Potential Use Increases thrombin generation on activated platelet
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Transcript Potential Use Increases thrombin generation on activated platelet
New Trends In The
Management Of Bleeding
Disorders
Galila Zaher
MRCPath
Consultant Hematologist
KAUH
Congenital Bleeding disorders
VWD
Hemophilia
A
Hemophilia B
Other congenital factor deficiency
Bernard Solier syndrome
Glanzman’Thrombathenia
Storage pool defect
Acquired Bleeding Disorders
Coagulation Factor
Liver Disease
DIC
Consumptions Coagulopathies
Vitamin K deficiency
Platelets defects
ITP
Renal impairment
Myelo-proliferate Disorders
Hemophilia
A
= F VIII deficiency
B = F IX deficiency
Affects one in 6000 males
A is 5 X > B
Mild >5,Moderate 2 -5, severe < 2 %
Levels remain stable throughout life
Both HA & HB are X linked
Clinical presentation
<
2 years: joint bleeds
– Rare
– Only bruising or mouth bleeds are seen
– Head injuries are a major concern
> 2 years
– Joint and muscle bleeds become more
common
Indication For Replacement
All
joint bleeds: Pain, swelling
,warmth or loss of movement .
Muscle bleeds : severe pain or are
in a dangerous location
Bruises usually don’t need
treatment
Treatment
Keep
weight off of joint
Ice pack
Factor replacement - the sooner
the better
Amicar or tranexamic acid : mouth
bleed
Factor replacement
Derived
from pooled human plasma
Derived from pig (porcine) plasma
Recombinant products
Factor VIII (AHF)
Mechanism of action
No tool to predict the efficacy
Allergic reactions
Transient (short t ½)
Expensive.
Risk of transmission of infection
Biotech Development of
Recombinant Factors
Amplification
Human FVII gene
hF
Gene
Single copy
of gene isolated
Liver gene library
hF
gene
®
Activation
and Purification
Expression of
rF in culture medium
hF = human factor
BHK = baby hamster kidney
BHK cells
Recombinant Factors
Advantages :
Safe and stable source of the agent
When sources are scarce
Problems :
Contaminating proteins :Infectious or
immunogenic agent
Expensive
Genetic Study
Study the development of inhibitors.
Gene Transfer
Sustained therapeutic production of factors
with No stimulation of an immune response .
The Tools of Genetic Engineering
DNA
gene fragment of interest
Endonucleases
Plasmid
Ligase
Host that is capable of accepting DNA
Insertion into the genetic machinery
Confirm that the gene is inserted.
Purify the protein of interest
Gene Transfer Clinical Trials
5
trials approved in the States .
Retroviral vector :B-domain deletion
Non-viral approach :reduction factor use
& spontaneous bleeding episodes.
Gutless adenovirus : eliminate immune
response
Results Of Clinical Trials
Long-term
therapeutic expression not
achieved, but data are encouraging.
Detectable factor levels observed.
The subjective : decreased bleeding .
No evidence of inhibitor.
Hepatic toxicity , thrombocytopenia.
Decline expression .
Shortcoming Of Treatment
Modalities
Short T 1/2
Coast
Infections & Immunologic
Hepatic toxicity ,low platelets
Decline expression.
Owing to the shortcoming of treatment
Modalities prompted the need for anew
hemostatic agent.
Initiation of Haemostasis
X
TF
IX
XIa
VIII/vWF
VIIa
TF-bearing cell
TF VIIa
IXa
X
X
IXa VIIIa
IX
prothrombin
Xa
Va
prothrombin
Xa Va
activated platelet
thrombin
platelet
thrombin
VIIIa
V
Va
XI
XIa
Fibrinogen
Fibrin
TF–independent mechanism of rFVIIa
enhanced hemostasis
Rational
Thrombin
crucial role in haemostasis.
Any agent that enhances the thrombin
generation 'general haemostatic agent'.
rFVII enhances thrombin generation on
activated platelets
Compensates for lack of FVIII and FIX.
Normalize fibrin clot permeability
Pharmacokinetic
t½ :2.7 h
Inter-subject variability.
Rapid clearance in children > adults.
No readily available assays
The haemostatic levels remains
uncertain.
Frequent bolus injections, IVI potential
to minimize usage.
Potential Use
Increases thrombin generation on activated
platelet
– Hemophilia (FVIII/FIX deficiency)
– Acquired hemophilia.
