1
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Escuriola Ettingshausen C, Yang R, Wu W, Meeks SL. Inhibitors: Diagnostic challenges, unknowns of inhibitor development, treatment of bleeding and surgery, and insights into diagnosis and treatment in China. Haemophilia 2022; 28 Suppl 4:111-118. [PMID: 35521731 DOI: 10.1111/hae.14553] [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: 01/07/2022] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 11/30/2022]
Abstract
Factor (F) VIII inhibitors develop in around 30% of previously untreated patients (PUPs) with severe haemophilia, to a lesser extend in moderate and mild haemophilia A and in up to 10% in severe haemophilia B. Diagnostic challenges and questions remain including access to high quality testing, the role for functional inhibitor testing and binding antibody testing, and the adaptations needed in the presence of non-factor replacement therapy. Despite significant gains in knowledge there are still many unanswered questions underlying the immunologic mechanisms of inhibitor development and tolerance. Therapeutic options include eradication of inhibitors using immune tolerance induction therapy (ITI), prophylaxis with bypassing agents (i.e., recombinant activated factor VII /rFVIIa or activated prothrombin complex concentrate/aPCC) or non-factor replacement therapies (e.g., emicizumab) and treatment of bleeds or coverage of surgeries/invasive procedure. Recently a haemophilia centre capacity building program was launched in China to further develop the infrastructure and support needed to improve the diagnosis of haemophilia, detection of inhibitors, and continue to improve the care of patients with haemophilia and inhibitors.
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Affiliation(s)
| | - Renchi Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Wenman Wu
- Department of Laboratory Medicine, Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shannon L Meeks
- Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta and Department of Pediatrics, Emory University, Atlanta, Georgia, USA
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2
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Hassan S, van Balen EC, Smit C, Mauser‐Bunschoten EP, van Vulpen LFD, Eikenboom J, Beckers EAM, Hooimeijer L, Ypma PF, Nieuwenhuizen L, Coppens M, Schols SEM, Leebeek FWG, Driessens MH, Rosendaal FR, van der Bom JG, Gouw SC. Health and treatment outcomes of patients with hemophilia in the Netherlands, 1972-2019. J Thromb Haemost 2021; 19:2394-2406. [PMID: 34117710 PMCID: PMC8518083 DOI: 10.1111/jth.15424] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/07/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION We conducted six cross-sectional nationwide questionnaire studies among all patients with hemophilia in the Netherlands from 1972 until 2019 to assess how health outcomes have changed, with a special focus on patients >50 years of age. METHODS Data were collected on patient characteristics, treatment, (joint) bleeding, joint impairment, hospitalizations, human immunodeficiency virus and hepatitis C infections, and general health status (RAND-36). RESULTS In 2019, 1009 patients participated, of whom 48% had mild, 15% moderate, and 37% severe hemophilia. From 1972 to 2019, the use of prophylaxis among patients with severe hemophilia increased from 30% to 89%. Their median annual bleeding rate decreased from 25 to 2 bleeds. Patients with severe hemophilia aged <16 years reported joint impairment less often over time, but in those aged >40 years joint status did not improve. In 2019, 5% of all 1009 patients were positive for the human immunodeficiency virus. The proportion of patients with an active hepatitis C infection drastically decreased from 45% in 2001 to 2% in 2019 due to new anti-hepatitis C treatment options. Twenty-five percent had significant liver fibrosis even after successful therapy. Compared to the general male population, patients aged >50 years reported much lower scores on the RAND-36, especially on physical functioning. DISCUSSION/CONCLUSION Our study shows that increased use of prophylactic treatment and effective hepatitis C treatment have improved joint health and nearly eradicated hepatitis C infection in patients with hemophilia in the Netherlands. However, patients still suffer from hemophilia-related complications, especially patients aged >50 years.
