Baxter BioScience Research Articles

Thinking big: the need for innovation in the production of lentivirus-based cell and gene therapies

<b>Elisa Manzotti</b>, Founder, BioInsights, speaks to <b>Hanna Leinonen, John Moscariello, Lee DaviesScott Cross </b>and <b>Will Junker</b> <div class="authors authors-lg"><div class="author"><div class="author-img"><img src="https://cdn.insights.bio/uploads/H Leinonen copy.jpg" data-image="1"></div><div class="author-det"><h3 class="author-name">Hanna Leinonen</h3><h5 class="author-title">Senior Scientist, Kuopio Center for Gene and Cell Therapy</h5> Hanna M. Leinonen holds a PhD in Molecular Medicine from the University of Eastern Finland (2014). She has 15 years’ experience on lentiviral vectors and 6 years’ experience on bioprocessing. She is currently working as a Senior Scientist in Kuopio Center for Gene and Cell Therapy (Finland) focusing on development of upstream processing for viral vectors (lentivirus, adenovirus, AAV). </div></div></div><div class="authors authors-lg"><div class="author"><div class="author-img"><img src="https://cdn.insights.bio/uploads/26118d9d52f34a12859025a3d5f4aabc.jpg" data-image="1"></div><div class="author-det"><h3 class="author-name">John Moscariello</h3><h5 class="author-title">Executive Director, Viral Vector and Gene Editing Process Development, Bristol Myers Squibb</h5> John Moscariello currently serves as Executive Director of Viral Vector and Gene Editing Process Development at Bristol-Myers Squib (BMS). At BMS, John’s group develops viral vector processes that enable rapid timelines to generate clinical viral vectors as well as the development and characterization of commercial viral vector processes. Prior to his work at BMS, John was the Vice President of Process Development at AGC Biologics where his team was responsible cell line development, upstream and downstream process development, analytical and formulation development, and technical support for AGC Biologic’s commercial manufacturing facility and supported development activities from generating processes for Toxicology/Phase 1 supply up to and including commercialization and post-approval process support. John is very active in the biotechnology community. He is on the Scientific Advisory Board for various conferences, including the BioProcess International conference series, and the CBI conference series on achieving efficient facilities and the next frontier of single-use technologies. John obtained his Ph.D. in Chemical and Biological Engineering from the University of Wisconsin-Madison, and his B.Eng. in Chemical Engineering from the University of Delaware. </div></div></div><div class="authors authors-lg"><div class="author"><div class="author-img"><img src="https://cdn.insights.bio/uploads/Lee Davies 1.jpg" data-image="1"></div><div class="author-det"><h3 class="author-name">Lee Davies</h3><h5 class="author-title">Director, Process Research &amp; Development, Oxford Biomedica</h5><p class="oneComWebmail-MsoNormal"><i>As Director of Process Research and Development, Lee helps drive development, innovation and improvements in&nbsp;</i><i>world-class lentiviral vector manufacturing processes,&nbsp;</i><i>applying scientific and engineering principles to all aspects of upstream and downstream process development, including process optimisation and scale-up, technology transfer to GMP manufacturing and process characterisation to support chemistry, manufacturing and controls (CMC) regulatory submissions.&nbsp;</i><i>As part of&nbsp;the</i><i>&nbsp;Process Research and Development team, Lee works</i><i>&nbsp;at the&nbsp;cutting edge of gene therapy, ensuring its applicability to the needs of the wider gene and cell therapy community. The team’s mission covers the&nbsp;</i><i>life cycle of gene therapies, taking</i><i>&nbsp;processes from the early phase development work through to&nbsp;fully optimised large scale, GMP-ready processes, manufacturing and commercialisation.&nbsp;</i><i>Prior to joining Oxford Biomedica 6 years ago, Lee worked at the University of Oxford as a postdoctoral researcher and obtained a D.Phil in Gene Therapy for Cystic Fibrosis.</i> </div></div></div><div class="authors authors-lg"><div class="author"><div class="author-img"><img src="https://cdn.insights.bio/uploads/Scott_122321_WebReady copy.jpg" data-image="1"></div><div class="author-det"><h3 class="author-name">Scott Cross</h3><h5 class="author-title">Senior Principal, Dark Horse Consulting</h5> Scott has over 20 years experience working with viral vectors, vaccines, and biologics in GMP environments. He has been responsible for cleanroom design, build out and commissioning of vector facilities, as well as the oversight of viral vector, cell therapy, fill finish and manufacturing support departments. Scott started his career at Merck and Co. where he worked on the development of an Adenovirus-based HIV vaccine and later, the development, optimization, and validation of release assays for live virus vaccines. He then moved to Indiana University (IU) where he managed the IU Vector Production Facility (IUVPF), overseeing GMP production and testing of Lentiviral and Retroviral vectors for the IUVPF and the National Gene Vector Laboratories (NGVL). While at the IUVPF he also managed the design, build and commissioning of a new viral vector GMP production and testing facility. After leaving the IUVPF, Scott joined Cincinnati Children’s Hospital Medical Center (CCHMC) managing the GMP Vector Production Facility, Viral Vector Core, and the Aseptic Processing Labs. Scott then moved to the University of Florida where he was the Director of Cell Therapy, Fill Finish and Manufacturing Support Operations for Florida Biologix and Brammer Bio. He was also responsible for the design of two new fill finish suites. Most recently, Scott served as Vice President of Vector Operations at Orchard Therapeutics where he was one of the original ten members and responsible for viral vector development, GMP vector production, plasmid production, oversight of 10 CDMOs, due diligence, and facility design. </div></div></div><div class="authors authors-lg"><div class="author"><div class="author-img"><img src="https://cdn.insights.bio/uploads/Will Junker headshot copy.jpg" data-image="1"></div><div class="author-det"><h3 class="author-name">Will Junker</h3><h5 class="author-title">Head of Vector Manufacturing Quality, Kite Pharma</h5> Will Junker is Head of Vector Quality and oversees the operation of QC, QA and QE to bring Kite’s vector manufacturing facility on line through licensure. Before this role, Will built Kite’s Quality Engineering function globally. His 35 year career in BioPharma includes 13 years at AstraZeneca and 15 years at Aventis/Sanofi as well as a few years at Baxter BioScience in technical/quality roles of increasing responsibility. </div></div></div>

Correlations between Patient-Reported Outcomes and Self-Reported Characteristics in Adults with Hemophilia B and Caregivers of Children with Hemophilia B: Analysis of the Bridging Hemophilia B Experiences, Results and Opportunities into Solutions (B-HERO-S) Study

Correlations between Patient-Reported Outcomes and Self-Reported Characteristics in Adults with Hemophilia B and Caregivers of Children with Hemophilia B: Analysis of the Bridging Hemophilia B Experiences, Results and Opportunities into Solutions (B-HERO-S) Study

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease.

Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease.

Telehematology: Expanding Comprehensive Care for Pediatric Patients with Blood Disorders through Telemedicine at Several Delivery Sites (Medical Homes, Hospital Clinics, Home Setting and Hemophilia Treatment Centers (HTC)) and with Interdisciplinary Providers

