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Young G, Pipe SW, Kenet G, Oldenburg J, Safavi M, Czirok T, Nissen F, Mahlangu J. Emicizumab is well tolerated and effective in people with congenital hemophilia A regardless of age, severity of disease, or inhibitor status: a scoping review. Res Pract Thromb Haemost 2024; 8:102415. [PMID: 38812987 PMCID: PMC11135026 DOI: 10.1016/j.rpth.2024.102415] [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: 01/22/2024] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 05/31/2024] Open
Abstract
Background With the treatment landscape continually evolving, it is vital that the hemophilia community have an overview of all published data for approved therapies, such as emicizumab, to support shared decision making. Objectives To bring together the clinical and real-world data for emicizumab use in people with congenital hemophilia A, regardless of age, disease severity, or factor VIII inhibitor status. Key focus areas were safety, efficacy, and quality of life (QoL). Methods This scoping review used citation databases (PubMed, Embase, and the Cochrane Library) and manual searches of abstract books. Publications reporting original data for emicizumab in people with hemophilia A, published in English after December 2014, and reporting select endpoints were included. This narrative synthesis focused on zero bleeds, treated annualized bleeding rate (ABR), adverse events, and QoL measures. Results Overall, 97 publications were included (cut-off: August 9, 2022). Treated ABR remained low (calculated mean and median treated ABRs ranged between 0.7-1.3 and 0.0-1.4, respectively), and the median percentage of people with zero treated bleeds was 66.7%. The proportion of people experiencing treatment-related adverse events ranged from 0.0% to 60.0%; most were injection-site reactions. Across 37 publications reporting on safety and enrolling >2300 individuals, 11 thrombotic events and 4 thrombotic microangiopathies were reported. Data from well-established tools show QoL benefits with emicizumab. Conclusion This scoping review consolidates the global published experience for emicizumab in people with hemophilia A and supports the fact that emicizumab has an acceptable safety profile, is effective and efficacious in bleed prevention, and is associated with improvements in QoL.
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Affiliation(s)
- Guy Young
- Cancer and Blood Disorders Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Steven W. Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Gili Kenet
- The Israeli National Hemophilia Center and Thrombosis Unit, Sheba Medical Center, Tel Hashomer, Israel
- The Amalia Biron Thrombosis Research Institute, Tel Aviv University, Tel Aviv, Israel
| | - Johannes Oldenburg
- Institute of Experimental Hematology and Transfusion Medicine, University Clinic Bonn, Bonn, Germany
| | - Mariam Safavi
- Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Tuende Czirok
- Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Francis Nissen
- Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - 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, Gauteng, South Africa
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Ay C, Benitez-Hidalgo O, Gidley G, Mancuso ME, Matino D, Nagao A, Nemes L, Waller J, Oldenburg J. Noninterventional study assessing joint health in persons with hemophilia A after switching to turoctocog alfa pegol: design of pathfinderReal. Res Pract Thromb Haemost 2024; 8:102363. [PMID: 38572481 PMCID: PMC10987329 DOI: 10.1016/j.rpth.2024.102363] [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: 02/01/2024] [Accepted: 02/14/2024] [Indexed: 04/05/2024] Open
Abstract
Background Joint damage affects the quality of life of persons with hemophilia A. The long-term safety and efficacy of turoctocog alfa pegol (N8-GP) prophylaxis in persons with hemophilia A has been investigated in pivotal phase 3 trials in children, adolescents, and adults (pathfinder program). However, there is a lack of data on joint health in adult persons with hemophilia A treated with N8-GP. Objectives To describe the design of the ongoing pathfinderReal study investigating the joint health status in adult persons with hemophilia A after switching to N8-GP. Methods pathfinderReal is a multicountry, noninterventional, single-arm study (NCT05621746) of joint health in adult (≥18 years) male persons with hemophilia A who have switched to N8-GP. Patients enrolled in other interventional studies and those who have previously terminated N8-GP treatment will be excluded. Approximately 124 adults with hemophilia A will be enrolled and followed up for a maximum of 24 months. Data from routine clinical assessments of patients' joint health will be collected. The primary endpoint is change in Hemophilia Joint Health Score (defined as a change in total score of ≤2) from initiation of N8-GP treatment until the end of the study. Secondary endpoints include number of bleeding episodes, number and resolution of target joints, patient-reported outcomes of problem joint score, pain score, and change in physical function levels. An exploratory endpoint is included to measure the number of patients achieving improved Hemophilia Joint Health Score from the initiation of N8-GP until the end of the study. Conclusion The pathfinderReal study will provide insights regarding the impact of N8-GP on joint health in persons with hemophilia A in a real-world setting.
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Affiliation(s)
- Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Olga Benitez-Hidalgo
- Hemophilia Unit, Hematology Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Gillian Gidley
- Haemophilia Comprehensive Care Centre, Department of Haematology, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - Maria Elisa Mancuso
- Centre for Thrombosis and Hemorrhagic Diseases, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Humanitas University, Pieve Emanuele, Milan, Italy
| | - Davide Matino
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Azusa Nagao
- Department of Blood Coagulation, Ogikubo Hospital, Tokyo, Japan
| | - Laszlo Nemes
- National Hemophilia Center and Hemostasis Department, Central Hospital of Northern Pest – Military Hospital, Budapest, Hungary
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Munawar Ali R, Abid M, Zafar S, Ali MS, Nadeem R, Ahmed R, Borhany M. Management of Severe Hemophilia A: Low-Dose Prophylaxis vs. On-Demand Treatment. Cureus 2023; 15:e41410. [PMID: 37546069 PMCID: PMC10402932 DOI: 10.7759/cureus.41410] [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] [Accepted: 06/30/2023] [Indexed: 08/08/2023] Open
Abstract
INTRODUCTION Prophylactic clotting factor infusion regimens to prevent bleeding and joint deformity has become the standard of care in severe hemophilia A patients. AIM To assess low-dose factor prophylaxis in our population as an alternative approach to managing severe hemophilia A. METHODS A prospective cohort study that included 68 hemophilia A patients divided into two groups, i.e., Prophylaxis and on-demand. The two groups were compared for annualized bleeding rate (ABR), hospitalization, units of factor VIII (FVIII) infused, or plasma products transfused, i.e., fresh frozen plasma (FFP) and cryoprecipitate (CP), and development of FVIII inhibitors. RESULTS Of the 68 patients recruited in this study, 25 (36.7%) were in the prophylaxis group, and 43(63.3%) were in the on-demand group. The on-demand group presented a higher median-IQR ABR [8(20-3) vs. 5(10-1.5), p-value 0.024], several hospitalizations (39.7% vs. 0, p-value 0.001), and inhibitor development (9.3% vs. 0, p-value 0.289) compared to the prophylaxis group. The prophylaxis approach demonstrated a significant negative correlation of ABR with FVIII prophylaxis (r=-0484, p=value=0.014). Moreover, no hospitalizations or inhibitor development was observed in the prophylaxis group. The estimated annual consumption of FVIII was 328 IU/kg/year in the on-demand group and 1662.6 IU/kg/year in the prophylaxis group. However, a highly significant difference in plasma product utilization was observed between the two groups, i.e., p-value <0.001 and 0.038 for FFP and CP, respectively. CONCLUSION Low-dose factor prophylaxis resulted in improved outcomes compared to on-demand treatment in terms of ABR, joint bleeding, hospitalization, and the development of inhibitors. This treatment approach should be adopted as an economically feasible alternative to high-dose Prophylaxis in resource-constrained countries.
