Anaphylactic response to factor IX replacement therapy in haemophilia B patients: complete gene deletions confer the highest risk

Haemophilia ◽  
1999 ◽  
Vol 5 (2) ◽  
pp. 101-105 ◽  
Author(s):  
E. C. THORLAND ◽  
J. B. DROST ◽  
J. M. LUSHER ◽  
I. WARRIER ◽  
A. SHAPIRO ◽  
...  
Keyword(s):  
Replacement Therapy ◽  
Factor Ix ◽  
Gene Deletions ◽  
Haemophilia B ◽  
Anaphylactic Response

MOLECULAR DEFECTS OF THE FACTOR IX GENE CAUSING SEVERE HAEMOPHILIA

1987 ◽  
Author(s):  
B M Ludwig ◽  
R Schwaab ◽  
H H Brackmann ◽  
H Egli ◽  
K Olek
Keyword(s):  
Restriction Analysis ◽  
Cdna Probe ◽  
Restriction Enzymes ◽  
Factor Ix ◽  
Functional Abnormality ◽  
Gene Deletions ◽  
Structural Alterations ◽  
Haemophilia B ◽  
Molecular Defects ◽  
Precise Data

Deficiency or functional abnormality of factor IX protein leads to the X-linked recessive haemorrhagic disorder known as haemophilia B. Using the factor IX cDNA probe pTG 397 we have studied DNA purified from 40 patients afflicted with haemophilia B. Restriction analysis was carried out using Eco RI, Taq I and Xmn I which give result to DNA fragments representing 99 % of the whole factor IX gene. Mapping the gene this way four patients were shown to have structural alterations in the factor IX gene. To obtain more precise data concerning these mutations we additionally used restriction enzymes Bgl II and Hind III.The results listed below indicate more patients have to be examined to conclude a strong correlation between inhibitors to factor IX and the presence of gross gene deletions. This view is supported by the findings that two further inhibitor forming patients had no sizable deletions.

Gene deletions in patients with haemophilia B and anti-factor IX antibodies

Nature ◽  
1983 ◽  
Vol 303 (5913) ◽  
pp. 181-182 ◽  
Author(s):  
F. Giannelli ◽  
K. H. Choo ◽  
D. J. G. Rees ◽  
Y. Boyd ◽  
C. R. Rizza ◽  
...  
Keyword(s):  
Factor Ix ◽  
Gene Deletions ◽  
Haemophilia B

Anaphylactic Reaction After Replacement Therapy In Haemophilia B Patient with Inhibitor to Factor IX

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 4662-4662
Author(s):  
Rosanna Scaraggi ◽  
Paola Giordano ◽  
Cosimo Pietro Ettorre ◽  
Giuseppe Malcangi ◽  
Renato Marino ◽  
...  
Keyword(s):  
Replacement Therapy ◽  
Anaphylactic Reaction ◽  
Conflicts Of Interest ◽  
Therapeutic Option ◽  
Factor Ix ◽  
Careful Monitoring ◽  
Haemophilia B ◽  
Bleeding Management ◽  
Post Traumatic ◽  
The Right

