1
|
Alcedo Andrade PE, Mannucci PM, Kessler CM. Emicizumab: the hemophilia A game-changer. Haematologica 2024; 109:1334-1347. [PMID: 37916312 PMCID: PMC11063855 DOI: 10.3324/haematol.2022.282099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/26/2023] [Indexed: 11/03/2023] Open
Abstract
In hemophilia, the unmet needs regarding adherence to prophylaxis and lack of effective long-term prophylaxis regimens, especially in patients with inhibitors, led to the production of emicizumab, the first non-factor medicine for subcutaneous administration in patients with severe and moderate hemophilia A with or without factor VIII inhibitors. This review describes the research steps behind the development of this game-changing medication as well as its success in the prophylaxis of bleeding episodes, as witnessed by the results of pivotal clinical trials but also by real-life use in the frame of a still expanding global market. We also discuss potential and actual adverse events and the nuances related to clinical use, such as laboratory monitoring, development of neutralizing antidrug antibodies, risk of thrombosis/hypercoagulability and role in the management of surgical operations. The potential of emicizumab to prevent bleeding in other congenital and acquired coagulation disorders is also outlined.
Collapse
Affiliation(s)
- Pedro E Alcedo Andrade
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC,
| | - Pier Mannuccio Mannucci
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi, Hemophilia and Thrombosis Center, Milan
| | - Craig M Kessler
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, District of Columbia.
| |
Collapse
|
2
|
Mould DR, Upton RN. "Getting the Dose Right"-Revisiting the Topic With Focus on Biologic Agents. Clin Pharmacol Ther 2024. [PMID: 38680029 DOI: 10.1002/cpt.3285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/14/2024] [Indexed: 05/01/2024]
Abstract
Nearly two decades after the Peck and Cross article '"Getting the dose right: facts, a blueprint, and encouragements" was published, a review of dose recommendations for biologics shows that the success in getting the dose right appears to have improved given the relatively low incidence of drug withdrawals and dosing/label changes. However, the clinical experience with monoclonal antibodies (MAbs) following approval has been less than perfect. In inflammatory diseases, the disease burden changes with time and high treatment failure rates have been reported. In addition, the use of concomitant steroids and immunosuppressant drugs with MAbs is common. These concomitant agents have their own safety issues and many immunosuppressant agents are not well-tolerated although they have been shown to reduce the incidence of anti-drug antibodies (ADA). This same complexity is seen in MAbs used in oncology as well, although with these agents the doses appear to be higher than needed, which results in high treatment costs and incidence of adverse events. Given the complexity of MAb pharmacokinetics, which makes providing a detailed description of dose options difficult, product labeling should include the options for alternative dose strategies and potentially include the use of therapeutic drug monitoring with dose individualization which have been shown to improve clinical response and reduce the incidence of ADA. So, while the recommended dosing for biologics seems improved over the issues noted 17 years ago, we still have some work to do.
Collapse
Affiliation(s)
- Diane R Mould
- Projections Research Inc, Phoenixville, Pennsylvania, USA
| | - Richard N Upton
- Projections Research Inc, Phoenixville, Pennsylvania, USA
- Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| |
Collapse
|
3
|
Patil R, Shanmukhaiah C, Gogtay NJ, Pandey P, Patil K, Jijina F, Madkaikar M. Low-dose emicizumab prophylaxis in patients with severe hemophilia A: a retrospective study bringing new hope for our patients. J Thromb Haemost 2024; 22:1024-1030. [PMID: 38160726 DOI: 10.1016/j.jtha.2023.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/24/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Low-dose emicizumab can potentially offer a cost-effective treatment option in persons with hemophilia A, especially in developing countries. OBJECTIVES To compare the efficacy and safety of low-dose emicizumab with those on low-dose factor (F)VIII prophylaxis via chart review. METHODS After ethics approval, chart data of 2 groups of patients were reviewed: group 1 (low-dose emicizumab, n = 10; 3 mg/kg monthly without a loading dose) and group 2 (low-dose FVIII prophylaxis, n = 10; 10-20 IU/kg of FVIII concentrates twice a week). Outcomes were target joints, annual bleeding rate, annual joint bleeding rate, Hemophilia Joint Health Score, nonactivated thromboelastometry-rotational thromboelastometry clotting time, plasma emicizumab levels, and direct costs of treatment. RESULTS All outcome measures were significantly better in the low-dose emicizumab group than in the low-dose FVIII prophylaxis group. For nonactivated thromboelastometry-rotational thromboelastometry, median values after 6 months in the low-dose emicizumab group were comparable with values seen in patients with mild hemophilia, while the values in the low-dose FVIII prophylaxis group were similar to those of patients with moderate hemophilia. The direct cost of low-dose emicizumab was found to be approximately US $6000 and that for low-dose recombinant FVIII prophylaxis used in our study was US $6282 (the cost may range from US $3432 to $7920 depending on the type of factor) when compared to approximately US $15 000 for standard-dose emicizumab. CONCLUSION Low-dose emicizumab offers a cost-effective treatment option and can improve access in developing countries. These findings need to be confirmed in a larger and better-controlled study.
Collapse
Affiliation(s)
- Rucha Patil
- Department of Haemostasis and Thrombosis, Indian Council of Medical Research-National Institute of Immunohematology, King Edward Memorial Hospital, Parel, Mumbai, India. https://twitter.com/RuchaPatil286
| | - Chandrakala Shanmukhaiah
- Department of Hematology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Parel, Mumbai, India.
| | - Nithya J Gogtay
- Department of Clinical Pharmacology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Parel, Mumbai, India
| | - Puloma Pandey
- Department of Haemostasis and Thrombosis, Indian Council of Medical Research-National Institute of Immunohematology, King Edward Memorial Hospital, Parel, Mumbai, India
| | - Kirti Patil
- Department of Occupational Therapy, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Parel, Mumbai, India
| | - Farah Jijina
- Department of Hematology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Parel, Mumbai, India
| | - Manisha Madkaikar
- Department of Haemostasis and Thrombosis, Indian Council of Medical Research-National Institute of Immunohematology, King Edward Memorial Hospital, Parel, Mumbai, India
| |
Collapse
|
4
|
Zwep LB, Guo T, Nagler T, Knibbe CAJ, Meulman JJ, van Hasselt JGC. Virtual Patient Simulation Using Copula Modeling. Clin Pharmacol Ther 2024; 115:795-804. [PMID: 37946529 DOI: 10.1002/cpt.3099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/31/2023] [Indexed: 11/12/2023]
Abstract
Virtual patient simulation is increasingly performed to support model-based optimization of clinical trial designs or individualized dosing strategies. Quantitative pharmacological models typically incorporate individual-level patient characteristics, or covariates, which enable the generation of virtual patient cohorts. The individual-level patient characteristics, or covariates, used as input for such simulations should accurately reflect the values seen in real patient populations. Current methods often make unrealistic assumptions about the correlation between patient's covariates or require direct access to actual data sets with individual-level patient data, which may often be limited by data sharing limitations. We propose and evaluate the use of copulas to address current shortcomings in simulation of patient-associated covariates for virtual patient simulations for model-based dose and trial optimization in clinical pharmacology. Copulas are multivariate distribution functions that can capture joint distributions, including the correlation, of covariate sets. We compare the performance of copulas to alternative simulation strategies, and we demonstrate their utility in several case studies. Our work demonstrates that copulas can reproduce realistic patient characteristics, both in terms of individual covariates and the dependence structure between different covariates, outperforming alternative methods, in particular when aiming to reproduce high-dimensional covariate sets. In conclusion, copulas represent a versatile and generalizable approach for virtual patient simulation which preserve relationships between covariates, and offer an open science strategy to facilitate re-use of patient data sets.
Collapse
Affiliation(s)
- Laura B Zwep
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Tingjie Guo
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - Thomas Nagler
- Department of Statistics, Ludwig Maximilian University of Munich, Munich, Germany
| | - Catherijne A J Knibbe
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jacqueline J Meulman
- LUXs Data Science, Leiden, The Netherlands
- Department of Statistics, Stanford University, Stanford, California, USA
| | - J G Coen van Hasselt
- Division of Systems Pharmacology and Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| |
Collapse
|
5
|
Kiialainen A, Adamkewicz JI, Petry C, Oldenburg J, Pipe SW, Young G, Mahlangu J, Lehle M, Niggli M, Castaman G, Jiménez-Yuste V, Shima M, Négrier C, Schmitt C. Pharmacokinetics and coagulation biomarkers in children and adults with hemophilia A receiving emicizumab prophylaxis every 1, 2, or 4 weeks. Res Pract Thromb Haemost 2024; 8:102306. [PMID: 38282901 PMCID: PMC10818085 DOI: 10.1016/j.rpth.2023.102306] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 10/25/2023] [Accepted: 11/28/2023] [Indexed: 01/30/2024] Open
Abstract
Background Emicizumab is a bispecific antibody that bridges activated factor (F)IX and FX, mimicking the function of missing activated FVIII and thus improving hemostasis in people with hemophilia A. The efficacy and safety of emicizumab were demonstrated in 4 phase III clinical trials (HAVEN 1-4). Objectives Here, we describe pharmacokinetics (PKs), pharmacodynamics (PDs), and exploratory safety biomarkers in HAVEN 1 to 4. Methods Participants received emicizumab at a loading dose of 3 mg/kg weekly for 4 weeks, followed by maintenance doses of 1.5 mg/kg weekly, 3 mg/kg every 2 weeks, or 6 mg/kg every 4 weeks. PKs, PDs, and safety biomarkers were assessed in samples collected at regular intervals during the trials. Results Emicizumab plasma trough concentrations increased during the loading dose period, reaching a mean of 52.9 μg/mL (SD, 13.6 μg/mL) at week 5, and were sustained at 42.1 to 52.3 μg/mL thereafter with maintenance dosing. Activated partial thromboplastin time shortened following the first emicizumab dose. Mean FVIII-like activity and thrombin generation peak height increased to 25.2 IU/dL (SD, 6.9 IU/dL) and 115.2 nM (SD, 42.5 nM) at week 5, with levels sustained at 17 to 23 IU/dL and >116 nM thereafter, respectively. Emicizumab did not notably affect FIX or FX plasma antigen levels, prothrombin time, or concentrations of exploratory safety markers of coagulation activation (D-dimer, prothrombin fragment 1 + 2, and fibrinogen). Conclusion In HAVEN 1 to 4, emicizumab demonstrated sustained PKs and PDs and improved coagulation parameters without affecting safety biomarkers.
Collapse
Affiliation(s)
| | | | | | | | | | - Guy Young
- Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Johnny Mahlangu
- University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | | | | | | | - Víctor Jiménez-Yuste
- Department of Hematology, La Paz University Hospital-IdiPAZ, Autónoma University, Madrid, Spain
| | | | | | | |
Collapse
|
6
|
Bertaggia Calderara D, Marchi Cappelletti R, Batista Mesquita Sauvage AP, Durual S, Gomez FJ, Zermatten MG, Aliotta A, Casini A, Alberio L. Pharmacodynamics Monitoring of Emicizumab in Patients with Hemophilia A. Thromb Haemost 2023; 123:955-965. [PMID: 37336473 DOI: 10.1055/s-0043-1769788] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Emicizumab is a bispecific antibody mimicking coagulation factor VIII (FVIII) employed to treat patients with hemophilia A (PwHA) regardless of FVIII inhibitor status. The identification of biological markers reflecting the hemostatic competence of patients under emicizumab therapy would have a great clinical value. Unfortunately, emicizumab over-corrects standard coagulation assays, precluding their use for evaluating the hemostatic correction achieved in vivo. Here, we investigated whether global coagulation assays (GCA) would allow monitoring the biological response to non-factor replacement therapy with emicizumab. MATERIALS AND METHODS Six adults PwHA received a weekly dose of emicizumab of 3 mg/kg during weeks (W) 1 4 and 1.5 mg/kg from W5 onwards. Response to treatment was monitored weekly by emicizumab plasma concentration, thrombin generation (TG), and fibrin clot formation (FCF) and structure. TG and FCF results were compared to patient baseline, FVIII replacement, and healthy donors. RESULTS TG and FCF significantly increased in PwHA after the loading period, reaching a plateau that lasted until the end of monitoring. Similarly, fibrin clot network became denser with thinner fibrin fibers. However, TG contrary to FCF remained at the lower limits of reference values. Remarkably, despite having similar plateau concentrations of emicizumab some patients showed markedly different degrees of TG and FCF improvement. CONCLUSION Our study enriches the knowledge on the use of GCA to monitor non-factor replacement therapy, indicating that TG and FCF could act as direct markers of emicizumab biological activity. GCA allow to capture and visualize the individually variable response to emicizumab, leading a step forward to the personalization of patient treatment.
