Guidelines for the management of


of APCC for management of joint bleeding



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of APCC for management of joint bleeding 

has been shown to be essentially equivalent 

(Level 2) [69].

9.  Notably, however, some patients respond better 



to one agent than the other, highlighting the 

need to individualize therapy. (Level 2) [69,70]

10. An anamnestic immune response should be 

expected in patients with hemophilia B and a 

FIX inhibitor treated with prothrombin complex 

concentrates – whether activated or not – since 

these concentrates all contain FIX. 

11. On the other hand, the risk of anamnesis in 

patients with hemophilia A and an inhib-

itor treated with a(n) (activated) prothrombin 


COMPLICATIONS OF HEMOPHILIA 

61

complex concentrate will vary depending on the 



concentrate and its content of FVIII, which is 

generally minimal. It is estimated that APCC 

leads to an anamnestic response in approximately 

30% of FVIII inhibitor patients.

12. Although there has been interest in the use of 

immunosuppressive therapies in patients with 

inhibitors, their role is not yet defined, and there 

is no consensus as to whether they have a place 

in the management of these patients. 

Allergic reactions in patients with hemophilia B

1.  Up to 50% of hemophilia B patients with inhibi-

tors may have severe allergic reactions, including 

anaphylaxis, to FIX administration. Such reac-

tions can be the first symptom of inhibitor 

development.

2.  Newly diagnosed hemophilia B patients, partic-

ularly those with a family history and/or with 

genetic defects predisposed to inhibitor devel-

opment, should be treated in a clinic or hospital 

setting capable of treating severe allergic reac-

tions during the initial 10-20 treatments with 

FIX concentrates. Reactions can occur later but 

may be less severe. (Level 4) [71-72]

Immune tolerance induction 

1.  In patients with severe hemophilia A, eradica-



tion of inhibitors is often possible by immune 

tolerance induction (ITI) therapy. (Level 2) 

[73,74]

2.  Before ITI therapy, high-responding patients 



should avoid FVIII products to allow inhibitor 

titres to fall and to avoid persistent anamnestic 

rise. As noted, some patients may develop an 

anamnestic response to the inactive FVIII mole-

cules in APCC as well. (Level 2) [75]

3.  Optimal regimen (product or dose) for ITI 

remains to be defined. An international trial 

comparing 50 IU/kg three times a week to 200 

IU/kg daily was recently stopped due to safety 

concerns (higher number of intercurrent bleeds) 

in the low-dose arm pending detailed analysis 

and interpretation of the data [76]. 

4.  Response to ITI may be less favourable in patients 

with moderate/mild hemophilia [63]. 

5.  Experience with ITI for hemophilia B inhibitor 

patients is limited. The principles of treatment in 

these patients are similar, but the success rate is 

much lower, especially in persons whose inhib-

itor is associated with an allergic diathesis. 

6.  Hemophilia B inhibitor patients with a history 

of severe allergic reactions to FIX may develop 

nephrotic syndrome during ITI, which is not 

always reversible upon cessation of ITI therapy. 

Alternative treatment schedules, including 

immunosuppressive therapies, are reported to 

be successful [77]. 



Patients switching to new concentrates 

1.  For the vast majority of patients, switching prod-

ucts does not lead to inhibitor development. 

2.  However in rare instances, inhibitors in previ-

ously treated patients have occurred with the 

introduction of new FVIII concentrates. 

3.  In those patients, the inhibitor usually disappears 

after withdrawal of the new product. 

4.  Patients switching to a new factor concentrate 

should be monitored for inhibitor develop-

ment. (Level 2) [53]

6.3  Transfusion-transmitted and other infection-related complications 

1.  The emergence and transmission of HIV, HBV 

and HCV through clotting factor products 

resulted in high mortality of people with hemo-

philia in the 1980s and early 1990s [78,79]. 

2.  Many studies conducted all over the world indi-

cate that HIV, HBV, and HCV transmission 

through factor concentrate has been almost 

completely eliminated [80,81]. 



GUIDELINES FOR THE MANAGEMENT OF HEMOPHILIA

62

3.  This is a result of the implementation of several 



risk-mitigating steps, which include careful selec-

tion of donors and screening of plasma, effective 

virucidal steps in the manufacturing process, and 

advances in sensitive diagnostic technologies for 

detection of various pathogens [82]. 

4.  Recombinant factor concentrates have been 

adopted over the past two decades, particularly 

in developed countries. Recombinant products 

have contributed significantly to infection risk 

reduction. 

