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Tardy-Poncet B, Montmartin A, Chambost H, Lienhart A, Frotscher B, Morange PE, Falaise C, Collange F, Dargaud Y, Toussaint-Hacquard M, Ardillon L, Wibaut B, Jeanpierre E, Nguyen P, Volot F, Tardy B. Relationship between plasma tissue Factor Pathway Inhibitor (TFPI) levels, thrombin generation and clinical risk of bleeding in patients with severe haemophilia A or B. Haemophilia 2024; 30:693-701. [PMID: 38650319 DOI: 10.1111/hae.15020] [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: 11/16/2023] [Revised: 04/05/2024] [Accepted: 04/07/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION Bleeding severity in severe haemophilic patients, with low thrombin generation (TG) capacity, can vary widely between patients, possibly reflecting differences in tissue factor pathway inhibitor (TFPI) level. AIM To compare free TFPI (fTFPI) levels in patients with severe haemophilia A (sHA) and severe haemophilia B (sHB) and to investigate in these patients as a whole the relationships between bleeding and TG potential, between TG potential and fTFPI level and between fTFPI level and bleeding tendency. METHODS Data on bleeding episodes retrospectively recorded during follow-up visits over 5-10 years were collected and used to calculate the annualised joint bleeding rate (AJBR). fTFPI levels and basal TG parameters were determined in platelet-poor plasma (PPP) and platelet-rich plasma (PRP) using calibrated automated tomography (CAT). RESULTS Mean fTFPI levels did not differ significantly between sHA (n = 34) and sHB (n = 19) patients. Mean values of endogenous thrombin potential (ETP) and thrombin peak (peak) in PPP and PRP were two-fold higher when fTFPI levels < 9.4 versus > 14.3 ng/mL. In patients treated on demand, ETP and peak in PRP were doubled when AJBR was≤ 4.9 $ \le 4.9$ , AJBR being halved in patients with a low fTFPI level (9.4 ng/mL). In patients on factor prophylaxis, no association was found between TG parameters and either fTFPI level or AJBR. CONCLUSION In patients treated on demand, bleeding tendency was influenced by fTFPI levels, which in turn affected basal TG potential. In patients on prophylaxis, bleeding tendency is probably determined primarily by the intensity of this treatment.
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Affiliation(s)
- Brigitte Tardy-Poncet
- Université Jean Monnet Saint-Étienne, CHUSaint-Étienne, Centre de traitement de l'hémophilie, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, Saint-Etienne, France
- Inserm CIC 1408, CHU Saint-Étienne, Saint-Etienne, France
| | - Aurélie Montmartin
- Université Jean Monnet Saint-Étienne, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, Saint-Etienne, France
| | - Hervé Chambost
- Hôpital Timone, Centre de Traitement de l'Hémophilie, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Anne Lienhart
- Hôpital Cardiologique Louis Pradel, Centre de Référence de l'Hémophilie, Lyon, France
| | - Birgit Frotscher
- Centre de Traitement de l'Hémophilie, CHU de Nancy, Nancy, France
| | - Pierre-Emmanuel Morange
- INSERM, INRAE, C2VN, Laboratoire d'Hématologie, Assistance Publique - Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France
| | - Céline Falaise
- Hôpital Timone, Centre de Traitement de l'Hémophilie, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Fanny Collange
- Inserm CIC 1408, CHU Saint-Étienne, Saint-Etienne, France
| | - Yesim Dargaud
- Hôpital Cardiologique Louis Pradel, Centre de Référence de l'Hémophilie, Lyon, France
- UR 4609 Hémostase & Thrombose, Université Claude Bernard Lyon 1, Lyon, France
| | | | - Laurent Ardillon
- Centre de Traitement de l'Hémophilie, CHU de Tours, Tours, France
| | - Bénédicte Wibaut
- Centre de Ressources et de Compétences des Maladies Hémorragiques Constitutionnelles Rares, Centre de Référence Maladie de Willebrand, CHU Lille, Lille, France
| | - Emmanuelle Jeanpierre
- Laboratoire d'Hémostase, Pôle de Biologie Pathologie Génétique Médicale, CHU Lille, Lille, France
| | | | - Fabienne Volot
- Centre de Traitement de l'Hémophilie, CHU Dijon, Dijon, France
| | - Bernard Tardy
- Inserm CIC 1408, CHU Saint-Étienne, Saint-Etienne, France
- Université Jean Monnet Saint-Étienne, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, Saint-Etienne, France
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Goedhart TM, Bukkems LH, Zwagemaker AF, Coppens M, Fijnvandraat K, Schols SE, Schutgens RE, Eikenboom J, Heubel-Moenen FC, Ypma PF, Nieuwenhuizen L, Meijer K, Leebeek FW, Mathôt RA, Cnossen MH. Predictive performance of pharmacokinetic-guided prophylactic dosing of factor concentrates in hemophilia A and B. Res Pract Thromb Haemost 2024; 8:102397. [PMID: 38689619 PMCID: PMC11058079 DOI: 10.1016/j.rpth.2024.102397] [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: 03/12/2024] [Accepted: 03/18/2024] [Indexed: 05/02/2024] Open
Abstract
Background Pharmacokinetic (PK)-guided dosing is used to individualize factor (F)VIII and FIX replacement therapy. Objectives This study investigates the reliability and feasibility of PK-guided prophylactic dosing of factor concentrates in hemophilia A and B. Methods In this multicenter, prospective cohort study, people of all ages with hemophilia received prophylactic treatment with factor concentrates based on individual PK parameters. During follow-up, at least 4 measured FVIII/FIX levels per patient were compared with corresponding predicted levels obtained by Bayesian forecasting. Predictive performance was defined as adequate when ≥80% of measured FVIII/FIX levels were within ±25% of prediction (relative error). Additionally, mean absolute error and mean error were calculated. In post hoc analyses, predictive performance was assessed allowing maximum absolute errors of 1 (trough), 5 (mid), and 15 (peak) IU/dL. Five-point scale questionnaires addressed feasibility of PK guidance. Results We included 50 patients (median age, 19 years; range: 2-72 years). Median follow-up was 36 weeks. Seventy-one percent of levels (58% trough, 83% mid, and 80% peak) were within ±25% of prediction. Mean absolute errors were 0.8 (trough), 2.0 (mid), and 8.6 (peak) IU/dL. In post hoc analyses, 81% (trough), 96% (mid), and 82% (peak) of levels were within set limits. Patients reported low burden and high satisfaction. Conclusion PK-guided dosing was reliable according to post hoc analyses, based on low absolute errors that were regarded as clinically irrelevant in most cases. The predefined predictive performance was achieved in mid and peak factor levels but not in trough factor levels due to measurement inaccuracy. PK guidance also seemed feasible.
