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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Röth A, He G, Tong H, Lin Z, Wang X, Chai-Adisaksopha C, Lee JH, Brodsky A, Hantaweepant C, Dumagay TE, Demichelis-Gómez R, Rojnuckarin P, Sun J, Höglund M, Jang JH, Gaya A, Silva F, Obara N, Kelly RJ, Beveridge L, Buatois S, Chebon S, Gentile B, Lundberg P, Sreckovic S, Nishimura JI, Risitano A, Han B. Phase 3 randomized COMMODORE 2 trial: Crovalimab versus eculizumab in patients with paroxysmal nocturnal hemoglobinuria naive to complement inhibition. Am J Hematol 2024; 99:1768-1777. [PMID: 38884175 DOI: 10.1002/ajh.27412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/10/2024] [Accepted: 05/29/2024] [Indexed: 06/18/2024]
Abstract
Crovalimab is a novel C5 complement inhibitor that enables rapid and sustained C5 inhibition with subcutaneous, low-volume self-administration every 4 weeks. COMMODORE 2 (NCT04434092) is a global, randomized, open-label, multicenter, phase 3 trial evaluating the non-inferiority of crovalimab versus eculizumab in patients with paroxysmal nocturnal hemoglobinuria not previously treated with C5 inhibition. C5 inhibitor-naive patients with lactate dehydrogenase (LDH) ≥2 × upper limit of normal (ULN) were randomized 2:1 to crovalimab or eculizumab. Co-primary efficacy endpoints were proportion of patients with hemolysis control (centrally assessed LDH ≤1.5 × ULN) and proportion with transfusion avoidance. Secondary efficacy endpoints were proportions of patients with breakthrough hemolysis, stabilized hemoglobin, and change in FACIT-Fatigue score. The primary treatment period was 24 weeks. Two hundred and four patients were randomized (135 crovalimab; 69 eculizumab). Crovalimab was non-inferior to eculizumab in the co-primary endpoints of hemolysis control (79.3% vs. 79.0%; odds ratio, 1.0 [95% CI, 0.6, 1.8]) and transfusion avoidance (65.7% vs. 68.1%; weighted difference, -2.8 [-15.7, 11.1]), and in the secondary efficacy endpoints of breakthrough hemolysis (10.4% vs. 14.5%; weighted difference, -3.9 [-14.8, 5.3]) and hemoglobin stabilization (63.4% vs. 60.9%; weighted difference, 2.2 [-11.4, 16.3]). A clinically meaningful improvement in FACIT-Fatigue score occurred in both arms. Complete terminal complement activity inhibition was generally maintained with crovalimab. The safety profiles of crovalimab and eculizumab were similar with no meningococcal infections. Most patients who switched from eculizumab to crovalimab after the primary treatment period preferred crovalimab. These data demonstrate the positive benefit-risk profile of crovalimab.
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Affiliation(s)
- Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Guangsheng He
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Collaborative Innovation Center for Cancer Personalized Medicine, Nanjing, China
| | - Hongyan Tong
- Department of Hematology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zenghua Lin
- Department of Hematology, Affiliated Hospital of Nantong University, Jiangsu, China
| | - Xiaoqin Wang
- Department of Hematology, Huashan Hospital, Fudan University, Shanghai, China
| | | | - Je-Hwan Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Andres Brodsky
- Hematology Division, Hospital de Clínicas José de San Martín, University of Buenos Aires, Buenos Aires, Argentina
| | - Chattree Hantaweepant
- Faculty of Medicine Siriraj Hospital, Division of Hematology, Department of Medicine, Mahidol University, Bangkok, Thailand
| | - Teresita E Dumagay
- Division of Hematology, Department of Medicine, University of the Philippines, Philippine General Hospital, Manila, Philippines
| | - Roberta Demichelis-Gómez
- Department of Hematology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ponlapat Rojnuckarin
- Center of Excellence in Translational Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Martin Höglund
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Jun Ho Jang
- Department of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Anna Gaya
- Hematology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Fernando Silva
- Hematology Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Naoshi Obara
- Department of Hematology, University of Tsukuba Hospital, Ibaraki, Japan
| | - Richard J Kelly
- Division of Haematology and Immunology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | | | | | | | | | | | | | | | - Antonio Risitano
- Hematology and BMT Unit, AORN San Giuseppe Moscati, Avellino, Italy
| | - Bing Han
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Peking, China
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3
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Gurnari C, Awada H, Pagliuca S, Dima D, Ullah F, Kawashima N, Kubota Y, Colak C, Visconte V, Patel BJ, Dhillon V, Marneni N, Balasubramanian SK, Kishtagari A, Bat T, Maciejewski JP. Paroxysmal nocturnal hemoglobinuria-related thrombosis in the era of novel therapies: a 2043-patient-year analysis. Blood 2024; 144:145-155. [PMID: 38513233 DOI: 10.1182/blood.2024023988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/27/2024] [Accepted: 03/12/2024] [Indexed: 03/23/2024] Open
Abstract
