Protocol - Individual Pharmacokinetic Study Using Chromogenic Substrate Assay - Extended Half-life Factor VIII Products

Description

This protocol provides instructions and guidance for collecting and processing samples for coagulation testing, performing an individual pharmacokinetic study using the chromogenic substrate assay, and interpreting pharmacokinetic results in response to infusion of extended half-life Factor VIII products. Because there are many comparable assays for performing the chromogenic 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 that in comparison to the one-stage clotting factor assay, the chromogenic substrate assay demonstrates less variation by reagents, thus enabling cross-laboratory comparisons.

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 FVIII
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.

Availability

Available

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Protocol

Individual Pharmacokinetic Study Using Chromogenic Substrate Assay - Extended Half-life Factor VIII Products

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 and processed plasma can be stored at -20^o C for 2 weeks and should be transferred to < -70^o C for longer storage, including shipment.

Extended Half-life Factor VIII Products: Chromogenic Substrate Assay

The WG notes that there are a number of different assays and instruments that are appropriate to perform the chromogenic substrate 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.

Extended Half-life Factor VIII Products: Individual Pharmacokinetic Study

Prior to pharmacokinetic evaluations, participants should undergo a treatment-free washout period lasting longer than five half-lives. Samples should be taken before infusion (baseline), 10-15 minutes after infusion, and then up to eight other time points that cover 2.5 half-lives of the extended half-life Factor VIII products. The WG notes that the list of timepoints necessary for the pharmacokinetic study to cover 2.5 half-lives will depend on the specific extended half-life Factor VIII product being used and can be identified in relevant pre-licensure studies. Investigators should report which timepoints were used.

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

The half-life of extended half-life Factor VIII products is highly variable and the level at which an inhibitor is suggested has not been established.

Personnel and Training Required

Phlebotomist

Equipment Needs

Laboratory with the ability to perform the chromogenic substrate assay.

Requirements

Requirement Category	Required
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

Lifestage

Toddler, Child, Adolescent, Adult

Participants

Any age

Selection Rationale

The 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.

Language

English

Standards

Standard	Name	ID	Source

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:

The presence of an inhibitor is indicated by the following:

lack of response (cessation of bleeding) to factor infusion for treatment of bleeding in a clinical setting
less than expected (< 66%) of Factor VIII levels after infusion (Response to Factor VIII Infusion - Individual Pharmacokinetic Study) and positive inhibitor titer (Quantitative Measure of Factor VIII Inhibitor Activity) in routine surveillance.

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 FVIII infusion, and
change in FVIII activity after factor infusion (Response to Factor VIII Infusion - Individual Pharmacokinetic Study).

Resolution of an Inhibitor

Inhibitor resolution is indicated by the following:

for patients receiving immune tolerance therapy for eradication of an FVIII 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 FVIII concentrate (Response to Factor VIII Infusion - Individual Pharmacokinetic Study).

Persistence of an Inhibitor

A persistent inhibitor is indicated by a decrease response to FVIII concentrate infusion (Response to Factor VIII Infusion - Individual Pharmacokinetic Study) 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.

Protocol Name from Source

Adcock Funk et al. Quality standards for sample processing, transportation, and storage in hemostasis testing. Semin Thromb Hemost, 2012

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.

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.

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.

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.

Teichman, J., Chaudhry, H. R., & Sholzberg, M. (2018). Novel assays in the coagulation laboratory: A clinical and laboratory perspective. Transfusion and Apheresis Science, 57(4), 480-484.