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Affiliation(s)
- Shermarke Hassan
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Erna C. van Balen
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Cees Smit
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | | | - Lize F. D. van Vulpen
- Van CreveldkliniekUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Jeroen Eikenboom
- Department of Internal MedicineDivision of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Erik A. M. Beckers
- Department of HematologyMaastricht University Medical CentreMaastrichtthe Netherlands
| | - Louise Hooimeijer
- Department of PaediatricsUniversity Medical Center GroningenGroningenthe Netherlands
| | - Paula F. Ypma
- Department of HematologyHagaZiekenhuisThe Haguethe Netherlands
| | | | - Michiel Coppens
- Department of Vascular MedicineAmsterdam University Medical CentresAmsterdamthe Netherlands
| | - Saskia E. M. Schols
- Department of HematologyRadboud University Medical CenterNijmegenthe Netherlands
- Hemophilia Treatment Center Nijmegen‐Eindhoven‐MaastrichtNijmegenthe Netherlands
| | | | | | - Frits R. Rosendaal
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Johanna G. van der Bom
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Center for Clinical Transfusion ResearchSanquin‐Leiden University Medical CenterLeidenthe Netherlands
| | - Samantha C. Gouw
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Pediatric HematologyEmma Children’s HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamthe Netherlands
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3
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Li Z, Chen Z, Liu G, Cheng X, Yao W, Huang K, Li G, Zhen Y, Wu X, Cai S, Poon M, Wu R. Low-dose immune tolerance induction alone or with immunosuppressants according to prognostic risk factors in Chinese children with hemophilia A inhibitors. Res Pract Thromb Haemost 2021; 5:e12562. [PMID: 34278191 PMCID: PMC8279128 DOI: 10.1002/rth2.12562] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/28/2021] [Accepted: 05/18/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND In developing countries, children with hemophilia A (HA) with high-titer inhibitor and poor immune tolerance induction (ITI) prognostic risk(s) cannot afford the recommended high- or intermediate-dose ITI. OBJECTIVES To determine the efficacy of low-dose ITI (plasma-derived factor VIII [FVIII]/von Willebrand factor at 50 FVIII IU/kg every other day) by itself (ITI-alone) or combined with immunosuppressants rituximab and prednisone (ITI-IS) in children with HA with high-titer inhibitor. METHODS All enrolled patients had pre-ITI inhibitor ≥10 BU. We used ITI-alone if inhibitor titer was <40 BU pre-ITI and during ITI, and ITI-IS if titer was ≥100 BU (historic) or ≥40 BU (pre- or during ITI) or if the patient was nonresponsive on ITI-alone. RESULTS Fifty-six children were analyzable, with median historic peak inhibitor titer 48.0 BU and followed for median 31.4 months. Overall, 35 (62.5%) achieved phase 2 success with negative inhibitor and normal FVIII recovery. The phase 2 success rate was 95% for the 20 patients receiving ITI-alone. For the 36 patients receiving ITI-IS, the phase 2 success rate was 44.4%, but would increase to 63.6% if the 14 patients with historic peak inhibitor titer ≥100 BU (and having phase 2 success rate of only 14.3%) were excluded. One patient developed repeated infection after IS treatment. Relapse occurred in 11.4% (4/35) patients with phase 2 success associated with rapid ITI dose reduction or irregular post-ITI FVIII prophylaxis. Our strategy reduced the cost from high-dose ITI by 74% to 90%. CONCLUSION The use of low-dose ITI with or without immunosuppressants according to ITI prognostic risk(s) is a clinically and economically feasible strategy for eradicating inhibitors in children with HA, particularly for those with historic peak inhibitor titer <100 BU.
