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Immune Tolerance and the Treatment of Hemophilacs with an Inhibitor 63 attention to acute bleeds because the kinetic neutralization is so different from allo-antibodies. A patient can be successfully treated by continuous infusion. What we do is to mix the plasma of the patient with concentrate and we test the neutralization after 5, 10, 20 and 30 minute intervals. In most patients you find a plateau at a certain level. From this plateau you can plan the continuous infusion. We were successful in 6 out of 7 patients regardless of the level of their inhibitor. Even in cases of high titer, neutralization is much slower. The seventh patient who didn’t respond to continuous infusion was treated with APPCs. She developed a massive myocardial infarction. CIAVARELLA: Speaking as a physician, I have a patient who is eighteen with an acquired inhibitor but no underlying disease. The patient is now stable after four years of treatment but she needs immunosuppressive therapy. She asked me about having children and would like to cure the disease. KESSLER: I’m glad she’s your patient. On a more serious note I think there are a lot of ways of approaching this and I hope you have success in your treatment. LUSHER: What about the patients that we all encounter with hemophilia who seem to have the bleeding manifestations and the reaction kinetics of an auto-antibody rather than an alloantibody; has that been studied I’d like to know about that group of people with severe hemophilia who start having excessive ecchymoses and the types of things you see in acquired hemophilia and if you do the kinetics they look like auto-antibodies. KESSLER: I don’t recall seeing anything in the literature. I don’t believe that anyone has looked at epitope specificity in those individuals even to confirm that they had changed from a type 1 to a type 2 antibody kinetics other than in Dr. David Green’s recent paper where he showed that to be possible after getting porcine factor VIII. Perhaps there is someone else in the audience who has some information on that. SAINT REMY: Professor Sultan why on earth would you consider an anti-factor VIII immune response during gestation or post-partum period to be an allo-immunization It’s obviously an auto-immunization. It might be an allo-factor VIII but we don’t know whether the mother’s immune system is exposed to the factor VIII of the baby and basically this is an autoimmune response. SULTAN: For a long time it was believed that women immunized with factor VIII could be immunized from the fetus factor VIII. That was something we believed twenty years ago. Dr.Aledort suggests something which could explain the relapsing of auto-antibody to factor VIII in a second pregnancy. SAINT REMY: I am not an expert on immunology of pregnancy but there is now ample evidence coming from animal experiments that the repertoire of the fetus as well as the immune repertoire of the mother is shaped towards the other. This is something which has been very well described in animal experiments. My other comment is that solid tumor might generate antibodies cross-reacting against factor VIII. Haematologica vol. 85(supplement to n. 10):October 2000
Haematologica 2000; 85(suppl. to n.10) p. 64-68 Acquired Factor VIII Inhibitors New protocol for immune tolerance induction in acquired hemophilia LASZLO NEMES,* ERVIN PITLIK° *Hemophilia Center, National Institute of Hematology and Immunology; °Department of Internal Medicine, Semmelweis University Medical School; Budapest, Hungary Abstract Background and objectives. Immune tolerance induction (ITI) regimens with human factor VIII concentrates are rarely if ever implemented in adult patients with auto-inhibitors, in contrast to alloantibody suppression, which is used primarily in young children with congenital hemophilia. On the basis of some earlier experience with synchronization of plasma exchange therapy of various autoimmune disorders we have developed a new aggressive protocol for the treatment of patients with acquired factor VIII (FVIII) antibody. We have evaluated the outcome of 14 consecutive nonhemophilic FVIII inhibitor patients treated in a single center with our ITI protocol between 1992 and 1999, comparing them to 6 historical control patients, treated with traditional immunosuppression therapy (steroid ± cyclophosphamide) between 1988 and 1992. Design and Methods. Our ITI protocol consists of three weeks of treatment with 1) human FVIII concentrates (30 U/kg/day for the 1st week, 20 U/kg/day for the 2nd, and 15 U/kg/day for the 3rd week), plus 2) iv. cyclophosphamide (200mg/day to a total dose of 2-3 grams), plus 3) methylprednisolone (100 mg/day iv. for one week and than tapering down the dose gradually over the next two weeks). The treatment of acute bleeding episodes in the two groups was not different. High purity and ultra-high purity factor VIII concentrates were used for the ITI. We performed aPTT and mixing tests before and after two hours of incubation, Bethesda inhibitor assay, porcine FVIII cross-reactivity, FVIII:C before and after FVIII administration (recovery), three times a week. The sex ratio and mean age (64 years for the ITI group versus 57 years for the controls), the initial and peak inhibitor titers, and residual FVIII: C values at the diagnosis were similar in the two groups. Results. Eradication