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Affiliation(s)
- Rabeea Munawar Ali
- Hematology, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
| | - Madiha Abid
- Hematology, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
| | - Sidra Zafar
- Research and Development, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
| | - Muhammad Shujat Ali
- Hematology, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
| | - Rukhshanda Nadeem
- Physical Medicine and Rehabilitation, Hemophilia Welfare Society, Karachi, PAK
| | - Raheel Ahmed
- Hematology, Haemophilia Welfare Society, Karachi, PAK
| | - Munira Borhany
- Hematology, National Institute of Blood Disease & Bone Marrow Transplantation, Karachi, PAK
- Hematology, Haemophilia Welfare Society, Karachi, PAK
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Escobar M, Bullano M, Mokdad AG, Caicedo J, Schultz BG, Fan Q, Verma S. A real-world evidence analysis of the impact of switching from factor VIII to emicizumab prophylaxis in patients with hemophilia A without inhibitors. Expert Rev Hematol 2023:1-8. [PMID: 37114481 DOI: 10.1080/17474086.2023.2198207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
BACKGROUND This study retrospectively compared annualized billed bleed rates (ABRb) in people with hemophilia A (PwHA) without inhibitors who switched from factor VIII (FVIII) prophylaxis to emicizumab. RESEARCH DESIGN AND METHODS A real-world comparison study was performed on the effect of switching from FVIII to emicizumab prophylaxis in male, non-inhibitor patients on ABRb using an all-payer claims database (APCD) dataset from 1 January 2014, to 31 March 2021. The identification period was from 1 November 2017, to 30 September 2020. RESULTS One hundred and thirty-one patients were included with a total of 82 and 45 bleeds in the pre- and post-switch periods, respectively. The average follow-up period pre-switch was 978.37 days (SD 555.03), whereas the average follow-up period post-switch was 522.26 days (SD 191.36). No significant differences in mean ABRb were observed pre-/post-switch (0.25 and 0.20, respectively; P = 0.4456). CONCLUSIONS The results of this study demonstrate no significant reduction in ABRb, suggesting that switching from FVIII to emicizumab may not deliver incremental benefits to PwHA receiving prophylactic care.
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Affiliation(s)
- Miguel Escobar
- University of Texas Health Science Center, Houston, TX, USA
| | | | | | | | | | - Qi Fan
- Takeda Pharmaceuticals USA, Lexington, MA, USA
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Packebush MH, Sanchez-Martinez S, Biswas S, Kc S, Nguyen KH, Ramirez JF, Nicholson V, Boothby TC. Natural and engineered mediators of desiccation tolerance stabilize Human Blood Clotting Factor VIII in a dry state. Sci Rep 2023; 13:4542. [PMID: 36941331 PMCID: PMC10027729 DOI: 10.1038/s41598-023-31586-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/14/2023] [Indexed: 03/23/2023] Open
Abstract
Biologics, pharmaceuticals containing or derived from living organisms, such as vaccines, antibodies, stem cells, blood, and blood products are a cornerstone of modern medicine. However, nearly all biologics have a major deficiency: they are inherently unstable, requiring storage under constant cold conditions. The so-called 'cold-chain', while effective, represents a serious economic and logistical hurdle for deploying biologics in remote, underdeveloped, or austere settings where access to cold-chain infrastructure ranging from refrigerators and freezers to stable electricity is limited. To address this issue, we explore the possibility of using anhydrobiosis, the ability of organisms such as tardigrades to enter a reversible state of suspended animation brought on by extreme drying, as a jumping off point in the development of dry storage technology that would allow biologics to be kept in a desiccated state under not only ambient but elevated temperatures. Here we examine the ability of different protein and sugar-based mediators of anhydrobiosis derived from tardigrades and other anhydrobiotic organisms to stabilize Human Blood Clotting Factor VIII under repeated dehydration/rehydration cycles, thermal stress, and long-term dry storage conditions. We find that while both protein and sugar-based protectants can stabilize the biologic pharmaceutical Human Blood Clotting Factor VIII under all these conditions, protein-based mediators offer more accessible avenues for engineering and thus tuning of protective function. Using classic protein engineering approaches, we fine tune the biophysical properties of a protein-based mediator of anhydrobiosis derived from a tardigrade, CAHS D. Modulating the ability of CAHS D to form hydrogels make the protein better or worse at providing protection to Human Blood Clotting Factor VIII under different conditions. This study demonstrates the effectiveness of tardigrade CAHS proteins and other mediators of desiccation tolerance at preserving the function of a biologic without the need for the cold-chain. In addition, our study demonstrates that engineering approaches can tune natural products to serve specific protective functions, such as coping with desiccation cycling versus thermal stress. Ultimately, these findings provide a proof of principle that our reliance on the cold-chain to stabilize life-saving pharmaceuticals can be broken using natural and engineered mediators of desiccation tolerance.
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Affiliation(s)
| | | | - Sourav Biswas
- Department of Molecular Biology, University of Wyoming, Laramie, WY, USA
| | - Shraddha Kc
- Department of Molecular Biology, University of Wyoming, Laramie, WY, USA
| | - Kenny H Nguyen
- Department of Molecular Biology, University of Wyoming, Laramie, WY, USA
| | - John F Ramirez
- Department of Molecular Biology, University of Wyoming, Laramie, WY, USA
| | - Vincent Nicholson
- Department of Molecular Biology, University of Wyoming, Laramie, WY, USA
| | - Thomas C Boothby
- Department of Molecular Biology, University of Wyoming, Laramie, WY, USA.
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Schaible P. Modifying enzyme replacement therapy - A perspective. J Cell Mol Med 2022; 27:165-173. [PMID: 36566487 PMCID: PMC9843529 DOI: 10.1111/jcmm.17653] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 11/23/2022] [Accepted: 11/28/2022] [Indexed: 12/26/2022] Open
Abstract
Several diseases are caused by the lack of functional proteins, including lysosomal storage diseases or haemophilia A and B. Patients suffering from one of these diseases are treated via enzyme replacement therapies to restore the missing protein. Although this treatment strategy prevents some disease symptoms, enzyme replacement therapies are very expensive and require very frequent infusions, which can cause infusion adverse reactions and massively impair the quality of life of the patients. This review proposes a technology to sustainably produce proteins within the patient to potentially make frequent protein-infusions redundant. This technology is based on blood circulating immune cells as producers of the needed therapeutic protein. To ensure a stable protein concentration over time the cells are equipped with a system, which induces cell proliferation when low therapeutic protein levels are detected and a system inhibiting cell proliferation when high therapeutic protein levels are detected.
