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Chandrakumara J, Wijesundara M, Amarakoon G. A child diagnosed with severe hemophilia A presenting with nephrotic syndrome: a case report. J Med Case Rep 2023; 17:206. [PMID: 37208723 DOI: 10.1186/s13256-023-03941-x] [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: 11/01/2021] [Accepted: 04/21/2023] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Nephrotic syndrome occurring as a complication of immune tolerance therapy for inhibitors in hemophilia B is well recognized. It is also known to occur in association with factor borne infections, especially hepatitis C. This is the first case report of nephrotic syndrome occurring in a child receiving prophylactic factor VIII in the absence of inhibitors of hepatitis infection. However, the pathophysiology of this phenomenon is poorly understood. CASE PRESENTATION A 7-year Sri Lankan boy diagnosed with severe hemophilia A on weekly factor VIII prophylaxis was diagnosed with three episodes of nephrotic syndrome, a condition in which there is leakage of plasma protein into urine. He had three episodes of nephrotic syndrome, all of which responded well to 60 mg/m2 daily dose of oral steroids, achieving remission within 2 weeks of starting daily prednisolone. He has not developed inhibitors for factor VIII. His hepatitis screening remained negative. CONCLUSIONS There is a possible link between factor therapy for hemophilia A and nephrotic syndrome, which can be a T-cell-mediated immune response. This case also highlights the importance of monitoring for renal involvement in patients treated with factor replacement.
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Affiliation(s)
- Janith Chandrakumara
- Department of Paediatrics, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Anuradhapura, Sri Lanka.
| | - Madushika Wijesundara
- Department of Paediatrics, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Anuradhapura, Sri Lanka
| | - Givani Amarakoon
- Department of Paediatrics, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Anuradhapura, Sri Lanka
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Dou X, Zhang W, Poon MC, Zhang X, Wu R, Feng X, Yang L, Cheng P, Chen S, Wang Y, Zhou H, Huang M, Song Y, Jin C, Zhang D, Chen L, Liu W, Zhang L, Xue F, Yang R. Factor IX inhibitors in haemophilia B: A report of National Haemophilia Registry in China. Haemophilia 2023; 29:123-134. [PMID: 36163649 DOI: 10.1111/hae.14665] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/25/2022] [Accepted: 09/12/2022] [Indexed: 01/27/2023]
Abstract
INTRODUCTION The development of inhibitors against factor FIX (FIX) is the most serious complication of FIX replacement therapy in haemophilia B (HB) patients. Currently, only few cohorts of HB inhibitor patients have been reported worldwide. AIM This Chinese nationwide study of HB inhibitor patients explored their risk factors for FIX inhibitor development and experience on their management. METHODS We retrospectively analysed patient characteristics, F9 genotypes, treatment strategies and outcomes of HB inhibitor patients registered to the Chinese National Registry and Patient Organization Registry. RESULTS Forty-four unique HB inhibitor patients were identified in 4485 unique HB patients registered by year 2021 to the two Registries. Inhibitor diagnosis were usually delayed and the low prevalence (.98%) may suggest some inhibitor patients were not identified. Their median age at inhibitor diagnosis was 7.5 (IQR, 3.0-14.8) years. Most patients (95.5%) had high-titre inhibitors. Allergic/Anaphylactic reactions occurred in 59.1% patients. Large deletions and nonsense mutations were the most common F9 mutation types in our FIX inhibitor patients. Patients with large F9 gene deletions were more likely to develop inhibitors (p = .0002), while those with missense mutations had a low risk (p < .0001). Thirteen (29.5%) patients received immune tolerance induction (ITI) therapy using low-dose prothrombin complex concentrate regimens. Twelve completed ITI with three (25.0%) achieving success. Nephrotic syndrome developed in two (16.7%) patients during ITI. CONCLUSION This study reports the largest Chinese cohort of HB inhibitor patients. Large deletions were most significantly associated with inhibitor development. Low-dose ITI might be feasible for FIX inhibitor eradication.
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Affiliation(s)
- Xueqing Dou
- 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, China.,National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wenhui Zhang
- 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, China
| | - Man-Chiu Poon
- Departments of Medicine, Pediatrics and Oncology, Cumming School of Medicine, University of Calgary, and the Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Hospital, Alberta Health Services, Calgary, Alberta, Canada
| | - Xinsheng Zhang
- Shandong Hemophilia Treatment Center, Shandong Blood Center, Jinan, China
| | - Runhui Wu
- Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoqin Feng
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Linhua Yang
- Second Hospital of Shanxi Medical University, Taiyuan, China
| | - Peng Cheng
- Department of Hematology, Guangxi Medical University First Affiliated Hospital, Nanning, China
| | - Shu Chen
- Department of Hematology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ying Wang
- Shenzhen Children's Hospital, Shenzhen, China
| | - Hu Zhou
- The Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer hospital, Zhengzhou, China
| | - Meijuan Huang
- Fujian Medical University Union Hospital, Fujian Institute of Haematology, Fuzhou, China
| | | | - Chenghao Jin
- Department of Hematology, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Donglei Zhang
- 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, China
| | - Lingling Chen
- 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, China
| | - Wei Liu
- 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, China
| | - Lei Zhang
- 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, China
| | - Feng Xue
- 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, China
| | - Renchi 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, China
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Li Z, Liu G, Yao W, Chen Z, Li G, Cheng X, Zhen Y, Ai D, Huang K, Sun J, Poon MC, Wu R. Eradication of FIX inhibitor in haemophilia B children using low-dose immune tolerance induction with rituximab-based immunosuppressive agent(s) in China. Haemophilia 2022; 28:625-632. [PMID: 35503087 DOI: 10.1111/hae.14577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/10/2022] [Accepted: 04/13/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Development of haemophilia B inhibitors (HBI) results in the ineffectiveness of FIX replacement therapy. Inhibitor eradication by immune tolerance induction (ITI) is therefore necessary. In HBI, ITI even at high FIX dose is less effective and has a higher risk of severe complications. AIM To characterize clinical features and outcome of ITI on HBI. METHODS This retrospective study was conducted in Haemophilia Paediatric Comprehensive Care Centre of China. We used low-dose ITI (25-50 FIX IU/kg/three-times-weekly to every-other-day) with domestic prothrombin complex concentrate (PCC), combined with two successive immunosuppressive (IS) regimens. RESULTS Sixteen HBI children, representing 5.7% of all and 14.4% of our severe registered HB patients, were enroled. Seven cases reported allergic reactions (ARs) proximal to inhibitor development. The historic peak inhibitor titre was median 54.2 (range 4.7-512) BU, and 15 (93.8%) had high-titre inhibitors. Twelve patients adherent to ITI were analysable. Of the nine ITI patients who received rituximab/prednisone (IS Regimen-1), four achieved tolerization in 1.4-43.3 months. Two subsequently relapsed but re-tolerized after a second course of IS Regimen-1. During ITI, the median treated bleed was .39/month (82.7% reduction from before ITI), and the incidence of AR and nephrotic syndrome (NS) complications was each at 22% (2/9). Three ITI patients received modified 'Beutel' protocol (IS Regimen-2) using multiple-IS-drugs, and two had rapid tolerization (.8 and 1.8 months). CONCLUSIONS Inhibitor eradication could be achieved by low-dose ITI protocol using PCC combined with IS. Larger studies are needed to confirm if ITI with IS Regimen-2 is more effective with less complications.
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Affiliation(s)
- Zekun Li
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Guoqing Liu
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Wanru Yao
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Zhenping Chen
- Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Gang Li
- Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiaoling Cheng
- Pharmacology Department, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yingzi Zhen
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Di Ai
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Kun Huang
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jie Sun
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China.,Haematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education; Beijing Pediatric Research Institute, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Man-Chiu Poon
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Department of Oncology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Southern Alberta Rare Blood and Bleeding Disorders Comprehensive Care Program, Foothills Hospital, Alberta Health Services, Calgary, Alberta, Canada
| | - Runhui Wu
- Haemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology Oncology; Key Laboratory of Major Diseases in Children, Ministry of Education, National Center for Children's Health, National Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical University, Beijing, China
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Bouyadmar M, Khorassani ME, Kababri ME, Kili A, Hessissen L. The prevalence of anti-factor VIII and anti-factor IX antibodies among patients with hemophilia in Rabat, Morocco: a single center experience. Pan Afr Med J 2022; 41:126. [PMID: 35480405 PMCID: PMC9011910 DOI: 10.11604/pamj.2022.41.126.29571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 01/08/2022] [Indexed: 11/25/2022] Open
Abstract
The emergence of anti-factor VIII and anti-factor IX antibodies in hemophilia A or B is the most serious complication of hemophilia. We aim to expose through a series of patient's data, collected between 02/2009 and 02/2016 in the pediatric service of university hospital of Rabat, Morocco, the epidemiological and clinical characteristics of these patients, and to highlight the therapeutic difficulties encountered during their treatment. Out of 120 hemophiliac patients, we included 22 hemophiliac patients (18.33%, p<0.004) who developed an antibody, 21 patients with hemophilia A. Among the patients, 54.5% (n=12) exhibited moderate hemophilia, while 45.5% (n=10) had major hemophilia. The average age at diagnosis is estimated to 12±6.6 years. The circumstances of diagnosis were dominated by therapeutic inefficiency (63.64% (n=14)), then came dental extraction (9.09% (n=2)), preoperative assessment 22.73% (n=5) and hemophiliac arthropathy in a single case. The titration of antibodies in a 12-person sample ranged from 0.6 UB to 84 UB, of which (41.67% (n=5)) were low responders. The therapeutic treatment was based on fresh frozen plasma (54.55% (n=7)), recombinant activated factor VII (18.2% (n=4)), recombinant activated factor VII and PFC (18.2% (n=4)), and induction of immune tolerance. The occurrence of an inhibitory antibody represents the major residual complication of replacement therapy.
