1
|
Shima M, Takedani H, Kitsukawa K, Taki M, Ishiguro A, Nagao A, Yamaguchi-Suita H, Kyogoku Y, Yoshida S, Nogami K. AOZORA: long-term safety and joint health in paediatric persons with haemophilia A without factor VIII inhibitors receiving emicizumab - protocol for a multicentre, open-label, phase IV clinical study. BMJ Open 2022; 12:e059667. [PMID: 35697445 PMCID: PMC9196178 DOI: 10.1136/bmjopen-2021-059667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Persons with haemophilia A (PwHA) commonly experience regular bleeding into joints, which may result in joint damage and complications such as degenerative arthritis. Emicizumab has previously demonstrated efficacy in reducing the occurrence of joint bleeds and target joints, along with having a favourable safety profile; however, data on the long-term effects on joint health are lacking. The AOZORA study will evaluate the long-term safety and joint health of paediatric PwHA without factor (F)VIII inhibitors taking emicizumab; here, we report the details of the study protocol and baseline data. METHODS AND ANALYSIS AOZORA is a multicentre, open-label, phase IV clinical study in Japan that aims to enrol approximately 30 PwHA aged <12 years without FVIII inhibitors. The primary endpoints include a long-term safety evaluation of adverse events, laboratory test abnormalities and FVIII inhibitor development; and a long-term joint health assessment using MRI and the Hemophilia Joint Health Score. Exploratory endpoints include characterising participants' physical activities and the number of activity-related bleeds requiring coagulation factor treatment. Currently, 30 participants have been enrolled, including 20 emicizumab-naïve participants and 10 who transferred from HOHOEMI, a previous study in paediatric PwHA. ETHICS AND DISSEMINATION The AOZORA study was approved by the Institutional Review Boards of Nara Medical University and the St Marianna University Group. The study will be conducted in compliance with the Declaration of Helsinki, the standards stipulated in paragraph 3 of Article 14 and Article 80-2 of the Pharmaceuticals, Medical Devices and Other Therapeutic Products Act, the Ministerial Ordinance on Good Clinical Practice and the Ministerial Ordinance on Good Post-marketing Study Practice. Data will be published in peer-reviewed journals and presented at Global congresses. TRIAL REGISTRATION NUMBER JapicCTI-194701.
Collapse
Affiliation(s)
- Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Hideyuki Takedani
- Department of Joint Surgery, IMSUT Hospital, The University of Tokyo, Tokyo, Japan
| | - Kaoru Kitsukawa
- Department of Radiology, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Masashi Taki
- Department of Pediatrics, St Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Akira Ishiguro
- Division of Hematology, National Center for Child Health and Development, Tokyo, Japan
| | - Azusa Nagao
- Department of Blood Coagulation, Ogikubo Hospital, Tokyo, Japan
| | | | - Yui Kyogoku
- Medical Affairs Division, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Seitaro Yoshida
- Clinical Development Division, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| |
Collapse
|
2
|
Mahlangu J, Levy H, Lee M, Del Greco F. Efficacy and safety of subcutaneous prophylaxis with dalcinonacog alfa in adults with haemophilia B. Haemophilia 2021; 27:574-580. [PMID: 33960073 PMCID: PMC8359950 DOI: 10.1111/hae.14315] [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: 12/28/2020] [Revised: 04/01/2021] [Accepted: 04/03/2021] [Indexed: 11/29/2022]
Abstract
Aim Phase 2b study to assess efficacy, safety, thrombogenicity, immunogenicity and tolerability with 28 days of daily dosing of subcutaneous (SQ) dalcinonacog alfa as prophylaxis for haemophilia B (HB). Methods Adult males with a confirmed diagnosis of congenital HB (factor IX [FIX] activity <2%) received daily dalcinonacog alfa 100 IU/kg SQ until day 28. The primary efficacy endpoint was the number of participants who achieved a steady‐state FIX activity level ≥12%. Tolerability, thrombogenicity and immunogenicity were study safety endpoints. Results Of 6 participants who received study drug, one discontinued the study on day 7 due to injection‐site reactions (ISR). Of the 5 participants completing the study, FIX activity level exceeded 12% in 3 participants at day 7, increasing to 4 participants on days 14, 21 and 28 and all 5 at day 29. Pharmacokinetic findings (including mean alpha and beta half‐life of 5.3 days and 3.9 days, respectively, and mean residence time of 6.2 days) supported prolonged effects. Thrombogenicity markers remained normal throughout prophylactic injections or showed some initial increases followed by decreases with continued dosing. Two participants had anti‐drug antibodies to dalcinonacog alfa at study end, none had neutralizing antibody. Two participants had ISR, both resolved. Reports of redness, swelling, tenderness or pain among the first 3 participants prompted dose‐splitting for the last 3 participants, leading to fewer ISR. Conclusion Subcutaneous dalcinonacog alfa is effective in raising FIX levels into the mild haemophilia range, comparable to intravenous extended half‐life FIX clotting factors.