ABSTRACT Thrombophilia is one of the principal features of paroxysmal nocturnal hemoglobinuria (PNH) and constitutes the main cause of disease morbidity/mortality. Anticomplement treatment has revolutionized the natural history of PNH, with control of the hemolytic process and abolition of thrombotic events (TEs). However, no guidelines exist for the management of thromboembolic complications in this setting, with type and duration of anticoagulation depending on individual practices. Besides, a scarcity of data is present on the efficacy of direct oral anticoagulants (DOACs). Herein, we accrued a large real-world cohort of patients with PNH from 4 US centers to explore features, predictors of TE, and anticoagulation strategies. Among 267 patients followed up for a total of 2043 patient-years, 56 (21%) developed TEs. These occurred at disease onset in 43% of cases, involving more frequently the venous system, typically as Budd-Chiari syndrome. Rate of TEs was halved in patients receiving complement inhibitors (21 vs 40 TEs per 1000 patient-years in untreated cases, with a 2-year cumulative incidence of thrombosis of 3.9% vs 18.3%, respectively), and varied according to PNH granulocytes and erythrocytes clone size, type, disease activity parameters, as well as number (≥2 mutations, or less) and variant allelic frequency of PIGA mutations. Anticoagulation with warfarin (39%), DOACs (37%), and low-molecular weight heparin (16%) was administered for a median of 29 months (interquartile range [IQR], 9-61.8). No thrombotic recurrence was observed in 19 patients treated with DOACs at a median observation of 17.1 months (IQR, 8.9-45) whereas 14 cases discontinued anticoagulation without TE recurrence at a median time of 51.4 months (IQR, 29.9-86.8).
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Affiliation(s)
- Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Hussein Awada
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Simona Pagliuca
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
- Department of Clinical Hematology, Centre Hospitalier Régional Universitaire Nancy and Unité Mixte de Recherche 7635, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Danai Dima
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Fauzia Ullah
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Naomi Kawashima
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Yasuo Kubota
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Ceylan Colak
- Imaging Institute, Cleveland Clinic, Cleveland, OH
| | - Valeria Visconte
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Bhumika J Patel
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Vikram Dhillon
- Department of Oncology, Karmanos Cancer Institute/Wayne State University, Detroit, MI
| | - Naimisha Marneni
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | | | - Ashwin Kishtagari
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Taha Bat
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jaroslaw P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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4
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Fahim SM, Makam AN, Suh K, Carlson JJ, Richardson M, Herce-Hagiwara B, Dickerson R, Pearson SD, Agboola F. Iptacopan and danicopan for paroxysmal nocturnal hemoglobinuria. J Manag Care Spec Pharm 2024; 30:618-623. [PMID: 38824627 PMCID: PMC11145001 DOI: 10.18553/jmcp.2024.30.6.618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Affiliation(s)
| | - Anil N. Makam
- Department of Medicine, University of California San Francisco
- University of California San Francisco Philip R. Lee Institute for Health Policy Studies
| | - Kangho Suh
- Department of Pharmacy & Therapeutics, School of Pharmacy, University of Pittsburgh, PA
| | - Josh J. Carlson
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle
| | | | | | - Ronald Dickerson
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle
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5
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Kelly RJ, Nishimori H, Horneff R, Hillmen P, Al-Adhami M, Lallier S, Gerber GF. Thrombosis and meningococcal infection rates in pegcetacoplan-treated patients with paroxysmal nocturnal hemoglobinuria in the clinical trial and postmarketing settings. Res Pract Thromb Haemost 2024; 8:102416. [PMID: 38812989 PMCID: PMC11135031 DOI: 10.1016/j.rpth.2024.102416] [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: 12/20/2023] [Revised: 04/10/2024] [Accepted: 04/10/2024] [Indexed: 05/31/2024] Open
Abstract
Background Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired hematologic disease characterized by complement-mediated hemolysis and thrombosis. Complement component 5 (C5) inhibitors have decreased PNH-related thrombosis rates and reduced mortality compared with those of age-matched controls. A small but significantly increased risk of life-threatening Neisseria infections, especially N meningitidis, represents a long-term safety risk of complement inhibition. Objectives To evaluate the rates of thrombosis and meningococcal infections in patients with PNH treated with the complement component 3-targeted therapy pegcetacoplan. Methods Cumulative patient-year exposure to pegcetacoplan was calculated, and thrombotic events and meningococcal infections were reviewed in 7 clinical trials and in the postmarketing setting. The clinical trial protocols and pegcetacoplan labeling required vaccination against Streptococcus pneumoniae, N meningitidis, and Haemophilus influenzae before pegcetacoplan use; the label allowed for prophylactic antibiotic use if pegcetacoplan must be administered before vaccination. Results As of November 13, 2022, 464 patients with PNH had 619.4 patient-years of pegcetacoplan exposure in completed/ongoing clinical trials and the postmarketing setting. Seven thrombotic events were reported: 5 in clinical trials (2 in the same patient) and 2 in the postmarketing setting. The overall thrombosis rate was 1.13 events per 100 patient-years (clinical trials: 1.22 events/100 patient-years in 409.4 years; postmarketing: 0.95 events/100 patient-years in 210.0 years). No infections with meningococcal bacteria were reported. Conclusion Event rates for thrombosis were comparable between pegcetacoplan and previously reported rates of C5 inhibitors in patients with PNH, and no cases of meningococcal infection were reported with pegcetacoplan. Continued follow-up is required.
