factor viii inhibitors: after seven decades still a nightmare and a mystery georges e rivard centre...

Factor VIII Inhibitors: After Seven Decades Still a Nightmare and a Mystery

Georges E RivardCentre Hospitalier Universitaire Sainte-Justine

Montréal

November 2009

For this presentation, I declare no conflict of interest with

any pharmaceutical industry

November 2009

My Disclosure

Lozner EI, Jolliffe LS, Taylor FHL. Hemorrhagic diathesis with prolonged coagulation time associated with a circulating anticoagulant. Am J Med Sc 1940;199:318-27

A 61 Y. old man with acquired hemophilia. Died of bleeding after removal of a lymph node which showed tuberculosis. Whole blood transfusion did not stop bleeding. Normal plasma did not shorten coagulation of patient’s plasma in vitro

Munro FL, Jones MD. The detrimental effect of frequent transfusions in the treatment of a patient with hemophilia. Am J Med Sc 1943;206:710-3

A 36 Y. old man with severe hemophilia from a family with many severe hemophiliacs.Treated successfully for hematuria "with 3 successive days of 50 cc. of plasma" . Further to this success, as need arose, he was successfully treated with 25 to 50 cc. of lyophilized plasma. After about 6 months this treatment failled to control his bleeds and his plasma inhibited clotting of normal plasma in vitro.

“We feel that in view of these observations, care should be taken in treating hemophiliacs by transfusions, and that they probably should not be given them as prophylactic measure…"

Coagulation Inhibitors: Not a New Story

Coagulation Inhibitors: Still a Very Serious Problem

• FS. 8 y boy. Severe FVIII def. High titre inhibitor since age of 12 m. Severe allergic reaction to any product that has even trace of FVIII. Multiple severe haemophilic arthropathies. Wheel-chair bound…for life!

• FR. 15 y boy. Severe FIX def. High titre inhibitor since age of 6 m. Severe allergic reaction to any product that has even trace of FIX. Has had 3 IC bleeds. Last one 6 m ago…and the next one…

• CO. 15 y girl. Severe FXIII def. High titre inhibitor since age of 2 y. IC bleed at

age 2 y. Died of IC bleed last summer…poor parents!

• YM. 42 y man. Severe FVII def. Father of two. High titre inhibitor for one month. No response to any treatment. Died of IC last year on Christmas eve. His 6 y old boy…when is daddy coming back?

A Crippling Problem in Congenital Hemophilia A

A Major Problem in the Frail Old Subject with Acquired hemophilia A

Cas # 1 Homme de 42 ans

- $

100,000 $

200,000 $

300,000 $

400,000 $

500,000 $

600,000 $

Novembre Décembre Janvier Février

MOIS

CÔ

UT

S

Feiba

Niastase

TOTAL DES COÛTS DES PRODUITS: 1 235 802

An Expensive Problem in Congenital Hemophilia A

Cost for Products: $1,285,892

Right Leg Amputation in a 42 y Man with Hemophilia A

- $100,000 $200,000 $300,000 $400,000 $500,000 $600,000 $700,000 $800,000 $900,000 $

1,000,000 $

Coût $

FVIII Porcin Feiba NiaStase

Produits

Cas # 2 Femme de 71 ans avec Inhibiteurs acquis en facteur VIII

JanvierFévrier

Total des coûts des produits utilisés: 1 518 768 $

An Expensive Problem in Acquired Hemophilia A

Cost for Products: $1,518,768

Surgery for Colon Cancer in a 71 y Woman with Acquired Hemophilia A

Cumulative Incidence of Factor VIII Inhibitors

HEMOPHILIACS : 10% to 30%

NON-HEMOPHILIACS : 1/106 per year

A Relatively Rare Condition

Plan of my Presentation

• Acquired hemophilia A in a nut shell

• Hemophilia A with inhibitors…in an egg shell

Acquired Haemophilia A UK National Surveillance Study

• From May 2001 to May 2003 with follow up until May 2004

• Data from 255/256 centers: 172 patients • Clinical information for 156/172 patients