Background: Telemedicine (TM) is the exchange of medical information from one site to another via electronic communications to improve patients' health status and access to care. We used telemedicine to provide comprehensive hematology services to patients with blood disorders at a variety of sites that included medical homes, hospital specialty clinics, HTC, patients home and teleconsultation with out of state HTC, all located at a distance from the Michigan State University Center for Bleeding and Clotting Disorders (MSU CBCD). The goals were to increase access to family centered and culturally competent specialty care and increase the numbers of patients with blood/bleeding/clotting disorder that were timely and accurately diagnosed, managed and referred for specialty care.Objectives: 1) To understand the feasibility of telemedicine between specialists and a variety of remote sites for children with bleeding/blood disorders 2) To assess the acceptability by patients, families, primary care physicians, remote site staff, specialist physicians, and specialist staff and 3) To assess the cost of telemedicine visits versus traditional visits from the societal perspective 4) To provide education and resources to distant providers.Methods: Telemedicine sites were 1) two medical homes-one at a pediatrician's office, Upper Great Lakes Family Health Center (UGLFHC)/Portage Health in Houghton MI and the other at a family medicine office, Iron Mountain/Iron River Upper Peninsula, MI 2) specialty clinics at Marquette General Hospital, Marquette MI 3) Hemophilia Treatment Centers (HTC) at Traverse City MI and Rush University IL 4) and a patient's home in MI. PolycomTM and/or VidyoTM systems were used to deliver HIPAA (Health Insurance Portability and Accountability Act) regulated bidirectional videoconferencing technology. Records of patient visits seen by local providers and via TM by MSU CBCD pediatric hematologists, nurse and social worker were obtained. Data included patient diagnosis, distance traveled, estimated time and travel costs saved, and education of distance provider. Measurable objectives included feasibility, acceptability. Technology issues were addressed. Site visits with Portage and Iron River Health Department were conducted to discuss local barriers and needs.Results: Beginning 1998, a total of 68 patients, ages 2 weeks to 17 years and their families were seen by TM at various sites. There were 97 TM visits and frequency of clinics varied monthly to as needed. Average distance travelled by patients to local clinics ranged from 12 - 70 miles (range 2-170 miles). In addition to coagulation disorders (hemophilia, von Willebrands disease, factor deficiencies, patients with bleeding symptoms such as epistaxis, menorrhagia etc.), other diagnosis such as cytopenias, spherocytosis, hemoglobinopathies, lymphadenopathy, Hereditary Hemorrhagic Telangiectasia, Ehlers Danlos Syndrome, and pediatric oncology patients in follow-up phase were also seen and in some cases family members tested. Physician and staff were educated regarding disease management; guidelines and educational materials shared. Estimated costs per patients to fly or drive to MSUCBCD were $999 ($579 -$1275) and $1653 ($1405-1887) respectively compared to obtaining care locally $87.6 ($73-117) via TM. This resulted in cost savings per patient of $911.4 and $1565.7 for driving and flying respectively. The MSU CBCD team also incurred significant cost savings by avoiding travel/lodging costs. Interviews with staff and physicians resulted in improvement in TM acceptance and delivery. A majority of laboratory testing were send-outs and local testing for platelet function defects were not available. Technology issues addressed included adjustments in bandwidth, firewall and network settings. It was feasible to do consultations with out-of-state HTCs as well as follow patients at home.Conclusion: Besides improving access to specialty care, TM with remote areas is feasible and acceptable in a variety of settings with considerable time and cost savings for both patients as well as the specialty care treatment team. Our study is in accordance with the American Academy of Pediatrics recent policy statement (Pediatrics 2015;136:202-209) recommending that TM services be coordinated through the medical homes thereby involving local primary care providers. DisclosuresKulkarni:Biogen: Research Funding, Speakers Bureau; Baxter: Membership on an entity's Board of Directors or advisory committees, Research Funding; Bayer: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novo Nordisk: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Pfizer: Membership on an entity's Board of Directors or advisory committees; Kedrion: Membership on an entity's Board of Directors or advisory committees; BPL: Membership on an entity's Board of Directors or advisory committees. Witkop:Pfizer: Other: Advisory Board, Research Funding; Baxter Bioscience: Other: Advisory Board; Novo Nordisk: Other: Advisory Board, Speakers Bureau.

Investigator-Initiated Phase 2 Trial of Rituximab in Adult Japanese Patients with Treatment-Resistant Acquired Thrombotic Thrombocytopenic Purpura

About 500 persons in Japan are estimated to have thrombotic thrombocytopenic purpura (TTP), which is a life-threatening disorder. In contrast with the USA and EU, off-label use of rituximab for TTP is not allowed by the Japanese public health insurance system. We therefore have limited experience of the effects of rituximab in Japanese patients with adult TTP and have not investigated possible ethnicity-related differences in its effects. To evaluate the safety and efficacy of rituximab in Japanese adult patients with TTP, we conducted an investigator-initiated phase 2 clinical trial in Japan between January and December of 2014. This study was sponsored by the Japanese government and the study design was based instructions from the regulatory agency, PMDA (Phamaceuticals and Medical Devices Agency). Adult Japanese patients with acquired TTP that had proven refractory to at least five plasma exchanges (PEX) or had serum concentrations of more than 2 BU/mL of ADAMTS13 inhibitor or both were eligible for this study. Rituximab was infused at 375 mg/m2 weekly for 4 weeks. The study protocol allowed use of both plasma exchange and corticosteroids with the investigational drug. Thirteen patients were registered and seven found to be eligible and treated with rituximab. All seven patients were evaluable for safety and six for efficacy. Three of these six (50%) were women; the median age was 41.5 years. Median platelet counts at baseline were 22 × 109/L. All of these six patients were refractory to previous PEX and ADMTS13 inhibitor concentrations were higher than 2 BU/mL in two (33%) of them. All six patients no longer required PEX after receiving rituximab treatment. Five (83%) and two (33%) patients achieved platelet counts of 100 × 109/L and 150 × 109/L 4 weeks after initiating rituximab, respectively. Median platelet counts at week 4 after commencing rituximab were 136 × 109/L (range: 64-201 × 109/L). The median time from initiating PEX to achieving platelet counts over 150 × 109/L was 22 days. By the study endpoint (4 weeks after initiating rituximab treatment), ADAMTS13 activity had normalized to 77.3% from 3.4%, accompanied by disappearance of ADAMTS13 inhibitor. Both anemia and neurological impairment also improved in all patients. The median percentages of peripheral blood CD20-positive B cells were 22.9% and 0.2% before and at the completion of treatment with rituximab, respectively. Serum IgG decreased slightly from 1,116 mg/dL at baseline to 921 mg/dL 4 weeks after rituximab treatment. Five of seven patients experienced adverse events, two of which were severe; namely septic shock and cytomegalovirus infection; no patients died. No unpublished severe adverse events were noted. No recurrence of TTP occurred during a median follow-up of 7 months. These data suggest that rituximab is safe and effective for acute refractory/high risk acquired TTP in Japanese patients and that there are no ethnic differences in effectiveness or safety of rituximab for adult TTP. However, there were too few patients to draw any firm conclusions. Further investigation is necessary to optimize the treatment schedule of rituximab. We are preparing to apply to the Japanese regulatory agency for approval of new indications for rituximab for TTP. DisclosuresOff Label Use: Investigational drug, rituximab, was provided by Zenyaku Kogyo Co. Ltd.. Matsumoto:Baxter Bioscience: Consultancy.

Impact of Pain and Functional Impairment in US Adult People with Hemophilia (PWH): Patient-Reported Outcomes and Musculoskeletal Evaluation in the Pain, Functional Impairment, and Quality of Life (P-FiQ) Study

Introduction: Pain and functional impairment associated with joint disease are major problems affecting adults with congenital hemophilia. Various standardized and disease-specific patient-reported outcome (PRO) instruments have been used in clinical studies of PWH or other diseases, but the use of these tools in the hemophilia comprehensive care setting for individual patient assessment or overall outcome tracking is limited and inconsistent. P-FiQ was designed to assess the impact of pain on functional impairment and quality of life (QoL) in adult PWH.Objectives: To assess pain and functional impairment in nonbleeding adult PWH through 5 PRO instruments and a clinical joint health evaluation.Methods: Adult males with mild to severe hemophilia and a history of joint pain or bleeding were enrolled from 15 US sites between October 2013 and October 2014. During routine clinical care visits, participants completed a pain history and 5 PROs (EQ-5D-5L with visual analog scale [VAS], Brief Pain Inventory v2 Short Form [BPI], International Physical Activity Questionnaire [IPAQ], SF-36v2, Hemophilia Activities List [HAL]) and underwent a Hemophilia Joint Health Score v2.1 (HJHS) evaluation completed by a trained physical therapist.Results: Overall 381 patients were enrolled, with a median age of 34.0 years. PRO and HJHS summary scores are presented in the table below. On EQ-5D-5L, most participants reported problems with mobility, usual activities, and pain/discomfort. On BPI, median worst pain was 6.0, least pain 1.0, average pain 3.0, and current pain 2.0. Ankles were most frequently reported as the joints with the most pain (37.4%), followed by knees (23.7%) and elbows (18.9%). On IPAQ, approximately half of participants (51.0%) reported no physical activity in the prior week. Median SF-36v2 subscores were lower for the 4 physical health domains than for the 4 mental health domains. Among HAL domains, self-care was the least impacted (median, 100.0) and functions of the legs (median, 66.7) and lying/sitting/kneeling/standing (median, 67.5) were the most impacted. On HJHS, elbow, knee, and ankle scores did not differ appreciably (median, 4.0, 4.0, and 6.0, respectively).TableAssessment ToolMedian (Q1, Q3)RangeEQ-5D-5LVAS Health index80.0 (66.0, 90.0) 0.796 (0.678, 0.861)0 to 100a-0.11 to 1.0aBPIPain severity Pain interference3.3 (1.3, 5.0) 2.7 (0.6, 5.4)0 to 10bIPAQTotal physical activity530.2 (264.0, 1039.5)Metabolic equivalents of task (MET)/minutes per week: Walking = 3.3 METs Moderate activities = 4.0 METs Vigorous activities = 8.0 METsSF-36v2Physical functioning Role physical Bodily pain General health Vitality Social functioning Role emotional Mental health Physical health summary Mental health summary Overall health44.4 (29.7, 52.8) 44.6 (32.4, 56.9) 41.8 (37.2, 51.1) 45.8 (35.3, 52.9) 49.0 (42.7, 55.2) 45.6 (34.9, 56.4) 55.9 (36.4, 55.9) 52.8 (41.6, 58.5) 39.2 (29.5, 49.4) 50.7 (41.4, 55.7) 3.0 (2.0, 4.0)0 to 100a1 to 5aHALUpper extremity activities Basic lower extremity activities Complex lower extremity activities Overall sum score88.9 (73.3, 97.8) 73.3 (46.7, 96.7) 55.6 (30.0, 88.9) 76.6 (58.0, 94.3)0 to 100aHJHSElbow Knee Ankle Global gait Total score4.0 (0.0, 11.0) 4.0 (0.0, 10.0) 6.0 (1.0, 15.0) 3.0 (0.0, 4.0) 19.5 (6.0, 36.0)0 to 40c0 to 124caHigher scores indicate better QoL or functional statusbLower scores indicate less pain severitycLower scores indicate better functionConclusions: Results of this analysis demonstrated challenges of lower extremity pain and functional impairment in US adult PWH. Pain was frequently observed, and it impacted physical function and quality of life across PROs and HJHS. Further analyses are underway to correlate assessments of pain and function across different PROs and with the exam-based HJHS. DisclosuresKempton:CSL Behring: Consultancy; Biogen: Consultancy; Baxter: Consultancy. Recht:Baxalta: Research Funding; Kedrion: Consultancy. Neff:Novo Nordisk: Other: Advisory Board; Kedrion: Other: Advisory Board. Wang:Biogen: Membership on an entity's Board of Directors or advisory committees; CSL Behring: Membership on an entity's Board of Directors or advisory committees; Novo Nordisk: Membership on an entity's Board of Directors or advisory committees; Baxalta: Membership on an entity's Board of Directors or advisory committees. Buckner:Novo Nordisk: Consultancy; Baxalta, Inc. US: Consultancy. Soni:Bayer: Other: member of the Global Emerging HEmophilia Panel (GEHEP); Novo Nordisk: Speakers Bureau. Quon:Bayer: Other: Advisory Board; Grifols: Speakers Bureau; Novo Nordisk: Other: Advisory Board, Speakers Bureau; Biogen: Other: Advisory Board, Speakers Bureau; Baxter: Other: Advisory Board, Speakers Bureau. Witkop:Pfizer: Other: Advisory Board, Research Funding; Baxter Bioscience: Other: Advisory Board; Novo Nordisk: Other: Advisory Board, Speakers Bureau. Boggio:Baxter: Consultancy, Research Funding; OctaPharma: Consultancy, Research Funding; OPKO: Research Funding; CSL Behring: Consultancy, Research Funding; Novo Nordisk: Consultancy, Research Funding; Selexys: Research Funding; Bayer: Consultancy, Research Funding. Cooper:Novo Nordisk: Employment.

