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CC BY 4.0 · TH Open 2020; 04(02): e94-e103
DOI: 10.1055/s-0040-1710032
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Synergistic Effect of Bypassing Agents and Sequence Identical Analogue of Emicizumab and Fibrin Clot Structure in the In Vitro Model of Hemophilia A

Yanan Zong
1   Department of Molecular Medicine and Surgery, Clinical Chemistry and Coagulation, Karolinska Institutet, Stockholm, Sweden
,
Aleksandra Antovic
2   Department of Medicine, Unit of Rheumatology, Karolinska Institutet and Academic Specialist Center, Center for Rheumatology, Stockholm Health Services, Stockholm, Sweden
,
Nida Mahmoud Hourani Soutari
1   Department of Molecular Medicine and Surgery, Clinical Chemistry and Coagulation, Karolinska Institutet, Stockholm, Sweden
3   Department of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
,
Jovan Antovic
1   Department of Molecular Medicine and Surgery, Clinical Chemistry and Coagulation, Karolinska Institutet, Stockholm, Sweden
3   Department of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
,
Iva Pruner
1   Department of Molecular Medicine and Surgery, Clinical Chemistry and Coagulation, Karolinska Institutet, Stockholm, Sweden
› Author Affiliations Funding This study was funded by Investigator-Initiated Research grant Baxalta US Inc. (part of Takeda group of companies), Bannockburn, IL (IIR SWE-001459).
Further Information

Publication History

06 November 2019

24 March 2020

Publication Date:
21 July 2020 (online)

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Abstract

Development of inhibitors to factor VIII (FVIII) occurs in approximately 30% of severe hemophilia A (HA) patients. These patients are treated with bypassing agents (activated prothrombin complex concentrate [aPCC] and recombinant activated FVII-rFVIIa). Recently, a bispecific FIX/FIXa- and FX/FXa-directed antibody (emicizumab) has been approved for the treatment of HA patients with inhibitors. However, the data from clinical studies imply that coadministration of emicizumab and bypassing agents, especially aPCC, could have a thrombotic effect.

This study was aimed to address the question of potential hypercoagulability of emicizumab and bypassing agents' coadministration, we have investigated fibrin clot formation and structure in the in vitro model of severe HA after adding sequence-identical analogue (SIA) of emicizumab and bypassing agents.

Combined overall hemostasis potential (OHP) and fibrin clot turbidity assay was performed in FVIII-deficient plasma after addition of different concentrations of SIA, rFVIIa, and aPCC. Pooled normal plasma was used as control. The fibrin clots were analyzed by scanning electron microscopy (SEM).

OHP and turbidity parameters improved with the addition of aPCC, while therapeutic concentrations of rFVIIa did not show substantial improvement. SIA alone and in combination with rFVIIa or low aPCC concentration improved OHP and turbidity parameters and stabilized fibrin network, while in combination with higher concentrations of aPCC expressed hypercoagulable pattern and generated denser clots.

Our in vitro model suggests that combination of SIA and aPCC could potentially be prothrombotic, due to hypercoagulable changes in fibrin clot turbidity and morphology. Additionally, combination of SIA and rFVIIa leads to the formation of stable clots similar to normal fibrin clots.

Keywords

emicizumab - bypassing agents - fibrin clot - hemophilia A

Supplementary Material

 