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Affiliation(s)
- Meryem Bouyadmar
- Department of Pediatrics, Cheikh Khalifa Ibn Zayed International University Hospital, Casablanca, Morocco.,Hemophilia Treatment Center and Bleeding Disorders, Hematology-Oncology Unit, Children's Hospital Rabat, Mohamed V University, Rabat, Morocco
| | - Mohamed El Khorassani
- Hemophilia Treatment Center and Bleeding Disorders, Hematology-Oncology Unit, Children's Hospital Rabat, Mohamed V University, Rabat, Morocco
| | - Maria El Kababri
- Hemophilia Treatment Center and Bleeding Disorders, Hematology-Oncology Unit, Children's Hospital Rabat, Mohamed V University, Rabat, Morocco
| | - Amina Kili
- Hemophilia Treatment Center and Bleeding Disorders, Hematology-Oncology Unit, Children's Hospital Rabat, Mohamed V University, Rabat, Morocco
| | - Laila Hessissen
- Hemophilia Treatment Center and Bleeding Disorders, Hematology-Oncology Unit, Children's Hospital Rabat, Mohamed V University, Rabat, Morocco
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Müller J, Miesbach W, Prüller F, Siegemund T, Scholz U, Sachs UJ. An Update on Laboratory Diagnostics in Haemophilia A and B. Hamostaseologie 2022; 42:248-260. [PMID: 35104901 PMCID: PMC9388220 DOI: 10.1055/a-1665-6232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Haemophilia A (HA) and B (HB) are X-linked hereditary bleeding disorders caused by lack of activity of coagulation factors VIII (FVIII) or IX (FIX), respectively. Besides conventional products, modern replacement therapies include FVIII or FIX concentrates with an extended half-life (EHL-FVIII/FIX). Two main strategies for measuring plasma FVIII or FIX activity are applied: the one-stage clotting assay (OSCA) and the chromogenic substrate assay (CSA), both calibrated against plasma (FVIII/FIX) standards. Due to the structural modifications of EHL-FVIII/FIX, reagent-dependent assay discrepancies have been described when measuring the activity of these molecules. Assay discrepancies have also been observed in FVIII/FIX gene therapy approaches. On the other hand, nonfactor replacement by the bispecific antibody emicizumab, a FVIIIa-mimicking molecule, artificially shortens activated partial thromboplastin time–based clotting times, making standard OSCAs inapplicable for analysis of samples from patients treated with this drug. In this review, we aim to give an overview on both, the currently applied and future therapies in HA and HB with or without inhibitors and corresponding test systems suitable for accompanying diagnostics.
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Affiliation(s)
- Jens Müller
- Institute for Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Bonn, Germany
| | - Wolfgang Miesbach
- Department of Haemostaseology and Hemophilia Center, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Thomas Siegemund
- Division of Hemostaseology, Department of Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Ute Scholz
- Center of Hemostasis, MVZ Labor Leipzig, Leipzig, Germany
| | - Ulrich J Sachs
- Department of Thrombosis and Haemostasis, Giessen University Hospital, Giessen, Germany
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Immunogenicity Challenges Associated with Subcutaneous Delivery of Therapeutic Proteins. BioDrugs 2021; 35:125-146. [PMID: 33523413 PMCID: PMC7848667 DOI: 10.1007/s40259-020-00465-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 12/12/2022]
Abstract
The subcutaneous route of administration has provided convenient and non-inferior delivery of therapeutic proteins compared to intravenous infusion, but there is potential for enhanced immunogenicity toward subcutaneously administered proteins in a subset of patients. Unwanted anti-drug antibody response toward proteins or monoclonal antibodies upon repeated administration is shown to impact the pharmacokinetics and efficacy of multiple biologics. Unique immunogenicity challenges of the subcutaneous route have been realized through various preclinical and clinical examples, although subcutaneous delivery has often demonstrated comparable immunogenicity to intravenous administration. Beyond route of administration as a treatment-related factor of immunogenicity, certain product-related risk factors are particularly relevant to subcutaneously administered proteins. This review attempts to provide an overview of the mechanism of immune response toward proteins administered subcutaneously (subcutaneous proteins) and comments on product-related risk factors related to protein structure and stability, dosage form, and aggregation. A two-wave mechanism of antigen presentation in the immune response toward subcutaneous proteins is described, and interaction with dynamic antigen-presenting cells possessing high antigen processing efficiency and migratory activity may drive immunogenicity. Mitigation strategies for immunogenicity are discussed, including those in general use clinically and those currently in development. Mechanistic insights along with consideration of risk factors involved inspire theoretical strategies to provide antigen-specific, long-lasting effects for maintaining the safety and efficacy of therapeutic proteins.
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Male C, Andersson NG, Rafowicz A, Liesner R, Kurnik K, Fischer K, Platokouki H, Santagostino E, Chambost H, Nolan B, Königs C, Kenet G, Ljung R, Van den Berg M. Inhibitor incidence in an unselected cohort of previously untreated patients with severe haemophilia B: a PedNet study. Haematologica 2021; 106:123-129. [PMID: 31919092 PMCID: PMC7776246 DOI: 10.3324/haematol.2019.239160] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/09/2020] [Indexed: 12/20/2022] Open
Abstract
The incidence of factor IX (FIX) inhibitors in severe hemophilia B (SHB) is not well defined. Frequencies of 3-5% have been reported but most studies to date have been small, including patients with different severities, and without prospective follow up for inhibitor incidence. The study objective was to investigate the inhibitor incidence in patients with SHB followed up for to 500 exposure days (ED), the frequency of allergic reactions, and the relationship with genotypes. Consecutive previously untreated patients (PUP) with SHB enrolled into the PedNet cohort were included. Detailed data was collected for the first 50 ED, followed by the annual collection of the inhibitor status and allergic re-actions. The presence of inhibitors was defined by at least two consecutive positive samples. Additionally, data on FIX gene mutation was collected. One hundred and fifty-four PUP with SHB were included; 75% were followed up until 75 ED, and 43% until 500 ED. Inhibitors developed in 14 patients (seven high-titer). The median number of ED at inhibitor manifestation was 11 (interquartile range [IQR]: 6.5-36.5). The cumulative inhibitor incidence was 9.3% (95% Confidence Interval [CI]: 4.4-14.1) at 75 ED, and 10.2% (95% CI: 5.1-15.3) at 500 ED. Allergic reactions occurred in four (28.6%) inhibitor patients. Missense mutations were most frequent (46.8%) overall but not associated with inhibitors. Nonsense mutations and deletions with large structural changes comprised all mutations among inhibitor patients and were associated with an inhibitor risk of 26.9% and 33.3%, respectively. In an unselected, well-defined cohort of PUP with SHB, the cumulative inhibitor incidence was 10.2% at 500 ED. Nonsense mutations and large deletions were strongly associated with the risk of inhibitor development. The ‘PedNet Registry’ is registered at clinicaltrials.gov; identifier: NCT02979119.