Collapse
Affiliation(s)
- Johnny Mahlangu
- Haemophilia Comprehensive Care Center, Charlotte Maxeke Johannesburg Academic Hospital, and University of the Witwatersrand, Johannesburg, South Africa
| | - Howard Levy
- Catalyst Biosciences, San Francisco, CA, USA
| | - Martin Lee
- Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | | |
Collapse
|
3
|
Nichols TC, Levy H, Merricks EP, Raymer RA, Lee ML. Preclinical evaluation of a next-generation, subcutaneously administered, coagulation factor IX variant, dalcinonacog alfa. PLoS One 2020; 15:e0240896. [PMID: 33112889 PMCID: PMC7592742 DOI: 10.1371/journal.pone.0240896] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 10/05/2020] [Indexed: 01/12/2023] Open
Abstract
Introduction The rapid clearance of factor IX necessitates frequent intravenous administrations to achieve effective prophylaxis for patients with hemophilia B. Subcutaneous administration has historically been limited by low bioavailability and potency. Dalcinonacog alfa was developed using a rational design approach to be a subcutaneously administered, next-generation coagulation prophylactic factor IX therapy. Aim This study aimed to investigate the pharmacokinetic, pharmacodynamic, and safety profile of dalcinonacog alfa administered subcutaneously in hemophilia B dogs. Methods Two hemophilia B dogs received single-dose daily subcutaneous dalcinonacog alfa injections for six days. Factor IX antigen and activity, whole blood clotting time, and activated partial thromboplastin time were measured at various time points. Additionally, safety assessments for clinical adverse events and evaluations of laboratory test results were conducted. Results There was an increase in plasma factor IX antigen with daily subcutaneous dalcinonacog alfa. Bioavailability of subcutaneous dalcinonacog alfa was 10.3% in hemophilia B dogs. Daily subcutaneous dosing of dalcinonacog alfa demonstrated the effects of bioavailability, time to maximal concentration, and half-life by reaching a steady-state activity sufficient to correct severe hemophilia to normal, after four days. Conclusion The increased potency of dalcinonacog alfa facilitated the initiation and completion of the Phase 1/2 subcutaneous dosing study in individuals with hemophilia B.
Collapse
Affiliation(s)
- Timothy C. Nichols
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Howard Levy
- Catalyst Biosciences, South San Francisco, California, United States of America
- * E-mail:
| | - Elizabeth P. Merricks
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Robin A. Raymer
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Martin L. Lee
- Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, California, United States of America
| |
Collapse
|
4
|
Scott MJ, Xiang H, Hart DP, Palmer B, Collins PW, Stephensen D, Sima CS, Hay CRM. Treatment regimens and outcomes in severe and moderate haemophilia A in the UK: The THUNDER study. Haemophilia 2018; 25:205-212. [DOI: 10.1111/hae.13616] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/25/2018] [Accepted: 09/08/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Martin J. Scott
- UK National Haemophilia Database Manchester UK
- University Department of Clinical Haematology Manchester Royal Infirmary Manchester UK
- Institute of Cancer Sciences, Faculty of Biology, Medicine and Health The University of Manchester Manchester UK
| | - Hua Xiang
- UK National Haemophilia Database Manchester UK
| | - Daniel P. Hart
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry Queen Mary University London London UK
| | | | - Peter W. Collins
- School of Medicine Cardiff University, University Hospital of Wales Cardiff UK
| | - David Stephensen
- The Royal London Hospital Haemophilia Centre, Barts and The London School of Medicine and Dentistry Queen Mary University London London UK
- Kent Haemophilia & Thrombosis Centre East Kent Hospitals University NHS Trust Canterbury UK
| | | | - Charles R. M. Hay
- UK National Haemophilia Database Manchester UK
- University Department of Clinical Haematology Manchester Royal Infirmary Manchester UK
- School of Vascular Medicine The University of Manchester Manchester UK
| |
Collapse
|
5
|
Dubé E, Bonnefoy A, Merlen C, Castilloux JF, Cloutier S, Demers C, Sabapathy CA, St-Louis J, Vezina C, Warner M, Rivard GÉ. A prospective surveillance study of inhibitor development in haemophilia A patients following a population switch to a third-generation B-domain-deleted recombinant factor VIII. Haemophilia 2018; 24:236-244. [DOI: 10.1111/hae.13410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2018] [Indexed: 01/04/2023]
