321.

BLOOD COAGULATION AND FIBRINOLYTIC FACTORS | NOVEMBER 13, 2019

Thrombin Generation Assay in Plasma from

Hemophilia a Patients with or without Inhibitors on
Concizumab Prophylaxis: Spiking with rFVIIa or aPCC
*,1 *,2 *,3 *,4
Marianne Kjalke, PhD, Mads Kjelgaard-Hansen, Søren Andersen, Ida Hilden
1
Novo Nordisk A/S, Maaloev, Denmark
2
Novo Nordisk A/S, Maeloev, Denmark
3
Global Development, Novo Nordisk A/S, Søborg, Denmark
4
Novo Nordisk, Maaloev, Denmark

bloodjournal Blood blood (2019) 134 (Supplement_1) : 3639.

http://doi.org/10.1182/blood-2019-122301

Introduction: Concizumab is a humanized monoclonal antibody that inhibits tissue factor pathway
inhibitor (TFPI). Concizumab is currently in clinical development as a subcutaneous prophylactic therapy
for hemophilia A and B patients with and without inhibitors. Breakthrough bleeding episodes experienced
by inhibitor patients while on concizumab prophylaxis may be treated with the bypassing agents
®
recombinant activated factor VII (rFVIIa; NovoSeven ) or activated prothrombin complex concentrate
®
(aPCC; FEIBA ).

Aim: To investigate the in vitro effect of rFVIIa and aPCC on hemophilia A plasma containing concizumab
using a thrombin generation assay and pooled plasma spiked with concizumab or samples from patients
treated prophylactically with concizumab.

Methods: Pooled hemophilia A plasma was spiked with concizumab at 1, 3 and 10 nM and patient
plasma samples from explorer4 (n=16; hemophilia with inhibitors; NCT03196284) and explorer5 (n=30;
hemophilia A; NCT03196297) before and during concizumab prophylaxis at steady state exposure levels
were assessed. Samples were spiked with rFVIIa (25 or 75 nM) or aPCC (0.25, 0.5 or 1 U/mL), and
analyzed using a thrombin generation assay initiated with tissue factor (PPP-Low, Thrombinoscope).
The effects of rFVIIa or aPCC in the absence or presence of concizumab were compared using ANOVA
methodology.
Results: Addition of rFVIIa or aPCC to hemophilia A plasma with or without inhibitors increased peak
thrombin generation both in the absence and presence of concizumab. A significant additional effect of
rFVIIa and aPCC was observed for all concizumab concentrations spiked to the plasma pool. Overall, the
effects of the combination of concizumab and rFVIIa or aPCC were mainly additive; however, a small but
statistically significant drug-drug interaction was observed for rFVIIa (25 nM or 75 nM) and aPCC (0.5 U/
ml or 1 U/mL) in the presence of 10 nM concizumab. At this concizumab concentration, the additive effect
of aPCC corresponded to 68% of the total observed effect and the additive effect of rFVIIa to 85% of the
total observed effect. At lower concizumab concentrations (1 and 3 nM), statistically significant drug-drug
effects were only observed in combination with aPCC. No excessive thrombin generation above the level
obtained with 1 IU/mL recombinant factor VIII (rFVIII) was observed at 1 nM concizumab combined with
either rFVIIa (25 and 75 nM) or aPCC 0.5 U/mL. However, addition of 1 U/mL aPCC to 1 nM concizumab
resulted in a thrombin peak modestly above the upper 95% confidence interval of the rFVIII range.

In the experiments using plasma from patients treated with concizumab, the increase in thrombin peak
upon addition of rFVIIa was within or below the range observed by spiking with 1 IU/mL rFVIII. The
increase in thrombin peak upon addition of aPCC was within or above the rFVIII range. The effects
of concizumab and rFVIIa or aPCC were mainly additive; however, a small, statistically significant
contribution caused by drug-drug interaction was observed for concizumab and rFVIIa (75 nM) in
both plasma from patients with and without inhibitors, and for 1 U/mL aPCC in plasma from patients
with inhibitors. The additive effects of concizumab and rFVIIa corresponded to between 60% (25 nM
rFVIIa, plasma without inhibitors) and 75% (75 nM rFVIIa, inhibitor plasma), and the additive effects of
concizumab and 1 U/mL aPCC corresponded to 77% of the total observed effects.

Conclusions: Addition of rFVIIa or aPCC to hemophilia A plasma with or without inhibitors increased
peak thrombin generation as expected both in the absence and presence of concizumab. Thus, the
bypassing agents function as expected in plasma containing concizumab. The effects of concizumab and
rFVIIa or aPCC were mainly additive. A small but statistically significant contribution was synergistic in
accordance with the concizumab mechanism of action (Hilden I et al, Blood, 2012). These in vitro results
support the concomitant use of bypassing agents to treat breakthrough bleeding episodes in hemophilia
with inhibitor patients on concizumab prophylactic treatment.

Disclosures
Kjalke: Novo Nordisk A/S: Employment, Honoraria. Kjelgaard-Hansen: Novo Nordisk A/S: Employment,
Equity Ownership. Andersen: Novo Nordisk A/S: Employment, Equity Ownership, Honoraria. Hilden:
Novo Nordisk A/S: Employment, Equity Ownership, Patents & Royalties.
Author notes
*Asterisk with author names denotes non-ASH members.

© 2019 by the American Society of Hematology