Rare Bleeding Disorders (RBDs)Rare Bleeding Disorders (RBDs)

Flora PeyvandiHemophilia and Thrombosis Center,

University of Milan

ISTH Educational Course: Advanced Course in

Haemostasis and Thrombosis

Moscow, September 17-19, 2014

Bleeding disorders

• Hemophilia A and B (prevalence 1:5,000 and 1:30,000)

• von Willebrand disease (VWD) (prevalence 1:100)

• Platelet disorders (prevalence 1:1,000,000)

• Rare bleeding disorders (deficiency of fibrinogen, FII, FV, FV+FVIII, FVII, FX, FXI and FXIII) (prevalence ranging from 1:500,000 for FVII deficiency to 1:2 million for FII and FXIII deficiencies)

Erhardtsen http://www.springerreference.com/index/chapterdbid/33723 2012Poon M-C et al. Vasc Health Risk Manag 2007;3:655–64Peyvandi F et al. Semin Thromb Hemost 2009;35:349–355Bolton Maggs P Pediatr Blood Cancer 2013;60(Suppl 1):S37-40

Inherited bleeding deficiencies affect 65,000 people in Europe

• RBDs represent 3-5% of all inherited coagulation deficiencies

• Usually transmitted as autosomal recessive traits• In some countries, prevalence is higher due to

consanguineous marriage

• Epidemiology

• Data collection: registers

• Clinical manifestations

• Phenotype diagnosis

• Association between laboratory phenotype and clinical severity

• Genotype characterization

• Treatments and available products

Outlines of discussion on RBDs

Epidemiology

WFH WORLD EU

N° of countries 109 28

N° of people identified with HA and B 172,373 44,49

4

N° of people with VWD 66,144 34,51

8

N° of people with rare coagulation disorders 17,519 8,959

N° of people with platelet disorders 11,430 2,716

N° of people with unknown type of hemophilia or coagulation disorder

4,192 1,763

Total 271,658 92,450

Funded by the European Community - action programme for public health (DG SANCO)

Survey updated to December 2013 (http://www1.wfh.org/publications/files/pdf-1574.pdf)

World map of bleeding disorders other than hemophilia and VWD

Bleeding disorders in Russia

Uncertain diagnosis

Data collection: registers

• Improving knowledge on prevalence

• Observing course of disease

• Understanding variations in symptoms

• Associating the laboratory phenotype and clinical picture

• Monitoring treatments

• Assessing effectiveness of existing treatments

F. Peyvandi, M. Spreafico. Blood Trand 2008; 6(Suppl. 3):s34-8.Soucie JM et al. Am J Prev Med 2010; 38:S475-81.Orphanet Report Series – Rare Disease collection. Rare Disease Registries in Europe. Jan 2014

National registries in EU

Belgian patient registry for rare

bleeding disorders

FranceCoag: French prospective cohort of patients affected with haemophilia or

severe form of other hereditary

hemorrhagic diseases except

platelet disorders

Austrian Haemophilia Registry

Serbian registry of patients with rare bleeding disorders

Slovenian registry of patients with inherited bleeding disorder

EMOWEB: Italian registry of

coagulopathies

Registry of inherited bleeding disorders in

Emilia Romagna region

UK - NHD: national haemophilia database

DHR: German Haemophilia Registry

European network of Rare Bleeding Disorders (EN-RBD)

PRO-RBDD : Prospective data collection on patients with coagulation fibrinogen and factor XIII deficiencies

Clinical manifestationsHighly variable bleeding tendency

• The most typical symptoms are- mucosal tract bleedings- excessive bleeding at the time of invasive procedures, - Bleeding at labour and delivery in women, bleeding after circumcision in affected

boys• CNS bleeding, umbilical cord bleeding, hemarthroses and soft tissue haematomas

are frequent in fibrinogen, FVII, FX and FXIII deficiencies• GI bleeding occurs mainly in FX deficiency

• Peyvandi F et al. Semin Thromb Hemost 2013;39:579-84; Peyvandi F et al. Hematology Education Book 2010;4(1):63-68; Karimi M et al. Haematologica 2008;93:934-938; Mariani G et al. Thromb Haemost 2005;93:481-7