  • References

  • 1 Mannucci PM, Tuddenham EG. The hemophilias—from royal genes to gene therapy. N Engl J Med 2001; 344 (23) 1773-1779
    CrossrefPubMedGoogle Scholar
  • 2 Geraghty S, Dunkley T, Harrington C, Lindvall K, Maahs J, Sek J. Practice patterns in haemophilia A therapy — global progress towards optimal care. Haemophilia 2006; 12 (01) 75-81
    PubMedGoogle Scholar
  • 3 Aznar JA, Marco A, Jiménez-Yuste V. , et al; Spanish Haemophilia Epidemiological Study Working Group. Is on-demand treatment effective in patients with severe haemophilia?. Haemophilia 2012; 18 (05) 738-742
    CrossrefPubMedGoogle Scholar
  • 4 Langer AL, Etra A, Aledort L. Evaluating the safety of emicizumab in patients with hemophilia A. Expert Opin Drug Saf 2018; 17 (12) 1233-1237
    CrossrefPubMedGoogle Scholar
  • 5 Ehrenforth S, Kreuz W, Scharrer I. , et al. Incidence of development of factor VIII and factor IX inhibitors in haemophiliacs. Lancet 1992; 339 (8793): 594-598
    CrossrefPubMedGoogle Scholar
  • 6 Astermark J. FVIII inhibitors: pathogenesis and avoidance. Blood 2015; 125 (13) 2045-2051
    CrossrefPubMedGoogle Scholar
  • 7 Hay CR, DiMichele DM. ; International Immune Tolerance Study. The principal results of the International Immune Tolerance Study: a randomized dose comparison. Blood 2012; 119 (06) 1335-1344
    CrossrefPubMedGoogle Scholar
  • 8 Ewing N, Escuriola-Ettingshausen C, Kreuz W. Prophylaxis with FEIBA in paediatric patients with haemophilia A and inhibitors. Haemophilia 2015; 21 (03) 358-364
    CrossrefPubMedGoogle Scholar
  • 9 Ju HY, Jang HL, Park YS. The efficacy of bypassing agents in surgery of hemophilia patients with inhibitors. Blood Res 2015; 50 (03) 173-178
    CrossrefPubMedGoogle Scholar
  • 10 Konkle BA, Ebbesen LS, Erhardtsen E. , et al. Randomized, prospective clinical trial of recombinant factor VIIa for secondary prophylaxis in hemophilia patients with inhibitors. J Thromb Haemost 2007; 5 (09) 1904-1913
    CrossrefPubMedGoogle Scholar
  • 11 Leissinger C, Gringeri A, Antmen B. , et al. Anti-inhibitor coagulant complex prophylaxis in hemophilia with inhibitors. N Engl J Med 2011; 365 (18) 1684-1692
    CrossrefPubMedGoogle Scholar
  • 12 Peyvandi F, Garagiola I, Biguzzi E. Advances in the treatment of bleeding disorders. J Thromb Haemost 2016; 14 (11) 2095-2106
    CrossrefPubMedGoogle Scholar
  • 13 Shima M, Hanabusa H, Taki M. , et al. Factor VIII-mimetic function of humanized bispecific antibody in hemophilia A. N Engl J Med 2016; 374 (21) 2044-2053
    CrossrefPubMedGoogle Scholar
  • 14 Kitazawa T, Igawa T, Sampei Z. , et al. A bispecific antibody to factors Ixa and X restores factor VIII hemostatic activity in a hemophilia A model. Nat Med 2012; 18 (10) 1570-1574
    CrossrefPubMedGoogle Scholar
  • 15 Oldenburg J, Mahlangu JN, Kim B. , et al. Emicizumab prophylaxis in hemophilia a with inhibitors. N Engl J Med 2017; 377 (09) 809-818
    CrossrefPubMedGoogle Scholar
  • 16 Hartmann R, Feenstra T, Valentino L, Dockal M, Scheiflinger F. In vitro studies show synergistic effects of a procoagulant bispecific antibody and bypassing agents. J Thromb Haemost 2018; (e-pub ahead of print) DOI: 10.1111/jth.14203.
    CrossrefPubMedGoogle Scholar
  • 17 Antovic A. The overall hemostasis potential: a laboratory tool for the investigation of global hemostasis. Semin Thromb Hemost 2010; 36 (07) 772-779
