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Ay C, Napolitano M, Hassoun A, Tomic R, Martin C, Seifert W, Pinachyan K, Oldenburg J. Classification of recombinant factor VIII products and implications for clinical practice: A systematic literature review. Haemophilia 2024; 30:577-588. [PMID: 38549463 DOI: 10.1111/hae.15001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 03/06/2024] [Accepted: 03/13/2024] [Indexed: 05/15/2024]
Abstract
INTRODUCTION Consensus over the definition of recombinant factor VIII (rFVIII) product classification in haemophilia A is lacking. rFVIII products are often classified as standard half-life (SHL) or extended half-life (EHL); despite this, no universally accepted definition currently exists. One proposed definition includes half-life, area under the curve, and technology designed to extend half-life; however, the International Society on Thrombosis and Haemostasis defines activity over time as the most intuitive information for building treatment regimens and the World Federation of Hemophilia describes rFVIII product classification in terms of infusion frequency. AIM To summarise published data on the clinical and pharmacokinetic criteria used to define rFVIII product classification. METHODS PubMed and EMBASE database searches of English-language articles (2002-2022) were conducted using search strings to identify the relevant population, intervention, and outcomes (e.g., clinical and pharmacokinetic parameters). Articles then underwent title/abstract and full-text screens. RESULTS Among 1147 identified articles, 62 were included. Half-life was the most widely reported outcome with no clear trends or product groupings observed. No clear groupings emerged among other outcomes, including infusion frequency, consumption, and efficacy. As activity over time was reported in few articles, further investigation of its relevance to rFVIII product classification is warranted. CONCLUSION The findings of this systematic literature review suggest that parameters other than half-life might be important for the development of a comprehensive and clinically relevant rFVIII product classification definition. There seems to be an opportunity to consider parameters that are clinically meaningful and useful for shared decision-making in haemophilia A treatment.
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Affiliation(s)
- Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | | | - Abel Hassoun
- Haemophilia Treatment Center, Simone Veil Hospital, GH Eaubonne-Montmorency, Eaubonne, France
| | | | | | | | | | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
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Genç CA, Gürlek Gökçebay D, Koşan Çulha V, Kaya Z, Özbek NY. Comparison Pharmacokinetic Dosing Tools in Hemophilia A Children. Indian J Hematol Blood Transfus 2024; 40:108-115. [PMID: 38312178 PMCID: PMC10830962 DOI: 10.1007/s12288-023-01671-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 05/11/2023] [Indexed: 02/06/2024] Open
Abstract
Prophylaxis is the gold standard for the management of hemophilia A patients. It has been shown that prophylaxis regulated with pharmacokinetic (PK) data reduces frequency of bleeding and cost of treatment. To determine the best prophylaxis regimen, PK dosing tools using the Bayesian method have been developed. We aimed to compare two PK dosing tools. Blood samples were drawn before, 4, 24, and 48 h after FVIII infusions from patients with severe hemophilia A and inhibitor negative. FVIII levels were measured by PTT-based one-stage assay method. PK parameters obtained using WAPPS and myPKFiT, which are web-accessible PK dosing tools using Bayesian algorithm, and daily prophylaxis dose estimated by the programs were compared. Forty-two hemophilia A patients [median age 13 years (IQR 8.9-16.4)] included in the study. There was no difference between the daily dose of FVIII given for prophylaxis and the dose recommended by the myPKFiT for the 1% trough level; whereas, a significant difference was found with the WAPPS. The half-lives of FVIII did not differ between the two dosing tools; however, significant differences were found in the estimated dose, clearances, and times to 1% trough level. There was no significant difference between PK data of patients who received Advate® and those who received non-Advate® factor concentrates. Choice of PK dosing tool can affect recommended FVIII dose. However, target trough levels should be individualized according to bleeding phenotype and daily activity of patient. Supplementary Information The online version contains supplementary material available at 10.1007/s12288-023-01671-0.
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Affiliation(s)
- Can Alp Genç
- Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Dilek Gürlek Gökçebay
- Department of Pediatric Hematology and Oncology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Vildan Koşan Çulha
- Department of Pediatric Hematology and Oncology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Zühre Kaya
- Department of Pediatric Hematology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Namık Yaşar Özbek
- Department of Pediatric Hematology and Oncology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
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Kraemmer D, Königsbrügge O, Moik F, Wildner B, Ay C, Pabinger I. Pharmacokinetic-guided versus standard prophylaxis in hemophilia: a systematic review and meta-analysis. J Thromb Haemost 2023; 21:3432-3449. [PMID: 37739039 DOI: 10.1016/j.jtha.2023.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/11/2023] [Accepted: 08/29/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND With population pharmacokinetic (PK) modeling more readily available and PK-guided prophylaxis endorsed by current hemophilia guidelines, we conducted a systematic review to summarize current evidence in the literature. OBJECTIVES To assess the efficacy of PK-guided compared with non-PK-guided prophylaxis. METHODS We did not restrict inclusion to specific study design labels and included all studies consisting of at least one distinct cohort arm receiving PK-guided prophylaxis. We searched the following databases from inception to date of search: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and the EU Clinical Trial Register. Following title, abstract, and full-text screening conducted independently by 2 review authors, we summarized studies qualitatively and synthesized included randomized clinical trials (RCTs) quantitatively by fitting random-effects models. RESULTS Search of databases on February 3, 2023, yielded 25 studies fitting our inclusion criteria. Of those, only 2 RCTs and 17 nonrandomized studies included a standard prophylaxis comparator group. Furthermore, risk of bias in the latter was substantial, primarily due to before-after study designs and retrospective comparator groups. Thus, nonrandomized studies were only presented qualitatively. A random-effects meta-analysis of the 2 identified RCT remained inconclusive with regards to bleeding outcomes (ratio of means, 1.15; 95% CI, 0.85-1.56) and factor consumption (ratio of means, 0.82; 95% CI, 0.58-1.18). CONCLUSION Evidence in the literature suggesting a clinical benefit of PK-guided over standard fixed-dose prophylaxis was weak and mainly found in nonrandomized studies limited by lack of concurrent controls, heterogeneity in outcome reporting, small sample sizes, and high risk of bias.
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Affiliation(s)
- Daniel Kraemmer
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Oliver Königsbrügge
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Florian Moik
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria; Division of Oncology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Brigitte Wildner
- University Library, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
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Goedhart TMHJ, Janssen A, Mathôt RAA, Cnossen MH. The road to implementation of pharmacokinetic-guided dosing of factor replacement therapy in hemophilia and allied bleeding disorders. Identifying knowledge gaps by mapping barriers and facilitators. Blood Rev 2023; 61:101098. [PMID: 37321952 DOI: 10.1016/j.blre.2023.101098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 04/02/2023] [Accepted: 05/07/2023] [Indexed: 06/17/2023]
Abstract
Clinical guidelines and expert groups recommend the use of pharmacokinetic (PK)-guided dosing of factor replacement therapy for the treatment of bleeding disorders, especially for patients with hemophilia. Although PK-guided dosing is increasingly applied, it is generally not considered standard clinical practice. The aim of this scoping review is to map barriers and facilitators for the implementation of PK-guided dosing in clinical practice and to identify knowledge gaps. A literature search was performed and 110 articles were included that describe PK-guided dosing in patients with bleeding disorders, mostly hemophilia A. We defined two overarching themes, efficacy and feasibility, and discuss five topics within each theme. For each topic, barriers, facilitators and knowledge gaps were described. Although consensus was found with regard to some topics, contradicting reports were found for others, especially with respect to the efficacy of PK-guided dosing. These contradictions highlight the need for future research to elucidate current ambiguities.
