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Chowdary P, Carcao M, Kenet G, Pipe SW. Haemophilia. Lancet 2025; 405:736-750. [PMID: 40023652 DOI: 10.1016/s0140-6736(24)02139-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 08/27/2024] [Accepted: 09/26/2024] [Indexed: 03/04/2025]
Abstract
Haemophilia A and B are congenital X-linked bleeding disorders resulting from deficiencies in clotting factors VIII (haemophilia A) and IX (haemophilia B). Patients with severe deficiency, defined as having less than 1% of normal plasma factor activivity, often have spontaneous bleeding within the first few years of life. Those with moderate and mild deficiencies typically present with post-traumatic or post-surgical bleeding later in life. A high index of suspicion and measurement of factor activity in plasma facilitates early diagnosis. In the 21st century, therapeutic advances and comprehensive care have substantially improved both mortality and morbidity associated with these conditions. Management strategies for haemophilia include on-demand treatment for bleeding episodes and all surgeries and regular treatment (ie, prophylaxis) aimed at reducing bleeds, morbidity, and mortality, thereby enhancing quality of life. Treatment options include factor replacement therapy, non-replacement therapies that increase thrombin generation, and gene therapies that facilitate in vivo clotting factor synthesis. The therapies differ in their use for prophylaxis and on-demand treatment, the mode and frequency of administration, duration of treatment effect, degree of haemostatic protection, and side-effects. Monitoring the effectiveness of these prophylactic therapies involves assessing annual bleeding rates and joint damage. Personalised management strategies, which align treatment with individual goals (eg, playing competitive sports), initiated at diagnosis and maintained throughout the lifespan, are crucial for optimal outcomes. These strategies are facilitated by a multidisciplinary team and supported by clinician-led education for both clinicians and patients.
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Affiliation(s)
- Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK; Department of Haematology, Cancer Institute, University College London, London, UK.
| | - Manuel Carcao
- Department of Paediatrics, Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Gili Kenet
- National Haemophilia Center and The Amalia Biron Institute of Thrombosis & Hemostasis Research, Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel
| | - Steven W Pipe
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA; Department of Pathology, University of Michigan, Ann Arbor, MI, USA
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2
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Pfrepper C, Siecke A, Klamroth R, Kühnöl C, Kentouche K, Holzhauer S, Fischer L, Aumann V, Trautmann-Grill K, Scholz U, Halm-Heinrich I, Krammer-Steiner B, Schilling K, Knöfler R, Hagedorn N. Changes in Hemophilia Treatment in the Eastern Part of Germany between 2015 and 2021-Data from the Kompetenznetz Hämorrhagische Diathese Ost (KHDO). Hamostaseologie 2025. [PMID: 39965757 DOI: 10.1055/a-2499-2912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2025] Open
Abstract
INTRODUCTION Treatment options for patients with hemophilia (PWH) have changed substantially in the last years. This study aimed to compare hemophilia treatment in the eastern part of Germany in 2021 with data from 2015. METHODS Substitution diaries and patient records of PWH from 2021 were collected in 13 hemophilia centers from the "Kompetenznetz Hämorrhagische Diathese Ost" (KHDO) and compared with 2015. RESULTS A total of 130 children and 357 adults, 411 hemophilia A (HA) and 76 hemophilia B (HB), were included in 2021, and 359 were already analyzed in 2015. In 2021, 97.8% of children and 95.7% of adults with severe hemophilia had prophylaxis compared with 98.8 and 80.2% in 2015. Plasma-derived concentrates were used in 25.6%, recombinant in 30.2%, extended half-life (EHL) factor concentrates in 24.4%, and emicizumab in 19.8% of the children with severe HA (sHA). In adults with sHA, plasma-derived, recombinant concentrates, EHL, and emicizumab were used in 21.0, 33.2, 31.2, and 14.2%, respectively. All children and 93.3% of the adults with severe HB (sHB) were on EHL. Median annual factor consumption per body weight increased in adults with sHA, remained stable in children with sHA and adults with sHB, and decreased in children with sHB between 2015 and 2021. Annualized bleeding rate (ABR) decreased in children with sHB and sHA. CONCLUSION The use of EHL and emicizumab has changed hemophilia treatment. About 50% of the sHA patients switched to EHL or emicizumab and almost all sHB patients to EHL. More adults with sHA received prophylaxis and ABR decreased in children.
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Affiliation(s)
- Christian Pfrepper
- Division of Hemostaseology, University of Leipzig Medical Center, Leipzig, Germany
| | - Annika Siecke
- Division of Hemostaseology, University of Leipzig Medical Center, Leipzig, Germany
| | - Robert Klamroth
- Department of Internal Medicine, Vascular Medicine and Coagulation Disorders, Vivantes Clinic Friedrichshain, Berlin, Germany
| | - Caspar Kühnöl
- Department of Pediatrics, University Hospital Halle, Halle (Saale), Germany
| | - Karim Kentouche
- Department of Pediatrics, University Hospital Jena, Jena, Germany
| | - Susanne Holzhauer
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
| | - Lars Fischer
- Department of Pediatrics, University Hospital Leipzig, Leipzig, Germany
| | - Volker Aumann
- Department of Pediatrics, University Hospital Magdeburg, Magdeburg, Germany
| | - Karolin Trautmann-Grill
- Medical Clinic I, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ute Scholz
- Centre of Coagulation Disorders, Leipzig, Germany
| | - Ines Halm-Heinrich
- Department of Transfusion Medicine, University Hospital Magdeburg, Magdeburg, Germany
| | - Beate Krammer-Steiner
- Department of Hematology and Oncology, Rostock South City Medical Centre, Rostock, Germany
| | - Kristina Schilling
- Department of Hematology and Oncology, University Hospital Jena, Jena, Germany
| | - Ralf Knöfler
- Department of Pediatric Hematology and Oncology, University Hospital Dresden, Technische Universität Dresden, Dresden, Germany
| | - Nikola Hagedorn
- Department of Pediatric Hematology and Oncology, Charité University Medicine, Berlin, Germany
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Brands MR, Taal EM, Voshaar MO, Driessens MH, van Veen CM, Kruip MJ, den Exter PL, Laros-van Gorkom BA, Stein-Wit MA, Fischer K, Meijer S, Meijer K, Beijlevelt M, Fijnvandraat K, Gouw SC. Real-world bleeding rates on emicizumab: the value of using nationwide digital treatment diary data in clinical research. Res Pract Thromb Haemost 2025; 9:102717. [PMID: 40206324 PMCID: PMC11981740 DOI: 10.1016/j.rpth.2025.102717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2024] [Revised: 01/21/2025] [Accepted: 01/24/2025] [Indexed: 04/11/2025] Open
Abstract
Background People with hemophilia in the Netherlands log bleeds and infusions through a digital treatment diary. With the current innovations in hemophilia treatments, the use of patient-reported bleeding data will become increasingly important. Objective To assess real-world bleeding rates on emicizumab in a nationwide cohort of people with severe hemophilia A, and assess the value of digital treatment diary data. Methods People with severe hemophilia A of all ages with and without inhibitors using emicizumab who use the digital treatment diary were included. From 2018 to October 2023, data on bleeds treated with clotting factor concentrate were collected from digital treatment diaries and electronic health records. Mean (95% CI) annualized (joint) bleeding rates were calculated using negative-binomial regression analyses. Proportions of people with zero-treated (joint) bleeds were assessed using Kaplan-Meier survival analysis. We calculated the proportion of all bleeds that were recorded in digital treatment diaries. Results The 232 included persons (median age, 27 years; IQR, 13-51) who used emicizumab for a median of 27 months (IQR, 14-31 months). The mean treated annualized bleeding rate and annualized joint bleeding rate were 1.5 (CI, 1.3-1.8) and 0.8 (CI, 0.6-1.0), respectively. At 24 weeks, 63% had zero-treated bleeds, and 80% had zero-treated joint bleeds. Of treated bleeds, 67% (310/460) were reported in digital treatment diaries. Conclusion Bleeding rates among Dutch people with severe hemophilia A using emicizumab were comparable to other real-world studies. We formulated recommendations to improve the quality of patient-reported bleeding data, such as establishing guidelines for recording bleeds and improving interoperability.
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Affiliation(s)
- Martijn R. Brands
- Department of Pediatric Hematology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Elisabeth M. Taal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- HemoNED Foundation, Leiden, the Netherlands
| | - Martijn Oude Voshaar
- Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | | | - Marieke J.H.A. Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Paul L. den Exter
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Britta A.P. Laros-van Gorkom
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
- Hemophilia Treatment Center Nijmegen-Eindhoven-Maastricht, Nijmegen, the Netherlands
| | - Marjet A. Stein-Wit
- Department of Pediatrics, University Medical Center Groningen, Groningen, the Netherlands
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- PedNet Haemophilia Research Foundation, Baarn, the Netherlands
| | - Stephan Meijer
- Netherlands Hemophilia Patient Society (NVHP), Nijkerk, the Netherlands
| | - Karina Meijer
- Department of Hematology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Marlène Beijlevelt
- Department of Pediatric Hematology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Department of Molecular Cellular Hemostasis, Sanquin Research and Landsteiner Laboratory, Amsterdam, Netherlands, the Netherlands
| | - Samantha C. Gouw
- Department of Pediatric Hematology, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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4
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Castaman G, Croteau SE, Quon D, Lee L, Polito L, Jiménez-Yuste V. A literature review of major surgery experience with emicizumab in people with hemophilia A without factor VIII inhibitors. Res Pract Thromb Haemost 2025; 9:102693. [PMID: 40093965 PMCID: PMC11909758 DOI: 10.1016/j.rpth.2025.102693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2024] [Revised: 01/02/2025] [Accepted: 01/24/2025] [Indexed: 03/19/2025] Open
Abstract
People with hemophilia A have a total or partial deficiency of factor (F)VIII, causing spontaneous and/or traumatic bleeding into the joints, muscles, and soft tissues. Major surgery may be required to restore joint mobility or treat the symptoms of common comorbidities in people with hemophilia A. Additional factor replacement is recommended during the perioperative period; collated information on the experience of emicizumab-treated people with hemophilia A during major surgery is currently lacking. To provide a consolidated narrative summary of the experience with emicizumab in people with hemophilia A without FVIII inhibitors undergoing major surgery, a comprehensive literature search was performed using PubMed/MEDLINE (cut-off date: March 31, 2024); the abstract books for applicable congresses (2016-2024) were searched manually. Studies were included if reporting original data on people with hemophilia A of all ages and hemophilia A severities without FVIII inhibitors on emicizumab prophylaxis who had undergone major surgery. Outcomes collected included perioperative surgical management, adverse events, and bleeding events. Twenty publications were included; 72 procedures were reported. Twenty-two orthopedic and 34 other major procedures were specifically described. FVIII replacement was used to manage 66 procedures perioperatively, and 25 procedures were managed in conjunction with antifibrinolytics. Fifteen procedures resulted in a bleeding event, and one individual experienced a thrombotic event. No deaths were reported. This review provides a consolidated narrative of the currently reported experiences of emicizumab-treated people with hemophilia A without FVIII inhibitors undergoing major surgery, helping to support the future management decisions of emicizumab-treated people with hemophilia A during surgery.
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Affiliation(s)
- Giancarlo Castaman
- Department of Oncology, Centre for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Stacy E. Croteau
- Boston Children’s Hospital, Boston Hemophilia Center, Boston, Massachusetts, USA
| | - Doris Quon
- Orthopedic Hemophilia Treatment Center at Orthopedic Institute for Children Los Angeles, Los Angeles, California, USA
| | - Lucy Lee
- Genentech, Inc., South San Francisco, California, USA
| | | | - Víctor Jiménez-Yuste
- Hematology Department, Hospital Universitario La Paz-IdiPaz, Autónoma University, Madrid, Spain
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Raventós A, Arias-Salgado EG, Pérez A, Alvarez-Román MT, Butta NV, Monzon Manzano E, Acuña P, Jiménez-Yuste V, Costa M, Bravo MI. Ex vivo evaluation of the effect of plasma-derived factor VIII/von Willebrand factor in patients with severe hemophilia A on emicizumab prophylaxis. Clin Exp Med 2024; 25:14. [PMID: 39708197 DOI: 10.1007/s10238-024-01528-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Accepted: 11/22/2024] [Indexed: 12/23/2024]
Abstract
Hemophilia A (HA) patients under emicizumab prophylaxis may require the concomitant use of procoagulant factors for breakthrough bleedings or immune tolerance induction (ITI). The aim of this study is to evaluate the ex vivo procoagulant effect of plasma-derived FVIII concentrates containing von Willebrand factor (pdFVIII/VWF) in samples from patients with severe HA without inhibitors on emicizumab prophylaxis. Samples from healthy controls (HC) and HA patients were drawn in sodium citrate plus corn trypsin inhibitor tubes and spiked with increasing concentrations of pdFVIII/VWF concentrates (10-400 IU/dL) (Fanhdi®/Alphanate®, Grifols), activated prothrombin complex concentrate (aPCC, 0.5 U/mL) or recombinant activated factor VII (rFVIIa, 0.9 µg/mL). Global coagulation was measured by rotational thromboelastometry (ROTEM) (clotting time [CT] and time to maximum clot formation velocity [MAXV-t]) and thrombin generation (TG) assay (thrombin peak [TP] and endogenous thrombin potential [ETP]). Samples from HA patients under emicizumab prophylaxis showed CT and MAXV-t values above HC levels, while TP and ETP were below HC levels. Ex vivo pdFVIII/VWF supplementation increased TP and ETP and shortened CT and MAXV-t dose-dependently. At 50 IU/dL (≈25 IU/kg), pdFVIII/VWF normalized clot formation and restored TG within HC normal range. The highest pdFVIII/VWF concentration (400 IU/dL) and rFVIIa did not result in an excessive procoagulant profile. However, aPCC induced ex vivo an excessive TG and markedly decreased ROTEM parameters (CT and MAXV-t). Coagulation parameters of both methods significantly correlated at baseline and with increasing concentrations of pdFVIII/VWF. High doses of pdFVIII/VWF concentrates, similar to those used for ITI, did not trigger a multiplying procoagulant effect to samples from HA patients on emicizumab prophylaxis, evidencing their low thrombotic risk in these patients.
