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Hassan E, Motwani J. Single centre experience of the use of emicizumab in previously untreated and minimally treated patients under 18 months of age. Pediatr Blood Cancer 2024; 71:e30941. [PMID: 38462765 DOI: 10.1002/pbc.30941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/12/2024]
Abstract
Emicizumab has revolutionised haemophilia A treatment landscape and significantly reduced treatment burden, particularly in the paediatric population. We conducted a retrospective study, focused on infants aged ≤18 months with severe haemophilia A. The study included 16 patients, with a median age of 8.2 months and median treatment duration of 61.6 weeks. Before commencing emicizumab, six patients were minimally treated with ≤5 exposure days while 10 were previously untreated patients. Notably, all patients had no inhibitors at baseline, and none developed new inhibitors during the study period. Emicizumab was well tolerated, with no observed side effects or major bleeding events.
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Affiliation(s)
- Eman Hassan
- Department of Paediatric Haematology, Birmingham Children's Hospital, Birmingham, UK
| | - Jayashree Motwani
- Department of Paediatric Haematology, Birmingham Children's Hospital, Birmingham, UK
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2
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Nagao A, Chikasawa Y, Hiroi Y, Ieko M. Treatment of thrombotic cardiovascular diseases in people with haemophilia: A Japanese consensus study. Haemophilia 2024. [PMID: 38783547 DOI: 10.1111/hae.15039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/09/2024] [Accepted: 05/09/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Cardiovascular diseases (CVD) that require long-term anticoagulant and antiplatelet therapy presents a problem in people with haemophilia (PWH) who receive factor replacement therapy to reduce bleeding risk. Currently, there are no Japanese guidelines for the management of PWH with CVD. AIM To develop expert guidance on managing CVD in PWH in Japan. METHODS A steering committee of four experts (two haemophilia specialists, one thrombosis specialist, one cardiologist) identified 44 statements related to five key themes. An online questionnaire was produced comprising a mix of 4-point Likert scale and multiple-choice questions that was sent to specialists in the management of PWH with CVD in Japan. Consensus was defined as high or very high if a respective ≥75% or ≥90% of respondents agreed with a statement. RESULTS Of 16 potential respondents, responses were received from 15 specialists. Of the Likert scale questions, 71% (29/41) achieved ≥90% agreement (very strong agreement), 17% (7/41) achieved 75%-89% agreement (strong agreement) and 15% (6/41) did not achieve consensus agreement. The three multiple-choice questions failed to identify a strong preference. Agreement on specific target trough clotting factor levels for managing certain clinical situations, such as when in the presence of non-valvular atrial fibrillation or myocardial infarction, was also achieved. CONCLUSION The results of this consensus study provide a framework for cardiologists and haematologists to manage PWH who are at risk of, or who have, CVD. Implementation of the recommendations provided herein may improve outcomes for PWH with CVD.
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Affiliation(s)
- Azusa Nagao
- Department of Blood Coagulation, Ogikubo Hospital, Tokyo, Japan
| | - Yushi Chikasawa
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Yukio Hiroi
- Department of Cardiology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masahiro Ieko
- Department of Nursing, Faculty of Health and Medical Sciences, Sapporo University of Health Sciences, Sapporo, Japan
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Young G, Pipe SW, Kenet G, Oldenburg J, Safavi M, Czirok T, Nissen F, Mahlangu J. Emicizumab is well tolerated and effective in people with congenital hemophilia A regardless of age, severity of disease, or inhibitor status: a scoping review. Res Pract Thromb Haemost 2024; 8:102415. [PMID: 38812987 PMCID: PMC11135026 DOI: 10.1016/j.rpth.2024.102415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 05/31/2024] Open
Abstract
Background With the treatment landscape continually evolving, it is vital that the hemophilia community have an overview of all published data for approved therapies, such as emicizumab, to support shared decision making. Objectives To bring together the clinical and real-world data for emicizumab use in people with congenital hemophilia A, regardless of age, disease severity, or factor VIII inhibitor status. Key focus areas were safety, efficacy, and quality of life (QoL). Methods This scoping review used citation databases (PubMed, Embase, and the Cochrane Library) and manual searches of abstract books. Publications reporting original data for emicizumab in people with hemophilia A, published in English after December 2014, and reporting select endpoints were included. This narrative synthesis focused on zero bleeds, treated annualized bleeding rate (ABR), adverse events, and QoL measures. Results Overall, 97 publications were included (cut-off: August 9, 2022). Treated ABR remained low (calculated mean and median treated ABRs ranged between 0.7-1.3 and 0.0-1.4, respectively), and the median percentage of people with zero treated bleeds was 66.7%. The proportion of people experiencing treatment-related adverse events ranged from 0.0% to 60.0%; most were injection-site reactions. Across 37 publications reporting on safety and enrolling >2300 individuals, 11 thrombotic events and 4 thrombotic microangiopathies were reported. Data from well-established tools show QoL benefits with emicizumab. Conclusion This scoping review consolidates the global published experience for emicizumab in people with hemophilia A and supports the fact that emicizumab has an acceptable safety profile, is effective and efficacious in bleed prevention, and is associated with improvements in QoL.
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Affiliation(s)
- Guy Young
- Cancer and Blood Disorders Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Steven W. Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Gili Kenet
- The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel
- The Amalia Biron Thrombosis Research Institute, Tel Aviv University, Tel Aviv, Israel
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Mariam Safavi
- Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Tuende Czirok
- Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Francis Nissen
- Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Johnny Mahlangu
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, Gauteng, South Africa
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Pierce GF, Fong S, Long BR, Kaczmarek R. Deciphering conundrums of adeno-associated virus liver-directed gene therapy: focus on hemophilia. J Thromb Haemost 2024; 22:1263-1289. [PMID: 38103734 DOI: 10.1016/j.jtha.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/07/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Abstract
Adeno-associated virus gene therapy has been the subject of intensive investigation for monogenic disease gene addition therapy for more than 25 years, yet few therapies have been approved by regulatory agencies. Most have not progressed beyond phase 1/2 due to toxicity, lack of efficacy, or both. The liver is a natural target for adeno-associated virus since most serotypes have a high degree of tropism for hepatocytes due to cell surface receptors for the virus and the unique liver sinusoidal geometry facilitating high volumes of blood contact with hepatocyte cell surfaces. Recessive monogenic diseases such as hemophilia represent promising targets since the defective proteins are often synthesized in the liver and secreted into the circulation, making them easy to measure, and many do not require precise regulation. Yet, despite initiation of many disease-specific clinical trials, therapeutic windows are often nonexistent, resulting in excess toxicity and insufficient efficacy. Iterative progress built on these attempts is best illustrated by hemophilia, with the first regulatory approvals for factor IX and factor VIII gene therapies eventually achieved 25 years after the first gene therapy studies in humans. Although successful gene transfer may result in the production of sufficient transgenic protein to modify the disease, many emerging questions on durability, predictability, reliability, and variability of response have not been answered. The underlying biology accounting for these heterogeneous responses and the interplay between host and virus is the subject of intense investigation and the subject of this review.
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Affiliation(s)
- Glenn F Pierce
- World Federation of Hemophilia, Montreal, Quebec, Canada.
| | - Sylvia Fong
- BioMarin Pharmaceutical Inc, Research and Early Development, Novato, California, USA
| | - Brian R Long
- BioMarin Pharmaceutical Inc, Research and Early Development, Novato, California, USA
| | - Radoslaw Kaczmarek
- Department of Pediatrics, Indiana University School of Medicine, Wells Center for Pediatric Research, Indiana, USA; Laboratory of Glycobiology, Hirszfeld Institute of Immunology and Experimental Therapy, Wroclaw, Poland
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5
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Hermans C, Pierce GF. Ultra-Long factor VIII: a major step forward toward a hemophilia-free mind. J Thromb Haemost 2024:S1538-7836(24)00228-9. [PMID: 38679336 DOI: 10.1016/j.jtha.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/19/2024] [Accepted: 04/18/2024] [Indexed: 05/01/2024]
Abstract
A remarkable step forward in the treatment of hemophilia A has recently been achieved with the development of an Ultra-Long modified factor (F)VIII. Leveraging expertise gained with fusion to immunoglobulin Fc fragments, disconnecting FVIII from endogenous von Willebrand factor (via a D'-D3 fragment), and benefiting from the pharmacokinetic prolongation provided by the addition of hydrophilic polypeptides, efanesoctocog alfa opens a new era in the treatment of hemophilia A. The term Ultra-Long FVIII has been proposed to designate it and differentiate it from extended half-life FVIII. The level of FVIII correction within the normal range for several days provided by this molecule should allow an increasing number of patients to free themselves from the physical and psychological constraints of hemophilia A. Certainly, the burden of weekly intravenous infusions persists but is compensated by a correction of hemostasis whose amplitude and duration remain unmatched by other therapeutic options currently available.
