British Iournal of Haematology. 1992. 80, 214-221
Clinical and biological evaluation in von Willebrand’s disease of a von Willebrand factor concentrate with low factor VIII activity J. GOUDEMAND, C. MAZURIER,* A. MAREY,C. CARON.B. COUPEZ,P. MIZONAND M. GOUDEMAND* Laboratoire d‘Himatologie B, Centre Hospitalier Rigional et Universitaire and *Laboratoire de Recherche sur I’Hemostase, Centre Rigional de Transfusion Sanguine, Lille, France Received 30 May 1991; acceptedfor publication 1 October 1991
Summary. This study was carried out to assess the clinical efficacy in von Willebrand’s disease (vWD) of a new, very high purity (VHP), solvent/detergent (SD)-treated, vWF concentrate (VHP Human von Willebrand Factor Concentrate, Biotransfusion)characterized by a high specific ristocet i cofactor (vWF:RCo) activity and a low factor VIII (FVIII) coagulant activity (FVII1:C). Nine patients (four type I. one type IIA, one type IIB, one type IIC, one type 111 and one acquired type 11) were infused on 1 3 occasions including a pharmacokinetic study. Satisfactory haemostasis was achieved in all cases, including the treatment of spontaneous haemorrhages and the prevention of bleeding following surgery. The bleeding time was corrected for 6-12 h in 6/9 patients and shortened in the others. Furthermore, it was shown that the plasma vWF multimeric pattern of types I1 and 111 patients was greatly improved. When measured in
eight patients 1 h after infusion, the vWF :RCo recovery was 77.3 ( f 10.7)% while the F VI1I:C recovery was strikingly higher (876f906?(,). This high recovery is likely related to the predominant ‘pseudo-synthesis’ of FVIII following the restoration of normal vWF levels. Maximum levels of FVIII: C occurred 6-1 2 h after the first infusion and normal levels of FVIII: C were maintained thrc;!ighout the treatments with a dosage of 26-39 IU/kg vWF:RCo and only 0.2-5 IU/kg FVIII: C. The half-lives of the vWF-related parameters determined in a type 111vWD patient were 20.6 h for vWF antigen, 17.8 h for vWF:RCo, 14 h for the high molecular weight multimers of vWF, 5 5 . 3 h for FVIII :Ag and 74 h for FVIII :C. In conclusion, it does not appear necessary that vWF concentrates intended for the treatment of vWD should contain FVIII in addition to vWF to be clinically effective in most patients.
When desmopressin acetate (dDAVP) is either ineffective or contraindicated, the bleeding diathesis of von Willebrand’s disease (vWD)has been efficiently treated with cryoprecipitates or Cohn fraction 1.0. However, repeated use of these products has been associated with a risk of fibrinogen accumulation and haemolytic reactions due to the presence of anti-A and -B antibodies. Moreover, as a major drawback, they carry a risk of transmitting viral infections such as hepatitis and human immunodeficiency virus (HIV)diseases. This problem has greatly enhanced interest in the clinical efficacy of virus-inactivated FVIII concentrates in the treatment of vWD. However, most of the commonly available FVIII concentrates have a very low amount of the highest molecular weight multimers (HMWM) of vWF which are the most effective in correcting the platelet adhesion defect
observed in vWD (Yoshioka et al, 1987: Berntorp & Nilsson, 1988: Lawrie et al, 1989). This is especially true for the immunopurified FVIII concentrates that contain only low levels of vWF (Fricke & Yu, 1989). There was therefore a real and urgent need for safe plasma products specifically intended for the management of vWD patients. Clinical studies conducted with commercial heat- or solvent/detergent (SD)-treated FVIII concentrates have already shown satisfactory therapeutic responses in vWD patients (Kohler et al, 1895: Fukui et al, 1988: Mazurier et al. 1989: Cumming et al, 1990: Pasi et al, 1990). These products are essentially FVIII concentrates processed with the aim of preserving maximum vWF integrity. However, it would not be necessary for these concentrates to also contain FVIII in order to be clinically efficient in vWD patients (Weiss et nl, 1977). Recently, a new purification procedure based on conventional chromatographic methods has been developed in the Plasma Fractionation Department of the Centre Regional de
Correspondence: Dr J. Goudemand. Laboratoire d’Hematologie B, HBpital Claude Huriez, Place de Verdun. 59 03 7 Lille Cedex. France.
214
In Vivo Evaluation of a vWF Concentrate
2 15
Table I. Patients treated with the vWF concentrate: patients’ details and indications for treatment
Basal data vWD
Patient type 1 2 3-1 3-2 4 5-1 5-2 5-3 6 7-1 7-2 8 9
Total units infused (mean dosage per infusion: U/kg)
Age BT* FVII1:C vWF:Ag vWF:RCo Sex (yr) (min) (IU/dl) (IU/dl) (IU/dl) Clinical indication
I
F F F
66 45 44
12 11 10
30 25 46
23 26 45
18 18 45
I IIA
F M
26 39
>15 220
31 30
22 40
12 5
IIB
M F
34 28
18 >20
38 15
25 15
10 3
I11 M IIAcq F
41 71
220t 3 20 6 0
40 IU/dl FVII1:C level was attained between 4 and 18 h after the infusion. 70 h later, FVIII: C was still greater than 20 IU/dl. The half-lives of FVIII:C and FVII1:Ag calculated for the samples taken from 18 to 70 h were 74 and 55.3 h respectively. On the other hand, maximum levels of vWF :Ag and vWF :RCo ( 116 and 120 IU/ dl) were respectively attained at 1 and 2 h after the infusion and then gradually decreased. The half-lives of vWF :Ag and vWF:RCo in this patient were 20.6 and 17.8 h respectively. The markedly prolonged BT (Duke's method) was normalized for at least 4 h. Other examples of kinetics differencesbetween FVIII: C and vWF:RCo activities in patients treated with the VHP vWF concentrate are given in Fig 2. Maximum levels of FVIII:C were attained from 6 to 12 h after the first infusion whereas maximum levels of vWF :Ag and vWF :RCo were observed 1h after the infusion. Due to this tinding, patient 7 with type IIC vWD, whose baseline FVIII:C was 18 IU/dl, received a first infusion (24 IU/kg vWF:RCo, 0.2 IU/kg FVIII:C) 12 h before surgery and a second one (48 IU/kg vWF :RCo, 0.4 IU/ kg FVII1:C) 1 h before starting dental extractions. At that time, FV1II:C was 113 IU/dl and vWF:RCo 128 IU/dl (Fig 2d). In the following days of treatment of this patient and the others, the residual FVIII: C activity was easily maintained above 70 IU/dl with dosage of 26-39 IU/kg vWF:RCo and only 0.2-5 IU/kg FWI:C. 36 h after the last infusion (Fig 2). FVIII:C was still largely above 70 IU/dl while vWF:RCo ranged from 50 to 80 IU/dl. The BT was normalized for 6
Duke's >20 3 BT[min] 2
200,
&*-
. ' .... .
