A. Gringeri

Consensus perspectives on prophylactic therapy for haemophilia: summary statement

Summary.  Participants in an international conference on prophylactic therapy for severe haemophilia developed a consensus summary of the findings and conclusions of the conference. In the consensus, participants agreed upon revised definitions for primary and secondary prophylaxis and also made recommendations concerning the need for an international system of pharmacovigilance. Considerations on starting prophylaxis, monitoring outcomes, and individualizing treatment regimens were discussed. Several research questions were identified as needing further investigation, including when to start and when to stop prophylaxis, optimal dosing and dose interval, and methods for assessment of long‐term treatment effects. Such studies should include carefully defined cohorts, validated orthopaedic and quality‐of‐life assessment instruments, and cost‐benefit analyses.

A randomized clinical trial of prophylaxis in children with hemophilia A (the ESPRIT Study).

Summary.  Background: Prevention of arthropathy is a major goal of hemophilia treatment. While studies in adults have demonstrated an impact of prophylaxis on the incidence of joint bleeds and patients’ well‐being in terms of improved quality of life (QoL), it is unclear whether or not prophylaxis influences the outcome and perception of well‐ of children with hemophilia. Objective: This randomized controlled study compared the efficacy of prophylaxis with episodic therapy in preventing hemarthroses and image‐proven joint damage in children with severe hemophilia A (factor VIII <1%) over a 10‐year time period. Methods: Forty‐five children with severe hemophilia A, aged 1–7 years (median 4), with negative clinical‐radiologic joint score at entry and at least one bleed during the previous 6 months, were consecutively randomized to prophylaxis with recombinant factor VIII (25 IU kg−1 3 × week) or episodic therapy with ≥25 IU kg−1 every 12–24 h until complete clinical bleeding resolution. Safety, feasibility, direct costs and QoL were also evaluated. Results: Twenty‐one children were assigned to prophylaxis, 19 to episodic treatment. Children on prophylaxis had fewer hemarthroses than children on episodic therapy: 0.20 vs. 0.52 events per patient per month (P < 0.02). Plain‐film radiology showed signs of arthropathy in six patients on prophylaxis (29%) vs. 14 on episodic treatment (74%) (P < 0.05). Prophylaxis was more effective when started early (≤36 months), with patients having fewer joint bleeds (0.12 joint bleeds per patient per month) and no radiologic signs of arthropathy. Conclusion: This randomized trial confirms the efficacy of prophylaxis in preventing bleeds and arthropathy in children with hemophilia, particularly when it is initiated early in life.

Transmission of Hepatitis A to Patients with Hemophilia by Factor VIII Concentrates Treated with Organic Solvent and Detergent To Inactivate Viruses