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Affiliation(s)
- Zekun Li
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Zhenping Chen
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Guoqing Liu
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Xiaoling Cheng
- Department of Pharmacy, Beijing Children’s Hospital, National Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Wanru Yao
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Kun Huang
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Gang Li
- Hematologic Disease LaboratoryHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Pediatric Research InstituteBeijing Children’s HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Yingzi Zhen
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Xinyi Wu
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
| | - Siyu Cai
- Center for Clinical Epidemiology and Evidence‐based MedicineCapital Medical UniversityBeijingChina
| | - Man‐Chiu Poon
- Departments of Medicine, Pediatrics and OncologySouthern Alberta Rare Blood and Bleeding Disorders Comprehensive Care ProgramFoothills HospitalAlberta Health ServicesUniversity of Calgary Cumming School of MedicineCalgaryABCanada
| | - Runhui Wu
- Hemophilia Comprehensive Care CenterHematology CenterBeijing Key Laboratory of Pediatric Hematology OncologyNational Key Discipline of Pediatrics (Capital Medical University)Key Laboratory of Major Diseases in ChildrenMinistry of EducationBeijing Children's HospitalNational Center for Children’s HealthCapital Medical UniversityBeijingChina
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Male C, Andersson NG, Rafowicz A, Liesner R, Kurnik K, Fischer K, Platokouki H, Santagostino E, Chambost H, Nolan B, Königs C, Kenet G, Ljung R, Van den Berg M. Inhibitor incidence in an unselected cohort of previously untreated patients with severe haemophilia B: a PedNet study. Haematologica 2021; 106:123-129. [PMID: 31919092 PMCID: PMC7776246 DOI: 10.3324/haematol.2019.239160] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/09/2020] [Indexed: 12/20/2022] Open
Abstract
The incidence of factor IX (FIX) inhibitors in severe hemophilia B (SHB) is not well defined. Frequencies of 3-5% have been reported but most studies to date have been small, including patients with different severities, and without prospective follow up for inhibitor incidence. The study objective was to investigate the inhibitor incidence in patients with SHB followed up for to 500 exposure days (ED), the frequency of allergic reactions, and the relationship with genotypes. Consecutive previously untreated patients (PUP) with SHB enrolled into the PedNet cohort were included. Detailed data was collected for the first 50 ED, followed by the annual collection of the inhibitor status and allergic re-actions. The presence of inhibitors was defined by at least two consecutive positive samples. Additionally, data on FIX gene mutation was collected. One hundred and fifty-four PUP with SHB were included; 75% were followed up until 75 ED, and 43% until 500 ED. Inhibitors developed in 14 patients (seven high-titer). The median number of ED at inhibitor manifestation was 11 (interquartile range [IQR]: 6.5-36.5). The cumulative inhibitor incidence was 9.3% (95% Confidence Interval [CI]: 4.4-14.1) at 75 ED, and 10.2% (95% CI: 5.1-15.3) at 500 ED. Allergic reactions occurred in four (28.6%) inhibitor patients. Missense mutations were most frequent (46.8%) overall but not associated with inhibitors. Nonsense mutations and deletions with large structural changes comprised all mutations among inhibitor patients and were associated with an inhibitor risk of 26.9% and 33.3%, respectively. In an unselected, well-defined cohort of PUP with SHB, the cumulative inhibitor incidence was 10.2% at 500 ED. Nonsense mutations and large deletions were strongly associated with the risk of inhibitor development. The ‘PedNet Registry’ is registered at clinicaltrials.gov; identifier: NCT02979119.
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Affiliation(s)
| | - Nadine G Andersson
- Centre for Thrombosis and Hemostasis, Skane University Hospital, Malmö, Sweden
| | | | - Ri Liesner
- Hemophilia Center, Dept. of Hematology, Great Ormond Street Hospital for Children, London
| | - Karin Kurnik
- Dr. V. Haunersches Kinderspital, University of Munich
| | | | - Helen Platokouki
- Haemophilia-Haemostasis Unit, St. Sophia Children Hospital, Athens
| | | | - Hervé Chambost
- APHM, La Timone Children Hospital, Center for Bleeding Disorders, Marseille
| | - Beatrice Nolan
- Department of Paediatric Hematology, Children Health Ireland at Crumlin, Dublin
| | - Christoph Königs
- J.W. Goethe University Hospital, Department of Pediatrics, Frankfurt
| | - Gili Kenet
- National Hemophilia Center, Ministry of Health, Sheba Medical Center, Tel Hashomer, Israel
| | - Rolf Ljung
- Department of Clinical Sciences, Department of Pediatrics, Lund University, Lund, Sweden
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5
