1
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Carcao M, Schiavulli M, Kulkarni R, Rendo P, Foster M, Santagostino E, Casiano S, Königs C. A post hoc analysis of previously untreated patients with severe hemophilia A who developed inhibitors in the PUPs A-LONG trial. Blood Adv 2024; 8:1494-1503. [PMID: 38266154 PMCID: PMC10951906 DOI: 10.1182/bloodadvances.2023011475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 01/10/2024] [Accepted: 01/14/2024] [Indexed: 01/26/2024] Open
Abstract
ABSTRACT Inhibitor development is a major therapeutic complication for people with hemophilia. The phase 3 PUPs A-LONG study evaluated the safety and efficacy of efmoroctocog alfa (a recombinant factor VIII Fc fusion protein, herein referred to as rFVIIIFc) in previously untreated patients (PUPs) with severe hemophilia A. Male PUPs <6 years old were enrolled and received rFVIIIFc; inhibitor development was the primary end point. Post hoc analyses, including patient treatment regimen patterns and timing of inhibitor development, descriptive and Kaplan-Meier analyses of time to first inhibitor-positive test by treatment regimen and by titer, and consumption, were performed to describe patients who developed inhibitors during PUPs A-LONG. We investigated patient characteristics (eg, demographics and genotype) and nongenetic risk factors (eg, intense factor exposure and central venous access device [CVAD] placement) that may predict inhibitor development and characteristics of inhibitor development (low-titer vs high-titer inhibitor). Baseline characteristics were similarly distributed for age, race, and ethnicity across both patients who were inhibitor-positive and those who were inhibitor-negative (all P > .05). High-risk F8 variants were associated with development of high-titer inhibitors (P = .028). High-titer inhibitor development was often preceded by the presence of a low-titer inhibitor. Patients whose low-titer inhibitor progressed to a high-titer inhibitor received a higher mean dose per infusion (98.4 IU/kg, n = 5) compared with those whose low-titer inhibitor resolved spontaneously (59.2 IU/kg, n = 7; P = .033) or persisted (45.0 IU/kg, n = 5; P = .047). There was no association between CVAD placement surgery and inhibitor development. Post hoc analyses suggest that F8 genotype and dose of factor are as important as inhibitor risk factors and require further investigation. This study was registered at ClinicalTrials.gov as #NCT02234323.
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Affiliation(s)
- Manuel Carcao
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | | | - Christoph Königs
- University Hospital Frankfurt, Goethe University, Frankfurt, Germany
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2
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Miesbach W, Carcao M, Mahlangu J, Dargaud Y, Jimenez-Yuste V, Hermans C. Eptacog beta for the management of patients with haemophilia A and B with inhibitors: A European perspective. Haemophilia 2024; 30:257-266. [PMID: 38317441 DOI: 10.1111/hae.14944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/25/2023] [Accepted: 10/20/2023] [Indexed: 02/07/2024]
Abstract
Eptacog beta (activated), a recombinant human factor VIIa (rFVIIa), was approved by the US Food and Drug Administration (FDA) in 2020 (SEVENFACT®, LFB & HEMA Biologics) and the European Medicines Agency (EMA) in 2022 (CEVENFACTA®, LFB). In Europe, eptacog beta is indicated for the treatment of bleeds and the prevention of bleeds during surgery or invasive procedures in adults and adolescents (≥12 years old) with congenital haemophilia A or B with high-titre inhibitors (≥5 BU) or with low-titre inhibitors who are expected to have a high anamnestic response to factor VIII or factor IX, or to be refractory to increased dosing of these factors. The efficacy and safety of eptacog beta were evaluated in three Phase III clinical studies, PERSEPT 1, 2 and 3. For the EMA filing dossier, the analysis of data from PERSEPT 1 and 2 differed from the analysis used to support the filing in the US. In this review, we summarise current data regarding the mode of action, clinical efficacy and safety of eptacog beta for the management of haemophilia A and B in patients with inhibitors from a European perspective. In addition to providing a valuable summary of the analyses of the clinical data for eptacog beta conducted for the EMA, our review summarises the potential differentiators for eptacog beta compared with other current bypassing agents.
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Affiliation(s)
- Wolfgang Miesbach
- Department of Haemostaseology and Hemophilia Center, Medical Clinic 2, Institute of Transfusion Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Manuel Carcao
- The Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Johnny Mahlangu
- Haemophilia Comprehensive Care Centre, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | - Yesim Dargaud
- Clinical Haemostasis Unit and Lyon Haemophilia Centre, Louis Pradel Hospital, Lyon, France
| | | | - Cédric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain (UCLouvain), Brussels, Belgium
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3
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[Chinese guidelines on the diagnosis and management of hemophilia with inhibitors (2023)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:881-889. [PMID: 38185516 PMCID: PMC10753256 DOI: 10.3760/cma.j.issn.0253-2727.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Indexed: 01/09/2024]
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4
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Nguyen NH, Jarvi NL, Balu-Iyer SV. Immunogenicity of Therapeutic Biological Modalities - Lessons from Hemophilia A Therapies. J Pharm Sci 2023; 112:2347-2370. [PMID: 37220828 DOI: 10.1016/j.xphs.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 05/25/2023]
Abstract
The introduction and development of biologics such as therapeutic proteins, gene-, and cell-based therapy have revolutionized the scope of treatment for many diseases. However, a significant portion of the patients develop unwanted immune reactions against these novel biological modalities, referred to as immunogenicity, and no longer benefit from the treatments. In the current review, using Hemophilia A (HA) therapy as an example, we will discuss the immunogenicity issue of multiple biological modalities. Currently, the number of therapeutic modalities that are approved or recently explored to treat HA, a hereditary bleeding disorder, is increasing rapidly. These include, but are not limited to, recombinant factor VIII proteins, PEGylated FVIII, FVIII Fc fusion protein, bispecific monoclonal antibodies, gene replacement therapy, gene editing therapy, and cell-based therapy. They offer the patients a broader range of more advanced and effective treatment options, yet immunogenicity remains the most critical complication in the management of this disorder. Recent advances in strategies to manage and mitigate immunogenicity will also be reviewed.
