1
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Carcao M, Schiavulli M, Kulkarni R, Rendo P, Foster M, Santagostino E, Casiano S, Königs C. A post hoc analysis of previously untreated patients with severe hemophilia A who developed inhibitors in the PUPs A-LONG trial. Blood Adv 2024; 8:1494-1503. [PMID: 38266154 PMCID: PMC10951906 DOI: 10.1182/bloodadvances.2023011475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 01/10/2024] [Accepted: 01/14/2024] [Indexed: 01/26/2024] Open
Abstract
ABSTRACT Inhibitor development is a major therapeutic complication for people with hemophilia. The phase 3 PUPs A-LONG study evaluated the safety and efficacy of efmoroctocog alfa (a recombinant factor VIII Fc fusion protein, herein referred to as rFVIIIFc) in previously untreated patients (PUPs) with severe hemophilia A. Male PUPs <6 years old were enrolled and received rFVIIIFc; inhibitor development was the primary end point. Post hoc analyses, including patient treatment regimen patterns and timing of inhibitor development, descriptive and Kaplan-Meier analyses of time to first inhibitor-positive test by treatment regimen and by titer, and consumption, were performed to describe patients who developed inhibitors during PUPs A-LONG. We investigated patient characteristics (eg, demographics and genotype) and nongenetic risk factors (eg, intense factor exposure and central venous access device [CVAD] placement) that may predict inhibitor development and characteristics of inhibitor development (low-titer vs high-titer inhibitor). Baseline characteristics were similarly distributed for age, race, and ethnicity across both patients who were inhibitor-positive and those who were inhibitor-negative (all P > .05). High-risk F8 variants were associated with development of high-titer inhibitors (P = .028). High-titer inhibitor development was often preceded by the presence of a low-titer inhibitor. Patients whose low-titer inhibitor progressed to a high-titer inhibitor received a higher mean dose per infusion (98.4 IU/kg, n = 5) compared with those whose low-titer inhibitor resolved spontaneously (59.2 IU/kg, n = 7; P = .033) or persisted (45.0 IU/kg, n = 5; P = .047). There was no association between CVAD placement surgery and inhibitor development. Post hoc analyses suggest that F8 genotype and dose of factor are as important as inhibitor risk factors and require further investigation. This study was registered at ClinicalTrials.gov as #NCT02234323.
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Affiliation(s)
- Manuel Carcao
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | | | - Christoph Königs
- University Hospital Frankfurt, Goethe University, Frankfurt, Germany
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2
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Nguyen NH, Jarvi NL, Balu-Iyer SV. Immunogenicity of Therapeutic Biological Modalities - Lessons from Hemophilia A Therapies. J Pharm Sci 2023; 112:2347-2370. [PMID: 37220828 DOI: 10.1016/j.xphs.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 05/25/2023]
Abstract
The introduction and development of biologics such as therapeutic proteins, gene-, and cell-based therapy have revolutionized the scope of treatment for many diseases. However, a significant portion of the patients develop unwanted immune reactions against these novel biological modalities, referred to as immunogenicity, and no longer benefit from the treatments. In the current review, using Hemophilia A (HA) therapy as an example, we will discuss the immunogenicity issue of multiple biological modalities. Currently, the number of therapeutic modalities that are approved or recently explored to treat HA, a hereditary bleeding disorder, is increasing rapidly. These include, but are not limited to, recombinant factor VIII proteins, PEGylated FVIII, FVIII Fc fusion protein, bispecific monoclonal antibodies, gene replacement therapy, gene editing therapy, and cell-based therapy. They offer the patients a broader range of more advanced and effective treatment options, yet immunogenicity remains the most critical complication in the management of this disorder. Recent advances in strategies to manage and mitigate immunogenicity will also be reviewed.
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Affiliation(s)
- Nhan H Nguyen
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA; Currently at Truvai Biosciences, Buffalo, NY, USA
| | - Nicole L Jarvi
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Sathy V Balu-Iyer
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.
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3
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Morfini M, Agnelli Giacchiello J, Baldacci E, Carulli C, Castaman G, Giuffrida AC, Malcangi G, Rocino A, Siragusa S, Zanon E. Managing Relevant Clinical Conditions of Hemophilia A/B Patients. Hematol Rep 2023; 15:384-397. [PMID: 37367088 DOI: 10.3390/hematolrep15020039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/21/2023] [Accepted: 05/31/2023] [Indexed: 06/28/2023] Open
Abstract
The Medical Directors of nine Italian Hemophilia Centers reviewed and discussed the key issues concerning the replacement therapy of hemophilia patients during a one-day consensus conference held in Rome one year ago. Particular attention was paid to the replacement therapy needed for surgery using continuous infusion (CI) versus bolus injection (BI) of standard and extended half-life Factor VIII (FVIII) concentrates in severe hemophilia A patients. Among the side effects, the risk of development of neutralizing antibodies (inhibitors) and thromboembolic complications was addressed. The specific needs of mild hemophilia A patients were described, as well as the usage of bypassing agents to treat patients with high-responding inhibitors. Young hemophilia A patients may take significant advantages from primary prophylaxis three times or twice weekly, even with standard half-life (SHL) rFVIII concentrates. Patients affected by severe hemophilia B probably have a less severe clinical phenotype than severe hemophilia A patients, and in about 30% of cases may undergo weekly prophylaxis with an rFIX SHL concentrate. The prevalence of missense mutations in 55% of severe hemophilia B patients allows the synthesis of a partially changed FIX molecule that can play some hemostatic role at the level of endothelial cells or the subendothelial matrix. The flow back of infused rFIX from the extravascular to the plasma compartment allows a very long half-life of about 30 h in some hemophilia B patients. Once weekly, prophylaxis can assure a superior quality of life in a large severe or moderate hemophilia B population. According to the Italian registry of surgery, hemophilia B patients undergo joint replacement by arthroplasty less frequently than hemophilia A patients. Finally, the relationships between FVIII/IX genotypes and the pharmacokinetics of clotting factor concentrates have been investigated.
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Affiliation(s)
- Massimo Morfini
- Italian Association of Haemophilia Centers (AICE), 21121 Milan, Italy
| | - Jacopo Agnelli Giacchiello
- Hemostasis and Thrombosis Center, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Erminia Baldacci
- Haematology, "Umberto I" Policlinico, Department of Translational and Precision Medicine, Sapienza University of Rome, 00118 Rome, Italy
| | - Christian Carulli
- Department of Orthopaedic Surgery, Orthopaedic Clinic, University of Florence, 50121 Florence, Italy
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, 50121 Florence, Italy
| | | | - Giuseppe Malcangi
- UOSD Centro Emofilia e Trombosi, Azienda Ospedaliero Universitaria Policlinico di Bari, 70121 Bari, Italy
| | - Angiola Rocino
- Haemophilia and Thrombosis Centre, Haematology, S.M. di Loreto Nuovo Hospital, 80121 Naples, Italy
| | - Sergio Siragusa
- Department PROMISE, University of Palermo, 90121 Palermo, Italy
| | - Ezio Zanon
- Haemophilia Centre, General Medicine, Padua University Hospital, 35121 Padua, Italy
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4
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Fraticelli L, Freyssenge J, Promé-Combel E, Agnellet E, Dargaud Y, Chamouard V. Evaluation of the Care Pathway in the Context of the Dispensing of Emicizumab (Hemlibra) in Community Pharmacies in France: Protocol for a Cross-sectional Study Based on the Kirkpatrick Model. JMIR Res Protoc 2023; 12:e43091. [PMID: 36884286 PMCID: PMC10034610 DOI: 10.2196/43091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Commercialized since 2019, emicizumab (Hemlibra) was available only in French hospital pharmacies for prophylaxis of hemophilia A with or without inhibitors. Since June 15, 2021, patients can choose between a hospital and community pharmacy. These changes in the care pathway have important organizational consequences for patients, their relatives, and health professionals. Two training programs are available for community pharmacists: the "HEMOPHAR" training program proposed by the national reference center for hemophilia and the Roche training program proposed by the laboratory that markets the product. OBJECTIVE The PASODOBLEDEMI study aims to evaluate the direct impact of the training programs provided to community pharmacists in the context of the dispensing of emicizumab, and to evaluate patients' satisfaction with their treatment whether they choose dispensation from a community pharmacy or retained dispensation from the hospital pharmacy. METHODS We designed a cross-sectional study based on the 4-level Kirkpatrick evaluation model: the immediate reaction of community pharmacists following training (Reaction), the knowledge acquired during the training (Learning), the professional practice of community pharmacists during dispensing of the product (Behavior), and patients' satisfaction related to the treatment whether it is dispensed from a hospital or from a community pharmacy (Results). RESULTS Considering that single outcome measures cannot adequately reflect the complexity of this new organization, the Kirkpatrick evaluation model provides 4 distinct outcomes: the immediate reaction after the HEMOPHAR training program, the level of knowledge acquired after the HEMOPHAR training program, the impact of training on professional practice, and patient satisfaction with access to emicizumab. We developed specialized questionnaires for each of the 4 levels of the Kirkpatrick evaluation model. All community pharmacists involved in dispensing emicizumab, whether they have followed the HEMOPHAR or the Roche training program or neither, were eligible for inclusion. All patients with severe hemophilia A were eligible, irrespective of inhibitor use, age, treatment with emicizumab, and whether they chose dispensation from a community pharmacy or retained dispensation from a hospital pharmacy. CONCLUSIONS The new organization for dispensing emicizumab to patients with hemophilia A in French community pharmacies must be accompanied by optimal safety and quality conditions due to the risk of serious and urgent bleeding situations in the management of rare bleeding diseases. The elaboration of the PASODOBLEDEMI protocol has already a positive impact with the commitment of all health professionals, physicians, hospital and community pharmacists, and the patient community. The results will be disseminated among the French authorities and will enable, if necessary, proposing this access model to other rare diseases. TRIAL REGISTRATION ClinicalTrials.gov NCT05449197, https://clinicaltrials.gov/ct2/show/NCT05449197?term=NCT05449197; ClinicalTrials.gov NCT05450640, https://clinicaltrials.gov/ct2/show/NCT05450640?term=NCT05450640. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/43091.
