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Chakrabartty A. Structural Basis for Monoclonal Antibody Therapy for Transthyretin Amyloidosis. Pharmaceuticals (Basel) 2024; 17:1225. [PMID: 39338387 PMCID: PMC11435174 DOI: 10.3390/ph17091225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Revised: 08/21/2024] [Accepted: 09/16/2024] [Indexed: 09/30/2024] Open
Abstract
The disease of transthyretin (TTR) amyloidosis (ATTR) has been known since the 1960s, and during the past 60 or so years, there has been a sustained period of steady discoveries that have led to the current model of ATTR pathogenesis. More recent research has achieved major advances in both diagnostics and therapeutics for ATTR, which are having a significant impact on ATTR patients today. Aiding these recent achievements has been the remarkable ability of cryo-electron microscopy (EM) to determine high-resolution structures of amyloid fibrils obtained from individual patients. Here, we will examine the cryo-EM structures of transthyretin amyloid fibrils to explore the structural basis of the two monoclonal antibody therapies for ATTR that are in clinical trials, ALXN-2220 and Coramitug, as well as to point out potential applications of this approach to other systemic amyloid diseases.
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Affiliation(s)
- Avi Chakrabartty
- Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 2M9, Canada
- Proteotoxicity Solutions, Toronto, ON L4K 2E1, Canada
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Lauerer AM, Caravia XM, Maier LS, Chemello F, Lebek S. Gene editing in common cardiovascular diseases. Pharmacol Ther 2024; 263:108720. [PMID: 39284367 DOI: 10.1016/j.pharmthera.2024.108720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 07/29/2024] [Accepted: 09/01/2024] [Indexed: 09/22/2024]
Abstract
Cardiovascular diseases are the leading cause of morbidity and mortality worldwide, highlighting the high socioeconomic impact. Current treatment strategies like compound-based drugs or surgeries are often limited. On the one hand, systemic administration of substances is frequently associated with adverse side effects; on the other hand, they typically provide only short-time effects requiring daily intake. Thus, new therapeutic approaches and concepts are urgently needed. The advent of CRISPR-Cas9 genome editing offers great promise for the correction of disease-causing hereditary mutations. As such mutations are often very rare, gene editing strategies to correct them are not broadly applicable to many patients. Notably, there is recent evidence that gene editing technology can also be deployed to disrupt common pathogenic signaling cascades in a targeted, specific, and efficient manner, which offers a more generalizable approach. However, several challenges remain to be addressed ranging from the optimization of the editing strategy itself to a suitable delivery strategy up to potential immune responses to the editing components. This review article discusses important CRISPR-Cas9-based gene editing approaches with their advantages and drawbacks and outlines opportunities in their application for treatment of cardiovascular diseases.
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Affiliation(s)
- Anna-Maria Lauerer
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Xurde M Caravia
- Department of Molecular Biology, Hamon Center for Regenerative Science and Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Lars S Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Francesco Chemello
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Simon Lebek
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany.
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Huang X, Sun C, Chen H, Zhao C, Lin J. Efficacy and safety of patisiran for ATTRv-PN: a systematic review and meta-analysis. Ther Adv Neurol Disord 2024; 17:17562864241273079. [PMID: 39282636 PMCID: PMC11393801 DOI: 10.1177/17562864241273079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 07/05/2024] [Indexed: 09/19/2024] Open
Abstract
Background Hereditary transthyretin amyloidosis (ATTRv; v for variant) with polyneuropathy is a rare, progressive, and fatal autosomal dominant disorder. Therapies such as liver transplantation and TTR stabilizations have limitations. Patisiran is a small interfering RNA (siRNA), offering potential as a genetic-level therapy for hereditary transthyretin amyloidosis with polyneuropathy (ATTRv-PN). However, evidence on patisiran's efficacy and safety for ATTRv-PN remains limited. Objectives This study aimed to further clarify patisiran's efficacy and safety for ATTRv-PN by meta-analysis. Design Systematic review and meta-analysis. Methods After literature searches in PubMed, Ovid MEDLINE, Embase, JBI EBP, Cochrane, and ClinicalTrials.gov databases on 7 June 2024, 11 studies with 503 patients were included and clinical data were extracted. Results Results showed an 88% (95% confidence interval (CI): 81%-94%) pooled responsiveness rate. The standardized mean difference of modified Neuropathy Impairment Score plus 7 nerve tests (mNIS + 7) scores was -0.18 (95% CI: -0.32 to -0.03, p-value 0.018) and Norfolk Quality of Life-Diabetic Neuropathy was -0.21 (95% CI: -0.35 to -0.08, p-value 0.002). In total, 413 adverse events (AEs) (84.8%), 158 serious AEs (32.4%), and 37 deaths (7.6%) were recorded. Most of AEs were mild to moderate. No deaths were attributed to patisiran. However, there is no statistically significant improvement in Neuropathy Impairment Scores. Conclusion In conclusion, patisiran was effective and safe for patients with ATTRv-PN. More large-scale clinical trials and long-term studies are necessary to further validate patisiran's efficacy and safety. Trial registration PROSPERO registration ID: CRD42023428838.
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Affiliation(s)
- Xinyue Huang
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Chong Sun
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Haofeng Chen
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Chongbo Zhao
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
| | - Jie Lin
- Department of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, 12# Wulumuqi Zhong Road, Shanghai 200040, China
- Rare Disease Center, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
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Bampatsias D, Wardhere A, Maurer MS. Treatment of transthyretin cardiac amyloidosis. Curr Opin Cardiol 2024; 39:407-416. [PMID: 38652263 PMCID: PMC11305969 DOI: 10.1097/hco.0000000000001156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
PURPOSE OF REVIEW Tafamidis is currently the only approved disease-modifying treatment for ATTR-CM. However, there have been important developments in the treatment of ATTR-CM, as the results of two phase 3 trials were published and several other trials are in their final stages. In this review, we summarize current and future therapies for ATTR-CM. RECENT FINDINGS Recently, acoramidis, a TTR stabilizer has been proven to be effective in reducing mortality and morbidity compared to placebo in the ATTRibute-CM trial. Additionally, patisiran, an RNA silencer, preserved functional capacity and quality of life compared to placebo in the APOLLO-B trial. However, the FDA declined to approve patisiran for ATTR-CM. The results of phase 1 trial of ALXN2220, an antiamyloid antibody raise hope for reversal of myocardial damage by amyloid depletion. Phase 3 trials evaluating the efficacy of different RNA silencers, gene editing with CRISPR-Cas9, and other anti-amyloid antibodies are ongoing. SUMMARY Therapies targeting different mechanism in the pathophysiology of ATTR-CM provide new alternatives for treating patients with ATTR-CM. Future research should focus on comparing their effectiveness, the potential of combined treatment with agents from different classes and on identifying the patients who will benefit most from each class of medication.
