immune tolerance induction (ITI) is the primary therapeutic strategy and only proven method to eradicate inhibitors to coagulation factor VIII (FVIII) in hemophilia A. Emicizumab, a humanized bispecific monoclonal antibody that mimics the function of activated FVIII, has expanded options to treat hemophilia A. The availability of emicizumab necessitates a revisit of recommendations for managing patients with inhibitors.Areas covered: Current evidence is reviewed about the concomitant use of emicizumab and FVIII concentrates during and after ITI. Areas where data are lacking are highlighted and ongoing studies designed to address these issues are described.Expert opinion: Inhibitor eradication remains a desirable goal. All patients with inhibitors should be offered at least one attempt at ITI. Emicizumab monotherapy is an option for inhibitor patients who are not candidates for ITI. Evidence is emerging about the use of emicizumab during ITI to prevent bleeds. Studies are currently addressing the safety, efficacy, and feasibility of concomitant emicizumab and FVIII in ITI. As evidence regarding the risk of inhibitor recurrence and need for continued FVIII to maintain immune tolerance post-ITI is limited, the role of emicizumab alone or in combination with FVIII after ITI is the subject of an upcoming study.
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Affiliation(s)
- Manuel Carcao
- Division of Haematology/Oncology and Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Guy Young
- Children's Hospital Los Angeles, Los Angeles, University of Southern California Keck School of Medicine, CA, USA
| | - Víctor Jiménez-Yuste
- Haematology Department, Hospital Universitario La Paz, Autónoma University, Madrid, Spain
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22
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Lacroix-Desmazes S, Pratt KP. Editorial: Tolerating Factor VIII: Novel Strategies to Prevent and Reverse Neutralizing Anti-FVIII Antibodies. Front Immunol 2021; 11:639386. [PMID: 33569066 PMCID: PMC7868532 DOI: 10.3389/fimmu.2020.639386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/18/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Kathleen P Pratt
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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23
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Li J, Chen J, Schroeder JA, Hu J, Williams CB, Shi Q. Platelet gene therapy induces robust immune tolerance even in a primed model via peripheral clonal deletion of antigen-specific T cells. Mol Ther Nucleic Acids 2021; 23:719-730. [PMID: 33575117 PMCID: PMC7851450 DOI: 10.1016/j.omtn.2020.12.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 12/30/2020] [Indexed: 11/08/2022]
Abstract
While platelet-specific gene therapy is effective in inducing immune tolerance to a targeted protein, how the reactivity of pre-existing immunity affects the efficacy, and whether CD8 T cells were involved in tolerization, is unclear. In this study, ovalbumin (OVA) was used as a surrogate protein. Platelet-OVA expression was introduced by 2bOVA lentivirus transduction of Sca-1+ cells from either wild-type (WT)/CD45.2 or OT-II/CD45.2 donors followed by transplantation into OVA-primed WT/CD45.1 recipients preconditioned with 6.6 Gy of irradiation. Sustained platelet-OVA expression was achieved in >85% of OVA-primed recipients but abolished in animals with high-reactive pre-existing immunity. As confirmed by OVA rechallenge and skin graft transplantation, immune tolerance was achieved in 2bOVA-transduced recipients. We found that there is a negative correlation between platelet-OVA expression and the percentage of OVA-specific CD4 T cells and a positive correlation with the OVA-specific regulatory T (Treg) cells. Using the OT-I/WT model, we showed that antigen-specific CD8 T cells were partially deleted in recipients after platelet-targeted gene transfer. Taken together, our studies demonstrate that robust antigen-specific immune tolerance can be achieved through platelet-specific gene therapy via peripheral clonal deletion of antigen-specific CD4 and CD8 T effector cells and induction of antigen-specific Treg cells. There is an antagonistic dynamic process between immune responses and immune tolerance after platelet-targeted gene therapy.
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Affiliation(s)
- Jing Li
- Blood Research Institute, Versiti Wisconsin, Milwaukee, WI, USA.,Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Juan Chen
- Blood Research Institute, Versiti Wisconsin, Milwaukee, WI, USA
| | - Jocelyn A Schroeder
- Blood Research Institute, Versiti Wisconsin, Milwaukee, WI, USA.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jianda Hu
- Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Calvin B Williams
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Microbiology and Immunology, Medical College of Wisconsin, Milwaukee, WI, USA.,Children's Research Institute, Children's Wisconsin, Milwaukee, WI, USA
| | - Qizhen Shi
- Blood Research Institute, Versiti Wisconsin, Milwaukee, WI, USA.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.,Children's Research Institute, Children's Wisconsin, Milwaukee, WI, USA.,Midwest Athletes Against Childhood Cancer Fund Research Center, Milwaukee, WI, USA
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24
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Carcao M, Shapiro A, Hwang N, Pipe S, Ahuja S, Lieuw K, Staber JM, Belletrutti M, Sun HL, Ding H, Wang M, Price V, Steele M, Tsao E, Feng J, Al-Khateeb Z, Dumont J, Jain N. Real-world data of immune tolerance induction using recombinant factor VIII Fc fusion protein in patients with severe haemophilia A with inhibitors at high risk for immune tolerance induction failure: A follow-up retrospective analysis. Haemophilia 2020; 27:19-25. [PMID: 33210397 PMCID: PMC8243250 DOI: 10.1111/hae.14192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 09/30/2020] [Accepted: 10/21/2020] [Indexed: 12/13/2022]
Affiliation(s)
| | - Amy Shapiro
- Indiana Hemophilia & Thrombosis Center, Inc, Indianapolis, IN, USA
| | - Nina Hwang
- Center For Inherited Blood Disorders, Orange, CA, USA
| | | | - Sanjay Ahuja
- University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Ken Lieuw
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Janice M Staber
- University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Mark Belletrutti
- University of Alberta Stollery Children's Hospital, Edmonton, AB, Canada
| | | | - Hilda Ding
- Rady Children's Hospital, San Diego, CA, USA
| | - Michael Wang
- Hemophilia and Thrombosis Center, University of Colorado, Aurora, CO, USA
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25
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Escuriola-Ettingshausen C, Auerswald G, Königs C, Kurnik K, Scholz U, Klamroth R, Oldenburg J. Optimizing the management of patients with haemophilia A and inhibitors in the era of emicizumab: Recommendations from a German expert panel. Haemophilia 2020; 27:e305-e313. [PMID: 32937002 DOI: 10.1111/hae.14010] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 12/14/2022]
Abstract
Standard treatment of haemophilia A is based on replacing the missing coagulation factor VIII (FVIII) to treat and prevent bleeding episodes. The most challenging complication of FVIII therapy is the development of neutralizing antibodies (inhibitors) that can render treatment ineffective. Eradication of the inhibitor through immune tolerance induction (ITI) remains the most effective strategy for managing these patients. Bypassing agents can be used to help restore haemostasis in inhibitor patients. Several novel agents have recently been developed, such as the FVIII mimetic agent emicizumab, which has been effective in reducing the annualized bleeding rate in haemophilia A patients with inhibitors. When coadministered with repetitive high doses of activated prothrombin complex concentrate (ie >100 U/kg/d for ≥24 hours), emicizumab was associated with thrombotic microangiopathy and thrombosis events. As a consequence the United Kingdom Haemophilia Centres Doctors' Organisation (UKHCDO) issued the first guidance on the treatment of bleeding episodes in patients receiving emicizumab. To build on and extend this work, a panel of German haemophilia specialists met to discuss the UK guidance, review current evidence and provide additional guidance for German healthcare professionals on how to optimize the management of patients with haemophilia A receiving emicizumab. Recommendations are provided on the use of bypassing and other agents to manage breakthrough bleeding, ITI in the emicizumab era, haemostatic support during surgery and issues relating to laboratory monitoring.