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Affiliation(s)
- Cedric Hermans
- Division of Haematology, Haemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain (UCLouvain), Brussels, Belgium; World Federation of Hemophilia, Montreal, Quebec, Canada.
| | - Glenn F Pierce
- World Federation of Hemophilia, Montreal, Quebec, Canada
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Bala NS, Thornburg CD. Gene Therapy in Hemophilia A: Achievements, Challenges, and Perspectives. Semin Thromb Hemost 2024. [PMID: 38588706 DOI: 10.1055/s-0044-1785483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Strides in advancements of care of persons with hemophilia include development of long-acting factor replacement therapies, novel substitution and hemostatic rebalancing agents, and most recently approved gene therapy. Several decades of preclinical and clinical trials have led to development of adeno-associated viral (AAV) vector-mediated gene transfer for endogenous production of factor VIII (FVIII) in hemophilia A (HA). Only one gene therapy product for HA (valoctocogene roxaparvovec) has been approved by regulatory authorities. Results of valoctocogene roxaparvovec trial show significant improvement in bleeding rates and use of factor replacement therapy; however, sustainability and duration of response show variability with overall decline in FVIII expression over time. Further challenges include untoward adverse effects involving liver toxicity requiring immunosuppression and development of neutralizing antibodies to AAV vector rendering future doses ineffective. Real-life applicability of gene therapy for HA will require appropriate patient screening, infrastructure setup, long-term monitoring including data collection of patient-reported outcomes and innovative payment schemes. This review article highlights the success and development of HA gene therapy trials, challenges including adverse outcomes and variability of response, and perspectives on approach to gene therapy including shared decision-making and need for future strategies to overcome the several unmet needs.
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Affiliation(s)
- Natasha S Bala
- Rady Children's Hospital San Diego, Hemophilia and Thrombosis Treatment Center, San Diego, California
- Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California
| | - Courtney D Thornburg
- Rady Children's Hospital San Diego, Hemophilia and Thrombosis Treatment Center, San Diego, California
- Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California
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Thornburg CD. The benefits of gene therapy in people with haemophilia. J Viral Hepat 2024; 31 Suppl 1:4-8. [PMID: 38606945 DOI: 10.1111/jvh.13882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/06/2023] [Indexed: 04/13/2024]
Abstract
Haemophilia is an inherited bleeding disorder which causes significant morbidity and mortality, especially in the severe form. Prophylaxis with factor replacement has high efficacy in reducing bleeding but is limited by the need for frequent intravenous infusion and fluctuations in haemostasis between doses. Additional prophylaxis therapies are being developed which may overcome some of the current treatment barriers. Gene therapy (GT) is being developed to provide a functional cure such that there is sustained factor expression and minimal to no need for additional haemostatic therapy. There are now two approved gene therapies for haemophilia which may be transformative for many individuals. Benefits of GT should go beyond increasing factor activity and reducing bleeding as persons with haemophilia aim to achieve a 'haemophilia-free mind' and health equity with optimal health and well-being.
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Affiliation(s)
- Courtney D Thornburg
- Hemophilia and Thrombosis Treatment Center, Rady Children's Hospital San Diego, San Diego, California, USA
- Department of Pediatrics, Division of Hematology/Oncology, UC San Diego School of Medicine, La Jolla, California, USA
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Carcao M, Selvaratnam V, Blatny J. How much prophylaxis is enough in haemophilia? Haemophilia 2024; 30 Suppl 3:86-94. [PMID: 38523288 DOI: 10.1111/hae.14964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION Prophylaxis has become standard of care for all persons with haemophilia (PWH) with a severe phenotype. However, 'standard prophylaxis' with either factor or non-factor therapies (currently only emicizumab available) is prohibitively expensive for much of the world. We sought to address the question of 'How much prophylaxis is enough?' and 'Can it be individualized?' and specifically 'Can emicizumab be individualized?'. METHODS We reviewed the literature on prophylaxis in haemophilia since its inception in the 1950s to the present, the development of more and less intense factor prophylaxis regimens and their outcomes and additionally the published outcomes of prophylaxis with low dose emicizumab. RESULTS What these experiences collectively show is that low dose emicizumab does result in significant benefits to patients whilst being much less expensive than a "one size fits all" emicizumab prophylaxis approach. We also took note that some non-factor therapies still in development are individualized given that high doses of these can potentially put patients at risk. CONCLUSIONS Prophylaxis is now clearly accepted as standard of care for PWH with a severe phenotype but now in a very short time a large assortment of different treatment options for prophylaxis have become/are becoming available and the haemophilia community will need to determine how to best use these recognizing that no 'one treatment fits all'.
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Affiliation(s)
- Manuel Carcao
- Division of Haematology/Oncology; Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Jan Blatny
- Hospital Bory, Bratislava, Slovakia and Masaryk University, Brno, Czech Republic
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9
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Srivastava A. Defining success in haemophilia care - Are we doing it right? Haemophilia 2024; 30 Suppl 3:52-59. [PMID: 38498584 DOI: 10.1111/hae.14958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION Transformational advances have occurred in the management of haemophilia in the last decade leading to much better outcomes. However, a detailed and critical examination of its assessment and reporting show gaps in many aspects. These are discussed in this review. METHODS The relevant literature related to different aspects of management of haemophilia was reviewed to identify gaps which need to be addressed. These include detection and diagnosis of haemophilia, documentation and reporting of joint bleeding, its management and methods of reporting in clinical trials and practice, aspects of personalizing care as well as access to therapeutic products and the need for and organization of comprehensive care. RESULTS Current diagnostic approaches have more than doubled the identified number of persons with haemophilia (PWH) over the last 25 years but still constitute only ∼30% of the expected number. Joint bleeding is the primary indicator of disease severity and treatment efficacy, but there is lack of consistency and standardization in the way it is recorded and reported. Its continued use as an efficacy measure of modern treatments which maintain steady state factor levels or equivalence of >5% will lack sensitivity. The treatment of acute haemarthrosis has focussed on haemostasis and pain control, ignoring the role of inflammation in joint damage. Phenotypic heterogeneity of severe haemophilia has recognized clinical and laboratory variations based on haemostasis but not differences in local response to blood in the joint. At the organizational level, IU/capita provides a relevant measure of access to therapeutic products when the detection rate is ∼100% but is fallaciously low when detection rates are very low. With highly effective modern therapies for haemophilia and nearly no bleeding, the concept of comprehensive care team will need modifications. CONCLUSION As haemophilia care advances, a deeper dive is needed into the details of various aspects its management to ensure consistency and contemporary relevance.
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Affiliation(s)
- Alok Srivastava
- Department of Haematology, Christian Medical College Vellore, Vellore, Tamil Nadu, India
- Centre for Stem Cell Research, a Unit of inStem, Bengaluru, CMC Campus, Vellore, Tamil Nadu, India
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10
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Meeks SL, Zimowski KL. Haemophilia in the era of novel therapies: Where do inhibitors feature in the new landscape? Haemophilia 2024; 30 Suppl 3:95-102. [PMID: 38539060 DOI: 10.1111/hae.14982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION The advent of therapeutic recombinant factor VIII (FVIII) and factor IX (FIX) protein infusions revolutionized the care of persons with haemophilia in the 1990s. It kicked off an era with the increasing use of prophylactic factor infusions for patients and transformed conversations around the ideal trough activity levels as well as the ultimate goals in tailored, individualized care. Our knowledge surrounding the immunologic basis of inhibitor development and treatment derives from a time when patients were receiving frequent factor infusions and focused on immune tolerance induction following inhibitor development. DISCUSSION More recently, care was revolutionized again in haemophilia A with the approval of emicizumab, a bispecific antibody mimicking activated FVIII function, to prevent bleeding. The use of emicizumab prophylaxis has resulted in a significantly slower accumulation of factor exposure days and continued effective prophylaxis in the case of inhibitor development. While emicizumab is effective at reducing the frequency of bleeding events in patients with haemophilia A, management of breakthrough bleeds, trauma, and surgeries still requires additional treatment. Ensuring that FVIII is a therapeutic option, particularly for life-threatening bleeding events and major surgeries is critical to optimizing the care of persons with haemophilia A. Other novel non-factor concentrate therapies, including rebalancing agents, will dramatically change the landscape for persons with haemophilia B with inhibitors. CONCLUSION This review discusses the changing landscape regarding the timing of inhibitor development and management strategies after inhibitor development, stressing the importance of education across the community to continue to vigilantly monitor for inhibitors and be prepared to treat persons with inhibitors.
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Affiliation(s)
- Shannon L Meeks
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Karen L Zimowski
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, Georgia, USA
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Abdelgawad HAH, Foster R, Otto M. Nothing short of a revolution: Novel extended half-life factor VIII replacement products and non-replacement agents reshape the treatment landscape in hemophilia A. Blood Rev 2024; 64:101164. [PMID: 38216442 DOI: 10.1016/j.blre.2023.101164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/14/2024]
Abstract
Hemophilia A, an X-linked genetic disorder, is characterized by a deficiency or dysfunction of clotting Factor VIII. The treatment landscape has substantially changed by introducing novel extended half-life factor VIII (EHL-FVIII) replacement therapies such as efanesoctocog Alfa and non-factor replacement therapy such as emicizumab. These agents signal a shift from treatments requiring multiple weekly infusions to advanced therapies with long half-lives, offering superior protection against bleeding and improving patient adherence and quality of life. While EHL-FVIII treatment might lead to inhibitor development in some patients, non-factor replacement therapy carries thrombotic risks. Therefore, ongoing research and the generation of robust clinical evidence remain vital to guide the selection of optimal and cost-effective first-line therapies for hemophilia A patients.
