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Platton S. Diagnosis and laboratory monitoring of hemophilia A. Hematology Am Soc Hematol Educ Program 2023; 2023:11-18. [PMID: 38066923 PMCID: PMC10727114 DOI: 10.1182/hematology.2023000460] [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] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Acquired hemophilia A (AHA) is a rare disorder in which autoantibodies against factor VIII (FVIII) lead to a bleeding phenotype that varies from life-threatening to no bleeding at all. Prolonged activated partial thromboplastin times (APTT) in patients with a bleeding phenotype should be investigated to rule out AHA and should never be ignored in a preprocedure patient. Most inhibitors in AHA are heat and time dependent, so mixing studies performed only on an immediate mix are not useful: both lupus anticoagulants and treatment with direct oral anticoagulants can coexist with AHA and confound the diagnosis. Assays for intrinsic coagulation factors and von Willebrand factor should always be performed, regardless of the results of mixing studies. A Bethesda or modified Bethesda assay should be performed to quantify any inhibitor, and if susoctocog alfa (rpFVIII) is available, then an assay for cross-reacting antibodies should also be performed. At diagnosis and until complete remission, if the FVIII in the patient sample is >5 IU/dL, heat inactivation should be performed before the inhibitor assays are performed. While there are no conventional tests available to measure the effects of FVIII bypassing therapies, newer therapies may require monitoring, or their effects may need to be considered when choosing appropriate assays. Measurement of rpFVIII requires a 1-stage clotting assay, and measurement of patient FVIII while on emicizumab requires a chromogenic assay that does not contain human FX. Close communication is required between the treating clinicians and the laboratory to ensure that the correct tests are performed while patients are receiving treatments.
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Affiliation(s)
- Sean Platton
- The Royal London Hospital Haemophilia Centre, Bart Health NHS Trust, London, UK
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Nguyen NH, Jarvi NL, Balu-Iyer SV. Immunogenicity of Therapeutic Biological Modalities - Lessons from Hemophilia A Therapies. J Pharm Sci 2023; 112:2347-2370. [PMID: 37220828 DOI: 10.1016/j.xphs.2023.05.014] [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] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 05/25/2023]
Abstract
The introduction and development of biologics such as therapeutic proteins, gene-, and cell-based therapy have revolutionized the scope of treatment for many diseases. However, a significant portion of the patients develop unwanted immune reactions against these novel biological modalities, referred to as immunogenicity, and no longer benefit from the treatments. In the current review, using Hemophilia A (HA) therapy as an example, we will discuss the immunogenicity issue of multiple biological modalities. Currently, the number of therapeutic modalities that are approved or recently explored to treat HA, a hereditary bleeding disorder, is increasing rapidly. These include, but are not limited to, recombinant factor VIII proteins, PEGylated FVIII, FVIII Fc fusion protein, bispecific monoclonal antibodies, gene replacement therapy, gene editing therapy, and cell-based therapy. They offer the patients a broader range of more advanced and effective treatment options, yet immunogenicity remains the most critical complication in the management of this disorder. Recent advances in strategies to manage and mitigate immunogenicity will also be reviewed.
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Affiliation(s)
- Nhan H Nguyen
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA; Currently at Truvai Biosciences, Buffalo, NY, USA
| | - Nicole L Jarvi
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Sathy V Balu-Iyer
- Department of Pharmaceutical Sciences, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.
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Sella C, Bardetta M, Valeri F, Dainese C, Valpreda A, Massaia M, Grimaldi D, Porreca A, Bruno B, Borchiellini A. Surgery and Prophylaxis with Susoctocog-Alfa in Acquired Hemophilia: Case Series and Literature Review. J Clin Med 2023; 12:4590. [PMID: 37510704 PMCID: PMC10380857 DOI: 10.3390/jcm12144590] [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: 05/19/2023] [Revised: 07/02/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Acquired hemophilia A (AHA) is a rare bleeding disease due to autoantibodies directed against clotting factor VIII (FVIII). Treatment of AHA consists of inhibitor eradication with immunosuppressive therapy (IST) and prompt control of bleeding obtained with bypassing agents or recombinant porcine FVIII (rpFVIII). The latter has recently been licensed for management of acute bleeding in AHA. Unlike treatment with bypassing agents, rpFVIII can be monitored to provide a successful hemostatic effect and avoid overtreatment. Correlation between rpFVIII inhibitor titers and efficacy of rpFVIII treatment remains a matter of debate. METHODS We report three cases of AHA in which rpFVIII was successfully used with an unconventional schedule despite the presence of medium-high titers of the rpFVIII. The modified Nijmegen-Bethesda inhibitor assay (NBA) was used to dose porcine FVIII inhibitors. RESULT The presence of rpFVIII inhibitors prior to the exposition to susoctocog-alfa, that may suggest a cross-reactivity with human FVIII inhibitors, did not affect hemostasis. CONCLUSION In our experience, rpFVIII demonstrates safety and efficacy in the presence of rpFVIII inhibitors and using an unconventional schedule in both the perioperative and outpatient settings. Laboratory measurement of inhibitors against rpFVIII during treatment is described for the first time.