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Affiliation(s)
| | - Günter Auerswald
- Department of Comprehensive Care in Haemostasis and Thrombosis, Professor Hess Children's Hospital, Bremen, Germany
| | - Christoph Königs
- Department of Pediatrics and Adolescent Medicine, Centre for Hemostasis, University Hospital Frankfurt, Frankfurt, Germany
| | - Karin Kurnik
- Department of Paediatric Haemostasis, University Children's Hospital, Munich, Germany
| | | | - Robert Klamroth
- Department for Internal Medicine, Vascular Medicine and Haemostaseology, Vivantes Klinikum, Berlin, Germany
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
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26
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Desai AK, Baloh CH, Sleasman JW, Rosenberg AS, Kishnani PS. Benefits of Prophylactic Short-Course Immune Tolerance Induction in Patients With Infantile Pompe Disease: Demonstration of Long-Term Safety and Efficacy in an Expanded Cohort. Front Immunol 2020; 11:1727. [PMID: 32849613 PMCID: PMC7424004 DOI: 10.3389/fimmu.2020.01727] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/29/2020] [Indexed: 01/19/2023] Open
Abstract
Immune tolerance induction (ITI) with a short-course of rituximab, methotrexate, and/or IVIG in the enzyme replacement therapy (ERT)-naïve setting has prolonged survival and improved clinical outcomes in patients with infantile Pompe disease (IPD) lacking endogenous acid-alpha glucosidase (GAA), known as cross-reactive immunologic material (CRIM)-negative. In the context of cancer therapy, rituximab administration results in sustained B-cell depletion in 83% of patients for up to 26–39 weeks with B-cell reconstitution beginning at approximately 26 weeks post-treatment. The impact of rituximab on serum immunoglobulin levels is not well studied, available data suggest that rituximab can cause persistently low immunoglobulin levels and adversely impact vaccine responses. Data on a cohort of IPD patients who received a short-course of ITI with rituximab, methotrexate, and IVIG in the ERT-naïve setting and had ≥6 months of follow-up were retrospectively studied. B-cell quantitation, ANC, AST, ALT, immunization history, and vaccine titers after B-cell reconstitution were reviewed. Data were collected for 34 IPD patients (25 CRIM-negative and 9 CRIM-positive) with a median age at ERT initiation of 3.5 months (0.1–11.0 months). B-cell reconstitution, as measured by normalization of CD19%, was seen in all patients (n = 33) at a median time of 17 weeks range (11–55 weeks) post-rituximab. All maintained normal CD19% with the longest follow-up being 248 weeks post-rituximab. 30/34 (88%) maintained negative/low anti-rhGAA antibody titers, even with complete B-cell reconstitution. Infections during immunosuppression were reported in five CRIM-negative IPD patients, all resolved satisfactorily on antibiotics. There were no serious sequelae or deaths. Of the 31 evaluable patients, 27 were up to date on age-appropriate immunizations. Vaccine titers were available for 12 patients after B-cell reconstitution and adequate humoral response was observed in all except an inadequate response to the Pneumococcal vaccine (n = 2). These data show the benefits of short-course prophylactic ITI in IPD both in terms of safety and efficacy. Data presented here are from the youngest cohort of patients treated with rituximab and expands the evidence of its safety in the pediatric population.
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Affiliation(s)
- Ankit K Desai
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, United States
| | - Carolyn H Baloh
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Duke University Health System, Durham, NC, United States
| | - John W Sleasman
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Duke University Health System, Durham, NC, United States
| | - Amy S Rosenberg
- Division of Biologics Review and Research 3, Office of Biotechnology Products, Center for Drug Evaluation and Research, US FDA, Bethesda, MD, United States
| | - Priya S Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, United States
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27
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Abstract
Emicizumab is a bispecific antibody that recognizes FIX(a)/FX, and mimics FVIIIa cofactor activity. Due to its unique characteristics including longer half-life and subcutaneous injectability, treatment for haemophilia A dramatically improved regardless of the presence of FVIII inhibitor. Protection from pathological change in joints, avoidance of inhibitor development and intra-cranial haemorrhage could be expected by introduction of emicizumab in early childhood. Applications in mild/moderate patients should be also considered. Clinical assessment tool should be standardized; however, since there are limitations to conventional ABR-based assessment. Laboratory monitoring is another practical issue due to the mode of action of emicizumab. Chromogenic assays and global assays could be utilized. The other emicizumab-related practical issue is immune tolerance induction for the inhibitor patients, since ITI remains the only effective means to inhibitor eradication. With the recently introduced Atlanta protocol, emicizumab prophylaxis is given in combination with 50-100 IU/kg FVIII three times a week. A single manuscript has been published, and multiple clinical trials are open to address the efficacy of this strategy. Whether the Atlanta protocol will be fully embraced is yet to be seen, but there is widespread consensus about attempts to tolerize every haemophilia A patient with an inhibitor.
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Affiliation(s)
- Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, Kashihara, Japan
| | - Robert F Sidonio
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
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28
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Mimoun A, Delignat S, Peyron I, Daventure V, Lecerf M, Dimitrov JD, Kaveri SV, Bayry J, Lacroix-Desmazes S. Relevance of the Materno-Fetal Interface for the Induction of Antigen-Specific Immune Tolerance. Front Immunol 2020; 11:810. [PMID: 32477339 PMCID: PMC7240014 DOI: 10.3389/fimmu.2020.00810] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 04/08/2020] [Indexed: 12/26/2022] Open
Abstract
In humans, maternal IgGs are transferred to the fetus from the second trimester of pregnancy onwards. The transplacental delivery of maternal IgG is mediated by its binding to the neonatal Fc receptor (FcRn) after endocytosis by the syncytiotrophoblast. IgGs present in the maternal milk are also transferred to the newborn through the digestive epithelium upon binding to the FcRn. Importantly, the binding of IgGs to the FcRn is also responsible for the recycling of circulating IgGs that confers them with a long half-life. Maternally delivered IgG provides passive immunity to the newborn, for instance by conferring protective anti-flu or anti-pertussis toxin IgGs. It may, however, lead to the development of autoimmune manifestations when pathological autoantibodies from the mother cross the placenta and reach the circulation of the fetus. In recent years, strategies that exploit the transplacental delivery of antigen/IgG complexes or of Fc-fused proteins have been validated in mouse models of human diseases to impose antigen-specific tolerance, particularly in the case of Fc-fused factor VIII (FVIII) domains in hemophilia A mice or pre-pro-insulin (PPI) in the case of preclinical models of type 1 diabetes (T1D). The present review summarizes the mechanisms underlying the FcRn-mediated transcytosis of IgGs, the physiopathological relevance of this phenomenon, and the repercussion for drug delivery and shaping of the immune system during its ontogeny.
