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Gómez-Moreno G, Cutando-Soriano A, Arana C, Scully C. Hereditary Blood Coagulation Disorders: Management and Dental Treatment. J Dent Res 2016; 84:978-85. [PMID: 16246926 DOI: 10.1177/154405910508401102] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Patients with hereditary hemostatic disorders, characterized by a tendency to bleeding or thrombosis, constitute a serious challenge in the dental practice. Advances in the medical diagnosis of hemostatic disorders have exposed dental professionals to new patients not amenable to the application of the management protocols associated with other, more well-known, disorders. It is the aim of this paper to review the evidence, to highlight the areas of major concern, and to suggest management regimens for patients with hereditary hemostatic disorders. An extensive review has been made (PubMed, Science Direct, Web of Knowledge, etc.) of literature pertaining to hereditary disorders affecting blood coagulation factors and how they affect the practice of dentistry. Several aspects relating to the care of such patients must be recognized and taken into consideration when dental treatment is planned. Replacement of deficient coagulation factors ensures that safe dental treatment will be carried out. However, the half-life of such coagulation factors requires that dental treatment be specifically planned and adapted to the type of pathology involved.
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Affiliation(s)
- G Gómez-Moreno
- Department of Special Care in Dentistry, School of Dentistry, University of Granada, Colegio Máximo s/n, Campus de Cartuja, E-18071 Granada, Spain
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Aledort LM. The evolution of comprehensive haemophilia care in the United States: perspectives from the frontline. Haemophilia 2016; 22:676-83. [PMID: 27354149 DOI: 10.1111/hae.12970] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2016] [Indexed: 12/19/2022]
Abstract
The establishment of dedicated comprehensive treatment centres more than a half century ago transformed the management of haemophilia in the United States. Formerly, a disease associated with crippling disability and premature death, today, persons with haemophilia who are treated appropriately from infancy and do not develop inhibitors can expect a normal life expectancy and relatively few bleeding episodes. The evolution of the comprehensive haemophilia care, while chastened by the viral epidemics of the 1980s, has been marked by ongoing advances, including prophylaxis, immune tolerance induction, new drugs and gene therapy research. Current challenges include sustaining the comprehensive care model despite decreased funding and expanding the delivery and affordability of comprehensive haemophilia care.
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Affiliation(s)
- L M Aledort
- Mount Sinai School of Medicine, New York, NY, USA.
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Leissinger CA. Advances in the clinical management of inhibitors in hemophilia A and B. Semin Hematol 2015; 53:20-7. [PMID: 26805903 DOI: 10.1053/j.seminhematol.2015.10.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2004] [Revised: 11/05/2004] [Accepted: 12/01/2005] [Indexed: 01/25/2023]
Abstract
Inhibitors to factor (F)VIII or FIX are the most serious and challenging complication of hemophilia treatment, increasing morbidity and mortality because bleeds no longer respond to standard clotting factor replacement therapy. For patients with high-titer inhibitors, immune tolerance induction achieved through regular factor exposure is the only proven therapy capable of Inhibitor eradication and is almost always indicated for inhibitors of recent onset. Bypassing therapy is used to treat and prevent bleeding, but neither of the two currently available bypassing agents has the predictable hemostatic efficacy of factor replacement in hemophilia patients without inhibitors. Major research efforts are focused on the development of new, more potent therapies for the management of patients with inhibitors.
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Affiliation(s)
- Cindy A Leissinger
- Departments of Medicine, Pediatrics, and Pathology, Tulane University School of Medicine, New Orleans, LA, USA.
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How I use bypassing therapy for prophylaxis in patients with hemophilia A and inhibitors. Blood 2015; 126:153-9. [DOI: 10.1182/blood-2014-10-551952] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 03/25/2015] [Indexed: 11/20/2022] Open
Abstract
Abstract
Inhibitor development poses a significant challenge in the management of hemophilia because once an inhibitor is present, bleeding episodes can no longer be treated with standard clotting factor replacement therapy. Consequently, patients with inhibitors are at increased risk for difficult-to-control bleeding and complications, particularly arthropathy and physical disability. Three clinical trials in patients with inhibitors have demonstrated that prophylaxis with a bypassing agent reduces joint and other types of bleeding and improves health-related quality of life compared with on-demand bypassing therapy. In hemophilia patients without inhibitors, the initiation of prophylaxis with factor (F) VIII or FIX prior to the onset of recurrent hemarthroses can prevent the development of joint disease. Whether this is also true for bypassing agent prophylaxis remains to be determined.
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Nayak S, Lee D, Patel-Hett S, Pittman DD, Martin SW, Heatherington AC, Vicini P, Hua F. Using a Systems Pharmacology Model of the Blood Coagulation Network to Predict the Effects of Various Therapies on Biomarkers. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2015; 4:396-405. [PMID: 26312163 PMCID: PMC4544053 DOI: 10.1002/psp4.50] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 04/23/2015] [Indexed: 01/09/2023]
Abstract
A number of therapeutics have been developed or are under development aiming to modulate the coagulation network to treat various diseases. We used a systems model to better understand the effect of modulating various components on blood coagulation. A computational model of the coagulation network was built to match in-house in vitro thrombin generation and activated Partial Thromboplastin Time (aPTT) data with various concentrations of recombinant factor VIIa (FVIIa) or factor Xa added to normal human plasma or factor VIII-deficient plasma. Sensitivity analysis applied to the model revealed that lag time, peak thrombin concentration, area under the curve (AUC) of the thrombin generation profile, and aPTT show different sensitivity to changes in coagulation factors' concentrations and type of plasma used (normal or factor VIII-deficient). We also used the model to explore how variability in concentrations of the proteins in coagulation network can impact the response to FVIIa treatment.
