SIPPET is currently ongoing and, to date, 270 (target 300) patients from 21 countries across four continents have been recruited. A major strength of SIPPET is that it is a pragmatic trial (Table 2). Although RCTs are the underlying basis of evidence-based medicine, strict inclusion and exclusion criteria mean Pim inhibitor that patient populations frequently do not accurately reflect

the type of patients who are treated in everyday practice. In contrast, pragmatic trials aim to reflect the variation among patients observed in everyday clinical practice [20]. Pragmatic trials also allow for the application of different treatments to different patients; in this manner, it is the management protocol rather than individual treatment that is the subject of investigation [20]. For example, patients in SIPPET can be treated with prophylaxis which is used widely in Europe but, to generate a result that would apply worldwide, the study protocol also allows for patients to be treated on demand. Among the limitations of SIPPET is the inclusion of patients minimally exposed to blood components who may have a degree of underlying immunological

response relating to their previous product. Moreover, in a Selleckchem AZD1152-HQPA pragmatic trial not all risk factors can be strictly balanced such as use of prophylaxis vs. on demand treatment, treatment intensity and the presence of danger signals. It is hoped that these issues may be overcome by sample size, as this is the largest RCT conducted to date in haemophilia. SIPPET is an independent study organized and conducted by the Angelo Bianchi Bonomi Hemophilia and Thrombosis Center in Milan, Italy. Some major problems that have been encountered during the course of the trial can be summed up in two categories: high costs and local/international http://www.selleck.co.jp/products/erastin.html over-regulation

(Table 3). The challenges of meeting the high costs of conducting a study such as SIPPET are further complicated by the difficulties encountered in obtaining independent funding. Arguably, the single biggest issue in conducting SIPPET has been the competition for patients with trials of recombinant products in PUPs organized and supported by the pharmaceutical industry. The issue of whether the source of FVIII concentrate (plasma-derived or recombinant) affects the incidence of inhibitor development in PUPs remains unsettled. It is anticipated that the results of the ongoing randomized, controlled SIPPET study will help clarify this issue. Meanwhile, there is solid evidence to indicate that switching among FVIII products does not influence inhibitor risk in PUPS or PTPs with haemophilia A. Q. SHI E-mail: [email protected] Although the association between von Willebrand factor (VWF) and FVIII has been investigated for decades, the effect of VWF on the reactivity of anti-FVIII antibodies (inhibitors) remains controversial.