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Affiliation(s)
| | - Nadine G Andersson
- Centre for Thrombosis and Hemostasis, Skane University Hospital, Malmö, Sweden
| | | | - Ri Liesner
- Hemophilia Center, Dept. of Hematology, Great Ormond Street Hospital for Children, London
| | - Karin Kurnik
- Dr. V. Haunersches Kinderspital, University of Munich
| | | | - Helen Platokouki
- Haemophilia-Haemostasis Unit, St. Sophia Children Hospital, Athens
| | | | - Hervé Chambost
- APHM, La Timone Children Hospital, Center for Bleeding Disorders, Marseille
| | - Beatrice Nolan
- Department of Paediatric Hematology, Children Health Ireland at Crumlin, Dublin
| | - Christoph Königs
- J.W. Goethe University Hospital, Department of Pediatrics, Frankfurt
| | - Gili Kenet
- National Hemophilia Center, Ministry of Health, Sheba Medical Center, Tel Hashomer, Israel
| | - Rolf Ljung
- Department of Clinical Sciences, Department of Pediatrics, Lund University, Lund, Sweden
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Gollomp KL, Doshi BS, Arruda VR. Gene therapy for hemophilia: Progress to date and challenges moving forward. Transfus Apher Sci 2019; 58:602-612. [DOI: 10.1016/j.transci.2019.08.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Roberts JC, Jesudas R, Tarantino MD. Development of an inhibitor in a child with severe hemophilia B. Blood Coagul Fibrinolysis 2019; 30:291-294. [DOI: 10.1097/mbc.0000000000000829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Xue F, Liu W, Cheng YF, Liu XF, Huang YT, Fu RF, Zhang L, Yang RC. [Immune tolerance induction in a case of hemophilia B with inhibitor with prothrombin complex concentrate and rituximab]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 38:749-753. [PMID: 29081190 PMCID: PMC7348358 DOI: 10.3760/cma.j.issn.0253-2727.2017.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
目的 探讨血友病B伴抑制物的免疫耐受诱导(ITI)治疗,提高血友病B伴抑制物的诊疗水平。 方法 应用基于APTT标准曲线的一期法测定重型血友病B患者凝血因子Ⅸ(FⅨ)活性,应用Bethesda法进行FⅨ抑制物定量测定;利用凝血酶原复合物(PCC)进行ITI并联合利妥昔单抗清除患者抑制物。 结果 患儿既往PCC暴露日为20 d,抑制物滴度峰值为56 BU/ml。在2015年11月患儿抑制物滴度降至10.4 BU/ml时开始ITI治疗,单用PCC一段时间无效,给予PCC联合利妥昔单抗治疗,17个月后成功清除患者体内FⅨ抑制物,未发生过敏反应及肾病综合征等并发症。ITI过程中患者年化出血率有所改善。 结论 该患者是国内首例报道的采用ITI联合利妥昔单抗成功治疗血友病B伴抑制物的病例。PCC联合利妥昔单抗ITI治疗是目前有希望清除血友病B抑制物的方法。
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Affiliation(s)
- F Xue
- State Key Laboratory of Experimental Hematology, Institute of Hematology & Hospital of Blood Diseases, CAMS & PUMC, Tianjin 300020, China
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11
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Barg AA, Levy-Mendelovich S, Avishai E, Dardik R, Misgav M, Kenet G, Livnat T. Alternative treatment options for pediatric hemophilia B patients with high-responding inhibitors: A thrombin generation-guided study. Pediatr Blood Cancer 2018; 65:e27381. [PMID: 30230231 DOI: 10.1002/pbc.27381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/15/2018] [Accepted: 06/08/2018] [Indexed: 11/07/2022]
Abstract
Little is known about the challenging treatment of pediatric patients with hemophilia B and inhibitors due to disease rarity. We describe three patients diagnosed in childhood and followed up to 9 years. All three had allergic reactions to Factor IX, but two were later safely treated for bleeding episodes with activated prothrombin complex concentrates (APCC = FEIBA). The third was given only recombinant activated Factor VIIa. Based on ex vivo thrombin generation analysis, a new alternative treatment of combined bypassing agents was administered for bleeding episodes and several minor surgical procedures with no treatment-associated adverse events or thrombosis.
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Affiliation(s)
- Assaf Arie Barg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Sarina Levy-Mendelovich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Einat Avishai
- The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Rima Dardik
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Mudi Misgav
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Gili Kenet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Tami Livnat
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel
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12
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Bypassing Agents for Bleeding Prophylaxis in Hemophilia B. Am J Ther 2018; 25:e770-e771. [DOI: 10.1097/mjt.0000000000000776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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Doshi BS, Arruda VR. Gene therapy for hemophilia: what does the future hold? Ther Adv Hematol 2018; 9:273-293. [PMID: 30210756 DOI: 10.1177/2040620718791933] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/09/2018] [Indexed: 01/19/2023] Open
Abstract
Recent phase I/II adeno-associated viral vector-mediated gene therapy clinical trials have reported remarkable success in ameliorating disease phenotype in hemophilia A and B. These trials, which highlight the challenges overcome through decades of preclinical and first in human clinical studies, have generated considerable excitement for patients and caregivers alike. Optimization of vector and transgene expression has significantly improved the ability to achieve therapeutic factor levels in these subjects. Long-term follow-up studies will guide standardization of the approach with respect to the combination of serotype, promoter, dose, and manufacturing processes and inform safety for inclusion of young patients. Certain limitations preclude universal applicability of gene therapy, including transient liver transaminase elevations due to the immune responses to vector capsids or as yet undefined mechanisms, underlying liver disease from iatrogenic viral hepatitis, and neutralizing antibodies to clotting factors. Integrating vectors show promising preclinical results, but manufacturing and safety concerns still remain. The prospect of gene editing for correction of the underlying mutation is on the horizon with considerable potential. Herein, we review the advances and limitations that have resulted in these recent successful clinical trials and outline avenues that will allow for broader applicability of gene therapy.
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Affiliation(s)
- Bhavya S Doshi
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Valder R Arruda
- Department of Pediatrics, The Children's Hospital of Philadelphia, 3501 Civic Center Blvd, 5056 Colket Translational Research Center, Philadelphia, PA 19104, USA
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Soto I, Martínez D, Ávila LF, Bernardo Á. A rare case of late development of inhibitor in haemophilia B with a complex course, and review of the literature. Haemophilia 2018; 24:e125-e128. [PMID: 29488670 DOI: 10.1111/hae.13442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2018] [Indexed: 06/08/2023]
Affiliation(s)
- I Soto
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - D Martínez
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - L F Ávila
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Á Bernardo
- Department of Hematology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
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Konkle BA, Johnsen JM, Wheeler M, Watson C, Skinner M, Pierce GF. Genotypes, phenotypes and whole genome sequence: Approaches from the My Life Our Future haemophilia project. Haemophilia 2018; 24 Suppl 6:87-94. [PMID: 29878652 PMCID: PMC6258054 DOI: 10.1111/hae.13506] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Information from the genes encoding factor VIII (F8) and IX (F9) is used in reproductive planning and to inform inhibitor formation, bleeding severity and response to therapies. Advances in technology and our understanding of the human genome now allows more comprehensive methods to study genomic variation and its impact on haemophilia. AIMS The My Life Our Future (MLOF) programme was begun in 2012 to provide genetic analysis and to expand research in haemophilia through a research repository. METHODS MLOF enrolled haemophilia A and B patients followed at haemophilia treatment centers in the U.S., including, since 2015, known and potential genetic carriers. Initial F8 and F9 DNA analysis was performed utilizing a next generation sequencing approach which allowed simultaneous detection of F8 inversions and other variants. Candidate variants were confirmed using a second method and multiplex ligation-dependent probe amplification was used to detect structural variants. RESULTS The initial phase of MLOF completed enrollment in December 2017 with 11,356 patients, genetic carriers, and potential carriers enrolled. In the 9453 subjects in whom analysis is complete, 687 unique previously unreported variants were found. Simultaneous sequencing of the F8 and F9 genes resulted in identification of non-deleterious variants previously reported as causative in haemophilia. DNA from 5141 MLOF subjects has undergone whole genome sequencing through the NHLBI TOPMed programme of the U.S. NIH. CONCLUSION MLOF has provided genetic information for patients and their families to help inform clinical care and has established a repository of data and biospecimens to further advance haemophilia research.