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Affiliation(s)
- Tine M.H.J. Goedhart
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Laura H. Bukkems
- Department of Clinical Pharmacology—Hospital Pharmacy, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Anne-Fleur Zwagemaker
- Department of Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Emma Children’s Hospital, Amsterdam, the Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Amsterdam UMC, University of Amsterdam, Emma Children’s Hospital, Amsterdam, the Netherlands
| | - Saskia E.M. Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - Roger E.G. Schutgens
- Van Creveldkliniek, Center for Benign Haematology, Thrombosis and Haemostasis, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeroen Eikenboom
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Paula F. Ypma
- Department of Hematology, Haga Hospital, the Hague, the Netherlands
| | | | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, Groningen, the Netherlands
| | - Frank W.G. Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ron A.A. Mathôt
- Department of Clinical Pharmacology—Hospital Pharmacy, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marjon H. Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children’s Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Cortesi PA, Fornari C, Conti S, Pollio B, Boccalandro E, Buzzi A, Carulli C, Coppola A, De Cristofaro R, Di Minno MND, Dolan G, Ferri Grazzi E, Fornari A, Gualtierotti R, Hermans C, Jiménez-Juste V, Kenet G, Lupi A, Martinoli C, Mansueto MF, Nicolò G, Tagliaferri A, Gringeri A, Molinari AC, Mantovani LG, Castaman G. The value-based healthcare approach to haemophilia: Development of outcome measures for the evaluation of care of people with haemophilia. Haemophilia 2024; 30:437-448. [PMID: 38314918 DOI: 10.1111/hae.14943] [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: 04/30/2023] [Revised: 10/16/2023] [Accepted: 11/12/2023] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Considering the advances in haemophilia management and treatment observed in the last decades, a new set of value-based outcome indicators is needed to assess the quality of care and the impact of these medical innovations. AIM The Value-Based Healthcare in Haemophilia project aimed to define a set of clinical outcome indicators (COIs) and patient-reported outcome indicators (PROIs) to assess quality of care in haemophilia in high-income countries with a value-based approach to inform and guide the decision-making process. METHODS A Value-based healthcare approach based on the available literature, current guidelines and the involvement of a multidisciplinary group of experts was applied to generate a set of indicators to assess the quality of care of haemophilia. RESULTS A final list of three COIs and five PROIs was created and validated. The identified COIs focus on two domains: musculoskeletal health and function, and safety. The identified PROIs cover five domains: bleeding frequency, pain, mobility and physical activities, Health-Related Quality of Life and satisfaction. Finally, two composite outcomes, one based on COIs, and one based on PROIs, were proposed as synthetic outcome indicators of quality of care. CONCLUSION The presented standard set of health outcome indicators provides the basis for harmonised longitudinal and cross-sectional monitoring and comparison. The implementation of this value-based approach would enable a more robust assessment of quality of care in haemophilia, within a framework of continuous treatment improvements with potential added value for patients. Moreover, proposed COIs and PROIs should be reviewed and updated routinely.
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Affiliation(s)
- Paolo Angelo Cortesi
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Monza, Italy
| | - Carla Fornari
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Monza, Italy
| | - Sara Conti
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Monza, Italy
| | - Berardino Pollio
- Regional Reference Centre for Inherited Bleeding and Thrombotic Disorders, Transfusion Medicine, "Regina Margherita" Children Hospital, Turin, Italy
| | - Elena Boccalandro
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | | | | | - Antonio Coppola
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | - Raimondo De Cristofaro
- Haemorrhagic and Thrombotic Disease Service, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Matteo Nicola Dario Di Minno
- Department of Clinical Medicine and Surgery, Regional Reference Center for Coagulation Disorders, Federico II University, Naples, Italy
| | | | | | - Arianna Fornari
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Monza, Italy
- Neurology, Public Health and Disability Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Roberta Gualtierotti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Cedric Hermans
- Haemostasis and Thrombosis Unit, Division of Haematology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Victor Jiménez-Juste
- Thrombosis and Haemostasis Unit - IdiPAZ, University Hospital La Paz, Madrid, Spain
| | - Gili Kenet
- National Hemophilia Center, Thrombosis Unit and Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Angelo Lupi
- Federation of Haemophilia Associations (FedEmo), Milan, Italy
| | - Carlo Martinoli
- Department of Health Science - DISSAL, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Gabriella Nicolò
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano, Department of Healthcare Professions, Milan, Italy
| | - Annarita Tagliaferri
- Regional Reference Centre for Inherited Bleeding Disorders, University Hospital of Parma, Parma, Italy
| | | | - Angelo Claudio Molinari
- Regional Reference Centre for Haemorrhagic Diseases, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Lorenzo Giovanni Mantovani
- Research Centre on Public Health (CESP), University of Milano-Bicocca, Monza, Italy
- CHARTA Foundation, Milan, Italy
- IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Giancarlo Castaman
- Department of Oncology, Centre for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