Hepatitis A virus (HAV) is usually transmitted enterically, through contaminated food and water, or directly from person to person. Transmission through transfusion of blood products is rare because although a period of viremia exists during the incubation period of hepatitis A, no chronic carrier state exists. Several Italian centers recently reported a large outbreak of hepatitis A in patients with hemophilia [1]. All of the 52 patients reported so far received, in the 2 months before diagnosis, a large-pool factor VIII concentrate produced by an Italian manufacturer that used a solvent-detergent-based method to inactivate blood-borne viruses [2] and a chromatographic procedure to purify factor VIII [3]. Although the chromatographic procedure should remove all types of viruses, HAV RNA has been detected in factor VIII preparations prepared in this manner [4]. Also, the virucidal process is effective only for lipid-enveloped viruses and hence would not inactivate HAV [2]. Hepatitis A has been reported subsequently in 13 patients with hemophilia from Germany [5], in 17 from Ireland [6], and in 6 from Belgium [7], all of whom were given concentrates produced in Austria or Germany by a German manufacturer that used the same chromatographic and virucidal methods as the Italian manufacturer. That as many as 88 cases have occurred during the past 3 years in four European countries with no concomitant epidemics in the general populations of these countries suggests that this could be a widespread, albeit rare, phenomenon among patients with hemophilia. We describe two approaches to determine whether the factor VIII preparations were the cause of HAV infection in the patients with hemophilia: the results of a casecontrol study carried out in the Italian cohort to determine the source of HAV infection and the results of sequence analyses of HAV cDNA amplified by reverse transcriptase and polymerase chain reactions from specific lots of factor VIII and from serum samples of recipients in whom hepatitis A developed. Description of the Outbreak The first 3 cases of hepatitis A were diagnosed in 1989, 10 cases were identified in 1990, 33 in 1991, and 6 in 1992 at 12 hemophilia centers located in Milan, Trent, Vicenza, Castelfranco Veneto, Bologna, and Pavia in Northern Italy; in Florence, Rome, and Perugia in Central Italy; and in Naples and Bari in Southern Italy. All but 1 of the 52 case patients had severe hemophilia A, and their median age was 24 years (range, 2 to 43 years). Most case patients were identified because jaundice developed (42 of 52 patients; 81%), and hepatitis A was diagnosed when serum samples were positive for IgM anti-HAV antibodies (HAVAB-M EIA; Abbott Laboratories, North Chicago, Illinois). The course of hepatitis was uncomplicated and all patients recovered completely. Within 2 months before the onset of jaundice (the upper limit of the incubation period of hepatitis A), all patients had been infused with a factor VIII concentrate manufactured in Italy from pooled plasma collected in the United States from paid plasmapheresis donors. No blood product other than factor VIII concentrate had been administered to the index case subjects during that period. A virucidal step based on treatment with an organic solvent and a detergent (tri-[n-butyl]-phosphate/polysorbate 80) was incorporated into the manufacturing process of the concentrate [2], followed by an ion-exchange chromatography step to purify factor VIII [3]. At least 20 different concentrate lots were administered to case patients in the 2-month period before jaundice developed, 12 of them to more than 1 patient. Hepatitis A has not been reported among patients with hemophilia receiving factor VIII concentrates treated with other virucidal methods, such as pasteurization [8] or vapor heating, or among patients with hemophilia B (who, in Italy, almost exclusively receive vapor-heated concentrates). No additional cases have been reported since June 1992, but most Italian patients with hemophilia have not been given the solvent-detergent-treated concentrate, and many of them have been vaccinated against hepatitis A since late 1992, when the hepatitis A vaccine became available in Europe. Methods Case-Control Study The first 29 consecutive patients with hepatitis A and jaundice were enrolled. One to three nonjaundiced control patients with hemophilia (n = 71), randomly chosen from the national registry of patients with congenital coagulation disorders (Istituto Superiore di Sanita, Rome, Italy), were matched to each case patient by age, province of residence, hemophilia center, type and severity of hemophilia, and exposure to factor VIII concentrate in the 2 months before the onset of jaundice. For both case patients and control patients we used a questionnaire to gather the following information about the 2-month period before the onset of jaundice in case patients: lots of concentrate and the corresponding virucidal methods used to treat