\ \
A---
Q\
-A-
5 1.
-- -- --
0VIII:Ag
Z55.3
0 VIII:C
:74
0 vWF:Ag
:20.6
A vWF:RCO :17.8
-A
A HMWM:Ag:14
5 IL
0
....
I
10
.
.
.
20
.
.
.
30
~
~
~
40
I
~
50
~
.
.
60
I
.
.
~
~
'
~
.
.
~
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.
~
70
lime after infusion (hours) Fig 1. Response of BT and FVIII/vWF-related parameters (FVIII:C, FVIII: Ag, vWF:RCo.vWF:Ag and HMWM:Ag) after infusion ofthe VHP vWF concentrate (53 IU/kg vWF:RCo and 0.5 IU/kg FV1II:C)in a patient with type 111vWD (patient 8). Half-lives (Tip) were determined from the log-linear decay curves established for each FVIII/vWF parameter.
~
~
'
AJ m
r;:
RCo: Vlllc:
n
1
T
A l
s
47 7
28 4
28 4
213 4
. T .....1 _ _ , _T ...
.
. . . ~ -
. _.. C
9
1 '. 50
Time after 1st infusion (haun)
u s
RCo: 54 V l l l c : 0.45
ge
39 0.3
39 0.3
39 0.3
39 0.3
Time after 1st infusion (hours)
:z
39 0.3
RCO: ~ ' V l l l c :
24 0.2
413 0.4
24 0.2
24
24
0.2
0.2
nA 250jLL-7 200c 0 \
3 = 150-.
->
100:
1 '.
5 LL
50i
OJ
+5 mE
12 4
r
. . A . ....................................... 0 10 20 30 40 50 60 70
:nr
i
J ;nr
h
Time after 1st infusion (hours)
e after 1st infuaion (houri)
Fig2.ResponseofBT9FVIII:C(O). vWF:RCo (A),~WF:Ag(O)andHMWM:Ag(A)duringthetreatmentofpatients 1 (typeIvWD, Fig2a), 5 (type IIA vWD. Fig 2b). 6 (type IIB vWD, Fig 2c) and 7 (type IIC vWD, Fig 2d) with the VHP vWF concentrate. S=surgery;nr=norrnal range for BT. (patients 1 and 6) to 12 h (patient 5) after infusion (Fig 2). A normalization of BT lasting from 6 to 8 h was also observed in patients 2 and 3 (not shown). The plasma vWF multimeric pattern following infusion of the VHP vWF concentrate clearly showed the appearance of HMWM in patients who were lacking them. When measured in a type I11 vWD patient, the half-life of HMWM: Ag was 1 4 h (Fig 1). Normal levels ofHMWM:Ag (i.e. greater than 50 U/ dl) were maintained for at least 24 h in this patient. Normal levels of HMWM :Ag were also maintained throughout the treatment in patients 5 (IIA vWD), 6 (IIB vWD) and 7 (IIC vWD) (Fig 2). As an example, the plasma vWF multimeric pattern ofpatient 7 (IIC vWD) when tested 1 , 6 and 12 h after the second infusion of vWF concentrate is shown in Fig 3 . The larger multimers which were absent from the pre-infusion plasma sample were found in normal range from 1 to 12 h after the infusion. However, the relatively increased intensity of the fastest moving multimer (which is a hallmark of type
IIC vWD) remained clearly detectable after the infusion. No additional subbands were found in this patient or the other tested patients. DISCUSSION The therapeutic effectiveness of a new vWF concentrate containing low amounts of FVIII: C was investigated in nine patients with various types of vWD. The safety of the product is ensured by a validated SD treatment that provides protection against HIV infection and hepatitis viruses. This VHP vWF concentrate provided satisfactory haemostasis in 12 different clinical situations. The vWF concentrate was proved to contain functional vWF as determined by the shortening of BT occurring in all patients. Rothschild et a1 (1991), using the same VHP vWF concentrate, found that the BT was totally corrected in 2/2 type III vWD patients and partially corrected in 2/2 type IIA
In Vivo Evaluation ofa vWF Concentrate
219
Fig 3. Multimeric pattern of plasma vWF from the type IIC vWD patient (PP, patient 7) before (0) and at various intervals (1.6 and 12 h) after infusion of the VHP vWF Concentrate. NP=pool of normal plasmas.
