Haemophilia (2013), 19 (Suppl. 1), 8–11
12050
REVIEW ARTICLE
More than a decade of international experience with
a pdFVIII/VWF concentrate in immune tolerance
E. SANTAGOSTINO
Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda Foundation, Ospedale Maggiore Policlinico,
Milan, Italy
Summary. Approximately 20–30% of patients with
severe haemophilia A develop alloantibodies (‘inhibitors’)
to infused FVIII rendering use of such replacement
therapy ineffective. Once an inhibitor emerges, immune
tolerance induction (ITI) is the standard treatment. ITI
involves giving regular doses of FVIII concentrate to
eradicate the inhibitor and achieve immunogenic
acceptance of administered FVIII. In the early 2000s, a
retrospective analysis of inhibitor patients treated at a
single centre in Germany indicated that success rates
were higher when patients were treated with von
Willebrand factor (VWF)-containing plasma-derived
FVIII (pdFVIII/VWF) concentrate compared with
recombinant or non-VWF-containing pdFVIII products.
Importantly, pdFVIII/VWF as rescue therapy was able
to convert 8 of 10 patients who had failed primary ITI
with recombinant or non-VWF-containing pdFVIII
product. A subsequent study from Italy in patients with
poor prognostic factors for ITI success also reported
good success rates with pdFVIII/VWF as rescue therapy
(53% success; 41% partial success).
The Grifols-Immune Tolerance Induction (G-ITI)
Study represents the largest group of haemophilia A
Introduction
Haemophilia A is a rare congenital bleeding disorder
characterized by mutations in the factor VIII (FVIII)
gene. FVIII concentrates are the mainstay of manage-
ment for both prevention and treatment of bleeding
episodes, but about 20–30% of patients with severe
disease develop alloantibodies (‘inhibitors’) to infused
FVIII rendering use of such replacement therapy
ineffective. Once an inhibitor emerges, immune toler-
Correspondence: Elena Santagostino, Angelo Bianchi Bonomi
Hemophilia and Thrombosis Center, IRCCS Cà Granda Founda-
tion, Ospedale Maggiore Policlinico, Milan, Italy.
Tel.: +34 (0)25 503 5273; fax: +34 (0)25 503 2072;
e-mail: elena.santagostino@policlinico.mi.it
Accepted after revision 31 October 2012
8 © 2012 Blackwell Publishing Ltd
DOI: 10.1111/hae.
inhibitor patients treated with a single pdFVIII/VWF
concentrate (Alphanate®/Fanhdi®) to be reported to
date. Data have been collected for 95 patients who
underwent primary or rescue ITI at 46 centres in
Europe and the US. Currently, published data are
available for 33 patients in the US cohort (11 centres),
and data from the European cohort are being
analysed. Both groups contained patients with poor
prognostic factors and most patients received a high-
dose regimen (  100 IU pdFVIII/VWF kg 1 daily). As
expected, the success rate was better for primary vs.
rescue ITI and for patients with good vs. poor
prognostic factors. However, more than half the
patients in the US cohort receiving rescue ITI achieved
success (33% complete success; 20% partial success).
These results should encourage clinicians to consider
the use of pdFVIII/VWF concentrates for rescue
ITI. Published outcomes data from the total global
G-ITI cohort (95 patients) are awaited with
anticipation.
Keywords: haemophilia, immune tolerance induction,
inhibitors, von Willebrand factor
ance induction (ITI) is the standard treatment. ITI
involves giving regular doses of FVIII concentrate in
an attempt to eradicate the inhibitor and achieve
immunogenic acceptance of administered FVIII. While
this may sound simple in theory, in practice ITI ther-
apy is far from straightforward.
The International ITI Study [1] terminated a couple
of years ago, yet a number of issues concerning this
therapeutic strategy remain unresolved. For example,
standardized ITI protocols are still lacking. In their
absence, clinicians remain obliged to rely on personal
experience when selecting the best regimen for indi-
vidual patients. At present, we are far from defining
optimal regimens and even further still from individu-
alizing such regimens for haemophilic patients. Based
on the published literature, success rates for ITI vary
from approximately 60 to 80% depending on the
 PDFVIII/VWF IN IMMUNE TOLERANCE INDUCTION 9

protocol used, and the time to immune toleriza- Table 2. German experience, from 1979 to 2000, with immune tolerance
tion ranges from just over a 1 month to more than induction (ITI) in patients with haemophilia A [5].