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Valke LLFG, Cloesmeijer ME, Mansouritorghabeh H, Barteling W, Blijlevens NMA, Cnossen MH, Mathôt RAA, Schols SEM, van Heerde WL. Pharmacokinetic-Pharmacodynamic Modelling in Hemophilia A: Relating Thrombin and Plasmin Generation to Factor VIII Activity After Administration of a VWF/FVIII Concentrate. Eur J Drug Metab Pharmacokinet 2024; 49:191-205. [PMID: 38367175 PMCID: PMC10904421 DOI: 10.1007/s13318-024-00876-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Hemophilia A patients are treated with factor (F) VIII prophylactically to prevent bleeding. In general, dosage and frequency are based on pharmacokinetic measurements. Ideally, an alternative dose adjustment can be based on the hemostatic potential, measured with a thrombin generation assay (TGA), like the Nijmegen hemostasis assay. OBJECTIVE The objective of this study was to investigate the predicted performance of a previously developed pharmacokinetic-pharmacodynamic model for FVIII replacement therapy, relating FVIII dose and FVIII activity levels with thrombin and plasmin generation parameters. METHODS Pharmacokinetic and pharmacodynamic measurements were obtained from 29 severe hemophilia A patients treated with pdVWF/FVIII concentrate (Haemate P®). The predictive performance of the previously developed pharmacokinetic-pharmacodynamic model was evaluated using nonlinear mixed-effects modeling (NONMEM). When predictions of FVIII activity or TGA parameters were inadequate [median prediction error (MPE) > 20%], a new model was developed. RESULTS The original pharmacokinetic model underestimated clearance and was refined based on a two-compartment model. The pharmacodynamic model displays no bias in the observed normalized thrombin peak height and normalized thrombin potential (MPE of 6.83% and 7.46%). After re-estimating pharmacodynamic parameters, EC50 and Emax values were relatively comparable between the original model and this group. Prediction of normalized plasmin peak height was inaccurate (MPE 58.9%). CONCLUSION Our predictive performance displayed adequate thrombin pharmacodynamic predictions of the original model, but a new pharmacokinetic model was required. The pharmacodynamic model is not factor specific and applicable to multiple factor concentrates. A prospective study is needed to validate the impact of the FVIII dosing pharmacodynamic model on bleeding reduction in patients.
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Affiliation(s)
- Lars L F G Valke
- Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
- Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, The Netherlands
| | - Michael E Cloesmeijer
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Hassan Mansouritorghabeh
- Clinical Research Development Unit, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Wideke Barteling
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, Location AMC, Amsterdam, The Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
- Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, The Netherlands
| | - Waander L van Heerde
- Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
- Hemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, The Netherlands.
- Enzyre BV, Novio Tech Campus, Nijmegen, The Netherlands.
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Leuci A, Dargaud Y. Blood-Induced Arthropathy: A Major Disabling Complication of Haemophilia. J Clin Med 2023; 13:225. [PMID: 38202232 PMCID: PMC10779541 DOI: 10.3390/jcm13010225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/19/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
Haemophilic arthropathy (HA) is one of the most serious complications of haemophilia. It starts with joint bleeding, leading to synovitis which, in turn, can cause damage to the cartilage and subchondral bone, eventually inducing degenerative joint disease. Despite significant improvements in haemophilia treatment over the past two decades and recent guidelines from ISTH and WFH recommending FVIII trough levels of at least 3 IU/dL during prophylaxis, patients with haemophilia still develop joint disease. The pathophysiology of HA is complex, involving both inflammatory and degenerative components. Early diagnosis is key for proper management. Imaging can detect joint subclinical changes and influence prophylaxis. Magnetic resonance imagining (MRI) and ultrasound are the most frequently used methods in comprehensive haemophilia care centres. Biomarkers of joint health have been proposed to determine osteochondral joint deterioration, but none of these biomarkers has been validated or used in clinical practice. Early prophylaxis is key in all severe haemophilia patients to prevent arthropathy. Treatment is essentially based on prophylaxis intensification and chronic joint pain management. However, there remain significant gaps in the knowledge of the mechanisms responsible for HA and prognosis-influencing factors. Better understanding in this area could produce more effective interventions likely to ultimately prevent or attenuate the development of HA.
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Affiliation(s)
- Alexandre Leuci
- UR4609 Hemostasis & Thrombosis Research Unit, Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69008 Lyon, France;
| | - Yesim Dargaud
- UR4609 Hemostasis & Thrombosis Research Unit, Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 69008 Lyon, France;
- Unité d’Hémostase Clinique—Centre de Référence de l’Hémophilie, Hôpital Louis Pradel Hospices Civils de Lyon, 69002 Lyon, France
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Goedhart TMHJ, Janssen A, Mathôt RAA, Cnossen MH. The road to implementation of pharmacokinetic-guided dosing of factor replacement therapy in hemophilia and allied bleeding disorders. Identifying knowledge gaps by mapping barriers and facilitators. Blood Rev 2023; 61:101098. [PMID: 37321952 DOI: 10.1016/j.blre.2023.101098] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 04/02/2023] [Accepted: 05/07/2023] [Indexed: 06/17/2023]
Abstract
Clinical guidelines and expert groups recommend the use of pharmacokinetic (PK)-guided dosing of factor replacement therapy for the treatment of bleeding disorders, especially for patients with hemophilia. Although PK-guided dosing is increasingly applied, it is generally not considered standard clinical practice. The aim of this scoping review is to map barriers and facilitators for the implementation of PK-guided dosing in clinical practice and to identify knowledge gaps. A literature search was performed and 110 articles were included that describe PK-guided dosing in patients with bleeding disorders, mostly hemophilia A. We defined two overarching themes, efficacy and feasibility, and discuss five topics within each theme. For each topic, barriers, facilitators and knowledge gaps were described. Although consensus was found with regard to some topics, contradicting reports were found for others, especially with respect to the efficacy of PK-guided dosing. These contradictions highlight the need for future research to elucidate current ambiguities.