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Affiliation(s)
- Laurie Fraticelli
- Laboratory P2S (Health Systemic Process), UR 4129, University Claude Bernard Lyon 1, University of Lyon, Lyon, France
| | - Julie Freyssenge
- Research on Healthcare Performance RESHAPE, INSERM U1290, University Claude Bernard Lyon 1, University of Lyon, Lyon, France
| | - Emilie Promé-Combel
- French Reference Center of Hemophilia and Rare Inherited Bleeding Disorder, Louis Pradel Hospital, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Eléonore Agnellet
- Pharmaceutical Unit, Louis Pradel Hospital, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Yesim Dargaud
- French Reference Center of Hemophilia and Rare Inherited Bleeding Disorder, Louis Pradel Hospital, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Valérie Chamouard
- French Reference Center of Hemophilia and Rare Inherited Bleeding Disorder, Louis Pradel Hospital, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
- Pharmaceutical Unit, Louis Pradel Hospital, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
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5
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Zwagemaker A, Kloosterman FR, Coppens M, Gouw SC, Boyce S, Bagot CN, Beckers EAM, Brons P, Castaman G, Eikenboom J, Jackson S, Kruip MJHA, Leebeek FWG, Meijer K, Nieuwenhuizen L, Pabinger I, Fijnvandraat K. Desmopressin for bleeding in non‐severe hemophilia A: Suboptimal use in a real‐world setting. Res Pract Thromb Haemost 2022; 6:e12777. [PMID: 36090159 PMCID: PMC9433315 DOI: 10.1002/rth2.12777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/28/2022] [Accepted: 06/23/2022] [Indexed: 12/03/2022] Open
Abstract
Background Desmopressin is an important treatment option in nonsevere hemophilia A because it has several benefits compared with factor (F) concentrates, including no inhibitor risk and much lower costs. Despite these advantages, data are limited on the real‐world use of desmopressin in the treatment of bleeds. Objective To describe the clinical use of desmopressin in relation to other therapeutic modalities in the treatment of bleeding episodes in patients with nonsevere hemophilia A. Methods Patients with nonsevere hemophilia A aged 12–55 years were included from the DYNAMO cohort study. Data on the desmopressin test response and treated bleeding events in the period January 2009 to July 2020 were retrospectively collected from medical files. An adequate desmopressin test response was defined based on a peak FVIII level of ≥30 IU/dl. Results A total of 248 patients with a median age of 38 years (interquartile range 25–49) were included. An adequate desmopressin test response was documented in 25% and 73% of patients with moderate and mild hemophilia, respectively. In adequate responders, 51% of bleeds were exclusively treated with FVIII concentrates, 24% exclusively with desmopressin, 21% with a combination of both and 4% with other treatments. In 54% of bleeds treated with a single dose of factor concentrates, the expected FVIII level after desmopressin exceeded the level targeted. Conclusion Most bleeds in patients with an adequate response to desmopressin are treated with factor concentrates. These findings may indicate a suboptimal use of desmopressin and that barriers to the use of desmopressin should be explored.
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Affiliation(s)
- Anne‐Fleur Zwagemaker
- Amsterdam UMC University of Amsterdam, Emma Children's Hospital, Pediatric Hematology Amsterdam The Netherlands
| | - Fabienne R. Kloosterman
- Amsterdam UMC University of Amsterdam, Emma Children's Hospital, Pediatric Hematology Amsterdam The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine Amsterdam University Medical Centers Amsterdam The Netherlands
| | - Samantha C. Gouw
- Amsterdam UMC University of Amsterdam, Emma Children's Hospital, Pediatric Hematology Amsterdam The Netherlands
| | - Sara Boyce
- Department of Haematology University Hospital Southampton Southampton UK
| | | | - Erik A. M. Beckers
- Department of Internal Medicine, Division of Hematology, CARIM School for Cardiovascular Diseases Maastricht University Medical Center Maastricht The Netherlands
| | - Paul Brons
- Department of Pediatric Hemato‐Oncology Radboud University Medical Center Nijmegen The Netherlands
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders Careggi University Hospital Florence Italy
| | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis Leiden University Medical Center Leiden The Netherlands
| | - Shannon Jackson
- Adult Bleeding Disorders Program of BC ‐ Adult Division St. Paul's Hospital Vancouver British Columbia Canada
| | - Marieke J. H. A. Kruip
- Department of Hematology Erasmus MC, Erasmus University Medical Center Rotterdam The Netherlands
| | - Frank W. G. Leebeek
- Department of Hematology Erasmus MC, Erasmus University Medical Center Rotterdam The Netherlands
| | - Karina Meijer
- Department of Hematology University Medical Center Groningen, University of Groningen Groningen The Netherlands
| | | | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology Medical University of Vienna Vienna Austria
| | - Karin Fijnvandraat
- Amsterdam UMC University of Amsterdam, Emma Children's Hospital, Pediatric Hematology Amsterdam The Netherlands
- Department of Molecular Cellular Hemostasis Sanquin Research and Landsteiner Laboratory Amsterdam The Netherlands
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6
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Nonneutralizing FVIII-specific antibody signatures in patients with Hemophilia A and in healthy donors. Blood Adv 2021; 6:946-958. [PMID: 34847225 PMCID: PMC8945293 DOI: 10.1182/bloodadvances.2021005745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/29/2021] [Indexed: 11/21/2022] Open
Abstract
Isotypes and IgG subclasses of nonneutralizing FVIII-specific antibodies are similar in hemophilia A patients and healthy subjects. Prevalences, titers, and affinities of nonneutralizing antibodies, however, differ significantly between patients and healthy subjects.
Previous studies identified nonneutralizing FVIII-specific antibodies in the circulation of severe and nonsevere hemophilia A (sHA and nsHA) patients without FVIII inhibitors and also in some healthy individuals. To gain a better understanding of the nature of these nonneutralizing antibody responses, we analyzed and compared anti-FVIII antibody signatures in 3 study cohorts: previously treated sHA as well as nsHA patients without FVIII inhibitors, and healthy donors. FVIII-binding IgM, IgG1-4, and IgA antibodies were differentiated, FVIII-specificity was assessed, and associated apparent affinity constants were determined. Our results indicate that the nonneutralizing FVIII-specific antibody response in all study cohorts is dominated by IgG1 and IgA. Prevalences, titers, and affinities of these nonneutralizing antibodies were higher in the hemophilia A cohorts than in healthy donors. Stratification for the anti-hepatitis C virus (HCV) antibody status demonstrated the presence of FVIII-specific IgA with elevated titers in sHA patients with an active or past HCV infection when compared with HCV antibody-positive nsHA patients or HCV antibody-negative patients and healthy donors. Increased titers and affinities of FVIII-specific IgG1 antibodies were observed in a considerable number of hemophilia A patients as opposed to healthy subjects independently of the patients’ anti-HCV antibody status. Overall, our findings support the hypothesis that the generation of nonneutralizing anti-FVIII antibodies in healthy individuals and in noninhibitor hemophilia A patients might be based on similar immune mechanisms. However, differences in prevalences, titers, and affinities of these antibodies indicate distinct differences in the antibody evolution between healthy individuals and patients.
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7
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Astermark J, Ay C, Carvalho M, D'Oiron R, Moerloose PD, Dolan G, Fontana P, Hermans C, Holme PA, Katsarou O, Kenet G, Klamroth R, Mancuso ME, Marquardt N, Núñez R, Pabinger I, Tait R, Valk PVD. New Inhibitors in the Ageing Population: A Retrospective, Observational, Cohort Study of New Inhibitors in Older People with Hemophilia. Thromb Haemost 2021; 122:905-912. [PMID: 34507368 DOI: 10.1055/a-1642-4067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION A second peak of inhibitors has been reported in patients with severe hemophilia A (HA) aged >50 years in the United Kingdom. The reason for this suggested breakdown of tolerance in the aging population is unclear, as is the potential impact of regular exposure to the deficient factor by prophylaxis at higher age. No data on hemophilia B (HB) have ever been reported. AIM The ADVANCE Working Group investigated the incidence of late-onset inhibitors and the use of prophylaxis in patients with HA and HB aged ≥40 years. METHODS A retrospective, observational, cohort, survey-based study of all patients aged ≥40 years with HA or HB treated at an ADVANCE hemophilia treatment center. RESULTS Information on 3,095 people aged ≥40 years with HA or HB was collected. Of the 2,562 patients with severe HA, the majority (73% across all age groups) received prophylaxis. In patients with severe HA, the inhibitor incidence per 1,000 treatment years was 2.37 (age 40-49), 1.25 (age 50-59), and 1.45 (age 60 + ). Overall, the inhibitor incidence was greatest in those with moderate HA (5.77 [age 40-49], 6.59 [age 50-59], and 4.69 [age 60 + ]) and the majority of inhibitor cases were preceded by a potential immune system challenge. No inhibitors in patients with HB were reported. CONCLUSION Our data do not identify a second peak of inhibitor development in older patients with hemophilia. Prophylaxis may be beneficial in older patients with severe, and possibly moderate HA, to retain a tolerant state at a higher age.