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Affiliation(s)
- Nhan H Nguyen
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA; Currently at Truvai Biosciences, Buffalo, NY, USA
| | - Nicole L Jarvi
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Sathy V Balu-Iyer
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.
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5
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Pipe SW, Arruda VR, Lange C, Kitchen S, Eichler H, Wadsworth S. Characteristics of BAY 2599023 in the Current Treatment Landscape of Hemophilia A Gene Therapy. Curr Gene Ther 2023; 23:81-95. [PMID: 36111754 DOI: 10.2174/1566523222666220914105729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/12/2022] [Accepted: 08/13/2022] [Indexed: 11/22/2022]
Abstract
Hemophilia A, a single gene disorder leading to deficient Factor VIII (FVIII), is a suitable candidate for gene therapy. The aspiration is for single administration of a genetic therapy that would allow the production of endogenous FVIII sufficient to restore hemostasis and other biological processes. This would potentially result in reliable protection from bleeding and its associated physical and emotional impacts. Gene therapy offers the possibility of a clinically relevant improvement in disease phenotype and transformational improvement in quality of life, including an opportunity to engage in physical activities more confidently. Gene therapy products for hemophilia A in advanced clinical development use adeno-associated viral (AAV) vectors and a codon-optimized B-domain deleted FVIII transgene. However, the different AAV-based gene therapies have distinct design features, such as choice of vector capsid, enhancer and promoter regions, FVIII transgene sequence and manufacturing processes. These, in turn, impact patient eligibility, safety and efficacy. Ideally, gene therapy technology for hemophilia A should offer bleed protection, durable FVIII expression, broad eligibility and limited response variability between patients, and long-term safety. However, several limitations and challenges must be overcome. Here, we introduce the characteristics of the BAY 2599023 (AAVhu37.hFVIIIco, DTX 201) gene therapy product, including the low prevalence in the general population of anti-AAV-hu37 antibodies, as well as other gene therapy AAV products and approaches. We will examine how these can potentially meet the challenges of gene therapy, with the ultimate aim of improving the lives of patients with hemophilia A.
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Affiliation(s)
- Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Valder R Arruda
- Division of Hematology, Department of Pediatrics, Center for Cell and Molecular Therapeutics at Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Stephen Kitchen
- Sheffield Haemophilia and Thrombosis Centre, Sheffield Teaching Hospitals, Sheffield, UK
| | - Hermann Eichler
- Institute of Clinical Hemostaseology and Transfusion Medicine, Saarland University and University Hospital, Homburg/Saar, Germany
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6
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Prezotti ANL, Frade-Guanaes JO, Yamaguti-Hayakawa GG, Ozelo MC. Immunogenicity of Current and New Therapies for Hemophilia A. Pharmaceuticals (Basel) 2022; 15:ph15080911. [PMID: 35893734 PMCID: PMC9331070 DOI: 10.3390/ph15080911] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 02/04/2023] Open
Abstract
Anti-drug antibody (ADA) development is a significant complication in the treatment of several conditions. For decades, the mainstay of hemophilia A treatment was the replacement of deficient coagulation factor VIII (FVIII) to restore hemostasis, control, and prevent bleeding events. Recently, new products have emerged for hemophilia A replacement therapy, including bioengineered FVIII molecules with enhanced pharmacokinetic profiles: the extended half-life (EHL) recombinant FVIII products. However, the main complication resulting from replacement treatment in hemophilia A is the development of anti-FVIII neutralizing alloantibodies, known as inhibitors, affecting approximately 25–30% of severe hemophilia A patients. Therefore, the immunogenicity of each FVIII product and the mechanisms that could help increase the tolerance to these products have become important research topics in hemophilia A. Furthermore, patients with inhibitors continue to require effective treatment for breakthrough bleedings and procedures, despite the availability of non-replacement therapy, such as emicizumab. Herein, we discuss the currently licensed treatments available for hemophilia A and the immunogenicity of new therapies, such as EHL-rFVIII products, compared to other products available.
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Affiliation(s)
- Alessandra N. L. Prezotti
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- HEMOES, Hematology and Hemotherapy Center Dr. Marcos Daniel Santos, Av. Marechal Campos, 1468, Maruípe, Vitória 29047-105, ES, Brazil
| | - Jéssica O. Frade-Guanaes
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
| | - Gabriela G. Yamaguti-Hayakawa
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
| | - Margareth C. Ozelo
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, UNICAMP, Rua Tessália Vieira de Camargo, 126, Cidade Universitária, Campinas 13083-887, SP, Brazil; (A.N.L.P.); (J.O.F.-G.); (G.G.Y.-H.)