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Affiliation(s)
- Angelina Mimoun
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Sandrine Delignat
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Ivan Peyron
- HITh, INSERM, UMR_S1176, Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Victoria Daventure
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Maxime Lecerf
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Jordan D Dimitrov
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Srinivas V Kaveri
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
| | - Jagadeesh Bayry
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Paris, France
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29
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Klukowska A, Komrska V, Vdovin V, Zozulya N, Lissitchkov T, Oldenburg J, Ettingshausen CE. octanate ®: over 20 years of clinical experience in overcoming challenges in haemophilia A treatment. Ther Adv Hematol 2020; 11:2040620720914692. [PMID: 32341775 PMCID: PMC7171997 DOI: 10.1177/2040620720914692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/18/2020] [Indexed: 01/01/2023] Open
Abstract
Treatment of haemophilia A with FVIII replacement has evolved over the past decades to adapt to the needs of patients. octanate®, a plasma-derived, double virus-inactivated, von Willebrand factor (VWF)-containing FVIII concentrate, has been used in clinics worldwide for over 20 years. First licensed in 1998 in Germany, octanate® is approved in over 80 countries for the prevention and treatment of bleeding and for surgical prophylaxis in patients with haemophilia A, and in over 40 countries for immune tolerance induction (ITI). The manufacturing process for octanate® was developed to ensure high viral safety and effectively eliminates both enveloped and nonenveloped viruses. Over the past 20 years, the excellent safety and efficacy of octanate® have been demonstrated in pivotal clinical trials in adult and paediatric previously treated patients (PTPs) for on-demand treatment, prophylaxis and as surgical cover. Importantly, octanate® has displayed low immunogenicity in previously untreated patients (PUPs), with only 9.8% of PUPs developing FVIII inhibitors. octanate® has also shown to be highly effective in inhibitor elimination when used as ITI therapy. In a population of patients with high risk of ITI failure, success was achieved in 79.2% of patients (70.8% complete success), even when using exceptionally stringent success criteria. No relapses were observed. Here we present an overview of the clinical data with octanate® that support its use in a range of patient populations and clinical indications.
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Affiliation(s)
- Anna Klukowska
- Department of Paediatric Oncology, Medical University of Warsaw, Haematology, Clinical Transplantology and Paediatrics, Warsaw, Poland
| | - Vladimír Komrska
- Department of Paediatric Hematology and Oncology, University Hospital Motol, Prague, Czech Republic
| | - Vladimír Vdovin
- Morozovskaya Children’s Hospital, Moscow, Russian Federation
| | - Nadezhda Zozulya
- National Research Centre for Hematology, Moscow, Russian Federation
| | - Toshko Lissitchkov
- Department of Disorders of Haemostasis, SBALHZ - EAD, Sofia, Bulgaria
- Department of Clinical Haematology in Haemorrhagic Diathesis and Anaemia, Specialized Hospital for Active Treatment “Joan Pavel”, Sofia, Bulgaria
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
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30
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Abstract
Replacement therapy with coagulation factor VIII (FVIII) represents the current clinical treatment for patients affected by hemophilia A (HA). This treatment while effective is, however, hampered by the formation of antibodies which inhibit the activity of infused FVIII in up to 30% of treated patients. Immune tolerance induction (ITI) protocols, which envisage frequent infusions of high doses of FVIII to confront this side effect, dramatically increase the already high costs associated to a patient's therapy and are not always effective in all treated patients. Therefore, there are clear unmet needs that must be addressed in order to improve the outcome of these treatments for HA patients. Taking advantage of preclinical mouse models of hemophilia, several strategies have been proposed in recent years to prevent inhibitor formation and eradicate the pre-existing immunity to FVIII inhibitor positive patients. Herein, we will review some of the most promising strategies developed to avoid and eradicate inhibitors, including the use of immunomodulatory drugs or molecules, oral or transplacental delivery as well as cell and gene therapy approaches. The goal is to improve and potentiate the current ITI protocols and eventually make them obsolete.
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Affiliation(s)
- Simone Merlin
- Laboratory of Histology, Department of Health Sciences, Università degli Studi del Piemonte Orientale "A. Avogadro", Novara, Italy.,Interdisciplinary Research Center of Autoimmune Diseases (IRCAD), Novara, Italy
| | - Antonia Follenzi
- Laboratory of Histology, Department of Health Sciences, Università degli Studi del Piemonte Orientale "A. Avogadro", Novara, Italy.,Interdisciplinary Research Center of Autoimmune Diseases (IRCAD), Novara, Italy
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31
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Abstract
Development of neutralizing antibodies against biotherapeutic agents administered to prevent or treat various clinical conditions is a longstanding and growing problem faced by patients, medical providers and pharmaceutical companies. The hemophilia A community has deep experience with attempting to manage such deleterious immune responses, as the lifesaving protein drug factor VIII (FVIII) has been in use for decades. Hemophilia A is a bleeding disorder caused by genetic mutations that result in absent or dysfunctional FVIII. Prophylactic treatment consists of regular intravenous FVIII infusions. Unfortunately, 1/4 to 1/3 of patients develop neutralizing anti-FVIII antibodies, referred to clinically as “inhibitors,” which result in a serious bleeding diathesis. Until recently, the only therapeutic option for these patients was “Immune Tolerance Induction,” consisting of intensive FVIII administration, which is extraordinarily expensive and fails in ~30% of cases. There has been tremendous recent progress in developing novel potential clinical alternatives for the treatment of hemophilia A, ranging from encouraging results of gene therapy trials, to use of other hemostatic agents (either promoting coagulation or slowing down anti-coagulant or fibrinolytic pathways) to “bypass” the need for FVIII or supplement FVIII replacement therapy. Although these approaches are promising, there is widespread agreement that preventing or reversing inhibitors remains a high priority. Risk profiles of novel therapies are still unknown or incomplete, and FVIII will likely continue to be considered the optimal hemostatic agent to support surgery and manage trauma, or to combine with other therapies. We describe here recent exciting studies, most still pre-clinical, that address FVIII immunogenicity and suggest novel interventions to prevent or reverse inhibitor development. Studies of FVIII uptake, processing and presentation on antigen-presenting cells, epitope mapping, and the roles of complement, heme, von Willebrand factor, glycans, and the microbiome in FVIII immunogenicity are elucidating mechanisms of primary and secondary immune responses and suggesting additional novel targets. Promising tolerogenic therapies include development of FVIII-Fc fusion proteins, nanoparticle-based therapies, oral tolerance, and engineering of regulatory or cytotoxic T cells to render them FVIII-specific. Importantly, these studies are highly applicable to other scenarios where establishing immune tolerance to a defined antigen is a clinical priority.
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Affiliation(s)
| | - Jan Voorberg
- Sanquin Research and Landsteiner Laboratory, Department of Molecular and Cellular Hemostasis, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - David W Scott
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Kathleen P Pratt
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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32
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Zanon E, Pasca S, Pollio B, Santagostino E, Linari S, Tagliaferri A, Santoro C, Rocino A, Marino R, Aru B, Borchiellini A, Siragusa S, Coppola A. Immune tolerance induction with moroctocog-alpha (Refacto/Refacto AF) in a population of Italian haemophilia A patients with high-titre inhibitors: Data from REF.IT Registry. Haemophilia 2019; 25:1003-1010. [PMID: 31603594 DOI: 10.1111/hae.13859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND The appearance of inhibitors is the most serious complication in haemophilia A (HA) patients. The primary objective is their eradication. Up to date, immune tolerance induction (ITI) was the only therapeutic option to achieve this. AIM To assess the efficacy of moroctocog-alpha as an ITI regimen in a population of HA patients with high-titre inhibitors. METHODS The REF.IT Registry is a retrospective-prospective study that collected data on all patients with HA and high-titre inhibitors treated with moroctocog-alpha as an ITI regimen at twelve Italian Haemophilia Centres. RESULTS We enrolled 27 patients, 85.2% were children. All patients were high responders, 88.9% had severe HA. We found 69.3% of them had one or more risk factors for poor ITI prognosis, 14.8% were ITI rescue. Overall 59.3% achieved a complete/partial success (complete in 51.9%). ITI failed in 11 patients, 63.6% of them with poor-prognosis risk factors. Inhibitors appeared after a mean of 27 exposure days. Mean historical peak was 78.8 BU/mL. The primary ITIs started on average 20.2 months after the diagnosis. A partial or complete success after a mean of 15 months of treatment was achieved in 56.6% of the children while the same result was obtained by 75.0% adults after 22 months from ITI onset. Patients who were treated with high-dose moroctocog-alpha (200 UI/kg/day) were 63.0%. CONCLUSION Our Registry showed that the use of moroctocog-alpha in the setting of ITI was effective and safe also in a population of patients with high-titre inhibitors, presenting one or more risk factors for poor ITI prognosis.