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Affiliation(s)
- Hussien Ahmed H Abdelgawad
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA; Department of Child Health, University of Arizona College of Medicine, Phoenix, AZ, USA.
| | - Rachel Foster
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Mario Otto
- Center for Cancer and Blood Disorders, Phoenix Children's Hospital, Phoenix, AZ, USA; Department of Child Health, University of Arizona College of Medicine, Phoenix, AZ, USA.
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Moser MM, Schoergenhofer C, Jilma B. Progress in von Willebrand Disease Treatment: Evolution towards Newer Therapies. Semin Thromb Hemost 2024. [PMID: 38331000 DOI: 10.1055/s-0044-1779485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
von Willebrand disease (VWD) is a very heterogenous disease, resulting in different phenotypes and different degrees of bleeding severity. Established therapies (i.e., desmopressin, antifibrinolytic agents, hormone therapy for heavy menstrual bleeding, and von Willebrand factor [VWF] concentrates) may work in some subtypes, but not in all patients. In recent years, progress has been made in improving the diagnosis of VWD subtypes, allowing for more specific therapy. The impact of VWD on women's daily lives has also come to the fore in recent years, with hormone therapy, tranexamic acid, or recombinant VWF as treatment options. New treatment approaches, including the replacement of lacking factor VIII (FVIII) function, may work in those subgroups affected by severe FVIII deficiency. Reducing the clearance of VWF is an alternative treatment pathway; for example, rondaptivon pegol is a VWFA1 domain-binding aptamer which not only improves plasma VWF/FVIII levels, but also corrects platelet counts in thrombocytopenic type 2B VWD patients. These approaches are currently in clinical development, which will be the focus of this review. In addition, half-life extension methods are also important for the improvement of patients' quality of life. Targeting specific mutations may further lead to personalized treatments in the future. Finally, a few randomized controlled trials, although relatively small, have been published in recent years, aiming to achieve a higher level of evidence in future guidelines.
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Affiliation(s)
- Miriam M Moser
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Leuci A, Robert M, Josset L, Marano M, Connes P, Désage S, Meunier S, Lienhart A, Dargaud Y. Stromal cell-derived factor 1 alpha (SDF-1alfa) and cartilage oligomeric matrix protein (COMP): Two potential signature biomarkers of radiological detectable hemophilic arthropathy. Int J Rheum Dis 2024; 27:e15061. [PMID: 38465833 DOI: 10.1111/1756-185x.15061] [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: 09/22/2023] [Revised: 01/12/2024] [Accepted: 01/19/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Hemophilia is a rare constitutional bleeding disorder due to a deficiency in Factor VIII or Factor IX. Recurrent hemarthroses, one of the major complications of the disease, lead to hemophilic arthropathy, a disabling condition that requires early diagnosis. Traditionally, clinical examination and plain film radiography have been used to diagnose hemophilic arthropathy. Magnetic resonance imaging (MRI) and ultrasound can be more useful for diagnosing soft-tissue changes. However, but each of these methods has limitations and diagnosis of arthropathy can be delayed. AIM The aim of this project was to assess plasmatic biomolecules indicative of osteo-cartilaginous damage in patients with hemophilia with or without known arthropathy, in order to improve the diagnosis of this major complication of the disease. METHODS In this monocentric retrospective study, 40 patients with hemophilia A or B, for whom a plasma sample was available, provided informed consent for further analyses (multiplex immunoassays and ELISA) and collection of relevant clinical information in their medical files. Correlations were sought for between biomarkers of interest and the severity of joint lesions assessed according to Pettersson's radiologic score. RESULTS Two biomarkers were identified, respectively SDF-1α and COMP. Their plasmatic levels were significantly increased in patients with arthropathy compared to controls and patients without arthropathy. These values correlated significantly with the Pettersson score in patients under regular prophylaxis. CONCLUSION Two plasma biomarkers have been identified that could help assess the presence and severity of hemophilic arthropathy.
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Affiliation(s)
- Alexandre Leuci
- UR4609 Hémostase et Thrombose, Université Claude Bernard Lyon 1, Lyon, France
| | - Mélanie Robert
- UR4609 Hémostase et Thrombose, Université Claude Bernard Lyon 1, Lyon, France
| | - Laurie Josset
- UR4609 Hémostase et Thrombose, Université Claude Bernard Lyon 1, Lyon, France
| | - Muriel Marano
- UR4609 Hémostase et Thrombose, Université Claude Bernard Lyon 1, Lyon, France
| | - Philippe Connes
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Team « Vascular Biology and Red Blood Cell, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Stéphanie Désage
- Centre de Référence de l'Hémophilie, Unité d'Hémostase Clinique, Hospices Civils de Lyon, Lyon, France
| | - Sandrine Meunier
- Centre de Référence de l'Hémophilie, Unité d'Hémostase Clinique, Hospices Civils de Lyon, Lyon, France
| | - Anne Lienhart
- Centre de Référence de l'Hémophilie, Unité d'Hémostase Clinique, Hospices Civils de Lyon, Lyon, France
| | - Yesim Dargaud
- UR4609 Hémostase et Thrombose, Université Claude Bernard Lyon 1, Lyon, France
- Centre de Référence de l'Hémophilie, Unité d'Hémostase Clinique, Hospices Civils de Lyon, Lyon, France
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Lillicrap D, Lenting P. Hemophilia A treatment innovation: factor VIII mimetic bispecific antibodies-generational enhancement. J Thromb Haemost 2024; 22:352-355. [PMID: 38309809 DOI: 10.1016/j.jtha.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 10/31/2023] [Indexed: 02/05/2024]
Affiliation(s)
- David Lillicrap
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada.
| | - Peter Lenting
- Inserm, UMRS 1176-Hemostasis-Inflammation-Thrombosis, Le Kremlin-Bicetre, Paris, France
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Mahlangu J, Jiménez-Yuste V, Ventriglia G, Niggli M, Barlera S, Hermans C, Lehle M, Chowdary P, Jew L, Windyga J, Frenzel L, Schmitt C, Castaman G, Pipe SW. Long-term outcomes with emicizumab in hemophilia A without inhibitors: results from the HAVEN 3 and 4 studies. Res Pract Thromb Haemost 2024; 8:102364. [PMID: 38559572 PMCID: PMC10978536 DOI: 10.1016/j.rpth.2024.102364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/14/2024] [Indexed: 04/04/2024] Open
Abstract
Background Emicizumab, a bispecific monoclonal antibody, bridges activated factor (F) IX and FX, mimicking the function of missing or deficient activated FVIII in people with hemophilia A (HA). Objectives To evaluate the long-term efficacy and safety of emicizumab prophylaxis in people with HA without FVIII inhibitors in the HAVEN 3 and 4 studies. Methods HAVEN 3 and 4 were phase 3 open-label studies. Participants received emicizumab maintenance doses of 1.5 mg/kg every week or 3 mg/kg every 2 weeks (HAVEN 3), or 6 mg/kg every 4 weeks (HAVEN 4). Long-term efficacy and safety were assessed. Results A total of 151 and 40 individuals without FVIII inhibitors received emicizumab in HAVEN 3 and 4, respectively. At the last patient, last visit dates (May 12, 2022 [HAVEN 3] and June 29, 2022 [HAVEN 4]), the median (range) duration of emicizumab exposure across the 2 studies was 248.1 (6.1-287.1) weeks. The mean (95% CI) annualized bleed rate for treated bleeds was 2.0 (0.23-7.15) for weeks 1 to 24, decreasing to 0.9 (0.01-5.28) by weeks 217 to 240. Overall, 188 (98.4%) participants experienced ≥1 adverse event (AE), with 185 treatment-related AEs in 71 (37.2%) participants. Forty-four (23.0%) participants reported a serious AE. Two thromboembolic events were reported, which were deemed unrelated to emicizumab by the investigator. No thrombotic microangiopathies were reported. Conclusion With nearly 5 years of emicizumab exposure across the HAVEN 3 and 4 studies in people with HA without inhibitors, these data indicate continued bleed control with no new safety signals observed during long-term follow-up.
