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Morfini M, Agnelli Giacchiello J, Baldacci E, Carulli C, Castaman G, Giuffrida AC, Malcangi G, Rocino A, Siragusa S, Zanon E. Managing Relevant Clinical Conditions of Hemophilia A/B Patients. Hematol Rep 2023; 15:384-397. [PMID: 37367088 DOI: 10.3390/hematolrep15020039] [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: 02/09/2023] [Revised: 04/21/2023] [Accepted: 05/31/2023] [Indexed: 06/28/2023] Open
Abstract
The Medical Directors of nine Italian Hemophilia Centers reviewed and discussed the key issues concerning the replacement therapy of hemophilia patients during a one-day consensus conference held in Rome one year ago. Particular attention was paid to the replacement therapy needed for surgery using continuous infusion (CI) versus bolus injection (BI) of standard and extended half-life Factor VIII (FVIII) concentrates in severe hemophilia A patients. Among the side effects, the risk of development of neutralizing antibodies (inhibitors) and thromboembolic complications was addressed. The specific needs of mild hemophilia A patients were described, as well as the usage of bypassing agents to treat patients with high-responding inhibitors. Young hemophilia A patients may take significant advantages from primary prophylaxis three times or twice weekly, even with standard half-life (SHL) rFVIII concentrates. Patients affected by severe hemophilia B probably have a less severe clinical phenotype than severe hemophilia A patients, and in about 30% of cases may undergo weekly prophylaxis with an rFIX SHL concentrate. The prevalence of missense mutations in 55% of severe hemophilia B patients allows the synthesis of a partially changed FIX molecule that can play some hemostatic role at the level of endothelial cells or the subendothelial matrix. The flow back of infused rFIX from the extravascular to the plasma compartment allows a very long half-life of about 30 h in some hemophilia B patients. Once weekly, prophylaxis can assure a superior quality of life in a large severe or moderate hemophilia B population. According to the Italian registry of surgery, hemophilia B patients undergo joint replacement by arthroplasty less frequently than hemophilia A patients. Finally, the relationships between FVIII/IX genotypes and the pharmacokinetics of clotting factor concentrates have been investigated.
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Affiliation(s)
- Massimo Morfini
- Italian Association of Haemophilia Centers (AICE), 21121 Milan, Italy
| | - Jacopo Agnelli Giacchiello
- Hemostasis and Thrombosis Center, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Erminia Baldacci
- Haematology, "Umberto I" Policlinico, Department of Translational and Precision Medicine, Sapienza University of Rome, 00118 Rome, Italy
| | - Christian Carulli
- Department of Orthopaedic Surgery, Orthopaedic Clinic, University of Florence, 50121 Florence, Italy
| | - Giancarlo Castaman
- Department of Oncology, Center for Bleeding Disorders and Coagulation, Careggi University Hospital, 50121 Florence, Italy
| | | | - Giuseppe Malcangi
- UOSD Centro Emofilia e Trombosi, Azienda Ospedaliero Universitaria Policlinico di Bari, 70121 Bari, Italy
| | - Angiola Rocino
- Haemophilia and Thrombosis Centre, Haematology, S.M. di Loreto Nuovo Hospital, 80121 Naples, Italy
| | - Sergio Siragusa
- Department PROMISE, University of Palermo, 90121 Palermo, Italy
| | - Ezio Zanon
- Haemophilia Centre, General Medicine, Padua University Hospital, 35121 Padua, Italy
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Sackstein P, Cooper P, Kessler C. The role of total ankle replacement in patients with haemophilia and end-stage ankle arthropathy: A review. Haemophilia 2020; 27:184-191. [PMID: 33164268 DOI: 10.1111/hae.14196] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/12/2022]
Abstract
Haemophilia is the most common X-linked bleeding disorder, affecting over 1 million individuals throughout the world. Patients are subclassified into mild, moderate and severe disease based on per cent factor activity level. Nearly, all patients with haemophilia develop haemophilic arthropathy (HA) by age 30 and HA is known to have a negative impact on physical health subscores in Haem-A-QOL, a validated quality of life scoring system for patients with haemophilia. Unfortunately, many patients progress to end-stage HA of the ankle, which is characterized by pain, contractures, decreased range of motion and muscle atrophy. Ankle arthrodesis (AAD) has been the standard of care in the definitive surgical management of end-stage HA of the ankle. While AAD is a safe surgical procedure known to improve HA-related pain, it decreases functional mobility and has been associated with secondary hindfoot arthritis as well as subtalar degeneration. In recent years, total ankle replacement (TAR) has emerged as an alternative surgical procedure that strives to improve functional mobility, pain and quality of life in end-stage HA of the ankle. However, the safety, durability, and efficacy of this procedure in these patients are unknown. In this review, we analyse the clinical studies investigating TAR in patients with end-stage HA of the ankle. We also discuss important considerations in the perioperative management of patients with haemophilia and compare the risks and benefits of AAD and TAR for patients with end-stage HA of the ankle.
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Affiliation(s)
| | - Paul Cooper
- Georgetown University Hospital, Washington, DC, USA
| | - Craig Kessler
- Georgetown University Hospital, Washington, DC, USA.,Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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Négrier C, Chamouard V, Lienhart A, Nougier C, Fleury R. A novel protocol for accurate and reliable postoperative bolus administration of recombinant factor VIIa using an automated mini-pump system. Haemophilia 2020; 25:1020-1027. [PMID: 31769912 DOI: 10.1111/hae.13863] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 09/09/2019] [Accepted: 10/02/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Recombinant FVIIa (rFVIIa) is widely used to manage bleeding risk during and after surgery in patients with haemophilia complicated by inhibitors. In the postoperative period, rFVIIa must be delivered frequently and regularly to maintain haemostasis, considering its short half-life. Preparation and manual administration of bolus doses of rFVIIa at regular intervals may place a strain on available nursing resources. A programmable mini-pump may offer an approach to facilitate regular administration of bolus doses of rFVIIa at specified intervals. AIM To investigate if a mini-pump is a practical and effective way to deliver rFVIIa in the postoperative period. METHODS It was first necessary to establish that rFVIIa remains stable and sterile in the mini-pump reservoir for an extended period. Four days after loading the mini-pump under sterile conditions no evidence of bacterial or fungal growth was observed and in vitro procoagulant activity of rFVIIa remained stable. The mini-pump was used to deliver rFVIIa as bolus doses to two patients with inhibitors who had undergone surgery. Nurses were asked to report their satisfaction with the use of the mini-pump using a specific questionnaire. RESULTS Haemostasis was evaluated as excellent in both cases; nurses were satisfied with use of the mini-pump. CONCLUSION This pilot study shows that intermittent delivery of rFVIIa at fixed intervals using an automated mini-pump offers accurate and reliable administration in the postoperative setting. This approach may reduce burden on nursing staff, potentially minimize the risk of human error and avoid delay in administration of rFVIIa.