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Affiliation(s)
- Dimitrios Bampatsias
- Cardiac Amyloidosis Program, Department of Cardiology, Columbia University Irving Medical Center, New York, USA
| | - Abdirahman Wardhere
- Cardiac Amyloidosis Program, Department of Cardiology, Columbia University Irving Medical Center, New York, USA
| | - Mathew S. Maurer
- Cardiac Amyloidosis Program, Department of Cardiology, Columbia University Irving Medical Center, New York, USA
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Hwu WL. Gene therapy for ultrarare diseases: a geneticist's perspective. J Biomed Sci 2024; 31:79. [PMID: 39138523 PMCID: PMC11321167 DOI: 10.1186/s12929-024-01070-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 08/06/2024] [Indexed: 08/15/2024] Open
Abstract
Gene therapy has made considerable strides in recent years. More than 4000 protein-coding genes have been implicated in more than 6000 genetic diseases; next-generation sequencing has dramatically revolutionized the diagnosis of genetic diseases. Most genetic diseases are considered very rare or ultrarare, defined here as having fewer than 1:100,000 cases, but only one of the 12 approved gene therapies (excluding RNA therapies) targets an ultrarare disease. This article explores three gene supplementation therapy approaches suitable for various rare genetic diseases: lentiviral vector-modified autologous CD34+ hematopoietic stem cell transplantation, systemic delivery of adeno-associated virus (AAV) vectors to the liver, and local AAV delivery to the cerebrospinal fluid and brain. Together with RNA therapies, we propose a potential business model for these gene therapies.
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Affiliation(s)
- Wuh-Liang Hwu
- Center for Precision Medicine, China Medical University Hospital, Taichung City, Taiwan.
- Department of Pediatrics and Medical Genetics, National Taiwan University Hospital, Taipei City, Taiwan.
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Llerena-Velastegui J, Zumbana-Podaneva K. Advances in the Diagnosis and Management of Cardiac Amyloidosis: A Literature Review. Cardiol Res 2024; 15:211-222. [PMID: 39205961 PMCID: PMC11349137 DOI: 10.14740/cr1664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 06/10/2024] [Indexed: 09/04/2024] Open
Abstract
Cardiac amyloidosis, increasingly recognized for its significant impact on global heart health and patient survival, demands a thorough review to understand its complexity and the urgency of improved management strategies. As a cause of cardiomyopathy and heart failure, particularly in patients with aortic stenosis and atrial fibrillation, this condition also relates to higher incidences of dementia in the affected populations. The objective of this review was to integrate and discuss the latest advancements in diagnostics and therapeutics for cardiac amyloidosis, emphasizing the implications for patient prognosis. We evaluated the latest literature from major medical databases such as PubMed and Scopus, focusing on research from 2020 to 2024, to gather comprehensive insights into the current landscape of this condition. Insights from our review highlight the complex pathophysiology of cardiac amyloidosis and the diagnostic challenges it presents. We detail the effectiveness of emerging treatments, notably gene silencing therapies like patisiran and vutrisiran, which offer transformative potential by targeting the production of amyloidogenic proteins. Additionally, the stabilization therapy acoramidis shows promise in modifying disease progression and improving clinical outcomes. This review underscores the critical need for updated clinical guidelines and further research to expand access to groundbreaking therapies and enhance disease management. Advocating for continued research and policy support, we emphasize the importance of advancing diagnostic precision and treatment effectiveness, which are vital for improving patient outcomes and addressing this debilitating disease globally.
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Affiliation(s)
- Jordan Llerena-Velastegui
- Medical School, Pontifical Catholic University of Ecuador, Quito, Ecuador
- Research Center, Center for Health Research in Latin America (CISeAL), Quito, Ecuador.
| | - Kristina Zumbana-Podaneva
- Medical School, Pontifical Catholic University of Ecuador, Quito, Ecuador
- Research Center, Center for Health Research in Latin America (CISeAL), Quito, Ecuador.
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Vogel J, Carpinteiro A, Luedike P, Buehning F, Wernhart S, Rassaf T, Michel L. Current Therapies and Future Horizons in Cardiac Amyloidosis Treatment. Curr Heart Fail Rep 2024; 21:305-321. [PMID: 38809394 PMCID: PMC11333534 DOI: 10.1007/s11897-024-00669-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW Cardiac amyloidosis (CA) is a condition characterized by misfolding and extracellular deposition of proteins, leading to organ dysfunction. While numerous forms of CA exist, two subtypes dominate clinical prevalence: Transthyretin amyloid (ATTR) and immunoglobulin light chain amyloid. RECENT FINDINGS The current scientific landscape reflects the urgency to advance therapeutic interventions with over 100 ongoing clinical trials. Heart failure treatment is affected by CA phenotype with poor tolerance of otherwise frequently used medications. Treating comorbidities including atrial fibrillation and valvular disease remains a challenge in CA, driven by technical difficulties and uncertain outcomes. Tafamidis is the first ATTR-stabilizer approved with a rapidly growing rate of clinical use. In parallel, various new therapeutic classes are in late-stage clinical trials including silencers, antibodies and genetic therapy. Managing CA is a critical challenge for future heart failure care. This review delineates the current standard-of-care and scientific landscape of CA therapy.
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Affiliation(s)
- Julia Vogel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Alexander Carpinteiro
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Florian Buehning
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Simon Wernhart
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany.
