Course at the SISET Training Center
Florence, 26-30th September 2016
Management of Inherited von Willebrand Disease:
Toward a more evidence-based approach
Augusto B. FEDERICI
Hematology and Transfusion Medicine
Luigi Sacco University Hospital, University of Milan
Employment NONE
Research support NONE
Scientific advisory board BAXALTA CSL-BEHRING, GRIFOLS,
KEDRION-LFB, OCTAPHARMA, WERFEN-IL
Consultancy NONE
Speakers bureau BAXALTA, CSL-BEHRING, GRIFOLS,
KEDRION-LFB, OCTAPHARMA, WERFEN-IL
Major stockholder NONE
Patents NONE
Honoraria BAXALTA CSL-BEHRING, GRIFOLS,
KEDRION-LFB, OCTAPHARMA, WERFEN-IL
Travel support NONE
Other NONE
Disclosures:
A.B. Federici
Milestones on VWD Management
(1926-2006)
1926
1951
1964
1971
1973
1977
1982
1985
1992
1994
2002
2006
First description by Erik von Willebrand
Cross transfusion by HA plasma in VWD
Pool’s cryoprecipitate in VWD
Immunologic difference of HA and VWD
Synthesis of VWF by cultured EC
First report on the use of DDAVP in VWD
Epidemiology of VWD in general population
Discovery of VWF gene by four laboratories
First PK trials with FVIII/VWF concentrates
Classification of VWD
National guidelines for VWD management
Molecular & clinical markers of VWD type 1
Milestones on VWD Management
(2006-2016)
2006
2008
2011
2013
2014
2015
2015
2016
2016
Updated Classification of VWD by ISTH
US Recommendation on VWD Management
ISTH Bleeding Assessment Tool (BAT)
PK and Safety of Recombinant VWF
BS and VWF in Clinical Outcomes in VWD
Prospective data about Prophylaxis in VWD
Novel tests Platelet-Dependent activities
More automatic lab diagnosis of VWD
Recombinant VWF available in US (FDA)
First Publication about VWD patients
By Erik A. von Willebrand (1926)
Erik Adolf von Willebrand (1870-1949)
The Pedigree of the First VWD Family
Located in Foglo
Classification of VWD Types
Based on Several Assays
NIH US Guidelines
• The most common inherited bleeding disorder
• More women VWD despite autosomic inheritance
• Type 1 VWD is the most frequent type
• Type 3 VWD is the most severe form
• Gastrointestinal bleeds occur only in severe VWD
• DDAVP is the treatment of choice in most VWD
• VWF/FVIII concentrates are always efficacious
Common Concepts reported in VWD:
Are all of them really true?
• Improve tests for VWF activity
• Identify risk factors of bleeding in VWD
• Better diagnose & treat GI bleeding
• Monitor VWF concentrates in surgery
• Identify & treat anti-VWF antibodies
• Indications & protocols of prophylaxis
Current Challenges and Unmet Needs
In VWD Management
List of Clinical and Laboratory Tools
Used for VWD Diagnosis
Basic Tests
Patient & Family History
Bleeding Score
Bleeding Time
PFA 100
PTT
FVIII:C
Specific tests
VWF:Ag
VWF:RCo
VWF:CB
VWF:RCo/Ag
VWF:CB/Ag
VIII:C/VWF:Ag
Additional tests
RIPA test
VWF:FVIIIB
Multimeric analysis
Molecular genetics
More Than One Test Always Needed
Criteria for Correct Diagnosis
(Bleeding History, Low VWF Activity, Inheritance)
Tosetto et al JTH 2006
Platelet
GPIb
A1
C C C C
A2
SubEndothelium Collagen I and III
Collagen VI
Heparin
Sulphatide
VWF:RCo
VWF:CBA3
ADAMTS 13
W
W
WI:1
III:3W
I
II
III
Platelet Dependent-VWF Activity(Nomenclature and Methodology)
Bodó et al on behalf of ISTH-SSC-SC on VWF JTH 2014
Flow chart for VWD Diagnosis
Used in Italian Registry
• VWD is the most common inherited bleeding
disorder and is due to quantitative (VWD3 &
VWD1) and/or qualitative (VWD2A, VWD2B,
VWD2M, VWD2N) defects of VWF: in severe
VWD3, VWD1 & VWD2N FVIII is also reduced
• Despite the complex and heterogeneous nature
of the VWF defects, nowadays all VWD types
can be managed efficiently in most patients.
