Major Orthopedic Procedures in Patients with Inhibitor Treated with Emicizumab

Patients Observed

Between 2018 and 2019, four major surgeries were performed on three patients with high inhibitor titers – one above-knee amputation and a total knee replacement on the same patient, one hip replacement, and one partial knee joint prosthetic revision on other patients. All these patients were on prophylactic emicizumab before the surgery. All received recombinant factor VIIa (rFVIIa) at a dose of 90 μg/kg before surgery and subsequently every 4 hours. This regimen was continued for the first 48 hours, then every 6 hours for the next 2 days, every 8 hours on the 4th and 6th day, and subsequently with prolonged intervals up to 14 days post-surgery.

Results

All patients underwent surgery without complications, and no complications were observed during the follow-up period. Bleeding control was assessed as effective. Only for the amputation surgery were drains placed for 3 postoperative days. All patients were discharged from orthopedics after initiating early rehabilitation, with an average hospital stay of 12 days. They all reported improvement in their condition, pain relief, and improved joint function post-surgery.

Conclusion

This experience suggests that in patients with inhibitors treated with emicizumab, even with lower doses of rFVIIa than traditionally required in such cases, major surgeries can be successfully performed with effective hemostatic control and without significant complications, leading to an overall improvement in quality of life.

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Source: Carulli Ch., Linari S., Pieri L. et al. Major orthopaedic surgery in subjects with haemophilia A and inhibitors treated with emicizumab and rFVIIa: a preliminary report. Abstracts of the World Federation of Hemophilia, Virtual Summit – Connecting the Global Bleeding Disorders Community, June 2020. Haemophilia 2020 Jun 1; 26 (S4): MED-PP-025 (101).