Sir,—Bleeding in hæmophiliacs with factor-VIII inhibitors of low-responder type is generally overcome by massive factor-VIII infusions.1 The addition of immunosuppressive therapy may be successful in high responders, delaying and possibly weakening the anamnestic response.2,3“Activated” factor-IX concentrates may also be useful.4 These regimens, however, are unsuitable when prolonged substitution therapy is necessary in a high responder. Our patient is a 20-year-old hæmophiliac with factor-VIII inhibitor. His elder brother, also a hæmophiliac with inhibitor, died aged 18 from a retroperitoneal hæmorrhage. Our patient has had bleeding episodes since birth and has been given many infusions of whole blood, plasma, cryoprecipitate, and factor-VIII concentrates in more than thirty hospital admissions, without much success. Inhibitor was detected when he was 12 years old. Three times he has received concentrates in combination with immunosuppressive therapy, the last (1973) being with cyclophosphamide (15 mg/kg intravenously followed by 2 mg/kg body-weight orally for 10 days) when the inhibitor concentration increased after 4–5 days from 0·5 units/ml to a peak of 30–40 units/ml after 2 weeks. The preinfusion level was regained after 2 months. In 1976 at the age of 18 he passed his final school examination, brilliantly, but he was confined to a wheelchair or bed and he wanted to be more independent. This would need prolonged physiotherapy, which could be achieved only if covered by factor-VIII after elimination of inhibitor. We decided to use the treatment given by the hæmophilic centre in Bonn5—a combination of daily massive infusions of factor VIII and activated factor IX until the increase in inhibitor, which follows infusions, has been eliminated, after which daily doses should keep the inhibitor level low and permit physiotherapy. Our patient was treated in Bonn. His factor-VIII level was 1% and his inhibitor level was 0.5 Bethesda units/ml on admission. The dosages and inhibitor levels are shown in the figure. At first he received 3000 units of factor VIII and 2500 units of concentrated factor IX daily. His inhibitor level increased during the first week to about 1100 units/ml and did not fall significantly until he had received 12 000 units of factor VIII per day for 10 days. The dose could then be reduced, and after 3 months with daily injections an inhibitor level of 1 unit/ml was obtained. The inhibitor concentration rose 3 weeks later, the daily dosage of factor VIII having been reduced too far, but the inhibitor concentration fell again when the dose was increased. After 7 months he has no demonstrable inhibitor while on 3000 units of factor VIII and 1000 units of factor IX concentrate (‘Feiba’) daily. He received, due to shortage of feiba, other factor-IX concentrates in between. —Factor VIII inhibitor during treatment. There have been a few bleeding episodes, mostly in one bad elbow but sometimes more general. In more general bleeds we often found a positive ethanol test, increased amounts of fibrinogen-related antigens, shortened euglobulin-lysis time, a low platelet-count, and a defect in A.D.P., adrenaline, and collagen- induced platelet aggregation in vitro. He has biochemically no hepatic or renal damage. Platelet or leucocyte antibodies and hepatitis B antigen or antibody have not been found. He has been able to do progressively more active physiotherapy, and is making great progress. Furthermore he has passed another examination, and is able to use his typewriter again. Except for the first days in Bonn he has administered the injections himself. A feature of this case is the very high level of inhibitor and the very large doses of factor VIII.
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Jan 1, 2013
Liu Hongyan + 4
Open Access