– Platelet disorders qualitative and quantitative
– Diffuse bleeding triggered by surgery and trauma.
Impaired initial hemostasis
– FVII-deficiency
– Liver disease
– Oral anticoagulant therapy
Hemophilia with inhibitors
FDA Approved Feb 1999
Bleeding during or prior to ITI therapy.
Control bleeding during surgery.
Safe and effective in 92% hemophilia
research society registry
Inhibitor titres are not boosted.
Home treatment: mild-moderate episodes.
Recommended dose 60-120 ug/kg q 2 -6 h or
IVI.
Acquired Hemophilia
Rare
but potentially life-threatening
condition mortality rate 20%.
Auto-antibodies against the deficient
factor.
rFVIIa is effective in major bleeding
Induces haemostasis independent of the
presence of FVIII or FIX.
Well tolerated in these patients
Liver Disease
Reduction
in the synthesis of factors
involved in coagulation and fibrinolysis.
Moderate thrombocytopenia.
Upper gastrointestinal tract.
Vitamin K .
FFP
PCCs : thromboembolic complications.
rFVII &Liver Disease
Acute
hepatic trauma, liver biopsy,
chronic liver disease ,cirrhosis, and
liver transplantation.
Experimental studies :seems to be safe
and effective.
No evidence of thrombosis .
Cirrhosis , achieved hemostasis in 74%
Jeffers et al
The Risk Of Thrombosis In LIVER
Patients
No
evidence of dose relationship
Many events have an alternative
aetiology
Few events within the first day after
dosing
No increase in events as compared with
background transplant population
Drug-Induced Coagulopathy
Oral anticoagulant treatment hemorrhage
:0.6%/ m .
Vitamin K, FFP or PCCs
rFVIIa in healthy volunteers :50% drop of
INR
Girard et al
An open, multicenter pilot trial is underway to
determine the efficacy
Fondaparinux. normalized PT, aPTT, and TT.
Bijsterveld et al
Glanzmann’s Thrombasthenia
Refractory to platelet transfusion
Increases the initial thrombin generation,
thereby compensating for defective platelet
Effective in 60% during surgery .
No adverse effects of rFVIIa
International registry data :relatively safe
and effective when used in GT.
Blood 1999; 94 (11): 3951-3953
Thrombocytopenia
Increased thrombin generation on
activated platelets compensate for the
low platelet number.
Reduction in bleeding time in 52.4% of
105 patients .
Kristensen et al
No
major adverse
Surgical &Trauma patients
Effective and safe in the management of
uncontrolled surgical in patients not known to
have inherited coagulopathy.
Trauma :surgical intervention failed to stop
life- threatening bleeding.
– Significant decrease to 2 packed RBC
– Shortening of PT & aPTT
Adjunctive hemostatic treatment
Theoretical risk of TED ,none observed
Building Strong Scientific
Evidence
Clinical area
Liver transplantation
Upper GI bleeds
Liver resection
BMT
Reversal of OAC
Traumatology
Status on project
Ph 2 study
Ph 2 study
Ph 2 study
Ph 2 study
Ph 2 to be started
Ph 2 to be started
Questions more than answers
Optimal
dosage.
Dosing interval.
Adjunctive hemostatic treatment .
‘General haemostatic agent.
Thromboembolic events .
Coat analysis studies.
Need for evidence-based guidelines
Local experience
Acquired
Hemophilia
Fresh PR bleeding
FFP. Cryoppt,FVIII conc
In preparation for molar root extract
FVIII conc 100IU/Kg
rFVII 30IU
Normal hemostasis
Tranexamic acid
Thank You
Amount of thrombin formed in the
initial burst is critical to assure
1.
assembly of a thick, strong fibrin
plug
2.
activation of FXIII to cross link
fibrin
3.
activation of TAFI to make
fibrin plug resistant to fibrinolysis
RNA repair
Pre-messenger RNA (pre-mRNA) repair.
splicing mechanisms to correct a portion of
the defective RNA.
The advantage :large genes or genes that
contain large regulatory elements.
Injection of a plasmid encoding a pre-mRNA
Useful for the treatment of autosomal
dominant disorders.
Inhibitors &Gene Transfer
Inhibitors :20% HA patients and 3% of HB
patients.
Antibodies inactivate the factor by changing
conformation.
Depends on type of genetic mutation.
A large deletion incidence of inhibitor .
Bleeding episodes are difficult to manage
Human/porcine
factor VIII
FEIBA