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Affiliation(s)
- Jan Astermark
- Department for Translational Medicine, Skane University Hospital, Lund University, Malmö, Sweden
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University Vienna, Vienna, Austria
| | - Manuela Carvalho
- Department of Immunohemotherapy, Centro Hospitalar de Sao Joao, Porto, Portugal
| | | | | | - Gerard Dolan
- Centre for Haemostasis and Thrombosis, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Pierre Fontana
- Haemostasis Unit and Laboratory, University Hospitals of Geneva, Geneva, Switzerland
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Saint-Luc University Hospital, Brussels, Belgium
| | - Pål Andre Holme
- Department of Haematology, Institute of Clinical Medicine, Oslo Universit Hospital, Rikshospitalet, Oslo, Norway
| | - Olga Katsarou
- Department of Hematology, Laiko University Hospital, Athens, Attica, Greece
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.,Sackler Faculty of Medicine, The Amalia Biron Thrombosis Research Institute, Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Robert Klamroth
- Department of Angiology and Coagulation Disorders, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Maria Elisa Mancuso
- Hemophilia and Thrombosis Center, Fondazione Ospedale Maggiore Policlinico, Milan, Italy.,Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Natascha Marquardt
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Ramiro Núñez
- Hemophilia Unit, Hospital Universitario Virgen del Rocio, Sevilla, Andalucía, Spain
| | - Ingrid Pabinger
- Department of Haematology and Haemostaseology, Allgemeines Krankenhaus (AKH) - Innere Medizin, Wien, Austria
| | - Robert Tait
- Haemophilia and Thrombosis Centre, Royal Infirmary Glasgow, Glasgow, Strathclyde, United Kingdom of Great Britain and Northern Ireland
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8
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Abdi A, Eckhardt CL, van Velzen AS, Vuong C, Coppens M, Castaman G, Hart DP, Hermans C, Laros‐van Gorkom B, Leebeek FWG, Mancuso ME, Mazzucconi MG, McRae S, Oldenburg J, Male C, van der Bom JG, Fijnvandraat K, Gouw SC. Treatment-related risk factors for inhibitor development in non-severe hemophilia A after 50 cumulative exposure days: A case-control study. J Thromb Haemost 2021; 19:2171-2181. [PMID: 34107158 PMCID: PMC8457239 DOI: 10.1111/jth.15419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/01/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Non-severe hemophilia A patients have a life-long inhibitor risk. Yet, no studies have analyzed risk factors for inhibitor development after 50 factor VIII (FVIII) exposure days (EDs). OBJECTIVES This case-control study investigated treatment-related risk factors for inhibitor development in non-severe hemophilia A and assessed whether these risk factors were different for early versus late inhibitor development. PATIENTS/METHODS Non-severe hemophilia A patients (FVIII:C 2%-40%) were selected from the INSIGHT study. Inhibitor-positive patients were defined as early (<50 EDs) or late (>50EDs) cases and matched to 1-4 inhibitor-negative controls by year of birth, cumulative number of EDs, and center/country. We investigated treatment intensity during the last 10 EDs prior to inhibitor development. Intensive treatment was defined as: surgery, peak treatment (10 consecutive EDs), and high mean FVIII dose (>45 IU/kg/ED). Odds ratios (OR) were calculated by logistic regression. RESULTS Of 2709 patients, we analyzed 63 early and 26 late cases and 195 and 71 respectively matched controls. Peak treatment was associated with early and late inhibitor risk (crude OR 1.8, 95% confidence interval [CI] 1.0-3.4; 4.0, 95%CI 1.1-14.3). This association was slightly less pronounced after adjustment for mean FVIII dose. High mean FVIII dose was also associated with early and late inhibitor risk (crude OR 2.8, 95%CI 1.5-5.1; 4.5, 95%CI 1.2-16.6). Surgery increased inhibitor risk for early cases. This was less pronounced for late cases. CONCLUSIONS Our findings suggest that intensive FVIII treatment remains a risk factor for inhibitor development in non-severe hemophilia A after more than 50 EDs. Therefore, persistent caution is required throughout the life-time treatment course.
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Affiliation(s)
- Amal Abdi
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Corien L. Eckhardt
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Alice S. van Velzen
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Caroline Vuong
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Michiel Coppens
- Vascular MedicineAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
| | - Giancarlo Castaman
- OncologyCenter for Bleeding Disorders and CoagulationCareggi University HospitalFlorenceItaly
| | - Dan P. Hart
- Barts and The London School of Medicine and DentistryThe Royal London Hospital Haemophilia CentreQMULLondonUK
| | - Cedric Hermans
- Haemostasis and Thrombosis UnitCliniques Universitaires Saint‐LucUniversité Catholique de LouvainBrusselsBelgium
| | | | - Frank W. G. Leebeek
- HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic DiseasesHumanitas Clinical and Research CenterRozzanoItaly
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center MilanFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
| | | | - Simon McRae
- HematologyLaunceston General HospitalLauncestonTasmaniaAustralia
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine BonnUniversity Clinic BonnBonnGermany
| | | | - Johanna G. van der Bom
- Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Center for Clinical Transfusion ResearchSanquin ResearchLeidenThe Netherlands
| | - Karin Fijnvandraat
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Molecular Cellular HemostasisSanquin Research and Landsteiner LaboratoryAmsterdamThe Netherlands
| | - Samantha C. Gouw
- Pediatric HematologyEmma Children’s HospitalAmsterdam University Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
- Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
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9
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Kocher F, Seeber A, Kerschbaumer J, Schmidt S, Wolf D, Feistritzer C. Case report: successful perioperative management of patients with haemophilia A using an extended half-life factor VIII (Efmoroctocog alfa) during neurosurgical procedures. Ther Adv Hematol 2021; 12:2040620721993686. [PMID: 33868623 PMCID: PMC8020741 DOI: 10.1177/2040620721993686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/14/2021] [Indexed: 11/17/2022] Open
Abstract
Patients with haemophilia A (HA) undergoing neurosurgical procedures have a high risk of haemorrhage with potential fatal outcome. Here, we present a successful perioperative haemostatic concept applying an extended half-life factor VIII (EHL FVIII), Efmoroctocog alfa, in two patients with HA undergoing neurosurgery for paramedian right-sided disc herniation (case 1) and astrocytoma (case 2). After adequate EHL FVIII treatment the surgical procedures were performed without any bleeding complications despite the high-risk interventions. Laboratory measurements confirmed stable FVIII levels throughout the hospital stay. We suggest close interdisciplinary collaboration between involved clinicians as mandatory prerequisite for an optimized perioperative management in patients with HA. The presented cases indicate, that the increased stability, safety and fewer injections provide a rationale to use EHL FVIII products in HA patients undergoing surgical interventions with a very high bleeding risk.
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Affiliation(s)
- Florian Kocher
- Department of Internal Medicine V, Hematology & Oncology, Medical University of Innsbruck, Austria
| | - Andreas Seeber
- Department of Internal Medicine V, Hematology & Oncology, Medical University of Innsbruck, Austria
| | | | - Stefan Schmidt
- Department of Internal Medicine V, Hematology & Oncology, Medical University of Innsbruck, Austria
| | - Dominik Wolf
- Department of Internal Medicine V, Hematology & Oncology, Medical University of Innsbruck, Austria
| | - Clemens Feistritzer
- Department of Internal Medicine V, Hematology & Oncology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, Tyrol 6020, Austria
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10
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Pabinger I, Mamonov V, Windyga J, Engl W, Doralt J, Tangada S, Spotts G, Ewenstein B. Results of a randomized phase III/IV trial comparing intermittent bolus versus continuous infusion of antihaemophilic factor (recombinant) in adults with severe or moderately severe haemophilia A undergoing major orthopaedic surgery. Haemophilia 2021; 27:e331-e339. [PMID: 33772963 PMCID: PMC8252548 DOI: 10.1111/hae.14219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 12/01/2022]
Abstract
Introduction In patients with haemophilia A undergoing surgery, factor VIII (FVIII) replacement therapy by continuous infusion (CI) may offer an alternative to bolus infusion (BI). Aim To compare the perioperative haemostatic efficacy and safety of antihaemophilic factor (recombinant) (ADVATE®; Baxalta US Inc., a Takeda company, Lexington, MA, USA) CI or BI administration. Methods In this multicentre, phase III/IV, controlled study (NCT00357656), 60 previously treated adult patients with severe or moderately severe disease undergoing elective unilateral major orthopaedic surgery (knee replacement, n = 48; hip surgery, n = 4; other, n = 8) requiring drain placement were randomized to receive antihaemophilic factor (recombinant) CI (n = 29) or BI (n = 31) through postoperative day 7. Primary outcome measure was cumulative packed red blood cell (PRBC)/blood volume in the drainage fluid within 24 h after surgery, used to establish non‐inferiority of CI to BI. Results CI:BI ratio of cumulative PRBC volume in the 24‐h drainage fluid was 0.92 (p‐value <.001 for non‐inferiority; 95% confidence interval, 0.82–1.05). Total antihaemophilic factor (recombinant) dose per kg body weight received in the combined trans‐ and postoperative periods was similar with CI and BI to maintain targeted FVIII levels during/after surgery. Treatment‐related adverse events (AEs) were reported in five patients treated by CI (eight events) and five treated by BI (six events), including two serious AEs in each arm. Conclusion CI administration of antihaemophilic factor (recombinant) is a viable alternative to BI in patients with haemophilia A undergoing major orthopaedic surgery, providing comparable efficacy and safety.
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Affiliation(s)
| | | | - Jerzy Windyga
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Werner Engl
- Baxalta Innovations GmbH, a Takeda company, Vienna, Austria
| | | | - Srilatha Tangada
- Baxalta US Inc., a Takeda company, Cambridge, Massachusetts, USA
| | - Gerald Spotts
- Baxalta US Inc., a Takeda company, Cambridge, Massachusetts, USA
| | - Bruce Ewenstein
- Baxalta US Inc., a Takeda company, Cambridge, Massachusetts, USA
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11
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Ganju N, Rajendran J, Aggarwal M, Dash N. Inhibitor development in mild haemophilia after a major surgery for periampullary cancer (Whipple's procedure) in an elderly man. BMJ Case Rep 2021; 14:e239207. [PMID: 33514621 PMCID: PMC7849882 DOI: 10.1136/bcr-2020-239207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2020] [Indexed: 01/31/2023] Open
Abstract
Around the world, with the availability of factor concentrates, patients with haemophilia have undergone major and minor surgeries. Inhibitor development in early postoperative period leading to inadequate factor recovery and ongoing bleeding is a nightmare for both operating surgeon as well as haematologists. We describe a case of an elderly man with mild haemophilia A, who was diagnosed with pancreatic carcinoma and underwent Whipple's procedure. After an uneventful procedure, he developed high-titre inhibitors and bleeding a week after surgery posing major challenges in his management. The case highlights the importance of experienced surgeons, trained haematologists, regular monitoring of factor assay/inhibitors, adequate factor and bypassing-agent support while performing such procedures.
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Affiliation(s)
- Neha Ganju
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Jayapal Rajendran
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, New Delhi, India
| | - Mukul Aggarwal
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Nihar Dash
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, New Delhi, India
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12
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Important decrease in invariant natural killer T, CD4+ regulatory T cells, CD8+ regulatory T cells, gamma-delta T cells, and CD4+ T lymphocytes in HIV-negative patients with hemophilia. Blood Coagul Fibrinolysis 2021; 32:8-15. [PMID: 33148947 DOI: 10.1097/mbc.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hereditary hemophilias are X-linked inherited bleeding disorders defined as deficiencies of the coagulation factors VIII or IX. They are characterized by easy to provoke or spontaneous bleeding. HIV infection in hemophilic patients is a risk factor for the reduction of CD4+ T cells. There is no information regarding the cellular immune function in HIV-negative patients with hemophilia. To evaluate the number of lymphocyte subsets in adult patients with hemophilia A or B as compared with healthy donors. 39 Adult hemophilics and 27 healthy donors were included. Lymphocyte subsets [CD4 and CD8 T cells, natural killer cells, natural killer T (NKT) cells, invariant NKT (iNKT) cells, gamma-delta T (γδT) cells, type 1 and 2 dendritic cells, CD14 monocytes, CD4 and CD8 regulatory T cells (Tregs), and B cells], were analyzed by flow cytometry. A significant decrease of CD4+ T lymphocytes, γδT cells, iNKT cells, CD4+ and CD8+ Tregs was observed in patients with hemophilia. Those patients having factor VIII inhibitor had the lowest CD4+ Treg and CD8+ Treg counts. CD14 monocytes were increased, as well as iNKT and type 2 dendritic cells in obese-overweight hemophilics. CD4+ lymphocytes, iNKT, γδT cells, and Tregs (CD4+ and CD8+), are significantly decreased in patients with hemophilia. Depletion of Tregs is more important in patients with factor VIII inhibitor. Physicians caring for hemophilia patients should realize that, even when they are not suffering infections frequently, may have early evidence of cellular immunodeficiency.