Collapse
Affiliation(s)
- Debora Bertaggia Calderara
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Rita Marchi Cappelletti
- Department of Genetic Medicine and Development, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Ana Patricia Batista Mesquita Sauvage
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Stéphane Durual
- Biomaterials Laboratory, University Clinics of Dental Medicine, University of Geneva, Switzerland
| | - Francisco J Gomez
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Maxime G Zermatten
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alessandro Aliotta
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alessandro Casini
- Department of Medicine, University of Geneva, Geneva, Switzerland
- Division of Angiology and Hemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| |
Collapse
|
7
|
Yoneyama K, Schmitt C, Portron A, Kiialainen A, Kotani N, Jaminion F, Retout S, Adamkewicz JI. Clinical pharmacology of emicizumab for the treatment of hemophilia A. Expert Rev Clin Pharmacol 2023; 16:775-790. [PMID: 37529848 DOI: 10.1080/17512433.2023.2243213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/22/2023] [Accepted: 07/28/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Emicizumab is a humanized bispecific antibody approved for the routine prophylaxis of bleeding episodes in patients with hemophilia A (PwHA) regardless of the presence of factor VIII (FVIII) inhibitors. It mimics the cofactor function of missing activated FVIII by bridging activated factor IX and factor X, thereby restoring hemostasis. AREAS COVERED This review covers the clinical pharmacology of emicizumab and the translation of its pharmacokinetics (PK) and pharmacodynamics (PD) to clinical efficacy and safety. The PK of emicizumab is linear, with an approximately 1-month half-life. Once-weekly to every-4-week subcutaneous (SC) administrations maintain effective trough concentrations throughout the dosing intervals, associated with a coagulation potential analogous to that in patients with mild hemophilia A. In combination with activated prothrombin complex concentrate, and to a lesser extent with recombinant activated factor VII, emicizumab exerts a synergistic effect, whereas combination with FVIII may result in a non-additive coagulation potential at normal FVIII activity. EXPERT OPINION The translation of emicizumab PK/PD into clinical effects was demonstrated in several phase III studies, which showed remarkable bleed control and a favorable safety profile in PwHA. These emicizumab attributes, together with the convenience of use (infrequent SC injections), offer a novel paradigm for the management of PwHA.
Collapse
|
8
|
Donners A, van der Zwet K, Egberts ACG, Fijnvandraat K, Mathôt R, Kruis I, Cnossen MH, Schutgens R, Urbanus RT, Fischer K. DosEmi study protocol: a phase IV, multicentre, open-label, crossover study to evaluate non-inferiority of pharmacokinetic-guided reduced dosing compared with conventional dosing of emicizumab in people with haemophilia A. BMJ Open 2023; 13:e072363. [PMID: 37369395 PMCID: PMC10410934 DOI: 10.1136/bmjopen-2023-072363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 06/11/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION Emicizumab effectively prevents bleeding in people with haemophilia A (PwHA), but is a burden for national healthcare budgets and consequently may limit access. According to the drug label, dosing of emicizumab is based on body weight with fixed intervals of 7, 14 or 28 days, which leads to mean plasma concentrations of 55 µg/mL (SD 15 µg/mL). However, a moderate variability of concentrations and a minimal effective concentration of 30 µg/mL have been suggested in studies. Therefore, a dose of emicizumab that targets a trough concentration of 30 µg/mL is hypothesised to be equally effective as conventional dosing in the prevention of bleeding. METHODS AND ANALYSIS We designed a phase IV, multicentre, open-label, crossover study to evaluate non-inferiority of bleed control of ≥6 months on conventional dosing in comparison to ≥6 months on dose intervention. This dose intervention consists of reducing the dose of emicizumab to target a trough concentrations of 30 µg/mL using individual pharmacokinetic (PK) parameters. Ninety-five PwHA aged >1 years who received conventional dosing of emicizumab for ≥12 months with good bleeding control during the last 6 months will be recruited from all Dutch haemophilia treatment centres. The study is powered to detect a clinically relevant decrease (risk difference) of 15% in the proportion of patients without treated bleeds during follow-up. Secondary endpoints are spontaneous joint or muscle bleeds, and annualised treated bleeding rates (using negative binomial regression). Cost-effectivity between conventional dosing and individualised PK-guided dosing of emicizumab will be compared. ETHICS AND DISSEMINATION The DosEmi study was approved by the Medical Ethics Review Committee NedMec of the University Medical Center of Utrecht, The Netherlands. Study results will be communicated through publications in international scientific journals and presentations at (inter)national conferences. TRIAL REGISTRATION NUMBER EUCTR2021-004039-10-NL at https://trialsearch.who.int. PROTOCOL VERSION V.4.1 on 28 October 2022 (DosEmi protocol_V4.1; NL81112.041.22).
Collapse
Affiliation(s)
- Anouk Donners
- Department of Clinical Pharmacy, University Medical Centre, Utrecht University, Utrecht, The Netherlands
| | - Konrad van der Zwet
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Antoine C G Egberts
- Department of Clinical Pharmacy, University Medical Centre, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Karin Fijnvandraat
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Ron Mathôt
- Department of Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Ilmar Kruis
- Netherlands Haemophilia Society, Nijkerk, The Netherlands
| | - Marjon H Cnossen
- Department of Paediatric Haematology and Oncology, Erasmus MC Sophia Children's Hospital, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Principal Investigator SYMPHONY NWO-NWA Consortium, Rotterdam, The Netherlands
| | - Roger Schutgens
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rolf T Urbanus
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Center for Benign Haematology, Thrombosis and Haemostasis, Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
9
|
Wei L, Tian Y, Chen X, Guo X, Chen C, Zheng Y, Xu J, Ye X. Data mining and analysis for emicizumab adverse event signals based on the Food and Drug Administration Adverse Event Reporting System database. Int J Clin Pharm 2023:10.1007/s11096-022-01514-4. [PMID: 36848023 DOI: 10.1007/s11096-022-01514-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 10/23/2022] [Indexed: 03/01/2023]
Abstract
BACKGROUND Emicizumab is the latest treatment for patients with hemophilia A. Its safety in real-world data is limited, and regulatory agencies and clinical researchers have raised concerns about the risk of adverse events. AIM This study aimed to detect potential adverse event signals of emicizumab using the FDA Adverse Event Reporting System (FAERS) database. METHOD Data in FAERS from the fourth quarter of 2017 to the second quarter of 2021 were searched. Cases of adverse events were extracted using the Preferred Term in the Medical Dictionary for Regulatory Activities (version 24.0). Disproportionality analysis was performed using the reporting odds ratio (ROR) and information component (IC) methods based on statistical shrinkage transformation. RESULTS A total of 5,598,717 patients were included, of which 1,244 took emicizumab. A total of 703 emicizumab-related adverse event signals were mined, and 101 positive signals were detected. Haemarthrosis (ROR/ROR975/ROR025 = 155.62/184.34/131.38, IC/IC975/IC025 = 7.28/7.48/7.01), haemorrhage (ROR/ROR975/ROR025 = 71.01/81.18/62.12, IC/IC975/IC025 = 6.15/6.31/5.94), muscle haemorrhage (ROR/ROR975/ROR025 = 53.38/75.83/37.58, IC/IC975/IC025 = 5.74/6.16/5.15), traumatic haemorrhage (ROR/ROR975/ROR025 = 27.78/46.29/16.67, IC/IC975/IC025 = 4.80/5.40/3.92), haematoma (ROR/ROR975/ROR025 = 18.15/26.35/12.51, IC/IC975/IC025 = 4.18/4.63/3.55), device-related thrombosis (ROR/ROR975/ROR025 = 21.27/37.57/12.04, IC/IC975/IC025 = 4.41/5.08/3.43), and activated partial thromboplastin time prolonged (ROR/ROR975/ROR025 = 20.68/36.51/11.71, IC/IC975/IC025 = 4.37/5.04/3.39) had the strongest signal intensities. Haemorrhage, haemarthrosis, arthralgia, fall, and injection site pain were reported more frequently. CONCLUSION This study found that mild arthralgia and injection site reaction were associated with emicizumab. Attention should also be paid to other serious adverse events related to emicizumab, such as acute myocardial infarction and sepsis, to ensure patient safety.
Collapse
Affiliation(s)
- Lianhui Wei
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, 200433, China
| | - Ye Tian
- Dapartment of Anesthesiology, The Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiao Chen
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, 200433, China
| | - Xiaojing Guo
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, 200433, China
| | - Chenxin Chen
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, 200433, China
| | - Yi Zheng
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, 200433, China
| | - Jinfang Xu
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, 200433, China
| | - Xiaofei Ye
- Department of Health Statistics, Faculty of Health Service, Naval Medical University, Shanghai, 200433, China.
| |
Collapse
|
10
|
Yamaguchi T, Shinozawa K, Nagatoishi S, Mitsuhashi A, Bingo M, Inaba H, Amano K, Tsumoto K, Kinai E. In vitro validation of chromogenic substrate assay for evaluation of surrogate FVIII-activity of emicizumab. Thromb Res 2023; 222:131-139. [PMID: 36657269 DOI: 10.1016/j.thromres.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/09/2022] [Accepted: 01/05/2023] [Indexed: 01/15/2023]
Abstract
[Introduction] Emicizumab, a bispecific antibody mimicking activated factor VIII (FVIII), is increasingly used in prophylaxis against bleeding in hemophilia A. Human factor-based chromogenic substrate assay (hCSA) shows concentration-dependency between emicizumab and reported FVIII activity. However, the assay measurement settings have not been optimized for emicizumab, and the reported FVIII activity cannot be directly referred as surrogate FVIII activity. [Materials and Methods] For in vitro validation of hCSA-reported surrogate FVIII activity, we compared the equation curves for emicizumab concentration with surrogate FVIII activity using spiked plasma in the thrombin generation assay (TGA), hCSA, and clot waveform analysis (CWA). Then, we generated conversion equations for hCSA-reported surrogate FVIII value to that of TGA. We also assessed the additive effect of rFVIII onto 340 nM (i.e., 50 μg/mL) emicizumab using the same assays. [Results] With 1:20 diluted plasma, halving hCSA-reported surrogate FVIII activity can be approximated to that in TGA triggered by the extrinsic pathway reagent (27.3 IU/dL vs. 13.9 IU/dL) under therapeutic emicizumab concentration. Both in TGA and hCSA, the additive effect of added FVIII on therapeutic emicizumab concentration (340 nM) was maintained at low levels of FVIII but gradually decreased at higher levels. [Conclusions] Surrogate FVIII activity can be estimated simply by halving hCSA-reported FVIII value, and the additive effect of FVIII on emicizumab diminishes at high concentrations. Based on our in vitro study, a clinical study is currently being conducted to compare individual variation of surrogate FVIII activity in hCSA and TGA.
Collapse
Affiliation(s)
- Tomoko Yamaguchi
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Keiko Shinozawa
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Satoru Nagatoishi
- The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Ayano Mitsuhashi
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan; Research Resident Fellowship, Japan Foundation for AIDS Prevention, Tokyo, Japan
| | - Masato Bingo
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Hiroshi Inaba
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Kagehiro Amano
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Kohei Tsumoto
- The Institute of Medical Science, The University of Tokyo, Tokyo, Japan; Department of Bioengineering, Graduate School of Engineering, The University of Tokyo, Tokyo, Japan
| | - Ei Kinai
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan.
| |
Collapse
|
11
|
Pipe SW, Trzaskoma B, Minhas M, Lehle M, Ko RH, Gao L, Mahlangu J, Kempton CL, Kessler CM, Kruse-Jarres R. Efficacy of emicizumab is maintained throughout dosing intervals for bleed prophylaxis. Res Pract Thromb Haemost 2023; 7:100077. [PMID: 36908770 PMCID: PMC9992752 DOI: 10.1016/j.rpth.2023.100077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/05/2022] [Accepted: 12/29/2022] [Indexed: 02/09/2023] Open
Abstract
Background Across the HAVEN clinical trial program, the efficacy of emicizumab has been demonstrated in children, adolescents, and adults with hemophilia A, with or without factor VIII inhibitors. After the 4-week loading dose period, emicizumab concentrations are expected to remain at levels that provide bleed protection throughout the entire dosing interval, regardless of the chosen maintenance dosing regimen, ie, weekly, every 2 weeks, or every 4 weeks. Objectives The objective of this study was to examine the timing of treated bleeds within the dosing intervals for emicizumab administered during the HAVEN 1 to 4 studies. Methods In this post hoc analysis, we pooled data from all the participants of the HAVEN 1 to 4 studies and analyzed the timing of treated bleeds in relation to the emicizumab dose. Results A total of 392 participants were included in this analysis, with a median (range) age of 28.0 years (1.1-77.0 years). Target joints were identified in 237 of 392 (60.5%) participants before the study entry. Overall, 211 of 392 (53.8%) participants experienced 907 treated bleeding events. The total mean (SD) annualized bleeding rate across the 4 studies was 1.6 (5.9). There was no evidence that bleeding events clustered on any 1 particular day in any dosing schedule from HAVEN 1 to 4 (P > .05 for all 3 treatment regimens). Conclusion Data from the HAVEN 1 to 4 trials show consistent bleed prevention within the dosing interval, regardless of the dosing regimen chosen. These findings provide further evidence of the sustained efficacy of emicizumab across all approved dosing regimens to reduce bleeding in people with hemophilia A.