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Affiliation(s)
- Aida Raventós
- Discovery Research, Scientific Innovation Office, Grifols, Palou 3, 08150, Parets del Vallès, Barcelona, Spain.
| | | | - Alba Pérez
- Discovery Research, Scientific Innovation Office, Grifols, Palou 3, 08150, Parets del Vallès, Barcelona, Spain
| | - María Teresa Alvarez-Román
- Hematology and Hemotherapy Unit, La Paz University Hospital-IdiPAZ, Madrid, Spain
- Universidad Autónoma de Madrid, Madrid, Spain
| | - Nora V Butta
- Hematology and Hemotherapy Unit, La Paz University Hospital-IdiPAZ, Madrid, Spain
| | - Elena Monzon Manzano
- Hematology and Hemotherapy Unit, La Paz University Hospital-IdiPAZ, Madrid, Spain
| | - Paula Acuña
- Hematology and Hemotherapy Unit, La Paz University Hospital-IdiPAZ, Madrid, Spain
| | - Víctor Jiménez-Yuste
- Hematology and Hemotherapy Unit, La Paz University Hospital-IdiPAZ, Madrid, Spain
- Universidad Autónoma de Madrid, Madrid, Spain
| | - Montserrat Costa
- Discovery Research, Scientific Innovation Office, Grifols, Palou 3, 08150, Parets del Vallès, Barcelona, Spain
| | - María Isabel Bravo
- Discovery Research, Scientific Innovation Office, Grifols, Palou 3, 08150, Parets del Vallès, Barcelona, Spain
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6
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Vujkov S, Bajkin B, Blagojević D, Nešković I, Komšić J, Tadić A, Petrović B. Dental Considerations in Children with Inherited Bleeding Disorders and Inhibitors: A Systematic Review. J Clin Med 2024; 13:7743. [PMID: 39768665 PMCID: PMC11678072 DOI: 10.3390/jcm13247743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2024] [Revised: 12/16/2024] [Accepted: 12/17/2024] [Indexed: 01/11/2025] Open
Abstract
Background/Objectives: This systematic review evaluates the effectiveness of various hematological treatment protocols and local hemostatic measures in preventing oral bleeding and other complications during and after dental treatments in children with inherited bleeding disorders and inhibitors. Methods: This study was registered in the PROSPERO database. The comprehensive search strategy for this systematic review was conducted across five databases, namely, PubMed, Google Scholar, Web of Science, Scopus, and Cochrane Library. The search was aimed at identifying relevant literature published from January 2000 up to February 2024. Eligible studies included those with various designs, such as randomized controlled trials (RCTs), observational studies, cohort studies, case-control studies, and cross-sectional studies. Data extraction was carried out systematically, and relevant information on study characteristics, interventions, treatment protocols, local measures, complications, and outcomes was collected. Results: The systematic review included a total of five studies, encompassing participants ranging from ages of 2 to 18 years. These studies varied in their scope, with some focusing on hemophilia A with inhibitors while others addressed broader inherited bleeding disorders. The interventions examined included various prophylactic and treatment measures such as Emicizumab, recombinant factor VIIa, and local hemostatic measures. The study outcomes primarily assessed the efficacy of these interventions in preventing postoperative bleeding and improving quality of life. Emicizumab has significantly shifted the treatment paradigm for children with inherited bleeding disorders and inhibitors. This prophylactic treatment has been associated with a marked reduction in the frequency of bleeding episodes, fewer hospital admissions for bleeding management, and enhanced participation in daily activities. Conclusions: This review highlights gaps in the management of dental care in children with inherited bleeding disorders and inhibitors. It underscores the need for standardized protocols that integrate new prophylactic treatments such as Emicizumab. Our findings suggest that adopting updated protocols can significantly reduce bleeding complications during dental procedures.
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Affiliation(s)
| | | | | | | | | | - Ana Tadić
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; (S.V.); (B.B.); (D.B.); (I.N.); (J.K.); (B.P.)
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7
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Hassan T, Zakaria M, Fathy M, Farag A, Abdelhady E, Gameil D, Hashem MA. Evaluation of Safety and Efficacy of Emicizumab Prophylaxis in Egyptian Pediatric Patients with Hemophilia A. Turk J Haematol 2024; 41:256-263. [PMID: 39169683 PMCID: PMC11628768 DOI: 10.4274/tjh.galenos.2024.2024.0220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Accepted: 08/22/2024] [Indexed: 08/23/2024] Open
Abstract
Objective Hemophilia A (HA) is a hereditary X-linked bleeding disorder secondary to deficiency of the clotting factor VIII (FVIII). Emicizumab is a monoclonal antibody that replaces the function of the activated FVIII and prevents bleeding in HA patients. Emicizumab is expected to ameliorate bleeding risk in those patients together with subsequent complications. However, there is a scarcity of data about its safety and efficacy in patients with HA. We aimed to evaluate the safety and efficacy of emicizumab prophylaxis in Egyptian pediatric patients with HA. Materials and Methods A prospective cohort study was carried out with 88 HA patients who received emicizumab prophylaxis. Breakthrough bleeding episodes and the annualized bleeding rate (ABR) were reported for all patients before and after emicizumab prophylaxis. Also, all adverse events during prophylaxis were documented to evaluate the safety of emicizumab. Results Joint bleeds occurred in 94% of the patients. Among those patients, 58% had one target joint, 36.4% had more than one target joint, and 5.6% had no target joints. Furthermore, 17% of patients were positive for FVIII inhibitors. The median annualized joint bleeding rate was reduced remarkably after emicizumab prophylaxis (36 before versus 0 after emicizumab). The median ABR was 48 before emicizumab versus 0 after emicizumab. Eight patients experienced mild breakthrough bleeding episodes. The most common adverse events were local reactions at injection sites, headache, arthralgia, fever, and diarrhea. Conclusion Prophylaxis using emicizumab was associated with a significantly lower bleeding rate in HA patients with and without inhibitors. The majority of patients had zero bleeds with emicizumab prophylaxis.
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MESH Headings
- Humans
- Hemophilia A/drug therapy
- Hemophilia A/complications
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/administration & dosage
- Child
- Male
- Egypt/epidemiology
- Child, Preschool
- Antibodies, Bispecific/therapeutic use
- Antibodies, Bispecific/adverse effects
- Antibodies, Bispecific/administration & dosage
- Prospective Studies
- Female
- Adolescent
- Hemorrhage/prevention & control
- Hemorrhage/chemically induced
- Infant
- Treatment Outcome
- Factor VIII/therapeutic use
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Affiliation(s)
- Tamer Hassan
- Zagazig University Faculty of Medicine Department of Pediatrics, Zagazig, Egypt
| | - Marwa Zakaria
- Zagazig University Faculty of Medicine Department of Pediatrics, Zagazig, Egypt
| | - Manar Fathy
- Zagazig University Faculty of Medicine Department of Pediatrics, Zagazig, Egypt
| | - Ahmed Farag
- Zagazig University Faculty of Medicine Department of Pediatrics, Zagazig, Egypt
| | - Eman Abdelhady
- Zagazig University Faculty of Medicine Department of Pediatrics, Zagazig, Egypt
| | - Dalia Gameil
- Zagazig University Faculty of Medicine Department of Pediatrics, Zagazig, Egypt
| | - Mustafa Abu Hashem
- Zagazig University Faculty of Medicine Department of Pediatrics, Zagazig, Egypt
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8
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Mao Q, Chen Z, Liu G, Li G, Zhen Y, Cheng X, Li Z, Yao W, Ai D, Li Z, Wang N, Poon M, Wu R. Real-world use of emicizumab in Chinese children with hemophilia A: Retrospective data from a comprehensive care center. Pediatr Investig 2024; 8:244-252. [PMID: 39720280 PMCID: PMC11664537 DOI: 10.1002/ped4.12439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 06/04/2024] [Indexed: 12/26/2024] Open
Abstract
Importance Emicizumab (EMI) is efficacious and safe for hemophilia A (HA) prophylaxis. However, its high cost poses a challenge in China. Objective To explore the possibility of using reduced-dosage EMI in Chinese HA children. Methods We conducted a retrospective study for HA children in our Comprehensive Care Center. Data were collected pre- and post-EMI treatment to evaluate bleeding rates. Laboratory analyses included factor VIII (FVIII)-like activity and EMI concentration measurements. Results Thirty-four HA children receiving EMI prophylaxis for a median (range) 24.5 (2.5-47.9) months by June 2023. Of these, 25 (73.5%) were under 3 years of age, 26 (76.5%) had severe hemophilia and 12 (35.3%) were minimally treated or previously untreated patients. Thirty-one (91.2%) of the 34 patients received reduced-dosage EMI for economic reasons. EMI concentration and FVIII-like activity measured showed a strong correlation. Overall, while on EMI, their annual treated bleeding rate (ATBR) and annual bleeding rate (ABR) decreased significantly (2-0) while their zero-bleeding rate (ZBR) increased significantly (11.5%-65.4%). After 6 months of EMI, there was no significant difference in ATBR and ABR among various maintenance dosages. However, ZBR was significantly lower in dosages under 4 mg/kg (P = 0.0156). Receiver operator characteristic curves suggested the following cutoff values for zero bleeding: EMI 4-weekly maintenance dosage 3.8 mg/kg, EMI concentration 48.1 μg/mL, and FVIII-like activity 15.4 IU/dL. Interpretation We showed EMI effectively prevented bleeding even at reduced dosages. However, the bleeding risk may be higher with EMI 4-weekly maintenance dosage <3.8 mg/kg, EMI concentration <48.1 μg/mL, and FVIII-like activity <15.4 IU/dL for zero bleeding. It is important that dosage reduction be done rationally. Dosage tailoring is possible.
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Affiliation(s)
- Qianqian Mao
- Hematology Department, Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Ministry of Education, Beijing Children's Hospital, Capital Medical UniversityBeijingChina
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical UniversityBeijingChina
| | - Zhenping Chen
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical UniversityBeijingChina
| | - Guoqing Liu
- Hematology Department, Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Ministry of Education, Beijing Children's Hospital, Capital Medical UniversityBeijingChina
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical UniversityBeijingChina
| | - Gang Li
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical UniversityBeijingChina
| | - Yingzi Zhen
- Hematology Department, Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Ministry of Education, Beijing Children's Hospital, Capital Medical UniversityBeijingChina
| | - Xiaoling Cheng
- Department of PharmacyBeijing Children's Hospital, Capital Medical University, National Center for Children's HealthBeijingChina
| | - Zekun Li
- Hematology Department, Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Ministry of Education, Beijing Children's Hospital, Capital Medical UniversityBeijingChina
| | - Wanru Yao
- Hematology Department, Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Ministry of Education, Beijing Children's Hospital, Capital Medical UniversityBeijingChina
| | - Di Ai
- Hematology Department, Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Ministry of Education, Beijing Children's Hospital, Capital Medical UniversityBeijingChina
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical UniversityBeijingChina
| | - Zhengping Li
- Hematology Department, Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Ministry of Education, Beijing Children's Hospital, Capital Medical UniversityBeijingChina
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical UniversityBeijingChina
| | - Nan Wang
- Hematology Department, Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Ministry of Education, Beijing Children's Hospital, Capital Medical UniversityBeijingChina
- Hematologic Disease Laboratory, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing Pediatric Research Institute, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Beijing Children's Hospital, Capital Medical UniversityBeijingChina
| | - Man‐Chiu Poon
- Departments of Medicine, Foothills Medical CentreUniversity of Calgary1403‐29th Street NWCalgaryT2N 2T9AlbertaCanada
| | - Runhui Wu
- Hematology Department, Hemophilia Comprehensive Care Center, Hematology Center, Beijing Key Laboratory of Pediatric Hematology‐Oncology, Key Laboratory of Major Diseases in Children, National Center for Children's HealthNational Key Discipline of Pediatrics (Capital Medical University), Ministry of Education, Beijing Children's Hospital, Capital Medical UniversityBeijingChina
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9
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Mashiach D, Mead P, Carneiro K, Malvar J, Knight S, Young G. CHIEF: A retrospective self-control study of children with severe hemophilia A without inhibitors comparing emicizumab to FVIII prophylaxis. Pediatr Blood Cancer 2024; 71:e31351. [PMID: 39367598 DOI: 10.1002/pbc.31351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 08/12/2024] [Accepted: 09/13/2024] [Indexed: 10/06/2024]
Abstract
BACKGROUND Hemophilia A (HA) is an X-linked bleeding disorder diagnosed by a deficiency in factor VIII (FVIII). For severe HA (SHA), prophylaxis clotting factor concentrates (CFC) has become the standard of care; however, it imparts a high treatment burden and typically results in an annualized bleeding rate (ABR) of 2-6. Emicizumab, a subcutaneously administered FVIII substitute, has become the de facto standard-of-care prophylaxis for children with SHA in many countries. Previous clinical trials of emicizumab have assessed ABR in patients greater than 12 years without inhibitors, and in children less than 12 years with inhibitors; however, there is little information published regarding the ABR of emicizumab compared to CFC in non-inhibitor SHA children. METHODS Using a retrospective electronic medical record chart review, we conducted a self-control analysis of 15 patients less than 12 years of age during equivalent periods of CFC versus emicizumab prophylaxis. RESULTS The mean ABR on CFC and emicizumab was 1.79 and 1.13 (p = .092), respectively, with a substantially decreased rate of joint bleeds (CFC 0.94; emicizumab 0.33; p = .001) and spontaneous bleeds (CFC 0.79; emicizumab 0.23; p = .008). No safety events were recorded for patients while administering emicizumab. The mean annual cost of CFC prophylaxis was $515,340 (SD $199,540), compared to $328,410 (SD $137,230) for emicizumab prophylaxis (p < .001). CONCLUSION Emicizumab resulted in an improved ABR compared to CFC, especially for joint and spontaneous bleeds, had fewer administration complications, and was substantially less expensive compared to CFC prophylaxis; however, more research is necessary for a complete understanding of the effect of emicizumab on joint health and muscle bleeds.
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Affiliation(s)
- Daniel Mashiach
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, California, USA
- Western University of Health Sciences, College of Osteopathic Medicine of the Pacific, Pomona, California, USA
| | - Patrice Mead
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Kendall Carneiro
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Jemily Malvar
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Susan Knight
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Guy Young
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Los Angeles, California, USA
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, California, USA
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10
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Kengkla K, Wilairat P, Natesirinilkul R, Sosothikul D, Phisalprapa P, Saokaew S. Evaluating the benefits of emicizumab prophylaxis for haemophilia A with inhibitors: A cost-effectiveness and budget impact analysis in Thailand's upper-middle income setting. Haemophilia 2024; 30:1288-1297. [PMID: 39368064 DOI: 10.1111/hae.15105] [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: 03/03/2024] [Revised: 09/21/2024] [Accepted: 09/22/2024] [Indexed: 10/07/2024]
Abstract
BACKGROUND In Thailand, an upper-middle-income country, managing haemophilia A (HA) with inhibitors poses significant challenges, often necessitating bypassing agents (BPAs) for bleeding control. This study evaluates the cost-effectiveness and budget impact of emicizumab, a novel prophylactic agent, as an alternative to both episodic and prophylactic BPA treatments from a societal perspective. METHODS A Markov model was employed to estimate the lifetime societal costs and outcomes of emicizumab prophylaxis for HA patients with inhibitors. Treatment efficacy, cost, and epidemiological data were obtained through a comprehensive literature review and incorporated into the model. A 5-year budget impact analysis complemented the cost-utility analysis, with a 3% annual discount rate applied to future costs and outcomes. RESULTS In the base-case scenario, emicizumab prophylaxis in HA patients aged 2 years and above demonstrated superior cost-effectiveness, yielding 18.1 quality-adjusted life years (QALYs) per patient over a lifetime and resulting in cost savings of 138 million Thai Baht (THB) compared to BPA prophylaxis. Compared to episodic BPA treatment, emicizumab yielded 30.5 QALYs and saved 25 million THB per patient. The 5-year budget impact was projected at 1775 million THB. CONCLUSIONS Emicizumab offers a cost-saving approach for HA treatment with inhibitors in Thailand, promising significant health benefits and budgetary savings. This supports its potential inclusion in Thailand's National List of Essential Medicines to enhance haemophilia care access. HIGHLIGHTS Managing haemophilia A (HA) with inhibitors in Thailand, an upper-middle-income country, faces challenges due to limited access to effective treatments or newer drugs for bleeding management. Emicizumab prophylaxis found to as a cost-effective and viable alternative to traditional treatments, effectively preventing bleeding in Thai HA patients over 2 years old with inhibitors. Demonstrating improved clinical outcomes and reduced costs, emicizumab prophylaxis outperforms episodic BPA treatments, positioning it as a superior treatment option for HA patients with inhibitors in Thailand.