VWD: what do we need to know
Background 2016 (1)
• However, correct VWD diagnosis & classification
cannot be always available in several Centers
to provide the best therapeutic approach.
• Differently from HA easily classified (severe,
moderate, mild) by baseline FVIII levels, VWD
severity is not well defined within types so far.
VWD: what do we need to know
Background 2016 (2)
• Identify patients at risk of bleeding
• Better diagnose & treat GI bleeding
• Monitor VWF concentrates in surgery
• Indications & protocols of prophylaxis
• Identify & treat anti-VWF antibodies
VWD: what do we need to know
Current challenges in VWD
• Type and/or severity of VWD patients:
baseline VWF & FVIII levels
• Clinical settings: acute bleeding
surgery
prophylaxis
• VWF Concentrates: VWF:FVIII ratios
Management of VWD patients
Three main factors
• Clinical and lab data obtained in VWD from the
registries and/or retrospective studies are not
always reliable due to non correct lab test for
VWD diagnosis & classification at local sites
• Therefore only prospective studies on VWD with
lab parameters tested by expert centers should
be considered in clinical trials
Move to evidence-based VWD management
The 10-year experience (2004-13)
• RENAWI-2 is a prospective observational cohort
study carried out in VWD patients with centrally
confirmed diagnosis and followed-up at 6
Hemophilia Centers, members of the Italian
Association of Hemophilia Centers (AICE)
• This study is the continuation of the previous
retrospective Italian Registry on VWD (RENAWI-1)
Design of RENAWI-2
To evaluate the incidence, types and severity of
spontaneous bleeding episodes requiring DDAVP
and/or VWF/FVIII concentrates in large cohort of
VWD patients: i.e. how to characterize bleeding
phenotype in different VWD types and to predict
clinical outcome in these patients.
Aims of RENAWI-2
1,529
1,234VWD confirmed
diagnosis
796included
in follow-up
295unmet
inclusion criteria
437not included
In follow-up
Cross sectional study
[RENAWI-1]
16 centers
Prospective study
[RENAWI-2]
6 centers
VWD1(n = 457)
VWD2A(n = 65)
VWD2B(n = 56)
VWD2M(n = 169)
VWD3(n = 49)
VWD1(n = 23)
VWD2A(n = 10)
VWD2B(n = 5)
VWD2M(n = 12)
VWD3(n = 25)
75bleeding
at follow-up
Flow Chart of the Italian Studies on VWD:
From RENAWI-1 to RENAWI-2
Heterogeneity of VWD Patients
Based on Cohort Studies
VWF:RCo <10 U/dL
+ FVIII:C < 20 U/dL
VWF:RCo 10-30 U/dL
+ FVIII:C 20-40 U/dL
VWF:RCo 30-50 U/dL
+ FVIII:C 40-70 U/dL
VWD Severe Forms:
VWD1, VWD2A, VWD3
VWD Moderate Forms
VWD1, VWD2B, VWD2M, VWD2N
Bleeders: VWD1 Mild Forms
Non bleeders:
Low Levels of VWF
Diagnosed VWD: the tip of the iceberg?
Federici AB et al, Blood 2014; 123: 4037-44.
Heterogeneous VWD Cohort:
Italian Registries (RENAWI)
Bleeders versus Non Bleeders
• For different risk categories, actual incidence
of mucosal and non mucosal bleedings was
calculated in the VWD followed for 1 year
• A Cox’s proportional hazard model was used to
assess the risk of bleeds in different categories:
BS = < 5; 5-10; > 10;
BT = < 10’; 10’-20’; > 20’(min);
VWF:RCo = < 10; 10-30; 31-54 (U/dL);
FVIII:C = < 20; 20-40; > 40 (U/dL).