Affiliation(s)
- E. Dubé
- Centre Hospitalier Universitaire Sainte-Justine; Montréal QC Canada
| | - A. Bonnefoy
- Centre Hospitalier Universitaire Sainte-Justine; Montréal QC Canada
| | - C. Merlen
- Centre Hospitalier Universitaire Sainte-Justine; Montréal QC Canada
| | - J.-F. Castilloux
- Centre Hospitalier Universitaire de Sherbrooke; Université Sherbrooke; Sherbrooke QC Canada
| | - S. Cloutier
- Centre Hospitalier Universitaire de Québec; Hôpital de l'Enfant Jésus; Québec QC Canada
| | - C. Demers
- Centre Hospitalier Universitaire de Québec; Hôpital de l'Enfant Jésus; Québec QC Canada
| | - C. A. Sabapathy
- McGill University Health Center; Montreal Children's Hospital; Montréal QC Canada
| | - J. St-Louis
- Centre Hospitalier Universitaire Sainte-Justine; Montréal QC Canada
- Hôpital Maisonneuve-Rosemont; Montréal QC Canada
| | - C. Vezina
- McGill University Health Center; Montreal Children's Hospital; Montréal QC Canada
| | - M. Warner
- McGill University Health Center; Montreal Children's Hospital; Montréal QC Canada
| | - G.-É. Rivard
- Centre Hospitalier Universitaire Sainte-Justine; Montréal QC Canada
| |
Collapse
|
6
|
Crivianu-Gaita V, Rivard GE, Carcao M, Teitel J, St-Louis J, Blanchette V, Pullenayegum E, Abad A, Feldman BM. Pilot study of once-a-day prophylaxis for youth and young adults with severe haemophilia A. Haemophilia 2016; 22:e401-5. [PMID: 27481574 DOI: 10.1111/hae.13058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Standard prophylaxis has been shown to be an effective treatment for severe haemophilia A. According to pharmacokinetic principles, daily factor infusions of smaller doses can maintain similar trough factor VIII (FVIII) levels, and perhaps the same protection as standard prophylaxis. AIM This multicentre study examined the feasibility of daily prophylaxis for youth and young adults with severe haemophilia A in Montreal and Toronto. METHODS Bleeding rates, joint status, quality of life and physical activity were monitored for 14 patients during this study. At baseline, subjects continued their regular treatment regimen and switched to daily prophylaxis after 4 months; nine had begun daily prophylaxis before enrolment. Additional visits occurred at 8 and 12 months which included a physical examination, inhibitor testing, HJHS and FISH assessments, the CHO-KLAT/Haemo-QoL-A and PDPAR. Treatment satisfaction was assessed using the Treatment Satisfaction Questionnaire for Medication ver.II and perceived difficulty questions at the end of study. RESULTS AND CONCLUSIONS There were no significant changes in quality of life except for concerns with the demanding daily infusion schedule. The number of bleeds did not statistically differ from the initial 4 months of the study to the last 8 months. Monthly bleeding rates from the year prior to the study and during the intervention phase were not statistically different. It was also found that daily prophylaxis used 24% less FVIII compared to standard prophylaxis. Taking all of this into account, we have found that providing daily prophylaxis is feasible and that it is feasible to prospectively study daily prophylaxis in youth and young adults.
Collapse
Affiliation(s)
- V Crivianu-Gaita
- Department of Chemistry, University of Toronto, Toronto, ON, Canada
| | - G E Rivard
- Division of Haematology/Oncology, Department of Paediatrics, Université de Montréal, CHU Sainte-Justine, Montreal, QC, Canada
| | - M Carcao
- Division of Haematology/Oncology, Department of Paediatrics and Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - J Teitel
- Division of Hematology and Oncology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - J St-Louis
- Hematology and Oncology Service, CHU Sainte-Justine, Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - V Blanchette
- Department of Pediatrics, University of Toronto, Pediatric Comprehensive Care Hemophilia Program, Division of Hematology/Oncology, Hospital for Sick Children, Toronto, ON, Canada
| | - E Pullenayegum
- Child Health Evaluative Sciences, The Hospital for Sick Children, The Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - A Abad
- Child Health Evaluative Sciences, The Hospital for Sick Children, The Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - B M Feldman
- Department of Pediatrics, Faculty of Medicine and the Institute of Health Policy Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Child Health Evaluative Sciences, Toronto, ON, Canada. .,Division of Rheumatology, The Hospital for Sick Children, Toronto, ON, Canada.