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Affiliation(s)
- B A Konkle
- Bloodworks Northwest, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - J M Johnsen
- Bloodworks Northwest, Seattle, WA, USA
- University of Washington, Seattle, WA, USA
| | - M Wheeler
- University of Washington, Seattle, WA, USA
| | - C Watson
- American Thrombosis and Hemostasis Network, Chicago, IL, USA
| | - M Skinner
- National Hemophilia Foundation, New York, NY, USA
| | - G F Pierce
- National Hemophilia Foundation, New York, NY, USA
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17
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Roman E, Larson PJ, Manno CS. Transfusion Therapy for Coagulation Factor Deficiencies. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00117-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Ljung RCR. How I manage patients with inherited haemophilia A and B and factor inhibitors. Br J Haematol 2017; 180:501-510. [DOI: 10.1111/bjh.15053] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Rolf C. R. Ljung
- Department of Clinical Sciences - Paediatrics; Lund University; Lund Sweden
- Centre for Thrombosis and Haemostasis; Skåne University Hospital Malmö; Malmo Sweden
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Cugno M, Mancuso ME, Tedeschi A, Santagostino E, Lorini M, Carbonelli V, Peyvandi F, Mannucci PM. Involvement of the IgE-basophil system and mild complement activation in haemophilia B with anti-factor IX neutralizing antibodies and anaphylaxis. Haemophilia 2017; 23:e348-e353. [DOI: 10.1111/hae.13282] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2017] [Indexed: 12/20/2022]
Affiliation(s)
- M. Cugno
- Internal Medicine; Department of Pathophysiology and Transplantation; Università degli Studi di Milano; Milan Italy
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan Italy
| | - M. E. Mancuso
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan Italy
| | - A. Tedeschi
- Internal Medicine; Ospedale Fatebenefratelli e Oftalmico; Milan Italy
| | - E. Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan Italy
| | - M. Lorini
- Dipartimento di Scienze Cliniche e di Comunità; Università degli Studi di Milano; Milan Italy
| | - V. Carbonelli
- Dipartimento di Scienze Cliniche e di Comunità; Università degli Studi di Milano; Milan Italy
| | - F. Peyvandi
- Internal Medicine; Department of Pathophysiology and Transplantation; Università degli Studi di Milano; Milan Italy
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan Italy
| | - P. M. Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico; Milan Italy
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Boylan B, Rice AS, Neff AT, Manco-Johnson MJ, Kempton CL, Miller CH. Survey of the anti-factor IX immunoglobulin profiles in patients with hemophilia B using a fluorescence-based immunoassay. J Thromb Haemost 2016; 14:1931-1940. [PMID: 27501440 PMCID: PMC5083216 DOI: 10.1111/jth.13438] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Indexed: 12/18/2022]
Abstract
Essentials Studies characterizing neutralizing antibodies (inhibitors) in hemophilia B (HB) are lacking. The current study describes anti-factor (F) IX antibody profiles in 37 patients who have HB. Anti-FIX IgG4 levels exhibited a strong positive correlation with Nijmegen-Bethesda results. These data will help to more clearly define, predict, and treat alloantibody formation in HB. SUMMARY Background Hemophilia B (HB) is an inherited bleeding disorder caused by the absence or dysfunction of coagulation factor IX (FIX). A subset of patients who have HB develop neutralizing alloantibodies (inhibitors) against FIX after infusion therapy. HB prevalence and the proportion of patients who develop inhibitors are much lower than those for hemophilia A (HA), which makes studies of inhibitors in patients with HB challenging due to the limited availability of samples. As a result, there is a knowledge gap regarding HB inhibitors. Objective Evaluate the largest group of patients with inhibitor-positive HB studied to date to assess the relationship between anti-FIX antibody profiles and inhibitor formation. Methods A fluorescence immunoassay was used to detect anti-FIX antibodies in plasma samples from 37 patients with HB. Results Assessments of antibody profiles showed that anti-FIX IgG1-4 , IgA, and IgE were detected significantly more often in patients with a positive Nijmegen-Bethesda assay (NBA). All NBA-positive samples were positive for IgG4 . Anti-FIX IgG4 demonstrated a strong correlation with the NBA, while correlations were significant, yet more moderate, for anti-FIX IgG1-2 and IgA. Conclusions The anti-FIX antibody profile in HB patients who develop inhibitors is diverse and correlates well with the NBA across immunoglobulin (sub)class, and anti-FIX IgG4 is particularly relevant to functional inhibition. The anti-FIX fluorescence immunoassay may serve as a useful tool to confirm the presence of antibodies in patients who have low positive NBA results and to more clearly define, predict, and treat alloantibody formation against FIX.
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Affiliation(s)
- B Boylan
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - A S Rice
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - A T Neff
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - M J Manco-Johnson
- Hemophilia and Thrombosis Center, University of Colorado and The Children's Hospital, Aurora, CO, USA
| | - C L Kempton
- Department of Hematology/Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - C H Miller
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Novais T, Meunier S, Trossaërt M, Salmon D, Chamouard V. La chimie au service de l’éducation thérapeutique des enfants atteints d’hémophilie et de leurs parents : représentation de phénomènes complexes liés au traitement. Arch Pediatr 2016; 23:798-805. [DOI: 10.1016/j.arcped.2016.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 05/11/2016] [Accepted: 05/27/2016] [Indexed: 10/21/2022]
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Özkasap S, Dereci S, Özdemir GN, Zülfikar B. Difficulties in the treatment of an Infant with Hemophilia B. TURK PEDIATRI ARSIVI 2016; 51:120-121. [PMID: 27489472 PMCID: PMC4959742 DOI: 10.5152/turkpediatriars.2016.3626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 03/01/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Serdar Özkasap
- Division of Hematology and Oncology, Department of Pediatrics, Recep Tayyip Erdoğan University School of Medicine, Rize, Turkey
| | - Selim Dereci
- Division of Pediatric Gastroenterology, Department of Pediatrics, Süleyman Demirel University School of Medicine, Isparta, Turkey
| | - Gül Nihal Özdemir
- Division of Hematology and Oncology, Department of Pediatrics, İstanbul University Cerrahpaşa School of Medicine, Rize, Turkey
- Hemophilia Society of Turkey
| | - Bülent Zülfikar
- Division of Hematology and Oncology, Department of Pediatrics, İstanbul University Cerrahpaşa School of Medicine, Rize, Turkey
- Hemophilia Society of Turkey
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23
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Abstract
Hemophilia B is an X-linked genetic deficiency of coagulation factor IX (FIX) activity associated with recurrent deep tissue and joint bleeding that may lead to long-term disability. FIX replacement therapy using plasma-derived protein or recombinant protein has significantly reduced bleeding and disability from hemophilia B, particularly when used in a prophylactic fashion. Although modern factor replacement has excellent efficacy and safety, barriers to the broader use of prophylaxis remain, including the need for intravenous (IV) access, frequent dosing, variability in individual pharmacokinetics, and cost. To overcome the requirement for frequent factor dosing, novel forms of recombinant FIX have been developed that possess extended terminal half-lives. Two of these products (FIXFc and rIX-FP) represent fusion proteins with the immunoglobulin G1 (IgG1) Fc domain and albumin, respectively, resulting in proteins that are recycled in vivo by the neonatal Fc receptor. The third product has undergone site-specific PEGylation on the activation peptide of FIX, similarly resulting in a long-lived FIX form. Clinical trials in previously treated hemophilia B patients have demonstrated excellent efficacy and confirmed less-frequent dosing requirements for the extended half-life forms. However, gaps in knowledge remain with regard to the risk of inhibitor formation and allergic reactions in previously untreated patient populations, safety in elderly patients with hemophilia, effects on in vivo FIX distribution, and cost-effectiveness. Additional strategies designed to rebalance hemostasis in hemophilia patients include monoclonal-antibody-mediated inhibition of tissue factor pathway inhibitor activity and siRNA-mediated reduction in antithrombin expression by the liver. Both of these approaches are long acting and potentially involve subcutaneous administration of the drug. In this review, we will discuss the biology of FIX, the evolution of FIX replacement therapy, the emerging FIX products possessing extended half-lives, and novel “rebalancing” approaches to hemophilia therapy.
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Affiliation(s)
- Moniba Nazeef
- Department of Medicine, Division of Hematology/Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; UW Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - John P Sheehan
- Department of Medicine, Division of Hematology/Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; UW Carbone Cancer Center, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Krishna M, Nadler SG. Immunogenicity to Biotherapeutics - The Role of Anti-drug Immune Complexes. Front Immunol 2016; 7:21. [PMID: 26870037 PMCID: PMC4735944 DOI: 10.3389/fimmu.2016.00021] [Citation(s) in RCA: 210] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 01/15/2016] [Indexed: 01/17/2023] Open
Abstract
Biological molecules are increasingly becoming a part of the therapeutics portfolio that has been either recently approved for marketing or those that are in the pipeline of several biotech and pharmaceutical companies. This is largely based on their ability to be highly specific relative to small molecules. However, by virtue of being a large protein, and having a complex structure with structural variability arising from production using recombinant gene technology in cell lines, such therapeutics run the risk of being recognized as foreign by a host immune system. In the context of immune-mediated adverse effects that have been documented to biological drugs thus far, including infusion reactions, and the evolving therapeutic platforms in the pipeline that engineer different functional modules in a biotherapeutic, it is critical to understand the interplay of the adaptive and innate immune responses, the pathophysiology of immunogenicity to biological drugs in instances where there have been immune-mediated adverse clinical sequelae and address technical approaches for their laboratory evaluation. The current paradigm in immunogenicity evaluation has a tiered approach to the detection and characterization of anti-drug antibodies (ADAs) elicited in vivo to a biotherapeutic; alongside with the structural, biophysical, and molecular information of the therapeutic, these analytical assessments form the core of the immunogenicity risk assessment. However, many of the immune-mediated adverse effects attributed to ADAs require the formation of a drug/ADA immune complex (IC) intermediate that can have a variety of downstream effects. This review will focus on the activation of potential immunopathological pathways arising as a consequence of circulating as well as cell surface bound drug bearing ICs, risk factors that are intrinsic either to the therapeutic molecule or to the host that might predispose to IC-mediated effects, and review the recent literature on prevalence and intensity of established examples of type II and III hypersensitivity reactions that follow the administration of a biotherapeutic. Additionally, we propose methods for the study of immune parameters specific to the biology of ICs that could be of use in conjunction with the detection of ADAs in circulation.