- Hemocentro UNICAMP, University of Campinas, Rua Carlos Chagas, 480, Cidade Universitária, Campinas 13083-878, SP, Brazil
- Correspondence: ; Tel.: +55-(19)-3521-8395
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7
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Dubé E, Merlen C, Bonnefoy A, Gauthier J, Castilloux JF, Charlebois J, Cloutier S, Demers C, Sabapathy CA, St-Louis J, Vézina C, Warner M, Rivard GÉ. Evaluation of anti-factor VIII antibodies in haemophilia A subjects switching products following a provincial tender. Haemophilia 2021; 28:e1-e4. [PMID: 34766421 DOI: 10.1111/hae.14434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/21/2021] [Accepted: 09/30/2021] [Indexed: 12/23/2022]
Affiliation(s)
- Evemie Dubé
- Centre Hospitalier Universitaire Sainte-Justine, Montréal, Canada
| | - Clémence Merlen
- Centre Hospitalier Universitaire Sainte-Justine, Montréal, Canada
| | - Arnaud Bonnefoy
- Centre Hospitalier Universitaire Sainte-Justine, Montréal, Canada
| | - Julie Gauthier
- Molecular Diagnostic Laboratory, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Canada.,Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Canada
| | | | - Janie Charlebois
- Centre Hospitalier Universitaire de Sherbrooke, Université Sherbrooke, Canada
| | - Stéphanie Cloutier
- Hôpital de l'Enfant Jésus, Centre Hospitalier Universitaire de Québec, Québec, Canada
| | - Christine Demers
- Hôpital de l'Enfant Jésus, Centre Hospitalier Universitaire de Québec, Québec, Canada
| | | | - Jean St-Louis
- Centre Hospitalier Universitaire Sainte-Justine, Montréal, Canada.,Hôpital Maisonneuve-Rosemont, Montréal, Canada
| | - Catherine Vézina
- Montreal Children's Hospital, McGill University Health Center, Montréal, Canada
| | - Margaret Warner
- Montreal Children's Hospital, McGill University Health Center, Montréal, Canada
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8
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Keipert C, Drechsel-Bäuerle U, Oberle D, Müller-Olling M, Hilger A. Epidemiological Challenges in Rare Bleeding Disorders: FVIII Inhibitor Incidence in Haemophilia A Patients-A Known Issue of Unknown Origin. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 18:ijerph18010225. [PMID: 33396748 PMCID: PMC7795862 DOI: 10.3390/ijerph18010225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/17/2020] [Accepted: 12/22/2020] [Indexed: 01/10/2023]
Abstract
There is a broad range of factor products approved in Germany for haemophilia A treatment. Since the introduction of recombinant coagulation factor VIII (FVIII) products in the 1990s, there has been substantial debate whether there is a difference in inhibitor incidence between single FVIII products or product classes. Neither haemophilia registries nor clinical studies, including a randomised controlled clinical trial, provided a consistent and definite answer. The reasons were mainly related to methodological challenges in conducting controlled studies in a rare disease. In this analysis, the most relevant epidemiological challenges and main problems were examined, including study bias, potential overlap of individual studies and advanced development of therapy and methods in the course of time. Meta-analyses on two levels showed that therapies using recombinant products resulted in different event rates when compared to plasma-derived products. These results are accompanied by substantial study heterogeneity evidenced by Cochran's Q tests. Only three studies have been identified that meet the standards of current clinical guidance. To finally resolve this ongoing and disputable safety issue of replacement therapy, collaboration among registry owners, academia and regulators must be fostered.
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Affiliation(s)
- Christine Keipert
- German Haemophilia Registry, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany
- Correspondence:
| | - Ursula Drechsel-Bäuerle
- Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (U.D.-B.); (D.O.)
| | - Doris Oberle
- Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (U.D.-B.); (D.O.)
| | - Mirco Müller-Olling
- Hematology and Transfusion Medicine, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (M.M.-O.); (A.H.)
| | - Anneliese Hilger
- Hematology and Transfusion Medicine, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, 63225 Langen, Germany; (M.M.-O.); (A.H.)
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9
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Klukowska A, Komrska V, Vdovin V, Zozulya N, Lissitchkov T, Oldenburg J, Ettingshausen CE. octanate ®: over 20 years of clinical experience in overcoming challenges in haemophilia A treatment. Ther Adv Hematol 2020; 11:2040620720914692. [PMID: 32341775 PMCID: PMC7171997 DOI: 10.1177/2040620720914692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/18/2020] [Indexed: 01/01/2023] Open
Abstract
Treatment of haemophilia A with FVIII replacement has evolved over the past decades to adapt to the needs of patients. octanate®, a plasma-derived, double virus-inactivated, von Willebrand factor (VWF)-containing FVIII concentrate, has been used in clinics worldwide for over 20 years. First licensed in 1998 in Germany, octanate® is approved in over 80 countries for the prevention and treatment of bleeding and for surgical prophylaxis in patients with haemophilia A, and in over 40 countries for immune tolerance induction (ITI). The manufacturing process for octanate® was developed to ensure high viral safety and effectively eliminates both enveloped and nonenveloped viruses. Over the past 20 years, the excellent safety and efficacy of octanate® have been demonstrated in pivotal clinical trials in adult and paediatric previously treated patients (PTPs) for on-demand treatment, prophylaxis and as surgical cover. Importantly, octanate® has displayed low immunogenicity in previously untreated patients (PUPs), with only 9.8% of PUPs developing FVIII inhibitors. octanate® has also shown to be highly effective in inhibitor elimination when used as ITI therapy. In a population of patients with high risk of ITI failure, success was achieved in 79.2% of patients (70.8% complete success), even when using exceptionally stringent success criteria. No relapses were observed. Here we present an overview of the clinical data with octanate® that support its use in a range of patient populations and clinical indications.
