Sequential Use of Recombinant Porcine Factor VIII and Early Emicizumab in Acquired Hemophilia A: A Case Series.

Background: Acquired hemophilia A (AHA) is a rare autoimmune bleeding disorder requiring prompt hemostatic control and sustained prevention of rebleeding. Recombinant porcine factor VIII (rpFVIII, susoctocog alfa) controls acute bleeding, while emicizumab provides prophylaxis. Real-world data on their sequential use are limited. Objective: To describe clinical outcomes of three patients with AHA who received rpFVIII for initial hemostasis followed by early emicizumab. Methods: This case series describes three adults with AHA who received 200 U/kg rpFVIII for acute bleeding, early emicizumab loading on Days 2-3 followed by weekly maintenance, and individualized prednisolone. FVIII activity and inhibitor titers were measured using an emicizumab-neutralized assay with anti-idiotype antibodies. Results: Single-dose rpFVIII achieved hemostasis within 24 h in all patients. No breakthrough bleeding, thrombosis, or adverse events occurred. Inhibitor titers decreased under immunosuppression. Two patients showed FVIII recovery by Day 49. One patient with persistently low FVIII activity remained stable on emicizumab. Hemostasis was achieved even in one patient with a baseline inhibitor titer of 105.8 BU/mL. Conclusions: Sequential rpFVIII followed by early emicizumab maintained bleeding control until inhibitor reduction and FVIII recovery occurred. This strategy was feasible and safe in these three patients. Larger studies are needed. Trial Registration: The authors have confirmed clinical trial registration is not needed for this submission.