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Affiliation(s)
- Claude Négrier
- Unité d'Hémostase Clinique, Centre Régional de Traitement de l'Hémophilie, Hôpital Louis Pradel, Université Lyon 1, Lyon, France
| | - Valerie Chamouard
- Unité d'Hémostase Clinique, Centre Régional de Traitement de l'Hémophilie, Hôpital Louis Pradel, Université Lyon 1, Lyon, France
| | - Anne Lienhart
- Unité d'Hémostase Clinique, Centre Régional de Traitement de l'Hémophilie, Hôpital Louis Pradel, Université Lyon 1, Lyon, France
| | - Christophe Nougier
- Laboratoire d'Hématologie, Hôpital Louis Pradel, Hospices Civils de Lyon, Bron, France
| | - Raphael Fleury
- Unité d'Hémostase Clinique, Centre Régional de Traitement de l'Hémophilie, Hôpital Louis Pradel, Université Lyon 1, Lyon, France
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Hart DP, Hay CRM, Liesner R, Tobaruela G, Du-Mont B, Makris M. Perioperative laboratory monitoring in congenital haemophilia patients with inhibitors: a systematic literature review. Blood Coagul Fibrinolysis 2019; 30:309-23. [PMID: 31397688 DOI: 10.1097/MBC.0000000000000840] [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] [Indexed: 01/19/2023]
Abstract
: Although the use of clotting factor concentrates is the mainstay of haemophilia care, the development of inhibitors complicates disease management. Perioperative management of patients with inhibitors is therefore a challenge. A systematic literature review was performed to identify literature reporting on the perioperative monitoring and management of haemophilia. MEDLINE, Embase and Cochrane databases were searched from database inception to 26 March 2018. Recent congress proceedings were also searched. Titles and abstracts, then full texts, were screened for relevance by two reviewers. Quality of included studies was assessed using the Critical Appraisal Skills Programme checklist. Of the 2033 individual entries identified, 86 articles met the inclusion criteria. The identified studies were screened again to find articles reporting perioperative laboratory monitoring in patients with congenital haemophilia A or B, resulting in 24 articles undergoing data extraction. Routine perioperative assay monitoring practices were the most commonly reported (n = 20/24); thrombin generation assay was the least commonly reported (n = 2/24). Other monitoring practices described were factor VII and factor VIII coagulation activity (n = 8/24, n = 5/24, respectively), and thromboelastography or rotational thromboelastometry assessments (n = 3/24). The impact of monitoring on treatment decisions was, however, rarely reported. In conclusion, many methods of perioperative monitoring of haemophilia patients with inhibitors have been identified in this review, yet there is a lack of reporting in larger scale cohort studies. More detailed reporting on the impact of monitoring outcomes on treatment decisions is also needed to share best practice, particularly as new therapeutic agents emerge.
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Erturan G, Guevel B, Alvand A, Goddard NJ. Over two decades of orthopaedic surgery in patients with inhibitors-Quantifying the complication of bleeding. Haemophilia 2018; 25:21-32. [PMID: 30507046 DOI: 10.1111/hae.13647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 05/29/2018] [Revised: 10/28/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022]
Abstract
Patients with haemophilia who have developed inhibitors against factor VIII (FVIII) or factor IX present a significant concern to those surgeons who operate on them. The evidence base for bypassing agents such as recombinant factor VIIa and activated prothrombin complex concentrate has amassed over several decades. The literature is open to positive interpretation on the successful use of these agents in the treatment of inhibitor-positive patients. However, there are equally persistent concerns amongst surgeons, in particular orthopaedic surgeons, regarding the high complication rate of bleeding. To explore and quantify this concern, we present a literature review spanning two decades of publications on haemophilia patients with inhibitors undergoing orthopaedic surgery. Irrespective of the progress made with haemostatic protocols, trepidation on embarking on surgery is valid. The high risk of bleeding is a function of the inherent complexity of the disease and rightfully translates into difficulties in its management. Combined with the prospect of orthopaedic surgery, those involved in the care of such patients are justified in their continued anxiety and diligence when considering the benefits in quality of life against the prevalent complications.
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Affiliation(s)
- Gurhan Erturan
- Department of Trauma & Orthopaedics, Royal Free Hospital, London, UK
| | - Borna Guevel
- Department of Trauma & Orthopaedics, Royal Free Hospital, London, UK
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Rajpurkar M, Cooper DL. Continuous infusion of recombinant activated factor VII: a review of data in congenital hemophilia with inhibitors and congenital factor VII deficiency. J Blood Med 2018; 9:227-239. [PMID: 30568523 PMCID: PMC6276614 DOI: 10.2147/jbm.s184040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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] [Indexed: 01/19/2023] Open
Abstract
Introduction Continuous infusion (CI) of clotting factors as a replacement therapy for perioperative hemostatic protection has been performed for many years, including with factors VIII and IX and recombinant activated factor VII (rFVIIa). This approach provides steady factor levels without requiring frequent administration of bolus doses. Aim To review safety, efficacy, and dosing data regarding CI of rFVIIa for hemostatic management of patients with congenital hemophilia with inhibitors (CHwI) or congenital factor VII deficiency (C7D). Materials and methods A literature review identified instances of CI of rFVIIa in patients with CHwI or C7D undergoing surgery or experiencing bleeding episodes. Data regarding safety, efficacy, and dosing were extracted. Results The safety and efficacy of 50 mcg/kg/h CI of rFVIIa following a 90 mcg/kg bolus injection, vs a standard bolus injection regimen, was reported for 24 patients with CHwI undergoing elective surgery in an open-label, randomized, Phase III trial. Efficacy was similar between CI and bolus injection groups at all postoperative time points assessed. Additionally, a postmarketing surveillance study reported effective (80%) and partially effective (20%) CI of rFVIIa in a Japanese cohort of ten patients with CHwI who underwent 15 surgical procedures. Finally, the safety and dosing of rFVIIa CI in 193 and 26 patients with CHwI and C7D, respectively, were reported in 11 prospective studies, 10 retrospective studies, and 30 case reports. No unexpected safety findings were reported. Conclusion rFVIIa CI has been performed safely and effectively in patients with CHwI and C7D undergoing surgery and during bleeding episodes in patients with CHwI.
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Affiliation(s)
- Madhvi Rajpurkar
- Division of Hematology/Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, USA,
| | - David L Cooper
- Clinical, Medical and Regulatory Affairs, Novo Nordisk Inc., Plainsboro, NJ, USA
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8
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Holme PA, Tjønnfjord GE, Batorova A. Continuous infusion of coagulation factor concentrates during intensive treatment. Haemophilia 2017; 24:24-32. [PMID: 28873263 DOI: 10.1111/hae.13331] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2017] [Indexed: 01/12/2023]
Abstract
In clinical management of bleeds and surgical procedures in patients suffering from bleeding disorders either repetitive bolus injections (BI) or continuous infusion (CI) can be used for coagulation factor replacement. Continuous infusion seems to be an attractive route of administration and may be considered if replacement therapy is required for more than 3 days. The strongest argument favouring continuous infusion is its superiority in providing the patient with a safe and constant level of the deficient coagulation factor by balancing input with clearance. Furthermore, several studies have shown that coagulation factor consumption may be reduced by CI compared to repetitive bolus injections (BI) since unnecessary peaks of factor level are avoided. Concerns have been raised whether continuous infusion of coagulation concentrates is associated with an increased risk of developing inhibitors. However, available data have so far not shown an increased risk for inhibitor development in severe haemophilia patients with more than 50 exposure days of coagulation factor concentrates. Further, previously reported complications when using CI such as phlebitis at the infusion site and pump failure are nowadays very seldom seen when small amounts of heparin are added to the infusion bag, and increased quality of the pumps are available. Over the last decades, numerous reports have confirmed CI to be a safe and effective mode of coagulation factor replacement even in the most challenging surgical procedures, such as total joint arthroplasties.
