Current Choices and Management of Treatment in Persons with Severe Hemophilia A without Inhibitors: A Mini-Delphi Consensus

The role of public health in rare diseases: hemophilia as an example

Introduction

The role of public health has evolved from addressing infectious diseases to encompass non-communicable diseases. Individuals with genetic disorders and rare diseases constitute a particularly vulnerable population, requiring tailored public health policies, practical implementation strategies, and a long-term vision to ensure sustainable support. Given the prolonged duration and significant costs often associated with these conditions, comprehensive, patient-centered, and cost-effective approaches are essential to safeguard their physical and mental well-being.

Aims

To summarize definitions and concepts related to health, public health, rare diseases, and to highlight the role of integrating public health interventions into routine care in improving patient outcomes. Hemophilia was selected as an exemplary rare disease due to its significant lifetime treatment costs and the recent approval and pricing of its gene therapy as the world's most expensive drug, highlighting the critical importance of public health policies in ensuring equitable access to care and treatment.

Methods

A narrative literature review was conducted between July 2023 and December 2024, searching PubMed, Google Scholar, and Google for various topics related to rare diseases, public health, and hemophilia.

Results

Public health can play an important role in improving the health outcomes of people with rare diseases by implementing conceptual and applied models to accomplish a set of objectives. Over the past two decades, legislative and regulatory support in high income countries (HICs) has facilitated the development and approval of diagnostics and treatments for several rare diseases leading to important advancements. In contrast, many low- and middle-income countries (LMICs) face obstacles in enacting legislation, developing regulations, and implementing policies to support rare disease diagnosis and treatment. More investment and innovation in drug discovery and market access pathways are still needed in both LMICs and HICs. Ensuring the translation of public health policies into regulatory measures, and in turn implementing, and regularly evaluating these measures to assess their effectiveness is crucial. In the case of hemophilia, public health can play a pivotal role.

Conclusion

Enhancing public health surveillance, policies, and interventions in hemophilia and other rare diseases can bridge data gaps, support access to equitable treatment, promote evidence-based care, and improve outcomes across the socioeconomic spectrum.

BAY 81-8973 Demonstrates Long-Term Safety and Efficacy in Children With Severe Haemophilia A: Results From the LEOPOLD Kids Extension Study

OBJECTIVES

To report the long-term safety and efficacy of BAY 81-8973 in the LEOPOLD Kids extension phase.

METHODS

Patients received BAY 81-8973 (25-50 IU/kg) at least twice weekly. The primary endpoint was safety, assessed in all patients who entered the extension phase (n = 82). Efficacy endpoints were assessed in patients without high-titre inhibitors/immune tolerance induction (n = 67).

RESULTS

Children (n = 82) received BAY 81-8973 for a median of 3.1 years per patient and a median of 405 exposure days per patient. Long-term BAY 81-8973 treatment was well tolerated, with no cases of de novo inhibitor development in the extension phase. Annualised bleeding rates (ABRs) within 48 h of prophylaxis were low for all bleeds (median [IQR], 0.7 [0-1.9]; mean, 1.4 [SD, 2.1]) and for joint bleeds (median [IQR], 0 [0-0.7]; mean, 0.5 [SD, 1.1]) (n = 67). Twenty-one of 67 patients (31.3%) had zero bleeds within 48 h of prophylaxis; the treatment response was 'good'/'excellent' in 87.9% of bleeds, and most bleeds resolved with ≤ 2 BAY 81-8973 infusions (83.5%).

CONCLUSION

Long-term BAY 81-8973 treatment is well tolerated and maintains low ABRs for all bleeds and joint bleeds in children with severe haemophilia A.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01311648.

The Evolution of Hemophilia Pharmacological Treatments and Therapeutic Targets at the Turn of the Third Millennium

Historically, the aim of treatment for hemophilia, the congenital X-linked hemorrhagic disorder due to deficiencies of coagulation Factor (F) VIII (hemophilia A) or FIX (hemophilia B), has been the replacement through factor concentrates, whose regular administration (i.e., prophylaxis) has been shown to be highly effective in preventing bleeding complications and it is currently considered the gold standard of hemophilia treatment. However, continuous technological progress (i.e., plasma-derived factor concentrates, recombinant standard and extended half-life [EHL] products) has allowed clinicians operating at hemophilia treatment centers to individualize the management of persons with hemophilia, improving outcomes, adherence to therapy, and their quality of life. The achievement of normal hemostasis, the final goal that now seems possible with new-generation EHL products, non-replacement and gene therapies, will translate into normalization of life for persons with hemophilia, also addressing health equity (i.e., rendering them indistinguishable from their healthy peers). The evolution of hemophilia treatment and, in parallel, of therapeutic targets in the management of hemophilia patients over the last decades will be critically discussed in this narrative review.