| |
Collapse
|
7
|
Abdel Ghany HM, Hassab HMA, El-Noueam KI. Hemophilic arthropathy: clinical, radiologic, and functional evaluation: a single-center experience in a limited resource country. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2016. [DOI: 10.4103/1110-161x.177425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
8
|
Valizadeh L, Hosseini FA, Zamanzadeh V, Heidarnezhad F, Jasemi M, Lankarani KB. Practice of Iranian Adolescents with Hemophilia in Prevention of Complications of Hemophilia. Indian J Palliat Care 2015; 21:328-37. [PMID: 26600702 PMCID: PMC4617041 DOI: 10.4103/0973-1075.164895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Prerequisite for management of a chronic disease involves knowledge about its complications and their prevention. Hemophilia in adolescents influences all the aspects of their lives and thier performance. OBJECTIVES The present study aimed to determine the performance of Iranian hemophilic adolescents in prevention of disease complications. PATIENTS AND METHODS In this descriptive-analytical study, 108 adolescents with hemophilia were selected through convenience sampling. Their performance in preventing the complications of hemophilia was evaluated by sending a semi-structured questionnaire to their addresses throughout Iran. Then, the data was analysed using the Statistical Package for Social Sciences (SPSS) software (v. 13) and descriptive and interferential statistics were used. RESULTS Overall, 32.1% of the participants controlled bleeding during the 1(st) hour. Inaccessibility of coagulation products was mainly responsible for inhibiting timely and proper bleeding control. In order to relieve bleeding associated pain, only 39.0% of the adolescents used analgesics. On the other hand, 19.8% of the subjects used nonpharmacological methods to relieve pain. The majority of the adolescents did not participate in sport activities (65.4%) others allocated less than 5 hours a week to physical activities (70.5%). In addition, the participants did not have favorable dietary patterns, exercise habits, and dental care. The results showed a significant relationship between the adolescents' preventive practice with coagulation disorders and utilization of pharmacological pain relief methods. Also, significant relationships were found between severity of the disease; participating in physical activities, number of hours of physical activities; and disease complications. CONCLUSIONS Iranian adolescents did not exhibit favorable practices towards complication prevention.
Collapse
Affiliation(s)
- Leila Valizadeh
- Department of Child and Family Health, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fahimeh Alsadat Hosseini
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Vahid Zamanzadeh
- Department of Medical-Surgical Nursing, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Heidarnezhad
- Department of Medical-Surgical Nursing, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Madineh Jasemi
- Department of Medical-Surgical Nursing, Urmia University of Medical Sciences, Urmia, Iran
| | - Kamran Bagheri Lankarani
- Department of Medical-Surgical Nursing, Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
9
|
Abstract
Primary prophylaxis is the standard of care for children and adolescents with severe haemophilia; however, its role in adults is less well defined. To establish to which extent prophylaxis is currently being used in adults with severe haemophilia A, we conducted a systematic review of the literature by searching MEDLINE using the terms "prophylaxis", "adult", "severe" and "haemophilia A". Evidence-based guidelines and national studies relating to the use of prophylaxis in adults with severe haemophilia A were identified and reviewed. One published evidence-based guideline and three published studies fulfilled our inclusion criteria. A combined analysis of published data suggests that almost 45% of adult patients with severe haemophilia A are being treated with prophylaxis. Withdrawal of prophylaxis is attempted relatively infrequently; however, when attempted, around 27% of adolescents and adults with severe haemophilia do not experience an increase in bleeding tendency over a specific treatment period. Prophylaxis (primary and secondary) is an important part of haemophilia treatment that should be granted to all patients depending on their clinical presentation. Further studies are needed to better define this treatment strategy in adults.
Collapse
Affiliation(s)
- Johannes Oldenburg
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany.
