Patrick F. Fogarty

Phase 3 study of recombinant factor VIII Fc fusion protein in severe hemophilia A

This phase 3 pivotal study evaluated the safety, efficacy, and pharmacokinetics of a recombinant FVIII Fc fusion protein (rFVIIIFc) for prophylaxis, treatment of acute bleeding, and perioperative hemostatic control in 165 previously treated males aged ≥12 years with severe hemophilia A. The study had 3 treatment arms: arm 1, individualized prophylaxis (25-65 IU/kg every 3-5 days, n = 118); arm 2, weekly prophylaxis (65 IU/kg, n = 24); and arm 3, episodic treatment (10-50 IU/kg, n = 23). A subgroup compared recombinant FVIII (rFVIII) and rFVIIIFc pharmacokinetics. End points included annualized bleeding rate (ABR), inhibitor development, and adverse events. The terminal half-life of rFVIIIFc (19.0 hours) was extended 1.5-fold vs rFVIII (12.4 hours; P < .001). Median ABRs observed in arms 1, 2, and 3 were 1.6, 3.6, and 33.6, respectively. In arm 1, the median weekly dose was 77.9 IU/kg; approximately 30% of subjects achieved a 5-day dosing interval (last 3 months on study). Across arms, 87.3% of bleeding episodes resolved with 1 injection. Adverse events were consistent with those expected in this population; no subjects developed inhibitors. rFVIIIFc was well-tolerated, had a prolonged half-life compared with rFVIII, and resulted in low ABRs when dosed prophylactically 1 to 2 times per week.

Presentation and management of acute coronary syndromes among adult persons with haemophilia: results of an international, retrospective, 10-year survey.

Sparse data are available on presentation and management of acute coronary syndromes (ACS), including unstable angina and non‐ST‐ and ST‐elevation myocardial infarction, among persons with haemophilia (PWH). The aim of this study was to determine demographics, bleeding disorder characteristics, cardiovascular risk factors (CRFs), interventions, haemostatic protocol, revascularization outcomes and complications among PWH with ACS. Members of an international consortium comprising >2000 adult PWH retrospectively completed case report forms for episodes of ACS in a >10‐year follow‐up period (2003–2013). Twenty ACS episodes occurred among 19 patients [rate, 0.8% (95% CI 0.4, 1.2)]. Seven patients (37%) were aged <50 years; 10 (53%) had ≥3 CRFs. In 5/20 episodes (25%), the initial ACS management protocol was altered because of the bleeding disorder. None of the eight patients with severe haemophilia underwent coronary artery bypass grafting (CABG), compared with 54.5% of patients with non‐severe disease (P = 0.02). Revascularization with percutaneous coronary intervention (PCI) or CABG was rated successful in 13/13 cases, with no excessive bleeding during initial management. During chronic exposure to antiplatelet agents, secondary haemophilia prophylaxis was more prevalent in patients with severe haemophilia compared with non‐severe haemophilia (85.7% vs. 30%, P = 0.05). No ACS‐related deaths occurred during initial management, but one patient with severe haemophilia A died of undetermined cause 36 months after the ACS event while on aspirin therapy. ACS occurs even among relatively younger PWH, typically in association with multiple CRFs. Revascularization with PCI/CABG is feasible, and antiplatelet agents plus secondary prophylaxis appears to be well tolerated in selected PWH with ACS.

Raphespinal and reticulospinal neurons project to the dorsal vagal complex in the rat

Stimulation of the caudal raphe nuclei alters visceral functions. The caudal raphe nuclei project to the nucleus of the solitary tract, which receives the central terminations of vagal afferents and plays an important role in the central integration of autonomic activities. The caudal raphe nuclei also project to the somatic and preganglionic autonomixc motoneurons of the spinal cord. Diamidino yellow was injected into the nucleus of the solitary tract, and fast blue was injected into either the cervical, thoracic, or lumbar spinal cord. Large numbers of double-labeled neurons were present within the caudal raphe nuclei and the adjacent reticular formation of the medial tegmental field. This observation documents that individual raphespinal and reticulospinal neurons project an axon collateral to the nucleus of the solitary tract. These data demonstrate the anatomic substrate for global modulation of the autonomic motoneuron pool by the caudal raphe nuclei.

Evaluation of the utility of the ISTH-BAT in haemophilia carriers: a multinational study

There has been increasing recognition in recent years that female carriers of haemophilia manifest abnormal bleeding; however, data on the use of bleeding assessment tools in this population are lacking.