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Affiliation(s)
| | - Hisakazu Nishimori
- Department of Hematology, Okayama University Hospital, Okayama, Japan
- Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | | | - Peter Hillmen
- Apellis Pharmaceuticals, Inc, Waltham, Massachusetts, USA
| | | | - Stacie Lallier
- Apellis Pharmaceuticals, Inc, Waltham, Massachusetts, USA
| | - Gloria F. Gerber
- Department of Medicine, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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6
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Yamada S, Asakura H. How We Interpret Thrombosis with Thrombocytopenia Syndrome? Int J Mol Sci 2024; 25:4956. [PMID: 38732176 PMCID: PMC11084439 DOI: 10.3390/ijms25094956] [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: 03/27/2024] [Revised: 04/16/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Platelets play an important role in hemostasis, and a low platelet count usually increases the risk of bleeding. Conditions in which thrombosis occurs despite low platelet counts are referred to as thrombosis with thrombocytopenia syndrome, including heparin-induced thrombocytopenia, vaccine-induced immune thrombotic thrombocytopenia, paroxysmal nocturnal hemoglobinuria, antiphospholipid syndrome, thrombotic microangiopathy (TMA), and disseminated intravascular coagulation. TMA includes thrombotic thrombocytopenic purpura, Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (HUS), and atypical HUS. Patients with these pathologies present with thrombosis and consumptive thrombocytopenia associated with the activation of platelets and the coagulation system. Treatment varies from disease to disease, and many diseases have direct impacts on mortality and organ prognosis if therapeutic interventions are not promptly implemented. Underlying diseases and the results of physical examinations and general laboratory tests as part of a thorough workup for patients should promptly lead to therapeutic intervention before definitive diagnosis. For some diseases, the diagnosis and initial treatment must proceed in parallel. Utilization of not only laboratory tests but also various scoring systems is important for validating therapeutic interventions based on clinical information.
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Affiliation(s)
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Takaramachi 13-1, Kanazawa City 920-8640, Ishikawa, Japan;
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7
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Kelly RJ, Holt M, Vidler J, Arnold LM, Large J, Forrest B, Barnfield C, Pike A, Griffin M, Munir T, Muus P, Nagumantry SK, Varghese A, Davies JR, Trikha R, Kulasekararaj AG, Mitchell L, Gandhi S. Treatment outcomes of complement protein C5 inhibition in 509 UK patients with paroxysmal nocturnal hemoglobinuria. Blood 2024; 143:1157-1166. [PMID: 38142401 DOI: 10.1182/blood.2023021762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/21/2023] [Accepted: 12/11/2023] [Indexed: 12/26/2023] Open
Abstract
ABSTRACT Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal hematopoietic disorder that occurs on a background of bone marrow failure (BMF). In PNH, chronic intravascular hemolysis causes an increase in morbidity and mortality, mainly because of thromboses. Over the last 20 years, treatment of PNH has focused on the complement protein C5 to prevent intravascular hemolysis using the monoclonal antibody eculizumab and more recently ravulizumab. In the United Kingdom, all patients are under review at 1 of 2 reference centers. We report on all 509 UK patients with PNH treated with eculizumab and/or ravulizumab between May 2002 and July 2022. The survival of patients with eculizumab and ravulizumab was significantly lower than that of age- and sex-matched controls (P = .001). Only 4 patients died of thromboses. The survival of patients with PNH (n = 389), when those requiring treatment for BMF (clonal evolution to myelodysplastic syndrome or acute leukemia or had progressive unresponsive aplastic anemia) were excluded, was not significantly different from that of age- and sex-matched controls (P = .12). There were 11 cases of meningococcal sepsis (0.35 events per 100 patient-years). Extravascular hemolysis was evident in patients who received treatment, with 26.7% of patients requiring transfusions in the most recent 12 months on therapy. Eculizumab and ravulizumab are safe and effective therapies that reduce mortality and morbidity in PNH, but further work is needed to reduce mortality in those with concomitant BMF.