5.  The new challenge remains emerging and 

re-emerging infections, many of which are not 

amenable to current risk reduction measures. 

These include the non-lipid enveloped viruses 

and prions, for which diagnosis and elimination 

methods are still a challenge [81,83,84]. 

6.  As new treatments are continually emerging in 

this rapidly changing field, transfusion-trans-

mitted infections in people with hemophilia are 

best managed by a specialist.



Principles of management of HIV infection in 

hemophilia

1.  Knowledge and expertise in the treatment of 

HIV-infected people with hemophilia is currently 

limited to case series and reports. HIV treatment 

in people with hemophilia is therefore largely 

informed by guidelines used in the non-hemo-

philia population. 

2.  As part of the hemovigilance program, all 



people with hemophilia treated with plasma-

derived products that are not adequately 

virus-inactivated should be tested for HIV at 

least every 6-12 months and whenever clini-

cally indicated. (Level 4) [85]

3.  The diagnosis, counselling, initiation of treat-



ment, and monitoring of HIV, as well as the 

treatment of HIV-associated complications 

in infected people with hemophilia, should be 

the same as in the non-hemophilic population. 

(Level 2) [86,87] 

4.  None of the currently available classes of anti-



HIV drugs are contraindicated in people with 

hemophilia. (Level 5) [88-90]

Principles of management of HCV infection 

in hemophilia

1.  Assessment of HCV in people with hemophilia 

should include: 

 ■ anti-HCV serology to determine exposure

 ■ HCV polymerase chain reaction (PCR) in 

those who are anti-HCV positive

 ■ HCV genotyping in those who are HCV PCR 

positive


 ■ liver function tests and non-invasive assess-

ment of fibrosis and liver architecture

2.  The current standard of treatment for HCV 

is pegylated interferon (PEG-INF) and riba-

virin, which give sustained virological response 

in 61% of people with hemophilia. (Level 1) 

[91-96]

3.  New antiviral therapies, in combination with 

these drugs, may improve sustained virologic 

response rates [97]. 

4.  HCV genotype 1 and HIV coinfection predict 

poorer response to anti-HCV therapy. 

5.  Where HCV eradication cannot be achieved, 

regular monitoring (every 6-12 months) for 

end-stage liver complication is recommended. 

(Level 3) [98]

Principles of management of HBV infection 

in hemophilia

1.  All people with hemophilia treated with plasma-



derived products that are not adequately 

virus-inactivated should be screened for hepa-

titis B antigen and anti-hepatitis B at least every 

6-12 months and whenever clinically indicated. 

(Level 4) [99]

2.  Active HBV infection should be managed as per 

local infectious disease guidelines and protocols.

3.  Those without HBV immunity should be 



given the anti-HBV vaccine. Protective 

COMPLICATIONS OF HEMOPHILIA 

63

seroconversion should be rechecked following 



vaccination. (Level 4) [99-101]

4.  People with hemophilia who do not seroconvert 



should be revaccinated with double the hepa-

titis B vaccine dose. (Level 4) [99,102]

Principles of management of bacterial 

infection in hemophilia

1.  The risk factors for bacterial infections in people 

with hemophilia are venous access catheter 

insertion, surgical arthroplasty, and other surgical 

interventions [103-105]. 

2.  In general, joint aspiration to treat hemarthrosis 

should be avoided, unless done early under appro-

priate cover of factor replacement and with strict 

aseptic precautions to prevent infection [106,107].

3.  Bleeding is likely to delay healing and worsen 

infection and should therefore be well controlled 

[108]. 


4.  Control of the source of infection is of paramount 

importance in PWH [109,110]. 

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Apr;37(2):88-93.

81.  Mauser-Bunschoten EP, Posthouwer D, Fischer K, 

van den Berg HM. Safety and efficacy of a plasma-

derived monoclonal purified factor VIII concentrate 

during 10 years of follow-up. Haemophilia 2007 

Nov;13(6):697-700.

82.  Ludlam CA, Mannucci PM, Powderly WG; European 

Interdisciplinary Working Group. Addressing 

current challenges in haemophilia care: consensus 

recommendations of a European Interdisciplinary 

Working Group. Haemophilia 2005;11(5):433-7.

83.  Farrugia A, Manno CS, Evatt BL. Emerging and 

receding risks of therapeutic regimens for haemophilia. 

