Efficacy and safety of Nuwiq® (human-cl rhFVIII) in patients with severe haemophilia A undergoing surgical procedures

Preoperative assessment of adults undergoing elective noncardiac surgery: Updated guidelines from the European Society of Anaesthesiology and Intensive Care

BACKGROUND

When considering whether a patient is fit for surgery, a comprehensive patient assessment represents the first step for an anaesthetist to evaluate the risks associated with the procedure and the patient's underlying diseases, and to optimise (whenever possible) the perioperative surgical journey. These guidelines from the European Society of Anaesthesiology and Intensive Care Medicine (ESAIC) update previous guidelines to provide new evidence on existing and emerging topics that consider the different aspects of the patient's surgical path.

DESIGN

A comprehensive literature review focused on organisation, clinical facets, optimisation and planning. The methodological quality of the studies included was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. A Delphi process agreed on the wording of recommendations, and clinical practice statements (CPS) supported by minimal evidence. A draft version of the guidelines was published on the ESAIC website for 4 weeks, and the link was distributed to all ESAIC members, both individual and national, encompassing most European national anaesthesia societies. Feedback was gathered and incorporated into the guidelines accordingly. Following the finalisation of the draft, the Guidelines Committee and ESAIC Board officially approved the guidelines.

RESULTS

In the first phase of the guidelines update, 17 668 titles were initially identified. After removing duplicates and restricting the search period from 1 January 2018 to 3 May 2023, the number of titles was reduced to 16 774, which were then screened, yielding 414 abstracts. Among these, 267 relevant abstracts were identified from which 204 appropriate titles were selected for a comprehensive GRADE analysis. Additionally, the study considered 4 reviews, 16 meta-analyses, 9 previously published guidelines, 58 prospective cohort studies and 83 retrospective studies. The guideline provides 55 evidence-based recommendations that were voted on by a Delphi process, reaching a solid consensus (>90% agreement).

DISCUSSION

This update of the previous guidelines has covered new organisational and clinical aspects of the preoperative anaesthesia assessment to provide a more objective evaluation of patients with a high risk of postoperative complications requiring intensive care. Telemedicine and more predictive preoperative scores and biomarkers should guide the anaesthetist in selecting the appropriate preoperative blood tests, x-rays, and so forth for each patient, allowing the anaesthetist to assess the risks and suggest the most appropriate anaesthetic plan.

CONCLUSION

Each patient should have a tailored assessment of their fitness to undergo procedures requiring the involvement of an anaesthetist. The anaesthetist's role is essential in this phase to obtain a broad vision of the patient's clinical conditions, to coordinate care and to help the patient reach an informed decision.

Design of an international, phase IV, open-label study of simoctocog alfa in women/girls with hemophilia A undergoing surgery (NuDIMENSION)

Background

Although hemophilia A mainly affects males, carriers (defined as females with hemophilia A, as well as symptomatic or asymptomatic hemophilia A carriers) are at risk of excessive bleeding, particularly during trauma or during surgical procedures. Clinical trials have focused on male patients with severe disease, and data for females are limited. Improved, evidence-based treatment guidelines for management of hemophilia A carriers are required.

Objectives and design

The NuDIMENSION study is a phase IV, prospective, open-label, single-arm study that will evaluate the perioperative efficacy and safety of simoctocog alfa (Nuwiq®), a recombinant factor VIII (FVIII), in women/girls with hemophilia A undergoing major surgery. The study will be conducted at approximately 15 centers worldwide. Women/girls aged ⩾12 years, with mild or moderate hemophilia A (residual FVIII activity (FVIII:C) ⩾1% to <40%) and with no current/past FVIII inhibitors are eligible. All patients must be scheduled to undergo a major surgical procedure during which simoctocog alfa will be administered.

Methods and analysis

The primary endpoint is overall perioperative hemostatic efficacy ("success" or "failure") of simoctocog alfa. Hemostatic efficacy will be assessed at the end of surgery and at the end of the postoperative period (i.e., completion of wound healing), with overall adjudication by an Independent Data Monitoring Committee. Safety endpoints will include the incidences of thrombotic events and FVIII inhibitor development. The aim is to recruit 28 patients to achieve 26 evaluable surgeries.

