J. Martin Johnston, MD

Pediatric Project ECHO 7 December 2018 Objectives

 Review history and physical exam as they relate to a potential bleeding disorder  Discuss step-wise laboratory evaluation: screening labs and follow-ups  Review some common congenital and acquired bleeding disorders, and their management Objectives

 Review history and physical exam as they relate to a potential bleeding disorder  Discuss step-wise laboratory evaluation: screening labs and follow-ups  Review some common congenital and acquired bleeding disorders, and their management Objectives

 Review history and physical exam as they relate to a potential bleeding disorder  Discuss step-wise laboratory evaluation: screening labs and follow-ups  Review some common congenital and acquired bleeding disorders, and their management The chief complaint

 “Easy” bruising  Nosebleeds  Petechiae  Menorrhagia  Bleeding after  Circumcision  Tonsillectomy/adenoidectomy, tooth extraction  Mild (head) trauma The problem….

• Everyone bleeds.

• All bleeding eventually stops. The bleeding history  Birth/neonatal  Tooth eruption/shedding  Bruising  Nosebleeds  Surgeries? (don’t forget circumcision!)  Orthopedic hx (traumas, joints)  Menstruation  Family history How much bleeding is too much?  Neonatal  ICH, needle/heel sticks, post-circumcision How much bleeding is too much?  Neonatal  ICH, needle/heel sticks, post-circumcision  Infant

 Petechiae, chest/back/buttock bruising Consider NAT How much bleeding is too much?  Neonatal  ICH, needle/heel sticks, post-circumcision  Infant

 Petechiae, chest/back/buttock bruising Consider  Toddler NAT  Soft tissue or joint bleeds, large/palpable bruises How much bleeding is too much?  Neonatal  ICH, needle/heel sticks, post-circumcision  Infant  Petechiae, chest/back/buttock bruising  Toddler  Soft tissue or joint bleeds, large/palpable bruises  Older child  Recurrent prolonged nosebleeds (bilateral), joint bleeds, hematomas, menorrhagia “Easy” bruising

 Without associated trauma (painless)  Unusual locations  Palpable (hematomas)  “Bigger than a quarter”? Petechiae

 Considerations:  Low platelets  Dysfunctional platelets  Vasculitis ○ Viral? HSP?  “Trauma” ○ Cough, vomiting, venous stasis (“choking”)  Collagen disorder: vascular integrity

↓ Menorrhagia  Definition:  Excessive but regular menstrual bleeding ○ > 80 mL blood loss / cycle Menorrhagia  Definition:  Excessive but regular menstrual bleeding ○ > 80 mL blood loss / cycle ○ > 7 days of menstruation Menorrhagia  Definition:  Excessive but regular menstrual bleeding ○ > 80 mL blood loss / cycle ○ > 7 days of menstruation  Passing clots  Saturating pad/tampon q 2 hours ○ Double barrier ○ Replacing overnight Menorrhagia  Definition:  Excessive but regular menstrual bleeding ○ > 80 mL blood loss / cycle ○ > 7 days of menstruation Pad  Passing clots

 Saturating pad/tampon q 2 hours Tampon ○ Double barrier ○ Replacing overnight  Not just number of pads/tampons Clots? 1x25¢ Overflow? “Bleeding Score” (history) to identify von Willebrand Disease

90%

Putting it all together…. 90% 25% 90%

Rodeghiero F et al. J Thromb Haemost 2005; 3:2619-26 The problem….

• Everyone bleeds. Family history  Known diagnoses?  “Free bleeders”  Unexplained death in childhood  Recurrent (prolonged) nosebleeds  Menorrhagia  Patterns of inheritance:  Dominant: vWD  X-linked: hemophilia Platelet disorders  Recessive: rare factor deficiencies Physical exam

 Conjunctival/mucosal hemorrhages  Petechiae  Distribution  Bruises  Age/color  Number/size  Palpable?  Tender?  Distribution Physical exam (cont)

 Joints 2  Warm/tender/tense  Boggy 2

 Range of motion: 2 ○ Chronic arthropathy? 2 ○ Hyperextensible? 1 May suggest an underlying collagen disorder Initial lab evaluation of suspected coagulopathy