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13
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Amos LE, Yoo B, Miller N, Farrow EG, Walter A, Gibson M, Durham S, Herd S, Soden S, Carpenter SL. Using dried blood spots for variant analysis for patients with haemophilia. Haemophilia 2019; 25:e339-e341. [PMID: 31361374 DOI: 10.1111/hae.13824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 06/19/2019] [Accepted: 06/26/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Lauren E Amos
- Division of Hematology/Oncology, Children's Mercy Hospital, Kansas City, Missouri, USA.,Center for Pediatric Genomic Medicine, Children's Mercy Hospital, Kansas City, Missouri, USA.,Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Byunggil Yoo
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Neil Miller
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Emily G Farrow
- Center for Pediatric Genomic Medicine, Children's Mercy Hospital, Kansas City, Missouri, USA.,Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Adam Walter
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Margaret Gibson
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Sara Durham
- Division of Hematology/Oncology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Suzanne Herd
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Sarah Soden
- Center for Pediatric Genomic Medicine, Children's Mercy Hospital, Kansas City, Missouri, USA.,Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Shannon L Carpenter
- Division of Hematology/Oncology, Children's Mercy Hospital, Kansas City, Missouri, USA.,Center for Pediatric Genomic Medicine, Children's Mercy Hospital, Kansas City, Missouri, USA.,Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri, USA
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14
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Chang CY, Perng CL, Cheng SN, Hu SH, Wu TY, Lin SY, Chen YC. Deep intronic variant c.5999-277G>A of F8 gene may be a hot spot mutation for mild hemophilia A patients without mutation in exonic DNA. Eur J Haematol 2019; 103:47-55. [PMID: 31063249 DOI: 10.1111/ejh.13242] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/25/2019] [Accepted: 04/26/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND In 10%-18% of mild-type hemophilia A (HA) patients, mutations cannot be found by routine DNA analysis. OBJECTIVE We aimed to identify the genetic defects by mRNA analysis of F8 gene in mild HA patients without mutation in exonic DNA. PATIENTS AND METHODS From 2006 to 2016, we identified F8 exon mutations in 39 of 49 mild HA patients using routine genetic testing. We then evaluated the 10 remaining patients from six unrelated families without exonic DNA mutation by performing cDNA sequence analysis. RESULTS Nine of the 10 (90%) patients were confirmed to have F8 gene mutation. Eight patients from four unrelated families were notably found to have presence of an aberrant 675-bp fragment. Sequencing of this fragment showed that there were two separate new alternative splicing exons of 35 bp and 55 bp within intron 18, which formed a 90-bp insertion between exon 18 and exon 19 (E18ins90bpE19) in the mRNA. Based on direct sequencing, this alternative splicing transcript appears to have resulted from deep intronic variant c.5999-277G>A of intron 18. CONCLUSIONS Our study suggests that deep intronic variant of c.5999-277G>A may be a hot spot mutation for mild hemophilia patients without mutation in exonic DNA.
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Affiliation(s)
- Chia-Yau Chang
- School of Medicine, Graduate Institute of Clinical Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Pediatric Hematology/Oncology, Hemophilia Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Cherng-Lih Perng
- Division of Clinical Pathology, Department of Pathology, Tri-Service General Hospital, Taipei, Taiwan.,Graduate Institute of Pathology, National Defense Medical Center, Taipei, Taiwan
| | - Shin-Nan Cheng
- Hemophilia Care and Research Center, Tri-Service General Hospital, Taipei, Taiwan.,Department of Pediatrics, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan.,Department of Pediatrics, National Defense Medical Center, Taipei, Taiwan
| | - Shu-Hsia Hu
- Hemophilia Care and Research Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Tzu-Ying Wu
- Hemophilia Care and Research Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Shyr-Yi Lin
- School of Medicine, Graduate Institute of Clinical Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Gastroenterology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yeu-Chin Chen
- Hemophilia Care and Research Center, Tri-Service General Hospital, Taipei, Taiwan.,Division of Hematology/Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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15
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Schep SJ, Boes M, Schutgens RE, van Vulpen LF. An update on the ‘danger theory’ in inhibitor development in hemophilia A. Expert Rev Hematol 2019; 12:335-344. [DOI: 10.1080/17474086.2019.1604213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Sarah J. Schep
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marianne Boes
- Department of Pediatrics, Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger E.G. Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lize F.D. van Vulpen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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16
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Holme PA, Tjønnfjord GE. Continuous infusion of simoctocog alfa in haemophilia A patients undergoing surgeries. Haemophilia 2018; 25:54-59. [PMID: 30394617 DOI: 10.1111/hae.13625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/04/2018] [Accepted: 10/04/2018] [Indexed: 01/19/2023]
Abstract
INTRODUCTION There are two major principles for coagulation factor replacement in the clinical management of surgical procedures in patients with haemophilia, repetitive bolus injections every 6-12 hours or administration of coagulation factor concentrates by continuous infusion. AIM The aim was to investigate the efficacy of simoctocog alfa (human-cl rhFVIII) delivered by continuous infusion for bleeding prophylaxis during surgery in patients with haemophilia A. METHODS We investigated the use of continuous infusion with simoctocog alfa in haemophilia A patients undergoing major surgical procedures at Oslo University Hospital from September 2015 to March 2018. The objectives were haemostatic outcome, in vivo recovery, stability over time at room temperature (3 days) and inhibitor development. RESULTS Simoctocog alfa demonstrated treatment success in terms of haemostatic efficacy in 100% of major surgeries used as CI: 87% (n=21) excellent; 13% (n=3) good. No erythrocyte transfusions were required in any patient, no adverse events occurred and no inhibitors developed. The product was stable for 3 days at room temperature without loss of activity. Mean in vivo recovery was 1.8 (0.3) (IU/mL/IU/kg). CONCLUSION Continuous infusion with simoctocog alfa was found to achieve good/excellent haemostatic efficacy in all procedures. No adverse events occurred and no inhibitors developed.
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Affiliation(s)
- Pål Andre Holme
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Geir E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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17
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Franchini M, Marano G, Pupella S, Vaglio S, Veropalumbo E, Liumbruno GM. Management of mild hemophilia A. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1529563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Massimo Franchini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy
| | - Giuseppe Marano
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Simonetta Pupella
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
| | - Eva Veropalumbo
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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18
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19
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Pfeiffer C, Batorova A, Giansily-Blaizot M, Schved J, Mariani G, Pinotti M, Branchini A, Baroni M, Bernardi F. Coagulation factor VII variants resistant to inhibitory antibodies. Thromb Haemost 2017; 112:972-80. [DOI: 10.1160/th14-03-0198] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 06/19/2014] [Indexed: 11/05/2022]
Abstract
SummaryReplacement therapy is currently used to prevent and treat bleeding episodes in coagulation factor deficiencies. However, structural differences between the endogenous and therapeutic proteins might increase the risk for immune complications. This study was aimed at identifying factor (F)VII variants resistant to inhibitory antibodies developed after treatment with recombinant activated factor VII (rFVIIa) in a FVII-deficient patient homozygous for the p.A354V-p.P464Hfs mutation, which predicts trace levels of an elongated FVII variant in plasma. We performed fluorescent bead-based binding, ELISA-based competition as well as fluorogenic functional (activated FX and thrombin generation) assays in plasma and with recombinant proteins. We found that antibodies displayed higher affinity for the active than for the zymogen FVII (half-maximal binding at 0.54 ± 0.04 and 0.78 ± 0.07 BU/ml, respectively), and inhibited the coagulation initiation phase with a second-order kinetics. Isotypic analysis showed a polyclonal response with a large predominance of IgG1. We hypothesised that structural differences in the carboxyl-terminus between the inherited FVII and the therapeutic molecules contributed to the immune response. Intriguingly, a naturally-occurring, poorly secreted and 5-residue truncated FVII (FVII-462X) escaped inhibition. Among a series of truncated rFVII molecules, we identified a well-secreted and catalytically competent variant (rFVII-464X) with reduced binding to antibodies (half-maximal binding at 0.198 ± 0.003 BU/ml) as compared to the rFVII-wt (0.032 ± 0.002 BU/ml), which led to a 40-time reduced inhibition in activated FX generation assays. Taken together our results provide a paradigmatic example of mutation-related inhibitory antibodies, strongly support the FVII carboxyl-terminus as their main target and identify inhibitor-resistant FVII variants.
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20
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Diagnosis and care of patients with mild haemophilia: practical recommendations for clinical management. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2017; 16:535-544. [PMID: 29328905 DOI: 10.2450/2017.0150-17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/26/2017] [Indexed: 12/17/2022]
Abstract
Mild haemophilia is defined by factor levels between 0.05 and 0.40 IU/mL and is characterised by traumatic bleeds. Major issues associated with mild haemophilia are that it may not present for many years after birth, and that awareness, even within families, may be low. Methodological problems exist in diagnosis, such as inconsistencies in results obtained from different assays used to measure factor levels in mild haemophilia. Advances in genetic testing provide insight into diagnosis as well as the likelihood of inhibitor development, which is not uncommon in patients with mild or moderate haemophilia and can increase morbidity. The management of patients with mild haemophilia is a challenge. This review includes suggestions around formulating treatment plans for these patients, encompassing the full spectrum from clinical care of the newly diagnosed neonate to that of the ageing patient with multiple comorbidities. Management strategies consider not only the vast differences in these patients' needs, but also risks of inhibitor development and approaches to optimally engage patients.
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21
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Sun HL, Chan S, Yenson P, Jackson S. Inhibitor Risk Stratification and Individualized Treatment in Patients With Nonsevere Hemophilia A: A Single-Institution Practice Audit. Clin Appl Thromb Hemost 2017; 24:303-309. [PMID: 29108420 PMCID: PMC6714690 DOI: 10.1177/1076029617737836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Inhibitor risk in nonsevere hemophilia A increases with cumulative factor VIII (FVIII)
exposure days and high-risk mutations. A standardized approach to minimize inhibitor risk
is warranted. Following establishment of a systematic approach to reduce inhibitor risk in
nonsevere hemophilia, we evaluated the uptake of these strategies into clinical practice.