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Affiliation(s)
- P A Holme
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - G E Tjønnfjord
- Department of Haematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - A Batorova
- Faculty of Medicine of Comenius University, Department of Haematology and Transfusion Medicine, National Haemophilia Centre, University Hospital, Bratislava, Slovakia
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9
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Castaman G. The role of recombinant activated factor VII in the haematological management of elective orthopaedic surgery in haemophilia A patients with inhibitors. Blood Transfus 2017; 15:478-86. [PMID: 28686157 DOI: 10.2450/2017.0369-16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/13/2017] [Indexed: 01/19/2023]
Abstract
The clinical profile and expectations of haemophilic patients with inhibitors have changed over the last three decades, mainly because of the prolongation of life-expectancy, often resulting in an increase of the orthopaedic burden. Recombinant activated factor VII (rFVIIa) is the most frequently used bypassing agent in haemophilia patients with inhibitors during elective orthopaedic surgery. For nearly 30 years, rFVIIa has been successfully used to control haemostasis in several major and minor surgical procedures. Clinical trials, case series, reports and surveys were progressively aimed at optimising rFVIIa usage in very demanding conditions managed in highly specialised centres. Recommendations from consensus opinions and guidelines have been provided on the basis of this clinical experience.
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Mingot-Castellano ME, Álvarez-Román MT, López-Fernández MF, Altisent-Roca C, Canaro-Hirnyk MI, Jiménez-Yuste V, Cid-Haro AR, Pérez-Garrido R, Sedano-Balbas C. Spanish consensus guidelines on prophylaxis with bypassing agents for surgery in patients with haemophilia and inhibitors. Eur J Haematol 2016; 96:461-74. [DOI: 10.1111/ejh.12730] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2015] [Indexed: 01/18/2023]
Affiliation(s)
| | | | | | | | | | | | - Ana Rosa Cid-Haro
- Thrombosis and Haemostasis Unit; Hospital Universitario La Fe; Valencia Spain
| | | | - Carmen Sedano-Balbas
- Haematology Department; Hospital Universitario Marqués de Valdecilla; Cantabria Spain
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Mahlangu JN, Weldingh KN, Lentz SR, Kaicker S, Karim FA, Matsushita T, Recht M, Tomczak W, Windyga J, Ehrenforth S, Knobe K. Changes in the amino acid sequence of the recombinant human factor VIIa analog, vatreptacog alfa, are associated with clinical immunogenicity. J Thromb Haemost 2015; 13:1989-98. [PMID: 26362483 DOI: 10.1111/jth.13141] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [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: 05/11/2015] [Accepted: 08/10/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Vatreptacog alfa, a recombinant human factor VIIa (rFVIIa) analog developed to improve the treatment of bleeds in hemophilia patients with inhibitors, differs from native FVIIa by three amino acid substitutions. In a randomized, double-blind, crossover, confirmatory phase III trial (adept(™) 2), 8/72 (11%) hemophilia A or B patients with inhibitors treated for acute bleeds developed anti-drug antibodies (ADAs) to vatreptacog alfa. OBJECTIVES To characterize the formation of anti-vatreptacog alfa ADAs in hemophilia patients with inhibitors. METHODS/PATIENTS This was a post hoc analysis of adept(™) 2. Immunoglobulin isotype determination, specificity analysis of rFVIIa cross-reactive antibodies, epitope mapping of rFVIIa single mutant analogs and pharmacokinetic (PK) profiling were performed to characterize the ADAs. RESULTS Immunoglobulin isotyping indicated that the ADAs were of the immunoglobulin G subtype. In epitope mapping, none of the rFVIIa single mutant analogs (V158D, E296V or M298Q) contained the complete antibody epitope, confirming that the antibodies were specific for vatreptacog alfa. In two patients, for whom PK profiling was performed both before and after the development of ADAs, vatreptacog alfa showed a prolonged elimination phase following ADA development. During the follow-up evaluation, the rFVIIa cross-reactivity disappeared after the last vatreptacog alfa exposure, despite continued exposure to rFVIIa as part of standard care. CONCLUSIONS Results from the vatreptacog alfa phase III trial demonstrate that the specific changes made, albeit relatively small, to the FVIIa molecule alter its clinical immunogenicity.
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Affiliation(s)
- J N Mahlangu
- Haemophilia Comprehensive Care Centre, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | | | - S R Lentz
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - S Kaicker
- Maimonides Medical Centre, New York, NY, USA
| | - F A Karim
- Haemophilia Centre, National Blood Centre, Kuala Lumpur, Malaysia
| | - T Matsushita
- Department of Transfusion Medicine, Nagoya University Hospital, Nagoya, Japan
| | - M Recht
- Hemophilia Center, Oregon Health and Science University, Portland, OR, USA
| | - W Tomczak
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - J Windyga
- Department of Disorders of Haemostasis and Internal Medicine, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | - K Knobe
- Novo Nordisk A/S, Bagsvaerd, Denmark
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Ju HY, Jang HL, Park YS. The efficacy of bypassing agents in surgery of hemophilia patients with inhibitors. Blood Res 2015; 50:173-8. [PMID: 26457285 PMCID: PMC4595584 DOI: 10.5045/br.2015.50.3.173] [Citation(s) in RCA: 18] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 08/20/2015] [Accepted: 08/20/2015] [Indexed: 11/25/2022] Open
Abstract
Background Inhibitory antibodies to factor VIII (FVIII) or IX (FIX) are important issues when managing patients with hemophilia A or B. Advances in bypassing agents such as recombinant activated FVII (rFVIIa) and activated prothrombin complex concentrates (APCC) have enabled the aggressive management of hemophilia with inhibitors during emergency or elective surgery. This study provides an updated evaluation of the safety and effectiveness of bypassing agents in treating perioperative bleeding. Methods We reviewed the records of hemophilia patients with inhibitors who underwent surgery between May 2008 and July 2014 using bypassing agents or high-dose FVIII concentrates at a single center. Results In total, 36 surgeries (24 orthopedic, 12 other) were conducted in 18 hemophilia patients with inhibitors. The median inhibitor titer at surgery was 14 (range, 0.7-1,900) Bethesda units. Most patients had high-responding inhibitors. In total, 25 patients received APCC, 9 with rFVIIa initially. In most cases, bleeding stopped or was well controlled; however, bleeding in 6 patients was controlled using sequential bypassing therapy. Hemostatic efficacy of bypassing agents in various surgeries, based on the final patient outcome, was 94.4% (34/36). Among 5 emergency surgeries, 2 deaths occurred. Conclusion Good control of hemostasis can be achieved using bypassing agents in hemophilia patients with inhibitors who are undergoing surgery. Thorough planning is needed before elective surgery and more active and aggressive management may be needed for emergency surgery. Use of bypassing agents can facilitate safe and successful surgeries in hemophilia patients with inhibitors.