patients. In our study, a complete normalization of BT lasting 4-12 h was observed in 6 / 9 tested patients. However, the BT was still prolonged in three patients (patient 4 with type I vWD. patient 7 with type IIC vWD and patient 9 with Acq type I1 vWD) at the time of surgery in contrast with a correction of the plasma vWF activities. It should also be noticed that the normalization of the BT in patient 8 with type 111 vWD was observed with the Duke’s BT, which is not the most sensitive method. However, it must be stressed that no bleeding manifestations occurred in the patients whose BT was not completely normalized. Such a discrepancy between BT and vWF activities (either vWF:Ag or vWF:RCo) has already been reported (Blatt et al, 1976; Green & Potter, 1976; Mannucci et al. 1987). The vWF:RCo increased to maximum levels 1-2 h after infusion and remained higher than 50 IU/dl. the accepted lower limit of the normal range, for at least 36 h after the last infusion. The per cent increase of vWF :RCo/U infused/kg ranged from 1 . 38 to 2 . 11 which is quite comparable to the results obtained in 10 patients infused with Haemate P (1.06-2.04) by Fukui et a1 (1988). In contrast, the half-life of vWF:RCo measured in a type 111 patient (patient 8 ) infused with the VHP vWF concentrate (1 7.8 h) appeared to be quite longer than the one measured in two patients with type 111 vWD infused with Haemate P ( 7 h) by the same authors (Fukui et al, 1988). It was also longer than the half-life ( 1 4 . 5 h) previously reported in the same patient infused with a SD-FVIII concentrate (Mazurier et al, 1989). The VHP vWF concentrate has already been shown to contain a significant amount of HMWM (Mazurier et al, 1991; Burnouf-Radosevich & Burnouf, 1991). thus it was not surprising to observe a satisfactory improvement of the plasma multimeric pattern of the type I1 (5, 6 , 7) and type I11 (8) vWD patients treated with this product. Furthermore, no additional sub-bands were noticed in the plasma vWF
multimeric pattern of the patients infused with the concentrate excluding abnormal proteolytic degradation of the exogenous vWF. The half-life of HMWM in patient 8 has been estimated to be 1 4 h, which is lower than the half-lives of vWF: Ag and vWF:RCo ( 2 0 . 6 and 1 7 . 8 h, respectively).This is in agreement with the fact that larger vWF multimers disappear faster than the small ones (Over et al. 1978; Cumming et al, 1990). However, as stated by Mannucci et a1 (1987), the HMWM content of a vWF concentrate is not the sole criterion for its therapeutic effectiveness, and the VHP vWF concentrate has also been shown to induce platelet adhesion to collagen when tested in a perfusion system (Mazurier et al, 1991). Finally, severe mucosal bleedings typically related to the primary haemostasis defect encountered in vWD patients were controlled by the product, providing an additional argument for the functional activity of vWF in this concentrate. When surgery is planned for vWD patients, it appears crucial to maintain a sufficient level of FVIII: C in addition to the correction of the primary haemostasis defect. Our data show that this goal can be attained with a concentrate having a low FVIII: C concentration. Weiss et a1 (1977) have already suggested that infusion of vWF alone should result in the stabilization and increased level of FVII1:C in vivo. In a previous study it has been shown that the infusion of the VHP vWF concentrate was able to correct the FVIII deficiency observed in patients with a vWD variant type characterized by the inability of their vWF to bind FVIII (Mazurier et aI, 1990). We confirm this finding in nine additional patients with various subtypes of vWD. The FVII1:C level measured 1 h after infusion of the VHP vWF concentrate, resulting in a ‘pseudo’ high FVII1:C recovery cannot be related to the FVIII :C content of the concentrate but mainly reflects the appearance of an endogenous FVIII: C (and FVIII: Ag) activity that occurs rapidly after infusion. Although the exact
220
I. Goudemand et a1
kinetics of FVIII: C needs to be determined more accurately, the maximum level of FVII1:C seems to be attained 6-12 h after the first infusion of the VHP vWF concentrate. If the baseline level of FVIII: Cis not too low (i.e. up to 20-2 5 IU/dl), which is the case in most of vWD patients, one can assume that the 1 h post-infusion FVII1:C level should be enough to undertake surgery or provide satisfactory haemostasis in most situations. Caution should be taken for patients with low baseline FVIII: C level, especially those with type 111vWD and some variants. In such cases, it is advisable to start the treatment 6-12 h before the surgical procedure in order to allow the complete normalization of plasma FVIII: C. A second infusion should be given 0.5-1 h before surgery to complete the correction of both the primary haemostasis and the coagulation defects during surgery. In emergency cases it should also be possible to infuse FVIII concentrate in addition to the VHP vWF concentrate to obtain an immediate correction of the FV1II:C level. However, if more than one infusion is needed, it should not be necessary to repeat the infusion of FVIII concentrate since we found that the half-life of FVIII measured in a type 111vWD patient seems to be longer than 50 h. Furthermore, the data obtained in the other patients treated with the VHP vWF concentrate have shown that haemostatic levels of FVIII: C can easily be maintained for several days by infusing vWF alone. In conclusion, this VHP vWF concentrate appears to represent an efficient plasma product specifically intended for the treatment of vWD. Other concentrates have also been shown to be clinically effective in vWD patients. Haemate P and the 8 Y preparation are useful alternatives to cryoprecipitates (Fukui et al. 1988: Cumming et al. 1990; Pasi et al, 1990). However, these products also contain FVIII: C. which is not really essential for vWD patients. Considering the permanent risk of a world-wide shortage of FVIII. it would therefore be more advisable to restrict the FVIII use to FVIII concentrates specially intended for haemophiliacs. However, replacement therapy of vWD patients with vWF alone requires a good knowledge of the disease since some patients with a low baseline FVIII:C level may have to be specially managed. ACKNOWLEDGMENTS We wish to thank Dr A. Parquet (CRTS, Lille) for her collaboration in the pharmacokinetic study, Dr T. Burnouf (CRTS. Lille) and Dr J. J. Huart (Director of CRTS, Lille) for the gift of the VHP vWF concentrate. REFERENCES Allain. J.P. (1 984) Principles of in vivo recovery and survival studies. Scandinavian Journal of Haematology. Suppl. 41, 123-145. Berntorp, E. & Nilsson, I. ( 1988)Biochemical and in vivo properties of commercial virus-inactivated factor VIII concentrates. European Journal of Haematology, 40, 205-214. Blatt, P.M., Brinkhous, K.M., Culp, H.R.. Krauss, J.S. &Roberts, H.R. (1976) Antihemophdic factor concentrate therapy in von Willebrand disease. Dissociation of bleeding-time factor and ristocetincofactor activities. Journal of American Medical Association, 236, 2 770-2 772. Burnouf, T., Burnouf-Radosevich. M., Huart. J.J. & Goudemand, M.