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van den Berg HM, Mancuso ME, Königs C, D'Oiron R, Platokouki H, Mikkelsen TS, Motwani J, Nolan B, Santagostino E. ITI Treatment is not First-Choice Treatment in Children with Hemophilia A and Low-Responding Inhibitors: Evidence from a PedNet Study. Thromb Haemost 2020; 120:1166-1172. [PMID: 32572865 DOI: 10.1055/s-0040-1713097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Limited data exist on the clinical impact of low-responding inhibitors and the requirement for immune tolerance induction (ITI) treatment to establish tolerance, reduce bleeding, and improve outcome. The aim of this article is to describe the therapeutic management of children with severe hemophilia A and low-responding inhibitors and its effect on bleeding phenotype. METHODS The REMAIN (Real-life Management of Inhibitors) study is a satellite study of the PedNet registry. It included unselected children with severe hemophilia A (factor VIII [FVIII] < 0.01 IU/mL) born between January 1, 1990 and December 31, 2009 who developed clinically relevant inhibitors and were followed-up for at least 3 years after the first positive inhibitor test. RESULTS A total of 260 patients with inhibitors were identified and 68 of them (26%) had low-responding inhibitors (peak < 5 BU/mL). Five patients were lost to follow-up and 63 were included in this study. The median follow-up was 3.7 years (interquartile range: 3.0-7.5). ITI was started in 51/63 (81%) patients. The median time from ITI start to first negative inhibitor titer was similar with low-dose and high-dose ITI regimens (2.5 and 3.1 months, respectively). Ten of the 12 patients who did not receive ITI were treated with regular prophylaxis and reached a negative titer after a median of 6.5 months. Bleeding rate was low in all patients with no difference between treatment regimens. CONCLUSION In children with low-responding inhibitors negative titers were reached with regular FVIII treatment irrespective of the regimen (i.e., prophylaxis or ITI).
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Affiliation(s)
| | - Maria Elisa Mancuso
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
| | - Christoph Königs
- Department of Paediatrics and Adolescent Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Roseline D'Oiron
- Centre de Référence pour le Traitement des Maladies Hémorragiques, Hôpital Bicêtre, Paris, France
| | - Helen Platokouki
- Haemophilia Centre, Haemostasis Unit, "Aghia Sophia" Children's Hospital, Athens, Greece
| | - Torben Stamm Mikkelsen
- Division of Pediatric and Adolescent Medicine, Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Jayashree Motwani
- Haematology Department, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | | | - Elena Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Ospedale Maggiore Policlinico, Fondazione IRCCS Ca' Granda, Milan, Italy
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6
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Pfrepper C, Krause M, Sigl-Kraetzig M, Königs C, Wendisch J, Olivieri M. Vaccination in patients with haemophilia-Results from an online survey among haemophilia treatment centres in Germany. Haemophilia 2019; 25:e304-e306. [DOI: 10.1111/hae.13781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/25/2019] [Accepted: 05/07/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Christian Pfrepper
- Division of Haemostaseology, Medical Department I; University Hospital Leipzig; Leipzig Germany
| | - Manuela Krause
- Internal Medicine; German Diagnostic Clinic; Wiesbaden Germany
| | - Michael Sigl-Kraetzig
- IPFW (Institute for Paediatric Research and Further Education) and Haemophilia Treatment Centre for Children and Adolescents (Gerinnungszentrum Süd); Blaubeuren Germany
| | - Christoph Königs
- Paediatric Haemophilia Centre, University Hospital Frankfurt; Goethe University Frankfurt; Frankfurt Germany
| | - Jörg Wendisch
- Health Department of the City of Dresden, Vaccination Centre; Dresden Germany
| | - Martin Olivieri
- Paediatric Haemophilia Centre, Dr. von Hauner Children’s Hospital; LMU Munich; Munich Germany
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7
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Volkers P, Hanschmann K, Calvez T, Chambost H, Collins PW, Demiguel V, Hart DP, Hay CR, Goudemand J, Ljung R, Palmer BP, Santagostino E, van Hardeveld EM, van den Berg M, Keller‐Stanislawski B. Recombinant factor VIII products and inhibitor development in previously untreated patients with severe haemophilia A: Combined analysis of three studies. Haemophilia 2019; 25:398-407. [DOI: 10.1111/hae.13747] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 03/05/2019] [Accepted: 03/08/2019] [Indexed: 12/29/2022]
Affiliation(s)
| | | | - Thierry Calvez
- INSERM, Institut Pierre Louis d'Épidémiologie et de Santé publique Sorbonne Universités Paris France
| | - Hervé Chambost
- Service d'Hématologie Oncologie Pédiatrique, La Timone APHM and Aix Marseille Université Marseille France
| | - Peter W. Collins
- The University Department of Haematology University Hospital of Wales Hospital Cardiff UK
| | - Virginie Demiguel
- Santé publique France French National Public Health Agency Saint‐Maurice France
| | - Daniel P. Hart
- Barts and The London School of Medicine & Dentistry, The Royal London Hospital Haemophilia Centre QMUL London UK
| | - Charles R.M. Hay
- Department of Haematology, Manchester Royal Infirmary Manchester University Manchester UK