| | - Hans-Hermann Brackmann
- Institute of Experimental Haematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| |
Collapse
|
10
|
Traore AN, Chan AKC, Webert KE, Heddle N, Ritchie B, St‐Louis J, Teitel J, Lillicrap D, Iorio A, Walker I. First analysis of 10‐year trends in national factor concentrates usage in haemophilia: data from
CHARMS
, the Canadian Hemophilia Assessment and Resource Management System. Haemophilia 2014; 20:e251-9. [PMID: 24948405 PMCID: PMC4140609 DOI: 10.1111/hae.12477] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2014] [Indexed: 11/27/2022]
Affiliation(s)
- A. N. Traore
- McMaster Transfusion Research ProgramMcMaster University Hamilton Ontario Canada
| | - A. K. C. Chan
- Department of PediatricsMcMaster University Hamilton Ontario Canada
| | - K. E. Webert
- Department of Medicine McMaster University Hamilton OntarioCanada
| | - N. Heddle
- Department of Medicine McMaster University Hamilton OntarioCanada
| | - B. Ritchie
- Department of Medicine University of Alberta Edmonton AlbertaCanada
| | - J. St‐Louis
- Department of Hematology Hôpital Maisonneuve‐Rosemont and Université de Montréal Montreal QuebecCanada
| | - J. Teitel
- St. Michael's Hospital Toronto & Central Ontario Hemophilia Program TorontoOntario Canada
| | - D. Lillicrap
- Department of Pathology and Molecular Medicine Queen's University KingstonOntario Canada
| | - A. Iorio
- Clinical Epidemiology and Biostatistics McMaster University Hamilton Ontario Canada
| | - I. Walker
- Department of Medicine McMaster University Hamilton OntarioCanada
| |
Collapse
|
11
|
Aznar JA, Marco A, Jiménez-Yuste V, Fernández-Fontecha E, Pérez R, Soto I, Parra R, Moreno M, Mingot ME, Moret A. Is on-demand treatment effective in patients with severe haemophilia? Haemophilia 2012; 18:738-42. [PMID: 22537601 DOI: 10.1111/j.1365-2516.2012.02806.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
On-demand therapy enables stopping haemorrhages rapidly, reducing joint pain and restoring joint mobility, but does not prevent the beginning and subsequent development of haemophilic arthropathy. The main objective of this study was to identify the clinical and orthopaedic status of severe haemophilic patients with bleeding phenotype receiving on-demand treatment in Spain. We conducted an epidemiological, observational, retrospective study, recruiting 167 patients from 36 centres (92% of them with haemophilia A), median age at enrolment of 35 years. Forty per cent of the patients received a combination of on-demand and short-term prophylaxis regimen; the rest was under on-demand treatment. One hundred and forty-five patients (87%) reported at least one bleeding episode and 22 (13%) of the biologically severe patients had no bleeding phenotype. Seventy-one per cent of the studied population presented established haemophilic arthropathy, reaching 80% if we exclude patients without bleeding phenotype. Forty-three per cent of these patients had one or two joints affected, 28% of them had three or four affected joints, 20% reported five or six affected joints and 9% more than six injured joints. An increase in established haemophilic arthropathy with age was observed. Forty-six patients underwent orthopaedic surgery at least once. These data show that on-demand therapy is not effective in preventing the development of haemophilic arthropathy in severe haemophilic population with bleeding phenotype. Therefore, we suggest that the optimal treatment in these patients should be based on prophylaxis. We recommend analysing the reasons for ending prophylaxis, in case its reinstatement should be necessary.
Collapse
Affiliation(s)
- J A Aznar
- Haemostasis and Thrombosis Unit, University and Polytechnic Hospital La Fe, Valencia.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Knobe K, Berntorp E. Haemophilia and joint disease: pathophysiology, evaluation, and management. JOURNAL OF COMORBIDITY 2011; 1:51-59. [PMID: 29090136 PMCID: PMC5556421 DOI: 10.15256/joc.2011.1.2] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 12/01/2011] [Indexed: 12/25/2022]
Abstract
In patients with haemophilia, regular replacement therapy with clotting factor concentrates (prophylaxis) is effective in preventing recurrent bleeding episodes into joints and muscles. However, despite this success, intra-articular and intramuscular bleeding is still a major clinical manifestation of the disease. Bleeding most commonly occurs in the knees, elbows, and ankles, and is often evident from early childhood. The pathogenesis of haemophilic arthropathy is multifactorial, with changes occurring in the synovium, bone, cartilage, and blood vessels. Recurrent joint bleeding causes synovial proliferation and inflammation (haemophilic synovitis) that contribute to end-stage degeneration (haemophilic arthropathy); with pain and limitation of motion severely affecting patients' quality of life. If joint bleeding is not treated adequately, it tends to recur, resulting in a vicious cycle that must be broken to prevent the development of chronic synovitis and degenerative arthritis. Effective prevention and management of haemophilic arthropathy includes the use of early, aggressive prophylaxis with factor replacement therapies, as well as elective procedures, including restorative physical therapy, analgesia, aspiration, synovectomy, and orthopaedic surgery. Optimal treatment of patients with haemophilia requires a multidisciplinary team comprising a haematologist, physiotherapist, orthopaedic practitioner, rehabilitation physician, occupational therapist, psychologist, social workers, and nurses. Journal of Comorbidity 2011;1:51-59.