Collapse
Affiliation(s)
- Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ben Trzaskoma
- US Medical Affairs, Genentech Inc, South San Francisco, California, USA
| | - Miranda Minhas
- US Medical Affairs, Genentech Inc, South San Francisco, California, USA
| | - Michaela Lehle
- Product Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Richard H Ko
- US Medical Affairs, Genentech Inc, South San Francisco, California, USA
| | - Ling Gao
- Analystat Corporation, Point Roberts, Washington, USA
| | - Johnny Mahlangu
- Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | - Christine L Kempton
- Department of Hematology and Medical Oncology and Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Craig M Kessler
- The Division of Coagulation, Georgetown University School of Medicine, Washington, DC, USA
| | - Rebecca Kruse-Jarres
- Division of Hematology, University of Washington and Washington Center for Bleeding Disorders, Seattle, Washington, USA
| |
Collapse
|
12
|
Schmitt C, Mancuso ME, Chang T, Podolak-Dawidziak M, Petry C, Sidonio R, Yoneyama K, Key NS, Niggli M, Lehle M, Peyvandi F, Oldenburg J. Emicizumab dose up-titration in case of suboptimal bleeding control in people with haemophilia A. Haemophilia 2023; 29:90-99. [PMID: 36271487 PMCID: PMC10091821 DOI: 10.1111/hae.14679] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/31/2022] [Accepted: 09/30/2022] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Emicizumab promotes effective haemostasis in people with haemophilia A (PwHA). It is indicated for routine prophylaxis of bleeding episodes in PwHA with or without factor (F)VIII inhibitors. AIM To investigate the effect of emicizumab dose up-titration in PwHA with suboptimal bleeding control. METHODS Data from seven completed or ongoing phase III studies were pooled. Pharmacokinetics, pharmacodynamics and bleeding events were evaluated before and after dose up-titration. Adverse events (AEs) were compared between PwHA with and without dose up-titration. RESULTS Of 675 PwHA evaluable for the analysis, 24 (3.6%) had their maintenance dose up-titrated to 3 mg/kg once weekly (QW). Two participants had neutralising antibodies (nAbs) associated with decreased emicizumab exposure, and dose increase did not compensate for the effect of nAbs. In the other 22 participants, mean emicizumab steady-state trough concentrations increased from 44.0 to 86.2 μg/mL after up-titration. The median (interquartile range [IQR]) efficacy period prior to up-titration was 24.6 (24.0-32.0) weeks. The model-based annualised bleed rate for 'treated bleeds' and 'all bleeds' decreased by 70.2% and 72.9%, respectively, after a median (IQR) follow-up of 97.1 (48.4-123.3) weeks in the up-titration period. Incidences of injection-site reactions and serious AEs were higher in PwHA with up-titration; however, this was already observed in these participants before the dose up-titration. Overall, the safety profile appeared similar between PwHA with and without up-titration. CONCLUSION The dose up-titration to 3 mg/kg QW was well tolerated. Bleed control improved in most participants whose bleeding tendency was inadequately controlled during clinical trials.
Collapse
Affiliation(s)
- Christophe Schmitt
- Department of Clinical Pharmacology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Maria Elisa Mancuso
- IRCCS Humanitas Research Hospital, Center for Thrombosis and Hemorrhagic Diseases, Rozzano, Milan, Italy
| | - Tiffany Chang
- Genentech, Inc., South San Francisco, California, USA.,Spark Therapeutics, Inc., Philadelphia, Pennsylvania, USA
| | - Maria Podolak-Dawidziak
- Department of Haematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wrocław, Poland
| | - Claire Petry
- Department of Clinical Pharmacology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Robert Sidonio
- Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | | | - Nigel S Key
- Department of Medicine and Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Markus Niggli
- Department of Clinical Pharmacology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Michaela Lehle
- Department of Clinical Pharmacology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | | |
Collapse
|
13
|
D'Albini L, Dorholt M, Gallucci L. Optimizing maintenance dosing of emicizumab-kxwh as prophylaxis in hemophilia A: Dosing to product labeling while minimizing drug waste. J Manag Care Spec Pharm 2023; 29:47-57. [PMID: 36580124 PMCID: PMC10387933 DOI: 10.18553/jmcp.2023.29.1.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND: The introduction of the bispecific antibody emicizumab-kxwh has driven a paradigm shift in the management of patients with hemophilia A. Emicizumab-kxwh is gradually replacing factor VIII as the treatment of choice for prophylaxis. The requirement to dose emicizumab-kxwh by weight can drive waste when the appropriate combination of various strengths of single-use vials is not considered, whereas inappropriate rounding to full vials can lead to significantly subtherapeutic or supratherapeutic doses. OBJECTIVE: To quantify waste reduction and impact to savings when a clinical program designed to optimize the emicizumab-kxwh dose, frequency, and vial combination is applied at the dispensing specialty pharmacy level. METHODS: The electronic medical records of 360 patients receiving emicizumab-kxwh as maintenance therapy were retrospectively reviewed. Patients were included in the sample if they were male, were aged 18 to 89 years, were inhibitor negative, and had at least 1 new or renewal maintenance prescription in 2021. Three hundred seventy discrete regimens were identified as evaluated per the Regimen Optimization Algorithm - emicizumab-kxwh and included in the final sample. Data collected for each regimen included patient weight, emicizumab-kxwh dose and interval originally prescribed, every 7-day equivalent regimen (to the hundredth of a milligram), vial combination originally ordered, and resulting waste generated. For those regimens failing the algorithm, additional review of pharmacist follow-up and prescriber engagement was performed. When the prescriber adopted a pharmacist recommendation to adjust dose, frequency of administration and/or vial combination, impact to cost was calculated (Medicare Part B 2022 average sale price). RESULTS: 48% (176/370) of reviewed regimens failed specialty pharmacist review because they drove a potentially subtherapeutic or supratherapeutic dose and/or resulted in the use of partial vials that required that the patient discard all emicizumab-kxwh over the prescribed amount with each dose. 112 (64%) of these failed regimens met full criteria for prescriber engagement to recommend a regimen adjustment to dose, frequency of administration, and/or vial combination. These recommendations were adopted in 43% of cases (48/112), resulting in a cumulative savings of 600 mg per dose while also avoiding significant subtherapeutic or supratherapeutic dosing. When factoring in the frequency of administration at the patient level, cumulative annual savings to payers across these 48 accepted recommendations was $1,793,549.76. CONCLUSIONS: These data illustrate that the application of an evidence-based Regimen Optimization Algorithm at the dispensing specialty pharmacy level can reduce waste and drive payer savings while avoiding significant subtherapeutic or supratherapeutic dosing. DISCLOSURES: Accredo, Inc, a specialty pharmacy dispensing emicizumab-kxwh to patients with hemophilia A, employs the authors. Accredo, Inc, is a subsidiary of EverNorth, which also includes Express Scripts, a PBM that adjudicates a portion of emicizumab-kxwh claims.
Collapse
|
14
|
Lee L, Gollen R, Fathallah AM, Gao L, Patil S. Bridging the Gap With Clinical Pharmacology in Innovative Rare Disease Treatment Modalities: Targeting DNA to RNA to Protein. J Clin Pharmacol 2022; 62. [DOI: 10.1002/jcph.2172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 10/12/2022] [Indexed: 12/04/2022]
|
15
|
Kershaw G, Dix C, Chen VM, Cai N, Khoo T. Emicizumab assay evaluations and results from an Australian field study of emicizumab measurement. Pathology 2022. [PMID: 35577608 DOI: 10.1016/j.pathol.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 12/26/2021] [Accepted: 02/08/2022] [Indexed: 11/19/2022]
Abstract
Emicizumab is a recombinant, humanised bispecific antibody which acts as a FVIII mimetic and is a therapeutic option for haemophilia A. Plasma emicizumab levels may sometimes be required. Multiple one-stage clotting assays (OSA) and one human component chromogenic assay (CSA) were used to measure emicizumab both centrally and by a field study. The study samples drug concentrations range included within therapy range of 35-70 μg/mL. All assays were modified from traditional FVIII assays to enable replacement of plasma calibrators with emicizumab calibrators. Central laboratory OSA mean recovery levels (target) for six spike levels of emicizumab were close to target at 120.5 (120), 81.6 (80), 40.9 (40), 21.4 (20), 10.7 (10) and 5.5 (5) μg/mL. Field study OSA mean recoveries were similarly close to target. Between method coefficients of variation were <9% in both the central laboratory and field study assays, except for the 5 μg/mL sample which was 12.3%. CSA mean recoveries were within 10% of target at 80, 50 and 20 μg/mL levels. This study affirms that emicizumab can be measured by OSA using many types of activated partial thromboplastin time (APTT) reagents and is also measurable by the human CSA. The assays showed good precision, accuracy and linearity both locally and in a field study setting.
Collapse
|
16
|
Wang L, Wang J, Feng J, Doi M, Pepe S, Pacanowski M, Schuck RN. Dose-finding studies in drug development for rare genetic diseases. Orphanet J Rare Dis 2022; 17:156. [PMID: 35382851 PMCID: PMC8985255 DOI: 10.1186/s13023-022-02298-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The small patient populations inherent to rare genetic diseases present many challenges to the traditional drug development paradigm. One major challenge is generating sufficient data in early phase studies to inform dose selection for later phase studies and dose optimization for clinical use of the drug. However, optimizing the benefit-risk profile of drugs through appropriate dose selection during drug development is critical for all drugs, including those being developed to treat rare diseases. Recognizing the challenges of conducting dose finding studies in rare disease populations and the importance of dose selection and optimization for successful drug development, we assessed the dose-finding studies and analyses conducted for drugs recently approved for rare genetic diseases. RESULTS Of the 40 marketing applications for new molecular entity (NME) drugs and biologics approved by the United States Food and Drug Administration for rare genetic diseases from 2015 to 2020, 21 (53%) of the development programs conducted at least one dedicated dose-finding study. In addition, the majority of drug development programs conducted clinical studies in healthy subjects and included population pharmacokinetic and exposure-response analyses; some programs also conducted clinical studies in patient populations other than the disease for which the drug was initially approved. The majority of primary endpoints utilized in dedicated dose-finding studies were biomarkers, and the primary endpoint of the safety and efficacy study matched the primary endpoint used in the dose finding study in 9 of 13 (69%) drug development programs where primary study endpoints were assessed. CONCLUSIONS Our study showed that NME drug development programs for rare genetic diseases utilize multiple data sources for dosing information, including studies in healthy subjects, population pharmacokinetic analyses, and exposure-response analyses. In addition, our results indicate that biomarkers play a key role in dose-finding studies for rare genetic disease drug development programs. Our findings highlight the need to develop study designs and methods to allow adequate dose-finding efforts within rare disease drug development programs that help overcome the challenges presented by low patient prevalence and other factors. Furthermore, the frequent reliance on biomarkers as endpoints for dose-finding studies underscores the importance of biomarker development in rare diseases.
