Hemophilia and HTCs How to tell our story Mark T. Reding, MD Associate Professor of Medicine Division of Hematology, Oncology, and Transplantation Director, Center for Bleeding and Clotting Disorders University of Minnesota Medical Center Minneapolis, MN Hemophilia Alliance – Spring Members Meeting Washington, DC – April 27, 2015 Basic Approach 1. Assume they know nothing about hemophilia 2. Show them what it really looks like – a picture with a story attached is a powerful tool 3. Don’t be afraid to brag a little 4. Set the expectation for an ongoing dialogue Topic Outline 1. What is hemophilia? 2. Clinical manifestations 3. Treatment of hemophilia 4. HTC care model Magnitude of the Problem How many people are affected? Obesity…………………90,500,000 Diabetes………………..25,800,000 COPD…………………..15,000,000 MS………………………….300,000 Hemophilia………………….20,000 Sources: Centers for Disease Control and Prevention (www.cdc.gov) National Institute of Neurological Disorders and Stroke (www.ninds.nih.gov) What is Hemophilia ? • Congenital bleeding disorder • Due to deficiency or absence of a coagulation cascade protein • Hemophilia A = factor VIII deficiency • Hemophilia B = factor IX deficiency Hemophilia A • Factor VIII deficiency • Classical hemophilia • 1 in 5,000 to 10,000 male births Hemophilia B • Factor IX deficiency • Christmas disease • 1 in 30,000 male births • 80% of total cases • 20% of total cases • Spontaneous • Spontaneous mutations = 30% mutations = 20% Clinical phenotypes are indistinguishable • Hemophilia affects all racial and socioeconomic groups equally • There are ~20,000 hemophiliacs in the United States • ~500,000 hemophiliacs worldwide Age Distribution of the US Hemophilia Population 2 – 19 8584 48% 20 – 44 6418 36% 45 – 64 2274 13% 65+ 524 3% Percent Age (y) Number Percent 50 45 40 35 30 25 20 15 10 5 0 2 to 19 Source: 20 to 44 45 to 64 Age Centers for Disease Control and Prevention Summary Report of UDC Activity (National) Report Date – May 30, 2011 65+ Genetics of Hemophilia • Genes for factors VIII and IX are located on the X chromosome • Females are carriers, males are affected High rate of spontaneous mutations: • Unaware female carriers • New mutation in baby boy • ~30% have no family history of hemophilia Diagnosis of Hemophilia + Family History • Identify carriers • Pre-conception counseling • Cord blood testing of male newborns • Defer testing of females until sx or considering pregnancy No Family History • Bleeding with birth trauma, circumcision, immunizations • Suspected child abuse • Joint bleeds and hematomas start to occur when learning to walk Clinical Features of Hemophilia Severity of bleeding tendency depends on the factor level • • Mild ( > 5% ) Moderate (1-5%) Bleed only after severe injury, trauma, or surgery • Bleed after injury, surgery • May have occasional spontaneous bleeding May not be diagnosed until adulthood Severe ( < 1 %) • Frequent spontaneous bleeding • Diagnosis made in early childhood Clinical Features of Hemophilia Joint bleed (hemarthrosis) ©2009 Rush University Medical Center The Clinical Problem of Joint Bleeding • Hemarthrosis, primarily involving the ankles, knees, and elbows, is the most common complication of hemophilia • 45% experience first joint bleed within the first year of life • 90% have at least one joint bleed by 4 years of age • 90% of those with severe hemophilia have chronic degenerative changes involving at least 1 joint by age 25 • 40% report restricted physical activities due to arthropathy Lafeber et al., Haemophilia 2008; 14(Suppl. 4):3-9 Valentino et al., Semin Hematol 2008; 45(Suppl. 1):S50-S57 Blood in joint Recurrent bleeding Inflammation Synovitis Normal knee Normal knee 47 year old with severe hemophilia B MD Clinical Features of Hemophilia Joint bleed (hemarthrosis) • 36 year old • Severe hemophilia A • Recurrent left knee bleeds • Severe hemophilic arthropathy TS Clinical Features of Hemophilia Joint bleed (hemarthrosis) • 36 year old • Severe hemophilia A • Recurrent left knee bleeds • Severe hemophilic arthropathy • Underwent total knee arthroplasty TS Normal ankle Severe hemophilia A, morbidly obese RS Normal elbow • • 36 year old, severe hemophilia A, followed by HTC since birth Target joint in childhood, no longer bleeds (or moves) NJ Clinical Features of Hemophilia Deep muscle bleeds • 52 year old with severe hemophilia B • Spontaneous bleed Clinical Features of Hemophilia Deep muscle bleeds • 20 year old with mild hemophilia A • • No trauma Bled after light jogging Clinical Features of Hemophilia Intracranial bleeds • 6 year old with severe hemophilia A • Bumped head on school playground equipment, did not appear to have any significant injury • Parents noted change in behavior later that evening Clinical Features of Hemophilia Intracranial bleeds • 52 year old with severe hemophilia A • Tripped coming out of restaurant, hit head