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Affiliation(s)
- Kirati Kengkla
- Division of Clinical Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Mueang Phayao, Phayao, Thailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Mueang Phayao, Phayao, Thailand
- Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Mueang Phayao, Phayao, Thailand
| | - Preyanate Wilairat
- Division of Clinical Pharmacy, Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Mueang Phayao, Phayao, Thailand
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Mueang Phayao, Phayao, Thailand
- Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Mueang Phayao, Phayao, Thailand
| | - Rungrote Natesirinilkul
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiangmai, Thailand
| | - Darintr Sosothikul
- Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok and Integrative and Innovative Hematology/Oncology Research Unit, Faculty of Medicine, Chulalongkorn, Bangkok, Thailand
| | - Pochamana Phisalprapa
- Division of Ambulatory Medicine, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Surasak Saokaew
- Center of Health Outcomes Research and Therapeutic Safety (Cohorts), School of Pharmaceutical Sciences, University of Phayao, Mueang Phayao, Phayao, Thailand
- Unit of Excellence on Clinical Outcomes Research and IntegratioN (UNICORN), School of Pharmaceutical Sciences, University of Phayao, Mueang Phayao, Phayao, Thailand
- Division of Social and Administrative Pharmacy (SAP), Department of Pharmaceutical Care, School of Pharmaceutical Sciences, University of Phayao, Mueang Phayao, Phayao, Thailand
- Center of Excellence in Bioactive Resources for Innovative Clinical Applications, Chulalongkorn University, Bangkok, Thailand
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11
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Kim SE, Kim JY, Park JA, Lyu CJ, Hahn SM, Han JW, Park YS. Real-world experience of emicizumab prophylaxis in Korean children with severe hemophilia A without inhibitors. Blood Res 2024; 59:34. [PMID: 39422843 PMCID: PMC11489370 DOI: 10.1007/s44313-024-00039-1] [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: 09/02/2024] [Accepted: 10/07/2024] [Indexed: 10/19/2024] Open
Abstract
PURPOSE Hemophilia A is a genetic disorder characterized by a lack of factor VIII (FVIII). Emicizumab, a recombinant humanized bispecific monoclonal antibody, mimics the function of FVIII. In this article, we present data on an initial real-world evaluation of emicizumab use in Korean children with severe hemophilia A without inhibitors. METHODS This study was conducted from June 2020 to March 2024 at 4 centers in Korea. The participants were pediatric patients with severe hemophilia A without inhibitors who had received emicizumab treatment for over 6 months. The mean and median annualized bleeding rates (ABRs) and mean and median annual joint bleeding rates (AJBRs) were compared. RESULTS Each of the 21 patients in the study received an emicizumab loading regimen of 3 mg/kg weekly for 4 weeks, followed by a modified maintenance regimen of which 2 patients (9.5%) received a 1.5 mg/kg weekly dose, 3 patients (14.3%) received a 6 mg/kg dose every 4 weeks, and the remaining 16 patients (76.2%) received a 3 mg/kg dose every 2 weeks. Before emicizumab prophylaxis initiation, the mean and median ABRs for all patients were 7.04 (SD ± 5.83) and 6.52 (range 0-21.74), respectively. After receiving emicizumab treatment, the mean and mediam ABRs decreased to 0.41 and zero, respectively. Additionally, 85.7% of the patients achieved no bleeding events within 6 months of starting the treatment. CONCLUSION These first real-world data in Korea indicate that emicizumab is effective and safe for pediatric patients with severe hemophilia A without inhibitors.
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Affiliation(s)
- Sung Eun Kim
- Department of Pediatrics, Kyungpook National University Hospital, Kyungpook National University Chilgok Hospital, 807 Hoguk-Ro, Buk-Gu, Daegu, 41404, Republic of Korea
| | - Ji Yoon Kim
- Department of Pediatrics, Kyungpook National University Hospital, Kyungpook National University Chilgok Hospital, 807 Hoguk-Ro, Buk-Gu, Daegu, 41404, Republic of Korea
- Department of Pediatrics, School of Medicine, Kyungpook National University, 680 Gukchaebosang-Ro, Jung-Gu, Daegu, 41944, Republic of Korea
| | - Jeong A Park
- Department of Pediatrics, Inha University Hospital, 27 Inhang-Ro, Jung-Gu, Incheon, 22332, Republic of Korea
| | - Chuhl Joo Lyu
- Department of Pediatrics, Yonsei University Severance Children's Hospital, 50-1 Yonseiro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Seung Min Hahn
- Department of Pediatrics, Yonsei University Severance Children's Hospital, 50-1 Yonseiro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Jung Woo Han
- Department of Pediatrics, Yonsei University Severance Children's Hospital, 50-1 Yonseiro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Young Shil Park
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, 892 Dongnam-Ro, Gangdong-Gu, Seoul, 05278, Republic of Korea.
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12
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Mahlangu J. Emicizumab and unmet needs of patients with hemophilia a who are managed with replacement therapies. Expert Rev Hematol 2024; 17:741-748. [PMID: 39252482 DOI: 10.1080/17474086.2024.2402304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 09/02/2024] [Accepted: 09/05/2024] [Indexed: 09/11/2024]
Abstract
INTRODUCTION Hemophilia A is managed with coagulation clotting factor VIII (FVIII) therapy that poses significant challenges, such as a high treatment burden, immunogenicity, inconsistent hemostatic cover, poor treatment outcomes, and musculoskeletal progression despite adequate prophylactic treatment. Various non-factor therapies, such as several natural anticoagulant inhibitors and factor FVIII mimetics, have been developed to address these unmet needs. However, the role of emicizumab in addressing these unmet needs remains underexplored. AREAS COVERED This review delves into the evolution of hemophilia A replacement clotting therapy from plasma-derived products to recombinant products and, more recently, nonfactor therapies. It underscores the unmet needs of replacement therapy and explores the nonfactor therapies developed to address them. The review then comprehensively summarizes the clinical trial and real-world experience data, demonstrating how emicizumab tackles these unsatisfied demands. EXPERT OPINION Replacement clotting factor therapies as the standard of care has exposed several needs that have yet to be addressed. However, data from numerous emicizumab clinical trials and real-world experience offer a promising outlook, suggesting that it may effectively address many unmet needs. As hemophilia treatment goals continue to evolve, the role of currently developed nonfactor therapies in hemophilia management is yet to be fully defined.
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Affiliation(s)
- Johnny Mahlangu
- Department of Molecular Medicine and Haematology, Faculty of Health Science, School of Pathology, University of the Witwatersrand and NHLS, Johannesburg, South Africa
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13
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Thota UR, Martha S, Ravula CJ, Cherukuri N. Emicizumab in Children with Severe Hemophilia A. Indian J Pediatr 2024:10.1007/s12098-024-05263-2. [PMID: 39320428 DOI: 10.1007/s12098-024-05263-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 08/28/2024] [Indexed: 09/26/2024]
Abstract
OBJECTIVES To assess the effectiveness and tolerability of emicizumab prophylaxis in hemophilia A (HA). Emicizumab is a novel therapeutic drug which is the first and only non-factor replacement agent licensed for use in people with HA. METHODS Pediatric patients aged 1 mo to 12 y with severe HA and frequent / life threatening bleeding events, with or without coagulation protein factor VIII inhibitors were enrolled (n = 18) in this observational pre-post study. Patients were switched from therapy involving on-demand or prophylactic factor VIII/bypassing agents/immune tolerance induction to emicizumab prophylaxis and followed up for 52 wk. RESULTS One year before initiating emicizumab, a total of 229 bleeding events occurred among the enrolled children. After emicizumab prophylaxis, 5 patients had one episode of bleeding event each with a mean bleeding duration of 1.2 d in one year. The mean annualized bleeding rate significantly reduced from 12.7 ± 8.61 events pre-emicizumab prophylaxis to 0.28 ± 0.46 events post-emicizumab prophylaxis (p < 0.001). Out of the total cohort (n = 18), 72.2% of patients (n = 13) had no bleeding events (95% Confidence interval: 46.4-89.3) while on emicizumab. The mean annualized joint bleeding rate reduced from 9.72 ± 7.44 to 0.17 ± 0.38 (p < 0.001). The target joint resolution was 100% and no adverse events were noted. CONCLUSIONS Emicizumab was found to be effective and safe as a prophylactic agent for the treatment of severe HA with and without factor VIII inhibitors. Emicizumab prophylaxis can optimize treatment outcomes and promote a better quality of life in children with severe HA.
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Affiliation(s)
- Usha Rani Thota
- Department of Pediatrics, Institute of Child Health - Niloufer Hospital for Women and Children, Osmania Medical College, Hyderabad, Telangana, India
| | - Sreelatha Martha
- Department of Pediatrics, Institute of Child Health - Niloufer Hospital for Women and Children, Osmania Medical College, Hyderabad, Telangana, India
| | - Chaitanya Jyothi Ravula
- Department of Pediatrics, Institute of Child Health - Niloufer Hospital for Women and Children, Osmania Medical College, Hyderabad, Telangana, India
| | - Nirmala Cherukuri
- Department of Pediatrics, Institute of Child Health - Niloufer Hospital for Women and Children, Osmania Medical College, Hyderabad, Telangana, India.
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14
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Chandran R, Tohit ERM, Stanslas J, Salim N, Mahmood TMT, Rajagopal M. Shifting Paradigms and Arising Concerns in Severe Hemophilia A Treatment. Semin Thromb Hemost 2024; 50:695-713. [PMID: 38224699 DOI: 10.1055/s-0043-1778103] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
The management of hemophilia A has undergone a remarkable revolution, in line with technological advancement. In the recent past, the primary concern associated with Factor VIII (FVIII) concentrates was the risk of infections, which is now almost resolved by advanced blood screening and viral inactivation methods. Improving patients' compliance with prophylaxis has become a key focus, as it can lead to improved health outcomes and reduced health care costs in the long term. Recent bioengineering research is directed toward prolonging the recombinant FVIII (rFVIII) coagulant activity and synthesising higher FVIII yields. As an outcome, B-domain deleted, polyethylene glycolated, single-chain, Fc-fused rFVIII, and rFVIIIFc-von Willebrand Factor-XTEN are available for patients. Moreover, emicizumab, a bispecific antibody, is commercially available, whereas fitusiran and tissue factor pathway inhibitor are in clinical trial stages as alternative strategies for patients with inhibitors. With these advancements, noninfectious complications, such as inhibitor development, allergic reactions, and thrombosis, are emerging concerns requiring careful management. In addition, the recent approval of gene therapy is a major milestone toward a permanent cure for hemophilia A. The vast array of treatment options at our disposal today empowers patients and providers alike, to tailor therapeutic regimens to the unique needs of each individual. Despite significant progress in modern treatment options, these highly effective therapies are markedly more expensive than conventional replacement therapy, limiting their access for patients in developing countries.
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Affiliation(s)
- Rubhan Chandran
- Department of Pathology, Haematology Unit, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
- Faculty of Pharmaceutical Sciences, Department of Pharmaceutical Biology, UCSI University, Jalan Puncak Menara Gading, Taman Connaught, Cheras, Kuala Lumpur, Malaysia
| | - Eusni R Mohd Tohit
- Department of Pathology, Haematology Unit, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Selangor, Malaysia
| | - Johnson Stanslas
- Department of Medicine, Pharmacotherapeutics Unit, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Norazlinaliza Salim
- Centre of Foundation Studies for Agricultural Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
- Integrated Chemical Biophysics Research, Faculty of Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Tuan M T Mahmood
- Faculty of Pharmacy, The National University of Malaysia (UKM), Jalan Raja Muda Abdul Aziz, Kuala Lumpur, Malaysia
| | - Mogana Rajagopal
- Faculty of Pharmaceutical Sciences, Department of Pharmaceutical Biology, UCSI University, Jalan Puncak Menara Gading, Taman Connaught, Cheras, Kuala Lumpur, Malaysia
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15
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Hassan E, Motwani J. Single centre experience of the use of emicizumab in previously untreated and minimally treated patients under 18 months of age. Pediatr Blood Cancer 2024; 71:e30941. [PMID: 38462765 DOI: 10.1002/pbc.30941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/12/2024]
Abstract
Emicizumab has revolutionised haemophilia A treatment landscape and significantly reduced treatment burden, particularly in the paediatric population. We conducted a retrospective study, focused on infants aged ≤18 months with severe haemophilia A. The study included 16 patients, with a median age of 8.2 months and median treatment duration of 61.6 weeks. Before commencing emicizumab, six patients were minimally treated with ≤5 exposure days while 10 were previously untreated patients. Notably, all patients had no inhibitors at baseline, and none developed new inhibitors during the study period. Emicizumab was well tolerated, with no observed side effects or major bleeding events.
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Affiliation(s)
- Eman Hassan
- Department of Paediatric Haematology, Birmingham Children's Hospital, Birmingham, UK
| | - Jayashree Motwani
- Department of Paediatric Haematology, Birmingham Children's Hospital, Birmingham, UK
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16
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Prudente TP, Camelo RM, Guimarães RA, Roberti MDRF. Emicizumab prophylaxis in people with hemophilia A and inhibitors: a systematic review and meta-analysis. SAO PAULO MED J 2024; 142:e2023102. [PMID: 38747872 PMCID: PMC11087007 DOI: 10.1590/1516-3180.2023.0102.r1.20022024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/06/2023] [Accepted: 02/20/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Until recently, the treatment of people with hemophilia A and inhibitors (PwHAi) was based on the use of bypassing agents (BPA). However, the advent of emicizumab as prophylaxis has demonstrated promising results. OBJECTIVES We aimed to compare the bleeding endpoints between PwHAi on BPA and those on emicizumab prophylaxis. DESIGN AND SETTING Systematic review of interventions and meta-analysis conducted at the Universidade Federal de Goiás, Goiânia, Goiás, Brazil. METHODS The CENTRAL, MEDLINE, Scopus, and LILACS databases were searched on February 21, 2023. Two authors conducted the literature search, publication selection, and data extraction. The selected publications evaluated the bleeding endpoints between PwHAi on emicizumab prophylaxis and those on BPA prophylaxis. The risk of bias was evaluated according to the Joanna Briggs Institute criteria. A meta-analysis was performed to determine the annualized bleeding rate (ABR) for treated bleeds. RESULTS Five publications (56 PwHAi) were selected from the 543 retrieved records. Overall, bleeding endpoints were lower during emicizumab prophylaxis than during BPA prophylaxis. All the publications had at least one risk of bias. The only common parameter for the meta-analysis was the ABR for treated bleeds. During emicizumab prophylaxis, the ABR for treated bleeds was lower than during BPA prophylaxis (standard mean difference: -1.58; 95% confidence interval -2.50, -0.66, P = 0.0008; I2 = 68.4%, P = 0.0031). CONCLUSION Emicizumab was superior to BPA in bleeding prophylaxis in PwHAi. However, both the small population size and potential risk of bias should be considered when evaluating these results. SYSTEMATIC REVIEW REGISTRATION CRD42021278726, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278726.
