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Protocol - Individual Pharmacokinetic Study Using One-stage Clotting Factor Assay - Standard Half-life Factor VIII Products

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Description:

This protocol provides instructions and guidance for collecting and processing samples for coagulation testing, performing an individual pharmacokinetic study using the one-stage clotting factor assay, and interpreting pharmacokinetic results in response to infusion of standard half-life Factor VIII products. Because there are many comparable assays for performing the one-stage clotting factor assay, the protocol also provides basic guidelines to aid comparability among different studies.

Specific Instructions:

The PhenX Hemophilia Inhibitor Research Working Group (WG) notes that these measures are intended for use in observational and interventional trials but are not sufficient to define hemophilia phenotypes when used in isolation.

The WG recommends that when measuring inhibitor recovery in non-severe patients, endogenous factor should be measured by the same assay that was optimized prior to inhibitor development.

The WG recommends that Factor VIII and IX assays, either by one-stage clotting factor or chromogenic substrate methodology, should be performed by a laboratory that is College American Pathologists (CAP) accredited or Clinical Laboratory Improvement Amendments of 1998 (CLIA) certified. For multi-center clinical trials, the use of a central laboratory is strongly encouraged.

The WG notes the one-stage clotting factor assay for determining Factor VIII activity in plasma can vary by reagent and instrument used and recommends that the investigator record the make and manufacturer of equipment, the repeatability and coefficients of variation for the assay, and the reagents used.

If a washout is not performed, comparison of pharmacokinetic data between studies should be conducted under steady-state conditions. Steady-state is defined as a patient-specific condition during which a pharmacokinetic assessment remains valid over a clinically useful period of time. Examples of non-steady state conditions include:

  • Bleeding state
  • Peri- and immediate post-surgical states in which patients are receiving continuous or regular high (non-routine prophylactic) doses of Factor VIII
  • Immune tolerance induction during which inhibiter titers are in flux
  • Children in whom age- and weight-based clearance is still developing toward adult physiologic states.
Protocol:

Standard Half-life Factor VIII Products: Individual Pharmacokinetic Study Using One-stage Clotting Factor Assay

Sample Collection

The PhenX Hemophilia Inhibitors Working Group (WG) recommends that investigators follow the sample collection procedures outlined in Lippi et al. (2012) to ensure quality specimens for coagulation testing. These recommendations include basic criteria for venipuncture (e.g., proper patient identification, use of correct techniques, appropriate devices and needles) as well as additional guidance for critical parameters which can affect the outcome of clot-based tests. These critical parameters include prevention of prolonged venous stasis, collection of nonhemolyzed samples, order of blood draw, and appropriate filling and mixing of collection tubes.

Additionally, the WG highlights that blood should be collected by direct venipuncture into 3.2% sodium citrate tubes and filled within 11% of fill line. A second tube should be collected. A discard tube should be drawn if using a winged butterfly collection system.

Sample Processing

The WG recommends that investigators follow the sample collection procedures outlined in Adcock Funk et al. (2012). The procedures include that:

  • unprocessed or processed sodium citrate samples remain capped and at room temperature until testing,
  • samples should not be refrigerated or stored on ice or in an ice bath,
  • samples should be transported vertically, and
  • processed samples should not be agitated during transportation to avoid remixing of components.

Additionally, samples can be transported and stored as:

  • unprocessed sodium citrate whole blood samples,
  • whole blood samples centrifuged and maintained in sodium citrate tubes, or
  • plasma processed by centrifugation and aliquoted into a second tube.

Ideally, whole blood samples should be processed to platelet poor plasma (PPP) within 1 hour of collection and assayed within 4 hours of collection.

If centrifuging samples, the centrifuge should be validated so that post-centrifuged samples contain less than 10,000 platelets/microliter. Centrifuged samples should be frozen immediately and can be stored at -20o C for 2 weeks. Samples should be transferred to < -70o C for longer storage, including shipment.

Standard Half-life Factor VIII Products: One-stage Clotting Factor Assay

The WG notes that there are a number of different assays and instruments that are appropriate to perform the one-stage clotting factor assay. Once an assay is chosen for a particular study, the WG recommends that no changes in the protocol be made over the course of the study. Because results can vary with the instrumentation and reagents, the WG recommends that the investigator record the make and manufacturer of equipment, the repeatability and coefficients of variation for the assay, and the reagents used.