on curb • • Received factor VIII within 30 minutes Presented to ER 2 days later because he had blood on Q-tip • No neurologic symptoms • No headache DD Clinical Features of Hemophilia Intracranial bleeds • 58 year old with severe hemophilia A, on regular factor VIII prophylaxis • Fell at grocery store, didn’t think he had significant injury, refused transfer to ER • Found unresponsive at home several hours later • Died of massive subdural hematoma TD Inhibitors in Congenital Hemophilia Inhibitors in Congenital Hemophilia • Some hemophilia patients “see” factor VIII or factor IX as a foreign protein • Infusion of factor concentrate to prevent or treat bleeding triggers an immune response • Antibodies (“inhibitors”) directed against factor VIII or factor IX neutralize the procoagulant effect and render standard treatment useless Inhibitors in Congenital Hemophilia • Development of inhibitors is currently the most serious complication of factor replacement therapy • Typically seen in those with severe hemophilia • May occur in those with mild or moderate hemophilia, usually after intense factor exposure related to trauma or surgery • No longer associated with increased mortality However . . . Bleeding more difficult to control Devastating joint disease and disability Major clinical and economic challenges Clinical Features of Hemophilia Joint bleed (hemarthrosis) • 26 yo with severe hemophilia A and fVIII inhibitor • Recurrent traumatic and spontaneous knee bleeds • Left side surgically replaced • Note severe muscular atrophy • Following right TKA he became fully ambulatory (again) SK 22 yo male with severe hemophilia A and fVIII inhibitor Rapid progression of arthropathy March 2008 May 2010 June 2010 LF Clinical Features of Hemophilia Joint bleed (hemarthrosis) • 28 yo severe hemophilia A with inhibitor and end stage arthropathy, severe pain even when non-weight bearing • Excellent functional outcome with right total hip arthroplasty SK Clinical Features of Hemophilia Soft tissue bleeding • Inhibitor patient, presented to ER with left elbow bleed • Failed attempts to place IV in right arm LF Clinical Features of Hemophilia Soft tissue bleeding • 56 year old with severe hemophilia A and inhibitor • Fell on icy sidewalk • Did not treat aggressively enough • Required transfusion of 6 units RBCs GR Clinical Features of Hemophilia Soft tissue bleeding Severe hemophilia A with inhibitor, neck bleed provoked by coughing GR Inhibitors in Congenital Hemophilia Unique Challenges • Factor replacement therapy not possible; treatment options currently limited to bypassing agents • Bypassing agents only have 75 – 90% efficacy in stopping acute bleeds • High degree of variability in response between patients and bleeding episodes • No established routine method of lab monitoring • Risks of thrombosis with bypassing agents • Extreme cost • Very small number of patients Treatment of Hemophilia 1. Historical perspectives 2. Clinical challenges 3. On-demand vs. prophylaxis 4. Treatment of inhibitor patients 5. New factor products Treatment of Hemophilia What happens if you don’t treat bleeds? • Severe hemophilia, no access to factor concentrate • Recurrent bleeds may lead to pseudotumors Historical Overview • • • • • • • • 1900 – 1940s: Hemophilic life expectancy 25 – 30 years, usually disabled by age 20 1960: Life expectancy increased to 40 years due to transfusions of whole blood and plasma, but most hemophiliacs still severely disabled and unemployed 1968: First commercially available factor VIII concentrate 1980: Life expectancy reaches 60 years 1982: First reported cases of AIDS in hemophilia patients. More than 50% ultimately infected with HIV and more than 75% infected with viral hepatitis 1985: Virally inactivated factor concentrates introduced 1992: Recombinant factor VIII 1997: Recombinant factor IX Historical Perspective Diabetes vs. Hemophilia First human treated with insulin (1922) First human pancreas transplant (1966) 1900 Commercially available insulin pump (1978) 2010 Commercially available factor concentrate (1968) Viral inactivation of factor concentrates (1985) Recombinant factor concentrates (1992, 1997) Ongoing Clinical Challenges • Managing orthopedic complications in those with already existing arthropathy • Managing medical co-morbidities (liver disease, HIV, cardiovascular health, weight management) • The aging hemophiliac • Inhibitor patients Factor Replacement Therapy • Plasma derived and recombinant factor VIII and factor IX concentrates are available • 1st, 2nd, and 3rd generation recombinant factor concentrates • No documented case of viral transmission in more than 25 years • Goal is for every child to learn self-infusion Factor Replacement Therapy On-Demand • Treatment of bleeds when they occur • Good at stopping bleeds after they start, but does not prevent bleeds • Does not prevent arthropathy