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Wang J, Gu J, Chen H, Wu Q, Xiong L, Qiao B, Zhang Y, Xiao H, Tong Y. A Novel Deletion Mutation of the F8 Gene for Hemophilia A. Diagnostics (Basel) 2022; 12:diagnostics12112876. [PMID: 36428936 PMCID: PMC9689134 DOI: 10.3390/diagnostics12112876] [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: 10/25/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Hemophilia A (HA) is an X-linked recessive blood coagulation disorder caused by a variety of abnormalities in F8 gene, resulting in the absence of impaired molecule production of factor VIII (FVIII) in the plasma. The genetic testing of the F8 gene encoding FVIII is used for confirmation of HA diagnosis, which significantly reduced serious complications of this disease and, ultimately, increased life expectancy. Methods: Sanger sequencing was performed in F8 gene exons of the suspected patients with blood coagulation-related indicators. Results: A novel F8 indel variant c.6343delC, p.Leu2115SerfsTer28 in exon 22 of the F8 gene was identified in the suspected families. The infant with this novel variant appeared the symptom of minor bleeding and oral cavity bleeding, and decreased activity of FVIII, which is consistent with that of F8 deleterious variants. The 3'D protein structural analysis of the novel variant shows a change in FVIII protein stability, which may be responsible for the pathogenesis of HA. Conclusions: A novel deleterious variant was identified in our case, which expands the F8 variants spectrum. Our result is helpful for HA diagnosis and benefits carrier detection and prenatal diagnosis. Our study also reveals that mutation screening of the F8 gene should be necessary for HA suspected patients.
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Affiliation(s)
- Jingwei Wang
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Clinical Molecular Diagnosis Institute, Wuhan University, Wuhan 430060, China
| | - Jian Gu
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Hongbing Chen
- Department of Pulmonary and Critical Care Medicine of Renmin Hospital, Wuhan University, Wuhan 430060, China
| | - Qian Wu
- Clinical Molecular Diagnosis Institute, Wuhan University, Wuhan 430060, China
| | - Liang Xiong
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Bin Qiao
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Yan Zhang
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Hongjun Xiao
- Medical Vocational and Technical School, Wuhan University, Wuhan 430060, China
- Correspondence: (H.X.); (Y.T.); Tel.: +86-27-88041911 (H.X.); +86-27-88041911 (Y.T.)
| | - Yongqing Tong
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Clinical Molecular Diagnosis Institute, Wuhan University, Wuhan 430060, China
- Correspondence: (H.X.); (Y.T.); Tel.: +86-27-88041911 (H.X.); +86-27-88041911 (Y.T.)
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Lubich C, Steinitz KN, Hoelbl B, Prenninger T, van Helden PM, Weiller M, Reipert BM. Modulating the microenvironment during FVIII uptake influences the nature of FVIII-peptides presented by antigen-presenting cells. Front Immunol 2022; 13:975680. [DOI: 10.3389/fimmu.2022.975680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background and aimsHemophilia A is a severe bleeding disorder caused by the deficiency of functionally active coagulation factor VIII (FVIII). The induction of neutralizing anti-drug antibodies is a major complication in the treatment of hemophilia A patients with FVIII replacement therapies. Why some patients develop neutralizing antibodies (FVIII inhibitors) while others do not is not well understood. Previous studies indicated that the induction of FVIII inhibitors requires cognate interactions between FVIII-specific B cells and FVIII-specific CD4+ T cells in germinal center reactions. In this study, we investigated the FVIII peptide repertoire presented by antigen-presenting cells (APCs) under different microenvironment conditions that are expected to alter the uptake of FVIII by APCs. The aim of this study was to better understand the association between different microenvironment conditions during FVIII uptake and the FVIII peptide patterns presented by APCs.MethodsWe used a FVIII-specific CD4+ T cell hybridoma library derived from humanized HLA-DRB1*1501 (human MHC class II) hemophilic mice that were treated with human FVIII. APCs obtained from the same mouse strain were preincubated with FVIII under different conditions which are expected to alter the uptake of FVIII by APCs. Subsequently, these preincubated APCs were used to stimulate the FVIII-specific CD4+ T cell hybridoma library. Stimulation of peptide-specific CD4+ T-cell hybridoma clones was assessed by analyzing the IL-2 release into cell culture supernatants.ResultsThe results of this study indicate that the specific microenvironment conditions during FVIII uptake by APCs determine the peptide specificities of subsequently activated FVIII-specific CD4+ T cell hybridoma clones. Incubation of APCs with FVIII complexed with von Willebrand Factor, FVIII activated by thrombin or FVIII combined with a blockade of receptors on APCs previously associated with FVIII uptake and clearance, resulted in distinct peptide repertoires of subsequently activated hybridoma clones.ConclusionBased on our data we conclude that the specific microenvironment during FVIII uptake by APCs determines the FVIII peptide repertoire presented on MHC class II expressed by APCs and the peptide specificity of subsequently activated FVIII-specific CD4+ T cell hybridoma clones.
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Kavaklı K, Antmen B, Okan V, Şahin F, Aytaç S, Balkan C, Berber E, Kaya Z, Küpesiz A, Zülfikar B. Gene therapy in haemophilia: literature review and regional perspectives for Turkey. Ther Adv Hematol 2022; 13:20406207221104591. [PMID: 35898436 PMCID: PMC9310332 DOI: 10.1177/20406207221104591] [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: 01/17/2022] [Accepted: 05/16/2022] [Indexed: 01/19/2023] Open
Abstract
Haemophilia is an X-linked lifelong congenital bleeding disorder that is caused by insufficient levels of factor VIII (FVIII; haemophilia A) or factor IX (FIX; haemophilia B) and characterized by spontaneous and trauma-related bleeding episodes. The cornerstone of the treatment, factor replacement, constitutes several difficulties, including frequent injections due to the short half-life of recombinant factors, intravenous administration and the risk of inhibitor development. While extended half-life factors and subcutaneous novel molecules enhanced the quality of life, initial successes with gene therapy offer a significant hope for cure. Although adeno-associated viral (AAV)-based gene therapy is one of the most emerging approaches for treatment of haemophilia, there are still challenges in vector immunogenicity, potency and efficacy, genotoxicity and persistence. As the approval for the first gene therapy product is coming closer, eligibility criteria for patient selection, multidisciplinary approach for optimal delivery and follow-up and development of new pricing policies and reimbursement models should be concerned. Therefore, this review addresses the unmet needs of current haemophilia treatment and explains the rationale and principles of gene therapy. Limitations and challenges are discussed from a global and national perspective and recommendations are provided to adopt the gene therapies faster and more sufficient for the haemophilia patients in developing countries like Turkey.