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Affiliation(s)
- Richard J Kelly
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Matthew Holt
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Jennifer Vidler
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Louise M Arnold
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Joanna Large
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Briony Forrest
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Catherine Barnfield
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Alexandra Pike
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Morag Griffin
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Talha Munir
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Petra Muus
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - Sateesh K Nagumantry
- Department of Haematology, Peterborough City Hospital, Peterborough, United Kingdom
| | - Abraham Varghese
- Department of Haematology, St. James's University Hospital, Leeds, United Kingdom
| | - John R Davies
- School of Molecular and Cellular Biology, Faculty of Biological Sciences, University of Leeds, Leeds, United Kingdom
| | - Roochi Trikha
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Austin G Kulasekararaj
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Lindsay Mitchell
- Department of Haematology, Monklands Hospital, Airdrie, United Kingdom
| | - Shreyans Gandhi
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
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8
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Jang JH, Kim JS, Lim CTK, Kleinman NJ, Myren KJ, Wang A, Patel Y, Lee JW. Impact of Lactate Dehydrogenase and Hemoglobin Levels on Clinical Outcomes in Patients With Paroxysmal Nocturnal Hemoglobinuria: Results From the National Korean PNH Registry. J Korean Med Sci 2024; 39:e81. [PMID: 38442722 PMCID: PMC10911938 DOI: 10.3346/jkms.2024.39.e81] [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: 08/07/2023] [Accepted: 01/10/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematologic disorder caused by uncontrolled terminal complement activation, which leads to intravascular hemolysis (IVH), thromboembolism (TE), renal failure, and premature mortality. METHODS We performed a secondary analysis of data collected from patients enrolled in the Korean National PNH Registry to assess the relative importance of risk factors, specifically lactate dehydrogenase (LDH) and hemoglobin (Hb), in predicting the incidence of TE, impaired renal function, and death in complement inhibitor-naïve patients with PNH. RESULTS Multivariate regression modeling indicated that LDH ≥ 1.5 × upper limit of normal (ULN), male sex, and pain were associated with increased risk of TE (P = 0.016, 0.045, and 0.033, respectively), hemoglobinuria and pain were associated with an increased risk of impaired renal function (P = 0.034 and 0.022, respectively), and TE was associated with an increased incidence of death (P < 0.001). Hb < 8 g/dL was not a predictor of TE, impaired renal function, or death in multivariate regression analyses. Standardized mortality ratio analysis indicated that LDH ≥ 1.5 × ULN (P < 0.001), Hb < 8 g/dL (P < 0.001), and Hb ≥ 8 g/dL (P = 0.004) were all risk factors for death; in contrast, patients with LDH < 1.5 × ULN had similar mortality to the general population. CONCLUSION In complement inhibitor-naïve patients with PNH, LDH ≥ 1.5 × ULN was a significant predictor of TE, and TE was a significant predictor of death. Hb was not a significant predictor of TE, impaired renal function, or death. Therefore, controlling IVH will improve clinical outcomes for patients with PNH.
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Affiliation(s)
- Jun Ho Jang
- Division of Hemato-oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | | | | | - Alice Wang
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | - Yogesh Patel
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | - Jong Wook Lee
- Division of Hematology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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9
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Belot A, Benezech S, Tusseau M. A new drug for rare diseases: pozelimab for CHAPLE disease. Lancet 2024; 403:592-593. [PMID: 38278169 DOI: 10.1016/s0140-6736(23)02652-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/23/2023] [Indexed: 01/28/2024]
Affiliation(s)
- Alexandre Belot
- Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, ENS de Lyon, Lyon, France; Pediatric Nephrology, Rheumatology, Dermatology, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron 69677, France.
| | - Sarah Benezech
- Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, ENS de Lyon, Lyon, France; Pediatric Immunology, Haematology, Oncology, Hospices Civils de Lyon, Lyon, France
| | - Maud Tusseau
- Centre International de Recherche en Infectiologie, Inserm U1111, Université Claude Bernard Lyon 1, CNRS UMR5308, ENS de Lyon, Lyon, France; Genetic Department, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
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10
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Höchsmann B, Peffault de Latour R, Hill A, Röth A, Devos T, Patriquin CJ, Chou WC, Jain D, Zu K, Wu C, Lee JW. Risk factors for thromboembolic events in patients with paroxysmal nocturnal hemoglobinuria (PNH): a nested case-control study in the International PNH Registry. Ann Hematol 2023; 102:2979-2988. [PMID: 37668788 PMCID: PMC10567964 DOI: 10.1007/s00277-023-05402-3] [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: 10/27/2022] [Accepted: 08/04/2023] [Indexed: 09/06/2023]
Abstract
The objective of this analysis was to identify risk factors for thromboembolic events (TE) in patients with paroxysmal nocturnal hemoglobinuria (PNH) who were not treated with C5 inhibitors. Patients with PNH and a history of ≥ 1 TE at enrollment in the International PNH Registry (NCT01374360; registration date, January 2011) were each matched with up to 5 patients without TE. Multivariable analysis was performed with the following variables: percentage glycosylphosphatidylinositol (GPI)-negative cells, high disease activity (HDA), non-TE major adverse vascular event history, and recent anticoagulation. Of 2541 eligible patients, 57 with TE and 189 matched controls were analyzed. Multivariable analysis (odds ratio [95% CI]) identified the following factors as being associated with increased thrombotic risk: patients with no history of TE (with recent anticoagulation, 9.30 [1.20-72.27]), patients with history of TE (with recent anticoagulation, 8.91 [0.86-92.62]; without recent anticoagulation, 5.33 [0.26-109.57]), patients with ≥ 30% GPI-negative granulocytes (≥ 30% to < 50%, 4.94 [0.54-45.32]; ≥ 50%, 1.97 [0.45-8.55]), or patients with lactate dehydrogenase (LDH) ratio ≥ 1.5 × upper limit of normal (ULN) plus ≥ 2 HDA criteria (2-3 criteria, 3.18 [0.44-23.20]; ≥ 4 criteria, 3.60 [0.38-33.95]). History of TE, ≥ 30% GPI-negative granulocytes, and LDH ratio ≥ 1.5 × ULN with ≥ 2 HDA criteria are TE risk factors for patients with PNH. These findings will aid physicians by providing important clinical and laboratory risk factors that can be used to identify and manage patients with PNH who are at risk of developing TE.
