MASAC Document 290 - MASAC Recommendations Concerning Products Licensed for the Treatment of Hemophilia and Selected Disorders of the Coagulation System

Revisions: 284, 280, 276, 272, 263, 259, 253, 250, 249, 246, 240, 237, 235, 230, 225, 218, 217, 215, 210, 205, 202, 195, 190, 187, 182, 177

1. Recommendations for Healthcare Providers and Physicians Treating Patients with Hemophilia A and B, von Willebrand Disease, and other Congenital Bleeding Disorders

1. Treatment of Hemophilia A

1. Recombinant Factor VIII Concentrates

Recombinant (r) factor VIII (FVIII) is often produced by two well-established hamster cell lines, baby hamster kidney (BHK) and Chinese hamster ovary (CHO), that have been transfected with the gene for human FVIII (F8). (1, 2) Two newer rFVIII products are produced in human embryonic kidney (HEK) cell lines. In some products, the rFVIII is full length, while in other products the B-domain is largely deleted. Either 14, 16 or 21 amino acids of the B-domain remain in the rFVIII, depending on the product. (3)

First generation rFVIII contains animal and/or human plasma-derived proteins in the cell culture medium and in the final formulation vial. Second generation rFVIII contains animal or human plasma-derived proteins in the culture medium but not in the final formulation vial. Third generation rFVIII does not contain any animal or human plasma-derived proteins in the culture medium or in the final formulation vial.

One third generation rFVIII product that is fused to the Fc fragment of human IgG (rFVIIIFc) inhibits lysosomal degradation of rFVIII by reticuloendothelial cells, thus prolonging FVIII half-life in the circulation. Another FVIII product (antihemophilic factor (recombinant), Fc-VWF-XTEN fusion protein-ehtl) incorporates Fc fusion as well as two XTEN polypeptides and the D’D3 domain of von Willebrand Factor (VWF) to further prolong FVIII half-life. These products are made in HEK cells. No additives of human or animal origin are used in the production of either product. (4)

Three other third generation recombinant FVIII products, two produced in CHO and one in BHK cells, are PEGylated to delay degradation and thereby prolong their half-lives. No additives of human or animal origin are used in the production of these products.

The risk of human viral contamination associated with rFVIII is exceedingly low. No seroconversions to human immunodeficiency virus (HIV), hepatitis B (HBV) or hepatitis C (HCV) have been reported with any of the currently available rFVIII products.

rFVIII products are the recommended treatment of choice for patients with hemophilia A. A possible exception to this recommendation is a newly diagnosed individual, who should also consider with their healthcare providers initiating treatment with a plasma-derived FVIII / von Willebrand Factor (VWF) product (see MASAC Recommendation on SIPPET, Document #243). (Table I)

1. Plasma-Derived Factor VIII Concentrates

Improved viral-depleting processes and donor screening practices have resulted in plasma-derived (pd) FVIII products that have greatly reduced risk for transmission of HIV, HBV, and HCV. No seroconversions to HIV, HBV, or HCV have been reported with any of the pdFVIII products currently marketed in the United States, including products that are dry-heated, heated in aqueous solution (pasteurized), solvent-detergent treated, and/or immunoaffinity purified. Thus, each of these methods appears to have greatly reduced the risk of viral transmission compared to older methods of viral inactivation (5-7).

There remains the slight possibility of HIV, HBV, or HCV transmission with the use of currently marketed, viral-inactivated, plasma-derived products. The non-lipid enveloped viruses human parvovirus B19 and hepatitis A virus were also previously transmitted by pdFVIII (8-10); however, additional steps such as nanofiltration have been added to the manufacturing process to reduce risks of these viral infections as well. (Table I)