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Affiliation(s)
- S Nayak
- Pharmacometrics, Global Innovative Pharma Business (GIPB), Pfizer Inc. Cambridge, Massachusetts, USA
| | - D Lee
- Quantitative Clinical Sciences, PharmaTherapeutics Clinical R&D, Pfizer Inc. Cambridge, Massachusetts, USA
| | - S Patel-Hett
- Rare Disease Research Unit Pfizer Inc. Cambridge, Massachusetts, USA
| | - D D Pittman
- Rare Disease Research Unit Pfizer Inc. Cambridge, Massachusetts, USA
| | - S W Martin
- Pharmacometrics, Global Innovative Pharma Business (GIPB), Pfizer Inc. Cambridge, Massachusetts, USA
| | - A C Heatherington
- Quantitative Clinical Sciences, PharmaTherapeutics Clinical R&D, Pfizer Inc. Cambridge, Massachusetts, USA
| | - P Vicini
- Pharmacokinetics, Dynamics and Metabolism, New Biological Entities, Pfizer Inc. Cambridge, Massachusetts, USA
| | - F Hua
- Quantitative Clinical Sciences, PharmaTherapeutics Clinical R&D, Pfizer Inc. Cambridge, Massachusetts, USA
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Villarrubia R, Oyagüez I, Álvarez-Román MT, Mingot-Castellano ME, Parra R, Casado MA. Cost analysis of prophylaxis with activated prothrombin complex concentrate vs. on-demand therapy with activated factor VII in severe haemophilia A patients with inhibitors, in Spain. Haemophilia 2015; 21:320-329. [DOI: 10.1111/hae.12681] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2015] [Indexed: 11/29/2022]
Affiliation(s)
- R. Villarrubia
- Pharmacoeconomics & Outcomes Research Iberia; Madrid Spain
| | - I. Oyagüez
- Pharmacoeconomics & Outcomes Research Iberia; Madrid Spain
| | | | | | - R. Parra
- Vall d'Hebron University Hospital; Barcelona Spain
| | - M. A. Casado
- Pharmacoeconomics & Outcomes Research Iberia; Madrid Spain
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Golestani M, Eshghi P, Rasekh HR, Cheraghali AM, Salamzadeh J, Imani A. Comparison of bypassing agents in bleeding reduction in treatment of bleeding episodes in patients with haemophilia and inhibitors. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 16:e24551. [PMID: 25763245 PMCID: PMC4341353 DOI: 10.5812/ircmj.24551] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 11/16/2014] [Accepted: 11/17/2014] [Indexed: 11/16/2022]
Abstract
CONTEXT Mild-to-moderate bleeding disorders in haemophilia are primarily treated via recombinant activated factor VII a (rFVIIa) or activated prothrombin complex concentrate (aPCC). However, the efficacy of each bypassing agents may vary and none of them is universally effective. EVIDENCE ACQUISITION After reviewing the databases of PubMed, Scopus, MD Consult, Ovid, Trip database, Google Scholar, ProQuest and the Cochrane Library, finally, 17 papers published from 2000 to 2013 were extracted. We used as a random effect model in meta-analysis. Comprehensive meta-analysis (CMA) software was used for calculating and estimating the mean of bleeding reduction and performing meta-analysis. RESULTS The mean of bleeding reduction in aPCC and rFVIIa were 71.2% with CI 95% (lower limit 86.8% and upper limit 82%) and 72.3% with CI 95% (lower limit 57.6% and upper limit 83.4%), respectively. CONCLUSIONS Although differences between the two products were very close to each other, they reported similar effects on joint bleeds. Further clinical studies should be performed by incorporating a standardized measurement in comparative efficacy of aPCC and rFVIIa.
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Affiliation(s)
- Mina Golestani
- School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Mina Golestani, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran. Tel: +98-9125160488, Fax: +98-4133351048, E-mail:
| | - Peyman Eshghi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Hamid Reza Rasekh
- School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | | | - Jamshid Salamzadeh
- School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Ali Imani
- Iranian Center of Excellence in Health Management, Faculty of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, IR Iran
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Ewing N, Escuriola‐Ettingshausen C, Kreuz W. Prophylaxis with FEIBA in paediatric patients with haemophilia A and inhibitors. Haemophilia 2015; 21:358-364. [DOI: 10.1111/hae.12602] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2014] [Indexed: 11/28/2022]
Affiliation(s)
- N. Ewing
- City of Hope National Medical Center Duarte CA USA
| | | | - W. Kreuz
- HZRM ‐ Hemophilia Centre Rhein Main Moerfelden‐Waldorf Germany
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Faranoush M, Abolghasemi H, Mahboudi F, Toogeh G, Karimi M, Eshghi P, Managhchi M, Hoorfar H, Dehdezi BK, Mehrvar A, khoeiny B, Vaziri B, Kamyar K, Heshmat R, Baghaeipour MR, Mirbehbahani NB, Fayazfar R, Ahmadinejad M, Naderi M. A Comparison of Efficacy Between Recombinant Activated Factor VII (Aryoseven) and Novoseven in Patients With Hereditary FVIII Deficiency With Inhibitor. Clin Appl Thromb Hemost 2014; 22:184-90. [DOI: 10.1177/1076029614555902] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Introduction: This study compared the efficacy of Aryoseven with Novoseven to control bleeding episodes in patients with hemophilia A with inhibitors. Methods: Sixty-six patients were randomized into 2 groups, with 4 consecutive block randomization. These groups received Aryoseven and Novoseven dosages of 90 to 120 μg/kg intravenously every 2 hours. Results: Median (interquartile range) level of factor VIII (FVIII) inhibitor in groups A and B was 15.0 and 19.0 Bethesda Unit (BU) preadministration. Bleeding onset in group A was 1246 ± 1104 minutes and in group B was 2301 ± 1693 minutes ( P = .311). The Kavakli global response scores and treatment success rate was comparable in both the groups. The side effects in groups A (9.7%) and B (2.9%) were comparable. Conclusion: Biosimilar recombinant activated FVII is found to be as effective as Novoseven in the treatment of acute joint bleeding in patients with hemophilia with inhibitors. Its usage will decrease the gaps in hemophilia.