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Affiliation(s)
- Johnny Mahlangu
- Faculty of Health Sciences, University of the Witwatersrand, National Health Laboratory Service, Johannesburg, South Africa
| | - Víctor Jiménez-Yuste
- Jefe de Servicio de Hematología, La Paz University Hospital-IdiPaz, Autónoma University, Madrid, Spain
| | - Giuliana Ventriglia
- Oncology and Hematology Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Markus Niggli
- Product Development Data Sciences, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Simona Barlera
- Department of Biometrics, Parexel International, Milan, Italy
| | - Cédric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Catholic University of Louvain, Brussels, Belgium
| | - Michaela Lehle
- Oncology and Hematology Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Unit, Royal Free London, London, United Kingdom
| | - Lyle Jew
- Product Development Safety, Genentech, Inc. South San Francisco, California, USA
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Laurent Frenzel
- Department of Hematology, Necker-Enfants Malades Hospital, Paris, France
| | - Christophe Schmitt
- Department of Clinical Pharmacology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Steven W. Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
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Weyand AC, Malec L, Pipe SW. Advancements in haemophilia A and health equity: is it time to redefine severity? Lancet Haematol 2024; 11:e90-e92. [PMID: 38302228 DOI: 10.1016/s2352-3026(23)00270-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/07/2023] [Accepted: 08/27/2023] [Indexed: 02/03/2024]
Affiliation(s)
- Angela C Weyand
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI 48109-5718, USA.
| | - Lynn Malec
- Blood Research Institute, Versiti, Milwaukee, Wisconsin, USA
| | - Steven W Pipe
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI 48109-5718, USA
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17
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Chandran R, Tohit ERM, Stanslas J, Salim N, Mahmood TMT, Rajagopal M. Shifting Paradigms and Arising Concerns in Severe Hemophilia A Treatment. Semin Thromb Hemost 2024. [PMID: 38224699 DOI: 10.1055/s-0043-1778103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
The management of hemophilia A has undergone a remarkable revolution, in line with technological advancement. In the recent past, the primary concern associated with Factor VIII (FVIII) concentrates was the risk of infections, which is now almost resolved by advanced blood screening and viral inactivation methods. Improving patients' compliance with prophylaxis has become a key focus, as it can lead to improved health outcomes and reduced health care costs in the long term. Recent bioengineering research is directed toward prolonging the recombinant FVIII (rFVIII) coagulant activity and synthesising higher FVIII yields. As an outcome, B-domain deleted, polyethylene glycolated, single-chain, Fc-fused rFVIII, and rFVIIIFc-von Willebrand Factor-XTEN are available for patients. Moreover, emicizumab, a bispecific antibody, is commercially available, whereas fitusiran and tissue factor pathway inhibitor are in clinical trial stages as alternative strategies for patients with inhibitors. With these advancements, noninfectious complications, such as inhibitor development, allergic reactions, and thrombosis, are emerging concerns requiring careful management. In addition, the recent approval of gene therapy is a major milestone toward a permanent cure for hemophilia A. The vast array of treatment options at our disposal today empowers patients and providers alike, to tailor therapeutic regimens to the unique needs of each individual. Despite significant progress in modern treatment options, these highly effective therapies are markedly more expensive than conventional replacement therapy, limiting their access for patients in developing countries.
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Affiliation(s)
- Rubhan Chandran
- Department of Pathology, Haematology Unit, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
- Faculty of Pharmaceutical Sciences, Department of Pharmaceutical Biology, UCSI University, Jalan Puncak Menara Gading, Taman Connaught, Cheras, Kuala Lumpur, Malaysia
| | - Eusni R Mohd Tohit
- Department of Pathology, Haematology Unit, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
| | - Johnson Stanslas
- Department of Medicine, Pharmacotherapeutics Unit, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Norazlinaliza Salim
- Centre of Foundation Studies for Agricultural Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
- Integrated Chemical Biophysics Research, Faculty of Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Tuan M T Mahmood
- Faculty of Pharmacy, The National University of Malaysia (UKM), Jalan Raja Muda Abdul Aziz, Kuala Lumpur, Malaysia
| | - Mogana Rajagopal
- Faculty of Pharmaceutical Sciences, Department of Pharmaceutical Biology, UCSI University, Jalan Puncak Menara Gading, Taman Connaught, Cheras, Kuala Lumpur, Malaysia
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18
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Pipe S, Sadeghi-Khomami A, Konkle BA, Kitchen S, Negrier C, Liu M, Santagostino E, Willemze A, Abad-Franch L, Knobe K, Seth Chhabra E. A global comparative field study to evaluate the factor VIII activity of efanesoctocog alfa by one-stage clotting and chromogenic substrate assays at clinical haemostasis laboratories. Haemophilia 2024; 30:214-223. [PMID: 37902390 DOI: 10.1111/hae.14831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/09/2023] [Accepted: 06/27/2023] [Indexed: 10/31/2023]
Abstract
INTRODUCTION Structural and chemical modifications of factor VIII (FVIII) products may influence their behaviour in FVIII activity assays. Hence, it is important to assess the performance of FVIII products in these assays. Efanesoctocog alfa is a new class of FVIII replacement therapy designed to provide both high sustained factor activity levels and prolonged plasma half-life. AIM Evaluate the accuracy of measuring efanesoctocog alfa FVIII activity in one-stage clotting assays (OSAs) and chromogenic substrate assays (CSAs). METHODS Human plasma with no detectable FVIII activity was spiked with efanesoctocog alfa or a full-length recombinant FVIII product comparator, octocog alfa, at nominal concentrations of 0.80 IU/mL, 0.20 IU/mL, or 0.05 IU/mL, based on labelled potency. Clinical haemostasis laboratories (N = 35) tested blinded samples using in-house assays. Data from 51 OSAs (14 activated partial thromboplastin time [aPTT] reagents) and 42 CSAs (eight kits) were analyzed. RESULTS Efanesoctocog alfa activity was reliably (±25% of nominal activity) measured across all concentrations using OSAs with Actin FSL and multiple other aPTT reagents. Under- and overestimation of FVIII activity occurred with some reagents. No specific trend was observed for any class of aPTT activators. A two- to three-fold overestimation was consistently observed using CSAs and the OSA with Actin FS as the aPTT reagent across evaluated concentrations. CONCLUSION Under- or overestimation occurred with some specific OSAs and most CSAs, which has been previously observed with other modified FVIII replacement products. Efanesoctocog alfa FVIII activity was measured with acceptable accuracy and reliability using several OSA methods and commercial plasma standards.
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Affiliation(s)
- Steven Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Barbara A Konkle
- Washington Center for Bleeding Disorders, Seattle, Washington, USA
- Division of Hematology, University of Washington, Seattle, Washington, USA
| | - Steve Kitchen
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Pietu G, Giraud N, Chamouard V, Duport G, Lienhart A, Dargaud Y. Perspectives and perception of haemophilia gene therapy by French patients. Haemophilia 2024; 30:68-74. [PMID: 38058235 DOI: 10.1111/hae.14908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/20/2023] [Accepted: 11/27/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION AND AIM A national survey was initiated by representatives of French patients with haemophilia (AFH) and the French reference centre for haemophilia, in order to appreciate the awareness and knowledge of these patients regarding haemophilia gene therapy (HGT) and understand better their position about this innovative treatment that will soon become available. RESULTS Of 143 answers received, 137 could be analysed, representing about 3.5% of patients with severe or moderate haemophilia over 16year-old. They were 80.3% with haemophilia A and 19.7 % with haemophilia B, with a severe form of the disease for 80.3 % of them. Curiosity for HGT was formulated by 64.2% of the participants, 33.6 % being interested by this approach as soon as it will be available and 38.7 % preferring to wait until more patients have been treated. Only 3.6 % of the participants would never consider receiving HGT. The level of awareness and knowledge was estimated to be limited by 39.5 % of the patients. More than 60 % of them declared having never or almost never discussed HGT with the team of their haemophilia centre. Before deciding to get HGT, 54.4 % of the participants considered that it will be very important to compare it with their current treatment and 53.7 % would like to be better informed by their care providers. CONCLUSIONS These results highlight the need for training and education for patients, but also for professionals at haemophilia centres, about HGT and the shared decision-making process. Objective, unbiased and transparent information must be available for patients about this very promising therapy which nonetheless carries more uncertainty and unknowns compared to other haemophilia treatments.
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Affiliation(s)
| | | | - Valérie Chamouard
- Centre de Référence de l'Haémophilie, Unité d'Hémostase Clinique, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | | | - Anne Lienhart
- Centre de Référence de l'Haémophilie, Unité d'Hémostase Clinique, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Yesim Dargaud
- Centre de Référence de l'Haémophilie, Unité d'Hémostase Clinique, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
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20
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Hou PX, Yang RC. [Recent advances in the replacement therapy for Hemophilia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:1052-1056. [PMID: 38503535 PMCID: PMC10834880 DOI: 10.3760/cma.j.issn.0253-2727.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Indexed: 03/21/2024]
Affiliation(s)
- P X Hou
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China Tianjin Institutes of Health Science, Tianjin 301600, China
| | - R C Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin Key Laboratory of Gene Therapy for Blood Diseases, CAMS Key Laboratory of Gene Therapy for Blood Diseases, Tianjin 300020, China Tianjin Institutes of Health Science, Tianjin 301600, China
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21
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Ryu JH, Bauer KA, Schulman S. Periprocedural management of type 2N von Willebrand disease with efanesoctocog alfa. J Thromb Haemost 2023; 21:3508-3510. [PMID: 37734716 DOI: 10.1016/j.jtha.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 09/23/2023]
Abstract
Type 2 Normandy von Willebrand disease (type 2N VWD) is a rare qualitative defect in von Willebrand factor (VWF) that results in impaired factor VIII (FVIII) binding and consequently reduced FVIII levels. Current perioperative strategies require VWF concentrates to attain durable hemostatic FVIII levels. This case highlights the successful perioperative management of a 78-year-old female with type 2N VWD and coronary artery disease utilizing efanesoctocog alfa, a novel long-acting recombinant FVIII product approved for hemophilia A. By decoupling the FVIII-VWF interaction, efanesoctocog alfa achieves prolonged FVIII circulation independent of VWF. A single administration targeting 90% FVIII levels yielded sustained FVIII elevation without achieving supraphysiologic VWF levels, thus mitigating potential cardiovascular risks. This is the first report of efanesoctocog alfa use in type 2N VWD. Further clinical studies are necessary to corroborate its efficacy and safety for this indication.