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Ioannou A, Fumagalli C, Razvi Y, Porcari A, Rauf MU, Martinez-Naharro A, Venneri L, Moody W, Steeds RP, Petrie A, Whelan C, Wechalekar A, Lachmann H, Hawkins PN, Solomon SD, Gillmore JD, Fontana M. Prognostic Value of a 6-Minute Walk Test in Patients With Transthyretin Cardiac Amyloidosis. J Am Coll Cardiol 2024; 84:43-58. [PMID: 38739065 PMCID: PMC11218050 DOI: 10.1016/j.jacc.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND The 6-minute walk test (6MWT) represents a comprehensive functional assessment that is commonly used in patients with heart failure; however, data are lacking in patients with transthyretin cardiac amyloidosis (ATTR-CA). OBJECTIVES This study aimed to assess the prognostic importance of the 6MWT in patients with ATTR-CA. METHODS A retrospective analysis of patients diagnosed with ATTR-CA at the National Amyloidosis Centre who underwent a baseline 6MWT between 2011 and 2023 identified 2,141 patients, of whom 1,118 had follow-up at 1 year. RESULTS The median baseline 6MWT distance was 347 m (Q1-Q3: 250-428 m) and analysis by quartiles demonstrated an increased death rate with each distance reduction (deaths per 100 person-years: 6.3 vs 9.2 vs 13.6 vs 19.0; log-rank P < 0.001). A 6MWT distance of <350 m was associated with a 2.2-fold higher risk of mortality (HR: 2.15; 95% CI: 1.85-2.50; P < 0.001), with a similar increased risk across National Amyloidosis Centre disease stages (P for interaction = 0.761) and genotypes (P for interaction = 0.172). An absolute (reduction of >35 m) and relative worsening (reduction of >5%) of 6MWT at 1 year was associated with an increased risk of mortality (HR: 1.80; 95% CI: 1.51-2.15; P < 0.001 and HR: 1.89; 95% CI: 1.59-2.24; P < 0.001, respectively), which was similar across the aforementioned subgroups. When combined with established measures of disease progression (N-terminal pro-B-type natriuretic peptide progression and outpatient diuretic intensification), each incremental increase in progression markers was associated with an increased death rate (deaths per 100 person-years: 7.6 vs 13.9 vs 22.4 vs 32.9; log-rank P < 0.001). CONCLUSIONS The baseline 6MWT distance can refine risk stratification beyond traditional prognosticators. A worsening 6MWT distance can stratify disease progression and, when combined with established markers, identifies patients at the highest risk of mortality.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Carlo Fumagalli
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom; Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Yousuf Razvi
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Aldostefano Porcari
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom; Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina, University of Trieste, Trieste, Italy
| | - Muhammad U Rauf
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Lucia Venneri
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - William Moody
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Richard P Steeds
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, United Kingdom
| | - Aviva Petrie
- University College London, London, United Kingdom
| | - Carol Whelan
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Helen Lachmann
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom.
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Ozdag Y, Koshinski JL, Carry BJ, Gardner JM, Garcia VC, Dwyer CL, Klena JC, Grandizio LC. A Comparison of Tenosynovial and Transverse Carpal Ligament Biopsy for Amyloid Detection in Open Carpal Tunnel Release. J Hand Surg Am 2024:S0363-5023(24)00210-7. [PMID: 38934987 DOI: 10.1016/j.jhsa.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/16/2024] [Accepted: 05/01/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE Our purpose was to compare differences in the incidence of amyloid deposition in tenosynovium (TS) versus transverse carpal ligament (TCL) biopsies obtained during open carpal tunnel release. We hypothesized that the incidence of amyloid would be similar between TCL and TS when obtaining both specimens from the same patient. METHODS All primary, elective open carpal tunnel release cases that underwent biopsy for amyloid between January 2022 and September 2023 were reviewed. Tenosynovial and TCL specimens were independently evaluated by a pathologist to assess for amyloid. Demographic data were collected, and incidence of amyloid deposition was compared between the two samples. Agreement statistics, sensitivity, and specificity were calculated for TCL, using TS as the reference standard. RESULTS A total of 196 cases met either Tier 1 (n=180) or Tier 2 (n=16) biopsy criteria. Forty-eight cases were excluded for missed biopsies or laboratory processing errors, leaving 148 cases available for analysis. Amyloid deposition was present in 31 out of 148 (21%) TS specimens and 33 out of 148 (22%) TCL specimens. Overall, the results of the TS biopsy agreed with TCL biopsy in 138 out of 148 cases (93%). In the 10 cases for which the results of the TCL and TS biopsy differed, six cases had (+) TCL and (-) TS, and four cases had amyloid deposition in TS without evidence of deposition in the TCL. Sensitivity and specificity values for the TCL specimen were 87% and 95%, respectively. Positive and negative predictive values were 82% and 97%, respectively. CONCLUSIONS For cases of open carpal tunnel release undergoing biopsy, amyloid deposition was noted in 21% of TS specimens and 22% of TCL specimens. Results of TS and TCL biopsies obtained from the same patient agreed in 93% of cases. Single-source biopsy for amyloid represents a reasonable diagnostic approach. Future cost analyses should be performed to determine whether the addition of two biopsy sources to improve diagnostic accuracy is justified. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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Affiliation(s)
- Yagiz Ozdag
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Jessica L Koshinski
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Brendan J Carry
- Department of Cardiology and Heart Institute, Geisinger Health System, Danville, PA
| | - Jerad M Gardner
- Departments of Laboratory Medicine and Dermatology, Geisinger Health System, Danville, PA
| | - Victoria C Garcia
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - C Liam Dwyer
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Joel C Klena
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA
| | - Louis C Grandizio
- Department of Orthopaedic Surgery, Geisinger Commonwealth School of Medicine, Geisinger Musculoskeletal Institute, Danville, PA.
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Ioannou A. Evolution of Disease-modifying Therapy for Transthyretin Cardiac Amyloidosis. Heart Int 2024; 18:30-37. [PMID: 39006464 PMCID: PMC11239131 DOI: 10.17925/hi.2024.18.1.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 05/28/2024] [Indexed: 07/16/2024] Open
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) represents an inexorably progressive and fatal cardiomyopathy. Increased understanding of the underlying pathogenesis responsible for the misfolding of transthyretin and the subsequent accumulation of amyloid fibrils within the myocardium has led to the development of several disease-modifying therapies that act on different stages of the disease pathway. Tafamidis is the first, and to date remains the only, therapy approved for the treatment of ATTR-CA, which, alongside acoramidis, stabilizes the transthyretin tetramer, preventing disaggregation, misfolding and formation of amyloid fibrils. Gene-silencing agents, such as patisiran, vutrisian and eplontersen, and novel gene-editing therapies, such as NTLA-2001, act to reduce the hepatic synthesis of transthyretin. Anti-amyloid therapies represent another strategy in the treatment of ATTR-CA and are designed to bind amyloid fibril epitopes and stimulate macrophage-mediated removal of amyloid fibrils from the myocardium. Many of these treatments are at an early investigational stage but represent an important area of unmet clinical need and could potentially reverse disease and restore cardiac functions even in patients with advanced disease.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
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11
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Nie T. Eplontersen: First Approval. Drugs 2024; 84:473-478. [PMID: 38413492 PMCID: PMC11101359 DOI: 10.1007/s40265-024-02008-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
Eplontersen (Wainua™) is a ligand-conjugated antisense oligonucleotide directed to TTR, which is being developed by Ionis Pharmaceuticals and AstraZeneca for the treatment of TTR-mediated amyloidosis (ATTR). Eplontersen, which is targeted to the liver by a ligand containing three N-acetyl galactosamine residues, binds to wild-type and variant TTR mRNA, thus reducing the levels of circulating TTR protein and amyloid deposition. Subcutaneous eplontersen reduced serum TTR levels, inhibited neuropathy progression and improved health-related quality of life in patients with polyneuropathy of hereditary ATTR (ATTRv-PN; v for variant) in a phase III trial. Based on these results, eplontersen was approved in the USA for the treatment of ATTRv-PN on 21 December 2023 and is currently undergoing regulatory review for a similar indication in the EU, the UK, Switzerland and Canada. Eplontersen is also undergoing phase III development for ATTR cardiomyopathy. This article summarizes the milestones in the development of eplontersen leading to this first approval for ATTRv-PN.