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Affiliation(s)
- Tiago Paiva Prudente
- Medical student, Faculty of Medicine, Universidade Federal de Goiás (UFG), Goiânia (GO), Brazil
| | - Ricardo Mesquita Camelo
- MD, PhD. Physician, Postdoctoral associate, Faculty of Medicine, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil
| | - Rafael Alves Guimarães
- RN, PhD. Epidemiologist, Professor, Faculty of Nursing, Universidade Federal de Goiás (UFG), Goiânia (GO), Brazil
| | - Maria do Rosário Ferraz Roberti
- MD, PhD. Physician, Professor, Faculty of Medicine, Universidade Federal de Goiás (UFG), Goiânia (GO), Brazil; Physician, Secretaria de Saúde do Estado de Goiás (SES/GERAT), Goiânia (GO), Brazil
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17
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Klukowska A, Sidonio RF, Young G, Mancuso ME, Álvarez-Román MT, Bhatnagar N, Jansen M, Knaub S. Simoctocog alfa (Nuwiq ®) in children: early steps in life's journey for people with severe hemophilia A. Ther Adv Hematol 2024; 15:20406207241245511. [PMID: 38737006 PMCID: PMC11085023 DOI: 10.1177/20406207241245511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/20/2024] [Indexed: 05/14/2024] Open
Abstract
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.
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Affiliation(s)
- Anna Klukowska
- Haemostasis Group of the Polish Society of Haematology and Transfusiology, 14 Indira Gandhi Street, Warsaw 02-776, Poland
| | - Robert F. Sidonio
- Hemophilia of Georgia Center for Bleeding and Clotting Disorders, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Guy Young
- Hemostasis and Thrombosis Center, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Maria Elisa Mancuso
- Center for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Humanitas University, Pieve Emanuele, Italy
| | | | - Neha Bhatnagar
- Oxford Haemophilia and Thrombosis Comprehensive Care Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Martina Jansen
- Clinical Research and Development, Octapharma Pharmazeutika Produktionsges m.b.H., Vienna, Austria
| | - Sigurd Knaub
- Clinical Research and Development, Octapharma AG, Lachen, Switzerland
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18
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Giacometto PC, Bavaresco MT, Alvares-Teodoro J, Camelo RM. Cholecystectomy in a man with hemophilia A and inhibitor on emicizumab prophylaxis: A case report. Hematol Transfus Cell Ther 2024; 46:201-204. [PMID: 36481198 DOI: 10.1016/j.htct.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/14/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- Paula Cella Giacometto
- Hospital Regional Universitário da Universidade Estadual de Maringá (HU UEM), Maringá, PR, Brazil; Centro de Hematologia e Hemoterapia do Paraná (HEMEPAR), Maringá, PR, Brazil
| | - Marcello Tortelli Bavaresco
- Hospital Regional Universitário da Universidade Estadual de Maringá (HU UEM), Maringá, PR, Brazil; Hospital Santa Casa de Maringá, Maringá, PR, Brazil; Faculdade de Medicina UniCesumar, Maringá, PR, Brazil
| | - Juliana Alvares-Teodoro
- Faculdade de Farmácia da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Ricardo Mesquita Camelo
- Faculdade de Farmácia da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.
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Krishnamoorthy Y, Govindan D, Kannan N, Majella MG, Hariharan VS, Valliappan V. Budget impact and cost-utility analysis of prophylactic emicizumab versus on-demand bypassing agents for adolescent severe haemophilia A patients with inhibitors in India. Heliyon 2024; 10:e27089. [PMID: 38468938 PMCID: PMC10926073 DOI: 10.1016/j.heliyon.2024.e27089] [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: 06/07/2023] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 03/13/2024] Open
Abstract
INTRODUCTION Severe Haemophilia A patients with inhibitors are currently being treated with bypassing agents like activated prothrombin complex concentrates (aPCC) and recombinant factor VIIa. Emicizumab is a recombinant humanized monoclonal antibody, introduced to reduce the bleeding events, improve treatment adherence, and quality of life. However, cost-effectiveness and long-term sustainability of the intervention is not studied in a low middle income setting like India. AIM The primary objective of this study was to evaluate the cost-utility of Emicizumab compared to traditional bypassing agents in the treatment of severe haemophilia A patients with inhibitors in India. Secondary objective was to analyze the budgetary impact of introducing Emicizumab for this patient population from the perspective of public health system in India. METHODS Markov model was created to compare the prophylactic emicizumab therapy against bypassing agents for a hypothetical cohort of 10-year-old adolescents in India. The time horizon was 10 years and model built based on health system perspective. Cost utility was expressed as costs per quality-adjusted life-years (QALYs) gained. All costs were expressed as 2021 US dollars. Probabilistic sensitivity analysis was performed to check the robustness of the estimates. RESULTS Prophylactic emicizumab was a cost saving intervention with negative Incremental Cost Utility Ratio (ICUR) against recombinant factor VIIa of -853,573 USD (INR -63,109,773), and negative ICUR of -211,675 USD (INR -15,650,403) against APCC. The estimated total budget for treating all the severe Haemophilia A patients with inhibitors in India was USD 59,042,000 (INR 4,365,329,312) for 10 years' time horizon (per patient cost of USD 295,210 [INR 21,826,646.56]). CONCLUSION Prophylactic emicizumab therapy is a cost saving intervention when compared to both the bypassing agents as it is less costly and more effective for severe Haemophilia A patients with inhibitors in India.
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Affiliation(s)
- Yuvaraj Krishnamoorthy
- PROPUL Evidence Synthesis Unit (PROPUL ESU), PROPUL (Partnership for Research Opportunity Planning Upskilling and Leadership) Evidence, Chennai, Tamilnadu, India
| | - Dhanajayan Govindan
- PROPUL Evidence Synthesis Unit (PROPUL ESU), PROPUL (Partnership for Research Opportunity Planning Upskilling and Leadership) Evidence, Chennai, Tamilnadu, India
| | - Narasimhapriyan Kannan
- Department of Hematology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Marie Gilbert Majella
- PROPUL Evidence Synthesis Unit (PROPUL ESU), PROPUL (Partnership for Research Opportunity Planning Upskilling and Leadership) Evidence, Chennai, Tamilnadu, India
| | | | - Vivek Valliappan
- Department of Pharmacology, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chengalpattu District, 603103, Tamilnadu, India
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20
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Kenet G, Fujii T. Safety of recombinant activated factor VII for treatment of breakthrough bleeds in patients with congenital haemophilia A and inhibitors receiving emicizumab prophylaxis: Review of the real-world evidence. Haemophilia 2024; 30:267-275. [PMID: 38291654 DOI: 10.1111/hae.14933] [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: 03/09/2023] [Revised: 12/20/2023] [Accepted: 01/02/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Emicizumab is used as a subcutaneous prophylaxis for prevention of bleeding episodes in patients with haemophilia A (HA) with and without inhibitors. While low bleeding rates were observed in clinical trials, patients still experience breakthrough bleeds (BTBs) with emicizumab in the real-world. Current guidelines recommend use of recombinant activated factor VII (rFVIIa) for treatment of BTBs in patients with inhibitors. Due to thrombotic events observed in the HAVEN 1 study, activated prothrombin complex concentrate (aPCC) should be used with caution. OBJECTIVES The objective of this review is to identify and discuss real-world data on the frequency of BTBs and the safety of concomitant rFVIIa use in patients with inhibitors on emicizumab prophylaxis. METHODS A search of the following databases was conducted on 15 July 2022: BIOSIS Previews® , Current Contents Search® , Embase® , MEDLINE® . Search terms included 'real world', 'haemophilia A', and 'emicizumab'. RESULTS AND CONCLUSIONS Eleven relevant publications were identified (seven original research articles and four congress abstracts). The frequency of BTBs specifically for HA patients with inhibitors was described in three publications with 5%-56% patients on emicizumab reporting ≥1 bleeding episode. Treatment of these BTBs appeared to be managed according to relevant guidelines. Importantly, no thrombotic complications occurred during concomitant rFVIIa use. Due to the nature of real-world studies, direct comparison of the results between studies is limited. However, real-world data show that BTBs in inhibitor patients during emicizumab prophylaxis can be safely treated with rFVIIa.
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Affiliation(s)
- Gili Kenet
- The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center and the Amalia Biron Research Institute of Thrombosis and Hemostasis, Tel Aviv University, Tel Hashomer, Israel
| | - Teruhisa Fujii
- Division of Blood Transfusion, Hiroshima University Hospital, Hiroshima, Japan
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21
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Olasupo OO, Noronha N, Lowe MS, Ansel D, Bhatt M, Matino D. Non-clotting factor therapies for preventing bleeds in people with congenital hemophilia A or B. Cochrane Database Syst Rev 2024; 2:CD014544. [PMID: 38411279 PMCID: PMC10897951 DOI: 10.1002/14651858.cd014544.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Management of congenital hemophilia A and B is by prophylactic or on-demand replacement therapy with clotting factor concentrates. The effects of newer non-clotting factor therapies such as emicizumab, concizumab, marstacimab, and fitusiran compared with existing standards of care are yet to be systematically reviewed. OBJECTIVES To assess the effects (clinical, economic, patient-reported, and adverse outcomes) of non-clotting factor therapies for preventing bleeding and bleeding-related complications in people with congenital hemophilia A or B compared with prophylaxis with clotting factor therapies, bypassing agents, placebo, or no prophylaxis. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, electronic databases, conference proceedings, and reference lists of relevant articles and reviews. The date of the last search was 16 August 2023. SELECTION CRITERIA Randomized controlled trials (RCTs) evaluating people with congenital hemophilia A or B with and without inhibitors, who were treated with non-clotting factor therapies to prevent bleeds. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed studies for eligibility, assessed risk of bias, and extracted data for the primary outcomes (bleeding rates, health-related quality of life (HRQoL), adverse events) and secondary outcomes (joint health, pain scores, and economic outcomes). We assessed the mean difference (MD), risk ratio (RR), 95% confidence interval (CI) of effect estimates, and evaluated the certainty of the evidence using GRADE. MAIN RESULTS Six RCTs (including 397 males aged 12 to 75 years) were eligible for inclusion. Prophylaxis versus on-demand therapy in people with inhibitors Four trials (189 participants) compared emicizumab, fitusiran, and concizumab with on-demand therapy in people with inhibitors. Prophylaxis using emicizumab likely reduced annualized bleeding rates (ABR) for all bleeds (MD -22.80, 95% CI -37.39 to -8.21), treated bleeds (MD -20.40, 95% CI -35.19 to -5.61), and annualized spontaneous bleeds (MD -15.50, 95% CI -24.06 to -6.94), but did not significantly reduce annualized joint and target joint bleeding rates (AjBR and AtjBR) (1 trial; 53 participants; moderate-certainty evidence). Fitusiran also likely reduced ABR for all bleeds (MD -28.80, 95% CI -40.07 to -17.53), treated bleeds (MD -16.80, 95% CI -25.80 to -7.80), joint bleeds (MD -12.50, 95% CI -19.91 to -5.09), and spontaneous bleeds (MD -14.80, 95% CI -24.90 to -4.71; 1 trial; 57 participants; moderate-certainty evidence). No evidence was available on the effect of bleed prophylaxis using fitusiran versus on-demand therapy on AtjBR. Concizumab may reduce ABR for all bleeds (MD -12.31, 95% CI -19.17 to -5.45), treated bleeds (MD -10.10, 95% CI -17.74 to -2.46), joint bleeds (MD -9.55, 95% CI -13.55 to -5.55), and spontaneous bleeds (MD -11.96, 95% CI -19.89 to -4.03; 2 trials; 78 participants; very low-certainty evidence), but not target joint bleeds (MD -1.00, 95% CI -3.26 to 1.26). Emicizumab prophylaxis resulted in an 11.31-fold increase, fitusiran in a 12.5-fold increase, and concizumab in a 1.59-fold increase in the proportion of participants with no bleeds. HRQoL measured using the Haemophilia Quality of Life Questionnaire for Adults (Haem-A-QoL) physical and total health scores was improved with emicizumab, fitusiran, and concizumab prophylaxis (low-certainty evidence). Non-serious adverse events were higher with non-clotting factor therapies versus on-demand therapy, with injection site reactions being the most frequently reported adverse events. Transient antidrug antibodies were reported for fitusiran and concizumab. Prophylaxis versus on-demand therapy in people without inhibitors Two trials (208 participants) compared emicizumab and fitusiran with on-demand therapy in people without inhibitors. One trial assessed two doses of emicizumab (1.5 mg/kg weekly and 3.0 mg/kg bi-weekly). Fitusiran 80 mg monthly, emicizumab 1.5 mg/kg/week, and emicizumab 3.0 mg/kg bi-weekly all likely resulted in a large reduction in ABR for all bleeds, all treated bleeds, and joint bleeds. AtjBR was not reduced with either of the emicizumab dosing regimens. The effect of fitusiran prophylaxis on target joint bleeds was not assessed. Spontaneous bleeds were likely reduced with fitusiran (MD -20.21, 95% CI -32.12 to -8.30) and emicizumab 3.0 mg/kg bi-weekly (MD -15.30, 95% CI -30.46 to -0.14), but not with emicizumab 1.5 mg/kg/week (MD -14.60, 95% CI -29.78 to 0.58). The percentage of participants with zero bleeds was higher following emicizumab 1.5 mg/kg/week (50% versus 0%), emicizumab 3.0 mg/kg bi-weekly (40% versus 0%), and fitusiran prophylaxis (40% versus 5%) compared with on-demand therapy. Emicizumab 1.5 mg/kg/week did not improve Haem-A-QoL physical and total health scores, EQ-5D-5L VAS, or utility index scores (low-certainty evidence) when compared with on-demand therapy at 25 weeks. Emicizumab 3.0 mg/kg bi-weekly may improve HRQoL measured by the Haem-A-QoL physical health score (MD -15.97, 95% CI -29.14 to -2.80) and EQ-5D-5L VAS (MD 9.15, 95% CI 2.05 to 16.25; 1 trial; 43 participants; low-certainty evidence). Fitusiran may result in improved HRQoL shown as a reduction in Haem-A-QoL total score (MD -7.06, 95% CI -11.50 to -2.62) and physical health score (MD -19.75, 95% CI -25.76 to -11.94; 1 trial; 103 participants; low-certainty evidence). The risk of serious adverse events in participants without inhibitors also likely did not differ following prophylaxis with either emicizumab or fitusiran versus on-demand therapy (moderate-certainty evidence). Transient antidrug antibodies were reported in 4% (3/80) participants to fitusiran, with no observed effect on antithrombin lowering. A comparison of the different dosing regimens of emicizumab identified no differences in bleeding, safety, or patient-reported outcomes. No case of treatment-related cancer or mortality was reported in any study group. None of the included studies assessed our secondary outcomes of joint health, clinical joint function, and economic outcomes. None of the included studies evaluated marstacimab. AUTHORS' CONCLUSIONS Evidence from RCTs shows that prophylaxis using non-clotting factor therapies compared with on-demand treatment may reduce bleeding events, increase the percentage of individuals with zero bleeds, increase the incidence of non-serious adverse events, and improve HRQoL. Comparative assessments with other prophylaxis regimens, assessment of long-term joint outcomes, and assessment of economic outcomes will improve evidence-based decision-making for the use of these therapies in bleed prevention.