| | - Jenny Goudemand
- Service d'Hématologie et de Transfusion, Faculté de Médecine, Centre Hospitalier Universitaire de Lille Université Lille 2 Lille France
| | - Rolf Ljung
- Department of Clinical Sciences–Paediatrics Lund University Lund Sweden
| | - Ben P. Palmer
- The United Kingdom National Haemophilia Database Manchester UK
| | - Elena Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
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8
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Mahlangu JN. Bispecific Antibody Emicizumab for Haemophilia A: A Breakthrough for Patients with Inhibitors. BioDrugs 2018; 32:561-570. [DOI: 10.1007/s40259-018-0315-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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9
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The inhibitors - a challenge for the management of patients with hereditary haemophilia A. ACTA ACUST UNITED AC 2018; 56:143-152. [PMID: 29791318 DOI: 10.2478/rjim-2018-0013] [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: 03/03/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Our research strategy was aimed at evaluating the possible implication of the type of factor VIII product administered as substitution treatment to haemophilia A patients in the occurrence of inhibitors and their consequences on the management. METHODS Scientific articles from July 2015 to July 2017 were searched using the PubMed and PubMed Central databases. The used search terms included "haemophilia A", "inhibitors", "plasma-derived factor VIII" and "recombinant factor VIII". RESULTS The risk factors for inhibitors occurrence may be patients-related (genetic and nongenetic) and treatment-related. The possibility of a correlation between the increased purity of factor VIII given as substitution treatment and the occurrence of inhibitors is discussed in the light of literature data. Plasma-derived factor VIII is less immunogenic, but not entirely safe from the point of view of the possibility of transmitting biological agents. It is obvious that there is not enough plasma-derived factor VIII for the planet's needs. Recombinant factor VIII products have revolutionized the treatment of patients with haemophilia A over the past 3 decades by the disappearance of transfusion-related infections and their complications. They are safer in terms of pathogens and the new long-acting factor VIII products are based on recombinant DNA technology. CONCLUSION Plasma-derived or recombinant factor VIII products must co-exist on the market for the benefit of haemophilic patients. Future solutions could be: less immunogenic factor VIII products, nonfactor replacement strategies, or bispecific antibody that mimics the function of coagulation factor VIII.
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10
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van den Berg HM. International collaboration is needed to reduce the risk for inhibitors in PUPs with severe haemophilia A. Haemophilia 2018; 24:e242-e243. [PMID: 29786919 DOI: 10.1111/hae.13512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2018] [Indexed: 06/08/2023]
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11
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Keipert C, Jonker CJ, van den Berg HM, Hilger A. Clinical trials and registries in haemophilia: Opponents or collaborators? Comparison of PUP data derived from different data sources. Haemophilia 2018; 24:420-428. [PMID: 29436084 DOI: 10.1111/hae.13421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2017] [Indexed: 01/28/2023]
Abstract
INTRODUCTION The "Guideline on the clinical investigation of recombinant and human plasma-derived factor VIII products" (ClinGL) provides the requirements for the performing of clinical trials (CTs) for marketing authorization in Europe. The number of eligible previously untreated patients (PUPs) for CTs might be difficult to meet because of the concurrent development of FVIII concentrates, and additional data sources must be explored. AIM The extent to which CTs and the PedNet registry met relevant parameters, identified in the ClinGL, as well as inhibitor incidences were investigated in patients from both sources. METHODS Anonymized data of eight CTs in 369 PUPs performed from 1987 to 2009 were compared with each other and with 632 PUPs (born 2000-2009) from PedNet. RESULTS Clinical trials in PUPs performed for marketing authorization were too heterogeneous in their investigated parameters; therefore, a comparison of single factor concentrates was not possible. Data collection in PedNet met relevant parameters required for PUPs in accordance with the ClinGL. The overall inhibitor incidences were comparable (CT = 30.9% vs PedNet = 30.6%) when only severe haemophilia A (HA) patients from both data sources were considered. CONCLUSIONS Previously performed CTs in PUPs were divergent, which prevented a direct comparison of outcomes. However, this study demonstrated that data from CTs and carefully designed registries may complement each other in the establishing of sufficient safety information for single products to improve clinical insights and support regulatory decisions.
