Wolfgang Miesbach: The Most Underappreciated Challenges in Haemophilia Care Tackled at WFH 2026
Wolfgang Miesbach, Professor of Medicine at Frankfurt University Hospital, shared a post on LinkedIn:
”WFH 2026 World Congress, Kuala Lumpur.
Today, Giancarlo Castaman tackled one of the most underappreciated challenges in haemophilia care: what do we do when a patient on non-factor therapy (NFT) needs emergency surgery?
As emicizumab, concizumab, marstacimab and fitusiran reach more patients, perioperative scenarios are becoming increasingly complex – and in an emergency, the stakes could not be higher.
Emicizumab
- rFVIIa preferred over aPCC – aPCC at >100 U/kg for ≥24h carries TMA/thrombosis risk (HAVEN 1)
- 233 surgeries in HAVEN 1–4: 83% major cases managed with CFC/BPA, 80% without post-op bleeding. No deaths, no thrombosis, no new FVIII inhibitors
- Real-world data from Florence (75 surgeries) confirm these results
- Critical: aPTT and one-stage FVIII assays uninterpretable on emicizumab – only FVIII chromogenic assay with bovine reagents is reliable
Concizumab (Explorer 7/8)
- Stop ≥4 days pre-op for major surgery, continue for minor procedures – 44 surgeries, no safety signals
Marstacimab
Stop 8–11 days pre-op for major surgery — 25 surgeries incl. one urgent orthopedic case, no safety issues
Fitusiran
- AT supplementation + low-dose CFC – 78% reduction in CFC need across 60 surgeries
- Two post-op DVTs: thrombotic vigilance remains mandatory
Therefore, NFTs do not eliminate the need for replacement therapy.
Structured guidance exists for emicizumab – for newer rebalancing agents, data granularity remains insufficient and management must be individualized.
The haemophilia treatment centre, its expertise and close patient follow-up remain irreplaceable.”
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