Acquired Inhibitors of Coagulation Factors: Part I—Acquired Hemophilia A

Abstract

Acquired hemophilia A (AHA) is a rare, but often severe, bleeding disorder caused by autoantibodies against clotting factor VIII (FVIII). AHA occurs more frequently in the elderly and in association with several conditions, such as malignancies, autoimmune diseases, postpartum, or drug exposure; however, about half of the cases remain idiopathic. At variance with congenital hemophilia, where hemarthroses are the most common bleeding symptoms, hemorrhages in AHA involving soft tissues (muscle, skin) are more frequently reported. AHA is diagnosed in patients: with negative personal or family bleeding history; in which prolonged activated partial thromboplastin time is not corrected after mixing and incubating equal volumes of patient and normal plasma for ~2 hours at 37°C; FVIII levels are reduced; and a specific FVIII-inhibiting activity is detected. Prompt recognition and treatment of AHA are mandatory, as inadequate management and complications of the disease are associated with high mortality rates. Therapeutic approaches should aim to control acute bleeds, eradicate FVIII-autoantibody production, treat associated diseases, and when possible, eliminate them. Present knowledge about this often overlooked and challenging condition has significantly increased following establishment of recent national and international studies, as will also be reviewed in this article.

Keywords

acquired hemophilia A - autoantibodies - bleeding - inhibitors

• References

• 1 Bouvry P, Recloux P. Acquired hemophilia. Haematologica 1994; 79 (6) 550-556
• 2 Delgado J, Jimenez-Yuste V, Hernandez-Navarro F, Villar A. Acquired haemophilia: review and meta-analysis focused on therapy and prognostic factors. Br J Haematol 2003; 121 (1) 21-35
• 3 Green D, Lechner K. A survey of 215 non-hemophilic patients with inhibitors to Factor VIII. Thromb Haemost 1981; 45 (3) 200-203
• 4 Collins PW, Hirsch S, Baglin TP , et al; UK Haemophilia Centre Doctors' Organisation. Acquired hemophilia A in the United Kingdom: a 2-year national surveillance study by the United Kingdom Haemophilia Centre Doctors' Organisation. Blood 2007; 109 (5) 1870-1877
• 5 Baudo F, de Cataldo F, Gaidano G ; Italian registry of acquired hemophilia. Treatment of acquired factor VIII inhibitor with recombinant activated factor VIIa: data from the Italian registry of acquired hemophilia. Haematologica 2004; 89 (6) 759-761
• 6 Ma A, Kessler CM, Gut RZ, Cooper DL. Treatment of acquired haemophilia with recombinant factor VIIa (rFVIIa): an updated analysis from the hemophilia and thrombosis research society (HTRS) registry. J Thromb Haemost 2011; 9 (Suppl. 02) 476 (abstract P-TU-532)
• 7 Borg I-Y, Negrier C, Durieu I , et al. Prospective clinical and biological evaluation of antihemorrhagic treatment with factor eight inhibitor bypassing activity in acquired hemophilia, FEIBHAC Study. J Thromb Haemost 2011; 9 (Suppl. 02) 938-939 (abstract P-TH-545)
• 8 Knoebl P, Marco P, Baudo F , et al; EACH2 Registry Contributors. Demographic and clinical data in acquired hemophilia A: results from the European Acquired Haemophilia Registry (EACH2). J Thromb Haemost 2012; 10 (4) 622-631
• 9 Huth-Kühne A, Baudo F, Collins P , et al. International recommendations on the diagnosis and treatment of patients with acquired hemophilia A. Haematologica 2009; 94 (4) 566-575