Collapse
Affiliation(s)
- Lingshan Wang
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Jie Wang
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Ji Feng
- Office of Translational Sciences Immediate Office, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Mary Doi
- Office of Translational Sciences Immediate Office, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Salvatore Pepe
- Office of Translational Sciences Immediate Office, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Michael Pacanowski
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Robert N Schuck
- Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA.
| |
Collapse
|
17
|
Lester W, Reilly-stitt C. Pitfalls in laboratory monitoring of treatment in people with Haemophilia. Blood Rev 2022. [DOI: 10.1016/j.blre.2022.100946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 11/18/2022]
|
18
|
Gras-Colomer E, Mangas-Sanjuán V, Martínez-Gómez MA, Climente-Martí M, Merino-Sanjuan M. Quantitative assessment of the exposure-efficacy relationship of glucocerebrosidase using Markovian elements in Gaucher patients treated with enzyme replacement therapy. Br J Clin Pharmacol 2021; 88:2727-2737. [PMID: 34957594 DOI: 10.1111/bcp.15198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 11/11/2021] [Accepted: 12/13/2021] [Indexed: 11/27/2022] Open
Abstract
AIMS The aims of this study are (i) to develop a population pharmacokinetic model of enzyme activity in Gaucher-type 1 (GD1) patients after intravenous administration of enzyme replacement therapy (ERT) and, (ii) to establish an exposure-efficacy relationship for bone marrow infiltration to propose dose adjustments according to patient covariate values. MATERIALS AND METHODS A prospective follow-up, semi-experimental multi-centre study was conducted in four hospitals to evaluate the pharmacokinetics, efficacy and safety of ERT in GD1 patients. 25 individuals with 266 glucocerebrosidase (GCase) observations in plasma and leukocytes and 14 individuals with 68 Spanish Magnetic Resonance Imaging (S-MRI) observations were enrolled. RESULTS A two concatenated compartments with zero-order endogenous production and first-order distribution (CL1 =3.85 x10-1 L/d) and elimination (CL2 = 1.25 L/d) allowed to describe GCase observations in plasma and leucocytes, respectively. An exponential time-dependency (kT =6.14 x10-1 d-1 ) effect on CL1 was incorporated. The final exposure-efficacy model was a longitudinal logistic regression model with a first-order Markov element. An Emax function (EC50 =15.73 U/L and Emax=2.33) linked steady-state concentrations of GCase in leucocytes to the probability of transition across the different S-MRI stages. CONCLUSION A population pharmacokinetic model successfully characterized the leukocyte activity-time profiles of GCase following intravenous administration of ERT in GD1 patients together with an exposure-efficacy relationship in bone marrow using markovian elements. The information obtained from this study could be of high clinical relevance in individualization of ERT in GD1 patients, as this could lead to anticipate decision-making regarding clinical response in bone and optimal dosing strategy. NONSTANDARD ABBREVIATIONS: -2LL: -2xlog(likelihood); ERT: enzyme replacement therapy; GCase: glucocerebrosidase activity; GD1: Gaucher disease type 1; GOF: goodness-of-fit plots; IIV: inter-individual variability; NLME: non-linear mixed effects modelling; OFV: objective function value; pc-VPC: prediction-corrected visual predictive check; PK: pharmacokinetic; RSE: relative standard error; RUV: residual unexplained variability, S-MRI: Spanish Magnetic Resonance Imaging, TDM: therapeutic drug monitoring.
Collapse
Affiliation(s)
| | - Víctor Mangas-Sanjuán
- Department of Pharmacy Technology and Parasitology, Faculty of Pharmacy, University of Valencia, Valencia, Spain.,Interuniversity Institute of Recognition Research Molecular and Technological Development
| | - María-Amparo Martínez-Gómez
- Pharmacy Department, University Hospital Doctor Peset of Valencia, Spain.,Foundation for the Promotion of Healthcare and Biomedical Research in the Valencian Community (FISABIO), Valencia, Spain
| | - Mónica Climente-Martí
- Department of Pharmacy Technology and Parasitology, Faculty of Pharmacy, University of Valencia, Valencia, Spain.,Pharmacy Department, University Hospital Doctor Peset of Valencia, Spain
| | - Matilde Merino-Sanjuan
- Department of Pharmacy Technology and Parasitology, Faculty of Pharmacy, University of Valencia, Valencia, Spain.,Interuniversity Institute of Recognition Research Molecular and Technological Development
| |
Collapse
|
19
|
Donners AAMT, Rademaker CMA, Bevers LAH, Huitema ADR, Schutgens REG, Egberts TCG, Fischer K. Pharmacokinetics and Associated Efficacy of Emicizumab in Humans: A Systematic Review. Clin Pharmacokinet 2021; 60:1395-1406. [PMID: 34389928 PMCID: PMC8585815 DOI: 10.1007/s40262-021-01042-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Emicizumab is an effective new treatment option for people with hemophilia A (PwHA). The approved dosing regimens are based on body weight, without the necessity for laboratory monitoring. This assumes a clear dose-concentration-response relationship, with acceptable variability due to factors other than body weight. To investigate this assumption, a systematic review on the pharmacokinetics (PK) and associated efficacy of emicizumab in humans was conducted. METHODS The EMBASE, Pubmed and CENTRAL databases were systematically searched to November 2020 to identify studies on the PK data of emicizumab in humans. Data on the study, population, PK and efficacy (annualized bleeding rate of treated [joint] bleeds) were extracted and synthesized, and exposure effects modeling was performed using non-linear least squares regression in a maximum effect (Emax) model. RESULTS The 15 included studies reported on data for 140 volunteers and 467 PwHA, including children (0 to <12 years) and adolescents and adults (≥12 years), both with and without factor VIII (FVIII) inhibitors. Emicizumab demonstrated dose-linear PK. The interindividual variability of trough concentrations was moderate (32%) and was similar across various subgroups, such as FVIII inhibitor status, age group and dosing interval. The control of bleeds did not further improve above emicizumab concentrations of 30 µg/mL, potentially enabling lower dosing in a substantial proportion of PwHA. CONCLUSION This review supports body weight-based dosing, although individualized monitoring of emicizumab concentrations may allow for more cost-effective dosing.
Collapse
Affiliation(s)
- Anouk A M T Donners
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands.
| | - Carin M A Rademaker
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands
| | - Lisanne A H Bevers
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands
| | - Alwin D R Huitema
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands
- Department of Pharmacy and Pharmacology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Toine C G Egberts
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, D.00.204, Postbus 85500, 3508 GA, Utrecht, The Netherlands
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
20
|
Svensson RJ, Ribbing J, Kotani N, Dolton M, Vadhavkar S, Cheung D, Staton T, Choy DF, Putnam W, Jin J, Budha N, Karlsson MO, Quartino A, Zhu R. Population repeated time-to-event analysis of exacerbations in asthma patients: A novel approach for predicting asthma exacerbations based on biomarkers, spirometry, and diaries/questionnaires. CPT Pharmacometrics Syst Pharmacol 2021; 10:1221-1235. [PMID: 34346168 PMCID: PMC8520748 DOI: 10.1002/psp4.12690] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/18/2021] [Accepted: 07/02/2021] [Indexed: 11/07/2022] Open
Abstract
Identification of covariates, including biomarkers, spirometry, and diaries/questionnaires, that predict asthma exacerbations would allow better clinical predictions, shorter phase II trials and inform decisions on phase III design, and/or initiation (go/no-go). The objective of this work was to characterize asthma-exacerbation hazard as a function of baseline and time-varying covariates. A repeated time-to-event (RTTE) model for exacerbations was developed using data from a 52-week phase IIb trial, including 502 patients with asthma randomized to placebo or 70 mg, 210 mg, or 490 mg astegolimab every 4 weeks. Covariate analysis was performed for 20 baseline covariates using the full random effects modeling approach, followed by time-varying covariate analysis of nine covariates using the stepwise covariate model (SCM) building procedure. Following the SCM, an astegolimab treatment effect was explored. Diary-based symptom score (difference in objective function value [dOFV] of -83.7) and rescue medication use (dOFV = -33.5), and forced expiratory volume in 1 s (dOFV = -14.9) were identified as significant time-varying covariates. Of note, time-varying covariates become more useful with more frequent measurements, which should favor the daily diary scores over others. The most influential baseline covariates were exacerbation history and diary-based symptom score (i.e., symptom score was important as both time-varying and baseline covariate). A (nonsignificant) astegolimab treatment effect was included in the final model because the limited data set did not allow concluding the remaining effect size as irrelevant. Without time-varying covariates, the treatment effect was statistically significant (p < 0.01). This work demonstrated the utility of a population RTTE approach to characterize exacerbation hazard in patients with severe asthma.
Collapse
Affiliation(s)
| | | | - Naoki Kotani
- GenentechSouth San FranciscoCaliforniaUSA
- Chugai PharmaceuticalTokyoJapan
| | | | | | | | | | | | | | - Jin Jin
- GenentechSouth San FranciscoCaliforniaUSA
| | | | - Mats O. Karlsson
- PharmetheusUppsalaSweden
- Department of PharmacyUppsala UniversityUppsalaSweden
| | | | - Rui Zhu
- GenentechSouth San FranciscoCaliforniaUSA
| |
Collapse
|
21
|
Retout S, Schmitt C, Petry C, Mercier F, Frey N. Population Pharmacokinetic Analysis and Exploratory Exposure-Bleeding Rate Relationship of Emicizumab in Adult and Pediatric Persons with Hemophilia A. Clin Pharmacokinet 2020; 59:1611-25. [PMID: 32504271 DOI: 10.1007/s40262-020-00904-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Emicizumab is a bispecific monoclonal antibody developed for routine prophylaxis of bleeding in people with hemophilia A (PwHA). This work characterizes the pharmacokinetics of emicizumab in adult and pediatric PwHA, identifies factors contributing to its between-person variabilities, compares the pharmacokinetics following different dosing regimens, and makes a descriptive assessment of the exposure–bleeding events relationship. Methods A population pharmacokinetic model was developed, using a database of 389 PwHA from five clinical studies. Potential baseline covariate effects were assessed, including body size, age, race, presence of factor VIII inhibitors, and albumin levels. Using the population pharmacokinetic model, the estimated individual average exposures over the administration period were compared across categories of annualized bleeding rate. Results A linear one-compartment model with first-order absorption and elimination processes and no lag time best described the emicizumab pharmacokinetics. Body weight, albumin levels, age, and black race were statistically correlated with primary pharmacokinetic parameters, but only body weight had an important influence on exposure. Dosing regimens of 1.5 mg/kg weekly, 3 mg/kg every 2 weeks, or 6 mg/kg every 4 weeks provided similar average concentrations at steady state. A trend for lower exposure was observed in the small proportion of PwHA having an annualized bleeding rate > 4 (11.9%), suggesting that reducing exposure to lower levels may potentially increase the bleeding risk. Conclusions Emicizumab pharmacokinetics in PwHA was described with dose-independent parameters. Body weight was an important predictor of emicizumab pharmacokinetics. All three dosing regimens are predicted to achieve similar exposure associated with clinically meaningful prevention of bleeding. Electronic supplementary material The online version of this article (10.1007/s40262-020-00904-z) contains supplementary material, which is available to authorized users.
Collapse
|
22
|
Yoneyama K, Schmitt C, Chang T, Dhalluin C, Nagami S, Petry C, Levy GG. A Model-Based Framework to Inform the Dose Selection and Study Design of Emicizumab for Pediatric Patients With Hemophilia A. J Clin Pharmacol 2021; 62:232-244. [PMID: 34545950 PMCID: PMC9298840 DOI: 10.1002/jcph.1968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/10/2021] [Indexed: 12/13/2022]
Abstract
Emicizumab is a bispecific antibody mimicking the cofactor function of activated coagulation factor VIII to prevent bleeds in patients with hemophilia A. The dose selection for the first-in-child phase III study of emicizumab was addressed by pediatric pharmacokinetic prediction using an adult/adolescent population pharmacokinetic model developed in phase I-I/II studies. The model was modified to incorporate functions describing the age-dependent increase in body weight (BW) with or without clearance maturation to account for the differences in emicizumab pharmacokinetics between adults/adolescents and children. A minimal dose anticipated to achieve in children the same target efficacious exposure as for adults/adolescents was identified when considering BW and clearance maturation. It was the same BW-based dose as for adults/adolescents and was selected for the starting dose for the pediatric study. Whether considering clearance maturation or not in addition to BW led to uncertainty in the pediatric pharmacokinetic prediction and dose selection, which informed implementation of a dose-adapting scheme in the study design. Exposure matching to adults/adolescents was ultimately achieved in children with the starting dose, indicating that consideration of clearance maturation in addition to BW provided adequate pediatric pharmacokinetic predictions for emicizumab. This pharmacokinetic finding in conjunction with exposure-response information served as a basis for the efficacy demonstrated in children, avoiding a time-consuming process for exploring an optimal pediatric dose of emicizumab. This experience indicates that a model-based framework helped optimize the pediatric dose selection and study design, thereby streamlining the development process with extrapolation, of emicizumab for children.
