Personalized Treatment of Hemophilia: Matching Therapies to Patient Needs in a Rapidly Evolving Landscape

The therapeutic landscape of hemophilia, a rare inherited bleeding disorder, has rapidly evolved, introducing several novel modalities: extended half-life (EHL) coagulation factor concentrates, non-factor therapies, hemostasis-rebalancing agents, and gene therapy. These advances have improved clinical outcomes by reducing bleeding and treatment burden. However, individualizing treatment in routine practice has become more complex. This narrative review aims to provide a practical summary of available treatment options for pharmacologists, policymakers, and other readers who are not hemophilia specialists. A practical decision framework integrates available data with the clinical indication (regular prophylaxis, management of breakthrough bleeding, and perioperative care), patient-specific modifiers (age, lifestyle, inhibitor status, venous access, joint phenotype, comorbidities, and thrombosis risk). Drug therapies are discussed according to clinical evidence, including pivotal phase 3 trials, long-term extension studies, real-world data, and late-stage development programs. Factor replacement remains critical for hemostatic control during acute bleeding, surgery, and other interventions where predictable and measurable exposure is needed, whereas non-factor and rebalancing therapies provide low-burden prophylactic alternatives with distinct safety profiles and monitoring challenges. Direct comparisons between treatment classes are limited, making treatment individualization essential. Gene therapy has demonstrated more durable outcomes in hemophilia B than in hemophilia A. This review supports shared decision-making and individualized treatment selection in modern hemophilia care. While clinical trial evidence is limited by the scarcity of head-to-head comparisons and incomplete integration of real-world determinants, registry data collection will be essential.