them, number of doses infused, contact with persons who had jaundice or hepatitis A, travel to countries reported to have a high attack rate for hepatitis A, and consumption of raw shellfish. None of the control patients were vaccinated against hepatitis A at the time of the survey. Statistical Analysis Odds ratios and 95% CIs were calculated for matched and unmatched analyses [9]. Polymerase Chain Reaction Analyses The RNA was prepared by a modification of the method of Chomczynski and Sacchi [10]. Briefly, 100 L of serum or 100 L of factor VIII concentrate that had been reconstituted with sterile water to a 10-fold concentration was mixed with 400 L denaturing buffer (5.2 mol/L guanidinium thiocyanate, 0.5% N-lauryl sarcosine, and 0.025 mol/L TRIS, pH 8.0), 50 L (10-fold concentration) phenol extraction buffer (1 mol/L TRIS, pH 8.0; 0.1 mol/L EDTA; and 10% sodium dodecyl sulfate), and 10 g glycogen (Boehringer Mannheim Corp., Indianapolis, Indiana), extracted twice with phenol-chloroform (at 65 C for 30 minutes; at room temperature for 5 minutes) and then with chloroform. After precipitation with isopropanol, RNA pellets were resuspended in 10 L water and the entire sample was used for the synthesis of cDNA. Nested primer sets were used [11]. Set one included 5-AGTGCAGTCAACTTTGAG (positions 1961 to 1978) and 5-ATCTGGAACATTCTGTTCTG (positions 2267 to 2248), and 5-ACAGGTATACAAAGTCAG (positions 2020 to 2037) and 5-CTCCAGAATCATCTCC (positions 2226 to 2211). Set two included 5-TCCCAGAGCTCCATTGAA (positions 2984 to 3001) and 5-CATTATTTCATGCTCCTCAG (positions 3284 to 3265), and 5-CAAATGCCATGTTATCCACTG (positions 3004 to 3024) and 5-GGTGGAAGTGCTTCATTTGAC (positions 3211 to 3191). Before cDNA synthesis, each 10-L RNA sample was annealed with 10 pmol of the reverse external primer at 65 C for 3 minutes. Synthesis of cDNA was performed in a 20-L reaction containing the annealed primer-template, 40 U RNasin (Promega Corp., Madison, Wisconsin), 8 U avian myeloblastosis virus reverse transcriptase (Promega), 1 mmol each of four deoxynucleoside triphosphates (Pharmacia, Piscataway, New Jersey), and polymerase chain reaction buffer (Perkin-Elmer Cetus, Norwalk, Connecticut) at 43 C for 60 minutes. The polymerase chain reaction was performed with each cDNA sample in a 100-L reaction containing 50 pmol of each primer, 2.5 U Taq polymerase (Amplitaq, Perkin-Elmer Cetus), 0.2 mmol each of four deoxynucleoside triphosphates and polymerase chain reaction buffer, and overlaid with mineral oil. The first amplification was for 36 cycles at 94 C for 1 minute, at 40 C for 30 seconds, and at 72 C for 1 minute. Ten L was then amplified with the inner set of primers for 45 cycles at 94 C for 1 minute, at 37 C for 30 seconds, and at 72 C for 1 minute. DNA products were analyzed by electrophoresis through 2% agarose gel and ethidium bromide staining, followed by photography under ultraviolet light. During RNA extraction and polymerase chain reaction amplification, special precautions were taken to avoid false-positive results [12]. In every experiment, one negative control sample was processed and tested in parallel with each test sample. Every sample was tested at least twice, and results were considered valid only if confirmed in repeated experiments. To determine the sensitivity of our polymerase chain reaction assay, we analyzed 10-fold serial dilutions of a laboratory stock of a cell culture-adapted strain of HAV [13]. This HAV stock, harvested from virus-infected cells in culture, contained 107 50% tissue culture infective doses (TCID50) per milliliter of virus, as determined from immunofluorescence assays (data not shown). Hepatitis A viral sequences were detected consistently in 100-L samples of stock diluted to 108, and therefore we estimated that the sensitivity of our assay was 0.01 TCID50. Determination of Nucleotide Sequences Polymerase chain reaction products were purified by fractionation through low-melting-temperature agarose. The DNA bands were excised and DNA was extracted [14]. Sequencing was done with Sequenase (United States Biochemical, Cleveland, Ohio) as previously described [15]. Animal Studies Seronegative juvenile chimpanzees were infused with selected lots of factor VIII, and blood samples were drawn weekly and tested for serum levels of alanine aminotransferase, isocitrate dehydrogenase, and -glutamyltransferase by standard methods (Metpath, Rockville, Maryland), for antibodies to HAV and hepatitis C virus by commercial assays (Abbott), and for antibodies to hepatitis E virus by an enzyme-linked immunosorbent assay using expressed hepatitis E virus nucleocapsid protein [16]. Results Case-Control Study: Implications of Factor VIII from a Specific Manufacturer Case patients ranged in age from 10 to 42 years (median, 22 years), control patients from 11 to 49 years (median, 22 years). Nine of 29 case patients and 19 of 71 control patients were seropositive for antibody to human immunodeficiency virus. Case patients

