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Grottke O, Rieg A, Ulmer F, Hein M. Bleeding management: rFVIIIFc in hemophilia A and liver transplantation. DIE ANAESTHESIOLOGIE 2023; 72:883-886. [PMID: 37563315 PMCID: PMC10692241 DOI: 10.1007/s00101-023-01320-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 06/22/2023] [Accepted: 06/27/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND In patients with severe hemophilia A prolonged bleeding may occur even in cases of minor trauma or surgery. OBJECTIVE To investigate the feasibility and efficacy of a recombinant extended half-life (EHL) FVIII concentrate for perioperative bleeding management in a patient with severe hemophilia A undergoing liver transplantation. MATERIAL AND METHODS Prior to transplantation FVIII activity and perioperatively required FVIII supply were estimated. In an individualized approach efmoroctocog alfa was supplemented if the intrinsic clotting time in the thrombelastometry was > 170 s. RESULTS The patient perioperatively received a total of 28,000 IU efmoroctocog alfa. No signs of hemorrhage or complications were detected and no further intervention was necessary. CONCLUSION The present case demonstrates that the use of an EHL FVIII is suitable for a successful perioperative bleeding control even in hemophilia patients at a high bleeding risk during major surgery. Due to the EHL constant FVIII levels could be achieved with relatively few injections. In order to confirm the obtained results, more real-world data in different operative settings are essential. Further research is needed on the use of thrombelastometry to guide substitution of factor VIII perioperatively.
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Affiliation(s)
- Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Annette Rieg
- Department of Anaesthesiology, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Florian Ulmer
- Department of Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Marc Hein
- Department of Anaesthesiology, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
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Chang YJ, Yeh SF, Chen PJ. A portable point-of-care testing device for forward blood typing with hemophilia diagnosis. Biomed Microdevices 2023; 25:38. [PMID: 37776382 DOI: 10.1007/s10544-023-00678-8] [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] [Accepted: 09/20/2023] [Indexed: 10/02/2023]
Abstract
This paper presents a portable point-of-care testing (POCT) device to conduct simultaneous and on-site tests of ABO and Rh(D) forward blood typing and hemophilia diagnosis using only a small amount of human whole blood sample. The POCT device consisted of a spinning module, a measuring circuit, an interdigitated electrode (IDE) for hemophilia diagnosis, and three disposable microfluidic chips for bioassays with anti-A, anti-B, and anti-D, respectively, and measurement of the concentration of factor VIII. Agglutination will occur if red blood cells (RBCs) are exposed to the corresponding antibody. To evaluate the degree of RBC agglutination, a linear sweep voltage, ranging from - 0.5 to + 0.5 V, was applied to the electrodes of the microfluidic chip and the resulting current was measured. For different levels of agglutination, the measured I-V curves were explicitly discriminated, providing five clinical levels from non-agglutination (level 0) to strong agglutination (level 4). The quantitative norm obtained from cubic fitting function of each I-V curve served as the criterion to represent this agglutination level. The ABO blood type was determined by both agglutination levels of the blood sample reacting with anti-A and anti-B. The degree of agglutination with anti-D gave the Rh(D) type. Moreover, the concentration of factor VIII was detected for the determination of hemophilia. Without requiring expensive equipment, this POCT device is especially suitable for usage in emergency or natural disasters to provide quantitative testing in rescue and relief operations.
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Affiliation(s)
- Yaw-Jen Chang
- Department of Mechanical Engineering, Chung Yuan Christian University, Chung Li District, Taoyuan City, Taiwan.