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Affiliation(s)
- Justine H Ryu
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Kenneth A Bauer
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Sol Schulman
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA.
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22
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Puetz J. Emergent data influences the risk/benefit assessment of hemophilia gene therapy using recombinant adeno-associated virus. Front Med (Lausanne) 2023; 10:1256919. [PMID: 38020165 PMCID: PMC10667906 DOI: 10.3389/fmed.2023.1256919] [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: 07/11/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
After decades of investigation, gene therapy has received regulatory approval to treat hemophilia. However, since gene therapy investigations were initially conceived, other avenues of treatment have revolutionized the care of hemophilia. Emergent data is showing that gene therapy may not be as beneficial as hoped and more toxic than planned. At a minimum, a reassessment of risk/benefit estimate of gene therapy for hemophilia is needed.
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Affiliation(s)
- John Puetz
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Saint Louis University School of Medicine, St. Louis, MO, United States
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23
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Ragni MV, Chan SY. Innovations in RNA therapy for hemophilia. Blood 2023; 142:1613-1621. [PMID: 37478403 PMCID: PMC10862240 DOI: 10.1182/blood.2022018661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/05/2023] [Accepted: 06/27/2023] [Indexed: 07/23/2023] Open
Abstract
Given the shortcomings of current factor-, nonfactor-, and adeno-associated virus gene-based therapies, the recent advent of RNA-based therapeutics for hemophilia is changing the fundamental approach to hemophilia management. From small interfering RNA therapeutics that knockdown clot regulators antithrombin, protein S, and heparin cofactor II, to CRISPR/Cas9 gene editing that may personalize treatment, improved technologies have the potential to reduce bleeds and factor use and avoid inhibitor formation. These novel agents, some in preclinical studies and others in early phase trials, have the potential to simplify treatment and improve hemostasis and quality of life. Furthermore, because these therapies arise from manipulation of the coagulation cascade and thrombin generation and its regulation, they will enhance our understanding of hemostasis and thrombosis and ultimately lead to better therapies for children and adults with inherited bleeding disorders. What does the future hold? With the development of novel preclinical technologies at the bench, there will be fewer joint bleeds, debilitating joint disease, orthopedic surgery, and improved physical and mental health, which were not previously possible. In this review, we identify current limitations of treatment and progress in the development of novel RNA therapeutics, including messenger RNA nanoparticle delivery and gene editing for the treatment of hemophilia.
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Affiliation(s)
- Margaret V. Ragni
- Division of Hematology Oncology, Department of Medicine, University of Pittsburgh, Hemophilia Center of Western Pennsylvania, Pittsburgh, PA
| | - Stephen Y. Chan
- Division of Cardiology, Department of Medicine, Vascular Medicine Institute, Pittsburgh, PA
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24
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Garcia J, Hammer MR, Zia A. Serious bleeds in pediatric persons with hemophilia A on emicizumab prophylaxis. Res Pract Thromb Haemost 2023; 7:102238. [PMID: 38053983 PMCID: PMC10694589 DOI: 10.1016/j.rpth.2023.102238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/01/2023] [Accepted: 09/22/2023] [Indexed: 12/07/2023] Open
Abstract
Background Clinical trials have shown success in bleed prevention with emicizumab, but real-world data on the effectiveness of emicizumab in preventing serious bleeds in the pediatric population are lacking. Objectives To report real-world data on the effectiveness of Emicizumab in pediatric persons with hemophilia A. Methods We completed a retrospective chart review of 37 pediatric male patients aged ≤18 years on emicizumab prophylaxis for a median duration of 30.5 months at Children's Medical Center in Dallas, Texas. Results We identified 4 pediatric persons with severe hemophilia A with and without inhibitors who experienced a provoked or unprovoked serious bleed requiring hospitalization. Conclusion This study highlights that serious bleeds, both provoked and unprovoked, can occur in pediatric persons with severe hemophilia A. These findings are important for clinicians to provide appropriate counseling/education and recommendation of treatment for pediatric persons with severe hemophilia A through shared decision making. Up-titration of emicizumab or factor VIII replacement needs consideration in persons with hemophilia with suboptimal bleeding control or who participate in activities categorized as moderate- to high-risk activities.
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Affiliation(s)
- Jessica Garcia
- Division of Hematology/Oncology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
- Children’s Medical Center, Dallas, Texas, USA
| | - Matthew R. Hammer
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
- Children’s Medical Center, Dallas, Texas, USA
| | - Ayesha Zia
- Division of Hematology/Oncology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
- Children’s Medical Center, Dallas, Texas, USA
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25
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Malec L, Matino D. Targeting higher factor VIII levels for prophylaxis in haemophilia A: a narrative review. Haemophilia 2023; 29:1419-1429. [PMID: 37758651 DOI: 10.1111/hae.14866] [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: 03/13/2023] [Revised: 09/07/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023]
Abstract
INTRODUCTION The standard of care in severe haemophilia A is prophylaxis, which has historically aimed for a factor VIII (FVIII) trough level of ≥1%. However, despite prophylactic treatment, people with haemophilia remain at risk of bleeds that have physical and quality of life implications, and that impact everyday life. AIM The aim of this review was to evaluate evidence supporting the relationship between targeting higher FVIII activity levels with prophylaxis and improved outcomes in people with haemophilia A. METHODS We conducted a narrative review that defined the unmet needs and treatment goals in people with haemophilia A, evaluated evidence to support targeting higher FVIII activity levels, and highlighted therapies that may support higher and sustained FVIII activity levels and improved outcomes for people with haemophilia A. RESULTS Despite recent advances in treatment, unmet needs remain, and people with haemophilia continue to experience joint and functional impairment, acute and chronic pain, and poor mental health. All these negatively impact their health-related quality of life. Evidence suggests that FVIII activity levels of up to 50% may be needed to achieve a near-zero joint bleed rate. However, achieving high FVIII activity levels with current standard and extended half-life (EHL) FVIII replacement therapies is associated with a high treatment burden. Innovative treatment options may provide high sustained FVIII activity levels and improved patient outcomes. CONCLUSION Evidence suggests that FVIII activity levels in people with haemophilia A should be sustained at higher levels to improve joint and patient outcomes and enable progression towards health equity.
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Affiliation(s)
- Lynn Malec
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- Division of Hematology & Oncology, Departments of Medicine and Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Davide Matino
- Division of Hematology & Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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26
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Mannucci PM, Agosti P, Lettino M. Guidance for the antithrombotic management of persons with haemophilia and cardiovascular disease. Haemophilia 2023; 29:1390-1393. [PMID: 37729476 DOI: 10.1111/hae.14874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/15/2023] [Accepted: 09/15/2023] [Indexed: 09/22/2023]
Affiliation(s)
- Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Pasquale Agosti
- Department of Pathophysiology and Transplantation and Fondazione Luigi Villa, Università degli Studi di Milano, Milan, Italy
| | - Maddalena Lettino
- Department for Cardiac, Thoracic and Vascular Diseases, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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27
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Matsumoto T, Wada H, Shiraki K, Suzuki K, Yamashita Y, Tawara I, Shimpo H, Shimaoka M. The Evaluation of Clot Waveform Analyses for Assessing Hypercoagulability in Patients Treated with Factor VIII Concentrate. J Clin Med 2023; 12:6320. [PMID: 37834964 PMCID: PMC10573981 DOI: 10.3390/jcm12196320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Regular prophylactic therapy has become an increasingly common treatment for severe hemophilia. Therefore, hypercoagulability-a potential risk factor of thrombosis-is a cause for concern in hemophilic patients treated with a high dose of FVIII concentrate. In clot waveform analysis (CWA)-thrombin time (TT), a small amount of thrombin activates clotting factor VIII (FVIII) instead of fibrinogen, resulting in FVIII measurements using CWA-TT with a small amount of thrombin. METHODS The coagulation ability of patients treated with FVIII concentrate or emicizumab was evaluated using activated partial thromboplastin time (APTT), TT and a small amount of tissue factor-induced FIX activation assay (sTF/FIXa) using CWA. RESULTS The FVIII activity based on CWA-TT was significantly greater than that based on the CWA-APTT or chromogenic assay. FVIII or FVIII-like activities based on the three assays in plasma without emicizumab were closely correlated; those in plasma with emicizumab based on CWA-TT and chromogenic assays were also closely correlated. CWA-APTT and CWA-TT showed different patterns in patients treated with FVIII concentrates compared to those treated with emicizumab. In particular, CWA-TT in patients treated with FVIII concentrate showed markedly higher peaks in platelet-rich plasma than in platelet-poor plasma. CWA-APTT showed lower coagulability in hemophilic patients treated with FVIII concentrate than in healthy volunteers, whereas CWA-sTF/FIXa did not. In contrast, CWA-TT showed hypercoagulability in hemophilic patients treated with FVIII concentrate. CONCLUSIONS CWA-TT can be used to evaluate the thrombin bursts that cause hypercoagulability in patients treated with emicizumab. Although routine APTT evaluations demonstrated low coagulation ability in patients treated with FVIII concentrate, CWA-TT showed hypercoagulability in these patients, suggesting that the evaluation of coagulation ability may be useful when using multiple assays.