Methods to assess severity of VWD
Prospective registry (RENAWI-2)
Bleeding Phenotype in VWD
Evidence-Based Methods
Federici AB et al, Blood 2014; 123: 4037-4044
Restricted Cubic Spline Curve Cox’s Proportional Hazard Model
Summary of results (1)
Prospective study (RENAWI-2)
Federici et al. Blood, 2014
In the prospective study based on 797/1234 (66%)
of the retrospective registry (RENAWI-1).
BS > 10
BT > 20’
VWF:RCo < 10 U/dL
FVIII:C < 20 U/dL
Parameters
6.80 (3.80-12.30)
5.67 (3.22-10.05)
3.27 (1.77-6.06)
4.20 (2.43-7.26)
Hazard ratio (95% CI)
are associated with high risk of bleeding
• By multivariate model including all variables,
BS > 10 [HR = 5.5 (2.8-10.8)] was the most
significant determinant of bleeds
• The incidence of bleeding at one year (%/year)
correlates with BS and increases significantly
from VWD1 (5.2), VWD2M (7.3), VWD2B (9.6)
to VWD2A (17.2) and VWD3 (80.4)
Summary of results (2)
Prospective study (RENAWI-2)
Federici et al. Blood, 2014
Bleeding survival (1)
VWD types versus BS and VWF:RCo
Federici AB et al, Blood 2014; 123: 4037-4044
Federici AB et al, Blood 2014; 123: 4037-4044
Bleeding survival (2)
BS in VWD1 (VWF:RCo) and VWD3 (FVIII)
Bleeding Phenotype in VWD typesType of Bleeding Symptoms
The bleeding score helps to predict clinical outcomes
in adult patients with VWD.
High bleeding scores correlate with intensive on
demand therapy and may identify cases requiring
regular prophylaxis
Conclusion of RENAWI-2
• DDAVP (endogenous VWF)
• VWF Concentrates (+ or – FVIII)
• Additional support (TA, Hormones)
Management of VWD
Therapeutic approaches
Summary on Desmopressin
(DDAVP: 1977-2016)
• DDAVP is a long-acting V2 receptor-selective analog of AVP.
• DDAVP has complex effects on the coagulation process with both pro-
hemostatic (dominant) and anti-fibrinolytic effects (t-PA).
• Doses of DDAVP required for effects on coagulation are leading to peak
plasma concentrations ~ 50-200 times above maximally anti-diuretic
plasma concentrations.
• High intra-individual reproducibility of desmopressin-induced increase
in FVIII plasma concentration.
• Tachyphylaxis of DDAVP-induced increase in FVIII and VWF plasma
concentrations by daily dosing is moderate, limited, and do not lead to
a clinically significant impairment of the hemostatic effects.
Biological
Response
in VWD1
No Biological
Response
in VWD2A
(Ruggeri et al Blood 1982)
DDAVP TreatmentBiological Response to Predict Effective Therapy
Blood 2008; 111: 3531-39
Blood 2004; 103: 2032-38
DDAVP TreatmentBiological Response to Predict Effective Therapy
Biological response to DDAVP
in VWD1 (n = 26)
Tachyphylaxis in Repeated Doses
FVIII VWF:RCo
Repeated DDAVP Administrations:
Lower Effect of the Drug
• DDAVP is considered the treatment of choice of VWD
but questions about its efficacy and safety remain
when DDAVP is repeated in bleeds and surgery.
• Most hematologists prefer to use VWF concentrates
during deliveries and major surgery also in VWD
patients proven to be responsive to DDAVP.
• No prospective data available to correlate biological
response with efficacy (See: Pro-Des-Will Study 2016).