2 years. Why is there such variation in outcomes? Can 1979–1993 1993–2000

any methods be identified to predict treatment FVIII/VWF
success? Type of FVIII Isolated Switched after
Several variables are believed to influence the out- concentrate FVIII/VWF FVIII FVIII/VWF ITI failure

come of ITI therapy (Table 1). Among these is a type
of concentrate which is the focus of this review. FVIII
products can be split into two main categories: recom-
binant FVIII (rFVIII) products; and plasma-derived
FVIII (pdFVIII) products which may or may not con-
tain von Willebrand factor (VWF). VWF is a large gly-
coprotein that binds to FVIII and transports it to sites
where it participates in the formation of fibrin clots
[2]. VWF is thought to have a protective role when
administered with FVIII. Some possible mechanisms
for this protection include blocking the binding of
inhibitors to FVIII by masking certain FVIII epitopes
(i.e. C2-domain) [3] and/or prolonging FVIII exposure
to the immune system by shielding it from degradation
[2]. An alternative theory is that components of low/
intermediate purity pdFVIII concentrates other than
VWF – such as immunomodulating proteins (e.g. cyto-
kines) – are responsible for conferring advantages. A
much debated issue in haemophilia care thus concerns
whether VWF-containing pdFVIII concentrates
(pdFVIII/VWF) should be used in preference to recom-
binant or non-VWF-containing plasma-derived prod-
ucts for ITI therapy.
Clinical use of pdFVIII/VWF in ITI therapy
Evidence for the potential benefits of pdFVIII/VWF over
non-VWF-containing FVIII products first came to light
through retrospective analyses of inhibitor patients
treated at two German centres (Frankfurt and Bremen;
Table 2) [4,5]. During the 14 year period from 1979 to
1993, 21 paediatric patients were evaluated, of whom
16 were high responders [inhibitor titres  5 Bethesda
units (BU)] and five were low responders (inhibitor
titres <5 BU) [4]. Fourteen of 16 (88%) patients with
high-responding inhibitors receiving ITI according to
the Bonn protocol (high doses of pdFVIII/VWF concen-
trate administered twice daily) achieved success. Over-
all, the median time to ITI success was relatively short
in these patients (4 months) although ITI was
prolonged (42 months) in an individual case. The char-
Table 1. Variables that may influence the outcome of immune tolerance
induction (ITI) therapy.
Age at ITI start
Time from inhibitor diagnosis to start of ITI
Inhibitor peak
Dose
Regimen
Type of concentrate
Patients (n) 21 14 2 10*
LR 5 0 1 0
HR 16 14 1 10
Success rate (%) 91 28 100 80
LR%(n/n) 100 (5/5) – 100 (1/1) –
HR%(n/n) 88 (14/16] 28 (4/14) 100 (1/1) 80 (8/10)
Median time (range) of HI achievement [months]
LR 1.5 (0.5–3) – 1.5 –
HR 4 (0.5–42) 3 (2–7) 3 17 (5–36)
*Coming from not successful ITI with isolated FVIII concentrates.
HR: high responders; ITI: immune tolerance induction; LR: low responders.
acteristics of the German cohort reveal some important
dose-related differences in terms of ITI success. In high
responders, the median pre-ITI inhibitor titre was
42 BU (range 0.8–1052), the median peak inhibitor
titre was 105 BU (range 11–1570) and the median
inhibitor elimination period was 4 months (range 0.5–
42). There was a trend for high initial FVIII doses (200–
300 IU kg 1 day 1) to be correlated (P = 0.049) with
a short FVIII inhibitor elimination period and a high
success rate. On the contrary, initial FVIII doses
 100 IU kg 1 day 1 (three patients) were associated
with prolonged treatment time needed to induce
immune tolerance (5, 8 and 42 months) and complete
failure in one patient. A high pre-ITI inhibitor titre was
associated with a lower success rate and a significantly
longer treatment time to tolerization; if BUmax was
>600, the success rate was only 50% and one patient
required 42 months of treatment to achieve immune
tolerance. Conversely, when the peak titre was
 600 BU, there was no correlation between maximal
FVIII inhibitor titre and the time required for inhibitor
eradication [4].
Between 1993 and 2000, when recombinant and
high-purity plasma-derived concentrates without VWF
came into primary use, the success rate dropped to
28% (4 of 14 patients) (Table 2) [5]. Ten of these
patients were subsequently switched to rescue ITI with
a VWF-containing product, eight of whom (80%)
achieved success in a median ITI duration time of
17 months. The major criticism of this analysis was
that patients in this latter group had received primary
ITI with non-VWF-containing FVIII products for only
a short time period (range 2–7 months) before being
considered an ITI failure. The counter argument was
that, in the absence of even a partial success, it was
clinically prudent to switch these patients to a VWF-
containing plasma-derived product.
Following on from the German experience, a num-
ber of other small studies have reported good success
with the use of pdFVIII/VWF products for immune

