To compare the cost – effectivity of intervention options in three patients with hemophilia A and low titre inhibitors.
Methodology: We used a longitudinal before and after design that was conducted in two stages assessed retrospectively: Phase I was 6 months predating the debut of R FVII a, during which patients received on-demand usual attention with plasma derived factor VIII governments, stage 2 was 6 month intervention on R FVII a. We determined the clinical response, and the cost of intervention with NovoSeven in 3 male childs with low titre inhibitors to factors VIII compared with other intervention regimes antecedently used in these patients ( Plasma derived factor VIII ) .
Consequences: handling haemophilia patients with low titre inhibitors with recombinant activated factor VII is cost – effectual compared to intervention with plasma derived factor VIII governments.
Decision: Our consequences confirm that rFVIIa is clinically effectual and resulted in 100 % decreases in the figure of re-treatment exigency room visits compared with the patients with plasma derived factor VIII.
Cardinal WORDS: Hemophilia, Inhibitors, rFVIIa.
Introduction
Inhibitors in haemophilia A against FVIII is debatable, ambitious, and hard to pull off. While the frequence of hemorrhage is non increased in hemophilia patient with inhibitors, one time shed blooding occurs, its control is more hard and frequently unpredictable.1 rFVIIa is a bypassing agent evaluated in compassionate usage and investigational surveies. rFVIIa appears to be effectual in 69-90 % of intervention classs embracing different types of bleedings and surgical procedures.2 The disposal of exogenic rFVIIa in high concentrations has been found to originate and keep haemostasis in hemophilia patients with inhibitors to FVIII/FIX. This consequence seems to be due to an increased coevals of thrombin on the thrombocyte surface after this has been activated by the thrombin molecules formed through the initial FX activation by the TF-FVIIa composite formed on the TF-bearing cells.3
rFVIIa provides site-specific thrombin coevals through pharmacological use of the curdling mechanism at the site of vessel hurt. Endothelial harm is associated with collagen and tissue factor ( TF ) exposure. Under normal physiological conditions, hint sums of go arounding FVIIa, in the order of 3.58A ng/mL, bind to organize the TFA : A FVIIa composite. This complex has now been recognized as the polar activator of the curdling cascade and consequences in localised thrombin coevals. Through thrombin-mediated thrombocyte activation and feedback up-regulation of the curdling mechanism, haemostatis occurs. At pharmacological concentrations in the order of 50A nanometers, rFVIIa has been shown to bring forth significantly more thrombin in a theoretical account imitating normal plasma, compared to haemophilic plasma.4
In the Gallic multicenter survey, patients assessed the efficaciousness of NovoSeven in serious shed blooding episodes 8h after an initial dosage of rFVIIa ( 90-120 Aµg/kg/dose ) . 132 episodes of acute hemarthrosis were treated and analyzed. Hemostasis was judged first-class or effectual in 90 % of episodes, partly effectual in 9 % , and uneffective in 0.6 % of the hemorrhage episodes. The average figure of doses was 2.9 per hemorrhage episode.5
In this paper we analyzed the responses and costs of giving rFVIIa Vs plasma-derived Factor VIII to patients with low-titer inhibitors.
Methodology
Three work forces, with terrible haemophilia A participated in this survey. These patients were go toing in the Gorgan intervention centre ofIran. Their ages in baseline were 7, 23 and 43 old ages old. Duration of inhibitors presence was non applicable. Maximum inhibitor degrees were 3.8, 2.9, 1.3 Bethesda units severally ( Table-I ) .
We used a longitudinal before and after design that was conducted in 2 stages. Phase 1 was 6 months predating the rFVIIa intervention during which all patients were treated with an on-demand plasma derived factor VIII government. Phase 2 was 6 months of on-demand intervention with rFVIIa. The intervention government was consisted of endovenous push injection of rFVIIa in a dosage of 90 Aµg/Kg and was repeated after 2 hours if shed blooding continued.
This survey was conducted in the position of the Persian Ministry of Health. Due to the un-availability of other medical resources unit costs, survey focused on intervention costs and excluded outpatient and inmate costs associated with the hemorrhage episodes.
Effectiveness of interventions was assessed through the demand for hospitalization and necessity for re-treatment ( a intervention was considered as effectual if shed blooding episode could be controlled in the outpatient puting within 24 hours ) . Clinical response to intervention and hence demand for hospitalization was assessed by a doctor.
Consequence
All shed blooding episodes happening during one of the two stages of the survey were treated foremost in outpatient scene and, if bleeding episode remained uncontrolled, patients were transferred to hospital. Tables II, III, and IV below describe the hemorrhage episodes and their single direction for each of the 3 patients involved in the survey.
Study consequences confirm that rFVIIa is clinically effectual. Indeed, each shed blooding managed with rFVIIa was managed in outpatient scene ( i.e. did non necessitate transportation to exigency room visit ) within 24 hours.
Table-V describes the entire factor ingestion and associated cost per patient in each survey stage. Study consequences showed that entire cost of intervention with rFVIIa was lower than plasma derived FVIII. Entire cost of factor VIII plasma derived was $ 98600 & A ; entire cost of rFVIIa was $ 77000.
Discussion
There are many published articles which report the success of different interventions for haemophilia A patients with low titer inhibitors, but really few, if any effort to compare the consequence between plasma derived factor VIII and rFVIIa. In published documents, effectivity of rFVIIa and high dose plasma-derived F VIII informations were 89.3 % and 71.4 % respectively.6 Cost analysis informations are now highly valuable for the development of intervention guidelines where there is argument over the most appropriate intervention in footings of cost-benefit ratio. Cost-effectiveness of utilizing rFVIIa Vs aPCC in patients with high titer inhibitors is good documented worldwide.3-8 This survey is really the first one measuring the cost and effectivity of giving rFVIIa to patients with low titer inhibitors. It is besides one of the lone surveies ( with the exclusion of Dundar S et al5 ) comparing the cost and effectivity of rFVIIa Vs high dose factor VIII.
Looking at the effectivity and the costs, consequences from our survey really back up the usage of rFVIIa Vs plasma derived factor VIII in patients with low titer inhibitors.
Furthermore, because this survey did non account for outpatient and inmate costs, but merely for drug costs, it is expected that the cost-savings associated with the usage of rFVIIa in this patients ‘ population would be even bigger since none of the patients taking rFVIIa were sent to infirmary and none of them required re-treatment within 24 H.
Finally, if the health-related quality of life ( HRQoL ) of patients was non assessed through the usage of externally validated questionnaires, it is expected that the HRQoL of patients having rFVIIa would really be improved due to the shorter declaration of shed blooding episodes and absence of hospitalization. Similar survey consequences were really described in a cost-utility survey performed in Australia.9-11
Study restrictions include the absence of accounting for outpatient and inmate costs associated with the hemorrhage episode, but besides clip to intervention which might really significantly impact the entire cost of handling shed blooding episodes. Further information aggregation will account for these parametric quantities.
