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{{Von Willebrand disease}}
{{Von Willebrand disease}}


{{CMG}} {{AE}} {{PTD}}
{{CMG}} {{shyam}} {{AE}} {{PTD}}  {{N.F}}


==Overview==
==Overview==
The mainstay of management of VWD is medical therapy. Medical therapy of [[von Willebrand's disease]] ( [[vWD]]) involves normalizing the [[von Willebrand factor]] and [[factor VIII]] levels. Endogenous factor levels can be increased by the use of [[desmopressin]] or by infusing exogenous coagulation factors example high-purity or low-purity [[von Willebrand factor]] concentrate. Medical therapy depends on the type of [[von Willebrand's disease]]. [[Desmopressin]] is used for type 1 and 2 [[von Willebrand's disease]]. [[von Willebrand factor]]-[[factor VIII]] or [[von Willebrand factor]] concentrate is used in some of type 2 [[von Willebrand's disease]] and all of type 3 [[von Willebrand's disease]]. Alternate  or additional therapy involves the use of tranexamic acid or [[aminocaproic acid]].
==Medical Therapy==
Pharmacologic medical therapies for VWD include [[Desmopressin|desmopressin (DDAVP]]), recombinant VWF , von Willebrand factor/factor VIII (vWF/FVIII) concentrates and [[Antifibrinolytic Agent|antifibrinolytic agents.]]<ref name="pmid17403090">{{cite journal| author=Borel-Derlon A, Federici AB, Roussel-Robert V, Goudemand J, Lee CA, Scharrer I et al.| title=Treatment of severe von Willebrand disease with a high-purity von Willebrand factor concentrate (Wilfactin): a prospective study of 50 patients. | journal=J Thromb Haemost | year= 2007 | volume= 5 | issue= 6 | pages= 1115-24 | pmid=17403090 | doi=10.1111/j.1538-7836.2007.02562.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17403090  }} </ref><ref name="pmid15086321">{{cite journal| author=Lethagen S, Carlson M, Hillarp A| title=A comparative in vitro evaluation of six von Willebrand factor concentrates. | journal=Haemophilia | year= 2004 | volume= 10 | issue= 3 | pages= 243-9 | pmid=15086321 | doi=10.1111/j.1365-2516.2004.00893.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15086321  }} </ref><ref name="pmid23937614">{{cite journal| author=Leissinger C, Carcao M, Gill JC, Journeycake J, Singleton T, Valentino L| title=Desmopressin (DDAVP) in the management of patients with congenital bleeding disorders. | journal=Haemophilia | year= 2014 | volume= 20 | issue= 2 | pages= 158-67 | pmid=23937614 | doi=10.1111/hae.12254 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23937614  }} </ref><ref name="pmid27913547">{{cite journal| author=Lavin M, O'Donnell JS| title=New treatment approaches to von Willebrand disease. | journal=Hematology Am Soc Hematol Educ Program | year= 2016 | volume= 2016 | issue= 1 | pages= 683-689 | pmid=27913547 | doi=10.1182/asheducation-2016.1.683 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27913547  }} </ref><ref name="pmid23633542">{{cite journal| author=Castaman G, Goodeve A, Eikenboom J, European Group on von Willebrand Disease| title=Principles of care for the diagnosis and treatment of von Willebrand disease. | journal=Haematologica | year= 2013 | volume= 98 | issue= 5 | pages= 667-74 | pmid=23633542 | doi=10.3324/haematol.2012.077263 | pmc=3640108 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23633542  }} </ref>


==Medical Therapy==
'''Desmopressin'''
* [[Desmopressin]] works by raising the patient's own [[Blood plasma|plasma]] levels of [[von Willebrand factor]] by inducing release of [[von Willebrand factor]] stored in the [[Weibel-Palade body|Weibel-Palade bodies]] in the endothelial cells.