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Affiliation(s)
- Omotola O Olasupo
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Canada
| | - Noella Noronha
- Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, Canada
| | - Megan S Lowe
- Department of Health Sciences, McMaster University, Hamilton, Canada
| | | | - Mihir Bhatt
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Davide Matino
- Department of Internal Medicine, McMaster University, Hamilton, Canada
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22
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Ozelo MC, Hermans C, Carcao M, Guillet B, Gu J, Guerra R, Tang L, Khair K. The effectiveness and safety of octocog alfa in patients with hemophilia A: up to 7-year follow-up of the real-world AHEAD international study. Ther Adv Hematol 2024; 15:20406207231218624. [PMID: 38371314 PMCID: PMC10874143 DOI: 10.1177/20406207231218624] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 11/16/2023] [Indexed: 02/20/2024] Open
Abstract
Background Real-world data assessing treatment outcomes in patients with hemophilia A in routine clinical practice are limited. Objective To evaluate the effectiveness and safety of octocog alfa in patients with moderate/severe hemophilia A receiving treatment in clinical practice. Design The international Antihemophilic Factor Hemophilia A Outcome Database study is an observational, noninterventional, prospective, multicenter study. Methods This planned interim data read-out was conducted following 7 years of observation of patients receiving octocog alfa (cut-off, 30 June 2020). The primary endpoint was joint health status, assessed by the Gilbert Score. Secondary endpoints included annualized bleeding rates (ABRs), Hemophilia Joint Health Score (HJHS), health-related quality of life, consumption, and safety. This post hoc analysis stratified data by hemophilia severity at baseline [moderate, factor VIII (FVIII) 1-5%; severe, FVIII <1%]. Results Of the 711 patients in this analysis, 582 (82%) were receiving prophylaxis with octocog alfa at enrollment, and 498 (70%) had severe disease. Median Gilbert Scores were higher with on-demand therapy versus prophylaxis and scores were comparable in moderate and severe disease. In patients receiving prophylaxis, there was an improvement in HJHS Global Gait Score over 7 years of follow-up overall and in patients with severe disease. ABRs and annualized joint bleeding rates were low across all 7 years. An ABR of zero was reported in 34-56% of prophylaxis patients versus 20-40% in the on-demand group. ABRs were similar in severe and moderate disease. In total, 13/702 (1.9%) patients experienced 18 treatment-related adverse events. Conclusion These data demonstrate the long-term effectiveness and safety of octocog alfa in patients with moderate and severe hemophilia A, especially in those receiving prophylaxis. The high number of patients receiving on-demand treatment experiencing zero bleeds could be due to selection bias within the study, with patients with less severe disease more likely to be receiving on-demand treatment. Trial registration ClinicalTrials.gov: NCT02078427.
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Affiliation(s)
| | - Cedric Hermans
- St-Luc University Hospital, Université catholique de Louvain, Louvain, Belgium
| | - Manuel Carcao
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - Benoît Guillet
- Haemophilia Treatment Center, Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000 Rennes, France
| | - Joan Gu
- Takeda Development Center Americas, Inc., Cambridge, MA, USA
| | - Randy Guerra
- Takeda Development Center Americas, Inc., 500 Kendal Street, Cambridge, MA 02142, USA
| | - Leilei Tang
- Takeda Pharmaceuticals International AG, Zurich, Switzerland
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23
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Vuong HL, Lan CT, Le HTT. The development and technologies of RNA therapeutics. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2024; 203:13-39. [PMID: 38359995 DOI: 10.1016/bs.pmbts.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Since it was discovered for over 20 years ago, the potentiality of siRNAs in gene silencing in vitro and in vivo models has been recognized. Several studies in the new generation, molecular mechanisms, target attachment, and purification of RNA have supported the development of RNA therapeutics for a variety of applications. RNA therapeutics are growing rapidly with various platforms contributing to the standard of personalized medicine and rare disease treatment. Therefore, understanding the development and technologies of RNA therapeutics becomes a crucial point for new drug generation. Here, the primary purpose of this review is to provide a general view of six therapeutic categories that make up RNA-based therapeutic approaches, including RNA-target therapeutics, protein-targeted therapeutics, cellular reprogramming and tissues engineering, RNA-based protein replacement therapeutics, RNA-based genome editing, and RNA-based immunotherapies based on non-coding RNAs and coding RNA. Furthermore, we present an overview of the RNA strategies regarding viral approaches and nonviral approaches in designing a new generation of RNA technologies. The advantages and challenges of using RNA therapeutics are also discussed along with various approaches for RNA delivery. Therefore, this review is designed to provide updated reference evidence of RNA therapeutics in the battle against rare or difficult-to-treat diseases for researchers in this field.
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Affiliation(s)
- Huong Lan Vuong
- Pharmacy Department, National Hospital for Tropical Diseases, Hanoi, Vietnam
| | - Chu Thanh Lan
- Department of Regenerative Medicine, Institute of Tissue Regeneration, College of Medicine, Soonchunghyang University, South Korea
| | - Hien Thi Thu Le
- Intestinal Signaling and Epigenetics, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
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24
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Andreeva TA, Zharkov PA, Zozulya NI, Zorenko VY, Konstantinova VN, Lavrentieva IN, Davydkin IL, Petrov VY, Polyanskaya TY, Soldatenkov VE, Shutov SA. [Methodological recommendations for surgical care in patients with hemophilia A receiving prophylactic therapy with emicizumab]. Khirurgiia (Mosk) 2024:3-20. [PMID: 38591217 DOI: 10.17116/hirurgia20240323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Methodological recommendations for surgical care in patients with hemophilia A receiving prophylactic therapy with emicizumab. Recommendations of the expert group. Moscow, 2024.
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Affiliation(s)
- T A Andreeva
- GBUZ "City Polyclinic #37", City Hemophilia Treatment Center, St. Petersburg, Russian Federation
| | - P A Zharkov
- FGBU "National Medical Research Center of Pediatric Hematology, Oncology and Immunology named after Dmitry Rogachev", St. Petersburg, Russia
| | - N I Zozulya
- FGBU "National Medical Research Center of Hematology", Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - V Y Zorenko
- FGBU "National Medical Research Center of Hematology", Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - V N Konstantinova
- GBUZ "City Polyclinic #37", City Hemophilia Treatment Center, St. Petersburg, Russian Federation
| | - I N Lavrentieva
- GBUZ "Morozov Children's City Clinical Hospital of the Moscow City Health Department", Moscow, Russian Federation
| | - I L Davydkin
- FGBOU VO "Samara State Medical University", Ministry of Health of the Russian Federation, Samara, Russian Federation
| | - V Y Petrov
- GBUZ "Morozov Children's City Clinical Hospital of the Moscow City Health Department", Moscow, Russian Federation
| | - T Yu Polyanskaya
- FGBU "National Medical Research Center of Hematology", Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - V E Soldatenkov
- FGBU "Russian Research Institute of Hematology and Transfusiology FMBA", St. Petersburg, Russian Federation
| | - S A Shutov
- FGBU "National Medical Research Center of Hematology", Ministry of Health of the Russian Federation, Moscow, Russian Federation
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25
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Castaman G, Peyvandi F, Kremer Hovinga JA, Schutgens RE, Robson S, Moreno K, Jiménez-Yuste V. Surgical Experience from the STASEY Study of Emicizumab Prophylaxis in People with Hemophilia A with Factor VIII Inhibitors. TH OPEN 2024; 8:e42-e54. [PMID: 38222041 PMCID: PMC10786707 DOI: 10.1055/s-0043-1777766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/28/2023] [Indexed: 01/16/2024] Open
Abstract
Background Guidelines surrounding emicizumab prophylaxis and perioperative treatment for people with hemophilia A (PwHA) with factor (F)VIII inhibitors undergoing surgeries are limited. The phase IIIb multicenter, single-arm STASEY study evaluated safety and tolerability of emicizumab prophylaxis in PwHA aged ≥12 years with FVIII inhibitors. This analysis assesses surgeries during study conduct, associated hemophilia medications, and postoperative bleeds (treated and untreated). Methods PwHA with FVIII inhibitors received emicizumab 3.0 mg/kg/week for 4 weeks, then 1.5 mg/kg/week until 2 years. Surgeries were managed and documented by treating physicians. Bleeds and treatments were recorded by physicians and participants. Results Forty-six participants had ≥1 on-study surgery, 37 underwent 56 minor surgeries, and 13 underwent 22 major surgeries. Four participants underwent both minor and major surgeries. Of 18 (81.8%) and 4 (18.2%) major surgeries managed with/without additional hemostatic medication, 33.3 and 25.0% were associated with a treated postoperative bleed, respectively. Of 24 (42.9%) and 32 (57.1%) minor surgeries managed with/without additional hemostatic medication, 15.6 and 25.0% were associated with a treated postoperative bleed, respectively. Recombinant activated FVII was the most common medication for prophylaxis and bleed treatment. There were no thrombotic microangiopathies (TMAs). One hypertrophic clot, considered unrelated to emicizumab, occurred following tooth extraction. Conclusion In this challenging population with a high bleeding risk, major surgeries were performed in PwHA receiving emicizumab with/without additional hemostatic medication. Postoperative bleeds occurred following 59.1% of major surgeries; 53.8% were treated. No arterial/venous thrombotic events or TMAs occurred due to concomitant emicizumab and bypassing agents. Trial registration This trial is registered at ClinicalTrials.gov (NCT03191799).
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Affiliation(s)
- Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Flora Peyvandi
- IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Johanna A. Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Roger E.G. Schutgens
- Center for Benign Haematology, Thrombosis and Haemostasis Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Susan Robson
- PD Data Science, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Katya Moreno
- Global Product Development/Medical Affairs, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Víctor Jiménez-Yuste
- Department of Hematology, Hospital Universitario La Paz, Autónoma University, Madrid, Spain
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López-Jaime FJ, Benítez O, Díaz Jordán BL, Montaño A, Coll J, Quintana París L, Gómez-Del Castillo Solano MDC. Expert opinion paper on the treatment of hemophilia a with emicizumab. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2023; 28:2166334. [PMID: 36636993 DOI: 10.1080/16078454.2023.2166334] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Prophylaxis with emicizumab, a bispecific monoclonal antibody that mimics FVIII function, has shown encouraging results in clinical trials in terms of efficacy and safety. However, current experience is limited, and many areas of concern to clinicians have yet to be reviewed. AREAS COVERED This paper reviews the experience of hemophilia A patients treated with emicizumab based on the results of clinical trials and real-life studies. The authors place special emphasis on issues such as the management of these patients in situations of hemorrhage and/or surgical interventions, joint health or laboratory monitoring. EXPERT OPINION Treatment with emicizumab has been shown to improve joint health and reduce bleeding, of particular interest to patients with inhibitors and high bleeding rates. However, there are still concerns about its administration in neonates and previously untreated patients due to limited reported experience. Laboratory monitoring is not strictly necessary due to the stable pharmacokinetics emicizumab has been shown to exhibit, however, tests that globally assess hemostasis may be useful especially in cases of bleeding or surgery. The authors are also of the opinion that prophylaxis before minor surgery is not necessary and that major surgeries can be safely performed with additional prophylactic coagulation factor.Trial registration ClinicalTrials.gov identifier: NCT04431726..
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Affiliation(s)
| | - Olga Benítez
- Departamento de Hematología Experimental, VHIO Vall d'Hebron Instituto de Oncología, Hospital Universitario Vall d'Hebron, Barcelona, Spain.,Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | - Adrián Montaño
- Unidad de Hemostasia y Trombosis, Hospital Universitario Regional de Málaga, IBIMA, Málaga, Spain.,Universidad de Salamanca, Salamanca, Spain
| | - Julia Coll
- Servicio de Hematología, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Laura Quintana París
- Servicio de Hematología, Hospital Universitario de Gran Canaria Dr. Negrín, Gran Canaria, Spain
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27
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Shimonishi N, Sasai K, Ogiwara K, Furukawa S, Nakajima Y, Mizumachi K, Yada K, Takeyama M, Shima M, Mizuno N, Nogami K. Longitudinal dynamic changes in factor VIII inhibitor titers in patients with hemophilia A and inhibitors receiving emicizumab prophylaxis. Int J Hematol 2023; 118:690-698. [PMID: 37803190 DOI: 10.1007/s12185-023-03667-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 10/08/2023]
Abstract
Emicizumab prophylaxis dramatically reduces bleeding events in patients with hemophilia A (PwHA) with or without factor VIII (FVIII) inhibitors. However, long-term dynamic changes in FVIII inhibitor titers during emicizumab prophylaxis remain to be investigated. We conducted a retrospective follow-up study of FVIII inhibitor titers after initiation of emicizumab prophylaxis in 25 PwHA carrying current or historical FVIII inhibitors. Nineteen PwHA had FVIII inhibitors at initiation of emicizumab prophylaxis (age: median 22 [range 4-60] years and inhibitor titer: 30 [1.0-1450] BU/mL). In 17 of the 19 patients, the inhibitor titers markedly decreased to a median of 1.2 (< 0.6-58) BU/mL at a median follow-up of 71 (38-111) months. In two patients, titers were slightly elevated after initiation of emicizumab but decreased in the long term. The remaining six patients had negative inhibitor status (< 0.6 BU/mL) when switched to emicizumab from FVIII prophylaxis. Five patients maintained negative titers. One patient had inhibitor recurrence, with a peak titer of 1.6 BU/mL that decreased to 0.9 BU/mL. In most cases, FVIII inhibitor titers can be expected to decrease spontaneously during emicizumab prophylaxis, but regular follow-up is necessary to manage breakthrough bleeds.
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Affiliation(s)
- Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan.
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan.
| | - Kana Sasai
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Kuniyoshi Mizumachi
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
- Division of Hemophilia, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8522, Japan
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Lee MW, Cheong MA, Ng HJ, Tien SL, Lam JCM. Real-world data on the use of emicizumab in patients with haemophilia A with and without inhibitors in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023; 52:580-589. [PMID: 38920147 DOI: 10.47102/annals-acadmedsg.2023100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Abstract
Introduction Emicizumab is a bispecific monoclonal antibody that mimics the function of factor VIII by binding to factor IXa and factor X to achieve haemostasis in haemophilia A. The long half-life and subcutaneous mode of administration makes emicizumab a compelling treatment option for bleeding prophylaxis. There is still limited real-world data on its use and management considerations, especially during surgical procedures. The objective of the study is to describe the real-world experience of emicizumab in a cohort of adult and paediatric haemophilia A patients in Singapore, including its use in the periprocedural setting. Method This was an observational study conducted at the 2 main haemophilia treatment centres in Singapore. All haemophilia A patients who commenced treatment with emicizumab before 1 July 2022 were recruited. Results A total of 18 patients with haemophilia A were included in this study. Ten (55.6%) patients had active inhibitors. The median annual bleeding rate for all patients before emicizumab use was 4.5 events (interquartile range [IQR] 2.8-8.3) compared with 0 events (IQR 0-0) after emicizumab was commenced (P=0). There were no adverse events of venous or arterial thrombosis, thrombotic microangiopathy, or death. A total of 6 procedures in 5 patients were performed during the study period with no major bleeding complications. Conclusion Emicizumab effectively protects against bleeding in haemophilia A patients with and without inhibitors, including in children less than 12 years old. More studies are required to address clinical nuances, such as periprocedural management and the role of immune tolerance in patients with inhibitors on emicizumab.