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Affiliation(s)
- Hee Young Ju
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Hye Lim Jang
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Young Shil Park
- Department of Pediatrics, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Korea
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Wiszniewski A, Szczepanik A, Misiak A, Bykowska K, Szopiński P. Prevention of bleeding and hemorrhagic complications in surgical patients with inherited factor VII deficiency. Blood Coagul Fibrinolysis 2015; 26:324-30. [DOI: 10.1097/mbc.0000000000000258] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Takedani H, Shima M, Horikoshi Y, Koyama T, Fukutake K, Kuwahara M, Ishiguro N. Ten‐year experience of recombinant activated factor VII use in surgical patients with congenital haemophilia with inhibitors or acquired haemophilia in Japan. Haemophilia 2014; 21:374-379. [DOI: 10.1111/hae.12611] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2014] [Indexed: 11/28/2022]
Affiliation(s)
- H. Takedani
- Hospital of the Institute of Medical Science of the University of Tokyo (IMSUT) TokyoJapan
| | - M. Shima
- Nara Medical University KashiharaJapan
| | | | - T. Koyama
- Tokyo Medical and Dental University TokyoJapan
| | | | | | - N. Ishiguro
- Nagoya University School of Medicine Nagoya Japan
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Lentz SR, Ehrenforth S, Karim FA, Matsushita T, Weldingh KN, Windyga J, Mahlangu JN. Recombinant factor VIIa analog in the management of hemophilia with inhibitors: results from a multicenter, randomized, controlled trial of vatreptacog alfa. J Thromb Haemost 2014; 12:1244-53. [PMID: 24931322 PMCID: PMC4238784 DOI: 10.1111/jth.12634] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 05/30/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND Vatreptacog alfa, a recombinant factor VIIa (rFVIIa) analog with three amino acid substitutions and 99% identity to native FVIIa, was developed to improve the treatment of hemophilic patients with inhibitors. OBJECTIVES To confirm the safety and assess the efficacy of vatreptacog alfa in treating bleeding episodes in hemophilic patients with inhibitors. PATIENTS AND METHODS In this international, multicenter, randomized, double-blind, active-controlled, crossover, confirmatory phase III trial (adept(™) 2) in patients with hemophilia A or B and inhibitors, bleeds were randomized 3 : 2 to treatment with vatreptacog alfa (one to three doses at 80 μg kg(-1) ) or rFVIIa (one to three doses at 90 μg kg(-1) ). Treatment failures after three doses of trial product (TP) were managed according to the local standard of care. RESULTS In the 72 patients enrolled, 567 bleeds were treated with TP. Both vatreptacog alfa and rFVIIa gave 93% effective bleeding control at 12 h. Vatreptacog alfa was superior to rFVIIa in secondary efficacy outcomes, including the number of doses used to treat a bleed and sustained bleeding control 24-48 h after the first dose. Eight patients (11%) developed antibodies against vatreptacog alfa, including four with cross-reactivity against rFVIIa and one with an in vitro neutralizing effect to vatreptacog alfa. CONCLUSIONS This large randomized controlled trial confirmed the well-established efficacy and safety profile of rFVIIa, and showed that vatreptacog alfa had similar or better efficacy than rFVIIa. However, because of the development of anti-drug antibodies, a positive benefit-risk profile is unlikely to be achieved with vatreptacog alfa.
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Affiliation(s)
- S R Lentz
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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Shapiro AD, Hedner U. Advances in bypassing agent therapy for hemophilia patients with inhibitors to close care gaps and improve outcomes. Ther Adv Drug Saf 2014; 2:213-25. [PMID: 25083214 DOI: 10.1177/2042098611415566] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In the past, patients with hemophilia and inhibitors have had less-than-optimal treatment and have experienced more orthopedic complications than patients without inhibitors. Bypassing agents offer the potential to close treatment gaps between inhibitor and noninhibitor patients by helping the former better attain key treatment goals, including: facilitating early initiation of treatment and hemostatic control in hemarthroses; providing effective treatment in serious hemorrhagic episodes; and performance of major surgery. Effective treatment with a bypassing agent minimizes joint and/or muscle damage and potentially can serve as an effective prophylactic agent to minimize the number of hemarthroses experienced per year, thereby mitigating the development of arthropathy. The reported efficacy of the currently available bypassing agents ranges from approximately 50-80% (50-64% in controlled studies) for plasma-derived activated prothrombin complex concentrate (pd-aPCC) and 81-91% (in controlled studies) for recombinant activated factor VII (rFVIIa), including use in major orthopedic surgery. Both bypassing agents have undergone key improvements in their formulation and/or properties in recent years. The nanofiltered, vapor-heated formulation of pd-aPCC has diminished the risk of acquiring blood-borne viral infections and the room temperature stable formulation of rFVIIa allows more convenient storage, increased ease to dissolve and inject, and smaller volumes, thereby increasing overall ease of administration. Use of recommended dosing has been demonstrated to provide effective hemostasis with a minimal number of injections for both agents. In this paper, we review the individual characteristics of pd-aPCC and rFVIIa and discuss clinical data from studies conducted in inhibitor patients that demonstrate the potential benefits of these bypassing agents in this difficult-to-treat population, and underscore the potential opportunities to close the gap in care between inhibitor and noninhibitor hemophilic patients.
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Affiliation(s)
- Amy D Shapiro
- Indiana Hemophilia and Thrombosis Center, 8402 Harcourt Road, Suite 500, Indianapolis, IN 46260, USA
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Abstract
INTRODUCTION Patients with haemophilia commonly develop arthropathy secondary to recurrent haemarthroses. Although modern treatment with replacement coagulation factors has reduced the prevalence of end-stage arthropathy, total joint replacement is still required in a small group of patients. These patients may be at higher risk of complications and the outcome of surgery may not be comparable to reports of outcomes of total joint replacement in the general population. The purpose of this study was to describe the change in function in patients undergoing total knee replacement for haemophilic arthropathy. PATIENTS AND METHODS Patients undergoing total knee arthroplasty in a tertiary centre had prospective evaluations of patient reported outcome measures and range of movement. Their post-operative function was evaluated in a combined orthopaedic-haematology clinic. Eight male patients underwent 13 total knee replacements from 1999 to 2007 and were followed up for a median of 78 months (range 17-116). RESULTS The median Oxford knee score improved from 45.5 pre-operatively to 28 (p = 0.049). There was a similar improvement in SF-12 physical (p = 0.017) and Knee Society scores (objective p = 0.001; function p = 0.002). Four total knee replacements were performed in patients with inhibitor antibodies and were treated with recombinant activated factor VIIa. These patients had reduced range of movement (p = 0.047). No patients suffered deep infection. CONCLUSIONS Total knee replacement in patients with haemophiliac arthropathy resulted in improvement in range of movement and function. The presence of factor VIII inhibitors resulted in reduced range of movement, but similar patient reported outcome measures.