Ethics

Ethical approval will be received from institutional review boards/independent ethics committees, and the study will be conducted in compliance with the Declaration of Helsinki.

Discussion

Data from NuDIMENSION will generate much-needed evidence on surgical management of women/girls with hemophilia A, which will help to enable the development of treatment guidelines specific for such patients.

Trial Registration

CT EU 2022-502061-17-00; NCT05936580.

Simoctocog alfa (Nuwiq®) in children: early steps in life's journey for people with severe hemophilia A

People with severe hemophilia A usually experience their first bleed early in life. In children with severe hemophilia A, primary prophylaxis is recommended to prevent recurrent and potentially life-threatening bleeds that significantly impact day-to-day life. Factor VIII (FVIII) prophylaxis is well-established in children and has been shown to reduce the development of hemophilic arthropathy. However, a major challenge of FVIII therapy is the development of neutralizing anti-FVIII antibodies (FVIII inhibitors). Simoctocog alfa (Nuwiq®) is a human cell line-derived recombinant FVIII (rFVIII) whose immunogenicity, efficacy, and safety have been studied in 167 children with severe hemophilia A across two prospective clinical trials and their long-term extensions. In 105 previously untreated children, the inhibitor rate of 16.2% for high-titer inhibitors (26.7% for all inhibitors) was lower than published rates for hamster cell line-derived rFVIII products. There was no inhibitor development in previously untreated children with non-null F8 mutations and in previously treated children. In a case series of 10 inhibitor patients, 8 (80%) underwent successful immune tolerance induction with simoctocog alfa with a median time to undetectable inhibitor of 3.5 months. In an analysis of 96 children who enrolled in the extension studies and received long-term simoctocog alfa prophylaxis for up to 5 years, median spontaneous, joint, and total annualized bleeding rates were 0.3, 0.4, and 1.8, respectively. No thromboembolisms were reported in any of the 167 children, and there were no treatment-related deaths. Optimal care of children should consider several factors, including minimization of inhibitor development risk, maintaining tolerance to FVIII, highly effective bleed prevention and treatment, safety, and impact on long-term outcomes such as bone and joint health. In this context we review the pediatric clinical data and ongoing studies with simoctocog alfa.

Turoctocog alfa pegol provides effective management for major and minor surgical procedures in patients across all age groups with severe haemophilia A: Full data set from the pathfinder 3 and 5 phase III trials

INTRODUCTION

Turoctocog alfa pegol is a glycoPEGylated recombinant factor VIII (FVIII) with an extended half-life developed for prophylaxis, treatment of bleeds and perioperative management in patients with haemophilia A.

AIM

Evaluate the efficacy and safety of turoctocog alfa pegol treatment for major and minor surgeries in the pathfinder 3 and 5 phase III trials.

METHODS

Adults/adolescents aged ≥12 years with severe haemophilia A (FVIII <1%) received perioperative turoctocog alfa pegol treatment planned to achieve FVIII activity levels >80% during major surgery (pathfinder 3). The primary end point was haemostatic efficacy during surgery; secondary end points were blood loss, haemostatic effect postsurgery, consumption, transfusions, safety and health economics. Children (0-11 years) undergoing minor surgeries received 20-75 IU/kg turoctocog alfa pegol at Investigator's discretion (pathfinder 5).

RESULTS

pathfinder 3 included 35 patients undergoing 49 major surgeries. Haemostasis was successful in 47/49 (95.9%) surgeries; two had moderate haemostatic responses. Median (mean) blood loss during major surgery was 75 (322.6) mL. Four bleeds were reported postsurgery; three were successfully treated with turoctocog alfa pegol (one was not evaluated). On the day of surgery, overall mean (median) dose was 75.5 (74.5) IU/kg and mean (median) number of doses was 1.7 (2.0). Five procedures required 11 transfusions on the day of surgery or days 1-6. No safety concerns or inhibitors were identified. Forty-five minor surgeries in 23 children were performed without complications.