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Affiliation(s)
- C Keipert
- Hematology and Transfusion Medicine, Paul-Ehrlich-Institut, Langen, Germany
| | - C J Jonker
- Medicine Evaluation Board, Utrecht, The Netherlands
| | | | - A Hilger
- Hematology and Transfusion Medicine, Paul-Ehrlich-Institut, Langen, Germany
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12
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Messori A, Peyvandi F, Mengato D, Mannucci PM. Incidence of low-titre factor VIII inhibitors in patients with haemophilia A: meta-analysis of observational studies. Haemophilia 2017; 23:e87-e92. [PMID: 28220685 DOI: 10.1111/hae.13193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2016] [Indexed: 01/02/2023]
Abstract
INTRODUCTION A few studies have been focused on low-titre inhibitors in patients with haemophilia A. Although several putative factors have been implicated in the development of these inhibitors, solid data are still lacking. AIM The aim of this study was to perform a proportion meta-analysis on the incidence of low-titre inhibitors in haemophilia A. METHODS We surveyed the PubMed database to identify studies on de novo development of low-titre inhibitors in haemophilia A patients. On the basis of these data, we carried out a proportion meta-analysis to summarize information on incidence and between-study variability. Furthermore, the following three covariates were assessed by meta-regression: (i) mild disease vs. severe haemophilia; (ii) status of previously untreated patient (PUP) as opposed to multi-transfused and (iii) type of factor VIII. RESULTS Our literature search on PubMed extracted 340 eligible articles. From these, we selected 33 patient cohorts that were included in our meta-analysis (19 cohorts for PUPs and 14 cohorts for multi-transfused or unselected patients). The pooled incidence of low-titre inhibitors was 10.3% (95%CI: 8.3-12.5%) for studies including PUPs and 5.8% (95%CI: 2.5-10.4%) for the other studies; the difference was statistically significant (P = 0.003). Meta-regression of 31 patient cohorts found that mild disease and type of factor VIII were not associated with an increased incidence of low-titre inhibitors. CONCLUSIONS Our results confirmed that PUPs show a higher incidence of low-titre inhibitors than the other patients. Furthermore, our data showed that mild haemophilia was not associated with an increased incidence of low-titre inhibitors.
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Affiliation(s)
- A Messori
- Health Technology Assessment Unit, ESTAR Regional Health Service, Florence, Italy
| | - F Peyvandi
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - D Mengato
- Pharmaceutical Chemistry and Pharmacology Department, University of Padua, Padua, Italy
| | - P M Mannucci
- A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and University of Milan, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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Peyvandi F, Ettingshausen CE, Goudemand J, Jiménez-Yuste V, Santagostino E, Makris M. New findings on inhibitor development: from registries to clinical studies. Haemophilia 2017; 23 Suppl 1:4-13. [PMID: 27990784 DOI: 10.1111/hae.13137] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2016] [Indexed: 02/06/2023]
Abstract
The high incidence of inhibitors against factor VIII (FVIII) concentrates in patients with haemophilia A has encouraged debate as to whether product-type plays a role. There is debate in the literature as to whether rFVIII concentrates are associated with a higher incidence of inhibitors compared to pdFVIII products. The management of haemophilia in patients with inhibitors includes on-demand/prophylaxis treatment with bypassing agents, and/or immune tolerance induction (ITI). However, these options create an economic and emotional burden on patients, their families and healthcare practitioners. Although ITI eliminates inhibitors successfully in 60-80% of cases, it is costly. Despite high costs, preliminary data from a decision analytical model have indicated that ITI is economically advantageous compared with on-demand/prophylactic treatment with bypassing agents. In patients with persistent inhibitors and those who are not candidates for ITI or have failed ITI, bleeding-related mortality and morbidity increase and quality of life decreases, compared with non-inhibitor patients. This article provides an update on the risk of inhibitor development and discusses best management approaches for patients with high-risk factors for inhibitor development.
