Additional Factor X Enhances Emicizumab-Driven Coagulation Function in Patients with Hemophilia A and Hemophilia A Mice

Abstract

Background Bypassing agents are used for breakthrough bleedings in patients with hemophilia A with inhibitor (PwHAwI) receiving emicizumab prophylaxis. Previous study demonstrated a weak binding affinity between emicizumab and factor (F)X (K _d; 1.85 μM), and that this value was much greater than the plasma FX concentration (∼130 nM). We speculated that increased FX levels could enhance coagulation potential in emicizumab-treated patients with hemophilia A (PwHA). To investigate the relationship between FX concentrations and emicizumab-driven coagulation.

Methods Plasma FX (up to 1,040 nM) and emicizumab (50 µg/mL) were added to FVIII-deficient plasmas, and plasma-derived FX (520 nM) or recombinant (r)FVIIa (2.2 µg/mL) was added to plasmas from three emicizumab-treated PwHAwI. The adjusted maximum coagulation velocity (Ad|min1|) by clot waveform analysis and peak thrombin (PeakTh) by thrombin generation assay in them were evaluated. Emicizumab (3.0 mg/kg), human (h)FIX (100 IU/kg), and various doses of hFX (100–500 IU/kg) were intravenously administered to HA mice. Clotting time/clot formation time (CT/CFT) were assessed using rotational thromboelastometry, and blood loss was estimated by a tail-clip assay.

Results The addition of FX to FVIII-deficient plasma with emicizumab increased Ad|min1| and PeakTh. The coagulation parameters in emicizumab-treated PwHAwI spiked with additional FX remained within the normal range as well as the additional rFVIIa. In animal models, hFX injection shortened the CT and CT + CFT. The shorter CT and CT + CFT, and the lower blood loss were evident after 200 or 500 IU/kg hFX administration, and those indices were comparable to those in wild-type mice.

Conclusion Supplementation with FX may improve emicizumab-driven hemostasis in PwHA.