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Affiliation(s)
- Tina Nie
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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12
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Planté-Bordeneuve V, Perrain V. Vutrisiran: a new drug in the treatment landscape of hereditary transthyretin amyloid polyneuropathy. Expert Opin Drug Discov 2024; 19:393-402. [PMID: 38281068 DOI: 10.1080/17460441.2024.2306843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/15/2024] [Indexed: 01/29/2024]
Abstract
INTRODUCTION Hereditary transthyretin (ATTRv) amyloidosis is a progressive, fatal disorder caused by mutations in the transthyretin (TTR) gene leading to deposition of the misfolded protein in amyloid fibrils. The main phenotypes are peripheral neuropathy (PN) and cardiomyopathy (CM). AREAS COVERED Gene silencing therapy, by dramatically reducing liver production of TTR, has transformed ATTRv-PN patient care in the last decade. In this drug discovery case history, the authors discuss the treatment history of ATTRv-PN and focus on the latest siRNA therapy: vutrisiran. Vutrisiran is chemically enhanced and N-acetylgalactosamin-conjugated, allowing increased stability and specific liver delivery. HELIOS-A, a phase III, multicenter randomized study, tested vutrisiran in ATTRv-PN and showed significant improvement in neuropathy impairment, disability, quality of life (QoL), gait speed, and nutritional status. Tolerance was acceptable, no safety signals were raised. EXPERT OPINION Vutrisiran offers a new treatment option for patients with ATTRv-PN. Vutrisian's easier delivery and administration route, at a quarterly frequency, as well as the absence of premedication, are major improvements to reduce patients' disease burden and improve their QoL. Its place in the therapeutic strategy is to be determined, considering affordability.
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Affiliation(s)
- Violaine Planté-Bordeneuve
- Department of Neurology, Henri Mondor University Hospital, AP-HP, Créteil, France
- Mondor Biomedical Research Institute - IMRB, INSERM, U955 Team 10 "Biology of the Neuromuscular System", Créteil, France
| | - Valentine Perrain
- Department of Neurology, Henri Mondor University Hospital, AP-HP, Créteil, France
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13
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Ioannou A, Cappelli F, Emdin M, Nitsche C, Longhi S, Masri A, Cipriani A, Zampieri M, Colio F, Poledniczek M, Porcari A, Razvi Y, Aimo A, Vergaro G, De Michieli L, Rauf MU, Patel RK, Villanueva E, Lustig Y, Venneri L, Martinez-Naharro A, Lachmann H, Wechalekar A, Whelan C, Petrie A, Hawkins PN, Solomon S, Gillmore JD, Fontana M. Stratifying Disease Progression in Patients With Cardiac ATTR Amyloidosis. J Am Coll Cardiol 2024; 83:S0735-1097(24)00251-1. [PMID: 38530684 PMCID: PMC11004588 DOI: 10.1016/j.jacc.2023.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 12/26/2023] [Accepted: 12/28/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND Transthyretin cardiac amyloidosis (ATTR-CA) is a progressive cardiomyopathy. The clinical course varies among individuals and there are no established measures to assess disease progression. OBJECTIVES The goal of this study was to assess the prognostic importance of an increase in N-terminal pro-B-type natriuretic peptide (NT-proBNP) and outpatient diuretic intensification (ODI) as markers of disease progression in a large cohort of patients with ATTR-CA. METHODS We evaluated landmark survival analysis based on worsening of NT-proBNP and requirement for ODI between time of diagnosis and a 1-year visit, and subsequent mortality in 2,275 patients with ATTR-CA from 7 specialist centers. The variables were developed in the National Amyloidosis Centre (NAC) cohort (n = 1,598) and validated in the external cohort from the remaining centers (n = 677). RESULTS Between baseline and 1-year visits, 551 (34.5%) NAC patients and 204 (30.1%) patients in the external validation cohort experienced NT-proBNP progression (NT-proBNP increase >700 ng/L and >30%), which was associated with mortality (NAC cohort: HR: 1.82; 95% CI: 1.57-2.10; P < 0.001; validation cohort: HR: 1.75; 95% CI: 1.32-2.33; P < 0.001). At 1 year, 451 (28.2%) NAC patients and 301 (44.5%) patients in the external validation cohort experienced ODI, which was associated with mortality (NAC cohort: HR: 1.88; 95% CI: 1.62-2.18; P < 0.001; validation cohort: HR: 2.05; 95% CI: 1.53-2.74; P < 0.001). When compared with patients with a stable NT-proBNP and stable diuretic dose, a higher risk of mortality was observed in those experiencing either NT-proBNP progression or ODI (NAC cohort: HR: 1.93; 95% CI: 1.65-2.27; P < 0.001; validation cohort: HR: 1.94; 95% CI: 1.36-2.77; P < 0.001), and those experiencing both NT-proBNP progression and ODI (NAC cohort: HR: 2.98; 95% CI: 2.42-3.67; P < 0.001; validation cohort: HR: 3.23; 95% CI: 2.17-4.79; P < 0.001). CONCLUSIONS NT-proBNP progression and ODI are frequent and consistently associated with an increased risk of mortality. Combining both variables produces a simple, universally applicable model that detects disease progression in ATTR-CA.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Christian Nitsche
- Division of Cardiology, Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Simone Longhi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Ahmad Masri
- OHSU Center for Hypertrophic Cardiomyopathy and Amyloidosis, Portland, Oregon, USA
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy; Cardiology Unit, University Hospital Padua, Padua, Italy
| | - Mattia Zampieri
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Federica Colio
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Michael Poledniczek
- Division of Cardiology, Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Aldostefano Porcari
- National Amyloidosis Centre, University College London, London, United Kingdom; Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Yousuf Razvi
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Alberto Aimo
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Laura De Michieli
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Muhammad U Rauf
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Rishi K Patel
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Eugenia Villanueva
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Yael Lustig
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Lucia Venneri
- National Amyloidosis Centre, University College London, London, United Kingdom
| | | | - Helen Lachmann
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Carol Whelan
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Aviva Petrie
- University College London, Biostatistics Unit, UCL Eastman Dental Institute, London, United Kingdom
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Scott Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, London, United Kingdom.