Evidence-based DDAVP efficacy-safety
Current Data in 2016
• Treatment Drug regimens: DDAVP was given
intravenously or subcutaneously (0.3 ug/Kg) or by
nasal spray (4 ug/Kg) according to preparations
available in the different countries;
• Anti-fibrinolytic agents (Epsilon-amino-caproic acid,
EACA or Tranexamic Acid, TA) could be used
together with DDAVP with standard doses;
• In case of major surgery, DDAVP was given together
with TA using a 3dayOn-4dayOff-3dayOn schedule
according to a pre-scheduled scheme.
DDAVP in inherited VWD
Methods: (III)
0 12 24
1 2 3 4 5 6 7 8 9 10
2 3 4 5
DDAVP ev o sc1 6 7 8
Tranexamic Acid
2 6
Surgery
Regimen of DDAVP administration with TA
in major surgery (3+4-3+)
2006-2016
BIOSTATE
WILATE
VONVENDI
(US)
List of VWF concentrates used in
Clinical practice (1982-2016)
Federici AB and Thompson A. Haemophilia, 2006
List of VWF concentrates used in
Clinical practice (1982-2006)
VWF/FVIII ConcentratesIn VWD3 patients
< 3
10
35
8
28
61
20
45
82
24
78
90
75
90
95
120
165
85
< 3
< 3
7
VWF:RCo =
VWF:Ag =
FVIII:C =
VWF/FVIII Concentrates in VWD3
WILATE PK studies
0
25
50
75
100
125
150
175
200
0 12 24 36 48 60 72
Hours post-injection
IU/d
l
vWF:RCo
vWF:Ag
FVIII:C
FVIII / vWF (60 IU/kg vWF:RCo)
0
25
50
75
100
125
150
175
200
0 12 24 36 48 60 72
Hours post-injection
IU/d
l
vWF: RCo
vWF:Ag
FVIII:C
WILFACTIN (60 IU/kg vWF:RCo)
VWF/FVIII WILFACTIN
VWF Concentrates with or without FVIII:
Pharmacokinetic (PK) studies in VWD3 (n = 6)
Days
Before D 2
n = 12
D 3
n = 11
D 4
n = 6
D 5
n = 6
D 6
n = 6
0
20
40
60
80
100
120
140
160
180
200
IU/d
l
endogenous FVIII
trough value for VWF:RCo
Days
Before
n = 26
D 2
n = 23
D 3
n = 18
D 4
n = 12
D 5
n = 11
D 6
n = 7
VWF and FVIII plasma levels (median) & repeated infusions of WILFACTIN
normal (hemostatic) FVIII levels
are obtained after repeated VWF injections
French studyEuropean study
Post-operative VWF/FVIII plasma levels
rhVWF pdVWF
Expressed in CHO cells Synthesized in endothelial cells and
megakaryocytes
Pro-peptide removal mediated in vitro
through exposure of the pro-VWF to a
second recombinant protein (the pro-
peptide-processing enzyme furin)
Post-translational modification of pro-peptide removal occurs intra-cellularly during passage of the protein to the Golgi and post-Golgi compartments
No exposure to ADAMTS13
intact VWF subunits
ultralarge VWF multimers present
Consists of VWF subunits that have been exposed to plasma ADAMTS13
subunits cleaved at TYR1605-MET1606
Ultralarge VWF multimers absent
Glycosylation: ABO blood group
glycans absent
Glycosylation: ABO blood group
glycans present
Plasma-derived VWF concentrate contain
other proteins incl. ADAMTS13
Differences between rhVWF (VONVENDI) &
plasma-derived VWF
* Low resolution agarose (1% Seakem) / Samples adjusted to VWF:Ag content
** SDS-PAGE / Immunoblot with polyclonal anti-VWF Ab / Samples undiluted
176 kDa
dimer
high
low
15
min
30
min
1
hr
3
hrs
6
hrs
9
hrs
12
hrs
24
hrs
28
hrs
32
hrs
48
hrs
72
hrs
96
hrs
VWF multimer analysis*
ADAMTS13 subunit cleavage products**
VWD
Type 2A
rhVWF multimers and ADAMTS13 cleavage