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Affiliation(s)
- M. Faranoush
- Iran university of Medical Sciences, Rasool Akram Hospital, Tehran, Iran
| | - H. Abolghasemi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - F. Mahboudi
- Biotechnology Research Center, Pasteur Institute of Iran, Tehran Iran
| | - Gh. Toogeh
- Thrombosis and Hemostasis Research Center, Tehran University of Medical Sciences, Imam Khomeini Hospital, Tehran, Iran
| | - M. Karimi
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - P. Eshghi
- Pediatric Congenital Hematologic Disorders Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M. Managhchi
- Thrombosis and Hemostasis Research Center, Tehran University of Medical Sciences, Imam Khomeini Hospital, Tehran, Iran
| | - H. Hoorfar
- Isfahan University of Medical Sciences, Isfahan, Iran
| | | | | | | | - B. Vaziri
- Biotechnology Research Center, Pasteur Institute of Iran, Tehran Iran
| | - K. Kamyar
- Aryogen Zist Darou Company, Karaj, Iran
| | - R. Heshmat
- Thrombosis and Hemostasis Research Center, Tehran University of Medical Sciences, Imam Khomeini Hospital, Tehran, Iran
| | | | | | - R. Fayazfar
- MD, Kerman University of Medical Sciences, Kerman, Iran
| | - M. Ahmadinejad
- High Institute of Research, Iranian Blood Transfusion Organization, Tehran, Iran
| | - M. Naderi
- Zahedan University of Medical Sciences, Ahwaz, Iran
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Teitel JM, Sholzberg M. Current status and future prospects for the prophylactic management of hemophilia patients with inhibitor antibodies. Blood Rev 2013; 27:103-9. [DOI: 10.1016/j.blre.2013.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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2013 revised edition : hemostatic treatment guidelines for inhibitors possess congenital hemophilia patients. ACTA ACUST UNITED AC 2013. [DOI: 10.2491/jjsth.24.640] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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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. CLINICOECONOMICS AND OUTCOMES RESEARCH 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] [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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Abstract
Rarely, patients with blood disorders may seek to undergo plastic surgery. Although plastic surgeons are not expected to diagnose or manage blood disorders, they should be able to recognize which patients are suitable for surgery and which should be referred to a hematologist before a procedure. This practice advisory provides an overview of the perioperative steps that should be completed to ensure appropriate care for patients with blood disorders.
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A retrospective study of Octaplex in the treatment of bleeding in patients with haemophilia A complicated by inhibitors. Blood Coagul Fibrinolysis 2010; 21:577-83. [DOI: 10.1097/mbc.0b013e32833c9ab9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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CARCAO M, LAMBERT T. Prophylaxis in haemophilia with inhibitors: update from international experience. Haemophilia 2010; 16 Suppl 2:16-23. [DOI: 10.1111/j.1365-2516.2009.02198.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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VALENTINO LA. Assessing the benefits of FEIBA prophylaxis in haemophilia patients with inhibitors. Haemophilia 2009; 16:263-71. [DOI: 10.1111/j.1365-2516.2009.02126.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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VALENTINO LA, CARCAO M, MATHEW P, LEISSINGER CA, BERNTORP E, BLANCHETTE V, ESCURIOLA-ETTINGSHAUSEN C, EWENSTEIN B, EWING N, GRINGERI A, HOOTS WK, NEGRIER C. The application of bypassing-agent prophylaxis in haemophilia A patients with inhibitors: a meeting report. Haemophilia 2009; 15:959-65. [DOI: 10.1111/j.1365-2516.2008.01953.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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SCALONE L, MANTOVANI LG, BORGHETTI F, VON MACKENSEN S, GRINGERI A. Patients’, physicians’, and pharmacists’ preferences towards coagulation factor concentrates to treat haemophilia with inhibitors: results from the COHIBA Study. Haemophilia 2009; 15:473-86. [DOI: 10.1111/j.1365-2516.2008.01926.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Yoo KY, Choi YM, Park YS. Maintenance Therapy with Activated Prothrombin Complex Concentrate (aPCC) for Hemophilia Patients with High Levels of Responding Inhibitors. THE KOREAN JOURNAL OF HEMATOLOGY 2009. [DOI: 10.5045/kjh.2009.44.4.205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ki Young Yoo
- Korea Hemophilia Foundation, Seoul, Korea
- Department of Pediatrics, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Yong Mook Choi
- Korea Hemophilia Foundation, Seoul, Korea
- Department of Pediatrics, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Young Shil Park
- Department of Pediatrics, College of Medicine, Kyung Hee University, Seoul, Korea
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Epidemiological survey of haemophiliacs with inhibitors in France: orthopaedic status, quality of life and cost – the ‘Statut Orthopédique des Patients Hémophiles’ avec Inhibiteur study. Blood Coagul Fibrinolysis 2009; 20:4-11. [DOI: 10.1097/mbc.0b013e328313fc8e] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kruse-Jarres R, Barnett B, Leissinger C. Immune tolerance induction for the eradication of inhibitors in patients with hemophilia A. Expert Opin Biol Ther 2008; 8:1885-96. [DOI: 10.1517/14712590802515537] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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FISCHER K, VALENTINO L, LJUNG R, BLANCHETTE V. Prophylaxis for severe haemophilia: clinical challenges in the absence as well as in the presence of inhibitors. Haemophilia 2008; 14 Suppl 3:196-201. [DOI: 10.1111/j.1365-2516.2008.01736.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Teitel J, Berntorp E, Collins P, D'Oiron R, Ewenstein B, Gomperts E, Goudemand J, Gringeri A, Key N, Leissinger C, Monahan P, Young G. A systematic approach to controlling problem bleeds in patients with severe congenital haemophilia A and high-titre inhibitors. Haemophilia 2007; 13:256-63. [PMID: 17498074 DOI: 10.1111/j.1365-2516.2007.01449.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
UNLABELLED The presence of inhibitory antibodies to clotting factors complicates the treatment of bleeding in haemophilia patients. For patients with high-titre inhibitors, bypassing agents are essential to haemostatic management. To determine optimal treatment practices, an international panel of physicians convened to develop a systematic treatment approach for problem bleeds (i.e. bleeds that are unresponsive to initial therapy with a single agent within a reasonable amount of time) in haemophilia patients with inhibitors. AIM The goal of this panel was to develop a consensus algorithm that would aid physicians in considering a variety of treatment approaches to optimize patient care by preventing extensive therapy with inadequate treatments that may lead to suboptimal patient outcomes and unnecessary costs. METHODS Consensus opinions were analyzed for clinical preferences at different time periods, depending on patient response to treatment. Decision-making points were defined based on the type of bleed: every 8-12 h for the first 24 h, then every 24 h thereafter for limb-threatening bleeds; every 2-4 h for 2-7 days for life-threatening bleeds. RESULTS The resultant consensus guidelines provide a generalized methodology to guide the treatment of problem bleeds in patients with severe haemophilia A and inhibitors, and emphasize changing treatment at the first sign of an inadequate haemostatic response. The treatment algorithms apply to both paediatric and adult patients, although the differences between the two groups were reviewed. CONCLUSION These guidelines are focused on optimising the timing of treatment decisions, which may lead to faster responses and improved outcomes.