(199 1)A highly purified Factor VIII :C concentrate prepared from cryoprecipitate by ion-exchange chromatography. Vor Sanguinis, 60, 8-15. Bumouf-Radosevich. M. & Bumouf, T. (1991 ) Chromatographic preparation of a therapeutic highly purified von Willebrand factor concentrate from human cryoprecipitate. Vox Sanguinis (in press). Cumming. A.M.. Fildes. S., Cumming, I.R.. Wensley, R.T., Redding. O.M. & Burn, A.M. (1990) Clinical and laboratory evaluation of National Health Service factor VIII concentrate (8Y) for the treatment of von Willebrand's disease. British Journal of Haematology, 75, 234-239. Fricke, W.A. & Yu. M.Y.M. (1989) Characterization of von Willebrand factor in factor VIII concentrates. American Journal of Hematology. 31, 41-45. Fukui, H.. Nishino. M., Terada, S.. Nishikubo. T., Yoshioka. A., Kinoshita. S., Niinomi. K. & Yoshioka, K. (1988) Hemostatic effect of a heat-treated factor VIII concentrate (Haemate P) in von Willebrand's disease. Blut, 56, 171-178. Girma. J.P., Lavergne. J.M., Meyer. D. & Larrieu, M.J. (1981) Immunoradiometric assay of factor VIII coagulant antigen using four human antibodies: study of 27 cases of haemophilia A. British Journal of Haematology. 47, 269-282. Goudemand. J., Samor, B., Caron, C., Jude, B., Gosset. D. & Mazurier. C. (1988) Acquired type I1 von Willebrand's disease: demonstration of a complexed inhibitor of the von Willebrand factor platelet interaction and response to treatment. British Journal of Haematology, 68, 227-233. Green, D. & Potter, E.V. (1976) Failure of AHF concentrate to control bleeding in von Willebrand's disease. American Journal of Medicine. 60, 357-360. Kohler, M., Hellstern. P. & Wenzel. E. (1985)The use of heat-treated factor VIII concentrates in von Willebrand's disease. Blut, 50, 25-27. Lawrie, AS., Harrison, P., Armstrong. A.L.. Wilbourn, B.R.. Dalton, R.G. & Savidge, G.F. (1989) Comparison of the in vitro characteristics of von Willebrand factor in British and commercial factor VIII concentrates. British lournal of Haematology. 73, 100-1 04. Mannucci, P.M., Moia, M., Rebulla, P., Altieri, D.. Monteagudo. J. & Castillo, R. (1987) Correction of the bleeding time in treated patients with severe von Willebrand disease is not solely dependent on the normal multimeric structure of plasma von Willebrand factor. American Journal of Hematology, 25, 55-65. Mazurier, C.. Parquet-Gernez, A. & Goudemand, M. (1977) Dosage de I'antigene lie au facteur VIII par la technique ELISA. Int6r.3 dans I'etude de la maladie de Willebrand. Pathologie Biologie, 25, 18-24. Mazurier. C., Mannucci. P.M.. Parquet-Gernez. A,, Goudemand. M. & Meyer, D. (1986a) Investigation of a case of subtype IIC von Willebrand disease: characterization of the variability of this subtype. American Journal of Hematology, 22, 301-31 1. Mazurier. C., Samor, B. & Goudemand. M. (1986b) Improved characterization of plasma von Willebrand factor heterogeneity when using 2.5% agarose gel electrophoresis. Thrombosis and Haemostasis. 55, 61-64. Mazurier, C.. de Romeuf, C., Parquet-Gernez. A. & Goudemand, M. (1989) In vitro and in vivo characterization of a high-purity, solvent detergent-treated factor VIII concentrate: evidence for its therapeutic efficacy in von Willebrand's disease. European Journal of Haematology, 43, 7-14. Mazurier, C., Gaucher, C., Jorieux. S.. Parquet-Gernez, A. & Goudemand, M. (1990) Evidence for a von Willebrand factor defect in factor VIII binding in three members of a family previously misdiagnosed mild haemophilia A and haemophilia A carriers: consequences for therapy and genetic counselling. British Journal of Haematology. 76, 372-379.
In Vivo Evaluation o f a vWF Concentrate Mazurier. C.. Jorieux, S.. de Romeuf, C., Samor, B. & Goudemand. M. (1991) ‘Invitro’evaluationofavery highpurity. solvent detergent treated von Willebrand factor concentrate. Vox Sanguinis, 61.1-7. Over. J., Sixma, J.J., Doucet-De Bruine. M.H.M.. Trieschnigg, A.M.C., Vlooswijk. N.H.. Beeser-Visser. N.H. & Bouma, B.N. (1978) Survival of 12 5 Iodine-labelled factor VIII in normals and patients with classical hemophilia. Observations on the heterogeneity of human factor VIII. Journal of Clinical Investigation. 62, 223-234. Pasi.K.J., Williams, M.D..Enayat. M.S. &Hill. F.G.H. (1990) Clinical and laboratory evaluation of the treatment of von Willebrand’s disease patients with heat-treated factor VIII concentrate (BPL 8Y). British Journal of Haematologg, 75, 228-233. Rothschild. C., Fressinaud, E.. Wolf, M.. Dreyfus, M., Laurian. Y.. Peynaud-Debayle, E., Gazengel, C., Meyer, D. & Larrieu. M.J.
