Validity of assessing inhibitor development in haemophilia PUPs using registry data: the EUHASS project

Inhibitory antibodies to exogenous FVIII/FIX are a major complication of haemophilia treatment. Up to 30% of previously untreated patients (PUPs) with severe haemophilia A develop inhibitors, most likely during the initial 50 exposure days to concentrate. In addition to classical cohort studies, a European monitoring system (EUHASS) has been set up to evaluate inhibitor development in PUPs. The present study addresses the reliability of estimating the cumulative incidence of inhibitor development in this registry. Data from the retrospective CANAL cohort study, including 288 PUPs with severe haemophilia A and complete treatment records until the 50th exposure to FVIII, were used to simulate the consequences of several cross-sectional sampling techniques on the estimated incidence of inhibitors. Both mathematical calculus and computer modelling were applied to study the effects of sample size and the introduction of a new product. For existing concentrates, both longitudinal cohort study methods and the EUHASS method yielded similar estimates of the cumulative incidence of inhibitor cases over a 5-year time period: 27.9% (95% CI: 21-36) vs. 29.4% (22-38). For a newly introduced concentrate, a reliable estimate of inhibitor incidence with the EUHASS method could only be made after 3-4 years, even in large datasets. The results from EUHASS in inhibitor incidence in PUPs are expected to be valid. After introduction of a new concentrate, the inhibitor incidence on this concentrate can only be reliably determined after an observation period of several years.