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Affiliation(s)
- Tine M H J Goedhart
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - A Janssen
- Department of Clinical Pharmacology - Hospital Pharmacy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Ron A A Mathôt
- Department of Clinical Pharmacology - Hospital Pharmacy, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands.
| | - Marjon H Cnossen
- Department of Pediatric Hematology and Oncology, Erasmus MC Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Verhagen MJ, van Heerde WL, van der Bom JG, Beckers EA, Blijlevens NM, Coppens M, Gouw SC, Jansen JH, Leebeek FW, van Vulpen LF, Meijer D, Schols SE. In patients with hemophilia, a decreased thrombin generation profile is associated with a severe bleeding phenotype. Res Pract Thromb Haemost 2023; 7:100062. [PMID: 36865907 PMCID: PMC9971314 DOI: 10.1016/j.rpth.2023.100062] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 12/20/2022] [Accepted: 01/02/2023] [Indexed: 02/04/2023] Open
Abstract
Background Heterogeneity in clinical bleeding phenotype has been observed in hemophilia patients with similar FVIII or FIX activity levels. Thrombin generation and plasmin generation, as a global hemostasis assay, may contribute to a better prediction of which patients are at an increased risk of bleeding. Objectives The objective of this study was to describe the association between clinical bleeding phenotype and thrombin generation and plasmin generation profiles in patients with hemophilia. Methods The Nijmegen Hemostasis Assay, which simultaneously measures thrombin and plasmin generation, was performed in plasma samples of patients with hemophilia participating in the sixth Hemophilia in the Netherlands study (HiN6). Patients receiving prophylaxis underwent a washout period. A severe clinical bleeding phenotype was defined as a self-reported annual bleeding rate of ≥5, a self-reported annual joint bleeding rate of ≥3, or the use of secondary/tertiary prophylaxis. Results In total, 446 patients, with a median age of 44 years, were included in this substudy. Thrombin generation and plasmin generation parameters differed between patients with hemophilia and healthy individuals. The median thrombin peak height was 1.0 nM, 25.9 nM, 47.1 nM, and 143.9 nM in patients with severe, moderate, and mild hemophilia and healthy individuals, respectively. A severe bleeding phenotype was observed in patients with a thrombin peak height of <49% and a thrombin potential of <72% compared to healthy individuals, and was independent of the hemophilia severity. The median thrombin peak height was 0.70% in patients with a severe clinical bleeding phenotype and 30.3% in patients with a mild clinical bleeding phenotype. The median thrombin potentials for these patients were 0.06% and 59.3%, respectively. Conclusion A decreased thrombin generation profile is associated with a severe clinical bleeding phenotype in patients with hemophilia. Thrombin generation in combination with bleeding severity may be a better tool to personalize prophylactic replacement therapy irrespective of hemophilia severity.
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Affiliation(s)
- Marieke J.A. Verhagen
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands,Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands,Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Waander L. van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands,Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands,Enzyre BV, Novio Tech Campus, Nijmegen, The Netherlands
| | - Johanna G. van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik A.M. Beckers
- Department of Hematology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Michiel Coppens
- Department of Vascular Medicine and Haemophilia Treatment Center, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Samantha C. Gouw
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands,Pediatric Hematology, Emma Children’s Hospital, Amsterdam University Medical Center, University of Amsterdam, The Netherlands
| | - Joop H. Jansen
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank W.G. Leebeek
- Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Lize F.D. van Vulpen
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Daniëlle Meijer
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Saskia E.M. Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands,Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands,Correspondence Saskia E. M. Schols, Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands. @radboudumc_weet
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8
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Persson S, Berndt C, Engstrand S, Trinczek A, Carlsson KS, Berntorp E. Area under the curve: Comparing the value of factor VIII replacement therapies in haemophilia A. Haemophilia 2023; 29:145-155. [PMID: 36445343 PMCID: PMC10098947 DOI: 10.1111/hae.14691] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION In factor VIII (FVIII) prophylaxis for haemophilia A, cost comparisons have used price per international unit (IU) based on the once reasonable assumption of equivalent outcome per IU. Now, with several extended half-life (EHL) products available, new outcome-oriented ways to compare products are needed. Area under the curve (AUC) quantifies FVIII levels over time after infusion providing comparable data. AIM To develop a decision analytical model for making indirect comparisons of FVIII replacement products based on AUC. METHODS A literature search identified 11 crossover studies with relevant pharmacokinetic data. A common comparator FVIII level curve was calculated using pooled data from selected studies. Absolute curves for other products were estimated based on relative differences to the common comparator (% difference vs the anchor). Three scenarios were investigated: (1) Kogenate® versus Kovaltry® and Jivi® ; (2) Advate® versus Elocta® , NovoEight® , Kovaltry, Adynovate® , Afstyla® , and ReFacto® ; and (3) Jivi versus Elocta, Adynovate, and Kogenate. Sensitivity analyses investigated effects of assay type and dose. RESULTS In scenario 1, Jivi (+50%) and Kovaltry (+14%) showed larger AUCs versus Kogenate. In scenario 2, EHL products, Elocta and Adynovate, had the largest AUC (+64% and +58%, respectively) versus Advate. Compared with all other products in scenario 3, Jivi had the largest AUC by +13%-28%. CONCLUSION This analysis concludes that EHL products differ in relative AUC, have a larger AUC compared with standard half-life, and thus, different FVIII levels over time after infusion. This model may aid decision makers in the absence of head-to-head data.