 CBC/smear  PT/INR  aPTT  Platelet function analysis? Thrombocytopenia

 If isolated and mild (>100k), often not significant (MPV?)  If isolated and severe, think ITP Thrombocytopenia

 If isolated and mild (>100k), often not significant (MPV?)  If isolated and severe, think ITP  Associated anemia?  Blood loss; hypersplenism, Evans syndrome, TTP Thrombocytopenia

 If isolated and mild (>100k), often not significant (MPV?)  If isolated and severe, think ITP  Associated anemia?  Blood loss, hypersplenism, Evans syndrome, TTP  Neutropenia?  Viral illness, autoimmune, acute leukemia Thrombocytopenia

 If isolated and mild (>100k), often not significant (MPV?)  If isolated and severe, think ITP  Associated anemia?  Blood loss, hypersplenism, Evans syndrome, TTP  Neutropenia?  Viral illness, autoimmune, acute leukemia  Pancytopenia?  Acute leukemias, aplastic anemia, neuroblastoma Platelet morphology

 Larger platelets often suggest a destructive process, e.g., ITP Platelet morphology

 Large platelets often suggest a destructive process  Dysfunctional platelets may look abnormal  Gray platelet syndrome

 Bernard-Soulier syndrome Bloodjournal.com Platelet morphology

 Large platelets often suggest a destructive process  Dysfunctional platelets may look abnormal  Gray platelet syndrome  Bernard-Soulier syndrome  But most dysfunctional platelets look normal Platelet function  PFA-100  in vitro “substitute” for template bleeding time  Theoretical screen for platelet function defects and vWD  Issues with sensitivity/specificity, reproducibility Platelet function

 Platelet function analysis  Platelet aggregometry  Not available in Reno  Patient must be sent (fresh specimen required)  Electron microscopy, gene profiles Contact system: HMWK, PK, F XII Kallikrein, F XIIa Cellular injury: Tissue Factor PT/INR F XI F XIa F VIIa F VII

F IX F IXa TFPI

F VIII F VIIIa F X F Xa Antithrombin

Prothrombin (F II) Heparin cofactor II F V F Va

Thrombin (F IIa)

Activated Protein Ca Fibrinogen Fibrin monomer Protein S

Protein C + thrombomodulin Crosslinked fibrin Fibrin multimer

F XIIIa F XIII Contact system: HMWK, PK, F XII Kallikrein, F XIIa Cellular injury: Tissue Factor

F XI F XIa aPTT F VIIa F VII

F IX F IXa TFPI

F VIII F VIIIa F X F Xa Antithrombin

Prothrombin (F II) Heparin cofactor II F V F Va

Thrombin (F IIa)

Activated Protein Ca Fibrinogen Fibrin monomer Protein S

Protein C + thrombomodulin Crosslinked fibrin Fibrin multimer

F XIIIa F XIII Prolonged aPTT with normal PT/INR  Deficiency versus inhibitor  Mixing studies help distinguish ○ Correction implies something is “missing” ○ Lack of correction implies “active” inhibition Prolonged aPTT with normal PT/INR  Deficiency versus inhibitor  Mixing studies help distinguish  Inhibitor: possible “Lupus anticoagulant”  In young children, usually benign/transient  If persistent, risk of clotting, not bleeding! Prolonged aPTT with normal PT/INR  Deficiency versus inhibitor  Mixing studies help distinguish  Inhibitor: possible Lupus anticoagulant  In young children, usually benign/transient  Risk of clotting, not bleeding!  Deficiency:  fVIII, fIX: hemophilia  vWF: “carrier” for fVIII  fXI: Ashkenazi? (“hemophilia C”)  fXII: relatively common; does not cause bleeding! 2nd-tier coag testing

 Mixing studies  Specific factor levels  von Willebrand panel  Fibrinogen  Thrombin time 775-982-5427  factor XIII 775-982-KIDS 912-658-5223 Questions?