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Affiliation(s)
- Tine M H J Goedhart
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - A Janssen
- Department of Clinical Pharmacology - Hospital Pharmacy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Ron A A Mathôt
- Department of Clinical Pharmacology - Hospital Pharmacy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Elsheikh E, Lavin M, Heck LA, Larkin N, Mullaney B, Doherty D, Kennedy M, Keenan C, Guest T, O'Mahony B, Fazavana J, Fallon PG, Preston RJS, Gormley J, Ryan K, O'Connell NM, Singleton E, Byrne M, McGowan M, Roche S, Doyle M, Crowley MP, O'Shea SI, Reipert BM, Johnsen JM, Pipe SW, Di Paola J, Turecek PL, O'Donnell JS. Heterogeneity in the half-life of factor VIII concentrate in patients with hemophilia A is due to variability in the clearance of endogenous von Willebrand factor. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:1123-1134. [PMID: 36775768 DOI: 10.1016/j.jtha.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/04/2023] [Accepted: 01/12/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Previous studies have reported marked interindividual variation in factor VIII (FVIII) clearance in patients with hemophilia (PWH) and proposed a number of factors that influence this heterogeneity. OBJECTIVES To investigate the importance of the clearance rates of endogenous von Willebrand factor (VWF) compared with those of other FVIII half-life modifiers in adult PWH. METHODS The half-life of recombinant FVIII was determined in a cohort of 61 adult PWH. A range of reported modifiers of FVIII clearance was assessed (including plasma VWF:antigen and VWF propeptide levels; VWF-FVIII binding capacity; ABO blood group; and nonneutralizing anti-FVIII antibodies). The FVIII-binding region of the VWF gene was sequenced. Finally, the effects of variation in FVIII half-life on clinical phenotype were investigated. RESULTS We demonstrated that heterogeneity in the clearance of endogenous plasma VWF is a key determinant of variable FVIII half-life in PWH. Both ABO blood group and age significantly impact FVIII clearance. The effect of ABO blood group on FVIII half-life in PWH is modulated entirely through its effect on the clearance rates of endogenous VWF. In contrast, the age-related effect on FVIII clearance is, at least in part, VWF independent. In contrast to previous studies, no major effects of variation in VWF-FVIII binding affinity on FVIII clearance were observed. Although high-titer immunoglobulin G antibodies (≥1:80) were observed in 26% of PWH, these did not impact FVIII half-life. Importantly, the annual FVIII usage (IU/kg/y) was significantly (p = .0035) increased in patients with an FVIII half-life of <12 hours. CONCLUSION Our data demonstrate that heterogeneity in the half-life of FVIII concentrates in patients with hemophilia A is primarily attributable to variability in the clearance of endogenous VWF.
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Affiliation(s)
- Einas Elsheikh
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Michelle Lavin
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Lilian Antunes Heck
- Department of Pediatrics, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Niamh Larkin
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Brendan Mullaney
- Haemostasis Molecular Diagnostics Laboratory, National Coagulation Centre, St. James's Hospital, Dublin, Ireland
| | - Dearbhla Doherty
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Megan Kennedy
- Discipline of Physiotherapy, Trinity Centre for Health sciences, Trinity College Dublin, St James's Hospital, Dublin, Ireland
| | - Catriona Keenan
- Haemostasis Molecular Diagnostics Laboratory, National Coagulation Centre, St. James's Hospital, Dublin, Ireland
| | - Thomas Guest
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Judicael Fazavana
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Padraic G Fallon
- Inflammation and Immunity Research Group, Trinity Translational Medicine Institute, St James's Hospital, Trinity College Dublin, Dublin, Ireland
| | - Roger J S Preston
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John Gormley
- Discipline of Physiotherapy, Trinity Centre for Health sciences, Trinity College Dublin, St James's Hospital, Dublin, Ireland
| | - Kevin Ryan
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | | | - Evelyn Singleton
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Mary Byrne
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Mark McGowan
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Sheila Roche
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Mairead Doyle
- National Coagulation Centre, St James's Hospital, Dublin, Ireland
| | - Maeve P Crowley
- Department of Haematology, Cork University Hospital, Cork, Ireland
| | - Susan I O'Shea
- Department of Haematology, Cork University Hospital, Cork, Ireland
| | | | - Jill M Johnsen
- Bloodworks Northwest Research Institute, Seattle, Washington, USA; Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jorge Di Paola
- Department of Pediatrics, School of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Peter L Turecek
- Baxalta Innovations GmbH, A Member of the Takeda Group of Companies, Vienna, Austria
| | - James S O'Donnell
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland; National Coagulation Centre, St James's Hospital, Dublin, Ireland.
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Iorio A, Königs C, Reding MT, Rotellini D, Skinner MW, Mancuso ME, Berntorp E. Prophylaxis use of clotting factor replacement products in people with non-severe haemophilia: A review of the literature. Haemophilia 2023; 29:33-44. [PMID: 36224704 PMCID: PMC10091955 DOI: 10.1111/hae.14676] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/24/2022] [Accepted: 09/29/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION People with non-severe haemophilia appear to be under-treated in many countries, and this may lead to joint damage and worsen quality of life. AIM To review literature for clotting factor replacement prophylaxis in people with non-severe haemophilia A and B (HA/HB) in relation to long-term outcomes to support clinical decision-making. METHODS A targeted literature search was performed to identify studies published between 2000 and 2021 that included prophylaxis in people with non-severe HA/HB and long-term outcomes, including annualized bleeding rates, joint health and quality of life. RESULTS Although eligible articles included 2737 and 2272 people with mild or moderate HA, respectively, only 22% (n = 609) and 29% (n = 668) reported treatment regimens. A total of 549 people with moderate HA were treated with factor replacement prophylaxis and were from high-income countries. On the contrary, nearly all people with mild HA received desmopressin (n = 599). Details of treatment regimens for women with haemophilia and people with HB were sparse. Three studies provided long-term outcomes for people with moderate haemophilia who received prophylaxis with factor concentrate, supporting early prophylaxis in people with a frequent bleeding phenotype regardless of their endogenous clotting factor level to preserve joint health. CONCLUSION There remain large knowledge gaps when considering how to provide optimal treatment for people with non-severe haemophilia. Nonetheless, there is a strong rationale that prophylaxis should be considered early in life according to similar strategies as for severe haemophilia for those with a frequent severe bleeding phenotype.