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Affiliation(s)
- Sofie Persson
- Swedish Institute for Health Economics, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Malmö, Sweden
| | | | | | | | - Katarina Steen Carlsson
- Swedish Institute for Health Economics, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Malmö, Sweden
| | - Erik Berntorp
- Department of Translational Medicine, Lund University, Lund, Malmö, Sweden
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9
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Valke LLFG, Rijpma S, Meijer D, Schols SEM, van Heerde WL. Thrombin generation assays to personalize treatment in bleeding and thrombotic diseases. Front Cardiovasc Med 2022; 9:1033416. [PMID: 36440026 PMCID: PMC9684194 DOI: 10.3389/fcvm.2022.1033416] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/26/2022] [Indexed: 07/30/2023] Open
Abstract
Treatment of bleeding and thrombotic disorders is highly standardized and based on evidence-based medicine guidelines. These evidence-based treatment schemes are well accepted but may lead to either insufficient treatment or over-dosing, because the individuals' hemostatic properties are not taken into account. This can potentially introduce bleeding or thrombotic complications in individual patients. With the incorporation of pharmacokinetic (PK) and pharmacodynamic (PK-PD) parameters, based on global assays such as thrombin generation assays (TGAs), a more personalized approach can be applied to treat either bleeding or thrombotic disorders. In this review, we will discuss the recent literature about the technical aspects of TGAs and the relation to diagnosis and management of bleeding and thrombotic disorders. In patients with bleeding disorders, such as hemophilia A or factor VII deficiency, TGAs can be used to identify patients with a more severe bleeding phenotype and also in the management with non-replacement therapy and/or bypassing therapy. These assays have also a role in patients with venous thrombo-embolism, but the usage of TGAs in patients with arterial thrombosis is less clear. However, there is a potential role for TGAs in the monitoring of (long-term) antithrombotic therapy, for example with the use of direct oral anticoagulants. Finally this review will discuss controversies, limitations and knowledge gaps in relation to the introduction of TGAs to personalize medicine in daily medical practice.
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Affiliation(s)
- Lars L. F. G. Valke
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
| | - Sanna Rijpma
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Danielle Meijer
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia E. M. Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
| | - Waander L. van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
- Enzyre BV, Novio Tech Campus, Nijmegen, Netherlands
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10
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Verhagen MJA, Valke LLFG, Schols SEM. Thrombin generation for monitoring hemostatic therapy in hemophilia A: A narrative review. J Thromb Haemost 2022; 20:794-805. [PMID: 35034413 PMCID: PMC9305107 DOI: 10.1111/jth.15640] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/17/2021] [Accepted: 01/10/2022] [Indexed: 11/29/2022]
Abstract
Patients with severe hemophilia A (HA) have an increased risk of spontaneous and trauma-related bleeding because of a congenital absence of factor VIII (FVIII). Most severe HA patients use prophylactic FVIII concentrate, the effect of which can be monitored with FVIII activity level measurement. However, FVIII activity level is less valuable in predicting the potential clinical bleeding risk. Some patients still experience breakthrough bleeds despite adequate FVIII trough levels, whereas others do not bleed with trough levels below threshold. This difference may be caused by inter-individual differences in pro- and anticoagulant factors, the so-called hemostatic balance. Thrombin generation assays (TGAs) measure the hemostatic balance as a whole. Thereby, the TGAs may be a better tool in the guidance and monitoring of treatment in HA patients. In addition, TGAs offer the opportunity to determine the response to bypassing agents and treatment with non-factor replacement therapy, in which FVIII activity assays are not suitable for monitoring. This review summarizes the current knowledge about monitoring different HA treatment modalities by TGA, as a single treatment option and when used in a concomitant fashion.
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Affiliation(s)
- Marieke J. A. Verhagen
- Department of HematologyRadboud University Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐MaastrichtNijmegenThe Netherlands
| | - Lars L. F. G. Valke
- Department of HematologyRadboud University Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐MaastrichtNijmegenThe Netherlands
| | - Saskia E. M. Schols
- Department of HematologyRadboud University Medical CenterNijmegenThe Netherlands
- Hemophilia Treatment CenterNijmegen‐Eindhoven‐MaastrichtNijmegenThe Netherlands
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11
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Cortesi PA, Rocino A, Preti D, Fragomeno A, Cucuzza F, Ceresi N, Santoro C, Ferretti A, Fornari A, Antonazzo IC, Facchetti R, Cozzolino P, Biasoli C, Cassone C, Coppola A, Mantovani LG. Haemophilia management and treatment: An Italian survey on patients’, caregivers’ and clinicians’ point of view. Haemophilia 2022; 28:254-263. [DOI: 10.1111/hae.14504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 01/13/2022] [Accepted: 01/24/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Paolo Angelo Cortesi
- Research Centre on Public Health (CESP) University of Milano‐Bicocca Monza Italy
- IRCCS Multimedica Sesto San Giovanni Italy
| | - Angiola Rocino
- UOC di Ematologia ‐ Centro Emofilia e Trombosi Ospedale del Mare ‐ ASL NA1 Napoli Italy
| | - Daniele Preti
- Italian Federation of Haemophilia Associations (FedEmo) Rome Italy
| | - Anna Fragomeno
- Italian Federation of Haemophilia Associations (FedEmo) Rome Italy
| | | | - Nicola Ceresi
- Italian Federation of Haemophilia Associations (FedEmo) Rome Italy
| | | | | | - Arianna Fornari
- Research Centre on Public Health (CESP) University of Milano‐Bicocca Monza Italy
| | | | - Rita Facchetti