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14
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Pilotte J, Huang AS, Khoury S, Zhang X, Tafreshi A, Vanderklish P, Sarraf ST, Pulido JS, Milman T. Detection of TTR Amyloid in the Conjunctiva Using a Novel Fluorescent Ocular Tracer. Transl Vis Sci Technol 2024; 13:11. [PMID: 38359019 PMCID: PMC10876017 DOI: 10.1167/tvst.13.2.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 12/15/2023] [Indexed: 02/17/2024] Open
Abstract
Background Transthyretin amyloidosis (ATTR) is a significant cause of cardiomyopathy and other morbidities in the elderly and Black Americans. ATTR can be treated with new disease-modifying therapies, but large shortfalls exist in its diagnosis. The objective of this study was to test whether TTR amyloid can be detected and imaged in the conjunctiva using a novel small-molecule fluorescent ocular tracer, with the implication that ATTR might be diagnosable by a simple eye examination. Methods Three approaches were used in this study. First, AMDX-9101 was incubated with in vitro aggregated TTR protein, and changes in its excitation and emission spectra were quantified. Second, a cadaver eye from a patient with familial amyloid polyneuropathy type II TTR mutation and a vitrectomy sample from an hATTR patient were incubated with AMDX-9101 and counterstained with Congo Red and antibodies to TTR to determine whether AMDX-9101 labels disease-related TTR amyloid deposits in human conjunctiva and eye. Last, imaging of in vitro aggregated TTR amyloid labeled with AMDX-9101 was tested in a porcine ex vivo model, using a widely available clinical ophthalmic imaging device. Results AMDX-9101 hyper-fluoresced in the presence of TTR amyloid in vitro, labeled TTR amyloid deposits in postmortem human conjunctiva and other ocular tissues and could be detected under the conjunctiva of a porcine eye using commercially available ophthalmic imaging equipment. Conclusions AMDX-9101 enabled detection of TTR amyloid in the conjunctiva, and the fluorescent binding signal can be visualized using commercially available ophthalmic imaging equipment. Translational Relevance AMDX-9101 detection of TTR amyloid may provide a potential new and noninvasive test for ATTR that could lead to earlier ATTR diagnosis, as well as facilitate development of new therapeutics.
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Affiliation(s)
| | - Alex S. Huang
- Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, CA, USA
| | | | - Xiaowei Zhang
- Hamilton Glaucoma Center, Shiley Eye Institute, Viterbi Family Department of Ophthalmology, University of California San Diego, La Jolla, CA, USA
| | | | | | | | - Jose S. Pulido
- Vickie and Jack Farber Vision Research Center and MidAtlantic Retina Service, Wills Eye Hospital, Philadelphia, PA, USA
| | - Tatyana Milman
- Vickie and Jack Farber Vision Research Center and MidAtlantic Retina Service, Wills Eye Hospital, Philadelphia, PA, USA
- Pathology Department, Wills Eye Hospital, Philadelphia, PA, USA
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15
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Chen P, Wei Y, Sun T, Lin J, Zhang K. Enabling safer, more potent oligonucleotide therapeutics with bottlebrush polymer conjugates. J Control Release 2024; 366:44-51. [PMID: 38145661 PMCID: PMC10922259 DOI: 10.1016/j.jconrel.2023.12.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 12/27/2023]
Abstract
Oligonucleotide therapeutics have the unique ability to address traditionally undruggable targets through various target engagement pathways. However, despite advances in chemically modified oligonucleotides and carrier-assisted delivery systems such as lipid nanoparticles and protein/peptide conjugates, the development of oligonucleotide drugs is still plagued with lackluster potency, narrow therapeutic window, poor delivery to non-liver target sites, and/or high potential for toxicity and unwanted immune system activation. In this perspective, we discuss an unconventional delivery solution based upon bottlebrush polymers, which overcomes many key challenges in oligonucleotide drug development. We address the molecular basis of the polymer's ability to enhance tissue bioavailability and drug potency, reduce side effects, and suppress anti-carrier immunity. Furthermore, we discuss the potential of the technology in advancing oligonucleotide-based therapies for non-liver targets.
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Affiliation(s)
- Peiru Chen
- Department of Chemistry and Chemical Biology, Northeastern University, Boston, MA 02115, USA
| | - Yun Wei
- Department of Chemistry and Chemical Biology, Northeastern University, Boston, MA 02115, USA
| | - Tingyu Sun
- Department of Chemistry and Chemical Biology, Northeastern University, Boston, MA 02115, USA
| | - Jiachen Lin
- Department of Chemistry and Chemical Biology, Northeastern University, Boston, MA 02115, USA
| | - Ke Zhang
- Department of Chemistry and Chemical Biology, Northeastern University, Boston, MA 02115, USA; Department of Chemical Engineering and Bioengineering, Northeastern University, Boston, MA 02115, USA.
