Pathophysiological Mechanisms of Endogenous FVIII Release following Strenuous Exercise in Non-severe Haemophilia: A Review

Introduction Non-severe haemophilia A is characterized by coagulation Factor VIII activity (FVIII:C) levels of 1 to 40 IU/dL. It has been reported that strenuous exercise increases the plasma FVIII:C in haemophilia A patients. This review highlights current knowledge about the pathophysiological mechanisms of endogenous FVIII release following strenuous exercise. Methods A literature search was performed to include relevant studies with data on pathophysiological mechanisms of FVIII release following strenuous exercise in haemophilia. Results The source of the released FVIII is most likely endothelial cells (ECs) from different vascular beds. ECs from human lung, lymph, heart, intestine, skin and pulmonary artery can release and even produce FVIII in response to activation by epinephrine. Ex vivo evidence suggests that FVIII is co-stored with von Willebrand factor in Weibel–Palade bodies in some forms of non-severe haemophilia. The β-adrenergic receptor pathway is involved in increased FVIII levels following strenuous exercise. Conclusion The current available ex vivo and in vivo evidence suggests that endogenous FVIII is released by ECs from different vascular beds in response to epinephrine following strenuous exercise in patients with non-severe haemophilia.

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Ex Vivo Gene Therapy for Haemophilia A: FVIII-Overexpressing Mesenchymal Stromal Cells Fail To Produce Sustained Therapeutic Levels of Circulating FVIII In Vivo.

Blood ◽

10.1182/blood.v108.11.5472.5472 ◽

2006 ◽

Vol 108 (11) ◽

pp. 5472-5472

Author(s):

Daniel L. Coutu ◽

Moira Francois ◽

Jessica Cuerquis ◽

Hideto Matsui ◽

David Lillicrap ◽

...

Keyword(s):

Progenitor Cells ◽

Mesenchymal Stromal Cells ◽

Stromal Cells ◽

Lentiviral Vector ◽

Ex Vivo ◽

Coagulation Factor ◽

Scid Mice ◽

Limiting Factor ◽

Haemophilia A

Abstract The use of ex vivo transfected autologous fibroblasts was explored for the delivery of coagulation factor VIII (FVIII) to treat haemophilia A patients, albeit with mitigated results (Roth et al., NEJM 2001). A limiting factor to this approach is the limited expansion potential of somatic cells and cellular dose manufactured for therapeutic use. The use of adult stem or progenitor cells offers a possible remedy to this specific challenge because of their high proliferative capacities, allowing the generation of large number of cells ex vivo. Mesenchymal stromal cells (MSCs) can easily be isolated by bone marrow aspiration and extensively expanded ex vivo using standard tissue culture procedures. They also possess endogenous wound healing properties and are relatively easy to gene engineer. When engineered to secrete therapeutic plasma-soluble proteins, they could be injected with a supporting matrix - as a subcutaneous plug - and used to treat a variety of haematological disorders responsive to secreted proteins such as haemophilia A and B and anaemia for instance. The retrievability of the implanted cells is desirable if unexpected side effects were to occur. The aim of this project was to test a gene engineered MSC platform to treat a clinically relevant model disease, haemophilia A. Canine MSCs (cMSCs) isolated from normal and haemophilia A dogs were genetically modified using a 3rd generation lentiviral vector carrying the B-domain deleted canine FVIII (cFVIII) gene. In vitro production of cFVIII was assessed by ELISA and found to be about 2,4 U/106 cells/24h. 107 of those cells were injected intraperitoneally in NOD-SCID mice and transient expression (8–10 days) of therapeutic levels of cFVIII (up to 10%) could be detected using an ELISA capable of discriminating cFVIII from murine FVIII. However, when these cells were embedded in an injectable human compatible collagen based scaffolding material (Contigen) and implanted subcutaneously into NOD-SCID mice no cFVIII could be detected above background in any animals. Because we previously demonstrated that erythropoietin gene-modified MSCs implanted as described led to an increase in hematocrit for an extended period (Eliopoulos et al. Mol Ther 2004), we believe that the failure of the present approach is attributable to idiosyncrasies of the FVIII system. Of particular relevance is the requirement for the presence of von Willebrand factor (vWF) in stabilizing the FVIII protein and protect it from degradation. We already have evidence that ex vivo transduced endothelial progenitor cells known to produce endogenous vWF can serve as better delivery vehicles for FVIII as part of a matrix embedded subcutaneous plug and lead to prolonged circulating levels of FVIII in mice (Matsui et al., submitted). These data support the hypothesis that FVIII delivery by engineered somatic and stem cells likely requires co-expression of key cofactors, such as vWF, for durable and clinically relevant effects in vivo.