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Affiliation(s)
- Alfonso Iorio
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.,Hamilton-Niagara Hemophilia Program, Ontario, Canada
| | - Christoph Königs
- Clinical and Molecular Hemostasis, University Hospital Frankfurt, Goethe University, Department of Paediatrics, Frankfurt am Main, Germany
| | - Mark T Reding
- Center for Bleeding and Clotting Disorders, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Mark W Skinner
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.,Institute for Policy Advancement, Ltd., Washington, District of Columbia, USA
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Erik Berntorp
- Lund University, Skane University Hospital, Malmo, Sweden
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Urasiński T, Paczóska K, Badowska W, Bobrowska H, Dakowicz Ł, Dobaczewski G, Latos-Grażyńska E, Karolczyk G, Klukowska A, Kołtan A, Wojdalska M, Łaguna P, Niedźwiedzki M, Pietrys D, Radoń-Proskura J, Radwańska M, Rurańska I, Szczepański T, Wasiński D, Woźnica-Karczmarz I, Zielezińska K, Królak A, Ociepa T. Real pandemic world results of pharmacokinetic-tailored personalized prophylaxis of bleeds in Polish children and adolescents with severe hemophilia A. Front Pediatr 2023; 11:1084539. [PMID: 36911027 PMCID: PMC9996297 DOI: 10.3389/fped.2023.1084539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 02/08/2023] [Indexed: 02/25/2023] Open
Abstract
Introduction In 2020, the new nationwide protocol of prophylaxis in Polish plasma-derived FVIII (pdFVIII) previously treated patients (PTPs) with severe hemophilia A (sHA) was introduced, resulting in the necessity of switching from pdFVIII to recombinant FVIII (octocog-alpha; rFVIII). The study aimed to: (1) assess the safety of switching from pdFVIII to rFVIII, (2) assess the safety and efficacy of pharmacokinetically based (PK-based) personalized prophylaxis in severe hemophilia A. Patients and methods 151 children and adolescents receiving prophylaxis with a standard dose (40 U/kg 3 x weekly) of pdFVIII were included in this study. Annualized bleeding rate (ABR) and annualized joint bleeding rate (AJBR) were analyzed for all patients before enrollment. Using myPKFiT application, pharmacokinetic (PK) analysis followed by the selection of the optimal model of prophylaxis was performed in all patients. Two possible models of prophylaxis (standard-dose rFVIII versus PK-based rFVIII) were discussed, with parents leaving the choice to their decision. Parents reported all episodes of bleeds. Screening for inhibitor was performed every 3 months. ABR and AJBR were prospectively analyzed again after a minimum follow-up time of 26 weeks. Results 141/151 (93.4%) patients completed the study. 34 patients decided to continue standard prophylaxis with rFVIII (Group I), whereas 107 were switched to PK-based prophylaxis (Group II). The risk of inhibitor development could be assessed in 137/151 (90.7%) patients. Only 2/137 (1.47%) patients (both on PK-based prophylaxis) developed low-titer inhibitor with its spontaneous elimination. The retrospective analysis of bleeds during the last 12 months of standard pdFVIII prophylaxis revealed that patients who decided to continue standard prophylaxis had historically lower ABR and AJBR than those who started PK-based personalized prophylaxis. After a minimum of 26 weeks, ABR and AJBR improved significantly in both groups. There was no significant difference in ABR and AJBR between Group I and Group II during the follow-up period. However, the rate of reduction of ABR and AJBR was higher in patients on PK-based personalized prophylaxis. Conclusion (1) Switching from pdFVIII to rFVIII (octocog-alpha) in PTPs with sHA is safe, (2) PK-based personalized prophylaxis may decrease ABR and AJBR in children and adolescents with sHA.
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Affiliation(s)
- Tomasz Urasiński
- Department of Pediatrics, Hemato-Oncology and Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - Klaudia Paczóska
- Department of Pediatrics, Hemato-Oncology and Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - Wanda Badowska
- Department of Pediatric Oncology and Hematology, School of Medicine, University of Warmia Mazury, Olsztyn, Poland
| | | | - Łucja Dakowicz
- Department of Pediatric Oncology and Hematology, Medical University of Białystok, Białystok, Poland
| | - Grzegorz Dobaczewski
- Department of Bone Marrow Transplantation, Pediatric Oncology and Hematology, Wrocław Medical University, Wrocław, Poland
| | - Elżbieta Latos-Grażyńska
- Department of Bone Marrow Transplantation, Pediatric Oncology and Hematology, Wrocław Medical University, Wrocław, Poland
| | - Grażyna Karolczyk
- II Department of Pediatrics, Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | - Anna Klukowska
- Department of Pediatric Oncology, Hematology and Transplantation, Medical University of Warsaw, Warszawa, Poland
| | - Andrzej Kołtan
- Department of Pediatrics, Hematology and Oncology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Magdalena Wojdalska
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Łódź, Poland
| | - Paweł Łaguna
- Department of Pediatric Oncology, Hematology and Transplantation, Medical University of Warsaw, Warszawa, Poland
| | - Maciej Niedźwiedzki
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdańsk, Gdańsk, Poland
| | - Danuta Pietrys
- Department of Pediatric Oncology and Hematology, Collegium Medicum, Jagiellonian University, Kraków, Poland
| | - Julia Radoń-Proskura
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdańsk, Gdańsk, Poland
| | - Monika Radwańska
- Department of Pediatric Oncology and Hematology, College of Medical Sciences, University of Rzeszów, Rzeszów, Poland
| | - Iwona Rurańska
- Department of Pediatrics, Hematology and Oncology, Medical University of Silesia, Katowice, Poland
| | - Tomasz Szczepański
- Department of Pediatrics, Hematology and Oncology, Medical University of Silesia, Katowice, Poland
| | - Dariusz Wasiński
- Department of Pediatric Hematology and Oncology, Collegium Medicum, University of Zielona Góra, Zielona Góra, Poland
| | | | - Karolina Zielezińska
- Department of Pediatrics, Hemato-Oncology and Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - Aleksandra Królak
- Department of Pediatrics, Hemato-Oncology and Gastroenterology, Pomeranian Medical University, Szczecin, Poland
| | - Tomasz Ociepa
- Department of Pediatrics, Hemato-Oncology and Gastroenterology, Pomeranian Medical University, Szczecin, Poland
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Huang K, Ai D, Li G, Zhen Y, Wang Y, Zhang N, Huo A, Liu G, Chen Z, Wu R. Individualised prophylaxis based on personalised target trough FVIII level optimised clinical outcomes in paediatric patients with severe haemophilia A. Haemophilia 2022; 28:e209-e218. [PMID: 35850182 PMCID: PMC9796890 DOI: 10.1111/hae.14635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/07/2022] [Accepted: 07/08/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION As standard care of severe haemophilia A (SHA), prophylaxis should be individualised. AIM This study aimed to investigate the effectiveness of this new-proposed individualised prophylaxis protocol. METHODS Boys with SHA were enrolled and followed a PK-guided, trough-level escalating protocol of prophylaxis after a six-month observational period. In the next 2 years, clinical assessments including joint bleeds, ultrasound (US) scores and Haemophilia Joint Health Score (HJHS) in both sides of ankles, knees and elbows were conducted every 6 months as a scoring system, which determined whether the trough level's escalation. Adjustment of dosing regimen was based on WAPPS-Hemo. RESULTS Fifty-eight SHA boys were finally analysed. Their age and bodyweight were 5.3(2.8,6.9) years and 21.5(16,25) kg. During the study, 47 escalations were conducted. At study exit, the patient number and proportion of different trough level groups were: < 1 IU/dl, 17.2% (10/58); 1-3 IU/dl, 53.5% (31/58); 3-5 IU/dl, 15.5% (9/58); > 5 IU/dl, 13.8% (8/58). Significantly reduced annualised bleeding rate [4(0,8) to 0(0,2), p < .0001] and annualised joint bleeding rate [2(0,4) to 0(0,.25), p < .0001] was observed at study exit as well as the continuous trend of increased zero bleeding proportion (ZBP) (27.6%-69.0%) and zero joint bleeding proportion (46.5%-81.3%). Besides, 85% (6/7) of the target joints vanished. Statistical improvements of US scores (p = .04) and HJHS (p = .02) were also reported at study exit. CONCLUSION Our results showed the effectiveness of our protocol based on individualised target trough level and emphasise the importance of personalised prophylaxis.