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Affiliation(s)
- Britta Höchsmann
- Institute of Transfusion Medicine, University of Ulm, and Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and University Hospital Ulm, Helmholtzstraße 10, 89081, Ulm, Germany.
| | - Regis Peffault de Latour
- Bone Marrow Transplantation Unit, Saint Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint Louis Hospital and University Paris Diderot, Paris, France
- Severe Aplastic Anemia Working Party of the European Group for Blood and Marrow Transplantation, Leiden, The Netherlands
| | - Anita Hill
- Department of Hematology, Leeds Teaching Hospitals, Leeds, England, UK
- Alexion, AstraZeneca Rare Disease, Leeds, UK
| | - Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Timothy Devos
- Department of Hematology, University Hospitals Leuven and Department of Microbiology and Immunology, Laboratory of Molecular Immunology (Rega Institute), KU Leuven, Leuven, Belgium
| | | | - Wen-Chien Chou
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Deepak Jain
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | - Ke Zu
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | - Chuntao Wu
- Alexion, AstraZeneca Rare Disease, Boston, MA, USA
| | - Jong Wook Lee
- Department of Hematology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
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11
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Grewal US, Thotamgari SR, Gaddam SJ, Lakra R, Perepu U. Characteristics and outcomes associated with venous thrombotic complications among patients with paroxysmal nocturnal hemoglobinuria. Ann Hematol 2023; 102:2631-2632. [PMID: 37347270 DOI: 10.1007/s00277-023-05316-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 06/08/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Udhayvir S Grewal
- Division of Hematology, Oncology and Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Sahith R Thotamgari
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Shiva J Gaddam
- Division of Hematology and Oncology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Rachaita Lakra
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Usha Perepu
- Division of Hematology, Oncology and Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
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12
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Menosi Gualandro SF, Salvino MA, Bassolli de Oliveira Alves L, Jehá T. Characteristics of paroxysmal nocturnal hemoglobinuria patients in Brazil: A retrospective administrative claims database analysis of PNH patients in Brazilian public healthcare system. PLoS One 2023; 18:e0288708. [PMID: 37494350 PMCID: PMC10370764 DOI: 10.1371/journal.pone.0288708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/03/2023] [Indexed: 07/28/2023] Open
Abstract
INTRODUCTION Few studies have reported the profile of patients with paroxysmal nocturnal hemoglobinuria (PNH) and their care in the Brazilian health system. OBJECTIVE To describe clinical and epidemiological characteristics of patients with PNH in the Brazilian public health system including procedures performed, associated comorbidities and visits to health care professionals. METHODS In a real-world observational, retrospective, population-based cohort study, anonymized secondary data provided by the Department of Informatics of the Brazilian Unified Health System (DATASUS) were analyzed. Patients were considered eligible if they had at least one procedure coded with the ICD-10 code D59.5 from January 1, 2008 to December 30, 2018. RESULTS In total, 675 individual PNH patients were identified (52.4% female; prevalence of 1:237,000 people). Around 15.8% of the patients included had myelodysplastic syndrome and about half of the sample had other aplastic anemias and/or other bone marrow failure syndromes. Portal vein thrombosis (I82 ICD code) was reported in 4.3% of patients. Regarding hospitalizations, 263 individual PNH patients had 416 inpatient admissions with the ICD code for PNH (D59.5) on admission. Twelve deaths occurred during the study period, of which two had the PNH ICD code related with the cause of death, while another three deaths were associated with acquired hemolytic anemia (D59.9), unspecified aplastic anemia (D61.9) and acute respiratory failure (J96.0), respectively. CONCLUSION Despite its limitations, this statistical analysis of data extracted from DATASUS reasonably describes PNH patients in Brazil and its variations across different regions of the country. Comorbidities frequently associated with PNH such as portal vein thrombosis were not as common in our study, but it is assumed that several thrombotic events at specific sites were coded under the broader I82 ICD code. The frequency of visits to different health professionals, including hematologists, increased after the diagnosis of PNH. Among hospitalized PNH patients, the mortality rate was 4.5%.
