Advancing personalized care in hemophilia A: ten years' experience with an advanced category antihemophilic factor prepared using a plasma/albumin-free method

Erik Berntorp, Gerald Spotts, Lisa Patrone, Bruce M Ewenstein, Erik Berntorp, Gerald Spotts, Lisa Patrone, Bruce M Ewenstein

Abstract

Detailed analysis of data from studies of recombinant antihemophilic factor produced using a plasma/albumin-free method (rAHF-PFM) in previously treated patients showed a substantial level of interpatient variation in pharmacokinetics (PKs), factor VIII dosing, and annualized bleed rate (ABR), suggesting that individual patient characteristics contributed to outcome. For example, plasma half-life (t1/2), recovery, and clearance appeared to differ between patients aged <6 years and 10-65 years. Prophylaxis resulted in lower ABRs than episodic treatment in both age groups; better adherence to the prophylactic regimen resulted in a lower ABR in patients aged 10-65 years. The weekly frequency of dosing and adherence to dosing were both significantly and inversely related to the rate of bleeding (young children, P<0.0001 for both all bleeds and joint bleeds; older patients, P<0.0001 for all bleeds and P<0.05 for joint bleeds), as was adherence to dosing frequency (P<0.0001 for all comparisons). A post-marketing randomized study of prophylaxis demonstrated that a PK-guided dosing regimen, based on an individual patient's rAHF-PFM PK (infusion interval, estimated t1/2, and recovery), was as effective as standard prophylaxis and that both prophylactic regimens were superior to episodic treatment with respect to ABR and quality of life measures. Thus, compared with standard prophylaxis, the PK-guided regimen achieved comparable efficacy with fewer weekly infusions. A two-compartment population PK model describes the PK data across the entire age range and forms the basis for future PK-guided therapy with rAHF-PFM. The model confirmed a shorter t1/2 and faster clearance of rAHF-PFM in children <6 years of age versus patients ≥10 years and predicted similar PK parameters with either a full or reduced blood sampling schedule, offering the potential for the use of PK-guided, individualized treatment in the routine clinical care setting.

Keywords: ADVATE; FVIII; individualized; pharmacokinetics; prophylaxis; rAHF-PFM.

Figures

Figure 1
Figure 1
Chronology of observations from studies of rAHF-PFM leading toward personalized care for patients with hemophilia A. Abbreviations: ABR, annual bleed rate (bleeds/patient/year); HRQOL, health-related quality of life; M-W-F, Monday-Wednesday-Friday; PK, pharmacokinetic; Tx, therapy; FVIII, factor VIII; rAHF-PFM, recombinant antihemophilic factor produced using a plasma/albumin-free method.
Figure 2
Figure 2
Predicted annual joint bleed rate as a function of time spent with factor (F)VIII Notes: Open circles (○) represent patients aged 1–6 years; asterisks (*) represent patients aged 10–65 years. Reprinted with permission from John Wiley and Sons. Collins PW, Blanchette VS, Fischer K, et al; rAHF-PFM Study Group. Break-through bleeding in relation to predicted factor VIII levels in patients receiving prophylactic treatment for severe hemophilia A. J Thromb Haemost. 2009;7(3):413–420. Copyright © International Society on Thrombosis and Haemostasis.
Figure 3
Figure 3
Study design for comparison of standard prophylaxis, PK-guided prophylaxis, and episodic treatment with rAHF-PFM. Abbreviations: ABR, annual bleed rate (bleeds/patient/year); EDs, exposure days; HRQOL, health-related quality of life; PK, pharmacokinetic; FVIII, factor VIII; rAHF-PFM, recombinant antihemophilic factor produced using a plasma/albumin-free method; q, every.

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