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16
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Rinaldi M, Tranfa F, Chiosi F, Campagna G, De Bernardo M, Gioia M, Natale F, Caiazza M, Dongiglio F, Verrillo F, Palmiero G, Limongelli G, Costagliola C. OCT angiography indices and the choroidal vascularity index in wild-type transthyretin (TTR) amyloidosis (ATTRwt). Front Med (Lausanne) 2024; 10:1174643. [PMID: 38288300 PMCID: PMC10823855 DOI: 10.3389/fmed.2023.1174643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 11/27/2023] [Indexed: 01/31/2024] Open
Abstract
Purpose Retinal angiopathy represents a well-known ocular manifestation of hereditary transthyretin amyloidosis (ATTRv). Until recently, there have been no reports on retinal changes in ATTRwt. In this retrospective observational clinical study, we aimed to determine whether vessel density (VD) indices and the choroidal vascularity index (CVI) could offer insights into retinal and choroidal vascular changes among patients affected by ATTRwt. Methods Eighteen patients with a confirmed diagnosis of ATTRwt underwent structural optical coherence tomography (OCT) and OCT angiography (OCTA). We established a control group consisting of 16 healthy subjects for statistical comparisons. The 3D OCT and OCTA datasets were analyzed to assess retinal and choroidal thickness and VD. For measuring CVI, we obtained measurements for the total choroid area (TCA), luminal area (LA), and stromal area (SA). Results The mean VD exhibited a statistically significant reduction in the superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillaris (CC) among the ATTRwt group in comparison to the control group (p < 0.0001). Notably, ATTRwt patients displayed decreased choroidal thickness (p = 0.08). Additionally, the median CVI was lower in the ATTRwt group than in the control group (p = 0.04). Conclusion The indices from OCTA and CVI have the potential to serve as non-invasive biomarkers for the quantitative evaluation of retinal and choroidal vascular involvement in patients with ATTRwt.
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Affiliation(s)
- Michele Rinaldi
- Department of Ophthalmology, Università degli studi della Campania “Luigi Vanvitelli”, Naples, Italy
| | - Fausto Tranfa
- Department of Neuroscience, Reproductive and Dentistry Sciences, Federico II University of Naples, Naples, Italy
| | - Flavia Chiosi
- Department of Ophthalmology, Azienda Ospedaliera dei Colli, Monaldi Hospital, Naples, Italy
| | - Giuseppe Campagna
- Department of Medical-Surgical Sciences and Translational Medicine, University of Rome “Sapienza”, Rome, Italy
| | - Maddalena De Bernardo
- Eye Unit, Department of Medicine Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, Italy
| | - Marco Gioia
- Eye Unit, Department of Medicine Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Baronissi, Italy
| | - Francesco Natale
- Department of Cardiothoracic Sciences, Università degli studi della Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples, Italy
| | - Martina Caiazza
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples, Italy
| | - Francesca Dongiglio
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples, Italy
| | - Federica Verrillo
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples, Italy
| | - Giuseppe Palmiero
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples, Italy
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Naples, Italy
| | - Ciro Costagliola
- Department of Neuroscience, Reproductive and Dentistry Sciences, Federico II University of Naples, Naples, Italy
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17
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Starr N, Ioannou A, Martinez-Naharro A. Monitoring cardiac amyloidosis with multimodality imaging. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:79-87. [PMID: 37696332 DOI: 10.1016/j.rec.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/30/2023] [Indexed: 09/13/2023]
Abstract
Cardiac amyloidosis (CA) refers to an infiltrative process involving amyloid fibril deposition in the myocardium causing restrictive cardiomyopathy. While various types can affect the heart, the predominant forms are immunoglobulin light-chain (AL) amyloidosis and transthyretin (ATTR) amyloidosis. This review article explores the expanding field of imaging techniques used to diagnose AL-CA and ATTR-CA, highlighting their usefulness in prognostication and disease surveillance. Echocardiography is often the initial imaging modality to suspect CA and, since the incorporation of nonbiopsy criteria using bone scintigraphy, diagnosing ATTR-CA has become more attainable following exclusion of plasma cell dyscrasia. Cardiac magnetic resonance is progressively emerging as a vital tool for imaging CA, and is used in diagnosis, prognostication, and disease surveillance. The use of cardiac magnetic resonance in AL-CA is discussed, as it has been shown to accurately evaluate organ response to chemotherapy. As novel drug treatments emerge in the realm of ATTR-CA, the use of cardiovascular imaging surveillance to monitor disease progression is discussed, as it is gaining prominence as a critical consideration. The ongoing phase III trials investigating treatments for patients with ATTR-CA, will undoubtedly enhance our understanding of cardiac imaging surveillance.
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Affiliation(s)
- Neasa Starr
- National Amyloidosis Centre, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Adam Ioannou
- National Amyloidosis Centre, Royal Free Hospital NHS Foundation Trust, London, United Kingdom
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, Royal Free Hospital NHS Foundation Trust, London, United Kingdom.
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18
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Golatkar V, Bhatt LK. Emerging therapeutic avenues in cardiac amyloidosis. Eur J Pharmacol 2023; 960:176142. [PMID: 37866746 DOI: 10.1016/j.ejphar.2023.176142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/15/2023] [Accepted: 10/19/2023] [Indexed: 10/24/2023]
Abstract
Cardiac Amyloidosis (CA) is a toxic infiltrative cardiomyopathy occurred by the deposition of the amyloid fibres in the extracellular matrix of the myocardium. This results in severe clinical complications such as increased left ventricular wall thickness and interventricular stiffness, a decrease in left ventricular stroke volume and cardiac output, diastolic dysfunction, arrhythmia, etc. In a prolonged period, this condition progresses into heart failure. The amyloid fibres affecting the heart include immunoglobulin light chain (AL - amyloidosis) and transthyretin protein (ATTR - amyloidosis) misfolded amyloid fibres. ATTRwt has the highest prevalence of 155 to 191 cases per million while ATTRv has an estimated prevalence of 5.2 cases per million. The pathological findings and therapeutic approaches developed recently have aided in the treatment regimen of cardiac amyloidosis patients. In recent years, understanding the pathophysiology of amyloid fibres formation and mechanistic pathways triggered in both types of cardiac amyloidosis has led to the development of new therapeutic approaches and agents. This review focuses on the current status of emerging therapeutic agents in clinical trials. Earlier, melphalan and bortezomib in combination with alkylating agents and immunomodulatory drugs were used as a standard therapy for AL amyloidosis. Tafamidis, approved recently by FDA is used as a standard for ATTR amyloidosis. However, the emerging therapeutic agents under development for the treatment of AL and ATTR cardiac amyloidosis have shown a potent and rapid effect with a safety profile.
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Affiliation(s)
- Vaishnavi Golatkar
- Department of Pharmacology, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, Vile Parle (W), Mumbai, India
| | - Lokesh Kumar Bhatt
- Department of Pharmacology, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, Vile Parle (W), Mumbai, India.