• 10 Franchini M, Lippi G, Favaloro EJ. Acquired inhibitors of coagulation factors: part II. Semin Thromb Haemost 2012; 38 (5) 447-453
• 11 Tufano A, Coppola A, Guida A , et al. Acquired haemophilia a in the elderly: case reports. Curr Gerontol Geriatr Res 2010; 2010: 927503
• 12 Collins P, Macartney N, Davies R, Lees S, Giddings J, Majer R. A population based, unselected, consecutive cohort of patients with acquired haemophilia A. Br J Haematol 2004; 124 (1) 86-90
• 13 Moraca RJ, Ragni MV. Acquired anti-FVIII inhibitors in children. Haemophilia 2002; 8 (1) 28-32
• 14 Solymoss S. Postpartum acquired factor VIII inhibitors: results of a survey. Am J Hematol 1998; 59 (1) 1-4
• 15 Hauser I, Schneider B, Lechner K. Post-partum factor VIII inhibitors. A review of the literature with special reference to the value of steroid and immunosuppressive treatment. Thromb Haemost 1995; 73 (1) 1-5
• 16 Baudo F, de Cataldo F ; Italian Association of Haemophilia Centres (AICE): Register of acquired factor VIII inhibitors (RIIA). Acquired factor VIII inhibitors in pregnancy: data from the Italian Haemophilia Registry relevant to clinical practice. BJOG 2003; 110: 311-314
• 17 Franchini M. Postpartum acquired factor VIII inhibitors. Am J Hematol 2006; 81 (10) 768-773
• 18 Kesley PR, Leyland MJ. Acquired inhibitor to human factor VIII associated with paraproteinemia and subsequent development of chronic lymphocytic leukemia. Br Med J (Clin Res Ed) 1982; 285 (6336) 174-175
• 19 Meiklejohn DJ, Watson HG. Acquired haemophilia in association with organ-specific autoimmune disease. Haemophilia 2001; 7 (5) 523-525
• 20 Coppola A, Tufano A, Di Capua M, Franchini M. Bleeding and thrombosis in multiple myeloma and related plasma cell disorders. Semin Thromb Hemost 2011; 37 (8) 929-945
• 21 Morrison AE, Ludlam CA, Kessler C. Use of porcine factor VIII in the treatment of patients with acquired hemophilia. Blood 1993; 81 (6) 1513-1520
• 22 Bossi P, Cabane J, Ninet J , et al. Acquired hemophilia due to factor VIII inhibitors in 34 patients. Am J Med 1998; 105 (5) 400-408
• 23 Yee TT, Taher A, Pasi KJ, Lee CA. A survey of patients with acquired haemophilia in a haemophilia centre over a 28-year period. Clin Lab Haematol 2000; 22 (5) 275-278
• 24 Tay L, Duncan E, Singhal D , et al. Twelve years of experience of acquired hemophilia A: trials and tribulations in South Australia. Semin Thromb Hemost 2009; 35 (8) 769-777
• 25 Hauser I, Lechner K. Solid tumors and factor VIII antibodies. Thromb Haemost 1999; 82 (3) 1005-1007
• 26 Sallah S, Wan JY. Inhibitors against factor VIII in patients with cancer. Analysis of 41 patients. Cancer 2001; 91 (6) 1067-1074
• 27 Sallah S, Nguyen NP, Abdallah JM, Hanrahan LR. Acquired hemophilia in patients with hematologic malignancies. Arch Pathol Lab Med 2000; 124 (5) 730-734
• 28 Franchini M, Targher G, Manzato F, Lippi G. Acquired factor VIII inhibitors in oncohematology: a systematic review. Crit Rev Oncol Hematol 2008; 66 (3) 194-199
• 29 Trotta F, Bajocchi G, La Corte R, Moratelli S, Sun LY. Long-lasting remission and successful treatment of acquired factor VIII inhibitors using cyclophosphamide in a patient with systemic lupus erythematosus. Rheumatology (Oxford) 1999; 38 (10) 1007-1009
• 30 Soriano RM, Matthews JM, Guerado-Parra E. Acquired haemophilia and rheumatoid arthritis. Br J Rheumatol 1987; 26 (5) 381-383