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Affiliation(s)
- Ezio Zanon
- Hemophilia Center, University Hospital of Padua, Padua, Italy
| | - Samantha Pasca
- Hemophilia Center, University Hospital of Padua, Padua, Italy
| | | | - Elena Santagostino
- Hemophilia Center, Angelo Bianchi Bonomi Center, IRCCS Ca 'Granda Foundation, Maggiore University Hospital of Milan, Milan, Italy
| | - Silvia Linari
- Centre for Bleeding Disorders, Careggi University Hospital of Florence, Florence, Italy
| | - Annarita Tagliaferri
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | - Cristina Santoro
- Cellular Biotecnology and Hematology Department, Umberto I University Hospital of Rome, Rome, Italy
| | - Angiola Rocino
- Hemophilia and Thrombosis Center, S.Giovanni Bosco Hospital of Neaples, Neaples, Italy
| | - Renato Marino
- Haemophilia and Thrombosis Center, Giovanni XXIII Hospital of Bari, Bari, Italy
| | - Brigida Aru
- Pediatric Onco-Haematology Center, Microcitemico Hospital of Cagliari, Cagliari, Italy
| | | | - Sergio Siragusa
- Hematology Department, Center of Hemorrhagic and Thrombotic Diseases, University of Palermo, Palermo, Italy
| | - Antonio Coppola
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
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33
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Li Z, Chen Z, Cheng X, Wu X, Li G, Zhen Y, Cai S, Poon M, Wu R. Low-dose immune tolerance induction for children with hemophilia A with poor-risk high-titer inhibitors: A pilot study in China. Res Pract Thromb Haemost 2019; 3:741-748. [PMID: 31624794 PMCID: PMC6781932 DOI: 10.1002/rth2.12248] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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] [Received: 01/16/2019] [Revised: 06/12/2019] [Accepted: 06/18/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Immune tolerance induction (ITI) therapy is currently unaffordable in China. Management of hemophilia A children with high-titer inhibitor is therefore a challenge. AIM To describe the ITI strategy using plasma-derived factor VIII/von Willebrand factor concentrate (pdFVIII/VWF) +/- immunosuppression and to report its efficacy in children with hemophilia A having poor-risk status for ITI success. METHODS A prospective pilot study on children with hemophilia A having poor-risk status (all with at least inhibitor titer > 10 BU pre-ITI initiation). Patients received ~50 IU/kg FVIII every other day using domestic intermediate purity pdFVIII/VWF products, either alone or in combination with rituximab +/- prednisone. RESULTS Sixteen patients with median age 2.9 (range, 2.2-13.2) years and median pre-ITI inhibitor titer 30.7 (range, 10.4-128) BU were enrolled. Analysis at median 14.7 (range, 12.4-22.6) months' follow-up showed a total response rate of 87.5%. This included success (achieving inhibitor < 0.6 BU) in 13 patients (81.3%) in a median of 8.8 (range, 3.2-11.8) months, and partial success (achieving inhibitor < 5 BU but > 0.6BU) in 1 (6.3%). Compared to the pre-ITI period, the mean bleeds/month during ITI was 0.51 (64.0% reduction), and joint bleeds/month was 0.34 (64.3% reduction). This low-dose ITI strategy cost less by 70% to 87% than that for the high-dose FVIII regimen. No severe adverse events were observed. CONCLUSION This low-dose ITI strategy of pdFVIII/VWF +/- immunosuppression achieved relatively satisfactory outcomes in children with hemophilia A inhibitor having poor-risk status. This low-dose regimen showed economic advantages and is therefore suitable for using in China. However, further study in a larger cohort with a longer follow-up time is needed.
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Affiliation(s)
- Zekun Li
- Hemophilia Work GroupHematology Oncology CenterBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Zhenping Chen
- Hemophilia Work GroupHematology Oncology CenterBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Xiaoling Cheng
- Hemophilia Work GroupHematology Oncology CenterBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Xinyi Wu
- Hemophilia Work GroupHematology Oncology CenterBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Gang Li
- Hemophilia Work GroupHematology Oncology CenterBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Yingzi Zhen
- Hemophilia Work GroupHematology Oncology CenterBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Siyu Cai
- Epidemiology DepartmentBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
| | - Man‐Chiu Poon
- Departments of Medicine, Pediatrics and OncologyUniversity of Calgary Cumming School of Medicine, and Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care ProgramFoothills HospitalAlberta Health ServicesCalgaryAlbertaCanada
| | - Runhui Wu
- Hemophilia Work GroupHematology Oncology CenterBeijing Children's Hospital Affiliated to Capital Medical UniversityBeijingChina
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Desai AK, Li C, Rosenberg AS, Kishnani PS. Immunological challenges and approaches to immunomodulation in Pompe disease: a literature review. Ann Transl Med 2019; 7:285. [PMID: 31392197 PMCID: PMC6642943 DOI: 10.21037/atm.2019.05.27] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/08/2019] [Indexed: 01/30/2023]
Abstract
Pompe disease is an autosomal recessive disorder caused by a deficiency of acid alpha-glucosidase resulting in intralysosomal glycogen accumulation in multiple tissue types, especially cardiac, skeletal, and smooth muscle. Enzyme replacement therapy (ERT) with alglucosidase alfa has led to improved clinical outcomes and prolonged survival in patients with Pompe disease. While ERT has changed the natural course of Pompe disease, with many long-term survivors, several factors affect the response to ERT. Previous studies in Pompe disease have shown that IgG antibodies to ERT can lead to a decline in muscle strength, pulmonary function, and overall and ventilator-free survival. Additionally, antibody responses to ERT can also cause hypersensitivity reactions. Various strategies to prevent or eliminate the IgG antibody response have been attempted in patients with Pompe disease. A detailed literature search was performed to compile data regarding the consequences of IgG antibodies, clinical approaches to prevent or eliminate IgG antibodies in patients with Pompe disease, and to expand our understanding of new modalities being developed in non-clinical settings. All qualifying articles describing the impact of IgG antibodies on the response to ERT, immunomodulation in patients with Pompe disease, and non-clinical settings identified via a PubMed database search were included in the review. Here, we provide a comprehensive review of combination- and single-agent therapies that have been investigated in the context of immune tolerance induction to ERT in Pompe disease to date. Immunomodulation strategies that successfully induce immune tolerance to ERT have improved overall survival, especially reflected in the decreased number of ventilator-dependent or deceased cross-reactive immunologic material (CRIM)-negative infantile Pompe disease (IPD) patients due to development of IgG antibodies when treated with ERT alone. Immunomodulation in CRIM-positive patients at the time they receive ERT also results in a decrease in the development of IgG antibodies compared to cases treated with ERT alone. Lessons learned from current approaches, alongside results from trials of novel immunomodulation strategies, may provide important insights into the development of next-generation therapies.