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Affiliation(s)
- Takeshi Matsumoto
- Department of Transfusion Medicine and Cell Therapy, Mie University Hospital, Tsu 514-8507, Japan;
| | - Hideo Wada
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan;
| | - Katsuya Shiraki
- Department of General and Laboratory Medicine, Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan;
| | - Kei Suzuki
- The Emergency and Critical Care Center, Mie University Hospital, Tsu 514-8507, Japan;
| | - Yoshiki Yamashita
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu 514-8507, Japan; (Y.Y.); (I.T.)
| | - Isao Tawara
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu 514-8507, Japan; (Y.Y.); (I.T.)
| | - Hideto Shimpo
- Mie Prefectural General Medical Center, Yokkaichi 510-0885, Japan;
| | - Motomu Shimaoka
- Department of Molecular Pathobiology and Cell Adhesion Biology, Mie University Graduate School of Medicine, Tsu 514-8507, Japan;
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Whyte CS, Morrow GB, Gauer JS, Montague SJ, Nicolson PLR. Novel therapeutics and emerging technology in haemostasis and thrombosis: highlights from the British society for haemostasis and thrombosis annual meeting. Front Cardiovasc Med 2023; 10:1225243. [PMID: 37745127 PMCID: PMC10512947 DOI: 10.3389/fcvm.2023.1225243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/17/2023] [Indexed: 09/26/2023] Open
Abstract
The 2023 annual meeting of the British Society for Haemostasis and Thrombosis (BSHT) was held in Birmingham, United Kingdom. The theme of this year's meeting was novel therapeutics and emerging technology. Here, the exciting research presented at the meeting is discussed.
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Affiliation(s)
- Claire S. Whyte
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Gael B. Morrow
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine, Medical Sciences and Nutrition, Institute of Medical Sciences, University of Aberdeen, Aberdeen, United Kingdom
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Julia S. Gauer
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Samantha J. Montague
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Philip L. R. Nicolson
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
- West Midlands Haemophilia Comprehensive Care Centre, University Hospitals Birmingham Foundation Trust, Birmingham, United Kingdom
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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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Thornburg CD, Simmons DH, von Drygalski A. Evaluating Gene Therapy as a Potential Paradigm Shift in Treating Severe Hemophilia. BioDrugs 2023; 37:595-606. [PMID: 37490225 PMCID: PMC10432364 DOI: 10.1007/s40259-023-00615-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 07/26/2023]
Abstract
Hemophilia is characterized by a deficiency in coagulation factors VIII or IX. The general standard of care for severe hemophilia is frequent intravenous recombinant or plasma-derived factor replacement to prevent bleeding. While this treatment is effective in preventing bleeding, frequent infusions are burdensome for patients. Nonadherence to the therapeutic regimen leaves people with hemophilia at risk for spontaneous and traumatic bleeds into joints as well as life-threatening bleeds such as intracranial hemorrhage. The chronicity of the disorder often leads to the formation of target joints, causing long-term pain and impairing mobility. As a monogenic disorder with well-understood genetics, hemophilia is an ideal disorder for implementing innovations in gene therapies. Indeed, recent approvals of two gene therapy products have the potential to shift the hemophilia treatment paradigm. Valoctocogene roxaparvovec and etranacogene dezaparvovec-drlb are gene therapies for hemophilia A and B, respectively. These therapies, given as a single intravenous infusion, may improve patients' quality of life, decreasing treatment burden and resulting in factor expression that virtually eliminates the need for factor replacement. Since both treatments involve viral vectors targeted to the liver, short- and long-term safety and efficacy monitoring involves monitoring liver enzymes to track liver health. Long-term monitoring of efficacy, durability of gene expression, and safety are ongoing. Gene therapy presents a promising new therapeutic option for patients with hemophilia and warrants continued innovation and investigation.
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Affiliation(s)
- Courtney D Thornburg
- Hemophilia and Thrombosis Treatment Center, Rady Children's Hospital San Diego, San Diego, CA, USA.
- Department of Pediatrics, University of California, San Diego, La Jolla, CA, USA.
| | | | - Annette von Drygalski
- Division of Hematology/Oncology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
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Valentino LA, Kaczmarek R, Pierce GF, Noone D, O'Mahony B, Page D, Rotellini D, Skinner MW. Hemophilia gene therapy: first, do no harm. J Thromb Haemost 2023; 21:2354-2361. [PMID: 37353081 DOI: 10.1016/j.jtha.2023.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/02/2023] [Accepted: 06/09/2023] [Indexed: 06/25/2023]
Abstract
The introduction of adeno-associated virus-mediated, liver-directed gene therapy into the hemophilia treatment landscape brings not only great promise but also considerable uncertainty to a community that has a history punctuated by the devastating effects of HIV and hepatitis C virus. These infections were introduced into people with hemophilia through the innovation of factor concentrates in the 1970s and 1980s. Concentrates, heralded as a major advance in treatment at the time, brought devastation and death to the community already challenged by the complications of bleeding into joints, vital organs, and the brain. Over the past 5 decades, considerable advances in hemophilia treatment have improved the survival, quality of life, and participation of people with hemophilia, although challenges remain and health equity with their unaffected peers has not yet been achieved. The decision to take a gene therapy product is one in which an informed, holistic, and shared decision-making approach must be employed. Bias on the part of health care professionals and people with hemophilia must be addressed and minimized. Here, we review data leading to the regulatory authorization of valoctocogene roxaparvovec, an adeno-associated virus 5 gene therapy, in Europe to treat hemophilia A and etranacogene dezaparvovec-drlb in the United States and Europe to treat hemophilia B. We also provide an overview of the decision-making process and recommend steps that should be taken by the hemophilia community to ensure the safety of and optimal outcomes for people with hemophilia who choose to receive a gene therapy product.
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Affiliation(s)
- Leonard A Valentino
- Rush University, Chicago, Illinois, USA; National Hemophilia Foundation, New York, New York, USA.
| | - Radoslaw Kaczmarek
- Indiana University School of Medicine, Indianapolis, Indiana, USA; Hirszfeld Institute of Immunology and Experimental Therapy, Wroclaw, Poland
| | - Glenn F Pierce
- World Federation of Hemophilia, Montreal, Quebec, Canada
| | - Declan Noone
- European Haemophilia Consortium, Brussels, Belgium; Irish Haemophilia Society, Dublin, Ireland
| | - Brian O'Mahony
- Irish Haemophilia Society, Dublin, Ireland; Trinity College, Dublin, Ireland
| | - David Page
- Canadian Hemophilia Society, Montreal, Quebec, Canada
| | | | - Mark W Skinner
- Institute for Policy Advancement, Washington, DC, USA; McMaster University, Hamilton, Ontario, Canada
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van den Berg HM, Srivastava A. Hemostasis - A Balancing Act. N Engl J Med 2023; 389:853-856. [PMID: 37646683 DOI: 10.1056/nejme2304535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- H Marijke van den Berg
- From PedNet Hemophilia Research Foundation, Baarn, the Netherlands (H.M.B.); and the Department of Hematology, Christian Medical College Vellore, Ranipet, and the Center for Stem Cell Research (a unit of inStem), Christian Medical College Vellore, Vellore - both in India (A.S.)
| | - Alok Srivastava
- From PedNet Hemophilia Research Foundation, Baarn, the Netherlands (H.M.B.); and the Department of Hematology, Christian Medical College Vellore, Ranipet, and the Center for Stem Cell Research (a unit of inStem), Christian Medical College Vellore, Vellore - both in India (A.S.)
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Puetz J. "Liver-related aspects of gene therapy for hemophilia: need for collaborations with hepatologists": comment. J Thromb Haemost 2023; 21:2305-2306. [PMID: 37468179 DOI: 10.1016/j.jtha.2023.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 07/21/2023]
Affiliation(s)
- John Puetz
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, St. Louis, Missouri, USA.
