title: Immune tolerance induction in patients with severe hemophilia with inhibitors: expert panel views and recommendations for clinical practice.
abstract: For hemophilia patients with inhibitors, immune tolerance induction (ITI) may help to restore clinical response to factor (F) VIII or FIX concentrates. Several ITI regimens and protocols exist; however, despite 30 yr of progressive investigation, the ITI evidence base relies mainly on observational data. Expert opinion, experience, and interpretation of the available evidence are therefore valuable to support clinical decision-making. At the Sixth Zürich Haemophilia Forum, an expert panel considered recent data and consensus to distill key practice points relating to ITI. The panel supported current recommendations that, where feasible, ITI should be offered early to children and adults (ideally ≤ 5 yr of inhibitor detection) when inhibitor titers are <10 Bethesda units (BU) and should be stopped when successful tolerance is achieved. For hemophilia A inhibitor patients, ITI can be founded on recombinant FVIII at high doses. The panel considered that patients with a high bleeding frequency should be offered additional prophylaxis with a bypassing agent. For patients with hemophilia B, there may be a benefit of genetic testing to indicate the risk for inhibitors. ITI is often less effective and associated with a greater risk of side effects in these patients. For high-titer inhibitor (≥ 5 BU) hemophilia B patients, the panel advised that bypassing agents could be offered on demand in addition to ITI. Within future ITI regimens, there may be a role for additional immunosuppressant therapies. Participants agreed that research is needed to find alternatives to ITI therapy that offer durable and sustained effects and reduced rates of complications.
authors.affiliation: Northern Ireland Haemophilia Comprehensive Care Centre, Belfast City Hospital, Belfast, UK. gary.benson@belfasttrust.hscni.net
authors.forename: Gary
authors.initials: G
authors.lastname: Benson
authors.forename: Günter
authors.initials: G
authors.lastname: Auerswald
authors.forename: Ivo
authors.initials: I
authors.lastname: Elezović
authors.forename: Thierry
authors.initials: T
authors.lastname: Lambert
authors.forename: Rolf
authors.initials: R
authors.lastname: Ljung
authors.forename: Massimo
authors.initials: M
authors.lastname: Morfini
authors.forename: Eduardo
authors.initials: E
authors.lastname: Remor
authors.forename: Silva Zupančić
authors.initials: SZ
authors.lastname: Salek
mesh_terms: D005169:Factor VIII / Q000627:therapeutic use*; D006467:Hemophilia A / Q000188:drug therapy* / Q000276:immunology; D006801:Humans; D007108:Immune Tolerance
chemical_list: D005169:Factor VIII