SummaryThe revised UKHCDO factor (F) VIII/IX Inhibitor Guidelines (2000) are presented. A schema is proposed for inhibitor surveillance, which varies according to the severity of the haemophilia and the treatment type and regimen used. The methodological and pharmacokinetic approach to inhibitor surveillance in congenital haemophilia has been updated. Factor VIII/IX genotyping of patients is recommended to identify those at increased risk. All patients who develop an inhibitor should be considered for immune tolerance induction (ITI). The decision to attempt ITI for FIX inhibitors must be carefully weighed against the relatively high risk of reactions and the nephrotic syndrome and the relatively low response rate observed in this group. The start of ITI should be deferred until the inhibitor has declined below 10 Bethesda Units/ml, where possible. ITI should continue, even in resistant patients, where it is well tolerated and so long as there is a convincing downward trend in the inhibitor titre. The choice of treatment for bleeding in inhibitor patients is dictated by the severity of the bleed, the current inhibitor titre, the previous anamnestic response to FVIII/IX, the previous clinical response and the side-effect profile of the agents available. We have reviewed novel dose-regimens and modes of administration of FEIBA (factor VIII inhibitor bypassing activity) and recombinant activated FVII (rVIIa) and the extent to which these agents may be used for prophylaxis and surgery. Bleeding in acquired haemophilia is usually treated with FEIBA or rVIIa. Immunosuppressive therapy should be initiated at the time of diagnosis with Prednisolone 1 mg/kg/d ± cyclophosphamide. In the absence of a response to these agents within 6 weeks, second-line therapy with Rituximab, Ciclosporin A, or other multiple-modality regimens may be considered.Keywords: diagnosis, management, factor VIII/IX inhibitors.Since the publication of the previous guideline on the detection and management of factor (F) VIII inhibitors (Hay et al, 2000), significant diagnostic and therapeutic advances have taken place. The UK Haemophilia Doctors Organisation (UKHCDO) has therefore revised and updated those sections of the earlier guideline covering areas of clinical practice which we felt had developed, to define best current practice internationally. Although all sections of the previous guideline have been reviewed, some sections required little revision whereas others required rewriting. For those areas that did not require revision, the reader is referred back to the previous guideline. The evidence-based approach used highlights the need for future clinical trials in areas where current treatment strategies are based on uncontrolled observations or where there is a dichotomy of clinical opinion.
MethodsThe guidelines were drafted by the UKHCDO Inhibitor Working Party and circulated to the Executive Committee of the UKHCDO for consultation. Members of UKHCDO and its working parties make an annual declaration of interest to UKHCDO and to their Ho...
