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Robert Klamroth,1 Piotr Wojciechowski,2 Samuel Aballéa,3 Françoise Diamand,4 Zalmai Hakimi,5 Jameel Nazir,5 Lydia Abad-Franch,6 Stefan Lethagen,7 Elena Santagostino,8 Michael D Tarantino9 1Department of Internal Medicine, Hemophilia Treatment Centre, Vivantes Klinikum im Friedrichshain, Berlin, Germany; 2Creativ-Ceutical, Krakow, Poland; 3Creativ-Ceutical, Rotterdam, the Netherlands; 4Creativ-Ceutical, Paris, France; 5Health Economics and Outcomes Research (Global), Sobi, Stockholm, Sweden; 6Global Medical Affairs Hematology, Sobi, Stockholm, Sweden; 7Medical and Clinical Sciences, Sobi, Stockholm, Sweden; 8Medical Affairs Hematology, Sobi, Stockholm, Sweden; 9The Bleeding and Clotting Disorders Institute, University of Illinois College of Medicine-Peoria, Peoria, IL, USACorrespondence: Robert KlamrothDepartment of Internal Medicine – Angiology and Hemostaseology, Center for Vascular Medicine, Hämophiliezentrum/Gerinnungssprechstunde, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, D, Berlin, 10249, Germany, Tel +49 (0)30 130 231575Fax +49 (0)30 130 231313Email robert.klamroth@vivantes.dePurpose: Primary prophylaxis, using factor VIII replacement, is the recognized standard of care for severe hemophilia A. Recombinant factor VIII-Fc fusion protein (rFVIIIFc) and emicizumab, a humanized, bispecific antibody, are approved for routine prophylaxis of bleeding episodes in severe hemophilia A. These products have different mechanisms of action, methods of administration and treatment schedules. In the absence of head-to-head trials, indirect treatment comparisons can provide informative evidence on the relative efficacy of the two treatments. The aim of the study was to compare the approved dosing regimens for each product, rFVIIIFc individualized prophylaxis and emicizumab administered once every week (Q1W), every 2 weeks (Q2W) or every 4 weeks (Q4W), based on clinical trial evidence.Patients and Methods: The comparison was conducted using matching-adjusted indirect comparison since clinical evidence did not form a connected network. Individual patient data for rFVIIIFc (A-LONG) were compared with data for emicizumab (HAVEN trial program) for mean annualized bleeding rate (ABR) and proportion of patients with zero bleeds. Safety data reported across the analyzed treatment arms were tabularized but not formally compared.Results: After matching, no significant differences were observed between mean ABR for rFVIIIFc and emicizumab administered Q1W, Q2W or Q4W. The proportion of patients with zero bleeds was significantly higher with rFVIIIFc compared with emicizumab administered Q4W (51.2% versus 29.3%, respectively; odds ratio 2.53; 95% confidence interval 1.09– 5.89); no significant differences noted when rFVIIIFc was compared with emicizumab administered Q1W or Q2W. The mean number of adverse events expressed per participant was 1.9 for individualized prophylaxis with rFVIIIFc and 3.7– 4.0, 4.1 and 3.6 for emicizumab administered Q1W, Q2W or Q4W, respectively.Conclusion: This indirect treatment comparison suggests that rFVIIIFc individualized prophylaxis is more efficacious than emicizumab Q4W, and at least as effective as more frequent emicizumab regimens, for the management of hemophilia A.Keywords: annualized bleeding rate, antibodies, bispecific, comparative effectiveness research, efmoroctocog alfa, factor VIII deficiency, treatment outcome

Giovanni Di Minno,1 Elena Santagostino,2 Massimo Morfini,3 Cosimo Ettorre,4 Dorina Cultrera,5 Erminia Baldacci,6 Eleonora Russo,7 Cristiano Gallucci7 On behalf of the Italian FusENGO B1831081 Study Group 1Department of Clinical Medicine and Surgery, Azienda Universitaria Policlinico Federico II, Naples, Italy; 2Hemophilia and Thrombosis Center, IRCCS Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy; 3Scientific Committee, Italian Association of Haemophilia Centres (AICE), Florence, Italy; 4Haemophilia and Thrombosis Center, Policlinico Giovanni XXIII, Bari, Italy; 5Hematology Unit, Regional Center for Hemophilia, Italy Ospedaliera-Universitaria “Policlinico – Vittorio Emanuele”, Catania, Italy; 6Hemophilia, Thrombosis, and Hematology Center, Dipartimento Biotecnologie cellulari ed Ematologia, Università la Sapienza, Rome, Italy; 7Medical Department, Pfizer srl Rome, Italy Background: FuseNGO is a relatively new device consisting of a prefilled dual-chamber syringe (DCS) that was recently introduced for the reconstitution of recombinant factor VIII. Herein, the DCS device was assessed using five questionnaires with the primary aim of evaluating patient perceptions and preferences.Methods: An observational, non-interventional, longitudinal study on 86 patients with a confirmed diagnosis of hemophilia A was carried out at 21 sites in Italy. Each patient underwent a baseline visit and final study visit within 3–6 months. Patients were administered five questionnaires: HemoPREF; Treatment Satisfaction Questionnaire for Medication (TSQM); VeritasPRO; Hemophilia Well-being Index (HWBI); Work Productivity and Activity Impairment Questionnaire (WPAI) + Classroom Impairment Questions (CIQ): Hemophilia Specific (HS).Results: Compared to baseline, scores for HemoPREF were higher at follow-up; significant increases in the percentage of positive responses were seen for all questions regarding the ease of use (P70% in the VeritasPRO questionnaire, and the majority of patients reported in the HWBI that hemophilia A did not affect their lives in a significant way. The perceived level of overall impairment was 30% as reported in the WPAI + CIQ: HS, indicating little impairment. There were no safety concerns.Conclusion: Considering patient-reported outcomes, the DCS device was associated with easier preparation, storage, disposal of equipment, and overall use. Of particular note, preparation times were reduced by around 50%. The majority of patients were satisfied with the device and overall adherence scores were high. Considering these results, the device has the potential to increase adherence to therapy and, possibly, reduce healthcare costs. Keywords: factor VIII delivery, device, hemophilia A, patient satisfaction, adherence