Standard Half-life Factor VIII Products: Individual Pharmacokinetic Study

The Hemophilia Inhibitors WG recommends that pharmacokinetic evaluations using the one-stage clotting factor assay be performed according to the parameters outlined by Subcommittee on Factor VIII and Factor VIII of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis (Lee et al., 2001). This includes infusing a 50 unit/kg dose of Factor VIII concentrate after a treatment-free washout period lasting longer than five half-lives. Factor VIII activity is then tested at 10 timepoints:

  • before infusion (baseline);
  • 10-15 minutes after infusion;
  • 30 minutes after infusion;
  • 1 hour after infusion;
  • 3 hours after infusion;
  • 6 hours after infusion;
  • 9 hours after infusion;
  • 24 hours after infusion;
  • 28 hours after infusion; and
  • 32 hours after infusion.

A sample taken at 48 hours after infusion is optional.

Standard Half-life Factor VIII Products: Interpretation of Individual Pharmacokinetic Study Results

A Factor VIII half-life (t) less than 6 hours is considered abnormal and evidence of an inhibitor.

Protocol Name from Source:

N/A; see source.

Availability:

Publicly available

Personnel and Training Required

Phlebotomist

Equipment Needs
Laboratory with the ability to perform the one-stage clotting factor assay.
Requirements
Requirement CategoryRequired
Major equipment No
Specialized training No
Specialized requirements for biospecimen collection Yes
Average time of greater than 15 minutes in an unaffected individual Yes
Mode of Administration

Bioassay

Life Stage:

Toddler, Child, Adolescent, Adult

Participants:

Any age

Selection Rationale

The PhenX Hemophilia Inhibitors Working Group selected the recommendations from Lippi et al. (2012) and Adcock Funk et al. (2012) as the best standardized methodology for collecting and processing samples for coagulation testing. The International Society on Thrombosis and Haemostasis (Lee et al., 2001) provides standard timepoints for consistent implementation of a pharmacokinetic study.

Language

English

Standards
StandardNameIDSource
Common Data Elements (CDE) Population Pharmacokinetic Study Coagulation Factor IX Standard Half Life One-stage Clotting Factor Assay Ê 6706641 CDE Browser
Derived Variables

The results of this protocol can be combined with the results of Determination of Factor VIII Inhibitors: Bethesda Assay with Nijmegen Modification Using Chromogenic Substrate Assay or Determination of Factor VIII Inhibitors: Bethesda Assay with Nijmegen Modification Using One-Stage Clotting Factor Assay to document:

Presence of an Inhibitor

The presence of an inhibitor is indicated by one or more of the following:

  • lack of clinical response (cessation of bleeding) to factor infusion for treatment of bleeding,
  • less than expected (< 66%) recovery of Factor VIII level immediately after infusion (Response to Factor VIII Infusion- Individual Pharmacokinetic Study), and
  • positive inhibitor titer (Quantitative Measure of Factor VIII Inhibitor Activity)
  • Reduced Factor VIII half-life below 6 hours.

Evolution of an Inhibitor

Inhibitor evolution is indicated by:

  • change in inhibitor titer over time (Quantitative Measure of Factor VIII Inhibitor Activity), with or without immune tolerance induction;
  • change in clinical response (i.e., bleeding) to Factor VIII infusion;
  • change in Factor VIII activity after factor infusion (Response to Factor VIII Infusion - Individual Pharmacokinetic Study); and
  • change in Factor VIII half-life.

Resolution of an Inhibitor

Inhibitor resolution is indicated by the following:

  • for patients receiving immune tolerance therapy for eradication of an Factor VIII inhibitor, success is defined as a negative inhibitor titer (Quantitative Measure of Factor VIII Inhibitor Activity) and a normal recovery (>= 66% of expected) and half-life >= 6 hours of infused Factor VIII concentrate (Response to Factor VIII Infusion - Individual Pharmacokinetic Study).

Persistence of an Inhibitor

A persistent inhibitor is indicated by a decreased response to Factor VIII concentrate infusion (Response to Factor VIII Infusion - Individual Pharmacokinetic Study) measured by recovery and/or half-life with or without a persistently positive inhibitor titer (Quantitative Measure of Factor VIII Inhibitor Activity).

Blanchette, V. S., Key, N. S., Ljung, L. R., Manco-Johnson, M. J., van den Berg, H. M., & Srivastava, A.; Subcommittee on Factor VIII, Factor IX and Rare Coagulation Disorders of the Scientific and Standardization Committee of the International Society on Thrombosis and Hemostasis. (2014). Definitions in hemophilia: Communication from the SSC of the ISTH. Journal of Thrombosis and Haemostasis, 12(11), 1935-1939.