© 2012 Blackwell Publishing Ltd Haemophilia (2013), 19 (Suppl. 1), 8--11

10 E. SANTAGOSTINO
tolerization, including that in patients with poor prog-
nostic factors.
Orsini & colleagues reported retrospectively on the
use of pdFVIII/VWF for primary ITI in a small homo-
geneous cohort of French patients with severe constit-
utive haemophilia A and good prognostic factors [6].
Treatment was successful in 7 of 8 patients (88%)
with complete disappearance of FVIII-inhibiting activ-
ity in a median ITI duration of 8 months (range 4.7–
36 months). Partial success was achieved in the
remaining patient who had relapsed after becoming
inhibitor-free, but with a low titre allowing resump-
tion of treatment with FVIII concentrates. The investi-
gators of this study considered that, since all eight
patients had resumed FVIII treatment (either on-
demand or as prophylaxis), ITI therapy was 100%
successful [6].
Guided by the experience of the Frankfurt group
in terms of using pdFVIII/VWF concentrates for res-
cue ITI in patients who had failed primary treatment
with non-VWF-containing FVIII products [4,5], an
Italian group evaluated the use of a single high-purity
pdFVIII/VWF complex concentrate (Fanhdi®) in
inhibitor patients with one or more poor prognostic
factors which placed them at high risk of failure
(Table 3) [7]. Seventeen patients (16 with severe hae-
mophilia, one moderate) ranging in age from 4 to 54
(median 23) years were treated in this prospective
study. The median interval from first inhibitor detec-
tion to start of ITI treatment was 8 years (range
1–33) and four patients had previously undergone
ITI with non-VWF-containing FVIII products for a
median period of 2 years (range 3–48 months). Suc-
cess was achieved in more than half the number of
patients (n = 9; 53%), including two of four patients
who had previously failed ITI, in a median time of
24 (range 4–30) months. Partial success was achieved
in seven patients (41%), who had sustained low
inhibitor titres, but an abnormal FVIII recovery/half-
life. The remaining patient was withdrawn from the
study after 12 months when the antibody titre was
70 BU. No patient relapsed, and response was main-
tained after a median follow-up of 8 (range 2–27)
months [7]. Despite the small sample size and vari-
able ITI regimens used in this study, the results were
considered highly encouraging as many of the
patients would typically be considered ineligible for
ITI.
Table 3. Poor prognostic factors for immune tolerance induction (ITI)
therapy.
Age > 6 years
Initiation of ITI > 1 year from inhibitor development
Inhibitor peaks > 200 BU
Inhibitor titre > 10 BU at start of ITI