An Observational Study of Glycopegylated Extended Half-Life Factor Prophylaxis in Hemophilia A and B in a Tertiary Care Center in India

Prophylactic treatment for hemophilia in India remains significantly underutilized compared to developed nations, leading to reliance on episodic therapy with limited long-term benefits. This study evaluated the efficacy and safety of glycopegylated extended half-life (EHL) clotting factors in patients with hemophilia A and B. A retrospective observational design was employed, including 25 patients aged ≥18 years with moderate or severe hemophilia A or B who transitioned to EHL therapy. Hemophilia A patients (n=19) switched from standard half-life (SHL) factor VIII (FVIII) to weekly EHL FVIII prophylaxis, while hemophilia B patients (n=6) transitioned from on-demand SHL factor IX (FIX) to glycopegylated EHL FIX prophylaxis every 21 days. Outcomes were assessed through the annual bleeding rate (ABR), functional independence score in hemophilia (FISH score), and hemophilia joint health score (HJHS). A subset analysis for quality of life (QoL) was also performed on hemophilia A patients using the Haem-A-QoL questionnaire in patients with hemophilia A. Glycopegylated EHL FVIII therapy significantly reduced ABR and improved joint health and functional scores over 24 months (p<0.001). Hemophilia B patients demonstrated a significant reduction in ABR and joint bleeding rates at eight months (p<0.05). The study found that prophylaxis with individualized doses of glycopegylated EHL factors is not only effective in reducing bleeding episodes and improving joint health but also safe with improved treatment adherence, offering a viable prophylactic option in resource-constrained settings.

Dexmedetomidine for awake craniotomy: Systematic review and meta-analysis

INTRODUCTION

For awake craniotomy, monitored anaesthesia care (MAC) had shown relatively lower failure rates. Nevertheless, the conclusion of the appropriate anaesthetic agents, and complications, has not been proposed. Therefore, the systematic review and meta-analysis was done to compare the clinical profile, surgical outcomes, and anesthesia-related complications between dexmedetomidine-based and non-dexmedetomidine regimens during monitored anesthesia care (MAC) for this procedure.

EVIDENCE ACQUISITION

Published clinical trials described MAC, including the amount of anaesthetic drugs, or the number of patients for awake craniotomy between January 1st, 2009 and March 31st, 2022 were reviewed through PubMed, Scopus, Google Scholar, and grey literature index. The standard methodological procedures were following the PRISMA statement with the PROSPERO registration. Twenty-two articles with 2,137 awake craniotomy patients identified as epilepsy surgery, deep brain stimulation procedure, and intracranial surgery closed to an eloquent area with intraoperative awakening for neuro-evaluation were included. The relative risk (RR) regarding surgical outcomes, and anaesthesia-related complications were compared.

EVIDENCE SYNTHESIS

Dexmedetomidine-based versus non-dexmedetomidine anaesthetic regimen revealed no statistically significant differences in surgical outcomes (RR 1.08, 95 %CI 0.94-1.24), conversion to general anaesthesia (RR 0.45, 95 %CI 0.05-3.83), respiratory complications (RR 0.4, 95 %CI 0.12-1.27), and intraoperative nausea and vomiting (RR 0.30, 95 %CI 0.08-1.14). However, the intraoperative seizure was higher in non-dexmedetomidine group (RR 4.26, 95 %CI 1.49-12.16).

CONCLUSION

MAC for awake craniotomy with dexmedetomidine seems to be effective and safe. Randomized controlled trials with standard protocol in specific group of patients and surgical interventions would further demonstrate a clear benefit of dexmedetomidine in awake craniotomy under MAC.

Shifting Paradigms and Arising Concerns in Severe Hemophilia A Treatment

The management of hemophilia A has undergone a remarkable revolution, in line with technological advancement. In the recent past, the primary concern associated with Factor VIII (FVIII) concentrates was the risk of infections, which is now almost resolved by advanced blood screening and viral inactivation methods. Improving patients' compliance with prophylaxis has become a key focus, as it can lead to improved health outcomes and reduced health care costs in the long term. Recent bioengineering research is directed toward prolonging the recombinant FVIII (rFVIII) coagulant activity and synthesising higher FVIII yields. As an outcome, B-domain deleted, polyethylene glycolated, single-chain, Fc-fused rFVIII, and rFVIIIFc-von Willebrand Factor-XTEN are available for patients. Moreover, emicizumab, a bispecific antibody, is commercially available, whereas fitusiran and tissue factor pathway inhibitor are in clinical trial stages as alternative strategies for patients with inhibitors. With these advancements, noninfectious complications, such as inhibitor development, allergic reactions, and thrombosis, are emerging concerns requiring careful management. In addition, the recent approval of gene therapy is a major milestone toward a permanent cure for hemophilia A. The vast array of treatment options at our disposal today empowers patients and providers alike, to tailor therapeutic regimens to the unique needs of each individual. Despite significant progress in modern treatment options, these highly effective therapies are markedly more expensive than conventional replacement therapy, limiting their access for patients in developing countries.