CONCLUSION

Turoctocog alfa pegol was effective for perioperative haemostatic management of major and minor surgeries in patients across age groups with severe haemophilia A.

Efficacy and safety of simoctocog alfa (Nuwiq®) in patients with severe hemophilia A: a review of clinical trial data from the GENA program

Simoctocog alfa (human-cl rhFVIII, Nuwiq®) is a 4th generation recombinant FVIII (rFVIII), without chemical modification or fusion with any other protein/fragment. Nuwiq® is produced in a human embryonic kidney cell line (HEK293F), which ensures human-specific post-translational protein processing. Nuwiq® was evaluated in seven prospective clinical studies in 201 adult and pediatric previously treated patients (PTPs) with severe hemophilia A. The NuProtect study in 110 previously untreated patients (PUPs) is ongoing. The mean half-life of Nuwiq® was 15.1–17.1 h in PTP studies with adults and adolescents, and 12.5 h in children aged 2–12 years. Clinical trials in PTPs demonstrated the efficacy and safety of Nuwiq® in the prevention and treatment of bleeds and as surgical prophylaxis. In the NuPreviq study of pharmacokinetic (PK)-guided personalized prophylaxis in 66 adult PTPs, 83% of patients had no spontaneous bleeds during 6 months of personalized prophylaxis and 57% were treated ⩽2 per week. No FVIII inhibitors were detected in PTPs after treatment with 43,267 injections and >80 million IU of Nuwiq®. Interim data for 66 PUPs with ⩾20 exposure days to Nuwiq® in NuProtect demonstrated a low cumulative high-titer inhibitor rate of 12.8% [actual incidence 12.1% (8/66)] and convincing efficacy and safety.

Blood, blood components, plasma, and plasma products

This review of 2018 publications identifies side effects of blood, blood components, and plasma products. In addition, albumin, blood transfusion (erythrocytes, granulocytes, and platelets), blood substitutes (hemoglobin-based oxygen carriers), plasma products (alpha1-antitrypsin, C1 esterase inhibitor concentrate, cryoprecipitate, and fresh frozen plasma), plasma substitutes (etherified starches, and gelatin), globulins (intravenous immunoglobulin, subcutaneous immunoglobulin, and anti-D immunoglobulin), coagulation proteins (factor I, factor II, factor VIIa, factor VIII, factor IX, prothrombin complex concentrate, antithrombin III, and von Willebrand factor/factor VIII concentrates), erythropoietin and derivatives, thrombopoietin and receptor agonists, transmission of infectious agents through blood donation, and stem cells are reviewed. This chapter informs the reader about newly recognized and published data in the blood product domain.

Continuous infusion of simoctocog alfa in haemophilia A patients undergoing surgeries

INTRODUCTION

There are two major principles for coagulation factor replacement in the clinical management of surgical procedures in patients with haemophilia, repetitive bolus injections every 6-12 hours or administration of coagulation factor concentrates by continuous infusion.

AIM

The aim was to investigate the efficacy of simoctocog alfa (human-cl rhFVIII) delivered by continuous infusion for bleeding prophylaxis during surgery in patients with haemophilia A.

METHODS

We investigated the use of continuous infusion with simoctocog alfa in haemophilia A patients undergoing major surgical procedures at Oslo University Hospital from September 2015 to March 2018. The objectives were haemostatic outcome, in vivo recovery, stability over time at room temperature (3 days) and inhibitor development.

RESULTS

Simoctocog alfa demonstrated treatment success in terms of haemostatic efficacy in 100% of major surgeries used as CI: 87% (n=21) excellent; 13% (n=3) good. No erythrocyte transfusions were required in any patient, no adverse events occurred and no inhibitors developed. The product was stable for 3 days at room temperature without loss of activity. Mean in vivo recovery was 1.8 (0.3) (IU/mL/IU/kg).

CONCLUSION

Continuous infusion with simoctocog alfa was found to achieve good/excellent haemostatic efficacy in all procedures. No adverse events occurred and no inhibitors developed.