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Affiliation(s)
- Ankit K. Desai
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, USA
| | - Cindy Li
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, USA
| | - Amy S. Rosenberg
- Division of Biologics Review and Research 3, Office of Biotechnology Products, Center for Drug Evaluation and Research, US FDA, Bethesda, MD, USA
| | - Priya S. Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Health System, Durham, NC, USA
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Carcao M, Escuriola‐Ettingshausen C, Santagostino E, Oldenburg J, Liesner R, Nolan B, Bátorová A, Haya S, Young G. The changing face of immune tolerance induction in haemophilia A with the advent of emicizumab. Haemophilia 2019; 25:676-684. [PMID: 31033112 PMCID: PMC6850066 DOI: 10.1111/hae.13762] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 03/20/2019] [Accepted: 03/28/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION As a result of the new treatment paradigm that the haemophilia community will face with the availability of novel (non-factor) therapies, an updated consensus on ITI recommendations and inhibitor management strategies is needed. AIM The Future of Immunotolerance Treatment (FIT) group was established to contemplate, determine and recommend the best management options for patients with haemophilia A and inhibitors. DISCUSSION AND CONCLUSIONS Despite the considerable success of emicizumab in the management of inhibitor patients, the FIT group still sees the importance of eradicating inhibitors. However, the availability of emicizumab and other non-factor therapies in the future might impact greatly on how ITI is undertaken. Theoretically, concomitant use of emicizumab and FVIII might allow emicizumab to effectively prevent bleeding with lower dose ITI regimens. This might allow for the greater adoption of low-dose/low-frequency FVIII ITI regimens, which may result in a reduced need for central venous access devices while still maintaining a reasonable likelihood of ITI success. The FIT group proposes a new management algorithm for current ITI (without emicizumab) and a hypothetical new approach with the availability of emicizumab. As there are no published data regarding the concomitant use of emicizumab and FVIII for ITI, the FIT Expert group encourages the undertaking of properly conducted prospective studies to explore these approaches further.
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Affiliation(s)
- Manuel Carcao
- Division of Haematology/Oncology, Department of Paediatrics and Child Health Evaluative Sciences, Research Institute, The Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | | | - Elena Santagostino
- Maggiore Hospital PoliclinicoAngelo Bianchi Bonomi Hemophilia and Thrombosis CenterMilanItaly
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion MedicineUniversity of BonnBonnGermany
| | - Ri Liesner
- Haemophilia Centre, Great Ormond Street Hospital for ChildrenNHS Trust Haemophilia CentreLondonUK
| | | | - Angelika Bátorová
- Department of Haematology and Transfusion Medicine and National Haemophilia CentreUniversity Hospital, Comenius UniversityBratislavaSlovakia
| | - Saturnino Haya
- Unit for Congenital Bleeding DisordersHospital Universitario y Politécnico La FeValenciaSpain
| | - Guy Young
- Children's Hospital Los AngelesUniversity of Southern California Keck School of MedicineLos AngelesCalifornia
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Carcao M, Shapiro A, Staber JM, Hwang N, Druzgal C, Lieuw K, Belletrutti M, Thornburg CD, Ahuja SP, Morales-Arias J, Dumont J, Miyasato G, Tsao E, Jain N, Pipe SW. Recombinant factor VIII Fc fusion protein for immune tolerance induction in patients with severe haemophilia A with inhibitors-A retrospective analysis. Haemophilia 2018; 24:245-252. [PMID: 29436077 DOI: 10.1111/hae.13413] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2018] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Immune tolerance induction (ITI) is the gold standard for eradication of factor VIII inhibitors in severe haemophilia A; however, it usually requires treatment for extended periods with associated high burden on patients and healthcare resources. AIM Review outcomes of ITI with recombinant factor VIII Fc fusion protein (rFVIIIFc) in patients with severe haemophilia A and high-titre inhibitors. METHODS Multicentre retrospective chart review of severe haemophilia A patients treated with rFVIIIFc for ITI. RESULTS Of 19 patients, 7 were first-time ITI and 12 were rescue ITI. Of 7 first-time patients, 6 had at least 1 high-risk feature for ITI failure. Four of 7 first-time patients were tolerized in a median of 7.8 months. The remaining 3 patients continue on rFVIIIFc ITI. Of 12 rescue patients, 7 initially achieved a negative Bethesda titre (≤0.6) in a median of 3.3 months, 1 had a decrease in Bethesda titre and continues on rFVIIIFc ITI and 4 have not demonstrated a decrease in Bethesda titre. Of these 4, 3 continue on rFVIIIFc ITI and 1 switched to bypass therapy alone. Two initially responsive patients transitioned to other factors due to recurrence. Overall, 16 of 19 patients remain on rFVIIIFc (prophylaxis or ITI). For those still undergoing ITI, longer follow-up is needed to determine final outcomes. No adverse events reported. CONCLUSIONS Recombinant factor VIII Fc fusion protein demonstrated rapid time to tolerization in high-risk first-time ITI patients. For rescue ITI, rFVIIIFc showed therapeutic benefit in some patients who previously failed ITI with other products. These findings highlight the need to further evaluate the use of rFVIIIFc for ITI.
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Affiliation(s)
- M Carcao
- Division of Haematology/Oncology, Department of Paediatrics, Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
| | - A Shapiro
- Indiana Hemophilia & Thrombosis Center, Indianapolis, IN, USA
| | - J M Staber
- University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - N Hwang
- Center for Inherited Blood Disorders, Orange, CA, USA
| | - C Druzgal
- University of Virginia Health System, Charlottesville, VA, USA
| | - K Lieuw
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - M Belletrutti
- University of Alberta Stollery Children's Hospital, Edmonton, AB, Canada
| | - C D Thornburg
- Rady Children's Hospital San Diego, San Diego, CA, USA
| | - S P Ahuja
- University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | | | - J Dumont
- Bioverativ Therapeutics, Inc., Waltham, MA, USA
| | | | - E Tsao
- Bioverativ Therapeutics, Inc., Waltham, MA, USA
| | - N Jain
- Bioverativ Therapeutics, Inc., Waltham, MA, USA
| | - S W Pipe
- University of Michigan, Ann Arbor, MI, USA
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Chen Y, Luo X, Schroeder JA, Chen J, Baumgartner CK, Hu J, Shi Q. Immune tolerance induced by platelet-targeted factor VIII gene therapy in hemophilia A mice is CD4 T cell mediated. J Thromb Haemost 2017; 15:1994-2004. [PMID: 28799202 PMCID: PMC5630523 DOI: 10.1111/jth.13800] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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: 02/01/2017] [Indexed: 02/03/2023]
Abstract
Essentials The immune response is a significant concern in gene therapy. Platelet-targeted gene therapy can restore hemostasis and induce immune tolerance. CD4 T cell compartment is tolerized after platelet gene therapy. Preconditioning regimen affects immune tolerance induction in platelet gene therapy. SUMMARY Background Immune responses are a major concern in gene therapy. Our previous studies demonstrated that platelet-targeted factor VIII (FVIII) (2bF8) gene therapy together with in vivo drug selection of transduced cells can rescue the bleeding diathesis and induce immune tolerance in FVIIInull mice. Objective To investigate whether non-selectable 2bF8 lentiviral vector (LV) for the induction of platelet-FVIII expression is sufficient to induce immune tolerance and how immune tolerance is induced after 2bF8LV gene therapy. Methods Platelet-FVIII expression was introduced by 2bF8LV transduction and transplantation. FVIII assays and tail bleeding tests were used to confirm the success of platelet gene therapy. Animals were challenged with rhF8 to explore if immune tolerance was induced after gene therapy. Treg cell analysis, T-cell proliferation assay and memory B-cell-mediated ELISPOT assay were used to investigate the potential mechanisms of immune tolerance. Results We showed that platelet-FVIII expression was sustained and the bleeding diathesis was restored in FVIIInull mice after 2bF8LV gene therapy. None of the transduced recipients developed anti-FVIII inhibitory antibodies in the groups preconditioned with 660 cGy irradiation or busulfan plus ATG treatment even after rhF8 challenge. Treg cells significantly increased in 2bF8LV-transduced recipients and the immune tolerance developed was transferable. CD4+ T cells from treated animals failed to proliferate in response to rhF8 re-stimulation, but memory B cells could differentiate into antibody secreting cells in 2bF8LV-transduced recipients. Conclusion 2bF8LV gene transfer without in vivo selection of manipulated cells can introduce immune tolerance in hemophilia A mice and this immune tolerance is CD4+ T cell mediated.