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Affiliation(s)
- J Teitel
- St Michael's Hospital, Toronto, ON, Canada.
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Rodriguez-Merchan EC, Quintana M, Jimenez-Yuste V, Hernández-Navarro F. Orthopaedic surgery for inhibitor patients: a series of 27 procedures (25 patients). Haemophilia 2007; 13:613-9. [PMID: 17880452 DOI: 10.1111/j.1365-2516.2007.01520.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We report on a series of 27 orthopaedic surgical procedures. It includes 20 radiosynoviortheses and seven major orthopaedic procedures, performed on 26 patients. The average age of patients was 36 years (range: 8-53) and the average follow-up time was 2.5 years (range:1-5). There were 23 good results and four fair. In the synoviorthesis group (20 patients, 20 synoviortheses) the average age was 13.5 years (range: 9-26) and the average follow-up was 4.5 years (range: 1-7). There were 19 good results and one fair. All synoviortheses were done with activated prothrombin complex concentrates (FEIBA), all the responses being good except in one case (which had the final fair result). The total dose of FEIBA used was 600 IU kg(-1,) except in a patient that had a haemorrhagic complication. In fact, he required a prolongation of treatment up to a total dose of 2000 IU kg(-1). In the group of major orthopaedic procedures, the average age of the six patients was 30.5 years (range: 11-53) and the average follow-up was 2.5 years (range: 1-5). There were six good results and one fair. Postoperative bleeding complications occurred in one of the seven major orthopaedic procedures performed (arterial pseudoaneurym after a total knee arthroplasty). Despite such complication, which had the final fair result, our study has shown that haemophilic patients with high inhibitor titres requiring orthopaedic surgery can undergo such procedures with a high expectation of success. In other words, orthopaedic surgery is now possible in haemophilia patients with high-titre inhibitors, leading to an improved quality of life for these patients.
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Affiliation(s)
- E C Rodriguez-Merchan
- Department of Orthopaedics and Haemophilia Unit, La Paz University Hospital, 28029-Madrid, Spain.
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DiMichele DM, Hoots WK, Pipe SW, Rivard GE, Santagostino E. International workshop on immune tolerance induction: consensus recommendations. Haemophilia 2007; 13 Suppl 1:1-22. [PMID: 17593277 DOI: 10.1111/j.1365-2516.2007.01497.x] [Citation(s) in RCA: 196] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Although immune tolerance induction (ITI) has been used for 30 years to eliminate inhibitors and restore normal factor pharmacokinetics in patients with hemophilia, there is a paucity of scientific evidence to guide therapeutic decision-making. In an effort to provide direction for physicians and hemophilia treatment center staff members, an international panel of hemophilia opinion leaders met to develop consensus recommendations for ITI in patients with severe and mild hemophilia A and hemophilia B. These recommendations draw on the available published literature and the collective clinical experience of the group and are rated based on the level of supporting evidence.
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Affiliation(s)
- D M DiMichele
- Department of Pediatrics, Weill Medical College of Cornell University, New York, NY 10021, USA.
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Leissinger CA, Becton DL, Ewing NP, Valentino LA. Prophylactic treatment with activated prothrombin complex concentrate (FEIBA�) reduces the frequency of bleeding episodes in paediatric patients with haemophilia A and inhibitors. Haemophilia 2007; 13:249-55. [PMID: 17498073 DOI: 10.1111/j.1365-2516.2007.01442.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Orthopaedic complications are among the most disabling sequelae occurring in patients with haemophilia and inhibitors. Recurrent or refractory joint bleeds can lead to joint damage, limiting mobility and causing permanent disability. Activated prothrombin complex concentrates (aPCCs) are effective in controlling acute, intraoperative and postoperative bleeding in patients with haemophilia and inhibitors. The relatively long, dosing interval and safety profile distinguish aPCCs as a well-suited option for prophylaxis. Therefore, it is postulated that long-term routine aPCC administration will decrease the frequency of recurrent bleeds, prevent damage to normal joints, and slow the progression of existing joint disease in patients with inhibitors. To test this hypothesis, a retrospective chart audit was performed. In four treatment centres, five patients were identified who received aPCC [Factor Eight Inhibitor Bypassing Activity, Anti-Inhibitor Coagulant Complex (FEIBA); Baxter AG, Vienna, Austria] prophylactically for > or = 6 months to prevent or reduce further joint deterioration, reduce bleeding and prevent postsurgical bleeding. Median treatment duration was 15 months and included administration of >1300 doses of aPCC. Dosages ranged from 50 to 75 U kg(-1) three times per week in four patients; one patient received 100 U kg(-1) daily. Orthopaedic status was maintained in four patients and improved in one; the frequency of bleeding episodes was reduced in all patients. No adverse events or thrombotic complications were reported. This case series demonstrates that routine aPCC administration may be used safely and effectively to reduce the occurrence of bleeding episodes and to maintain or improve clinical joint status in some patients.
