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Escobar M, Castaman G, Boix SB, Callaghan M, de Moerloose P, Ducore J, Hermans C, Journeycake J, Leissinger C, Luck J, Mahlangu J, Miesbach W, Mitha IH, Négrier C, Quon D, Recht M, Schved JF, Shapiro AD, Sidonio R, Srivastava A, Stasyshyn O, Vilchevska KV, Wang M, Young G, Alexander WA, Al-Sabbagh A, Bonzo D, Macie C, Wilkinson TA, Kessler C. The safety of activated eptacog beta in the management of bleeding episodes and perioperative haemostasis in adult and paediatric haemophilia patients with inhibitors. Haemophilia 2021; 27:921-931. [PMID: 34636112 PMCID: PMC9292935 DOI: 10.1111/hae.14419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/31/2021] [Accepted: 09/06/2021] [Indexed: 01/19/2023]
Abstract
Introduction Haemophilia patients with inhibitors often require a bypassing agent (BPA) for bleeding episode management. Eptacog beta (EB) is a new FDA‐approved recombinant activated human factor VII BPA for the treatment and control of bleeding in haemophilia A or B patients with inhibitors (≥12 years of age). We describe here the EB safety profile from the three prospective Phase 3 clinical trials performed to date. Aim To assess EB safety, immunogenicity and thrombotic potential in children and adults who received EB for treatment of bleeding and perioperative care. Methods Using a randomized crossover design, 27 subjects in PERSEPT 1 (12‐54 years) and 25 subjects in PERSEPT 2 (1‐11 years) treated bleeding episodes with 75 or 225 μg/kg EB initially followed by 75 μg/kg dosing at predefined intervals as determined by clinical response. Twelve PERSEPT 3 subjects (2‐56 years) received an initial preoperative infusion of 75 μg/kg (minor procedures) or 200 μg/kg EB (major surgeries) with subsequent 75 μg/kg doses administered intraoperatively and post‐operatively as indicated. Descriptive statistics were used for data analyses. Results Sixty subjects who received 3388 EB doses in three trials were evaluated. EB was well tolerated, with no allergic, hypersensitivity, anaphylactic or thrombotic events reported and no neutralizing anti‐EB antibodies detected. A death occurred during PERSEPT 3 and was determined to be unlikely related to EB treatment by the data monitoring committee. Conclusion Results from all three Phase 3 trials establish an excellent safety profile of EB in haemophilia A or B patients with inhibitors for treatment of bleeding and perioperative use.
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Affiliation(s)
- Miguel Escobar
- Gulf States Hemophilia and Thrombophilia Center, Houston, Texas, USA
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | | | | | | | - Jonathan Ducore
- Hematology/Oncology Clinic, University of California at Davis, Sacramento, California, USA
| | - Cédric Hermans
- Cliniques Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Janna Journeycake
- Oklahoma Bleeding and Clotting Disorders Center at OU Health, Oklahoma City, Oklahoma, USA
| | - Cindy Leissinger
- Section of Hematology/Oncology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - James Luck
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Johnny Mahlangu
- Hemophilia Comprehensive Care Center, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | | | | | | | - Doris Quon
- Orthopaedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, New York, USA.,Oregon Health & Science University, Portland, Oregon, USA
| | - Jean François Schved
- Haemophilia Treatment Centre, University Hospital Montpellier, Montpellier, France
| | - Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Robert Sidonio
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, Georgia, USA
| | | | | | | | - Michael Wang
- Hemophilia and Thrombosis Center, University of Colorado, Aurora, Colorado, USA
| | - Guy Young
- Children's Hospital Los Angeles, Los Angeles, California, USA.,Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | | | | | | | | | - Craig Kessler
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
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2
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Meeks SL, Leissinger CA. The evolution of factor VIIa in the treatment of bleeding in haemophilia with inhibitors. Haemophilia 2019; 25:911-918. [PMID: 31489759 PMCID: PMC6899648 DOI: 10.1111/hae.13845] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/07/2019] [Accepted: 08/19/2019] [Indexed: 01/19/2023]
Abstract
The use of activated factor VII (FVIIa) for the treatment of bleeding events in haemophilia patients with inhibitors was first reported over 30 years ago. Since then clinical trials, registries, case series, real‐world experience and an understanding of its mechanism of action have transformed what was originally a scientific curiosity into one of the major treatments for inhibitor patients, with innovative therapeutic regimens, dose optimization and individualized care now widely practiced. Given current understanding and use, it might be easy to forget the years of clinical research that led up to this point; in this review, we lay out changes based on broad eras of rFVIIa use. These eras cover the original uncertainty associated with dosing, efficacy and safety; the transformation of care ushered in with its widespread use; and the optimization and individualization of patient care and the importance of specialized support provided by haemophilia treatment centres. Today with the introduction of novel prophylactic agents such as emicizumab, we once again find ourselves dealing with the uncertainties of how best to utilize rFVIIa and newer investigational variants such as marzeptacog alfa and eptacog beta; we hope that the experiences of the past three decades will serve as a guide for this new era of care.
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Affiliation(s)
- Shannon L Meeks
- Department of Pediatrics, Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Cindy A Leissinger
- Section of Hematology/Oncology, Tulane University School of Medicine, New Orleans, LA, USA
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3
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Rajpurkar M, Cooper DL. Continuous infusion of recombinant activated factor VII: a review of data in congenital hemophilia with inhibitors and congenital factor VII deficiency. J Blood Med 2018; 9:227-239. [PMID: 30568523 PMCID: PMC6276614 DOI: 10.2147/jbm.s184040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Introduction Continuous infusion (CI) of clotting factors as a replacement therapy for perioperative hemostatic protection has been performed for many years, including with factors VIII and IX and recombinant activated factor VII (rFVIIa). This approach provides steady factor levels without requiring frequent administration of bolus doses. Aim To review safety, efficacy, and dosing data regarding CI of rFVIIa for hemostatic management of patients with congenital hemophilia with inhibitors (CHwI) or congenital factor VII deficiency (C7D). Materials and methods A literature review identified instances of CI of rFVIIa in patients with CHwI or C7D undergoing surgery or experiencing bleeding episodes. Data regarding safety, efficacy, and dosing were extracted. Results The safety and efficacy of 50 mcg/kg/h CI of rFVIIa following a 90 mcg/kg bolus injection, vs a standard bolus injection regimen, was reported for 24 patients with CHwI undergoing elective surgery in an open-label, randomized, Phase III trial. Efficacy was similar between CI and bolus injection groups at all postoperative time points assessed. Additionally, a postmarketing surveillance study reported effective (80%) and partially effective (20%) CI of rFVIIa in a Japanese cohort of ten patients with CHwI who underwent 15 surgical procedures. Finally, the safety and dosing of rFVIIa CI in 193 and 26 patients with CHwI and C7D, respectively, were reported in 11 prospective studies, 10 retrospective studies, and 30 case reports. No unexpected safety findings were reported. Conclusion rFVIIa CI has been performed safely and effectively in patients with CHwI and C7D undergoing surgery and during bleeding episodes in patients with CHwI.