The Effect of Inhibitory Antibodies on Acute Treatment of Bleeding Episodes with OΒΙ-1, an Antihemophilic Factor VIII (recombinant), Porcine Sequence, in Patients with Acquired Hemophilia Α

▪Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder, caused by auto-antibodies that inhibit the activity of endogenous human factor VIII (hFVIII). In most cases, the inhibition is governed by non-linear non-saturable (Type II) kinetics, resulting in incomplete inhibition and thus, underestimation of the FVIII inhibitor titer. A highly pure, B-domain deleted, antihemophilic FVIII (recombinant), porcine sequence (OBI-1) that is less susceptible to the inhibitory activity of anti-hFVIII antibodies has been developed as a replacement therapy to manage bleeding episodes in AHA patients.In one study of patients with AHA, the presence of pre-treatment anti-porcine FVIII (pFVIII) antibodies was reported not to correlate with the efficacy of a plasma-derived pFVIII1. However, cross-reactivity of anti-hFVIII antibodies with the recombinant pFVIII OBI-1 or de novodevelopment of anti-pFVIII antibodies could impair efficacy of OBI-1 treatment in subjects treated with pFVIII replacement therapy.This phase 2/3 open-label clinical trial investigated the efficacy and safety of OBI-1 in the treatment of serious bleeds in 28 adults with AHA. The primary efficacy endpoint was assessed at 24 hours (e.g., effective, partially effective). Subjects received an initial dose of OBI-1 (200 U/kg); additional doses were based on the subject’s target FVIII levels, anti-pFVIII titer, and clinical factors. This evaluation aims to address potential concerns regarding anti-pFVIII antibodies and their effect on the response to OBI-1 treatment in AHA patients.Overall 10/28 subjects (36%) had detectable anti-pFVIII inhibitors (range 0.8-29 BU) prior to treatment, presumably due to cross-reactive anti-hFVIII auto-antibodies also neutralizing pFVIII. The rise in FVIII activity level immediately after the first OBI-1 infusion was lower in subjects with baseline anti-pFVIII inhibitors ≥5 BU/mL (median rise: 29%, n = 4) than in subjects without detectable or with low anti-pFVIII inhibitor levels (<5 BU/mL, median rise: 96%; n=6). However, with tailored dosing all 10 subjects achieved clinically relevant FVIII activity levels. Furthermore, all had a positive response to treatment at or before 24 hours.All subjects received immunosuppressive therapy to treat their underlying autoimmune disease during the study. After treatment, 2 subjects with baseline anti-pFVIII inhibitors had an increase in anti-pFVIII titer (from 3 to 6 BU and from 15 to 183 BU); 8/10 subjects had a decline in anti-pFVIII titer to non-detectable levels. Five subjects did not have baseline anti-pFVIII but developed antibodies de novo (range 0.6-166 BU at final assessment). These de novo titers were first detected between 8 and 85 days after treatment initiation while the median duration of exposure to OBI-1 was 7 days. As 2 of these subjects had a concomitant increase in anti-hFVIII antibody titers, the de novoanti-pFVIII titers were possibly due to either, i) an anamnestic reaction to pFVIII that resulted in an increase in cross-reactive anti-hFVIII inhibitors, or ii) an immunogenic response to pFVIII yielding anti-pFVIII antibodies cross-reacting with hFVIII. Another 2/5 subjects had a concurrent decrease in anti-hFVIII antibody titers, suggesting an immunogenic response to pFVIII. These data indicate that immunosuppressive therapy used to treat auto-antibodies may not have the same suppressive effect on allo-antibodies.The presence of anti-pFVIII antibodies prior to treatment appears to have had an effect on the immediate FVIII activity level rise after the first dose, particularly if the titer was greater than 5 BU. However, this early low FVIII activity level could be overcome by a tailored dosing regimen, guided by measuring FVIII activity levels. Consistent with previous reports with a plasma-derived pFVIII1, our findings indicate a lack of correlation between baseline anti-pFVIII antibody titers and efficacy of OBI-1. OBI-1 replacement therapy facilitates objective and successful assessment of efficacy independently of inhibitors through monitoring of FVIII activity levels.1Morrison et al. (1993), Blood. 81:1513 DisclosuresFarin:Baxter Healthcare: Employment. Novack:Baxter Healthcare: Employment. Mo:Baxter Healthcare: Employment. Bourgeois:Baxter BioScience: Employment. Horling:Baxter BioScience: Employment. Ewenstein:Baxer Healthcare: Employment.

Age-Associated Bone Disease in Factor VIII-Deficient Mice

BACKGROUNDBone disease is increasingly being clinically recognized in hemophilia. We previously demonstrated bone disease in factor VIII (FVIII)-deficient mice at peak bone mass that was independent of activity, hemarthroses, and weight compared to wild-type littermates. These findings are consistent with the hypothesis that FVIII-deficiency directly impacts skeletal health. However, the impact of FVIII-deficiency on skeletal health at different stages of growth and aging remains unknown. Addressing this issue is critical for understanding the potential underlying mechanisms as well developing therapeutic interventions to ameliorate bone disease in hemophilia. METHODSThe skeletal health of FVIII-deficient and wild-type littermate controls were characterized during growth (10 weeks of age), peak bone mass (20 weeks), and during aging (40 weeks). Characterization included micro computerized tomography (CT) imaging, bone mineral density, biomechanical testing, histomorphometry (quantitative histology), gene expression using reverse transcription polymerase chain reaction (RT-PCR), and bone biomarker evaluation. RESULTSFemoral bone mineral density in FVIII-deficient mice is decreased compared to wild-type littermate controls with increasing statistical significance with age; p = 0.108 at 10 weeks (12 FVIII-deficient and 15 wild-type mice), p = 0.064 at 20 weeks (19 FVIII-deficient and 22 wild-type mice) and p= 0.017 at 40 weeks (18 FVIII-deficient and 23 wild-type mice) of age. Cortical bone (outer hard bone) thickness differences decrease with age, with FVIII-deficient mice having statistically thinner cortices at 10 weeks (p = 0.0004) compared to 20 (p = 0.008) and 40 weeks (p = 0.079). Trabecular bone (softer inner bone), measured by trabecular number, decreased in FVIII-deficient mice, has a similar trend: 10 weeks (p = 0.035), 20 weeks (p = 0.048), and 40 weeks (p = 0.643). Histomorphometry also shows an age-dependent pattern. At 10 weeks in the FVIII-deficient mice there is higher osteoclast (cells that break down bone) (p = 0.0010) and no change in osteoblast (cells that build bone) numbers; at 20 weeks there is higher osteoclast (p = 0.0011) and lower osteoblast (p = 0.027) numbers; while at 40 weeks there is no difference in osteoclast and lower osteoblast (p = 0.0017) numbers. Dynamic histomorphometry demonstrates lower bone formation rate at 40 weeks (p = 0.002) but no difference at 20 weeks. Biomechanical strength, as measured by ultimate force, is decreased in FVIII-deficient mice at 20 weeks (p = 0.017) and 40 weeks (p= 0.023). 10 week bones were not evaluated for biomechanical strength due to small size. No statistical difference in CTX-1 (biomarker for bone resorption) or osteocalcin (biomarker for bone formation) is observed at any age group. Levels of gene expression using RT-PCR was characterized from the bone marrow cells in the 20 week cohorts evaluating genes related to bone metabolism. Normalized to beta-actin and glyceraldehyde 3-phosphate dehydrogenase, differential gene expression is not seen in osteocalcin, tumor necrosis factor-alpha, receptor activator of nuclear factor-kappa B (RANK), RANK ligand, interferon-beta or tartrate-resistant acid phosphatase. There is lower FBJ osteosarcoma oncogene (c-fos) gene expression (p < 0.01), a transcriptional regulator of osteoclast formation, in the bone marrow from FVIII-deficient mice. There is also a trend for lower osteoprotegerin gene expression (p < 0.10). CONCLUSIONSEvidence for bone disease is present in growing, mature and aging bones in FVIII-deficient mice compared to littermate controls but the form of bone disease differs with age. Differences in imaging parameters are most pronounced at 10 weeks while BMD is most pronounced in bones of older mice. Furthermore, FVIII-deficient mice have an age-dependent pattern of osteoblast and osteoclast numbers with a relative increase in osteoclasts during growth and relative decrease in osteoblasts with aging. Even with these changes, the decreases in biomechanical strength, measured against aged-matched wild-type controls, are similar at both 20 and 40 weeks. The observed bone pathology is not associated with global changes in biomarkers of bone formation or bone resorption at any age. These results suggest that FVIII-associated bone disease is a complex age-dependent process that begins during development and continues throughout life. DisclosuresTaylor:Baxter BioScience: Research Funding; Novo Nordisk: Research Funding.