Haemophilia 2004;10(Suppl 4):47-54.

84.  Tapper ML. Emerging viral diseases and infectious 

disease risks. Haemophilia 2006;12(Suppl 1):3-7.

85.  Evatt BL, Austin H, Leon G, Ruiz-Sáez A, de Bosch 

N. Haemophilia therapy: assessing the cumulative 

risk of HIV exposure by cryoprecipitate. Haemophilia 

1999;5(5):295-300.

86.  Mannucci PM, Gringeri A, Savidge G, et al; European-

Australian Haemophilia Collaborative Study Group. 

Randomized double-blind, placebo-controlled trial of 

twice-daily zidovudine in asymptomatic haemophiliacs 

infected with the human immunodeficiency virus type 

1. Br J Haematol 1994;86(1):174-9.

87.  Ragni MV, Amato DA, LoFaro ML, et al. 

Randomized study of didanosine monotherapy and 

combination therapy with zidovudine in hemophilic 

and nonhemophilic subjects with asymptomatic 

human immunodeficiency virus-1 infection. Blood 

1995;85(9):2337-46.

88.  Humphreys EH, Chang LW, Harris J. Antiretroviral 

regimens for patients with HIV who fail first-line 

antiretroviral therapy. Cochrane Database Syst Rev 2010 

Jun 16;(6):CD006517.

89.  Spaulding A, Rutherford GW, Siegfried N. Tenofovir 

or zidovudine in three-drug combination therapy with 

one nucleoside reverse transcriptase inhibitor and 

one non-nucleoside reverse transcriptase inhibitor for 

initial treatment of HIV infection in antiretroviral-

naïve individuals. Cochrane Database Syst Rev 2010 Oct 

6;(10):CD008740. 

90.  Spaulding A, Rutherford GW, Siegfried N. Stavudine 

or zidovudine in three-drug combination therapy for 

initial treatment of HIV infection in antiretroviral-

naïve individuals. Cochrane Database Syst Rev 2010 Aug 

4;(8):CD008651.

91.  Denholm JT, Wright EJ, Street A, Sasadeusz JJ. HCV 

treatment with pegylated interferon and ribavirin in 

patients with haemophilia and HIV/HCV co-infection. 

Haemophilia 2009;15(2):538-543.

92.  Franchini M, Mengoli C, Veneri D, Mazzi R, Lippi 

G, Cruciani M. Treatment of chronic hepatitis 

C in haemophilic patients with interferon and 

ribavirin: a meta-analysis. J Antimicrob Chemother 

2008;61(6):1191-200.

93.  Hartwell D, Jones J, Baxter L, Shepherd J. Peginterferon 

alfa and ribavirin for chronic hepatitis C in patients 

eligible for shortened treatment, re-treatment or in 

HCV/HIV co-infection: a systematic review and 

economic evaluation. Health Technol Assess 2011 

Apr;15(17):i-xii, 1-210.

94.  Operskalski EA, Kovacs A. HIV/HCV co-infection: 

pathogenesis, clinical complications, treatment, and 

new therapeutic technologies. Curr HIV/AIDS Rep 2011 

Mar;8(1):12-22.

95.  Posthouwer D, Mauser-Bunschoten EP, Fischer 

K, Makris M. Treatment of chronic hepatitis C in 

patients with haemophilia: a review of the literature. 

Haemophilia 2006;12(5):473-8.

96.  Schulze Zur Wiesch J, Pieper D, et al. Sustained 

virological response after early antiviral treatment of 

acute hepatitis C virus and HIV coinfection. Clin Infect 

Dis 2009;49(3):466-72.

97.  Lok AS, Gardiner DF, Lawitz E, et al. Preliminary Study 

of Two Antiviral Agents for Hepatitis C Genotype 1. 

NEJM 2012;366(3):216-224.

98.  Santagostino E, Colombo M, Rivi M, et al. A 6-month 

versus a 12-month surveillance for hepatocellular 

carcinoma in 559 hemophiliacs infected with the 

hepatitis C virus. Blood 2003;102(1):78-82.

99.  Steele M, Cochrane A, Wakefield C, Stain AM, Ling 

S, Blanchette V, et al. Hepatitis A and B immunization 

for individuals with inherited bleeding disorders. 

Haemophilia 2009;15:437–447.