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Affiliation(s)
| | | | | | - Thainá Jehá
- Alexion Pharmaceuticals, São Paulo, São Paulo, Brazil
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13
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Rovó A, Gavillet M, Drexler B, Keller P, Schneider JS, Colucci G, Beauverd Y, van Dorland HA, Pollak M, Schmidt A, De Gottardi A, Bissig M, Lehmann T, Duchosal MA, Zeerleder S. Swiss Survey on current practices and opinions on clinical constellations triggering the search for PNH clones. Front Med (Lausanne) 2023; 10:1200431. [PMID: 37564039 PMCID: PMC10410560 DOI: 10.3389/fmed.2023.1200431] [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] [Accepted: 07/03/2023] [Indexed: 08/12/2023] Open
Abstract
This national survey investigated the current practice in Switzerland by collecting participants' opinions on paroxysmal nocturnal hemoglobinuria (PNH) clone assessment and clinical practice. Aim This study aimed to investigate clinical indications prompting PNH clones' assessment and physician's accessibility of a flow cytometry facility, and also to understand clinical attitudes on the follow-up (FU) of patients with PNH clones. Methods The survey includes 16 multiple-choice questions related to PNH and targets physicians with a definite level of experience in the topic using two screener questions. Opinion on clinical management was collected using hypothetical clinical situations. Each participant had the option of being contacted to further discuss the survey results. This was an online survey, and 264 physicians were contacted through email once a week for 5 weeks from September 2020. Results In total, 64 physicians (24.2%) from 23 institutions participated (81.3% hematologists and 67.2% from university hospitals). All had access to flow cytometry for PNH clone testing, with 76.6% having access within their own institution. The main reasons to assess for PNH clones were unexplained thrombosis and/or hemolysis, and/or aplastic anemia (AA). Patients in FU for PNH clones were more likely to be aplastic anemia (AA) and symptomatic PNH. In total, 61% of the participants investigated PNH clones repetitively during FU in AA/myelodysplastic syndromes patients, even when there was no PNH clone found at diagnosis, and 75% of the participants tested at least once a year during FU. Opinions related to clinical management were scattered. Conclusion The need to adhere to guidelines for the assessment, interpretation, and reporting of PNH clones emerges as the most important finding, as well as consensus for the management of less well-defined clinical situations. Even though there are several international guidelines, clear information addressing specific topics such as the type of anticoagulant to use and its duration, as well as the indication for treatment with complement inhibitors in some borderline situations are needed. The analysis and the discussion of this survey provide the basis for understanding the unmet needs of PNH clone assessment and clinical practice in Switzerland.
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Affiliation(s)
- Alicia Rovó
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Mathilde Gavillet
- Service and Central Laboratory of Hematology, Department of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Department of Laboratory Medicine and Pathology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Beatrice Drexler
- Division of Hematology, University Hospital Basel, Basel, Switzerland
| | | | - Jenny Sarah Schneider
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | | | - Yan Beauverd
- Division of Hematology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | | | - Matthias Pollak
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Adrian Schmidt
- Department of Internal Medicine, Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zürich, Switzerland
| | - Andrea De Gottardi
- Servizio di Gastroenterología e Epatologia, Ente Ospedaliero Cantonale, Università della Svizzera Italiana, Lugano, Switzerland
| | - Marina Bissig
- Department of Medical Oncology and Hematology, University Hospital of Zürich, Zürich, Switzerland
| | - Thomas Lehmann
- Kantonsspital St. Gallen, Clinic for Medical Oncology and Hematology, St. Gallen, Switzerland
| | - Michel A. Duchosal
- Service and Central Laboratory of Hematology, Department of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Sacha Zeerleder
- Department of Hematology, Kantonsspital Luzern, Lucerne and University of Bern, Bern, Switzerland
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14
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Röth A, Ichikawa S, Ito Y, Kim JS, Nagy Z, Obara N, Panse J, Schrezenmeier H, Sica S, Soret J, Usuki K, Yoon SS, Balachandran N, Buri M, Lundberg P, Patel H, Shinomiya K, Sostelly A, Nishimura JI. Crovalimab treatment in patients with paroxysmal nocturnal haemoglobinuria: Long-term results from the phase I/II COMPOSER trial. Eur J Haematol 2023. [PMID: 37321625 DOI: 10.1111/ejh.14011] [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: 01/16/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVES This study reports long-term outcomes from the open-label extension (OLE) period of the Phase I/II COMPOSER trial (NCT03157635) that evaluated crovalimab in patients with paroxysmal nocturnal haemoglobinuria, who were treatment-naive or switched from eculizumab at enrolment. METHODS COMPOSER consists of four sequential parts followed by the OLE. The primary OLE objective was to assess long-term crovalimab safety, with a secondary objective to assess crovalimab pharmacokinetics and pharmacodynamics. Exploratory efficacy endpoints included change in lactate dehydrogenase (LDH), transfusion avoidance, haemoglobin stabilisation and breakthrough haemolysis (BTH). RESULTS A total 43 of 44 patients entered the OLE after completing the primary treatment period. Overall, 14 of 44 (32%) experienced treatment-related adverse events. Steady state exposure levels of crovalimab and terminal complement inhibition were maintained over the OLE. During the OLE, mean normalised LDH was generally maintained at ≤1.5× upper limit of normal, transfusion avoidance was achieved in 83%-92% of patients and haemoglobin stabilisation was reached in 79%-88% of patients across each 24-week interval. Five BTH events occurred with none leading to withdrawal. CONCLUSIONS Over a 3-year median treatment duration, crovalimab was well tolerated and sustained C5 inhibition was achieved. Intravascular haemolysis control, haemoglobin stabilisation and transfusion avoidance were maintained, signifying long-term crovalimab efficacy.