High Uintas Wilderness Area, Utah “Common” pediatric bleeding disorders

 ITP  von Willebrand disease  Hemophilia ITP (idiopathic thrombocytopenic purpura) ITP (immune thrombocytopenic purpura) ITP (immune thrombocytopenia) ITP (immune thrombocytopenia)

• Antibody-mediated platelet destruction • “Acute” (resolves within 6-12 months) most common in toddlers • Abrupt onset of bruising/petechiae; otherwise “well” • Isolated, profound thrombocytopenia • Debate re best management: observation is often appropriate • More likely to persist (“chronic” ITP) in older/female patients • Immune suppression • Splenectomy • Thrombopoietin analogues von Willebrand disease

 Hereditary Pseudohaemophilia (1926) von Willebrand disease

 Dominantly inherited (types 1 and 2)  Relatively common  Rarely life-threatening von Willebrand disease

 Dominantly inherited (types 1 and 2)  Relatively common  Rarely life-threatening  Mucocutaneous bleeds  Menorrhagia  Dental/oral bleeds  Post-tonsillectomy/adenoidectomy von Willebrand disease

(Type 1) (Type 2)  Deficiency or dysfunction of von Willebrand factor (vWF) von Willebrand disease

(Type 1) (Type 2)  Deficiency or dysfunction of von Willebrand factor (vWF), which:  Mediates initial platelet adhesion at sites of vascular injury von Willebrand disease

 Deficiency or dysfunction of von Willebrand factor (vWF)  Mediates initial platelet adhesion at sites of vascular injury

“von Willebrand panel” assays all of these

 Self-polymerizes to form multimers  Binds and stabilizes factor VIII von Willebrand disease

 Work-up:  aPTT may be normal or mildly prolonged  PFA-100 “should” be abnormal von Willebrand disease

 Work-up:  aPTT may be normal or mildly prolonged  PFA-100 “should” be abnormal  von Willebrand panel ○ Notoriously variable ○ Lower limits of normal are debated von Willebrand disease

 Work-up:  aPTT may be normal or mildly prolonged  PFA-100 “should” be abnormal  von Willebrand panel ○ Notoriously variable ○ Lower limits of normal are debated  <50% suggestive  <40% suspicious  <30% definitive von Willebrand disease

 Work-up:  aPTT may be normal or mildly prolonged  PFA-100 “should” be abnormal  von Willebrand panel ○ Notoriously variable ○ Lower limits of normal are debated  <50% suggestive  <40% suspicious  <30% definitive (maybe) von Willebrand panel/profile  vWF antigen  How much protein?  vWF (a.k.a. ristocetin cofactor) activity  How well does it function?  fVIII activity  Because vWF “carries” factor VIII von Willebrand panel/profile (multimeric)  vWF antigen  How much protein?  vWF (a.k.a. ristocetin cofactor) activity  How well does it function?  fVIII activity  Because vWF “carries” factor VIII  Multimer pattern  Gel electrophoresis to assess “stacking” of vWF von Willebrand panel/profile (multimeric)

 Type 1 vWD (most common)  Quantitative deficiency: antigen/activity +/- VIII

↓ von Willebrand panel/profile (multimeric)

 Type 1 vWD  Quantitative deficiency: antigen/activity +/- VIII  Type 3 vWD (very rare)↓  Homozygous Type 1: absent antigen/activity/VIII von Willebrand panel/profile (multimeric)

 Type 1 vWD  Quantitative deficiency: antigen/activity +/- VIII  Type 3 vWD ↓  Homozygous Type 1: absent antigen/activity/VIII  Type 2 vWD  Qualitative defect: ○ 2A: activity with antigen +/- abnormal ○ activity/antigen + platelets ↓ ↓ ↓ ↓ multimers ○ 2N: activity/antigen + fVIII 2B: ↓ ↓ ↓ ↓ ↓ von Willebrand panel/profile (multimeric)

 Type 1 vWD  Quantitative deficiency: antigen/activity +/- VIII  Type 3 vWD ↓  Homozygous Type 1: absent antigen/activity/VIII  Type 2 vWD  Qualitative defect: ○ activity with antigen ○ activity/antigen + platelets 2A: ↓ ↓ ↓ ↓ ○ 2N: activity/antigen + fVIII 2B: ↓ ↓ ○ 2M: activity with antigen w normal multimers ↓ ↓ ↓ ↓ ↓ ↓ ↓ von Willebrand panel/profile (multimeric)