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Affiliation(s)
- P J Jenkins
- Specialist Registrar, Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
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Lenk C, Unterthurner S, Schuster M, Weiller M, Antoine G, Malisauskas M, Scheiflinger F, Schwarz HP, de la Rosa M, Reipert BM. Development of a transgenic mouse model with immune tolerance for human coagulation factor VIIa. Pharm Res 2013; 30:2855-67. [PMID: 23775444 DOI: 10.1007/s11095-013-1115-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Accepted: 06/04/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Human factor VIIa (FVIIa) is commonly used as bypassing therapy to treat bleeding episodes in hemophilia patients with neutralizing antibodies to factors VIII (FVIII) or IX (FIX). There is a need for a suitable animal model to assess the immunogenicity of new FVIIa products during preclinical development. The aim of this study was the design of a novel transgenic mouse model with immune tolerance to human FVIIa. METHODS The model was generated by transgenic expression of human F7 cDNA. FVIIa-specific immune responses after treatment with human FVIIa were assessed by analyzing circulating antibodies, antibody producing plasma cells and CD4(+) T cells. RESULTS In contrast to wild-type mice, human FVII transgenic mice did not develop antibodies when treated with human FVIIa. The immune tolerance was specific and could be broken by application of human FVIIa together with a strong stimulus of the innate immune system. Break of tolerance was associated with increased numbers of pro-inflammatory FVIIa-specific CD4(+) T cells. CONCLUSIONS The new mouse model is suitable to study the influence of the innate immune system on maintenance and break of immune tolerance against FVIIa and could be used to assess the immunogenicity of new FVIIa products during pre-clinical development.
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Kozek-langenecker SA, Afshari A, Albaladejo P, Santullano CAA, De Robertis E, Filipescu DC, Fries D, Görlinger K, Haas T, Imberger G, Jacob M, Lancé M, Llau J, Mallett S, Meier J, Rahe-meyer N, Samama CM, Smith A, Solomon C, Van der Linden P, Wikkelsø AJ, Wouters P, Wyffels P. Management of severe perioperative bleeding: Guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2013; 30:270-382. [DOI: 10.1097/eja.0b013e32835f4d5b] [Citation(s) in RCA: 642] [Impact Index Per Article: 58.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Négrier C, Lienhart A, Numerof R, Stephens D, Wong WY, Baghaei F, Yee TT. SURgical interventions with FEIBA (SURF): international registry of surgery in haemophilia patients with inhibitory antibodies. Haemophilia 2013; 19:e143-50. [DOI: 10.1111/hae.12080] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2012] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - R. Numerof
- Baxter Healthcare Corporation; Westlake Village; CA; USA
| | - D. Stephens
- Baxter Healthcare Corporation; Westlake Village; CA; USA
| | - W. Y. Wong
- Baxter Healthcare Corporation; Westlake Village; CA; USA
| | - F. Baghaei
- Sahlgrenska University Hospital; Gothenburg; Sweden
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21
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2013 revised edition : hemostatic treatment guidelines for inhibitors possess congenital hemophilia patients. ACTA ACUST UNITED AC 2013; 24:640-58. [DOI: 10.2491/jjsth.24.640] [Citation(s) in RCA: 5] [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] [Indexed: 01/19/2023]
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Collins PW, Chalmers E, Hart DP, Liesner R, Rangarajan S, Talks K, Williams M, Hay CR. Diagnosis and treatment of factor VIII and IX inhibitors in congenital haemophilia: (4th edition). Br J Haematol 2012; 160:153-70. [DOI: 10.1111/bjh.12091] [Citation(s) in RCA: 159] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Peter W. Collins
- School of Medicine; Cardiff University; University Hospital of Wales; Wales; UK
| | | | - Daniel P. Hart
- The London School of Medicine and Dentistry; Royal London Hospital; Barts, Queen Mary University; London; UK
| | - Ri Liesner
- Great Ormond Street NHS Trust; London; UK
| | - Savita Rangarajan
- Hampshire Hospital NHS Foundation Trust; Basingstoke & North Hampshire Hospital; Basingstoke; UK
| | - Kate Talks
- Royal Victoria Infirmary; Newcastle upon Tyne; UK
| | - Mike Williams
- Birmingham Childrens' Hospital NHS Foundation Trust; Birmingham; UK
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Escobar M, Maahs J, Hellman E, Donkin J, Forsyth A, Hroma N, Young G, Valentino LA, Tachdjian R, Cooper DL, Shapiro AD. Multidisciplinary management of patients with haemophilia with inhibitors undergoing surgery in the United States: perspectives and best practices derived from experienced treatment centres. Haemophilia 2012; 18:971-81. [DOI: 10.1111/j.1365-2516.2012.02894.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2012] [Indexed: 11/28/2022]
Affiliation(s)
- M. Escobar
- Gulf States Hemophilia and Thrombophilia Center; Houston; TX; USA
| | - J. Maahs
- Indiana Hemophilia & Thrombosis Center; Indianapolis; IN; USA
| | - E. Hellman
- OrthoIndy Bone, Joint, Spine & Muscle Care; Indiana Orthopedic Hospital; Indianapolis; IN; USA
| | - J. Donkin
- Children's Hospital Los Angeles; USC Keck School of Medicine; Los Angeles; CA; USA
| | - A. Forsyth
- Penn Hemophilia and Thrombosis Program; Philadelphia; PA; USA
| | - N. Hroma
- Children's Memorial Hospital; Chicago; IL; USA
| | - G. Young
- Children's Hospital Los Angeles; USC Keck School of Medicine; Los Angeles; CA; USA
| | | | - R. Tachdjian
- David Geffen UCLA School of Medicine; Los Angeles; CA; USA
| | | | - A. D. Shapiro
- Indiana Hemophilia & Thrombosis Center; Indianapolis; IN; USA
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Christensen A, Jensen JT, Nøhr AM, Cooper DL. Room-temperature-stable recombinant activated coagulation factor VII recombinant: chemical and microbiologic stability over 24 hours during continuous in vitro infusion. Clin Ther 2011; 33:1997-2001. [PMID: 22088413 DOI: 10.1016/j.clinthera.2011.10.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2011] [Indexed: 10/15/2022]
Abstract
rFVIIa-25C is a recombinant coagulation factor VIIa (rFVIIa) formulated to remain stable at room temperature (up to 25°C) for up to 2 hours. The bolus injection of rFVIIa-25C has been reported to be bioequivalent to that of rFVIIa. With alternative administration by continuous infusion (50 μg/kg/h) for surgical hemostatic coverage in hemophilia patients with inhibitors, rFVIIa has been reported to be stable. This research letter presents data from an in vitro study of the activity and chemical stability (rFVIIa content, clot activity, and degradation products), physical stability, and microbiologic stability of rFVIIa-25C administered as a continuous infusion. The findings suggest that rFVIIa-25C remained biochemically stable and aseptic during 24-hour continuous infusion in vitro at 19.3°C to 20.7°C, with no clinically significant changes in clot activity, solution constituents, or concentrations.