• Heterozygous patients (coagulant activity level >30%):– 20% have mucocutaneous bleedings and bleeding during surgery – Post-traumatic hemarthrosis and hematomas are rarely reported in FVII and FX

deficiencies– Menorrhagia, spontaneous abortion and bleeding during vaginal delivery were

reported in roughly 20% of women with all type of deficiencies

Menstruation

Pregnancy

Delivery

• Bleeding during pregnancy • Miscarriage

• Post-partum hemorrhage

• Menorrhagia

Age

Women with RBDs: clinical problems

Kadir R and James A WFH Reproductive health in women with bleeding disorders 2008

Bleeding disorder Menorrhagia Abortion Post partum haemorrhage

Rare bleeding disorders

35-78%(Lak 1999, Siboni 2009, James 2010,

Khair 2013, Mariani 2013, Shetty 2014, Napolitano 2014)

Afibrinogenemia 30-50%Hypofibrinogenemia 29%Dysfibrinogenemia 38%

FXI 10%FXIII 50-63%

(Goodwin 1989, Haverkate 1995, Burrows 2000, Lak 2003, Myers 2007,

Mensah 2011)

Hypofibrinogenemia 45%FV 76%

FVII,FX,FXI,FXIII high rates(Goodwin 1989, Noia 1997, Kadir 1998, Burrows

2000, Kulkarni 2006, Teixeira 2012, Baumann Kreuziger 2013)

Haemophilia A and B carriers

10-67%(Siboni 2009, James 2010, Khair 2013)

14-20%(Chi 2008, Knol 2010)

the most significant cases in women with FVIII <50% and no

hemostatic coverage during labor and postpartum

(Kadir et 1997)

VWD32-100%

(Lak 2000, Siboni 2009, James 2010 and 2011,

Khair 2013)

15-25%(Kadir 1998, Kirtava 2003)

16-29% primary20-29% secondary

(Ramsahoye 1995, Kadir 1998)

Glanzmann’s thrombasthenia

50-98%(James 2010, Khair

2013)

11% (Siddiq 2011)

34% primary24% secondary

(Siddiq 2011)

Prevalence of obstetric-gynecological symptoms

Full references in slide notes

• Anemia due to iron deficiency• Dysmenorrhea• Hysterectomy: effective and definitive treatment

- However, it is a major surgical procedure with significant physical and emotional complications and social and economic costs

• Maternal death (post-partum bleeding)

Complications in women12

Peyvandi F Expert Opinion 2014

Geographical variation in causes of maternal death

Khan K et al. Lancet 2006;367:1066–74

*Represents HIV/AIDS. †Represents embolism. ‡Represents ectopic pregnancy. §Represents anaemia.

Phenotype diagnosis

aPTT PT

TT

TR

D-Dimer

Fibrinolysis

VII

Tissue factor + calcium

Extrinsic pathway

Trombin

Fibrinogen Fibrin

Reptilase

(XII)

XIIX

VIII

Kallikrein + Kininogen + calcium

Intrinsic pathway

X

II

V

XIII

Screening tests

aPTT and PT tests:• Usually sensitive enough to detect abnormal coagulant factor actiivity:

fibrinogen, FII, FV, FV+FVIII, FVII, FX and FXI• May be normal in mild deficiencies, especially fibrinogen and FII • Normal in FXIII deficiency

Mixing tests:• Correction of the abnormality indicates that a factor deficiency• No correction indicates presence of an inhibitor

TT test:• Required for the diagnosis of fibrinogen deficiency

Interpretation in relation to the personal and family history

Kitchen S, McCraw A, Echenagucia A. Diagnosis of Hemophilia and Other Bleeding Disorders. A LABORATORY MANUAL. Second Edition. WFH 2010

Factor activity level• One-stage coagulation assays:

- aPTT based – FXI deficiency- PT based – FII, FV, FVII, FX deficiencies

• Fibrinogen assays• FXIII assays

Factor antigen level• Immunochemical methods

Specific factor assays

Not mandatory except for fibrinogen and FII deficiencies.

Kitchen S, McCraw A, Echenagucia A. Diagnosis of Hemophilia and Other Bleeding Disorders. A LABORATORY MANUAL. Second Edition. WFH 2010Peyvandi F et al. Semin Thromb Hemost 2009; 35(4): 349-55.

Fibrinogen activity assays

• Clauss fibrinogen assay• PT-derived Fg assay

Recommendations• Clauss fibrinogen assay remains the reference method• PT-Fg assays are not recommended for routine clinical use

Mackie IJ et al. Guidelines on fibrinogen assays. Br J Haematol 2003; 121: 396-404.