Collapse
Affiliation(s)
| | | | - Tiffany Chang
- Genentech, Inc., South San Francisco, California, USA
| | | | | | | | - Gallia G Levy
- Genentech, Inc., South San Francisco, California, USA
| |
Collapse
|
23
|
Schmitt C, Emrich T, Chebon S, Fernandez E, Petry C, Yoneyama K, Kiialainen A, Howard M, Niggli M, Paz-Priel I, Chang T. Low immunogenicity of emicizumab in persons with haemophilia A. Haemophilia 2021; 27:984-992. [PMID: 34480814 PMCID: PMC9292930 DOI: 10.1111/hae.14398] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/13/2021] [Accepted: 08/13/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Emicizumab is a humanised, bispecific monoclonal antibody mimicking the cofactor function of activated factor (F)VIII. It is indicated for routine prophylaxis of bleeding episodes in persons with haemophilia A (PwHA) with/without FVIII inhibitors. AIM To evaluate the development of anti-emicizumab antibodies and their impact on pharmacokinetics (PK), pharmacodynamics (PD), efficacy and safety in PwHA. METHODS Data from seven completed or ongoing phase 3 studies were pooled. The assessment of the immunogenicity profile of emicizumab included anti-drug antibody (ADA) measurement and the association of ADAs with PK, PD, bleeding events, and adverse events. RESULTS Of 668 PwHA evaluable for immunogenicity analysis, 34 (5.1%) developed ADAs after exposure to emicizumab. ADAs were transient in 14/34 PwHA (41.2%). ADAs were neutralising in vitro in 18/34 PwHA (52.9%) and associated with decreased emicizumab concentration in 4/668 evaluable PwHA (.6%); of those, one (.1%) discontinued emicizumab due to loss of efficacy. ADAs without decreased exposure did not impact emicizumab efficacy. The proportion of PwHA who had injection-site reactions (ISRs) was higher in ADA-positive PwHA (29.4% vs. 20.8%); however, the safety profile was similar between ADA-positive and ADA-negative PwHA, overall. No cases of anaphylaxis or hypersensitivity were reported in ADA-positive participants. CONCLUSION The immunogenicity risk of emicizumab in phase 3 studies was low. ADAs, including in vitro neutralising ADAs, were not associated with a change in safety profile. Routine surveillance is, therefore, not warranted; however, in cases where a loss and/or waning of efficacy are observed, prompt evaluation by a healthcare provider should be sought.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ido Paz-Priel
- Genentech, Inc., South San Francisco, California, USA
| | - Tiffany Chang
- Genentech, Inc., South San Francisco, California, USA
| |
Collapse
|
24
|
Abstract
INTRODUCTION Emicizumab is a bispecific antibody exerting cofactor function of FVIIIa irrespective of the presence of FVIII inhibitors. Long-term data of phase 1/2 and phase 3 studies have been accumulated. Various questions such as indicated patients, ITI, application to PUPs, hemostatic treatment including surgeries, and emicizumab-related morbidity remain to be solved. AREAS COVERED The review describes the mode of action, data from pre-/post-marketing and ongoing clinical studies according to PubMed search and our own works. EXPERT OPINION For patients with a persistent inhibitor, emicizumab is a definite therapeutic option, although the possibility of BPAs-associated thromboembolic/TMA events raises concerns. The use of ITI together with emicizumab prophylaxis is being examined in clinical trials. For non-inhibitor, especially pediatric patients, emicizumab prophylaxis can be an option. Outcome assessment 'beyond ABR' such as joint health, physical/mental activity, QOL is required. Furthermore, continuous data collection for emicizumab-related adverse events and morbidity would be recommended.
Collapse
Affiliation(s)
- Midori Shima
- Thrombosis and Hemostasis Research Center, Nara Medical University, Kashihara-shi, Japan
| |
Collapse
|
25
|
Bukkems LH, Fischer K, Kremer-Hovinga I, Donners AAM, Fijnvandraat K, Schutgens REG, Cnossen MH, Mathôt RAA. Emicizumab Dosing in Children and Adults with Hemophilia A: Simulating a User-Friendly and Cost-Efficient Regimen. Thromb Haemost 2021; 122:208-215. [PMID: 33946119 DOI: 10.1055/a-1499-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND When emicizumab is dosed according to label, clinicians are obligated to discard or overdose medication due to discrepancies between calculated dose and vial content. The aim of this study was to compose a cost-efficient emicizumab maintenance dosing regimen using Monte Carlo simulation based on vial size, patient-friendly intervals, and patient characteristics, while striving for similar plasma concentrations as observed in clinical trials. METHODS Monte Carlo simulations were used to investigate alternative dosing regimens in patients weighing 3 to 150 kg. Simulated regimens were targeted to achieve median emicizumab plasma concentrations at a steady state (C av,ss) of 40 to 60 (90% range: 25-95) µg/mL. The cost-efficiency of the alternative dosing regimen was calculated in mg and costs saved per patient per year. RESULTS The developed alternative dosing regimen achieved similar emicizumab C av,ss levels compared with the registered dosing regimen with a median deviation of less than 2 µg/mL in 78% of the body-weight categories. A dose of 60 mg every 3 weeks was advised for children weighing 12 to 16 kg, while adults weighing 76 to 85 kg can receive 120 mg emicizumab every week. Compared with the registered weekly dosing of 1.5 mg/kg, alternative dosing saved €35,434 per year in children weighing between 12 and 16 kg. For patients weighing 76 to 85 kg, the median saving was €29,529 (range: €0-€59,057). CONCLUSION This alternative maintenance dosing scheme-applicable in patients with hemophilia A receiving emicizumab prophylaxis-reduces financial costs, avoids medication spillage, and is patient-friendly without loss of efficacy.
Collapse
Affiliation(s)
- Laura H Bukkems
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, The Netherlands
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Idske Kremer-Hovinga
- Van Creveldkliniek, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Anouk A M Donners
- Department of Clinical Pharmacy, Division of Laboratory, Pharmacy, and Biomedical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karin Fijnvandraat
- Pediatric Hematology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roger E G Schutgens
- Van Creveldkliniek, Center for Benign Hematology, Thrombosis and Hemostasis, UMC Utrecht, Utrecht, The Netherlands
| | - Marjon H Cnossen
- Department of Pediatric Hematology, Erasmus University Medical Center - Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands
| | - Ron A A Mathôt
- Hospital Pharmacy-Clinical Pharmacology, Amsterdam University Medical Center, The Netherlands
| |
Collapse
|
26
|
Abstract
Bispecific antibodies (BsAbs) are novel drugs, with only a few approved for clinical use. BsAbs are versatile molecules that come in many different forms and are designed and produced via genetic engineering. Although BsAbs share several pharmacokinetic (PK) and pharmacodynamic (PD) properties with monoclonal antibodies, they have their own unique characteristics based on their overall structure and specificities. BsAbs are generally more complex to investigate and develop than monoclonal antibodies, because they recognize at least 2 different antigens. Understanding their relative affinities to each target is crucial for determining their mechanism of action and efficacy. Moreover, the presence or absence of an Fc region determines, in part, their in vivo stability, distribution, and half-life. This study summarizes several PK and PD aspects that are specific for BsAbs and are important for the success of these new drugs. We emphasize previous PK/PD studies that have been fundamental for the correct prediction of appropriate dosages and schedules of these new drugs in clinical trials or for defining which drugs may take advantage of individualized and standardized drug monitoring for improved efficacy and safety.
Collapse
|
27
|
Nagao A, Koganei H, Yamaguchi T, Fukutake K. Successful emicizumab prophylaxis during dual antiplatelet therapy for insertion of drug-eluting stents after acute coronary syndrome: A case report. Haemophilia 2021; 27:e549-e550. [PMID: 33780095 DOI: 10.1111/hae.14305] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/07/2021] [Accepted: 03/15/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Azusa Nagao
- Department of Blood Coagulation, Ogikubo Hospital, Tokyo, Japan
| | | | - Tomoko Yamaguchi
- Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| | - Katsuyuki Fukutake
- Department of Blood Coagulation, Ogikubo Hospital, Tokyo, Japan.,Department of Laboratory Medicine, Tokyo Medical University, Tokyo, Japan
| |
Collapse
|
28
|
Jonsson F, Schmitt C, Petry C, Mercier F, Frey N, Retout S. Exposure-Bleeding Count Modeling of Emicizumab for the Prophylaxis of Bleeding in Persons with Hemophilia A with/Without Inhibitors Against Factor VIII. Clin Pharmacokinet 2021; 60:931-41. [PMID: 33709296 DOI: 10.1007/s40262-021-01006-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 12/26/2022]
Abstract
Background and Objective Emicizumab is a monoclonal antibody that bridges activated coagulation factor IX and factor X to restore effective hemostasis in persons with hemophilia A. It is indicated for routine prophylaxis of bleeding episodes in persons with hemophilia A. The aim of the present study is to describe the exposure–response relationship between emicizumab concentrations and bleeding frequency, and to confirm adequate bleeding control of the investigated dosing regimens 1.5 mg/kg once weekly, 3 mg/kg every 2 weeks, and 6 mg/kg every 4 weeks. Methods Treated bleeding events were pooled from 445 persons with hemophilia A with and without inhibitors against factor VIII, participating in six clinical studies. Emicizumab concentrations were predicted using a previously developed population pharmacokinetic model. A count model was used to quantify the exposure–response relationship. These models were used to illustrate the relationship between emicizumab concentrations and cumulative count of bleeding over 1 year (annualized bleeding rate). Results The final exposure–response model, based on a generalized Poisson distribution and an inhibitory Emax relationship, adequately describes the relationship between daily emicizumab concentrations and daily bleed frequency. A significant effect of factor VIII prophylaxis among persons with hemophilia A without inhibitors was found. Annualized bleeding rate simulations show that the three emicizumab dosing regimens maintain the concentrations close to the plateau of the effect. At the average steady-state concentration across all regimens (53.5 µg/mL), the predicted mean annualized bleeding rate is 1.28, corresponding to a 94.0% reduction from baseline. Conclusions These results confirm that average emicizumab concentrations achieved with all three emicizumab dosing regimens provide adequate bleeding control. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01006-0.
Collapse
|
29
|
Yu JK, Iorio A, Chelle P, Edginton AN. Pharmacokinetic implications of dosing emicizumab based on vial size: A simulation study. Haemophilia 2021; 27:358-365. [PMID: 33650745 DOI: 10.1111/hae.14292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/15/2021] [Accepted: 02/22/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Emicizumab is dosed as mg/kg and, according to the label, any unused drug left in the vial(s) must be discarded, thereby wasting expensive resources. The aim of this study was to use population pharmacokinetics to illustrate the implications of changing the dosing interval to avoid wastage. METHODS We used a previously published emicizumab PopPK model after extending its validation to children. We simulated PK parameters for labelled dosing regimens and for regimens using full vials with infusion frequency varied to keep the steady-state drug concentration unchanged. Cost and drug savings were calculated. RESULTS The model evaluation was successful. When rounding up, the average individual below 53, 47 and 39 has a time-to-trough increase of up to 5.7, 7.9 and 5.8 days for the QW, Q2 W and Q4 W regimen, respectively. This resulted in an annual cost reduction of up to $173,136, $75,747 and $61,319 USD per patient. At higher body weights, rounding down the dose to the nearest vial resulted in negligible changes in the steady state concentration and cost savings of up to $93,781, $46,891 and $23,446 USD per patient, respectively. CONCLUSION Individuals with a lower body weight may benefit from increasing dose intervals and rounding up dose up to the nearest vial, and individuals with a higher body weight from maintaining the injection frequency and rounding dose down to the nearest vial without significant change in emicizumab levels. Administering the entire vial may result in a reduction of vials used annually and potential cost savings.
Collapse
Affiliation(s)
- Jacky K Yu
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | - Alfonso Iorio
- McMaster-Bayer Endowed Research Chair for Clinical Epidemiology of Congenital Bleeding Disorders, Department of Medicine; and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Pierre Chelle
- School of Pharmacy, University of Waterloo, Waterloo, ON, Canada
| | | |
Collapse
|
30
|
Schmitt C, Adamkewicz JI, Xu J, Petry C, Catalani O, Young G, Negrier C, Callaghan MU, Levy GG. Pharmacokinetics and Pharmacodynamics of Emicizumab in Persons with Hemophilia A with Factor VIII Inhibitors: HAVEN 1 Study. Thromb Haemost 2020; 121:351-360. [PMID: 33086400 PMCID: PMC7895541 DOI: 10.1055/s-0040-1717114] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Emicizumab, a bispecific monoclonal antibody, bridges activated factor IX (FIXa) and FX, replacing the function of missing FVIIIa to restore effective hemostasis in persons with hemophilia A (PwHA). Here we assess pharmacokinetic (PK) and pharmacodynamic (PD) biomarkers in PwHA with FVIII inhibitors in the Phase III HAVEN 1 study (NCT02622321). Blood samples from 112 PwHA receiving 1.5 mg/kg once-weekly subcutaneous emicizumab were analyzed at central laboratories. Emicizumab concentrations for PK analysis were measured via validated immunoassay. PD effects were assessed using FVIII chromogenic activity assay containing human factors (Hyphen Biophen FVIII:C), and by FXIa-triggered thrombin generation (TG). Activated partial thromboplastin time (aPTT), prothrombin time (PT), antigen levels of FIX and FX, fibrinogen, D-dimer, and prothrombin fragment 1.2 (PF1.2) levels were determined. Emicizumab trough concentrations ≥ 50 µg/mL were maintained throughout the study. FVIII-like activity and TG (peak height) correlated with emicizumab concentrations and remained above 20 U/dL and 100 nM, respectively, with a weekly maintenance dose, theoretically converting persons with severe hemophilia A to a mild disease phenotype. aPTT was normalized at subtherapeutic concentrations of emicizumab. Plasma concentrations of target antigens FIX and FX were not significantly affected by emicizumab treatment; nor were fibrinogen, PT (international normalized ratio), D-dimer, or PF1.2. The PK profile of once-weekly emicizumab in HAVEN 1 provides sustained therapeutic plasma levels, consistent with population PK models. Both the PK profile and the PD and safety biomarkers are consistent with the established efficacy of emicizumab prophylaxis in PwHA with FVIII inhibitors.