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Affiliation(s)
- Anna Klukowska
- Department of Paediatric Oncology, Medical University of Warsaw, Haematology, Clinical Transplantology and Paediatrics, Warsaw, Poland
| | - Vladimír Komrska
- Department of Paediatric Hematology and Oncology, University Hospital Motol, Prague, Czech Republic
| | - Vladimír Vdovin
- Morozovskaya Children’s Hospital, Moscow, Russian Federation
| | - Nadezhda Zozulya
- National Research Centre for Hematology, Moscow, Russian Federation
| | - Toshko Lissitchkov
- Department of Disorders of Haemostasis, SBALHZ - EAD, Sofia, Bulgaria
- Department of Clinical Haematology in Haemorrhagic Diathesis and Anaemia, Specialized Hospital for Active Treatment “Joan Pavel”, Sofia, Bulgaria
| | - Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
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10
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Pratap R, Misra M, N V, Morampudi S, Patil A, Reddy J. The existing scenario of haemophilia care in Canada and China - A review. Hematol Transfus Cell Ther 2019; 42:356-364. [PMID: 31810896 PMCID: PMC7599277 DOI: 10.1016/j.htct.2019.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 08/23/2019] [Indexed: 01/25/2023] Open
Abstract
Hemophilia is an X-linked recessive genetic disorder which affects approximately 400,000 people globally. Differing healthcare reimbursement systems, budgetary constraints and geographical and cultural factors make it difficult for any country to fully deliver ideal care. Although developed countries have sufficient treatment products available, they are burdened by the higher expectation of outcomes, coupled with insufficient supportive care to monitor adherence and outcomes and to implement regular follow-up. In contrast, developing regions may not have ready access to factor replacement, but have developed excellent physiotherapy and rehabilitation programs. Although there are multiple studies that have attempted to assess country-specific variations in hemophilia care, very few compare hemophilia care between economically unequal countries and the challenges in achieving optimal hemophilia care. This literature review tries to bridge this gap and throws light on the country-specific differences in epidemiology, standard of hemophilia care and challenges faced in Canada and China. Data sources resulted in 20 studies (11 from Canada and 9 from China), which were reviewed. In a developed country, the main advantages are: the early treatment of bleeding episodes and the presence of a specialized interdisciplinary and comprehensive treatment concept. This is not the case in most developing countries, where the government does not have the resources to buy the necessary quantities of coagulation factors in the face of more urgent health priorities and hardly a few patients can afford to pay for their own treatment, even the on-demand home therapy.
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Affiliation(s)
- Rohan Pratap
- Focus Scientific Research Center, Phamax Analytics Resources Pvt Ltd., Bengaluru, India.
| | - Monali Misra
- Focus Scientific Research Center, Phamax Analytics Resources Pvt Ltd., Bengaluru, India
| | - Varun N
- Focus Scientific Research Center, Phamax Analytics Resources Pvt Ltd., Bengaluru, India
| | - Suman Morampudi
- Focus Scientific Research Center, Phamax Analytics Resources Pvt Ltd., Bengaluru, India
| | - Anand Patil
- Focus Scientific Research Center, Phamax Analytics Resources Pvt Ltd., Bengaluru, India
| | - Jayachandra Reddy
- Focus Scientific Research Center, Phamax Analytics Resources Pvt Ltd., Bengaluru, India
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11
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Volkers P, Hanschmann K, Calvez T, Chambost H, Collins PW, Demiguel V, Hart DP, Hay CR, Goudemand J, Ljung R, Palmer BP, Santagostino E, van Hardeveld EM, van den Berg M, Keller‐Stanislawski B. Recombinant factor VIII products and inhibitor development in previously untreated patients with severe haemophilia A: Combined analysis of three studies. Haemophilia 2019; 25:398-407. [DOI: 10.1111/hae.13747] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 03/05/2019] [Accepted: 03/08/2019] [Indexed: 12/29/2022]
Affiliation(s)
| | | | - Thierry Calvez
- INSERM, Institut Pierre Louis d'Épidémiologie et de Santé publique Sorbonne Universités Paris France
| | - Hervé Chambost
- Service d'Hématologie Oncologie Pédiatrique, La Timone APHM and Aix Marseille Université Marseille France
| | - Peter W. Collins
- The University Department of Haematology University Hospital of Wales Hospital Cardiff UK
| | - Virginie Demiguel
- Santé publique France French National Public Health Agency Saint‐Maurice France
| | - Daniel P. Hart
- Barts and The London School of Medicine & Dentistry, The Royal London Hospital Haemophilia Centre QMUL London UK
| | - Charles R.M. Hay
- Department of Haematology, Manchester Royal Infirmary Manchester University Manchester UK
| | - Jenny Goudemand
- Service d'Hématologie et de Transfusion, Faculté de Médecine, Centre Hospitalier Universitaire de Lille Université Lille 2 Lille France
| | - Rolf Ljung
- Department of Clinical Sciences–Paediatrics Lund University Lund Sweden
| | - Ben P. Palmer
- The United Kingdom National Haemophilia Database Manchester UK
| | - Elena Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
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12
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Schep SJ, Boes M, Schutgens RE, van Vulpen LF. An update on the ‘danger theory’ in inhibitor development in hemophilia A. Expert Rev Hematol 2019; 12:335-344. [DOI: 10.1080/17474086.2019.1604213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Sarah J. Schep
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marianne Boes
- Department of Pediatrics, Laboratory of Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger E.G. Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lize F.D. van Vulpen
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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13
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Wang SX, Yang RC. [Advances in Hemophilia A inhibitors]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2018; 38:444-448. [PMID: 28565748 PMCID: PMC7354181 DOI: 10.3760/cma.j.issn.0253-2727.2017.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
| | - R C Yang
- Institute of Hematology & Blood Disease Hospital, CAMS & PUMC, Tianjin 300020, China
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14
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Meta-analysis on incidence of inhibitors in patients with haemophilia A treated with recombinant factor VIII products. Blood Coagul Fibrinolysis 2018; 28:627-637. [PMID: 28678027 DOI: 10.1097/mbc.0000000000000647] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
: Recent cohort studies showed differences in inhibitor incidence in previously untreated patients (PUPs) with haemophilia A treated with recombinant factor VIII (rFVIII) concentrates. We carried out a systematic literature search and meta-analysis for all randomized clinical trials and observational studies published from 1 January 1988 to 31 August 2015, to assess the incidence of inhibitor development and the relationship with rFVIII product used in PUPs and minimally treated patients (MTPs, ≤5 previous exposure days), with severe haemophilia. The primary outcome measure was development of all inhibitors and high-titre inhibitors. We computed pooled meta-analytic estimates according to the rFVIII product used with the inverse-variance method, assuming a fixed, or a random-effects model if significant between-studies heterogeneity was present. Out of 781 articles, 16 published between 1998 and 2015 were included in the meta-analysis, involving a total of 2094 haemophilia A PUPs or MTPs. The pooled estimate of all inhibitors was 0.27 (95% confidence interval 0.23-0.31). No significant difference in pooled inhibitor incidence across products was found (P = 0.72). Meta-analysis of studies reporting inhibitor hazard ratios with different rFVIII products, adjusted to different risk factors, showed that PUPs/MTPs treated with Advate had a pooled inhibitor hazard ratio estimate of 0.63 (95% confidence interval 0.48-0.83) as compared with Kogenate FS. The overall inhibitor incidence in PUPs/MTPs was 27%. Differences between products were found considering hazard ratios in which potential confounders were taken into account.
