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Factor Activity Assays for Monitoring Extended Half-Life FVIII and Factor IX Replacement Therapies

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Factor Activity Assays for Monitoring Extended Half-Life FVIII and Factor IX Replacement Therapies 331 Factor Activity Assays for Monitoring Extended Half-Life FVIII and Factor IX Replacement Therapies Steve Kitchen, PhD1 Stefan Tiefenbacher, PhD2 Robert Gosselin, CLS3 1 Sheffield Haemophilia and Thrombosis Centre, Sheffield, United Address for correspondence Steve Kitchen, PhD, Department of Kingdom Coagulation, Royal Hallamshire Hospital, Glossop Road, 2 Colorado Coagulation, Laboratory Corporation of America® Sheffield S10 2JF, United Kingdom Holdings, Englewood, Colorado (e-mail: [email protected]). 3 Department of Pathology and Laboratory Medicine, University of California Davis Health System, Sacramento, California Semin Thromb Hemost 2017;43:331–337. Abstract The advent of modified factor VIII (FVIII) and factor IX (FIX) molecules with extended half-lives (EHLs) compared with native FVIII and FIX represents a major advance in the field of hemophilia care, with the potential to reduce the frequency of prophylactic injections and/or to increase the trough level prior to subsequent injections. Monitor- ing treatment through laboratory assays will be an important part of ensuring patient safety, including any tailoring of prophylaxis. Several approaches have been used to extend half-lives, including PEGylation, and fusion to albumin or immunoglobulin. Some of these modifications affect factor assays as routinely performed in hemophilia centers; so, laboratories will need to use FVIII and FIX assays which have been shown to be suitable on a product-by-product basis. For some products, there are marked differences between results obtained using one-stage or chromogenic assays and Keywords results obtained using different reagents in the one-stage assay. The laboratory should ► Factor VIII assay use an assay in which the recovery of the product closely aligns with the assay used by ► FIX assay the pharmaceutical company to assign potency to the product, so that the units ► extended half-life reported by the laboratory agree with those used to demonstrate efficacy of the FVIII product during clinical trials. Reportedassay differences in relation to several of the EHL ► extended half-life FIX FVIII and FIX molecules will be reviewed in this article. Hemophilia describes the pathologic conditions where there is pitate; this was followed in time by the use of isolated clotting a hereditary deficiency of factor (F) VIII or FIX and includes both factor concentrates. The unfortunate morbidities associated hemophilia A (FVIII) and hemophilia B (FIX). The diagnosis is with this early mode of plasma-based factor replacement typically made using laboratory methods to assess factor were the development of antibodies to transfused factor and activity levels, and confirmed, in some countries, with addi- inadvertent transmission of viral infections, including hepatitis tional genetic testing. Detailed guidance on the management of and, tragically, acquired immunodeficiency syndrome (AIDS). This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. these conditions, including diagnosis, has been published by the In an effort to reduce both immune responses and reduce the World Federation of Hemophilia (WFH) in print1 and online.2 risk of human plasma exposure, pharmaceutical companies Once properly diagnosed, severe hemophilia patients require developed more specific replacement therapies. Recombinant frequent and constant replacement therapy to avoid clinical and factor material became the standard of practice for hemophilia subclinical bleeding. Replacement therapy has substantially A factor replacement in some countries in the 1990s, and evolved over the years. When replacement therapy was first shortly thereafter for hemophilia B patients, and today it is implemented, it was primarily based on treatment with human the treatment of choice in many developed countries.3 The sources of plasma, either as fresh frozen plasma or cryopreci- frequency of dosing is related to the half-life (clearance) of the published online Issue Theme Laboratory Assessment of Copyright © 2017 by Thieme Medical DOI http://dx.doi.org/ March 6, 2017 Hemostatic and Anticoagulant Therapy; Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0037-1598058. GuestEditors:RobertC.Gosselin,CLS, New York, NY 10001, USA. ISSN 0094-6176. and Dorothy M. Adcock, MD. Tel: +1(212) 584-4662. 