1
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Bouwman HB, Guchelaar HJ. The efficacy and safety of eculizumab in patients and the role of C5 polymorphisms. Drug Discov Today 2024; 29:104134. [PMID: 39111540 DOI: 10.1016/j.drudis.2024.104134] [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: 03/14/2024] [Revised: 07/11/2024] [Accepted: 07/31/2024] [Indexed: 08/13/2024]
Abstract
Eculizumab is an orphan drug with indications for extremely rare autoimmune disorders. It is primarily prescribed for use in patients with paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome; but is also highly effective in the treatment of myasthenia gravis, among others. By binding to the C5 protein in the complement system, eculizumab effectively inhibits cellular hemolysis and autoimmune reactions. Despite this effective treatment, some patients reported no improvement in symptoms. Genetic sequencing revealed three distinct C5 mutations in the non-responders and these polymorphisms appeared to be most prevalent among Japanese, Korean and African populations. Here, we present an overview of the current and potential future applications of eculizumab, as well as the disadvantages of eculizumab treatment in patients with C5 polymorphisms.
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Affiliation(s)
| | - Henk-Jan Guchelaar
- Clinical Pharmacy and Toxicology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands.
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2
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Michael M, Bagga A, Sartain SE, Smith RJH. Haemolytic uraemic syndrome. Lancet 2022; 400:1722-1740. [PMID: 36272423 DOI: 10.1016/s0140-6736(22)01202-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 11/05/2022]
Abstract
Haemolytic uraemic syndrome (HUS) is a heterogeneous group of diseases that result in a common pathology, thrombotic microangiopathy, which is classically characterised by the triad of non-immune microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. In this Seminar, different causes of HUS are discussed, the most common being Shiga toxin-producing Escherichia coli HUS. Identifying the underlying thrombotic microangiopathy trigger can be challenging but is imperative if patients are to receive personalised disease-specific treatment. The quintessential example is complement-mediated HUS, which once carried an extremely high mortality but is now treated with anti-complement therapies with excellent long-term outcomes. Unfortunately, the high cost of anti-complement therapies all but precludes their use in low-income countries. For many other forms of HUS, targeted therapies are yet to be identified.
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Affiliation(s)
- Mini Michael
- Division of Pediatric Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| | - Arvind Bagga
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Sarah E Sartain
- Pediatrics-Hematology/Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Richard J H Smith
- Department of Otolaryngology, Pediatrics and Molecular Physiology & Biophysics, The University of Iowa, Iowa City, IA, USA
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3
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Wong RS. Safety and efficacy of pegcetacoplan in paroxysmal nocturnal hemoglobinuria. Ther Adv Hematol 2022; 13:20406207221114673. [PMID: 35923770 PMCID: PMC9340389 DOI: 10.1177/20406207221114673] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 07/04/2022] [Indexed: 11/15/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired, hematologic disease characterized by complement-mediated hemolysis, thrombosis, and various degrees of bone marrow dysfunction. Until recently, C5 inhibition with eculizumab or ravulizumab represented the only therapies approved for patients with PNH by the United States Food and Drug Administration (US FDA). Although C5-inhibitors reduce PNH-related signs and symptoms, many patients continue to exhibit persistent anemia and require frequent blood transfusions. In May 2021, pegcetacoplan became the third US FDA-approved treatment for adults with PNH, and the first to target C3, a complement component upstream of C5. The novel strategy of inhibiting proximal complement activity with pegcetacoplan controls C5-mediated intravascular hemolysis and prevents C3-mediated extravascular hemolysis. Here, we review the results from multiple pegcetacoplan clinical studies on the efficacy and safety of pegcetacoplan treatment in adults with PNH. This review summarizes findings from three studies in complement-inhibitor-naïve patients with PNH (PADDOCK [phase Ib], PALOMINO [phase IIa], PRINCE [phase III; pegcetacoplan versus standard treatment excluding complement-inhibitors]), and one phase III study (PEGASUS) that compared eculizumab to pegcetacoplan in patients who remained anemic (hemoglobin levels < 10.5 g/dL) despite stable eculizumab treatment (⩾3 months). These studies found that pegcetacoplan contributed to superior improvements in primary and secondary endpoints related to hemoglobin levels and other hematologic parameters and provided effective management of anemia and anemia-related complications (i.e. transfusion burden, reticulocyte production, and fatigue). Furthermore, we summarize results from the 32-week open-label period from the PEGASUS trial, which confirmed the long-term safety and durable efficacy of pegcetacoplan as demonstrated by sustained improvements in clinical and hematologic outcomes in pegcetacoplan-treated patients. Pegcetacoplan is approved for the treatment of adults with PNH in the United States (Empaveli™) and for adult patients who remain anemic after at least 3 months of stable C5-inhibitor therapy in the European Union (Aspaveli®) and Australia (Empaveli; also approved for patients intolerant to C5-inhibitors).