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Peyvandi F, Garagiola I. Product type and other environmental risk factors for inhibitor development in severe hemophilia A. Res Pract Thromb Haemost 2018; 2:220-227. [PMID: 30046724 PMCID: PMC6055565 DOI: 10.1002/rth2.12094] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/28/2018] [Indexed: 12/15/2022] Open
Abstract
The development of FVIII inhibitory antibodies is currently the most challenging complication of treatment, affecting ~30% of severe hemophilia A patients. These inhibitors inactivate FVIII, rendering the treatment ineffective, causing disability and increasing morbidity and mortality. Inhibitor development results from a complex multicausal immune response involving both genetic and environmental risk factors. One of the most important modifiable risk factors is the source of FVIII products, eg, plasma-derived or recombinant FVIII. Other environmental risk factors, such as age at first treatment, regimen, and intensity of treatment, could contribute to inhibitor development. Severe bleeds, surgery, concomitant infections, or vaccinations may all be events initiating danger signaling resulting in an immune reaction towards administered FVIII. All in all, the etiology of inhibitor development still remains unclear. The risk factors have been stratified into genetic and environmental, but there are no definitive data to determine the impact of each of them.
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Affiliation(s)
- Flora Peyvandi
- Department of Pathophysiology and TransplantationUniversità degli Studi di MilanoMilanItaly
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoFondazione Luigi VillaMilanItaly
| | - Isabella Garagiola
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoFondazione Luigi VillaMilanItaly
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Klukowska A, Komrska V, Vdovin V, Pavlova A, Jansen M, Lowndes S, Belyanskaya L, Walter O, Laguna P. Low incidence of factor VIII inhibitors in previously untreated patients with severe haemophilia A treated with octanate ® : Final report from a prospective study. Haemophilia 2018; 24:221-228. [PMID: 29314439 DOI: 10.1111/hae.13385] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2017] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Octanate® is a human, plasma-derived, von Willebrand factor-stabilized coagulation factor VIII (FVIII) concentrate with demonstrated haemostatic efficacy in previously treated patients with haemophilia A. AIM This prospective, open-label study aimed to assess the immunogenicity of octanate® in previously untreated patients (PUPs). METHODS The study monitored development of FVIII inhibitors in 51 PUPs. Tolerability, viral safety, FVIII recovery and efficacy of octanate® for the prevention and treatment of bleeds and in surgical procedures were also assessed. RESULTS Five (9.8%) of the 51 patients developed inhibitors during the study, 4 of which (7.8%) were high titre. Three inhibitor cases (5.9%) were considered clinically relevant; 2 were transient inhibitors that disappeared during regular octanate® treatment without a change in dose or treatment frequency. Amongst 45 patients with FVIII:C <1% at baseline and who received ≥20 exposure days (EDs) or had <20 EDs but developed an inhibitor, inhibitor incidence was 11.1% (6.7% clinically relevant). All clinically relevant inhibitors developed within 20 EDs of on-demand treatment. No inhibitors developed in PUPs receiving prophylaxis. All patients who developed inhibitors had either intron 22 inversions or large deletions. Irrespective of the reason for administration, haemostatic efficacy was rated as "excellent" in 99.6% of all infusions (4700 of 4717 infusions), and no complications were reported in 23 surgical procedures. Mean incremental in vivo recovery was 2.0%/IU/kg (±0.7) and 1.9%/IU/kg (±0.5) for the first and second assessments, respectively. Tolerability was rated "very good" in 99.9% of infusions. CONCLUSION In PUPs with severe haemophilia A, octanate® demonstrated haemostatic efficacy with a low rate of inhibitor development.