- Research Centre on Public Health (CESP) University of Milano‐Bicocca Monza Italy
| | | | - Chiara Biasoli
- Hemophilia Center and Transfusion Department Hospital of Cesena Cesena Italy
| | - Cristina Cassone
- Italian Federation of Haemophilia Associations (FedEmo) Rome Italy
| | - Antonio Coppola
- Regional Reference Center for Inherited Bleeding Disorders University Hospital of Parma Parma Italy
| | - Lorenzo G. Mantovani
- Research Centre on Public Health (CESP) University of Milano‐Bicocca Monza Italy
- IRCCS Multimedica Sesto San Giovanni Italy
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12
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Bukkems LH, Valke LLFG, Barteling W, Laros-van Gorkom BAP, Blijlevens NMA, Cnossen MH, van Heerde WL, Schols SEM, Mathôt RAA. Combining factor VIII levels and thrombin/plasmin generation: a population pharmacokinetic-pharmacodynamic model for patients with hemophilia A. Br J Clin Pharmacol 2021; 88:2757-2768. [PMID: 34921439 PMCID: PMC9304184 DOI: 10.1111/bcp.15185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/07/2021] [Accepted: 12/05/2021] [Indexed: 11/28/2022] Open
Abstract
Aims Prophylactic treatment of haemophilia A patients with factor VIII (FVIII) concentrate focuses on maintaining a minimal trough FVIII activity level to prevent bleeding. However, due to differences in bleeding tendency, the pharmacokinetic (PK)‐guided dosing approach may be suboptimal. An alternative approach could be the addition of haemostatic pharmacodynamic (PD) parameters, reflecting a patient's unique haemostatic balance. Our aim was to develop a population PK/PD model, based on FVIII activity levels and Nijmegen Haemostasis Assay (NHA) patterns, a global haemostatic assay that measures thrombin/plasmin generation simultaneously. Methods PK/PD measurements were collected from 30 patients treated with standard half‐life FVIII concentrate. The relationship between FVIII activity levels and the thrombin/plasmin generation parameters (thrombin potential, thrombin peak height and plasmin peak height), were described by sigmoidal Emax functions. Results The obtained EC50 value was smallest for the normalized thrombin potential (11.6 IU/dL), followed by normalized thrombin peak height (56.6 IU/dL) and normalized plasmin peak height (593 IU/dL), demonstrating that normalized thrombin potential showed 50% of the maximal effect at lower FVIII activity levels. Substantial inter‐individual variability in the PD parameters, such as EC50 of thrombin potential (86.9%) was observed, indicating that, despite similar FVIII activity levels, haemostatic capacity varies significantly between patients. Conclusion These data suggest that dosing based on patients' individual PK/PD parameters may be beneficial over dosing solely on individual PK parameters. This model could be used as proof‐of‐principle to examine the application of PK/PD‐guided dosing. However, the relation between the PD parameters and bleeding has to be better defined.
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Affiliation(s)
- Laura H Bukkems
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Lars L F G Valke
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Hemophilia Treatment Centre, Nijmegen Eindhoven Maastricht, The Netherlands
| | - Wideke Barteling
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Britta A P Laros-van Gorkom
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Hemophilia Treatment Centre, Nijmegen Eindhoven Maastricht, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Waander L van Heerde
- Hemophilia Treatment Centre, Nijmegen Eindhoven Maastricht, The Netherlands.,Enzyre BV, Novio Tech Campus, Nijmegen, The Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands.,Hemophilia Treatment Centre, Nijmegen Eindhoven Maastricht, The Netherlands
| | - Ron A A Mathôt
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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13
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Cortesi PA, Giampaolo A, Abbonizio F, Molinari AC, Castaman G, Biffoni M, Mantovani LG. Variability of treatment modalities and intensity in patients with severe haemophilia A on prophylaxis: Results from the Italian national registry. Eur J Haematol 2021; 107:408-415. [PMID: 34110639 DOI: 10.1111/ejh.13676] [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: 04/08/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND A shift from a standard to a personalized prophylaxis has been increasingly adopted in patients with severe haemophilia A (SHA). This approach has raised the likelihood of a significant variability in the prophylactic approaches and the relative Factor VIII (FVIII) consumptions. The aim of our study was to assess the treatment variability of SHA patients without inhibitors and on prophylaxis regimen in Italy. MATERIAL AND METHODS Data reported in the National Registry of Congenital Coagulopathies (NRCC) were analysed to assess treatment distribution within SHA patients without inhibitors, focussing on FVIII consumption in 2017, associated with prophylaxis regimen. The analysis was stratified based on age groups and Italian regions to describe the variability of FVIII consumption in Italy. RESULTS In 2017, the Registry reported the therapeutic plans of 1068 SHA patients without inhibitors on prophylaxis. The mean (95% CI) individual consumption ranges from 123 127 IU (99 736-146 518) in the age group 0-6 years to 345 000 IU (336 000-354 000) in the age group >20 years. A significant FVIII consumption variability was identified within the adult population. Regions with less than 50 patients reported the higher variability in mean FVIII consumption per patient-year within the different age groups. Similar difference in FVIII consumption variability was reported also in the age groups comparing "low," "middle" and "high" patient volume regions. DISCUSSION A reliable estimation of FVIII consumption for patients' treatment is necessary to manage and plan the appropriate budget and keep treatment's costs affordable. However, without the implementation of a methodology aiming to assess the overall value produced by these FVIII consumptions, the scenario will keep driven by FVIII consumptions, its costs and the budget available. An effort by haemophilic community, haemophilia treatment centres and institutions is required to develop and share this cultural shift in improving haemophilia management and assessment.