PW Collins et al. Blood 2007

Presenting Characteristics

• Incidence: 1.48/million/y• Median age: 78 (range 2-98)• Sex: 43% men, 4/4 women in age group 21-40• Associated with pregnancy 4.3%,

or 1 case per 350 000 births• Underlying diagnosis: 5/5 under age 40 55% between 40 and 59 42% between 60 and 79 23% over 80 PW Collins et al. Blood 2007

Underlying Diagnosis

• None 95 (63.3%)• Autoimmune disease 25 (16.7%)• Malignancy 22 (14.7%)• Dermatologic 5 (3.3%)• Pregnancy 3 (2%)


Sites of Bleeding


More on Presenting Characteristics

• No hemostatic therapy required for 34%• Bleeding as cause of death in 9% (at 1-146 d)• Factor VIII level and inhibitor titer did not

predict severity of bleeding• Older patients more likely to have died during

follow up (P < 0.001) but achieved remission more quickly (P< 0.042)


International Recommendations on the Diagnosis and Treatment of Patients with Acqquired Hemophilia A

• Anti-hemorrhagic treatment - rFVIIa 90 µg/kg every 2-3 h until hemostasis is achieved

OR

- aPCC 50-100 IU/kg every 8-12 h until hemostasis is achieved

• Inhibitor eradication - Corticosteroids 1 mg/kg/day for 4-6 weeks alone or with:

- Cyclophosphamide 1.5 – 2 mg/kg/day for up to 6 weeks

A Huth-Kühne et al. Haematologica 2009;94:566-75

Long-term Prognosis: Overall SurvivalQuebec Reference Center for Inhibitors

Years

At 5 years: 69% (95% CI: 55–80%)

St-Louis J, et al. Haemophilia 2008;14(suppl 2):1 (abstract)

Plan of my Presentation

• Acquired hemophilia in a nut shell

• Hemophilia A with inhibitors…in an egg shell

Laboratory Investigation

• APTT: 78/34

• APTT ( 1P + 1N): 65/34

• Factor VIII inhibitor: 10 BU

Age and Number of Exposure Days at Inhibitor Development

Median age at inhibitor development: 16 m

Cumulative Incidence of Inhibitors: 23.8% (n=87/366)

Number of exposure days

50403020100

% in

hibi

tors 30

20

10

0

HM van den Berg et al. 2006

Median number of exposure daysat inhibitor development: 12

Facteur VIII Inhibitors

Nature: Antibodies directed against one or more epitopes of factor VIII and leading to partial or complete inhibition of its procoagulant function

Factor VIII Inhibitors : Nature

622Kappa + Lambda

55Only Lambda

2615Only Kappa

ALLOANTIBODIESAUTOANTIBODIESLIGHT CHAINS

02IgA

12IgM

00Only IgG1

00Only IgG2

31Only IgG3

127Only IgG4

128IgG + Other subtypes

ALLOANTIBODIESAUTOANTIBODIESHEAVY CHAINS

Hoyer 1982

The Bethesda Unit

Kasper, 1975

One Bethesda Unit:The amount of antibody thatinhibits half of the factor VIIIactivity in a 1 to 1 mixture ofpatient plasma and normalplasma incubated at 37°C for 2 hours

Type I Alloantibodies Type II Autoantibodies

Inactivation of Factor VIII by Inhibitors

Facteur VIII Inhibitors

Nature: Antibodies directed against one or more epitopes of factor VIII and leading to partial or complete inhibition of its procoagulant function

A2Activatedprotein

A1 A3 C1 C2

Me2+

Matureprotein NH2 COOHA1 A2 B C1 C2A3

2332 aa300 kDa

26 exons

186 kbFVIII-gene

Exon 2614 221

cDNA 7 kb

Factor VIII: From Gene to Protein

Slide courtesy of Dr. Johannes Oldenburg

Astermark J. et al. Haemophilia 2008; 14 (Suppl.3):36-42

Binding of Factor VIII to von Willebrand Factor

vWF/PL

Factor VIII Inhibitory Antibodies

FIXavWFFIXaFX

COOH

2332217320251648719336

NH2

Inhibitory antibodies measured by the Bethesda assay interfere with: – Xase function– Binding to phospholipids– Binding to von Willebrand factor – Behave as serine esterase and hydrolyse FVIII– The Bethesda assay does not see antibodies against the B

domain Modified from Oldenburg et al. Haemophilia. 2002;8(suppl 2):23-29.