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Affiliation(s)
- Madhvi Rajpurkar
- Division of Hematology/Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, USA,
| | - David L Cooper
- Clinical, Medical and Regulatory Affairs, Novo Nordisk Inc., Plainsboro, NJ, USA
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4
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Teitel JM. Treatment and prevention of bleeding in congenital hemophilia A patients with inhibitors. Transfus Apher Sci 2018; 57:466-471. [DOI: 10.1016/j.transci.2018.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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5
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Fernando RJ, Farmer BE, Augoustides JG, Gardner JC, Johnson SD, Ha B, Friess JO, Luedi MM, Erdoes G, Miller PJ, Ripat C, Fabbro M. Perioperative Management of Mild Hemophilia B During and After Coronary Artery Bypass Grafting: Challenges and Solutions. J Cardiothorac Vasc Anesth 2018; 33:549-555. [PMID: 30177475 DOI: 10.1053/j.jvca.2018.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Rohesh J Fernando
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| | - Blaine E Farmer
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| | - John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Jeffrey C Gardner
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| | - Sean D Johnson
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| | - Bao Ha
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jan-Oliver Friess
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus M Luedi
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Peter J Miller
- Critical Care Section, Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC; Hematology and Oncology Section, Department of Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - Caroline Ripat
- Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Michael Fabbro
- Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
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Ducore J, Lawrence JB, Simpson M, Boggio L, Bellon A, Burggraaf J, Stevens J, Moerland M, Frieling J, Reijers J, Wang M. Safety and dose-dependency of eptacog beta (activated) in a dose escalation study of non-bleeding congenital haemophilia A or B patients, with or without inhibitors. Haemophilia 2017; 23:844-851. [PMID: 28984010 DOI: 10.1111/hae.13357] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2017] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Varying initial doses of activated eptacog beta (recombinant human FVIIa, rhFVIIa) may provide therapeutic options when treating bleeding in patients with congenital haemophilia who have developed inhibitory antibodies to factor VIII (FVIII) or factor IX (FIX). This study evaluated escalated doses of a new rhFVIIa product as a prelude to selecting the doses for clinical efficacy evaluation in haemophilia patients. AIM To assess the safety, pharmacokinetics, and laboratory pharmacodynamics of 3 doses of rhFVIIa in non-bleeding patients with congenital haemophilia A or B with or without inhibitors. METHODS Adult male patients (18-75 years old) with congenital haemophilia A or B (with or without inhibitors) received infusions of rhFVIIa at doses of 25, 75 or 225 μg/kg body weight. Ten patients were treated at each dose level, and each patient received 2 different dose levels. Descriptive methods were used to analyse the data. RESULTS Administration of rhFVIIa at all doses was well tolerated. Pharmacokinetic analyses showed that peak FVIIa plasma levels (Cmax ) were approximately proportional to dose and correlated well with peak thrombin generation. Total AUC0-inf also was approximately dose proportional. Clot formation and duration correlated with FVIIa activity. Repeat doses did not produce an immunological response. CONCLUSION In the first dose-escalation study of rhFVIIa to support product registration, eptacog beta at doses of 25, 75, and 225 μg/kg was pharmacodynamically active and well tolerated in non-bleeding patients with congenital haemophilia A or B.
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Affiliation(s)
- J Ducore
- University of California, Davis Health System, Sacramento, CA, USA
| | | | - M Simpson
- Rush University Medical Center, Chicago, IL, USA
| | - L Boggio
- Rush University Medical Center, Chicago, IL, USA
| | | | - J Burggraaf
- Centre for Human Drug Research, Leiden, The Netherlands
| | - J Stevens
- Centre for Human Drug Research, Leiden, The Netherlands
| | - M Moerland
- Centre for Human Drug Research, Leiden, The Netherlands
| | | | - J Reijers
- Centre for Human Drug Research, Leiden, The Netherlands
| | - M Wang
- Hemophilia & Thrombosis Center, University of Colorado, Aurora, CO, USA
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7
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Wang M, Lawrence JB, Quon DV, Ducore J, Simpson ML, Boggio LN, Mitchell IS, Yuan G, Alexander WA, Schved JF. PERSEPT 1: a phase 3 trial of activated eptacog beta for on-demand treatment of haemophilia inhibitor-related bleeding. Haemophilia 2017; 23:832-843. [DOI: 10.1111/hae.13301] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 01/19/2023]
Affiliation(s)
- M. Wang
- Hemophilia and Thrombosis Center; University of Colorado; Aurora CO USA
| | | | - D. V. Quon
- Orthopaedic Hemophilia Treatment Center; Orthopaedic Institute for Children; Los Angeles CA USA
| | - J. Ducore
- University of California, Davis; Comprehensive Cancer Center; Hematology/Oncology Clinic; Sacramento CA USA
| | | | | | | | - G. Yuan
- LFB USA Inc.; Framingham MA USA
| | | | - J.-F. Schved
- Département d'Hématologie Biologique; Hôpital Saint-Eloi; CHU Montpellier; Montpellier France
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8
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Croteau SE, Nakar C, Neufeld EJ, Shapiro A, Cooper DL. Safety and efficacy of recombinant factor VIIa by pediatric age cohort: reassessment of compassionate use and trial data supporting US label. Pediatr Blood Cancer 2016; 63:1822-8. [PMID: 27232114 DOI: 10.1002/pbc.26082] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND The relative safety and efficacy of recombinant activated coagulation factor VII (rFVIIa, NovoSeven® RT) across pediatric age cohorts is poorly defined. The objective of this analysis was to assess the safety and efficacy of rFVIIa in pediatric patients with congenital hemophilia with inhibitors (CHwI) in the clinical studies supporting the U.S. labeling. PROCEDURE Pediatric data were derived from seven studies (five acute and two perioperative treatments) and pooled. All data were stratified by age (<2, 2 to <6, 6 to <12, and 12-16 years) and study category (acute treatment of bleeding episodes or surgery). RESULTS The pediatric dataset included 172 patients; 144 received rFVIIa for the treatment of bleeding episodes and 28 for the control of bleeding perioperatively. Recombinant FVIIa was effective for 95.4% (1,026/1,076) of the evaluable bleeding episodes and had similar treatment effectiveness across pediatric age groups (range, 94.1-97.2%). The majority received doses of 90 mcg/kg. rFVIIa was effective in achieving perioperative hemostasis across pediatric age groups (range, 91-100%), with greater efficacy observed with the recommended (90 mcg/kg) versus lower dose (35 mcg/kg). A total of 88 pediatric patients experienced a total of 285 adverse drug reactions, similar in type to those reported among adult patients. A total of seven thrombotic events were recorded in seven pediatric patients; only one was confirmed related to rFVIIa upon individual case review. CONCLUSIONS rFVIIa is safe and effective in the treatment of bleeding episodes and prevention of periprocedure bleeding in CHwI with no apparent differences observed among pediatric age groups.
