Pharmacokinetic-guided versus standard prophylaxis in hemophilia: a systematic review and meta-analysis.

Background: With population pharmacokinetic (PK) modeling more readily available and PK-guided prophylaxis endorsed by current hemophilia guidelines, we conducted a systematic review to summarize current evidence in the literature.
Objectives: To assess the efficacy of PK-guided compared with non-PK-guided prophylaxis.
Methods: We did not restrict inclusion to specific study design labels and included all studies consisting of at least one distinct cohort arm receiving PK-guided prophylaxis. We searched the following databases from inception to date of search: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, and the EU Clinical Trial Register. Following title, abstract, and full-text screening conducted independently by 2 review authors, we summarized studies qualitatively and synthesized included randomized clinical trials (RCTs) quantitatively by fitting random-effects models.
Results: Search of databases on February 3, 2023, yielded 25 studies fitting our inclusion criteria. Of those, only 2 RCTs and 17 nonrandomized studies included a standard prophylaxis comparator group. Furthermore, risk of bias in the latter was substantial, primarily due to before-after study designs and retrospective comparator groups. Thus, nonrandomized studies were only presented qualitatively. A random-effects meta-analysis of the 2 identified RCT remained inconclusive with regards to bleeding outcomes (ratio of means, 1.15; 95% CI, 0.85-1.56) and factor consumption (ratio of means, 0.82; 95% CI, 0.58-1.18).
Conclusion: Evidence in the literature suggesting a clinical benefit of PK-guided over standard fixed-dose prophylaxis was weak and mainly found in nonrandomized studies limited by lack of concurrent controls, heterogeneity in outcome reporting, small sample sizes, and high risk of bias.
Competing Interests: Declaration of competing interests B.W. and F.M. have no conflicts of interest to declare. C.A. received personal fees for lectures and/or participation in advisory boards from Bayer, CSL Behring, Sobi, Roche, Takeda, LFB, and Novo Nordisk. D.K. has received honoraria for advisory boards from CSL Behring. I.P. is a consultant for CSL Behring and has received honoraria for lectures and advisory board sessions from Bayer, CSL Behring, Pfizer, Roche, Sobi, and Takeda and a research grant to the Institution from CSL Behring and Sobi. O.K. has received honoraria for advisory boards from CSL Behring.
(Copyright © 2023 International Society on Thrombosis and Haemostasis. Published by Elsevier Inc. All rights reserved.)