von Willebrand Disease Treatment & Management
- Author: Eleanor S Pollak, MD; Chief Editor: Srikanth Nagalla, MBBS, MS, FACP more...
The main treatment options for patients with von Willebrand disease (vWD) are desmopressin (DDAVP), recombinant von Willebrand factor (rVWF), and von Willebrand factor/factor VIII (vWF/FVIII) concentrates. DDAVP is a synthetic analogue of the antidiuretic hormone vasopressin; it has enhanced antidiuretic activity and no pressor activity related to vasopressin. Recombinant von Willebrand factor is indicated for on-demand treatment of minor or major hemorrhage in adults with vWD. Purified plasma-derived concentrates of vWF/FVIII are used for treatment of bleeds and for surgical prophylaxis when DDAVP is ineffective or contraindicated.[2, 8]
Recombinant von Willebrand factor (Vonvendi) was approved by the US Food and Drug Administration (FDA) in December 2015. Approval was based on a phase 3 trial that showed that rVWF was safe and effective in treating 192 bleeds in 22 patients with vWD and stabilized endogenous FVIII:C levels. Control of bleeding was rated good or excellent, with excellent control in 96.9% (119 of 122 minor bleeds, 59 of 61 moderate bleeds, and 6 of 7 major bleeds). A single infusion was effective in 81.8% of bleeds.
In addition, antifibrinolytic drugs (ie, aminocaproic acid, tranexamic acid) can be used orally or intravenously to treat mild mucocutaneous bleeding. Topical agents (eg, fibrin sealants) may be considered as optional adjunctive therapy for dental surgery and for surface wound bleeding that is unresponsive to drugs and concentrates; however, the safety of these agents remains unconfirmed.
Platelet transfusions may be helpful in some patients with vWD (eg, type 3) to control bleeding that is refractory to other therapies. Cryoprecipitate and fresh frozen plasma contain functional von Willebrand factor (vWF) but should be avoided if at all possible because of the potential transmission of viral disease. An additional drawback of fresh frozen plasma is the large infusion volume most often required.[8, 9]
For prophylaxis in major surgery or for treatment of serious bleeding episodes, rVWF (with or without FVIII) or vWF-containing factor VIII (FVIII) concentrates are the treatment of choice. However, a hematologist experienced in the management of bleeding disorders should be consulted prior to all surgical/dental procedures.
In extremely rare cases, vWD patients who receive FVIII concentrates as prophylaxis for surgery may experience venous thromboembolic complications. A literature review by Franchini et al found only 11 reported cases, most of which involved orthopedic procedures. Nevertheless, these authors advise that the need for thromboprophylaxis with vWF/FVIII concentrates in patients with vWD who undergo major surgery should be individually assessed, after a careful risk/benefit analysis.
vWF in pregnancy
During pregnancy, the vWF level increases in most patients with non–type III vWD. Thus, in patients with functionally normal vWF, labor and delivery usually proceed normally.
However, patients with type II disease may experience hemorrhagic problems. In particular, patients with type IIB may experience thrombocytopenia due to the increased plasma levels associated with abnormal vWF. All patients should be monitored for excessive bleeding, particularly during the first week post partum.
Advise patients to avoid aspirin-containing compounds. In addition, patients should be wary of any physical activity associated with an increased risk of hemorrhage.
Type I von Willebrand disease
DDAVP is the treatment of choice for individuals with vWD type I. The infusion of DDAVP into healthy individuals and individuals with vWD type I results in a rapid increase in circulating levels of vWF:Ag and FVIII and RCoF activity.
Typically, a maximal rise of vWF and FVIII is observed in 30-60 minutes. The typical maximal rise is 2- to 4-fold for vWF and 3- to 6-fold for FVIII. Additionally, hemostatic levels of both factors are usually maintained for at least 6 hours.
DDAVP can be administered not only through intravenous infusion but also via a highly concentrated nasal spray; 300 mcg intranasally produces levels comparable to those observed with an intravenous infusion. Intranasal treatment is particularly useful for home therapy of menorrhagia and recurrent epistaxis.
DDAVP regimens are not standardized. A review by Neff notes the following :
Dosing DDAVP at 24 hour intervals may reduce the risk of side effects without significantly compromising vWF activity/FVIII:C levels; most treatment centers will not prescribe more than three doses at this frequency
Standard intravenous and subcutaneous DDAVP doses are 0.3 µg/kg, but for patients over 50 kg, a fixed dose of 15 µg may provide acceptable efficacy with less risk of serious side effects
Fluid retention and hyponatremia are common complications of DDAVP therapy. Consequently, most treatment centers recommend weight-based fluid restriction, particularly in patients undergoing surgery, along with monitoring of serum sodium levels in children younger than 2 years and in patients receiving repeated doses of DDAVP.[2, 15]
Type II von Willebrand disease
Responses to DDAVP are variable in patients with type II disease; some patients respond while others should receive vWF concentrates. United Kingdom guidelines recommend performing a trial infusion of DDAVP in patients with type IIA, IIM, and IIN vWD and measuring vWF antigen, vWF activity, and FVIII at baseline, 30–60 min, and 4–6 h.
Many individuals with vWD type IIA have a response to DDAVP, with peak vWF and FVIII levels at 30-60 minutes. This is similar to responses observed in patients with vWD type I. However, rapid loss of vWF, FVIII, and particularly ristocetin cofactor (RCoF) activity occurs as the high-molecular-weight multimers are degraded, with return to baseline levels at 4 hours post infusion. Although the response is transient, it may be adequate therapy in certain clinical situations.
DDAVP trials may be contraindicated in patients with type IIB, because of thrombocytopenia and possible thrombotic complications. DDAVP is usually not effective in patients with type IIM and is rarely effective in patients with type IIN.
Type III von Willebrand disease
Individuals with vWD type III have a virtually complete deficiency of vWF. Thus, DDAVP, which causes the release of stored vWF, has no effect in patients with this disorder.
The treatment of choice for patients with vWD type III (as with other vWD types unresponsive to DDAVP) is rVWF (with or without FVIII) or virus-inactivated, vWF-containing FVIII concentrates that contain a near-normal complement of high-molecular-weight vWF multimers. Most experience reported in the literature has been with the use of Humate-P, a plasma-derived product of intermediate purity. Two other FVIII concentrates, Alphanate and Koate-HP, have been reported to be effective in the treatment of vWD. Too little vWF is present in monoclonally purified FVIII concentrates and recombinant FVIII concentrates to allow their use in the treatment of vWD.
Alloantibody formation occurs in 10-15% of patients with type III disease. Therefore, the possibility of this complication must be managed appropriately, because patients are at increased risk for life-endangering anaphylactic reactions to vWF-FVIII preparations. With hemostatic stress in emergency situations, infusion of FVIII preparations devoid of vWF, while adjusting for the markedly decreased FVIII half-life, may be necessary.
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