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Affiliation(s)
- Stacy E Croteau
- Dana-Farber/Boston Children's Cancer & Blood Disorders Center, Boston Hemophilia Center, Boston Children's Hospital, Boston, Massachusetts
| | - Charles Nakar
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana
| | - Ellis J Neufeld
- Dana-Farber/Boston Children's Cancer & Blood Disorders Center, Boston Hemophilia Center, Boston Children's Hospital, Boston, Massachusetts
| | - Amy Shapiro
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana
| | - David L Cooper
- Clinical, Medical and Regulatory Affairs, Novo Nordisk Inc, Plainsboro, New Jersey
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9
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Beyond stopping the bleed: short-term episodic prophylaxis with recombinant activated factor FVII in haemophilia patients with inhibitors. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 15:77-84. [PMID: 26674816 DOI: 10.2450/2015.0127-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 07/30/2015] [Indexed: 12/28/2022]
Abstract
Preventing haemarthroses and arthropathy is a major challenge in patients with haemophilia and inhibitors, as treatment options are limited. One potential strategy is short-term episodic prophylaxis, which extends bypassing agent therapy beyond the resolution of bleeding to include the post-bleed inflammatory phase. At the 13th Zürich Haemophilia Forum, an expert panel reviewed the rationale behind this strategy, explored its current use with recombinant activated factor VII (rFVIIa) and considered treatment monitoring and optimisation. Two protocols are currently used for short-term episodic prophylaxis, both of which stipulate on-demand rFVIIa until resolution of bleeding, followed by daily dosing for ≥3 days to prevent re-bleeds. Short-term episodic prophylaxis should be individualised to optimise outcomes, perhaps through early treatment initiation or by combining rFVIIa with other treatments (e.g. factor VIII, tranexamic acid). Encouraging treatment compliance can also improve outcomes. Additionally, there is a need to develop objective clinical outcome measures, biomarkers and imaging protocols that can monitor treatment outcomes and joint disease in patients with inhibitors. A proactive approach incorporating a systematic package of care is needed. Currently, short-term episodic prophylaxis with rFVIIa may be an alternative treatment option to on-demand treatment for patients with inhibitors.
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10
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Morfini M. Rapid rFVIIa enhanced on-demand dosing in haemophilia inhibitor patients. Eur J Haematol 2015; 96:111-8. [PMID: 26172449 DOI: 10.1111/ejh.12631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2015] [Indexed: 01/19/2023]
Abstract
Recombinant factor VII activated (rFVIIa) is a bypassing agent widely used in haemophilia A and B patients with antibodies against coagulation factors VIII or IX. When used according to the correct doses, rFVIIa may control bleeding, subclinical bleeding and rebleeding, avoiding the effect of neutralising inhibitors. Because of the fast action of the rFVIIa, haemostasis occurs promptly and enables a fast bleeding control with on-demand treatment in home or in surgical setting. Rapidity is also a distinguishing feature in preparation and injection of rFVIIa to cope the restraining times of busy patients and parents. The effective haemostatic activity of rFVIIa enables a sustained bleeding control, which is implemented with every other day (eod) administration and suited for enhanced on-demand therapy and short-term repeated infusions use of rFVIIa to prevent microhaemorrhages or rebleeding. Comprehensive appreciation of these pharmacological and pharmacodynamic' characteristics will likely be a further stimulus to the wider enhanced on-demand use of rFVIIa.
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Affiliation(s)
- Massimo Morfini
- Past President of Italian Association of Haemophilia Centers (AICE), Florence, Italy
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11
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Recombinant activated factor VII in the treatment of bleeds and for the prevention of surgery-related bleeding in congenital haemophilia with inhibitors. Blood Rev 2015; 29 Suppl 1:S9-18. [DOI: 10.1016/s0268-960x(15)30003-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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12
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Young G, Teitel J, d'Oiron R, Leissinger C, Berntorp E. Evaluation of algorithms for the treatment of problem bleeding episodes in patients with hemophilia having inhibitors. Clin Appl Thromb Hemost 2014; 21:10-8. [PMID: 25343956 DOI: 10.1177/1076029614554993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The correlation between real-world clinical decisions and adherence to published treatment algorithms for problem bleeding episodes in patients with severe hemophilia and inhibitors and the resultant impact on clinical outcomes were assessed. Nine cases documenting treatment for problem bleeding episodes in patients with severe hemophilia and inhibitors were retrospectively reviewed. Adherence to treatment algorithms was rated on a scale of 1 to 5, 1 being no adherence and 5 being very high adherence. Adherence ratings >3 were assigned to 7 cases in which high adherence was associated with ≤4 days to achieve hemostatic control; hospitalization for ≤7 days was noted in 6 of these cases. In cases rated ≤3 (n = 2), time to hemostatic control ranged from 5 to 8 days and hospitalization duration ranged from 10 to 16 days. These findings suggest that adherence to treatment algorithms may be beneficial in treating problem bleeding events in patients with hemophilia and inhibitors.
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Affiliation(s)
- Guy Young
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Jerome Teitel
- Division of Hematology and Oncology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Roseline d'Oiron
- Haemophilia Centre, APHP Bicêtre Hospital, University Paris XI, Le Kremlin-Bicêtre, France
| | - Cindy Leissinger
- Louisiana Center for Bleeding and Clotting Disorders, Tulane University School of Medicine, New Orleans, LA, USA
| | - Erik Berntorp
- Malmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Lund University, Lund, Sweden
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13
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Shapiro AD, Hedner U. Advances in bypassing agent therapy for hemophilia patients with inhibitors to close care gaps and improve outcomes. Ther Adv Drug Saf 2014; 2:213-25. [PMID: 25083214 DOI: 10.1177/2042098611415566] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In the past, patients with hemophilia and inhibitors have had less-than-optimal treatment and have experienced more orthopedic complications than patients without inhibitors. Bypassing agents offer the potential to close treatment gaps between inhibitor and noninhibitor patients by helping the former better attain key treatment goals, including: facilitating early initiation of treatment and hemostatic control in hemarthroses; providing effective treatment in serious hemorrhagic episodes; and performance of major surgery. Effective treatment with a bypassing agent minimizes joint and/or muscle damage and potentially can serve as an effective prophylactic agent to minimize the number of hemarthroses experienced per year, thereby mitigating the development of arthropathy. The reported efficacy of the currently available bypassing agents ranges from approximately 50-80% (50-64% in controlled studies) for plasma-derived activated prothrombin complex concentrate (pd-aPCC) and 81-91% (in controlled studies) for recombinant activated factor VII (rFVIIa), including use in major orthopedic surgery. Both bypassing agents have undergone key improvements in their formulation and/or properties in recent years. The nanofiltered, vapor-heated formulation of pd-aPCC has diminished the risk of acquiring blood-borne viral infections and the room temperature stable formulation of rFVIIa allows more convenient storage, increased ease to dissolve and inject, and smaller volumes, thereby increasing overall ease of administration. Use of recommended dosing has been demonstrated to provide effective hemostasis with a minimal number of injections for both agents. In this paper, we review the individual characteristics of pd-aPCC and rFVIIa and discuss clinical data from studies conducted in inhibitor patients that demonstrate the potential benefits of these bypassing agents in this difficult-to-treat population, and underscore the potential opportunities to close the gap in care between inhibitor and noninhibitor hemophilic patients.