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Affiliation(s)
- Raymond S.M. Wong
- Sir Y.K. Pao Centre for Cancer and Department
of Medicine & Therapeutics, Prince of Wales Hospital, The Chinese
University of Hong Kong, 30-32 Ngan Shing Street, Shatin, Hong Kong
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4
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Abstract
Atypical hemolytic uremic syndrome (aHUS) is an atypical type of thrombotic microangiopathy (TMA), which is characterized by microangiopathic hemolytic anemia (MAHA), thrombocytopenia, and thrombi in small blood vessels, leading to end-organ damage. aHUS causes an over-activation of the complement pathway. There are many etiologies of aHUS, including inherited and acquired. This condition has a high mortality rate, as it is often detected late in the disease course. Eculizumab, an inhibitor of the terminal complement pathway, needs to be prescribed as soon as the diagnosis is confirmed. There is limited evidence, however, regarding the duration of treatment. Therefore, it is vital to conduct further analysis on other alternatives and pharmacokinetics with this type of complement inhibitor.
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Affiliation(s)
- Ashish Sethi
- Internal Medicine, Allegheny Health Network, Pittsburgh, USA
| | - Raj Moses
- Oncology, Allegheny Health Network, Pittsburgh, USA
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5
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Pharmacology, Pharmacokinetics and Pharmacodynamics of Eculizumab, and Possibilities for an Individualized Approach to Eculizumab. Clin Pharmacokinet 2020; 58:859-874. [PMID: 30758736 PMCID: PMC6584251 DOI: 10.1007/s40262-019-00742-8] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Eculizumab is the first drug approved for the treatment of complement-mediated diseases, and current dosage schedules result in large interindividual drug concentrations. This review provides insight into the pharmacokinetic and pharmacodynamic properties of eculizumab, both for reported on-label (paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome, generalized myasthenia gravis) and off-label (hematopoietic stem cell transplantation-associated thrombotic microangiopathy) indications. Furthermore, we discuss the potential of therapeutic drug monitoring to individualize treatment and reduce costs.
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Yesilbas O, Yozgat CY, Akinci N, Sonmez S, Tekin E, Talebazadeh F, Jafarov U, Temur HO, Yozgat Y. Acute Myocarditis and Eculizumab Caused Severe Cholestasis in a 17-Month-Old Child Who Has Hemolytic Uremic Syndrome Associated with Shiga Toxin-Producing Escherichia coli. J Pediatr Intensive Care 2020; 10:216-220. [PMID: 34395040 DOI: 10.1055/s-0040-1713111] [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: 02/14/2020] [Accepted: 05/02/2020] [Indexed: 10/23/2022] Open
Abstract
Cardiovascular involvement is uncommon in pediatric patients with hemolytic uremic syndrome associated with Shiga toxin-producing Escherichia coli (STEC-HUS). In this case report we presented a case of 17-month-old toddler who had a sporadic type of STEC-HUS complicated by acute myocarditis. The patient was successfully treated by a single dose of eculizumab after six doses of therapeutic plasma exchange (TPE) were inefficient to prevent the cardiac complication. Hepatotoxicity was observed after a single dose of eculizumab. Hepatic and cholestatic enzyme levels slowly returned to normal within 6 months. To the best of our knowledge, this is the first case of myocarditis/cardiomyopathy treated with eculizumab in STEC-HUS. This case illustrates the need for vigilance regarding myocardial involvement and eculizumab-induced hepatotoxicity in STEC-HUS.