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RODRIGUEZ-MERCHAN EC, JIMENEZ-YUSTE V, AZNAR JA, HEDNER U, KNOBE K, LEE CA, LJUNG R, QUEROL F, SANTAGOSTINO E, VALENTINO LA, CAFFARINI A. Joint protection in haemophilia. Haemophilia 2011; 17 Suppl 2:1-23. [DOI: 10.1111/j.1365-2516.2011.02615.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Notarnicola A, Pesce V, Scaraggi A, Maccagnano G, Vicenti G, Moretti B. Total hip replacement in a patient with acquired haemophilia a: a case report and literature review. Blood Coagul Fibrinolysis 2011; 22:436-9. [DOI: 10.1097/mbc.0b013e32834689fa] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
This review describes the background for the development of recombinant FVIIa (rFVIIa; NovoSeven) for use in haemophilic patients with inhibitors. The first proof of principle for using pharmacological doses of FVIIa as a haemostatic agent was obtained by producing small amounts of pure plasma-derived FVIIa, which showed encouraging effect in two patients with haemophilia A and inhibitors. To make pure FVIIa available for use in a larger number of patients, rFVIIa was produced that was approved for use in patients with inhibitors against coagulation factors (congenital haemophilia and acquired haemophilia) in 1996 (EU), 1999 (USA) and 2000 (Japan). The efficacy rate in severe bleedings and in major surgery including major orthopaedic surgery has been found to be around 90% in controlled studies, and no serious safety concerns have been demonstrated. The availability of rFVIIa has facilitated the performance of elective major surgery in haemophilia patients with inhibitors. Further steps along the vision of providing a treatment for inhibitor patients similar to non-inhibitor patients have been the efficacy of rFVIIa in home-treatment and recently the encouraging experience in prophylaxis. The concept of using pharmacological doses of rFVIIa as a haemostatic agent is a new one, which has caused difficulties in finding the correct dose. A step forward has been the demonstration that similar efficacy can be achieved after one single dose of 270 μg kg(-1) instead of three injections of a dose of 90 μg kg(-1). The higher clearance rate in children suggests that higher doses may be beneficial in children. The availability of rFVIIa has made advances in the understanding of coagulation processes possible. In a cell-based in vitro model, it has been shown that rFVIIa binds to preactivated platelets if present in concentrations of 30 nm or higher. By doing so, it activates FX into FXa and enhances the thrombin generation on the activated platelet surface in the absence of FVIII/FIX. Through the increased thrombin generation, a firm, well-structured fibrin haemostatic plug, which is resistant to premature lysis, is formed. By exploiting this mechanism of action, rFVIIa may also be effective in situations other than haemophilia, characterized by an impaired thrombin generation.
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Affiliation(s)
- U Hedner
- Department of Medicine, University of Lund, Lund, Sweden.
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Caviglia H, Candela M, Galatro G, Neme D, Moretti N, Bianco RP. Elective orthopaedic surgery for haemophilia patients with inhibitors: single centre experience of 40 procedures and review of the literature. Haemophilia 2011; 17:910-9. [PMID: 21342367 DOI: 10.1111/j.1365-2516.2011.02504.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
With the introduction of safe and effective factor VIII/IX-bypassing agents--recombinant activated factor VII (rFVIIa) and plasma-derived activated prothrombin complex concentrates (pd-APCC)--elective orthopaedic surgery (EOS) is a viable option for haemophilia patients with inhibitors. We report a series of patients with haemophilia and inhibitors undergoing EOS between 1997 and 2008 using bypassing agents to provide haemostatic cover. All inhibitor patients undergoing EOS and receiving rFVIIa, plasma-derived prothrombin complex concentrates (pd-PCC) or pd-APCC as haemostatic cover were included. Patients were operated on by the same surgeon and were managed by the same haemophilia treatment centre. Forty procedures (25 minor and 15 major) were conducted in 18 patients. Twenty-one minor cases were covered using rFVIIa, three with pd-PCC, and one with pd-APCC; all major cases were covered using rFVIIa. Bleeding was no greater than expected compared with a non-haemophilic population in all 25 minor procedures. In the major procedure group, there was no excessive bleeding in 40% of cases (6/15) and bleeding completely stopped in response to rFVIIa. For the remaining nine cases, bleeding response to rFVIIa was described as 'markedly decreased' or 'decreased' in 4/15 cases and 'unchanged' in 5/15 cases. Overall, efficacy of rFVIIa, based on final patient outcome, was 85%. One death occurred as a result of sepsis secondary to necrotizing fasciitis. Good control of haemostasis can be achieved with bypassing agents in haemophilia patients with inhibitors undergoing minor EOS; rFVIIa was used as an effective bypassing agent, enabling EOS in patients undergoing minor and major procedures.
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Affiliation(s)
- H Caviglia
- Haemophilia Foundation, Buenos Aires, Argentina.
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29
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VALENTINO LA, COOPER DL, GOLDSTEIN B. Surgical Experience with rFVIIa (NovoSeven) in congenital haemophilia A and B patients with inhibitors to factors VIII or IX. Haemophilia 2011; 17:579-89. [DOI: 10.1111/j.1365-2516.2010.02460.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Johansson PI, Ostrowski SR. Evidence supporting the use of recombinant activated factor VII in congenital bleeding disorders. Drug Des Devel Ther 2010; 4:107-16. [PMID: 20689697 PMCID: PMC2915535 DOI: 10.2147/dddt.s11764] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/26/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND Recombinant activated factor VII (rFVIIa, NovoSeven) was introduced in 1996 for the treatment of hemophilic patients with antibodies against coagulation factor VIII or IX. OBJECTIVE To review the evidence supporting the use of rFVIIa for the treatment of patients with congenital bleeding disorders. PATIENTS AND METHODS English-language databases were searched in September 2009 for reports of randomized controlled trials (RCTs) evaluating the ability of rFVIIa to restore hemostasis in patients with congenital bleeding disorders. RESULTS Eight RCTs involving 256 hemophilic patients with antibodies against coagulation factors, also known as inhibitors, were identified. The evidence supporting the use of rFVIIa in these patients was weak with regard to dose, clinical setting, mode of administration, efficacy, and adverse events, given the limited sample size of each RCT and the heterogeneity of the studies. CONCLUSION The authors suggest that rFVIIa therapy in hemophilic patients with inhibitors should be based on the individual's ability to generate thrombin and form a clot, and not on the patient's weight alone. Therefore, assays for thrombin generation, such as whole-blood thromboelastography, have the potential to significantly improve the treatment of these patients.
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Affiliation(s)
- Pär I Johansson
- Capital Region Blood Bank, Section for Transfusion Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
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31
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Puetz J. Optimal use of recombinant factor VIIa in the control of bleeding episodes in hemophilic patients. Drug Des Devel Ther 2010; 4:127-37. [PMID: 20689699 PMCID: PMC2915537 DOI: 10.2147/dddt.s6628] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [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: 06/26/2010] [Indexed: 12/05/2022]
Abstract
One of the last remaining clinical hurdles in the treatment of people with hemophilia is the development of inhibitors. Alloantibodies or autoantibodies directed at coagulation factors render the infusion of coagulation factor concentrates ineffective, and alternative means must be used to achieve hemostasis. Recombinant factor VIIa (rFVIIa) was developed to control bleeding episodes in hemophilic patients with inhibitors. Clinical efficacy in achieving hemostasis in inhibitor patients was demonstrated by a compassionate-use protocol, as well as in randomized controlled trials. To date, over 1.5 million doses of rFVIIa have been given to inhibitor patients, with an excellent efficacy and safety record. Because of its short half-life, alternative means of dosing and infusing rFVIIa have been explored and are reviewed here.
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Affiliation(s)
- John Puetz
- Department of Pediatrics, Saint Louis University, St Louis, Missouri, USA.
