This has been interpreted to be maintaining a baseline factor level >1%. Given impending product advances and taking note that normal FVIII/FIX activity is 50%–150%, it may be time to consider whether a 1% target is sufficient to prevent bleeding or if it is simply conveniently based on existing economics and treatment protocol burdens (frequency of dosing and venous access). Although it may seem impossible to imagine, based on currently available therapies, the paradigm may shift to a point were treatment goals could more closely mimic a ABC294640 chemical structure normal state. Recognition of the significance and benefit of preventing sub-clinical

bleeds (microhemorrhages) may be an important factor in optimizing long-term outcomes [40]. Until recently, there has been little evidence to suggest a baseline FVIII/FIX level >1% might be preferred for some patients. A recent analysis of low frequency bleeding data demonstrated the association between joint bleeds and baseline FVIII check details activity levels. Clinical data on bleeding according to baseline FVIII levels suggest that absence of joint bleeding may only be reached when approaching FVII levels of 15% [41,42]. Patients with low baseline factor

levels (<5%) had the highest risk for joint bleeds, and patients with clotting factor activity levels of 10% and higher had a very low risk, which approximated no expected joint bleeds in patients with baseline factor activity of 15% and higher. The analysis also demonstrated an 18% reduction in joint bleed frequency with every percent increase MCE in residual clotting factor activity in moderate and mild patients treated on demand [42]. With FVIII/FIX activity levels of 1% significant care is still required in daily living thus limiting the ability for full social integration equivalent to someone without a bleeding disorder. It is wholly insufficient to accommodate major or accidental trauma causing bleeding. The fear of traumatic injury remains a constant. Although advances over the past 50 years have brought us closer to the opportunity of having a near normal life expectancy, over time, future generations of patients should aspire to achieve full integration opportunities

in all aspects of life. Improving patient quality of life should drive treatment decisions, not economics. Although theoretically a trough level of 15% may be ideal to achieve the absence of joint bleeding, it is, in the near term, unattainable given economic constraints on demand. However, we should aspire to an absence of joint bleeds. Moving forward incrementally from 1% to higher baseline factor levels (e.g. 3% or 5%) would be a step in the right direction. Prophylaxis, even as currently practiced in countries where there are no significant resource constraints, is an expensive treatment and is only possible if significant resources are allocated to haemophilia care. The high cost is a barrier to widespread acceptance of prophylaxis globally [40].