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Affiliation(s)
- Osman Yesilbas
- Department of Pediatric Critical Care Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | | | - Nurver Akinci
- Department of Pediatric Nephrology, Bezmialem Vakif University, Istanbul, Turkey
| | - Sirin Sonmez
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
| | - Eser Tekin
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
| | - Faraz Talebazadeh
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
| | - Uzeyir Jafarov
- Department of Pediatrics, Bezmialem Vakif University, Istanbul, Turkey
| | - Hafize Otcu Temur
- Department of Radiology, Bezmialem Vakif University, Istanbul, Turkey
| | - Yilmaz Yozgat
- Department of Pediatric Cardiology, Bezmialem Vakif University, Istanbul, Turkey
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7
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Haninger-Vacariu N, Aigner C, Kain R, Prohászka Z, Gaggl M, Böhmig GA, Piggott LC, Sunder-Plassmann R, Sunder-Plassmann G, Schmidt A. Successful Pregnancies During Ongoing Eculizumab Therapy in Two Patients With Complement-Mediated Thrombotic Microangiopathy. Kidney Med 2020; 2:213-217. [PMID: 32734241 PMCID: PMC7380370 DOI: 10.1016/j.xkme.2019.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
In patients with pregnancy-associated complement gene variant-mediated thrombotic microangiopathy (cTMA), terminal complement blockade is used for treatment of cTMA flares during pregnancy or following delivery. We report pregnancy and delivery outcomes of 2 genetically high-risk patients with cTMA, including 1 kidney transplant recipient, during ongoing eculizumab therapy. In both patients, the first manifestation of cTMA occurred independent from pregnancy. One patient has a history of 2 uneventful pregnancies with prophylactic plasma infusions, and the other has a history of early abortion during long-term eculizumab therapy following kidney transplantation. Overall, pregnancy and delivery outcomes under ongoing eculizumab therapy in our 2 patients with preserved kidney function were excellent as compared with other patients reported in the literature. Eculizumab plasma concentrations were maintained in the therapeutic range during pregnancy and were also detectable in cord blood. Results of cord blood analysis showed deficient complement activity, with low factor and regulator levels, most likely reflecting the age of the neonates and presence of eculizumab in cord blood. In conclusion, pregnancy during ongoing eculizumab treatment appeared to be safe in 2 women with a history of high-risk genetic cTMA and excellent kidney function, even following kidney transplantation.
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Affiliation(s)
- Natalja Haninger-Vacariu
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Christof Aigner
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Renate Kain
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Zoltán Prohászka
- Research Laboratory, 3rd Department of Internal Medicine, and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Martina Gaggl
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Leah Charlotte Piggott
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Raute Sunder-Plassmann
- Genetics Laboratory, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Gere Sunder-Plassmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alice Schmidt
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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Wijnsma KL, Duineveld C, Wetzels JFM, van de Kar NCAJ. Eculizumab in atypical hemolytic uremic syndrome: strategies toward restrictive use. Pediatr Nephrol 2019; 34:2261-2277. [PMID: 30402748 PMCID: PMC6794245 DOI: 10.1007/s00467-018-4091-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 09/14/2018] [Accepted: 09/17/2018] [Indexed: 12/19/2022]
Abstract
With the introduction of the complement C5-inhibitor eculizumab, a new era was entered for patients with atypical hemolytic uremic syndrome (aHUS). Eculizumab therapy very effectively reversed thrombotic microangiopathy and reduced mortality and morbidity. Initial guidelines suggested lifelong treatment and recommended prophylactic use of eculizumab in aHUS patients receiving a kidney transplant. However, there is little evidence to support lifelong therapy or prophylactic treatment in kidney transplant recipients. Worldwide, there is an ongoing debate regarding the optimal dose and duration of treatment, particularly in view of the high costs and potential side effects of eculizumab. An increasing but still limited number of case reports and small cohort studies suggest that a restrictive treatment regimen is feasible. We review the current literature and focus on the safety and efficacy of restrictive use of eculizumab. Our current treatment protocol is based on restrictive use of eculizumab. Prospective monitoring will provide more definite proof of the feasibility of such restrictive treatment.
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Affiliation(s)
- Kioa L. Wijnsma
- Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Department of Pediatric Nephrology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Caroline Duineveld
- Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Department of Pediatric Nephrology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands ,Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jack F. M. Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole C. A. J. van de Kar
- Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Department of Pediatric Nephrology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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9
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Yesilbas O, Sevketoglu E, Petmezci MT, Kihtir HS, Benzer M, Arikan C, Berdeli A, Baloglu H, Baskan O. Infant onset severe complement-mediated hemolytic uremic syndrome complicated by secondary sclerosing cholangitis. J Clin Apher 2018; 33:619-623. [PMID: 30168181 DOI: 10.1002/jca.21651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/06/2018] [Accepted: 07/08/2018] [Indexed: 12/12/2022]
Affiliation(s)
- Osman Yesilbas
- Pediatric Intensive Care Unit, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Esra Sevketoglu
- Pediatric Intensive Care Unit, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Mey Talip Petmezci
- Pediatric Intensive Care Unit, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Hasan Serdar Kihtir
- Pediatric Intensive Care Unit, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Meryem Benzer
- Department of Pediatric Nephrology, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Cigdem Arikan
- Departments of Pediatric Gastroenterology, Hepatology and Nutrition, Memorial Health Group, Istanbul, Turkey
| | - Afig Berdeli
- Department of Pediatrics, Molecular Medicine Laboratory and Stem Cell Department of Health Science Institute, Ege University Medical Faculty, Izmir, Turkey
| | - Huseyin Baloglu
- Department of Pathology, Anadolu Medical Center, Kocaeli, Turkey
| | - Ozdil Baskan
- Department of Radiology, Memorial Health Group, Istanbul, Turkey
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