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Affiliation(s)
- Ming Wei Lee
- Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore
| | - May Anne Cheong
- Department of Haematology, Singapore General Hospital, Singapore
| | - Heng Joo Ng
- Department of Haematology, Singapore General Hospital, Singapore
| | - Sim Leng Tien
- Department of Haematology, Singapore General Hospital, Singapore
| | - Joyce Ching Mei Lam
- Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore
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Garcia J, Hammer MR, Zia A. Serious bleeds in pediatric persons with hemophilia A on emicizumab prophylaxis. Res Pract Thromb Haemost 2023; 7:102238. [PMID: 38053983 PMCID: PMC10694589 DOI: 10.1016/j.rpth.2023.102238] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/01/2023] [Accepted: 09/22/2023] [Indexed: 12/07/2023] Open
Abstract
Background Clinical trials have shown success in bleed prevention with emicizumab, but real-world data on the effectiveness of emicizumab in preventing serious bleeds in the pediatric population are lacking. Objectives To report real-world data on the effectiveness of Emicizumab in pediatric persons with hemophilia A. Methods We completed a retrospective chart review of 37 pediatric male patients aged ≤18 years on emicizumab prophylaxis for a median duration of 30.5 months at Children's Medical Center in Dallas, Texas. Results We identified 4 pediatric persons with severe hemophilia A with and without inhibitors who experienced a provoked or unprovoked serious bleed requiring hospitalization. Conclusion This study highlights that serious bleeds, both provoked and unprovoked, can occur in pediatric persons with severe hemophilia A. These findings are important for clinicians to provide appropriate counseling/education and recommendation of treatment for pediatric persons with severe hemophilia A through shared decision making. Up-titration of emicizumab or factor VIII replacement needs consideration in persons with hemophilia with suboptimal bleeding control or who participate in activities categorized as moderate- to high-risk activities.
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Affiliation(s)
- Jessica Garcia
- Division of Hematology/Oncology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
- Children’s Medical Center, Dallas, Texas, USA
| | - Matthew R. Hammer
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
- Children’s Medical Center, Dallas, Texas, USA
| | - Ayesha Zia
- Division of Hematology/Oncology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
- Children’s Medical Center, Dallas, Texas, USA
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Rener K, Anžej Doma S, Fink M, Podgornik H, Preložnik Zupan I. Management and Outcomes of Invasive Procedures in Individuals with Hemophilia A on Emicizumab Prophylaxis: A Single Center Experience. Hematol Rep 2023; 15:597-607. [PMID: 37987318 PMCID: PMC10660500 DOI: 10.3390/hematolrep15040062] [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: 04/28/2023] [Revised: 07/12/2023] [Accepted: 10/25/2023] [Indexed: 11/22/2023] Open
Abstract
Prophylactic treatment with emicizumab has become an important and effective bleeding prevention for people with hemophilia A (PwHA). Perioperative management of PwHA using emicizumab prophylaxis is still challenging due to a lack of experience. Medical records of perioperative management and outcomes were reviewed, and data were collected for adult PwHA receiving emicizumab and undergoing surgical procedures between August 2019 and July 2022 at the University Medical Center Ljubljana. Twelve surgical procedures were performed in eight PwHA (one with FVIII inhibitors) while on emicizumab prophylaxis. Three minor procedures included cataract surgery, cystoscopic lithotripsy, and percutaneous coronary intervention. Nine major surgeries included four osteosyntheses, necrectomy of chronic osteomyelitis with new ankle arthrodesis, two below-knee amputations, total knee replacement, and placement of ventriculostomy after a spontaneous intraventricular hemorrhage. No major bleeds, thrombotic events or deaths, or new inhibitors appeared. Our real-world experience demonstrates that minor and major surgeries can be performed safely in PwHA on emicizumab prophylaxis. Additional data are needed to optimize dosing/duration of additional hemostatic agents in diverse invasive procedures and complex clinical situations.
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Affiliation(s)
- Karla Rener
- Department of Hematology, University Medical Center Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (K.R.); (S.A.D.); (M.F.); (H.P.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
| | - Saša Anžej Doma
- Department of Hematology, University Medical Center Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (K.R.); (S.A.D.); (M.F.); (H.P.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
| | - Martina Fink
- Department of Hematology, University Medical Center Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (K.R.); (S.A.D.); (M.F.); (H.P.)
| | - Helena Podgornik
- Department of Hematology, University Medical Center Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (K.R.); (S.A.D.); (M.F.); (H.P.)
- Faculty of Pharmacy, University of Ljubljana, Aškerčeva cesta 7, 1000 Ljubljana, Slovenia
| | - Irena Preložnik Zupan
- Department of Hematology, University Medical Center Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia; (K.R.); (S.A.D.); (M.F.); (H.P.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
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Hermans C, Ventriglia G, Obaji S, Beckermann BM, Lehle M, Catalani O, d’Oiron R, Frenzel L. Emicizumab use in females with moderate or mild hemophilia A without factor VIII inhibitors who warrant prophylaxis. Res Pract Thromb Haemost 2023; 7:102239. [PMID: 38193069 PMCID: PMC10772889 DOI: 10.1016/j.rpth.2023.102239] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 09/14/2023] [Accepted: 10/16/2023] [Indexed: 01/10/2024] Open
Abstract
Background Hemophilia A (HA) is predominantly associated with males due to X-linked inheritance. Males and females with HA have shared unmet medical needs, highlighting the necessity for comprehensive care irrespective of sex. Objectives This analysis investigated the efficacy and safety of emicizumab prophylaxis in 3 females with HA. Methods HAVEN 6 (NCT04158648) is a phase III study of emicizumab in people with non-severe HA without factor (F)VIII inhibitors warranting prophylaxis per investigator assessment, and the study methodology has been reported previously. Female-specific endpoints included menstruation-related quality of life and menstruation heaviness. Results HAVEN 6 enrolled 3 females aged ≥18 years and within reproductive age (n = 2 mild HA; n = 1 moderate HA; n = 2 receiving prior FVIII prophylaxis; n = 1 receiving prior episodic FVIII). Participants presented with diverse bleeding phenotypes at baseline: 2 had no bleeds in the 24 weeks prior to enrollment, while 1 had an annualized bleed rate for all bleeds of 208.6. On-study annualized bleed rates for all bleeds were 0, 2.8, and 11.6, respectively. The 2 evaluable participants indicated improved menstruation-related quality of life vs baseline. Two participants experienced 3 grade 1/2 treatment-related adverse events; no new safety signals were identified. All 3 participants preferred emicizumab over their previous treatment and reported a better score for treatment burden and preoccupation domains of the Comprehensive Assessment Tool of Challenges in Hemophilia questionnaire. Conclusion Overall, results were consistent with those reported in the male population enrolled in the HAVEN 6 study, suggesting efficacy and a favorable safety profile for emicizumab in females with non-severe HA warranting prophylaxis.
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Affiliation(s)
- Cedric Hermans
- Division of Haematology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Giuliana Ventriglia
- Product Development Clinical Science Hematology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Samya Obaji
- Cardiff Haemophilia Centre, University Hospital of Wales, Cardiff, United Kingdom
| | - Benjamin M. Beckermann
- Product Development Clinical Science Oncology & Hematology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Michaela Lehle
- Product Development Clinical Science Oncology & Hematology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | | | - Roseline d’Oiron
- Reference centre for Haemophilia and Rare Congenital Bleeding Disorders, Bicêtre Hospital AP-HP, University of Paris-Saclay and UMR-S1176 INSERM, Le Kremlin-Bicêtre, France
| | - Laurent Frenzel
- Centre de Traitement de l'Hémophilie, AP-HP, Hôpital Necker Enfants Malades, Paris, France
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Takeyama M, Matsumoto N, Abe H, Harada S, Ogiwara K, Furukawa S, Shimonishi N, Nakajima Y, Yada K, Soeda T, Nogami K. Coagulant potentials of emicizumab in the plasmas from infant and toddler patients with hemophilia A. Pediatr Blood Cancer 2023; 70:e30590. [PMID: 37467119 DOI: 10.1002/pbc.30590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Emicizumab significantly reduces bleedings in patients with hemophilia A (PwHA). A clinical study (HAVEN 7; NCT04431726) for PwHA aged less than or equal to 12 months is ongoing, but emicizumab-driven coagulation potential in PwHA in early childhood remains to be clarified. AIM To investigate the in vitro or in vivo coagulation potential of emicizumab in plasmas obtained from infant and toddler PwHA. METHODS Twenty-seven plasma samples from 14 infant/toddler PwHA (aged 0-42 months, median 19 months) who received emicizumab (n = 9), factor (F)VIII products (n = 8), or no treatment (n = 10) were obtained. FVIII activity in FVIII-treated plasmas was cancelled by the addition of anti-FVIII monoclonal antibody (mAb). Emicizumab-treated plasmas (in vivo) and emicizumab-spiked plasmas (in vitro) were analyzed. Emicizumab-untreated plasma or emicizumab-treated plasma supplemented with two anti-emicizumab mAbs were used as references. Adjusted maximum coagulation velocity (Ad|min1|) by clot waveform analysis and peak thrombin (Peak-Th) by thrombin generation assay was assessed. RESULTS Ad|min1| values in 24 samples were improved by the presence of emicizumab. Values did not improve in the three remaining samples (aged 1, 23, and 31 months). Although the presence of emicizumab showed an age-dependent increase in Peak-Th in 20 samples, this increase was not observed in seven samples (aged 0, 1, 1, 2, 8, 19, and 36 months). Emicizumab-dependent increases in both Ad|min1| and Peak-Th were shown in 18 samples, and increases in either parameter were shown in eight samples. One sample (from patient aged 1 month) showed no increase in both, however. CONCLUSION Emicizumab could improve coagulant potential in plasmas from infant/toddler patients with hemophilia A.
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Affiliation(s)
- Masahiro Takeyama
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | | | - Hiroto Abe
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | - Suguru Harada
- Chugai Pharmaceutical Co., Ltd., Yokohama, Kanagawa, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, Kashihara, Nara, Japan
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
- Division of Hemophilia, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | | | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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Cohen O, Levy-Mendelovich S, Budnik I, Ludan N, Lyskov SK, Livnat T, Avishai E, Efros O, Lubetsky A, Lalezari S, Misgav M, Brutman-Barazani T, Kenet G, Barg AA. Management of surgery in persons with hemophilia A receiving emicizumab prophylaxis: data from a national hemophilia treatment center. Res Pract Thromb Haemost 2023; 7:102178. [PMID: 37876894 PMCID: PMC10593567 DOI: 10.1016/j.rpth.2023.102178] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 07/06/2023] [Accepted: 07/09/2023] [Indexed: 10/26/2023] Open
Abstract
Background Persons with hemophilia A may require surgical procedures. Real-world data on invasive procedures in persons with hemophilia A receiving emicizumab prophylaxis are limited. Objectives To evaluate the safety of invasive procedures in persons with hemophilia A receiving emicizumab prophylaxis and their outcomes in a longitudinally followed cohort. Methods Data from medical records of persons with hemophilia A with and without factor VIII (FVIII) inhibitors longitudinally followed at our tertiary center, who received emicizumab prophylaxis and underwent all types of invasive procedures, were retrieved. Outcomes of interest were bleeding and thrombotic complications. Results Overall, 35 patients underwent 56 invasive procedures, 18 (32.1%) were major. The median age was 36.3 years (IQR, 8.8-55.9 years); 12 patients (34.3%) were younger than 18 years at the time of procedure; 17 (48.6%) were patients with FVIII inhibitors. Among major procedures, orthopedic surgeries prevailed. All patients who underwent major procedures received factor replacement with either recombinant activated factor VII (patients with inhibitors) or FVIII (patients without inhibitors). Factor concentrates were administered prior to 32 (84.2%) of the minor procedures. Repeated doses were given according to international expert opinion recommendations and patients' condition.There were 7 bleeding events in 6 patients, 5 were major bleeds, including 1 patient who underwent a minor procedure without factor replacement. None of the patients experienced a thrombotic complication. Conclusion Invasive procedures can be performed safely in patients receiving emicizumab prophylaxis with close surveillance after surgery. Factor concentrates may be advised in selected patients undergoing minor procedures.
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Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Sarina Levy-Mendelovich
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sheba Talpiot Medical leadership program, Sheba Medical Center, Tel Hashomer, Israel
| | - Ivan Budnik
- Division of Hematology/Oncology, Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Noa Ludan
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Tami Livnat
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Einat Avishai
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Efros
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aharon Lubetsky
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shadan Lalezari
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mudi Misgav
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Brutman-Barazani
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assaf A. Barg
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Hahn SM, Han JW, Kim JS, Shim YJ, Kim S, Kim HC, Park YS, Lyu CJ. Real-world data for the use of emicizumab in haemophilia A patients with inhibitors - First nationwide report from Korea. Haemophilia 2023; 29:1163-1166. [PMID: 37347590 DOI: 10.1111/hae.14819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/30/2023] [Accepted: 06/06/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Seung Min Hahn
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung Woo Han
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Seok Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Ye Jee Shim
- Department of Pediatrics, Keimyung University School of Medicine, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Soyon Kim
- Kim & Lee's Internal Medicine Clinic, Seoul, South Korea
| | - Hugh Chul Kim
- Kim & Lee's Internal Medicine Clinic, Seoul, South Korea
| | - Young Shil Park
- Department of Pediatrics, Kyung Hee University College of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, South Korea
| | - Chuhl Joo Lyu
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, South Korea
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Chen Y, Cheng SJ, Thornhill T, Solari P, Sullivan SD. Health care costs and resource use of managing hemophilia A: A targeted literature review. J Manag Care Spec Pharm 2023; 29:647-658. [PMID: 37276036 PMCID: PMC10387983 DOI: 10.18553/jmcp.2023.29.6.647] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND: Hemophilia A (HA) is a rare, inherited, serious bleeding disorder characterized by a deficiency of blood clotting factor VIII (FVIII). HA is associated with considerable economic burden. OBJECTIVE: To identify, review, and summarize published studies on the health care resource use and costs of managing HA in the United States using a targeted literature review. METHODS: A comprehensive and targeted literature search was conducted in Embase, MEDLINE, and Cochrane Database of Systematic Reviews covering the period 2010 to 2022. We supplemented the search by searching gray literature (relevant abstracts, posters, and presentations of relevant scientific conferences from the past 6 years [2016 to 2022], reference lists, the Institute for Clinical and Economic Review reports, and other sources). Eligibility criteria were developed based on the population, interventions, comparators, and outcomes framework. For comparability, costs were adjusted to 2021 US dollars. RESULTS: A total of 40 publications, including 17 full-text papers, 21 abstracts, and 2 Institute for Clinical and Economic Review reports, met eligibility criteria. Total annual health care costs per patient ranged from $213,874 to $869,940 and are mainly driven by the cost and intensity of prophylaxis with FVIII replacement concentrates, bypassing agents, and, most recently, emicizumab. Generally, we observed substantial heterogeneity in estimated treatment costs for HA, which varied depending on HA severity, treatment type and intensity, age, weight, and inhibitor status. Patients with inhibitors incurred much higher costs, but annual FVIII treatment costs are increasing over time among a subset of adult patients without inhibitors. Only 2 studies reported indirect costs; these were $13,220 and $27,978 annually among patients without and with inhibitors, respectively. Parents of children with HA spent $8,252 on non-mental health services and $258 on mental health services annually. CONCLUSIONS: The annual health care costs of managing HA are substantial and vary widely, depending on the study population definitions and intensity of prophylaxis. Total health care costs are dominated by the cost of prophylaxis. Indirect costs are also important. More robust studies in various settings, subpopulations, and assessing the impact of emerging therapies are required to fully elucidate the changing societal and economic impact, particularly regarding indirect costs and productivity loss for individuals living with HA. DISCLOSURES: Drs Solari and Thornhill are employees of Spark Therapeutics and Roche Group Shareholders. Ms Chen and Drs Cheng and Sullivan are employees of Curta, Inc. Spark Therapeutics paid Curta, Inc., to conduct the literature search. This study was funded by Spark Therapeutics. Spark Therapeutics was involved in the study design, collection, analysis and interpretation of data, article review, and the decision to submit the report for publication. Medical writing support was provided by Ashfield MedComms, an Inizio company.