Protocol ID

911104

Variables

Export Variables

Variable Name	Variable ID	Variable Description	dbGaP Mapping
PX911104_Factor_Eight_Individual_Chromogenic_Extended_One_Stage_Clotting_Factor_Assay_Changes
	PX911104030100	Were any changes made in the protocol over more the course of the study? show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_One_Stage_Clotting_Factor_Assay_Record
	PX911104030200	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
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Collection
	PX911104010100	Were the sample collection procedures more outlined in Lippi et al. (2012) followed? show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Collection_Blood_Draw
	PX911104010400	Was the order of blood draw recorded?	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Collection_Nonhemolyzed
	PX911104010300	Were nonhemolyzed samples collected?	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Collection_Tubes
	PX911104010500	Were collection tubes filled and mixed as more outlined in Lippi et al. (2012)? show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Collection_Tubes_Discard
	PX911104011000	Was a discard tube drawn?	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Collection_Tubes_Filled
	PX911104010700	Were the tubes filled within 11% of the fill line?	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Collection_Tubes_Second
	PX911104010800	Was a second tube collected?	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Collection_Tubes_Winged
	PX911104010900	Was a winged butterfly collection system used?	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Collection_Venipuncture
	PX911104010600	Was blood collected by direct venipuncture more into 3.2% sodium citrate tubes? show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Collection_Venous_Statsis
	PX911104010200	Were steps taken to prevent prolonged venous more stasis? show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Processing
	PX911104020100	Were the sample collection and processing more procedures outlined in Adcock Funk et al. (2012) followed? show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Processing_Agitation
	PX911104020500	Were samples agitated during transportation?	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Processing_Assayed
	PX911104021000	Were samples assayed within 4 hours of collection?	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Processing_Centrifuge_Validated
	PX911104021100	Was the centrifuge validated so that process more results in less than 10,000 platelets/microliter show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Processing_Deep_Freeze
	PX911104021300	Was the sample transferred to <= -70 C, more including shipment? show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Processing_Frozen
	PX911104021200	Was the sample frozen immediately and stored more at -20 C for at most 2 weeks? show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Processing_Platelet_Poor_Plasma
	PX911104020900	Were samples processed to platelet poor more plasma (PPP) within 1 hour of collection? show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Processing_Refrigerated
	PX911104020300	Were samples refrigerated or stored on ice more or in an ice bath? show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Processing_Sodium_Citrate
	PX911104020200	Did unprocessed or processed sodium citrate more samples remain capped and at room temperature until testing? show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Processing_Storage_Plasma
	PX911104020800	Were samples stored as plasma processed by more centrifugation and aliquoting into a second tube? show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Processing_Storage_Unprocessed
	PX911104020600	Were samples stored as unprocessed sodium more citrate whole blood samples? show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Processing_Storage_Whole_Blood
	PX911104020700	Were samples stored as whole blood samples more centrifuged and maintained in sodium citrate tubes? show less	N/A
PX911104_Factor_Eight_Individual_Chromogenic_Extended_Sample_Processing_Transportation
	PX911104020400	Were samples transported vertically?	N/A
PX911104_Factor_Eight_Individual_Clotting_Extended_Pharmacokinetic_Interpretation
	PX911104050100	During interpretations of the results, was more it taken into account that the half-life of extended half-life Factr VIII products is highly variable and the level at which an inhibitor is suggested has not be established? show less	N/A
PX911104_Factor_Eight_Individual_Clotting_Extended_Pharmacokinetic_Study_After_Infusion_Minutes_10
	PX911104040300	Was a sample collected 10-15 minutes after more infusion? show less	N/A
PX911104_Factor_Eight_Individual_Clotting_Extended_Pharmacokinetic_Study_Infusion_Baseline
	PX911104040200	Was a sample collected before infusion (baseline)?	N/A
PX911104_Factor_Eight_Individual_Clotting_Extended_Pharmacokinetic_Study_Timepoints
	PX911104040500	Was it taken into account that the more timepoints necessary for the pharmacokinetic study to cover 2.5 half-lives depend on the specific extended half-life Factor VIII product being used? show less	N/A
PX911104_Factor_Eight_Individual_Clotting_Extended_Pharmacokinetic_Study_Timepoints_Eight
	PX911104040400	Were samples collected at up to eight other more time points that cover 2.5 half-lives of the extended half-life Factor VIII products? show less	N/A
PX911104_Factor_Eight_Individual_Clotting_Extended_Pharmacokinetic_Study_Timepoints_Recorded
	PX911104040600	Were sample collection timepoints recorded?	N/A
PX911104_Factor_Eight_Individual_Clotting_Extended_Pharmacokinetic_Study_Washout
	PX911104040100	Did the patient undergo a treatment-free more washout period lasting longer than file half-lives? show less	N/A

Hemophilia Inhibitor

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

Measure Protocols

Protocol ID	Protocol Name
911101	Individual Pharmacokinetic Study Using One-stage Clotting Factor Assay - Standard Half-life Factor VIII Products
911102	Individual Pharmacokinetic Study Using One-stage Clotting Factor Assay - Extended Half-life Factor VIII Products
911103	Individual Pharmacokinetic Study Using Chromogenic Substrate Assay - Standard Half-life Factor VIII Products
911104	Individual Pharmacokinetic Study Using Chromogenic Substrate Assay - Extended Half-life Factor VIII Products

Publications

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