| | - Shang-Fen Yeh
- Department of Mechanical Engineering, Chung Yuan Christian University, Chung Li District, Taoyuan City, Taiwan
| | - Pin-Jyun Chen
- Department of Mechanical Engineering, Chung Yuan Christian University, Chung Li District, Taoyuan City, Taiwan
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Windyga J, Guillet B, Rugeri L, Fournel A, Stefanska-Windyga E, Chamouard V, Pujol S, Henriet C, Bridey F, Negrier C. Continuous Infusion of Factor VIII and von Willebrand Factor in Surgery: Trials with pdFVIII LFB or pdVWF LFB in Patients with Bleeding Disorders. Thromb Haemost 2022; 122:1304-1313. [PMID: 35642281 PMCID: PMC9393085 DOI: 10.1055/a-1865-6978] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION A plasma-derived factor VIII product (pdFVIII, Factane 100 or 200 IU/mL) and a plasma-derived von Willebrand factor product (pdVWF, Wilfactin 100 IU/mL) are approved for replacement therapy by intravenous bolus injections in haemophilia A (HA) and von Willebrand disease (VWD), respectively. However, in situations requiring intensive treatment, continuous infusion (CI) may be desirable to better control target plasma factor levels. AIM To evaluate the perioperative haemostatic efficacy and safety of these concentrates administered by CI. METHODS Three phase III trials were conducted. Adults with HA (FVIII:C <1%) (Studies 1 and 2) or VWD (VWF:RCo <20%) (Study 3) received a preoperative bolus followed by CI of undiluted concentrate for at least 6 days. Bolus doses and CI rates were based on individual recovery and clearance, respectively. Initial infusion rate had to be higher for 48 hours for HA and 24 hours for VWD patients to anticipate potential fluctuations of factor concentrations during major surgery. Target levels of FVIII:C in HA and VWF:RCo in VWD were 80 and 70 IU/dL, respectively. Efficacy was assessed using a global haemostatic efficacy score. RESULTS Studies 1, 2, and 3 included 12, 4 and 6 patients, respectively. Efficacy outcomes were excellent/good in all 22 major surgeries including 18 orthopaedic procedures. Most daily measured FVIII and VWF levels (92%) were on target. No safety concerns, thrombotic events or inhibitors were identified. CONCLUSION pdFVIII and pdVWF administered by CI represent an effective and safe alternative to bolus injections in patients with severe HA or VWD undergoing surgery.
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Affiliation(s)
- Jerzy Windyga
- Department of Disorders of Haemostasis and Internal Medicine, Institute of Haematology and Transfusion Medicine, Warsaw, Poland
| | - Benoit Guillet
- Haemophilia treatment center, University Hospital Centre Rennes, Rennes, France.,Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Université de Rennes 1, Rennes, France
| | - Lucia Rugeri
- Unité hémostase Clinique, Centre Hospitalier Universitaire de Lyon, Bron, France
| | | | - Ewa Stefanska-Windyga
- Department of Disorders of Haemostasis and Internal Medicine, Institute of Haematology and Transfusion Medicine, Warsaw, Poland
| | - Valérie Chamouard
- Unité Hémostase Clinique, Centre Hospitalier Universitaire de Lyon, Lyon, France
| | - Sonia Pujol
- Clinical Development, Laboratoire Francais du Fractionnement et des Biotechnologies, Les Ulis, France
| | - Celine Henriet
- Clinical development, Laboratoire Francais du Fractionnement et des Biotechnologies, Les Ulis, France
| | - Françoise Bridey
- Clinical Development, Laboratoire Francais du Fractionnement et des Biotechnologies, Les Ulis, France
| | - Claude Negrier
- Unite Hemostase, Inflammation & Sepsis EAM 4174, Universite Lyon1-Hospices Civils de Lyon, Faculte de Medecine Laennec, Lyon cedex O8, France.,Laboratoire d'Hemostase, Hopital Edouard Herriot, Lyon, France
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Lehtinen AE, Baghaei F, Astermark J, Holme PA. Surgical outcomes in patients with haemophilia A or B receiving extended half-life recombinant factor VIII and IX Fc fusion proteins: Real-world experience in the Nordic countries. Haemophilia 2022; 28:713-719. [PMID: 35575446 PMCID: PMC9542088 DOI: 10.1111/hae.14585] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 04/13/2022] [Accepted: 04/27/2022] [Indexed: 11/28/2022]
Abstract
Introduction Perioperative dosing recommendations vary across Nordic haemophilia treatment centres (HTCs) for extended half‐life (EHL) factor concentrates in haemophilia A/B (HA/HB) patients. Aim To summarise Nordic real‐world surgical experiences with EHL recombinant factor VIII/IX Fc (rFVIIIFc/rFIXFc) fusion proteins using retrospective data from clinical records at four HTCs in Finland, Sweden and Norway. Methods Factor dosing and surgical outcomes were recorded from HA/HB patients who underwent surgery and were treated with rFVIIIFc/rFIXFc. Perioperative factor dosing regimens were clinician‐determined based on local practises. Results Twenty five surgeries were performed on 20 patients, all covered by bolus injections except one minor HA surgery; eight minor surgeries were in paediatric patients. Median preoperative rFVIIIFc dose for major HA surgeries (n = 8) was 48 IU/kg (range: 35–57), with total consumption up to Day 14 of 427 IU/kg (196–568). For the two major HB surgeries (in one patient), preoperative rFIXFc doses were 50 IU/kg and 20 IU/kg; total consumption up to Day 14 was 130 IU/kg and 40 IU/kg. Median preoperative rFVIIIFc/rFIXFc bolus doses for minor HA (n = 10) and HB (n = 4) surgeries were 50 IU/kg (24–79) and 47 IU/kg (40–71), with total consumption up to Day 5 of 138 IU/kg (49–404) and 100 IU/kg (43–125), respectively. Intraoperative and postoperative haemostatic responses were rated as at least good/excellent for 24/25 surgeries, with bleeding episodes reported in only three surgeries. Conclusion Nordic real‐world experiences suggest that EHL products can be used safely and effectively for peri‐operative haemostasis. Further research is required to develop local dosing guidelines for optimised treatment schedules.