1. Bispecific Antibody for Hemophilia A
   1. Emicizumab-kxwh

Emicizumab is a humanized, bispecific, monoclonal antibody that binds to FIX / FIXa and FX / FXa, thereby standing in for the missing FVIII to prevent or reduce the occurrence of bleeding in patients with hemophilia A. It was shown in phase 3 clinical trials to be safe and effective in adults, adolescents, children, and infants with hemophilia A with and without inhibitors (11-13). Subcutaneous administration of emicizumab is often viewed as being easier and/or less time consuming compared to intravenous administration of FVIII. Dosing intervals are also much longer than FVIII, with prophylaxis regimens for emicizumab with weekly, every 2 weeks, or every 4 weeks dosing. In those undergoing major surgery, preliminary experience suggests standard preoperative dose FVIII and tapering postoperative doses may be safe and effective, while in some minor surgeries, low dose or no FVIII may be appropriate. (14) (Table V)

1. Cryoprecipitate Not Recommended for Hemophilia A

FVIII products are available that are manufactured by recombinant technology and thus theoretically do not transmit human viruses. Moreover, methods of viral inactivation (dry heat, pasteurization, solvent-detergent treatment, immunoaffinity purification) have resulted in a reduced risk of HIV, HBV and HCV transmission with pdFVIII concentrates (6-7, 15-17).

Despite donor screening by nucleic acid testing (NAT) for HIV, HBV, and HCV, cryoprecipitate might still be infectious. The current estimate for the risk of HIV or HCV infection from a single unit of blood is approximately one in 1,000,000 donations. (18)

For these reasons, cryoprecipitate, which has not had any viral elimination steps applied, should not be used as a treatment alternative for hemophilia A unless there is a risk to loss of life or limb and no FVIII concentrate is available.

1. Treatment of Mild Hemophilia A

Desmopressin (DDAVP) may be used for patients with mild hemophilia A who have been documented by a DDAVP trial to have a clinically significant rise in FVIII. DDAVP is available in both a parenteral form (DDAVP Injection) and a highly concentrated (1.5 mg/ml) intranasal spray formulation . (19) (Table I)

Desmopressin should not be used in certain categories of patients:

1. Children under the age of 2 years and

2. Patients with mild hemophilia A in whom desmopressin does not provide adequate FVIII levels for the specific intended treatment purpose. 

These patients should be treated as per section I.A.1 or I.A.2 above. 

Desmopressin should be used with caution in pregnant women during labor and delivery. (20)

In all patients, careful attention should be paid to fluid restriction since excessive water intake can lead to hyponatremia and seizures.

1. Gene Therapy

Valoctocogene roxaparvovec-rvox is a gene therapy product approved for use in adults with severe hemophilia A (congenital factor VIII deficiency with factor VIII activity < 1 IU/dL) without pre-existing antibodies to adeno-associated virus serotype 5 (AAV5) detected by an FDA-approved test. The gene therapy product uses an AAV5 vector for in vivo gene transfer and is administered by a single intravenous infusion. The safety and efficacy of valoctocogene roxaparvovec-rvox in patients with a history of FVIII inhibitors have not been established. Liver health should be assessed prior to gene therapy (e.g., by measuring hepatic enzymes and obtaining hepatic ultrasound and/or elastography). Recommendations for patient monitoring and management after gene therapy has been administered are discussed in MASAC Document 277 (MASAC Recommendations on Hemophilia Treatment Center Preparedness for Delivering Gene Therapy for Hemophilia) and will be expanded upon in forthcoming documents. (Table I)

1. Treatment of Hemophilia B

1. Recombinant Factor IX Concentrates

Recombinant FIX (rFIX) is produced in CHO or HEK cells; no human or animal plasma-derived proteins are used in the manufacturing process or in the final formulation vial (third generation products). Thus, the risk of human blood-borne viral contamination is much lower than for plasma-derived factor IX concentrates. (21)

Two third generation rFIX products are fused with either the Fc fragment of human IgG (rFIXFc) or with albumin (rFIX-FP), both of which inhibit lysosomal degradation of rFIX by endothelial cells. Another product is conjugated with PEG (N9-GP) to reduce clearance, thus prolonging the half-life of rFIX in the circulation. rFIXFc is produced in an HEK cell line (22), while rFIX-FP and N9-GP are produced in CHO cells (23). There are no human or animal proteins employed in the cell culture or in the final formulation vial (third generation recombinant product). (22)

rFIX products are the recommended treatment of choice for patients with hemophilia B. (Table II)