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Affiliation(s)
- Y Chen
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
- Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - X Luo
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
- Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - J A Schroeder
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Chen
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
| | - C K Baumgartner
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
| | - J Hu
- Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Q Shi
- Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
- Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
- Children's Research Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
- MACC Fund Research Center, Milwaukee, WI, USA
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Han SO, Ronzitti G, Arnson B, Leborgne C, Li S, Mingozzi F, Koeberl D. Low-Dose Liver-Targeted Gene Therapy for Pompe Disease Enhances Therapeutic Efficacy of ERT via Immune Tolerance Induction. Mol Ther Methods Clin Dev 2017; 4:126-136. [PMID: 28344998 PMCID: PMC5363303 DOI: 10.1016/j.omtm.2016.12.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 12/30/2016] [Indexed: 11/18/2022]
Abstract
Pompe disease results from acid α-glucosidase (GAA) deficiency, and enzyme replacement therapy (ERT) with recombinant human (rh) GAA has clinical benefits, although its limitations include the short half-life of GAA and the formation of antibody responses. The present study compared the efficacy of ERT against gene transfer with an adeno-associated viral (AAV) vector containing a liver-specific promoter. GAA knockout (KO) mice were administered either a weekly injection of rhGAA (20 mg/kg) or a single injection of AAV2/8-LSPhGAA (8 × 1011 vector genomes [vg]/kg). Both treatments significantly reduced glycogen content of the heart and diaphragm. Although ERT triggered anti-GAA antibody formation, there was no detectable antibody response following AAV vector administration. The efficacy of three lower dosages of AAV2/8-LSPhGAA was evaluated in GAA-KO mice, either alone or in combination with ERT. The minimum effective dose (MED) identified was 8 × 1010 vg/kg to reduce glycogen content in the heart and diaphragm of GAA-KO mice. A 3-fold higher dose was required to suppress antibody responses to ERT. Efficacy from liver gene therapy was slightly greater in male mice than in female mice. Vector dose correlated inversely with anti-GAA antibody formation, whereas higher vector doses suppressed previously formed anti-GAA antibodies as late as 25 weeks after the start of ERT and achieved biochemical correction of glycogen accumulation. In conclusion, we identified the MED for effective AAV2/8-LSPhGAA-mediated tolerogenic gene therapy in Pompe disease mice.
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Affiliation(s)
- Sang-oh Han
- Division of Medical Genetics, Department of Pediatrics, Duke University School of Medicine, Durham, NC 27710, USA
| | | | - Benjamin Arnson
- Division of Medical Genetics, Department of Pediatrics, Duke University School of Medicine, Durham, NC 27710, USA
| | | | - Songtao Li
- Division of Medical Genetics, Department of Pediatrics, Duke University School of Medicine, Durham, NC 27710, USA
| | - Federico Mingozzi
- Genethon and INSERM U951, 91002 Evry, France
- University Pierre and Marie Curie – Paris 6, 75005 Paris, France
| | - Dwight Koeberl
- Division of Medical Genetics, Department of Pediatrics, Duke University School of Medicine, Durham, NC 27710, USA
- Department of Molecular Genetics and Microbiology, Duke University, Durham, NC 27710, USA
- Corresponding author: Dwight Koeberl, Duke University Medical Center, Box 103856, Durham, NC 27710, USA.
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Walsh CE, Jiménez-Yuste V, Auerswald G, Grancha S. The burden of inhibitors in haemophilia patients. Thromb Haemost 2016; 116 Suppl 1:S10-7. [PMID: 27528280 DOI: 10.1160/th16-01-0049] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [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: 01/20/2016] [Accepted: 07/07/2016] [Indexed: 01/19/2023]
Abstract
The burden of disease in haemophilia patients has wide ranging implications for the family and to society. There is evidence that having a current inhibitor increases the risk of morbidity and mortality. Morbidity is increased by the inability to treat adequately and its consequent disabilities, which then equates to a poor quality of life compared with non-inhibitor patients. The societal cost of care, or `burden of inhibitors', increases with the ongoing presence of an inhibitor. Therefore, it is clear that successful eradication of inhibitors by immune tolerance induction (ITI) is the single most important milestone one can achieve in an inhibitor patient. The type of factor VIII (FVIII) product used in ITI regimens varies worldwide. Despite ongoing debate, there is in vitro and retrospective clinical evidence to support the use of plasma-derived VWF-containing FVIII concentrates in ITI regimens in order to achieve early and high inhibitor eradication success rates.
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Affiliation(s)
| | - Víctor Jiménez-Yuste
- Victor Jiménez-Yuste, Hospital Universitario La Paz - Hematology, Paseo de la Castellana 261 Apostol Santiago 61 1 J, Madrid 28017, Spain, Tel.: +34 619452698, Fax: +34 917277226, E-mail:
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Groomes CL, Gianferante DM, Crouch GD, Parekh DS, Scott DW, Lieuw K. Reduction of Factor VIII Inhibitor Titers During Immune Tolerance Induction With Recombinant Factor VIII-Fc Fusion Protein. Pediatr Blood Cancer 2016; 63:922-4. [PMID: 26739399 DOI: 10.1002/pbc.25874] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 11/23/2015] [Accepted: 11/25/2015] [Indexed: 11/09/2022]
Abstract
The development of inhibitors toward factor VIII (FVIII) is a common and serious complication of hemophilia A (HA) therapy. Patients with hemophilia who develop inhibitors often undergo time- and resource-intensive immune tolerance induction (ITI) protocols. We report a 15-month-old male with severe HA and a high-titer inhibitor that occurred while receiving prophylactic treatment with recombinant FVIII (rFVIII), in whom significant inhibitor titer reduction was achieved with thrice weekly infusions of a new, prolonged half-life rFVIII-Fc fusion protein product (trade name Eloctate). Further studies are warranted to explore the potential of Eloctate in ITI protocols.
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Affiliation(s)
- Charles L Groomes
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Gary D Crouch
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Dina S Parekh
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Walter Reed National Military Medical Center, Bethesda, Maryland
| | - David W Scott
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Kenneth Lieuw
- Department of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Walter Reed National Military Medical Center, Bethesda, Maryland
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Stenger EO, Kazi Z, Lisi E, Gambello MJ, Kishnani P. Immune Tolerance Strategies in Siblings with Infantile Pompe Disease-Advantages for a Preemptive Approach to High-Sustained Antibody Titers. Mol Genet Metab Rep 2015; 4:30-34. [PMID: 26167453 PMCID: PMC4497810 DOI: 10.1016/j.ymgmr.2015.05.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Enzyme replacement therapy (ERT) has led to a significant improvement in the clinical course of patients with infantile Pompe disease (IPD), an autosomal recessive glycogen storage disorder characterized by the deficiency in lysosomal acid α-glucosidase. A subset of IPD patients mount a substantial immune response to ERT developing high sustained anti-rhGAA IgG antibody titers (HSAT) leading to the ineffectiveness of this treatment. HSAT have been challenging to treat, although preemptive approaches have shown success in high-risk patients (those who are cross-reactive immunological material [CRIM]-negative). More recently, the addition of bortezomib, a proteasome inhibitor known to target plasma cells, to immunotherapy with rituximab, methotrexate, and intravenous immunoglobulin has shown success at significantly reducing the anti-rhGAA antibody titers in three patients with HSAT. In this report, we present the successful use of a bortezomib-based approach in a CRIM-positive IPD patient with HSAT and the use of a preemptive approach to prevent immunologic response in an affected younger sibling. We highlight the significant difference in clinical course between the two patients, particularly that a pre-emptive approach was simple and effective in preventing the development of high antibody titers in the younger sibling, thus supporting the role of immune tolerance induction (ITI) in the ERT-naïve high-risk setting.