Collapse
Affiliation(s)
- Christophe Schmitt
- Department of Clinical Pharmacology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Joanne I Adamkewicz
- Department of Oncology Biomarker Development, Genentech, Inc., South San Francisco, California, United States
| | - Jin Xu
- Department of Clinical Research, Genentech, Inc., South San Francisco, California, United States
| | - Claire Petry
- Department of Clinical Pharmacology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Olivier Catalani
- Department of Pharma-Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Guy Young
- Hemostasis and Thrombosis Program, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, United States
| | - Claude Negrier
- Hematology Department, Louis Pradel Hospital, University Claude Bernard, Lyon, France
| | - Michael U Callaghan
- Division of Hematology/Oncology, Children's Hospital of Michigan, Detroit, Michigan, United States
| | - Gallia G Levy
- Department of Pharma Development, Genentech, Inc., South San Francisco, California, United States
| |
Collapse
|
31
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
32
|
Linari S, Castaman G. Concomitant Use of rFVIIa and Emicizumab in People with Hemophilia A with Inhibitors: Current Perspectives and Emerging Clinical Evidence. Ther Clin Risk Manag 2020; 16:461-469. [PMID: 32547043 PMCID: PMC7251291 DOI: 10.2147/tcrm.s205310] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/23/2020] [Indexed: 01/19/2023] Open
Abstract
Emicizumab, a humanized, bi-specific, monoclonal antibody subcutaneously administered, mimicking the function of FVIIIa, represents a milestone in treatment of patients affected by hemophilia A complicated with inhibitors. The HAVEN 1 and 2 studies have clearly established its superiority compared to bypassing agents for routine prophylaxis in preventing or reducing bleeding episodes in adult and pediatric patients with inhibitors. However, its protection against bleeding is only partial, and concomitant use of a bypassing agent may be required with potential prothrombotic risk. The emicizumab Phase III trials (HAVEN 1, 2 and 4) have shown that the traditional bypassing agents, activated prothrombin complex concentrates or recombinant activated factor VII (rFVIIa), may be necessary for the treatment of breakthrough bleeds or surgery management. A post hoc analysis in particular has shown that the concomitant use of emicizumab and rFVIIa is safe and no thrombotic events have been described. The review describes the state of the art of the concomitant use of emicizumab and rFVIIa for treating acute bleeding and surgeries, its efficacy and safety and the lack of thrombotic events associated with this treatment modality. Data still derive mainly from HAVEN trials; however, the availability of emicizumab in clinical practice is progressively increasing the number of patients treated and no adverse events directly attributed to this agent have occurred. The availability of guidelines for the use and dosing of rFVIIa during emicizumab prophylaxis is useful in clinical practice for managing suspected or ongoing bleeding, emergency situations and elective invasive procedures. In the next years, careful prospective post-licensure surveillance to monitor safety of rFVIIa use during prophylaxis with emicizumab is highly recommended.
Collapse
Affiliation(s)
- Silvia Linari
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, Florence, Italy
| |
Collapse
|
33
|
Li H, Zhang W, Petry C, Li L, Fernandez E, Kiialainen A, Feng S, Hsu W, Li L, Wei Y, Schmitt C. Evaluation of the Pharmacokinetics, Pharmacodynamics, and Safety of a Single Dose of Emicizumab in Healthy Chinese Subjects. Clin Pharmacol Drug Dev 2020; 10:30-38. [PMID: 32433829 PMCID: PMC7818492 DOI: 10.1002/cpdd.805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/24/2020] [Indexed: 12/16/2022]
Abstract
This phase 1, open‐label, single‐center study evaluated the pharmacokinetics (PK), pharmacodynamics, safety, and tolerability of single‐dose emicizumab in healthy Chinese males. Overall, 16 subjects received a single subcutaneous dose of 1‐mg/kg emicizumab. Blood samples were obtained before dosing on day 1 and at regular intervals over 16 weeks after dosing for PK evaluation. A single 1‐mg/kg subcutaneous dose of emicizumab was safe and well tolerated in healthy Chinese male subjects in the study. Mean (± standard deviation) area under the concentration‐time curve from time 0 to infinity and maximum concentration were 287 ± 74.2 μg⋅d/mL and 7.11 ± 1.77 μg/mL, respectively, with a terminal half‐life of 26.7 (±4.3) days. Emicizumab administration did not show significant impact on pharmacodynamic markers tested, which mostly remained stable throughout the study. One subject tested positive for antidrug antibody, with no impact on his PK or safety profile. Compared with results from healthy Japanese and Caucasian subjects receiving the same dose in previous clinical trials, the current results further indicated the absence of difference of emicizumab PK profile across Chinese, Japanese, and Caucasian subjects, validating the use of similar therapeutic doses in Asian and non‐Asian populations.
Collapse
MESH Headings
- Adult
- Antibodies/blood
- Antibodies, Bispecific/adverse effects
- Antibodies, Bispecific/blood
- Antibodies, Bispecific/pharmacokinetics
- Antibodies, Bispecific/pharmacology
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/blood
- Antibodies, Monoclonal, Humanized/pharmacokinetics
- Antibodies, Monoclonal, Humanized/pharmacology
- Asian People
- Factor VIII/analysis
- Healthy Volunteers
- Humans
- Injections, Subcutaneous
- Male
- White People
- Young Adult
Collapse
Affiliation(s)
- Haiyan Li
- Drug Clinical Trial Center and the Department of CardiologyPeking UniversityThird HospitalBeijingChina
| | | | | | - Lindong Li
- F. Hoffmann–La Roche LtdRoche Product Development ShanghaiShanghaiChina
| | | | | | - Sheng Feng
- F. Hoffmann–La Roche LtdpRED Roche ShanghaiChina
| | - Wanling Hsu
- F. Hoffmann–La Roche LtdRoche Product Development ShanghaiShanghaiChina
| | - Li Li
- F. Hoffmann–La Roche LtdRoche Product Development ShanghaiShanghaiChina
| | - Yudong Wei
- Drug Clinical Trial CenterPeking UniversityThird HospitalBeijingChina
| | | |
Collapse
|
34
|
Shima M. Bispecific Antibodies and Advances in Non-Gene Therapy Options in Hemophilia. Res Pract Thromb Haemost 2020; 4:446-454. [PMID: 32548546 PMCID: PMC7292667 DOI: 10.1002/rth2.12337] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/07/2020] [Accepted: 02/17/2020] [Indexed: 12/28/2022] Open
Abstract
Regular prophylaxis has markedly improved the treatment for patients with hemophilia A, especially after the introduction of highly purified factor VIII (FVIII) concentrates. However, frequent intravenous infusions and the development of FVIII inhibitors remain as unsolved difficulties. To overcome these unmet needs, a bispecific antibody mimicking activated FVIII has been developed in Japan. This bispecific antibody, emicizumab, recognizes activated factor IX (FIXa) and activated factor X (FXa), and promotes FIXa-catalyzed activation of FX in the absence of FVIII. Emicizumab initially reacts with FIXa generated by the action of factor VIIa/tissue factor complexes. Subsequently, thrombin generation is enhanced in the presence of higher amounts of FIXa derived from FXIa-dependent mechanisms. Hence, emicizumab-driven FXa and thrombin generation is maintained by a FXI activation loop in the intrinsic coagulation pathway. Reactions downstream of emicizumab are regulated by natural anticoagulants including activated protein C, antithrombin, and tissue factor pathway inhibitor. Phase 3 studies (HAVEN 1-4 and HOHOEMI studies) demonstrated a remarkable reduction in bleeding rates together with a high percentage of patients with zero treated bleeds irrespective of the presence of inhibitors. In general, emicizumab proved to be well tolerated, although isolated thromboembolic and thrombotic microangiopathic complications were observed in the HAVEN 1 studies, and 3 out of a total of 400 patients developed neutralizing antidrug antibodies. In addition, several questions remain to be discussed with respect to open-use clinical practice, including when to start treatment, how to monitor therapy, and optimum dosage for surgical procedures and immune tolerance induction.
Collapse
Affiliation(s)
- Midori Shima
- Thrombosis and Hemostasis Research CenterNara Medical UniversityKashihara CityNaraJapan
| |
Collapse
|
35
|
Hooimeijer HL, Lukens MV, Verhagen MV, Meijer K, Stein-Wit MA, Tamminga RYJ. A boy with joint pain associated with emicizumab treatment: The importance of plasma level measurement. Haemophilia 2020; 26:e138-e140. [PMID: 32297683 DOI: 10.1111/hae.13965] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 02/26/2020] [Accepted: 02/28/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Hélène L Hooimeijer
- Department of Paediatric Haematology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Michael V Lukens
- Department of Laboratory Medicine, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Martijn V Verhagen
- Department of Radiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Karina Meijer
- Department of Internal Haematology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Marjet A Stein-Wit
- Department of Paediatric Haematology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Rienk Y J Tamminga
- Department of Paediatric Haematology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| |
Collapse
|
36
|
Parra-Guillen ZP, Fontanellas A, Jiang L, Jericó D, Martini P, Vera-Yunca D, Hard M, Guey LT, Troconiz IF. Disease pharmacokinetic-pharmacodynamic modelling in acute intermittent porphyria to support the development of mRNA-based therapies. Br J Pharmacol 2020; 177:3168-3182. [PMID: 32133631 DOI: 10.1111/bph.15040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 02/11/2020] [Accepted: 02/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND PURPOSE Acute intermittent porphyria (AIP) results from haplo-insufficiency of the porphobilinogen deaminase (PBGD) gene encoding the third enzyme in the haem biosynthesis pathway. As liver is the main organ of pathology for AIP, emerging therapies that restore enzyme hepatic levels are appealing. The objective of this work was to develop a mechanistic-based computational framework to describe the effects of novel PBGD mRNA therapy on the accumulation of neurotoxic haem precursors in small and large animal models. EXPERIMENTAL APPROACH Liver PBGD activity data and/or 24-hr urinary haem precursors were obtained from genetic AIP mice and wild-type mice, rats, rabbits, and macaques. To mimic acute attacks, porphyrogenic drugs were administered over one or multiple challenges, and animals were used as controls or treated with different PBGD mRNA products. Available experimental data were sequentially used to build and validate a semi-mechanistic mathematical model using non-linear mixed-effects approach. KEY RESULTS The developed framework accounts for the different biological processes involved (i.e., mRNA sequence, release from lipid nanoparticle and degradation, mRNA translation, increased PBGD activity in liver, and haem precursor metabolism) in a simplified mechanistic fashion. The model, validated using external data, shows robustness in the extrapolation of PBGD activity data in rat, rabbit, and non-human primate species. CONCLUSION AND IMPLICATIONS This quantitative framework provides a valuable tool to compare PBGD mRNA drug products during early preclinical stages, optimize the amount of experimental data required, and project results to humans, thus supporting drug development and clinical dose and dosing regimen selection.