221
(199 1) Unexpected results following treatment of patients with von Willebrand disease with a new highly purified von Willebrand factor concentrate. (Abstract). Thrombosis and Huemostasis, 65, 1126. Sultan, Y. & Rossi. J. (1977) Methode de mesure de I’activite Willebrand sur plaque de microtitration. Nouvelle Presse Midicale. 6.44-46. Weiss, J.H., Sussman. I.T. & Hoyer, L.W. (1977) Stabilization of factor VIII in plasma by the von Willebrand factor. Journal of Clinical Investigation. 60, 390-404. Yoshioka, A.. Shima, M., Nishino, M., Yoshikawa. N. & Fukui. H. (198 7) In vitro characterization of various heat-treated factor VIII concentrates. Arzneimittelforsch, 37, 753-756.
Clinical and biological evaluation in von Willebrand’s disease of a von Willebrand factor concentrate with low factor VIII activity J. GOUDEMAND, C. MAZURIER,* A. MAREY,C. CARON.B. COUPEZ,P. MIZONAND M. GOUDEMAND* Laboratoire d‘Himatologie B, Centre Hospitalier Rigional et Universitaire and *Laboratoire de Recherche sur I’Hemostase, Centre Rigional de Transfusion Sanguine, Lille, France Received 30 May 1991; acceptedfor publication 1 October 1991
Summary. This study was carried out to assess the clinical efficacy in von Willebrand’s disease (vWD) of a new, very high purity (VHP), solvent/detergent (SD)-treated, vWF concentrate (VHP Human von Willebrand Factor Concentrate, Biotransfusion)characterized by a high specific ristocet i cofactor (vWF:RCo) activity and a low factor VIII (FVIII) coagulant activity (FVII1:C). Nine patients (four type I. one type IIA, one type IIB, one type IIC, one type 111 and one acquired type 11) were infused on 1 3 occasions including a pharmacokinetic study. Satisfactory haemostasis was achieved in all cases, including the treatment of spontaneous haemorrhages and the prevention of bleeding following surgery. The bleeding time was corrected for 6-12 h in 6/9 patients and shortened in the others. Furthermore, it was shown that the plasma vWF multimeric pattern of types I1 and 111 patients was greatly improved. When measured in
eight patients 1 h after infusion, the vWF :RCo recovery was 77.3 ( f 10.7)% while the F VI1I:C recovery was strikingly higher (876f906?(,). This high recovery is likely related to the predominant ‘pseudo-synthesis’ of FVIII following the restoration of normal vWF levels. Maximum levels of FVIII: C occurred 6-1 2 h after the first infusion and normal levels of FVIII: C were maintained thrc;!ighout the treatments with a dosage of 26-39 IU/kg vWF:RCo and only 0.2-5 IU/kg FVIII: C. The half-lives of the vWF-related parameters determined in a type 111vWD patient were 20.6 h for vWF antigen, 17.8 h for vWF:RCo, 14 h for the high molecular weight multimers of vWF, 5 5 . 3 h for FVIII :Ag and 74 h for FVIII :C. In conclusion, it does not appear necessary that vWF concentrates intended for the treatment of vWD should contain FVIII in addition to vWF to be clinically effective in most patients.
When desmopressin acetate (dDAVP) is either ineffective or contraindicated, the bleeding diathesis of von Willebrand’s disease (vWD)has been efficiently treated with cryoprecipitates or Cohn fraction 1.0. However, repeated use of these products has been associated with a risk of fibrinogen accumulation and haemolytic reactions due to the presence of anti-A and -B antibodies. Moreover, as a major drawback, they carry a risk of transmitting viral infections such as hepatitis and human immunodeficiency virus (HIV)diseases. This problem has greatly enhanced interest in the clinical efficacy of virus-inactivated FVIII concentrates in the treatment of vWD. However, most of the commonly available FVIII concentrates have a very low amount of the highest molecular weight multimers (HMWM) of vWF which are the most effective in correcting the platelet adhesion defect
observed in vWD (Yoshioka et al, 1987: Berntorp & Nilsson, 1988: Lawrie et al, 1989). This is especially true for the immunopurified FVIII concentrates that contain only low levels of vWF (Fricke & Yu, 1989). There was therefore a real and urgent need for safe plasma products specifically intended for the management of vWD patients. Clinical studies conducted with commercial heat- or solvent/detergent (SD)-treated FVIII concentrates have already shown satisfactory therapeutic responses in vWD patients (Kohler et al, 1895: Fukui et al, 1988: Mazurier et al. 1989: Cumming et al, 1990: Pasi et al, 1990). These products are essentially FVIII concentrates processed with the aim of preserving maximum vWF integrity. However, it would not be necessary for these concentrates to also contain FVIII in order to be clinically efficient in vWD patients (Weiss et nl, 1977). Recently, a new purification procedure based on conventional chromatographic methods has been developed in the Plasma Fractionation Department of the Centre Regional de
Correspondence: Dr J. Goudemand. Laboratoire d’Hematologie B, HBpital Claude Huriez, Place de Verdun. 59 03 7 Lille Cedex. France.