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Affiliation(s)
- Anna-Elina Lehtinen
- Coagulation Disorders Unit, Department of Haematology, Helsinki University Hospital Comprehensive Cancer Centre and University of Helsinki, Helsinki, Finland
| | - Fariba Baghaei
- Coagulation Centre, Department of Medicine/Section of Haematology and Coagulation, Sahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan Astermark
- Institution for Translational Medicine, Lund University and Department for Haematology, Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden
| | - Pål André Holme
- Department of Haematology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Mancuso ME, Apte S, Hermans C. Managing invasive procedures in haemophilia patients with limited resources, extended half-life concentrates or non-replacement therapies in 2022. Haemophilia 2022; 28 Suppl 4:93-102. [PMID: 35521735 DOI: 10.1111/hae.14551] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 01/15/2023]
Abstract
New treatment possibilities and modalities are now available globally for patients with haemophilia requiring surgery or invasive procedures. The first is the appropriate application of low-dose protocols of clotting factor concentrates (CFC) achieving adequate perioperative haemostasis in resources constraint environments. The increasing availability of CFC through humanitarian aid programs allows more invasive surgeries to be performed for which efficacy and safety data should be more widely collected and reported. Second, extended half-life CFC that are increasingly available in many countries represent valuable alternatives to standard half-life products in surgical patients allowing reduced number of infusions and lower consumption, in particular for extended half-life factor IX. Third, in the era of recently introduced nonfactor prophylaxis, some minor surgical procedures can now be performed without additional haemostatic treatment, others with few low-dose administrations of CFC or bypassing agents. Additional factor VIII/IX or recombinant activated factor VII has proven to be safe and effective in association with emicizumab for major surgeries and it was effectively given at low doses in association with fitusiran (including activated prothrombin complex concentrate). No thrombotic complications have been reported in the surgical setting so far. A multidisciplinary team/facility remains crucial to manage major surgery in patients on prophylaxis with these new agents.
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Affiliation(s)
- Maria Elisa Mancuso
- Center for Thrombosis and Haemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Cedric Hermans
- Division of Haematology, Haemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université catholique de Louvain (UCLouvain), Brussels, Belgium
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Hermans C, Mancuso ME, Nolan B, Pasi KJ. Recombinant factor VIII Fc for the treatment of haemophilia A. Eur J Haematol 2021; 106:745-761. [PMID: 33650192 PMCID: PMC8252769 DOI: 10.1111/ejh.13610] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/24/2021] [Indexed: 12/13/2022]
Abstract
Prophylaxis with factor VIII (FVIII) is the current therapeutic approach for people with haemophilia A. However, standard half-life (SHL) FVIII products must be injected frequently, imposing a substantial burden on the individual and making it difficult to tailor therapy according to patient need and lifestyle, which could impact adherence. Recombinant FVIII Fc fusion protein (rFVIIIFc; Elocta® , Sobi; Eloctate® , Sanofi) is a recombinant fusion protein that undergoes slower clearance from the body than SHL FVIII products. This pharmacokinetic property of rFVIIIFc allows prophylactic administration every 3-5 days, or once weekly in selected patients, with doses adjusted to patient needs and clinical outcomes. Higher FVIII levels can be achieved maintaining dosing frequency similar to that usually applied with SHL FVIII. This review provides a summary of recent data from the A-LONG, Kids A-LONG, ASPIRE and PUPs A-LONG studies and recently published real-world experience relevant to rFVIIIFc use in individualised regimens. The review also introduces ongoing studies of rFVIIIFc, including its use for induction of immune tolerance, and discusses some aspects to consider when switching patients to rFVIIIFc and managing ongoing treatment. In summary, rFVIIIFc is suitable for individualised prophylaxis regimens that can be tailored according to patient clinical needs and lifestyle.