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Affiliation(s)
- Elizabeth O Stenger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, United States
| | - Zoheb Kazi
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | - Emily Lisi
- Division of Medical Genetics, Department of Human Genetics, Emory University, Atlanta, GA, United States
| | - Michael J Gambello
- Division of Medical Genetics, Department of Human Genetics, Emory University, Atlanta, GA, United States
| | - Priya Kishnani
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
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Holstein K, Schneppenheim R, Schrum J, Bokemeyer C, Langer F. Successful second ITI with factor IX and combined immunosuppressive therapy. A patient with severe haemophilia B and recurrence of a factor IX inhibitor. Hamostaseologie 2015; 34 Suppl 1:S5-8. [PMID: 25382771 DOI: 10.5482/hamo-14-01-0010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 09/17/2014] [Indexed: 11/05/2022] Open
Abstract
Immune tolerance induction (ITI) in patients with haemophilia B and inhibitors may be complicated by anaphylactic reactions and nephrotic syndrome with lower success rates than in haemophilia A (25% vs. 50-90%). According to case reports, immunosuppressive therapy in addition to high doses of factor IX (FIX) appears to be promising. We report an 18-year-old patient with severe haemophilia B and a FIX inhibitor with a maximum titre of 2.6 Bethesda units and allergic skin reactions to FIX infusions. At 5 years of age, this patient already had a FIX inhibitor with allergic reactions to FIX and activated prothrombin complex concentrate. ITI at 11 years of age with high-dose FIX, dexamethasone, rituximab, mycophenolate mofetil and intravenous immunoglobulins had induced a sustained response until the current presentation. The patient was restarted on the same ITI regimen with aforementioned immunosuppressants, which were initiated one week before high-dose FIX. No allergic reactions, nephrotic syndrome or serious infection occurred during ITI. The FIX inhibitor was undetectable after five weeks of treatment and remained so until 19 months of follow-up.
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Affiliation(s)
- K Holstein
- Dr. Katharina Holstein, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany, Tel. +49/(0)40/741 05-24 53, Fax -5193, E-mail:
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Kreuz W, Escuriola Ettingshausen C, Vdovin V, Zozulya N, Plyushch O, Svirin P, Andreeva T, Bubanská E, Campos M, Benedik-Dolničar M, Jiménez-Yuste V, Kitanovski L, Klukowska A, Momot A, Osmulskaya N, Prieto M, Šalek SZ, Velasco F, Pavlova A, Oldenburg J, Knaub S, Jansen M, Belyanskaya L, Walter O. First prospective report on immune tolerance in poor risk haemophilia A inhibitor patients with a single factor VIII/von Willebrand factor concentrate in an observational immune tolerance induction study. Haemophilia 2015. [PMID: 26202305 DOI: 10.1111/hae.12774] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION/BACKGROUND Development of neutralizing inhibitors against factor VIII (FVIII) is a major complication of haemophilia A treatment. AIM The ongoing, international, open-label, uncontrolled, observational immune tolerance induction (ObsITI) study evaluates ITI, the standard of care in patients with inhibitors. PATIENTS/METHODS Forty-eight prospective patients in this interim analysis received a single plasma-derived, von Willebrand factor-stabilized, FVIII concentrate (pdFVIII/VWF) for ITI. According to recommended Bonn protocol, 'low responders' at ITI start (<5 BU) received 50-100 IU FVIII kg(-1) daily, or every other day; 'high responders' (≥5 BU) received 100 IU FVIII kg(-1) every 12 h. RESULTS Forty of 48 patients (83.3%), had at least one risk factor for poor ITI-prognosis at ITI start (i.e. age ≥7 years, >2 years since inhibitor diagnosis, inhibitor titre ≥10 BU at the start of ITI, or prior ITI failure). Nonetheless, 34 patients (70.8%) achieved complete success, 3 (6.3%) partial success, 1 (2.1%) partial response; ITI failed in 10 patients (20.8%), all with poor prognosis factors. All six low responders achieved complete success. ITI outcome was significantly associated with inhibitor titre level at ITI start (P = 0.0068), number of poor prognosis factors for ITI success (P = 0.0187), monthly bleeding rate during ITI (P = 0.0005) and peak inhibitor titre during ITI (P = 0.0007). Twenty-two of 35 high responder patients (62.9%) with ≥1 poor prognosis factor achieved complete success. CONCLUSION Treatment with a single pdFVIII/VWF concentrate, mainly according to the Bonn protocol, resulted in a high ITI success rate in haemophilia A patients with inhibitors and poor prognosis for ITI success.
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Affiliation(s)
- W Kreuz
- HZRM, Hämophilie-Zentrum Rhein Main Frankfurt-Mörfelden, Mörfelden-Walldorf, Germany
| | | | - V Vdovin
- Izmaylovo Children's Hospital Haematological Centre, Moscow, Russia
| | - N Zozulya
- The State Haematological Scientific Centre RAMS, Moscow, Russia
| | - O Plyushch
- The State Haematological Scientific Centre RAMS, Moscow, Russia
| | - P Svirin
- Izmaylovo Children's Hospital Haematological Centre, Moscow, Russia
| | - T Andreeva
- St. Petersburg State Healthcare Institution, St. Petersburg, Russia
| | - E Bubanská
- Children Faculty Hospital with Policlinic, Banská Bystrica, Slovakia
| | - M Campos
- Centro Hospitalar Porto, Hospital de Santo António, Porto, Portugal
| | - M Benedik-Dolničar
- Children's Hospital Oncology-Hematology Unit, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - L Kitanovski
- Children's Hospital Oncology-Hematology Unit, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - A Momot
- Altai Hematological Center, Altai, Russia
| | - N Osmulskaya
- State Healthcare Institution of Omsk Region, Omsk, Russia
| | - M Prieto
- Hospital General Yagüe, Castilla Leon, Spain
| | - S Z Šalek
- University Hospital REBRO, Zagreb, Croatia
| | - F Velasco
- Hospital Reina Sofía, Córdoba, Spain
| | - A Pavlova
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - J Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - S Knaub
- Octapharma AG, Lachen, Switzerland
| | - M Jansen
- Octapharma Pharmazeutika Produktionsges.mbH, Vienna, Austria
| | | | - O Walter
- Octapharma AG, Lachen, Switzerland
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Bon A, Morfini M, Dini A, Mori F, Barni S, Gianluca S, de Martino M, Novembre E. Desensitization and immune tolerance induction in children with severe factor IX deficiency; inhibitors and adverse reactions to replacement therapy: a case-report and literature review. Ital J Pediatr 2015; 41:12. [PMID: 25887512 PMCID: PMC4347657 DOI: 10.1186/s13052-015-0116-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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: 11/19/2014] [Accepted: 02/02/2015] [Indexed: 11/10/2022] Open
Abstract
Hemophilia B is a rare X-linked recessive disorder with plasma factor IX (FIX) deficiency. 1-3% of patients treated with exogenous FIX-containing products develop inhibitors (i.e. polyclonal high affinity immunoglobulins) that neutralize the procoagulant activity of a specific coagulation factor. Although the incidence of inhibitors in hemophilia B patients is low, most are "high titer" and frequently associated with the development of severe allergic or anaphylactic reactions. Immune tolerance induction as a strategy for inhibitor eradication was first described in 1984. Unfortunately, the overall reported success of immune tolerance induction in FIX deficiency with inhibitors is approximately 25-40%.We report the case of a 2-year-old boy with hemophilia B severe FIX deficiency (<1%), inhibitor antibodies to FIX development, and a history of adverse reactions to FIX infusions, who underwent a successful desensitization and immune tolerance induction with a daily FIX infusion. With this regimen the inhibitor titer decreased with effective bleeding prevention.