214
In Vivo Evaluation of a vWF Concentrate
2 15
Table I. Patients treated with the vWF concentrate: patients’ details and indications for treatment
Basal data vWD
Patient type 1 2 3-1 3-2 4 5-1 5-2 5-3 6 7-1 7-2 8 9
Total units infused (mean dosage per infusion: U/kg)
Age BT* FVII1:C vWF:Ag vWF:RCo Sex (yr) (min) (IU/dl) (IU/dl) (IU/dl) Clinical indication
I
F F F
66 45 44
12 11 10
30 25 46
23 26 45
18 18 45
I IIA
F M
26 39
>15 220
31 30
22 40
12 5
IIB
M F
34 28
18 >20
38 15
25 15
10 3
I11 M IIAcq F
41 71
220t 3 20 6 0
40 IU/dl FVII1:C level was attained between 4 and 18 h after the infusion. 70 h later, FVIII: C was still greater than 20 IU/dl. The half-lives of FVIII:C and FVII1:Ag calculated for the samples taken from 18 to 70 h were 74 and 55.3 h respectively. On the other hand, maximum levels of vWF :Ag and vWF :RCo ( 116 and 120 IU/ dl) were respectively attained at 1 and 2 h after the infusion and then gradually decreased. The half-lives of vWF :Ag and vWF:RCo in this patient were 20.6 and 17.8 h respectively. The markedly prolonged BT (Duke's method) was normalized for at least 4 h. Other examples of kinetics differencesbetween FVIII: C and vWF:RCo activities in patients treated with the VHP vWF concentrate are given in Fig 2. Maximum levels of FVIII:C were attained from 6 to 12 h after the first infusion whereas maximum levels of vWF :Ag and vWF :RCo were observed 1h after the infusion. Due to this tinding, patient 7 with type IIC vWD, whose baseline FVIII:C was 18 IU/dl, received a first infusion (24 IU/kg vWF:RCo, 0.2 IU/kg FVIII:C) 12 h before surgery and a second one (48 IU/kg vWF :RCo, 0.4 IU/ kg FVII1:C) 1 h before starting dental extractions. At that time, FV1II:C was 113 IU/dl and vWF:RCo 128 IU/dl (Fig 2d). In the following days of treatment of this patient and the others, the residual FVIII: C activity was easily maintained above 70 IU/dl with dosage of 26-39 IU/kg vWF:RCo and only 0.2-5 IU/kg FWI:C. 36 h after the last infusion (Fig 2). FVIII:C was still largely above 70 IU/dl while vWF:RCo ranged from 50 to 80 IU/dl. The BT was normalized for 6
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lime after infusion (hours) Fig 1. Response of BT and FVIII/vWF-related parameters (FVIII:C, FVIII: Ag, vWF:RCo.vWF:Ag and HMWM:Ag) after infusion ofthe VHP vWF concentrate (53 IU/kg vWF:RCo and 0.5 IU/kg FV1II:C)in a patient with type 111vWD (patient 8). Half-lives (Tip) were determined from the log-linear decay curves established for each FVIII/vWF parameter.
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Fig2.ResponseofBT9FVIII:C(O). vWF:RCo (A),~WF:Ag(O)andHMWM:Ag(A)duringthetreatmentofpatients 1 (typeIvWD, Fig2a), 5 (type IIA vWD. Fig 2b). 6 (type IIB vWD, Fig 2c) and 7 (type IIC vWD, Fig 2d) with the VHP vWF concentrate. S=surgery;nr=norrnal range for BT. (patients 1 and 6) to 12 h (patient 5) after infusion (Fig 2). A normalization of BT lasting from 6 to 8 h was also observed in patients 2 and 3 (not shown). The plasma vWF multimeric pattern following infusion of the VHP vWF concentrate clearly showed the appearance of HMWM in patients who were lacking them. When measured in a type I11 vWD patient, the half-life of HMWM: Ag was 1 4 h (Fig 1). Normal levels ofHMWM:Ag (i.e. greater than 50 U/ dl) were maintained for at least 24 h in this patient. Normal levels of HMWM :Ag were also maintained throughout the treatment in patients 5 (IIA vWD), 6 (IIB vWD) and 7 (IIC vWD) (Fig 2). As an example, the plasma vWF multimeric pattern ofpatient 7 (IIC vWD) when tested 1 , 6 and 12 h after the second infusion of vWF concentrate is shown in Fig 3 . The larger multimers which were absent from the pre-infusion plasma sample were found in normal range from 1 to 12 h after the infusion. However, the relatively increased intensity of the fastest moving multimer (which is a hallmark of type
IIC vWD) remained clearly detectable after the infusion. No additional subbands were found in this patient or the other tested patients. DISCUSSION The therapeutic effectiveness of a new vWF concentrate containing low amounts of FVIII: C was investigated in nine patients with various types of vWD. The safety of the product is ensured by a validated SD treatment that provides protection against HIV infection and hepatitis viruses. This VHP vWF concentrate provided satisfactory haemostasis in 12 different clinical situations. The vWF concentrate was proved to contain functional vWF as determined by the shortening of BT occurring in all patients. Rothschild et a1 (1991), using the same VHP vWF concentrate, found that the BT was totally corrected in 2/2 type III vWD patients and partially corrected in 2/2 type IIA
In Vivo Evaluation ofa vWF Concentrate
219
Fig 3. Multimeric pattern of plasma vWF from the type IIC vWD patient (PP, patient 7) before (0) and at various intervals (1.6 and 12 h) after infusion of the VHP vWF Concentrate. NP=pool of normal plasmas.