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Affiliation(s)
- C A Leissinger
- Section of Hematology/Oncology, Tulane University School of Medicine, New Orleans, LA 70112, USA.
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Abstract
The presence of high titre inhibitors makes the treatment of bleeding episodes in haemophilia patients difficult and increases the risk of uncontrollable bleeding and disability, despite optimum on-demand treatment with bypassing agents. The inability to effectively control joint bleeding leads to progressive joint disease in many patients with inhibitors. Significant mobility impairments are far more prevalent in patients with inhibitors than in those without inhibitors. Emerging data suggest that prophylaxis using bypassing agents may be effective and safe in reducing the incidence of joint bleeding during immune tolerance induction (ITI), and for patients who failed ITI or who were never candidates for ITI. Only controlled clinical trials will ultimately demonstrate whether prophylaxis can prevent joint bleeding and damage, and improve quality of life in patients with inhibitors. This article will review the published data on the use of bypassing agents in the prevention of bleeding, and will discuss ongoing clinical prophylaxis trials in inhibitor patients.
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Affiliation(s)
- C A Leissinger
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana 70112, USA.
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Di Paola J, Aledort L, Britton H, Carcao M, Grabowski E, Hutter J, Journeycake J, Kempton C, Leissinger C. Application of current knowledge to the management of bleeding events during immune tolerance induction. Haemophilia 2006; 12:591-7. [PMID: 17083508 DOI: 10.1111/j.1365-2516.2006.01343.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The development of inhibitors to factor VIII is the most serious adverse event associated with the treatment of haemophilia A, predisposing patients to uncontrollable haemorrhage, disability and premature death. Eradication of inhibitors via immune tolerance induction (ITI) is effective in the majority of patients, but may require months to years to achieve success. In the interim, the treatment and prevention of acute bleeding episodes are primary foci of care. Regrettably, there is a paucity of information regarding management of bleeding episodes in inhibitor patients undergoing tolerization. Until specific data from ongoing clinical trials are available to provide more guidance in this patient group, it is reasonable and useful to rely on the broader base of medical literature pertaining to patients not being tolerized to deduce strategies for controlling acute and perioperative bleeding episodes in inhibitor patients during ITI.
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Affiliation(s)
- J Di Paola
- Department of Pediatrics, University of Iowa, Iowa City, IA 52242, USA.
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Girolami A, Ruzzon E, Fabris F, Varvarikis C, Sartori R, Girolami B. Myocardial infarction and other arterial occlusions in hemophilia a patients. A cardiological evaluation of all 42 cases reported in the literature. Acta Haematol 2006; 116:120-5. [PMID: 16914907 DOI: 10.1159/000093642] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2005] [Accepted: 02/02/2006] [Indexed: 01/16/2023]
Abstract
Myocardial infarction and other arterial occlusions are considered to be rare in hemophilia A. However, a systematic study of the subject has never been attempted. All case reports of myocardial infarction or other arterial occlusions have been now gathered and properly evaluated from a cardiological point of view. Thirty-six patients with myocardial infarction and 6 patients with documented cerebrovascular event were retrieved from the literature. The age of the patients varied between 7 and 79 years, with a mean of 44 years. In 16 cases, the arterial occlusion occurred in men <40 years of age. The majority of myocardial infarctions (MIs) were anterolateral (12 cases). Posterior-inferior MI was present in 6 cases whereas it was of the non-Q type in 4 patients. It was multiple in 6 cases, and in the remaining patients the type of infarction could not be determined. In 26 cases, the thrombotic event (22 myocardial infarctions and 4 ischemic cerebrovascular accidents) occurred during or after the infusion of factor VIII concentrates and, more frequently, after prothrombin complex concentrates (activated or non-activated ones) or recombinant factor VIIa preparations. In 3 cases, the vascular complication occurred after intravenous desmopressin administration. MI was fatal in 7 instances. After the event, signs and symptoms of heart failure were seen as sequels in 7 patients. One patient had to undergo cardiac transplant 5 months after the MI. No death occurred after ischemic cerebrovascular accidents. Since not all hemophilia patients develop inhibitors and therefore are not usually treated with activated concentrates, this series of patients is somewhat biased and does not allow general conclusions. The high prevalence of MI and other arterial complications which occurred after transfusion therapy, usually in patients with inhibitors, clearly indicates the need for a careful evaluation of the appropriate therapeutic approach in each single patient.
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Affiliation(s)
- A Girolami
- Department of Medical and Surgical Sciences, University of Padua Medical School, Padua, Italy.
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Abstract
Acquired hemophilia A is a rare but severe autoimmune bleeding disorder, resulting from the presence of autoantibodies directed against clotting factor VIII. The etiology of the disorder remains obscure, although approximately half of all cases are associated with other underlying conditions. A prompt diagnosis and appropriate management enable effective control of this acquired hemorrhagic disorder: the aims of therapy are to terminate the acute bleeding episode and eliminate or reduce the inhibitor. The recent availability of bypassing agents, first activated prothrombin complex concentrates and then recombinant activated factor VII, has significantly reduced mortality during the acute phase of the disease in patients with high titer inhibitors. On another front, immunosuppressive therapy (corticosteroids and cytotoxic agents, alone or in various combinations) has resulted in long-term inhibitor suppression in up to 70% of the cases. Moreover, new therapeutic strategies (anti-CD20 monoclonal antibody and immune tolerance protocols) are very promising and may further improve the prognosis of acquired hemophilia A.