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Affiliation(s)
- Kun Huang
- Hematology Center, Beijing Children's Hospital, Capital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Di Ai
- Hematology Center, Beijing Children's Hospital, Capital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Gang Li
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Yingzi Zhen
- Hematology Center, Beijing Children's Hospital, Capital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Yan Wang
- Rehabilitation Department, Beijing Children's Hospital, Capital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Ningning Zhang
- Radiology Center, Beijing Children's Hospital, Capital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Aihua Huo
- Radiology Center, Beijing Children's Hospital, Capital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Guoqing Liu
- Hematology Center, Beijing Children's Hospital, Capital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Zhenping Chen
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Runhui Wu
- Hematology Center, Beijing Children's Hospital, Capital Medical UniversityNational Center for Children's HealthBeijingChina
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9
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Chaweephisal P, Poparn H, Chiengthong K, Seksarn P, Techavichit P, Lauhasurayotin S, Sosothikul D. Complicated bleeding challenge and intraoperative safety strategies in a case of hemophilia a with rhabdomyosarcoma. Pediatr Hematol Oncol 2022; 39:672-677. [PMID: 35138216 DOI: 10.1080/08880018.2022.2038316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Phumin Chaweephisal
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Hansamon Poparn
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Integrative and Innovative Hematology/Oncology Research Unit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kanhatai Chiengthong
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Integrative and Innovative Hematology/Oncology Research Unit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Panya Seksarn
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Piti Techavichit
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Integrative and Innovative Hematology/Oncology Research Unit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Supanun Lauhasurayotin
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Integrative and Innovative Hematology/Oncology Research Unit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Darintr Sosothikul
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Integrative and Innovative Hematology/Oncology Research Unit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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10
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Huang K, Chen Z, Wu R. "A personalized limited sampling approach to better estimate terminal half-life of FVIII concentrates": Comment from Huang et al. J Thromb Haemost 2022; 20:2444-2445. [PMID: 36123571 DOI: 10.1111/jth.15833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/18/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Kun Huang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhenping Chen
- Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Runhui Wu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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11
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Núñez R, Álvarez-Román MT, Bonanad S, González-Porras JR, De La Corte-Rodriguez H, Berrueco R, Jiménez-Yuste V. The Limitations and Unmet Needs of the Five Cornerstones to Guarantee Lifelong Optimization of Prophylaxis in Hemophilia Patients. TH OPEN 2022; 6:e365-e377. [DOI: 10.1055/s-0042-1757745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
AbstractProphylaxis to prevent bleeding is highly recommended for hemophilia patients. The development of new drugs and tools for modeling personalized prophylaxis provides the means for people with hemophilia to lead active lives with a quality of life comparable to that of nonhemophilic individuals. The choice of regimens must be made on a highly individual basis. Unfortunately, reference guides neither always concur in their recommendations nor provide directions to cover all possible scenarios. In this review, a group of experts identify the significant limitations and unmet needs of prophylaxis, taking advantage of their clinical experience in the disease, and supported by a rigorous literature update. To perform a more systematic and comprehensive search for gaps, the main cornerstones that influence decisions regarding prophylactic patterns were first identified.Bleeding phenotype, joint status, physical activity, pharmacokinetics/medication properties, and adherence to treatment were considered as the primary mainstays that should allow physicians guiding prophylaxis to secure the best outcomes. Several challenges identified within each of these topics require urgent attention and agreement. The scores to assess severity of bleeding are not reliable, and lead to no consensus definition of severe bleeding phenotype. The joint status is to be redefined in light of new, more efficient treatments with an agreement to establish one scale as the unique reference for joint health. Further discussion is needed to establish the appropriateness of high-intensity physical activities according to patient profiles, especially because sustaining trough factor levels within the safe range is not always warranted for long periods. Importantly, many physicians do not benefit from the advantages provided by the programs based on population pharmacokinetic models to guide individualized prophylaxis through more efficient and cost-saving strategies. Finally, ensuring correct adherence to long-term treatments may be time-consuming for practitioners, who often have to encourage patients and review complex questionnaires.In summary, we identify five cornerstones that influence prophylaxis and discuss the main conflicting concerns that challenge the proper long-term management of hemophilia. A consensus exercise is warranted to provide reliable guidelines and maximize benefit from recently developed tools that should notably improve patients' quality of life.
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Affiliation(s)
- Ramiro Núñez
- Hemophilia Unit, Hospital Universitario Virgen del Rocío, Sevilla, Andalucía, Spain
| | | | - Santiago Bonanad
- Haemostasis and Thrombosis Unit, Hospital Universitari i Politècnic La Fe, València, Spain
| | - José Ramón González-Porras
- Hematology Department, Hospital Universitario de Salamanca, Instituto Biosanitario de Salamanca (Ibsal), Salamanca, Spain
| | | | - Rubén Berrueco
- Pediatric Hematology Department, Hospital Sant Joan de Déu Barcelona, Esplugues de Llobregat, Barcelona, Spain
- Institut de Recerca, Pediàtrica Hospital Sant Joan de Déu de Barcelona (IRP-HSJD0), Barcelona, Spain
- Instituto Nacional de Investigación Biomédica en Enfermedades Raras (CIBER ER), Instituto de Salud Carlos III, Madrid, Spain
| | - Víctor Jiménez-Yuste
- Department of Hematology and Hemotherapy, La Paz University Hospital-IdiPaz, Madrid, Spain
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12
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Gu C, Huang H, Han Y. Cost-Effectiveness Analysis of Pharmacokinetic-Guided Prophylaxis Versus Standard Prophylaxis in Adults with Severe Hemophilia A in China. Adv Ther 2022; 39:3777-3788. [PMID: 35768709 PMCID: PMC9309149 DOI: 10.1007/s12325-022-02220-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/08/2022] [Indexed: 01/19/2023]
Abstract
Introduction Multiple studies have demonstrated the effectiveness of pharmacokinetic (PK)-guided individualized prophylaxis with human coagulation factor VIII (FVIII) compared with standard prophylaxis, but no studies have evaluated the economics of PK-guided prophylaxis in China. Hence, we conducted this study to assess the cost-effectiveness of PK-guided prophylaxis with recombinant FVIII (rFVIII) versus standard prophylaxis in Chinese adult patients with severe hemophilia A. Methods A discrete event simulation model was developed to simulate 10,000 patients with hemophilia A who received rFVIII treatment over a 1-year time horizon. The standard prophylaxis rFVIII dose was 30 IU/kg by intravenous injection. The PK-guided prophylaxis dosage was adjusted for each patient to maintain FVIII trough level at 1–5 IU/dL. Dosing interval for both approaches was kept fixed at 48 h. The health outcomes included annual joint bleed rate (AJBR) and quality-adjusted life years (QALYs). The model considered the costs of drug. Incremental cost-effectiveness ratio (ICER) was estimated and scenario analysis was performed. Results A total of 94.3% of patients receiving PK-guided individualized prophylaxis achieved the goal of maintaining the trough concentration at 1–5 IU/dL compared with 62.7% on standard prophylaxis. AJBR and QALYs gained in PK-guided and standard prophylaxis were 1.527 vs 1.601, and 0.8384 vs 0.8383, respectively. Costs of drug prophylaxis and costs of treatment for bleeding events in PK-guided prophylaxis (148,641.47 USD; 4546.43 USD) were lower than those in standard prophylaxis (159,620.93 USD; 4753.39 USD). An average saving of USD 11,186.47 was obtained by the PK-guided approach. The prophylaxis treatment scenarios were the most influential factors. Conclusion PK-guided individualized prophylaxis appeared to be a dominant treatment compared with standard prophylaxis, with slightly higher QALYs but lower total costs. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02220-3.