• 31 Vignes S, Le Moing V, Meekel P, Papo T, Wechsler B, Godeau P. Acquired hemophilia: a rare complication of Sjögren's syndrome. Clin Exp Rheumatol 1996; 14 (5) 559-560
• 32 Hoyle C, Ludlam CA. Acquired factor VIII inhibitor associated with multiple sclerosis, successfully treated with porcine factor VIII. Thromb Haemost 1987; 57 (2) 233
• 33 Seidler CW, Mills LE, Flowers ME, Sullivan KM. Spontaneous factor VIII inhibitor occurring in association with chronic graft-versus-host disease. Am J Hematol 1994; 45 (3) 240-243
• 34 Sievert R, Goldstein ML, Surks MI. Graves' disease and autoimmune factor VIII deficiency. Thyroid 1996; 6 (3) 245-247
• 35 Stewart AJ, Manson LM, Dasani H , et al. Acquired haemophilia in recipients of depot thioxanthenes. Haemophilia 2000; 6 (6) 709-712
• 36 Sallah S, Wan JY. Inhibitors against factor VIII associated with the use of interferon-alpha and fludarabine. Thromb Haemost 2001; 86 (4) 1119-1121
• 37 Regina S, Colombat P, Fimbel B, Guerois C, Gruel Y. Acquired inhibitor to factor VIII in a patient with Hodgkin's disease following treatment with interferon-alpha. Haemophilia 2001; 7 (5) 526-527
• 38 Mauser-Bunschoten EP, Damen M, Reesink HW, Roosendaal G, Chamuleau RA, van den Berg HM. Formation of antibodies to factor VIII in patients with hemophilia A who are treated with interferon for chronic hepatitis C. Ann Intern Med 1996; 125 (4) 297-299
• 39 Capra F, Nicolini N, Franchini M. Is the periodic repetition of a coagulation check necessary during anti-hepatitis C virus therapy?. Gut 2006; 55 (6) 902
• 40 Tiplady CW, Hamilton PJ, Galloway MJ. Acquired haemophilia complicating the remission of a patient with high grade non-Hodgkin's lymphoma treated by fludarabine. Clin Lab Haematol 2000; 22 (3) 163-165
• 41 Franchini M, Capra F, Nicolini N , et al. Drug-induced anti-factor VIII antibodies: a systematic review. Med Sci Monit 2007; 13 (4) RA55-RA61
• 42 Dentale N, Fulgaro C, Guerra L, Fasulo G, Mazzetti M, Fabbri C. Acquisition of factor VIII inhibitor after acute hepatitis C virus infection. Blood 1997; 90 (8) 3233-3234
• 43 Michiels JJ. Acquired hemophilia A in women postpartum: clinical manifestations, diagnosis, and treatment. Clin Appl Thromb Hemost 2000; 6 (2) 82-86
• 44 Santoro RC, Prejanò S. Postpartum-acquired haemophilia A: a description of three cases and literature review. Blood Coagul Fibrinolysis 2009; 20 (6) 461-465
• 45 Coller BS, Hultin MB, Hoyer LW , et al. Normal pregnancy in a patient with a prior postpartum factor VIII inhibitor: with observations on pathogenesis and prognosis. Blood 1981; 58 (3) 619-624
• 46 Ries M, Wölfel D, Maier-Brandt B. Severe intracranial hemorrhage in a newborn infant with transplacental transfer of an acquired factor VII:C inhibitor. J Pediatr 1995; 127 (4) 649-650
• 47 Franchini M, Capra F, Capelli C, de Maria E, Lippi G, Gandini G. Clinical efficacy of recombinant activated factor VII (rFVIIa) during acute bleeding episode and surgery in a patient with acquired hemophilia A with high inhibitor titer. Haematologica 2001; 86 (4) E12
• 48 Hultin MB. Acquired inhibitors in malignant and nonmalignant disease states. Am J Med 1991; 91 (5A) 9S-13S
• 49 Lottenberg R, Kentro TB, Kitchens CS. Acquired hemophilia. A natural history study of 16 patients with factor VIII inhibitors receiving little or no therapy. Arch Intern Med 1987; 147 (6) 1077-1081
• 50 Favaloro EJ, Bonar R, Duncan E , et al; RCPA QAP in Haematology Haemostasis Committee. Identification of factor inhibitors by diagnostic haemostasis laboratories: a large multi-centre evaluation. Thromb Haemost 2006; 96 (1) 73-78
