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. 2021 Jan;27(1):90-99. doi: 10.1111/hae.14212. Epub 2020 Nov 27.


Introduction: Surgery is frequently required in persons with haemophilia A (PwHA). Emicizumab, a bispecific, humanized monoclonal antibody, bridges activated factor (F) IX and FX. Management of patients undergoing surgery while receiving emicizumab is of clinical interest due to paucity of data.

Aim: Review real-world experience of PwHA with/without FVIII inhibitors who required surgery while receiving emicizumab prophylaxis.

Methods: Data regarding peri-operative management, including type of surgery, haemostatic agent use and bleeding complications, were collected for PwHA receiving emicizumab undergoing surgery between 25/10/18 and 31/12/19 at the Indiana Hemophilia and Thrombosis Center. Analyses were exploratory and descriptive.

Results: Twenty minor and five major surgeries were performed in 17 and five patients, respectively. Overall, 9/20 minor surgeries were planned to occur with emicizumab as the sole haemostatic agent; of these, four required additional coagulation factor (2 due to haematomas following port removals, 1 due to oozing at port removal site, 1 due to bleeding following squamous cell carcinoma removal). Three of the 11 minor surgeries with planned additional coagulation factor resulted in non-major bleeds; all were safely managed with additional coagulation factor. All five major surgeries were planned with additional haemostatic agents; there was 1 bleed in a patient undergoing elbow synovectomy with nerve transposition, likely triggered by physical/occupational therapy. There were no major bleeds, thrombotic events or deaths.

Conclusions: Additional haemostatic agent use is safe in PwHA undergoing surgery while receiving emicizumab. Additional data are needed to determine the optimal dosing/length of treatment of additional haemostatic agents to lower bleeding risk.

Keywords: emicizumab; haemophilia; real-world evidence; surgery.

MeSH terms

  • Antibodies, Bispecific* / therapeutic use
  • Antibodies, Monoclonal, Humanized / therapeutic use
  • Blood Coagulation Factors
  • Factor VIII / therapeutic use
  • Hemophilia A* / complications
  • Hemophilia A* / drug therapy
  • Humans


  • Antibodies, Bispecific
  • Antibodies, Monoclonal, Humanized
  • Blood Coagulation Factors
  • emicizumab
  • Factor VIII