CO-34 | SIMPLIFIED PERIOPERATIVE MANAGEMENT WITH N8-GP (TUROCTOCOG ALFA PEGOL) IN MAJOR ABDOMINAL SURGERY IN MILD HEMOPHILIA A WITH SEVERE BLEEDING PHENOTYPE: A CASE REPORT

J. Di Paolo, R. Malizia, M. Luongo, P. Massaro, M. Di Mascio, S. Verna | Immunohematology Service, ASL 02 Abruzzo, Chieti, Italy

Background. Mild hemophilia A (HA; residual FVIII activity 5-40 IU/dL) is characterized by heterogeneous bleeding manifestations that are not always predicted by baseline FVIII levels. Perioperative management should be individualized according to bleeding history, surgical complexity, factor-level monitoring, and pharmacokinetic response. Current WFH guidance recommends near-normal FVIII activity (80-100%) before major surgery, followed by sustained postoperative coverage and close monitoring. Extended half-life FVIII concentrates, including N8-GP (turoctocog alfa pegol), may reduce infusion frequency while maintaining haemostatic protection, as supported by Pathfinder surgical data.
Case Report. We describe the case of a 52-year-old man with mild HA (baseline FVIII approximately 6%) and a severe bleeding phenotype, receiving weekly prophylaxis with N8-GP 5000 IU (~60 IU/kg), who underwent elective laparoscopic cholecystectomy on 19 May 2026. The last prophylactic infusion had been administered 5 days before surgery. Perioperative management consisted of a single preoperative intravenous bolus of turoctocog alfa pegol 5000 IU, serial FVIII activity monitoring using a chromogenic bovine assay, and clinical/laboratory follow-up. FVIII activity reached 222% 30 minutes after infusion and remained above 50% for at least 48 hours (168% at 8h, 117% at 24h, 68% at 48h; Figure 1). One outpatient booster dose was administered after discharge before resumption of the usual prophylactic schedule. No perioperative or postoperative bleeding events occurred, and no adverse events were reported. Hemoglobin and platelet count remained stable until discharge (Hb 15.5 g/dL; platelets 166,000/uL). Haemostatic efficacy was rated as excellent.
Conclusions. This case shows that major abdominal surgery in a patient with mild HA but a severe bleeding phenotype can be managed using an individualized, low-frequency perioperative regimen with turoctocog alfa pegol. A single preoperative bolus provided effective hemostatic coverage for approximately 48 hours, allowing early discharge and reduced treatment burden, with potential advantages in terms of healthcare resource utilization. Although conclusions are limited by the single-case design and require confirmation in larger real-world cohorts, these findings support a phenotype-driven and pharmacokinetic-informed approach to surgical management in hemophilia, particularly when baseline FVIII activity does not fully reflect bleeding risk.