The relevance of collaborative work: the Latin American Society for Immunodeficiencies (LASID) registry model.

The Latin American Society for Immunodeficiencies (LASID) registry was established in April 2009 with the support of the European Society for Immunodeficiencies (ESID), the Jeffrey Modell Foundation, Baxter Bioscience and Conselho Nacional de Pesquisa e Desenvolvimento Científico (CNPq, Brazil). The mission of LASID is to educate and increase awareness of primary immunodeficiencies (PIDs), and educate doctors in Latin America to recognize PIDs according to the different phenotypes. The LASID registry has evolved from 25 centres in seven countries in April 2009, to now include 93 centres in 14 countries in July 2014. In total, 5203 PID cases have been reported. To date, the rate of response has been highest in Argentina, with 1942 (37%) reported cases, followed by Brazil with 1175 (23%) cases, Mexico with 854 (16%) cases and Columbia with 817 (16%) cases. Of the 5203 cases, antibody defects were recorded in 56% of patients, followed by well-established syndromes with immunodeficiency in 18% of patients, combined immunodeficiency in 10% of patients and phagocytic disorders in 9% of patients. Based on an estimated frequency of one PID case for every 10 000 people in Latin America, and the patients currently recorded in the registry, we can estimate the number of patients still to be identified in each country. For example, Argentina has identified the greatest proportion of PID cases, with 1942 cases of an expected total of 3900 cases identified. In comparison, 1175 of 18 600 have been identified in Brazil, 854 of 10 600 have been identified in Mexico and 817 of 4200 have been identified in Columbia. Evaluation of hyper-immunoglobulin (Ig)M syndrome is one of three clinical epidemiological projects developed within the LASID registry programme 1. Hyper-IgM syndrome is a group of disorders characterized by normal to elevated levels of IgM, and absent or decreased levels of IgA, IgE and IgG. CD40 ligand (CD40L) deficiency is the most common form of hyper-IgM syndrome, which is estimated to represent 75% of cases 1. Another form of hyper-IgM is a deficiency of activation-induced cytidine deaminase (AID). Patients with AID-deficiency are susceptible to extracellular bacterial infections, while patients with CD40L-deficiency are additionally susceptible to viral, fungal and intracellular bacterial infections 1, 2. A recent publication from the LASID registry summarizes the clinical and molecular characteristics of a cohort of 58 hyper-IgM patients 1. In this cohort, genetic defects were found in 37 patients, 35 of whom were CD40L-deficient (causing an X-linked form of hyper-IgM syndrome) and two were AID-deficient. Following genetic analysis, five novel mutations which abolished CD40L protein production on activated CD4+ T cells were identified 1. The most frequently observed clinical manifestation of hyper-IgM syndrome was pneumonia, which affected 80% of CD40L-deficient patients. Pneumocystis jirovecii was the most frequent cause of pneumonia, followed by cytomegalovirus, Pseudomonas aeruginosa, Streptococcus pneumoniae, parainfluenza virus type II and other unknown pathogens. Other common clinical manifestations of hyper-IgM syndrome included upper respiratory tract infections (63%), neutropenia (48%) and chronic diarrhoea (46%) 1. Our study identified several microorganisms that were not previously associated with hyper-IgM syndrome, including Aspergillus spp., Microsporidium spp. and Isospora belli, which caused infections such as severe pneumonia and chronic diarrhoea in CD40L-deficient patients. In addition, CD40L-deficient patients frequently developed other fungal infections such as paracoccidioidomycosis. Recent studies have found that paracoccidioidomycosis, an infection endemic to South America which has been previously associated with a mutation in the beta 1 subunit of the interleukin-12 receptor, can also occur in CD40-deficient patients 1-3. It should be noted that the different clinical phenotypes observed may be attributed to different environmental pressures. For instance, the occurrence of fungal infections may be higher in Latin America due to the prevailing warm and humid conditions. In conclusion, the LASID registry programme has evolved significantly to become a centralized resource for clinical immunologists throughout Latin America and beyond. The clinical epidemiological data are beginning to indicate that PIDs may present with distinct clinical features, which must be communicated to Latin American physicians in order to achieve early diagnosis and treatment. LASID thank Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPQ, http://www.cnpq.br), Fundação de Amparo a Pesquisa do Estado de São Paulo (FAPESP, http://www.fapesp.br) and Baxter Bioscience, CSL Behring, Octapharma, and Grifols for unrestricted educational grants supporting the LASID registry initiative. The author would also like to thank Meridian HealthComms Ltd for providing medical writing services. A. C. N. has no conflicts of interest to disclose.

Reversal of Dabigatran-induced Bleeding by Coagulation Factor Concentrates in a Rat-tail Bleeding Model and Lack of Effect on Assays of Coagulation

Dabigatran is a potent oral anticoagulant. Like any anticoagulant, there is an increased risk of bleeding associated with its use, and reversal may be needed in cases of severe bleeding. In this study, six coagulation factor concentrates (CFCs) were tested for their ability to reduce bleeding induced by oral dabigatran etexilate (30 mg/kg) in a rat-tail bleeding model (n = 5 to 8 per group): three-factor (Profilnine [Grifols Biologicals Inc., Los Angeles, CA] and Bebulin [Baxter BioScience, Westlake Village, CA]) and four-factor prothrombin complex concentrates (Beriplex [CSL Behring, Marburg, Germany] and Octaplex [Octapharma AG, Lachen, Switzerland]), activated prothrombin complex concentrate (Factor Eight Inhibitor Bypassing Activity; Baxter AG, Vienna, Austria), and recombinant factor VIIa (NovoSeven; NovoNordisk, Bagsværd, Denmark). The effect of CFCs on prolongation of coagulation assays was measured. Thrombin generation after administration of each CFC was compared in vitro using human plasma (n = 5) spiked with dabigatran in concentrations corresponding to median peak (200 ng/ml) and supratherapeutic values (600 and 1,000 ng/ml). Dabigatran resulted in an approximately three-fold increase in bleeding time, consistent with supratherapeutic dabigatran plasma levels. Beriplex (35 and 50 IU/kg), Octaplex (40 IU/kg), Profilnine (50 IU/kg), Bebulin (60 IU/kg), Factor Eight Inhibitor Bypassing Activity (100 U/kg), and NovoSeven (500 μg/kg) significantly decreased this prolonged bleeding time over 30 min (P < 0.001). The coagulation assays were prolonged three- to eight-fold over baseline (P = 0.01). None of the CFCs produced a consistent change in these assays that was predictive of reduced bleeding. Thrombin generation reversal was dependent on the concentration of dabigatran and each CFC; normalization occurred at the lower concentration of dabigatran with most CFCs, but not at higher concentrations. In this animal model, bleeding induced by high doses of dabigatran can be reduced by CFCs. However, routine coagulation assays do not predict this effect.

