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Inhibitors

Inhibitors are the body’s way of fighting off what it sees as a foreign agent. In inhibitors to factor concentrates, the rejection of the infused factor starts to happen as soon as the blood product is infused. This means that the factor concentrate is destroyed before it can stop the bleeding.
In haemophilia, inhibitors occur more often in individuals with the severe form than those with moderate or mild haemophilia. It is estimated that approximately 30% of patients with haemophilia A and 1.5% to 3% of patients with haemophilia B develop inhibitors to factor VIII and factor IX concentrates, respectively. For rare bleeding disorders, figures are unclear due to the limited patient population and the lack of treatment.
This is a very serious complication of haemophilia because factor concentrates are no longer effective. Treatment for bleeding just does not work. People with inhibitors are at risk for crippling from bleeding into their joints. They can die from serious internal bleeding. Newer treatment options have been licensed and in clinical trials are changing these outcomes.
How is it diagnosed?
Inhibitors typically occur in the first 75 exposures to the treatment, this is why it is important that people with bleeding disorders receive their first treatment under medical supervision in a treatment centre where the right medical facilities and expertise are available in case of inhibitor development or other allergic reactions. In fact, allergic reactions may amplify when treatment is given over time. Ideally, children and adults who are newly diagnosed with haemophilia should be tested regularly for inhibitors between the 1st and 50th days of treatment. Even after the 50th day of treatment, they should be checked at least twice a year until they have received 150-200 doses and at least once a year after that. Testing for inhibitors should also be done before any major surgery.
How is it treated?
New products for those with haemophilia A inhibitors do provide a prophylactic effect, but without the use of factor concentrate. These are called Non-(factor) Replacement Therapies (NRTs). Currently, there is only one product licenced. They are called bi-specific anti-bodies which are often referred to as mimetics.
High-dose factor concentrates
Administering factor concentrates at higher doses and/or more frequent intervals is the preferred treatment for acute bleeding in those with low inhibitor levels.
Immune tolerance induction therapy
Immune tolerance induction (ITI) therapy involves giving the person with inhibitors frequent doses of factor concentrates over several months, or sometimes years, to train the body to recognise the treatment product without reacting to it. This process is called tolerance induction. If a person plans to undergo immune tolerance induction therapy, but has not yet started, it is better not to use factor products to treat acute bleeding episodes because they are likely to provoke a rise in inhibitor titer.
Bi-Specific Antibodies (Haemophilia A inhibitors only)
An antibody is a type of protein made in a laboratory that can bind to substances in the body. A bi-specific antibody is one that is made to bind specifically to two substances- in this case Factor IXa (9) and Factor X (10) This is not a factor protein. When you take FVIII, you are replacing the FVIII that is missing from the body. FVIII connects two other proteins activated FIX (FIXa) and FX protein. FVIII creates the bridge between these proteins so the clotting process continues to form a clot and stop bleeding. Instead of the FVIII protein bridging the other two proteins, it is the antibody that does this connection. The inhibitors to FVIII do not recognise bi-specific antibodies. The person will still have an inhibitor so there will need to be a plan for the management of trauma or surgery.
These have several benefits. Firstly, they provide a consistent level of protection without peaks or troughs. There is no actual clotting factor infused provided, so they are not affected by FVIII inhibitors. Secondly, they are given subcutaneously (under the skin). They have long half-life’s so how the number of injections per month is less. On the other hand, unlike factor concentrates they cant target the level of protection required for certain activities and they cant be used to treat a bleed. So conversations with a clinician are important to find which treatment is best to suit your lifestyle and activities and give you the best protection for your body short and long term.
Bypassing agents
For the treatment of bleeding in people with inhibitors can receive activated prothrombin complex concentrate (aPCC) or recombinant factor VIIa. These are called by-passing agents. They can be used to skip steps in the clotting process. Whilst these are good for the treatment of bleeding, they do not replace the missing factor and therefore are not quiet as good in stopping bleeding. Also it is very difficult to give these as prophylaxis, to prevent bleeding and joint damage.
Tranexamic acid
Tranexamic acid (also known as Cyklokapron) is an anti-fibrinolytic agent. This means that it slows the breakdown of blood clots. It is used to prevent or treat bleeding from mucous membranes such as the inside of the mouth, nose, gut or womb. It may be given before dental work, for nosebleeds. However, it should not be used in combination with APCCs.
Plasmapheresis
Plasmapheresis is a procedure that removes inhibitors from the person’s bloodstream. It is usually done when the inhibitor titer needs to be brought down quickly (for example, before major surgery or in cases of severe bleeding that are not well controlled with bypassing agents).
Clinical Trials
Unfortunately, there are not alternative licensed products for those with Haemophilia B with inhibitors that have the same prophylactic effect. There are however, many in clinical trials and currently look promising, such as rebalancing agents. The same also applies for vonWillebrands with inhibitors. Some reports have been published on the use of licenced non replacement therapies being successfully used and broader research is now taking place. (read more)

European Principles of Inhibitor Management
The European Principles of Inhibitor Management in Patients with Haemophilia were developed through a collaboration between EAHAD DEFINE WHO THEY ARE and the European Haemophilia Consortium (EHC). Their purpose is to serve as a benchmark for improving the multidisciplinary and practical management of inhibitors in haemophilia.
The 10 principles put forth were defined by a multidisciplinary group of health professionals and patients and emphasise the importance and benefits of a centralised, multidisciplinary, expert, and holistic approach in addressing this most serious complication in haemophilia.
The 10 Principles of comprehensive inhibitor management are:

  1. Awareness of the incidence of inhibitors and risk factors throughout life
  2. Early recognition and accurate diagnosis
  3. Optimal organization of care and communication between all stakeholders
  4. Haemostatic treatment with bypassing agents in inhibitor patients
  5. Inhibitor eradication by immune tolerance induction (ITI) therapy
  6. Access to, and optimal preparation for, surgery and other invasive procedures
  7. Provision of specialist nursing care
  8. Provision of tailored physiotherapy care and monitoring
  9. Access to psychosocial support
  10. Involvement in research and innovation
    See more here LINK TO PRINCIPLES

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