Abstract Abstract 4662 Replacement therapy is a very hard challenge in haemophilia B with inhibitor. We describe the case of a child with severe haemophilia B and with a family history positive for development of inhibitor to factor IX (FIX) and for occurrence of allergic reaction after replacement therapy. Genetic analysis demonstrated an almost complete deletion of FIX gene. The child received replacement therapy first in his life when he was 5 years old because of the occurrence of a large haematoma of the left thigh. He was treated with recombinant FIX concentrate at the dosage of 30 IU/kg daily for three days and no inhibitor to FIX was evidenced after this therapy. Two months later the patient was treated with a single dose of recombinant FIX concentrate at the same dosage for the occurrence of a post-traumatic joint bleeding of the right knee. An inhibitor towards FIX (1.7 B.U.) was detected two weeks after this treatment and confirmed in a subsequent analysis performed after ten days (1.4 B.U.). One month later the patient was hospitalized for a post traumatic hemarthrosis of the right shoulder. In this occasion it was planned to treat the patient with recombinant FIX under careful monitoring in intensive care unit considering of the inhibitor. After the slow endovenous infusion of 200 IU of recombinant FIX concentrate we stopped immediately the administration because the child presented cough, mild respiratory failure, tachycardia, tongue and lips oedema, lips cyanosis, diffuse vasodilatation, psychomotor agitation. He received also hydrocortisone, antihistaminic by intramuscular injection and oxygen by facial mask. The presence of inhibitor towards FIX and anaphylactic reaction occurrence preclude forever any replacement therapy with FIX both recombinant and plasmatic (PCC and/or aPCC). After this episode the patient needed another hospitalization for a tonsil bleeding with severe anaemization. We treat him with recombinant activated FVII (rFVIIa) first at the dosage of 270 mcg/kg in bolus, and after at the dosage of 90 mcg/kg every three hours for one day with complete bleeding remission. We encourage the careful monitoring of inhibitor towards FIX in haemophilic B patients especially with large FIX gene deletion. It could prevent severe anaphylactic reaction during replacement therapy. Considering the previous anaphylactic reaction, in this child rFVIIa represents the only therapeutic option for bleeding management. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Phase 1-2 Clinical Trial of a Recombinant AAV5 Vector Containing the Human FIX Gene in Patients with Severe or Moderately Severe Haemophilia B

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 5948-5948 ◽  
Author(s):  
Wolfgang A. Miesbach ◽  
Christian Meyer ◽  
Bart Nijmeijer ◽  
Florence Salmon ◽  
Nadina Grosios ◽  
...  
Keyword(s):  
Gene Therapy ◽  
Replacement Therapy ◽  
Research Funding ◽  
Factor Ix ◽  
Activity Level ◽  
Severe Haemophilia ◽  
Haemophilia B ◽  
Commercial Scale ◽  
Number Of Patients ◽  
History Of

Abstract Gene therapy has been successfully used in a research setting in a limited number of patients with severe haemophilia B, primarily using vectors based on adeno-associated virus (AAV) serotype 2 and 8. Several research groups and companies are exploring new developments to improve current treatment strategies to eventually make gene therapy available for a larger number of patients. Pre-existing immunity to AAV capsid proteins may limit the availability of such therapies to small sub-groups of patients. A low prevalence of natural neutralizing antibodies against AAV5 compared with other serotypes has been demonstrated (Calcedo et al., Clin Vaccine Immunol 2009, 18:1586-1588). We use a recombinant AAV5 containing the codon optimized human factor IX gene (AAV5-hFIX), using a baculovirus production process that allows commercial scale manufacturing of the AAV5-hFIX drug product. Human FIX expression levels in macaques treated i.v. with AAV5-hFIX at a dose of 5 × 10^12 gc/kg were high enough to expect therapeutic effect on the haemophiliac phenotype in haemophilia B patients. Such levels were achieved in humans during AAV8-hFIXco clinical study (Nathwani et al., NEJM 2011, 365:2357-2365). hFIX levels in dose-escalating GLP toxicity studies in cynomolgus monkeys and mice showed linear dose responses using doses up to 1 × 10˄14 and 2.3 × 10^14 cg/kg, respectively, and no specific safety concerns. In human studies with AAV5 containing the human porbilinogen deaminase (PBGD) gene, administered in doses up to 2 x 10^13 gc/kg to patients with acute intermittent porphyria, no safety concerns were raised (D’Avola et al., ASGCT, Washington DC, 2014). Importantly, in this study no liver enzyme perturbations were observed following administration of AAV5. The primary objective of the proposed study is to investigate the safety of systemic administration of AAV5-hFIX to adult patients with severe or moderately severe haemophilia B. The multicentre trial has an open-label, uncontrolled, single-dose, dose-ascending design and consists of two cohorts. The study population consists of male patients, aged ≥18 years, with severe or moderately severe haemophilia B and a severe bleeding phenotype [i.e. known FIX deficiency with plasma FIX activity level <1% (severe), or plasma FIX activity level ≥1% and ≤2% (moderately severe) and currently on prophylactic FIX replacement therapy for a history of bleeding, or currently on on-demand therapy with a current or past history of frequent bleeding defined as four or more bleeding episodes in the last 12 months, or chronic haemophilic arthropathy. Patients should have had more than 150 previous exposure days of treatment with FIX protein. Subjects are allocated to one of two cohorts with the following planned dose levels: Cohort 1 (5 subjects) with AAV5-hFIX 5.0 × 10^12 gc/kg and Cohort 2 (5 subjects) with AAV5-hFIX 2.0 × 10^13 gc/kg. Key efficacy assessments include factor IX plasma levels, the need for FIX replacement therapy, incidence of spontaneous bleedings and health-related quality of life measurements. In conclusion, AAV5-hFIX produced in commercial scale represents a novel approach to gene therapy of haemophilia B. Disclosures Miesbach: uniQure: Consultancy; Bayer: Research Funding; Baxter: Research Funding; CSL Behring: Research Funding; Biotest: Research Funding; Octapharma: Research Funding. Meyer:uniQure B. V.: Employment. Nijmeijer:uniQure B. V.: Employment. Salmon:uniQure B. V.: Employment. Grosios:uniQure B. V.: Employment. Petry:uniQure B. V,: Employment. Leebeek:uniQure B. V.: Consultancy; CSL Behring: Research Funding; Baxter: Research Funding.