Rate of inhibitor development in previously untreated hemophilia A patients treated with plasma-derived or recombinant factor VIII concentrates: a systematic review

Summary.  Background: Different rates of inhibitor development after either plasma‐derived (pdFVIII) or recombinant (rFVIII) FVIII have been suggested. However, conflicting results are reported in the literature. Objectives: To systematically review the incidence rates of inhibitor development in previously untreated patients (PUPs) with hemophilia A treated with either pdFVIII or rFVIII and to explore the influence of both study and patient characteristics. Methods: Summary incidence rates (95% confidence interval) from all included studies for both pdFVIII and rFVIII results were recalculated and pooled. Sensitivity analysis was used to investigate the effect of study design, severity of disease and inhibitor characteristics. Meta‐regression and analysis‐of‐variance were used to investigate the effect of covariates (testing frequency, follow‐up duration and intensity of treatment). Results: Two thousand and ninety‐four patients (1167 treated with pdFVIII, 927 with rFVIII; median age, 9.6 months) from 24 studies were investigated and 420 patients were observed to develop inhibitors. Pooled incidence rate was 14.3% (10.4–19.4) for pdFVIII and 27.4% (23.6–31.5) for rFVIII; high responding inhibitor incidence rate was 9.3% (6.2–13.7) for pdFVIII and 17.4% (14.2–21.2) for rFVIII. In the multi‐way anova study design, study period, testing frequency and median follow‐up explained most of the variability, while the source of concentrate lost statistical significance. It was not possible to analyse the effect of intensity of treatment or trigger events such as surgery, and to completely exclude multiple reports of the same patient or changes of concentrate. Conclusions: These findings underscore the need for randomized controlled trials to address whether or not the risk of inhibitor in PUPs with hemophilia A differs between rFVIII and pdFVIII.

Quality‐of‐life differences between prophylactic and on‐demand factor replacement therapy in European haemophilia patients

The European Study on the Clinical Outcomes and Resource Utilization associated with Haemophilia Care was designed to compare various health outcomes associated with on‐demand and prophylactic factor substitution methods in European haemophilia patients. While the primary objective of this research is to conduct an economic analysis, an important component of this study is to evaluate quality‐of‐life differences that may exist between patients who utilize these two styles of therapy. Quality‐of‐life research has emerged as a primary measure of health outcomes because it allows the augmentation of traditional clinical indicators of health with data gathered from the patients perspective. A total of 1033 haemophilia patients from 16 European haemophilia treatment centres were enrolled in this study. The SF‐36, a multidimensional quality‐of‐life instrument, was administered to all participants. This instrument measures eight health‐related quality‐of‐life dimensions: physical functioning, physical role limitations, bodily pain, general health, vitality, social functioning, emotional role limitations, and mental health. All haemophilia subjects enrolled in the study scored significantly lower than the population normative means in the three physical dimensions and in the general health dimension. HIV‐negative haemophiliac subjects differed significantly by factor substitution type in a multivariate analysis examining all eight health dimensions. Univariate analyses testing each dimension separately indicated that patients treated prophylactically reported significantly less bodily pain, better general health, and scored significantly higher in the physical functioning, mental health, and social functioning dimensions. While these results suggest that health‐related quality‐of‐life may be better for haemophilia patients treated prophylactically, future prospective studies that gather periodic quality‐of‐life data over time should be conducted.

Anti-Inhibitor Coagulant Complex Prophylaxis in Hemophilia with Inhibitors

BACKGROUND Patients with severe hemophilia A and factor VIII inhibitors are at increased risk for serious bleeding complications and progression to end-stage joint disease. Effective strategies to prevent bleeding in such patients have not yet been established. METHODS We enrolled patients with hemophilia A who were older than 2 years of age, had high-titer inhibitors, and used concentrates known as bypassing agents for bleeding in a prospective, randomized, crossover study comparing 6 months of anti-inhibitor coagulant complex (AICC), infused prophylactically at a target dose of 85 U per kilogram of body weight (±15%) on 3 nonconsecutive days per week, with 6 months of on-demand therapy (AICC at a target dose of 85 U per kilogram [±15%] used for bleeding episodes). The two treatment periods were separated by a 3-month washout period, during which patients received on-demand therapy for bleeding. The primary outcome was the number of bleeding episodes during each 6-month treatment period. RESULTS Thirty-four patients underwent randomization; 26 patients completed both treatment periods and could be evaluated per protocol for the efficacy analysis. As compared with on-demand therapy, prophylaxis was associated with a 62% reduction in all bleeding episodes (P<0.001), a 61% reduction in hemarthroses (P<0.001), and a 72% reduction in target-joint bleeding (≥3 hemarthroses in a single joint during a 6-month treatment period) (P<0.001). Thirty-three randomly assigned patients received at least one infusion of the study drug and were evaluated for safety. One patient had an allergic reaction to the study drug. CONCLUSIONS AICC prophylaxis at the dosage evaluated significantly and safely decreased the frequency of joint and other bleeding events in patients with severe hemophilia A and factor VIII inhibitors. (Funded by Baxter BioScience; Pro-FEIBA ClinicalTrials.gov number, NCT00221195.).