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Affiliation(s)
- Massimo Franchini
- Servizio di Immunoematologia e Trasfusione, Centro Emofilia, Azienda Ospedaliera di Verona, Verona, Italy.
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Abstract
Patients with haemophilia who develop inhibitors have unique treatment needs; bypassing agents such as Factor Eight Inhibitor Bypassing Activity, Anti-Inhibitor Coagulant Complex (FEIBA; Baxter AG, Vienna, Austria) are part of this therapeutic armamentarium. This study sought to increase comprehension of the full therapeutic profile of FEIBA by evaluating its safety and efficacy in the settings of acute bleeding, surgery, and prophylaxis. Information was collected through a postmarketing surveillance study; questionnaire booklets were distributed to 72 treatment centers in the United States and Europe. The booklets contained questions related to patient demographics, inhibitor titre determinations, and FEIBA treatment. Information comprising 200 FEIBA treatment periods and representing >4500 infusions was available for 63 patients with inhibitors (n = 60, haemophilia A; n = 3, haemophilia B). Twelve patients were in more than one treatment group. Efficacy was determined by a subjective global evaluation and was good or excellent in 82% of all acute, and 91% of all surgical, treatments. Additionally, prophylactic treatment resulted in improved or stabilised clinical orthopaedic status in 11 of 13 patients (85%). Based on available data, FEIBA was judged safe in all treatment situations by the small number of adverse events (<0.04%). No thrombotic complications occurred during any treatment episode. Results indicated that FEIBA was safe and effective in acute, surgical, and prophylactic treatment settings, supporting the utility of FEIBA as a treatment option for patients with inhibitors. However, prospective studies are advised.
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Affiliation(s)
- D Dimichele
- New York Presbyterian Weill Cornell Center, Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, NY 10021, USA.
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Van den Berg HM, Dunn A, Fischer K, Blanchette VS. Prevention and treatment of musculoskeletal disease in the haemophilia population: role of prophylaxis and synovectomy. Haemophilia 2006; 12 Suppl 3:159-68. [PMID: 16684012 DOI: 10.1111/j.1365-2516.2006.01281.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Prophylaxis is defined as primary (started before the onset of joint damage) or secondary (started after the onset of joint damage). The aim of primary prophylaxis is to prevent recurrent bleeding into joints and the development of chronic arthropathy in later life. When started early, and at most after two joint bleeds, the result is predictably excellent if there is compliance with the primary prophylaxis regimen. In order to decrease the need for central venous access devices to assure reliable venous access, a number of centres start primary prophylaxis with once weekly infusions with dose-escalation based on frequency of joint bleeding. A major unanswered question is whether primary prophylaxis can be safely discontinued in adolescents/young adults and if so, when. A promising predictor for the milder bleeding phenotype in persons with severe haemophilia is a later onset of joint bleeding. Once joint damage has occurred as a result of recurrent bleeding, secondary prophylaxis can only retard, but not prevent, ongoing joint damage. Other strategies to decrease recurrent bleeding from target joints include surgical synovectomy (ideally performed using an arthroscopic technique), radionuclide synovectomy and chemical synovectomy. These interventions have very good outcomes when performed by an experienced team. Given the very high cost of factor concentrates required for programmes of prophylaxis prospective studies that document benefits to the child and family, e.g. quality of life are to be encouraged.
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Affiliation(s)
- H M Van den Berg
- Van Creveldkliniek, Dutch National Hemophilia Center, Department of Internal Medicine, University Medical Center, Utrecht, The Netherlands
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Gringeri A, Mannucci PM. Italian guidelines for the diagnosis and treatment of patients with haemophilia and inhibitors. Haemophilia 2006; 11:611-9. [PMID: 16236111 DOI: 10.1111/j.1365-2516.2005.01161.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The Italian Association of Haemophilia Centres reviewed and finally approved in November 2004 the new Italian Guidelines for the diagnosis and treatment of patients with clotting factor inhibitors. The recommendations have been based on the identification of levels of clinical evidence derived from the systematic review carried out in 2003 by the School of Health and Related Research, the University of Sheffield, UK, and further integrated by clinical studies published from 2003 to 2004. The Italian guidelines consist of six major domains concerning inhibitor definition, epidemiology, risk factors, diagnosis, inhibitor eradication, management of bleeding episodes, in patients with congenital and acquired coagulation disorders, with 121 statements, 59 synthesis and 54 recommendations. We report here recommendations and open issues concerning the diagnosis and monitoring of inhibitors, inhibitor eradication and the management of bleeding in patients with haemophilia A and B.
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Affiliation(s)
- A Gringeri
- Department of Internal Medicine and Dermatology, Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Milan, Italy.
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Franchini M, Gandini G, Di Paolantonio T, Mariani G. Acquired hemophilia A: a concise review. Am J Hematol 2005; 80:55-63. [PMID: 16138334 DOI: 10.1002/ajh.20390] [Citation(s) in RCA: 191] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Acquired hemophilia A is a rare but severe autoimmune bleeding disorder. It is more frequent in the elderly and results from the presence of autoantibodies directed against clotting factor VIII. In this review, we briefly report on the present state of knowledge regarding acquired hemophilia A, analyzing its epidemiology, pathogenesis, diagnostic, and clinical features. We also describe the main characteristics of this disorder according to its association with different conditions and the most important advances in the treatment of bleeding episodes and the eradication of the autoantibody.
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Affiliation(s)
- Massimo Franchini
- Servizio di Immunoematologia e Trasfusione--Centro Emofilia, Azienda Ospedaliera di Verona, Italy.
