Many of these countries have only identified 25–50% of the expect

Many of these countries have only identified 25–50% of the expected number of PWH in their populations. Identifying the rest and accurately diagnosing them is a major task [27]. With regard to the treatment of those already identified, while support from governments is increasing in many countries, there are challenges related to regular procurement and distribution of CFCs so as to allow access to those who need it [28, 29]. Introduction of the concepts of prophylaxis and making that acceptable to PWH and their families is also a big task. While many of these issues need to be addressed at the bureaucratic, social and educational levels, there is an urgent need to develop suitable models

of replacement therapy that are practical and effective in those circumstances [30]. Until about 5 years BGB324 mw ago, CFC replacement in most developing countries was episodic only. Much of this was done not at home but in hospitals, usually only after large bleeds. Given the wide socioeconomic diversity in the region of the developing world, the doses used varied between <100 IU kg−1 year−1 to about 1500 IU kg−1 yr−1, depending DAPT on availability. Data on long-term outcome were limited and showed generally poor results [31, 32]. This has been confirmed in a recent prospective

observational study [33] which showed that ABR and joint damage did not improve over a wide range of doses from 100–2000 IU kg−1 year−1 given as episodic replacement. These data therefore showed that episodic CFC replacement over a wide range of doses do not meaningfully alter the bleeding profile 上海皓元 and joint damage in severe haemophilia. Good long-term outcome therefore cannot be expected from such treatment protocols. How should healthcare providers in

these countries decide how much CFC to provide in their health budgets for haemophilia? More importantly, what outcomes can they expect with what they will provide? This becomes increasingly relevant in countries that have access to about 1000–2000 IU kg−1 year−1 but think that they cannot implement prophylaxis as per current models? This would include many developing countries as is evident from the WFH annual global survey [27] including some of the larger ones such as Russia, Brazil and South Africa [34, 35]. The important question therefore is whether these countries should continue to practice episodic treatment or move to the best form of prophylaxis that is practical at the quantities available to them. Prophylactic CFC replacement therapy aims at reducing the number of days a PWH is at risk of spontaneous haemorrhage. In a PWH with severe disease, the ‘time at risk’ of bleeding can be considered 100% without any replacement therapy. Now if his factor level is raised to >1%, taken as a marker of successful replacement therapy, then even at 10 IU kg−1 dose−1 given twice a week, a severe PWH reduces this ‘time at risk’ by ~33% (taking a t½ of ~8 h for FVIII).

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