COMPLICATIONS OF HEMOPHILIA 

67

100. Miller EJ, Lee CA, Karayiannis P, Holmes S, Thomas 



HC, Kernoff PB. Immune response of patients with 

congenital coagulation disorders to hepatitis B vaccine: 

suboptimal response and human immunodeficiency 

virus infection. J Med Virol 1989;28:96–100.

101. Pillay D, Pereira C, Sabin C, Powell L, Zuckerman 

AJ, Lee CA. A long-term follow-up of hepatitis B 

vaccination in patients with congenital clotting 

disorders. Vaccine 1994;12:978–83.

102. Mannucci PM, Gringeri A, Morfini M, et al. 

Immunogenicity of a recombinant hepatitis B vaccine in 

hemophiliacs. Am J Hematol 1988;29(4):211-4.

103. Buehrer JL, Weber DJ, Meyer AA, et al. Wound infection 

rates after invasive procedures in HIV-1 seropositive 

versus HIV-1 seronegative hemophiliacs. Ann Surg 

1990;211(4):492-8.

104. Monch H, Kostering H, Schuff-Werner P, et al. 

Hemophilia A, idiopathic thrombocytopenia and 

HTLV-III-infection impressive remission after 

splenectomy: a case report. Onkologie 1986; 9(4):239-40.

105. Trieb K, Panotopoulos J, Wanivenhaus A. Risk of 

infection after total knee arthroplasty in HIV-positive 

hemophilic patients. J Bone Joint Surg Am 

2003;85-A(5):969-70.

106. Ashrani AA, Key NS, Soucie JM, Duffy N, Forsyth 

A, Geraghty S; Universal Data Collection Project 

Investigators. Septic arthritis in males with haemophilia. 

Haemophilia 2008;14:494 –503.

107. Zuber TJ. Knee joint aspiration and injection. Am Fam 

Physician 2002;66(8):1497-500.

108. Tourbaf KD, Bettigole RE, Southard SA. Infection in 

hemophilia. Local bleeding and prophylactic treatment. 

NY State J Med 1976;76(12):2034-6.

109. Heyworth BE, Su EP, Figgie MP, Acharya SS, Sculco TP. 

Orthopedic management of hemophilia. Am J Orthop 

2005 Oct;34(10):479-86.

110. Rodriguez-Merchan EC. Orthopaedic surgery 

of haemophilia in the 21st century: an overview. 

Haemophilia 2002 May;8(3):360-8.



69

7.1  Choice of factor replacement therapy protocols

1.  The correlation shown in Figure 7-1 between 

possible factor replacement therapy protocols 

and overall outcome depicts the choices that one 

needs to make when selecting doses and regimen 

of clotting factor concentrates. 

2.  While enabling a completely normal life should 

remain the ultimate goal of factor replacement 

therapy, this cannot be achieved immediately in 

people with hemophilia in all situations. 

3.  The availability of treatment products varies 

significantly around the world and there will 

therefore always be a range of doses with which 

people with hemophilia are treated. Lower doses 

may increase as the global availability of treat-

ment products improves incrementally over time.

7

PLASMA FACTOR LEVEL AND 



DURATION OF ADMINISTRATION

FIGURE 7-1: STRATEGIES FOR CLOTTING FACTOR REPLACEMENT AT DIFFERENT AGES AND IMPACT ON OUTCOMES

    10         15       20        25       30        35        40 

Age in years

Incr

easing


 intensity

 o

f factor



 r

eplacement

5

0

Episodic treatment



Treatment of

pain and serious

bleeding

Short-term prophylaxis

Improvement 

of target joints 

Tertiary prophylaxis

 

(after onset of joint disease)



Improves normal 

activities of 

daily life 

Secondary prophylaxis

 

(after second joint bleed)



Minimal

musculoskeletal

disease

Primary prophylaxis



 

(before second joint bleed)

Near normal

musculoskeletal

& psycho-social

development

Adapted from Blood Transfus 2008 Sep;6 Suppl 2:s4-11


GUIDELINES FOR THE MANAGEMENT OF HEMOPHILIA

70

4.  Table 7-1 and Table 7-2 present commonly 



followed guidelines on plasma factor peak levels 

and duration of replacement that reflect the 

different practices in countries where there is 

no significant resource constraint (Table 7-1) and 

countries where treatment products are limited 

(Table 7-2). 

5.  With the lower doses for treating musculoskel-

etal bleeds listed in Table 7-2, it may only be 

possible to avoid major target joints and crip-

pling deformities. 

6.  Higher doses listed in Table 7-1 have been shown 

to avoid joint damage, but the optimal dose 

needed to achieve this remains to be defined.