1. Plasma-Derived Factor IX Concentrates

Improved viral depleting processes and donor screening practices have resulted in pdFIX products with greatly reduced risk for HIV, HBV, and HCV transmission (24). Viral attenuation methods used in the production of pdFIX products that appear to be effective for reducing the risk of HIV and hepatitis are dry heating at 60oC for 144 hours, solvent-detergent treatment, vapor treatment, and sodium thiocyanate plus ultrafiltration. Purification steps involved in the preparation of the more purified pdFIX products are associated with loss of several additional logs of virus.

There remains the slight possibility of viral transmission with the currently marketed viral-inactivated, pdFIX products. Transmission of human parvovirus B19 and hepatitis A virus by these products did occur, but the risk has been reduced with the addition of viral attenuation methods such as nanofiltration. (Table II)

1. Gene Therapy

Etranacogene dezaparvovec-drlb is a gene therapy product approved for use in adults with congenital hemophilia B who currently use FIX prophylaxis therapy or who have current or historical life-threatening bleeding or repeated, serious spontaneous bleeding episodes. The gene therapy product uses an adeno-associated virus serotype 5 (AAV5) vector for in vivo gene transfer using a modified FIX Padua variant with a liver-specific promoter sequence. The drug is administered by a single intravenous infusion. The safety and efficacy of etranacogene dezaparvovec-drlb in patients with a history of FIX inhibitors have not been established. Patients considering gene therapy should be tested for anti-AAV5 neutralizing antibodies. Those with positive antibodies should discuss the impact on FIX expression with their healthcare team. Liver health should also be assessed prior to gene therapy (e.g., by measuring hepatic enzymes and obtaining hepatic ultrasound and/or elastography). Recommendations for patient monitoring and management after gene therapy has been administered are discussed in MASAC Document 277 (MASAC Recommendations on Hemophilia Treatment Center Preparedness for Delivering Gene Therapy for Hemophilia) and will be expanded upon in forthcoming documents. (Table II)

Fidanacogene elaparvovec-dzkt is a gene therapy product approved for use in adults with moderate to severe congenital hemophilia B who currently use FIX prophylaxis therapy or who have current or historical life-threatening bleeding or repeated, serious spontaneous bleeding episodes. The drug is not approved for individuals who have neutralizing antibodies to adeno-associated virus serotype Rh74var (AAVRh74var) capsid. The gene therapy product uses an adeno-associated virus serotype Rh74var (AAVRH74var) vector for in vivo gene transfer using a modified FIX Padua variant with a liver-specific promoter sequence. The drug is administered by a single intravenous infusion. The safety and efficacy of fidanacogene elaparvovec-dzkt in patients with a history of FIX inhibitors or hypersensitivity reactions to FIX products have not been established. Liver health should be assessed prior to gene therapy (e.g., by measuring hepatic enzymes and obtaining hepatic ultrasound and/or elastography). Recommendations for patient monitoring and management after gene therapy has been administered are discussed in MASAC Document 277 (MASAC Recommendations on Hemophilia Treatment Center Preparedness for Delivering Gene Therapy for Hemophilia) and will be expanded upon in forthcoming documents.

1. Treatment of von Willebrand Disease (VWD)

1. Desmopressin

Most persons with VWD type 1 may be treated with desmopressin, given either parenterally (DDAVP Injection) or by highly concentrated (1.5 mg/ml) nasal spray. Some VWD Type 2A patients may respond to DDAVP; a DDAVP trial should be done to determine whether DDAVP can be used for these patients. (19) (Table III)

Desmopressin should not be used in certain categories of patients:

1. Children under the age of 2 years and

2. Patients with VWD in whom desmopressin does not provide adequate VWF levels for the specific intended treatment purpose.

These patients should be treated as per section I.C.2 or I.C.3 below.