MOLECULAR GENETICS OF HAEMOPHILIA

1987 ◽  
Author(s):  
B F Giannelli
Keyword(s):  
Signal Peptide ◽  
Point Mutations ◽  
Factor Ix ◽  
Indirect Detection ◽  
Gene Deletions ◽  
Gene Markers ◽  
Haemophilia B ◽  
Familial Cases ◽  
Number Of Patients ◽  
Gene Defects

Haemophilia B, an X-linked recessive disease with an incidence of 1/30,000 newborn males, is due to defects in the gene for coagulation factor IX, which is on the long am of the X chromosome at band Xq27.1. This gene consists of approximately 34 Kb and contains 8 exons which specify a mRtfc of 2803 residues coding for a protein of 415 aa preceded by a prepro signal peptide of 46 aa. Coripanson of the functional domains of the factor IX protein with the exon structure of the gene supports the exon/protein domain hypothesis of gene evolution. The factor IX gene seems to be formed by a number of functionally and evolutionally independent modules. The signal peptide and the gla (γcarboxy-glutamic) region encoded in the first three exons are homologous to those of factor X, protein C and prothrombin. Thevfourth and fifth exons which code for the connecting peptide are homologous to one another and to the epidermal growth factor, a module that has been used in the construction of a great variety of proteins including different members of the coagulation and fibrinolytic pathways. The sixth exon encodes the activation peptide region, while the catalytic region of factor IX is coded by the seventh and eighth exon. This is at variance with other serine protease genes that have different exons for the segments containing the cardinal ami no-acids of the active centre (histidine, aspartic acid and serine).Natural selection acts against detrimental mutations of the factor IX gene and at each generation a proportion of haemophilia B genes is eliminated, as a significant number of patients does not reproduce. There appears to be no selective advantage to the heterozygote and therefore haemophilia B is maintained in the population by new mutations. Consequently, a significant proportion of patients should be born to non-carrier mothers, and unrelated patients should carry different gene defects, as recently verified by detailed analysis of individual haemophilia B genes.The defects of factor IX described so far comprise both point mutations and gene deletions. The latter affect either part or the whole of the gene and are often associated with the development of antibodies against therapeutically adninistered factor IX (the inhibitor complication). Since gene deletions may result in the complete absenceof factor IX synthesis or in the production of an extremely abnormal product, it has been suggested that mutationspreventing the synthesis of a factor IX gene product capable of inducing immune tolerance to normal factor IX is important in predisposing to the inhibitor complication.Among the point mutations described so far, those affecting the signal peptide are of particular interest. Substitutions of the arginine at positions -4 and -1 cause failure of propeptide cleavage. Thus they indicate that the propeptide consists of 18 aa an(lthat lts excision is necessary for factor IX function. It appears also that the propeptide contains a signal for γcarboxylation which has been conserved during the evolution of different γcarboxylated proteins.In spite of coagulant treatment, haemophilia B is a serious disease and one for which genetic counselling is required. Paramount for this is the detection of carriers and the diagnosis ofaffected male fetuses. DNA probes derived from the cloned factor IX gene have been used for this purpose. Carrier and first or second trimester prenatal diagnoses have been done using factors IX gene markers to follow the transmission of haemophilia B genes. Six sequence variations causing restriction fragment length polymorphisms (RFLP) in the factor IX gene have been detected and used as markers for such indirect diagnoses The efficiency of the above markers is reduced by linkage disequilibrium but, nevertheless, they offer definite carrier and nremtal diagnoses in 75-80% of the relatives of familial cases of haemophilia B.The indirect detection of gene defects is of modest help in the counselling of individuals from the families of isolated patients, but new methods for the direct detection of gene mutations promise better results in such families and also the attainment of % diagnostic success in relatives of familial cases.Finally the successful expression of recombinant factor IX genes in tissue culture and transgenic mammals raises hopes of therapeutic advances.

