E Berntorp

Skåne University Hospital, Malmö, Skåne, Sweden

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Publications (218)958.64 Total impact

  • Haemophilia 08/2014; · 3.17 Impact Factor
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    ABSTRACT: Haemophilia A is a sex-linked disorder characterised chiefly by recurrent, spontaneous joint and muscle bleedings resulting from deficiency of factor VIII (FVIII). Recurrent joint bleeds result in haemophilic arthropathy. Unless treated with factor replacement therapy, many patients with severe haemophilia become disabled. The first clinical evidence favouring prophylaxis originated from the studies in Sweden and the Netherlands in the 1960s. Later on, it was shown that prophylaxis could prevent arthropathy, if started early in life, or slow its progression in adults with established arthropathy. The optimal dosing of FVIII in long-term prophylaxis has still not been determined, and there is growing evidence that the dose and frequency of FVIII should be individualised. We conducted a systematic search of PubMed to identify all relevant articles on FVIII prophylaxis in severe haemophilia A. We focused on articles with detailed information about individualisation of prophylaxis. Long-term prophylaxis in haemophilia was introduced in Sweden in the late 1950s. However, standard prophylactic regimens may not be appropriate for all patients with severe haemophilia. Factors such as age, joint status, co-morbidities and differences in pharmacokinetics lead to interindividual variation in factor requirement. Dose tailoring of FVIII by clinical outcome was first described in 1994. Since then, several dose-finding studies questioned the necessity to maintain preinfusion levels of FVIII above 1%. Individualising prophylaxis by dose tailoring is now recommended. Each country should adopt policies for individualising prophylaxis in patients with severe haemophilia. This would lead to a better distribution of the available source of factor concentrates.
    European journal of haematology. Supplementum 08/2014; 76:16-20.
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    ABSTRACT: Detailed analysis of data from studies of recombinant antihemophilic factor produced using a plasma/albumin-free method (rAHF-PFM) in previously treated patients showed a substantial level of interpatient variation in pharmacokinetics (PKs), factor VIII dosing, and annualized bleed rate (ABR), suggesting that individual patient characteristics contributed to outcome. For example, plasma half-life (t1/2), recovery, and clearance appeared to differ between patients aged <6 years and 10-65 years. Prophylaxis resulted in lower ABRs than episodic treatment in both age groups; better adherence to the prophylactic regimen resulted in a lower ABR in patients aged 10-65 years. The weekly frequency of dosing and adherence to dosing were both significantly and inversely related to the rate of bleeding (young children, P<0.0001 for both all bleeds and joint bleeds; older patients, P<0.0001 for all bleeds and P<0.05 for joint bleeds), as was adherence to dosing frequency (P<0.0001 for all comparisons). A post-marketing randomized study of prophylaxis demonstrated that a PK-guided dosing regimen, based on an individual patient's rAHF-PFM PK (infusion interval, estimated t1/2, and recovery), was as effective as standard prophylaxis and that both prophylactic regimens were superior to episodic treatment with respect to ABR and quality of life measures. Thus, compared with standard prophylaxis, the PK-guided regimen achieved comparable efficacy with fewer weekly infusions. A two-compartment population PK model describes the PK data across the entire age range and forms the basis for future PK-guided therapy with rAHF-PFM. The model confirmed a shorter t1/2 and faster clearance of rAHF-PFM in children <6 years of age versus patients ≥10 years and predicted similar PK parameters with either a full or reduced blood sampling schedule, offering the potential for the use of PK-guided, individualized treatment in the routine clinical care setting.
    Targets & therapy 01/2014; 8:115-127.