Desmopressin should be used with caution in pregnant women during labor and delivery. (20) (Table III)

In all patients, careful attention should be paid to fluid restriction since excessive water intake can lead to hyponatremia and seizures.

1. Recombinant VWF Concentrate

Recombinant VWF (rVWF) concentrate is available to treat patients with type 2B and type 3 VWD; it can also be used in patients with types 1, 2A, 2M, and 2N VWD who are not responsive to DDAVP and in children under 2 years of age regardless of VWD type. rVWF is approved for use as routine prophylaxis only in individuals with severe type 3 VWD who were previously treated with VWF (recombinant or plasma-derived) on-demand. It is produced in CHO cells; there are no human or animal-derived proteins used in its cell culture or in the final formulation vial (third generation rVWF). It contains ultra-large VWF multimers in addition to the high, medium, and low molecular weight VWF multimers normally found in plasma. There are trace amounts of rFVIII in the product as well. (25) (Table III)

1. Plasma-Derived VWF-Containing Factor VIII Concentrates

Certain viral-inactivated pdFVIII concentrates that are rich in VWF may be used in patients with certain types of VWD who do not respond to DDAVP, i.e. Type 2B VWD and Type 3 VWD, and also in patients with Types 1, 2A, 2M and 2N VWD who are unresponsive to DDAVP, as well as in surgical situations, and especially in young children under the age of 2 years. One plasma-derived product is approved for routine prophylaxis in children 6 years of age and older and adults with VWD. (26-31) (Table III)

1. Cryoprecipitate Not Recommended for VWD

Because it has not undergone any viral attenuation steps, cryoprecipitate should not be used to treat patients with VWD except in life- and limb-threatening emergencies when VWD-containing factor concentrate is not immediately available.

1. Treatment of Patients with Inherited Hemophilia A or B and Inhibitors to Factor VIII or Factor IX

Inhibitor development is the most severe complication of treatment for patients with inherited hemophilia A or B. The following products have been licensed for treatment and/or prevention of bleeding episodes in these patients with inhibitors. However, these products are not necessarily interchangeable. Choice of product depends on multiple factors, including type of inhibitor (low- or high-responding), current titer of inhibitor, location of the bleed, previous response to these products, availability of clinical trial data supporting use of these products, and concomitant medications (e.g., emicizumab). For high-titer inhibitors, immune tolerance induction (ITI) is the best option for inhibitor eradication. Consultation with a Hemophilia Treatment Center is strongly recommended. (32)

1. Bypassing Agents (BPA) for Hemophilia A or B with Inhibitors
   1. Anti-inhibitor coagulant complex, also known as activated prothrombin complex concentrate [aPCC]

aPCC contains activated factors IIa, VIIa, IXa and Xa. These factors are able to bypass an inhibitor to FVIII or FIX in order to promote hemostasis. This product is derived from human plasma and is treated with vapor steam heat and nanofiltration to eliminate viruses (33). (Table IV)

1. Recombinant Activated Factor VII Concentrates (rFVIIa)
   1. Eptacog alfa is licensed for use in patients with inherited hemophilia A or B and inhibitors to FVIII or FIX. It is produced in BHK cells; newborn calf serum is used in the culture medium; no human or other animal proteins are used in its final formulation vial (second generation recombinant product). Thus, the risk of transmission of human viruses is essentially zero (34). (Table IV)
   2. Eptacog beta is licensed for use in patients with inherited hemophilia A or B and inhibitors to FVIII or FIX. It is produced in genetically engineered rabbits that produce the protein in the mammary glands and secrete it into the milk. It may contain trace amounts of rabbit proteins. (Table IV)

Note: The recommended dosing differs between eptacog alfa and eptacog beta; refer to each product’s package insert for details. Given the lack of in vivo data demonstrating the safety of using higher doses of rFVIIa products in patients with hemophilia A and inhibitors receiving emicizumab, at this time we recommend using either the 70-90 mcg/kg (eptacog alfa) or 75 mcg/kg (eptacog beta) initial dose regimens in these patients.