Neutralization Assay of Plasmas from 21 Autoantibody Inhibitors

Inhibitor% Neutralization by FVIII Region Epitopes of Major inhibitor(s)

A2 C2 Domain(s)

EM ≥ 95 - A2

JM ≥ 95 ≤ 5 A2

NS ≥ 95 ≤ 5 A2

MR ≤ 5 ≥ 95 C2

MS ≤ 5 ≥ 95 C2

D ≤ 5 81 C2

SLC ≤ 5 70 C2

HR ≤10 ≥ 95 C2

LK ≤ 5 ≥ 95 C2

AA ≤10 79 C2

UJ ≤10 74 C2

DP ≤ 5 ≥ 95 C2

D. Scandella et al. Blood 1997;89; 3663-71

Neutralization Assay of Plasmas from 21 Autoantibody Inhibitors (suite)

Inhibitor% Neutralization by FVIII Region Epitopes of Major

inhibitor(s)

A2 C2 Domain(s)

PF ≤ 5 91 C2

FM 81 19 A2, C2

WC 59 32 A2, C2, AR3-A3-C1

F ≤ 5 65 C2

EH ≤ 5 82 C2, AR3-A3-C1

SL ≤10 57 C2, AR3-A3-C1

WT ≤ 5 48 C2, AR3-A3-C1

SC 51 25 A2, C2, AR3-A3-CA

D. Scandella et al. Blood 1997

Neutralization Assay of Plasmas from 23 Hemophilic Inhibitor Patients Treated with Plasma-Derived FVIII

Inhibitor

% Neutralization by FVIII Region Major Inhibitor

Epitope(s) Domain(s)A2 C2

CHA ≥ 95 - A2

RC ≥ 95 - A2

RM 86 - A2

L ≤ 10 ≥ 95 C2

WD 56 ≤10 A2, PEP 341-63

RJ ≥ 95 14 A2, C2

RDU 70 28 A2, C2

CC 67 37 A2, C2

RMA 62 39 A2, C2

KB ≤ 5 33 C2, AR3-A3-C1

YA ≤ 10 62 C2, AR3-A3-C1

MP ≤ 5 20 C2, AR3-A3-C1

D. Scandella et al. Blood 1997; 89; 3663-71

Neutralization Assay of Plasmas from 23 Hemophilic Inhibitor Patients Treated with Plasma-Derived FVIII

(suite)

Inhibitor

% Neutralization by FVIII Region Major Inhibitor

Epitope(s) Domain(s)A2 C2

GK ≤ 5 31 C2, AR3-A3-C1

MU ≤ 5 15 C2, AR3-A3-C1

SCN ≤ 5 33 C2, AR3-A3-C1

GK ≤ 5 40 C2, AR3-A3-C1

RI ≤ 10 26 C2, AR3-A3-C1

JR 31 29 A2, C2, AR3-A3-C1

WG 42 26 A2, C2, AR3-A3-C1

HG 50 25 A2, C2, AR3-A3-C1

GK 12 28 A2, C2, AR3-A3-C1

MS 27 30 A2, C2, AR3-A3-C1

GK 40 19 A2, C2, AR3-A3-C1

D. Scandella et al. Blood 1997; 89; 3663-71

Neutralization Assay of Plasmas from 11 Hemophilic Inhibitors Treated only with Recombinant Factor VIII

Inhibitor

No.