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Affiliation(s)
- A Klukowska
- Department of Paediatrics, Haematology and Oncology, Medical University of Warsaw, Warsaw, Poland
| | - V Komrska
- Motol University Hospital, Prague, Czech Republic
| | - V Vdovin
- Morozovskaya Children's Hospital, Moscow, Russia
| | - A Pavlova
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic, Bonn, Germany
| | | | | | | | - O Walter
- Octapharma AG, Lachen, Switzerland
| | - P Laguna
- Department of Paediatrics, Haematology and Oncology, Medical University of Warsaw, Warsaw, Poland
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Kim SK, Yoo KY, Lee KS, Hwang T, Choi YM, Choi EJ, Park SK. Safety and Efficacy of B-domain Deleted Third Generation Recombinant Factor VIII (GreenGene F™) in Korean Patients with Hemophilia A: Data from a Post-marketing Surveillance Study. J Korean Med Sci 2018; 33:e5. [PMID: 29215814 PMCID: PMC5729640 DOI: 10.3346/jkms.2018.33.e5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 09/24/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND New B-domain deleted third generation recombinant factor VIII (FVIII; GreenGene F™, beroctocog alfa) was launched in 2010. We determined safety and efficacy of GreenGene F™ during routine clinical practice in patients with hemophilia A over a period of 12 months. METHODS From July 2010 to July 2014, a total of 136 hemophilia A patients were enrolled in a post-marketing surveillance (PMS) study. Among them, 134 patients were assessed for drug safety and 114 patients were analyzed for drug efficacy. Patients with differing hemophilia A severities and medical histories were monitored during 12 months of prophylactic and/or on-demand therapy. RESULTS Among 134 patients evaluated, 85 (63.4%) had severe hemophilia. Ninety-two received a total of 1,266,077 units for prophylaxis, and 42 received 516,491 units for bleeding episodes. Three patients developed inhibitors. In 112 previously treated patients, one patient (0.9%) developed inhibitor after intensive FVIII treatment for surgery. Among 22 previously untreated patients, inhibitors were observed in 2 infants (9.1%). Overall, there were a total of 47 adverse events (other than inhibitors) of all types in 30 patients (22.4%), 11 in 10 patients (7.5%) of which were considered showing serious adverse events (SAEs); most of which were hemorrhages at different sites. None of the SAEs were judged as product related. An excellent/good efficacy rate of 91.3% for hemostasis and 89.4% for hemorrhage prevention was recorded. CONCLUSION The results of this PMS study support the use of GreenGene F™ as safe and efficacious in hemorrhage prevention and treatment of hemophilia A. These results are consistent with the findings from previously published GreenGene F™ studies.
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Affiliation(s)
- Soon Ki Kim
- Department of Pediatrics, Inha University College of Medicine, Incheon, Korea
| | | | - Kun Soo Lee
- Department of Pediatrics, Kyungpook National University Hospital, Daegu, Korea
| | | | | | - Eun Jin Choi
- Department of Pediatrics, Daegu Catholic University Hospital, Daegu, Korea
| | - Sang Kyu Park
- Department of Pediatrics, University of Ulsan College of Medicine, Ulsan, Korea.
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Astermark J, Hart D, Lobet S, Blatný J, d'Oiron R, Kenet G, Dolan G, Libotte V, Hermans C. Partnering to change the world for people with haemophilia: 6(th) Haemophilia Global Summit, Prague, Czech Republic, 24-26(th) September 2015. Eur J Haematol 2017; 97 Suppl 84:3-23. [PMID: 27292051 DOI: 10.1111/ejh.12761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The 6(th) Haemophilia Global Summit was held in Prague, Czech Republic, in September 2015. The programme was designed by an independent Scientific Steering Committee of haemophilia experts and aimed to share optimal management strategies for haemophilia at all life stages, explore recent potential advances in the management of haemophilia A and B and discuss challenges in haemophilia care. In this supplement from the meeting, Dan Hart reviews the lessons that can be learnt from cost-constrained environments with regard to improving care for people with haemophilia globally. Sébastien Lobet discusses the importance of physical activity for optimising care and Roseline d'Oiron and Jan Blatný consider the role of real-world data in understanding the effect of treatment in a clinical setting over the long term and the true impact of treatment on the day-to-day life of the patient. Gili Kenet addresses the current challenges relating to the optimal management of prophylaxis, and Gerry Dolan and Cedric Hermans discuss the value of pharmacokinetic (PK) parameters in informing treatment decisions. Cedric Hermans and Valérie Libotte explore the importance of considering social and occupational development factors as an integral part of haemophilia care, and Jan Astermark reviews key strategies to predict and prevent inhibitor development.
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Affiliation(s)
- Jan Astermark
- Department of Hematology and Vascular Diseases, Skåne University Hospital, Malmö, Sweden
| | - Dan Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry, QMUL, London, UK
| | - Sébastien Lobet
- Haemostasis and Thrombosis Unit, Division of Haematology, Haemophilia Clinic, Saint-Luc University Hospital, Brussels, Belgium
| | - Jan Blatný
- Children's University Hospital Brno, Brno, Czech Republic
| | - Roseline d'Oiron
- Hôpital Bicêtre AP-HP, Paris XI University, Le Kremlin-Bicêtre, France
| | - Gili Kenet
- National Hemophilia Center, Sheba Medical Center, Tel HaShomer, Israel
| | | | - Valérie Libotte
- Service externe de prévention et de protection au travail - CESI - 1200 Brussels, Belgium
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Afonja O, Kozak R, Petraro P, Michaels LA, Mathew P, Lemm G, Kessler C. Baby hamster kidney cell-derived recombinant factor VIII: a quarter century of learning and clinical experience. Expert Rev Hematol 2016; 9:1151-1164. [PMID: 27841041 DOI: 10.1080/17474086.2017.1259559] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Management and care of individuals with hemophilia A advanced immensely with the introduction of recombinant factor VIII (rFVIII) replacement products. This review provides a historical overview of rFVIII development with a focus on Bayer's rFVIII (with albumin) and sucrose-formulated rFVIII (rFVIII-FS), the only rFVIII products cloned in baby hamster kidney (BHK) cells with >25 years of proven safety and efficacy. Areas covered: We review the advances in rFVIII technology and the efficacy and safety data for BHK-derived rFVIII/rFVIII-FS from clinical trials, investigator-initiated studies, and observational studies. Innovative products with new treatment potentials (eg, BAY 81-8973 and BAY 94-9027) built on this established safety and efficacy profile are also briefly discussed. The literature search strategy included targeted searches (PubMed) with manual article selection and other product-specific searches. Expert commentary: Development of rFVIII products and related improvements in viral safety and manufacturing efficiency have guaranteed an adequate supply of factor products worldwide and increased prophylaxis use. The net effects have been joint health preservation, reduction in morbidity and mortality, and quality-of-life enhancements. Current treatment challenges include lack of adherence to prophylaxis and inhibitor development; extended-half-life rFVIII products and non-FVIII replacement therapies in development may help overcome these challenges.