1. Bispecific Antibody for Hemophilia A with Inhibitors
   1. Emicizumab-kxwh

Emicizumab is a humanized, bispecific, monoclonal antibody that binds to FIX / FIXa and FX / FXa, thereby standing in for the missing FVIII to prevent or reduce the occurrence of bleeding in adults, adolescents, children and infants with hemophilia A and inhibitors (35, 13).  In those undergoing major surgery, preliminary experience suggests standard preoperative dose rFVIIa and tapering postoperative doses may be safe and effective, while in some minor surgeries, low dose or no rFVIIa may be appropriate (14). (Table IV)

1. Thromboembolic Risk

Thrombotic risks exist with the use of each of these products. It is important that physicians and patients not exceed recommended doses due to the risk of thromboses. In particular, in those using emicizumab prophylaxis, concomitant aPCC should be avoided during and up to six months after emicizumab use, as residual emicizumab levels may persist in the plasma (MASAC Document #268).

1. Treatment of Patients with Acquired Hemophilia A

Under certain conditions, individuals who were not born with hemophilia may develop antibodies or inhibitors that cause destruction of FVIII, resulting in clinical bleeding due to very low levels of this clotting factor. Such inhibitors may be seen in patients with cancer, systemic lupus erythematosus, and other autoimmune disorders. Often no associated condition can be identified. Individuals with acquired hemophilia A (AHA) should be treated by hematologists experienced in the management of such patients. These patients may be treated with the following recombinant clotting factor concentrates:

1. Eptacog alfa is a rFVIIa that is produced in BHK cells. It is licensed for use in patients with AHA due to inhibitors. It is a second-generation recombinant product. (Table V.A.)

1. A recombinant porcine factor VIII (rpFVIII) is produced in BHK cells transfected with the B-domain deleted porcine F8 gene. This product is a second-generation recombinant product that is approved by the United States Food and Drug Administration (FDA) for use only in AHA. Often the human FVIII inhibitor does not cross-react with the porcine species of FVIII, thus allowing for measurable factor levels and cessation of bleeding with rpFVIIItreatment. (36) (Table VI)

1. aPCC: Although not currently licensed to treat AHA, aPCC is included here to enable healthcare providers to advise and treat patients with AHA. aPCC contains activated factors IIa, VIIa, IXa and Xa. These factors are able to bypass an inhibitor to FVIII or FIX in order to promote hemostasis. This product is derived from human plasma and is treated with vapor steam heat and nanofiltration to eliminate viruses (33). (Table IV)

1. Treatment of Patients with Rare Congenital Bleeding Disorders

1. Fibrinogen (Factor I) Deficiency
   1. Plasma-Derived Fibrinogen Concentrates

There are two plasma-derived fibrinogen concentrate products available for treatment of Factor I deficiency. One fibrinogen concentrate (human) product is heated in aqueous solution (pasteurized) at 60°C for 20 hours. The other available fibrinogen concentrate product undergoes solvent/detergent treatment and nanofiltration. Both products can be used to treat patients with congenital hypo-fibrinogenemia and afibrinogenemia. Neither product has been approved for use in patients with dysfibrinogenemia. (37) (Table VII)

1. Cryoprecipitate is the only currently available product for dysfibrinogenemia. Because it has not undergone any viral attenuation steps, cryoprecipitate should not be used to treat patients with afibrinogenemia except in life- and limb-threatening emergencies when fibrinogen concentrate is not immediately available. (Table IX)

1. Factor VII Deficiency
   1. Recombinant Activated Factor VII Concentrate

Eptacog alfa can be used to treat patients with congenital factor VII deficiency. It is produced by BHK cells. Newborn calf serum is used in the culture medium; no human or other animal protein is used in the final formulation vial (second generation recombinant product). Thus, the risk of transmission of human viruses is essentially zero. (34) (Table VII)