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Franchini M, Focosi D. Targeting von Willebrand disease: the current status and future directions of management therapies. Expert Rev Hematol 2023; 16:871-878. [PMID: 37800892 DOI: 10.1080/17474086.2023.2268282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/04/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION von Willebrand disease (VWD) is the commonest inherited bleeding disorder, and is typically caused by deficits in the quantity or quality of von Willebrand factor (VWF). AREAS COVERED This review describes the main clinical, diagnostic, and therapeutic aspects of VWD, with particular attention to its management. In addition, standard and avant-garde replacement therapies based on the use of VWF are discussed. EXPERT OPINION The goal of treatment for VWD is to reverse the double hemostatic defect resulting from the abnormal or reduced expression of VWF and the concomitant factor VIII (FVIII) deficiency. Treatment consists of managing any bleeds and both short-term prophylaxis (i.e. for surgery or invasive procedures) and long-term prophylaxis. While desmopressin is suitable for most patients with type 1 VWD, VWF/FVIII concentrates are the treatment of choice for the other types of VWD. Beside plasma-derived VWF/FVIII concentrates, whose safety and efficacy have been demonstrated by several clinical trials, products containing only VWF, obtained by plasma fractionation and recombinant DNA technology, have become available and marketed more recently. The clinical use of these VWF-only products is particularly attractive in the setting of surgery and long-term prophylaxis, such as the prevention of recurrent gastrointestinal bleeding in cases of angiodysplasia.
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Affiliation(s)
- Massimo Franchini
- Department of Transfusion Medicine and Hematology, Carlo Poma Hospital, Mantova, Italy
| | - Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
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Pipe SW, Dunn AL, Young G. Efficacy and safety evaluation of eptacog beta (coagulation factor VIIa [recombinant]-jncw) for the treatment of hemophilia A and B with inhibitors. Expert Rev Hematol 2023; 16:715-729. [PMID: 37602448 DOI: 10.1080/17474086.2023.2248385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/26/2023] [Accepted: 08/11/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION Bypassing agents (BPAs) are used to treat acute bleeding episodes, manage bleeding during perioperative care, and prophylactically minimize bleed occurrence in persons with hemophilia A or B with inhibitors (PwHABI). However, the effectiveness of BPAs that have been prescribed for the last several decades can be variable, motivating the development of a new recombinant activated factor VII, eptacog beta. AREAS COVERED This review covers key eptacog beta findings from phase 1b and phase 3 (PERSEPT) clinical trials, which formed the basis for its regulatory approval to treat PwHABI ages 12 and older. Descriptions of eptacog beta structure and glycosylation profile, mechanism of action, preclinical study results, and cost analyses are also presented. EXPERT OPINION PwHABI have had only two options for bleed treatment for the past several decades. With its distinct glycosylation profile, eptacog beta offers a novel therapy aiming to improve upon BPAs currently in use, providing an option with more than one dosing regimen and a rapid response that allows most bleeds to be treated with just one dose. This has become particularly important given the use of subcutaneous medications (e.g., emicizumab) for prophylaxis of bleeding. Clinicians should consider eptacog beta as a BPA for all PwHABI.
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Affiliation(s)
- Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Amy L Dunn
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Guy Young
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Yoneyama K, Schmitt C, Portron A, Kiialainen A, Kotani N, Jaminion F, Retout S, Adamkewicz JI. Clinical pharmacology of emicizumab for the treatment of hemophilia A. Expert Rev Clin Pharmacol 2023; 16:775-790. [PMID: 37529848 DOI: 10.1080/17512433.2023.2243213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/22/2023] [Accepted: 07/28/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Emicizumab is a humanized bispecific antibody approved for the routine prophylaxis of bleeding episodes in patients with hemophilia A (PwHA) regardless of the presence of factor VIII (FVIII) inhibitors. It mimics the cofactor function of missing activated FVIII by bridging activated factor IX and factor X, thereby restoring hemostasis. AREAS COVERED This review covers the clinical pharmacology of emicizumab and the translation of its pharmacokinetics (PK) and pharmacodynamics (PD) to clinical efficacy and safety. The PK of emicizumab is linear, with an approximately 1-month half-life. Once-weekly to every-4-week subcutaneous (SC) administrations maintain effective trough concentrations throughout the dosing intervals, associated with a coagulation potential analogous to that in patients with mild hemophilia A. In combination with activated prothrombin complex concentrate, and to a lesser extent with recombinant activated factor VII, emicizumab exerts a synergistic effect, whereas combination with FVIII may result in a non-additive coagulation potential at normal FVIII activity. EXPERT OPINION The translation of emicizumab PK/PD into clinical effects was demonstrated in several phase III studies, which showed remarkable bleed control and a favorable safety profile in PwHA. These emicizumab attributes, together with the convenience of use (infrequent SC injections), offer a novel paradigm for the management of PwHA.
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Hermans C, Pierce GF. Towards achieving a haemophilia-free mind. Haemophilia 2023; 29:951-953. [PMID: 37262437 DOI: 10.1111/hae.14807] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/08/2023] [Accepted: 05/21/2023] [Indexed: 06/03/2023]
Affiliation(s)
- Cedric Hermans
- Division of Haematology, Haemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain (UCLouvain), Brussels, Belgium
- World Federation of Hemophilia, Montreal, Canada
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Konkle BA. Efanesoctocog alfa for the prevention and treatment of bleeding in patients with hemophilia A. Expert Rev Hematol 2023; 16:567-573. [PMID: 37289594 DOI: 10.1080/17474086.2023.2223925] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/06/2023] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Hemophilia A is an inherited bleeding disorder due to a deficiency of coagulation factor VIII (FVIII). Prevention and treatment of bleeding is traditionally through intravenous infusion of a FVIII concentrate. Modifications of recombinant FVIII (rFVIII) with an aim to prolong the half-life have been modest, thought because FVIII is dependent on plasma von Willebrand factor (VWF) for its half-life. Efanesoctocog alfa (ALTUVIIIO), approved by the Federal Drug Administration (FDA) in February 2023, was made independent of endogenous VWF by linking of the FVIII-binding D'D3 domain of VWF to B-domain deleted single chain FVIII. AREAS COVERED This review will outline the development of efanesoctocog alfa and the pharmacokinetic and safety data from clinical trials, as well as efficacy data from the phase 3 trials. These data formed the basis for the FDA approval. EXPERT OPINION Efanesoctocog alfa is a new type of FVIII replacement with an extended half-life allowing once weekly dosing to achieve hemostasis and FVIII trough levels of 13-15 IU/dL. This provides a highly effective option for treatment and prevention of bleeding in hemophilia A, where FVIII levels are easily measured. It also provides an option for treatment of bleeding and coverage for surgery with few infusions.
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Affiliation(s)
- Barbara A Konkle
- Washington Center for Bleeding Disorders, Division of Hematology, University of Washington, Seattle, WA, USA
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Rodriguez-Merchan EC. Point-of-care ultronography can help detect subclinical hemarthrosis in hemophilic patients undergoing regular optimal clotting factor prophylaxis to achieve zero bleeding. Expert Rev Hematol 2023; 16:565-566. [PMID: 37289642 DOI: 10.1080/17474086.2023.2223927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/14/2023] [Accepted: 06/06/2023] [Indexed: 06/10/2023]
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Mannucci PM, Kessler CM, Germini F, Nissen F, Ofori-Asenso R, Brocchieri C, Bendinelli S, Iorio A. Bleeding events in people with congenital haemophilia A without factor VIII inhibitors receiving prophylactic factor VIII treatment: A systematic literature review. Haemophilia 2023. [PMID: 37289855 DOI: 10.1111/hae.14803] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/28/2023] [Accepted: 05/14/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Evidence on bleeding rates in people with congenital haemophilia A (PwcHA) without inhibitors on factor VIII (FVIII) replacement products is inconsistent. AIM This systematic literature review assessed bleeding outcomes in PwcHA using FVIII-containing products as prophylactic treatment. METHODS A search was conducted using the bibliographic databases Medline, Embase and Cochrane Central Register of Controlled Trials on the Ovid platform. The search involved a bibliographic review of clinical trial studies, routine clinical care studies and registries and a search of ClinicalTrials.gov, EU Clinical Trials Register and conference abstracts. RESULTS The search yielded 5548 citations. A total of 58 publications were included for analysis. In 48 interventional studies, the pooled estimated mean (95% confidence interval [CI]) annualized bleeding rate (ABR), annualized joint bleeding rate (AJBR) and proportion of participants with zero bleeding events were 3.4 (3.0-3.7), 2.0 (1.6-2.5), and 38.5% (33.1-43.9), respectively. In 10 observational studies, the pooled estimated mean (95% CI) ABR, AJBR and proportion of participants with zero bleeding events were 4.8 (4.0-5.5), 2.6 (2.1-3.2), and 21.8% (19.9-47.5), respectively. A large variation in mean effect size for ABR, AJBR and zero bleeding event data across cohorts and cohort types was observed. Funnel plots indicated potential reporting bias for publications incorporating ABR and AJBR data across both interventional and observational studies. CONCLUSION This meta-analysis shows that PwcHA without inhibitors still have bleeds despite FVIII prophylaxis. Improved standardization on capturing and reporting bleeding outcomes is needed so that effective comparisons between treatments can be made.