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Affiliation(s)
| | | | | | | | - Prasad Mathew
- a Bayer , Whippany , NJ , USA.,c Department of Pediatric Hematology/Oncology , University of New Mexico , Albuquerque , NM , USA
| | | | - Craig Kessler
- e Department of Medicine and Pathology , Georgetown University Medical Center , Washington , DC , USA
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20
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Berntorp E. Plasma-derived versus recombinant factor concentrates in PUPs: a never ending debate? Hamostaseologie 2016; 37:53-57. [PMID: 27878207 DOI: 10.5482/hamo-16-10-0040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 11/14/2016] [Indexed: 01/03/2023] Open
Abstract
Inhibitor development in haemophilia is a serious complication to treatment with factor concentrates. Since the advent of more pure products, especially developed using recombinant DNA technology, some studies have shown an increased incidence of inhibitors in previously untreated patients (PUPs) receiving recombinant products whereas plasma-derived concentrates sometimes have been claimed to have a protective role, probably due to the content of von Willebrand factor (VWF). In fact, experiments indicate that the VWF may block uptake of factor VIII into macrophages for further processing to the immune system. Also, a competition between VWF and inhibitor binding to the C2 domain of factor VIII has been suggested. Recently, large cohort and surveillance studies have created a vigorous debate about the role of product class for inhibitor development as results have been conflicting. The only randomised prospective study, the SIPPET study, was published in 2016, and substantiated previous reports claiming that plasma derived concentrates give less inhibitors in patients with severe haemophilia A, previously not exposed to factor VIII. The debate will continue.
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Affiliation(s)
- Erik Berntorp
- Prof. Erik Berntorp, Centre for Thrombosis and Hemostasis, Lund University, Skane University Hospital, Jan Waldenströms gata 14, SE-205 02, Malmö, Sweden, Tel: +46705752496, E-Mail:
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22
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Lövgren KM, Søndergaard H, Skov S, Wiinberg B. Non-genetic risk factors in haemophilia A inhibitor management - the danger theory and the use of animal models. Haemophilia 2016; 22:657-66. [DOI: 10.1111/hae.13075] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2016] [Indexed: 12/20/2022]
Affiliation(s)
- K. M. Lövgren
- Department of Veterinary Disease Biology; University of Copenhagen; Frederiksberg Denmark
- Translational Haemophilia Pharmacology, Global Research; Novo Nordisk A/S; Maaloev Denmark
| | - H. Søndergaard
- Diabetes Complications Pharmacology; Global Research; Novo Nordisk A/S; Maaloev Denmark
| | - S. Skov
- Department of Veterinary Disease Biology; University of Copenhagen; Frederiksberg Denmark
| | - B. Wiinberg
- Haemophilia Translational Biology, Global Research; Novo Nordisk A/S; Maaloev Denmark
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23
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Goudemand J, Peyvandi F, Lacroix-Desmazes S. Key insights to understand the immunogenicity of FVIII products. Thromb Haemost 2016; 116 Suppl 1:S2-9. [PMID: 27528279 DOI: 10.1160/th16-01-0048] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 07/04/2016] [Indexed: 11/05/2022]
Abstract
The treatment of haemophilia has made significant progress in recent decades, and patients are now being treated safely with great clotting products. However, inhibitor development remains the largest problem, particularly in children. Consequently, the haemostasis that was obtained with traditional clotting factors is not being achieved. Moreover, inhibitor complications translate into adult life and there are an increasing number of situations where adult patients with an inhibitor require major surgery but the clinician is faced with the knowledge that required haemostasis levels are difficult to achieve. Therefore, it is of upmost importance to consider factors relating to inhibitor development, and to determine how inhibitors can be prevented and/or eliminated. Of the various factors at play with regard to inhibitor development, it is important to consider the immunogenicity of factor VIII (FVIII) products, and this topic is the focus of the current paper.
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Affiliation(s)
| | | | - Sébastien Lacroix-Desmazes
- Sebastien Lacroix-Desmazes, INSERM U872 eq16 - Centre de Recherche des Cordeliers, 15 Rue de l'école de medicine, Paris 75006, France, Tel.: +33 0155438265, Fax: +33 0155426261, E-mail:
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24
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Punzalan RC, Gottschall JL. Use and Future Investigations of Recombinant and Plasma-Derived Coagulation and Anticoagulant Products in the Neonate. Transfus Med Rev 2016; 30:189-96. [PMID: 27576087 DOI: 10.1016/j.tmrv.2016.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 07/18/2016] [Indexed: 12/27/2022]
Abstract
Although congenital bleeding disorders can manifest in the newborn period, the most common causes of bleeding and thrombosis in neonates are acquired conditions. Factor concentrates are used for specific diagnoses (hemophilia with inhibitors, specific factor deficiency, von Willebrand disease) and approved indications, and increasingly for off-label indications (bleeding in surgery cardiopulmonary bypass, extracorporeal membrane oxygenation). We will review the approved indications for factor products in the neonate and discuss the evidence and rationale for off-label use of factor products in management of bleeding and thrombosis in the neonate.