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Affiliation(s)
- Carola Sella
- Regional Centre for Hemorrhagic and Thrombotic Diseases, AOU Città della Salute e della Scienza, 10126 Turin, Italy
- Division of Hematology, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, 10124 Turin, Italy
| | - Marco Bardetta
- Regional Centre for Hemorrhagic and Thrombotic Diseases, AOU Città della Salute e della Scienza, 10126 Turin, Italy
- Division of Hematology, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, 10124 Turin, Italy
| | - Federica Valeri
- Regional Centre for Hemorrhagic and Thrombotic Diseases, AOU Città della Salute e della Scienza, 10126 Turin, Italy
- Division of Hematology, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
| | - Cristina Dainese
- Regional Centre for Hemorrhagic and Thrombotic Diseases, AOU Città della Salute e della Scienza, 10126 Turin, Italy
- Division of Hematology, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
| | - Alessandra Valpreda
- Central Laboratory Baldi and Riberi, AOU Città della Salute e della Scienza, University of Turin, 10124 Turin, Italy
| | - Massimo Massaia
- Hematology Unit, Santa Croce e Carle Hospital, 12100 Cuneo, Italy
| | - Daniele Grimaldi
- Hematology Unit, Santa Croce e Carle Hospital, 12100 Cuneo, Italy
| | - Annamaria Porreca
- Department of Medical, Oral and Biotechnologies Science, University of Chieti-Pescara, 66100 Chieti, Italy
| | - Benedetto Bruno
- Division of Hematology, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
- Department of Molecular Biotechnology and Health Sciences, University of Turin, 10124 Turin, Italy
| | - Alessandra Borchiellini
- Regional Centre for Hemorrhagic and Thrombotic Diseases, AOU Città della Salute e della Scienza, 10126 Turin, Italy
- Division of Hematology, AOU Città della Salute e della Scienza, University of Turin, 10126 Turin, Italy
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Bowyer A, Gray E, Lowe A, Murphy P, Platton S, Riddell A, Chowdary P, Lester W, Jenkins PV. Laboratory coagulation tests and recombinant porcine factor VIII: A United Kingdom Haemophilia Centre Doctors’ Organisation guideline. Haemophilia 2022; 28:515-519. [DOI: 10.1111/hae.14536] [Citation(s) in RCA: 2] [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: 10/20/2021] [Revised: 02/18/2022] [Accepted: 02/25/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Annette Bowyer
- Department of Coagulation Royal Hallamshire Hospital Sheffield UK
| | - Elaine Gray
- Haemostasis Section National Institute for Biological Standards and Control Potters Bar UK
| | - Anna Lowe
- UK National External Quality Assurance Scheme for Blood Coagulation Sheffield UK
| | - Paul Murphy
- Department of Haematology Newcastle Upon Tyne Hospitals Newcastle upon Tyne UK
| | - Sean Platton
- The Royal London Hospital Haemophilia Centre Barts Health NHS Trust London UK
| | - Anne Riddell
- Katharine Dormandy Haemophilia Centre Royal Free Hospital London UK
| | - Pratima Chowdary
- Katharine Dormandy Haemophilia Centre Royal Free Hospital London UK
| | - Will Lester
- Haemophilia Unit University Hospitals Birmingham Birmingham UK
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Dargaud Y, Escuriola‐Ettingshausen C. Recombinant porcine factor VIII: Lessons from the past and place in the management of hemophilia A with inhibitors in 2021. Res Pract Thromb Haemost 2021; 5:e12631. [PMID: 34849451 PMCID: PMC8606027 DOI: 10.1002/rth2.12631] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 10/25/2021] [Accepted: 10/31/2021] [Indexed: 11/09/2022] Open
Abstract
The most serious complication of factor VIII (FVIII) replacement therapy is the occurrence of anti-FVIII alloantibodies that can strongly reduce or abolish the effect of human FVIII products. Bypassing agents to control bleeding episodes are recommended for these patients, but their efficacy is difficult to predict and monitor. FVIII products derived from porcine plasma had an important role in the treatment of hemophilia A for 50 years, from 1954 to 2004. Indeed, porcine FVIII could achieve hemostasis in patients in whom human FVIII products were ineffective. A recombinant porcine FVIII product is now available. This highly purified protein has the same biochemical and hemostatic properties, but much lower risks of infection and toxicity compared with plasma-derived porcine FVIII. The product is licensed in the United States and Europe for the treatment of acquired hemophilia A. However, this recombinant molecule could also be of clinical interest for people with inherited hemophilia A and inhibitors, particularly for the management of bleeding episodes in people receiving emicizumab as prophylactic treatment in the absence of anti-porcine FVIII antibodies.
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Affiliation(s)
- Yesim Dargaud
- Unite d’Hemostase CliniqueCentre National de Reference de l'HemophilieHôpital Louis PradelLyonFrance
- UR 4609 Hemostase and ThromboseUniversite Claude Bernard Lyon 1LyonFrance
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