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    ABSTRACT: Haemophilia is an X-linked inherited rare bleeding disorder affecting mainly men. The treatment consists of replacement therapy that has been associated with severe side effects, such as blood transmitted viral infections, but has markedly improved over the last decades. The aim of this study was to study family structure over time among Swedish persons with haemophilia (PWH), focusing on children, siblings and marital status. PWH A or B were identified from the haemophilia centres and the national Patient Registry. Each PWH was compared to five age- and gender-matched controls. The national Multi-Generation Registry was used to identify children and siblings. A total of 1365 children with a father suffering from haemophilia A or B and 1938 siblings of the PWH were identified. Having one or more children was significantly less common (P = 0.003) for PWH than for controls. Significantly lower rates of having a child were also found for the subgroups of persons suffering from severe haemophilia and those infected with HIV (P < 0.001). A higher proportion of PWH, with or without HIV and/or viral hepatitis had siblings compared to the controls (P < 0.001). However, the mean number of siblings was significantly lower for persons with severe haemophilia (P = 0.001). The number of marriages and divorces did not differ between PWH and controls. Our data indicate a negative impact of HIV and viral hepatitis on family structure for PWH despite the relatively good access to treatment in Sweden over the last few decades. This was particularly true for those with a severe form of haemophilia.
    Haemophilia 12/2013; · 3.17 Impact Factor
  • E Berntorp
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    ABSTRACT: The concept of using pharmacokinetics for prophylactic dose tailoring with limited blood sampling in clinical practice has been demonstrated for factor VIII but not for factor IX. The pharmacokinetics of factor IX are more complicated than for factor VIII and also differ between plasma-derived and recombinant factor IX. Therefore, the pharmacokinetics of factor IX need to be further explored in clinical trials including comparative studies of prophylaxis with different factor IX concentrates. These are the main conclusions drawn from two of the last manuscripts written by Professor Sven Björkman and published in Haemophilia. Professor Björkman suddenly and unexpectedly died last summer. Thanks to the academic network created around his skill and through his enthusiasm for the pharmacokinetics of clotting factors and ability to convey his wisdom to others, this work will continue. Sven Björkman opened a new era in hemophilia prophylaxis.
    Haemophilia 11/2013; 19(6):805-7. · 3.17 Impact Factor
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    ABSTRACT: Patients with haemophilia A and inhibitors are at high risk for severe bleeding, progression of joint disease and deterioration of health-related quality of life (HRQoL). To determine the impact of prophylaxis with an activated prothrombin complex concentrate (aPCC) on HRQoL, HRQoL was assessed using the Short-Form (SF)-36 Health Survey and the EQ-5D questionnaire in subjects ≥14 years participating in a prospective, randomized, crossover study comparing 6 months of aPCC prophylaxis with 6 months of on-demand therapy. Eighteen of 19 patients completed the survey or questionnaire before and after the on-demand therapy and prophylaxis periods. A general trend towards improved HRQoL after prophylaxis was observed for the 18 evaluable patients in all SF-36 dimensions except for vitality/energy and physical functioning. After prophylaxis, 'good responders,' defined as patients experiencing ≥50% reduction in bleeding, exhibited statistically and clinically significant differences in the physical component score (P = 0.021), role - physical (P = 0.042), bodily pain (P = 0.015), and social functioning (P = 0.036). Similarly, the EQ-5D health profile showed a trend towards improvement after prophylaxis in all evaluable patients. Among the good responders, improvements did not differ from those observed after on-demand treatment. EQ visual analogue scale values were slightly improved following prophylaxis for all evaluable patients and the EQ-5D utility index improved in the good responders only. During prophylaxis, patients missed significantly fewer days from school or work because of bleeding than during on-demand treatment (P = 0.01). In conclusion, by significantly reducing bleeding frequency in good responders, aPCC prophylaxis improved HRQoL compared with on-demand treatment.
    Haemophilia 06/2013; · 3.17 Impact Factor
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    Haemophilia 05/2013; · 3.17 Impact Factor
  • E Berntorp
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    ABSTRACT: Venous thromboembolism is common in the general population with increasing age as one of the most important risk factors. The care of hemophilia and von Willebrand disease has improved in recent decades, resulting in the expectation of a growing population of aging people with these disorders. Thrombosis seems rare in hemorrhagic disorders but studies documenting the true epidemiology are virtually lacking. Events have been reported, however, primarily catheter-related thrombophlebitis in hemophilia, but also deep vein thrombosis and pulmonary embolism have been described in von Willebrand disease, usually in conjunction with major surgery and prolonged replacement therapy with high factor levels. Thromboprophylaxis is likely not warrented in most cases. Instead, well-designed therapy and careful monitoring are important measures to prevent risk. In von Willebrand disease particularly, the variation of the phenotype and products used for replacement are challenges, as infusion of von Willebrand factor will increase the endogenous level of factor VIII. Long-term replacement therapy into old age is becoming more common in hemophilia but will not increase occurrence of thromboembolic disease, as factor levels still will be low and have a preventive effect.
