The use of additional hemostatic agents appears to be safe for patients with hemophilia A who are treated with emicizumab prophylaxis while undergoing surgery, according to research published in Haemophilia.

Current data on patients undergoing surgery who are taking emicizumab, a monoclonal antibody that bridges activated factor IX and factor X, is limited. Emicizumab replaces the function of activated factor VIII and was approved for prophylaxis in patients with hemophilia A.

As knowledge surrounding emicizumab treatment and peri-operative management is limited, a team of investigators reviewed real-world evidence on patients with hemophilia A treated with emicizumab, with or without factor VIII inhibitors, who underwent major or minor surgery.

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The authors analyzed data from 25 surgeries in 22 patients at the Indiana Hemophilia and Thrombosis Center in Indianapolis, Indiana; 17 patients underwent 20 minor surgeries and 5 patients each underwent 1 major surgery. The majority of patients (86%) had severe factor VIII deficiency, and 18% had active factor VIII inhibitors at the time of their surgery.

Emicizumab was the only hemostatic agent planned for use in 9 of the 20 minor surgeries, with the most common of these surgeries being port removal (n=8). Five of the portal removals did not require additional hemostatic agents, but 4 required an additional coagulation factor.

Planned additional hemostatic agents were used in 11 minor procedures. All patients who underwent major surgery planned to receive emicizumab and additional hemostatic agents.

No thrombotic events or deaths occurred in any of the patients undergoing surgery and none required red blood cell transfusion.

The authors concluded that prophylactic emicizumab in patients with hemophilia A is safe with other hemostatic agents during surgery. It may be beneficial to follow guidelines for patients with mild hemophilia A for patients not treated with emicizumab.

Patients with mild hemophilia A tend to have additional hemostatic agents before most procedures. The authors noted that breakthrough bleeding is possible, and the decision to use additional hemostatic agents should be based on each patient’s bleeding risk. 

Disclosure: Some authors have declared affiliations with or received grant support from the pharmaceutical industry. Please refer to the original study for a full list of disclosures.


Lewandowska M, Randall N, Bakeer N, et al. Management of people with haemophilia A undergoing surgery while receiving emicizumab prophylaxis: real-world experience from a large comprehensive treatment centre in the US. Haemophilia. Published online November 27, 2020. doi:10.1111/hae.14212