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Intranasal DDAVP induced increases in plasma von Willebrand factor alter the pharmacokinetics of high-purity factor VIII concentrates in severe haemophilia A patients

Haemophilia ◽

10.1046/j.1365-2516.1999.00282.x ◽

1999 ◽

Vol 5 (2) ◽

pp. 88 ◽

Cited By ~ 2

Author(s):

STEVEN R. DEITCHER

Keyword(s):

Factor Viii ◽

Von Willebrand Factor ◽

High Purity ◽

Haemophilia A ◽

Severe Haemophilia ◽

Factor Viii Concentrates ◽

Von Willebrand ◽

Willebrand Factor

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Significance of Platelet β-Adrenoceptors for Platelet Responses In Vivo and In Vitro

Thrombosis and Haemostasis ◽

10.1055/s-0038-1646345 ◽

1992 ◽

Vol 68 (06) ◽

pp. 687-693 ◽

Cited By ~ 24

Author(s):

P T Larsson ◽

N H Wallén ◽

A Martinsson ◽

N Egberg ◽

P Hjemdahl

Keyword(s):

Ex Vivo ◽

High Dose ◽

Platelet Aggregability ◽

Adrenoceptor Agonist ◽

Dose Infusion ◽

Von Willebrand ◽

Willebrand Factor ◽

Factor Antigen

SummaryThe significance of platelet β-adrenoceptors for platelet responses to adrenergic stimuli in vivo and in vitro was studied in healthy volunteers. Low dose infusion of the β-adrenoceptor agonist isoprenaline decreased platelet aggregability in vivo as measured by ex vivo filtragometry. Infusion of adrenaline, a mixed α- and β-adrenoceptor agonist, increased platelet aggregability in vivo markedly, as measured by ex vivo filtragometry and plasma β-thromboglobulin levels. Adrenaline levels were 3–4 nM in venous plasma during infusion. Both adrenaline and high dose isoprenaline elevated plasma von Willebrand factor antigen levels β-Blockade by propranolol did not alter our measures of platelet aggregability at rest or during adrenaline infusions, but inhibited adrenaline-induced increases in vWf:ag. In a model using filtragometry to assess platelet aggregability in whole blood in vitro, propranolol enhanced the proaggregatory actions of 5 nM, but not of 10 nM adrenaline. The present data suggest that β-adrenoceptor stimulation can inhibit platelet function in vivo but that effects of adrenaline at high physiological concentrations are dominated by an α-adrenoceptor mediated proaggregatory action.

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Orphan designation: Recombinant human coagulation factor VIII Fc - von Willebrand factor - XTEN fusion protein, Treatment of haemophilia A

Case Medical Research ◽

10.31525/cmr-1f3d2fd ◽

2019 ◽

Author(s):

Keyword(s):

Fusion Protein ◽

Factor Viii ◽

Von Willebrand Factor ◽

Coagulation Factor ◽

Coagulation Factor Viii ◽

Haemophilia A ◽

Orphan Designation ◽

Von Willebrand ◽

Willebrand Factor ◽

Protein Treatment

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RPR120844, a Novel, Specific Inhibitor of Coagulation Factor Xa Inhibits Venous Thrombosis in the Rabbit

Thrombosis and Haemostasis ◽

10.1055/s-0037-1614434 ◽

1999 ◽

Vol 81 (01) ◽

pp. 157-160 ◽

Cited By ~ 14

Author(s):

Ross Bentley ◽

Suzanne Morgan ◽

Karen Brown ◽

Valeria Chu ◽

Richard Ewing ◽

...

Keyword(s):

Jugular Vein ◽

Drug Effect ◽

Ex Vivo ◽

Thrombus Formation ◽

Specific Inhibitor ◽

Factor Xa ◽

Coagulation Factor ◽

Antithrombotic Activity ◽

Fxa Inhibitor

SummaryThe in vivo antithrombotic activity of RPR120844, a novel synthetic coagulation factor Xa (fXa) inhibitor (Ki = 7 nM), was assessed by its ability to inhibit thrombus formation in a damaged segment of the rabbit jugular vein. Intravenous dose-response studies were performed and thrombus mass (TM), activated partial thromboplastin time (APTT), prothrombin time (PT), inhibition of ex vivo fXa activity and plasma drug levels (PDL) were determined. TM, measured at the end of a 50 min infusion, was significantly reduced (p <0.05 vs saline-treated animals) by RPR120844 at 30 and 100 μg/kg/min. At doses of 10, 30 and 100 μg/kg/min, APTT was prolonged by 2.1, 4.2 and 6.1-fold, and PT was prolonged by 1.4, 2.2 and 3.5-fold, respectively. PDL were determined by measuring anti-fXa activity using an amidolytic assay. Peak PDL were 0.8 ± 0.3, 1.5 ± 0.9 and 2.4 ± 0.6 μM, respectively. The drug effect was reversible with APTT, PT and PDL returning toward pretreatment values 30 min after termination of treatment. The results suggest that RPR120844, or similar compounds, may provide an efficacious, yet easily reversible, means of inhibiting thrombus formation.