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Affiliation(s)
- Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, 8402 Harcourt Road, Suite 500, Indianapolis, IN 46260, USA
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14
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Successful urgent neurosugery management with rFVIIa mega doses in a child with haemophilia A and high titre inhibitor. Blood Coagul Fibrinolysis 2014; 25:518-21. [DOI: 10.1097/mbc.0000000000000074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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15
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Salaj P, Kubes R, Cetkovsky P, Capova I, Penka M, Ovesná P, Mesterton J, Lindgren P. Economic evaluation of rFVIIa high initial dose compared to rFVIIa standard initial dose in patients with haemophilia with inhibitors using the Czech HemoRec registry. Thromb Res 2014; 133:162-7. [DOI: 10.1016/j.thromres.2013.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 10/07/2013] [Accepted: 11/07/2013] [Indexed: 11/17/2022]
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16
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Shapiro AD, Neufeld EJ, Blanchette V, Salaj P, Gut RZ, Cooper DL. Safety of recombinant activated factor VII (rFVIIa) in patients with congenital haemophilia with inhibitors: overall rFVIIa exposure and intervals following high (>240 μg kg−1) rFVIIa doses across clinical trials and registries. Haemophilia 2013; 20:e23-31. [PMID: 24354484 DOI: 10.1111/hae.12329] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2013] [Indexed: 01/19/2023]
Affiliation(s)
- A. D. Shapiro
- Indiana Hemophilia and Thrombosis Center; Indianapolis IN USA
| | - E. J. Neufeld
- Division of Hematology/Oncology; Boston Children's Hospital; Boston MA USA
| | - V. Blanchette
- Department of Pediatrics, Hospital for Sick Children; Toronto Canada
| | - P. Salaj
- Institute of Hematology and Blood Transfusion; Prague Czech Republic
| | - R. Z. Gut
- Clinical Development and Medical Affairs - Biopharm, Novo Nordisk Inc.; Plainsboro NJ USA
| | - D. L. Cooper
- Clinical Development and Medical Affairs - Biopharm, Novo Nordisk Inc.; Plainsboro NJ USA
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17
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Bakhtiari K, Kamphuisen PW, Mancuso ME, Hamulyak K, Schutgens REG, Santagostino E, Meijers JCM. Clot lysis phenotype and response to recombinant factor VIIa in plasma of haemophilia A inhibitor patients. Br J Haematol 2013; 162:827-35. [DOI: 10.1111/bjh.12470] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 06/12/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Kamran Bakhtiari
- Department of Experimental Vascular Medicine; Academic Medical Centre; Amsterdam; The Netherlands
| | - Pieter W. Kamphuisen
- Department of Vascular Medicine; Academic Medical Centre; Amsterdam; The Netherlands
| | - Maria E. Mancuso
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre; Fondazione IRCCS Ca’ Granda; Ospedale Maggiore Policlinico; Milan; Italy
| | - Karly Hamulyak
- Department of Haematology; University Hospital; Maastricht; The Netherlands
| | - Roger E. G. Schutgens
- Department of Haematology/van Creveldkliniek; University Medical Centre; Utrecht; The Netherlands
| | - Elena Santagostino
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre; Fondazione IRCCS Ca’ Granda; Ospedale Maggiore Policlinico; Milan; Italy
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Neufeld EJ, Saxena K, Kessler CM, Cooper DL. Dosing, efficacy, and safety of recombinant factor VIIa (rFVIIa) in pediatric versus adult patients: the experience of the Hemostasis and Thrombosis Research Society (HTRS) Registry (2004-2008). Pediatr Blood Cancer 2013; 60:1178-83. [PMID: 23335449 DOI: 10.1002/pbc.24472] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Accepted: 12/17/2012] [Indexed: 01/19/2023]
Abstract
BACKGROUND The longitudinal registry of the Hemostasis and Thrombosis Research Society (HTRS) provided data on treatment of bleeding episodes for pediatric and adult patients with congenital hemophilia complicated by inhibitors to factor VIII or IX. PROCEDURE Data from 2,041 recombinant factor VIIa (rFVIIa)-treated episodes were recorded in the HTRS Registry between January 2004 and November 2008 and included in this retrospective analysis. The authors compared dosing, efficacy, and safety in 1,712 episodes in 284 children (age ≤18 years) and 329 episodes in 145 adults (>18 years). RESULTS Patients were predominantly non-Hispanic white (52% of children, 68% of adults) with hemophilia A (91%). The majority of bleeds were spontaneous (55% pediatric, 69% adult) and occurred in the joint (55% pediatric, 65% adult). rFVIIa was used first line in most episodes (90% pediatric, 93% adult); 27% of episodes in both age groups were treated with a single dose. Children and adults received comparable median number of doses (three) and duration of therapy (1 day); adults had lower median [range] initial doses (90 [46-400] µg/kg vs. 120 [37-400] µg/kg) and median [range] total doses (270 [46-21,392] µg/kg vs. 480 [50-43,200] µg/kg) than children. Effectiveness was comparable between the groups. No thromboembolic complications were reported. CONCLUSIONS Dosing of rFVIIa was somewhat higher in pediatric than adult patients in the HTRS registry population, with similar effectiveness. Safety assessment, demonstrating lack of thromboembolic events associated with treatment of bleeding episodes, was similar between the children and adults in this retrospective registry.
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Affiliation(s)
- Ellis J Neufeld
- Boston Children's Hospital, Boston, Massachusetts 02115, USA.
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19
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Abstract
The management of patients with inhibitors is the greatest challenge facing haemophilia health professionals. Immune tolerance induction (ITI) can be successful in eliminating the inhibitor in the majority of patients, provided it is started soon after the inhibitor develops and the titre of the inhibitor is <10 BU at commencement of ITI. Acute bleeding is treated using one of two bypassing agents, which exhibit similar efficacy and safety. Surgery in inhibitor patients is challenging and should only be carried out in experienced centres.
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Affiliation(s)
- M Makris
- Department of Cardiovascular Science, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK.
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20
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21
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Young G, Cooper DL, Gut RZ. Dosing and effectiveness of recombinant activated factor VII (rFVIIA) in congenital haemophilia with inhibitors by bleed type and location: the experience of the Haemophilia and Thrombosis Research Society (HTRS) Registry (2004-2008). Haemophilia 2012; 18:990-6. [DOI: 10.1111/j.1365-2516.2012.02864.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2012] [Indexed: 11/28/2022]
Affiliation(s)
- G. Young
- Children's Center for Cancer and Blood Disorders; Children's Hospital Los Angeles; University of Southern California Keck School of Medicine; Los Angeles; CA
| | | | - R. Z. Gut
- Novo Nordisk Inc.; Princeton; NJ; USA
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22
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Pipe SW. The hope and reality of long-acting hemophilia products. Am J Hematol 2012; 87 Suppl 1:S33-9. [PMID: 22389200 DOI: 10.1002/ajh.23146] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 01/30/2012] [Indexed: 02/03/2023]
Abstract
Recombinant DNA technology and protein engineering are creating hope that we can address ongoing challenges in hemophilia care such as reducing the costs of therapy, increasing the availability to the developing world, and improving the functional properties of these proteins. Technological advances to improve the half-life of recombinant clotting factors have brought long-acting clotting factors for hemophilia replacement therapy closer to reality. Preclinical and clinical trial results are reviewed as well as the potential benefits and risks of these novel therapies.