7.  Observational studies documenting the musculo-

skeletal outcome of doses and protocols of factor 

replacement are extremely important in defining 

these issues.

8.  Doses for prophylactic replacement of factor 

concentrates vary between different countries 

and also among centres in the same country. 

9.  Commonly-used dosage for prophylactic factor 

replacement is 25-40 IU/kg 2-3 times weekly in 

countries with less resource constraints (see 

Section 1 for details). [1-3] 

10. In situations where there are greater constraints 



on supply of factor concentrates, prophylaxis 

may be initiated with lower doses of 10-20 

IU/kg 2-3 times per week. (Level 2) [4,5]

PLASMA FACTOR LEVEL AND DURATION OF ADMINISTRATION

71

TABLE 7-1: SUGGESTED PLASMA FACTOR PEAK LEVEL AND DURATION OF ADMINISTRATION (WHEN THERE IS NO 



SIGNIFICANT RESOURCE CONSTRAINT) [6]

TYPE OF HEMORRHAGE

HEMOPHILIA A

HEMOPHILIA B

DESIRED 

LEVEL 


(IU/DL)

DURATION (DAYS)

DESIRED 

LEVEL 


(IU/DL)

DURATION (DAYS)

Joint 

40–60


1–2, may be longer if 

response is inadequate

40–60

1–2, may be longer if 



response is inadequate

Superficial muscle/no NV 

compromise (except iliopsoas)

40–60


2–3, sometimes longer if 

response is inadequate

40–60

2–3, sometimes longer if 



response is inadequate

Iliopsoas and deep muscle with NV 

injury, or substantial blood loss 

 

■ initial



80–100

1–2


60–80

1–2


 

■ maintenance

30–60

3–5, sometimes longer as 



secondary prophylaxis 

during physiotherapy

30–60

3–5, sometimes longer as 



secondary prophylaxis 

during physiotherapy

CNS/head

 

■ initial



80–100

1–7


60–80

1–7


 

■ maintenance

50

8–21


30

8–21


Throat and neck

 

■ initial



80–100

1–7


60–80

1–7


 

■ maintenance

50

8–14


30

8–14


Gastrointestinal

 

■ initial



80–100

7–14


60–80

7–14


 

■ maintenance

50

30

Renal



50

3–5


40

3–5


Deep laceration

50

5–7



40

 5–7


Surgery (major)

 

■ Pre-op



80–100

60–80


 

■ Post-op

60–80

40–60


30–50

1–3


4–6

7–14


40–60

30–50


20–40

1–3


4–6

7–14


Surgery (minor)

 

■ Pre-op



50–80

50–80


 

■ Post-op

30–80

1-5, depending on  



type of procedure

30–80


1–5, depending on  

type of procedure

NV; neurovascular


72

GUIDELINES FOR THE MANAGEMENT OF HEMOPHILIA

TABLE 7-2: PLASMA FACTOR PEAK LEVEL AND DURATION OF ADMINISTRATION (WHEN THERE IS SIGNIFICANT RESOURCE 

CONSTRAINT)

TYPE OF HEMORRHAGE

HEMOPHILIA A

HEMOPHILIA B

DESIRED 


LEVEL 

(IU/DL)


DURATION (DAYS)

DESIRED 


LEVEL 

(IU/DL)


DURATION (DAYS)

Joint 


10–20

1–2 may be longer if 

response is inadequate

10–20


1–2, may be longer if 

response is inadequate

Superficial muscle/no NV 

compromise (except iliopsoas)

10–20

2–3, sometimes longer if 



response is inadequate

10–20


2–3, sometimes longer if 

response is inadequate

Iliopsoas and deep muscle with NV 

injury, or substantial blood loss 

 

■ initial



20–40

15–30


 

■ maintenance

10–20

3–5, sometimes longer as 



secondary prophylaxis 

during physiotherapy

10–20

3–5, sometimes longer as 



secondary prophylaxis 

during physiotherapy

CNS/head

 

■ initial



50–80

1–3


50–80

1–3


 

■ maintenance

30–50

20–40


4–7

8–14


30–50

20–40


4–7

8–14


Throat and neck

 

■ initial



30–50

1–3


30–50

1–3


 

■ maintenance

10–20

4–7


10–20

4–7


Gastrointestinal

 

■ initial



30–50

1–3


30–50

1–3


 