    Minerva medica 04/2013; 104(2):169-73. · 0.77 Impact Factor
  • Haemophilia 03/2013; · 3.17 Impact Factor
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    E Berntorp
    Haemophilia 03/2013; 19(2):163-5. · 3.17 Impact Factor
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    ABSTRACT: The first meeting of international specialists in the field of von Willebrand disease (VWD) was held in the Åland islands in 1998 where Erik von Willebrand had first observed a bleeding disorder in some members of a family from Föglö and a summary of the meeting was published in 1999. The second meeting was held in 2010 and a report of the meeting was published in 2012. Topics covered included progress in understanding of VWD over the last 50 years; multimers; classification of VWD; pharmacokinetics and laboratory assays; genetics; treating the paediatric patient; prophylaxis; geriatrics; gene therapy and treatment guidelines. This third meeting held over 3 days covered the structure and function of von Willebrand factor (VWF); type 1 VWD, the most common form of the disease; a lifespan of pharmacokinetics in VWD; detecting inhibitors in VWD patients; and special challenges in understanding and treating the female VWD patient.
    Haemophilia 03/2013; 19(s3). · 3.17 Impact Factor
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    ABSTRACT: Sweden has been a pioneer in the treatment of haemophilia, with the first concentrate available in the 1950s. Treatment has improved over the years to its current state-of-the art. The aim of the current study was to evaluate the long-term outcome of haemophilia in terms of incidence, morbidity and mortality. Patients diagnosed with haemophilia A or B registered at the national haemophilia centres and/or the Patient Registry and born before 2009 and alive in 1968 were enrolled and linked to the Cause of Death-, Migration- and Medical Birth registries. Five age- and sex-matched controls were selected for each patient. A total of 1431 patients with haemophilia A or B were compared with 7150 controls. The 3-year moving average incidence rate per 100 000 population varied between 21 and 36. The hazard ratio for all-cause mortality compared with controls was 2.2, 95% CI: [1.8; 2.7], P < 0.001 for the entire group of patients and 1.7, 95% CI: [1.3; 2.2], P < 0.001 when patients with HIV and/or viral hepatitis were excluded. The corresponding figures for the severe haemophilia subgroup were 6.6, 95% CI: [4.5; 10.0], P < 0.001 and 8.2, 95% CI [3.2; 20.8], P < 0.001 respectively. The most common causes of death were related to malignancies and the haemostatic defect. People with haemophilia were 57% less likely to die from ischaemic heart disease than controls. People with haemophilia in Sweden demonstrate higher mortality over time, independent of HIV and viral hepatitis, despite relatively advantageous access to clotting factor concentrates.
    Haemophilia 02/2013; · 3.17 Impact Factor
  • Erik Berntorp
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    ABSTRACT: Long-term prophylaxis is not as well known in Von Willebrand disease (VWD) as in hemophilia but attempts to evaluate prophylaxis scientifically in VWD have started. A few cohort studies have been reported. In an international effort the Von Willebrand disease prophylaxis network (VWD PN) has been formed to investigate the role of prophylaxis in clinically severe VWD (e.g., patients with type 3 VWD) that is nonresponsive to other treatments. Findings from the VWD PN studies will hopefully provide more robust evidence for which patients might best benefit from prophylaxis and for appropriate dosing regimens for prophylaxis in patients with VWD. Pediatr Blood Cancer 2012; 60: S34–S36. © 2012 Wiley Periodicals, Inc.