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Affiliation(s)
- Andrea Bon
- Department of Pediatrics, University of Udine, Udine, Italy.
| | - Massimo Morfini
- Haemophilia Agency, Careggi University Hospital, Florence, Italy.
| | - Alessandro Dini
- Department of Pediatrics, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
| | - Sottilotta Gianluca
- Haemophilia Centre, "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy.
| | - Maurizio de Martino
- Department of Health Sciences, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
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Singh N, Mishra P, Tyagi S, Pati HP, Mahapatra M, Seth T, Saxena R. Clinicohematologic Profile of Patients With Factor VIII Inhibitors: A Case Series. Clin Appl Thromb Hemost 2014; 21:246-50. [PMID: 25172870 DOI: 10.1177/1076029614548720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Factor VIII (FVIII) inhibitors present major clinical challenge as a complication of hemophilia A in patients on treatment with FVIII concentrates and as acquired autoantibodies in patients without hemophilia A. We aimed to study the prevalence of FVIII inhibitors in Indian settings, risk factors involved in early development of inhibitors in patients with hemophilia, differences in their clinical behavior, and approach to treatment, in comparison to patients with acquired hemophilia. The overall prevalence of FVIII inhibitors in patients with severe hemophilia A was found to be 22.3%. Two cases of acquired hemophilia were reported. Due to heterogeneity of our study population, cases have been discussed individually. We observed that the early development of FVIII inhibitors in patients with hemophilia A is dependent upon an interplay of several risk factors that need to be studied in a multivariable analysis to bring out significant correlation with response to treatment. Also, they differ from patients without hemophilia A entirely in terms of presentation and management.
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Affiliation(s)
- Neha Singh
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Pravas Mishra
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Seema Tyagi
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - H P Pati
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - M Mahapatra
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Tulika Seth
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Renu Saxena
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Wang Z, Okamoto P, Keutzer J. A new assay for fast, reliable CRIM status determination in infantile-onset Pompe disease. Mol Genet Metab 2014; 111:92-100. [PMID: 24044919 DOI: 10.1016/j.ymgme.2013.08.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 08/21/2013] [Accepted: 08/22/2013] [Indexed: 11/19/2022]
Abstract
Pompe disease is caused by a deficiency of acid α-glucosidase (GAA; EC, 3.2.1.20), and the infantile-onset form is rapidly fatal if left untreated. However, recombinant human GAA (rhGAA) enzyme replacement therapy (ERT) extends survival for infantile Pompe patients. Although cross-reactive immunologic material (CRIM)-negative patients, who lack detectable endogenous GAA, mount an immune response to rhGAA that renders the therapy ineffective, timely induction of immune tolerance in these patients may improve clinical outcomes. Previously, CRIM status has been determined by Western blot analysis in cultured skin fibroblasts, a process that can take a few weeks. We present a blood-based CRIM assay that can yield results within 48 to 72 h. Results from this assay have been confirmed by GAA Western blot analysis in fibroblasts or by GAA sequencing in a small number of Pompe disease patients. Rapid classification of CRIM status will assist in identifying the most effective treatment course and minimizing treatment delays in patients with infantile-onset Pompe disease.
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Affiliation(s)
- Zhaohui Wang
- Integrated Genetics, Esoterix Genetic Laboratories, LLC, a wholly-owned subsidiary of Laboratory Corporation of America® Holdings, 3400 Computer Drive Westborough, MA 01581, USA.
| | - Patricia Okamoto
- Integrated Genetics, Esoterix Genetic Laboratories, LLC, a wholly-owned subsidiary of Laboratory Corporation of America® Holdings, 3400 Computer Drive Westborough, MA 01581, USA.
| | - Joan Keutzer
- Genzyme Corporation, a Sanofi company, Cambridge, MA, USA.
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Rasekh HR, Imani A, Karimi M, Golestani M. Cost-utility analysis of immune tolerance induction therapy versus on-demand treatment with recombinant factor VII for hemophilia A with high titer inhibitors in Iran. Clinicoecon Outcomes Res 2011; 3:207-12. [PMID: 22163168 PMCID: PMC3234155 DOI: 10.2147/ceor.s25909] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background In developing countries, the treatment of hemophilia patients with inhibitors is presently the most challenging and serious issue in hemophilia management, direct costs of clotting factor concentrates accounting for >98% of the highest economic burden absorbed for the health care of patients in this setting. In the setting of chronic diseases, cost-utility analysis, which takes into account the beneficial effects of a given treatment/health care intervention in terms of health-related quality of life, is likely to be the most appropriate approach. Objective The aim of this study was to assess the incremental cost-effectiveness ratios of immune tolerance induction (ITI) therapy with plasma-derived factor VIII concentrates versus on-demand treatment with recombinant-activated FVIIa (rFVIIa) in hemophilia A with high titer inhibitors from an Iranian Ministry of Health perspective. Methods This study was based on the study of Knight et al, which evaluated the cost- effectiveness ratios of different treatments for hemophilia A with high-responding inhibitors. To adapt Knight et al’s results to the Iranian context, a few clinical parameters were varied, and cost data were replaced with the corresponding Iranian estimates of resource use. The time horizon of the analysis was 10 years. One-way sensitivity analyses were performed, varying the cost of the clotting factor, the drug dose, and the administration frequency, to test the robustness of the analysis. Results Comparison of the incremental cost-effectiveness ratios between the three ITI protocols and the on-demand regimen with rFVIIa shows that all three ITI protocols dominate the on-demand regimen with rFVIIa. Between the ITI protocols the low-dose ITI protocol dominates both the Bonn ITI protocol and the Malmö ITI protocol and would be the preferred ITI protocol. All of the three ITI protocols dominate the on-demand strategy, as they have both a lower average lifetime cost and higher quality-adjusted life-years (QALYs) gained. The cost per QALY gained for the Bonn ITI protocol compared with the Malmö ITI protocol was $249,391.84. The cost per QALY gained for the Bonn ITI protocol compared with the low-dose ITI protocol was $842,307.69. Conclusion The results of data derived from our study suggest that the low-dose ITI protocol may be a less expensive and/or more cost-effective option compared with on-demand first-line treatment with rFVIIa.
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Affiliation(s)
- Hamid Reza Rasekh
- Shahid Beheshti University of Medical Sciences, Department of Pharmaceutical Management and Pharmacoeconomics, School of Pharmacy, Tehran
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Di Minno G, Coppola A. A role for von Willebrand factor in immune tolerance induction in patients with haemophilia A and inhibitors? Blood Transfus 2011; 9 Suppl 2:s14-20. [PMID: 21839028 PMCID: PMC3159912 DOI: 10.2450/2011.004s] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Giovanni Di Minno
- Regional Reference Centre for Coagulation Disorders, Department of Clinical and Experimental Medicine, Federico II University Hospital, Naples, Italy
| | - Antonio Coppola
- Regional Reference Centre for Coagulation Disorders, Department of Clinical and Experimental Medicine, Federico II University Hospital, Naples, Italy
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