    Article in Thieme ConnectPubMedGoogle Scholar
  • 18 Gidley GN, Holle LA, Burthem J, Bolton-Maggs PHB, Lin FC, Wolberg AS. Abnormal plasma clot formation and fibrinolysis reveal bleeding tendency in patients with partial factor XI deficiency. Blood Adv 2018; 2 (10) 1076-1088
    CrossrefPubMedGoogle Scholar
  • 19 Mahlangu J, Oldenburg J, Paz-Priel I. , et al. Emicizumab prophylaxis in patients who have hemophilia A without inhibitors. N Engl J Med 2018; 379 (09) 811-822
    CrossrefPubMedGoogle Scholar
  • 20 Antovic A. Screening haemostasis—looking for global assays: the Overall Haemostasis Potential (OHP) method—a possible tool for laboratory investigation of global haemostasis in both hypo- and hypercoagulable conditions. Curr Vasc Pharmacol 2008; 6 (03) 173-185
    CrossrefPubMedGoogle Scholar
  • 21 Wolberg AS, Campbell RA. Thrombin generation, fibrin clot formation and hemostasis. Transfus Apheresis Sci 2008; 38 (01) 15-23
    CrossrefPubMedGoogle Scholar
  • 22 He S, Blombäck M, Jacobsson Ekman G, Hedner U. The role of recombinant factor VIIa (FVIIa) in fibrin structure in the absence of FVIII/FIX. J Thromb Haemost 2003; 1 (06) 1215-1219
    CrossrefPubMedGoogle Scholar
  • 23 Al Dieri R, Peyvandi F, Santagostino E. , et al. The thrombogram in rare inherited coagulation disorders: its relation to clinical bleeding. Thromb Haemost 2002; 88 (04) 576-582
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Allen GA, Wolberg AS, Oliver JA, Hoffman M, Roberts HR, Monroe DM. Impact of procoagulant concentration on rate, peak and total thrombin generation in a model system. J Thromb Haemost 2004; 2 (03) 402-413
    CrossrefPubMedGoogle Scholar
  • 25 Wolberg AS, Monroe DM, Roberts HR, Hoffman M. Elevated prothrombin results in clots with an altered fiber structure: a possible mechanism of the increased thrombotic risk. Blood 2003; 101 (08) 3008-3013
    CrossrefPubMedGoogle Scholar
  • 26 Dai L, Bevan D, Rangarajan S, Sørensen B, Mitchell M. Stabilization of fibrin clots by activated prothrombin complex concentrate and tranexamic acid in FVIII inhibitor plasma. Haemophilia 2011; 17 (05) e944-e948
    CrossrefPubMedGoogle Scholar
  • 27 Mosnier LO, Lisman T, van den Berg HM, Nieuwenhuis HK, Meijers JC, Bouma BN. The defective down regulation of fibrinolysis in haemophilia A can be restored by increasing the TAFI plasma concentration. Thromb Haemost 2001; 86 (04) 1035-1039
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Wolberg AS, Allen GA, Monroe DM, Hedner U, Roberts HR, Hoffman M. High dose factor VIIa improves clot structure and stability in a model of haemophilia B. Br J Haematol 2005; 131 (05) 645-655
    CrossrefPubMedGoogle Scholar
  • 29 Luong V, Soutari N, Berndtsson M, Holmström M, Antovic JP, Chaireti R. Difference in fibrin clot structure in haemophilia A and haemophilia B. Blood 2016; 28 (22) 563
    PubMedGoogle Scholar
  • 30 Tanaka KA, Taketomi T, Szlam F, Calatzis A, Levy JH. Improved clot formation by combined administration of activated factor VII (NovoSeven) and fibrinogen (Haemocomplettan P). Anesth Analg 2008; 106 (03) 732-738
    CrossrefPubMedGoogle Scholar
  • 31 Lak M, Scharling B, Blemings A. , et al. Evaluation of rFVIIa (NovoSeven) in Glanzmann patients with thromboelastogram. Haemophilia 2008; 14 (01) 103-110
    PubMedGoogle Scholar