Collapse
Affiliation(s)
- Zinnia P Parra-Guillen
- Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain.,Navarra Institute for Health Research (IdisNA), Pamplona, Spain
| | - Antonio Fontanellas
- Navarra Institute for Health Research (IdisNA), Pamplona, Spain.,Hepatology Program, Centre for Applied Medical Research, University of Navarra, Pamplona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Lei Jiang
- Moderna, Inc, Cambridge, Massachusetts
| | - Daniel Jericó
- Hepatology Program, Centre for Applied Medical Research, University of Navarra, Pamplona, Spain
| | | | - Diego Vera-Yunca
- Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain.,Navarra Institute for Health Research (IdisNA), Pamplona, Spain
| | | | | | - Iñaki F Troconiz
- Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra, Pamplona, Spain.,Navarra Institute for Health Research (IdisNA), Pamplona, Spain
| |
Collapse
|
37
|
Butterfield JSS, Hege KM, Herzog RW, Kaczmarek R. A Molecular Revolution in the Treatment of Hemophilia. Mol Ther 2020; 28:997-1015. [PMID: 31843450 PMCID: PMC7132613 DOI: 10.1016/j.ymthe.2019.11.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 10/31/2019] [Accepted: 11/05/2019] [Indexed: 12/15/2022] Open
Abstract
For decades, the monogenetic bleeding disorders hemophilia A and B (coagulation factor VIII and IX deficiency) have been treated with systemic protein replacement therapy. Now, diverse molecular medicines, ranging from antibody to gene to RNA therapy, are transforming treatment. Traditional replacement therapy requires twice to thrice weekly intravenous infusions of factor. While extended half-life products may reduce the frequency of injections, patients continue to face a lifelong burden of the therapy, suboptimal protection from bleeding and joint damage, and potential development of neutralizing anti-drug antibodies (inhibitors) that require less efficacious bypassing agents and further reduce quality of life. Novel non-replacement and gene therapies aim to address these remaining issues. A recently approved factor VIII-mimetic antibody accomplishes hemostatic correction in patients both with and without inhibitors. Antibodies against tissue factor pathway inhibitor (TFPI) and antithrombin-specific small interfering RNA (siRNA) target natural anticoagulant pathways to rebalance hemostasis. Adeno-associated virus (AAV) gene therapy provides lasting clotting factor replacement and can also be used to induce immune tolerance. Multiple gene-editing techniques are under clinical or preclinical investigation. Here, we provide a comprehensive overview of these approaches, explain how they differ from standard therapies, and predict how the hemophilia treatment landscape will be reshaped.
Collapse
Affiliation(s)
| | - Kerry M Hege
- Department of Pediatrics, Indiana University School of Medicine, IUPUI-Wells Center for Pediatric Research, Indianapolis, IN, USA
| | - Roland W Herzog
- Department of Pediatrics, University of Florida, Gainesville, FL, USA; Department of Pediatrics, Indiana University School of Medicine, IUPUI-Wells Center for Pediatric Research, Indianapolis, IN, USA.
| | - Radoslaw Kaczmarek
- Department of Pediatrics, Indiana University School of Medicine, IUPUI-Wells Center for Pediatric Research, Indianapolis, IN, USA; Laboratory of Glycobiology, Hirszfeld Institute of Immunology and Experimental Therapy, Wroclaw, Poland.
| |
Collapse
|
38
|
Young G, Liesner R, Chang T, Sidonio R, Oldenburg J, Jiménez-Yuste V, Mahlangu J, Kruse-Jarres R, Wang M, Uguen M, Doral MY, Wright LY, Schmitt C, Levy GG, Shima M, Mancuso ME. A multicenter, open-label phase 3 study of emicizumab prophylaxis in children with hemophilia A with inhibitors. Blood 2019; 134:2127-38. [PMID: 31697801 DOI: 10.1182/blood.2019001869] [Citation(s) in RCA: 217] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 09/22/2019] [Indexed: 12/13/2022] Open
Abstract
Emicizumab, a bispecific humanized monoclonal antibody, bridges activated factor IX (FIX) and FX to restore the function of missing activated FVIII in hemophilia A. Emicizumab prophylaxis in children with hemophilia A and FVIII inhibitors was investigated in a phase 3 trial (HAVEN 2). Participants, previously receiving episodic/prophylactic bypassing agents (BPAs), were treated with subcutaneous emicizumab: 1.5 mg/kg weekly (group A), 3 mg/kg every 2 weeks (group B), or 6 mg/kg every 4 weeks (group C). Pharmacokinetics, safety, and efficacy (including an intraindividual comparison of participants from a noninterventional study) were evaluated. Eighty-five participants aged <12 years were enrolled. In group A (n = 65), the annualized rate of treated bleeding events (ABRs) was 0.3 (95% confidence interval [CI], 0.17-0.50), and 77% had no treated bleeding events. Intraindividual comparison of 15 participants who previously took BPA prophylaxis showed that emicizumab prophylaxis reduced the ABR by 99% (95% CI, 97.4-99.4). In groups B (n = 10) and C (n = 10), ABRs were 0.2 (95% CI, 0.03-1.72) and 2.2 (95% CI, 0.69-6.81), respectively. The most frequent adverse events were nasopharyngitis and injection-site reactions; no thrombotic events occurred. Two of 88 participants developed antidrug antibodies (ADAs) with neutralizing potential, that is, associated with decreased emicizumab plasma concentrations: 1 experienced loss of efficacy, and, in the other, ADAs disappeared over time without intervention or breakthrough bleeding. All other participants achieved effective emicizumab plasma concentrations, regardless of the treatment regimen. Emicizumab prophylaxis has been shown to be a highly effective novel medication for children with hemophilia A and inhibitors. This trial was registered at www.clinicaltrials.gov as #NCT02795767.
Collapse
|
39
|
Le Quellec S. Clinical Evidence and Safety Profile of Emicizumab for the Management of Children with Hemophilia A. Drug Des Devel Ther 2020; 14:469-481. [PMID: 32099331 PMCID: PMC7007498 DOI: 10.2147/dddt.s167731] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 01/22/2020] [Indexed: 01/03/2023]
Abstract
Emicizumab is a bispecific, humanized, monoclonal antibody mimicking the factor (F) VIII cofactor activity in mediating the generation of FXa by FIXa in patients with hemophilia A (HA). This subcutaneous non-factor agent has been recently extensively approved for the prophylaxis of patients of HA patients with and without FVIII-inhibitors of all ages, although few data are currently available in children. In Phase 3 clinical trials and case series, emicizumab prophylaxis significantly reduced bleeding rates compared to previous treatment in HA adolescents and children with or without FVIII-inhibitors and was generally well tolerated. In addition, subcutaneous administration of emicizumab provided beneficial effects on health-related quality of life, and lessened the burden of the disease in HA patients as well as in their caregivers. However, additional prospective studies are required to evaluate the long-term safety of emicizumab prophylaxis in very young patients, including previously untreated patients. The aim of this paper was to review the limited data available on the use of emicizumab prophylaxis in children and to highlight the need for further studies to address remaining concerns.
Collapse
Affiliation(s)
- Sandra Le Quellec
- Unité d'hémostase Clinique - Hôpital Cardiologique Louis Pradel - Hospices Civils de Lyon, Lyon, France.,Service d'hématologie biologique, Groupement Hospitalier Est - Hospices Civils de Lyon, Lyon, France
| |
Collapse
|
40
|
Okamoto S, Suzuki N, Suzuki A, Suzuki S, Tamura S, Suzuki M, Takahashi N, Kojima T, Kanematsu T, Kojima T, Kiyoi H, Ishiguro N, Matsushita T. Successful Perioperative Combination of High-Dose FVIII Therapy Followed by Emicizumab in a Patient with Hemophilia A with Inhibitors. TH Open 2019; 3:e364-e366. [PMID: 31815248 PMCID: PMC6894946 DOI: 10.1055/s-0039-3401001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/25/2019] [Indexed: 12/26/2022] Open
Abstract
We managed perioperative hemostasis for a 72-year-old man with hemophilia A and low inhibitor titers (3 BU/mL), who underwent osteosynthesis for supracondylar fracture of the left humerus. He was treated perioperatively using the combination of high doses of factor VIII (FVIII) with recombinant human Factor VIII Fc fusion protein (rFVIIIFc), followed by emicizumab. On the day of surgery (day 0), he was administered bolus infusion of 150 IU/kg rFVIIIFc, followed by continuous infusion at a dose of 4 IU/kg/h. Emicizumab, 3 mg/kg, was injected subcutaneously once a week, on days 5, 12, 19, and 26. Inhibitors were detected on day 6 at a titer of 4 BU/mL and FVIII:C decreased to below assay sensitivity limits on day 10. The rate of increase in inhibitor titers was high, with inhibitors increasing to 343.4 BU/mL on day 14. The transition of thrombin production by thrombin generation assay (TGA) showed temporary decrease in thrombin production on day 7, although it was restored by day 10, i.e., five days after commencement of emicizumab therapy. Rotational thromboelastometry displayed consistent results with TGA, showing that clotting time was prolonged and the alpha angle decreased to less than measurable levels on day 6, although they were improved by day 10. There were no bleeding-related events or other adverse events throughout the perioperative period. In conclusion, emicizumab was effective for the management of perioperative hemostasis after development of an anamnestic response in a patient with hemophilia A with inhibitors. Combination therapy with high doses of FVIII followed by emicizumab could be a workable alternative for patients with hemophilia A with inhibitors.
Collapse
Affiliation(s)
- Shuichi Okamoto
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuaki Suzuki
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - Atsuo Suzuki
- Department of Medical Technique, Nagoya University Hospital, Nagoya, Japan
| | - Sachiko Suzuki
- Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Nursing and Health, Aichi Prefectural University, Aichi, Japan
| | - Shogo Tamura
- Department of Orthopaedics/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mochihito Suzuki
- Department of Orthopaedics/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobunori Takahashi
- Department of Orthopaedics/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshihisa Kojima
- Department of Orthopaedics/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Kanematsu
- Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan
| | - Tetsuhito Kojima
- Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hitoshi Kiyoi
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Ishiguro
- Department of Orthopaedics/Rheumatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tadashi Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan.,Department of Clinical Laboratory, Nagoya University Hospital, Nagoya, Japan
| |
Collapse
|
41
|
Larsen MS, Vestergaard Juul R, Zintner SM, T Kristensen A, Margaritis P, Kjelgaard-Hansen M, Wiinberg B, Simonsson USH, Kreilgaard M. Rotational thromboelastometry can predict the probability of bleeding events in a translational rat model of haemophilia A following gene-based FVIIa prophylaxis. Haemophilia 2019; 26:164-172. [PMID: 31797491 DOI: 10.1111/hae.13899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 11/15/2019] [Accepted: 11/15/2019] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Monitoring of clinical effectiveness of bypassing agents in haemophilia patients is hampered by the lack of validated laboratory assays. Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) have been evaluated for predicting clinical effectiveness of bypassing agents, however, with limited success. AIM Application of a longitudinal model-based approach may allow for a quantitative characterization of the link between ROTEM parameters and the probability of bleeding events. METHODS We analyse longitudinal data from haemophilia A rats receiving gene-based FVIIa prophylaxis in terms of total circulatory levels of FVII/FVIIa, clotting time (CT) measured using ROTEM and the probability of bleeding events. RESULTS Using population pharmacokinetic-pharmacodynamic (PKPD) modelling, a PK-CT-repeated time-to-event (RTTE) model was developed composed of three submodels (a) a FVII/FVIIa PK model, (b) a PK-CT model describing the relationship between predicted FVIIa expression and CT and (c) a RTTE model describing the probability of bleeding events as a function of CT. The developed PK-CT-RTTE model accurately described the vector dose-dependent plasma concentration-time profile of total FVII/FVIIa and the exposure-response relationship between AAV-derived FVIIa expression and CT. Importantly, the developed model accurately described the occurrence of bleeding events over time in a quantitative manner, revealing a linear relationship between predicted change from baseline CT and the probability of bleeding events. CONCLUSION Using PK-CT-RTTE modelling, we demonstrated that ROTEM parameters can accurately predict the probability of bleeding events in a translational animal model of haemophilia A.
Collapse
Affiliation(s)
- Malte Selch Larsen
- Haemophilia Research, Global Research, Novo Nordisk A/S, Maaloev, Denmark.,Department of Veterinary Clinical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | | | - Shannon M Zintner
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Annemarie T Kristensen
- Department of Veterinary Clinical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Paris Margaritis
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,The Raymond G. Perelman Center for Cellular and Molecular Therapeutics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,The University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Bo Wiinberg
- Haemophilia Research, Global Research, Novo Nordisk A/S, Maaloev, Denmark
| | | | - Mads Kreilgaard
- Haemophilia Research, Global Research, Novo Nordisk A/S, Maaloev, Denmark
| |
Collapse
|
42
|
Spadarella G, Di Minno A, Milan G, Franco N, Polimeno M, Castaldo F, Di Minno G. Paradigm shift for the treatment of hereditary haemophilia: Towards precision medicine. Blood Rev 2019; 39:100618. [PMID: 31676141 DOI: 10.1016/j.blre.2019.100618] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 12/17/2022]
Abstract
Patients with haemophilia A (HA) or B (HB) experience spontaneous limb- or life-threatening bleedings which are prevented by regular prophylactic intravenous infusions of the deficient coagulation factor (FVIII or FIX). Prophylaxis with subcutaneous long-acting non-factor products that improve in vivo thrombin generation is now under intensive investigation (concizumab, fitusiran) or successfully employed (emicizumab) in haemophilia patients. Both haemophilia patients with/without inhibitors take advantage of non-factor products employed alone. In those who also need bypassing agents (or FVIII concentrates) for breakthrough bleeds, thromboembolic events and/or thrombotic microangiopathy may occur. By enhancing thrombin generation, prothrombotic mutations co-segregating with FVIII/FIX gene mutations may trigger thrombotic episodes in HA patients carrying acquired thrombogenic factors (e.g. venous catheters). A thorough knowledge of individual needs increasingly contributed to improve comprehensive care and personalize treatments in haemophilia. Integrating genomics, lifestyle and environmental data is expected to be key to: 1) identify which haemophilia patients are less likely to benefit from a given intervention; 2) define optimal dosing and scheduling of bypassing agents (or FVIII) to employ in combination with non-factor products; 3) establish tests to monitor in vivo thrombin generation; 4) improve communication and deliver results to individuals. As individual outcomes will be improved and the risk of adverse events minimized, non-factor products will come into wider use within the haemophilia community, and patients will hopefully have no more risks of breakthrough bleeds. The risks of a normal life for a "former haemophilia patient" is likely to change the treatment landscape and the structure of haemophilia Centers.