332 Factor Activity Assays for Monitoring Extended Half-Life Products Kitchen et al. infused product. Doses required depend on the concentration of the immunodepletion process. The source of FVIII- required to maintain sufficient factor levels to prevent bleeding deficient plasma used in the FVIII one-stage assay has been and are patient dependent. B-domain deleted (BDD) recombi- shown to influence the FVIII activity results.10 Additionally, nant FVIII was the first modified FVIII product introduced. More the analyzers used for factor activity testing (i.e., mechanical recently, efforts have focused on modifications to the factor or optical clot detection) and/or the particular assay proto- protein to extend the half-life and thus decrease the frequency cols and setups used for factor activity testing (single, dual, or of therapy without increasing the risk of bleeding.4 The new hybrid calibration curves with or without extrapolation), as long-acting therapeutic replacement products include modifi- well as the material used for calibration, may influence or cations to the factor by fusion of Fc region of IgG1 immunoglob- limit accurate measurement of factor activity, especially at ulin (-Fc) or albumin, or nonspecific or site-specific attachment trough or factor levels below 0.10 IU/mL.11 of polyethylene glycol (PEG) of different molecular weights5 Discrepancies in reported FVIII activity when assayed by (►Table 1). one-stage or chromogenic methods in mild hemophilia A – In addition to the initial diagnostic role, the laboratory patients have been described.12 14 Typically, the result plays a continuous and important ancillary role for hemo- obtained from one-stage assays are higher than the chromo- philia patients. To ensure optimal therapy, the laboratory genic methods, although the reverse may also occur. Some must be able to accurately measure the native plasma and cases in which the chromogenic result is greater do not have replacement FVIII and FIX activity at trough, peak, or during a clinical picture consistent with mild hemophilia and some therapy to confirm that factor levels, achieved during a of these subjects are thought to have a polymorphism rather particular dosing regimen for a specific product, are ade- than a clinically relevant defect.15 When measuring post- quate for each patient. infusion levels, differences between the one-stage clot and Factor activity testing can be performed using several chromogenic FVIII activity from patients receiving certain different techniques, including the one-stage clotting assay full-length recombinant FVIII products16 or ReFacto, a BDD based on activated partial thromboplastin time (APTT), two- recombinant FVIII replacement product, have been re- – stage clotting assay based on thromboplastin generation test, ported.17 20 Other full-length recombinant products can and chromogenic methods.6 It is clear from several profi- be accurately measured with either chromogenic or one- ciency testing programs such as WFH IEQAS, UK NEQAS, stage assays.21,22 The discrepancy between the one-stage ECAT, RCPAQAP, and CAP7,8 and from field surveys of prac- clot and chromogenic FVIII activity assay in postinfusion tice9 that the vast majority of clinical laboratories currently samples can be mitigated using a specific reference standard, use one-stage clotting factor assays for clinical diagnosis of which has been adopted as an approach in the United hemophilia and for monitoring factor replacement therapies. Kingdom21 but has not been widely accepted elsewhere. For one-stage APTT-based clotting assays, there are a wide The newer recombinant FVIII (rFVIII) products, which con- variety of APTT reagents used for FVIII and FIX activity tain modifications to either the b-domain and/or modifica- testing, which differ in phospholipid source (synthetic or tions to the actual therapeutic protein (e.g., single chain extract from plant or animal), type, and concentration, as protein sequence modification, Fc-coupling, PEGylation), well as activator type (e.g., ellagic acid, celite, kaolin, silica of have raised awareness about the appropriate method for various types, polyphenols). Factor-depleted plasma used monitoring patients receiving these agents.5,23 The purpose may either be sourced from congenital-deficient hemophilia of this article is to review the available assay data for A or B patients or is more commonly prepared by targeted measuring the new generation of extended half-life (EHL) removal of FVIII or FIX from normal pooled plasma using products for FVIII and FIX. immunodepletion. Removal of von Willebrand factor (VWF) from FVIII-depleted plasma may be an unwanted side effect Hemophilia A rFVIII and Modified Replacement Therapy Table 1 Characteristics of some extended half-life FVIII and FIX Published information on the behavior of the new generation This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. replacement products rFVIII replacement products is limited to selected field – studies for some of the products,24 26 as well as data a Product Manufacturer Property Mean half-life (h) presented by the respective product manufacturers at a N8 GP Novo Nordisk 40 KD peg 19 (age >17) workshop
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