Long-Term Orthopedic Effects Of Delaying Prophylaxis In Severe Hemophilia A Until Age 6 Years: Results Of The Joint Outcome Study Continuation (JOSc)

The Joint Outcome Study (JOS) was a randomized controlled clinical trial in boys with severe factor VIII deficiency comparing prophylaxis consisting of 25 IU/kg factor VIII every other day begun prior to age 30 months with an enhanced episodic regimen given only in response to bleeding. At JOS exit at age 6 years, joint outcome by sensitive magnetic resonance image (MRI) and joint physical examination (PE) of 6 index joints (both ankles, knees and elbows) determined superiority of prophylaxis over episodic therapy (p < 0.05). At JOS end, all parents were informed of the study results and boys in the episodic arm were counseled to initiate prophylaxis therapy; all but 1 JOS participant on episodic therapy switched to prophylaxis. The JOS Continuation Study is being performed to determine the results of early prophylaxis on joint development until the age of 18 years and to determine the impact of delaying prophylaxis initiation until age 6 years. All boys in the original JOS were eligible to enroll in the continuation study. Study data collected includes cumulative number of index joint and total hemorrhages, joint PE score of 6 index joints using the Colorado Pediatric Joint Assessment Scale as previously described (Haemophilia 6:649) and MRI soft tissue, osteochondral and total scores of 6 index joints using the expanded MRI 45 Scale as recently presented (ISTH OP Mon 7/1/13, 9 am). Additional data are collected on prophylaxis adherence, activities, surgeries, quality of life and replacement factor utilization. To date, results of 26 (40%) of the original 65 boys (16 on early and 10 on delayed prophylaxis) including 156 index joints are available for analysis. Results, expressed as a cumulative score for all 6 index joints, are shown in Table 1. While still enrolling, the JOS Continuation Study is documenting an ongoing disparity in joint outcome in children with initiation of prophylaxis delayed until age 6 years, compared with prophylaxis started before 30 months of age. Following delayed initiation of prophylaxis, adolescents manifest increased numbers of hemarthroses and increased MRI damage particularly affecting bone and cartilage. Joint PE is less sensitive than MRI in determination of joint outcome in hemophilia.Table 1Results for hemarthroses and joint PE and MRI scores in adolescents relative to age at prophylaxis initiation.Study ArmAge (yrs) Mean, (SD)Cumulative Hemarthroses Mean, (SD)Total Joint PE Score Mean, (SD)Total MRI Score Mean, (SD)Soft Tissue MRI Score Mean, (SD)Osteochondral MRI Score Mean, (SD)Prophylaxis JOS Exit6 (0)2.6 (2.3)6.69 (6.32)0.92 (1.25)0.88 (1.18)0.03 (0.18)Prophylaxis Follow-up13.5 (2.1)20.2 (19.0)16.08 (12.56)4.12 (3.84)3.93 (3.00)0.43 (1.60)Episodic JOS Exit6 (0)20.1 (14.9)8.25 (8.01)4.88 (5.51)3.1 (2.96)1.78 (2.75)Episodic Follow-up12.9 (1.54)59.4 (60.7)20.33 (12.02)12.44 (14.28)7.67 (9.97)4.78 (7.16) Disclosures:Manco-Johnson:Bayer HealthCare: Membership on an entity's Board of Directors or advisory committees, Research Funding; CSL Behring: Membership on an entity's Board of Directors or advisory committees, Research Funding; Baxter BioScience: Membership on an entity's Board of Directors or advisory committees; Biogen Idec: Membership on an entity's Board of Directors or advisory committees; NovoNordisk: Membership on an entity's Board of Directors or advisory committees; Eisai: Research Funding. Manco-Johnson:Bayer HealthCare: Research Funding. Lane:Bayer HealthCare: Honoraria; Baxter BioScience: Paid travel to attend a meeting, Paid travel to attend a meeting Other. Shapiro:Bayer HealthCare: Research Funding; Baxter BioScience: Research Funding; Biogen Idec: Research Funding; Cangene: Research Funding. Valentino:Baxter BioScience: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Bayer HealthCare: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; CSL Behring: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; GTC Biotherapeutics: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Inspiration Bioscience: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; NovoNordisk: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Brown:Baxter BioScience: Research Funding; Biogen Idec: Research Funding; CSL Behring: Research Funding.

Prompt Immune Tolerance Induction at Inhibitor Diagnosis Regardless of Titer May Increase Overall Success in Hemophilia A With Inhibitors: Experience of Two US Centers

IntroductionImmune tolerance induction (ITI) for patients (pts) with hemophilia A with inhibitors is the only modality known to effectively eradicate inhibitors with an overall reported success of ∼60-80%. One debate concerns the optimal time to start ITI; recent guidelines recommend delaying ITI until inhibitor titer is <10 Bethesda units (BU). AimWe report results of an analytic project to determine the success of ITI relative to time from inhibitor detection to ITI initiation. MethodsData was collected retrospectively at 2 US hemophilia centers on pts with severe/moderate (≤5%) factor VIII (FVIII) deficiency undergoing ITI including time interval from inhibitor detection to ITI start, inhibitor titer and outcome. High-dose ITI was practiced by both centers (i.e. ≥100 IU/kg/day). Success, partial success and failure were defined practically with success as a negative inhibitor titer and ability to use FVIII concentrate routinely for treatment and prevention of bleeding; partial success was an inhibitor titer <5 BU with ability to use FVIII concentrate to treat bleeding episodes; failure as ongoing ITI >3 years without achieving success/partial success or discontinuation of ITI. IRB approvals were obtained at both centers for this data analysis.Pts were first divided into low responding inhibitor (LRI) and high responding inhibitor (HRI) based on peak inhibitor titer; the HRI subgroup was further subdivided based on time to start ITI, including within 1 month, 1-6 months and greater than 6 months. The HRI subgroup starting ITI within 1 month was analyzed based on pre-ITI inhibitor titer. ResultsFifty eight male pts with adequate ITI history documentation were included; 55 (95%) were severe (<1%), 3 moderately deficient (1-3%). Forty-seven pts (48%) were Caucasian, 6 Hispanic, 2 African American, 2 Asian and 1 Native American. Outcome is summarized in Table 1. Overall, 49 of 58 pts (84%) underwent successful ITI.Low responding Inhibitors: Among 19 (33%) pts with LRI, ITI success was 100%. Most pts with LRI 15/19 (79%) started ITI within 1 month from inhibitor detection.High responding inhibitors: Among 39 (67%) pts with HRI, 30/39 (77%) achieved tolerance, 1 achieved partial success and continued ITI, 1 was ongoing, 7 pts failed. The 39 pts with HRI were further subdivided based on time to ITI start.ITI start within 1 month of detection: Twenty three pts started ITI within 1 month from detection; 21 achieved success (91%), 1 partially succeeded and 1 failed. Eight of 10 pts (80%) with a pre-ITI titer <10 BU achieved success, 1 partially succeeded and 1 failed. All 13 pts (100%) starting ITI with pre-ITI inhibitor titer ≥ 10 BU achieved success.ITI start > 6 months: Eleven pts had an interval > 6 months until ITI start; 7 (64%) achieved success and 4 (36%) failed. ConclusionsThese results suggest that the time interval from inhibitor detection to start of ITI may play a critical role in outcome. A titer ≥10 BU did not influence outcome in pts where ITI was utilized within 1 month, supporting this approach in contrast to the commonly accepted practice of delaying ITI start until a titer <10 BU is achieved. Pts may benefit from prompt ITI regardless of current inhibitor titer and are not subjected to wait periods where bleeding is more likely to occur. Prompt ITI should be considered a viable therapeutic option in newly identified inhibitor pts regardless of current inhibitor titer. Disclosures:Manco-Johnson:Bayer HealthCare: Membership on an entity's Board of Directors or advisory committees, Research Funding; CSL Behring: Membership on an entity's Board of Directors or advisory committees, Research Funding; Baxter BioScience: Membership on an entity's Board of Directors or advisory committees; Biogen Idec: Membership on an entity's Board of Directors or advisory committees; Novo Nordisk: Membership on an entity's Board of Directors or advisory committees; Eisai: Research Funding. Maahs:Baxter BioScience: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Biogen Idec: Membership on an entity's Board of Directors or advisory committees; Novo Nordisk: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Shapiro:Baxter BioScience: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novo Nordisck: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Bayer Healthcare: Membership on an entity's Board of Directors or advisory committees, Research Funding; Biogen Idec: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Chugai Pharma: Consultancy; Kedrion Biopharma: Consultancy, Research Funding; Cangene Pharmaceuticals: Research Funding; CSL Behring: Research Funding; Octopharma: Research Funding; PTC Therapeutics: Research Funding; Eli Lilly: Research Funding.