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Chuansumrit A, Angchaisuksiri P, Sirachainan N. Critical appraisal of the role of recombinant activated factor VII in the treatment of hemophilia patients with inhibitors. J Blood Med 2010; 1:37-48. [PMID: 22282682 PMCID: PMC3262327 DOI: 10.2147/jbm.s6209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 03/27/2010] [Indexed: 11/30/2022] Open
Abstract
Hemophilia patients with inhibitors faced the constraint of inadequate treatment for several years before the era of recombinant factor VIIa (rFVII). Initially, rFVIIa was used in the compassionate-use programs. After a worldwide license was issued, more than 1.5 million doses were administered. Bleeding of joints and muscles was controlled effectively by means of an early home treatment program, with either a standard dose of 90 μg/kg every 2 to 3 hours for a few doses or a single dose of 270 μg/kg. For more serious bleeding episodes or minor surgery, an initial dose of 90 μg/kg was given every 2 hours for 24 to 48 hours followed by increased intervals of 3 to 6 hours according to the severity of bleeding and efficacy of bleeding control. In cases of major surgery such as orthopedic procedures, the same regimen can be applied except for a higher initial dose of 120 to 180 μg/kg. However, increasing the dose should be considered if there are unexpected bleeding complications since the half-life and clearance of rFVIIa differ between individuals. In addition, prophylaxis is administered to a small number of patients. Finally, the reported thromboembolic events found in hemophilia patients with inhibitors receiving rFVIIa are extremely low, much less than 1%.
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Affiliation(s)
| | - Pantep Angchaisuksiri
- Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Thompson CA, Kyle R, Gertz M, Heit J, Pruthi R, Pardanani A. Systemic AL amyloidosis with acquired factor X deficiency: A study of perioperative bleeding risk and treatment outcomes in 60 patients. Am J Hematol 2010; 85:171-3. [PMID: 20052750 PMCID: PMC2896569 DOI: 10.1002/ajh.21603] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [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: 11/10/2022]
Abstract
Systemic light-chain (AL) amyloidosis may be associated with acquired factor X (FX) deficiency and optimal management of this coagulopathy is unknown. We reviewed our experience with 60 patients with isolated FX deficiency (< or =50%) due to AL amyloidosis that underwent an invasive procedure between 1975 and 2007. They were classified as having severe (<10%; n = 6), moderate (10-25%; n = 15), or mild (26-50%; n = 39) FX deficiency. The patients underwent a total of 112 procedures, 19 (17%) of which were managed with periprocedural treatment with one or more hemostatic agents. There were complications in 14 (13%) procedures (bleeding = 12, thrombosis = 1, death = 1). Baseline FX level was not predictive of bleeding risk; the only association with postintervention bleeding was central venous catheter placement. However, bleeding complications were relatively infrequent, particularly in patients with mild or moderate FX deficiency undergoing nonvascular procedures. Activated recombinant factor VII might be considered in patients undergoing major surgical procedures, but further experience is needed. Optimal management of AL patients with FX deficiency undergoing invasive procedures remains to be determined.
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AOUBA A, DEZAMIS E, SERMET A, ROTHSCHILD C, HERMINE O, LASNE D, TORCHET MF. Uncomplicated neurosurgical resection of a malignant glioneuronal tumour under haemostatic cover of rFVIIa in a severe haemophilia patient with a high-titre inhibitor: a case report and literature review of rFVIIa use in major surgeries. Haemophilia 2010; 16:54-60. [DOI: 10.1111/j.1365-2516.2009.02089.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Mannucci PM, Schutgens REG, Santagostino E, Mauser-bunschoten EP. How I treat age-related morbidities in elderly persons with hemophilia. Blood 2009; 114:5256-63. [DOI: 10.1182/blood-2009-07-215665] [Citation(s) in RCA: 142] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Abstract
In persons with hemophilia, life expectancy is now approaching that of the general male population, at least in countries that can afford regular replacement therapy with coagulation factor concentrates. The new challenges for comprehensive treatment centers are thus to provide optimal health care for this aging population of patients, who often present not only with the comorbidities typically associated with hemophilia (arthropathy, chronic pain, blood-borne infections), but also with common age-related illnesses such as cardiovascular disease and cancer. There are no evidence-based guidelines for the management of these conditions, which often require drugs that interfere with hemostasis, enhance the bleeding tendency, and warrant more intensive replacement therapy. At the moment, elderly patients with hemophilia affected by other diseases should be managed like their age-group peers without hemophilia, provided replacement therapy is tailored to the heightened risk of bleeding associated with the need for invasive procedures and drugs that further compromise the deranged hemostasis. More detailed advice is provided on the schedules of replacement therapy needed to tackle cardiovascular diseases, such as acute coronary syndromes and nonvalvular atrial fibrillation, because these conditions will become more and more frequent challenges for the comprehensive treatment centers.
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GIANGRANDE PLF, WILDE JT, MADAN B, LUDLAM CA, TUDDENHAM EGD, GODDARD NJ, DOLAN G, INGERSLEV J. Consensus protocol for the use of recombinant activated factor VII [eptacog alfa (activated); NovoSeven®] in elective orthopaedic surgery in haemophilic patients with inhibitors. Haemophilia 2009; 15:501-8. [DOI: 10.1111/j.1365-2516.2008.01952.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rajic N, Savic A, Popovic S, Urosevic I, Savic I. Successful control of bleeding during supracondylar amputation caused by severe compartment syndrome in patient with haemophilia A and high titre of inhibitor. Haemophilia 2009; 15:601-2. [PMID: 19175420 DOI: 10.1111/j.1365-2516.2008.01943.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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TEITEL JM, CARCAO M, LILLICRAP D, MULDER K, RIVARD GE, ST-LOUIS J, SMITH F, WALKER I, ZOURIKIAN N. Orthopaedic surgery in haemophilia patients with inhibitors: a practical guide to haemostatic, surgical and rehabilitative care. Haemophilia 2009; 15:227-39. [DOI: 10.1111/j.1365-2516.2008.01840.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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RODRIGUEZ-MERCHAN EC, HEDNER U, HEIJNEN L, JIMENEZ-YUSTE V, LEE CA, MORFINI M, QUEROL F, ROOSENDAAL G, SANTAGOSTINO E, SOLIMENO LP. Prevention of haemophilic arthropathy during childhood. May common orthopaedic management be extrapolated from patients without inhibitors to patients with inhibitors? Haemophilia 2008; 14 Suppl 6:68-81. [DOI: 10.1111/j.1365-2516.2008.01892.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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O'CONNELL NM, RIDDELL AF, PASCOE G, PERRY DJ, LEE CA. Recombinant factor VIIa to prevent surgical bleeding in factor XI deficiency. Haemophilia 2008; 14:775-81. [DOI: 10.1111/j.1365-2516.2008.01663.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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DEHMEL H, WERWITZKE S, TRUMMER A, GANSER A, TIEDE A. Thrombelastographic monitoring of recombinant factor VIIa in acquired haemophilia. Haemophilia 2008; 14:736-42. [DOI: 10.1111/j.1365-2516.2008.01759.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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OBERGFELL A, AUVINEN MK, MATHEW P. Recombinant activated factor VII for haemophilia patients with inhibitors undergoing orthopaedic surgery: a review of the literature. Haemophilia 2008; 14:233-41. [DOI: 10.1111/j.1365-2516.2007.01617.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
In the last few decades dramatic improvements in the management of haemophilia patients have occurred. Haemophilia has moved from a fatal or disabling disease to a hereditary disorder with available treatment and much better clinical outcomes. The safety of antihaemophilic factor concentrates has been dramatically improved and, in a multidisciplinary environment including haematologists, orthopaedic surgeons, paediatrics, infectiologists, specialised nurses and physiotherapists, complications related to haemophilia are now limited, markedly improving the quality of life of haemophiliacs. One can even think that the cure of haemophilia through gene therapy might occur in the next decades. Keeping this ultimate aim in mind, efforts at present are mainly focused on bioengineered Factor VIII/Factor IX concentrates with increased efficacy or longer half-life or decreased immunogenicity. In addition, several preclinical and clinical studies are being carried out for optimising and individually tailoring the therapeutic regimens of antihaemophilic therapies using global haemostasis tests in combination with the routine coagulation assays.