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Affiliation(s)
- Cedric Hermans
- Haemostasis and Thrombosis UnitDivision of HaematologyCliniques Universitaires Saint‐LucUniversité catholique de Louvain (UCLouvain)BrusselsBelgium
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic DiseasesHumanitas Clinical and Research Center ‐ IRCCSRozzanoItaly
| | | | - K. John Pasi
- Royal London Haemophilia CentreBarts and the London School of Medicine and DentistryLondonUK
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Kocher F, Seeber A, Kerschbaumer J, Schmidt S, Wolf D, Feistritzer C. Case report: successful perioperative management of patients with haemophilia A using an extended half-life factor VIII (Efmoroctocog alfa) during neurosurgical procedures. Ther Adv Hematol 2021; 12:2040620721993686. [PMID: 33868623 PMCID: PMC8020741 DOI: 10.1177/2040620721993686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/14/2021] [Indexed: 11/17/2022] Open
Abstract
Patients with haemophilia A (HA) undergoing neurosurgical procedures have a high risk of haemorrhage with potential fatal outcome. Here, we present a successful perioperative haemostatic concept applying an extended half-life factor VIII (EHL FVIII), Efmoroctocog alfa, in two patients with HA undergoing neurosurgery for paramedian right-sided disc herniation (case 1) and astrocytoma (case 2). After adequate EHL FVIII treatment the surgical procedures were performed without any bleeding complications despite the high-risk interventions. Laboratory measurements confirmed stable FVIII levels throughout the hospital stay. We suggest close interdisciplinary collaboration between involved clinicians as mandatory prerequisite for an optimized perioperative management in patients with HA. The presented cases indicate, that the increased stability, safety and fewer injections provide a rationale to use EHL FVIII products in HA patients undergoing surgical interventions with a very high bleeding risk.
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Affiliation(s)
- Florian Kocher
- Department of Internal Medicine V, Hematology & Oncology, Medical University of Innsbruck, Austria
| | - Andreas Seeber
- Department of Internal Medicine V, Hematology & Oncology, Medical University of Innsbruck, Austria
| | | | - Stefan Schmidt
- Department of Internal Medicine V, Hematology & Oncology, Medical University of Innsbruck, Austria
| | - Dominik Wolf
- Department of Internal Medicine V, Hematology & Oncology, Medical University of Innsbruck, Austria
| | - Clemens Feistritzer
- Department of Internal Medicine V, Hematology & Oncology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, Tyrol 6020, Austria
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Hermans C, Apte S, Santagostino E. Invasive procedures in patients with haemophilia: Review of low-dose protocols and experience with extended half-life FVIII and FIX concentrates and non-replacement therapies. Haemophilia 2020; 27 Suppl 3:46-52. [PMID: 32469134 DOI: 10.1111/hae.13978] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 03/05/2020] [Indexed: 12/11/2022]
Abstract
The performance of surgery and invasive procedures in patients with haemophilia is currently facing new challenges globally. The first is the appropriate application of low-dose protocols of clotting factor concentrates (CFC) achieving adequate perioperative haemostasis in resource constraint environments. The increasing availability of CFC through humanitarian aid programmes allows more invasive surgeries to be performed for which efficacy and safety data should be more widely collected and reported. Second, extended half-life CFC that are increasingly available in many countries represent valuable alternatives to standard half-life products in surgical patients allowing reduced number of infusions and lower consumption, in particular for extended half-life factor IX. Third, in the era of recently introduced non-factor prophylaxis, some minor surgical procedures can now be performed without additional haemostatic treatment, others with few low-dose administrations of CFC or bypassing agents. Additional factor VIII or bypassing treatment has proven to be safe and effective in association with emicizumab for major surgeries, and it was effectively given at low doses in association with fitusiran. No thrombotic complications have been reported in the surgical setting so far. A multidisciplinary team/facility remains crucial to manage major surgery in patients on prophylaxis with these new agents.
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Affiliation(s)
- Cedric Hermans
- Hemostasis and Thrombosis Unit, Division of Hematology, Saint-Luc University Hospital, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | | | - Elena Santagostino
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Maggiore Hospital Policlinico, Foundation IRCCS Ca'Granda, Milan, Italy
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