Biomarkers Of Bone Disease In Subjects With Hemophilia

BackgroundIndividuals with hemophilia have abnormally low bone density, despite prophylactic factor infusion with the associated reduction in the joint disabling complications of bleeding. Previously, we demonstrated decreased bone mineral density, skeletal strength, and increased bone resorption in factor VIII (FVIII)-deficient mice without differences in physical activity or joint bleeding compared to control mice. Thus, we hypothesize that factor deficiency is an independent risk factor for decreased skeletal health. MethodsTo test this hypothesis, we evaluated platelet-poor plasma from 80 male subjects with severe FVIII deficiency, 20 male patients with severe factor IX (FIX) deficiency and 52 healthy male controls. Samples were assessed for three markers of bone turnover: receptor activator of nuclear factor kappa-B ligand (RANKL), osteoprotegerin (OPG) and carboxy-terminal collagen crosslinks (CTX-1). RANKL binding to the RANK receptor induces the proliferation and differentiation of osteoclasts resulting in increased bone resorption. OPG competitively inhibits RANKL binding to RANK, blocking these osteoclastic effects. CTX-1 is formed through the degradation of bone and thus is a direct marker of bone resorption. ResultsNo differences in RANKL levels are seen between any of the groups. A significant increase in OPG is identified in plasma from FIX-deficient subjects compared to FVIII-deficient subjects (p = 0.0046) and control subjects (p = 0.0095), without differences seen between FVIII-deficient and control subjects (p = 0.920). CTX-1 is higher in samples from FVIII-deficient subjects compared to FIX-deficient subjects (p = 0.020) and control subjects (p = 0.0024), without differences seen between FIX-deficient and control subjects (p = 0.947) samples. In a subset analysis, subjects receiving FVIIII concentrate replacement within 12 hours of plasma collection have decreased CTX-1 (p = 0.022) but not OPG (p= 0.850) compared to those subjects receiving factor concentrate replacement greater than12 hours from plasma collection. We are currently evaluating other plasma markers of bone turnover and cytokine expression in the same cohort of samples. ConclusionsSubjects with FVIII deficiency but not FIX deficiency have evidence of increased bone resorption compared to control samples. Increased OPG levels are present in FIX-deficient plasma and may contribute to the differences seen in CTX-1 production between subjects with FIX and FVIII deficiency. Furthermore, FVIII replacement within 12 hours of plasma collection reverses CTX-1 elevation seen in FVIII-deficiency. This study suggests that bone disease is intrinsic to FVIII-deficiency and that aggressive FVIII replacement may ameliorate this pathology. Disclosures:Manco-Johnson:Novo Nordisk: Membership on an entity's Board of Directors or advisory committees; Biogen Idec: Membership on an entity's Board of Directors or advisory committees; Baxter BioScience: Membership on an entity's Board of Directors or advisory committees; CSL Behring: Membership on an entity's Board of Directors or advisory committees, Research Funding; Bayer HealthCare: Membership on an entity's Board of Directors or advisory committees, Research Funding; Eisai: Research Funding. Taylor:Novo Nordisk: Research Funding; Baxter BioScience: Research Funding.

Registry Of Patients Treated With Protein C Concentrate (Human) In The United States and Europe: Interim Results

BackgroundProtein C (PC) is a naturally occurring, vitamin-K dependent anticoagulant produced by the liver. Deficiency of PC, which can be congenital or acquired, results in a hypercoagulable state. Patients with severe PC deficiency may manifest severe, often life-threatening, disseminated intravascular coagulation (DIC), purpura fulminans (PF), and/or thromboembolism. Highly purified protein C concentrate prepared from human donor plasma (Ceprotin; Baxter Healthcare Corporation, Westlake Village, CA) is an approved therapy for prevention and treatment of venous thrombosis and PF in patients with severe congenital PC deficiency (SCPCD) in the United States. It is indicated in patients with SCPCD for PF and coumarin-induced skin necrosis, and short-term prophylaxis in the European Union and other countries. Use of protein C concentrate (human) has been reported in patients with acquired PC deficiency. The Ceprotin Treatment Registry is a prospective, international, multi-center, open-label, non-interventional, observational study designed to examine the long-term safety and effectiveness of protein C concentrate (human) in the clinical setting. This is the first large, real-world assessment of the treatment of a rare disease with protein C concentrate (human). Here we report data from the first interim analysis in June 2013 covering a 3-year enrollment period. MethodsPatients of any age who received, or were initiating/receiving protein C concentrate are included. The study duration is 5 years (3-year enrollment period plus 2 years of follow-up). All study visits/assessments are in accordance with standard of care, with protein C concentrate dose, dose frequency, duration and route of administration determined by the investigator. The study objectives are to determine the most common medical diagnoses associated with protein C concentrate treatment, protein C concentrate treatment regimens, and safety information based on all serious adverse events (SAEs) and rate of treatment-related AE. Other objectives include: an examination of the relationship between protein C concentrate treatment and outcomes in all registry participants, as well as various subgroups. Descriptive statistical analyses are used. ResultsAt the time of data extraction, 34 patients were enrolled from 26 centers; 10 centers in the United States and 16 centers in Europe. Half of the patients were males. The primary diagnosis of PC deficiency was congenital in 25 patients (73.5%) and acquired in 9 patients (26.5%). The median age at diagnosis was 0.03 years (range 0–19.9). Mean plasma PC activity level was 9% (range 1–40.0). The most common (in ≥3 patients) thrombotic disease-associated conditions were PF (50.0%); blindness (44.1%); thromboembolic disease (41.2%), which included deep vein thrombosis, arterial thrombosis and DIC; stroke (32.4%), and renal dysfunction (8.8%). Of the 23 patients being treated with protein C concentrate, 15 were administered protein C concentrate intravenously, and 8 patients received protein C concentrate subcutaneously. The body weights of patients receiving subcutaneous treatment ranged from 10.0 kg to 57.9 kg. A total of 15 patients received an anticoagulant treatment in addition to protein C concentrate. Eight patients reported 23 SAEs, all of which were considered not related to treatment. Eighteen (52.9%) patients reported 72 AEs; only 1 of them, an episode of upper respiratory infection, was considered possibly treatment-related. In 18 patients in whom PC activity recovery was determined after protein C concentrate treatment, there were no patients documented with poor recovery. Protein C concentrate was used during 18 surgeries/invasive procedures and considered effective in all interventions for which data were available. ConclusionsData from the first interim analysis of the Ceprotin Treatment Registry demonstrate that patients with both congenital and acquired severe PC deficiency who are treated with protein C concentrate (human) have a low incidence of treatment related SAEs and AEs, and treatment with protein C concentrate appears to be effective when used during surgery/invasive procedures. Further patient follow up will shed light onto clinical treatment outcomes. Disclosures:Manco-Johnson:CSL Behring: Membership on an entity's Board of Directors or advisory committees, Research Funding; Novo Nordisk: Membership on an entity's Board of Directors or advisory committees; Biogen Idec: Membership on an entity's Board of Directors or advisory committees; Baxter BioScience: Membership on an entity's Board of Directors or advisory committees; Bayer HealthCare: Membership on an entity's Board of Directors or advisory committees, Research Funding; Eisai: Research Funding. Knoebl:Novo Nordisk: Consultancy, Honoraria; Baxter: Consultancy, Honoraria. Shapiro:Cangene: Research Funding; Biogen Idec: Research Funding; Baxter BioScience: Research Funding; Bayer HealthCare: Research Funding. Finnerty:Baxter: Employment, Equity Ownership. Yel:Baxter: Employment, Equity Ownership. Gelmont:Baxter: Employment, Equity Ownership.

Natural History Of Hemophilic Joint Disease Using Sensitive Imaging With Magnetic Resonance Imaging (MRI)