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Affiliation(s)
- Congling Gu
- Takeda International Trading Co. Ltd, Beijing, China
| | - Hui Huang
- Takeda International Trading Co. Ltd, Beijing, China
| | - Yi Han
- Sun Yat-Sen University, No. 132 Waihuan East Road, Guangzhou, 510006, China.
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13
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Ketteler C, Hoffmann I, Davidson S, Tiede A, Richter N. Monitoring of different factor VIII replacement products using a factor VIII one-stage clotting assay on cobas t 511/711 analysers. Haemophilia 2021; 27:e704-e712. [PMID: 34590394 PMCID: PMC9291471 DOI: 10.1111/hae.14416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 08/04/2021] [Accepted: 09/06/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Recombinant coagulation factor VIII (FVIII) products are the standard of care for patients with haemophilia A. The development of modified FVIII products has provided benefit for patients but presented challenges for monitoring FVIII activity. AIM This single-centre study evaluated the Roche FVIII one-stage clotting assay (OSA) in measuring FVIII activity in plasma samples spiked with seven FVIII products at clinically relevant concentrations. METHODS FVIII-deficient plasma samples were spiked with two batches of recombinant FVIII products (octocog alfa, moroctocog alfa, simoctocog alfa, efmoroctocog alfa, damoctocog alfa pegol, rurioctocog alfa pegol, lonoctocog alfa) at 1-120 IU/dL FVIII activity, according to their labelled potency. Measurement was conducted on the cobas t 511/711 analysers using the Roche FVIII OSA and the Technoclone TECHNOCHROM FVIII:C chromogenic substrate assay (CSA). RESULTS Using the OSA, FVIII activity was close to labelled potency for most analysed FVIII products including a recombinant FVIII Fc fusion protein. PEGylated FVIII product, damoctocog alfa pegol, was marginally above and single-chain product, lonoctocog alfa, below the predefined acceptance criteria: for FVIII activity < 25 IU/dL: ± 5 IU/dL; for FVIII activity ≥ 25 IU/dL: ± 20% (relative). The different principles of OSA and CSA led to discrepancies in the estimation of all analysed FVIII products. Additionally, in vitro recovery was increased at lower levels of FVIII activity using the OSA, whereas recovery was more consistent using the CSA. CONCLUSION These data allow the interpretation of FVIII activity results for different FVIII products using the Roche FVIII OSA on the cobas t 511/711 analysers.
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Affiliation(s)
| | | | - Simon Davidson
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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14
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Megías-Vericat JE, Bonanad S, Haya S, Cid AR, Marqués MR, Ferrada A, Monte-Boquet E, Pérez-Alenda S, Bosch P, Querol-Giner F, Poveda JL. Clinical benefits of a Bayesian model for plasma-derived factor VIII/VWF after one year of pharmacokinetic-guided prophylaxis in severe/moderate hemophilia A patients. Thromb Res 2021; 205:99-105. [PMID: 34293540 DOI: 10.1016/j.thromres.2021.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/05/2021] [Accepted: 07/12/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Individual pharmacokinetic (PK) profiling in hemophilia A (HA) helps to individualize prophylaxis using population PK models (popPK). A specific popPK model for plasma-derived factor VIII containing von-Willebrand Factor (pdFVIII/VWF) was developed. AIM To compare standard versus PK-driven prophylaxis, using a generic or a specific popPK model for pdFVIII/VWF. MATERIALS AND METHODS A prospective study conducted in HA patients in prophylaxis with pdFVIII/VWF (Fanhdi®) comparing three one-year study periods: (1) standard prophylaxis, (2) PK-guided prophylaxis using a generic pdFVIII popPK model which described FVIII activity irrespective of FVIII concentrate, and (3) PK-guided prophylaxis with specific pdFVIII/VWF popPK model. PK parameters analyzed were half-life, trough levels (TL) at 24, 48 and 72 h, and time to reach FVIII levels of 1, 2, 5% (T5%). Clinical outcomes were dose/kg, FVIII consumption, annualized bleeding rate (ABR), annualized joint bleeding rate (AJBR), spontaneous and traumatic bleeds. RESULTS Of the 30 analyzed patients, 28 had severe HA and the median age was 31.2. Fifteen patient's prophylaxis doses were PK-adjusted. After the generic PK-guided prophylaxis period, younger patients showed more joint bleeds, a shorter half-life, and lower TL48, TL72 and T5%. Using the specific pdFVIII/VWF popPK model compared with standard prophylaxis, a lower spontaneous AJBR was observed in the entire cohort and in patients aged >15 years. Additionally, lower spontaneous ABR was reported in patients aged ≤15 years comparing specific and generic models. CONCLUSIONS PK-guided prophylaxis with a specific pdFVIII/VWF popPK model allowed treatment individualization and improved bleeding control in routine clinical practice, especially in younger patients with short pdFVIII/VWF half-lives.
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Affiliation(s)
- Juan Eduardo Megías-Vericat
- Hospital Universitari i Politècnic La Fe, Pharmacy Department, Valencia, Spain; Hospital Universitari i Politècnic La Fe, Haemostasis and Thrombosis Unit, Valencia, Spain.