Elena Santagostino, Maria Elisa Mancuso Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Ca’ Granda Foundation, Maggiore Hospital Policlinic, Milan, Italy Abstract: Decisions over hemophilia treatment selection and switching involve balancing many clinical and patient-related factors. The current standard of care for patients with hemophilia B is prophylaxis with plasma-derived or recombinant factor IX (rFIX) concentrates. However, several extended half-life (EHL) rFIX products have recently been developed to improve treatment convenience and clinical outcomes for these patients. Nonacog beta pegol, an rFIX product that combines the FIX protein with a 40 kDa polyethylene glycol moiety, has been evaluated in 115 previously treated patients with hemophilia B (including 25 children) in the paradigm clinical trial program. FIX activity levels and pharmacokinetics were monitored throughout these trials and showed that nonacog beta pegol offers significant pharmacological improvements over standard FIX products. Once-weekly prophylaxis with nonacog beta pegol 40 IU/kg resulted in fewer bleeds in all patients (median annualized bleeding rate of 1.0 across all ages), resolved 90% of target joints, and improved health-related quality of life. No patients developed FIX inhibitors, and there were no thromboembolic events or unexpected safety concerns. Nonacog beta pegol was also safe and effective in the perioperative setting. These findings show that nonacog beta pegol is highly effective, while also offering more convenient dosing than standard FIX products. Nonacog beta pegol represents a significant advance in the current context of treatment for hemophilia B, offering effective management across several treatment modalities and settings, and potentially easing the treatment burden for patients of all ages. Meanwhile, the development of novel treatment strategies, such as gene therapy, anti-tissue factor pathway inhibitor antibodies, and RNA interference therapy, may provide patients with additional therapeutic options, which would require reassessment of the role of EHL products in the future. Keywords: long-acting FIX, PEGylated rFIX, extended half-life, prophylaxis

Silvia Riva,1 Alessandro Nobili,2 Codjo D Djade,2 Maria Elisa Mancuso,3 Elena Santagostino,3 Gabriella Pravettoni1–4 1Department of Health Sciences, Università degli Studi di Milano, Milan, Italy; 2Department of Neuroscience, IRCCS, Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy; 3Angelo Bianchi Bonomi Hemophilia and Thrombosis Centre, IRCCS Ca’ Granda, Policlinic Hospital, Milan, Italy; 4European Institute of Oncology, Milan, Italy Abstract: Elderly patients with hemophilia have to face new challenges linked to concomitant pathologies and concurrent use of different treatments. In order to promote optimal care in the elderly hemophilia population, this study is aimed to analyze treatment compliance in relation to the presence of comorbidities and the role of potential determinants that can affect compliance (positively or negatively), including health-related quality of life, cognitive decline, and sociodemographic parameters (eg, living situation, partnership, presence of caregivers). This will be an observational study of elderly patients with hemophilia (aged >60 years). Patients will be interviewed during their routine medical visits. The data interview will pertaining to several dimension of treatment management. This study will detect more vulnerable patients with special care needs and will highlight psychological factors that should be considered for future psychosocial interventions.Keywords: hemophilia, cognitive assessment, cognitive decline, compliance, treatment, aging

Elena Santagostino Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy Abstract: Advances in recombinant technology and knowledge about coagulation factor VIII (FVIII) are building a platform for new therapeutic options in patients with hemophilia A. The development of turoctocog alfa, a novel, high-purity, third-generation, B-domain truncated recombinant FVIII, has been produced and formulated without the use of animal-derived or human serum-derived components, in the wake of understanding of the new biochemical characteristics of FVIII, namely its protein structure, and glycosylation and sulfating patterns. Culture conditions and a five-step purification process have been developed to optimize the safety of turoctocog alfa. The results of two pilot clinical trials using turoctocog alfa confirmed high safety levels, with no patient developing inhibitors during the period of observation. The purpose of this review is to describe briefly the molecular and biological properties of turoctocog alfa, together with details of its clinical development, with emphasis on the needs of patients with hemophilia A. Keywords: hemophilia A, recombinant factor VIII, turoctocog alfa, purification, inhibitor, safety