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Affiliation(s)
- Yilin Chen
- CHOICE Institute, School of Pharmacy, University of Washington, Seattle
| | - Spencer J Cheng
- CHOICE Institute, School of Pharmacy, University of Washington, Seattle
| | | | | | - Sean D Sullivan
- CHOICE Institute, School of Pharmacy, University of Washington, Seattle
- Department of Health Policy, London School of Economics and Political Science, UK
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El Maamari J, Amid A, Pelland-Marcotte MC, Tole S. Between Scylla and Charybdis: thrombosis in children with hemophilia. Front Pediatr 2023; 11:1173549. [PMID: 37287631 PMCID: PMC10242037 DOI: 10.3389/fped.2023.1173549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/27/2023] [Indexed: 06/09/2023] Open
Abstract
Thromboembolism is an infrequent complication in children with hemophilia that has been traditionally associated with the presence of a central venous access device. Novel rebalancing agents have shown promising results as prophylactic therapies to minimize the risk of bleeding but both thromboembolism and thrombotic microangiopathy have been reported as complications. The management of thrombosis in children with hemophilia is particularly challenging given the inherent risk of bleeding. In this paper, we present clinical vignettes to review the literature, highlight challenges, and describe our approach to managing thromboembolism in children with hemophilia.
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Affiliation(s)
- Jad El Maamari
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, BC Children’s Hospital, Vancouver, BC, Canada
| | - Ali Amid
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, BC Children’s Hospital, Vancouver, BC, Canada
| | - Marie-Claude Pelland-Marcotte
- Division of Pediatric Hematology-Oncology, CHU deQuébec—Centre Mère-Enfant Soleil, Quebec City, QC, Canada
- Research Center of the CHU de Québec, Axe Reproduction, Santé de la Mère et de l’Enfant, Quebec City, Canada
| | - Soumitra Tole
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Department of Pediatrics, Division of Hematology/Oncology, London Health Sciences Centre, London, ON, Canada
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Castaman G, Linari S, Pieri L, Carulli C, Prosperi P, Tonelli P, Demartis F, Fjerza R, Attanasio M, Coppo M, Salvianti F. Safe and Successful Surgical Outcome in Persons with Hemophilia A with and without Inhibitors Treated with Emicizumab: A Large, Single Center, Real-World Experience. J Clin Med 2023; 12:jcm12062317. [PMID: 36983317 PMCID: PMC10055920 DOI: 10.3390/jcm12062317] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/09/2023] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
Emicizumab is a humanized recombinant bispecific antibody, bridging together activated factor IX (FIXa) and factor X (FX), thus mimicking the activity of FVIII in vivo. Emicizumab is designed for long-term prophylaxis in patients with severe hemophilia A with and without inhibitors. This approach provides constant protection, with significant reduction in bleeding rate and improved quality of life. However, protection provided by emicizumab is not absolute, and clotting factor concentrates (FVIII, rFVIIa, aPCC) may be necessary for post-traumatic bleeding or surgery, with a potential thrombotic risk or difficulty in preventing bleeding. Real world evidence is still scanty, especially for managing major surgery. In this study, 75 surgeries were managed in 28 patients (27 major procedures in 15 patients and 48 minor procedures in 20 patients. In 17 patients without inhibitors, 30 minor surgeries were carried out by using FVIII in 5, with only a bleeding event, which was successfully treated with FVIII concentrate. Six major surgeries were uneventfully performed with FVIII concentrate. Eleven PWHA and high-titer inhibitors underwent 39 surgical procedures (18 minor and 21 major surgeries). Minor surgeries were mostly performed without prophylaxis with rFVIIa, with only a single bleeding complication. All 21 major surgeries were covered with a homogeneous protocol using rFVIIa. In four instances, bleeding complications occurred, treated with rFVIIa. Of them, a single patient only failed to respond and died because of an uncontrollable bleeding from a large ruptured retroperitoneal pseudotumor. Surgery in patients with emicizumab can be safely carried out with the use of appropriate replacement therapy protocols.
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Affiliation(s)
- Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
- Correspondence: ; Tel.: +39-55-7947587
| | - Silvia Linari
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
| | - Lisa Pieri
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
| | - Christian Carulli
- Department of Orthopedic Surgery, University Hospital of Florence, 50139 Florence, Italy
| | - Paolo Prosperi
- Emergency Surgery Department, Careggi University Hospital, 50134 Florence, Italy
| | - Paolo Tonelli
- Department of Surgery and Translational Medicine, University of Florence, 50121 Florence, Italy
| | - Francesco Demartis
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
| | - Rajmonda Fjerza
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
| | - Monica Attanasio
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
| | - Mirella Coppo
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
| | - Francesca Salvianti
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, 50134 Florence, Italy
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Wall C, Xiang H, Palmer B, Chalmers E, Chowdary P, Collins PW, Fletcher S, Hall GW, Hart DP, Mathias M, Sartain P, Shapiro S, Stephensen D, Talks K, Hay CRM. Emicizumab prophylaxis in haemophilia A with inhibitors: Three years follow-up from the UK Haemophilia Centre Doctors' Organisation (UKHCDO). Haemophilia 2023; 29:743-752. [PMID: 36811304 DOI: 10.1111/hae.14762] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/20/2023] [Accepted: 01/29/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION The UK National Haemophilia Database (NHD) collects data from all UK persons with haemophilia A with inhibitors (PwHA-I). It is well-placed to investigate patient selection, clinical outcomes, drug safety and other issues not addressed in clinical trials of emicizumab. AIMS To determine safety, bleeding outcomes and early effects on joint health of emicizumab prophylaxis in a large, unselected cohort using national registry and patient reported Haemtrack (HT) data between 01 January 2018 and 30 September 2021. METHODS Prospectively collected bleeding outcomes were analysed in people with ≥6 months emicizumab HT data and compared with previous treatment if available. Change in paired Haemophilia Joint Health Scores (HJHS) were analysed in a subgroup. Adverse events (AEs) reports were collected and adjudicated centrally. RESULTS This analysis includes 117 PwHA-I. Mean annualised bleeding rate (ABR) was .32 (95% CI, .18; .39) over a median 42 months treatment with emicizumab. Within-person comparison (n = 74) demonstrated an 89% reduction in ABR after switching to emicizumab and an increase in zero treated bleed rate from 45 to 88% (p < .01). In a subgroup of 37 people, total HJHS improved in 36%, remained stable in 46% and deteriorated in 18%, with a median (IQR) within-person change of -2.0 (-9, 1.5) (p = .04). Three arterial thrombotic events were reported, two possibly drug related. Other AEs were generally non-severe and usually limited to early treatment, included cutaneous reactions (3.6%), headaches (1.4%), nausea (2.8%) and arthralgia (1.4%). CONCLUSIONS Emicizumab prophylaxis is associated with sustained low bleeding rates and was generally well-tolerated in people with haemophilia A and inhibitors.
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Affiliation(s)
| | - Hua Xiang
- National Haemophilia Database, Manchester, UK
| | - Ben Palmer
- National Haemophilia Database, Manchester, UK
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | | | | | | | - Daniel P Hart
- The Royal London Hospital, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Paul Sartain
- Patient Representative, The Haemophilia Society, UK
| | | | | | - Kate Talks
- Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Charles R M Hay
- Manchester Royal Infirmary, Manchester, UK.,National Haemophilia Database, Manchester, UK
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Pipe SW, Trzaskoma B, Minhas M, Lehle M, Ko RH, Gao L, Mahlangu J, Kempton CL, Kessler CM, Kruse-Jarres R. Efficacy of emicizumab is maintained throughout dosing intervals for bleed prophylaxis. Res Pract Thromb Haemost 2023; 7:100077. [PMID: 36908770 PMCID: PMC9992752 DOI: 10.1016/j.rpth.2023.100077] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/05/2022] [Accepted: 12/29/2022] [Indexed: 02/09/2023] Open
Abstract
Background Across the HAVEN clinical trial program, the efficacy of emicizumab has been demonstrated in children, adolescents, and adults with hemophilia A, with or without factor VIII inhibitors. After the 4-week loading dose period, emicizumab concentrations are expected to remain at levels that provide bleed protection throughout the entire dosing interval, regardless of the chosen maintenance dosing regimen, ie, weekly, every 2 weeks, or every 4 weeks. Objectives The objective of this study was to examine the timing of treated bleeds within the dosing intervals for emicizumab administered during the HAVEN 1 to 4 studies. Methods In this post hoc analysis, we pooled data from all the participants of the HAVEN 1 to 4 studies and analyzed the timing of treated bleeds in relation to the emicizumab dose. Results A total of 392 participants were included in this analysis, with a median (range) age of 28.0 years (1.1-77.0 years). Target joints were identified in 237 of 392 (60.5%) participants before the study entry. Overall, 211 of 392 (53.8%) participants experienced 907 treated bleeding events. The total mean (SD) annualized bleeding rate across the 4 studies was 1.6 (5.9). There was no evidence that bleeding events clustered on any 1 particular day in any dosing schedule from HAVEN 1 to 4 (P > .05 for all 3 treatment regimens). Conclusion Data from the HAVEN 1 to 4 trials show consistent bleed prevention within the dosing interval, regardless of the dosing regimen chosen. These findings provide further evidence of the sustained efficacy of emicizumab across all approved dosing regimens to reduce bleeding in people with hemophilia A.
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Affiliation(s)
- Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ben Trzaskoma
- US Medical Affairs, Genentech Inc, South San Francisco, California, USA
| | - Miranda Minhas
- US Medical Affairs, Genentech Inc, South San Francisco, California, USA
| | - Michaela Lehle
- Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Richard H Ko
- US Medical Affairs, Genentech Inc, South San Francisco, California, USA
| | - Ling Gao
- Analystat Corporation, Point Roberts, Washington, USA
| | - Johnny Mahlangu
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | - Christine L Kempton
- Department of Hematology and Medical Oncology and Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Craig M Kessler
- The Division of Coagulation, Georgetown University School of Medicine, Washington, DC, USA
| | - Rebecca Kruse-Jarres
- Division of Hematology, University of Washington and Washington Center for Bleeding Disorders, Seattle, Washington, USA
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Belletrutti M, Bhatt M, Samji N. Management of children with hemophilia A on emicizumab who need surgery. Front Pediatr 2023; 11:1155853. [PMID: 37082707 PMCID: PMC10110896 DOI: 10.3389/fped.2023.1155853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/14/2023] [Indexed: 04/22/2023] Open
Abstract
The introduction of emicizumab into the treatment regime of persons with hemophilia A has dramatically reduced frequency of bleeding in patients with and without inhibitors. However, in children with Hemophilia A (CwHA) who require surgical or other invasive procedures, additional treatment with factor replacement or other hemostatic agents may still be needed to prevent intraoperative or postoperative bleeding. This review will look at the reported outcomes in CwHA on emicizumab who have had surgery and propose recommendations for the best perioperative management of major and minor procedures.
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Affiliation(s)
- Mark Belletrutti
- BC Children’s Hospital, Oncology/Hematology/BMT, University of British Columbia, Vancouver, BC, Canada
- Correspondence: Mark Belletrutti
| | - Mihir Bhatt
- McMaster Children’s Hospital, Hematology/Oncology, McMaster University, Hamilton, ON, Canada
| | - Nasrin Samji
- McMaster Children’s Hospital, Hematology/Oncology, McMaster University, Hamilton, ON, Canada
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Peyvandi F, Kavakli K, El‐Beshlawy A, Rangarajan S. Management of haemophilia A with inhibitors: A regional cross-talk. Haemophilia 2022; 28:950-961. [PMID: 35868021 PMCID: PMC9796719 DOI: 10.1111/hae.14638] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/04/2022] [Accepted: 07/09/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The development of inhibitors with factor VIII (FVIII) replacement therapy is one of the most common and challenging complications of haemophilia A (HA) treatment, jeopardising treatment efficacy and predisposing patients to high risks of morbidity and mortality. The management of patients with inhibitors is particularly challenging in countries where resources are limited. AIM To provide a comprehensive summary of the management of HA with inhibitors while focusing on differences in practice between Western and non-Western countries and how resource scarcity can impact HA management, leading to suboptimal outcomes in patients with inhibitors. METHODS Summary of key evidence and regional expert opinion. RESULTS We address, particularly, the diagnosis of and testing for inhibitors, as well as the epidemiology of inhibitors, including incidence, prevalence and disease burden. Secondly, we provide an overview of the current treatment landscape in HA with inhibitors regarding the eradication of inhibitors with immune tolerance induction and the treatment and prevention of bleeding with bypassing agents, non-factor replacement agents and other experimental therapies. This is complemented with insights from the authors around the applicability of, and challenges associated with, such therapies in their settings of practice. CONCLUSIONS We conclude by proposing some key steps towards bridging the gaps in the management of HA with inhibitors in resource-limited countries, including: (1) the collection of quality data that can inform healthcare reforms and policies; (2) improving disease knowledge among healthcare practitioners and patients with the aim of standardising disease management across centres and (3) working towards promoting equal access to HA care and therapies for everyone.