▪ IntroductionArthropathy, the most costly chronic complication of severe hemophilia A (HemA) can be prevented by routine replacement of factor VIII (FVIII) when initiated prior to joint bleeding (primary prophylaxis) [NEJM;357:535]. However, the efficacy of prophylaxis initiated after the onset of recurrent hemarthroses or with established arthropathy (secondary or tertiary prophylaxis) is unknown. This individual patient meta-analysis was performed to derive the natural history of arthropathy in HemA patients treated only in response to acute bleeding (on demand therapy) as a baseline for future work to estimate the amelioration of arthropathy attributable to secondary or tertiary prophylaxis. MethodsData from individual participants in 3 studies who received on demand therapy were aggregated into a single database. Eligibility for this analysis included FVIII ≤ 2%, negative history for inhibitor, bleeding history for 12 months prior to study data acquisition and assessment of both ankles, knees and elbows; joints were assessed using physical examination (PE) and T2* gradient echo MRI scored as previously described using the World Federation of Hemophilia Gilbert score and the 45 point extended MRI scales [Haemophilia;6:649; ISTH OP Mon 7/1/13, 9 am]. MRI data were divided into soft tissue and osteochondral changes. Bleeding and Gilbert data for all 6 joints and MRI data for knees and ankles were analyzed using standard descriptive statistics and regression methods to quantify the rate of change in scores of joint damage with age. ResultsThe 3 studies included the Joint Outcome Study [NEJM;357:535] and the JOS Continuation Study (JOSc), the Spinart Study baseline results [JTH;11:1119] and a Cross-Sectional MRI study [Haemophilia;189 Suppl3:117]. The 3 studies provide data on 275 individuals aged 1 to 50 years. Clinical, Gilbert and MRI data were extracted and analyzed from multiple joints in each of 157 individuals who were receiving on-demand treatment only. The median age was 21 (range 1 – 50), and across all studies the median number of bleeding episodes in the prior 12 months was 18 (range 0 to 82). The rate of change in outcomes as a function of age is shown in Table 1 and Figure 1. The number of bleeding episodes was approximately constant at 20 bleeding episodes per year regardless of age (Figure 1a; p = 0.72 for relationship with age). Gilbert scores showed a steeper rise in young patients but did not increase after the late teens (Figure 1b; change of 0.34 Gilbert points/year of life, p=0.07). [Display omitted] MRI scores, in contrast to bleeding rates and Gilbert scores, showed continued age-related deterioration (Figure 1c; change of 2 MRI points/year of life, p < 0.0001). Age-related total and osteochondral deterioration on MRI increased steadily with age (on average 2 MRI-points/year of age, p < 0.0001 for each), whereas soft tissue scores increased rapidly to approximately 9 by age 20, and then plateaued at a score of approximately 10 for ages 20-50 (0.08 MRI points/year, p =0.28). ConclusionsIndividual patient meta-analysis of bleeding frequency, joint PE and MRI joint structure was useful to determine the natural history of hemophilic arthropathy in patients treated with on-demand therapy, and showed a continuous increase in joint bone and cartilage abnormalities across the age span despite an early leveling in bleeding rate and joint physical function. These data will be critical to determine the quantitative effects of prophylaxis on mitigation of joint deterioration when initiated at various ages following the onset of joint bleeding. Disclosures:Manco-Johnson:Bayer HealthCare: Research Funding. Lundin:Bayer HealthCare: Research Funding. Hong:Bayer HealthCare: Employment. Oldenburg:Octapharma AG: Consultancy, Investigator Other. Manco-Johnson:Biogen Idec: Membership on an entity's Board of Directors or advisory committees; Baxter BioScience: Membership on an entity's Board of Directors or advisory committees; CSL Behring: Membership on an entity's Board of Directors or advisory committees, Research Funding; Bayer HealthCare: Membership on an entity's Board of Directors or advisory committees, Research Funding; NovoNordisk: Membership on an entity's Board of Directors or advisory committees; Eisai: Research Funding.▪▪

Natural History Of Inhibitor Recurrence Following Successful Immune Tolerance Induction

Introduction The formation of Factor VIII (FVIII) inhibitory antibodies is a major complication of hemophilia A. Currently immune tolerance induction (ITI) is successful in up to 70% of patients. Outside of the International Immune Tolerance Registry, where 6 of 128 patients had a recurrent inhibitor between 1 and 6 years, little is known about the probability of inhibitor recurrence following successful ITI. Objective To determine the probability of inhibitor recurrence and the influence of adherence to post-ITI prophylaxis on inhibitor recurrence following successful ITI. Methods All persons with hemophilia A (FVIII level 6 hours and/or FVIII recovery > 66% in addition to inhibitor titer 80% of prescribed infusions vs. < 80% of prescribed infusions) and inhibitor recurrence was assessed using the chi-square test. Results Eighty-three male subjects were enrolled. The median age at start of ITI was 3.3 years (range: 0.08 - 39). The majority of the subjects were white (73%) and non-Hispanic (73.5%). Seventy-one (85.6%) had severe hemophilia. The median peak inhibitor titer was 8.5 BU/ml (range: 0.6 - 950). Four subjects (5%) had a prior unsuccessful course of ITI. FVIII alone was used in 85% of subjects. Sixty-seven (80.7%) met criteria for tolerance and 64 had follow-up data available, with a median follow up time of 3.4 years (range: 0.08-12.4). Forty-four subjects (68.7%) remained tolerant without a recurrent inhibitor titer after a median 4.7 years (range: 0.25-12.4) of follow-up. Twenty subjects (31.3%) had at least one inhibitor titer ≥ 0.6 BU/ml after a median of 1.6 years (range 0.08-5.7). The probability of recurrent inhibitor at 1 year is 0.15 (95% CI: [0.05, 0.20]); at 3 years is 0.30 (95% CI: [0.2, 0.4]) and 5 years is 0.35 (95% CI: [0.2, 0.5]) ([Figure 1][1]). Four subjects discontinued post-ITI prophylaxis anywhere from 6 months to greater than 6 years after tolerance was achieved, of whom 2 (50%) developed a recurrent inhibitor. Of those that remained on post-ITI prophylaxis, 41 subjects (64.1%) were adherent (took >80% of prescribed infusions) to their post-ITI prophylaxis regimen, of whom 13 (31.7%) developed a recurrent inhibitor. Twenty-three (35.9%) who were non-adherent (took <80% of the prescribed infusions) of which 7 (30.4%) subjects developed a recurrent inhibitor; no statistically significant association was found between adherence and inhibitor-free status (p=0.92). ![Figure 1][2] Figure 1 Conclusion ITI is currently the most effective treatment to eradicate FVIII inhibitors, however 5 years after completion, 30-35% of patients will have at least one inhibitor titer ≥ 0.6 BU/ml. A recurrent inhibitor is unlikely after 5 years. Adherence to post-ITI prophylaxis does not appear to be a major driver of inhibitor recurrence. It is imperative to elucidate the factors that influence the durability of successful ITI to improve quality of life and cost of treatment in these patients. Disclosures: Monahan: Baxter: Consultancy, Honoraria, Research Funding, travel support, travel support Other; Bayer: Honoraria, Membership on an entity’s Board of Directors or advisory committees; Novo Nordisk: Consultancy, Honoraria, Research Funding; Pfizer: Honoraria; Prolor Biotech: Research Funding; Asklepios: Consultancy, Research Funding, travel support Other. Manco-Johnson: Eisai: Research Funding; Novo Nordisk: Membership on an entity’s Board of Directors or advisory committees; Biogen Idec: Membership on an entity’s Board of Directors or advisory committees; Baxter BioScience: Membership on an entity’s Board of Directors or advisory committees; CSL Behring: Membership on an entity’s Board of Directors or advisory committees, Research Funding; Bayer HealthCare: Membership on an entity’s Board of Directors or advisory committees, Research Funding. Carpenter: Novo Nordisk: Honoraria, Research Funding; Pfizer: Honoraria, Research Funding; CSL Behring: Honoraria, Research Funding; Grifols: Honoraria, Research Funding. Kruse-Jarres: Bayer HealthCare: Consultancy; Biogen IDEC: Consultancy; Grifols: Consultancy; Kedrion: Consultancy; Novo Nordisk: Consultancy; Baxter Healthcare: Consultancy. Ragni: Novo Nordisk: Research Funding; Merck: Research Funding; CSL Behring: Research Funding; Bayer: Research Funding; Baxter: Research Funding; Tacere Benitec: Consultancy; Smith Kline Glaxo: Consultancy, Research Funding; Bristol Myers Squibb: Consultancy, Research Funding; Biogen Idec: Membership on an entity’s Board of Directors or advisory committees, Research Funding; Pfizer: Research Funding. Kempton: Novo Nordisk: Research Funding; Baxter Healthcare: Membership on an entity’s Board of Directors or advisory committees. [1]: #F1 [2]: pending:yes

Feasibility Study Of a Randomized Control Trial To Evaluate An Internet-Based Self-Management Program For Adolescents With Hemophilia

IntroductionAs adolescents with hemophilia approach adulthood, they must assume responsibility for their health and management of their disease. An online self-management program was developed to support adolescents during this transition. AimTo determine the feasibility of studying the online educational program using a non-blind, randomized control trial(RCT) design in terms of 1)Study accrual and attrition rates, 2) willingness to be randomized 3) compliance with the program and completion of the outcome measures, and 4) satisfaction with the program. MethodsAdolescents, ages 13-18, were enrolled from three tertiary care centres in Canada in a pilot RCT (NCT01477437). After providing informed consent, adolescents were randomized to the intervention (8 week program with telephone coaching) or the control arm (no access, weekly telephone call as attention-strategy). Adolescents in both arms of the study were asked to complete pre- and post- outcome measures. Following completion of the program, quantitative analysis addressed the feasilibity measures and qualitative interviews were conducted to assess satisfaction. Results29 teens participated (intervention group, n=16, control group, n=13).Participants in the intervention arm spent an average of 50 minutes on the website per week completed the 8 modules in an average of 14 weeks (SD= 4.9). Among those randomized to the intervention, 2 participants dropped out of the study and 2 were lost to follow-up, resulting in an attrition rate of 25% (4/16). The control arm had a higher attrition rate of 54% (7/13) with 5 participants being lost to follow-up and 2 participants dropping out. For participants who completed the program, 17/18 (94%) completed the post-study outcome measures. Despite the study not being powered to assess efficacy, teens on the intervention arm showed significant improvement in disease-specific knowledge (p=0.004), self-efficacy (p=0.007) and transition preparedness (p=0.046) over time. There was a statistically significant improvement in the knowledge measure in the intervention group when compared to the control group (p=0.01). Overall, the teens found the website to be informative, comprehensive and easy to use and were satisfied with the program. ConclusionsThis feasibility study suggests benefit to the program and indicates a full scale RCT to be a reasonable next step with minor adjustments to the protocol. The higher than expected attrition rate in the control group, suggests the need to improve the strategies for maintaining participant engagement using a more active attention control group (static educational materials) in the design of this web-based intervention prior to a larger study to assess efficacy. Disclosures:Breakey:Baxter Bioscience: Research Funding.