• 51 Favaloro EJ, Bonar R, Duncan E , et al. Mis-identification of factor inhibitors by diagnostic haemostasis laboratories: recognition of pitfalls and elucidation of strategies. A follow up to a large multicentre evaluation. Pathology 2007; 39 (5) 504-511
• 52 Ewing NP, Kasper CK. In vitro detection of mild inhibitors to factor VIII in hemophilia. Am J Clin Pathol 1982; 77 (6) 749-752
• 53 Kershaw G, Jayakodi D, Dunkley S. Laboratory identification of factor inhibitors: the perspective of a large tertiary hemophilia center. Semin Thromb Hemost 2009; 35 (8) 760-768
• 54 Kershaw G, Favaloro EJ. Laboratory identification of factor inhibitors: an update. Pathology 2012; 44 (4) 293-302
• 55 Verbruggen B, Novakova I, Wessels H, Boezeman J, van den Berg M, Mauser-Bunschoten E. The Nijmegen modification of the Bethesda assay for factor VIII:C inhibitors: improved specificity and reliability. Thromb Haemost 1995; 73 (2) 247-251
• 56 Collins P, Baudo F, Huth-Kühne A , et al. Consensus recommendations for the diagnosis and treatment of acquired haemophilia A. BMC Res Notes 2010; 3: 161
• 57 Cohen AJ, Kessler CM. Acquired inhibitors. Baillieres Clin Haematol 1996; 9 (2) 331-354
• 58 Reding MT. Immunological aspects of inhibitor development. Haemophilia 2006; 12 (Suppl. 06) 30-35 , discussion 35–36
• 59 Bray GL, Kroner BL, Arkin S , et al. Loss of high-responder inhibitors in patients with severe hemophilia A and human immunodeficiency virus type 1 infection: a report from the Multi-Center Hemophilia Cohort Study. Am J Hematol 1993; 42 (4) 375-379
• 60 Reding MT, Lei S, Lei H, Green D, Gill J, Conti-Fine BM. Distribution of Th1- and Th2-induced anti-factor VIII IgG subclasses in congenital and acquired hemophilia patients. Thromb Haemost 2002; 88 (4) 568-575
• 61 Reding MT, Okita DK, Diethelm-Okita BM, Anderson TA, Conti-Fine BM. Human CD4+ T-cell epitope repertoire on the C2 domain of coagulation factor VIII. J Thromb Haemost 2003; 1 (8) 1777-1784
• 62 Oldenburg J, Zeitler H, Pavlova A. Genetic markers in acquired haemophilia. Haemophilia 2010; 16 (Suppl. 03) 41-45
• 63 Kasper CK. Complications of hemophilia A treatment: factor VIII inhibitors. Ann N Y Acad Sci 1991; 614: 97-105
• 64 Franchini M, Lippi G. Acquired factor VIII inhibitors. Blood 2008; 112 (2) 250-255
• 65 Toschi V, Baudo F. Diagnosis, laboratory aspects and management of acquired hemophilia A. Intern Emerg Med 2010; 5 (4) 325-333
• 66 Collins PW. Management of acquired haemophilia A. J Thromb Haemost 2011; 9 (Suppl. 01) 226-235
• 67 Paisley S, Wight J, Currie E, Knight C. The management of inhibitors in haemophilia A: introduction and systematic review of current practice. Haemophilia 2003; 9 (4) 405-417
• 68 Hay CR, Brown S, Collins PW, Keeling DM, Liesner R. The diagnosis and management of factor VIII and IX inhibitors: a guideline from the United Kingdom Haemophilia Centre Doctors Organisation. Br J Haematol 2006; 133 (6) 591-605
• 69 Hay CRM, Negrier C, Ludlam CA. The treatment of bleeding in acquired hemophilia with recombinant factor VIIa: a multicenter study. Thromb Haemost 1997; 78 (6) 1463-1467
• 70 Sumner MJ, Geldziler BD, Pedersen M, Seremetis S. Treatment of acquired haemophilia with recombinant activated FVII: a critical appraisal. Haemophilia 2007; 13 (5) 451-461