Keywords

FVIII - FVIII inhibitor - coagulation - hemophilia - hemostasis

• References

• 1 Gouw SC, van der Bom JG, Ljung R. et al; PedNet and RODIN Study Group. Factor VIII products and inhibitor development in severe hemophilia A. N Engl J Med 2013; 368 (03) 231-239
• 2 Walsh CE, Jiménez-Yuste V, Auerswald G, Grancha S. The burden of inhibitors in haemophilia patients. Thromb Haemost 2016; 116 (Suppl. 01) S10-S17
• 3 Astermark J, Rocino A, Von Depka M. et al; EHTSB. Current use of by-passing agents in Europe in the management of acute bleeds in patients with haemophilia and inhibitors. Haemophilia 2007; 13 (01) 38-45
• 4 Berntorp E. Differential response to bypassing agents complicates treatment in patients with haemophilia and inhibitors. Haemophilia 2009; 15 (01) 3-10
• 5 Ogiwara K, Nogami K, Matsumoto T, Shima M. Tissue factor pathway inhibitor in activated prothrombin complex concentrates (aPCC) moderates the effectiveness of therapy in some severe hemophilia A patients with inhibitor. Int J Hematol 2014; 99 (05) 577-587
• 6 Tomokiyo K, Nakatomi Y, Araki T. et al. A novel therapeutic approach combining human plasma-derived Factors VIIa and X for haemophiliacs with inhibitors: evidence of a higher thrombin generation rate in vitro and more sustained haemostatic activity in vivo than obtained with Factor VIIa alone. Vox Sang 2003; 85 (04) 290-299
• 7 Nakatomi Y, Nakashima T, Gokudan S. et al. Combining FVIIa and FX into a mixture which imparts a unique thrombin generation potential to hemophilic plasma: an in vitro assessment of FVIIa/FX mixture as an alternative bypassing agent. Thromb Res 2010; 125 (05) 457-463
• 8 Shirahata A, Fukutake K, Takamatsu J. et al. A phase II clinical trial of a mixture of plasma-derived factor VIIa and factor X (MC710) in haemophilia patients with inhibitors: haemostatic efficacy, safety and pharmacokinetics/pharmacodynamics. Haemophilia 2013; 19 (06) 853-860
• 9 Shinkoda Y, Shirahata A, Fukutake K. et al. A phase III clinical trial of a mixture agent of plasma-derived factor VIIa and factor X (MC710) in haemophilia patients with inhibitors. Haemophilia 2017; 23 (01) 59-66
• 10 Kitazawa T, Igawa T, Sampei Z. et al. A bispecific antibody to factors IXa and X restores factor VIII hemostatic activity in a hemophilia A model. Nat Med 2012; 18 (10) 1570-1574
• 11 Sampei Z, Igawa T, Soeda T. et al. Identification and multidimensional optimization of an asymmetric bispecific IgG antibody mimicking the function of factor VIII cofactor activity. PLoS One 2013; 8 (02) e57479
• 12 Shima M, Hanabusa H, Taki M. et al. Factor VIII-mimetic function of humanized bispecific antibody in hemophilia A. N Engl J Med 2016; 374 (21) 2044-2053
• 13 Shima M, Hanabusa H, Taki M. et al. Long-term safety and efficacy of emicizumab in a phase 1/2 study in hemophilia A patients with or without inhibitors. Blood Adv 2017; 1 (22) 1891-1899
• 14 Oldenburg J, Mahlangu JN, Kim B. et al. Emicizumab prophylaxis in hemophilia A with inhibitors. N Engl J Med 2017; 377 (09) 809-818
• 15 Young G, Liesner R, Chang T. et al. A multicenter, open-label phase 3 study of emicizumab prophylaxis in children with hemophilia A with inhibitors. Blood 2019; 134 (24) 2127-2138
• 16 Mahlangu J, Oldenburg J, Paz-Priel I. et al. Emicizumab prophylaxis in patients who have hemophilia A without inhibitors. N Engl J Med 2018; 379 (09) 811-822
• 17 Pipe SW, Shima M, Lehle M. et al. Efficacy, safety, and pharmacokinetics of emicizumab prophylaxis given every 4 weeks in people with haemophilia A (HAVEN 4): a multicentre, open-label, non-randomised phase 3 study. Lancet Haematol 2019; 6 (06) e295-e305
• 18 Shima M, Nogami K, Nagami S. et al. A multicentre, open-label study of emicizumab given every 2 or 4 weeks in children with severe haemophilia A without inhibitors. Haemophilia 2019; 25 (06) 979-987
• 19 Nakajima Y, Mizumachi K, Shimonishi N. et al. Comparisons of global coagulation potential and bleeding episodes in emicizumab-treated hemophilia A patients and mild hemophilia A patients. Int J Hematol 2022; 115 (04) 489-498
• 20 Muto A, Yoshihashi K, Takeda M. et al. Anti-factor IXa/X bispecific antibody (ACE910): hemostatic potency against ongoing bleeds in a hemophilia A model and the possibility of routine supplementation. J Thromb Haemost 2014; 12 (02) 206-213
• 21 Kizilocak H, Marquez-Casas E, Phei Wee C, Malvar J, Carmona R, Young G. Comparison of bypassing agents in patients on emicizumab using global hemostasis assays. Haemophilia 2021; 27 (01) 164-172
• 22 Hertzberg M. Biochemistry of factor X. Blood Rev 1994; 8 (01) 56-62
• 23 Mann KG, Nesheim ME, Church WR, Haley P, Krishnaswamy S. Surface-dependent reactions of the vitamin K-dependent enzyme complexes. Blood 1990; 76 (01) 1-16
• 24 Kamikubo Y, Mendolicchio GL, Zampolli A. et al. Selective factor VIII activation by the tissue factor-factor VIIa-factor Xa complex. Blood 2017; 130 (14) 1661-1670