Process and Review

Not applicable.

Source

Adcock Funk, D. M., Lippi, G., & Favaloro, E. J. (2012). Quality standards for sample processing, transportation, and storage in hemostasis testing. Seminars in Thrombosis and Hemostasis, 38(6), 576-585.

Lee, M., Morfini, M., Schulman, S., & Ingerslev, J.; Factor VIII/Factor VIII Scientific and Standardization Committee of the International Society for Thrombosis and Haemostasis (2001). Scientific and Standardization Committee communication. The design and analysis of pharmacokinetic studies of coagulation factors. https://www.isth.org/members/group_content_view.asp?group=100348&id=159244. Retrieved August 30, 2018.

Lippi, G., Salvagno, G. L., Montagnana, M., Lima-Oliveira, G., Guidi, G. C., & Favaloro, E. J. (2012). Quality standards for sample collection in coagulation testing. Seminars in Thrombosis and Hemostasis, 38(6), 565-575.

General References

Blanchette, V. S., Key, N. S., Ljung, L. R., Manco-Johnson, M. J., van den Berg, H. M., & Srivastava, A.; Subcommittee on Factor VIII, Factor VIII and Rare Coagulation Disorders of the Scientific and Standardization Committee of the International Society on Thrombosis and Hemostasis. (2014). Definitions in hemophilia: Communication from the SSC of the ISTH. Journal of Thrombosis and Haemostasis, 12(11), 1935-1939.

Hay, C. R., & DiMichele, D. M.; International Immune Tolerance Study. (2012). The principal results of the International Immune Tolerance Study: A randomized dose comparison. Blood, 119(6), 1335-1344.

Iorio, A., Edginton, A.N., Blanchette, V., Blatny, J., Boban, A., Cnossen, M., Collins, P., Croteau, S.E., Fischer, K., Hart, D.P., Ito, S., Korth-Bradley, J., Lethagen, S., Lillicrap, D., Makris, M., Matht, R., Morfini, M., Neufeld, E.J., Spears, J. (2018). Performing and interpreting individual pharmacokinetic profiles in patients with Hemophilia A or B: Rationale and general considerations. Research and Practice in Thrombosis and Haemostasis, 2(3), 535-548.

Kitchen, S., Kershaw, G., & Tiefenbacher, S. (2016). Recombinant to modified Factor VIII and Factor VIII Chromogenic and one-stage assays issues. Haemophilia, 22(Suppl. 5), 72-77.

Morfini, M., Lee, M., Messori, A. and the Factor VIII/Factor IX Scientific and Standardization Committee of the International Society for Thrombosis and Haemostasis. (1991). The design and analysis of half-life and recovery studies for Factor VIII and factor IX. Thrombosis and Haemostasis, 66(3), 384-386.

Peyvandi, F., Oldenburg, J., & Friedman, K. D. (2006). A critical appraisal of one-stage and chromogenic assays of Factor VIII activity. Journal of Thrombosis and Haemostasis, 14(2), 248-261.

Protocol ID:

911101

Variables:
Export Variables
Variable NameVariable IDVariable DescriptionVersiondbGaP Mapping
PX911101_Factor_Eight_Individual_Clotting_Standard_One_Stage_Clotting_Factor_Assay_Changes PX911101030100 Were any changes made in the protocol over more
the course of the study? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_One_Stage_Clotting_Factor_Assay_Record PX911101030200 Were the make and manufacturer of equipment, more
repeatability and coefficients of variation for the assay, and the reagents used recorded? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Pharmacokinetic_Interpretation PX911101050100 Was the Factor VIII half-life (t) less than more
6 hours? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Pharmacokinetic_Study PX911101040100 Were the parameters outlined by the more
Subcommittee on Factor VIII and Factor VIII of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis (Lee et al., 2001) followed? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Pharmacokinetic_Study_After_Infusion PX911101040400 Was Factor VIII activity tested 10-15 more
minutes after infusion? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Pharmacokinetic_Study_After_Infusion_Hours_1 PX911101040600 Was Factor VIII activity tested 1 hour after more
infusion? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Pharmacokinetic_Study_After_Infusion_Hours_24 PX911101041000 Was Factor VIII activity tested 24 hours more
after infusion? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Pharmacokinetic_Study_After_Infusion_Hours_28 PX911101041100 Was Factor VIII activity tested 28 hours more
after infusion? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Pharmacokinetic_Study_After_Infusion_Hours_3 PX911101040700 Was Factor VIII activity tested 3 hours more
after infusion? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Pharmacokinetic_Study_After_Infusion_Hours_32 PX911101041200 Was Factor VIII activity tested 32 hours more
after infusion? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Pharmacokinetic_Study_After_Infusion_Hours_48 PX911101041300 Was Factor VIII activity tested 48 hours more
after infusion? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Pharmacokinetic_Study_After_Infusion_Hours_6 PX911101040800 Was Factor VIII activity tested 6 hours more
after infusion? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Pharmacokinetic_Study_After_Infusion_Hours_9 PX911101040900 Was Factor VIII activity tested 9 hours more
after infusion? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Pharmacokinetic_Study_After_Infusion_Minutes_30 PX911101040500 Was Factor VIII activity tested 30 minutes more
after infusion? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Pharmacokinetic_Study_Dose PX911101040200 Was the patient infused with a 50 unit/kg more
dose of Factor VIII concentrate after a treatment-free washout period lasting longer than five half-lives? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Pharmacokinetic_Study_Infusion_Baseline PX911101040300 Was Factor VIII activity tested before more
infusion (baseline)? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Collection PX911101010100 Were the sample collection procedures more
outlined in Lippi et al. (2012) followed? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Collection_Blood_Draw PX911101010400 Was the order of blood draw recorded? N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Collection_Nonhemolyzed PX911101010300 Were nonhemolyzed samples collected? N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Collection_Tubes PX911101010500 Were collection tubes filled and mixed? N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Collection_Tubes_Discard PX911101011000 Was a discard tube drawn? N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Collection_Tubes_Filled PX911101010700 Were the tubes filled within 11% of the fill line? N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Collection_Tubes_Second PX911101010800 Was a second tube collected? N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Collection_Tubes_Winged PX911101010900 Was a winged butterfly collection system used? N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Collection_Venipuncture PX911101010600 Was blood collected by direct venipuncture more
into 3.2% sodium citrate tubes? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Collection_Venous_Statsis PX911101010200 Were steps taken to prevent prolonged venous more
stasis? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Processing PX911101020100 Were the sample collection and processing more
procedures outlined in Adcock Funk et al. (2012) followed? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Processing_Agitation PX911101020500 Were samples agitated during transportation? N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Processing_Assayed PX911101021000 Were samples assayed within 4 hours of collection? N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Processing_Centrifuge_Validated PX911101021100 Was the centrifuge validated so that process more
results in less than 10,000 platelets/microliter show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Processing_Deep_Freeze PX911101021300 Was the sample transferred to <= -70 C, more
including shipment? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Processing_Frozen PX911101021200 Was the sample frozen immediately and stored more
at -20 C for at most 2 weeks? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Processing_Platelet_Poor_Plasma PX911101020900 Were samples processed to platelet poor more
plasma (PPP) within 1 hour of collection? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Processing_Refrigerated PX911101020300 Were samples refrigerated or stored on ice more
or in an ice bath? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Processing_Sodium_Citrate PX911101020200 Did unprocessed or processed sodium citrate more
samples remain capped and at room temperature until testing? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Processing_Storage_Plasma PX911101020800 Were samples stored as plasma processed by more
centrifugation and aliquoting into a second tube? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Processing_Storage_Unprocessed PX911101020600 Were samples stored as unprocessed sodium more
citrate whole blood samples? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Processing_Storage_Whole_Blood PX911101020700 Were samples stored as whole blood samples more
centrifuged and maintained in sodium citrate tubes? show less
N/A
PX911101_Factor_Eight_Individual_Clotting_Standard_Sample_Processing_Transportation PX911101020400 Were samples transported vertically? N/A
Hemophilia Inhibitor Research
Measure Name:

Response to Factor VIII Infusion - Individual Pharmacokinetic Study

Release Date:

May 7, 2019

Definition

A series of plasma Factor VIII activity determinations in blood samples are obtained immediately prior to, and at timepoints after, infusion of Factor VIII concentrate.

Purpose

The results of an individual pharmacokinetic study (i.e., initial recovery and half-life) of infused Factor VIII concentrate can characterize an individual’s response to a new drug or can confirm the success of immune tolerance induction (ITI).

Keywords

Hemophilia inhibitors, Factor VIII, FVIII, hemophilia A, inhibitors, pharmacokinetic study, immune tolerance induction, prophylaxis, half-life, recovery