1. Factor X Deficiency
   1. Plasma-Derived Factor X Concentrate

FX concentrate is a plasma-derived concentrate approved in the US for treatment of FX deficiency. It has three viral attenuation steps: solvent/detergent, nanofiltration, and dry heat at 80° for 72 hours. (Table VII)

1. Factor XIII Deficiency
   1. Plasma-Derived Factor XIII Concentrate

Plasma-derived Factor XIII concentrate is heated in aqueous solution (pasteurized) at 60°C for 10 hours and undergoes ion exchange chromatography for viral inactivation and removal. It can be used for patients with absent or decreased levels of FXIII. (38) (Table VII)

1. Recombinant Factor XIII-A Subunit Concentrate

Recombinant Factor XIII-A subunit (rFXIII-A) concentrate is produced in yeast. No human or animal-derived proteins are used in the production vat or in the final formulation vial (third generation recombinant concentrate). This product is approved for use in individuals who lack FXIII-A subunit. It will not work in those patients who only lack FXIII-B subunit. (39) (Table VII)

1. Cryoprecipitate

Because it has not undergone any viral attenuation steps, cryoprecipitate should not be used to treat patients with FXIII deficiency except in life- and limb-threatening emergencies when FXIII concentrate is not immediately available. (Table IX)

1. Other Rare Bleeding Disorders

Although there are no products currently licensed to treat other rare bleeding disorders, the following products are listed to enable healthcare providers to advise and treat these patients.

1. Prothrombin Complex Concentrates

Plasma-derived prothrombin complex concentrates (pd-PCC) can be used to treat patients with deficiencies of factors II and X. It should be noted, however, that these products vary considerably in the amounts of these factors that they contain. Not only is there a marked difference in factor content between the two different commercial preparations, but factor content varies among lots produced by the same manufacturer. (40) (Table VII)

1. Fresh Frozen Plasma (FFP)

FFP can be used to treat patients with deficiencies of any of the clotting factors for which specific clotting factor concentrates are not available.

1. One type of FFP, donor retested FFP, is produced from single units of plasma; the donor must return and test negative on a second donation in order for the first donation to be released. This product is available from some community blood centers. (Table IX)
2. A second type of frozen plasma is licensed in the US . Plasma from 630-1520 donors is pooled, treated with solvent/detergent, and subjected to prion affinity ligand chromatography. It is then frozen in 200-ml bags. It must be given as blood group-specific frozen plasma. (Table IX)

1. Treatment of Patients with Rare Congenital Clotting Disorders

1. Antithrombin Deficiency
   1. One is a recombinant produced by introducing the human AT gene into the mammary glands of goats. AT is secreted into the goat milk and then extracted, purified, and lyophilized. It is subjected to three viral attenuation steps. (Table VIII)

There are two products available for treatment of Antithrombin (AT) deficiency:

1. The second product is a plasma-derived human AT concentrate that is subjected to pasteurization and nanofiltration as viral attenuation methods. (Table VIII)

1. Protein C Deficiency

There is a plasma-derived Protein C product licensed in the U.S. to treat Protein C deficiency. It has three viral attenuation steps. (Table VIII)

1. Plasminogen Deficiency

A plasma-derived plasminogen concentrate is available in the US to treat individuals with plasminogen deficiency type 1. This product is subjected to viral attenuation by affinity chromatography, solvent/detergent treatment, and nanofiltration. (Table VIII)

1. Ancillary Medications

1. Vitamin K. Newborn infants with hemophilia and other bleeding disorders should be given an intramuscular dose of Vitamin K in the delivery room per the recommendations of the American Academy of Pediatrics (AAP). For infants who are known or suspected to have a bleeding disorder, we recommend that the following procedures be followed for intramuscular administration of vitamin K (see MASAC Document #221):
   1. A fine-gauge needle (23 gauge or smaller caliber) should be used.
   2. Firm pressure should be applied to the site for at least 2 minutes without rubbing.
   3. The parent / caregiver should be informed that there is a risk of hematoma development at the injection site.
   4. Anticipatory guidance should be given regarding when to call the provider or hemophilia treatment center (HTC) regarding any adverse reactions, such as hematoma, warmth, or redness. 