 Type 1 vWD  Quantitative deficiency: antigen/activity +/- VIII  Type 3 vWD ↓  Homozygous Type 1: absent antigen/activity/VIII  Type 2 vWD  Qualitative defect: Hemophilia A? ○ activity with antigen OR ○ activity/antigen + platelets OR 2A: ↓ ↓ ↓ ↓ ○ 2N: activity/antigen + fVIII 2B: ↓ ↓ ↓ ↓ ↓ vWD treatment

 DDAVP (desmopressin, Stimate® spray)  Effective for type 1  “Releases” vWF from platelets and endothelium

 2- to 3-fold “boost” with T1/2 ~12 hours vWD treatment

 DDAVP (desmopressin, Stimate® spray)  Effective for type 1  “Releases” vWF from platelets and endothelium

 2- to 3-fold “boost” with T1/2 ~12 hours  vWF concentrates (I.V.)  Effective for all types  Plasma-derived (Humate-P ®, Wilate ®, etc.)  New recombinant (VONVENDI) “Non-specific” tx for bleeding (e.g., vWD)

 Avoid “blood thinners” (ASA, NSAIDs)  For menorrhagia, hormonal therapies are often most effective even in the setting of a coag disorder  Anti-fibrinolytics:  Oral or topical  Tranexamic acid (Lysteda™)  Aminocaproic acid (Amicar™) Hemophilia:

Congenital deficiency of clotting factor VIII or IX. Factors VIII and IX

 Factor IX is vitamin K-dependent serine protease  Factor VIII is cofactor for IXa; circulates bound (noncovalently) to vWF  IXa + VIIIa = “factor Xase”  Both involved in “intrinsic” pathway; deficiencies cause prolonged aPTT  Both genes on X chromosome; affected males, carrier females (+/- symptomatic) AND: BUT: Many female 25-30% of cases carriers are result from new symptomatic: mutation menorrhagia bruising arthritis

Fully manifest in males only BUT: * All daughters of affected males are carriers Factor levels are Offspring of carrier females at 50% risk: not always Hemophilia if male predictive; Carrier if female consider genetic testing Hemophilia A

 Congenital factor VIII deficiency  ~1 in 6000 live male births  ~400 new US cases per year  ~30% are de novo mutations Hemophilia B

 Congenital factor IX deficiency  ~1 in 20,000 live male births  ~100 new US cases per year  25-30% are de novo mutations Bleeding in hemophiliacs

 Post-circumcision; ↑ aPTT  Mucous membranes  Soft tissue  Hemarthroses (“target” joints)  Intracranial  Menorrhagia (in carrier females) Hemophilia work-up

 Prompted by family history (maternal carrier or affected male sibling) or by bleeding symptoms  aPTT prolonged with factor < ~40% Hemophilia work-up  aPTT prolonged with factor < ~40%  Is it fVIII or fIX? (or fXI or fXII….)  Specific activity Hemophilia work-up  aPTT prolonged with factor < ~40%  Is it fVIII or fIX? (or fXI or fXII….)  Specific activity  Genetic testing can I.D. F8 or F9 mutation/deletion in >95% of cases  Knowing mutation can help predict, e.g., risk of developing an inhibitor  Once mutation is known, screening female family members is easier/cheaper Hemophilia severity

 Normal range for VIII or IX is ~50 to ~150%  Levels below 40% = hemophilia  5-39% = “mild” Some female carriers  1-5% = “moderate” have <40% fVIII activity; often symptomatic  <1% = “severe”  Correlates with bleeding tendency, especially spontaneous bleeds (but significant variability within groups) Managing bleeds

 Remember the basics:  RICE for joint / soft tissue bleeds Managing bleeds

 Remember the basics:  RICE for joint / soft tissue bleeds  For nosebleeds, pressure, ice Managing bleeds

 Remember the basics:  RICE for joint / soft tissue bleeds  For nosebleeds, pressure, ice, Afrin Managing bleeds