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Affiliation(s)
- Kaan Kavaklı
- Division of Hematology, Department of Pediatrics, Ege University Faculty of Medicine, Bornova, 35100 İzmir, Turkey
| | - Bülent Antmen
- Division of Hematology, Department of Pediatrics, Acıbadem Adana Hospital, Adana, Turkey
| | - Vahap Okan
- Division of Hematology, Department of Internal Diseases, Gaziantep University Faculty of Medicine, Gaziantep, Turkey
| | - Fahri Şahin
- Division of Hematology, Department of Internal Diseases, Ege Adult Hemophilia and Thrombosis Center, Ege University Faculty of Medicine, İzmir, Turkey
| | - Selin Aytaç
- Division of Hematology, Department of Pediatrics, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Can Balkan
- Division of Hematology, Department of Pediatrics, Ege University Faculty of Medicine, İzmir, Turkey
| | - Ergül Berber
- Department of Molecular Biology and Genetics, İstanbul Arel University, İstanbul, Turkey
| | - Zühre Kaya
- Division of Hematology, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Alphan Küpesiz
- Division of Hematology, Department of Pediatrics, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Bülent Zülfikar
- Division of Hematology, Department of Pediatrics, İstanbul University Faculty of Medicine, İstanbul, Turkey
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Zerra PE, Parker ET, Baldwin WH, Healey JF, Patel SR, McCoy JW, Cox C, Stowell SR, Meeks SL. Engineering a Therapeutic Protein to Enhance the Study of Anti-Drug Immunity. Biomedicines 2022; 10:1724. [PMID: 35885029 PMCID: PMC9313379 DOI: 10.3390/biomedicines10071724] [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: 06/01/2022] [Revised: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022] Open
Abstract
The development of anti-drug antibodies represents a significant barrier to the utilization of protein-based therapies for a wide variety of diseases. While the rate of antibody formation can vary depending on the therapeutic employed and the target patient population receiving the drug, the antigen-specific immune response underlying the development of anti-drug antibodies often remains difficult to define. This is especially true for patients with hemophilia A who, following exposure, develop antibodies against the coagulation factor, factor VIII (FVIII). Models capable of studying this response in an antigen-specific manner have been lacking. To overcome this challenge, we engineered FVIII to contain a peptide (323-339) from the model antigen ovalbumin (OVA), a very common tool used to study antigen-specific immunity. FVIII with an OVA peptide (FVIII-OVA) retained clotting activity and possessed the ability to activate CD4 T cells specific to OVA323-339 in vitro. When compared to FVIII alone, FVIII-OVA also exhibited a similar level of immunogenicity, suggesting that the presence of OVA323-339 does not substantially alter the anti-FVIII immune response. Intriguingly, while little CD4 T cell response could be observed following exposure to FVIII-OVA alone, inclusion of anti-FVIII antibodies, recently shown to favorably modulate anti-FVIII immune responses, significantly enhanced CD4 T cell activation following FVIII-OVA exposure. These results demonstrate that model antigens can be incorporated into a therapeutic protein to study antigen-specific responses and more specifically that the CD4 T cell response to FVIII-OVA can be augmented by pre-existing anti-FVIII antibodies.
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Affiliation(s)
- Patricia E. Zerra
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University, Atlanta, GA 30322, USA; (P.E.Z.); (J.W.M.)
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; (E.T.P.); (W.H.B.); (J.F.H.); (S.R.P.); (C.C.)
| | - Ernest T. Parker
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; (E.T.P.); (W.H.B.); (J.F.H.); (S.R.P.); (C.C.)
| | - Wallace Hunter Baldwin
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; (E.T.P.); (W.H.B.); (J.F.H.); (S.R.P.); (C.C.)
| | - John F. Healey
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; (E.T.P.); (W.H.B.); (J.F.H.); (S.R.P.); (C.C.)
| | - Seema R. Patel
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; (E.T.P.); (W.H.B.); (J.F.H.); (S.R.P.); (C.C.)
| | - James W. McCoy
- Center for Transfusion Medicine and Cellular Therapies, Department of Laboratory Medicine and Pathology, Emory University, Atlanta, GA 30322, USA; (P.E.Z.); (J.W.M.)
| | - Courtney Cox
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; (E.T.P.); (W.H.B.); (J.F.H.); (S.R.P.); (C.C.)
| | - Sean R. Stowell
- Joint Program in Transfusion Medicine, Department of Pathology, Harvard Medical School, Boston, MA 02115, USA
| | - Shannon L. Meeks
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University, Atlanta, GA 30322, USA; (E.T.P.); (W.H.B.); (J.F.H.); (S.R.P.); (C.C.)
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Shen SN, Wu DX, Lv SJ, Tong PJ. Hidden blood loss of total knee arthroplasty in hemophilia arthritis: an analysis of influencing factors. BMC Musculoskelet Disord 2022; 23:587. [PMID: 35715793 PMCID: PMC9206270 DOI: 10.1186/s12891-022-05535-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 06/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Total knee arthroplasty is the leading way to treat hemophilia arthritis. At present, there is a lack of research on the influencing factors of blood loss in total knee arthroplasty for hemophilia arthritis. This study comprehensively explores the definite factors affecting the hidden blood loss in total knee arthroplasty for hemophilia patients. MATERIALS AND METHODS Ninety-two hemophilia A patients who underwent total knee arthroplasty in our center were included. Demographics, laboratory data, surgical data, and complications were collected. The Gross equation and Sehat equation were used to calculate the estimated value of hidden blood loss. Multivariate linear regression analysis was used to determine the influencing factors of hidden blood loss. RESULT The hidden blood loss of hemophilia A patients undergoing total knee arthroplasty was 1069.51 ± 341.99 mL, and the age was positively correlated with the hidden blood loss (P < 0.001), while tranexamic acid, FVIII prophylaxis, and incremental invivo recovery were negatively correlated with the hidden blood loss (P < 0.001, P = 0.008, P = 0.017). CONCLUSION Elderly patients have a greater risk of blood loss, and additional preventive measures can be appropriately added. Intraoperative intra-articular injection of tranexamic acid is recommended to reduce hidden blood loss, FVIII prophylaxis is recommended for every patient. We recommend that all HA patients measure the incremental invivo recovery and develop a personalized infusion regimen of coagulation factor.
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Affiliation(s)
- Shao Ning Shen
- The First Clinical College of Zhejiang Chinese Medical University, The First Affiliated Hospital of Zhejiang Chinese Medical University, 548# BinWen Road, HangZhou, ZheJiang Province, People's Republic of China
| | - Dong Xiao Wu
- The First Clinical College of Zhejiang Chinese Medical University, The First Affiliated Hospital of Zhejiang Chinese Medical University, 548# BinWen Road, HangZhou, ZheJiang Province, People's Republic of China
| | - Shuai Jie Lv
- The First Clinical College of Zhejiang Chinese Medical University, The First Affiliated Hospital of Zhejiang Chinese Medical University, 548# BinWen Road, HangZhou, ZheJiang Province, People's Republic of China
| | - Pei Jian Tong
- The First Clinical College of Zhejiang Chinese Medical University, The First Affiliated Hospital of Zhejiang Chinese Medical University, 548# BinWen Road, HangZhou, ZheJiang Province, People's Republic of China.