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19
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Ardiana M, Fadila AN, Zuhra Z, Kusuma NM, Surya Erlangga Rurus ME, Oceandy D. Non-coding RNA therapeutics in cardiovascular diseases and risk factors: Systematic review. Noncoding RNA Res 2023; 8:487-506. [PMID: 37483458 PMCID: PMC10362275 DOI: 10.1016/j.ncrna.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 07/25/2023] Open
Abstract
At present, RNA-based therapy which includes therapies using non-coding RNAs (ncRNAs), antisense oligonucleotides (ASOs), and aptamers are gaining widespread attention as possible ways to target genes in various cardiovascular diseases (CVDs), thereby serving as a promising therapeutic approach for CVDs and risk factors management. However, data are primarily in an early stage. A systematic review was carried out using literature from several databases (Pubmed, Cochrane, Scopus, and DOAJR) following the PRISMA guidelines. Of the 64 articles reviewed, 39 papers were included in this review with three main types of RNAs: aptamers, antisense oligonucleotides (ASOs), and small-interfering RNA (siRNA). All studies were human clinical trials. RNA-based therapies were demonstrated to be efficacious in treating various CVDs and controlling cardiovascular risk factors. They are generally safe and well-tolerated. However, data are still in the early stage and warrant further investigation.
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Affiliation(s)
- Meity Ardiana
- Department of Cardiology and Vascular Medicine, Dr.Soetomo General Hospital, Surabaya, Indonesia
- Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Asiyah Nurul Fadila
- Department of Cardiology and Vascular Medicine, Dr.Soetomo General Hospital, Surabaya, Indonesia
- Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | - Zakirah Zuhra
- Department of Cardiology and Vascular Medicine, Dr.Soetomo General Hospital, Surabaya, Indonesia
- Faculty of Medicine, Airlangga University, Surabaya, Indonesia
| | | | | | - Delvac Oceandy
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
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20
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Zhou J, Li Y, Geng J, Zhou H, Liu L, Peng X. Recent Progress in the Development and Clinical Application of New Drugs for Transthyretin Cardiac Amyloidosis. J Cardiovasc Pharmacol 2023; 82:427-437. [PMID: 37678276 PMCID: PMC10691666 DOI: 10.1097/fjc.0000000000001478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/26/2023] [Indexed: 09/09/2023]
Abstract
ABSTRACT Transthyretincardiac amyloidosis is a rare disease that has gained significant attention in recent years because of misfolding of transthyretin fibrils produced by the liver, leading to their deposition in the myocardium. The disease has an insidious onset, nonspecific clinical manifestations, and historically lacked effective drugs, making early diagnosis and treatment challenging. The survival time of patients largely depends on the extent of heart involvement at the time of diagnosis, and conventional treatments for cardiovascular disease do not provide significant benefits. Effective management of the disease requires treatment of its underlying cause. Orthotopic liver transplantation and combined hepato-heart transplantation have been clinically effective means of treating transthyretin cardiac amyloidosis mutants for many years. However, transplantation has many limitations in clinical practice. In recent years, the development of new drugs has brought new hope to patients. This review presents the latest advances in drug development and clinical application to provide a reference for clinicians managing transthyretin cardiac amyloidosis.
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Affiliation(s)
- Juan Zhou
- Department of Cardiology, The First Affiliated Hospital of Yangtze University, Jingzhou, Hubei, China
- Department of Medical, Health Science Center, Yangtze University, Jingzhou, Hubei, China
| | - Yanfang Li
- Department of Gastroenterology, First Hospital Affiliated to Air Force Medical University, Xian, China
| | - Jing Geng
- Department of Medical, Health Science Center, Yangtze University, Jingzhou, Hubei, China
| | - Hong Zhou
- Department of Medical, Health Science Center, Yangtze University, Jingzhou, Hubei, China
| | - Lian Liu
- Department of Pharmacology, Health Science Center, Yangtze University, Jingzhou, Hubei, China
| | - Xiaochun Peng
- Laboratory of Oncology, Center for Molecular Medicine, School of Basic Medicine, Health Science Center, Yangtze University, Jingzhou, China; and
- Department of Pathophysiology, School of Basic Medicine, Health Science Center, Yangtze University, Jingzhou 434023 Hubei, China
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21
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Nie T, Heo YA, Shirley M. Vutrisiran: A Review in Polyneuropathy of Hereditary Transthyretin-Mediated Amyloidosis. Drugs 2023; 83:1425-1432. [PMID: 37728865 DOI: 10.1007/s40265-023-01943-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 09/21/2023]
Abstract
Silencing the transthyretin (TTR) gene is an effective strategy in the treatment of hereditary transthyretin-mediated (hATTR) amyloidosis. Vutrisiran (Amvuttra®), an RNA interference (RNAi) therapeutic targeting TTR mRNA, is approved in the USA and EU for the treatment of adults with polyneuropathy of hATTR amyloidosis. N-acetylgalactosamine conjugation and enhanced stabilisation chemistry are utilised to target vutrisiran to the liver and increase stability, respectively, allowing for subcutaneous administration once every 3 months. In a pivotal phase 3 study in patients with hATTR amyloidosis with polyneuropathy, subcutaneous vutrisiran 25 mg every 3 months significantly reduced neuropathy impairment versus external placebo. Vutrisiran was also associated with significant improvements in neuropathy-specific quality of life, gait speed, nutritional status and disability scores. Vutrisiran was generally well tolerated; the only common adverse events to occur at a greater incidence than with external placebo were pain in extremity and arthralgia. Vutrisiran reduces serum vitamin A levels and vitamin A supplementation is recommended. In conclusion, vutrisiran is an efficacious and generally well-tolerated alternative option for the treatment of polyneuropathy of hATTR amyloidosis, which has the potential advantage of infrequent subcutaneous dosage.
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Affiliation(s)
- Tina Nie
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
| | - Young-A Heo
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand
| | - Matt Shirley
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand
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22
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Pernice HF, Hahn K. [Neurological manifestations of ATTR amyloidosis]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:848-854. [PMID: 37555967 DOI: 10.1007/s00108-023-01570-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/10/2023]
Abstract
Transthyretin amyloidosis (ATTR) is a rare disease in which the protein transthyretin (TTR) is deposited in the form of amyloid fibrils in various tissues and organs and secondarily leads to functional impairment, especially in peripheral nerves and the heart. A differentiation is made between hereditary and sporadic forms. The hereditary variant is inherited in an autosomal dominant manner and usually occurs in the younger to middle-aged, while the sporadic form occurs in older age and has no known genetic cause. Typical signs of hereditary ATTR amyloidosis (ATTRv, v for variant) include a rapidly progressing sensorimotor and autonomic polyneuropathy (PNP), cardiac dysfunction as well as ocular and gastrointestinal symptoms. A carpal tunnel syndrome often precedes the manifestation. Various options (tafamidis, patisiran, inotersen or vutrisiran) are available for the treatment of patients with ATTRv with PNP in Germany, depending on the severity. In the sporadic variant of wild-type ATTR amyloidosis (ATTRwt), symptoms of progressive cardiomyopathy are usually prominent; however, neurological assessment of these patients often also reveals a concomitant sensory ataxic PNP. The tetramer stabilizer tafamidis can be used for treatment. Because of this complex presentation, the management of patients with ATTR amyloidosis should be performed in interdisciplinary centers specialized in amyloidosis.