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Affiliation(s)
- Flora Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly,Department of Pathophysiology and TransplantationUniversità degli Studi di MilanooMilanItaly
| | - Kaan Kavakli
- Department of Pediatric HematologyEge University Children's HospitalIzmirTurkey
| | - Amal El‐Beshlawy
- Department of Pediatric Hematology, Faculty of MedicineCairo UniversityCairoEgypt
| | - Savita Rangarajan
- Department of HaematologyUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK,Clinical Trials and Research UnitKJ Somaiya Super Specialty Hospital and Research CentreMumbaiIndia
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Sun SX, Frick A, Balasa V, Roberts JC. Real-world study of rurioctocog alfa pegol and emicizumab in US clinical practice among patients with hemophilia A. Expert Rev Hematol 2022; 15:943-950. [PMID: 36000620 DOI: 10.1080/17474086.2022.2112171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND FVIII replacement is standard treatment for hemophilia A without inhibitors, but non-factor therapies, such as emicizumab, are changing the treatment landscape. We explore the ramifications of switching treatment. METHODS Pharmacy database data (July 2017-May 2020) from patients with hemophilia A without inhibitors who switched to rurioctocog alfa pegol or emicizumab prophylaxis after ≥6 months' prophylaxis with another FVIII product were analyzed for total mean weekly consumption, dosing frequency, product wastage, and ABR. RESULTS Post-switch mean weekly consumption of prophylactic rurioctocog alfa pegol and emicizumab were 6224 IU/kg and 109 mg, respectively. Dosing schedules for emicizumab were primarily weekly (48.2%) and every 2 weeks (40.0%). Most patients in the rurioctocog alfa pegol cohort received treatment twice-weekly (83.3%). Mean product wastage of emicizumab (8.4%) was significantly higher versus rurioctocog alfa pegol (-0.3%; P < 0.001). Mean annualized emicizumab and rurioctocog alfa pegol wastage during prophylaxis was 330.82 mg and -974.80 IU, respectively. ABR change was not significantly different (P = 0.527) for patients switching to emicizumab (-1.05) or rurioctocog alfa pegol (-1.53). CONCLUSIONS Bleed rates were similar for patients receiving prophylaxis with emicizumab or rurioctocog alfa pegol after switching from prophylaxis with another FVIII. However, wastage associated with dispensing inaccuracies was greater with emicizumab.
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Affiliation(s)
- Shawn X Sun
- Takeda Development Center Americas, Inc, Global Evidence and Outcomes Department, Cambridge, MA, USA
| | - Andrew Frick
- Trio Health Inc, Analytics Department, Louisville, CO, USA
| | - Vinod Balasa
- Valley Chidren's Hospital, Hematology Department, Madera, CA, USA
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43
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Glonnegger H, Andresen F, Kapp F, Malvestiti S, Büchsel M, Zieger B. Emicizumab in children: bleeding episodes and outcome before and after transition to Emicizumab. BMC Pediatr 2022; 22:487. [PMID: 35965332 PMCID: PMC9377120 DOI: 10.1186/s12887-022-03546-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/05/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Real-world data and study data regarding therapy with Emicizumab in pediatric cohorts with haemophilia A is scarce. Especially, data on previously untreated pediatric patients (PUPs) and minimally treated patients (MTPs) are missing. METHODS Thirteen pediatric patients with haemophilia A and treatment with Emicizumab were retrospectively evaluated for Annual Bleeding Rates (ABR) pre-and post-Emicizumab treatment. Safety data and data on management of minor surgery as well as laboratory results were collected. Additionally, we describe the clinical features of two PUPs and one MTP that are included in our cohort. RESULTS Median age at initiation of Emicizumab was 5.3 (range: 0.26-17.5) years, three patients were younger than one year at initiation of treatment with Emicizumab. Median follow-up time on Emicizumab was 23.8 (range: 0.7-40) months. Total ABR (p = 0.009) as well as spontaneous (p = 0.018), traumatic (p = 0.018), and joint (p = 0.027) ABR reduced significantly post-Emicizumab transition. Safety profile was favourable as only one local site reaction occurred; no cessation of treatment was necessary. Surgery was successfully performed in three patients receiving rFVlla pre- and post-surgery. Emicizumab trough levels showed a median of 43.2 μg/ml (range: 23.9-56.8) after three doses of 3 mg/kg and 51.9 μg/ml (range: 30.4-75) at first follow-up with 1.5 mg/kg. CONCLUSION Emicizumab is safe and efficient in pediatric patients with and without inhibitors. More data on larger multicenter cohorts and especially on PUPs/MTPs are still needed.
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Affiliation(s)
- Hannah Glonnegger
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Felicia Andresen
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedrich Kapp
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefano Malvestiti
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Büchsel
- Institute of Clinical Chemistry and Laboratory Medicine, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Barbara Zieger
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Surgical outcomes in people with hemophilia A taking emicizumab prophylaxis: experience from the HAVEN 1-4 studies. Blood Adv 2022; 6:6140-6150. [PMID: 35939785 PMCID: PMC9768240 DOI: 10.1182/bloodadvances.2022007458] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 07/21/2022] [Accepted: 07/21/2022] [Indexed: 12/30/2022] Open
Abstract
Many people with hemophilia A (PwHA) undergo surgery in their lifetime, often because of complications of their disease. Emicizumab is the first bispecific monoclonal antibody prophylactic therapy for PwHA, and its efficacy and safety have been previously demonstrated; however, there is a need to build an evidence base on the management of PwHA on emicizumab undergoing surgery. Data from the HAVEN 1-4 phase 3 clinical trials were pooled to provide a summary of all minor and major surgeries in PwHA with or without factor VIII (FVIII) inhibitors who were receiving emicizumab prophylaxis. Overall, 233 surgeries were carried out during the HAVEN 1-4 trials: 215 minor surgeries (including minor dental and joint procedures, central venous access device placement or removal, and endoscopies) in 115 PwHA (64 with FVIII inhibitors) and 18 major surgeries (including arthroplasty and synovectomy) in 18 PwHA (10 with FVIII inhibitors). Perioperative hemostatic support was at the discretion of the treating physician. Overall, the median (interquartile range [IQR]) age was 33.5 (13.0-49.0) years and the median (IQR) emicizumab exposure time before surgery was 278.0 (177.0-431.0) days. Among the 215 minor surgeries, 141 (65.6%) were managed without additional prophylactic factor concentrate, and of those, 121 (85.8%) were not associated with a postoperative bleed. The majority (15 of 18 [83.3%]) of major surgeries were managed with additional prophylactic factor concentrate. Twelve (80.0%) of these 15 surgeries were associated with no intraoperative or postoperative bleeds. The data demonstrate that minor and major surgeries can be performed safely in PwHA receiving emicizumab prophylaxis. These trials are registered at www.clinicaltrials.gov as #NCT02622321, #NCT02795767, #NCT02847637, and #NCT03020160.
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Mahajerin A, Faghmous I, Kuebler P, Howard M, Xu T, Flores C, Chang T, Nissen F. Channeling effects in the prescription of new therapies: the case of emicizumab for hemophilia A. J Comp Eff Res 2022; 11:717-728. [PMID: 35535702 DOI: 10.2217/cer-2021-0278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To determine if emicizumab was channeled to clinically complex people with hemophilia A upon approval. Methods: Claims data (16 November 2017, through 31 December 2019) from US-based insurance databases were analyzed to compare the clinical complexity of people with hemophilia A initiating emicizumab with matched individuals receiving factor VIII (FVIII) episodically or prophylactically. People with hemophilia A with evidence of previous bypassing agent use (indicating FVIII inhibitors) were excluded. Outcomes included bleeding events, arthropathy, pain, comorbidities and healthcare costs. Results: A larger proportion of emicizumab users had bleeding events, comorbidities and arthropathy and greater healthcare costs in the year prior to starting emicizumab compared with FVIII users. Conclusion: Claims-based data limitations prevent an absolute conclusion. Nevertheless, emicizumab users appear more clinically complex than FVIII users, suggesting post-approval channeling.
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Affiliation(s)
- Arash Mahajerin
- Divisions of Pediatric Hematology and Oncology, University of California, Irvine and CHOC Children's Specialists, Irvine, CA 92868, USA
| | - Imi Faghmous
- Department of Real-World Data Oncology-Hematology, F Hoffmann-La Roche Ltd., Basel, CH-4070, Switzerland.,Current affiliation: Faculty of Health, Medicine and Life Sciences, University of Maastricht, Maastricht, P Debyeplein15, DEB15, 6229 HA, The Netherlands
| | - Peter Kuebler
- Department of Personalized Healthcare Safety Interface, Genentech, Inc., South San Francisco, CA 94080, USA
| | - Monet Howard
- Department of Clinical Safety, F Hoffmann-La Roche Ltd., Mississauga, ON, L5N 5M8, Canada
| | - Tao Xu
- Department of Personalized Healthcare Product Development, F Hoffmann-La Roche Ltd., Basel, CH-4070, Switzerland
| | - Carlos Flores
- Department of Evidence Strategy, Genesis Research, Hoboken, NJ 07030, USA
| | - Tiffany Chang
- Department of Personalized Healthcare Safety Interface, Genentech, Inc., South San Francisco, CA 94080, USA.,Current affiliation: Department of Hematology, Spark Therapeutics, PA 19104, USA
| | - Francis Nissen
- Department of Real-World Data Oncology-Hematology, F Hoffmann-La Roche Ltd., Basel, CH-4070, Switzerland
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Mahlangu J, Iorio A, Kenet G. Emicizumab state-of-the-art update. Haemophilia 2022; 28 Suppl 4:103-110. [PMID: 35521723 PMCID: PMC9321850 DOI: 10.1111/hae.14524] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/15/2022] [Accepted: 02/15/2022] [Indexed: 12/20/2022]
Abstract
Introduction Emicizumab is a bispecific monoclonal antibody developed to address the unmet needs of clotting factor replacement therapy and has become the benchmark for optimal prophylaxis in managing patients with haemophilia A with inhibitors. We describe the emicizumab rollout and pharmacokinetic strategies and their use in paediatric patients. Methods The evolving real‐world experience in using emicizumab has confirmed its safety, efficacy and pharmacokinetic profile in paediatric, adolescent and adult patients receiving emicizumab at various prophylactic dosing regimens. The emicizumab current global rollout includes over 100 countries with 29 low to middle‐income countries accessing emicizumab through the World Federation of Haemophilia (WFH) Humanitarian Aid Program. The diversity of emicizumab dosing and pharmacokinetic tools such as the Calibra® and the WAPPS‐Hemo platforms make it possible to achieve prophylaxis goals in line with the WFH Haemophilia treatment guidelines recommendations, with minimal drug wastage. The emerging experience from long term clinical trials and long‐term real‐world follow‐up confirm the safety, efficacy, and pharmacokinetic profile of emicizumab in paediatric haemophilia A patients. A few questions, including inhibitor recurrence, concurrent use of emicizumab with various replacement therapies and inhibitor eradication, are being addressed through multiple ongoing clinical studies. Conclusion The current global rollout of emicizumab is remarkable, and versatile dosing regimens and evolving pharmacokinetic tools such as the Calibra® and WAPPS‐Hemo platforms make it a treatment choice available also for pharmacokinetic guided personalised treatment. Data from paediatric studies are consistent with those seen in adolescent and adult Haemophilia A.
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Affiliation(s)
- Johnny Mahlangu
- Haemophilia Comprehensive Care Centre, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand and NHLS, Johannesburg, South Africa
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence and Impact (HEI), Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gili Kenet
- National Hemophilia, Center, Sheba Medical Center, Tel Hashomer, Israel.,Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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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: 10] [Impact Index Per Article: 3.3] [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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Escobar M, Dunn A, Quon D, Trzaskoma B, Lee L, Ko RH, Carpenter SL. A phase IV, multicentre, open-label study of emicizumab prophylaxis in people with haemophilia A with or without FVIII inhibitors undergoing minor surgical procedures. Haemophilia 2022; 28:e105-e108. [PMID: 35510949 PMCID: PMC9544354 DOI: 10.1111/hae.14574] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/17/2022] [Accepted: 04/09/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Miguel Escobar
- University of Texas Health Science Center, Houston, Texas, USA
| | - Amy Dunn
- Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Doris Quon
- Orthopedic Hemophilia Treatment Center, Los Angeles, California, USA
| | - Ben Trzaskoma
- Genentech, Inc., South San Francisco, California, USA
| | - Lucy Lee
- Genentech, Inc., South San Francisco, California, USA
| | - Richard H Ko
- Genentech, Inc., South San Francisco, California, USA
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Wieland I. Emicizumab for All Pediatric Patients with Severe Hemophilia A. Hamostaseologie 2022; 42:104-115. [PMID: 35488163 DOI: 10.1055/a-1727-1384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Emicizumab is the first approved nonreplacement therapy for bleeding prophylaxis in hemophilia A (HA) patients. In 2018, it was licensed for HA patients with inhibitors, subsequently followed by an "European Medicines Agency (EMA)" approval for patients with severe HA in the absence of inhibitors in 2019. This is immediately raising the question whether emicizumab is suitable as a first-line treatment for all pediatric patients with severe HA. In this review, we want to discuss what we have, what we know, and what we would like to know. Severe HA is characterized by severe spontaneous and traumatic bleedings, particularly into muscles and joints leading to chronic joint damage. Standard of care is the regular, prophylactic replacement of factor VIII to prevent bleedings. Due to approval of emicizumab-the first nonreplacement therapy for bleeding prophylaxis-in HA patients with inhibitors, and severe HA patients without inhibitors, it is of pivotal interest whether emicizumab could be the first-line treatment in all pediatric patients with severe HA. Clinical trials and real-world observational studies could demonstrate a good efficacy and safety for bleeding prevention during emicizumab treatment in HA patients with and without inhibitors. This clearly indicates that emicizumab could improve HA treatment. However, some crucial and critical questions are remaining with regard to the use of emicizumab. Some of this missing information is already under investigation in the context of clinical trials. Until getting finalized data to shed insights into the points that are currently being discussed, there is a variety of expert and expert group recommendations, which are tackling questions concerning the treatment of HA patients. This review will address major information that is already available, but will also focus on important points that remain to be elucidated in the context of HA treatment.
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Affiliation(s)
- Ivonne Wieland
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
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Ozelo MC, Yamaguti‐Hayakawa GG. Impact of novel hemophilia therapies around the world. Res Pract Thromb Haemost 2022; 6:e12695. [PMID: 35434467 PMCID: PMC9004233 DOI: 10.1002/rth2.12695] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/02/2022] [Accepted: 03/22/2022] [Indexed: 12/22/2022] Open
Abstract
Hemophilia A and B are hereditary bleeding disorders, characterized by factor VIII or IX deficiencies, respectively. For many decades, prophylaxis with coagulation factor concentrates (replacement therapy) was the standard‐of‐care approach in hemophilia. Since the 1950s, when prophylaxis started, factor concentrates have been improved with virus inactivation and molecule modification to extend its half‐life. The past years have brought an intense revolution in hemophilia care, with the development of nonfactor therapy and gene therapy. Emicizumab is the first and only nonreplacement agent to be licensed for prophylaxis in people with hemophilia A, and real‐world data show similar efficacy and safety from the pivotal studies. Other nonreplacement agents and gene therapy have ongoing studies with promising results. Innovative approaches, like subcutaneous factor VIII and lipid nanoparticles, are in the preclinical phase. These novel agents, such as extended half‐life concentrates and emicizumab, have been available in resource‐constrained countries through the constant efforts of the World Federation of Haemophilia Humanitarian Aid Program. Despite the wide range of new approaches and therapies, the main challenge remains the same: to guarantee treatment for all. In this article, we discuss the evolution of hemophilia care, global access to hemophilia treatment, and the current and future strategies that are now under development. Finally, we summarize relevant new data on this topic presented at the ISTH 2021 virtual congress.
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Affiliation(s)
- Margareth C. Ozelo
- Hemocentro UNICAMP University of Campinas Campinas Brazil
- Department of Internal Medicine School of Medical Sciences University of Campinas UNICAMP Campinas Brazil
| | - Gabriela G. Yamaguti‐Hayakawa
- Hemocentro UNICAMP University of Campinas Campinas Brazil
- Department of Internal Medicine School of Medical Sciences University of Campinas UNICAMP Campinas Brazil
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