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41
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Young G, McDaniel M, Nugent DJ. Prophylactic recombinant factor VIIa in haemophilia patients with inhibitors. Haemophilia 2005; 11:203-7. [PMID: 15876264 DOI: 10.1111/j.1365-2516.2005.01096.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Prevention of bleeding, especially into joints, with prophylactic factor infusions is the most effective treatment for severe haemophilia patients. Approximately 15-30% of patients with factor VIII deficiency and 3-5% of patients with factor IX deficiency develop neutralizing antibodies (inhibitors) to factor precluding their use. Such patients often have significant bleeding complications including life- and limb-threatening bleeds and severe joint disease. Prophylaxis for such patients is not generally considered because of the fact that the standard (bypassing) agents for such patients are not as effective as natural factor replacement, because of concerns for thrombotic complications and also because of the very high cost of bypassing agents. We treated two patients with high titre inhibitors with prophylactic recombinant factor VIIa (rFVIIa). The first patient was treated as a result of development of a target joint and to reduce the use of agents that can lead to anamnesis of his inhibitor. The second patient had multiple severe bleeds and was hospitalized 20% of the time over a 2-year period. He had a very poor quality of life. Both patients had shown good responses previously to rFVIIa for treatment of bleeds. Both patients had an outstanding response to prophylaxis albeit at a very high cost. Prophylaxis with rFVIIa can be an effective approach in select inhibitor patients with severe complications related to bleeding.
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Affiliation(s)
- G Young
- Department of Pediatric Hematology, Children's Hospital of Orange County, Orange, CA 92868, USA.
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Dunn AL, Abshire TC. Recent advances in the management of the child who has hemophilia. Hematol Oncol Clin North Am 2004; 18:1249-76, viii. [PMID: 15511615 DOI: 10.1016/j.hoc.2004.06.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This article discusses recent advances in the management of the child who has hemophilia.
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Affiliation(s)
- Amy L Dunn
- AFLAC Cancer Center and Blood Disorders Service, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 2040 Ridgewood Drive NE, Suite 100, Atlanta, GA 30322, USA.
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43
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Monahan PE, Aledort LM. Factors affecting choice of hemostatic agent for the hemophilia patient with an inhibitor antibody. Am J Hematol 2004; 77:346-50. [PMID: 15558804 DOI: 10.1002/ajh.20204] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Achieving adequate hemostasis in patients with hemophilia and high-titer inhibitor antibodies remains a challenge despite the development of plasma-derived and recombinant therapies to bypass the inhibitory effect. A group of hemophilia treaters met to examine the factors that influence physician choices among the very costly and cumbersome available therapies. Specific knowledge deficits in need of prospective research were identified with respect to the rational treatment of inhibitor patients.
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Affiliation(s)
- Paul E Monahan
- Department of Pediatrics, University of North Carolina at Chapel Hill, North Carolina, USA.
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Abstract
Prophylaxis, the regular infusion of coagulation factor concentrates to severe hemophiliacs, has been an evolving therapeutic tool of management for the past three decades. Multiple clinical trials have and continue to be conducted in the field of prophylaxis in an attempt to determine ideal regimens of prophylaxis, its benefits, its risks and costs, and to address still unanswered questions; who to place on prophylaxis, when to start prophylaxis, when (if ever) to stop prophylaxis, etc. We present a detailed review and discussion of the evolution of prophylaxis as a tool in managing patients with hemophilia and we address the major issues and still unanswered questions.
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Affiliation(s)
- Manuel D Carcao
- Department of Paediatrics, Division of Haematology/Oncology, Hospital for Sick Children, University of Toronto, Toronto, Canada
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45
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Leissinger CA. Prevention of bleeds in hemophilia patients with inhibitors: emerging data and clinical direction. Am J Hematol 2004; 77:187-93. [PMID: 15389908 DOI: 10.1002/ajh.20162] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In patients with hemophilia, the development of high-responding inhibitors to factor VIII prevents adequate replacement therapy and results in increased risk of serious bleeding episodes, poor control of joint bleeding, and progressive, debilitating joint disease. Immune tolerance therapy can eradicate inhibitors, but it is not uniformly successful. Emerging data suggest that prophylaxis using activated prothrombin complex concentrates may be effective and safe in reducing the incidence of joint bleeding during immune tolerance therapy and for patients in whom immune tolerance induction fails. However, only controlled clinical trials will ultimately demonstrate whether prophylaxis can prevent joint bleeding and damage, and improve quality of life in patients with inhibitors.
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Affiliation(s)
- Cindy A Leissinger
- Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana 70112, USA.
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Quintana-Molina M, Martínez-Bahamonde F, González-García E, Romero-Garrido J, Villar-Camacho A, Jiménez-Yuste V, Fernández-Bello I, Hernández-Navarro F. Surgery in haemophilic patients with inhibitor: 20 years of experience. Haemophilia 2004; 10 Suppl 2:30-40. [PMID: 15385044 DOI: 10.1111/j.1365-2516.2004.00938.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Surgery in haemophilic patients with inhibitor against factor (F)VIII or FIX is high risk. Surgery may be performed with the administration of sufficiently high dose of FVIII in patients with low-response inhibitor or who, despite having a high response, present a low inhibitor titre at the time of surgery. The use of high doses of FX is more complicated in patients with a low-titre FIX inhibitor, as there is a high risk of anaphylactic reactions. In the case of patients with high-titre inhibitors, several treatments have been proposed, such as porcine FVIII, recombinant FVIIa (rFVIIa), and activated prothrombin complex concentrate (APCC). We present our 20 years' experience in the treatment and subsequent management of haemophilic patients with inhibitor in surgery and evaluate the results obtained with the products available for haemostatic control in 64 surgical procedures. The efficacy we obtained with FVIII is good in 100% of the cases described; we had no haemorrhagic complication (HC) in the 18 procedures in which it was used (three major and 15 minor surgery). With APCC we obtained excellent results with only one HC in a synoviorthesis in the form of bleeding and haematomas out of 32 procedures. Good results were obtained with rFVIIa with few haemorrhagic episodes. Thus, in major surgery there was one HC out of three cases. In minor surgery, greater efficacy was observed using extremely large doses of rFVIIa (> or =120 mg kg(-1) 2 h(-1)) because of the shorter half-life of this factor in this type of patients.