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Affiliation(s)
- Paolo Angelo Cortesi
- Value-Based Healthcare Unit, IRCCS MultiMedica, Sesto San Giovanni, Italy.,Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | - Adele Giampaolo
- Department of Oncology and Molecular Medicine, Italian National Institute of Health, Rome, Italy
| | - Francesca Abbonizio
- Department of Oncology and Molecular Medicine, Italian National Institute of Health, Rome, Italy
| | - Angelo Claudio Molinari
- Regional Reference Center for Hemorrhagic Diseases, Giannina Gaslini Institute, Genova, Italy
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Mauro Biffoni
- Department of Oncology and Molecular Medicine, Italian National Institute of Health, Rome, Italy
| | - Lorenzo Giovanni Mantovani
- Value-Based Healthcare Unit, IRCCS MultiMedica, Sesto San Giovanni, Italy.,Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
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14
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Crépin R, Morin C, Montmartin A, Tardy-Poncet B, Chelle P. Use of population PK/PD approach to model the thrombin generation assay: assessment in haemophilia A plasma samples spiked by a TFPI antibody. J Pharmacokinet Pharmacodyn 2021; 48:563-580. [PMID: 33846873 DOI: 10.1007/s10928-021-09752-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 03/22/2021] [Indexed: 11/28/2022]
Abstract
The thrombin generation (TG) assay is a well-established tool to capture the clotting potential of any healthy or haemophiliac subject. It measures ex vivo the kinetics of thrombin activation throughout the coagulation. Clinical studies allowed to create two databases gathering the coagulation factor levels and the thrombin generation profile of 40 healthy and 40 haemophiliac A (HA) subjects. Besides, portions of all HA samples were spiked with increasing levels of a TFPI antibody (considered as a possible therapeutic target) and corresponding TG profiles were determined. The non-linear mixed-effect (NLME) modelling aims at describing and explaining the experimentally observed important variability of the TG curves between subjects and the individual effects of spiking with a TFPI antibody. The models consist of an empirical description of the TG kinetics, accounting for an additive residual error and between-subject variability on its parameters. Factor VIII and TFPI were found to significantly explain and reduce the variability of the TG of haemophilia A samples. Besides, the model is shown to correctly reproduce the variability in the response to the ex vivo spiking with the TFPI antibody, by combining the empirical description of TG to a simple Hill equation that accounts for the binding between TFPI and different doses of its antibody. Such models can be useful for clinical practice, with the analysis and comparison of the distributions of TG profiles in healthy and haemophilia populations; and also for research, with the analysis of the effect of TFPI and its neutralization on individual TG profiles.
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Affiliation(s)
- Raphaël Crépin
- Mines Saint-Etienne, Univ Lyon, Univ Jean Monnet, INSERM, U1059 Sainbiose, Centre CIS, 42023, Saint-Étienne, France
| | - Claire Morin
- Mines Saint-Etienne, Univ Lyon, Univ Jean Monnet, INSERM, U1059 Sainbiose, Centre CIS, 42023, Saint-Étienne, France.
| | - Aurélie Montmartin
- INSERM, U1059, SAINBIOSE, Université de Lyon, UJM Saint Etienne, Saint-Étienne, France
| | - Brigitte Tardy-Poncet
- INSERM, U1059, SAINBIOSE, Université de Lyon, UJM Saint Etienne, Saint-Étienne, France
| | - Pierre Chelle
- School of Pharmacy, University of Waterloo, Kitchener, ON, Canada
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15
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Valke LL, Bukkems LH, Barteling W, Laros‐van Gorkom BA, Blijlevens NM, Mathôt RA, van Heerde WL, Schols SE. Pharmacodynamic monitoring of factor VIII replacement therapy in hemophilia A: Combining thrombin and plasmin generation. J Thromb Haemost 2020; 18:3222-3231. [PMID: 32979031 PMCID: PMC7756259 DOI: 10.1111/jth.15106] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/09/2020] [Accepted: 09/14/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Clinical severity of hemophilia A (HA) varies, possibly due to interplay of many factors in the hemostatic pathway. Pharmacokinetic monitoring of factor VIII (FVIII) replacement therapy in HA patients consists of measuring FVIII activity levels and subsequent dose adjustment. The Nijmegen Hemostasis Assay (NHA) measures thrombin generation (TG) and plasmin generation (PG). OBJECTIVE To determine differences in TG and PG between HA patients before and during a pharmacokinetic study and identify best parameters to develop a pharmacodynamic model. METHODS Twenty-five HA patients (baseline FVIII < 1-9 IU/dL) underwent a pharmacokinetic study with a single dose of 25-50 IU/kg standard half-life FVIII concentrate. At baseline and after administration of FVIII TG and PG parameters were measured with the NHA. RESULTS FVIII activity level increased from median 1.0 IU/dL (interquartile range < 1.0-6.0) to 71 IU/dL (62-82) 15 minutes after administration and decreased to 15 IU/dL (10-26) at 24 hours. TG was enhanced simultaneously, with thrombin peak height (TPH) increasing from 22nM (15-35) to 222nM (159-255), and thrombin potential (TP) from 404nM/min (undetectable-876) to 1834nM/min (1546-2353). Twenty-four hours after infusion, TG parameters remained high (TPH 73nM [58.5-126.3]; TP 1394nM/min [1066-1677]) compared to FVIII activity level. PG showed hyperfibrinolysis in severe HA patients compared to mild patients and controls, which normalized after FVIII supplementation. CONCLUSION HA patients showed clear differences in baseline TG and PG despite having comparable FVIII activity levels. These results reveal a discrepancy between FVIII activity level and TG, in which the latter may be a better parameter to monitor individualized treatment in HA patients.
