If you or a loved one has hemophilia A, you know how important it is to manage bleeding risks—especially when facing major surgery. Emicizumab (brand name Hemlibra®) is a common prophylactic (preventive) treatment for hemophilia A, but how does it work during surgeries like joint replacements or cardiac procedures? A recent literature review (a study that combines findings from multiple research papers) set out to answer this question, focusing on people with hemophilia A without factor VIII inhibitors (antibodies that block standard treatments).
This article breaks down what the review found, why it matters for patients, and what you should discuss with your care team.
What You’ll Learn From This Article
We’ll summarize key findings from the review about:
- How emicizumab is used alongside other treatments during major surgery
- The risk of bleeding or blood clots (thrombotic events) during and after surgery
- What this means for your care if you’re on emicizumab and need surgery
- Gaps in our knowledge that future research should address
A Quick Look at Hemophilia A
Hemophilia A is a genetic disorder where the body doesn’t make enough factor VIII—a protein needed to form blood clots. This leads to frequent or severe bleeding, especially in joints (like knees or elbows) or muscles. For many people, daily or weekly injections of factor VIII (or newer treatments like emicizumab) are used to prevent bleeds (called prophylaxis).
Emicizumab is a bispecific antibody that mimics factor VIII’s role in clotting. Unlike traditional factor VIII replacement, it’s given subcutaneously (under the skin) once a week or less often, making it more convenient for many patients.
Why This Research Is Important
Major surgery (like hip replacements, heart surgery, or cancer procedures) is common for people with hemophilia A—often to treat complications from repeated bleeding (like joint damage) or other health issues. But until now, there hasn’t been a single, comprehensive summary of how emicizumab works during these surgeries.
This review brings together data from 20 studies (including 72 surgeries) to help patients and doctors:
- Understand the safety of emicizumab during surgery
- Plan for bleeding management
- Make informed decisions about treatment
The Core of the Review: Emicizumab and Major Surgery
The review focused on people with hemophilia A without factor VIII inhibitors who were on emicizumab prophylaxis and underwent major surgery. Here’s what it found:
1. Most Surgeries Used Emicizumab + Factor VIII Replacement
Nearly all (66 out of 72) surgeries included factor VIII replacement (the standard treatment for hemophilia A) alongside emicizumab. This is because emicizumab provides ongoing clotting support, but surgery requires extra "boosts" of factor VIII to prevent excessive bleeding.
- Before surgery: Patients got factor VIII to raise their levels to 50–120% (a safe range for clotting).
- During surgery: Factor VIII was given as a bolus (single dose) or continuous infusion.
- After surgery: Factor VIII was continued for 3–20 days to keep levels high as the body heals.
2. Bleeding Events Were Common but Manageable
Fifteen (15) out of 72 surgeries (21%) resulted in bleeding events, including:
- Breakthrough bleeds: Bleeding that happened despite treatment (e.g., after knee replacement)
- Surgical site bleeding: Blood loss from the incision or area being operated on
- Gastrointestinal or urinary bleeding: Rare, but seen in some non-orthopedic surgeries
Most bleeds were treated with additional factor VIII or antifibrinolytic drugs (medicines that prevent blood clots from breaking down). Importantly, no deaths were reported from bleeding.
3. Thrombotic Events (Blood Clots) Were Rare
Only one patient developed a blood clot (a left atrial appendage thrombus after cardiac surgery). This was treated with blood thinners (anticoagulants) and resolved without complications.
4. Emicizumab Was Usually Continued After Surgery
Most patients stayed on emicizumab after surgery, with no reports of new factor VIII inhibitors (a common concern with traditional treatments).
What This Means for Patients and Families
If you’re on emicizumab and facing major surgery, here’s what the review suggests:
1. Emicizumab Is Generally Safe During Surgery
The low rate of severe bleeding or blood clots (and no deaths) suggests emicizumab is a safe option for most people with hemophilia A without inhibitors.
2. Factor VIII Replacement Is Still Key
Emicizumab isn’t a "replacement" for factor VIII during surgery—your team will likely use both to maximize clotting. This is standard practice and has been shown to reduce bleeding risk.
3. Bleeding Can Still Happen—But It’s Manageable
While bleeding events were reported, most were treated successfully with additional factor VIII or antifibrinolytics. Your care team will monitor you closely before, during, and after surgery to catch and treat bleeding early.
4. Personalized Care Is Essential
Every patient is different. Factors like your hemophilia severity, type of surgery, and other health conditions (e.g., heart disease) will affect your treatment plan. Don’t hesitate to ask your doctor about:
- How factor VIII will be used alongside emicizumab
- What to expect for bleeding risk
- Plans for pain management and physical therapy
Gaps in Our Knowledge & Future Research
The review highlighted areas where we still need more information:
- Physical therapy: Few studies reported on post-surgery rehab, even though it’s critical for recovery (especially after joint surgery).
- Long-term outcomes: We don’t know much about how emicizumab affects recovery over months or years.
- Consistent reporting: Studies varied in how they tracked bleeding, clotting, and other outcomes—making it hard to compare results.
Future research will focus on these gaps to improve care for people with hemophilia A undergoing surgery.
Key Points to Remember
- Emicizumab + factor VIII is the standard approach for major surgery in hemophilia A without inhibitors.
- Bleeding risk is low but not zero: Most bleeds are treatable with additional factor VIII.
- Thrombotic events are rare: Only one case was reported in 72 surgeries.
- Personalized care matters: Your treatment plan will depend on your unique needs.
Talk to Your Doctor
This review provides a snapshot of current research, but your care team knows your specific situation best. Before surgery, ask:
- How will emicizumab and factor VIII be combined?
- What steps will be taken to prevent bleeding?
- What should I watch for after surgery (e.g., signs of bleeding or blood clots)?
- How will physical therapy be integrated into my recovery?
By working with your doctor, you can feel confident in your surgery plan and focus on healing.
This article summarizes findings from a 2025 literature review published in Research and Practice in Thrombosis and Haemostasis. For more details, ask your doctor or visit the National Hemophilia Foundation website.