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A randomised pilot trial of the anti-von Willebrand factor aptamer ARC1779 in patients with type 2b von Willebrand disease

Thrombosis and Haemostasis ◽

10.1160/th10-01-0027 ◽

2010 ◽

Vol 104 (09) ◽

pp. 563-570 ◽

Cited By ~ 44

Author(s):

Petra Paulinska ◽

Petra Jilma-Stohlawetz ◽

James Gilbert ◽

Renta Hutabarat ◽

Paul Knöbl ◽

...

Keyword(s):

Pilot Trial ◽

Coagulation Factor ◽

Von Willebrand Disease ◽

Double Blind ◽

Clinical Trial Registration ◽

Maximal Increase ◽

Double Blind Design ◽

Von Willebrand

SummaryDesmopressin aggravates thrombocytopenia in type 2B von Willebrand disease (VWF type 2B) by release of large and hyper-adhesive von Wille-brand Factor (VWF) multimers. This pilot study investigated whether the anti-VWF aptamer ARC1779 can prevent desmopressin-induced thrombocytopenia and interferes with the excessive VWF turnover in patients with VWF type 2B. Concentration effect curves of ARC1779 were established for five patients in vitro and two patients with VWF type 2B were treated by infusion of ARC1779, desmopressin, or their combination in a randomised, controlled, double-blind design. ARC1779 concentrations in the range of 1–3 μg/ml blocked free A1 domain binding sites by 90% in vitro. In vivo, desmopressin alone induced a profound (-90%) drop in platelet counts in one of the patients. ARC1779 (4–5 μg/ml) completely inhibited VWF A1 domains and prevented this desmopress-in-induced platelet drop. Desmopressin alone increased VWF antigen two- to three-fold, accompanied by concordant changes in VWF Ristocetin cofactor activity (RCo) and coagulation factor VIII activity. ARC1779 substantially enhanced the desmopressin-induced maximal increase in these parameters, and improved multimer patterns. No treatment related adverse events were observed and no bleeding occurred despite marked thrombocytopenia. These data provide first proof of concept in humans and evidence that ARC1779 is a potent inhibitor of VWF. ARC1779 prevented the rapid consumption of VWF multimers together with agglutinated platelets that occurred in response to desmopressin challenge in patients with VWD type 2B.Clinical Trial registration number: NCT00632242.

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Desmopressin treatment combined with clotting factor VIII concentrates in patients with non-severe haemophilia A: protocol for a multicentre single-armed trial, the DAVID study

BMJ Open ◽

10.1136/bmjopen-2018-022719 ◽

2019 ◽

Vol 9 (4) ◽

pp. e022719 ◽

Cited By ~ 2

Author(s):

Lisette M Schütte ◽

Marjon H Cnossen ◽

Reinier M van Hest ◽

Mariette H E Driessens ◽

Karin Fijnvandraat ◽

...

Keyword(s):

Factor Viii ◽

Combination Treatment ◽

Bleeding Risk ◽

Clotting Factor ◽

Haemophilia A ◽

Severe Haemophilia ◽

Registration Number ◽

Concentrate Treatment ◽

Factor Viii Concentrates ◽

Von Willebrand

IntroductionHaemophilia A is an inherited bleeding disorder characterised by factor VIII (FVIII) deficiency. In patients with non-severe haemophilia A, surgery and bleeding are the main indications for treatment with FVIII concentrate. A recent study reported that standard dosing frequently results in FVIII levels (FVIII:C) below or above FVIII target ranges, leading to respectively a bleeding risk or excessive costs. In addition, FVIII concentrate treatment carries a risk of development of neutralising antibodies. An alternative is desmopressin, which releases endogenous FVIII and von Willebrand factor. In most patients with non-severe haemophilia A, desmopressin alone is not enough to achieve FVIII target levels during surgery or bleeding. We hypothesise that combined pharmacokinetic (PK)-guided administration of desmopressin and FVIII concentrate may improve dosing accuracy and reduces FVIII concentrate consumption.Methods and analysisIn the DAVID study, 50 patients with non-severe haemophilia A (FVIII:C ≥0.01 IU/mL) with a bleeding episode or undergoing surgery will receive desmopressin and FVIII concentrate combination treatment. The necessary dose of FVIII concentrate to reach FVIII target levels after desmopressin administration will be calculated with a population PK model. The primary endpoint is the proportion of patients reaching FVIII target levels during the first 72 hours after start of the combination treatment. This approach was successfully tested in one pilot patient who received perioperative combination treatment.Ethics and disseminationThe DAVID study was approved by the medical ethics committee of the Erasmus MC. Results of the study will be communicated trough publication in international scientific journals and presentation at (inter)national conferences.Trial registration numberNTR5383; Pre-results.