    Pediatric Blood & Cancer 01/2013; 60(S1). · 2.35 Impact Factor
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    ABSTRACT: Ancestral background, specifically African descent, confers higher risk for development of inhibitory antibodies to factor VIII (FVIII) in haemophilia A. It has been suggested that differences in the distribution of FVIII gene (F8) haplotypes, and mismatch between endogenous F8 haplotypes and those comprising products used for treatment could contribute to risk. Data from the Hemophilia Inhibitor Genetics Study (HIGS) Combined Cohort were used to determine the association between F8 haplotype 3 (H3) vs. haplotypes 1 and 2 (H1 + H2) and inhibitor risk among individuals of genetically determined African descent. Other variables known to affect inhibitor risk including type of F8 mutation and human leucocyte antigen (HLA) were included in the analysis. A second research question regarding risk related to mismatch in endogenous F8 haplotype and recombinant FVIII products used for treatment was addressed. Haplotype 3 was associated with higher inhibitor risk among those genetically identified (N = 49) as of African ancestry, but the association did not remain significant after adjustment for F8 mutation type and the HLA variables. Among subjects of all racial ancestries enrolled in HIGS who reported early use of recombinant products (N = 223), mismatch in endogenous haplotype and the FVIII proteins constituting the products used did not confer greater risk for inhibitor development. Haplotype 3 was not an independent predictor of inhibitor risk. Furthermore, our findings did not support a higher risk of inhibitors in the presence of a haplotype mismatch between the FVIII molecule infused and that of the individual.
    Haemophilia 09/2012; · 3.17 Impact Factor
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    ABSTRACT: von Willebrand's disease (VWD) is probably the most common bleeding disorder, with some studies indicating that up to 1% of the population may have the condition. Over recent years interest in VWD has fallen compared to that of haemophilia, partly the result of focus on blood-borne diseases such as HIV and hepatitis. Now the time has come to revisit VWD, and in view of this some 60 international physicians with clinical and scientific interest in VWD met over 4 days in 2010 in the Åland islands to discuss state-of-the-art issues in the disease. The Åland islands are where Erik von Willebrand had first observed a bleeding disorder in a number of members of a family from Föglö, and 2010 was also the 140th anniversary of his birth. This report summarizes the main papers presented at the symposium; topics ranged from genetics and biochemistry through to classification of VWD, pharmacokinetics and laboratory assays used in the diagnosis of the disease, inhibitors, treatment guidelines in different age groups including the elderly who often have comorbid conditions that present challenges, and prophylaxis. Other topics included managing surgeries in patients with VWD and the role of FVIII in VWF replacement, a controversial subject.
    Haemophilia 09/2012; 18 Suppl 6:1-13. · 3.17 Impact Factor
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    ABSTRACT: The bleeding patterns of severe von Willebrand's disease (VWD) adversely affect quality of life, and may be life threatening. There is a presumed role for prophylaxis with VWF-containing concentrates, but data are scarce. The von Willebrand Disease Prophylaxis Network (VWD PN) was formed to investigate the role of prophylaxis in clinically severe VWD that is not responsive to other treatment(s).Using a retrospective design, the effect of prophylaxis was studied. Availability of records to document, or reliably assess, the type and frequency of bleeding episodes prior to, and after, the initiation of prophylaxis was required. Annualized bleeding rates were calculated for the period prior to prophylaxis, during prophylaxis and by primary bleeding indication defined as the site accounting for more than half of all bleeding symptoms. The Wilcoxon signed-rank test of differences in the medians was used. Sixty-one subjects from 20 centres in 10 countries were enrolled. Data for 59 were used in the analysis. The median age at onset of prophylaxis was 22.4 years. Type 3 VWD accounted for the largest number (N = 34, 57.6%). Differences in bleeding rates within individuals during compared with before prophylaxis were significant for the total group (P < 0.0001), and for those with primary bleeding indications of epistaxis (P = 0.0005), joint bleeding (P = 0.002) and GI bleeding (P = 0.001). The effect of prophylaxis was similar among those age < 18 years and those ≥18. One person developed an inhibitor during treatment. We conclude that prophylactic treatment of VWD is efficacious.