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Affiliation(s)
- Rowena C Punzalan
- BloodCenter of Wisconsin, Milwaukee, WI; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.
| | - Jerome L Gottschall
- BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
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25
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Fruchtman Y, Dardik R, Barg AA, Livnat T, Feldman Z, Rubinstein M, Grinberg G, Rosenberg N, Kenet G. Spinal Epidural Hematoma Following Cupping Glass Treatment in an Infant With Hemophilia A. Pediatr Blood Cancer 2016; 63:1120-2. [PMID: 26844816 DOI: 10.1002/pbc.25921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 01/05/2016] [Indexed: 11/11/2022]
Abstract
A 6 months old infant, diagnosed with a rare mutation causing severe hemophilia A, presented with spinal epidural hematoma. Parents later admitted the infant had glass cupping therapy performed within 2 weeks of the onset of symptoms. The rare mutation, rare bleeding complication, and the eventual course of therapy applied in this case will be discussed in our case report.
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Affiliation(s)
- Yariv Fruchtman
- Department of Pediatric Emergency Care and Pediatric Hematology Unit, Soroka Medical Center, Ben Gurion University of the Negev, Beer-Sheba, Israel.,Thrombosis Institute and National Hemophilia Center, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rima Dardik
- Thrombosis Institute and National Hemophilia Center, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assaf Arie Barg
- Thrombosis Institute and National Hemophilia Center, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Livnat
- Thrombosis Institute and National Hemophilia Center, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zeev Feldman
- Pediatric Neurosurgery Department, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Marina Rubinstein
- Department of Critical Care, Safra Children's Hospital, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gahl Grinberg
- Department of Diagnostic Imaging, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nurit Rosenberg
- Thrombosis Institute and National Hemophilia Center, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- Thrombosis Institute and National Hemophilia Center, Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Mathew P, Dinter H, Church N, Humphries TJ, Kulkarni R. Inhibitors in haemophilia A: a perspective on clotting factor products as a potential contributing factor. Haemophilia 2016; 22:334-41. [PMID: 26843214 DOI: 10.1111/hae.12888] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2015] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The occurrence of a neutralizing antibody in previously untreated patients (PUPs) with haemophilia A appears to be the result of an intricate interplay of both genetic and environmental factors. Recently, the type of factor VIII (FVIII) product used in the PUPs population has been implicated as a risk factor for inhibitor development. AIM The aim of this review was to explore in a systematic manner potential hypotheses for the product-related findings in these studies (i.e. differences in the expression system of the cell lines used to produce recombinant FVIII [rFVIII], differences in the administered antigen load or changes in clinical practice over time). RESULTS Review of the available clinical studies illustrates the high degree of variability for the risk of inhibitor development for the same products across different studies. Differences in cell lines or antigen load were not found to provide a reasonable explanation. CONCLUSION The possibility of changes in clinical practice over time and patient selection bias (i.e. the preferential use of one product over another in patients at higher risk for inhibitors) offers a potential explanation and should be carefully considered when evaluating the studies.
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Affiliation(s)
- P Mathew
- Bayer HealthCare Pharmaceuticals Inc., Whippany, NJ, USA
| | - H Dinter
- Bayer Pharma AG, Leverkusen, Germany
| | - N Church
- Bayer HealthCare Pharmaceuticals Inc., Whippany, NJ, USA
| | - T J Humphries
- Bayer HealthCare Pharmaceuticals Inc., Whippany, NJ, USA
| | - R Kulkarni
- Michigan State University, East Lansing, MI, USA
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Carcao M, Re W, Ewenstein B. The role of previously untreated patient studies in understanding the development of FVIII inhibitors. Haemophilia 2015; 22:22-31. [PMID: 26315604 DOI: 10.1111/hae.12790] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2015] [Indexed: 01/01/2023]
Abstract
Development of inhibitors against factor VIII (FVIII), the major complication of haemophilia A treatment today, is influenced by multiple factors. Genetic (F8 mutation, family history, ethnicity, polymorphisms in immune modulating genes) and non-genetic (intensive exposure to FVIII, presence of pro-inflammatory signals as might occur with large bleeds, infections, surgery, or other immune stimulants [e.g. vaccines]) risk factors as well as their complex inter-relationships contribute to the inhibitor risk profile of haemophilia patients, particularly in the previously untreated patient (PUP) population. Studies in PUPs have been fundamental to furthering the understanding of FVIII inhibitor development, as well as discovering previously unappreciated risk factors. The multi-factorial nature of inhibitor development makes it difficult to ascertain the contribution of FVIII products in inhibitor development through individual PUP studies. Sufficiently powered studies of large cohorts may overcome these limitations but interpretations should be conducted cautiously. Proper design and implementation of PUP safety studies will become even more important with the introduction of new molecules, such as extended half-life or human cell-line derived FVIII that propose reduced immunogenicity. Despite these difficulties, carefully performed clinical studies in PUPs may provide important insights into the natural history of the immune response to FVIII and may suggest targets for intervention to reduce immunogenicity.
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Affiliation(s)
- M Carcao
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - W Re
- Baxter Healthcare Corporation, West Lake, CA, USA
| | - B Ewenstein
- Baxter Healthcare, Clinical Research and Development, Westlake Village, CA, USA
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28
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Risk of inhibitors in previously untreated patients with hemophilia: a meta-analysis of literature studies. Blood 2015; 125:3819-21. [PMID: 26069336 DOI: 10.1182/blood-2015-01-621383] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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