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Affiliation(s)
- Yesim Dargaud
- Hôpital Edouard Herriot, Comprehensive Haemophilia Treatment Centre, Lyon, France.
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Ng HJ, Lee LH. Recombinant activated clotting factor VII (rFVIIa) in the treatment of surgical and spontaneous bleeding episodes in hemophilic patients. Vasc Health Risk Manag 2007; 2:433-40. [PMID: 17323597 PMCID: PMC1994012 DOI: 10.2147/vhrm.2006.2.4.433] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Inhibitors against replacement clotting factors occur in approximately 30%–40% of patients with hemophilia A and 1.5%–3% of patients with hemophilia B. In this group of patients, bleeding events are best treated with bypassing agents. Recombinant activated factor VII (rFVIIa) has become the first-line agent in treating surgical and non-surgical bleeding in many centres with efficacy at standard 90 μg/kg doses approaching 90%. The greater efficacy is associated with early initiation of treatment, as well as, possibly larger doses of rFVIIa. A higher concentration appears to be essential in initiating an adequate thrombin burst, which results in a stable clot. Higher dosage regimens, home therapy and continuous infusion regimens are continuously evolving as we strive to define optimal dosing strategies in hemophilia patients. rFVIIa has been a remarkably safe agent for hemophiliacs but with high dosages being advocated and older patients being given such doses outside a trial setting, thromboembolic events remain a concern.
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Affiliation(s)
- Heng Joo Ng
- Department of Haematology, Singapore General Hospital, Singapore.
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Gopalan PK, Clohisy JC, Cashen AF, Eby CS. Use of recombinant factor VIIa for hip surgery in a patient with factor-VII deficiency. A case report. J Bone Joint Surg Am 2007; 89:389-91. [PMID: 17272455 DOI: 10.2106/jbjs.f.00132] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Priya K Gopalan
- Department of Medicine, Washington University School of Medicine, Mailstop 8056, 660 South Euclid Avenue, St. Louis, MO 63110, USA
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Abstract
PURPOSE OF REVIEW To review the most recent reports on continuous infusion of coagulation factors, focusing on the current issues relating to this mode of therapy. RECENT FINDINGS Continuous infusion has been extensively used as an alternative to intermittent bolus factor replacement since the 1990s. To date, more than 100 reports comprising more than 800 continuous infusion treatments in various clinical situations have been published, with an increase in the current utilization of recombinant coagulation factors. An excellent hemostatic efficacy of continuous infusion has been reported. Continuous infusion protocols, however, still vary widely in terms of the different hemostatic levels targeted, dosage regimens, modes of continuous infusion and duration of therapy, which obviously result in variations in the cost-effectiveness reported by different centers. SUMMARY Continuous infusion has been shown to be a safe and cost-effective mode of replacement for treatment of hemophilia. The lack of evidence-based information on the hemostatic levels to be maintained in specific clinical situations, and recent concerns regarding the development of inhibitors, particularly in patients with mild hemophilia treated with continuous infusion, need to be addressed by prospective, randomized studies that compare traditional intermittent injections and the continuous infusion mode of factor replacement.
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Affiliation(s)
- Angelika Batorova
- National Hemophilia Center, University Hospital, Bratislava, Slovak Republic, Israel
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Abstract
Today, total joint replacement is the treatment of choice for chronic haemophilic arthropathy of the knee and hip in developed and developing countries. After the last World Haemophilia Congress and Musculoskeletal Congress, we cannot say the same for haemophilic patients with inhibitors because elective surgery today is still limited to few centres and extremely few patients. This is because until the first half of the 1990s, performing surgery in haemophilic patients with inhibitors was associated with a high risk of bleeding. With the availability of activated recombinant factor VII, the first surgical procedures were performed, but they still remain limited because of the elevated costs of replacement therapy. Our goal for the future must be to ensure the same possibility of surgical intervention in haemophilic patients both with and without inhibitors. This will be possible, thanks to the experience of some centres with an increased number of patients, where today this kind of surgery is routinely performed.
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Affiliation(s)
- L P Solimeno
- Department of Orthopaedics, Hemophilic Arthropathy Treatment Centre M.G. Gatti-Randi, Milan, Italy.
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Hay CRM, Brown S, Collins PW, Keeling DM, Liesner R. The diagnosis and management of factor VIII and IX inhibitors: a guideline from the United Kingdom Haemophilia Centre Doctors Organisation. Br J Haematol 2006; 133:591-605. [PMID: 16704433 DOI: 10.1111/j.1365-2141.2006.06087.x] [Citation(s) in RCA: 214] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The revised UKHCDO factor (F) VIII/IX Inhibitor Guidelines (2000) are presented. A schema is proposed for inhibitor surveillance, which varies according to the severity of the haemophilia and the treatment type and regimen used. The methodological and pharmacokinetic approach to inhibitor surveillance in congenital haemophilia has been updated. Factor VIII/IX genotyping of patients is recommended to identify those at increased risk. All patients who develop an inhibitor should be considered for immune tolerance induction (ITI). The decision to attempt ITI for FIX inhibitors must be carefully weighed against the relatively high risk of reactions and the nephrotic syndrome and the relatively low response rate observed in this group. The start of ITI should be deferred until the inhibitor has declined below 10 Bethesda Units/ml, where possible. ITI should continue, even in resistant patients, where it is well tolerated and so long as there is a convincing downward trend in the inhibitor titre. The choice of treatment for bleeding in inhibitor patients is dictated by the severity of the bleed, the current inhibitor titre, the previous anamnestic response to FVIII/IX, the previous clinical response and the side-effect profile of the agents available. We have reviewed novel dose-regimens and modes of administration of FEIBA (factor VIII inhibitor bypassing activity) and recombinant activated FVII (rVIIa) and the extent to which these agents may be used for prophylaxis and surgery. Bleeding in acquired haemophilia is usually treated with FEIBA or rVIIa. Immunosuppressive therapy should be initiated at the time of diagnosis with Prednisolone 1 mg/kg/d +/- cyclophosphamide. In the absence of a response to these agents within 6 weeks, second-line therapy with Rituximab, Ciclosporin A, or other multiple-modality regimens may be considered.
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Affiliation(s)
- Charles R M Hay
- University Department of Haematology, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
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