Previously failed ITI
Haemophilia (2013), 19 (Suppl. 1), 8--11
Table 4. 2006 Immune Tolerance Induction International Workshop
Consensus: outcome criteria [8].
Inhibitor FVIII FVIII
(BU) recovery half-life Clinical
Complete <0.6 >66% of >6 h No anamnesis
success predicted
Partial <5 <66% of <6 h Clinical response to FVIII
success predicted
Failure: <20% reduction in the inhibitor titre for any 6-month period dur-
ing ITI after the first 3 months of treatment and/or failure to fulfil all the
criteria for complete or partial success within 33 months.
Grifols-Immune Tolerance Induction (G-ITI)
Study
On this basis of reported experience with the use of
pdFVIII/VWF, the pharmaceutical company Grifols
had a strong interest in collecting and analysing data
from inhibitor patients treated around the world with
their pdFVIII/VWF product (Alphanate® in the US;
Fanhdi® in the EU). The Grifols-Immune Tolerance
Induction (G-ITI) Study was thus initiated in which
data were collected retrospectively for patients with
severe haemophilia A (FVIII <2 IU dL 1) and inhibi-
tors who had completed primary or rescue ITI with
Alphanate®/Fanhdi® during the years 1996–2011. To
overcome possible differences in outcome reporting
among the various centres involved in the global
study, primary endpoints for ITI were evaluated
according to the criteria for success, partial success
and failure of the 2006 ITI International Workshop
consensus (Table 4) [8].
Outcome assessment
The G-ITI Study represents the largest group of hae-
mophilia A inhibitor patients treated with a single
pdFVIII/VWF concentrate reported to date. Currently,
data have been collected retrospectively for 95
patients at 46 centres in Spain (n = 26), Italy
(n = 19), Germany (n = 17) and the US (n = 33). The
global database of patient data is currently being anal-
ysed; while this information is awaited eagerly, results
for the 33 patients treated at 11 centres in the US
have been published recently [9]. From this cohort,
eight (24%) patients received primary ITI and the
remaining 25 (76%) patients received rescue ITI. The
clinical characteristics of the patients are summarized
in Table 5. Although mean values for clinical parame-
ters were generally higher in the group of patients
who received rescue ITI, the ranges were wide in both
groups indicating a high degree of heterogeneity.
Notably, both the primary and rescue ITI groups
included adult patients.
Seven patients in the primary ITI group received
pdFVIII/VWF 100–200 IU kg 1 day 1 (high-dose),
while the remaining patient received pdFVIII/VWF
© 2012 Blackwell Publishing Ltd
 PDFVIII/VWF IN IMMUNE TOLERANCE INDUCTION 11