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Leissinger CA. Advances in the clinical management of inhibitors in hemophilia A and B. Semin Hematol 2015; 53:20-7. [PMID: 26805903 DOI: 10.1053/j.seminhematol.2015.10.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2004] [Revised: 11/05/2004] [Accepted: 12/01/2005] [Indexed: 01/25/2023]
Abstract
Inhibitors to factor (F)VIII or FIX are the most serious and challenging complication of hemophilia treatment, increasing morbidity and mortality because bleeds no longer respond to standard clotting factor replacement therapy. For patients with high-titer inhibitors, immune tolerance induction achieved through regular factor exposure is the only proven therapy capable of Inhibitor eradication and is almost always indicated for inhibitors of recent onset. Bypassing therapy is used to treat and prevent bleeding, but neither of the two currently available bypassing agents has the predictable hemostatic efficacy of factor replacement in hemophilia patients without inhibitors. Major research efforts are focused on the development of new, more potent therapies for the management of patients with inhibitors.
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Affiliation(s)
- Cindy A Leissinger
- Departments of Medicine, Pediatrics, and Pathology, Tulane University School of Medicine, New Orleans, LA, USA.
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26
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Holstein K, Schneppenheim R, Schrum J, Bokemeyer C, Langer F. Successful second ITI with factor IX and combined immunosuppressive therapy. A patient with severe haemophilia B and recurrence of a factor IX inhibitor. Hamostaseologie 2015; 34 Suppl 1:S5-8. [PMID: 25382771 DOI: 10.5482/hamo-14-01-0010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 09/17/2014] [Indexed: 11/05/2022] Open
Abstract
Immune tolerance induction (ITI) in patients with haemophilia B and inhibitors may be complicated by anaphylactic reactions and nephrotic syndrome with lower success rates than in haemophilia A (25% vs. 50-90%). According to case reports, immunosuppressive therapy in addition to high doses of factor IX (FIX) appears to be promising. We report an 18-year-old patient with severe haemophilia B and a FIX inhibitor with a maximum titre of 2.6 Bethesda units and allergic skin reactions to FIX infusions. At 5 years of age, this patient already had a FIX inhibitor with allergic reactions to FIX and activated prothrombin complex concentrate. ITI at 11 years of age with high-dose FIX, dexamethasone, rituximab, mycophenolate mofetil and intravenous immunoglobulins had induced a sustained response until the current presentation. The patient was restarted on the same ITI regimen with aforementioned immunosuppressants, which were initiated one week before high-dose FIX. No allergic reactions, nephrotic syndrome or serious infection occurred during ITI. The FIX inhibitor was undetectable after five weeks of treatment and remained so until 19 months of follow-up.
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Affiliation(s)
- K Holstein
- Dr. Katharina Holstein, II. Medizinische Klinik und Poliklinik, Universitätsklinikum Eppendorf, Martinistr. 52, 20246 Hamburg, Germany, Tel. +49/(0)40/741 05-24 53, Fax -5193, E-mail:
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Simhadri VL, Banerjee AS, Simon J, Kimchi-Sarfaty C, Sauna ZE. Personalized approaches to the treatment of hemophilia A and B. Per Med 2015; 12:403-415. [PMID: 29771661 DOI: 10.2217/pme.15.6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The recognition that individuals respond differently to the same medication is not new and dates almost to the founding of western medicine. In the last century it came to be recognized that genetic factors influence the heterogeneity of individual responses to medications with respect to both toxicity and effectiveness. Nonetheless, it has been challenging to integrate pharmacogenetic approaches in the routine practice of medicine as the identification of biomarkers is difficult due to the inherent complexity of biological systems. Here, we present potential applications of pharmacogenetics in managing hemophilia A and B. We discuss how predicting and circumventing immunogenicity, an important impediment to treating hemophilia patients, particularly lends itself to a pharmacogenetic approach. In addition, we discuss new trends toward personalizing the management of hemophilia in clinical settings.
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Affiliation(s)
- Vijaya L Simhadri
- Laboratory of Hemostasis, Division of Hematology Research & Review, Center for Biologics Evaluation & Research, Food & Drug Administration, New Hampshire Ave, Silver Spring, MD 20993, USA
| | - Aditi Sengupta Banerjee
- Laboratory of Hemostasis, Division of Hematology Research & Review, Center for Biologics Evaluation & Research, Food & Drug Administration, New Hampshire Ave, Silver Spring, MD 20993, USA
| | - Jonathan Simon
- Laboratory of Hemostasis, Division of Hematology Research & Review, Center for Biologics Evaluation & Research, Food & Drug Administration, New Hampshire Ave, Silver Spring, MD 20993, USA
| | - Chava Kimchi-Sarfaty
- Laboratory of Hemostasis, Division of Hematology Research & Review, Center for Biologics Evaluation & Research, Food & Drug Administration, New Hampshire Ave, Silver Spring, MD 20993, USA
| | - Zuben E Sauna
- Laboratory of Hemostasis, Division of Hematology Research & Review, Center for Biologics Evaluation & Research, Food & Drug Administration, New Hampshire Ave, Silver Spring, MD 20993, USA
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Abstract
INTRODUCTION The recent success of early-phase clinical trials for adeno-associated viral (AAV) liver-directed gene therapy for hemophilia B (HB) demonstrates the potential for gene therapy, in the future, to succeed protein-based prophylaxis therapy for HB. Significant obstacles, however, need to be overcome prior to widespread adoption. The largest obstacles include immune responses to the AAV capsid including preexisting neutralizing antibodies (NAbs) and a delayed cellular immune response. Emerging evidence suggests that the latter is vector-dose dependent. Furthermore, the development and eradication of inhibitors remains a significant safety concern. Similarly, biological differences between Factor VIII and Factor IX (FIX) impose challenges to direct adoption of the successes for HB to hemophilia A (HA). AREAS COVERED The advantages and limitations of the current strategies addressing these obstacles for gene therapy for HB and HA are discussed, as well as vector manufacturing issues relevant to widespread adoption. Alternative strategies including both ex-vivo and in-vivo lentiviral-based methods are discussed, though we focus on AAV-based approaches because of their recent clinical success and potential. EXPERT OPINION Our opinion is that these obstacles can be overcome with current approaches, and AAV-based gene therapy for HB will likely translate into future clinical care. Innovative approaches are, however, likely needed to solve the current problems obstructing HA gene therapy.
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Affiliation(s)
- Valder R Arruda
- University of Pennsylvania, The Children's Hospital of Philadelphia, 3501 Civic Center Blvd, 5056 Colket Translational Research Center, Philadelphia, PA 19104, USA ; University of Pennsylvania, Center for Cell and Molecular Therapeutics, Philadelphia, PA 19104, USA ; University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Ben J Samelson-Jones
- University of Pennsylvania, The Children's Hospital of Philadelphia, 3501 Civic Center Blvd, 5056 Colket Translational Research Center, Philadelphia, PA 19104, USA
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How I use bypassing therapy for prophylaxis in patients with hemophilia A and inhibitors. Blood 2015; 126:153-9. [DOI: 10.1182/blood-2014-10-551952] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 03/25/2015] [Indexed: 11/20/2022] Open
Abstract
Abstract
Inhibitor development poses a significant challenge in the management of hemophilia because once an inhibitor is present, bleeding episodes can no longer be treated with standard clotting factor replacement therapy. Consequently, patients with inhibitors are at increased risk for difficult-to-control bleeding and complications, particularly arthropathy and physical disability. Three clinical trials in patients with inhibitors have demonstrated that prophylaxis with a bypassing agent reduces joint and other types of bleeding and improves health-related quality of life compared with on-demand bypassing therapy. In hemophilia patients without inhibitors, the initiation of prophylaxis with factor (F) VIII or FIX prior to the onset of recurrent hemarthroses can prevent the development of joint disease. Whether this is also true for bypassing agent prophylaxis remains to be determined.
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Rup B, Pallardy M, Sikkema D, Albert T, Allez M, Broet P, Carini C, Creeke P, Davidson J, De Vries N, Finco D, Fogdell-Hahn A, Havrdova E, Hincelin-Mery A, C Holland M, H Jensen PE, Jury EC, Kirby H, Kramer D, Lacroix-Desmazes S, Legrand J, Maggi E, Maillère B, Mariette X, Mauri C, Mikol V, Mulleman D, Oldenburg J, Paintaud G, R Pedersen C, Ruperto N, Seitz R, Spindeldreher S, Deisenhammer F. Standardizing terms, definitions and concepts for describing and interpreting unwanted immunogenicity of biopharmaceuticals: recommendations of the Innovative Medicines Initiative ABIRISK consortium. Clin Exp Immunol 2015; 181:385-400. [PMID: 25959571 PMCID: PMC4557374 DOI: 10.1111/cei.12652] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2015] [Indexed: 12/17/2022] Open
Abstract
Biopharmaceuticals (BPs) represent a rapidly growing class of approved and investigational drug therapies that is contributing significantly to advancing treatment in multiple disease areas, including inflammatory and autoimmune diseases, genetic deficiencies and cancer. Unfortunately, unwanted immunogenic responses to BPs, in particular those affecting clinical safety or efficacy, remain among the most common negative effects associated with this important class of drugs. To manage and reduce risk of unwanted immunogenicity, diverse communities of clinicians, pharmaceutical industry and academic scientists are involved in: interpretation and management of clinical and biological outcomes of BP immunogenicity, improvement of methods for describing, predicting and mitigating immunogenicity risk and elucidation of underlying causes. Collaboration and alignment of efforts across these communities is made difficult due to lack of agreement on concepts, practices and standardized terms and definitions related to immunogenicity. The Innovative Medicines Initiative (IMI; http://www.imi-europe.org), ABIRISK consortium [Anti-Biopharmaceutical (BP) Immunization Prediction and Clinical Relevance to Reduce the Risk; http://www.abirisk.eu] was formed by leading clinicians, academic scientists and EFPIA (European Federation of Pharmaceutical Industries and Associations) members to elucidate underlying causes, improve methods for immunogenicity prediction and mitigation and establish common definitions around terms and concepts related to immunogenicity. These efforts are expected to facilitate broader collaborations and lead to new guidelines for managing immunogenicity. To support alignment, an overview of concepts behind the set of key terms and definitions adopted to date by ABIRISK is provided herein along with a link to access and download the ABIRISK terms and definitions and provide comments (http://www.abirisk.eu/index_t_and_d.asp).