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12
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Xu R, Kalluri AL, Sun LR, Lawrence CE, Lee JK, Kannan S, Cohen AR. The neurosurgical management of Severe Hemophilia A and Moyamoya (SHAM): challenges, strategies, and literature review. Childs Nerv Syst 2022; 38:1077-1084. [PMID: 35262754 DOI: 10.1007/s00381-022-05489-5] [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: 12/28/2021] [Accepted: 03/03/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Severe Hemophilia A and Moyamoya arteriopathy (SHAM syndrome) is a rare genetic disorder caused by deletion of portions of the cytogenic band Xq28. A case of SHAM syndrome requiring bilateral cerebral revascularization is described with an emphasis on perioperative management. CASE REPORT A 5-year-old boy with severe hemophilia A complicated by factor VIII inhibition presented with right-sided weakness. Imaging revealed multiple strokes and vascular changes consistent with Moyamoya disease. The patient underwent two-staged indirect cerebral bypass revascularizations, first on the left side and several months later on the right. Perioperative management required balancing the administration of agents to prevent coagulopathy and perioperative hemorrhage while mitigating the risk of thromboembolic events associated with bypass surgery. Despite a multidisciplinary effort by the neurosurgery, hematology, critical care, and anesthesiology teams, the post-operative course after both surgeries was complicated by stroke. Fortunately, the patient recovered rapidly to his preoperative functional baseline. CONCLUSION We describe a rare case of SHAM syndrome in a pediatric patient who required bilateral revascularizations and discuss strategies for managing the perioperative risk of hemorrhage and stroke. We also review existing literature on SHAM syndrome.
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Affiliation(s)
- Risheng Xu
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Anita L Kalluri
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Lisa R Sun
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Courtney E Lawrence
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Jennifer K Lee
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Sujatha Kannan
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA
| | - Alan R Cohen
- Johns Hopkins University School of Medicine, Phipps Building 554, 600 N Wolfe St, Baltimore, MD, 21287, USA.
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13
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Batorova A, Boban A, Brinza M, Lissitchkov T, Nemes L, Zupan Preložnik I, Smejkal P, Zozulya N, Windyga J. Expert opinion on current and future prophylaxis therapies aimed at improving protection for people with hemophilia A. J Med Life 2022; 15:570-578. [PMID: 35646171 PMCID: PMC9126455 DOI: 10.25122/jml-2022-0103] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 03/28/2022] [Indexed: 11/17/2022] Open
Abstract
The next frontier in hemophilia A management has arrived. However, questions remain regarding the broader applicability of new and emerging hemophilia A therapies, such as the long-term safety and efficacy of non-factor therapies and optimal regimens for individual patients. With an ever-evolving clinical landscape, it is imperative for physicians to understand how available and future hemophilia A therapies could potentially be integrated into real-life clinical practice to improve patient outcomes. Against this background, nine hemophilia experts from Central European countries participated in a pre-advisory board meeting survey. The survey comprised 11 multiple-choice questions about current treatment practices and future factor and non-factor replacement therapies. The survey questions were developed to reflect current unmet needs in hemophilia management reflected in the literature. The experts also took part in a follow-up advisory board meeting to discuss the most important unmet needs for hemophilia management as well as the pre-meeting survey results. All experts highlighted the challenge of maintaining optimal trough levels with prophylaxis as their most pressing concern. Targeting trough levels of ≥30-50 IU/L or even higher to achieve less bleeding was highlighted as their preferred strategy. However, the experts had an equal opinion on how this could be achieved (i.e., more efficacious non-factor therapies or factor therapy offering broader personalization possibilities such as targeting trough levels to individual pharmacokinetic data). In summary, our study favors personalized prophylaxis to individual pharmacokinetic data rather than a "one-size-fits-all" approach to hemophilia A management to maintain optimal trough levels for individual patients.
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Affiliation(s)
- Angelika Batorova
- Department of Hematology and Transfusion Medicine, National Hemophilia Center, Faculty of Medicine of Comenius University and University Hospital, Bratislava, Slovakia
| | - Ana Boban
- Haemophilia Centre, University Hospital Centre Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Melen Brinza
- Centre of Hematology and Bone Marrow Transplant, European Haemophilia Comprehensive Care Centre, Fundeni Clinical Institute, Bucharest, Romania
| | | | - Laszlo Nemes
- National Haemophilia Centre and Haemostasis Department, Medical Centre of Hungarian Defence Forces, Budapest, Hungary
| | - Irena Zupan Preložnik
- Department of Haematology, University Medical Centre Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Petr Smejkal
- Department of Clinical Haematology, University Hospital Brno, Brno, Czech Republic,Department of Laboratory Methods, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland,Corresponding Author: Jerzy Windyga, Department of Hemostasis Disorders and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland. E-mail:
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14
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Wang M, Negrier C, Driessler F, Goodman C, Skinner MW. The Hemophilia Gene Therapy Patient Journey: Questions and Answers for Shared Decision-Making. Patient Prefer Adherence 2022; 16:1439-1447. [PMID: 35707346 PMCID: PMC9191577 DOI: 10.2147/ppa.s355627] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 05/13/2022] [Indexed: 01/19/2023] Open
Abstract
PURPOSE The anticipated emergence of hemophilia gene therapy will present people with hemophilia (PWH) and treating clinicians with increasingly complex treatment options. It will be critical that PWH and their families be empowered to participate fully in decision-making through transparent communication and the development of targeted educational resources. METHODS The Council of Hemophilia Community (CHC) convened across a series of roundtable meetings to define the patient journey for hemophilia gene therapy, and to develop a question-and-answer style resource to guide discussion between healthcare professionals (HCPs) and their patients. Patient groups were also consulted during the development of this tool. RESULTS The CHC defined 5 key stages in the hemophilia gene therapy patient journey: pre-gene therapy (information-seeking and decision-making), treatment initiation, short- and long-term post-gene therapy follow-up. PWH will have different questions and concerns at each stage of their journey, which should be discussed with their HCP to aid decision-making. The resulting patient journey infographic and Q&A resource (see Supplementary Materials) has been developed for HCPs and PWH to provide a novel and practical roadmap of key issues and considerations throughout all stages. CONCLUSION These resources support a collaborative, patient-centric, shared decision-making approach to inform treatment decision discussions between HCPs and PWH. The value of such discussions will be influenced by the language adopted; health literacy is a particularly important consideration, and these discussions should be accessible and tailored to PWH. HCPs and PWH can benefit from awareness of the common questions and uncertainties as they progress together along the patient journey. While the contents of this article are specific to hemophilia gene therapy, the concepts developed here could be adapted to aid patients in other disease states.