Collapse
Affiliation(s)
- Karin Knobe
- Lund University, Malmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden
| | - Erik Berntorp
- Lund University, Malmö Centre for Thrombosis and Haemostasis, Skåne University Hospital, Malmö, Sweden
| |
Collapse
|
13
|
Tyshenko MG, ElSaadany S, Oraby T, Darshan S, Aspinall W, Cooke R, Catford A, Krewski D. Expert elicitation for the judgment of prion disease risk uncertainties. JOURNAL OF TOXICOLOGY AND ENVIRONMENTAL HEALTH. PART A 2011; 74:261-285. [PMID: 21218351 DOI: 10.1080/15287394.2011.529783] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
There is a high level of uncertainty surrounding the potential for iatrogenic prion transmission through transplantation, medical instrument reuse, blood transfusion, and blood product use due to a lack of evidence-based research on this important risk issue. A group of specialists was enlisted to evaluate some of the knowledge gaps in this area using the "Classical Model," a structured elicitation procedure for weighting and pooling expert judgment. The elicitation exercise was undertaken in March 2009 with 11 transmissible spongiform encephalopathy (TSE) experts who were first calibrated using a series of seed questions for which the answers are known; they were then asked to answer a number of target questions that are important for risk assessment purposes, but for which there remains high uncertainty at this time. The target questions focused on variant Creutzfeldt-Jakob disease (vCJD) prevalence, incubation times for vCJD, genetic susceptibility to prion disease, blood infectivity, prion reduction of blood and blood products, surgical instrument risks, and interspecies transmission of TSEs. The experts were also asked to perform pairwise risk rankings for 12 different potential routes of infection. Dura mater transplantation was seen as having the highest risk, while dental tissue grafts were viewed as presenting the lowest risk of iatrogenic transmission. The structured elicitation procedure provides a rational, auditable, and repeatable basis for obtaining useful information on prion disease risk issues, for which data are sparse.
Collapse
Affiliation(s)
- Michael G Tyshenko
- McLaughlin Centre for Population Health Risk Assessment, Institute of Population Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Valentino LA. Controversies regarding the prophylactic management of adults with severe haemophilia A. Haemophilia 2010; 15 Suppl 2:5-18, quiz 19-22. [PMID: 20041959 DOI: 10.1111/j.1365-2516.2009.02159.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- L A Valentino
- Department of Pediatrics and Internal Medicine, Rush University Medical Center, Chicago, IL 60612-3833, USA.
| |
Collapse
|
15
|
Stonebraker JS, Bolton-Maggs PHB, Soucie JM, Walker I, Brooker M. A study of variations in the reported haemophilia A prevalence around the world. Haemophilia 2009; 16:20-32. [PMID: 19845775 DOI: 10.1111/j.1365-2516.2009.02127.x] [Citation(s) in RCA: 158] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The objectives of this paper were to study the reported haemophilia A prevalence (per 100 000 males) on a country-by-country basis and address the following: Does the reported prevalence of haemophilia A vary by national economies? We collected prevalence data for 106 countries from the World Federation of Hemophilia (WFH) annual global surveys and the literature. We found that the reported haemophilia A prevalence varied considerably among countries, even among the wealthiest of countries. The prevalence (per 100 000 males) for high income countries was 12.8 +/- 6.0 (mean +/- SD) whereas it was 6.6 +/- 4.8 for the rest of the world. Within a country, there was a strong trend of increasing prevalence over time--the prevalence for Canada ranged from 10.2 in 1989 to 14.2 in 2008 (R = 0.94 and P < 0.001) and for the United Kingdom it ranged from 9.3 in 1974 to 21.6 in 2006 (R = 0.94 and P < 0.001). Prevalence data reported from the WFH compared well with prevalence data from the literature. Patient registries generally provided the highest quality of prevalence data. The lack of accurate country-specific prevalence data has constrained planning efforts for the treatment and care of people with haemophilia A. With improved information, healthcare agencies can assess budgetary needs to develop better diagnostic and treatment facilities for affected patients and families and work to ensure adequate supplies of factor VIII concentrates for treatment. In addition, this information can help manufacturers plan the production of concentrates and prevent future shortages.
Collapse
Affiliation(s)
- J S Stonebraker
- College of Management, North Carolina State University, Raleigh, NC 27695-7229, USA.