• 71 Knoebl P, Baudo F, Collins PW , et al. Management of Bleeding In Acquired Hemophilia: Results of the European Acquired Hemophilia Registry (EACH2). Blood 2010; 116 (21) 716
• 72 Sallah S. Treatment of acquired haemophilia with factor eight inhibitor bypassing activity. Haemophilia 2004; 10 (2) 169-173
• 73 Goudemand J. Treatment of bleeding episodes occurring in patients with acquired haemophilia with FEIBA: the French experience. Haemophilia 2004; 10 (Suppl. 03) abstract PO14
• 74 Dehmel H, Werwitzke S, Trummer A, Ganser A, Tiede A. Thrombelastographic monitoring of recombinant factor VIIa in acquired haemophilia. Haemophilia 2008; 14 (4) 736-742
• 75 Sørensen B, Ingerslev J. Tailoring haemostatic treatment to patient requirements - an update on monitoring haemostatic response using thrombelastography. Haemophilia 2005; 11 (Suppl. 01) 1-6
• 76 Sørensen B, Ingerslev J. Whole blood clot formation phenotypes in hemophilia A and rare coagulation disorders. Patterns of response to recombinant factor VIIa. J Thromb Haemost 2004; 2 (1) 102-110
• 77 Váradi K, Negrier C, Berntorp E , et al. Monitoring the bioavailability of FEIBA with a thrombin generation assay. J Thromb Haemost 2003; 1 (11) 2374-2380
• 78 Aledort LM. Factor VIII inhibitor bypassing activity (FEIBA) - addressing safety issues. Haemophilia 2008; 14 (1) 39-43
• 79 Holmström M, Tran HT, Holme PA. Combined treatment with APCC (FEIBA^®) and tranexamic acid in patients with haemophilia A with inhibitors and in patients with acquired haemophilia A - a two-centre experience. Haemophilia 2012;
• 80 Aledort LM. Comparative thrombotic event incidence after infusion of recombinant factor VIIa versus factor VIII inhibitor bypass activity. J Thromb Haemost 2004; 2 (10) 1700-1708
• 81 Ehrlich HJ, Henzl MJ, Gomperts ED. Safety of factor VIII inhibitor bypass activity (FEIBA): 10-year compilation of thrombotic adverse events. Haemophilia 2002; 8 (2) 83-90
• 82 Franchini M, Lippi G. Recombinant activated factor VII: mechanisms of action and current indications. Semin Thromb Hemost 2010; 36 (5) 485-492
• 83 Mahlangu JN, Coetzee MJ, Laffan M , et al. Phase I, randomized, double-blind, placebo-controlled, single-dose escalation study of the recombinant factor VIIa variant BAY 86-6150 in hemophilia. J Thromb Haemost 2012; 10 (5) 773-780
• 84 Schulte S. Pioneering designs for recombinant coagulation factors. Thromb Res 2011; 128 (Suppl. 01) S9-S12
• 85 Franchini M, Lippi G. The use of desmopressin in acquired haemophilia A: a systematic review. Blood Transfus 2011; 9 (4) 377-382
• 86 Toschi V. OBI-1, porcine recombinant Factor VIII for the potential treatment of patients with congenital hemophilia A and alloantibodies against human Factor VIII. Curr Opin Mol Ther 2010; 12 (5) 617-625
• 87 Négrier C, Dechavanne M, Alfonsi F, Tremisi PJ. Successful treatment of acquired factor VIII antibody by extracorporeal immunoadsorption. Acta Haematol 1991; 85 (2) 107-110
• 88 Jansen M, Schmaldienst S, Banyai S , et al. Treatment of coagulation inhibitors with extracorporeal immunoadsorption (Ig-Therasorb). Br J Haematol 2001; 112 (1) 91-97
• 89 Franchini M, Sassi M, Dell'Anna P , et al. Extracorporeal immunoadsorption for the treatment of coagulation inhibitors. Semin Thromb Hemost 2009; 35 (1) 76-80
• 90 Zeitler H, Ulrich-Merzenich G, Hess L , et al. Treatment of acquired hemophilia by the Bonn-Malmo Protocol: documentation of an in vivo immunomodulating concept. Blood 2005; 105 (6) 2287-2293