• 25 Furukawa S, Nogami K, Ogiwara K, Shima M. Potential role of activated factor VIII (FVIIIa) in FVIIa/tissue factor-dependent FXa generation in initiation phase of blood coagulation. Int J Hematol 2019; 109 (04) 390-401
• 26 Louvain-Quintard VB, Bianchini EP, Calmel-Tareau C, Tagzirt M, Le Bonniec BF. Thrombin-activable factor X re-establishes an intrinsic amplification in tenase-deficient plasmas. J Biol Chem 2005; 280 (50) 41352-41359
• 27 Bunce MW, Toso R, Camire RM. Zymogen-like factor Xa variants restore thrombin generation and effectively bypass the intrinsic pathway in vitro. Blood 2011; 117 (01) 290-298
• 28 Muczynski V, Verhenne S, Casari C. et al. A thrombin-activatable factor X variant corrects hemostasis in a mouse model for hemophilia A. Thromb Haemost 2019; 119 (12) 1981-1993
• 29 Abache T, Fontayne A, Grenier D. et al. A mutated factor X activatable by thrombin corrects bleedings in vivo in a rabbit model of antibody-induced hemophilia A. Haematologica 2020; 105 (09) 2335-2340
• 30 Kitazawa T, Esaki K, Tachibana T. et al. Factor VIIIa-mimetic cofactor activity of a bispecific antibody to factors IX/IXa and X/Xa, emicizumab, depends on its ability to bridge the antigens. Thromb Haemost 2017; 117 (07) 1348-1357
• 31 Cooper DN, Millar DS, Wacey A, Pemberton S, Tuddenham EG. Inherited factor X deficiency: molecular genetics and pathophysiology. Thromb Haemost 1997; 78 (01) 161-172
• 32 Okuda M, Yamamoto Y. Usefulness of synthetic phospholipid in measurement of activated partial thromboplastin time: a new preparation procedure to reduce batch difference. Clin Lab Haematol 2004; 26 (03) 215-223
• 33 Nakajima Y, Takami E, Nakano H, Nogami K. In vitro evaluation of global coagulation potentials in the co-presence of plasma-derived factors Viia/X products (Byclot^® ) and emicizumab in patients with haemophilia A and inhibitors and acquired haemophilia A: a pilot study. Haemophilia 2022; 28 (05) e149-e152
• 34 Nogami K, Matsumoto T, Tabuchi Y. et al. Modified clot waveform analysis to measure plasma coagulation potential in the presence of the anti-factor IXa/factor X bispecific antibody emicizumab. J Thromb Haemost 2018; 16 (06) 1078-1088
• 35 Nakajima Y, Takeyama M, Oda A, Shimonishi N, Nogami K. Factor VIII mutated with Lys1813Ala within the factor IXa-binding region enhances intrinsic coagulation potential. Blood Adv 2023; 7 (08) 1436-1445
• 36 Ferrière S, Peyron I, Christophe OD. et al. A hemophilia A mouse model for the in vivo assessment of emicizumab function. Blood 2020; 136 (06) 740-748
• 37 Collins PW, Liesner R, Makris M. et al. Treatment of bleeding episodes in haemophilia A complicated by a factor VIII inhibitor in patients receiving Emicizumab. Interim guidance from UKHCDO Inhibitor Working Party and Executive Committee. Haemophilia 2018; 24 (03) 344-347
• 38 Yada K, Nogami K, Ogiwara K. et al. Global coagulation function assessed by rotational thromboelastometry predicts coagulation-steady state in individual hemophilia A patients receiving emicizumab prophylaxis. Int J Hematol 2019; 110 (04) 419-430
• 39 Ogiwara K, Nogami K, Matsumoto N. et al. A modified thrombin generation assay to evaluate the plasma coagulation potential in the presence of emicizumab, the bispecific antibody to factors IXa/X. Int J Hematol 2020; 112 (05) 621-630
• 40 Gilbert GE, Arena AA. Activation of the factor VIIIa-factor IXa enzyme complex of blood coagulation by membranes containing phosphatidyl-L-serine. J Biol Chem 1996; 271 (19) 11120-11125
• 41 Mak S, Marszal A, Matscheko N, Rant U. Kinetic analysis of ternary and binary binding modes of the bispecific antibody emicizumab. MAbs 2023; 15 (01) 2149053
• 42 Frostell A, Vinterbäck L, Sjöbom H. Protein-ligand interactions using SPR systems. Methods Mol Biol 2013; 1008: 139-165
• 43 Bolliger D, Szlam F, Molinaro RJ, Rahe-Meyer N, Levy JH, Tanaka KA. Finding the optimal concentration range for fibrinogen replacement after severe haemodilution: an in vitro model. Br J Anaesth 2009; 102 (06) 793-799
• 44 Kizilocak H, Yukhtman CL, Marquez-Casas E, Lee J, Donkin J, Young G. Management of perioperative hemostasis in a severe hemophilia A patient with inhibitors on emicizumab using global hemostasis assays. Ther Adv Hematol 2019; 10: 2040620719860025
• 45 Villar A, Aronis S, Morfini M. et al. Pharmacokinetics of activated recombinant coagulation factor VII (NovoSeven) in children vs. adults with haemophilia A. Haemophilia 2004; 10 (04) 352-359
• 46 Roberts HR, Lechler E, Webster WP, Penick GD. Survival of transfused factor X in patients with stuart disease. Thromb Diath Haemorrh 1965; 13: 305-313
• 47 Simioni P, Tormene D, Tognin G. et al. X-linked thrombophilia with a mutant factor IX (factor IX Padua). N Engl J Med 2009; 361 (17) 1671-1675