Levels measured by different assays may vary significantly

Uncertainty in assigning the severity of the hypofibrinogenemia

FXIII activity assays

• Clot solubility assay• Functional FXIII activity assays:

- Photometric assays- Fluorimetric assays- Putrescine incorporation assays

Note• Association in patients with FXIII < 5% is

difficult to interpret and may not be accurate• Clot solubility assay is no longer

recommended since it is qualitative, poorly standardized, and detects only severe FXIII deficiency

Schroeder V et al. FXIII deficiency: An Update. Semin Thromb Hemost 2013; 39: 632-41

Recommendations by the FXIII and Fibrinogen SSCsubcommittee of the ISTH

1. First-line screening testQuantitative functional FXIII activity assay

If FXIII activity is decreased

2. Establish subtype of FXIII deficiencyMeasurement of antigen concentration(FXIII-A2B2, FXIII-A, FXIII-B)

Only in case of suspected acquired FXIII deficiency:3. Detection of autoantibodiesMixing study (detection of neutralizing antibodiesagainst FXIII-A)Binding assay (detection of nonneutralizing antibodies)

For research purpose only:Characterization of molecular genetic defect

Phenotype diagnosis: a summary

Second screeningTT PT APTT activity antigen

Afibrinogenemia no no Low erythrocyte sedimentation rates

Hypofibrinogenemia TT is the most sensitive

Dysfibrinogenemia normal normal When activity is normal, gnetic mutations is nedeed

FII, FV, FV+FVIII, FX normal normal -

FVII normal normal normal

PT performed with rTF is extremely sensitive to tiny amount of FVII, attention needs to be payd to level <1%

FXI normal normal normal -

FXIII normal normal normal

First screeningDeficiency Notes

If plasmatic FXIII-A2B2 :FXIII-A in plasma and platelet lysate could be or normal (FXIII-B >30%)FXIII-B in plasma and in platelet lysate

Problems with clotting assaysDespite the existence of recommendations, a number of problems still remain, particularly for some deficiencies (Fibrinogen and FXIII):

─ Assay accuracy at low factor levels─ Lack of standardization – high inter-laboratory variability

Laboratory phenotype and clinical severity

• 3 years of data collection • 13 European centers from 11 countries• 489 patients registered in the database

Assigned categories of clinical bleeding severity

• Peyvandi F et al J Thromb Haemost2012;10:615-621

Linear regression analysis: adjusted for age, gender, and country where diagnosis was made

Excellent correlation Good correlation No correlation

Factor activity (Y) = Beta* Bleeding severity (X) + Constant

Results

SSC – ISTH recommendations on RBDS

Coagulant factordeficiency

Laboratory phenotype

Severe (coagulant activity associated

with spontaneous major bleeding)

Moderate(coagulant activity associated with minor spontaneous or

triggered bleeding)

Mild(coagulant activity associated with a mostly asymptomatic

disease course)

Coagulant activity

Fibrinogen undetectable clot ≤0,1 g/L >0,1 g/L

FII undetectable activity ≤10% >10%

FV undetectable activity 10% ≥10%

FV+FVIII <20% 20-40% >40%

FVII <10% 10-20% >20%

FX <10% 10-40% >40%

FXIII undetectable activity 30% ≥30%

Do clotting factor levels predict severity?

• The relationship between coagulation factor activity level and clinical bleeding severity is heterogeneous

• A strong association exists for fibrinogen, FX and FXIII deficiencies • No association for FXI deficiency• The minimum factor levels to prevent spontaneous major

bleeding is different in various deficiencies

It is not appropriate to use a single criterion of classification for all types of RBDs

Global hemostasis assaysTests investigating the global hemostatic capacity could help:- to predict clinical phenotype - to determine the effectiveness of therapies - to monitor treatment particularly FXI deficiency where standard assays fail to correlate with bleeding risk

TGT TEG

• Recently, these tests have been used to evaluate hemostasis in patients with RBDs, specifically FV and FXI deficiency

• However test standardization to reproduce reliable measurements facilitated by standardized pre-analytical and analytical procedures is required before widespread clinical use.