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Affiliation(s)
- Michael Wang
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Claude Negrier
- National Reference Center for Haemophilia, Louis Pradel Cardiology Hospital, University of Lyon, Lyon, France
| | - Frank Driessler
- Bayer, Basel, Switzerland
- Correspondence: Frank Driessler, Bayer AG, Peter Merian Straße 84, Basel, CH-4052, Switzerland, Tel +41 79 422 32 18, Email
| | | | - Mark W Skinner
- Institute for Policy Advancement Ltd, Washington, DC, USA
- McMaster University, Hamilton, ON, Canada
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15
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Konkle BA, Quon DV, Raffini L, Recht M, Radulescu VC, Carpenter SL, Dunn AL, Lu M, Watt M. A Prospective Observational Study of Antihemophilic Factor (Recombinant) Prophylaxis Related to Physical Activity Levels in Patients with Hemophilia A in the United States (SPACE). J Blood Med 2021; 12:883-896. [PMID: 34703348 PMCID: PMC8523903 DOI: 10.2147/jbm.s327180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/15/2021] [Indexed: 12/31/2022] Open
Abstract
Introduction High collision-risk physical activity can increase bleeding risk in people with hemophilia A, as can increasing the time between factor VIII (FVIII) administration and physical activity. FVIII prophylaxis may be tailored to planned activities to prevent activity-related bleeding. Aim To explore the relationship between physical activity levels, FVIII infusion timing, and occurrence of bleeding in patients with severe/moderately severe hemophilia A without FVIII inhibitors receiving antihemophilic factor (recombinant) (rAHF; ADVATE®; Baxalta US Inc., a Takeda company, Lexington, MA, USA). Methods SPACE was a 6-month, prospective, multicenter, observational outcomes study (NCT02190149). Enrolled patients received an eDiary application and a wearable activity tracker, which recorded physical activity, rAHF infusion, and occurrence of bleeding. Physical activity risks were ranked using National Hemophilia Foundation criteria. Results Fifty-four patients aged 11–58 years (n = 47 prophylaxis, n = 7 on-demand) were included in the analysis. Patients had a mean (SD) 8.14 (10.94) annualized bleeding rate, and recorded 4980 intervals between an rAHF infusion and physical activity; 1759 (35.3%) of these intervals were ≤24 hours. Analysis of recorded eDiary data showed that the risk of activity-related bleeding did not significantly increase with time between last infusion and activity, but did increase with higher-risk physical activities. Analysis of activity tracker recorded data showed that the risk of bleeding reported by patients as spontaneous increased with prolonging time (≤24 to >24 hours) from last infusion to physical activity start (odds ratio 2.65, p < 0.05). Joint health data collected at baseline were not included in the regression analysis because of small sample size; therefore the study could not assess whether patients with more joint disease at baseline were at higher risk of injury-related and reported spontaneous occurrence of bleeding. Conclusion These results show that activities with a high risk of collision lead to an increased risk of bleeding. Further investigation is warranted to explore potential benefits of FVIII infusion timing to reduce the risks of activity-related occurrence of bleeding.
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Affiliation(s)
- Barbara A Konkle
- Department of Medicine, The University of Washington and Bloodworks Northwest, Seattle, WA, USA
| | - Doris V Quon
- Orthopaedic Hemophilia Treatment Center, Orthopaedic Institute for Children, Los Angeles, CA, USA
| | - Leslie Raffini
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael Recht
- The Hemophilia Center, Oregon Health & Science University, Portland, OR, USA
| | - Vlad C Radulescu
- Department of Pediatric Hematology and Oncology, University of Kentucky Medical Center, Lexington, KY, USA
| | - Shannon L Carpenter
- Department of Hematology/Oncology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Amy L Dunn
- Hemophilia Treatment Center, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH, USA
| | - Mei Lu
- Takeda Development Center Americas, Inc, Lexington, MA, USA
| | - Maureen Watt
- Outcomes Research & Epidemiology, Takeda Pharmaceuticals International AG, Zurich, Switzerland
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16
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Meng L, Zhuang J, Sun X, Liu Z, Zhou X, Liu H, Zhou F, Li Y, Sun J. [Effect of FVIII doses on joint structure and function in adolescents with severe hemophilia A: mid-term results of a prospective cohort study]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2021; 41:536-542. [PMID: 33963712 DOI: 10.12122/j.issn.1673-4254.2021.04.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To explore the clinical phenotype and changes in joint structure and function in adolescent patients with severe hemophilia A under different doses of FVIII. OBJECTIVE Forty- three adolescents with severe hemophilia A aged 4-18 years were divided into on-demand group (n=7), low-dose group (FVIII dose of 10-15 U/kg, 2-3 times a week, and ≤30 U/kg a week; n=17), and intermediate-dose group (FVIII dose of 15-20 U/kg, 2-3 times a week, and 45-60 U/kg a week (n=19). The 3 groups were compared for their clinical bleeding phenotype, annual bleeding rate (ABR), annual joint bleeding rate (AJBR), annual the most severe joint bleeding rate, joint imaging scores (ultrasound HEAD-US score and IPSG MRI score), Hemophilia Joint Health Score (HJHS) and Functional Independence Score in Hemophilia (FISH) within 24 months. OBJECTIVE Compared with that in on-demand group, the ABR was significantly reduced in the low- and intermediate-dose groups (P=0.004 and 0.000, respectively), and was reduced by 32.87% in the intermediate-dose group as compared with the low-dose group. The AJBR (P < 0.01) and annual the most severe joint bleeding rate (P < 0.05) also differed significantly among the 3 groups. The number of bleeding episodes increased progressively with time in the on-demand group, remained stable in the low- dose group, and tended to decrease in the intermediate-dose group. The imaging scores of the most severe joints showed lesion progression in all the 3 groups. The ultrasound scores, which increased steadily in the on-demand group, showed significantly lowered increment rates in the low- and intermediate-dose groups (P=0.002 and 0.000, respectively). The MRI scores showed also delayed increment in the low- and intermediate-dose groups as compared with the on-demand group (P=0.041 and 0.000, respectively), and the increment was accelerated in the on-demand and low-dose group but remained stable in the intermediate-dose group. The increment of the HJHS scores was significantly higher in the on-demand group than in the lowand intermediate-dose groups (P=0.003 and 0.000, respectively), and the scores increased at a steady rate in the on-demand group but tended to decrease in the latter two groups. The FISH score was decreased by 0.29±3.09 in the on-demand group but was increased significantly in the low- and intermediate-dose groups compared with the on-demand group (P=0.000). OBJECTIVE In Chinese adolescents with severe hemophilia A, low- and intermediate-dose FVIII prophylaxis, especially at the intermediate dose, is better than on- demand treatment for protecting joint structure and function.