All adult males with nonsevere hemophilia A followed by British Columbia Adult Hemophilia
Program from 2004 to 2016 were included in this retrospective audit. Quality-of-care
indicators on inhibitor prevention were examined. Of 108 patients, 18 patients had
high-risk FVIII mutations for inhibitor development. Rates of FVIII genotyping and
1-deamino-8-d-arginine-vasopressin (DDAVP) testing in mild patients without
contraindications were both over 90%, although DDAVP was used for surgical prophylaxis in
only 70% of procedures. Inhibitor testing and clinic visits occurred at a median interval
of 22 months. Over 80% of patients with high-risk mutations had documentation and
education on their inhibitor risk. Our practice audit demonstrated a high level of
recognition and patient education of individual inhibitor risk. Impact of our standardized
approach on the incidence of inhibitor development is yet to be determined.
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Affiliation(s)
- Haowei Linda Sun
- 1 Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Stella Chan
- 2 Simon Fraser University, Vancouver, British Columbia, Canada
| | - Paul Yenson
- 3 Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shannon Jackson
- 3 Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,4 British Columbia Provincial Bleeding Disorders Program-Adult Division, Vancouver, British Columbia, Canada
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22
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Holme PA, Tjønnfjord GE, Batorova A. Continuous infusion of coagulation factor concentrates during intensive treatment. Haemophilia 2017; 24:24-32. [PMID: 28873263 DOI: 10.1111/hae.13331] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2017] [Indexed: 01/12/2023]
Abstract
In clinical management of bleeds and surgical procedures in patients suffering from bleeding disorders either repetitive bolus injections (BI) or continuous infusion (CI) can be used for coagulation factor replacement. Continuous infusion seems to be an attractive route of administration and may be considered if replacement therapy is required for more than 3 days. The strongest argument favouring continuous infusion is its superiority in providing the patient with a safe and constant level of the deficient coagulation factor by balancing input with clearance. Furthermore, several studies have shown that coagulation factor consumption may be reduced by CI compared to repetitive bolus injections (BI) since unnecessary peaks of factor level are avoided. Concerns have been raised whether continuous infusion of coagulation concentrates is associated with an increased risk of developing inhibitors. However, available data have so far not shown an increased risk for inhibitor development in severe haemophilia patients with more than 50 exposure days of coagulation factor concentrates. Further, previously reported complications when using CI such as phlebitis at the infusion site and pump failure are nowadays very seldom seen when small amounts of heparin are added to the infusion bag, and increased quality of the pumps are available. Over the last decades, numerous reports have confirmed CI to be a safe and effective mode of coagulation factor replacement even in the most challenging surgical procedures, such as total joint arthroplasties.
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Affiliation(s)
- P A Holme
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - G E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - A Batorova
- Faculty of Medicine of Comenius University, Department of Haematology and Transfusion Medicine, National Haemophilia Centre, University Hospital, Bratislava, Slovakia
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23
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van Velzen AS, Eckhardt CL, Peters M, Leebeek FWG, Escuriola-Ettingshausen C, Hermans C, Keenan R, Astermark J, Male C, Peerlinck K, le Cessie S, van der Bom JG, Fijnvandraat K. Intensity of factor VIII treatment and the development of inhibitors in non-severe hemophilia A patients: results of the INSIGHT case-control study. J Thromb Haemost 2017; 15:1422-1429. [PMID: 28440011 DOI: 10.1111/jth.13711] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Indexed: 12/14/2022]
Abstract
Essentials Research suggests that intensive treatment episodes may increase the risk to develop inhibitors. We performed an international nested case-control study with 298 non-severe hemophilia A patients. Surgery and a high dose of factor VIII concentrate were associated with increased inhibitor risk. Physicians need to review arguments for factor VIII dose and elective surgery extra critically. SUMMARY Background Inhibitor development is a major complication of treatment with factor VIII concentrates in hemophilia. Findings from studies among severe hemophilia A patients suggest that intensive treatment episodes increase the risk of developing inhibitors. Objectives We set out to assess whether intensive treatment is also associated with an increased risk of inhibitor development among non-severe hemophilia A patients. Patients/Methods We performed a nested case-control study. A total of 75 inhibitor patients (cases) and 223 control patients were selected from 2709 non-severe hemophilia A patients (FVIII:C, 2-40%) of the INSIGHT cohort study. Cases and controls were matched for date of birth and cumulative number of exposure days (EDs) to FVIII concentrates. Conditional logistic regression was used to calculate both unadjusted and adjusted odds ratios (aOR); the latter were adjusted for a priori specified confounders. Results Peak treatment of 5 or 10 consecutive EDs did not increase inhibitor risk (aOR, 1.0; 95% confidence interval (CI), 0.4-2.5; and aOR, 1.8; CI, 0.6-5.5, respectively). Both surgical intervention (aOR, 4.2; CI, 1.7-10.3) and a high mean dose (> 45 IU kg-1 /ED) of FVIII concentrate (aOR, 7.5; CI, 1.6-35.6) were associated with an increased inhibitor risk. Conclusions Our findings suggest that high-dose FVIII treatment and surgery increase the risk of inhibitor development in non-severe hemophilia A. Together with the notion that non-severe hemophilia A patients are at a lifelong risk of inhibitor development, we suggest that in the future physicians will review the arguments for the FVIII dose and elective surgery extra critically.
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Affiliation(s)
- A S van Velzen
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - C L Eckhardt
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - M Peters
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - F W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - C Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, St-Luc University Hospital, Brussels, Belgium
| | - R Keenan
- Liverpool Paediatric Haemophilia Centre, Haematology Treatment Centre, Alderhey Childrens Hospital, Liverpool, UK
| | - J Astermark
- Centre for Thrombosis and Haemostasis, Lund University, Skåne University Hospital Malmö, Malmo, Sweden
| | - C Male
- Universitätsklinik für Kinder- und Jugendheilkunde, Medical University of Vienna, Vienna, Austria
| | - K Peerlinck
- Department of Vascular Medicine and Haemostasis, University of Leuven, Leuven, Belgium
| | - S le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - J G van der Bom
- Center for Clinical Transfusion Research, Sanquin Research and Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - K Fijnvandraat
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
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24
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Nonneutralizing antibodies against factor VIII and risk of inhibitor development in severe hemophilia A. Blood 2017; 129:1245-1250. [DOI: 10.1182/blood-2016-06-720086] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 12/15/2016] [Indexed: 01/22/2023] Open
Abstract
Key Points
Nonneutralizing antibodies against FVIII are detected in untreated or minimally treated patients with hemophilia A. The presence of nonneutralizing antibodies is associated with a substantially increased risk of inhibitor development.
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25
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Messori A, Peyvandi F, Mengato D, Mannucci PM. Incidence of low-titre factor VIII inhibitors in patients with haemophilia A: meta-analysis of observational studies. Haemophilia 2017; 23:e87-e92. [PMID: 28220685 DOI: 10.1111/hae.13193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2016] [Indexed: 01/02/2023]
Abstract
INTRODUCTION A few studies have been focused on low-titre inhibitors in patients with haemophilia A. Although several putative factors have been implicated in the development of these inhibitors, solid data are still lacking. AIM The aim of this study was to perform a proportion meta-analysis on the incidence of low-titre inhibitors in haemophilia A. METHODS We surveyed the PubMed database to identify studies on de novo development of low-titre inhibitors in haemophilia A patients. On the basis of these data, we carried out a proportion meta-analysis to summarize information on incidence and between-study variability. Furthermore, the following three covariates were assessed by meta-regression: (i) mild disease vs. severe haemophilia; (ii) status of previously untreated patient (PUP) as opposed to multi-transfused and (iii) type of factor VIII. RESULTS Our literature search on PubMed extracted 340 eligible articles. From these, we selected 33 patient cohorts that were included in our meta-analysis (19 cohorts for PUPs and 14 cohorts for multi-transfused or unselected patients). The pooled incidence of low-titre inhibitors was 10.3% (95%CI: 8.3-12.5%) for studies including PUPs and 5.8% (95%CI: 2.5-10.4%) for the other studies; the difference was statistically significant (P = 0.003). Meta-regression of 31 patient cohorts found that mild disease and type of factor VIII were not associated with an increased incidence of low-titre inhibitors. CONCLUSIONS Our results confirmed that PUPs show a higher incidence of low-titre inhibitors than the other patients. Furthermore, our data showed that mild haemophilia was not associated with an increased incidence of low-titre inhibitors.
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Affiliation(s)
- A Messori
- Health Technology Assessment Unit, ESTAR Regional Health Service, Florence, Italy
| | - F Peyvandi
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - D Mengato
- Pharmaceutical Chemistry and Pharmacology Department, University of Padua, Padua, Italy
| | - P M Mannucci
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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26
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Batty P, Austin SK, Khair K, Millar CM, Palmer B, Rangarajan S, Stümpel JP, Thanigaikumar M, Yee TT, Hart DP. Treatment burden, haemostatic strategies and real world inhibitor screening practice in non-severe haemophilia A. Br J Haematol 2017; 176:796-804. [PMID: 28198996 DOI: 10.1111/bjh.14543] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/03/2016] [Indexed: 12/11/2022]
Abstract
Inhibitor formation in non-severe haemophilia A is a life-long risk and associated with morbidity and mortality. There is a paucity of data to understand real-world inhibitor screening practice. We evaluated the treatment burden, haemostatic strategies, F8 genotyping and inhibitor screening practices in non-severe haemophilia A in seven London haemophilia centres. In the 2-year study period, 44% (377/853) patients received at least one haemostatic treatment. Seventy-nine percent of those treated (296/377) received factor VIII (FVIII) concentrate. F8 genotype was known in 88% (331/377) of individuals. Eighteen per cent (58/331) had 'high-risk' F8 genotypes. In patients with 'standard-risk' F8 genotypes treated on-demand with FVIII concentrate, 51·3% episodes (243/474) were screened within 1 year. However, poor screening compliance was observed after 'high-risk' treatment episodes. In patients with 'standard-risk' F8 genotypes, 12·3% (28/227) of treatment episodes were screened in the subsequent 6 weeks after surgery or a bleed requiring ≥5 exposure days. Similarly, in the context of 'high-risk' F8 genotypes after any FVIII exposure, only 13·6% (12/88) of episodes were screened within 6 weeks. Further study is required to assess optimal practice of inhibitor screening in non-severe haemophilia A to inform subsequent clinical decisions and provide more robust prevalence data to further understand the underlying immunological mechanism.
