Extracorporeal Immunoadsorption for the Treatment of Coagulation Inhibitors

Abstract

Extracorporeal immunoadsorption is a widely used technique for the removal of pathogenic antibodies in a variety of immunologic disorders. This procedure has been used in patients with high-titer inhibitors against coagulation factors for the temporary removal of antibodies before initiating replacement therapy to achieve hemostasis and stop acute bleeding or to cover a surgical procedure. Inhibitor removal by immunoadsorption has also been included at the onset of immune tolerance protocols in both acquired and congenital hemophilia. This article summarizes the current knowledge on the use of this technique in patients with inhibitors against coagulation factors. Overall, the published literature documents that extracorporeal immunoadsorption is a safe and useful technique for the elimination of coagulation inhibitors. However, further randomized clinical trials are needed to better assess the cost-effectiveness of such procedures.

Acquired hemophilia A: a review of recent data and new therapeutic options

“…In patients with a high titer of inhibitor and severe hemorrhages, the extracorporeal removal of the autoantibody by therapeutic plasmapheresis, or its immunoadsorption to staphylococcal protein A or to polyclonal sheep antibodies against human immunoglobulins, can be used for achieving a prompt, although transient, inhibitor removal and enabling treatment with FVIII concentrates [58][59][60].…”

Therapeutic plasma exchange as part of multimodal treatment of acquired hemophilia in a patient with concurrent acute intracerebral bleed and pulmonary embolism

“…His need for TPE was not due to failure of first‐line therapy (as the bleed size was unchanged) but rather due to the risk of worsened thrombotic burden by continued use of bypassing agents. Immunoadsorption would have been an ideal method to remove FVIII inhibitor in this case . However, due to the lack of availability of immunoadsorption technology in the United States, we utilized TPE to remove the inhibitor, although TPE unfortunately removes rVIIa concurrently with FVIII inhibitor—thereby adding still greater cost to an already extremely costly therapeutic regimen.…”

“…FVIII immunotolerance regimens have been described for AHA patients with high‐titer inhibitors with life‐threatening bleeding (Bonn‐Malmo protocol and its modifiers). These protocols involve a combination of inhibitor removal (immunoadsorption or, less ideally, therapeutic plasma exchange [TPE]), intravenous immune globulin, immunosuppression with cyclophosphamide and corticosteroids, and FVIII administration .…”

Unexpected hemorrhage: An unusual and potentially catastrophic clinical challenge

“…In the event that severe hemorrhage occurs in conjunction with high‐titer inhibitors, extracorporeal techniques such as plasmapheresis or immunoadsorption can be used to physically remove the FVIII inhibitor from the patient's plasma, especially if the patient responds poorly to treatment with either rFVIIa or pd‐aPCC (Franchini et al, ; Hay, Brown, Collins, Keeling, & Liesner, ; Huth‐Kühne et al, ). This approach can be used adjunctively with the administration of rFVIII to increase FVIII levels and curtail bleeding; however, this strategy requires specialized equipment and expertise found only at certain medical centers and hemophilia treatment centers.…”