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Affiliation(s)
- Steven W Pipe
- Department of Pediatrics, University of Michigan Medical Center, Ann Arbor, Michigan 48109, USA.
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23
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Montes R, Puy C, Molina E, Hermida J. Is EPCR a multi-ligand receptor? Pros and cons. Thromb Haemost 2012; 107:815-26. [PMID: 22318610 DOI: 10.1160/th11-11-0766] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 01/05/2012] [Indexed: 02/06/2023]
Abstract
In the last decade, the endothelial cell protein C/activated protein C receptor (EPCR) has received considerable attention. The role initially attributed to EPCR, i.e. the enhancement of protein C (PC) activation by the thrombin-thrombomodulin complex on the surface of the large vessels, although important, did not go beyond the haemostasis scenario. However, the discovery of the cytoprotective, anti-inflammatory and anti-apoptotic features of the activated PC (APC) and the required involvement of EPCR for APC to exert such actions did place the receptor in a privileged position in the crosstalk between coagulation and inflammation. The last five years have shown that PC/APC are not the only molecules able to interact with EPCR. Factor VII/VIIa (FVII/VIIa) and factor Xa (FXa), two other serine proteases that play a central role in haemostasis and are also involved in signalling processes influencing wound healing, tissue remodelling, inflammation or metastasis, have been reported to bind to EPCR. These observations have paved the way for an exploration of unsuspected new roles for the receptor. This review aims to offer a new image of EPCR in the light of its extended panel of ligands. A brief update of what is known about the APC-evoked EPCR-dependent cell signalling mechanisms is provided, but special care has been taken to assemble all the information available about the interaction of EPCR with FVII/VIIa and FXa.
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Affiliation(s)
- Ramón Montes
- Division of Cardiovascular Sciences, Laboratory of Thrombosis and Haemostasis, Centre for Applied Medical Research, University of Navarra, Pamplona, Spain.
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de Paula EV, Kavakli K, Mahlangu J, Ayob Y, Lentz SR, Morfini M, Nemes L, Šalek SZ, Shima M, Windyga J, Ehrenforth S, Chuansumrit A. Recombinant factor VIIa analog (vatreptacog alfa [activated]) for treatment of joint bleeds in hemophilia patients with inhibitors: a randomized controlled trial. J Thromb Haemost 2012; 10:81-9. [PMID: 22470921 DOI: 10.1111/j.1538-7836.2011.04549.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A recombinant factor VIIa analog (NN1731; vatreptacog alfa [activated]) was developed to provide safe, rapid and sustained resolution of bleeds in patients with hemophilia and inhibitors. PATIENTS/METHODS This global, prospective, randomized, double-blinded, active-controlled, dose-escalation trial evaluated and compared one to three doses of vatreptacog alfa at 5, 10, 20, 40, and 80 lg kg(-1) with one to three doses of recombinant FVIIa (rFVIIa) at 90 lg kg(-1) in the treatment of acute joint bleeds in hemophilia patients with inhibitors. The primary endpoint comprised adverse events; secondary endpoints were evaluations of immunogenicity, pharmacokinetics, and efficacy. RESULTS AND CONCLUSIONS Overall, 96 joint bleeds in 51 patients (> 12 years of age) were dosed. Vatreptacog alfa was well tolerated, with a low frequency of adverse events. No immunogenic or thrombotic events related to vatreptacog alfa were reported. A high efficacy rate of vatreptacog alfa in controlling acute joint bleeds was observed; 98% of bleeds were controlled within 9 h of the initial dose in a combined evaluation of 20–80 lg kg(-1) vatreptacog alfa. The efficacy rate observed for rFVIIa (90%) is consistent with data from published clinical trials. The trial was not powered to compare efficacy, and further trials are needed to investigate the efficacy of vatreptacog alfa as compared with that of rFVIIa. The trial was registered at ClinicalTrials.gov ( REGISTRATION NUMBER NCT00486278).
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Affiliation(s)
- Erich V de Paula
- Hematology and Hemotherapy Center, University of Campinas, São Paulo, Brazil.
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25
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Young G, Shapiro AD, Walsh CE, Gruppo RA, Gut RZ, Cooper DL. Patient/caregiver-reported recombinant factor VIIa (rFVIIa) dosing: home treatment of acute bleeds in the Dosing Observational Study in Hemophilia (DOSE). Haemophilia 2011; 18:392-9. [PMID: 22171621 DOI: 10.1111/j.1365-2516.2011.02704.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Patients with congenital haemophilia with inhibitors experience acute bleeds managed with bypassing agents, such as recombinant FVIIa (rFVIIa). Home-based treatment and dosing patterns in the US remain poorly described. This study aimed to assess the prescribed and actual rFVIIa dosing in frequently bleeding inhibitor patients (≥4 bleeds in 3 months) prescribed first-line therapy with rFVIIa. Patients or caregivers recorded daily diaries, including the details of all bypassing agent infusions for 3-6 months. Median (range) initial rFVIIa dose prescribed for joint, muscle and other bleeds was 167.5 (61.0-289.0) mcg kg(-1). Additional rFVIIa doses prescribed were 90 (61-270) mcg kg(-1) at an interval of 2.5-3 (1-24) h. The actual initial rFVIIa dose reported by patients/caregivers for 158 bleeds was 212 (59-400) mcg kg(-1), with total dose per episode of 695 (74-21257) mcg kg(-1). Patient/caregiver-reported average dose per bleed was 146 (40-400) mcg kg(-1) across 5 (1-106) infusions. The initial rFVIIa dose was higher for haemarthrosis (223 [59-400] mcg kg(-1)) than muscle bleeds (148 [74-300] mcg kg(-1); P = 0.07). Initial and mean dose per day changed as treatment progressed. The DOSE study indicates that frequently bleeding inhibitor patients are prescribed and use higher rFVIIa dosing for all bleed types than recommended in the package insert (90 mcg kg(-1)). The rFVIIa dosing was highly variable within and across bleed types, with higher initial doses used for joint bleeds than muscle and other bleed types, particularly in the first days of treatment. This suggests that patients/caregivers have adopted home treatment strategies based on physician discretion and individual responses and experience.
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Affiliation(s)
- G Young
- Children's Hospital Los Angeles, Los Angeles, CA 90027, USA.