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Affiliation(s)
- L Meng
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - J Zhuang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - X Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Z Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - X Zhou
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - H Liu
- Department of Ultrasound, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - F Zhou
- Department of Diagnostic Imaging, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Y Li
- Department of Ultrasound, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - J Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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17
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Klamroth R, Wojciechowski P, Aballéa S, Diamand F, Hakimi Z, Nazir J, Abad-Franch L, Lethagen S, Santagostino E, Tarantino MD. Efficacy of rFVIIIFc versus Emicizumab for the Treatment of Patients with Hemophilia A without Inhibitors: Matching-Adjusted Indirect Comparison of A-LONG and HAVEN Trials. J Blood Med 2021; 12:115-122. [PMID: 33664606 PMCID: PMC7921628 DOI: 10.2147/jbm.s288283] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/25/2021] [Indexed: 12/17/2022] Open
Abstract
Purpose Primary prophylaxis, using factor VIII replacement, is the recognized standard of care for severe hemophilia A. Recombinant factor VIII-Fc fusion protein (rFVIIIFc) and emicizumab, a humanized, bispecific antibody, are approved for routine prophylaxis of bleeding episodes in severe hemophilia A. These products have different mechanisms of action, methods of administration and treatment schedules. In the absence of head-to-head trials, indirect treatment comparisons can provide informative evidence on the relative efficacy of the two treatments. The aim of the study was to compare the approved dosing regimens for each product, rFVIIIFc individualized prophylaxis and emicizumab administered once every week (Q1W), every 2 weeks (Q2W) or every 4 weeks (Q4W), based on clinical trial evidence. Patients and Methods The comparison was conducted using matching-adjusted indirect comparison since clinical evidence did not form a connected network. Individual patient data for rFVIIIFc (A-LONG) were compared with data for emicizumab (HAVEN trial program) for mean annualized bleeding rate (ABR) and proportion of patients with zero bleeds. Safety data reported across the analyzed treatment arms were tabularized but not formally compared. Results After matching, no significant differences were observed between mean ABR for rFVIIIFc and emicizumab administered Q1W, Q2W or Q4W. The proportion of patients with zero bleeds was significantly higher with rFVIIIFc compared with emicizumab administered Q4W (51.2% versus 29.3%, respectively; odds ratio 2.53; 95% confidence interval 1.09–5.89); no significant differences noted when rFVIIIFc was compared with emicizumab administered Q1W or Q2W. The mean number of adverse events expressed per participant was 1.9 for individualized prophylaxis with rFVIIIFc and 3.7–4.0, 4.1 and 3.6 for emicizumab administered Q1W, Q2W or Q4W, respectively. Conclusion This indirect treatment comparison suggests that rFVIIIFc individualized prophylaxis is more efficacious than emicizumab Q4W, and at least as effective as more frequent emicizumab regimens, for the management of hemophilia A.
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Affiliation(s)
- Robert Klamroth
- Department of Internal Medicine, Hemophilia Treatment Centre, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | | | | | | | - Zalmai Hakimi
- Health Economics and Outcomes Research (Global), Sobi, Stockholm, Sweden
| | - Jameel Nazir
- Health Economics and Outcomes Research (Global), Sobi, Stockholm, Sweden
| | | | | | | | - Michael D Tarantino
- The Bleeding and Clotting Disorders Institute, University of Illinois College of Medicine-Peoria, Peoria, IL, USA
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18
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Armeni P, Cavazza M, Xoxi E, Taruscio D, Kodra Y. Reflections on the Importance of Cost of Illness Analysis in Rare Diseases: A Proposal. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:1101. [PMID: 33530652 PMCID: PMC7908548 DOI: 10.3390/ijerph18031101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/09/2021] [Accepted: 01/20/2021] [Indexed: 11/23/2022]
Abstract
In the field of rare diseases (RDs), the evidence standard is often lower than that required by health technology assessment (HTA) and payer authorities. In this commentary, we propose that appropriate economic evaluation for rare disease treatments should be initially informed by cost-of-illness (COI) studies conducted using a societal perspective. Such an approach contributes to improving countries' understanding of RDs in their entirety as societal and not merely clinical, or product-specific issues. In order to exemplify how the disease burden's distribution has changed over the last fifteen years, key COI studies for Hemophilia, Fragile X Syndrome, Cystic Fibrosis, and Juvenile Idiopathic Arthritis are examined. Evidence shows that, besides methodological variability and cross-country differences, the disease burden's share represented by direct costs generally grows over time as novel treatments become available. Hence, to support effective decision-making processes, it seems necessary to assess the re-allocation of the burden produced by new medicinal products, and this approach requires identifying cost drivers through COI studies with robust design and standardized methodology.
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Affiliation(s)
- Patrizio Armeni
- Cergas (Centre for Research on Health and Social Care Management), SDA Bocconi School of Management, 20136 Milan, Italy;
| | - Marianna Cavazza
- Cergas (Centre for Research on Health and Social Care Management), SDA Bocconi School of Management, 20136 Milan, Italy;
| | - Entela Xoxi
- Independent Pharmacologist Scientific Advisor in Rare Disease Pharmaceuticals and Registries, 00184 Rome, Italy;
| | - Domenica Taruscio
- National Centre for Rare Diseases, Istituto Superiore di Sanità, 00162 Rome, Italy; (D.T.); (Y.K.)
| | - Yllka Kodra
- National Centre for Rare Diseases, Istituto Superiore di Sanità, 00162 Rome, Italy; (D.T.); (Y.K.)
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19
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Lacroix-Desmazes S, Pratt KP. Editorial: Tolerating Factor VIII: Novel Strategies to Prevent and Reverse Neutralizing Anti-FVIII Antibodies. Front Immunol 2021; 11:639386. [PMID: 33569066 PMCID: PMC7868532 DOI: 10.3389/fimmu.2020.639386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/18/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Kathleen P Pratt
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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20
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Ansteatt KT, Unzicker CJ, Hurn ML, Olaiya OO, Nugent DJ, Tarantino MD. The Need for Comprehensive Care for Persons with Chronic Immune Thrombocytopenic Purpura. J Blood Med 2020; 11:457-463. [PMID: 33364868 PMCID: PMC7751596 DOI: 10.2147/jbm.s289390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/04/2020] [Indexed: 11/23/2022] Open
Abstract
Chronic platelet disorders (CPD), including chronic immune thrombocytopenic purpura (cITP), thrombotic thrombocytopenic purpura (TTP) and platelet function disorders are among the most common bleeding disorders and are associated with morbidity and mortality. The clinical phenotype and complexity of cITP is much like that of hemophilia. In cITP and hemophilia, bleeding is problematic for many, complicating employability, insurability and overall quality-of-life (QoL). While myriad drug therapies are available for cITP and hemophilia, each are variable in their effectiveness, very few (except for clotting factor concentrates for hemophilia) alter the natural history of the disorder and sometimes contribute to specific morbidities and mortality. Like in hemophilia, the management of cITP is not solely based on access to effective treatment but also includes accurate diagnosis and comprehensive care by a multidisciplinary team of specialists trained in the management of bleeding disorders. The model of comprehensive care in Hemophilia Treatment Centers (HTCs) has been recognized as highly effective, improving life expectancy for persons with hemophilia. cITP, and other CPDs, are complex disorders requiring specialized care. However, an integrated care model with a systematic and reliable population-based surveillance program does not exist. Extending the Comprehensive Care model with all its related benefits to the community of persons with cITP is sorely needed. This review will focus on cITP as a prototype chronic platelet disorder that could benefit greatly from the Comprehensive Care model.