Prophylaxis • Regular administration of factor to prevent bleeds form occurring • Goal is elimination of all bleeds • Current standard of care Summary of Prophylaxis Studies (in adolescents and adults) Median ABR Study On-demand Prophylaxis Zero bleeds Collins 2010 41 0 53% Fischer 2011 n/a 2.1 – 3.3 17 – 31% Valentino 2012 43.9 1.0 – 2.0 27 – 41% Manco-Johnson 2013 27.9 0 52% Mahlangu 2014 33.6 1.6 – 3.6 17 – 45% ABR = annualized bleed rate (how many bleeds per year) Economic Burden of Hemophilia • Proper treatment of hemophilia is expensive, but the long term economic impact of poorly managed hemophilia is even greater • Factor concentrates account for the majority of the cost of treating hemophilia • Routine prophylaxis for severe hemophilia A, dosed at 25-40 u/kg 3x/week: Age Weight Annual factor consumption (units) 5y 20 kg 78,000 – 124,800 15 y 60 kg 234,000 – 374,400 Adult 80 kg 312,000 – 499,200 (Rough estimate of the cost of factor – $1 per unit) Treatment of Inhibitor Patients 1. This is very complicated 2. This can be extremely expensive 3. This absolutely requires HTC expertise Why? • These patients are rare • Treatment options have significant limitations Treatment of Inhibitor Patients Immune Tolerance Therapy • Costs approximately $ 1 million per patient • Only 70% effective, BUT . . . • The effects of a long-term inhibitor can be devastating Bypassing Agents • 2 options: aPCC and rfVIIa • Efficacy is incomplete (75 - 90%) and unpredictable • No standard laboratory monitoring exists • Thrombosis is a real risk Treatment of Hemophilia Where are we headed? New Factor Products • Long-acting factor concentrates have been in development for several years • Extended half-life should result in similar or improved protection from bleeds with fewer infusions • Methods to prolong half-life: PEG-ylation Fc fusion Albumin fusion Degree of success Old products New products Factor VIII 12 h 18-20 h Factor IX 18-24 h 80-90 h New Factor Products Where are we now? • The following all have long-acting factor VIII and/or factor IX products in late stage clinical development: Bayer, Baxter, CSL Behring, Novo Nordisk • First long-acting factor products recently approved, both made by Biogen Idec: Factor IX – Alprolix (March 2014) Factor VIII – Eloctate (June 2014) New Factor Concentrates What we know . . . • Highly effective for prophylaxis, acute bleeds, surgery • Safety comparable to existing products • Longer half-life allows for fewer infusions to maintain protective factor levels What is expected . . . • More effective treatment and improved adherence for a greater number of those with hemophilia To be determined. . . • How other long acting products will compare • Role in immune tolerance therapy • Economic implications (for all involved!) What’s New for Inhibitor Patients? Obizur (OBI-1) • Recombinant porcine fVIII • FDA approved October 2014 for use in acquired hemophilia • Hopefully will expand to use in congenital inhibitor patients Other products… • Several drugs are in pre-clinical or early phase development • Cautiously optimistic Center for Bleeding and Clotting Disorders Program History • • • • • • Began in 1977 as one of 145 federally funded Hemophilia Treatment Centers in the US One of the first such programs in the upper Midwest There are currently 135 HTCs in the US, with 3 in Minnesota Our program was broadened to include serving thrombosis patients in 1996 Children’s Hospitals and Clinics of Minnesota separated from our program in 2007, making us an adult focused program Name changed to the Center for Bleeding and Clotting Disorders in 2008 Center for Bleeding and Clotting Disorders Hemophilia & Other Bleeding Disorders Thrombosis Women’s Hemostasis Program Patient Centered Care Delivery Comprehensive Care Model Guiding Principles: • The center exists to promote patient care, teaching, and research related to bleeding and clotting disorders • We serve as a learning laboratory for the latest in diagnosis and treatment • Our care delivery is seamless and timely • We provide an environment that promotes the development of the next generation of care providers Program Description Who we are . . . Interdisciplinary team: physician, advanced practice providers, nurse clinicians, social worker, physical therapist, genetic counselor, coagulation laboratory, pharmacy coordinator, program manager, administrative support (~120 years of combined experience) What we do . . . 