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26
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Gray LD, Hussey MA, Larson BM, Machlus KR, Campbell RA, Koch G, Ezban M, Hedner U, Wolberg AS. Recombinant factor VIIa analog NN1731 (V158D/E296V/M298Q-FVIIa) enhances fibrin formation, structure and stability in lipidated hemophilic plasma. Thromb Res 2011; 128:570-6. [PMID: 21561645 PMCID: PMC3156970 DOI: 10.1016/j.thromres.2011.04.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 03/22/2011] [Accepted: 04/13/2011] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The bypassing agent recombinant factor VIIa (rFVIIa) is efficacious in treating bleeding in hemophilia patients with inhibitors. Efforts have focused on the rational engineering of rFVIIa variants with increased hemostatic potential. One rFVIIa analog (V158D/E296V/M298Q-FVIIa, NN1731) improves thrombin generation and clotting in purified systems, whole blood from hemophilic patients and factor VIII-deficient mice. METHODS We used calibrated automated thrombography and plasma clotting assays to compare effects of bypassing agents (rFVIIa, NN1731) on hemophilic clot formation, structure, and ability to resist fibrinolysis. RESULTS Both rFVIIa and NN1731 shortened the clotting onset and increased the maximum rate of fibrin formation and fibrin network density in hemophilic plasma clots. In the presence of tissue plasminogen activator, both rFVIIa and NN1731 shortened the time to peak turbidity (TTPeak(tPA)) and increased the area under the clot formation curve (AUC(tPA)). Phospholipids increased both rFVIIa and NN1731 activity in a lipid concentration-dependent manner. Estimated geometric mean concentrations of rFVIIa and NN1731 producing similar onset, rate, TTPeak(tPA), and AUC(tPA) as seen with 100% factors VIII and IX were: 24.5, 74.3, 29.7, and 37.1 nM rFVIIa, and 8.6, 31.2, 9.0, and 11.3 nM NN1731, respectively. In each case, the NN1731 concentration was significantly lower than rFVIIa. CONCLUSIONS These findings suggest that like rFVIIa, NN1731 improves the formation, structure, and stability of hemophilic clots. Higher lipid concentrations may facilitate assessment of both rFVIIa and NN1731 activity. NN1731 appears likely to support rapid clot formation in tissues with high endogenous fibrinolytic activity.
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Affiliation(s)
- Laura D. Gray
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael A. Hussey
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Brittany M. Larson
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kellie R. Machlus
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Robert A. Campbell
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Gary Koch
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mirella Ezban
- Novo Nordisk A/S, Novo Nordisk Park, Maaloev, Denmark
| | - Ulla Hedner
- Novo Nordisk A/S, Novo Nordisk Park, Maaloev, Denmark
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Gringeri A, Muça-Perja M, Mangiafico L, von Mackensen S. Pharmacotherapy of haemophilia A. Expert Opin Biol Ther 2011; 11:1039-53. [PMID: 21682657 DOI: 10.1517/14712598.2011.570006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Haemophilia A is due to factor VIII (FVIII) deficiency. The main treatment is replacement therapy with FVIII concentrates. However, these concentrates carried a high risk of blood-borne viral infections and still have a high risk of inducing anti-FVIII inhibitors. AREAS COVERED An overview of products available and therapeutic options for haemophilia A management in order to help in decision making. A literature search using Medline with the keywords: 'haemophilia', 'factor VIII', 'therapy', 'inhibitor', 'concentrate', 'bleeding', 'prophylaxis', 'on demand', 'plasma-derived', 'recombinant', 'coagulation factors', 'immunotolerance' was performed. The years 1960 - 2010 are included. EXPERT OPINION Progress in management of patients with haemophilia A has allowed increased life expectancy and quality of life. There is evidence that prophylaxis prevents or, at least, slows down arthropathy development when started early in childhood. FVIII concentrates have achieved high levels of blood-borne pathogen safety. However, treatment is frequently complicated by development of FVIII-neutralizing inhibitors, which prevent control of bleeding and predispose to a high morbidity and mortality risk. Bypassing agents are effective in bleeding treatment in a high percentage of cases. Prophylaxis with bypassing agents and their use in combination are offering opportunities in management of inhibitor patients. More evidence is necessary to understand how to prevent and manage this complication.
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28
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Abstract
Proteases are an expanding class of drugs that hold great promise. The U.S. FDA (Food and Drug Administration) has approved 12 protease therapies, and a number of next generation or completely new proteases are in clinical development. Although they are a well-recognized class of targets for inhibitors, proteases themselves have not typically been considered as a drug class despite their application in the clinic over the last several decades; initially as plasma fractions and later as purified products. Although the predominant use of proteases has been in treating cardiovascular disease, they are also emerging as useful agents in the treatment of sepsis, digestive disorders, inflammation, cystic fibrosis, retinal disorders, psoriasis and other diseases. In the present review, we outline the history of proteases as therapeutics, provide an overview of their current clinical application, and describe several approaches to improve and expand their clinical application. Undoubtedly, our ability to harness proteolysis for disease treatment will increase with our understanding of protease biology and the molecular mechanisms responsible. New technologies for rationally engineering proteases, as well as improved delivery options, will expand greatly the potential applications of these enzymes. The recognition that proteases are, in fact, an established class of safe and efficacious drugs will stimulate investigation of additional therapeutic applications for these enzymes. Proteases therefore have a bright future as a distinct therapeutic class with diverse clinical applications.
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29
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MORFINI M, BJERRE J. Pharmacokinetics and safety of a 270 mcg kg−1 dose of room temperature stable recombinant activated factor VII in patients with haemophilia. Haemophilia 2011; 17:860-6. [DOI: 10.1111/j.1365-2516.2011.02498.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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30
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Spira J, Plyushch O, Zozulya N, Yatuv R, Dayan I, Bleicher A, Robinson M, Baru M. Safety, pharmacokinetics and efficacy of factor VIIa formulated with PEGylated liposomes in haemophilia A patients with inhibitors to factor VIII--an open label, exploratory, cross-over, phase I/II study. Haemophilia 2011; 16:910-8. [PMID: 20491957 DOI: 10.1111/j.1365-2516.2010.02273.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Recombinant activated factor VIIa (FVIIa) is a bypassing agent used to treat bleeding episodes in haemophilia patients with inhibitors to factor VIII (FVIII) and factor IX. The pharmacological effect of FVIIa is short-lived and therefore with the recommended dose of 90 μg kg(-1), a bleeding episode is treated with multiple injections. A long-acting form of FVIIa that can ensure adequate haemostasis with a single infusion, without increasing the thrombotic risk, would therefore be beneficial. PEGylated liposomes (PEGLip) have been shown to bind FVIIa and to improve haemostatic efficacy in preclinical experiments. In the present phase I/II clinical trial, we assessed the safety and efficacy of PEGLip-formulated FVIIa in severe haemophilia A patients (FVIII≤1%) with inhibitors to FVIII. Each patient received one prophylactic infusion of standard FVIIa and one prophylactic infusion of PEGLip-formulated FVIIa. The order of the infusions was randomized and the two infusions were separated by a ten-day washout period. Efficacy assessed by thromboelastography revealed that PEGLip-FVIIa induced significantly shorter clotting times and produced higher clot firmnesses than standard FVIIa. Thrombin generation assays showed that PEGLip-FVIIa induced faster thrombin generation and higher peak levels of thrombin than standard FVIIa. These effects lasted up to 5 h postinfusion. Measurements of D-dimer, prothrombin fragment 1+2 and fibrinogen showed no significant differences between the PEGLip-FVIIa and standard FVIIa treatments. PEGLip-FVIIa therefore showed improved haemostatic efficacy without increased risk of thrombosis and may be further developed for the treatment for bleeding episodes in haemophilia patients with inhibitors.