• In global hemostasis assays, a number of barriers may prevent implementation and quality assurance. Quality assurance studies have observed that regular proficiency testing is needed to ensure accuracy of such methods

Al Dieri R et al, Thromb Haemost. 2002; Strey RF et al, Pathophysiol Haemost Thromb. 2005; Schols SE et al, Thromb Haemost 2008; Rugeri L et al, Haemophilia 2010; Guegen P et al, Br J Haematol 2011; Riddell A et al, Thromb Haemost 2011: Van Geffen M et al, Haemophilia. 2012; Spiezia L et al, Haemophilia. 2012; Livnat T et al. Blood Coag Fibrynol 2012

Genotype characterization

• Currently based on the mutation search in the genes that encode each corresponding coagulation factor

• Exceptions:- combined deficiency of coagulation FV and FVIII (mutations in genes for

FV and FVIII intracellular transport – MCFD2 and LMAN1)- combined deficiency of the vitamin-K-dependent proteins (mutations in

genes for post-translational modifications and vitamin K metabolism (GGCX and VKORC1)

• Pattern of inheritance is autosomal recessive for all RBDs, except for some cases of FXI, where some missense mutations were shown to exert a dominant negative effect, and of dysfibrinogenemia

• 5-10% of patients remain with no identified genetic defect

• The use of next generation sequencing (NGS) might help to identify novel pathways in coagulation disorders

• While the potential of these genome-wide strategies is indisputable, these approaches have yet to be utilized in the analysis of RBDs for which causative mutations remain elusive

Type of deficiency Gene Indels (%) Missense (%) Nonsense (%) Splicing (%) 3'-5' UTR (%)

FibrinogenFGAFGBFGG

20,9 57,3 11,5 7,5 2,8

FII F2 13 77,8 5,5 3,7 0

FV F5 27,3 48,5 12,9 11,3 0

FV+VIIILMAN1 50 8,8 20,6 20,6 0

MCFD2 27,3 50 4,5 18,2 0

FVII F7 12,3 62,2 7,8 11,5 6,2

FX F10 10,5 80 1,9 7,6 0

FXI F11 10,4 70 10,5 8,2 0,9

FXIII F13 29 47,1 9,1 14 0,8

Vit-K factorsGGCX 10 60 0 30 0

VKORC1 0 100 0 0 0

• Peyvandi F et al. Blood 2013;122:3423-31.

Mutations causing RBDs

Treatment of RBDs

Non-transfusional treatment:• antifibrinolytic amino acids• fibrin glue• oestrogen-progesterone preparations• desmopressin (DDAVP)

Replacement therapy:• FFP• Cryoprecipitate (also virus-inactivated)• prothrombin complex concentrates (PCC)• single factor concentrates (plasma-derived or recombinant)

Flora Peyvandi

Registered RBDs concentrates

Registry of Clotting Factor Concentrate, Ninth EditionMark Brooker, WFH

PCC FIBRINOGEN FV FVII FX FXI FXIII FVIII FIX0

5

10

15

20

25

30

35

40

15

4

0

4

12 2

39

18

Novel PD concentrates: ongoing studies

• Fibrinogen ─ NCT01575756 – Octapharma (safety/efficacy, phase 2)─ NCT02065882 – Biotest (PK/safety/efficacy, phase 1-2) ─ NCT00916656 – CSL (Phase 3b non inferiority safety/efficacy - withdrawn prior

to enrollment)─ NCT02094430 – LFB (Phase 2-3 - clinical pharmacology/efficacy/safety in

paediatric patients)─ FIBGrifols

• FX (high purity)─ NCT01721681 – BPL (prophylaxis in <12 years, phase 3)

• FV ─ Only recently a concentrate has been developed. Preclinical studies are

currently being performed for the orphan drug designation application (EMA and FDA)

Deficient factor Plasma half-life Recommended

trough levels On demand dosagesRecommended trough levels to

maintain asymptomatic state after publication of the EN-RBD results

Fibrinogen 2–4 days 0.5-1g/LCryoprecipitate (15-20 mL/kg)SD-treated plasma (15–30 mL/kg)Fibrinogen concentrate (50–100 mg/kg)

1 g/L

Prothrombin 3–4 days 20–30% SD-treated plasma (15–25 mL/kg)FIX concentrate and PCC (20–40 units/kg) >10 %

Factor V 36 hours 10–20% SD-treated plasma (15–25 mL/kg) 10%Factor V and factor VIII

FV 36 hoursFVIII 10–14 hours 10–15% As for FV 40%

Factor VII 4–6 hours 10–15%FVII concentrate (30–40 mL/kg)PCC (20–30 units/kg)rFVIIa (15–30 μg/kg every 4–6 hours)

>20%

Factor X 40–60 hours 10–20%SD-treated plasma (10–20 mL/kg)PCC (20–30 units/kg)FX/FIX concentrate (10–20 units/kg)