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Affiliation(s)
- B Rup
- Pfizer, Immunogenicity Sciences Disciple, Pharmacokinetics, Dynamics and Metabolism
| | - M Pallardy
- INSERM, UMR996, Faculté Pharmacie, Université Paris Sud, France
| | - D Sikkema
- GlaxoSmithKline, Clinical Immunology-Biopharm, King of Prussia, PA, USA
| | - T Albert
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - M Allez
- Hôpital Saint-Louis, Department of Gastroenterology, GETAID, Paris, France
| | - P Broet
- INSERM, UMR669, University of Paris Sud, France
| | - C Carini
- Pfizer, Early Biotech Clinical Development, Cambridge, MA, USA
| | - P Creeke
- Centre for Neuroscience and Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - J Davidson
- GlaxoSmithKline, Worldwide Epidemiology, Southall, UK
| | - N De Vries
- Clinical Immunology and Rheumatology, University of Amsterdam, Amsterdam, the Netherlands
| | - D Finco
- Pfizer, Drug Safety R&D, Groton, CT, USA
| | - A Fogdell-Hahn
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - E Havrdova
- Department of Neurology and Center for Clinical Neuroscience, MS Center, Charles University in Prague, Prague, Czech Republic
| | - A Hincelin-Mery
- Sanofi-Aventis, Clinical Exploratory and Pharmacology, Chilly-Mazerin, FR
| | - M C Holland
- GlaxoSmithKline, Clinical Immunology-Biopharm R&D, King of Prussia, PA, USA
| | - P E H Jensen
- Department of Neurology, University of Copenhagen, Copenhagen, Denmark
| | - E C Jury
- Centre for Rheumatology, University College London, London, UK
| | - H Kirby
- UCB Pharma, Bioanalytical R&D, Slough, UK
| | - D Kramer
- Merck-Serono, Institute of Drug Metabolism and Pharmacokinetics, Grafing, Germany
| | | | - J Legrand
- Ipsen Innovation, Pharmacokinetics Drug Metabolism Department, Les Ulis, France
| | - E Maggi
- Dipartimento di Medicina Sperimentale e Clinica, Universita di Firenze, Firenze, Italy
| | - B Maillère
- CEA-Saclay Institute of Biology and Technologies, Gif sur Yvette, France
| | - X Mariette
- INSERM, U1012, Hôpitaux Universitaires Paris Sud, Rhumatologie, Paris, France
| | - C Mauri
- Centre for Rheumatology Research, University College London, London, UK
| | - V Mikol
- Sanofi Aventis, Structural Biology, Paris, France
| | - D Mulleman
- University of Tours Francois Rabelais, CNRS UMR 7292, Tours, France
| | - J Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - G Paintaud
- CNRS UMR 7292 'GICC', Faculty of Medicine, Tours, France
| | | | - N Ruperto
- Istituto Giannina Gaslini, Pediatria II, Rheumatology, Genova, Italy
| | - R Seitz
- Division of Haematology/Transfusion Medicine, Paul-Ehrlich-Institut, Langen, Germany
| | - S Spindeldreher
- Drug Metabolism Pharmacokinetics-Biologics, Novartis Institutes for Biomedical Research, Basel, Switzerland
| | - F Deisenhammer
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
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Principles of treatment and update of recommendations for the management of haemophilia and congenital bleeding disorders in Italy. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 12:575-98. [PMID: 25350962 DOI: 10.2450/2014.0223-14] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Therapeutic outcomes, assessments, risk factors and mitigation efforts of immunogenicity of therapeutic protein products. Cell Immunol 2015; 295:118-26. [DOI: 10.1016/j.cellimm.2015.03.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/06/2015] [Accepted: 03/09/2015] [Indexed: 12/20/2022]
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Leissinger CA, Konkle BA, Antunes SV. Prevention of bleeding in hemophilia patients with high-titer inhibitors. Expert Rev Hematol 2015; 8:375-82. [DOI: 10.1586/17474086.2015.1036733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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34
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Bon A, Morfini M, Dini A, Mori F, Barni S, Gianluca S, de Martino M, Novembre E. Desensitization and immune tolerance induction in children with severe factor IX deficiency; inhibitors and adverse reactions to replacement therapy: a case-report and literature review. Ital J Pediatr 2015; 41:12. [PMID: 25887512 PMCID: PMC4347657 DOI: 10.1186/s13052-015-0116-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 02/02/2015] [Indexed: 11/10/2022] Open
Abstract
Hemophilia B is a rare X-linked recessive disorder with plasma factor IX (FIX) deficiency. 1-3% of patients treated with exogenous FIX-containing products develop inhibitors (i.e. polyclonal high affinity immunoglobulins) that neutralize the procoagulant activity of a specific coagulation factor. Although the incidence of inhibitors in hemophilia B patients is low, most are "high titer" and frequently associated with the development of severe allergic or anaphylactic reactions. Immune tolerance induction as a strategy for inhibitor eradication was first described in 1984. Unfortunately, the overall reported success of immune tolerance induction in FIX deficiency with inhibitors is approximately 25-40%.We report the case of a 2-year-old boy with hemophilia B severe FIX deficiency (<1%), inhibitor antibodies to FIX development, and a history of adverse reactions to FIX infusions, who underwent a successful desensitization and immune tolerance induction with a daily FIX infusion. With this regimen the inhibitor titer decreased with effective bleeding prevention.
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Affiliation(s)
- Andrea Bon
- Department of Pediatrics, University of Udine, Udine, Italy.
| | - Massimo Morfini
- Haemophilia Agency, Careggi University Hospital, Florence, Italy.
| | - Alessandro Dini
- Department of Pediatrics, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
| | - Sottilotta Gianluca
- Haemophilia Centre, "Bianchi-Melacrino-Morelli" Hospital, Reggio Calabria, Italy.
| | - Maurizio de Martino
- Department of Health Sciences, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, University of Florence, A. Meyer Children's University Hospital, Florence, Italy.
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AAV liver expression of FIX-Padua prevents and eradicates FIX inhibitor without increasing thrombogenicity in hemophilia B dogs and mice. Blood 2015; 125:1553-61. [PMID: 25568350 DOI: 10.1182/blood-2014-07-588194] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Emerging successful clinical data on gene therapy using adeno-associated viral (AAV) vector for hemophilia B (HB) showed that the risk of cellular immune response to vector capsid is clearly dose dependent. To decrease the vector dose, we explored AAV-8 (1-3 × 10(12) vg/kg) encoding a hyperfunctional factor IX (FIX-Padua, arginine 338 to leucine) in FIX inhibitor-prone HB dogs. Two naïve HB dogs showed sustained expression of FIX-Padua with an 8- to 12-fold increased specific activity reaching 25% to 40% activity without antibody formation to FIX. A third dog with preexisting FIX inhibitors exhibited a transient anamnestic response (5 Bethesda units) at 2 weeks after vector delivery following by spontaneous eradication of the antibody to FIX by day 70. In this dog, sustained FIX expression reached ∼200% and 30% of activity and antigen levels, respectively. Immune tolerance was confirmed in all dogs after challenges with plasma-derived FIX concentrate. Shortening of the clotting times and lack of bleeding episodes support the phenotypic correction of the severe phenotype, with no clinical or laboratory evidence of risk of thrombosis. Provocative studies in mice showed that FIX-Padua exhibits similar immunogenicity and thrombogenicity compared with FIX wild type. Collectively, these data support the potential translation of gene-based strategies using FIX-Padua for HB.