% Neutralization by FVIII Region Epitopes of Major inhibitor(s)

A2 C2 Domain(s)

R7611 74 27 A2, C2

R1911 37 74 A2, C2

R1113 85 26 A2, C2

R3511 49 41 A2, C2

R7717 ≤ 5 ≤ 10 AR3-A3-C1

R2113 27 54 A2, C2, AR3-A3-C1

K66 ≥ 95 ≤ 5 A2

K126 68 51 A2, C2

K129 24 26 A2, C2, AR3-A3-C1

K147 37 43 A2, C2, AR3-A3-C1

K184 28 51 A2, C2, AR3-A3-C1

Scandella et al. Blood 1997

vWF/PL

Factor VIII Inhibitory AntibodiesFIXavWFFIXaFX

COOH

2332217320251648719336

NH2

The Bethesda assay does not see antibodies against the B

domainModified from Oldenburg et al. Haemophilia. 2002;8(suppl 2):23-29.

Vincent AM, Lillicrap D, Boulanger A, Meilleur C, Amesse C, St-Louis J, Rivard GE. Non-neutralizing anti-FVIII antibodies: different binding specificity to different recombinant FVIII concentrates. Haemophilia 2009;15:374-6

ELISA with 3 coating antigens: Kogenate FS, Advate, ReFacto

Bethesda +: ≥ 0.6 BU

ELISA +: AU ≥ 3

AU: SD of the mean OD of 6 N plasma

Number of AU for a given specimen =OD of the specimen – (OD of blank + mean OD of 6 N plasma)

SD of the mean OD of 6 N plasma

Subjects with Acquired Hemophilia A

25105< 0.6*Lymphoma76M

46861Pancreatitis36F

91851057Idiopathic87F

62605210Idiopathic63M

81818430Idiopathic83M

90100134160Autoimmune

vasculitis49M

941411331984Colon cancer71M

AUAUAUBUAssociated condition Age

Gender

ReFacto

Advate

Kogenate FS

ELISABETHESDA

*Subject known to have been Bethesda positive in the past

4114< 0.6*5< 0,016

1837460.64< 0,015

136111.5> 20< 0,0147

23764.210< 0,0112

30192782< 0,012

509251166< 0,018

8514591366< 0,017

1019510678> 20< 0,0160

971131211654< 0,015

9580130512> 20< 0,0134

125711185703< 0,015

AUAUAUBUDuration of inhibitor

(years)Baseline

FVIIIAge

ReFactoAdvateKogenate FS

ELISABETHESDA

*Subject known to have been Bethesda positive in the past.

Subjects with Congenital Hemophilia A and Inhibitor

0.223 < 0.60,03

0.124< 0.6< 0,01

0310< 0.6< 0,01

-12321 < 0.6< 0,01

-0.54436 < 0.6< 0,01

0.26366< 0.60,05

AUAUAUBUBaseline FVIII

ReFacto Advate Kogenate FS

ELISABETHESDA

Subjects with Congenital Hemophilia A without Inhibitor

Contributing Factors to Development of FVIII Inhibitors

• Genetic Related to factor VIII Unrelated to factor VIII

• Environmental Conditions of treatment Therapeutic product

Family IncidenceMalmo International Brother Study

• 388 hemophilia A

• Overall inhibitor incidence 32%

• Risk if inhibitor in family 48%

• Risk if inhibitor in brother 78%

Astermark J, et al. Haemophilia 2001;7:267-72

Race and Inhibitor Incidence in Severe Hemophilia A

Meta-Analysis on PUP Studies(Scharrer et al. 1999)Kogenate (Lusher et al. 1997) Recombinate (Gruppo et al. 1998) U.S. retrospective study (Addiego et al. 1994)

Caucasians inhibitors: 51/198 25.8% African origin inhibitors: 14/27 51.9%

MIBS (Astermark et al. 2001)Caucasians inhibitors 27.4%African origin inhibitors 55.6%

3641

7.4%Small deletion or insertion

35.7%Large deletion or insertion

4.3%Missense

38.4%Nonsense

34.4%Intron 22 inversion

Inhibitor Prevalence

Type of Mutation

1Schwaab R et al. Thromb Haemost. 1995; 74: 1402-1406 2Oldenburg J and Pavlova A. Haemophilia 2006;12 (Suppl.6)15-22

Factor VIII Mutations and Inhibitor Development

7532

21%

31%

5%

41%

16%

Nonsynonymous Single Nucleotide Polymorphisms of Factor VIII Gene

Viel KR et al. NEJM 2009;360: 1618-27

Inhibitor of Factor VIII in Black Patients with Hemophilia Kevin R. Viel et al. NEJM 2009; 360: 1618-27

Nonsynonymous Single Nucleotide Polymorphisms of Factor VIII Gene and Risk of Inhibitor Development

Non-Factor VIII Genetics and Inhibitor Development

OR 19.2 (95% Cl, 2.4 – 156.5; P < 0.001) for presence of TNFA – 308 A/A among patients with severe hemophilia A and inhibitors.