1. Comprehensive clinic visits 2. Problem focused clinic visits 3. Pre-op planning and care coordination 4. Inpatient care coordination and discharge planning 5. Patient, provider, and community education 6. Patient counseling and advocacy 7. Research and clinical trials 8. Consultation for other health care providers (local, regional, national) Care Planning • Weekly care planning meetings are held with the interdisciplinary team • Discuss previous week’s clinic visits, upcoming week’s clinic visits • Review current inpatient admissions and any recent ED / UC visits • Review recent visits and plan for upcoming visits to other specialty clinics • Update care plans, identify need for additional referrals, community resources Patient Type Number Severe hemophilia A / B 8 Severe von Willebrand disease 2 Moderate hemophilia A / B 2 Inhibitors 4 Note: These are the BCBS patients actively followed / managed by our HTC. There may be other BCBS patients who have prescriptions filled by Fairview who are not included on this list. The 16 BCBS patients actively followed / managed by our HTC represent the broad range of diagnoses, severity, and health care utilization typical of the bleeding disorders population as a whole Diagnosis Number Hospital / ED visits (last 5 years) Severe HA/HB (age <26) 4 None Severe vWD (age <26) Severe HA/HB (age 26-55) Moderate HA/HB (age 26-55) Severe HA with past h/o inhibitor 2 None 4 • 2 with none • 1 appendectomy • 23 ED visits and 2 hospitalizations all unrelated to hemophilia 2 • 3 ED visits, all unrelated to hemophilia • 1 ankle fusion • 1 hernia repair 1 2 hospitalizations (elbow surgery, iliopsoas bleed) Prophylaxis Employment Co-morbid conditions Functional status Yes All in school or completed and working HIV – HCV – No limitations; 3 competitive athletes Yes Both in school or completed and working HIV – HCV – No limitations 3 on prophy 1 on-demand All working full time 2 HIV / HCV – 1 HIV / HCV + 1 HCV + (both HCV + on study) Some limitations but all able to maintain full employment 1 prophy 1 on-demand 1 getting doctorate in nursing 1 unemployed 1 HCV + (on study) 1 morbid obesity, DM, HTN 1 with minor limitations, 1 with major limitations prophylaxis Works full time, selfemployed HIV – HCV – Works full time, physical job Individuals with active inhibitors Diagnosis Mild HA with inhibitor to exogenous fVIII Severe HA with high titer inhibitor Severe HA with high titer inhibitor Number Hospital / ED visits (last 5 years) Prophylaxis Employment Co-morbid conditions Functional status College graduate, working full time HIV – HCV – No limitations 1 None On-demand with PCC 1 4 hospitalizations (iliopsoas bleed, THA, arthropathy, arthropathy / pain) On-demand with aPCC and rfVIIa Works full time for BCBS HIV – HCV + Major limitations but very active after joint replacements 1 Multiple admissions for bleeds / uncontrolled pain: 2005-2010 = 26 2011-present = 4 (and 1 ED visit) On-demand with rfVIIa Completed college, on disability, does some web design from home HIV – HCV + Chronic pain Severe limitations, wheelchair bound Importance of the 340B Pharmacy Program • HTCs offer unmatched expertise and comprehensive care for • • • • hemophilia patients, along with the most competitive factor pricing Proceeds from the 340B program allow us to offer expert nursing, physical therapy, genetic counseling, and social work services, as well as 24/7 on-call hematologists and pharmacy access The 340B program funds tailored, personalized, and coordinated medical care for our patients The 340B program also supports activities and services such as educational events and support groups through partnership with our local hemophilia foundation By providing customized and comprehensive care, we are able to improve health outcomes while reducing treatment costs How Can We Improve the Management of Hemophilia? 1. The Easy Stuff • Effective factor replacement therapy • Safe factor products • Access to factor How Can We Improve the Management of Hemophilia? 2. Every patient followed by an HTC • Approximately 30% of hemophilia patients in the US receive care outside of an HTC • HTCs offer multidisciplinary team approach to care for these complex patients • 40% reduction in mortality among those who receive HTC care vs. those who do not • We need to educate patients, community providers, and managed care organizations about the benefits of HTC-based care, and eliminate barriers Soucie JM et al. Blood 2000; 96:437-42 How Can We Improve the Management of Hemophilia? 3. Address cost issues • Factor accounts for 45 - 93% of the total health care cost of hemophilia, depending on severity and treatment regimen • 340B pricing is generally 20 - 40% lower than non-340B pricing • We must take action to eliminate barriers to accessing HTC / 340B programs Johnson KA, Zhou ZY. Hematology, Am Soc Hematol Educ Prog 2011; 437-42 Take Home Points Hemophilia is a rare condition, with a large economic burden on our healthcare system We have made great progress in the management of hemophilia, but we still have work to do HTC-based care is key to the optimal management of this complex condition We need more collaboration across the boundaries of academia, industry, and managed care Questions and Discussion
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