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Sack BK, Wang X, Sherman A, Rogers GL, Markusic DM. Immune responses to human factor IX in haemophilia B mice of different genetic backgrounds are distinct and modified by TLR4. Haemophilia 2014; 21:133-9. [PMID: 25417755 PMCID: PMC4309508 DOI: 10.1111/hae.12522] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2014] [Indexed: 12/18/2022]
Abstract
Our laboratory develops protocols to prevent or reverse ongoing anti-hFIX IgG inhibitors in haemophilia B mice with a F9 gene deletion on BALB/c and C3H/HeJ backgrounds. C3H/HeJ F9−/Y mice develop high titre anti-hFIX IgG1 inhibitors and anaphylaxis, whereas most BALB/c F9−/Y mice have mild anti-hFIX IgG1 inhibitors and no anaphylaxis. Our aim was to determine if hFIX-specific B- and T-cell responses in BALB/c and C3H/HeJ F9−/Y mice trigger the difference in anti-hFIX immune responses. BALB/c and C3H/HeJ F9−/Y mice were challenged weekly with recombinant hFIX protein. Humoral immune responses were determined by IgG1 and IgG2a anti-hFIX ELISA, Bethesda assay for inhibitors and B-cell ELISpot on bone marrow and spleen cells. T-cell studies measured the TH1 (IFN-γ) and TH2 (IL-4) cytokine responses in splenocytes at the mRNA and protein level in response to hFIX protein. Antibody responses were also measured in C3H/HeJ/OuJ F9−/Y mice with restored toll-like receptor 4 (TLR4) function. BALB/c F9−/Y mice have a TH2 skewed response and a reduction in anti-hFIX secreting plasma cells in the bone marrow. Independent antigen challenge revealed both strains generated equivalent IgG1 antibody titres to an intravenously delivered antigen. C3H/HeJ F9−/Y mice have a mixed TH1 and TH2 response (mainly TH2). Importantly, TLR4 signalling has a modulatory role in the C3H background on the levels of anti-hFIX IgG1 and incidence of anaphylaxis. The background strain strongly impacts the immune response to hFIX, which can be significantly impacted by mutations in innate immune sensors.
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Affiliation(s)
- B K Sack
- Seattle Biomedical Research Institute, Seattle, WA, USA; Department of Pediatrics, University of Florida, Gainesville, FL, USA
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Windyga J, Solano Trujillo MH, Hafeman AE. BAX326 (RIXUBIS): a novel recombinant factor IX for the control and prevention of bleeding episodes in adults and children with hemophilia B. Ther Adv Hematol 2014; 5:168-80. [PMID: 25324957 DOI: 10.1177/2040620714550573] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Hemophilia B management has improved considerably since the introduction of high-purity plasma-derived factor IX (pdFIX) products in the early 1990s. Recombinant FIX (rFIX) was introduced more recently and has potential safety advantages over the older blood-based products. Until recently, only one such product, nonacog alfa (BeneFIX(®), Pfizer, Inc.), has been available. However, a new rFIX product, BAX326 (RIXUBIS, Baxter Healthcare Corp.), has now been approved by the US Food and Drug Administration. BAX326 undergoes rigorous virus elimination and purification steps during manufacture, and has low activated FIX activity, which confers low thrombogenic potential in humans. Preclinical studies showed promising pharmacokinetic and safety profiles, and these early findings have since been expanded in a series of prospective, multicenter, clinical studies. Foremost among these is a pivotal phase I/III study of BAX326 and its use in routine prophylaxis or on-demand treatment in patients aged 12-65 years with severe (FIX level <1%) or moderately severe (FIX level ≤2%) hemophilia B. This study confirmed the pharmacokinetic equivalence of BAX326 and nonacog alfa, and showed a significant reduction in annualized bleeding rate with BAX326 prophylaxis compared with on-demand treatment (79% versus historic controls; p < 0.001). The hemostatic efficacy of BAX326 was rated as 'excellent' or 'good' in 96% of bleeds. BAX326 was also associated with statistically significant and clinically meaningful improvements in physical health-related quality of life. Results are similarly encouraging in a pediatric study in children aged up to 12 years and in a study in hemophilia B patients undergoing surgery. A further study showed safe transition, with no inhibitor formation in any patient, from treatment with a pdFIX product to BAX326. Overall, the safety profile of BAX326 in clinical trials has been strong, with no inhibitor or specific antibody formation, thrombosis, or treatment-related serious adverse events or anaphylaxis.
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Affiliation(s)
- Jerzy Windyga
- Department of Disorders of Hemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, 14 I. Gandhi Str., 02-776 Warsaw, Poland
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38
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Abstract
Hemophilia B is an inherited coagulopathy caused by the partial or complete deficiency of factor (F) IX. Factor replacement therapy, involving the intravenous infusion of plasma-derived or recombinant (r) FIX concentrate, is the cornerstone of treatment, used to control and prevent bleeding episodes. Although several plasma-derived FIX products are available, until recently, only a single rFIX concentrate was on the market. The aim of this paper is to review the pharmacokinetics, hemostatic efficacy, and safety of Rixubis™ (Baxter Healthcare Corporation, CA, USA), a newly licensed rFIX product.
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Affiliation(s)
- Leonard A Valentino
- Hemophilia & Thrombophilia Center, Rush University Medical Center, Chicago, IL USA
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39
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Solano Trujillo MH, Stasyshyn O, Rusen L, Serban M, Lamas JL, Perina FG, Urasinski T, Oh M, Knowlton WB, Valenta-Singer B, Pavlova BG, Abbuehl B. Safe switching from a pdFIX (Immunine®) to a rFIX (Bax326). Haemophilia 2014; 20:674-81. [DOI: 10.1111/hae.12444] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 03/19/2014] [Indexed: 11/27/2022]
Affiliation(s)
| | - O. Stasyshyn
- Institute of Blood Pathology and Transfusion Medicine of Academy of Medical Sciences of Ukraine; Lviv Ukraine
| | - L. Rusen
- S.C. Sanador SRL; Bucharest Romania
| | - M. Serban
- Louis Turcanu Emergency Clinical Children′s Hospital; Timisoara Romania
| | | | - F. G. Perina
- Regional Clinical Hospital Ekaterinburg; Ekaterinburg Russia
| | - T. Urasinski
- Department of Paediatrics, Paediatric Hematology and Oncology; Pomeranian Medical University; Szczecin Poland
| | - M. Oh
- Baxter Healthcare Corporation; Westlake Village CA USA
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40
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Cugno M, Gualtierotti R, Tedeschi A, Meroni PL. Autoantibodies to coagulation factors: From pathophysiology to diagnosis and therapy. Autoimmun Rev 2014; 13:40-8. [DOI: 10.1016/j.autrev.2013.08.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 08/06/2013] [Indexed: 12/20/2022]
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41
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Markusic DM, Hoffman BE, Perrin GQ, Nayak S, Wang X, LoDuca PA, High KA, Herzog RW. Effective gene therapy for haemophilic mice with pathogenic factor IX antibodies. EMBO Mol Med 2013; 5:1698-709. [PMID: 24106230 PMCID: PMC3840486 DOI: 10.1002/emmm.201302859] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 08/15/2013] [Accepted: 08/19/2013] [Indexed: 11/30/2022] Open
Abstract
Formation of pathogenic antibodies is a major problem in replacement therapies for inherited protein deficiencies. For example, antibodies to coagulation factors (‘inhibitors’) seriously complicate treatment of haemophilia. While immune tolerance induction (ITI) protocols have been developed, inhibitors against factor IX (FIX) are difficult to eradicate due to anaphylactic reactions and nephrotic syndrome and thus substantially elevate risks for morbidity and mortality. However, hepatic gene transfer with an adeno-associated virus (AAV) serotype 8 vector expressing FIX (at levels of ≥4% of normal) rapidly reversed pre-existing high-titre inhibitors in haemophilia B mice, eliminated antibody production by B cells, desensitized from anaphylaxis (even if protein therapy was resumed) and provided long-term correction. High levels of FIX protein suppressed memory B cells and increased Treg induction, indicating direct and indirect mechanisms of suppression of inhibitor formation. Persistent presence of Treg was required to prevent relapse of antibodies. Together, these data suggest that hepatic gene transfer-based ITI provides a safe and effective alternative to eradicate inhibitors. This strategy may be broadly applicable to reversal of antibodies in different genetic diseases.
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Affiliation(s)
- David M Markusic
- Department of Pediatrics, University of Florida, Gainesville, FL, USA
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42
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Castaman G, Bonetti E, Messina M, Morfini M, Rocino A, Scaraggi FA, Tagariello G. Inhibitors in haemophilia B: the Italian experience. Haemophilia 2013; 19:686-90. [PMID: 23601006 DOI: 10.1111/hae.12158] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2013] [Indexed: 11/29/2022]
Abstract
The prevalence of inhibitors in haemophilia B is significantly lower than that of patients with haemophilia A. However, the peculiar occurrence of allergic reactions associated with the onset of inhibitor in haemophilia B (HB) may render immune tolerance a risky procedure. We have carried out a detailed survey among all the Italian Hemophilia Centers to analyse all the patients with HB and inhibitors. A total of eight patients were reported among 282 living patients (2.8%) with severe factor IX (FIX) deficiency (FIX < 1 U dL(-1)). In addition, two deceased patients were also identified. Six patients carried nonsense mutations while in four partial or complete gene deletions were detected. Three patients (one deceased) had history of allergic/anaphylactic reaction upon substitutive treatment, which in one case was recurrent and resolved after switching to plasma derived FIX. Immune tolerance was adopted in five patients and in four complete response was achieved while in the remaining it was partial. No nephrotic syndrome was observed. Our data confirm that inhibitors in HB occur in patients with null mutations or complete/partial gene deletion. Immune tolerance can be achieved also in HB patients, without allergic reactions or nephrotic syndrome upon replacement therapy.