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Affiliation(s)
- J Spira
- Omri Laboratories Ltd., Nes Ziona, Israel
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31
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Neufeld EJ, Kessler CM, Gill JC, Wilke CT, Cooper DL. Exposure and safety of higher doses of recombinant factor VIIa ≥250 μg kg−1 in individuals with congenital haemophilia complicated by alloantibody inhibitors: the Haemophilia and Thrombosis Research Society Registry experience (2004-2008). Haemophilia 2011; 17:650-6. [PMID: 21299750 DOI: 10.1111/j.1365-2516.2010.02483.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- E J Neufeld
- Children's Hospital Boston, Boston, MA, USA.
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Abstract
Abstract
Therapeutic advances for patients with hemophilia have resulted in reduced mortality, improved joint outcomes, safety from blood-transmitted pathogens, improved quality of life, and a normalized life span in the developed world. The production of recombinant coagulation factors has increased the worldwide capacity for replacement therapy and facilitated aggressive prophylactic therapy. However, this has come at significant cost, and barriers remain to broad application of prophylaxis. Recombinant DNA technology remains a promising platform to develop novel hemophilia therapeutics with improved functional properties to try to overcome some of these remaining barriers. Bioengineering strategies have produced novel therapeutics with increased production efficiency, increased potency and resistance to inactivation, prolonged plasma half-lives, and reduced immunogenicity. Alternative nonbiologic therapies may lead to new treatment paradigms. The current pipeline of new technologies and products is promising and growing with several agents already advancing from preclinical to clinical trials.
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35
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Amby LK, Seremetis S, Obergfell A, Bjerre J. Challenges of defining reliable clinical surrogate end points in haemophilia trials: a critical review. Blood Coagul Fibrinolysis 2010; 20:488-93. [PMID: 19543078 DOI: 10.1097/mbc.0b013e32832c8803] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The success of a treatment in haemophilia patients experiencing a bleeding episode is very difficult to define. A variety of efficacy assessment tools have been developed in an effort to better assess when haemostasis has been achieved. These assessment tools are particularly important for the evaluation of the efficacy of therapeutic agents whose mechanism of action is based on pharmacological activity in haemostasis rather than upon the principle of 'replacement therapy'. This review focuses on a number of efficacy measures, summarizing their methodology and discussing their validity. In addition, future developments and requirements in order to evaluate the effectiveness of haemostatic treatment are discussed. The majority of end points used for evaluation of haemostasis relate to the relief of symptoms arising from bleeds. The results of this review highlight that several efficacy end points are frequently combined in order to provide a more comprehensive assessment of efficacy. Key limitations of current methodology are the subjectivity of assessment by either the patient or clinician, and the incomparability of results between trials.
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36
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Puetz J. Optimal use of recombinant factor VIIa in the control of bleeding episodes in hemophilic patients. DRUG DESIGN DEVELOPMENT AND THERAPY 2010; 4:127-37. [PMID: 20689699 PMCID: PMC2915537 DOI: 10.2147/dddt.s6628] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2010] [Indexed: 12/05/2022]
Abstract
One of the last remaining clinical hurdles in the treatment of people with hemophilia is the development of inhibitors. Alloantibodies or autoantibodies directed at coagulation factors render the infusion of coagulation factor concentrates ineffective, and alternative means must be used to achieve hemostasis. Recombinant factor VIIa (rFVIIa) was developed to control bleeding episodes in hemophilic patients with inhibitors. Clinical efficacy in achieving hemostasis in inhibitor patients was demonstrated by a compassionate-use protocol, as well as in randomized controlled trials. To date, over 1.5 million doses of rFVIIa have been given to inhibitor patients, with an excellent efficacy and safety record. Because of its short half-life, alternative means of dosing and infusing rFVIIa have been explored and are reviewed here.
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Affiliation(s)
- John Puetz
- Department of Pediatrics, Saint Louis University, St Louis, Missouri, USA.
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37
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Abstract
For patients with haemophilia, the development of inhibitors complicates treatment, and inhibitor patients may thus have a range of unmet needs. Although successful inhibitor eradication will render patients responsive to factor replacement therapy, with potentially beneficial effects on long-term outcomes, this may not always be possible. Physicians treating inhibitor patients should aim to achieve reliable control of bleeding episodes, and the prevention of joint disease should also be a priority. Patients with high-titre inhibitors require therapy with bypassing agents--recombinant activated factor VII (rFVIIa) or a plasma-derived activated prothrombin complex concentrate (pd-APCC)--for the treatment of bleeding. When treating joint haemorrhage in inhibitor patients, both aggressive treatment of intercurrent joint bleeds and prophylaxis should be considered, although evidence is needed as to whether prophylaxis with bypassing agents can significantly delay/prevent the development of osteochondral changes in patients with inhibitors. Despite physicians' best efforts, joint disease may ultimately occur in inhibitor patients, and in such instances optimizing treatment, of both early and late stages, is important. There is no single therapeutic modality for dealing with the various treatment challenges posed by inhibitor patients, but overall goals should be to improve quality of life, with the provision of cost-effective care that aims to maintain physical function.
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Affiliation(s)
- V S Blanchette
- Division of Hematology/Oncology, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
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38
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Combining FVIIa and FX into a mixture which imparts a unique thrombin generation potential to hemophilic plasma: an in vitro assessment of FVIIa/FX mixture as an alternative bypassing agent. Thromb Res 2010; 125:457-63. [DOI: 10.1016/j.thromres.2009.12.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Revised: 12/03/2009] [Accepted: 12/09/2009] [Indexed: 11/18/2022]
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AlGahtani FH, Alshaikh M, AlDiab A. Recombinant activated factor VII in controlling bleeding in non-hemophiliac patients. Ann Saudi Med 2010; 30:198-202. [PMID: 20427935 PMCID: PMC2886869 DOI: 10.4103/0256-4947.62830] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There have been recent reports on the successful use of recombinant factor VIIa (rFVIIa) in non-hemophiliac patients who have experienced heavy blood loss due to trauma with extensive organ damage and who have received multiple blood transfusions with hemostatic changes without success. The timing of administration, dosage, mortality, units of blood transfusion saved, risk of thrombotic events, and the risk/benefit ratio are still poorly defined. PATIENTS AND METHODS We conducted a retrospective review of all medical records of patients who received rFVIIa between January 2003 and March 2008. Data collection included demographic characteristics, diagnosis, indications, comorbidities, and amount of blood products used with rFVIIa, dose of rFVIIa, mortality, and adverse events. RESULTS We identified 45 patients, 27 (60%) males and 18 (40%) females, with a median age of 52 years. The median dose of rFVIIa was 40 microg/kg (range, 20-120 microg/kg). Five (11.1%) patients needed a second dose of rFVIIa (dose range of 20-85 microg/kg) whereas three patients (6.7%) needed a third dose of rFVIIa (dose range of 40-60 microg/kg). There was a marked and significant reduction in transfusion requirements for packed red blood cells (P=.0078). Overall transfusion requirements significantly decreased after the infusion of rFVIIa (P=.0323). Nineteen patients (42.2%) died and thrombosis was documented in 3 patients (6.7%). CONCLUSION Use of rFVIIa should be based on sound clinical evidence to balance the risks, benefits, and cost if used among non-hemophiliacs. Prospective randomized studies are needed to investigate the efficacy and cost-effectiveness of rFVIIa for this indication and to allow a final assessment of the importance of this treatment.