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Affiliation(s)
- Alexander Röth
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Satoshi Ichikawa
- Department of Hematology, Tohoku University Hospital, Miyagi, Japan
| | - Yoshikazu Ito
- Department of Hematology, Tokyo Medical University, Tokyo, Japan
| | - Jin Seok Kim
- Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
| | - Zsolt Nagy
- Department of Internal Medicine and Hematology, Semmelweis University, Budapest, Hungary
| | - Naoshi Obara
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Jens Panse
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Aachen, Germany
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf (ABCD), Aachen, Germany
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen und University Hospital Ulm, Ulm, Germany
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Juliette Soret
- Centre d'Investigations Cliniques, Hôpital Saint-Louis, Paris, France
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | | | - Muriel Buri
- Biostatistics Oncology Hematology, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Pontus Lundberg
- Oncology Biomarker Development, F. Hoffmann-La Roche Ltd, Basel, Switzerland
| | - Himika Patel
- Product Development Hematology, Genentech, Inc., South San Francisco, California, USA
| | - Kenji Shinomiya
- Primary Clinical Science and Strategy, Chugai Pharmaceutical Co., Tokyo, Japan
| | | | - Jun-Ichi Nishimura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
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15
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Fishman J, Kuranz S, Yeh MM, Brzozowski K, Chen H. Changes in Hematologic Lab Measures Observed in Patients with Paroxysmal Nocturnal Hemoglobinuria Treated with C5 Inhibitors, Ravulizumab and Eculizumab: Real-World Evidence from a US Based EMR Network. Hematol Rep 2023; 15:266-282. [PMID: 37092521 PMCID: PMC10123631 DOI: 10.3390/hematolrep15020027] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/13/2023] [Accepted: 04/17/2023] [Indexed: 04/25/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH), a rare acquired hematologic disorder, can be treated with C5 inhibitors (C5i) such as eculizumab or ravulizumab. This retrospective study is the first to describe real-world treatment patterns and changes in hematologic PNH-monitoring laboratory tests among C5i-treated US patients. Data were extracted from TriNetX Dataworks Network and included patients with a PNH diagnosis between 1 January 2010, and 20 August 2021. Patients were stratified into three cohorts based on their C5i usage: eculizumab, ravulizumab (prior eculizumab), and ravulizumab (eculizumab naïve). Hematological markers (hemoglobin [Hb], lactate dehydrogenase [LDH], and absolute reticulocyte count [ARC]) and relevant clinical events (e.g., breakthrough hemolysis [BTH], complement-amplifying conditions [CAC], thrombosis, infection, and all-cause mortality) were captured any time within 12 months post-index treatment. Of the 143 (eculizumab), 43 (ravulizumab, prior eculizumab), and 33 (ravulizumab, eculizumab naïve) patients, mean age across cohorts was 42-51 years, 55-61% were female, 63-73% were White, and 33-40% had aplastic anemia. Among all cohorts 12 months post-C5i treatment, 50-82% remained anemic, 8-32% required ≥1 transfusion, and 13-59% had BTH, of which 33%-54% had CACs. Additionally, thrombosis was seen in 7-15% of patients, infection in 20-25%, and mortality in 1-7%. These findings suggest many C5i-treated patients experience suboptimal disease control.
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Affiliation(s)
- Jesse Fishman
- Apellis Pharmaceuticals, Inc., Waltham, MA 02451, USA
| | | | - Michael M Yeh
- Apellis Pharmaceuticals, Inc., Waltham, MA 02451, USA
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16
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Biggart R, Davies C, Joshi N. A Review of Systemic Hematological Manifestations and Stent Thrombosis. Cardiol Rev 2023; Publish Ahead of Print:e000535. [PMID: 36825903 DOI: 10.1097/crd.0000000000000535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Stent thrombosis (ST) has significant morbidity and mortality following percutaneous coronary intervention (PCI). ST is uncommon making the identification of nonprocedural predictors challenging. Numerous case reports of ST in both benign and malignant hematological conditions exist. Given ST could be a Herald event of an undiagnosed condition and condition-specific treatment may be available, it is important to consider specialist testing in an unexplained ST. This review included a case presentation of ST in previously undiagnosed paroxysmal nocturnal hemoglobinuria (PNH) and a literature review of ST in other acquired thrombophilias including myeloproliferative disorders (MPNs), antiphospholipid syndrome, hematological malignancies, and heparin-induced thrombocytopenia (HIT). Inherited thrombophilias and common pitfalls in thrombophilia and coagulation testing are also discussed. The cardiac-hematology landscape is becoming increasingly complex and there is a paucity of how to best manage ST in these patients. There is clear variability in practice and the use of multidisciplinary input between cardiologists and hematologists is essential.