 Remember the basics:  RICE for joint / soft tissue bleeds  For nosebleeds, pressure, ice, Afrin  Bacon fat (source of thrombin)  For mouth bleeds: tea bags  Various OTC proprietary clotting agents Managing bleeds

 Remember the basics:  RICE for joint / soft tissue bleeds  For nosebleeds, pressure, ice, Afrin  Bacon fat (source of thrombin)  For mouth bleeds: tea bags  Various OTC proprietary clotting agents  Antifibrinolytics (Rx)  Aminocaproic acid (Amicar™)  Tranexamic acid (Lysteda™) Managing bleeds (cont.)

 DDAVP (for mild-moderate hemophilia A or symptomatic carriers)  “Stimate” nasal spray (Desmopressin1.5 mg/mL)  Causes release of stored vWF/fVIII  Typically, 2- to 3-fold increase in VIII activity ○ So not useful in severe hemophilia  Tachyphylaxis  Fluid retention (may cause hyponatremia) Dosing factor 8 or 9 (I.V.)

 For management of bleeding, goal is to attain level commensurate with risk:  20-40% for soft tissue bleeds  50-70% for joint bleeds  >100% for life-threatening bleed/injury Dosing factor 8 or 9 (I.V.)

 For management of bleeding, goal is to attain level commensurate with risk:  20-40% for soft tissue bleeds  50-70% for joint bleeds  >100% for life-threatening bleed/injury  For factor 8, activity increases ~2% for

each unit/kg; T1/2 ~12 hours  For factor 9, activity increases ~1% for

each unit/kg; T1/2 ~20 hours Factors for managing hemophilia

 Factor VIII  Recombinant ○ 1st generation  Recombinate – Baxter ○ 2nd generation  Helixate FS – CSL-Behring No albumin in final product  Kogenate FS – Bayer ○ 3rd generation  Advate – Baxter  Kovaltry – Bayer No albumin in cell culture or final product  NovoEight – Novo-Nordisk  Xyntha (B-domain-deleted) – Wyeth  Eloctate (Fc fusion) – Biogen  Adynovate (PEGylated) – Baxter  Jivi (PEGylated) – Bayer “Engineered” products  Afstyla (single chain) – CSL Behring  Nuwiq (human cell line) – OctaPharma  Plasma-derived  Hemofil-M – Baxter  Koate-DVI – Kedrion  Monoclate – CSL Behring Factors for managing hemophilia

 Factor IX  Recombinant ○ 3rd generation  Benefix – Pfizer  Rixubis – Baxter  Alprolix (Fc fusion) – Biogen  Idelvion (PEGylated) – CSL Behring  Plasma-derived  Bebulin – Baxter  Mononine – CSL-Behring Different approaches to hemophilia prophylaxis (…in hemophilia) Novel approaches • Emicizumab (“ACE 910,” Hemlibra®) – Bi-specific antibody – Binds factors IX and X – Similar to what fVIII does: Novel approaches • Emicizumab (“ACE 910,” Hemlibra®) – Bi-specific antibody – Binds factors IX and X – Similar to what fVIII does: – Initial trials in inhibitor patients – Significant benefit given SQ q 2-4 wks – Recently FDA approved for non-inhibitor pts Novel approaches

• Fitusiran (Alnylam pharmaceuticals) – siRNA against antithrombin III – Phase 3 trials coming soon – Phase 1-2 trials suggest safety and efficacy given SQ q 4 weeks – Effective in hemophilia A or B and potentially in other rare bleeding disorders Gene therapy

 Hemophilia as a model disease for GT  Protein circulates in blood  Small amounts have clinical benefit  No need for complex regulation  Hemophilia B first (smaller gene)  Two types of vector under development  AAV – primarily extrachromosomal  Lentivirus - integrates  Trials underway Objectives  Review history and physical exam as they relate to a potential bleeding disorder  Discuss step-wise laboratory evaluation: screening labs and follow-ups  Review some common congenital and acquired bleeding disorders, and their management

775-982-5427 775-982-KIDS 912-658-5223 QUESTIONS?