    Haemophilia 07/2012; · 3.17 Impact Factor
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    ABSTRACT: Antibodies directed towards non-neutralizing epitopes on the factor VIII protein (FVIII) may be detected in patients with haemophilia A. We evaluated the prevalence of non-neutralizing antibodies, in 201 inhibitor-negative brother pairs with severe haemophilia A, enrolled in the Malmö International Brother Study and the Haemophilia Inhibitor Genetics Study. To evaluate binding specificity of the antibodies, ELISA plates were coated with two recombinant full-length (FL) FVIII-products and one recombinant B-domain-deleted (BDD) product. Seventy-nine patients (39.3%) had a history of positive inhibitor titre measured by Bethesda assay, and FVIII antibodies were detected in 20 of them (25.3%). Additional 23 samples from subjects without a history of FVIII inhibitors were ELISA-positive corresponding to a frequency of non-neutralizing antibodies of 18.9%. The antibody response towards the different FVIII products was heterogenous, and was raised not only towards the non-functional B-domain but also towards both FL-rFVIII and BDD-rFVIII. In patients considered successfully treated with immune tolerance induction, 25.4% had remaining FVIII antibodies. The number of families with an antibody response in all siblings was increased when the total antibody response was taken into account, further supporting the concept of a genetic predisposition of the immune response. Further studies and careful monitoring over time are required to appreciate the immune response on the risk of inhibitor development or recurrence in the future.
    Haemophilia 07/2012; · 3.17 Impact Factor
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    ABSTRACT: Background A recent Swedish health technology assessment of replacement treatment strategies in moderate and severe haemophilia, high-lighted the lack of suitable data available for analyzing comparative effectiveness and cost-effectiveness. As a consequence, studies published to date have been limited by retrospective and incomplete data, small sample size, lack of generalization due to specific and narrow target populations, and sometimes inappropriate design. Notably, there is a paucity of data on outcomes of on-demand treatment, which is the only treatment available for many patients in a global perspective. Aims To introduce and present the aims, design and progress of the KAPPA (Key Aspects of medical Practice in Patients with haemophilia A) registry Methods Lund University (LU) has initiated the KAPPA project to collect valid evidence on the impact of treatment regiments on Health Related Quality of Life (HRQL) of haemophilia A patients. We will enrol 1000 patients from 8 different centres in Algeria, Denmark, Norway, Latvia, Lithuania, Sweden, Tunisia and Turkey between February 2013 and January 2016. We use an online Electronic Data Capturing (EDC) system for data collection and storage. KAPPA database is in English and includes questions encompassing the following: socio-demographics, treatment, bleeds, HRQL, Haemophilia Joint Health Score (HJHS), co-morbidities and adverse reactions. Physicians will consecutively enrol eligible patients as they visit the centre. Eligibility criteria include: a Factor VIII activity at diagnosis equal to or less than 5%, the patient must visit the centre at least once a year and provide informed consent. Clinicians have access to their patients’ identifying information for treatment's follow-up, however we will transfer anonymous data for the study. The Ethics Committee (EC) of LU approved the study and separate permissions from EC in each participating country will be obtained. In a multivariate model, we will predict the utility of treatment after adjustment for age, socio-economic status and co-morbidities. Results As of January 2013, we have assessed and confirmed the feasibility of performing the study in each centre, prepared the EDC, and have submitted ethics proposals in the pilot sites. We will implement the pilot study between February and March 2013 with the aim of testing the database’s functions and the study's training package as well as communication process between the centres and study teams. An interim report will be prepared at the end of 2013. Summary/conclusion Prospective registries are the best choice for collecting evidence for research as well as recording patients’ data for better clinical decisions. By providing the infra-structure for collecting and summarizing real world patient data, the KAPPA registry will also assist patients, clinicians and health decision makers. It enables clinicians to develop and maintain a comprehensive and secure haemophilia database for use in the clinic and for future research. Better decisions can be made by clinicians through access to patients’ treatment history. Finally, the final report of KAPPA will enable health decision makers to be better informed when having to make decisions on resource utilization and budget allocation for the haemophilia A treatment. Link to online page: http://www.eventure-online.com/eventure/publicAbstractView.do?id=215098&congressId=6839
    International Society on Thrombosis and Haemostasis (ISTH) 2012, Amsterdam, The Netherlands; 07/2012
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    ABSTRACT: Progress in the evidence-based care of haemophilia A and B worldwide has been historically challenged by the dearth of evaluable outcome data, including but not limited to the safety and effectiveness of therapeutic interventions. These challenges are partially rooted in the inherent difficulty of conducting prospective clinical trials and observational studies with statistically meaningful endpoints in a rare disease such as haemophilia. Despite the logistical barriers, the need for outcome data has never been more critical than in this time of expansive therapeutic advance tempered by the shrinking economic capacity to fund the rapidly increasing cost of treatment. Given that systematic analyses of published literature have been largely unsuccessful in compensating for the lack of rigorous and purposeful data collection, new approaches to clinical study design and statistical modelling are urgently needed. However, even as these are considered, the lack of broadly accepted and well-defined clinical outcome endpoints poses an additional barrier to progress. The three presentations encompassed by this paper highlight the timely need for quality data from the perspectives of the clinicians, regulatory agencies and health care funders, and describe the ongoing coordinated efforts by the international haemophilia community to further understand and dismantle the barriers to harmonized and standardized data collection on a global scale using well-defined clinical outcome endpoints.