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Efficacy and safety of the drug Octofactor in prophylactic treatment in patients with severe haemophilia A

Russian Journal of Pediatric Hematology and Oncology ◽

10.17650/2311-1267-2018-5-3-60-73 ◽

2018 ◽

Vol 5 (3) ◽

pp. 60-73 ◽

Cited By ~ 1

Author(s):

T. A. Andreeva ◽

V. Yu. Zorenko ◽

I. L. Davydkin ◽

V. N. Konstantinova ◽

O. E. Zalepukhina ◽

...

Keyword(s):

Hemophilia A ◽

Bleeding Episode ◽

Coagulation Factor ◽

Preventive Treatment ◽

Haemophilia A ◽

Severe Haemophilia ◽

Efficacy And Safety ◽

Spontaneous Bleeding ◽

Bleeding Episodes ◽

Blood Coagulation Factor Viii

Relevance.The development of a new recombinant blood coagulation factor VIII preparation is a promising step towards optimizing the treatment of hemophilia A. An introduction of a new medication into clinical practice precedes a clinical trials to evaluate the efficacy and safety.Materials and methods.The efficacy and safety of the domestic recombinant B-domain deleted blood coagulation factor VIII (FVIII) (moroctocog alfa, Octofactor®, JSC “GENERIUM”) were studied in the preventive treatment of 31 patients aged 21 to 52 years with severe haemophilia A. The Octofactor was administered in doses of 40 ± 5 IU/kg 3 times per week at intervals of at least 48 hours for 21 ± 1 weeks.Results.The efficacy of therapy was evaluated in 30 patients, since 1 patient refused to participate in the trial after the first injection of the study medication. There were registered 43 episodes of bleeding among 11 patients in the course of the preventive treatment with Octofactor. The average number of bleeding episodes was 1.4 ± 2.58. There were 43 bleeding episodes, 9 (20.9 %) of them were posttraumatic, 34 (79.1 %) of them were spontaneous. The average number of the spontaneous bleeding episodes (a major criterion of the efficacy) was 1.13 ± 2.19, which showed a low incidence of exacerbations of the hemorrhagic syndrome in the course of preventive treatment with Octofactor. Among all registered bleeding episodes there were 6 (14 %) mild episodes, 37 (86 %) moderate episodes. Among all spontaneous bleedings there were 6 mild episodes (17.6 %), 28 (82.4 %) moderate episodes. All posttraumatic bleedings were moderate. The vast majority (36, or 83.7 %) of bleeding episodes were stopped with administration of the Octofactor. The average number of administrations of the Octofactor for arresting 1 bleeding episode was 1.2 ± 0.56, for 1 spontaneous bleeding episode – 1.2 ± 0.59. On average, it was required to administer 3534.9 ± 2329.02 IU of the Octofactor to stop 1 episode of bleeding. In the vast majority of patients with severe hemophilia A (83.3–86.7 %), the remaining activity FVIII was 1 % or more after the administration of the Octofactor in 48 hours. The total amount of the Octofactor, introduced for the prevention of bleeding, was 6,107,000 IU, to stop bleeding – 152,000 IU. The safety of therapy was evaluated in 31 patients. There were recorded 25 adverse events (AE) in 17 patients. Among them the laboratory ones prevailed in 23 (92 %) cases, which is not associated with the use of the trial medication. There were noted nausea and an unpleasant aftertaste in the mouth in 1 patient during the first administration of the Octofactor, and therefore he refused to continue to participate in the trial. Causality 2 AE with the study drug was regarded as definite. Such AE are expected and described in the instructions to the preparation. All AE were not serious and mild and resolved without outcomes. There were no presented thromboembolic events and immunogenic reactions.Conclusions.The obtained data testify to the efficacy and safety of the Octofactor both for preventive measures and for stopping bleeding in adult patients with severe hemophilia A.

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