Medical treatment of [[vWD]] involves normalizing the von Willebrand factor and factor VIII levels. Endogenous factor levels can be increased by the use of desmopressin or by infusing exogenous coagulation factors example high-purity or low-purity von Willebrand factor concentrate.<ref name="pmid17403090">{{cite journal| author=Borel-Derlon A, Federici AB, Roussel-Robert V, Goudemand J, Lee CA, Scharrer I et al.| title=Treatment of severe von Willebrand disease with a high-purity von Willebrand factor concentrate (Wilfactin): a prospective study of 50 patients. | journal=J Thromb Haemost | year= 2007 | volume= 5 | issue= 6 | pages= 1115-24 | pmid=17403090 | doi=10.1111/j.1538-7836.2007.02562.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17403090  }} </ref><ref name="pmid15086321">{{cite journal| author=Lethagen S, Carlson M, Hillarp A| title=A comparative in vitro evaluation of six von Willebrand factor concentrates. | journal=Haemophilia | year= 2004 | volume= 10 | issue= 3 | pages= 243-9 | pmid=15086321 | doi=10.1111/j.1365-2516.2004.00893.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15086321  }} </ref>
* It is used to treat patients with mild to moderately severe type 1 and some cases of type 2A vWD
* [[Desmopressin]] is usually not effective in type 2B, 2N, and 3 disease.
* [[Desmopressin]] is contraindicated in patients with type 2B disease.
* A test dose is given by nasal spray (1.5 mg/mL) or intravenously or [[Subcutaneous|subcutaneously]] (0.3 µg/kg).  
* Fluids are to be restricted for 24 hours following the dose to avoid [[hyponatremia]].


Pharmacologic medical therapy is recommended in vWD patients as shown below:<ref name="pmid23937614">{{cite journal| author=Leissinger C, Carcao M, Gill JC, Journeycake J, Singleton T, Valentino L| title=Desmopressin (DDAVP) in the management of patients with congenital bleeding disorders. | journal=Haemophilia | year= 2014 | volume= 20 | issue= 2 | pages= 158-67 | pmid=23937614 | doi=10.1111/hae.12254 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23937614  }} </ref><ref name="pmid27913547">{{cite journal| author=Lavin M, O'Donnell JS| title=New treatment approaches to von Willebrand disease. | journal=Hematology Am Soc Hematol Educ Program | year= 2016 | volume= 2016 | issue= 1 | pages= 683-689 | pmid=27913547 | doi=10.1182/asheducation-2016.1.683 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27913547  }} </ref><ref name="pmid23633542">{{cite journal| author=Castaman G, Goodeve A, Eikenboom J, European Group on von Willebrand Disease| title=Principles of care for the diagnosis and treatment of von Willebrand disease. | journal=Haematologica | year= 2013 | volume= 98 | issue= 5 | pages= 667-74 | pmid=23633542 | doi=10.3324/haematol.2012.077263 | pmc=3640108 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23633542  }} </ref>
* Preferred regimen (1) IV: 0.3 mcg/kg in 50 mL saline over 20 minutes


{| class="wikitable"
* Preferred regimen (2) Nasal spray: weight >50 kg: 300 mcg (1 spray in each nostril); <50 kg: 150 mcg (1 spray in one nostril)
!Type
* May repeat dose after 12 hours and 24 hours
!Treatment
* DDAVP should not be used along [[Antifibrinolytic Agent|antifibrinolytic agents]] such as [[tranexamic acid]] or [[aminocaproic acid]].
!Additional/Alternative treatement
|-
|Low vWF
|Desmopressin administered intravenously 0.3μg per kilogram body weight,
intranasally 300μg (150μg per nostril);  


in patients with body weight <50Kg, only one dose of 150μg or subcutaneously 0.3μg/kilogram
'''VWF concentrates containing all VWF multimers'''
|Tranexamic acid 1g 3 to 4 times daily
* Patients with type 3 VWD,  more severe type 1, and those with types 2A, 2B, and 2M disease will need replacement therapy with a VWF-containing product,.
|-
* Patients with more serious bleeding when other measures have failed.
|1
* In those patients who require more prolonged treatment like  post-surgery
|Demospressin at same dose as above
* '''Major bleeding or surgery:''' Preferred regimen : 40 to 60 ristocetin cofactor units/kg followed by 20 to 40 ristocetin cofactor units/kg every 12 to 24 hours to keep VWF level 50 to 100 international units/dL for 7 to 14 days,
|Tranexamic acid 1g 3 to 4 times daily
* '''Minor bleeding or surgery:''' Preferred regimen: 30 to 60 ristocetin cofactor units/kg followed by 20 to 40 ristocetin cofactor units/kg every 12 to 48 hours to keep VWF level >30 international units/dL for 3 to 5 days,
|-
* Cryoprecipitate can also be used to treat vWD, since cryoprecipitate contains factor I, factor VIII, and vWF.
|2
|Demospressin at same dose as above or vWF-Factor VIII or vWF concentrate
|Tranexamic acid 1g 3 to 4 times daily
|-
|3
|vWF-Factor VIII or vWF concentrate
|Tranexamic acid 1g 3 to 4 times daily
|}
Desmopressin is contraindicated in patients with type 2B disease.