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Affiliation(s)
| | | | - Marsha L Hurn
- The Bleeding and Clotting Disorders Institute, Peoria, IL, USA
| | | | - Diane J Nugent
- The Center for Inherited Blood Disorders, Santa Ana, CA, USA
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21
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Gelbenegger G, Schoergenhofer C, Knoebl P, Jilma B. Bridging the Missing Link with Emicizumab: A Bispecific Antibody for Treatment of Hemophilia A. Thromb Haemost 2020; 120:1357-1370. [PMID: 32717759 PMCID: PMC7649063 DOI: 10.1055/s-0040-1714279] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hemophilia A, characterized by absent or ineffective coagulation factor VIII (FVIII), is a serious bleeding disorder that entails severe and potentially life-threatening bleeding events. Current standard therapy still involves replacement of FVIII, but is often complicated by the occurrence of neutralizing alloantibodies (inhibitors). Management of patients with inhibitors is challenging and necessitates immune tolerance induction for inhibitor eradication and the use of bypassing agents (activated prothrombin complex concentrates or recombinant activated factor VII), which are expensive and not always effective. Emicizumab is the first humanized bispecific monoclonal therapeutic antibody designed to replace the hemostatic function of activated FVIII by bridging activated factor IX and factor X (FX) to activate FX and allow the coagulation cascade to continue. In the majority of hemophilic patients with and without inhibitors, emicizumab reduced the annualized bleeding rate to almost zero in several clinical trials and demonstrated a good safety profile. However, the concurrent use of emicizumab and activated prothrombin complex concentrate imposes a high risk of thrombotic microangiopathy and thromboembolic events on patients and should be avoided. Yet, the management of breakthrough bleeds and surgery remains challenging with only limited evidence-based recommendations being available. This review summarizes published clinical trials and preliminary reports of emicizumab and discusses the clinical implications of emicizumab in treatment of hemophilia A.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Paul Knoebl
- Division of Hematology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Zerra PE, Arthur CM, Chonat S, Maier CL, Mener A, Shin S, Allen JWL, Baldwin WH, Cox C, Verkerke H, Jajosky RP, Tormey CA, Meeks SL, Stowell SR. Fc Gamma Receptors and Complement Component 3 Facilitate Anti-fVIII Antibody Formation. Front Immunol 2020; 11:905. [PMID: 32582142 PMCID: PMC7295897 DOI: 10.3389/fimmu.2020.00905] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/20/2020] [Indexed: 01/02/2023] Open
Abstract
Anti-factor VIII (fVIII) alloantibodies, which can develop in patients with hemophilia A, limit the therapeutic options and increase morbidity and mortality of these patients. However, the factors that influence anti-fVIII antibody development remain incompletely understood. Recent studies suggest that Fc gamma receptors (FcγRs) may facilitate recognition and uptake of fVIII by recently developed or pre-existing naturally occurring anti-fVIII antibodies, providing a mechanism whereby the immune system may recognize fVIII following infusion. However, the role of FcγRs in anti-fVIII antibody formation remains unknown. In order to define the influence of FcγRs on the development of anti-fVIII antibodies, fVIII was injected into WT or FcγR knockout recipients, followed by evaluation of anti-fVIII antibodies. Anti-fVIII antibodies were readily observed following fVIII injection into FcγR knockouts, with similar anti-fVIII antibody levels occurring in FcγR knockouts as detected in WT mice injected in parallel. As antibodies can also fix complement, providing a potential mechanism whereby anti-fVIII antibodies may influence anti-fVIII antibody formation independent of FcγRs, fVIII was also injected into complement component 3 (C3) knockout recipients in parallel. Similar to FcγR knockouts, C3 knockout recipients developed a robust response to fVIII, which was likewise similar to that observed in WT recipients. As FcγRs or C3 may compensate for each other in recipients only deficient in FcγRs or C3 alone, we generated mice deficient in both FcγRs and C3 to test for potential antibody effector redundancy in anti-fVIII antibody formation. Infusion of fVIII into FcγRs and C3 (FcγR × C3) double knockouts likewise induced anti-fVIII antibodies. However, unlike individual knockouts, anti-fVIII antibodies in FcγRs × C3 knockouts were initially lower than WT recipients, although anti-fVIII antibodies increased to WT levels following additional fVIII exposure. In contrast, infusion of RBCs expressing distinct alloantigens into FcγRs, C3 or FcγR × C3 knockout recipients either failed to change anti-RBC levels when compared to WT recipients or actually increased antibody responses, depending on the target antigen. Taken together, these results suggest FcγRs and C3 can differentially impact antibody formation following exposure to distinct alloantigens and that FcγRs and C3 work in concert to facilitate early anti-fVIII antibody formation.
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Affiliation(s)
- Patricia E Zerra
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States.,Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Connie M Arthur
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Satheesh Chonat
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Amanda Mener
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Sooncheon Shin
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Jerry William L Allen
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - W Hunter Baldwin
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Courtney Cox
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Hans Verkerke
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Ryan P Jajosky
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, United States.,Pathology and Laboratory Medicine Service, VA Conneciticut Healthcare System, West Haven, CT, United States
| | - Shannon L Meeks
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Sean R Stowell
- Department of Pathology and Laboratory Medicine, Center for Transfusion Medicine and Cellular Therapies, Emory University School of Medicine, Atlanta, GA, United States
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Mannucci PM. Hemophilia therapy: the future has begun. Haematologica 2020; 105:545-553. [PMID: 32060150 PMCID: PMC7049365 DOI: 10.3324/haematol.2019.232132] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 01/20/2020] [Indexed: 02/06/2023] Open
Abstract
The success story of hemophilia care first began in the 1970s, when the availability of plasma-derived concentrates of coagulation factor VIII (FVIII) and factor IX (FIX) provided efficacious treatment of bleeding in patients with hemophilia A and B. This positive scenario was consolidated in terms of greater safety and availability in the 1990s, when the first recombinant coagulation factors were produced. This meant that, instead of only treating episodic bleeding events, prophylaxis regimens could be implemented as a preventive measure. Following the demonstration of its superiority in the frame of two randomized clinical trials, prophylaxis became evidence-based standard of care. In high-income countries, these achievements have led to a patients’ life expectancy being extended to close to that of the general male population. Alongside this, the last decade has witnessed further spectacular therapeutic progress, such as the availability of coagulation factors with a longer plasma half-life that allow for wider intervals between treatment. Moreover, new therapeutic products based on new mechanisms other than the replacement of the deficient factor, have become available (emicizumab) or are at an advanced stage of development. This review celebrates the success story of hemophilia care, while also discussing current limitations, issues and as yet unmet needs. The prospects of cure by means of gene therapy are also outlined.
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Affiliation(s)
- Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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