High prevalence of antibody to hepatitis C virus in multitransfused hemophiliacs with normal transaminase levels.

Excerpt Non-A, non-B hepatitis is common in hemophiliacs infused with clotting factors concentrates (1, 2). Using serum alanine aminotransferase (ALT) as a surrogate test for diagnosis, the proport...

European principles of haemophilia care

Summary.  As the management of haemophilia is complex, it is essential that those with the disorder should have ready access to a range of services provided by a multidisciplinary team of specialists. This document sets out the principles of comprehensive haemophilia care in Europe. Within each country there should be a national organization which oversees the provision of specialist Comprehensive Care Centres that provide the entire spectrum of clinical and laboratory services. Depending upon the size and geographical distribution of the population, a network of smaller haemophilia centres may also be necessary. There should be arrangements for the supply of safe clotting factor concentrates which can also be used in home treatment and prophylaxis programmes. A national register of patients is recommended along with collection of treatment statistics. As comprehensive haemophilia care is multidisciplinary by nature, the need for education and research programmes for all staff members is emphasized: Members of the Interdisciplinary Working Group not represented in the list of authors are mentioned in Section 4 of this document.

Quality of life is associated to the orthopaedic status in haemophilic patients with inhibitors

Summary.  Inhibitors represent one major complication of haemophilia treatment, as they increase the risk of bleeding, physical disability and mortality. The Cost Of Care Inhibitors Study (COCIS) showed that modern strategies applied to manage patients with inhibitors adsorb high amounts of resources but provide satisfactory levels of Health‐Related Quality‐of‐Life (HR‐QoL). This paper focuses on determinants of HR‐QoL in inhibitory patients. Fifty adult patients, enrolled by 11 Italian Haemophilia Centres, were clinically assessed and filled in two HR‐QoL generic questionnaires: the EuroQol instrument (EQ‐5D) and the Short Form‐36 (SF‐36). According to our results, bleeding frequency and inhibitor titres were not found associated with HR‐QoL. Global HR‐QoL, and in particular the physical component of wellbeing in these patients was found negatively associated with their orthopaedic condition: the EQ‐5D Visual Analogue Scale (P < 0.001) scores, the SF‐36 domain ‘physical functioning’ and ‘physical component summary’ (P < 0.01) scores were found significantly correlated with the orthopaedic joint score, even after adjusting for patients’ age. These results were confirmed by those from the EQ‐5D profile. To conclude, the COCIS study is the first study showing that HR‐QoL in inhibitory patients is impaired by their orthopedic status, while other aspects do not seem to influence patients’ global wellbeing. Our results suggest that while the management of this complication is satisfactory, the attention has now to be focused on the prevention of the orthopaedic problems in these patients, which nowadays constitute one of the most important aspects to be considered in the haemophilia care.

Home treatment with recombinant activated factor VII in patients with factor VIII inhibitors: the advantages of early intervention.

To evaluate the feasibility, efficacy and safety of home treatment with recombinant activated factor VII (rFVIIa), 10 inhibitor patients (all haemophiliacs except one acquired post‐partum) self‐administered up to four doses of 90 μg/kg rFVIIa every 3 ± 1 h. The response was rated by the patient as effective (haemorrhage stopped or decreased substantially), partially effective (reduced) or ineffective (unchanged or worsened). 45 haemarthroses and eight haematomas were treated within a median time of 1.0 h (range 0.3–11.9) from the onset of bleeding, with a median of two rFVIIa doses per course (range 1–4). rFVIIa was effective in 42 episodes (79%), partially effective in six (11%) and failed in five (10%). Compared with partially effective and ineffective treatments, effective treatments started earlier (median time: 0.6 v 2.7 h, P = 0.02) and required a smaller number of doses (median: 1.5 v 3, P = 0.007). The risk of a partially effective or ineffective treatment was smaller for treatments started within 6 h from the onset of bleeding than for those which started later (OR 0.24, 95% CI 0.09–0.63). Mild side‐effects were reported only after 3/113 self‐infusions (2.6%). Early home treatment with rFVIIa is safe, feasible and effective, inducing and maintaining haemostasis with a small number of doses.