A Long-Term Phenotype Analysis Of 51 Patients With Upshaw–Schulman Syndrome In Japan, With Special References To Pregnancy and Renal Failure That Requires Hemodialysis

Backgrounds and AimsThe classic hallmarks of Upshaw Schulman syndrome (USS) are severe newborn jaundice with a negative Coombs test that requires an exchange transfusion and repeated childhood episodes of thrombocytopenia and microangiopathic hemolytic anemia that are reversed by infusions of fresh frozen plasma. But now, it is well established that USS is a hereditary deficiency in the activity of von Willebrand factor (VWF)-cleaving protease, termed ADAMTS13. The inheritance mode is autosomal recessive, and their parents are usually asymptomatic carriers having one disease-causing mutation (DCM) of the gene.In the absence of ADAMTS13, unusually large VWF multimers (UL-VWFMs) released from vascular endothelial cells are inappropriately cleaved, leading to platelet hyperagglutination under high shear stress. Thus, USS is alternatively called congenital thrombotic thrombocytopenic purpura (TTP). But, unlike acquired TTP, clinical signs of USS patients are usually mild during childhood and often an isolated thrombocytopenia is found. Further, now it is known that TTP-bouts are aggravated or initiated by the following factors: 1) severe infections such as influenza, 2) pregnancy, 3) 1-deamino-8-D-arginine vasopressin (DDAVP) administration, 4) interferon therapy, 5) heavily drinking alcohol, and 6) aging.So far, in worldwide approximately 150 patients with USS have been found, of which we identified 51 patients in Japan. Among them, 48 patients were received ADAMTS13 gene analysis, and a pair of DCMs, either homozygotes or compound heterozygotes, was identified in all patients except for one. Interestingly, these DCMs are quite different from those found in patients of Western countries and United States, but several DCMs in Japanese patients are also found in Korean and Chinese patients. Thus, it appears that Caucasians and Asians have two different DCM routs for ADAMTS13. Further, since USS is an extremely rare disease, no one can predict the life-long clinical outcome in these patients. Thus, in this study using our cohort of 51 Japanese USS patients, we have extensively analyzed a long-term phenotype, with special references to pregnancy and renal failure that requires hemodialysis. Methods and PatientsADAMTS13 activity and its neutralizing antibodies (inhibitors) were determined by chromogenic ADAMTS13-act-ELISA [Kato et al. Transfusion, 2006], and the IgG type binding antibodies were assayed as described [Ferrari et al, JTH 2009]. Fifty-one patients with USS (19 males and 32 females, born in 1931-2013) were enrolled in this study. None of the patients had the neutralizing antibodies, but 6 patients (6/51, 12%) developed the IgG type non-neutralizing antibodies. Results and DiscussionPregnancy: We identified 26 episodes of pregnancy in 15 patients with USS (Table 1). Briefly, 22 pregnancies were identified before a diagnosis of USS, and as consequence 3 episodes are related to abortion, 10 episodes to stillbirth, and 9 episodes to live birth, in which 6 babies were premature. In contrast, 4 pregnancies were after a diagnosis of USS, and they all had the planned FFP infusions from the early phase of pregnancy, resulting in all successful deliveries, but with 2 premature babies.Renal failure: We identified that 6 male patients finally fell into the end-stage severe renal diseases that required hemodialysis, of which 4 patients were deceased (Table 2). Median time from a diagnosis of USS to dialysis initiation was 15 years (range 1-25). Curiously, all these patients except for one had received FFP infusions biweekly after a diagnosis of USS. Causes of death in these 4 patients were the followings: heart failure (n=1), renal failure (n=1), and sudden death (n=2). The reason why all the patients, who fell into severe renal dysfunction, are male left unaddressed. [Display omitted] [Display omitted] Disclosures:Fujimura:Alexion Pharma: Membership on an entity's Board of Directors or advisory committees; Baxter BioScience: Membership on an entity's Board of Directors or advisory committees. Matsumoto:Alexion Pharma: Membership on an entity's Board of Directors or advisory committees.

Atypical Hemolytic Uremic Syndrome In Japan Characterized By The Inhibitory Antibody-Based Hemolytic Assay and The Gene Analysis

Backgrounds and AimsAtypical hemolytic uremic syndrome (aHUS) is a life-threatening generalized disease, featured by a clinical triad of microangiopathic hemolytic anemia, thrombocytopenia, and renal failure. Now it is well established that most of aHUS is caused by uncontrolled complement activation due to gene mutations involved in the alternative pathway, which includes C3, factor H (CFH), factor I (CFI), membrane cofactor protein (MCP), thrombomodulin (THBD) and factor B (CFB). Gene mutations in complement factor H- related proteins 1-5 (CFHR1-5) are also included in a category of aHUS. On the other hand, HUS and thrombotic thrombocytopenic purpura (TTP) are both categorized with a common pathological diagnosis, thrombotic microangiopathy (TMA). TTP, however, is now clearly defined by a deficient activity of ADAMTS13Our laboratory of Nara Medical University has been functioning as a TMA referral center in Japan through analyzing ADAMTS13 since 1998. Through this study we identified 51 patients with hereditary deficiency of ADAMTS13 activity and 63 patients with aHUS with almost normal ADAMTS13 activity. To characterize these aHUS patients, as a first step we prepared 6 murine monoclonal antibodies (mAbs) against CFH, purified from normal plasma. One of anti-CFH mAbs, termed O-72 (IgG1-k), totally inhibited CFH function in the hemolytic assay described below. Epitope analysis of the mAb O-72 using yeast constructs clearly indicated that it resides on short consensus repeat 18 of CFH molecule. Patients and Methods(1) Patients: Of 63 patients with aHUS, 35 patients whose blood specimen were obtained within 3 months were extensively analyzed in this study. (2) Hemolytic assay: Using the mAb O-72, sheep red blood cells, and citrated plasmas, we were able to establish a quantitative hemolytic assay, according to the method of Sanchez-Corral et al (Mol Immunol 2004). The hemolysis obtained in the presence of the mAb O-72 (200 µg IgG/ml, final) was defined as a 100% hemolysis as the control. In this study, we consistently used citrated plasmas as test specimen, which were either freshly prepared or deep-frozen at -80oC within 3 months, and did not use sera. This is because our preliminary experiments clearly indicated that hemolytic activity using freshly prepared plasmas gives a consistent result, but that using sera was not. (3) Anti-CFH autoantibody: This was performed by western blot (WB) analysis using purified plasma derived CFH, (4) The comprehensive gene analyses on complement and complement regulatory factors, such as C3, CFH, CFI, MCP, THBD and CFB: These were performed as previously described [Fan et al. Molecular Immunology 2013], (5) Semi-quantitative WB analysis on antigens of CFHR1 and CFHR3, and (6) MLPA analyses for the exons of CFHR1 and CFHR3. Results and DiscussionIn the hemolytic assay, 3 unrelated patients with CFH-R1215Q mutation had a strong hemolysis (100% of the control). Interestingly, 4 individuals belonged to these 3 families, but without clinical signs of HUS, also showed an enhanced hemolysis as did the patients. Thus, it is important to note that our hemolytic assay can detect asymptomatic carriers of CFH-R1215Q mutation. To strengthen this observation, 3 patients with positive anti-CFH autoantibody but without CFH gene mutations also had an enhanced hemolysis (50-70% of the control), and one patient indeed had the homozygous deletion of CFHR1 gene.Fifteen patients carried C3 gene mutations, of which 13 patients had the same mutation of C3-I1157T (13/35, 37%). None of these patients, however, showed an enhanced hemolysis in our hemolytic assay. But, the C3-I1157T mutation can be easily detected with PCR followed by restriction fragments length polymorphism (RFLP) assay. Thus, using these combined assays of hemolysis, anti-CFH autoantibody detection, and RFLP for C3-I1157T, we can make a solid diagnosis on approximately 60% of Japanese aHUS patients within 5 days. But, the remaining 40% of the aHUS patients required the comprehensive gene analysis. A summary of the gene mutations in our 35 patients with aHUS is shown in Table 1. [Display omitted] As consequence, here we have shown a major cause of aHUS (approximately 37% of the total) in Japan is a missense mutation of C3-I1157T, and a missense mutation of CFH (-R1215Q) is likely to be less (approximately 9% of the total) than those in Western countries-US. Disclosures:Matsumoto:Alexion Pharma: Membership on an entity's Board of Directors or advisory committees. Fujimura:Baxter BioScience: Membership on an entity's Board of Directors or advisory committees; Alexion Pharma: Membership on an entity's Board of Directors or advisory committees.