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Affiliation(s)
- Farjah H AlGahtani
- Division of Hematology, Department of Medicine, King Saud University, Riyadh, Saudi Arabia
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Chuansumrit A, Angchaisuksiri P, Sirachainan N. Critical appraisal of the role of recombinant activated factor VII in the treatment of hemophilia patients with inhibitors. J Blood Med 2010; 1:37-48. [PMID: 22282682 PMCID: PMC3262327 DOI: 10.2147/jbm.s6209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2010] [Indexed: 11/30/2022] Open
Abstract
Hemophilia patients with inhibitors faced the constraint of inadequate treatment for several years before the era of recombinant factor VIIa (rFVII). Initially, rFVIIa was used in the compassionate-use programs. After a worldwide license was issued, more than 1.5 million doses were administered. Bleeding of joints and muscles was controlled effectively by means of an early home treatment program, with either a standard dose of 90 μg/kg every 2 to 3 hours for a few doses or a single dose of 270 μg/kg. For more serious bleeding episodes or minor surgery, an initial dose of 90 μg/kg was given every 2 hours for 24 to 48 hours followed by increased intervals of 3 to 6 hours according to the severity of bleeding and efficacy of bleeding control. In cases of major surgery such as orthopedic procedures, the same regimen can be applied except for a higher initial dose of 120 to 180 μg/kg. However, increasing the dose should be considered if there are unexpected bleeding complications since the half-life and clearance of rFVIIa differ between individuals. In addition, prophylaxis is administered to a small number of patients. Finally, the reported thromboembolic events found in hemophilia patients with inhibitors receiving rFVIIa are extremely low, much less than 1%.
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Affiliation(s)
| | - Pantep Angchaisuksiri
- Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Levy JH, Levi M. A modified recombinant factor VIIa: can we make it work harder, better, faster, stronger? J Thromb Haemost 2009; 7:1514-6. [PMID: 19583825 DOI: 10.1111/j.1538-7836.2009.03546.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J H Levy
- Department of Anesthesiology, Emory University Hospital, Atlanta, GA, USA.
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Holmberg HL, Lauritzen B, Tranholm M, Ezban M. Faster onset of effect and greater efficacy of NN1731 compared with rFVIIa, aPCC and FVIII in tail bleeding in hemophilic mice. J Thromb Haemost 2009; 7:1517-22. [PMID: 19566792 DOI: 10.1111/j.1538-7836.2009.03532.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa, Novoseven) is currently used to control bleeding in hemophiliacs with inhibitors. A new rFVIIa variant, NN1731, with increased activity on the surface of activated platelets, has demonstrated a more potent and faster onset of reactivity than rFVIIa in various in vitro models. The present study aimed to investigate whether this translates into greater efficacy and faster promotion of hemostasis in vivo. METHOD AND RESULTS In a severe tail-bleeding model in hemophilia A mice, NN1731 demonstrated significantly greater efficacy than rFVIIa, plasma-derived activated prothrombin complex concentrate (pd-aPCC, FEIBA or FVIII (Refacto). Assessment of the blood loss over time showed that NN1731 significantly and dose-dependently reduced the blood loss in the first 5-min observation period, whereas the effect of rFVIIa, FVIII and pd-aPCC first became evident 5-10 min after injury. CONCLUSION This study shows that NN1731 has a greater efficacy and faster resolution of bleeding in a severe bleeding model in hemophilia A mice compared with any of the other agents tested.
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Affiliation(s)
- H L Holmberg
- Department of Haemostasis Pharmacology, Novo Nordisk, Maaloev, Denmark
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MARTINOWITZ U, LIVNAT T, ZIVELIN A, KENET G. Concomitant infusion of low doses of rFVIIa and FEIBA in haemophilia patients with inhibitors. Haemophilia 2009; 15:904-10. [DOI: 10.1111/j.1365-2516.2009.02028.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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PAN-PETESCH B, LAGUNA P, MITAL A, STANLEY J, TORCHET MF, SALEK SZ, SALAJ P. Single-dose (270 μg kg−1) recombinant activated factor VII for the treatment and prevention of bleeds in haemophilia A patients with inhibitors: experience from seven European haemophilia centres. Haemophilia 2009; 15:760-5. [DOI: 10.1111/j.1365-2516.2008.01968.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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SALAJ P, BRABEC P, PENKA M, POHLREICHOVA V, SMEJKAL P, CETKOVSKY P, DUSEK L, HEDNER U. Effect of rFVIIa dose and time to treatment on patients with haemophilia and inhibitors: analysis of HemoRec registry data from the Czech Republic. Haemophilia 2009; 15:752-9. [DOI: 10.1111/j.1365-2516.2009.02007.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tellier Z, André MH, Polack B. Management of Haemophilia A-Inhibitor Patients: Clinical and Regulatory Perspectives. Clin Rev Allergy Immunol 2009; 37:125-34. [DOI: 10.1007/s12016-009-8115-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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BERNTORP E. Differential response to bypassing agents complicates treatment in patients with haemophilia and inhibitors. Haemophilia 2009; 15:3-10. [DOI: 10.1111/j.1365-2516.2008.01931.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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TEITEL JM, CARCAO M, LILLICRAP D, MULDER K, RIVARD GE, ST-LOUIS J, SMITH F, WALKER I, ZOURIKIAN N. Orthopaedic surgery in haemophilia patients with inhibitors: a practical guide to haemostatic, surgical and rehabilitative care. Haemophilia 2009; 15:227-39. [DOI: 10.1111/j.1365-2516.2008.01840.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pereira J. Control of bleeding in cancer. Cancer Treat Res 2009; 148:305-326. [PMID: 19377932 DOI: 10.1007/978-0-387-79962-9_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Jaime Pereira
- Department of Hematology-Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Mechanisms of action of recombinant activated factor VII in the context of tissue factor concentration and distribution. Blood Coagul Fibrinolysis 2008; 19:743-55. [DOI: 10.1097/mbc.0b013e3283104093] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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