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Affiliation(s)
- Paul Batty
- The Royal London Hospital Haemophilia Centre, QMUL, Barts and The London School of Medicine and Dentistry, London, UK
| | - Steve K Austin
- St George's Healthcare NHS Trust, Haemophilia Centre, London, UK.,The Centre for Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - Kate Khair
- Great Ormond Street Haemophilia Centre, London, UK
| | | | - Ben Palmer
- The United Kingdom National Haemophilia Database, Manchester, UK
| | - Savita Rangarajan
- The Centre for Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - Jan-Phillip Stümpel
- The Royal London Hospital Haemophilia Centre, QMUL, Barts and The London School of Medicine and Dentistry, London, UK
| | | | - Thynn T Yee
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Daniel P Hart
- The Royal London Hospital Haemophilia Centre, QMUL, Barts and The London School of Medicine and Dentistry, London, UK
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27
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Current view and outcome of ITI therapy - A change over time? Thromb Res 2016; 148:38-44. [DOI: 10.1016/j.thromres.2016.10.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/28/2016] [Accepted: 10/14/2016] [Indexed: 01/19/2023]
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28
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Suzuki N, Hirakawa A, Kishimoto M, Kanematsu T, Ogawa M, Kiyoi H, Matsushita T. Retrospective analysis ofin vivorecovery and clearance during continuous infusion of recombinant factor VIII products: a single-institution study. Haemophilia 2016; 23:215-221. [DOI: 10.1111/hae.13082] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2016] [Indexed: 11/29/2022]
Affiliation(s)
- N. Suzuki
- Department of Transfusion Medicine; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - A. Hirakawa
- Biostatistics Section; Center for Advanced Medicine and Clinical Research; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - M. Kishimoto
- Department of Clinical Laboratory Medicine; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - T. Kanematsu
- Department of Hematology and Oncology; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - M. Ogawa
- Department of Hematology and Oncology; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - H. Kiyoi
- Department of Hematology and Oncology; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - T. Matsushita
- Department of Transfusion Medicine; Nagoya University Graduate School of Medicine; Nagoya Japan
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29
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Bambauer R, Latza R, Burgard D, Schiel R. Therapeutic Apheresis in Hematologic, Autoimmune and Dermatologic Diseases With Immunologic Origin. Ther Apher Dial 2016; 20:433-452. [PMID: 27633388 DOI: 10.1111/1744-9987.12474] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Indexed: 01/04/2023]
Abstract
The process of curing a patient by removing his illness by extracting blood is a very old one. Many years ago, phlebotomy was practiced to cure illness. Now, this old process, placed on a rational basis with therapeutic apheresis (TA), is being followed in clinical practice. Therapeutic plasma exchange (TPE) with hollow fiber modules has been used in different severe diseases for more than 40 years. Based on many years of experience with the extracorporeal circulation in end-stage renal disease, the authors herein give an overview of TA in immunological diseases, especially in hematologic, autoimmune and dermatologic diseases. Updated information on immunology and molecular biology of different immunological diseases is discussed in relation to the rationale for apheresis therapy and its place in combination with other modern therapies. With the introduction of novel and effective biologic agents, TA is indicated only in severe cases, such as in rapid progression despite immunosuppressive therapy and/or biologic agents. In mild forms of autoimmune disease, treatment with immunosuppressive therapies and/or biologic agents seems to be sufficient. The prognosis of autoimmune diseases with varying organ manifestations has improved in recent years, due in part to very aggressive therapy schemes. For the immunological diseases that can be treated with TA, the guidelines of the German Working Group of Clinical Nephrology and of the Apheresis Applications Committee of the American Society for Apheresis are cited. TA has been shown to effectively remove the autoantibodies from blood and lead to rapid clinical improvement.
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Affiliation(s)
- Rolf Bambauer
- Formerly: Institute for Blood Purification, 66424, Homburg, Germany.
| | | | | | - Ralf Schiel
- Inselklinik Heringsdorf GmbH, 17424, Seeheilbad Heringsdorf, Germany
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30
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Tabriznia-Tabrizi S, Gholampour M, Mansouritorghabeh H. A close insight to factor VIII inhibitor in the congenital hemophilia A. Expert Rev Hematol 2016; 9:903-13. [PMID: 27367203 DOI: 10.1080/17474086.2016.1208554] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Hemophilia A (HA) has an X-linked pattern of inheritance and is the most common of the hemorrhagic disorders. HA is caused by a decreased or deficiency of the functional clotting factor VIII (FVIII) and effects 1 in 5000-10,000 male births. The common treatment for hemophilia is replacement therapy by plasma-derived or recombinant FVIII. Approximately 20-30% of people with a severe type of HA develop an inhibitor and this phenomenon is the main challenge in the management of these patients. Genetic factors and environmental determinants contribute to inhibitor development. Here, the roles of various genetic and environmental factors such as the type of FVIII concentrate used, the number of exposure days, and peak treatment time will be discussed in detail. It seems this information is helpful for hematologists. AREAS COVERED A literature review was done in January 2016 on PubMed and Scopus using the following keywords:' h(a)emophilia A & factor VIII inhibitor', 'h(a)emophilia A & factor VIII alloantibody', 'h(a)emophilia A & inhibitor'. There was no time limitation; however, there was an English language limitation placed on the articles selected. Expert commentary: Influential genetic and environmental factors in developing inhibitors have been discussed. Most of the risk factors are related to previously untreated patients with hemophili.
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Affiliation(s)
| | - Marzie Gholampour
- a Haematology , Mashhad University of Medical sciences (MUMS) , Mashhad , Iran
| | - Hassan Mansouritorghabeh
- b Allergy Research Center, Ghaem hospital, School of Medicine , Mashhad University of Medical Sciences , Mashhad , Iran
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31
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Chapin J, Bamme J, Hsu F, Christos P, DeSancho M. Outcomes in Patients With Hemophilia and von Willebrand Disease Undergoing Invasive or Surgical Procedures. Clin Appl Thromb Hemost 2016; 23:148-154. [PMID: 27418638 DOI: 10.1177/1076029616658116] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Adults with hemophilia A (HA), hemophilia B (HB), and von Willebrand disease (VWD) frequently require surgery and invasive procedures. However, there is variability in perioperative management guidelines. We describe our periprocedural outcomes in this setting. A retrospective chart review from January 2006 to December 2012 of patients with HA, HB, and VWD undergoing surgery or invasive procedures was conducted. Type of procedures, management including the use of continuous factor infusion, and administration of antifibrinolytics were reviewed. Adverse outcomes were defined as acute bleeding (<48 hours), delayed bleeding (≥48 hours), transfusion, inhibitor development, and thrombosis. We identified 59 patients with HA and HB. In all, 24 patients had severe hemophilia and 12 had mild/moderate hemophilia. Twelve patients had inhibitors. There were also 5 female carriers of HA and 6 patients with VWD. There were 34 major surgeries (26 orthopedic, 8 nonorthopedic) and 129 minor surgeries. Continuous infusion was used in 55.9% of major surgeries versus 8.5% of minor surgeries. Antifibrinolytics were administered in 14.7% of major surgeries versus 23.2% of minor surgeries. In all, 4 patients developed acute bleeding and 10 patients developed delayed bleeding. Delayed bleeding occurred in 28.6% of genitourinary procedures and in 16.1% of dental procedures. Five patients acquired an inhibitor and 2 had thrombosis. In conclusion, patients with HA, HB, or VWD had similar rates of adverse outcomes when undergoing minor surgeries or major surgeries. This finding underscores the importance of an interdisciplinary management and procedure-specific guidelines for patients with hemophilia and VWD prior to even minor invasive procedures.
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Affiliation(s)
- John Chapin
- 1 Division of Hematology/Oncology, Weill Cornell Medicine, New York, NY, USA.,2 Weill Cornell Comprehensive Hemophilia Treatment Center, New York, NY, USA
| | - Jaqueline Bamme
- 1 Division of Hematology/Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Fraustina Hsu
- 2 Weill Cornell Comprehensive Hemophilia Treatment Center, New York, NY, USA
| | - Paul Christos
- 3 Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Maria DeSancho
- 1 Division of Hematology/Oncology, Weill Cornell Medicine, New York, NY, USA.,2 Weill Cornell Comprehensive Hemophilia Treatment Center, New York, NY, USA
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Abstract
Haemophilia A and B are hereditary haemorrhagic disorders characterised by deficiency or dysfunction of coagulation protein factors VIII and IX, respectively. Recurrent joint and muscle bleeds lead to severe and progressive musculoskeletal damage. Existing treatment relies on replacement therapy with clotting factors, either at the time of bleeding (ie, on demand) or as part of a prophylactic schedule. The major complication of such therapy is the development of neutralising antibodies (ie, inhibitors), which is most frequent in haemophilia A. Treatment might improve considerably with the availability of new modified drugs, which might overcome existing prophylaxis limitations by reducing dosing frequency and thereby rendering therapy less distressing for the patient. Subcutaneous administration of some new therapies would also simplify prophylaxis in children with poor venous access. Gene therapy has the potential for a definitive cure, and important results have been obtained in haemophilia B. Despite improvements in haemophilia care, the availability of clotting factor concentrates for all affected individuals worldwide remains the biggest challenge.
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Affiliation(s)
- Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Isabella Garagiola
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Guy Young
- The Saban Research Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA; University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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33
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Lyu C, Xue F, Liu X, Liu W, Fu R, Sun T, Wu R, Zhang L, Li H, Zhang D, Yang R, Zhang L. Identification of mutations in the F8 and F9 gene in families with haemophilia using targeted high-throughput sequencing. Haemophilia 2016; 22:e427-34. [PMID: 27292088 DOI: 10.1111/hae.12924] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION At present, many methods are available for the genetic diagnosis of haemophilia, including indirect linkage analysis, direct sequencing. However, these methods are time-consuming, labourious, and limited in their application. Therefore, the development of new, more effective techniques is necessary. AIM To detect the F8 and F9 gene mutations in patients with haemophilia and their female relatives in 29 haemophilia A (HA) and 11 haemophilia B (HB) families. METHODS FVIII C and FIX:C were analyzed using one-stage method, and factor VIII and factor IX inhibitors were tested using the Bethesda method. Intron 22 and one inversions were identified using long-distance polymerase chain reaction (PCR) and standard PCR. Non-inversion mutations of the F8 and F9 gene were identified by targeted high-throughput sequencing. All mutations were verified by Sanger sequencing. RESULTS Intron 22 inversion was detected in eight HA families and intron one inversion was detected in one HA family. Apart from the inversion mutations, 20 mutations were identified in HA families, including 17 previously reported and three novel mutations: c.5724G>A (p.Trp1908*), c.6116-1_6120delGAGTGTinsTCC (p.Lys2039Ilefs*13), and c.5220-2A>C. We found a complex rearrangement in HA: intron one inversion concomitant with exon one deletion. In HB, eight recurrent mutations were detected, including six missense mutations and two nonsense mutations. CONCLUSION Targeted high-throughput sequencing is an effective technique to detect the F8 and F9 gene mutations, especially for the discovery of novel mutations. The method is highly accurate, time-saving and shows great advantage in uncovering large deletion mutations and also in distinguishing the wild-type genotype and heterozygous large deletions.