• 91 Spero JA, Lewis JH, Hasiba U. Corticosteroid therapy for acquired F VIII:C inhibitors. Br J Haematol 1981; 48 (4) 635-642
• 92 Lian EC, Larcada AF, Chiu AY. Combination immunosuppressive therapy after factor VIII infusion for acquired factor VIII inhibitor. Ann Intern Med 1989; 110 (10) 774-778
• 93 Green D, Rademaker AW, Briët E. A prospective, randomized trial of prednisone and cyclophosphamide in the treatment of patients with factor VIII autoantibodies. Thromb Haemost 1993; 70 (5) 753-757
• 94 Shaffer LG, Phillips MD. Successful treatment of acquired hemophilia with oral immunosuppressive therapy. Ann Intern Med 1997; 127 (3) 206-209
• 95 Schulman S, Langevitz P, Livneh A, Mortinowitz U, Seligsohn U, Varon D. Cyclosporine therapy for acquired factor VIII inhibitor in a patient with systemic lupus erythematosus. Thromb Haemost 1996; 76 (3) 344-346
• 96 Petrovic M, Derom E, Baele G. Cyclosporine treatment of acquired hemophilia due to factor VIII antibodies. Haematologica 2000; 85 (8) 895-896
• 97 Pardos-Gea J, Ordi-Ros J, Altisent C, Balada E, Pérez-López J, Vilardell M. Acquired haemophilia A: successful treatment with immunosuppression, methylprednisolone pulses and oral cyclosporin. Thromb Haemost 2006; 95 (4) 735-737
• 98 Collins PW, Baudo F, Knoebl P , et al. Inhibitor Eradication In Acquired Haemophilia A: Final Results of European Acquired Haemophilia Registry (EACH2). Blood 2010; 116 (21) abstract 715
• 99 Nicolaides AN, Breddin HK, Carpenter P , et al; European Genetics Foundation; Cardiovascular Disease Educational and Research Trust; International Union of Angiology; Mediterranean League on Thromboembolism. Thrombophilia and venous thromboembolism. International consensus statement. Guidelines according to scientific evidence. Int Angiol 2005; 24 (1) 1-26
• 100 Stasi R, Pagano A, Stipa E, Amadori S. Rituximab chimeric anti-CD20 monoclonal antibody treatment for adults with chronic idiopathic thrombocytopenic purpura. Blood 2001; 98 (4) 952-957
• 101 Wiestner A, Cho HJ, Asch AS , et al. Rituximab in the treatment of acquired factor VIII inhibitors. Blood 2002; 100 (9) 3426-3428
• 102 Onitilo AA, Skorupa A, Lal A , et al. Rituximab in the treatment of acquired factor VIII inhibitors. Thromb Haemost 2006; 96 (1) 84-87
• 103 Field JJ, Fenske TS, Blinder MA. Rituximab for the treatment of patients with very high-titre acquired factor VIII inhibitors refractory to conventional chemotherapy. Haemophilia 2007; 13 (1) 46-50
• 104 Franchini M. Rituximab in the treatment of adult acquired hemophilia A: a systematic review. Crit Rev Oncol Hematol 2007; 63 (1) 47-52
• 105 Aggarwal A, Grewal R, Green RJ , et al. Rituximab for autoimmune haemophilia: a proposed treatment algorithm. Haemophilia 2005; 11 (1) 13-19
• 106 Castaman G, Tosetto A. Is a reduced intensity treatment with rituximab effective in acquired haemophilia A?. Haemophilia 2011; 17 (5) 817-818
• 107 Coppola A, Di Minno MND, Santagostino E. Optimizing management of immune tolerance induction in patients with severe haemophilia A and inhibitors: towards evidence-based approaches. Br J Haematol 2010; 150 (5) 515-528
• 108 Green D. Suppression of an antibody to factor VIII by a combination of factor VIII and cyclophosphamide. Blood 1971; 37 (4) 381-387
• 109 Nemes L, Pitlik E. New protocol for immune tolerance induction in acquired hemophilia. Haematologica 2000; 85 (Suppl. 10) 64-68