Efficacy of eltrombopag in management of bleeding symptoms associated with chronic immune thrombocytopenia.

Bleeding is of particular clinical importance in the management of chronic immune thrombocytopenia (ITP), which involves impaired platelet production and accelerated destruction. We report the first comprehensive analysis of the impact of eltrombopag on bleeding in five clinical studies of adult chronic ITP: two 6-week phase 2 (TRA100773A) and phase 3 (TRA100773B) studies; a 6-month phase 3 study (RAISE); a phase 2 repeat-dose study (REPEAT); and a phase 3 extension study (EXTEND). Bleeding was assessed using the World Health Organization Bleeding Scale and categorized as no bleeding (grade 0), any bleeding (grades 1–4), and clinically significant bleeding (grades 2–4). Bleeding was also assessed using National Cancer Institute Common Terminology Criteria for Adverse Events v3.0. Across all studies, bleeding at baseline ranged from 50 to 73% for eltrombopag-treated patients; by week 2, bleeding had decreased, ranging from 26 to 39%. This trend was maintained throughout treatment. Similar results were observed for clinically significant bleeding. No such trend was seen in placebo-treated patients for any bleeding or clinically significant bleeding. For TRA100773B and RAISE, the odds of any bleeding across the entire treatment period were 51 and 76% lower for eltrombopag-treated versus placebo-treated patients (P = 0.021, P < 0.001). The odds of clinically significant bleeding in RAISE were 65% lower (P < 0.001). In conclusion, analysis of prospective data from five clinical studies demonstrates that eltrombopag significantly reduces bleeding in adult patients with chronic ITP.

How we manage prostate biopsy and prostate cancer therapy in men with haemophilia

A 56‐year‐old African American male with severe haemophilia A [baseline factor VIII (FVIII) activity <1%] and chronic hepatitis C virus infection started annual serial monitoring of prostate‐specific antigen (PSA) at age 40 because of a family history of prostate cancer (his father died from the disease at age 63). His most recent PSA level was 4.4 ng L −1 ; previous values were <3 ng L−1. Digital rectal examination was unrevealing.

ITP: tolerance lost.

Despite a seemingly unifying phenotype comprising a reduced platelet count and mucocutaneous bleeding in many newly identified cases, immune thrombocytopenia (ITP) is a disorder of diverse pathogenesis. In this issue of Blood , Cuker and colleagues describe a little-recognized form of secondary ITP

An algorithmic approach to peripheral artery disease in hemophilia: extrapolation of management principles from noncoagulopathic patients.

The development of peripheral artery disease (PAD), a marker for systemic atherosclerosis and ischemic risk, is an increasingly important concern in the aging hemophilia population. A growing body of data suggests that an absence or deficiency of factor VIII or factor IX may not protect against atherogenesis, implying that the prevalence of PAD in men with hemophilia (MWH) may be higher than previously believed. This article describes special considerations in PAD screening, risk-factor modification, and management in older MWH.

Prevalence of and risk factors for cerebral microbleeds among adult patients with haemophilia A or B

Cerebral microbleeds (CMBs) represent clinically silent haemorrhagic events. Cerebral microbleeds (CMBs) portend negative neurovascular and cognitive outcomes in the general population and are associated with cognitive impairment in persons with haemophilia (PWH). Prevalence, patterns, and risk factors for CMBs in PWH have not been directly compared to persons without coagulopathy.

Pilot randomized, non-inferiority, cross-over trial of once-weekly vs. three times-weekly recombinant factor VIII prophylaxis in adults with severe haemophilia A

M. V. RAGNI,*† J . G. YABES,‡ P. F. FOGARTY,§ N. C. JOSEPHSON,¶ C. M. KESSLER,** A. T. NEFF,†† L. RAFFINI,‡‡ K. BRUMMEL-ZIEDINS§§ and C. G. MOORE‡ *Department of Medicine University of Pittsburgh Medical Center; †Hemophilia Center of Western Pennsylvania; ‡Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh; §University of Pennsylvania, Philadelphia, PA; ¶Puget Sound Blood Center, Seattle, WA; **Georgetown University Medical Center, Washington, DC; ††Vanderbilt University Medical Center, Nashville, TN; ‡‡Children’s Hospital of Philadelphia, Philadelphia, PA; and §§Department of Biochemistry University of Vermont, Colchester, VT, USA