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Affiliation(s)
- G Castaman
- Department of Cell Therapy and Hematology, Hemophilia and Thrombosis Center, San Bortolo Hospital, Vicenza, Italy.
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43
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Collins PW, Chalmers E, Hart DP, Liesner R, Rangarajan S, Talks K, Williams M, Hay CR. Diagnosis and treatment of factor VIII and IX inhibitors in congenital haemophilia: (4th edition). Br J Haematol 2012; 160:153-70. [DOI: 10.1111/bjh.12091] [Citation(s) in RCA: 159] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Peter W. Collins
- School of Medicine; Cardiff University; University Hospital of Wales; Wales; UK
| | | | - Daniel P. Hart
- The London School of Medicine and Dentistry; Royal London Hospital; Barts, Queen Mary University; London; UK
| | - Ri Liesner
- Great Ormond Street NHS Trust; London; UK
| | - Savita Rangarajan
- Hampshire Hospital NHS Foundation Trust; Basingstoke & North Hampshire Hospital; Basingstoke; UK
| | - Kate Talks
- Royal Victoria Infirmary; Newcastle upon Tyne; UK
| | - Mike Williams
- Birmingham Childrens' Hospital NHS Foundation Trust; Birmingham; UK
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45
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Radic CP, Rossetti LC, Abelleyro MM, Candela M, Pérez Bianco R, de Tezanos Pinto M, Larripa IB, Goodeve A, De Brasi CD. Assessment of the F9 genotype-specific FIX inhibitor risks and characterisation of 10 novel severe F9 defects in the first molecular series of Argentinian patients with haemophilia B. Thromb Haemost 2012; 109:24-33. [PMID: 23093250 DOI: 10.1160/th12-05-0302] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 09/13/2012] [Indexed: 11/05/2022]
Abstract
In haemophilia B (HB) (factor IX [FIX] deficiency), F9 genotype largely determines clinical phenotype. Aimed to characterise Argentinian families with HB, this study presents F9 genotype frequencies and their specific FIX inhibitor risk and 10 novel F9 mutations. Ninety-one DNA samples from HB patients and relatives were subjected to a new scheme: a primary screen for large deletions, a secondary screen for point mutations using conformation sensitive gel electrophoresis, DNA-sequencing and bioinformatic analysis. Our unbiased HB population (N=52) (77% with severe, 11.5% moderate and 11.5% mild HB) showed 32 missense (61.5%), including three novel mutations predicting specific structural/functional defects in silico , seven nonsense (13.5%) (one novel), five large deletions, four splice including three novel mutations affecting predicted splicing scores, three indels (two novel) and one Leiden mutation. Our comprehensive HB population included five patients with long-lasting FIX inhibitors: three nonsense (p.E35* (novel), p.R75*, p.W240*) and two entire- F9 deletions. Another patient with an indel (p.A26Rfs*14) developed transient inhibitors. A case-control analysis, based on our global prevalence of 3.05% for developing inhibitors in HB revealed that missense mutations were associated with a low risk odds ratio (OR) of 0.05 and a prevalence of 0.39%, whereas nonsense and entire- F9 deletions had significantly higher risks (OR 11.0 and 32.7) and prevalence (14.3% and 44.5%, respectively). Our cost-effective practical approach enabled identification of the causative mutation in all 55 Argentine families with HB, analysis of the molecular pathology of novel F9 defects and determination of mutation-associated FIX inhibitor risks.
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Affiliation(s)
- Claudia Pamela Radic
- Molecular Genetics of Haemophilia Laboratory, Instituto de Medicina Experimental IMEX, CONICET-Academia Nacional de Medicina, Pacheco de Melo 3081, Ciudad de Buenos Aires 1425, Argentina.
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46
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Immunogenicity to biologics: mechanisms, prediction and reduction. Arch Immunol Ther Exp (Warsz) 2012; 60:331-44. [PMID: 22930363 DOI: 10.1007/s00005-012-0189-7] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 05/11/2012] [Indexed: 01/06/2023]
Abstract
Currently, there is a significant rise in the development and clinical use of a unique class of pharmaceuticals termed as Biopharmaceuticals or Biologics, in the management of a range of disease conditions with, remarkable therapeutic benefits. However, there is an equally growing concern regarding development of adverse effects like immunogenicity in the form of anti-drug antibodies (ADA) production and hypersensitivity. Immunogenicity to biologics represents a significant hurdle in the continuing therapy of patients in a number of disease settings. Efforts focussed on the identification of factors that contribute towards the onset of immunogenic response to biologics have led to reductions in the incidence of immunogenicity. An in-depth understanding of the cellular and molecular mechanism underpinning immunogenic responses will likely improve the safety profile of biologics. This review addresses the mechanistic basis of ADA generation to biologics, with emphasis on the role of antigen processing and presentation in this process. The article also addresses the potential contribution of complement system in augmenting or modulating this response. Identifying specific factors that influences processing and presentation of biologic-derived antigens in different genotype and disease background may offer additional options for intervention in the immunogenic process and consequently, the management of immunogenicity to biologics.
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47
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Safety and pharmacokinetics of a novel recombinant fusion protein linking coagulation factor IX with albumin (rIX-FP) in hemophilia B patients. Blood 2012; 120:2405-11. [PMID: 22859609 DOI: 10.1182/blood-2012-05-429688] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A recombinant fusion protein linking coagulation factor IX (FIX) with human albumin (rIX-FP) has been developed to facilitate hemophilia B treatment by less frequent FIX dosing. This first-in-human dose-escalation trial in 25 previously treated subjects with hemophilia B (FIX ≤ 2 IU/dL) examined the safety and pharmacokinetics of 25, 50, and 75 IU/kg rIX-FP. Patients in the 50-IU/kg cohort underwent a comparative pharmacokinetics assessment with their previous FIX product (plasma-derived or recombinant). No allergic reactions or inhibitors were observed. Four mild, possibly treatment-related adverse events were reported. In the 50-IU/kg cohort (13 subjects), the mean half-life of rIX-FP was 92 hours, more than 5 times longer than the subjects' previous FIX product. After 25 or 50 IU/kg rIX-FP administration, the baseline-corrected mean FIX activity remained elevated at day 7 (7.4 IU/dL and 13.4 IU/dL, respectively) and day 14 (2.5 IU/dL and 5.5 IU/dL, respectively). The incremental recovery of rIX-FP was higher than both recombinant and plasma-derived FIX (1.4 vs 0.95 and 1.1 IU/dL per IU/kg, respectively). These results demonstrated both the safety and improved pharmacokinetics of rIX-FP, thus indicating this new product with extended half-life as possibly able to control and prevent bleeding with less frequent injection.
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Alraies MC, Kumar A. Assessing and Managing Hematologic Disorders. Perioper Med (Lond) 2012. [DOI: 10.1002/9781118375372.ch13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Successful immune tolerance induction to enzyme replacement therapy in CRIM-negative infantile Pompe disease. Genet Med 2012; 14:135-42. [PMID: 22237443 DOI: 10.1038/gim.2011.4] [Citation(s) in RCA: 160] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE Infantile Pompe disease resulting from a deficiency of lysosomal acid α-glucosidase (GAA) requires enzyme replacement therapy (ERT) with recombinant human GAA (rhGAA). Cross-reactive immunologic material negative (CRIM-negative) Pompe patients develop high-titer antibody to the rhGAA and do poorly. We describe successful tolerance induction in CRIM-negative patients. METHODS Two CRIM-negative patients with preexisting anti-GAA antibodies were treated therapeutically with rituximab, methotrexate, and gammaglobulins. Two additional CRIM-negative patients were treated prophylactically with a short course of rituximab and methotrexate, in parallel with initiating rhGAA. RESULTS In both patients treated therapeutically, anti-rhGAA was eliminated after 3 and 19 months. All four patients are immune tolerant to rhGAA, off immune therapy, showing B-cell recovery while continuing to receive ERT at ages 36 and 56 months (therapeutic) and 18 and 35 months (prophylactic). All patients show clinical response to ERT, in stark contrast to the rapid deterioration of their nontolerized CRIM-negative counterparts. CONCLUSION The combination of rituximab with methotrexate ± intravenous gammaglobulins (IVIG) is an option for tolerance induction of CRIM-negative Pompe to ERT when instituted in the naïve setting or following antibody development. It should be considered in other conditions in which antibody response to the therapeutic protein elicits robust antibody response that interferes with product efficacy.
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Benson G, Auerswald G, Elezović I, Lambert T, Ljung R, Morfini M, Remor E, Šalek SZ. Immune tolerance induction in patients with severe hemophilia with inhibitors: expert panel views and recommendations for clinical practice. Eur J Haematol 2012; 88:371-9. [DOI: 10.1111/j.1600-0609.2012.01754.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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