Transcript IVIG Effects on Cytokines

Factor VIII Inhibitors: After Seven
Decades Still a Nightmare and a Mystery
Georges E Rivard
Centre Hospitalier Universitaire Sainte-Justine
Montréal
November 2009
My Disclosure
For this presentation, I declare
no conflict of interest with
any pharmaceutical industry
November 2009
Coagulation Inhibitors: Not a New Story
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:
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 Crippling Problem in Congenital Hemophilia A
A Major Problem in the Frail Old Subject with
Acquired hemophilia A
An Expensive Problem in Congenital Hemophilia A
Cas # 1inHomme
42 ans
Right Leg Amputation
a 42 y de
Man
with Hemophilia A
600,000 $
TOTALfor
DESProducts:
COÛTS DES PRODUITS:
1 235 802
Cost
$1,285,892
500,000 $
CÔUTS
400,000 $
Feiba
Niastase
300,000 $
200,000 $
100,000 $
-
$
Novembre
Décembre
MOIS
Janvier
Février
An Expensive Problem in Acquired Hemophilia A
Surgery for Colon Cancer in a 71 y Woman
with Acquired Hemophilia A
Cost for Products: $1,518,768
A Relatively Rare Condition
Cumulative Incidence of Factor VIII Inhibitors
HEMOPHILIACS :
10% to 30%
NON-HEMOPHILIACS :
1/106 per year
Plan of my Presentation
• Acquired hemophilia A in a nut shell
• Hemophilia A with inhibitors…in an egg shell
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
Autoimmune disease
Malignancy
Dermatologic
Pregnancy
95 (63.3%)
25 (16.7%)
22 (14.7%)
5 (3.3%)
3 (2%)
PW Collins et al. Blood 2007
Sites of Bleeding
PW Collins et al. Blood 2007
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)
PW Collins et al. Blood 2007
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 Survival
Quebec Reference Center for Inhibitors
At 5 years: 69% (95% CI: 55–80%)
Years
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
Cumulative Incidence of Inhibitors: 23.8% (n=87/366)
30
Median age at inhibitor
development: 16 m
20
10
Median number of exposure days
at inhibitor development: 12
0
0
10
20
30
40
50
Number of exposure days
HM van den Berg et al. 2006
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
HEAVY CHAINS
AUTOANTIBODIES
ALLOANTIBODIES
IgG + Other subtypes
8
12
Only IgG4
7
12
Only IgG3
1
3
Only IgG2
0
0
Only IgG1
0
0
IgM
2
1
IgA
2
0
AUTOANTIBODIES
ALLOANTIBODIES
Only Kappa
15
26
Only Lambda
5
5
Kappa + Lambda
22
6
LIGHT CHAINS
Hoyer 1982
The Bethesda Unit
One Bethesda Unit:
The amount of antibody that
inhibits half of the factor VIII
activity in a 1 to 1 mixture of
patient plasma and normal
plasma incubated at 37°C
for 2 hours
Kasper, 1975
Inactivation of Factor VIII by Inhibitors
Type I Alloantibodies
Type II Autoantibodies
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: From Gene to Protein
FVIIIgene
Exon 1
14
22
26
cDNA
Mature
protein
186 kb
26 exons
7 kb
NH2
Activated
protein
A1
A1
A2
B
A2
2332 aa
A3
C1
C2 COOH 300 kDa
A3
C1
C2
Me2+
Slide courtesy of Dr. Johannes Oldenburg
Binding of Factor VIII to von Willebrand Factor
Astermark J. et al. Haemophilia 2008; 14 (Suppl.3):36-42
Factor VIII Inhibitory Antibodies
FX FIXa
vWF
FIXa
vWF/PL
NH2
COOH
336
719
1648
2025 2173
2332
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
% Neutralization by FVIII Region
Inhibitor
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)
% Neutralization by FVIII Region
Inhibitor
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
≤ 10
≥ 95
C2
56
≤10
A2, PEP 341-63
≥ 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
L
WD
RJ
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
A2
C2
Epitopes of Major inhibitor(s)
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
R2113
27
54
A2, C2, AR3-A3-C1
≥ 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
K66
AR3-A3-C1
Scandella et al. Blood 1997
Factor VIII Inhibitory Antibodies
FX FIXa
vWF
FIXa
vWF/PL
NH2
COOH
336
719
1648
2025 2173
2332
The Bethesda assay does not see
antibodies against the B domain
Modified 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
BETHESDA
ELISA
Kogenate FS
Advate
ReFacto
Gender
Age
Associated condition
BU
AU
AU
AU
M
71
Colon cancer
1984
133
141
94
M
49
Autoimmune
vasculitis
160
134
100
90
M
83
Idiopathic
30
84
81
81
M
63
Idiopathic
10
52
60
62
F
87
Idiopathic
7
105
85
91
F
36
Pancreatitis
1
6
8
46
M
76
Lymphoma
< 0.6*
5
10
25
*Subject known to have been Bethesda positive in the past
Subjects with Congenital Hemophilia A and Inhibitor
ELISA
BETHESDA
Kogenate FS
Advate
ReFacto
Age
Baseline
FVIII
Duration of inhibitor
(years)
BU
AU
AU
AU
5
< 0,01
3
570
118
71
125
34
< 0,01
> 20
512
130
80
95
5
< 0,01
4
165
121
113
97
60
< 0,01
> 20
78
106
95
101
7
< 0,01
6
36
91
145
85
8
< 0,01
6
16
51
92
50
2
< 0,01
2
8
27
19
30
12
< 0,01
10
4.2
6
7
23
47
< 0,01
> 20
1.5
11
6
13
5
< 0,01
4
0.6
46
37
18
6
< 0,01
5
< 0.6*
4
11
4
*Subject known to have been Bethesda positive in the past.