Polymorphisms in the TNFA gene and the risk of inhibitor development in patients with hemophilia A. Astermark J. et al. Blood 2006;108:3739-45

OR 5.4 (95% Cl 2.1-13.7 : P < 0.001) for the presence of allele 134 among patients with severe hemophilia A and inhibitors.

Polymorphisms in the IL10 but not in the IL1Beta and IL4 genes are associated with inhibitor development in patients with hemophilia A. Astermark J. et al. Blood 2006;107:3167-72

OR 0.3 (95% CI 0.1-0.8; P = 0.012) for the presence of the T allele among all patients with severe hemophilia A and inhibitors.

Polymorphisms in the CTLA-4 gene and inhibitor development in patients with severehemophilia A. Astermark J. et al. J Thromb Haemost 2007;5:263-5

– Associated inflammatory reactions

– Continuous infusion1

– Age at first treatment2

– Episodes of intensive treatment

1Sharathkumar 2003; 2van der Bom 2003

Contributing Factors to Development of FVIII Inhibitors: Conditions of Treatment

Contributing Factors to Development of FVIII Inhibitors:Therapeutic Product

• In vivo human data

• In vivo animal data

• In vitro data

Influence of the type of factor VIII concentrate on the incidence of factor VIII inhibitors in previously untreated patients with severe hemophilia A.

Goudemand J. et al. Blood 2006; 107: 46-51

Cumulative incidence of inhibitors at 50 ED rFVIII 32.3%VWF-FVIII 10.3%

Univariate analysis Multivariate analysis p < 0.05 p < 0.009*

*adjusted for intron 22, ethnic origin and age at first exposure

n = 62 on plasma VWF-FVIII n = 86 on rFVIII (62 Recombinate®; 24 Kogenate®)

Median ED120 86

Early factor VIII exposure and subsequent inhibitor development in children with severe haemophilia A. Chalmers EA.et al. Haemophilia 2007; 13: 149-155

N = 172 on rFVIII

N = 132 on plasma vWF- FVIII

Cumulative incidence of inhibitors at 50 ED

rFVIII = 27 %

vWF-FVIII = 14 %

P=0.009

Kreuz

Courte

r

Wight J, Paisley S. The epidemiology of inhibitors in haemophilia A: a systematic review. Haemophilia 2003; 9: 318-35

Cumulative risk of inhibitor

The Proof of the Poutine is in the Poutine

*

*

* Addition to the original figure

Treatment of Subjects with Hemophilia A and FVIII Inhibitors: General Comments

• Control of hemostasis: Human FVIII, not effective except in low titres

Porcine FVIII, no longer available

Activated Prothrombin Concentrates (FEIBA)

Recombinant Activated FVII (NiaStase)

• Elimination of inhibitors: Immune Tolerance Induction

Immunosuppression/Immunomodulation

Summary

• Acquired hemophilia A is a rare but serious condition with a peak of incidence in elderly subjects; it could be life threatening but usually responds well to appropriate treatment

• Factor VIII inhibitor development is a common and severe complication of hemophilia A treatment

• There are many genetic and environment factors that contribute to development of inhibitors in hemophilia A

• There are some reasonably effective treatment for the control of hemostasis and the eradication of inhibitors: both aspects of treatment are extremely expensive

• Better strategies for prevention and treatment of this condition are badly needed; more research is needed…

An Interesting Bed Time Story…

Interesting???

factor viii inhibitors: after seven decades still a nightmare and a mystery georges e rivard centre...

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