For women with heavy menstrual bleeding, the [[combined oral contraceptive pill]] may be effective in reducing bleeding or in reducing the length or frequency of periods. Prophylactic treatment is sometimes given for patients with vWD who are scheduled for surgery. They can be treated with human derived medium purity [[factor VIII]] concentrates complexed to vWF (antihemophilic factor, more commonly known as [http://www.cslbehring-us.com/s1/cs/enus/1151517250474/page/1151517250857/ProductsList.htm Humate-P]) Mild cases of vWD can be trialled on [[desmopressin]] (1-desamino-8-D-arginine vasopressin, DDAVP) (desmopressin acetate, [http://www.cslbehring-us.com/s1/cs/enus/1151517250474/page/1151517250857/ProductsList.htm Stimate]), which works by raising the patient's own plasma levels of vWF by inducing release of vWF stored in the [[Weibel-Palade body|Weibel-Palade bodies]] in the endothelial cells.
'''Antifibrinolytic agents:''' [[Aminocaproic acid]],[[Tranexamic acid]]
* Used alone or in conjunction with other therapy except [[DDAVP]].  
* Useful for mucosal bleeding specially for [[dental]] procedures.


Daily subcutaneous administration of [[interleukin-11]] have been used with success as an alternative modality which increases von Willebrand factor and factor VIII levels by a factor of 1.3 to 2. It is presumabed to increase [[von Willebrand factor]] messenger RNA levels in patients with type 1 von Willebrand’s disease that is unresponsive to treatment with desmopressin.<ref name="pmid23238591">{{cite journal| author=Ragni MV, Novelli EM, Murshed A, Merricks EP, Kloos MT, Nichols TC| title=Phase II prospective open-label trial of recombinant interleukin-11 in desmopressin-unresponsive von Willebrand disease and mild or moderate haemophilia A. | journal=Thromb Haemost | year= 2013 | volume= 109 | issue= 2 | pages= 248-54 | pmid=23238591 | doi=10.1160/TH12-06-0447 | pmc=3689588 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23238591  }} </ref> [[Interleukin-11]] reduced the severity of bleeding in women with menorrhagia.<ref name="pmid21833452">{{cite journal| author=Ragni MV, Jankowitz RC, Jaworski K, Merricks EP, Kloos MT, Nichols TC| title=Phase II prospective open-label trial of recombinant interleukin-11 in women with mild von Willebrand disease and refractory menorrhagia. | journal=Thromb Haemost | year= 2011 | volume= 106 | issue= 4 | pages= 641-5 | pmid=21833452 | doi=10.1160/TH11-04-0274 | pmc=3947632 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21833452  }} </ref>
* Use after trial of DDAVP or other measures in patients with acquired von Willebrand syndrome (aVWS), particularly when associated with [[autoimmune diseases]].
* May be used in conjunction with VWF concentrates to increase the half-life of VWF.
* Preferred regimen (1) : Aminocaproic acid, 25 to 50 mg/kg PO, QID (maximum 5 g dose)
* Preferred regimen (2) : Tranexamic acid, 10 mg/kg, I/V TDS.
For women with heavy menstrual bleeding, the [[combined oral contraceptive pill]] may be effective in reducing bleeding or in reducing the length or frequency of periods.


==References==
==References==
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[[Category:Disease]]
[[Category:Pediatrics]]
[[Category:Blood disorders]]
[[Category:Genetic disorders]]
[[Category:Hematology]]
[[Category:Mature chapter]]

Latest revision as of 00:03, 21 December 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Shyam Patel [2] Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [3] Nazia Fuad M.D.

Overview

The mainstay of management of VWD is medical therapy. Medical therapy of von Willebrand's disease ( vWD) involves normalizing the von Willebrand factor and factor VIII levels. Endogenous factor levels can be increased by the use of desmopressin or by infusing exogenous coagulation factors example high-purity or low-purity von Willebrand factor concentrate. Medical therapy depends on the type of von Willebrand's disease. Desmopressin is used for type 1 and 2 von Willebrand's disease. von Willebrand factor-factor VIII or von Willebrand factor concentrate is used in some of type 2 von Willebrand's disease and all of type 3 von Willebrand's disease. Alternate or additional therapy involves the use of tranexamic acid or aminocaproic acid.