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Affiliation(s)
- C Lyu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - F Xue
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
| | - X Liu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - W Liu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - R Fu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - T Sun
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - R Wu
- BGI-Tianjin, Tianjin, China
| | - L Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - H Li
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - D Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - R Yang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
| | - L Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
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Fruchtman Y, Dardik R, Barg AA, Livnat T, Feldman Z, Rubinstein M, Grinberg G, Rosenberg N, Kenet G. Spinal Epidural Hematoma Following Cupping Glass Treatment in an Infant With Hemophilia A. Pediatr Blood Cancer 2016; 63:1120-2. [PMID: 26844816 DOI: 10.1002/pbc.25921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 01/05/2016] [Indexed: 11/11/2022]
Abstract
A 6 months old infant, diagnosed with a rare mutation causing severe hemophilia A, presented with spinal epidural hematoma. Parents later admitted the infant had glass cupping therapy performed within 2 weeks of the onset of symptoms. The rare mutation, rare bleeding complication, and the eventual course of therapy applied in this case will be discussed in our case report.
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Affiliation(s)
- Yariv Fruchtman
- Department of Pediatric Emergency Care and Pediatric Hematology Unit, Soroka Medical Center, Ben Gurion University of the Negev, Beer-Sheba, Israel.,Thrombosis Institute and National Hemophilia Center, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rima Dardik
- Thrombosis Institute and National Hemophilia Center, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assaf Arie Barg
- Thrombosis Institute and National Hemophilia Center, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Livnat
- Thrombosis Institute and National Hemophilia Center, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zeev Feldman
- Pediatric Neurosurgery Department, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marina Rubinstein
- Department of Critical Care, Safra Children's Hospital, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gahl Grinberg
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nurit Rosenberg
- Thrombosis Institute and National Hemophilia Center, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- Thrombosis Institute and National Hemophilia Center, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Eckhardt CL, van Velzen AS, Fijnvandraat CJ, van der Bom JG. Dissecting intensive treatment as risk factor for inhibitor development in haemophilia. Haemophilia 2016; 22:e241-4. [PMID: 27076357 DOI: 10.1111/hae.12944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2016] [Indexed: 01/25/2023]
Affiliation(s)
- C L Eckhardt
- Department of Pediatric hematology, Emma Children's hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - A S van Velzen
- Department of Pediatric hematology, Emma Children's hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - C J Fijnvandraat
- Department of Pediatric hematology, Emma Children's hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - J G van der Bom
- Jon J. van Rood Center for Clinical Transfusion Research, Sanquin Research and Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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Low-dose continuous infusion of factor VIII in patients with haemophilia A. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 14:474-80. [PMID: 26674820 DOI: 10.2450/2015.0080-15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 07/13/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patients with haemophilia A (HA) or B (HB) can be given prophylactic or on-demand treatment administered by continuous infusion or bolus injections of factor VIII (FVIII) or IX (FIX). In this study we evaluated the efficacy and safety of low-dose continuous infusion of FVIII or FIX. MATERIAL AND METHODS We studied all eligible patients with HA or HB treated with continuous infusion of factor concentrates over an 18-year period in a single Slovenian Haemophilia Comprehensive Care Centre. Treatment started with a bolus injection of FVIII or FIX, followed by continuous infusion at the initial rate of 2 IU/kg/h of FVIII in HA patients and 4.5 IU/kg/h of FIX in HB patients. The infusion rate was subsequently adjusted according to the indication for therapy. RESULTS A total of 66 continuous infusions (40 in major surgery, 10 in minor surgery and 16 with bleeding episode) in 46 HA patients and 16 (15 in severe and 1 in mild HA) in eight HB patients were included in the study. During the first week of treatment, the median continuous infusion rates in HA patients undergoing major surgery, minor surgery and a bleeding event were 2.18 (0.75-3.68), 1.48 (1.0-2.54) and 2.24 (1.33-3.93) IU/kg/h, respectively. The median FVIII activities were 0.69 (0.37-1.19), 0.47 (0.39-0.84) and 0.52 (0.36-1.06) IU/mL. After the first week of treatment, even lower doses of FVIII were needed. Red blood cell transfusions had to be administered to three patients (2 with severe and 1 with moderate HA) during the continuous infusion and inhibitors developed in five patients. In HB patients, the median continuous infusion rate was 1.85 (1.07-2.94) IU/kg/h and the median FIX activity was 0.62 (0.30-1.04) IU/mL. Red blood cell transfusions were not required, and thrombophlebitis and inhibitors did not appear. DISCUSSION Overall, low-dose continuous infusion was shown to be an effective and safe way of treating patients with HA. The protocol used also proved efficient and safe in all HB patients.
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37
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Yu DU, Park JK, Park YS. Two Cases of Infant Hemophilia A Patients with Inhibitors. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2015. [DOI: 10.15264/cpho.2015.22.2.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Dong Uk Yu
- Department of Pediatrics, Inje University College of Medicine, Busan Paik Hospital, Busan, Korea
| | - Ji Kyoung Park
- Department of Pediatrics, Inje University College of Medicine, Busan Paik Hospital, Busan, Korea
| | - Young Sil Park
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
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Kocot C, Schindler AR, Le Blanc A, Schmalenberg M, Miesbach W, Spannagl M, Luppa PB. Biomimetic biosensor to distinguish between inhibitory and non-inhibitory factor VIII antibodies. Anal Bioanal Chem 2015; 407:5685-93. [PMID: 25957847 DOI: 10.1007/s00216-015-8751-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 04/27/2015] [Accepted: 04/28/2015] [Indexed: 11/28/2022]
Abstract
Patients with hereditary or acquired haemophilia A may develop inhibitory factor VIII (FVIII) antibodies. These disrupt FVIII activity predominantly by preventing the formation of the tenase complex, leading to a serious bleeding disorder. Antibodies without inhibiting activity, however, can also be found when screening patients with haemophilia A under FVIII supplementation. Therefore, the detection of only these allo- or autoantibodies from plasma is not sufficient. Rather, the characterization of the antibody-induced effects on the coagulation cascade should be considered due to its great diagnostic importance. Currently, inhibitory activities are detected by the functional Bethesda assay, which directly measures the delay in clotting time by the patient plasma. However, this assay does not provide information on the cause of the inhibition. Here, we report the development of a surface plasmon resonance (SPR) biosensor that has the potential to integrate both quantitative and functional information on patient antibody characteristics in one measurement. Recombinant FVIII protein was immobilized on the sensor surface to detect antibodies from patient plasma. The interaction of the FIX- and FXa-clotting proteins with the formed anti-FVIII/FVIII complex could be detected subsequently within the same SPR measurement cycle. Inhibitory antibodies led to the prevention of these interactions. Thus, discrimination between the clinically relevant inhibitory and non-inhibitory antibodies was enabled. In a group of 16 patients with inhibitory antibodies (both ELISA- and Bethesda-positive), 5 patients with non-inhibitory antibodies (ELISA-positive but Bethesda-negative) and 12 healthy controls, diagnostic sensitivity and specificity data of 100% for the FIX interaction were achieved using this biomimetic biosensor approach. The new method allows for detection and quantification, as well as for evaluation of inhibitory activity of allo- and autoantibodies, using small sample volume and short analysis time.
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Affiliation(s)
- Carmen Kocot
- Klinikum rechts der Isar der TU München, Institute of Clinical Chemistry and Pathobiochemistry, Ismaninger Str. 22, 81675, Munich, Germany
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Zhou J, Ding Q, Chen Z, Yang H, Lin L, Wang H, Wang X, Wu R. Risk factors associated with inhibitor development in Chinese patients with haemophilia B. Haemophilia 2015; 21:e286-93. [PMID: 25929987 DOI: 10.1111/hae.12684] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Inhibitor development is a severe complication of factor IX substitution treatment for haemophilia B (HB). Current research examined the association between inhibitor development and F9 genotypes and polymorphisms in immune response genes in Chinese HB patients. MATERIALS AND METHODS 11 inhibitor-positive HB patients and 41 inhibitor-negative HB patients were enrolled. Direct sequencing, copy number variation (CNV) detection and fragment length analysis were applied to identify F9 genotypes and 15 polymorphisms in immune response genes. RESULTS 7 patients developed high titer inhibitors, with 5 of them having histories of consecutive exposure to FIX products on demand for at least 5 days. Allergic reactions/anaphylaxis to prothrombin complex concentrates (PCC) occurred in 3 patients before inhibitors were detected. Five nonsense mutations (E54X, R75X, Q185X, R298X and R379X), two large deletions (E1~6del and E1~8del) and one missense mutation (S411G) were identified in patients with inhibitors. Missense mutations had a low odds ratio for FIX inhibitors development (IOR) of 0.078 (P = 0.02), while nonsense mutation presented a high IOR of 8.500 (P = 0.0044). The frequency of allele T in CD44(95102) (A/T) was significantly higher in inhibitor-negative patients, with OR of 0.324 (P = 0.04). CONCLUSIONS Nonsense mutations conferred a higher risk for while allele T in CD44(95102) (A/T) might play a protective role against inhibitor development in Chinese HB patients.