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Affiliation(s)
- F Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | | | - J Goudemand
- School of Medicine, University of Lille, Lille, France
| | - V Jiménez-Yuste
- Department of Haematology, Autónoma University Madrid and La Paz University Hospital, Madrid, Spain
| | - E Santagostino
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - M Makris
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, United Kingdom
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14
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Batty P, Austin SK, Khair K, Millar CM, Palmer B, Rangarajan S, Stümpel JP, Thanigaikumar M, Yee TT, Hart DP. Treatment burden, haemostatic strategies and real world inhibitor screening practice in non-severe haemophilia A. Br J Haematol 2017; 176:796-804. [PMID: 28198996 DOI: 10.1111/bjh.14543] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/03/2016] [Indexed: 12/11/2022]
Abstract
Inhibitor formation in non-severe haemophilia A is a life-long risk and associated with morbidity and mortality. There is a paucity of data to understand real-world inhibitor screening practice. We evaluated the treatment burden, haemostatic strategies, F8 genotyping and inhibitor screening practices in non-severe haemophilia A in seven London haemophilia centres. In the 2-year study period, 44% (377/853) patients received at least one haemostatic treatment. Seventy-nine percent of those treated (296/377) received factor VIII (FVIII) concentrate. F8 genotype was known in 88% (331/377) of individuals. Eighteen per cent (58/331) had 'high-risk' F8 genotypes. In patients with 'standard-risk' F8 genotypes treated on-demand with FVIII concentrate, 51·3% episodes (243/474) were screened within 1 year. However, poor screening compliance was observed after 'high-risk' treatment episodes. In patients with 'standard-risk' F8 genotypes, 12·3% (28/227) of treatment episodes were screened in the subsequent 6 weeks after surgery or a bleed requiring ≥5 exposure days. Similarly, in the context of 'high-risk' F8 genotypes after any FVIII exposure, only 13·6% (12/88) of episodes were screened within 6 weeks. Further study is required to assess optimal practice of inhibitor screening in non-severe haemophilia A to inform subsequent clinical decisions and provide more robust prevalence data to further understand the underlying immunological mechanism.
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Affiliation(s)
- Paul Batty
- The Royal London Hospital Haemophilia Centre, QMUL, Barts and The London School of Medicine and Dentistry, London, UK
| | - Steve K Austin
- St George's Healthcare NHS Trust, Haemophilia Centre, London, UK.,The Centre for Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - Kate Khair
- Great Ormond Street Haemophilia Centre, London, UK
| | | | - Ben Palmer
- The United Kingdom National Haemophilia Database, Manchester, UK
| | - Savita Rangarajan
- The Centre for Haemostasis and Thrombosis, St Thomas' Hospital, London, UK
| | - Jan-Phillip Stümpel
- The Royal London Hospital Haemophilia Centre, QMUL, Barts and The London School of Medicine and Dentistry, London, UK
| | | | - Thynn T Yee
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Daniel P Hart
- The Royal London Hospital Haemophilia Centre, QMUL, Barts and The London School of Medicine and Dentistry, London, UK
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15
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Abstract
Inhibitors are the most serious side effect of haemophilia treatment; they occur in 25–30 % of all patients with severe haemophilia A. Over the last 2 decades, conflicting data on the impact of clotting products have been published. Due to small studies of selected cases, appreciation of the impact of any particular product has been difficult. Moreover, the emphasis on inhibitor testing has led to increased detection of low-titre inhibitors (to >10 %), while the percentage of high-titre inhibitors is still around 20 %. Other non-genetic risk factors, such as dosing and intensive treatment, are able to increase individual inhibitor risk. Early prophylaxis might reduce inhibitor risk. Well-defined large PUP studies including products should be considered. This can only be achieved in collaboration with all stakeholders. In conclusion, while the impact of FVIII products on inhibitor development is large, presently the actual impact of any specific product is unclear.
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Affiliation(s)
- H Marijke van den Berg
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
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