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Affiliation(s)
- Helena F Pernice
- Amyloidosis Center Charité Berlin (ACCB), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Katrin Hahn
- Amyloidosis Center Charité Berlin (ACCB), Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
- Klinik für Neurologie mit Experimenteller Neurologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland.
- Berlin Institute of Health at Charité (BIH), Universitätsmedizin Berlin, Berlin, Deutschland.
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23
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Leonardi L, Costanzo R, Forcina F, Morino S, Antonini G, Salvetti M, Luigetti M, Romano A, Primiano G, Guglielmino V, Fionda L, Garibaldi M, Lauletta A, Rossini E, Tufano L, Ceccanti M, Esposito N, Falco P, di Pietro G, Truini A, Galosi E. Quantitative sensory testing and skin biopsy findings in late-onset ATTRv presymptomatic carriers: Relationships with predicted time of disease onset (PADO). J Peripher Nerv Syst 2023; 28:390-397. [PMID: 37535421 DOI: 10.1111/jns.12586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Hereditary transthyretin amyloidosis polyneuropathy (ATTRv-PN) presymptomatic carriers often show preclinical abnormalities at small fiber-related diagnostic tests. However, no validated biomarker is currently available to use for presymptomatic carriers' follow-up, thus helping therapeutic decision making. Our study aimed at assessing nerve conduction study (NCS), quantitative sensory testing (QST), and skin biopsy parameters in a large cohort of late-onset ATTRv presymptomatic carriers and to evaluate whether they correlated with predicted age of disease onset (PADO). METHODS Late-onset ATTRv presymptomatic carriers were consecutively enrolled and underwent NCS, QST, and skin biopsy with intraepidermal nerve fiber density (IENFD) evaluation from a distal and a proximal site. Douleur Neuropathique-4 (DN4) and Small Fiber Neuropathy-Symptoms Inventory (SFN-SIQ) were used to assess painful and small fiber neuropathy-related symptoms. PADO and time-to-PADO (delta-PADO) were estimated for each carrier, and correlations with diagnostic test measures were analyzed. RESULTS Forty presymptomatic ATTRv subjects were enrolled. Twenty carriers (50%) had distal IENFD reduction, with a non-length-dependent distribution in 73% of cases. Eleven subjects (27.5%) had cold and/or warm detection threshold (CDT and/or WDT) abnormalities at QST. Delta-PADO positively correlated with sural sensory nerve action potential (SNAP) amplitude (r = .416, p = .004), and z-values of QST parameters like CDT (r = .314, p = .028), WDT (r = -.294, p = .034), and mechanical detection threshold (MDT; r = -.382, p = .012). Simple linear regression models showed a linear relation between delta-PADO and sural SAP, CDT, and MDT. CONCLUSIONS Our findings confirm that IENFD reduction and QST abnormalities may occur early in ATTRv presymptomatic carriers, often with a non-length-dependent pattern. However, only sural SAP amplitude and QST parameters correlated with delta-PADO, suggesting that serial combined QST and NCS evaluation could be useful in ATTRv presymptomatic carriers' follow-up.
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Affiliation(s)
- Luca Leonardi
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Rocco Costanzo
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Francesca Forcina
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Stefania Morino
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Giovanni Antonini
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Marco Salvetti
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
- Neuromed Institute IRCCS, Pozzilli, Isernia, Italy
| | - Marco Luigetti
- UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore. Sede di Roma, Rome, Italy
| | - Angela Romano
- UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Guido Primiano
- UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valeria Guglielmino
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore. Sede di Roma, Rome, Italy
| | - Laura Fionda
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Matteo Garibaldi
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Antonio Lauletta
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Elena Rossini
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Laura Tufano
- Department of Neuroscience, Mental Health and Sensory Organs (NESMOS), Sapienza University of Rome, Rome, Italy
| | - Marco Ceccanti
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Nicoletta Esposito
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Pietro Falco
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Giuseppe di Pietro
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Andrea Truini
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Eleonora Galosi
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
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Chneiweiss H. [Genome editing for the clinics: First successes and new issues]. Med Sci (Paris) 2023; 39:589-590. [PMID: 37695141 DOI: 10.1051/medsci/2023110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Affiliation(s)
- Hervé Chneiweiss
- Neuroscience Paris Seine, IBPS, Sorbonne Université, CNRS UMR8246, Inserm 1130, Campus Pierre et Marie Curie, 75005 Paris, France
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Ioannou A, Fontana M, Gillmore JD. Patisiran for the Treatment of Transthyretin-mediated Amyloidosis with Cardiomyopathy. Heart Int 2023; 17:27-35. [PMID: 37456349 PMCID: PMC10339464 DOI: 10.17925/hi.2023.17.1.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/24/2023] [Indexed: 07/18/2023] Open
Abstract
Transthyretin (TTR) is a tetrameric protein, synthesized primarily by the liver, that acts as a physiological transport protein for retinol and thyroxine. TTR can misfold into pathogenic amyloid fibrils that deposit in the heart and nerves, causing a life-threatening transthyretin amyloidosis cardiomyopathy (ATTR-CM), and a progressive and debilitating polyneuropathy (ATTR-PN). Recent therapeutic advances have resulted in the development of drugs that reduce TTR production. Patisiran is a small interfering RNA that disrupts the complimentary mRNA and inhibits TTR synthesis, and is the first gene-silencing medication licensed for the treatment of ATTR amyloidosis. After encouraging results following the use of patisiran for the treatment of patients with ATTR-PN, there has been increasing interest in the use of patisiran for the treatment of ATTR-CM. Various studies have demonstrated improvements across a wide range of cardiac biomarkers following treatment with patisiran, and have changed the perception of ATTR-CM from being thought of as a terminal disease process, to now being regarded as a treatable disease. These successes represent a huge milestone and have the potential to revolutionize the landscape of treatment for ATTR-CM. However, the long-term safety of patisiran and how best to monitor cardiac response to treatment remain to be determined.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, London, UK
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