| | | | | | | | | |
Collapse
|
16
|
Jayandharan GR, Nair SC, Poonnoose PM, Thomas R, John J, Keshav SK, Cherian RS, Devadarishini M, Lakshmi KM, Shaji RV, Viswabandya A, George B, Mathews V, Chandy M, Srivastava A. Polymorphism in factor VII gene modifies phenotype of severe haemophilia. Haemophilia 2009; 15:1228-36. [PMID: 19686262 DOI: 10.1111/j.1365-2516.2009.02080.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The basis for 10-15% of patients with severe haemophilia having clinically mild disease is not fully understood. We hypothesized that polymorphisms in various coagulant factors may affect frequency of bleeding while functionally significant polymorphisms in inflammatory and immunoregulatory genes may also contribute to variations in the extent of joint damage. These variables were studied in patients with severe haemophilia, who were categorized as 'mild' (<5 bleeds in the preceding year, <10 World Federation of Haemophilia clinical and <10 Pettersson scores, n = 14) or 'severe' (all others, n = 100). A total of 53 parameters were studied in each individual for their association with the clinical severity. Age, F8:c activity and the incidence of thrombotic markers were comparable between the groups while the median number of bleeds, number of affected joints, clinical, radiological and functional joint scores (P < or = 0.001) and life-time clotting factor use (P < or = 0.007) were different. Patients with severe molecular defects had a 4.1-fold increased risk for a severe phenotype (95% CI: 1.18-14.42, P = 0.026) compared with other mutations. Of the polymorphisms studied, the FVII353Q (RR = 3.5, 95% CI: 1.04-12.05, P = 0.044) allele was associated with a severe phenotype. This data shows that apart from the F8/F9 genotype, functional polymorphisms in FVII gene affect the phenotype of patients with severe haemophilia.
Collapse
Affiliation(s)
- G R Jayandharan
- Departments of Haematology, Christian Medical College, Vellore, India
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Feldman BM, Funk S, Lundin B, Doria AS, Ljung R, Blanchette V. Musculoskeletal measurement tools from the International Prophylaxis Study Group (IPSG). Haemophilia 2008; 14 Suppl 3:162-9. [PMID: 18510537 DOI: 10.1111/j.1365-2516.2008.01750.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- B M Feldman
- Division of Rheumatology, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
| | | | | | | | | | | | | |
Collapse
|
18
|
Abstract
The indications for and the efficacy of prophylaxis in adults with haemophilia remain controversial. It is unclear whether the benefits of secondary prophylaxis outweigh the costs, because adults with haemophilia usually already have established arthropathy. The objectives of secondary prophylaxis in this group are therefore more limited than the objectives of primary prophylaxis in children. It is also uncertain whether primary prophylaxis should stop or continue once adulthood is reached. Some individuals with near-normal joints may stop prophylaxis in early adulthood and then bleed infrequently. Others who stop prophylaxis begin to bleed frequently and suffer progressive arthropathy; these patients should probably have continued prophylaxis. There is no satisfactory method for selecting patients for continued prophylaxis. Adult prophylaxis is less well studied than prophylaxis in children. A few studies with a small number of patients suggest that adults treated with prophylaxis experienced fewer bleeding episodes, less pain and improved quality of life compared with those treated on demand. The mean annual cost of prophylaxis tends be substantially higher for adults than for children, largely owing to the high cost of clotting factor. Here we review the literature regarding the prophylactic treatment of adult patients with haemophilia A, including studies of the discontinuation of prophylaxis. These studies and others all show clinical benefit from prophylaxis in adulthood and suggest the possibility that optimized prophylaxis (e.g. tailoring an intermediate- or low-dose regimen in patients who bleed infrequently) may improve clinical outcome. The cost-effect argument is more difficult to sustain in adults compared with children; however, the cost of prophylaxis may be counterbalanced by indirect factors, such as days gained at work, reduced hospitalizations, reduced need for orthopaedic surgery and improved quality of life.
Collapse
Affiliation(s)
- C R M Hay
- University Department of Haematology, Manchester Royal Infirmary, Manchester, UK.
| |
Collapse
|
19
|
Hacker MR, Page JH, Shapiro AD, Rich-Edwards JW, Manco-Johnson MJ. Central venous access device infections in children with hemophilia: a comparison of prophylaxis and episodic therapy. J Pediatr Hematol Oncol 2007; 29:458-64. [PMID: 17609623 DOI: 10.1097/mph.0b013e318068b1d6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Prophylaxis was recommended as the optimal treatment regimen for severe hemophilia by several expert committees. This led to increased utilization of prophylaxis and, subsequently, central venous access devices (CVADs). Although prophylaxis is the preferred treatment, episodic therapy is used by many. CVADs are employed to facilitate administration of prophylactic and episodic infusions; however, there are no data on the risk of CVAD-related infections for prophylaxis compared with episodic therapy. Data from the Study for the Prevention of Joint Disease in Preschool Children with Severe Hemophilia, a randomized clinical trial of prophylaxis versus episodic therapy, were used to evaluate the association between CVAD-related infection and treatment. The crude and adjusted rate ratios for first CVAD-related infection per 1000 CVAD days associated with episodic therapy versus prophylaxis were 1.42 (95% confidence interval: 0.46-4.40) and 1.23 (95% confidence interval: 0.33-4.56), respectively. Although we cannot make a definitive statement about treatment and CVAD-related infection risk, this study suggests that prophylaxis likely does not put children at higher risk of CVAD-related infection than episodic therapy. Given the need for CVADs in some children and the benefits of prophylaxis, we conclude there is no reason to recommend against prophylaxis on the basis of existing knowledge of CVAD-related infection risk.