1. Antifibrinolytics
   1. Aminocaproic acid is an antifibrinolytic agent that can be used to treat mouth and other mucosal bleeds. It comes as a syrup with a concentration of 1.25 g/5ml or in pill form. The dose is 50-100 mg/kg. Note that a dose of factor concentrate must be given first to form the clot; aminocaproic acid is then given every 6 hours to preserve the clot until healing has taken place (10-14 days). It can also be given IV following oral (e.g. wisdom tooth extraction) or ENT (e.g. tonsillectomy) surgery (Table X)
   2. Tranexamic acid (TXA) is an antifibrinolytic agent that is approved for treatment of heavy menstrual bleeding in females ≥12 years of age. The dose is 1300 mg (two 650 mg tablets) every 8 hours for 5 days during menstruation. Note that women taking TXA should not take pdFIX Complex Concentrates or aPCC for inhibitors. (Table X)

1. Unless recommended by one of their medical providers in consultation with their treating hematologist or hematology provider, individuals with inherited bleeding disorders should not use anti-platelet medications or non-selective non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin, ibuprofen, naproxen and others). 

Although NSAID use should generally be discouraged in individuals with bleeding disorders, these medications may be used to provide analgesia in some patients, particularly those with chronic joint pain who prefer or need to avoid or minimize the use of opioid medications. If using NSAIDs to treat pain, we recommend using the lowest effective dose for short durations only, given the risk of gastrointestinal (GI) ulcer formation and significant GI bleeding when NSAIDs are used continuously. Patients should also be monitored for increases in the frequency or severity of joint bleeds or other types of bleeding if they use NSAIDs for pain exacerbations.

1. Vaccination for Hepatitis A and B

1. Hepatitis B vaccine is recommended for all children by the AAP. In persons with hemophilia and other congenital bleeding disorders, this immunization is particularly important and should be started at birth or at the time of hemophilia diagnosis if the individual has not been previously immunized. Primary immune response should be documented.

1. Hepatitis A vaccine is recommended for all children over the age of 1 year by the AAP. Older individuals with hemophilia and other congenital bleeding disorders who are HAV seronegative should also be immunized. (41-42)

1. Other Issues of Importance

1. Decisions about the selection of products for treatment of hemophilia are complicated for patients, families, and treating physicians. When choosing the appropriate products for their patients with hemophilia, physicians will need to continue to exercise their best judgment based on their assessment of emerging data. Education, psychosocial support, and financial counseling for patients and families are critical components of comprehensive care.

1. If a previously seronegative patient has a confirmed seroconversion to any blood-borne infectious agent that is felt by the local public health department to possibly be due to use of a blood component or blood product, this should be reported immediately to the FDA, to the manufacturer of the product received, and to the Centers for Disease Control and Prevention.

1. Patients should enroll in the voluntary National Notification System in order to be notified promptly of any recalls of factor products they may be using.

1. Recommendations to Manufacturers of Coagulation Products

1. We recommend continued vigilance in donor screening and donor testing at blood and plasma collection facilities.

1. Manufacturers of plasma-derived products should use only plasma that is collected utilizing Plasma Protein Therapeutics Association (PPTA) guidelines and recommendations.

1. Donors diagnosed with CJD or vCJD or who are at risk for CJD or vCJD should continue to be deferred from donating blood and plasma.

1. Efforts should continue to exclude from further processing the plasma from donors who are infected with HIV, HBV, HCV, HAV, human parvovirus, and vCJD.

1. Priority of test implementation should focus on viral agents that are poorly inactivated by current viral elimination techniques, namely, HAV and parvovirus B19.

1. Improved viral inactivation and elimination procedures are required in coagulation products.

1. All recombinant products made with human or animal proteins, including use of albumin in the final formulation, should be phased out.

1. Research to identify methods to eliminate infectious pathogens should be given higher priority.

1. Reporting of adverse events associated with coagulation products should occur more expeditiously.
   1. Manufacturers should report suspected viral transmission events to the FDA immediately upon confirmation.