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Affiliation(s)
- Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi, Hemophilia and Thrombosis Center, Milan, Italy
| | - Craig M Kessler
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington District of Columbia, USA
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Hermans C. Thrombosis and Hemophilia: Little More Evidence, Much More Guidance. Hemasphere 2023; 7:e918. [PMID: 37304930 PMCID: PMC10256429 DOI: 10.1097/hs9.0000000000000918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023] Open
Affiliation(s)
- Cedric Hermans
- Division of Hematology, Haemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain (UCLouvain), Brussels, Belgium
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Young G. Nonfactor Therapies for Hemophilia. Hemasphere 2023; 7:e911. [PMID: 37292115 PMCID: PMC10247213 DOI: 10.1097/hs9.0000000000000911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/09/2023] [Indexed: 06/10/2023] Open
Affiliation(s)
- Guy Young
- Cancer and Blood Disorders Institute, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
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Sarafanov AG. Plasma Clearance of Coagulation Factor VIII and Extension of Its Half-Life for the Therapy of Hemophilia A: A Critical Review of the Current State of Research and Practice. Int J Mol Sci 2023; 24:ijms24108584. [PMID: 37239930 DOI: 10.3390/ijms24108584] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/05/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
Factor VIII (FVIII) is an important component of blood coagulation as its congenital deficiency results in life-threatening bleeding. Current prophylactic therapy of the disease (hemophilia A) is based on 3-4 intravenous infusions of therapeutic FVIII per week. This poses a burden on patients, demanding reduction of infusion frequency by using FVIII with extended plasma half-life (EHL). Development of these products requires understanding FVIII plasma clearance mechanisms. This paper overviews (i) an up-to-date state of the research in this field and (ii) current EHL FVIII products, including recently approved efanesoctocog alfa, for which the plasma half-life exceeds a biochemical barrier posed by von Willebrand factor, complexed with FVIII in plasma, which results in ~1 per week infusion frequency. We focus on the EHL FVIII products' structure and function, in particular related to the known discrepancy in results of one-stage clotting (OC) and chromogenic substrate (CS) assays used to assign the products' potency, dosing, and for clinical monitoring in plasma. We suggest a possible root cause of these assays' discrepancy that is also pertinent to EHL factor IX variants used to treat hemophilia B. Finally, we discuss approaches in designing future EHL FVIII variants, including those to be used for hemophilia A gene therapy.
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Affiliation(s)
- Andrey G Sarafanov
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA
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Moonla C, Sosothikul D, Pongtanakul B, Suwanawiboon B, Traivaree C, Natesirinilkul R, Sirachainan N, Angchaisuksiri P. Practices and challenges for hemophilia management under resource constraints in Thailand. Orphanet J Rare Dis 2023; 18:110. [PMID: 37161533 PMCID: PMC10170808 DOI: 10.1186/s13023-023-02718-1] [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: 03/06/2023] [Accepted: 04/30/2023] [Indexed: 05/11/2023] Open
Abstract
Hemophilia is an inherited bleeding disorder caused by deficiency of a specific coagulation factor. Factor VIII deficiency is responsible for hemophilia A while factor IX deficiency is responsible for hemophilia B. As per the 2020 annual global survey by the World Federation of Hemophilia, only 1828 Thai hemophiliacs have been registered to the national healthcare system. The reason for the low number is the underdiagnosis which is a major concern in the real-world practice among Asian countries. In Thailand, most hemophiliacs are diagnosed by general practitioners, pediatricians or internists at rural hospitals and are referred to hemophilia specialists at the Hemophilia Treatment Centers (HTCs). Despite the challenges pertaining to infrastructure and cost of treatment, Thailand has progressed substantially in providing the required hemophilia care, as evidenced by an evolution in acquiring and sharing knowledge as well as collaborative efforts among multiple stakeholders over the past three decades. In this letter-to-the-editor, the authors have summarized the practices for and challenges faced with hemophilia management in Thailand.
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Affiliation(s)
- Chatphatai Moonla
- Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Darintr Sosothikul
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Rama IV Road, Pathumwan, Bangkok, 10330, Thailand.
- Integrative and Innovative Hematology/Oncology Research Unit, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
| | - Bunchoo Pongtanakul
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Bundarika Suwanawiboon
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanchai Traivaree
- Department of Pediatrics, Phramongkutklao College of Medicine and Phramongkutklao Hospital, Bangkok, Thailand
| | - Rungrote Natesirinilkul
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University and Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand
| | - Nongnuch Sirachainan
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pantep Angchaisuksiri
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Lissitchkov T, Willemze A, Jan C, Zilberstein M, Katragadda S. Pharmacokinetics of recombinant factor VIII in adults with severe hemophilia A: fixed-sequence single-dose study of octocog alfa, rurioctocog alfa pegol, and efanesoctocog alfa. Res Pract Thromb Haemost 2023; 7:100176. [PMID: 37538505 PMCID: PMC10394562 DOI: 10.1016/j.rpth.2023.100176] [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: 01/06/2023] [Revised: 04/20/2023] [Accepted: 05/03/2023] [Indexed: 08/05/2023] Open
Abstract
Background Efanesoctocog alfa is a new class of factor (F) VIII replacement therapy designed to provide high sustained factor levels for longer by overcoming the von Willebrand factor half-life ceiling. Objectives To assess the pharmacokinetics and safety of standard half-life (octocog alfa) and extended half-life (rurioctocog alfa pegol) FVIIIs and efanesoctocog alfa. Methods This phase 1 study (NCT05042440; EudraCT 2021-000228-37) enrolled previously treated adult men with severe hemophilia A. Patients received sequential single 50-IU/kg doses of octocog alfa, rurioctocog alfa pegol, and efanesoctocog alfa after appropriate washout periods between each dose. Results Thirteen participants were enrolled. Geometric mean elimination half-life of octocog alfa, rurioctocog alfa pegol, and efanesoctocog alfa was 11.0, 15.4, and 43.3 hours, respectively, and area under the FVIII activity-time curve was 1670, 2820, and 10,100 IU × h/dL, respectively. Efanesoctocog alfa maintained mean FVIII activity levels of >40 IU/dL for up to 4 days and at ∼10 IU/dL on day 7. Corresponding times for >40 IU/dL and >10 IU/dL were <1 and <2 days, respectively, for octocog alfa and 1 day and <3 days, respectively, for rurioctocog alfa pegol. No serious treatment-emergent adverse events were reported for efanesoctocog alfa, and no inhibitor development to FVIII was detected. Conclusion Efanesoctocog alfa had 3- to 4-fold longer elimination half-life and 3- to 6-fold greater exposure (area under the FVIII activity-time curve, 6.03 and 3.57 folds) than octocog alfa and rurioctocog alfa pegol. Efanesoctocog alfa provided high sustained FVIII activity in the normal-to-near-normal range (>40 IU/dL) for up to 4 days after the dose and at ∼10 IU/dL on day 7.
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Affiliation(s)
- Toshko Lissitchkov
- Specialized Hospital for Active Treatment of Hematological Diseases, Department of Chemotherapy, Hemotherapy and Hereditary Blood Diseases at Clinical Hematology Clinic, Sofia, Bulgaria
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Abstract
Efanesoctocog alfa (ALTUVIIIOTM; [antihemophilic factor (recombinant), Fc-VWF-XTEN fusion protein-ehtl]), a von Willebrand factor (VWF) independent, recombinant DNA-derived Factor VIII (FVIII) concentrate, has been developed by Bioverativ Therapeutics, Inc (a Sanofi company) and Swedish Orphan Biovitrum AB (Sobi). Efanesoctocog alfa was approved in February 2023 in the USA for use in adults and children with hemophilia A (congenital FVIII deficiency) for: routine prophylaxis to reduce the frequency of bleeding episodes; on-demand treatment and control of bleeding episodes; perioperative management of bleeding. This article summarizes the milestones in the development of efanesoctocog alfa leading to this first approval for hemophilia A.
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Affiliation(s)
- Susan J Keam
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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Pierce GF, Herzog RW. Two gene therapies for hemophilia available: Now what? Mol Ther 2023; 31:919-920. [PMID: 36931266 PMCID: PMC10124068 DOI: 10.1016/j.ymthe.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/01/2023] [Accepted: 03/01/2023] [Indexed: 03/18/2023] Open
Affiliation(s)
| | - Roland W Herzog
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
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Mannucci PM. Hemophilia treatment innovation: 50 years of progress and more to come. J Thromb Haemost 2023; 21:403-412. [PMID: 36858789 DOI: 10.1016/j.jtha.2022.12.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/01/2022] [Accepted: 12/28/2022] [Indexed: 03/02/2023]
Abstract
With the goal of emphasizing the striking advances that materialized in hemophilia care particularly in the last 10 years, the progress of knowledge that started from the 1970s will first be sketched as background. Subsequently, the unmet needs pertaining to therapeutic adherence and thus to prophylaxis effectiveness led to the availability of factor VIII and IX products with an extended plasma half-life as well as to emicizumab, the first nonfactor medicine for subcutaneous administration in patients with hemophilia A with or without inhibitor. The issue of a still lacking cure for the disease is approached by means of gene therapy, the first products of which were approved in 2022 for adults with both hemophilia types. Finally, views will be offered on further progress that is expected in the next few years and how patients and their care providers may make personalized choices among the wide array of therapeutic options.
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Affiliation(s)
- Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.
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