Collapse
Affiliation(s)
- Michele R Hacker
- Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, Denver, USA.
| | | | | | | | | |
Collapse
|
20
|
Spira J, Plyushch OP, Andreeva TA, Andreev Y. Prolonged bleeding-free period following prophylactic infusion of recombinant factor VIII reconstituted with pegylated liposomes. Blood 2006; 108:3668-73. [PMID: 16888098 DOI: 10.1182/blood-2006-03-008276] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractProphylactic treatment for hemophilia A involves infusion of factor VIII (FVIII) concentrates every 2 to 3 days. Liposomes can be efficacious vehicles for medicines, and surface modification by PEGylation can prolong liposome circulation time. When reconstituted with PEGylated liposomes (PEGLip's), recombinant FVIII binds noncovalently but with high affinity to the external liposome surface. This preparation showed prolongation of FVIII half-life and increased protection from bleeding in preclinical models. Here we report a blinded, controlled, crossover, multicenter clinical study that evaluated the time free from bleeding episodes in patients with hemophilia A during prophylaxis with standard rFVIII (no liposomes) or PEGLip rFVIII (PEGLip reconstituted) at 25 and 35 IU/kg doses. Of 24 enrolled patients, 23 were eligible for efficacy analysis. Mean number of days without bleeds was 7.2 ± 1.7 with standard rFVIII compared with 13.3 ± 4.8 with PEGLip rFVIII at the 35 IU/kg dose and 5.9 ± 1.7 with standard rFVIII versus 10.9 ± 2.9 with PEGLip rFVIII at the 25 IU/kg dose (P < .05 between treatment groups for each dose). PEGLip rFVIII was well tolerated. These data suggest that reconstitution of rFVIII with PEGLip's may reduce the frequency of treatment during prophylaxis.
Collapse
|
21
|
Van den Berg HM, Dunn A, Fischer K, Blanchette VS. Prevention and treatment of musculoskeletal disease in the haemophilia population: role of prophylaxis and synovectomy. Haemophilia 2006; 12 Suppl 3:159-68. [PMID: 16684012 DOI: 10.1111/j.1365-2516.2006.01281.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Prophylaxis is defined as primary (started before the onset of joint damage) or secondary (started after the onset of joint damage). The aim of primary prophylaxis is to prevent recurrent bleeding into joints and the development of chronic arthropathy in later life. When started early, and at most after two joint bleeds, the result is predictably excellent if there is compliance with the primary prophylaxis regimen. In order to decrease the need for central venous access devices to assure reliable venous access, a number of centres start primary prophylaxis with once weekly infusions with dose-escalation based on frequency of joint bleeding. A major unanswered question is whether primary prophylaxis can be safely discontinued in adolescents/young adults and if so, when. A promising predictor for the milder bleeding phenotype in persons with severe haemophilia is a later onset of joint bleeding. Once joint damage has occurred as a result of recurrent bleeding, secondary prophylaxis can only retard, but not prevent, ongoing joint damage. Other strategies to decrease recurrent bleeding from target joints include surgical synovectomy (ideally performed using an arthroscopic technique), radionuclide synovectomy and chemical synovectomy. These interventions have very good outcomes when performed by an experienced team. Given the very high cost of factor concentrates required for programmes of prophylaxis prospective studies that document benefits to the child and family, e.g. quality of life are to be encouraged.
Collapse
Affiliation(s)
- H M Van den Berg
- Van Creveldkliniek, Dutch National Hemophilia Center, Department of Internal Medicine, University Medical Center, Utrecht, The Netherlands
| | | | | | | |
Collapse
|
22
|
Abstract
Haemophilia B is an inherited bleeding disorder associated with a deficiency of coagulation factor IX. The hallmark of the severe phenotype is recurrent and spontaneous bleeding into joints, which can lead to joint deformity and arthritis at an early age. Recombinant factor IX is now increasingly regarded as the treatment of choice because it does not transmit human pathogens. All patients in the UK now receive this product exclusively. Conventional treatment now consists of the administration of recombinant factor IX concentrate on a prophylactic basis to prevent bleeds and, hence, minimise disability in the long term. Trials of gene therapy are also underway, but these are in the very early stages and will not be a realistic option for at least another 20 years.
Collapse
Affiliation(s)
- Paul Giangrande
- Oxford Haemophilia Centre and Thrombosis Unit, Churchill Hospital,OX3 7LJ, UK.
| |
Collapse
|