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Affiliation(s)
- M Quintana-Molina
- Coagulopathies Centre, Department of Haematology, La Paz University Hospital, Madrid, Spain.
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Tcheng WY, Donkin J, Konzal S, Wong WY. Recombinant factor VIIa prophylaxis in a patient with severe congenital factor VII deficiency. Haemophilia 2004; 10:295-8. [PMID: 15086331 DOI: 10.1111/j.1365-2516.2004.00885.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Use of recombinant factor VIIa (rFVIIa, NovoSeven in patients with congenital FVII deficiency has been reported for the prophylactic management of surgical bleeding and for the treatment of acute bleeding episodes. Because of its short half-life, the use of rFVIIa on a regular prophylactic regimen has not been routinely adopted. In this report, we describe our successful experience with rFVIIa prophylaxis in preventing recurrent target joint bleeding in a severely FVII-deficient adolescent.
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Affiliation(s)
- W Y Tcheng
- Childrens Hospital Los Angeles, Department of Hematology-Oncology, Los Angeles, CA, USA
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48
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Abstract
The demonstrated benefits of home care for haemophilia include improved quality of life, less pain and disability, fewer hospitalizations, and less time lost from work or school. Although reduced mortality has not been demonstrated, the substantial increase in longevity since the early 1980s correlates with the introduction of home treatment and prophylaxis programmes. These programmes must be designed and monitored by haemophilia treatment centres (HTC), which are staffed with professionals with broad and complementary expertise in the disease and its complications. In return, patients and their families must be willing to accept the reciprocal responsibilities that come from administering blood products or their recombinant equivalents at home. Patients with inhibitors to factors VIII or IX pose special challenges, but these complications do not obviate participation in home care programmes. Home care was an essential prerequisite to the introduction of effective prophylactic factor replacement therapy. Prophylaxis offers significant improvements in quality of life, but requires a substantial commitment. The use of implantable venous access devices can eliminate some of the difficulty and discomfort of peripheral venous access in small children, but brings additional risks. The future holds the promise of factor concentrates for home use that have longer half-lives, or can be administered by alternate routes. Knowledge of patient genotypes may allow treatments tailored to avoid complications such as inhibitor development. Gene therapy trials, which are currently ongoing, will ultimately lead to gene-based treatments as a complement to traditional protein-based therapy.
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Affiliation(s)
- J M Teitel
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
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Rodriguez-Merchan EC, Wiedel Jd JD, Wallny T, Caviglia H, Hvid I, Berntorp E, Rivard GE, Goddard Nj NJ, Querol F. Elective orthopedic surgery for hemophilia patients with inhibitors: new opportunities. Semin Hematol 2004; 41:109-16. [PMID: 14872431 DOI: 10.1053/j.seminhematol.2003.11.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We report a series of 108 elective orthopedic surgical procedures in hemophilia patients with inhibitors, comprising 88 cases in which radiosynoviorthesis was performed and 20 cases in which major orthopedic procedures were carried out. Hemostatic cover was provided by recombinant factor VIIa (rFVIIa, NovoSeven(R), Novo Nordisk, Bagsvaerd, Denmark) in 17 cases, and by FVIII anti-inhibitor product (FEIBA, Baxter Corp, Toronto, Canada) in the remaining three procedures. A total of 51 patients from nine centers worldwide were included. The results of the procedures were characterized as good (82 procedures), fair (15), or poor (11). Postoperative bleeding complications requiring further surgical intervention occurred in three (15%) of the 20 major orthopedic procedures; all three procedures used rFVIIa as a hemostatic agent. Despite these complications, however, our study has shown that rFVIIa allows hemophilic patients with high inhibitor titers to undergo elective orthopedic surgery (EOS) with a greater expectation of success, leading to an improved quality of life. Thorough analysis of each case as part of a multidisciplinary team will help to identify further inhibitor patients in whom EOS can be performed both safely and effectively.
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50
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Carcao MD, Connolly BL, Chait P, Stain AM, Acebes M, Massicotte P, Blanchette VS. Central venous catheter-related thrombosis presenting as superior vena cava syndrome in a haemophilic patient with inhibitors. Haemophilia 2003; 9:578-83. [PMID: 14511297 DOI: 10.1046/j.1365-2516.2003.00791.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We report the case of a 10.5-year-old boy with severe haemophilia A (SHA) and inhibitors who presented with superior vena cava (SVC) obstruction while on immune tolerance induction (ITI) with daily recombinant factor VIII (rFVIII) and factor eight bypassing activity (FEIBA) (75 U kg(-1)) twice a week. The boy had a right-sided implanted central venous catheter. Imaging revealed a large occlusive thrombus in the SVC with all upper venous system drainage occurring through the azygos and collateral veins. Despite initial success with local thrombolytic therapy using recombinant tissue plasminogen activator, the thrombus persisted. Mechanical thrombolysis and angioplasty resulted in the successful removal of the thrombus and resolution of the SVC syndrome. Unfractionated heparin was used to prevent thrombus reformation/propagation. A work-up did not reveal any underlying genetic prothrombotic risk factors. The occurrence of such a profoundly symptomatic thromboembolism (TE) in a boy with SHA with inhibitors is unusual. A combination of risk factors, including the ongoing infusion of high doses of FVIII in the context of a disappearance of inhibitors together with the infusion of clotting factors known to be potentially thrombogenic, may place haemophilic patients on ITI (immune tolerance induction) at risk for this rare, life-threatening complication. The appropriate management of TEs in such a setting is unknown.
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Affiliation(s)
- M D Carcao
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
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