■ maintenance

10–20

4–7


10–20

4–7


Renal

20–40


3–5

15–30


3–5

Deep laceration

20–40

5–7


15–30

5–7


Surgery (major)

 

■ Pre-op



60–80

50–70


 

■ Post-op

30–40

20–30


10–20

1–3


4–6

7–14


30–40

20–30


10–20

1–3


4–6

7–14


Surgery (minor)

 

■ Pre-op



40–80

40–80


 

■ Post-op

20–50

1–5, depending on  



type of procedure

20–50


1–5, depending on  

type of procedure

NV; neurovascular


73

PLASMA FACTOR LEVEL AND DURATION OF ADMINISTRATION

References

1.  Astermark J, Petrini P, Tengborn L, Schulman S, 

Ljung R, Berntorp E. Primary prophylaxis in severe 

haemophilia should be started at an early age but can be 

in dividualized. Br J Haematol 1999 Jun;105(4):1109-13.

2.  Blanchette VS. Prophylaxis in the haemophilia 

population. Haemophilia 2010;16(Suppl 5):181-8.

3.  Gringeri A, Lundin B, von Mackensen S, Mantovani L, 

Mannucci PM; ESPRIT Study Group. A randomized 

clinical trial of prophylaxis in children with hemophilia 

A (the ESPRIT Study). J Thromb Haemost 2011 

Apr;9(4):700-10.

4.  Fischer K, van der Bom JG, Mauser-Bunschoten 

EP, Roosendaal G, Prejs R, Grobbee DE, van den 

Berg HM. Changes in treatment strategies for severe 

haemophilia over the last 3 decades: effects on clotting 

factor consumption and arthropathy. Haemophilia 2001 

Sep;7(5):446-52.

5.  Wu R, Luke KH, Poon MC, Wu X, Zhang N, Zhao L, 

Su Y, Zhang J. Low dose secondary prophylaxis reduces 

joint bleeding in severe and moderate haemophilic 

children: a pilot study in China. Haemophilia 2011 

Jan;17(1):70-4.

6.  Rickard KA. Guidelines for therapy and optimal dosages 

of coagulation factors for treatment of bleeding and 

surgery in haemophilia. Haemophilia 1995;1(S1):8–13.



APPENDIX 

I: Oxfor


Centr


e for Evidence-Based 

Medicine, 

2011 Levels of 

Evidence


QUESTION

STEP 1 (LEVEL 1*)

STEP 2 (LEVEL 2*)

STEP 3 (LEVEL 3*)

STEP 4 (LEVEL 4*)

STEP 5 (LEVEL 5)

How common is the 

pr

oblem?



Local and curr

ent random 

sample surveys (or censuses)

Systematic r

eview of surveys 

that allow matching to local 

cir

cumstances**



Local non-random sample**

Case-series**

n/a

Is this 


diagnostic 

 

or monitoring test 



accurate? 

 

(Diagnosis)



Systematic r

eview of cr

oss 

sectional studies with 



consistently applied 

refer


ence standar

d and 


blinding

Individual cr

oss sectional 

studies with consistently 

applied r

efer


ence standar

and blinding



Non-consecutive studies, or 

studies without consistently 

applied r

efer


ence 

standar


ds**

Case-contr

ol studies, or 

“poor or non-independent 

refer

ence standar



d**

Mechanism-based r

easoning

What will happen 

 

if we do 



not add 

therapy? 



 

(Pr


ognosis)

Systematic r

eview of 

inception cohort studies

Inception cohort studies

Cohort study or contr

ol arm 

of randomized trial*



Case-series or case contr

ol 


studies, or poor quality 

pr

ognostic cohort study**



n/a

Does 


this 

 

intervention 



help? 

(T

reatment Benefits)



Systematic r

eview of 

randomized trials or 

n-of-1 

trials


Randomized trial or 

observational study with 

dramatic ef

fect


Non-randomized contr

olled 


cohort/ follow-up study**

Case-series, case-contr

ol 

studies, or historically 



contr

olled studies**

Mechanism-based r

easoning


What ar

e the 


 

COMMON har

ms? 