Collapse
Affiliation(s)
- Gaia Spadarella
- Postgraduation School in Radiodiagnostics, Università degli studi di Milano, Italy
| | - Alessandro Di Minno
- Dipartimento di Farmacia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Graziella Milan
- Centro Geriatrico "Frullone" ASL Napoli-1 Centro, Naples, Italy.
| | - Nicoletta Franco
- Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Mariateresa Polimeno
- Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Francesco Castaldo
- Dipartimento di Farmacia, Università degli Studi di Napoli "Federico II", Naples, Italy
| | - Giovanni Di Minno
- Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy.
| |
Collapse
|
43
|
Le Quellec S, Negrier C. Emicizumab should be prescribed independent of immune tolerance induction. Blood Adv 2018; 2:2783-6. [PMID: 30352952 DOI: 10.1182/bloodadvances.2018015859] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 09/14/2018] [Indexed: 01/01/2023] Open
Abstract
Abstract
This article has a companion Point by Young.
Collapse
|
44
|
Pipe SW. New treatment paradigm for hemophilia poses challenges for legacy bioassays. J Thromb Haemost 2019; 17:1446-1448. [PMID: 31479189 DOI: 10.1111/jth.14550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/17/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
45
|
Ahmed MA, Okour M, Brundage R, Kartha RV. Orphan drug development: the increasing role of clinical pharmacology. J Pharmacokinet Pharmacodyn 2019; 46:395-409. [PMID: 31338634 DOI: 10.1007/s10928-019-09646-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 07/04/2019] [Indexed: 12/11/2022]
Abstract
Over the last few decades there has been a paradigm shift in orphan drug research and development. The development of the regulatory framework, establishment of rare disease global networks that support drug developments, and advances in technology, has resulted in tremendous growth in orphan drug development. Nevertheless, several challenges during orphan drug development such as economic constraints; insufficient clinical information; fewer patients and thus inadequate power; etc. still exist. While the standard regulatory requirements for drug approval stays the same, applications of scientific judgment and regulatory flexibility is significantly important to help meeting some of the immense unmet medical need in rare diseases. Clinical pharmacology presents a vital role in accelerating orphan drug development and overcoming some of these challenges. This review highlights the critical contributions of clinical pharmacology in orphan drug development; for example, dose finding, optimizing clinical trial design, indication expansion, and population extrapolation. Examples of such applications are reviewed in this article.
Collapse
Affiliation(s)
- Mariam A Ahmed
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Twin Cities, MN, USA.
- , 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA.
| | - Malek Okour
- Clinical Pharmacology Modeling and Simulation (CPMS), GlaxoSmithKline, Upper Providence, PA, USA
| | - Richard Brundage
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Twin Cities, MN, USA
- Center for Orphan Drug Research, University of Minnesota, Twin Cities, MN, USA
| | - Reena V Kartha
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Twin Cities, MN, USA
- Center for Orphan Drug Research, University of Minnesota, Twin Cities, MN, USA
| |
Collapse
|
46
|
Susen S, Gruel Y, Godier A, Harroche A, Chambost H, Lasne D, Rauch A, Roullet S, Fontana P, Goudemand J, de Maistre E, Chamouard V, Wibaut B, Albaladejo P, Négrier C. Management of bleeding and invasive procedures in haemophilia A patients with inhibitor treated with emicizumab (Hemlibra ® ): Proposals from the French network on inherited bleeding disorders (MHEMO), the French Reference Centre on Haemophilia, in collaboration with the French Working Group on Perioperative Haemostasis (GIHP). Haemophilia 2019; 25:731-737. [PMID: 31294904 DOI: 10.1111/hae.13817] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Emicizumab (Hemlibra® ) recently became available and requires an adaptation for managing bleeding, suspected bleeding and emergency or scheduled invasive procedures in haemophilia A patients with inhibitor. This implicates a multidisciplinary approach and redaction of recommendations for care that must be regularly adapted to the available data. AIM The following text aims to provide a guide for the management of people with haemophilia A with inhibitor treated with emicizumab in case of bleeding or invasives procedures. METHODS The French network on inherited bleeding disorders (MHEMO), the French Reference Centre on Haemophilia (CRH), in collaboration with the French Working Group on Perioperative Haemostasis (GIHP) have been working together to make proposals for the management of these situations. RESULTS Haemostatic treatment and other medications should be given stepwise, according to the severity and location of the bleeding or the risk of bleeding of the procedure as well as the haemostatic response obtained at each step in order to ensure an optimal benefit/risk ratio. CONCLUSION The lack of data means that it is only possible to issue proposals rather than recommendations.
Collapse
Affiliation(s)
| | - Yves Gruel
- Département d'Hématologie-Hémostase, Hôpital Universitaire de Tours, Tours, France
| | - Anne Godier
- Service d'Anesthésie Réanimation, AP-HP, Hôpital Européen Georges Pompidou, Paris, France.,Inserm UMR-S1140, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Annie Harroche
- CRC MHC, Service d'Hématologie Clinique Hôpital Universitaire Necker Enfants Malades, Laboratoire d'Hématologie Générale, Hôpital Necker, AP-HP, Paris, France
| | - Herve Chambost
- APHM, Hôpital d'Enfants La Timone, Service d'Hématologie Oncologie Pédiatrique et Aix Marseille Univ, INSERM, INRA, C2VN, Marseille, France
| | - Dominique Lasne
- CRC MHC, Service d'Hématologie Clinique Hôpital Universitaire Necker Enfants Malades, Laboratoire d'Hématologie Générale, Hôpital Necker, AP-HP, Paris, France
| | | | - Stephanie Roullet
- Inserm U 1034, Service Anesthésie-Réanimation Pellegrin, Université de Bordeaux, CHU de Bordeaux, Bordeaux, France
| | - Pierre Fontana
- Service d'Angiologie et d'Hémostase, Département de Médecine, Hôpitaux Universitaires de Genève, Genève, Switzerland.,Geneva Platelet Group, Faculté de Médecine, Université de Genève, Genève, Switzerland
| | | | - Emmanuel de Maistre
- Service d'Hématologie Biologique - Secteur Hémostase, Plateau Technique de Biologie, CHU Dijon-Bourgogne, Dijon, France
| | - Valerie Chamouard
- Unité d'Hémostase Clinique, Louis Pradel Hospital, University Claude Bernard, Lyon, France
| | | | - Pierre Albaladejo
- Département d'Anesthésie-Réanimation, CHU Grenoble-Alpes, Grenoble, France.,ThEMAS, TIMC, UMR CNRS 5525, Université Grenoble-Alpes, Grenoble, France
| | - Claude Négrier
- Unité d'Hémostase Clinique, Louis Pradel Hospital, University Claude Bernard, Lyon, France
| |
Collapse
|
47
|
Yada K, Nogami K. Spotlight on emicizumab in the management of hemophilia A: patient selection and special considerations. J Blood Med 2019; 10:171-181. [PMID: 31308776 PMCID: PMC6613000 DOI: 10.2147/jbm.s175952] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/17/2019] [Indexed: 11/23/2022] Open
Abstract
Emicizumab is a factor (F)VIIIa-mimicking bispecific antibody recognizing FIXa and FX molecules. In the phase 1/2 clinical studies, once-weekly subcutaneous administration of emicizumab has shown a favorable safety profile with encouraging efficacy in the patients with hemophilia A (PwHA) irrespective of the presence of anti-FVIII inhibitors. Moreover, in the following phase 3 studies, emicizumab treatment by once-weekly, bi-weekly or tetra-weekly administration have been still well-tolerated, but some thromboembolic events or thrombotic microangiopathy were observed associated with the concomitant use of activated prothrombin complex concentrates (aPCC) for breakthrough bleeds. Since approved for routine prophylaxis in PwHA in the US, EU, and Japan, a compass on patient selection for emicizumab treatment and special considerations on the practical situations such as concomitant treatment by bypassing agents (BPAs) or clotting factor concentrates (CFCs) with less thrombotic risk, inhibitor eradication by immune tolerance induction (ITI) should be provided. There is no doubt that emicizumab is an alternate first-line therapy for any existing BPA as hemostatic treatment for PwHA with inhibitor, but we should be more cautious in combination with aPCC on breakthrough bleeds under emicizumab prophylaxis because of thrombotic risk. For severe PwHA without inhibitor, since most patients are under CFCs prophylaxis, switching from CFCs to emicizumab should be considered when the advantage of emicizumab prophylaxis surpasses that of CFCs prophylaxis from the viewpoint of hemostatic effect by treatment, physical activity according to the life stage, health condition of the joints, adherence and complication. There are pros and cons on the timing of introduction of emicizumab for cases scheduled to start ITI or cases of ongoing ITI. Introduction of emicizumab to previously untreated patients and nonsevere PwHA without inhibitor is also required to discuss in consideration of risk of inhibitor development and unforeseen safety issues.
Collapse
Affiliation(s)
- Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| |
Collapse
|
48
|
Affiliation(s)
- Lorraine Cafuir
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Maria Elisa Mancuso
- Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Christine L Kempton
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
49
|
Pipe SW, Shima M, Lehle M, Shapiro A, Chebon S, Fukutake K, Key NS, Portron A, Schmitt C, Podolak-dawidziak M, Selak Bienz N, Hermans C, Campinha-bacote A, Kiialainen A, Peerlinck K, Levy GG, Jiménez-yuste V. Efficacy, safety, and pharmacokinetics of emicizumab prophylaxis given every 4 weeks in people with haemophilia A (HAVEN 4): a multicentre, open-label, non-randomised phase 3 study. The Lancet Haematology 2019; 6:e295-305. [DOI: 10.1016/s2352-3026(19)30054-7] [Citation(s) in RCA: 178] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/01/2019] [Accepted: 03/05/2019] [Indexed: 01/04/2023]
|
50
|
Nogami K, Shima M. New therapies using nonfactor products for patients with hemophilia and inhibitors. Blood 2019; 133:399-406. [DOI: 10.1182/blood-2018-07-820712] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/28/2018] [Indexed: 12/18/2022] Open
Abstract
Abstract
Regular prophylaxis with factor VIII (FVIII) or FIX products to prevent bleeding in patients with severe hemophilia A (HA) and HB, respectively, results in marked suppression of the onset of arthropathy and contributes greatly to improvements in quality of life. Some issues remain with the use of clotting factor replacement therapy, however. The need for multiple IV infusions is associated with a substantial mental and physical burden, and the hemostatic effect of bypassing agents (BPAs) in patients with inhibitor is inconsistent. The development of subcutaneous products with prolonged hemostatic efficiency, irrespective of the presence of inhibitors, has been a longtime wish for patients. A new class of therapeutic agents that act by enhancing coagulation (emicizumab) and inhibiting anticoagulant pathways (fitusiran and concizumab) have been established, and clinical trials using these nonfactor products are ongoing. The current findings have demonstrated that prophylaxis by nonfactor products supports marked reductions of bleeding episodes in hemophilia patients with or without inhibitor. Emicizumab has already been approved for use internationally. Some concerns are evident, however. Thrombotic microangiopathy and thromboembolism have occurred in 5 emicizumab-treated patients receiving repeated infusions of activated prothrombin complex concentrates, and a sinus vein thrombosis has occurred in a fitusiran-treated patient receiving repeated infusions of FVIII product. Moreover, reliable techniques to monitor hemostatic function in patients receiving nonfactor products with concomitant BPA or FVIII/FIX therapies require further assessment. These novel therapeutic agents have promising hemostatic properties, although wider experience in hemophilia centers is warranted to establish appropriate therapeutic strategies.
Collapse
|