Subjects with Congenital Hemophilia A without Inhibitor
ELISA
BETHESDA
Kogenate FS
Advate
ReFacto
Baseline FVIII
BU
AU
AU
AU
0,05
< 0.6
66
63
0.2
< 0,01
< 0.6
36
44
-0.5
< 0,01
< 0.6
21
23
-1
< 0,01
< 0.6
10
3
0
< 0,01
< 0.6
4
2
0.1
0,03
< 0.6
3
2
0.2
Contributing Factors to Development of
FVIII Inhibitors
• Genetic
Related to factor VIII
Unrelated to factor VIII
• Environmental
Conditions of treatment
Therapeutic product
Contributing Factors to Development of
FVIII Inhibitors
• Genetic
Related to factor VIII
Unrelated to factor VIII
• Environmental
Conditions of treatment
Therapeutic product
Family Incidence
Malmo 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
African origin
inhibitors: 51/198
inhibitors: 14/27
25.8%
51.9%
MIBS (Astermark et al. 2001)
Caucasians
African origin
inhibitors
inhibitors
27.4%
55.6%
Contributing Factors to Development of
FVIII Inhibitors
• Genetic
Related to factor VIII
Unrelated to factor VIII
• Environmental
Conditions of treatment
Therapeutic product
Factor VIII Mutations and Inhibitor
Development
Inhibitor Prevalence
Type of Mutation
3641
7532
Intron 22 inversion
34.4%
Nonsense
38.4%
21%
31%
Missense
4.3%
5%
Large deletion or insertion
35.7%
41%
Small deletion or insertion
7.4%
16%
1Schwaab
R et al. Thromb Haemost. 1995; 74: 1402-1406
J and Pavlova A. Haemophilia 2006;12 (Suppl.6)15-22
2Oldenburg
Nonsynonymous Single Nucleotide Polymorphisms of Factor VIII Gene
Viel KR et al. NEJM 2009;360: 1618-27
Nonsynonymous Single Nucleotide Polymorphisms
of Factor VIII Gene and Risk of Inhibitor Development
Inhibitor of Factor VIII in Black Patients with Hemophilia
Kevin R. Viel et al. NEJM 2009; 360: 1618-27
Contributing Factors to Development of
FVIII Inhibitors
• Genetic
Related to factor VIII
Unrelated to factor VIII
• Environmental
Conditions of treatment
Therapeutic product
Non-Factor VIII Genetics and
Inhibitor Development
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 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 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 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 CTLA-4 gene and inhibitor development in patients with severe
hemophilia A. Astermark J. et al. J Thromb Haemost 2007;5:263-5
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.
Contributing Factors to Development of
FVIII Inhibitors
• Genetic
Related to factor VIII
Unrelated to factor VIII
• Environmental
Conditions of treatment
Therapeutic product
Contributing Factors to Development of
FVIII Inhibitors: Conditions of Treatment
– 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
• Genetic
Related to factor VIII
Unrelated to factor VIII
• Environmental
Conditions of treatment
Therapeutic product
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
n = 62 on plasma VWF-FVIII
n = 86 on rFVIII
Median ED
120
86
(62 Recombinate®; 24 Kogenate®)
Cumulative incidence of inhibitors at 50 ED
rFVIII
32.3%
VWF-FVIII
10.3%
Univariate analysis
p < 0.05
Multivariate analysis
p < 0.009*
*adjusted for intron 22, ethnic origin and age at first exposure
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
The Proof of the Poutine is in the Poutine
*
*
Cumulative risk of inhibitor
Wight J, Paisley S. The epidemiology of inhibitors in haemophilia A: a systematic review. Haemophilia 2003; 9: 318-35
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???