(T

reatment Harms)



Systematic r

eview of 

randomized trials, systematic 

review of nested case-

contr

ol studies,



 n

-of-1 trial 

with the patient you ar

raising the question about, 



or observational study with 

dramatic ef

fect

Individual randomized trial 



or (exceptionally) 

observational study with 

dramatic ef

fect


Non-randomized contr

olled 


cohort/ follow-up study 

(post-marketing surveillance) 

pr

ovided ther



e ar

e suf


ficient 

numbers to rule out a 

common harm. (For long-

term harms the duration of 

follow-up must be 

suf


ficient.)**

Case-series, case-contr

ol, or 

historically contr



olled 

studies**

Mechanism-based r

easoning


What ar

e the 


 

RARE har


ms?

(T

reatment Harms)



Systematic r

eview of 

randomized trials or 

n-of-1 

trial


Randomized trial or 

(exceptionally) observational 

study with dramatic ef

fect


Is this 

(early detection) 

test worthwhile? 

(Scr


eening)

Systematic r

eview of 

randomized trials

Randomized trial

Non -randomized contr

olled 

cohort/follow-up study**



Case-series, case-contr

ol, or


 

historically contr

olled

 

studies**



Mechanism-based r

easoning


* Level may be graded down on the basis of study quality

, impr


ecision, indir

ectness (study PICO does not match questions PICO), because of inconsistency between studies, or because the 

absolute ef

fect size is very small; Level may be graded up if ther

e is a lar

ge or very lar

ge ef

fect size.



** As always, a systematic r

eview is generally better than an individual study

.

OCEBM Levels of Evidence W



orking Gr

oup*. “The Oxfor

d 2011 Levels of Evidence”. Oxfor

d Centr


e for Evidence-Based Medicine. http://www

.cebm.net/index.aspx?o=5653



APPENDIX 

I: Oxfor


Centr


e for Evidence-Based 

Medicine, 

2011 Levels of 

Evidence


QUESTION

STEP 1 (LEVEL 1*)

STEP 2 (LEVEL 2*)

STEP 3 (LEVEL 3*)

STEP 4 (LEVEL 4*)

STEP 5 (LEVEL 5)

How common is the 

pr

oblem?



Local and curr

ent random 

sample surveys (or censuses)

Systematic r

eview of surveys 

that allow matching to local 

cir

cumstances**



Local non-random sample**

Case-series**

n/a

Is this 


diagnostic 

 

or monitoring test 



accurate? 

 

(Diagnosis)



Systematic r

eview of cr

oss 

sectional studies with 



consistently applied 

refer


ence standar

d and 


blinding

Individual cr

oss sectional 

studies with consistently 

applied r

efer


ence standar

and blinding



Non-consecutive studies, or 

studies without consistently 

applied r

efer


ence 

standar


ds**

Case-contr

ol studies, or 

“poor or non-independent 

refer

ence standar



d**

Mechanism-based r

easoning

What will happen 

 

if we do 



not add 

therapy? 



 

(Pr


ognosis)

Systematic r

eview of 

inception cohort studies

Inception cohort studies

Cohort study or contr

ol arm 

of randomized trial*



Case-series or case contr

ol 


studies, or poor quality 

pr

ognostic cohort study**



n/a

Does 


this 

 

intervention 



help? 

(T

reatment Benefits)



Systematic r

eview of 

randomized trials or 

n-of-1 

trials


Randomized trial or 

observational study with 

dramatic ef

fect


Non-randomized contr

olled 


cohort/ follow-up study**

Case-series, case-contr

ol 

studies, or historically 



contr

olled studies**

Mechanism-based r

easoning


What ar

e the 


 

COMMON har

ms? 

(T

reatment Harms)



Systematic r

eview of 

randomized trials, systematic 

review of nested case-

contr

ol studies,



 n

-of-1 trial 

with the patient you ar

raising the question about, 



or observational study with 

dramatic ef

fect

Individual randomized trial 



or (exceptionally) 

observational study with 

dramatic ef

fect


Non-randomized contr

olled 


cohort/ follow-up study 

(post-marketing surveillance) 

pr

ovided ther



e ar

e suf


ficient 

numbers to rule out a 

common harm. (For long-

term harms the duration of 

follow-up must be 

suf


ficient.)**

Case-series, case-contr

ol, or 

historically contr



olled 

studies**

Mechanism-based r

easoning


What ar

e the 


 

RARE har


ms?

(T

reatment Harms)



Systematic r

eview of 

randomized trials or 

n-of-1 

trial


Randomized trial or 

(exceptionally) observational 

study with dramatic ef

fect


Is this 

(early detection) 

test worthwhile? 