patients. In our study, a complete normalization of BT lasting 4-12 h was observed in 6 / 9 tested patients. However, the BT was still prolonged in three patients (patient 4 with type I vWD. patient 7 with type IIC vWD and patient 9 with Acq type I1 vWD) at the time of surgery in contrast with a correction of the plasma vWF activities. It should also be noticed that the normalization of the BT in patient 8 with type 111 vWD was observed with the Duke’s BT, which is not the most sensitive method. However, it must be stressed that no bleeding manifestations occurred in the patients whose BT was not completely normalized. Such a discrepancy between BT and vWF activities (either vWF:Ag or vWF:RCo) has already been reported (Blatt et al, 1976; Green & Potter, 1976; Mannucci et al. 1987). The vWF:RCo increased to maximum levels 1-2 h after infusion and remained higher than 50 IU/dl. the accepted lower limit of the normal range, for at least 36 h after the last infusion. The per cent increase of vWF :RCo/U infused/kg ranged from 1 . 38 to 2 . 11 which is quite comparable to the results obtained in 10 patients infused with Haemate P (1.06-2.04) by Fukui et a1 (1988). In contrast, the half-life of vWF:RCo measured in a type 111 patient (patient 8 ) infused with the VHP vWF concentrate (1 7.8 h) appeared to be quite longer than the one measured in two patients with type 111 vWD infused with Haemate P ( 7 h) by the same authors (Fukui et al, 1988). It was also longer than the half-life ( 1 4 . 5 h) previously reported in the same patient infused with a SD-FVIII concentrate (Mazurier et al, 1989). The VHP vWF concentrate has already been shown to contain a significant amount of HMWM (Mazurier et al, 1991; Burnouf-Radosevich & Burnouf, 1991). thus it was not surprising to observe a satisfactory improvement of the plasma multimeric pattern of the type I1 (5, 6 , 7) and type I11 (8) vWD patients treated with this product. Furthermore, no additional sub-bands were noticed in the plasma vWF
multimeric pattern of the patients infused with the concentrate excluding abnormal proteolytic degradation of the exogenous vWF. The half-life of HMWM in patient 8 has been estimated to be 1 4 h, which is lower than the half-lives of vWF: Ag and vWF:RCo ( 2 0 . 6 and 1 7 . 8 h, respectively).This is in agreement with the fact that larger vWF multimers disappear faster than the small ones (Over et al. 1978; Cumming et al, 1990). However, as stated by Mannucci et a1 (1987), the HMWM content of a vWF concentrate is not the sole criterion for its therapeutic effectiveness, and the VHP vWF concentrate has also been shown to induce platelet adhesion to collagen when tested in a perfusion system (Mazurier et al, 1991). Finally, severe mucosal bleedings typically related to the primary haemostasis defect encountered in vWD patients were controlled by the product, providing an additional argument for the functional activity of vWF in this concentrate. When surgery is planned for vWD patients, it appears crucial to maintain a sufficient level of FVIII: C in addition to the correction of the primary haemostasis defect. Our data show that this goal can be attained with a concentrate having a low FVIII: C concentration. Weiss et a1 (1977) have already suggested that infusion of vWF alone should result in the stabilization and increased level of FVII1:C in vivo. In a previous study it has been shown that the infusion of the VHP vWF concentrate was able to correct the FVIII deficiency observed in patients with a vWD variant type characterized by the inability of their vWF to bind FVIII (Mazurier et aI, 1990). We confirm this finding in nine additional patients with various subtypes of vWD. The FVII1:C level measured 1 h after infusion of the VHP vWF concentrate, resulting in a ‘pseudo’ high FVII1:C recovery cannot be related to the FVIII :C content of the concentrate but mainly reflects the appearance of an endogenous FVIII: C (and FVIII: Ag) activity that occurs rapidly after infusion. Although the exact
220
I. Goudemand et a1
kinetics of FVIII: C needs to be determined more accurately, the maximum level of FVII1:C seems to be attained 6-12 h after the first infusion of the VHP vWF concentrate. If the baseline level of FVIII: Cis not too low (i.e. up to 20-2 5 IU/dl), which is the case in most of vWD patients, one can assume that the 1 h post-infusion FVII1:C level should be enough to undertake surgery or provide satisfactory haemostasis in most situations. Caution should be taken for patients with low baseline FVIII: C level, especially those with type 111vWD and some variants. In such cases, it is advisable to start the treatment 6-12 h before the surgical procedure in order to allow the complete normalization of plasma FVIII: C. A second infusion should be given 0.5-1 h before surgery to complete the correction of both the primary haemostasis and the coagulation defects during surgery. In emergency cases it should also be possible to infuse FVIII concentrate in addition to the VHP vWF concentrate to obtain an immediate correction of the FV1II:C level. However, if more than one infusion is needed, it should not be necessary to repeat the infusion of FVIII concentrate since we found that the half-life of FVIII measured in a type 111vWD patient seems to be longer than 50 h. Furthermore, the data obtained in the other patients treated with the VHP vWF concentrate have shown that haemostatic levels of FVIII: C can easily be maintained for several days by infusing vWF alone. In conclusion, this VHP vWF concentrate appears to represent an efficient plasma product specifically intended for the treatment of vWD. Other concentrates have also been shown to be clinically effective in vWD patients. Haemate P and the 8 Y preparation are useful alternatives to cryoprecipitates (Fukui et al. 1988: Cumming et al. 1990; Pasi et al, 1990). However, these products also contain FVIII: C. which is not really essential for vWD patients. Considering the permanent risk of a world-wide shortage of FVIII. it would therefore be more advisable to restrict the FVIII use to FVIII concentrates specially intended for haemophiliacs. However, replacement therapy of vWD patients with vWF alone requires a good knowledge of the disease since some patients with a low baseline FVIII:C level may have to be specially managed. ACKNOWLEDGMENTS We wish to thank Dr A. Parquet (CRTS, Lille) for her collaboration in the pharmacokinetic study, Dr T. Burnouf (CRTS. Lille) and Dr J. J. Huart (Director of CRTS, Lille) for the gift of the VHP vWF concentrate. REFERENCES Allain. J.P. (1 984) Principles of in vivo recovery and survival studies. Scandinavian Journal of Haematology. Suppl. 41, 123-145. Berntorp, E. & Nilsson, I. ( 1988)Biochemical and in vivo properties of commercial virus-inactivated factor VIII concentrates. European Journal of Haematology, 40, 205-214. Blatt, P.M., Brinkhous, K.M., Culp, H.R.. Krauss, J.S. &Roberts, H.R. (1976) Antihemophdic factor concentrate therapy in von Willebrand disease. Dissociation of bleeding-time factor and ristocetincofactor activities. Journal of American Medical Association, 236, 2 770-2 772. Burnouf, T., Burnouf-Radosevich. M., Huart. J.J. & Goudemand, M.