| | - Santiago Bonanad
- Hospital Universitari i Politècnic La Fe, Haemostasis and Thrombosis Unit, Valencia, Spain
| | - Saturnino Haya
- Hospital Universitari i Politècnic La Fe, Haemostasis and Thrombosis Unit, Valencia, Spain
| | - Ana Rosa Cid
- Hospital Universitari i Politècnic La Fe, Haemostasis and Thrombosis Unit, Valencia, Spain
| | | | - Alejandra Ferrada
- Hospital Universitari i Politècnic La Fe, Pharmacy Department, Valencia, Spain
| | - Emilio Monte-Boquet
- Hospital Universitari i Politècnic La Fe, Pharmacy Department, Valencia, Spain
| | - Sofía Pérez-Alenda
- Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), Department of Physiotherapy, University of Valencia
| | - Pau Bosch
- Hospital Universitari i Politècnic La Fe, Haemostasis and Thrombosis Unit, Valencia, Spain
| | - Felipe Querol-Giner
- Physiotherapy in Motion Multispeciality Research Group (PTinMOTION), Department of Physiotherapy, University of Valencia
| | - Jose Luis Poveda
- Hospital Universitari i Politècnic La Fe, Pharmacy Department, Valencia, Spain
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15
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Huang K, Zhen Y, Li G, Wu X, Chen Z, Wu R. Pharmacokinetic-guided prophylaxis improved clinical outcomes in paediatric patients with severe haemophilia A. Haemophilia 2021; 27:e450-e457. [PMID: 34015176 DOI: 10.1111/hae.14336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/22/2021] [Accepted: 04/29/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND The traditional weight-based dosing regimen can lead to under- or overdosage due to the interindividual variability of pharmacokinetic (PK) parameters. PK-guided prophylaxis can be an optimized therapy choice. AIM This study aimed to investigate the clinical outcomes of PK-guided prophylaxis in 46 boys with severe haemophilia A. METHODS Forty-six boys with severe haemophilia A were enrolled in Beijing Children's Hospital. The PK tests were performed using a five-point assay. PK parameters were calculated using WinNonlin software. The dosing regimen and bleeding rates recorded during the observation period. The adjustment was based on PK evaluation, bleeding details, doctor's advice and patients' choice. RESULTS The half-life time, in vivo recovery and clearance of Kovaltry were 14.34 ± 2.68 h, 1.78 ± 0.29 kg/dl and 3.38 ± 0.94 ml/kg/h, respectively. In 18 patients without any change in the dosing regimen, the trough level was 4.0 ± 2.41 IU/dl and the bleeding rates were similar after PK tests. For patients with a higher trough level after adjustment, higher dose and frequency were observed, as well as a higher trough level. Also, reduced annual bleeding rate (ABR), annual joint bleeding rate and annual spontaneous bleeding rate (ASBR) were found. In five patients with a reduced trough level, lower infusion frequency and weekly coagulation factor VIII (FVIII) consumption were observed, with no statistically significant difference in ABR and ASBR. CONCLUSION PK-guided prophylaxis can help haemophiliac patients improve quality of life by decreasing bleeds with appropriate FVIII consumption and reducing infusion frequency without increments in bleeds, thus optimizing haemophilia treatment.
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Affiliation(s)
- Kun Huang
- Hematology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.,Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yingzi Zhen
- Hematology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.,Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Gang Li
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.,Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xinyi Wu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.,Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Zhenping Chen
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.,Hematologic Disease Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Runhui Wu
- Hematology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China.,Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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16
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Arvanitakis A, Berntorp E, Astermark J. A comparison of MyPKFiT and WAPPS-Hemo as dosing tools for optimizing prophylaxis in patients with severe haemophilia A treated with Octocog alfa. Haemophilia 2021; 27:417-424. [PMID: 33751755 DOI: 10.1111/hae.14295] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 01/18/2023]
Abstract
INTRODUCTION MyPKFiT and the Web-Accessible Population Pharmacokinetic service-Hemophilia (WAPPS-Hemo) are web-based population-based applications developed for helping physicians individualize and optimize replacement therapy. Although MyPKFiT is intended for Octocog alfa and Rurioctocog alfa pegol use only, the WAPPS-Hemo is applicable to all factor VIII concentrates. AIM To compare MyPKFiT and WAPPS-Hemo as dosing tools for optimizing treatment of patients with severe haemophilia A on regular prophylaxis with Octocog alfa in a real-world setting. METHODS Fourteen patients with severe haemophilia A (median age 30.8 years; range 20-71) were enrolled. The FVIII activity was measured twice after a regular dose of Octocog alfa by the chromogenic and the one-stage assays. PK analyses were performed using each tool and dosing estimations to reach trough levels of 1%, 3% or 5% after 48 h. Findings were calculated and compared. RESULTS The two PK algorithms yielded similar t½ independent of the type of FVIII assay used. However, there were significant differences in the time to reach 1%, 3% and 5%. The WAPPS-Hemo generated 10-12 h longer time to a trough of 1% and up to 4 h for the troughs of 3% and 5%. Accordingly, the doses estimated by WAPPS-Hemo for a daily regimen were between 28% and 100% of those proposed by MyPKFiT. CONCLUSIONS MyPKFiT and WAPPS-Hemo provided similar half-life estimations for Octocog alfa independent of the FVIII assay used. The doses suggested by WAPPS-Hemo to reach specific troughs were overall lower, which may have implications for treatment optimization.
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Affiliation(s)
- Alexandros Arvanitakis
- Department of Translational Medicine, Lund University, Malmö, Sweden.,Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
| | - Erik Berntorp
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Jan Astermark
- Department of Translational Medicine, Lund University, Malmö, Sweden.,Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
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17
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Chen Z, Huang K, Li G, Zhen Y, Wu X, Di A, Liu G, Li Z, Alfonso I, Wu R. Pharmacokinetic variability of factor VIII concentrates in Chinese pediatric patients with moderate or severe hemophilia A. Pediatr Investig 2021; 5:38-45. [PMID: 33778426 PMCID: PMC7983998 DOI: 10.1002/ped4.12252] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 06/12/2020] [Indexed: 11/11/2022] Open
Abstract
IMPORTANCE The use of factor VIII (FVIII) concentrates under pharmacokinetic (PK) guidance has become the main approach for treatment of hemophilia. However, limited PK research has been conducted in Chinese pediatric patients. OBJECTIVE To investigate the PK parameters of various FVIII concentrates in Chinese pediatric patients. METHODS Seventy-nine patients were enrolled (28 treated with Kogenate FS®, 23 treated with Advate ®, and 28 treated with GreenMono™). All enrolled patients participated in single-dose PK analysis after at least a 3-day washout period. Blood samples were collected predose, as well as at 1 h, 9 h, 24 h, and 48 h after infusion; FVIII levels were measured using a one-stage clotting assay. von Willebrand Factor Antigen (VWF:Ag) levels and blood types were also determined. PK parameters were evaluated by WAPPS-Hemo. RESULTS Mean values of terminal elimination half-life time (t1/2) for the Kogenate FS®, Advate®, and GreenMono™ FVIII groups were 12.24 h, 10.18 h, and 9.62 h; median clearance values were 4.16, 6.23, and 5.11 mL·kg-1·h-1; and median in vivo recovery values were 1.97, 1.55, and 1.61 IU/dL per IU/kg. Longer t1/2, higher in vivo recovery, and lower clearance were observed in patients with higher VWF:Ag level who were treated with recombinant concentrates. INTERPRETATION Chinese pediatric patients with hemophilia had FVIII PK characteristics similar to those previously observed in non-Chinese children, including large variation among individuals. VWF:Ag level and FVIII brand were associated with differences in FVIII PK. Thus, PK-guided dosing should be used to optimize individualized therapy in Chinese children.