1. New products are often approved after small numbers of patients are evaluated in clinical trials. Manufacturers are strongly encouraged to conduct Phase IV post-licensure studies for efficacy and for surveillance of inhibitor development and other expected and unexpected serious adverse events.

1. Notification to consumers and their health care providers of safety and regulatory problems must occur in a more expeditious fashion.

1. Manufacturers are responsible for notifying their consignees of any withdrawals. The FDA has defined the consignee as "anyone who received, purchased, or used the product being recalled" (21 CFR 7.3(n)), e.g., the customer, direct account, or person with a coagulation disorder and his or her healthcare provider. Manufacturers should accept the responsibility for notifying their customers if they have purchased a product that is out of compliance.

1. Notification to customers must occur early in any investigation.

1. While the voluntary National Notification System implemented by some companies does provide a good mechanism for notification, it should not be considered a substitute for the responsibility the manufacturers have to notify their customers directly.

1. Intermediaries, including home care companies and 340B programs, must keep accurate records of the lots their customers use and have systems in place to notify patients and their healthcare providers immediately upon learning of a compromised product lot.

1. Research and development of improved coagulation products that would expedite the transition to total prophylaxis for all persons with coagulation disorders are strongly encouraged.

1. Recombinant products should continue to be developed that could be taken less frequently and administered by routes other than intravenously.

1. As improvements in production efficiencies are made, cost reductions of coagulation products should be passed on to the consumer.

1. Biosimilar FVIII and FIX products are now available and should be a vehicle for substantial cost reductions, as they are in all other therapeutic areas.

1. Inhibitor development is the single most important complication of treatment of Hemophilia A and B. BioPharma should apply their resources toward technologies which would limit the development of this complication.

1. BioPharma should facilitate the clinical development of gene therapies to cure bleeding disorders.

1. Manufacturers should take necessary steps to ensure the continued availability of plasma-derived clotting factor concentrates for individuals with rare bleeding disorders.

1. Such concentrates are safer than the alternatives of FFP and cryoprecipitate, which are not virally attenuated.

1. Such concentrates provide the ability to raise clotting factor levels to 100% without the risk of volume overload, which is another drawback of FFP.

1. Such concentrates allow for prophylactic treatment, if indicated by severity of the disease and frequency of bleeding episodes.

1. Such concentrates provide the convenience of storage and treatment at home and while traveling.

1. Recommendations to the U.S. Food and Drug Administration

The FDA is responsible for regulating the manufacturers of coagulation products to ensure that licensed products are safe and effective. Many of our recommendations for manufacturers should be regulated proactively by the FDA.

1. Elimination of Infectious Agents

1. Research to identify improved inactivation and elimination techniques for non-lipid enveloped viruses should be actively encouraged by the FDA.

1. Validation studies to identify the amount of removal of vCJD prions should be recommended by the FDA to each manufacturer for each of their products.

1. Investigation and Reporting of Complications of Therapies

1. The FDA should maintain sufficient compliance checks to ensure that manufacturers are expeditiously reporting any and all suspected infections, inhibitor development from clinical trials, and any other unexpected serious adverse events associated with coagulation products, both established and newer prolonged half-life agents.

1. The FDA should communicate promptly with consumer organizations such as NHF whenever an event occurs, such as a recall, voluntary withdrawal, consent decree or plant closure, which could have an impact on the supply and availability of clotting factor, concentrates.

1. Expedited Review and Harmonization

1. All products offering incremental safety and efficacy advantages to the bleeding disorders community should have expedited regulatory review. This includes experimental gene therapies.

1. The FDA should work with the European Medicines Agency (EMA) to harmonize requirements for licensing approval of clotting factor concentrates for use in individuals with rare bleeding disorders. This is especially important in the design of pivotal clinical studies in adults and children.

1. Previously untreated patient (PUP) trials of single agents should not be required and should be discouraged in favor of interventional trials designed to decrease rates of inhibitor formation.

REFERENCES

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