(199 1)A highly purified Factor VIII :C concentrate prepared from cryoprecipitate by ion-exchange chromatography. Vor Sanguinis, 60, 8-15. Bumouf-Radosevich. M. & Bumouf, T. (1991 ) Chromatographic preparation of a therapeutic highly purified von Willebrand factor concentrate from human cryoprecipitate. Vox Sanguinis (in press). Cumming. A.M.. Fildes. S., Cumming, I.R.. Wensley, R.T., Redding. O.M. & Burn, A.M. (1990) Clinical and laboratory evaluation of National Health Service factor VIII concentrate (8Y) for the treatment of von Willebrand's disease. British Journal of Haematology, 75, 234-239. Fricke, W.A. & Yu. M.Y.M. (1989) Characterization of von Willebrand factor in factor VIII concentrates. American Journal of Hematology. 31, 41-45. Fukui, H.. Nishino. M., Terada, S.. Nishikubo. T., Yoshioka. A., Kinoshita. S., Niinomi. K. & Yoshioka, K. (1988) Hemostatic effect of a heat-treated factor VIII concentrate (Haemate P) in von Willebrand's disease. Blut, 56, 171-178. Girma. J.P., Lavergne. J.M., Meyer. D. & Larrieu, M.J. (1981) Immunoradiometric assay of factor VIII coagulant antigen using four human antibodies: study of 27 cases of haemophilia A. British Journal of Haematology. 47, 269-282. Goudemand. J., Samor, B., Caron, C., Jude, B., Gosset. D. & Mazurier. C. (1988) Acquired type I1 von Willebrand's disease: demonstration of a complexed inhibitor of the von Willebrand factor platelet interaction and response to treatment. British Journal of Haematology, 68, 227-233. Green, D. & Potter, E.V. (1976) Failure of AHF concentrate to control bleeding in von Willebrand's disease. American Journal of Medicine. 60, 357-360. Kohler, M., Hellstern. P. & Wenzel. E. (1985)The use of heat-treated factor VIII concentrates in von Willebrand's disease. Blut, 50, 25-27. Lawrie, AS., Harrison, P., Armstrong. A.L.. Wilbourn, B.R.. Dalton, R.G. & Savidge, G.F. (1989) Comparison of the in vitro characteristics of von Willebrand factor in British and commercial factor VIII concentrates. British lournal of Haematology. 73, 100-1 04. Mannucci, P.M., Moia, M., Rebulla, P., Altieri, D.. Monteagudo. J. & Castillo, R. (1987) Correction of the bleeding time in treated patients with severe von Willebrand disease is not solely dependent on the normal multimeric structure of plasma von Willebrand factor. American Journal of Hematology, 25, 55-65. Mazurier, C.. Parquet-Gernez, A. & Goudemand, M. (1977) Dosage de I'antigene lie au facteur VIII par la technique ELISA. Int6r.3 dans I'etude de la maladie de Willebrand. Pathologie Biologie, 25, 18-24. Mazurier. C., Mannucci. P.M.. Parquet-Gernez. A,, Goudemand. M. & Meyer, D. (1986a) Investigation of a case of subtype IIC von Willebrand disease: characterization of the variability of this subtype. American Journal of Hematology, 22, 301-31 1. Mazurier. C., Samor, B. & Goudemand. M. (1986b) Improved characterization of plasma von Willebrand factor heterogeneity when using 2.5% agarose gel electrophoresis. Thrombosis and Haemostasis. 55, 61-64. Mazurier, C.. de Romeuf, C., Parquet-Gernez. A. & Goudemand, M. (1989) In vitro and in vivo characterization of a high-purity, solvent detergent-treated factor VIII concentrate: evidence for its therapeutic efficacy in von Willebrand's disease. European Journal of Haematology, 43, 7-14. Mazurier, C., Gaucher, C., Jorieux. S.. Parquet-Gernez, A. & Goudemand, M. (1990) Evidence for a von Willebrand factor defect in factor VIII binding in three members of a family previously misdiagnosed mild haemophilia A and haemophilia A carriers: consequences for therapy and genetic counselling. British Journal of Haematology. 76, 372-379.
In Vivo Evaluation o f a vWF Concentrate Mazurier. C.. Jorieux, S.. de Romeuf, C., Samor, B. & Goudemand. M. (1991) ‘Invitro’evaluationofavery highpurity. solvent detergent treated von Willebrand factor concentrate. Vox Sanguinis, 61.1-7. Over. J., Sixma, J.J., Doucet-De Bruine. M.H.M.. Trieschnigg, A.M.C., Vlooswijk. N.H.. Beeser-Visser. N.H. & Bouma, B.N. (1978) Survival of 12 5 Iodine-labelled factor VIII in normals and patients with classical hemophilia. Observations on the heterogeneity of human factor VIII. Journal of Clinical Investigation. 62, 223-234. Pasi.K.J., Williams, M.D..Enayat. M.S. &Hill. F.G.H. (1990) Clinical and laboratory evaluation of the treatment of von Willebrand’s disease patients with heat-treated factor VIII concentrate (BPL 8Y). British Journal of Haematologg, 75, 228-233. Rothschild. C., Fressinaud, E.. Wolf, M.. Dreyfus, M., Laurian. Y.. Peynaud-Debayle, E., Gazengel, C., Meyer, D. & Larrieu. M.J.
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(199 1) Unexpected results following treatment of patients with von Willebrand disease with a new highly purified von Willebrand factor concentrate. (Abstract). Thrombosis and Huemostasis, 65, 1126. Sultan, Y. & Rossi. J. (1977) Methode de mesure de I’activite Willebrand sur plaque de microtitration. Nouvelle Presse Midicale. 6.44-46. Weiss, J.H., Sussman. I.T. & Hoyer, L.W. (1977) Stabilization of factor VIII in plasma by the von Willebrand factor. Journal of Clinical Investigation. 60, 390-404. Yoshioka, A.. Shima, M., Nishino, M., Yoshikawa. N. & Fukui. H. (198 7) In vitro characterization of various heat-treated factor VIII concentrates. Arzneimittelforsch, 37, 753-756.