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Affiliation(s)
- Zhenping Chen
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of PediatricsMinistry of EducationHematology Oncology CenterBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Kun Huang
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of PediatricsMinistry of EducationHematology Oncology CenterBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Gang Li
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of PediatricsMinistry of EducationHematology Oncology CenterBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Yingzi Zhen
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of PediatricsMinistry of EducationHematology Oncology CenterBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Xinyi Wu
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of PediatricsMinistry of EducationHematology Oncology CenterBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Ai Di
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of PediatricsMinistry of EducationHematology Oncology CenterBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Guoqing Liu
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of PediatricsMinistry of EducationHematology Oncology CenterBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Zekun Li
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of PediatricsMinistry of EducationHematology Oncology CenterBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
| | - Iorio Alfonso
- Clinical Epidemiology and BiostatisticsMcMaster UniversityHamiltonONCanada
| | - Runhui Wu
- Beijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of PediatricsMinistry of EducationHematology Oncology CenterBeijing Children’s HospitalCapital Medical UniversityNational Center for Children’s HealthBeijingChina
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18
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Teitel J, Sholzberg M, Iorio A. Extended half-life factor VIII concentrates in adults with hemophilia A: Comparative pharmacokinetics of two products. Res Pract Thromb Haemost 2021; 5:349-355. [PMID: 33733034 PMCID: PMC7938611 DOI: 10.1002/rth2.12476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/16/2020] [Accepted: 11/24/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The use of pharmacokinetic (PK) studies to help design personalized prophylaxis regimens for factor VIII (FVIII) concentrate in individuals with hemophilia A has been recognized for many years but only became practical for routine clinical use with the availability of web-accessible population PK applications based on Bayesian analysis. OBJECTIVE To compare PK variables using population PK studies done on 2 extended half-life recombinant FVIII concentrates in 23 individuals with hemophilia A after switching from one product to the other. METHODS We retrospectively analyzed PK parameters derived from the Web-Accessible Population Pharmacokinetic Service-Hemophilia (WAPPS-HEMO) application on 23 individuals with severe or moderately severe hemophilia A who were required to switch from recombinant FVIII Fc (Eloctate; Biogen, Cambridge, MA, USA) to recombinant antihemophilic factor PEGylated (Adynovate; Takeda Pharmaceutical Company, Osaka, Japan) between 2016 and 2017. RESULTS There were minor PK differences between Eloctate and Adynovate, but some parameters did reach statistical significance, namely in vivo recovery (mean, 2.73 IU/dL per IU/kg vs 2.41 IU/dL per IU/kg), clearance (mean, 0.163 mL/h vs 0.194 mL/h), and volume of distribution at steady state (mean, 42.5 ml/kg vs 49.8 mL/kg). Smaller nonsignificant trends toward higher values for Adynovate were seen in terminal half-life, area under the curve, and predicted times to 5% and 1% residual FVIII after infusion. CONCLUSION Population PK analysis revealed differences between the two extended half-life FVIII concentrates, reaching significance for in vivo recovery, clearance, and volume of distribution.
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Affiliation(s)
- Jerome Teitel
- Department of MedicineSt. Michael’s HospitalUniversity of TorontoTorontoONCanada
| | - Michelle Sholzberg
- Departments of Medicine and Laboratory Medicine and PathobiologySt. Michael’s HospitalUniversity of TorontoTorontoONCanada
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence, and ImpactMcMaster UniversityTorontoONCanada
- Hemophilia Treatment CentreSt. Michael’s HospitalTorontoONCanada
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19
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ADHERENCE TO PROPHYLAXIS IN RELATION TO QUALITY OF LIFE AND ANXIETY LEVEL IN TURKISH PATIENTS WITH SEVERE HAEMOPHILIA A. INTERNATIONAL JOURNAL OF HEALTH SERVICES RESEARCH AND POLICY 2020. [DOI: 10.33457/ijhsrp.738665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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20
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Hermans C, Dolan G. Pharmacokinetics in routine haemophilia clinical practice: rationale and modalities-a practical review. Ther Adv Hematol 2020; 11:2040620720966888. [PMID: 33194165 PMCID: PMC7594230 DOI: 10.1177/2040620720966888] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 09/24/2020] [Indexed: 01/19/2023] Open
Abstract
Prophylactic therapy with exogenous clotting factor concentrates in haemophilia A
and B aims to achieve levels of circulating FVIII or FIX that are adequate for
the prevention or reduction of spontaneous joint bleeding. Historically, a
minimum trough level of at least 1% of the normal levels of circulating clotting
factor has been targeted using standardised protocols. However, clearance of
clotting factor varies between products and patients, and other pharmacokinetic
(PK) parameters such as the frequency and magnitude of peaks may be important
for ensuring optimal coverage. Thus, it is increasingly recognised that an
individualised, PK-based approach to prophylaxis is necessary to achieve optimal
protection. This review focuses on the clinical implications of using PK-guided,
individualised prophylaxis in haemophilia to improve patient outcomes and
considers practical methods of establishing patients’ PK parameters. The most
useful PK parameters will depend on the aim of the specific treatment (e.g.
preventing activity-related and traumatic bleeds or addressing subclinical
bleeding). In clinical practice, lengthy and frequent post-infusion sampling for
PK analysis is costly and a significant burden for patients. However, a Bayesian
analysis allows for the estimation of different PK parameters (e.g. half-life,
factor concentrations over time, etc.) with only a minimum number of samples
(e.g. 4, 24 and 48 h for haemophilia A), by using the patient’s data to adjust a
relevant population PK value towards the actual value. Numerous tools are
available to aid in the practical use of Bayesian PK-guided dosing in the
clinic, including the Web-based Application for the Population Pharmacokinetic
Service hosted by McMaster University, Canada. The PK data can be used to
determine the appropriate prophylaxis regimen for the individual patient, which
can be monitored by assessment of the trough level at each clinic visit. Collection of PK data and subsequent PK-guided dosing should become standard
practice when determining treatment strategies for people with haemophilia.
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Affiliation(s)
- Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Adult Haematology, St-Luc University Hospital, Université catholique de Louvain (UCLouvain), Avenue Hippocrate 10, Brussels, 1200, Belgium
| | - Gerry Dolan
- Haemophilia and Thrombosis Centre, St Thomas' Hospital, London, UK
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21
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Real Life Population Pharmacokinetics Modelling of Eight Factors VIII in Patients with Severe Haemophilia A: Is It Always Relevant to Switch to an Extended Half-Life? Pharmaceutics 2020; 12:pharmaceutics12040380. [PMID: 32326156 PMCID: PMC7238177 DOI: 10.3390/pharmaceutics12040380] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/10/2020] [Accepted: 04/17/2020] [Indexed: 01/19/2023] Open
Abstract
We retrospectively analysed the data files of 171 adults and 87 children/adolescents with severe haemophilia, except for 14 patients (moderate; minor) (1), to develop a global population pharmacokinetic (PK) model for eight factors VIII (FVIII) that could estimate individual PK parameters for targeting the desired level of FVIII activity (FVIII:C); and (2) to compare half-life (HL) in patients switching from a standard half-life (SHL) to an extended half-life (EHL) and evaluate the relevance of the switch. One-stage clotting assay for the measurement of FVIII activity (FVIII:C, IU/mL) was used for population PK modelling. The software, Monolix version 2019R1, was used for non-linear mixed-effects modelling. A linear two-compartment model best described FVIII:C. The estimated PK parameters (between-subject variability) were: 2640 mL (23.2%) for volume of central compartment (V1), 339 mL (46.8%) for volume of peripheral compartment (V2), 135 mL/h for Q (fixed random effect), and 204 mL/h (34.9%) for clearance (Cl). Weight, age, and categorical covariate EHL were found to influence Cl and only weight for V1. This model can be used for all of the FVIII cited in the study. Moreover, we demonstrated, in accordance with previous studies, that Elocta had longer half-life (EHL) than SHL (mean ratio: 1.48) as compared to Advate, Factane, Kogenate, Novoeight, and Refacto.