GENE DELETIONS IN THE FACTOR IX LOCUS

1987 ◽  
Author(s):  
R J Matthews ◽  
D S Anson ◽  
I R Peake ◽  
A L Bloom
Keyword(s):  
Southern Blotting ◽  
Large Deletion ◽  
Factor Ix ◽  
Flanking Sequence ◽  
Gene Deletions ◽  
Haemophilia B ◽  
Intact Gene ◽  
Plasma Factor ◽  
I Factor ◽  
Flanking Sequences

Previous studies have indicated that the majority of haemophilia B patients who produce anti-factor IX inhibitors (antibodies) have some kind of deletion of the factor IX gene. We have analysed DNA from nine haemophilia B inhibitor patients using the Southern blotting method and hybridisation with (i) factor IX cDNA and intragenomic probes (ii) probes originating from flanking sequences up to 60kb 5' and 170kb 3' to the factor IX gene that have been isolated by gene walking experiments (D.S.Anson and G.G.Brownlee, unpublished observations).Two patients who are brothers (haemophilia B (Chicago I)) were shown to have a presumably identical complex rearrangement of the factor IX gene involving two separate deletions. The first deletion is approx. 5.0kb and removes exon e. The second deletion is between 9 and 29kb and removes exons g and h but leaves exon f intact. An abnormal TaqI fragment at one end of the deletions junctions acted as a marker for the inheritance of haemophilia B in the patients' family. Furthermore, an abnormal llkb Bglll fragment (detected with an intragenomic probe containing exon f) in DNA from both patients and their mother acted as a marker for the presence of both deletions. Since the patients' grandmother only showed the normal 12kb Bgl II fragment then both deletions appear to have arisen at the same time. We believe that haemophilia B (Chicago 1) is the first observation of a natural gene rearrangement involving two separate deletions within the same gene.Patient haemophilia B (Jersey 1) was revealed to have a deletion of at least 170kb including the entire factor IX gene and > 60kb of 5' flanking sequence. The 3' breakpoint of this deletion was mapped to between 80 and 140kb 3' to the factor IX gene. One further patient, haemophilia B (Boston I) was shown to have a deletion of > 230kb including the factor IX gene, > 60kb of 5' flanking sequence and >140kb of 3' flanking sequence. Five other inhibitor patients had a structurally intact gene as detected by this method.Although all nine haemophilia B inhibitor patients studied did not have a detectable plasma factor IX only in four of them is this absence due to a large deletion of the factor IX gene.

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