of the inhibitor occurred in 13/14 patients in the ITI vs. 4/6 patients in the control group. The main difference between the two groups was in the time needed for the complete disappearance of the inhibitor (4.6 weeks for ITI vs. Correspondence: Dr. Laszlo Nemes , National Institute of Hematology and Immunology, Hemophilia Center, Budapest, Daroczi u. 24, H-1113 Hungary; Phone: international 36-1-3852457 – Fax: international 36-1-2092311 E-mail address: peer@bel2.sote.hu 28.3 weeks for controls). In the ITI group we have observed only two relapses during the relatively long follow-up period (26 months), and in both cases the same re-induction protocol was successful again. No bleeding-related mortality occurred in this group in contrast to that of 33 % in the controls. Apart from the well-known adverse effects of glucocorticoid therapy, we have observed only one patient with transient cytopenia. We have not seen any adverse event which could be attributed to the use of FVIII concentrates. Interpretation and Conclusions. We conclude that the ITI protocol described here is highly effective for the treatment of acquired hemophilia, induces quick therapeutic responses and favorably influences the underlying autoimmune disorder. We suggest that our ITI protocol is suitable for the eradication of idiopathic and autoimmune-associated FVIII autoantibodies in patients presenting with severe bleeding. ©2000, Ferrata Storti Foundation Key words: acquired hemophilia, FVIII autoantibodies, immunosuppression therapy, immune tolerance induction Acquired hemophilia is caused by IgG1- IgG4 anti-factor VIII autoantibodies emerging either spontaneously (idiopathic inhibitor in the elderly) or in connection with pregnancy, various autoimmune and malignant diseases and drug therapy. The reported incidence of this rare condition is 0.2-1.0/10 6 population/year. 1 The bleeding manifestations are often dramatic with 80-90% major hemorrhage and 10-22% mortality rates directly or indirectly attributable to the inhibitor. 2 The long-term management of acquired hemophilia is still controversial. It is possible that different treatments should be used for different subgroups of patients (a conservative approach for children, peripartum and druginduced cases in whom spontaneous remission can be reasonably expected, and combined immunomodulatory therapy for idiopathic and autoimmune-associated cases). 3 However, indi- Haematologica vol. 85(supplement to n. 10):October 2000
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Acknowledgments We wish to thank th
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4 J.M. Lusher (range 1-34) for pati
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6 J.M. Lusher ALEDORT: I’d just l
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8 J. Oldenburg et al. Tuddenham et
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10 J. Oldenburg et al. Table 4. Mut
Page 15 and 16: 12 J. Oldenburg et al. reactions ac
Page 17 and 18: 14 J. Oldenburg et al. Dr. Schwaab
Page 19 and 20: 16 J. Ingerslev be established more
Page 21 and 22: 18 J. Ingerslev sion monitoring dem
Page 23 and 24: 20 J. Ingerslev REFERENCES 1. Hay C
Page 25 and 26: 22 CRM Hay Side effects of Hyate:C
Page 27 and 28: 24 CRM Hay tion by porcine factor V
Page 29 and 30: Haematologica 2000; 85(suppl. to n.
Page 31 and 32: 28 P. Lollar these epitopes by site
Page 33 and 34: 30 P. Lollar titer and an anti-porc
Page 35 and 36: 32 Immune Tolerance and the Treatme
Page 37 and 38: 34 Immune Tolerance and the Treatme
Page 39 and 40: 36 B.M. Ewenstein et al. exposed, 7
Page 41 and 42: 38 B.M. Ewenstein et al. Table 1. H
Page 45 and 46: 42 D. DiMichele et al. Discussion T
Page 47 and 48: 44 D. DiMichele et al. Italy and in
Page 49 and 50: 46 H. Lenk et al. Figure 1. Maximum
Page 53 and 54: 50 E. Berntorp et al. standing inhi
Page 57 and 58: 54 C.R.M. Hay Logistic barriers to
Page 59 and 60: 56 C.R.M. Hay ed to go for a fully
Page 61 and 62: 58 C.M. Kessler hemophilia A, have
Page 63 and 64: 60 C.M. Kessler in eradicating allo
Page 65: 62 C.M. Kessler ously. Do you see d
Page 69 and 70: 66 L. Nemes et al. Figure 1. A gian
Page 71 and 72: 68 L. Nemes et al. trast to the ear
Page 73 and 74: 70 E. Berntorp Hemophilia A severe
Page 75 and 76: 72 E. Berntorp VIII. MARIANI: It wo
Page 77 and 78: 74 R. Landolfi et al. Table 1. Resu
Page 79 and 80: 76 H-H. Brackmann et al. Table 1a.
Page 83 and 84: 80 R.B. Butler of progress and perm
Page 85 and 86: 82 B. Gargallo emotional consequenc
Page 87 and 88: 84 L.M. Aledort et al. Success rate
Page 91 and 92: 88 D. Scandella et al. Seven non-in
Page 93 and 94: 90 S. Lacroix-Desmazes et al. demon
Page 95 and 96: 92 S. Lacroix-Desmazes et al. 244:1
Page 97 and 98: 94 J-M.R. Saint-Remy linking of sur
Page 99 and 100: 96 J-M.R. Saint-Remy identification
Page 101 and 102: 98 M.D. Kazatchkine et al. normal l
Page 105 and 106: 102 L.W. Hoyer et al. have prevente
Page 107 and 108: 104 J.G. Gilles et al. Table 1. The
Page 109 and 110: 106 J.G. Gilles et al. typic intera
Page 113 and 114: 110 D. Lillicrap a transgene in tis
Page 115 and 116: 112 D. Lillicrap DI MICHELE: I am a
Page 117 and 118:
114 G.C. White et al. cost, time, a
Page 119 and 120:
116 G.C. White et al. Blood 62:141-
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II Immune Tolerance and the Treatme
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