>40%

Factor XI 50 hours 15–20% SD-treated plasma (15–20 mL/kg)FXI concentrate (15–20 units/kg) 15-20%

Factor XIII 9–12 days 2–5%

Cryoprecipitate (2–3 bags)SD-treated plasma (3 mL/kg)FXIII concentrate (till 50 units/kg for highhemorrhagic events)rFXIII-A (35 units/kg)

30%

Vitamin K dependent

Vitamin K (10 mg) IV. or SC. for minor bleedingPCC (20–30 units/kg) with vitaminK (5–20 mg) for severe bleeding or major surgeryFFP 15–25 ml/kg is an alternative to PCC

No data available

On-demand treatment

Peyvandi F. Haemophilia 2002; Mannucci PM. Blood. 2004; Peyvandi F et al J Thromb Haemost2012;10:615-621; Mumford AD, Br J Haematol 2014

Prophylaxis

The choice of prophylaxis is related to:– the frequency of bleeding– the risk of severe spontaneous bleeding– the risk of long-term disabilities associated with the occurrence of

bleeding in a particular region of the body despite on-demand treatment (e.g., CNS, GI and joint bleedings)

Deficient factor Recommended trough levels

Reported dose schedule for successful long-term prophylaxisNotes

Products Dose Frequency

Fibrinogen 0.5-1g/LCryoprecipitate

1 unit 3 times/weekAfibrinogenemic patients with

recurrent life-threatening bleedings or undergoing surgeries

3 units Every 7–10 daysFibrinogen concentrate 30–100 mg/kg Every week

Prothrombin 20–30% PCC 20–40 units/kg 1/ week —

Factor V 10–20% SD-treated plasma 20-30 mL/kg 2/week Only in patients with life-threatening bleedings, as CNS

Factor V and Factor VIII 10–15% No data —

Factor VII 10–15%SD-treated plasma 10–15 mL/kg 2/week Prevention of bleeding during

surgery or in children with recurrent hemarthrosis or CNS

pdFVII 10–40 units/kg 3 times/weekrFVIIa 20–40 µg/kg 2-3 times/week

Factor X 10–20%PCC 20–40 units/kg 2-3 times/week Patients with recurrent life-

threatening bleedings or undergoing surgeriesFX/FIX concentrate

20–40 units/kg1-2 times/week

Factor XI 15–20% No data —

Factor XIII 2–5%

Cryoprecipitate 2 units Every 3 weeks

Highly recommended in severe patients

SD-treated plasma 15–20 mL/kg Every 4–6 weeks

FXIII concentrate 10-40 units/kg Every 4–6 weeksrFXIII-A 35 units/kg Every 4

Vitamin K dependent

Vitamin K 5-20 mg 1/week orally—

Mannucci PM. Blood. 2004; Castaman G. Blood Transfusion 2008; Mumford AD, Br J Haematol 2014

Prophylactic treatment

• Due to the RBDs rarity, little information is available on the optimal management of patients with these disorders, particularly on long-term prophylaxis

• In addition, the technical limitations of laboratory testing, particularly in patients with factor activity <5%, make difficult to adopt the appropriate prophylactic treatment

• To overcome these limitations, new strategies are required:– creation of global partnerships– networking between treatment centers– increasing the support provided by public health organizations– Prospective data collection– Better and more sensitive assays

Conclusion

The needs

SPECIALISED CARE

IN HOSPITALSInstitutions

FUNDING AND COORDINATION

Patients association

TRAINING AND SUPPORT

Companies

NEW PRODUCTS

CLINICAL AND SCIENTIFIC RESEARCH

PreventionEarly diagnosis

Assays developmentData collection

Clinical trialsGuidelines

DATA COLLECTION

“The PRO-RBDD project”

Write toinfo@rbdd.eu

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ACKNOWLEDGMENTS

• European Commission

• Executive Agency for Health and Consumers (EAHC)

• European Commission

• Executive Agency for Health and Consumers (EAHC)

• Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico

• University of Milan

• Luigi Villa Foundation

• Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico

• University of Milan

• Luigi Villa Foundation

• The European Hemophilia Network project (EUHANET)

• The European Hemophilia Network project (EUHANET)

• Novo Nordisk Health Care AG (for Extra-EU support

• Novo Nordisk Health Care AG (for Extra-EU support

All patients and clinicians who are collaborating with usAll patients and clinicians who are collaborating with us