Medical Therapy

Pharmacologic medical therapies for VWD include desmopressin (DDAVP), recombinant VWF , von Willebrand factor/factor VIII (vWF/FVIII) concentrates and antifibrinolytic agents.[1][2][3][4][5]

Desmopressin

  • It is used to treat patients with mild to moderately severe type 1 and some cases of type 2A vWD
  • Desmopressin is usually not effective in type 2B, 2N, and 3 disease.
  • Desmopressin is contraindicated in patients with type 2B disease.
  • A test dose is given by nasal spray (1.5 mg/mL) or intravenously or subcutaneously (0.3 µg/kg).
  • Fluids are to be restricted for 24 hours following the dose to avoid hyponatremia.
  • Preferred regimen (1) IV: 0.3 mcg/kg in 50 mL saline over 20 minutes

VWF concentrates containing all VWF multimers

  • Patients with type 3 VWD, more severe type 1, and those with types 2A, 2B, and 2M disease will need replacement therapy with a VWF-containing product,.
  • Patients with more serious bleeding when other measures have failed.
  • In those patients who require more prolonged treatment like post-surgery
  • Major bleeding or surgery: Preferred regimen : 40 to 60 ristocetin cofactor units/kg followed by 20 to 40 ristocetin cofactor units/kg every 12 to 24 hours to keep VWF level 50 to 100 international units/dL for 7 to 14 days,
  • Minor bleeding or surgery: Preferred regimen: 30 to 60 ristocetin cofactor units/kg followed by 20 to 40 ristocetin cofactor units/kg every 12 to 48 hours to keep VWF level >30 international units/dL for 3 to 5 days,
  • Cryoprecipitate can also be used to treat vWD, since cryoprecipitate contains factor I, factor VIII, and vWF.

Antifibrinolytic agents: Aminocaproic acid,Tranexamic acid

  • Used alone or in conjunction with other therapy except DDAVP.
  • Useful for mucosal bleeding specially for dental procedures.
  • Use after trial of DDAVP or other measures in patients with acquired von Willebrand syndrome (aVWS), particularly when associated with autoimmune diseases.
  • May be used in conjunction with VWF concentrates to increase the half-life of VWF.
  • Preferred regimen (1) : Aminocaproic acid, 25 to 50 mg/kg PO, QID (maximum 5 g dose)
  • Preferred regimen (2) : Tranexamic acid, 10 mg/kg, I/V TDS.

For women with heavy menstrual bleeding, the combined oral contraceptive pill may be effective in reducing bleeding or in reducing the length or frequency of periods.

References

  1. Borel-Derlon A, Federici AB, Roussel-Robert V, Goudemand J, Lee CA, Scharrer I; et al. (2007). "Treatment of severe von Willebrand disease with a high-purity von Willebrand factor concentrate (Wilfactin): a prospective study of 50 patients". J Thromb Haemost. 5 (6): 1115–24. doi:10.1111/j.1538-7836.2007.02562.x. PMID 17403090.
  2. Lethagen S, Carlson M, Hillarp A (2004). "A comparative in vitro evaluation of six von Willebrand factor concentrates". Haemophilia. 10 (3): 243–9. doi:10.1111/j.1365-2516.2004.00893.x. PMID 15086321.
  3. Leissinger C, Carcao M, Gill JC, Journeycake J, Singleton T, Valentino L (2014). "Desmopressin (DDAVP) in the management of patients with congenital bleeding disorders". Haemophilia. 20 (2): 158–67. doi:10.1111/hae.12254. PMID 23937614.
  4. Lavin M, O'Donnell JS (2016). "New treatment approaches to von Willebrand disease". Hematology Am Soc Hematol Educ Program. 2016 (1): 683–689. doi:10.1182/asheducation-2016.1.683. PMID 27913547.
  5. Castaman G, Goodeve A, Eikenboom J, European Group on von Willebrand Disease (2013). "Principles of care for the diagnosis and treatment of von Willebrand disease". Haematologica. 98 (5): 667–74. doi:10.3324/haematol.2012.077263. PMC 3640108. PMID 23633542.

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