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22
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Patel AM, Corman SL, Chaplin S, Raimundo K, Sidonio RF. Economic impact model of delayed inhibitor development in patients with hemophilia a receiving emicizumab for the prevention of bleeding events. J Med Econ 2019; 22:1328-1337. [PMID: 31530050 DOI: 10.1080/13696998.2019.1669614] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Aims: Cumulative exogenous factor VIII (FVIII) exposure is an important predictor of developing neutralizing antibodies (inhibitors) to FVIII in patients with persons with hemophilia A (PwHA). The aim of this study was to model the costs of emicizumab versus FVIII prophylaxis and total treatment costs for patients with severe HA.Materials and Methods: An Excel-based decision model was developed to calculate cumulative costs in PwHA over a 20-year time horizon from the US payer perspective. The model considered persons with severe HA beginning at age 12 months with no prior FVIII exposure and initiating prophylaxis with emicizumab or FVIII. PwHA could develop inhibitors on accumulation of 20 FVIII exposure days. PwHA with inhibitors replaced FVIII with bypassing agents until inhibitors resolved spontaneously, following immune tolerance induction (ITI), or at the end of the time horizon. The primary model outcome was the difference in emicizumab versus FVIII treatment costs in 2019 USD. Sensitivity analyses were performed to test the robustness of results.Results: Total incremental cost over 20 years was -$1,945,480 (emicizumab arm, $4,919,058; FVIII arm, $6,864,538). Prophylaxis costs (emicizumab arm, $4,096,105; FVIII arm, $6,290,919) comprised the majority of costs in both groups, followed by breakthrough bleed treatment for the FVIII arm ($342,652) and ITI costs for the emicizumab arm ($733,671). Higher costs in the FVIII group reflected earlier inhibitor development (FVIII, 4 months; emicizumab, 162 months) and switch to bypassing agents.Limitations: The model design reflects a simplified treatment pathway for patients with severe HA who initiate FVIII or emicizumab prophylaxis. In the absence of clinical data, a key conservative assumption of the model is that patients receiving emicizumab and FVIII prophylaxis have the same risk of developing inhibitors.Conclusions: This study suggests that prophylaxis with emicizumab results in cost savings compared to FVIII prophylaxis in HA.
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MESH Headings
- Antibodies, Bispecific/economics
- Antibodies, Bispecific/immunology
- Antibodies, Bispecific/therapeutic use
- Antibodies, Monoclonal, Humanized/economics
- Antibodies, Monoclonal, Humanized/immunology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Coagulants/administration & dosage
- Coagulants/immunology
- Coagulants/therapeutic use
- Factor VIII/administration & dosage
- Factor VIII/immunology
- Factor VIII/therapeutic use
- Hemophilia A/drug therapy
- Hemorrhage/prevention & control
- Humans
- Models, Economic
- Severity of Illness Index
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Affiliation(s)
| | | | | | | | - Robert F Sidonio
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, GA, USA
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23
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Savings without changing: How to use the MyPKfit® device to improve treatment strategies in a cohort of patients with haemophilia A. Thromb Res 2019; 183:1-3. [DOI: 10.1016/j.thromres.2019.08.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/02/2019] [Accepted: 08/24/2019] [Indexed: 01/19/2023]
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24
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Abrantes JA, Solms A, Garmann D, Nielsen EI, Jönsson S, Karlsson MO. Bayesian Forecasting Utilizing Bleeding Information to Support Dose Individualization of Factor VIII. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2019; 8:894-903. [PMID: 31668021 PMCID: PMC6930854 DOI: 10.1002/psp4.12464] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/08/2019] [Indexed: 01/19/2023]
Abstract
Bayesian forecasting for dose individualization of prophylactic factor VIII replacement therapy using pharmacokinetic samples is challenged by large interindividual variability in the bleeding risk. A pharmacokinetic‐repeated time‐to‐event model‐based forecasting approach was developed to contrast the ability to predict the future occurrence of bleeds based on individual (i) pharmacokinetic, (ii) bleeding, and (iii) pharmacokinetic, bleeding and covariate information using observed data from the Long‐Term Efficacy Open‐Label Program in Severe Hemophilia A Disease (LEOPOLD) clinical trials (172 severe hemophilia A patients taking prophylactic treatment). The predictive performance assessed by the area under receiver operating characteristic (ROC) curves was 0.67 (95% confidence interval (CI), 0.65–0.69), 0.78 (95% CI, 0.76–0.80), and 0.79 (95% CI, 0.77–0.81) for patients ≥ 12 years when using pharmacokinetics, bleeds, and all data, respectively, suggesting that individual bleed information adds value to the optimization of prophylactic dosing regimens in severe hemophilia A. Further steps to optimize the proposed tool for factor VIII dose adaptation in the clinic are required.
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Affiliation(s)
- João A Abrantes
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | | | | | - Elisabet I Nielsen
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Siv Jönsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
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25
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Megías‐Vericat JE, Bonanad S, Haya S, Cid AR, Marqués MR, Monte‐Boquet E, Pérez‐Alenda S, Bosch P, Querol F, Poveda JL. Cross‐sectional comparative study of pharmacokinetics and efficacy between sucrose‐formulated recombinant factor VIII (Kogenate
®
) and BAY 81‐8973 (Kovaltry
®
) in patients with severe or moderate haemophilia A in prophylaxis. Haemophilia 2019; 25:e215-e218. [DOI: 10.1111/hae.13733] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 02/19/2019] [Accepted: 02/19/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Juan Eduardo Megías‐Vericat
- Pharmacy Department, Drug Clinical Area Hospital Universitari i Politècnic La Fe Valencia Spain
- Haemostasis and Thrombosis Unit Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Santiago Bonanad
- Haemostasis and Thrombosis Unit Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Saturnino Haya
- Haemostasis and Thrombosis Unit Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Ana Rosa Cid
- Haemostasis and Thrombosis Unit Hospital Universitari i Politècnic La Fe Valencia Spain
| | - María Remedios Marqués
- Pharmacy Department, Drug Clinical Area Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Emilio Monte‐Boquet
- Pharmacy Department, Drug Clinical Area Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Sofía Pérez‐Alenda
- Haemostasis and Thrombosis Unit Hospital Universitari i Politècnic La Fe Valencia Spain
- Department of Physiotherapy University of Valencia Valencia Spain
| | - Pau Bosch
- Haemostasis and Thrombosis Unit Hospital Universitari i Politècnic La Fe Valencia Spain
| | - Felipe Querol
- Haemostasis and Thrombosis Unit Hospital Universitari i Politècnic La Fe Valencia Spain
- Department of Physiotherapy University of Valencia Valencia Spain
| | - José Luis Poveda
- Pharmacy Department, Drug Clinical Area Hospital Universitari i Politècnic La Fe Valencia Spain
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