(Scr


eening)

Systematic r

eview of 

randomized trials

Randomized trial

Non -randomized contr

olled 

cohort/follow-up study**



Case-series, case-contr

ol, or


 

historically contr

olled

 

studies**



Mechanism-based r

easoning


* Level may be graded down on the basis of study quality

, impr


ecision, indir

ectness (study PICO does not match questions PICO), because of inconsistency between studies, or because the 

absolute ef

fect size is very small; Level may be graded up if ther

e is a lar

ge or very lar

ge ef

fect size.



** As always, a systematic r

eview is generally better than an individual study

.

OCEBM Levels of Evidence W



orking Gr

oup*. “The Oxfor

d 2011 Levels of Evidence”. Oxfor

d Centr


e for Evidence-Based Medicine. http://www

.cebm.net/index.aspx?o=5653



Document Outline

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  • Summary 
  • GENERAL CARE AND MANAGEMENT OF HEMOPHILIA 
    • 1.2 Principles of care
    • 1.3 Comprehensive care 
      • Comprehensive care team
      • Functions of a comprehensive care program
    • 1.4 Fitness and physical activity
    • 1.5 Adjunctive management 
    • 1.6 Prophylactic factor replacement therapy
      • Administration and dosing schedules
    • 1.7 Home therapy 
    • 1.8 Monitoring health status and outcome 
    • 1.9 Pain management 
      • Pain caused by venous access
      • Pain caused by joint or muscle bleeding
      • Post-operative pain
      • Pain due to chronic hemophilic arthropathy
    • 1.10 Surgery and invasive procedures
    • 1.11 Dental care and management 
    • References 
  • SPECIAL MANAGEMENT ISSUES
    • 2.2 Genetic testing/counselling and prenatal diagnosis 
    • 2.3 Delivery of infants with known or suspected hemophilia 
    • 2.4 Vaccinations
    • 2.5 Psychosocial issues 
    • 2.6 Sexuality 
    • 2.7 Ageing hemophilia patients 
      • Osteoporosis
      • Obesity
      • Hypertension
      • Diabetes mellitus (DM)
      • Hypercholesterolemia
      • Cardiovascular disease 
      • Psychosocial impact 
    • 2.8 Von Willebrand disease and rare bleeding disorders
    • References
  • LABORATORY DIAGNOSIS
    • 3.2 Use of the correct equipment and reagents
      • Equipment 
      • Reagents 
    • 3.3 Quality assurance 
      • Internal quality control (IQC)
      • External quality assessment (EQA) 
    • References
  • HEMOSTATIC AGENTS
    • FVIII concentrates
      • FIX concentrates 
    • 4.2 Other plasma products
      • Fresh frozen plasma (FFP)
      • Cryoprecipitate
    • 4.3 Other pharmacological options 
      • Desmopressin (DDAVP)
      • Tranexamic acid
      • Epsilon aminocaproic acid
    • References
  • TREATMENT OF SPECIFIC HEMORRHAGES
    • Arthrocentesis
    • 5.2 Muscle hemorrhage 
      • Iliopsoas hemorrhage 
    • 5.3 Central nervous system hemorrhage/head trauma 
    • 5.4 Throat and neck hemorrhage
    • 5.5 Acute gastrointestinal (gi) hemorrhage
    • 5.6 Acute abdominal hemorrhage 
    • 5.7 Ophthalmic hemorrhage
    • 5.8 Renal hemorrhage
    • 5.9 Oral hemorrhage
    • 5.10 Epistaxis 
    • 5.11 Soft tissue hemorrhage 
    • 5.12 Lacerations and abrasions
    • References
  • COMPLICATIONS OF HEMOPHILIA 
    • Chronic hemophilic arthropathy
      • Principles of physiotherapy/physical medicine in hemophilia
      • Pseudotumours
      • Fractures
      • Principles of orthopedic surgery in hemophilia
    • 6.2 Inhibitors
      • Management of bleeding 
      • Allergic reactions in patients with hemophilia B
      • Immune tolerance induction 
      • Patients switching to new concentrates 
    • 6.3 Transfusion-transmitted and other infection-related complications 
      • Principles of management of HIV infection in hemophilia
      • Principles of management of HCV infection in hemophilia
      • Principles of management of HBV infection in hemophilia
      • Principles of management of bacterial infection in hemophilia
    • References
  • PLASMA FACTOR LEVEL AND DURATION OF ADMINISTRATION
    • References
    • APPENDIX I: Oxford Centre for Evidence-Based Medicine, 2011 Levels of Evidence

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