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Affiliation(s)
- J Zhou
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Q Ding
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Z Chen
- Hematology-Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - H Yang
- Department of Hemotology, Xiangya Hospital, Central South University, Changsha, China
| | - L Lin
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - H Wang
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - X Wang
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - R Wu
- Hematology-Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
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Coppola A, Windyga J, Tufano A, Yeung C, Di Minno MND. Treatment for preventing bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgery. Cochrane Database Syst Rev 2015:CD009961. [PMID: 25922858 DOI: 10.1002/14651858.cd009961.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND In people with haemophilia or other congenital bleeding disorders undergoing surgical interventions, haemostatic treatment is needed in order to correct the underlying coagulation abnormalities and minimise the bleeding risk. This treatment varies according to the specific haemostatic defect, its severity and the type of surgical procedure. The aim of treatment is to ensure adequate haemostatic coverage for as long as the bleeding risk persists and until wound healing is complete. OBJECTIVES To assess the effectiveness and safety of different haemostatic regimens (type, dose and duration, modality of administration and target haemostatic levels) administered in people with haemophilia or other congenital bleeding disorders for preventing bleeding complications during and after surgical procedures. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews.Date of the last search: 20 November 2014. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing any hemostatic treatment regimen to no treatment or to another active regimen in children and adults with haemophilia or other congenital bleeding disorders undergoing any surgical intervention. DATA COLLECTION AND ANALYSIS Two authors independently assessed trials (eligibility and risks of bias) and extracted data. Meta-analyses were performed on available and relevant data. MAIN RESULTS Of the 16 identified trials, four (112 participants) were eligible for inclusion.Two trials evaluated 59 people with haemophilia A and B undergoing 63 dental extractions. Trials compared the use of a different type (tranexamic acid or epsilon-aminocaproic acid) and regimen of antifibrinolytic agents as haemostatic support to the initial replacement treatment. Neither trial specifically addressed mortality (one of this review's primary outcomes); however, in the frame of safety assessments, no fatal adverse events were reported. The second primary outcome of blood loss was assessed after surgery and these trials showed the reduction of blood loss and requirement of post-operative replacement treatment in people receiving antifibrinolytic agents compared with placebo. The remaining primary outcome of need for re-intervention was not reported by either trial.Two trials reported on 53 people with haemophilia A and B with inhibitors treated with different regimens of recombinant activated factor VII (rFVIIa) for haemostatic coverage of 33 major and 20 minor surgical interventions. Neither of the included trials specifically addressed any of the review's primary outcomes (mortality, blood loss and need for re-intervention). In one trial a high-dose rFVIIa regimen (90 μg/kg) was compared with a low-dose regimen (35 μg/kg); the higher dose showed increased haemostatic efficacy, in particular in major surgery, with shorter duration of treatment, similar total dose of rFVIIa administered and similar safety levels. In the second trial, bolus infusion and continuous infusion of rFVIIa were compared, showing similar haemostatic efficacy, duration of treatment and safety. AUTHORS' CONCLUSIONS There is insufficient evidence from randomised controlled trials to assess the most effective and safe haemostatic treatment to prevent bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgical procedures. Ideally large, adequately powered, and well-designed randomised controlled trials would be needed, in particular to address the cost-effectiveness of such demanding treatments in the light of the increasing present economic constraints, and to explore the new challenge of ageing patients with haemophilia or other congenital bleeding disorders. However, performing such trials is always a complex task in this setting and presently does not appear to be a clinical and research priority. Indeed, major and minor surgeries are effectively and safely performed in these individuals in clinical practice, with the numerous national and international recommendations and guidelines providing regimens for treatment in this setting mainly based on data from observational, uncontrolled studies.
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Buckner TW, Nielsen BI, Key NS, Ma A. Factor VIII inhibitory antibody in a patient with combined factor V/factor VIII deficiency. Haemophilia 2014; 21:e77-80. [PMID: 25472918 DOI: 10.1111/hae.12557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2014] [Indexed: 01/23/2023]
Affiliation(s)
- T W Buckner
- Harold R. Roberts Comprehensive Hemophilia and Thrombosis Center, University of North Carolina, Chapel Hill, NC, USA
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Meijer K, Rauchensteiner S, Santagostino E, Platokouki H, Schutgens REG, Brunn M, Tueckmantel C, Valeri F, Schinco PC. Continuous infusion of recombinant factor VIII formulated with sucrose in surgery: Non-interventional, observational study in patients with severe haemophilia A. Haemophilia 2014; 21:e19-25. [DOI: 10.1111/hae.12530] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2014] [Indexed: 12/13/2022]
Affiliation(s)
- K. Meijer
- University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | | | - E. Santagostino
- IRCCS Ca' Granda Foundation Maggiore Hospital Policlinico; Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre; Milan Italy
| | | | - R. E. G. Schutgens
- Van Creveldkliniek; University Medical Center Utrecht; Utrecht The Netherlands
| | - M. Brunn
- Bayer HealthCare Pharmaceuticals; Berlin Germany
| | | | - F. Valeri
- SSCVD Mal. Trombotiche/Emorragiche; Molinette University Hospital; Turin Italy
| | - P. C. Schinco
- SSCVD Mal. Trombotiche/Emorragiche; Molinette University Hospital; Turin Italy
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Ivaskevicius V, Goldmann G, Horneff S, Marquardt N, Klein C, Albert T, Zeitler H, Oldenburg J. Inhibitor development and management in three non-severe haemophilia A patients with T295A variant. Hamostaseologie 2014; 34 Suppl 1:S9-12. [PMID: 25382774 DOI: 10.5482/hamo-14-02-0013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Accepted: 05/21/2014] [Indexed: 11/05/2022] Open
Abstract
Missense mutations are the most common F8 gene defects among the patients with non-severe haemophilia A. This type of mutation is typically associated with low (5%) inhibitor risk. In the present retrospective study we analysed the clinical data of 16 haemophiliacs with the T295A missense mutation treated at Bonn Haemophilia Centre. In total, three patients developed inhibitors: two patients experienced low-titer and one high-titer inhibitors. Both patients with low titer inhibitors underwent successful ITI. The third patient, at the age of 81, developed initially low-titer inhibitors (3 BU/ml) after rFVIII therapy because of knee surgery. He experienced spontaneous multiple large skin haematomas and haemarthrosis. Immunosuppressive therapy was not applicable because of the infectious origin of discitis (Th3-Th4). Immunoadsorption was performed, but the inhibitor titer increased up to 42 BU/ml nine weeks after termination. A successful treatment of discitis with antibiotics finally allowed a weekly therapy (four times) with rituximab (375 mg/m(2)). This resulted in a decrease of inhibitor titre to 0.7 BU/ml eight weeks after the fourth rituximab application. Patient had endogenous FVIII levels of 3-5%. Twelve months after rituximab therapy (after B cells recovery) he relapsed with low-titer inhibitors and therefore was treated with single rituximab dose (375 mg/m(2)) again. This resulted in his depletion of B cells, measurable endogenous FVIII levels and non measurable inhibitors. This study demonstrated T295A variant to be associated with significantly increased (3/16 patients, 17%) inhibitor development.
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Affiliation(s)
- V Ivaskevicius
- Vytautas Ivaskevicius, Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany, Tel. +49/(0)228/28 71 51 75, Fax +49/228/28 71 43 20, E-mail:
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Prospective study of continuous infusion with Beriate® P in patients with severe haemophilia A undergoing surgery – a subgroup analysis. Thromb Res 2014; 134 Suppl 1:S43-7. [DOI: 10.1016/j.thromres.2013.10.009] [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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45
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Molecular and clinical predictors of inhibitor risk and its prevention and treatment in mild hemophilia A. Blood 2014; 124:2333-6. [PMID: 25139352 DOI: 10.1182/blood-2014-02-546127] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The risk for inhibitor development in mild hemophilia A (factor VIII levels between 5 and 40 U/dL) is larger than previously anticipated, continues throughout life, and is particularly associated with certain mutations in F8. Desmopressin may reduce inhibitor risk by avoiding exposure to FVIII concentrates, but the heterogenous biological response to desmopressin, showing large interindividual variation, may limit its clinical use. However, predictors of desmopressin response have been recently identified, allowing the selection of the best candidates to this treatment.
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Lochan A, Macaulay S, Chen WC, Mahlangu JN, Krause A. Genetic factors influencing inhibitor development in a cohort of South African haemophilia A patients. Haemophilia 2014; 20:687-92. [PMID: 24953131 DOI: 10.1111/hae.12436] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2014] [Indexed: 11/29/2022]
Abstract
A critical complication of factor VIII (FVIII) replacement therapy in Haemophilia A (HA) treatment is inhibitor development. Known genetic factors predisposing to inhibitor development include FVIII (F8) gene mutations, ethnicity, a family history of inhibitors and FVIII haplotype mismatch. The aim of this study was to characterize and correlate these genetic factors in a cohort of South African HA patients. This was a retrospective study that included 229 patients and involved the analysis of patient files, HA molecular and clinical databases and molecular analysis of the F8 gene haplotype. Of the 229 patients, 51% were of black ethnicity, 49% were white, 5% had mild HA, 4% were moderate and 91% were severe, 36% were int22 positive and 13% were inhibitor positive. Of the inhibitor positive patients, 72% were black patients. Inhibitors were reported in 27% of black int22 positive patients, 13% of black int22 negative patients, 9% of white int22 positive patients and 7% of white int22 negative. The H1 haplotype was more common in whites (75%) and H2 was more common in blacks (74%). H3 and H5 were only found in black patients and had a higher frequency of inhibitor development than H1 and H2. In this small HA cohort, black patients had a significantly higher frequency of inhibitor development and the results were indicative of an association between inhibitor development, ethnicity and haplotype.
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Affiliation(s)
- A Lochan
- Division of Human Genetics, National Health Laboratory Service (NHLS) and School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
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Lillicrap D, Fijnvandraat K, Santagostino E. Inhibitors - genetic and environmental factors. Haemophilia 2014; 20 Suppl 4:87-93. [DOI: 10.1111/hae.12412] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2014] [Indexed: 12/24/2022]
Affiliation(s)
- D. Lillicrap
- Department of Pathology and Molecular Medicine; Richardson Laboratory; Queen's University; Kingston ON Canada
| | - K. Fijnvandraat
- Hemophilia Treatment Center; Department of Pediatric Hematology; Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - E. Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre; IRCCS Ca’ Granda Foundation; Maggiore Hospital Policlinico; Milan Italy
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Plasma exchange and immunosuppressive therapy in a case of mild haemophilia A with inhibitors and a life-threatening lower limb haemorrhage. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2014; 12:119-23. [PMID: 24553597 DOI: 10.2450/2014.0160-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 09/30/2013] [Indexed: 01/04/2023]
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Cugno M, Gualtierotti R, Tedeschi A, Meroni PL. Autoantibodies to coagulation factors: From pathophysiology to diagnosis and therapy. Autoimmun Rev 2014; 13:40-8. [DOI: 10.1016/j.autrev.2013.08.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 08/06/2013] [Indexed: 12/20/2022]
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50
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Xuan M, Xue F, Fu R, Yang Y, Zhang L, Tian M, Yang R. Retrospective analysis of 1,226 Chinese patients with haemophilia in a single medical centre. J Thromb Thrombolysis 2013; 38:92-7. [DOI: 10.1007/s11239-013-1009-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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