    Haemophilia 07/2012; 18 Suppl 4:18-23. · 3.17 Impact Factor
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    Erik Berntorp, Kathelijn Fischer, Alec Miners
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    ABSTRACT: Long-term, continuous prophylaxis for haemophilia began at a modest scale during the 1950s and 1960s in Sweden and The Netherlands. In the face of high cost and impediments to the performance of longitudinal, well-designed studies, it was decades before prophylaxis was considered to be the best practice in countries that could afford the cost. In 2007 and 2011, the only prospective randomized studies ever performed confirmed what large cohort studies in Europe had long since shown. Today, focus is on when to start prophylaxis, dosing and when/if to stop. Retrospective comparisons of the Swedish and Dutch cohorts, where different strategies have been used, indicate that a costly, high-dose regimen improves outcome, but not dramatically. A prospective comparison is now underway. Treatment, clinical outcome, clotting factor consumption and socioeconomic parameters will be compared between the two strategies. Results are expected to provide greater insight into the long-term consequences of the different prophylactic treatment strategies. The economic justification for prophylaxis has been addressed in several studies with varying results. While the majority (implicitly) suggest that prophylaxis is not cost effective at conventional willingness to pay for additional units in health thresholds, their results vary markedly. Closer inspection suggests that the primary reasons results differ include different definitions of prophylaxis, clotting factor price, discount rates, choice of outcome measures and time horizon.
    Haemophilia 07/2012; 18 Suppl 4:136-40. · 3.17 Impact Factor

Publication Stats

4k Citations
958.64 Total Impact Points


  • 2010–2013
    • Skåne University Hospital
      Malmö, Skåne, Sweden
  • 1979–2013
    • Lund University
      • • Department of Paediatrics
      • • Department of Endocrinology
      Lund, Skåne, Sweden
  • 2012
    • BloodCenter of Wisconsin
      Milwaukee, Wisconsin, United States
    • National Heart, Lung, and Blood Institute
      • Division of Blood Diseases and Resources
      Maryland, United States
  • 1996–2012
    • Malmö University
      • Department of Cariology
      Malmö, Skåne, Sweden
  • 2011
    • Hannover Medical School
      Hanover, Lower Saxony, Germany
  • 2007–2009
    • University of Verona
      • Section of Internal Medicine
      Verona, Veneto, Italy
    • Mid Sweden University
      Härnösand, Västernorrland, Sweden
  • 2008
    • RHO
      North Carolina, United States
  • 2006
    • University of Milan
      Milano, Lombardy, Italy
  • 2002
    • The Bracton Centre, Oxleas NHS Trust
      Дартфорде, England, United Kingdom
  • 2000
    • Akademiska Sjukhuset
      Uppsala, Uppsala, Sweden
  • 1998
    • Ludwig-Maximilian-University of Munich
      München, Bavaria, Germany
    • Sahlgrenska University Hospital
      Goeteborg, Västra Götaland, Sweden
  • 1988
    • Karolinska University Hospital
      Tukholma, Stockholm, Sweden