Table 5. Clinical characteristics (mean and range) of patients in the US who had failed primary ITI, 52% of patients
cohort (33 patients) of the Grifols Immune Tolerance Induction (ITI) Study achieved complete or partial success with rescue ITI
[9].
(Table 6).
Primary ITI (n = 8) Rescue ITI (n = 25)
Age at start of ITI (months) 55 (6–137) 86 (11–278)
Inhibitor peak (BU) 621 (5–2898) 537 (8–2582) Conclusions
Titre at start of ITI (BU) 75 (0–416) 100 (0–848)
Duration of ITI (months) 16.5 (5–34) 20.9 (6–34)
The US cohort of the G-ITI Study represents the largest
group to date of primarily paediatric, high-titre inhibi-
tor patients with haemophilia A treated with a single
Table 6. Outcomes data from the Grifols Immune Tolerance Induction pdFVIII/VWF concentrate for whom data have been
(ITI) Study – US cohort [9]. published. The overall success rate of primary ITI with
Complete Partial Complete &
Alphanate® in the US cohort was 75% (37.5% com-
success success partial success Failure plete success, 37.5% partial success). The overall
Primary ITI 3 (37.5%) 3 (37.5%) 6 (75%) 2 (25%) success rate of rescue ITI was 52% (32% complete
(n = 8) success, 20% partial success). Although the success
Rescue ITI 8 (32%) 5 (20%) 13 (52%) 12 (48%) rate was higher in patients with a good prognosis, it is
(n = 25)
noteworthy that more than half the number of patients
with poor prognostic features also achieved success. In
fact, the success rate achieved with pdFVIII/VWF res-
50 IU kg 1 day 1. In the rescue ITI group, 23 of 25 cue ITI in the published US cohort of the G-ITI Study
patients received pdFVIII/VWF 100–200 IU kg 1 should encourage providers and clinicians to consider
day 1 and the remaining two patients received 50 IU it as a possible therapeutic modality for this subgroup
kg 1 day 1 [9]. of patients, albeit on a patient-by-patient basis. Pub-
Although the complete success rate in the primary lished outcomes data from the total global G-ITI
ITI group was only 37.5%, 75% of patients attained cohort of 95 patients are awaited with anticipation.
complete or partial success (Table 6). Importantly,
these patients were then able to use FVIII products
for prophylaxis and treatment of bleeding episodes Disclosures
rather than using bypassing agents. Furthermore, it is
The author received an honorarium from Grifols S.A. for participating in
noteworthy that three-quarters of the primary ITI the symposium and production of the article. The author thanks Content
patients had characteristics that would have made Ed Net for providing valuable editorial assistance in the preparation of
them ineligible for ITI therapy in the International the article; funding for this assistance was provided by Grifols S.A.
Immune Tolerance Study [1]. In the group of patients

References 4 Kreuz W, Ehrenforth S, Funk M et al. 7 Gringeri A, Musso R, Mazzucconi MG et al.

1 Hay CR, DiMichele DM, on behalf of the
International Immune Tolerance Study. The
principal results of the International Immune
Tolerance Study: a randomized dose com-
parison. Blood 2012; 119: 1335–44.
2 Franchini M, Lippi G. von Willebrand factor-
containing factor VIII concentrates and inhibi-
tors in haemophilia A. A critical literature
review. Thromb Haemost 2010; 104: 931–40.
3 Suzuki T, Arai M, Amano K, Kagawa K,
Fukutake K. Factor VIII inhibitor antibodies
with C2 domain specificity are less inhibi-
tory to factor VIII complexed with von
Willebrand factor. Thromb Haemost 1996;
76: 749–54.
Immune tolerance therapy in paediatric hae-
mophiliacs with factor VIII inhibitors: 14
years follow-up. Haemophilia 1995; 1: 24–
32.
5 Kreuz W, Escuriola-Ettingshausen C, Auers-
wald G et al. Immune tolerance induction
(ITI) in haemophilia A with inhibitors: the
choice of concentrate affecting success. Hae-
matologica 2001; 86(Suppl. 4): 16–20.
6 Orsini F, Rotschild C, Beurrier P, Faradji A,
Goudemand J, Polack B. Immune tolerance
induction with highly purified plasma-
derived factor VIII containing von Wille-
brand factor in hemophilia A patients with
high-responding inhibitors. Haematologica
2005; 90: 1288–90.
Immune tolerance induction with a high pur-
ity von Willebrand factor/VIII complex con-
centrate in haemophilia A patients with
inhibitors at high risk of a poor response.
Haemophilia 2007; 13: 373–9.
8 Di Michele DM, Hoots WK, Pipe SW,
Rivard GE, Santagostino E. International
workshop on immune tolerance induction:
consensus recommendations. Haemophilia
2007; 13(Suppl. 1): 1–22.
9 Kurth M, Puetz J, Kouides P et al. The use
of a single von Willebrand factor-containing,
plasma-derived FVIII product in hemophilia
A immune tolerance induction: the US expe-
rience. J Thromb Haemost 2011; 9: 2229–
34.

© 2012 Blackwell Publishing Ltd Haemophilia (2013), 19 (Suppl. 1), 8--11