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Affiliation(s)
- Lars L.F.G. Valke
- Department of HematologyRadboud University Medical CentreNijmegenthe Netherlands
- Hemophilia Treatment CentreNijmegen Eindhoven Maastrichtthe Netherlands
| | - Laura H. Bukkems
- Department of Hospital Pharmacy‐Clinical PharmacologyAmsterdam University Medical CentersAmsterdamthe Netherlands
| | - Wideke Barteling
- Department of Laboratory MedicineLaboratory of HematologyRadboud University Medical CentreNijmegenthe Netherlands
| | - Britta A.P. Laros‐van Gorkom
- Department of HematologyRadboud University Medical CentreNijmegenthe Netherlands
- Hemophilia Treatment CentreNijmegen Eindhoven Maastrichtthe Netherlands
| | | | - Ron A.A. Mathôt
- Department of Hospital Pharmacy‐Clinical PharmacologyAmsterdam University Medical CentersAmsterdamthe Netherlands
| | - Waander L. van Heerde
- Hemophilia Treatment CentreNijmegen Eindhoven Maastrichtthe Netherlands
- Enzyre BVNovio Tech CampusNijmegenthe Netherlands
| | - Saskia E.M. Schols
- Department of HematologyRadboud University Medical CentreNijmegenthe Netherlands
- Hemophilia Treatment CentreNijmegen Eindhoven Maastrichtthe Netherlands
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16
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Assessing the Performance of Extended Half-Life Coagulation Factor VIII, FC Fusion Protein by Using Chromogenic and One-Stage Assays in Saudi Hemophilia A Patients. Adv Hematol 2020; 2020:8768074. [PMID: 32963537 PMCID: PMC7499282 DOI: 10.1155/2020/8768074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/25/2020] [Accepted: 07/15/2020] [Indexed: 11/19/2022] Open
Abstract
Background The one-stage assay is the most common method to measure factor VIII activity (FVIII : C) in hemophilia A patients. The chromogenic assay is another two-stage test involving purified coagulation factors followed by factor Xa-specific chromogenic substrate. Aim This study aimed to assess the discrepancy and correlation between the chromogenic and one-stage assays in measuring FVIII : C levels in hemophilia patients receiving Extended Half-Life Elocta® as a recombinant extended half-life coagulation factor. Methods We performed a study comparing the measurements of FVIII : C levels by the chromogenic versus the one-stage assays at different drug levels. Data of FVIII : C levels, dosage, and the time interval from administration to measurement were retrieved from the hospital records. The correlation, mean differences, and discrepancy between the two assays were calculated. The linear regression analysis was used to predict the time interval till reaching 1% FVIII : C. Results Fourteen patients with 56 samples were included in the study. Of them, 13 patients were receiving Elocta® as a prophylactic, while one was receiving Elocta® on demand. One-third of these samples showed a discrepancy between the chromogenic and one-stage assays. The two assays were well correlated. Mean differences were significant at the individual and the time interval level. The time since the last Elocta® injection could significantly predict FVIII : C levels (β = 0.366, P < 0.001). Conclusion Our findings suggested a significant difference between both methods; the FVIII : C levels measured by the one-stage assay were less than those estimated by the chromogenic assay. However, the measurements of FVIII levels by the two assays were well correlated but discrepant in one-third of the samples. The levels of FVIII : C reach 1% after 5.4 days since the last Elocta® administration.
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17
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Parunov LA, Surov SS, Chattopadhyay M, Liang Y, Lee TK, Ovanesov MV. Thrombin generation assay modifications needed for its application to monitoring of replacement therapy for haemophilia. Haemophilia 2020; 27:e129-e132. [PMID: 32897618 DOI: 10.1111/hae.14024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/27/2020] [Accepted: 04/15/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Leonid A Parunov
- Center for Biologics Evaluation and Research (CBER), U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Stepan S Surov
- Center for Biologics Evaluation and Research (CBER), U.S. Food and Drug Administration, Silver Spring, Maryland, USA.,Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences, Moscow, Russia
| | - Maitreyi Chattopadhyay
- Center for Biologics Evaluation and Research (CBER), U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Yideng Liang
- Center for Biologics Evaluation and Research (CBER), U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Timothy K Lee
- Center for Biologics Evaluation and Research (CBER), U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Mikhail V Ovanesov
- Center for Biologics Evaluation and Research (CBER), U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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18
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Delavenne X, Ollier E, Lienhart A, Dargaud Y. A new paradigm for personalized prophylaxis for patients with severe haemophilia A. Haemophilia 2020; 26:228-235. [PMID: 32100950 PMCID: PMC7154752 DOI: 10.1111/hae.13935] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/12/2019] [Accepted: 01/17/2020] [Indexed: 02/04/2023]
Abstract
AIM For patients with severe haemophilia A, guidelines recommend prophylactic treatment with FVIII, with dose calculations targeting a predetermined FVIII trough level. However, this pharmacokinetic (PK) approach is suboptimal, with some patients experiencing breakthrough bleeds. We aimed to improve FVIII dosing by incorporating the thrombin generation assay, a global haemostasis assay whose main pharmacodynamic (PD) parameter, endogenous thrombin potential (ETP), predicts spontaneous bleeding risk. METHODS We performed post hoc combined PK-PD modelling using data from 66 adults who received human-cl rhFVIII (Nuwiq® , Octapharma AG) in a phase IIIb study. Time-to-event analyses simulated the probability of spontaneous bleeding for different FVIII exposures and baseline ETPs. RESULTS Ninety-one spontaneous bleeds occurred in 20/66 patients. The relationship between FVIII:C and ETP was non-linear, and the sigmoid Emax model adequately described the data. Individual PK-PD Bayesian estimation significantly improved predictive performance. Simulations showed that the mean spontaneous annual bleeding rate decreased with increasing baseline ETP or dosing: with ETP values of 200, 400 and 600 (nmol/L)·min annual bleeding rates were 2.36, 1.25 and 0.66, respectively, on 40 IU/kg human-cl rhFVIII every 3 days; and annual bleeding rates were 2.09, 1.10, and 0.60, respectively, on 60 IU/kg every 3 days. CONCLUSION Prophylactic FVIII dosing is more clinically meaningful when incorporating ETP alongside FVIII level. For the first time, FVIII dosing can be personalized with the aim of eliminating spontaneous breakthrough bleeds.
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Affiliation(s)
- Xavier Delavenne
- Institut national de la santé et de la recherche médicale (Inserm), UMR 1059, Dysfonction Vasculaire et de l'Hémostase, Université de Lyon, Saint Etienne, France
| | - Edouard Ollier
- Institut national de la santé et de la recherche médicale (Inserm), UMR 1059, Dysfonction Vasculaire et de l'Hémostase, Université de Lyon, Saint Etienne, France
| | - Anne Lienhart
- Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, Université Lyon 1, Lyon, France
| | - Yesim Dargaud
- Unité d'Hémostase Clinique, Hôpital Cardiologique Louis Pradel, Université Lyon 1, Lyon, France
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