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Affiliation(s)
- Rachael Biggart
- From the Bristol Haematology & Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, England
| | - Claire Davies
- Great Western Hospitals NHS Foundation Trust, Bristol, England
| | - Nikhil Joshi
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust 22 Horfield Rd, Bristol BS2 8ED, Bristol, England
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17
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Schaap CCM, Heubel-Moenen FCJI, Nur E, Bartels M, van der Heijden OWH, de Jonge E, Preijers FWMB, Blijlevens NMA, Langemeijer SMC. Nationwide study of eculizumab in paroxysmal nocturnal hemoglobinuria: Evaluation of treatment indications and outcomes. Eur J Haematol 2023; 110:648-658. [PMID: 36811247 DOI: 10.1111/ejh.13946] [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: 11/29/2022] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
Eculizumab is an effective treatment for paroxysmal nocturnal hemoglobinuria (PNH). However, considering the risk of life-threatening meningococcal disease, life-long duration and costs, there are strict criteria for initiation of therapy. To evaluate the application and real-world effectiveness of eculizumab in the Netherlands, a multicenter retrospective cohort study was conducted: indications and treatment outcomes were collected for 105 Dutch PNH patients. In all patients, eculizumab was initiated conforming to indications as formulated in the Dutch PNH guideline. According to recently published response criteria, 23.4% of the patients had reached a complete hematological response, 53.2% a good or partial response, and 23.4% a minor response after 12 months of therapy. In the majority of patients the response remained stable during long-term follow-up. The degree and relevance of extravascular hemolysis significantly differed between response groups (p = 0.002). Improvements of EORTC-QLQc30 and FACIT-fatigue scores were observed, however patients reported lower scores than the general population. A detailed evaluation of 18 pregnancies during eculizumab showed no maternal or fetal deaths, and no thromboembolic events during pregnancy. This study demonstrates that the majority of patients benefit from eculizumab when adhering to the indications as formulated in the Dutch PNH guideline. However, novel therapies are needed to further improve real-world outcomes, such as hematological responses and quality of life.
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Affiliation(s)
- Charlotte C M Schaap
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Floor C J I Heubel-Moenen
- Department of Hematology, Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Erfan Nur
- Department of Clinical Hematology, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| | - Marije Bartels
- Pediatric Hematology Department, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Emiel de Jonge
- Department of Laboratory Medicine-Laboratory for Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frank W M B Preijers
- Department of Laboratory Medicine-Laboratory for Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
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18
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Experience of compassionate-use pegcetacoplan for paroxysmal nocturnal hemoglobinuria. Blood 2023; 141:116-120. [PMID: 36054920 DOI: 10.1182/blood.2022017266] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/12/2022] [Accepted: 08/12/2022] [Indexed: 01/10/2023] Open
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19
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Chatzileontiadou S, Hatjiharissi E, Angelopoulou M, Asimakopoulos JV, Loutsidi NE, Chatzikonstantinou T, Zikos P, Bouchla A, Bezirgiannidou Z, Kouvata E, Frouzaki C, Chaloudis P, Sotiropoulos D, Douka V, Sirigou A, Mandala E, Psyllaki M, Papadaki HA, Marinakis T, Viniou NA, Kokkori S, Kontopidou F, Skepetari A, Vassilopoulos G, Kotsianidis I, Pappa V, Lalayanni C, Baltadakis I, Delimpassi S, Pagoni M, Papaioannou M. Thromboembolic events in patients with paroxysmal nocturnal hemoglobinuria (PNH): Real world data of a Greek nationwide multicenter retrospective study. Front Oncol 2023; 13:1128994. [PMID: 36959785 PMCID: PMC10028290 DOI: 10.3389/fonc.2023.1128994] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/07/2023] [Indexed: 03/09/2023] Open
Abstract
Thrombosis is the most common and a life-threatening complication in patients with Paroxysmal Nocturnal Hemoglobinuria. One-third of patients with PNH experience at least one thromboembolic event during the course of the disease, with thrombosis being the most common cause of death in these patients. The mechanism of thrombosis in PNH is complex and continues to be of great research interest. Since the introduction of C5 complement inhibitors in the treatment of PNH, the incidence of thromboembolic events has decreased substantially. We retrospectively analyzed data concerning the thrombotic episodes of 41 patients with PNH from 14 different national hematology centers in Greece. Sixteen patients (39%) experienced at least one episode of thrombosis, including, seven (43.8%) at diagnosis, seven (43.8%) during the course of the disease and two (12.5%) patients prior to PNH diagnosis. Nearly half of these individuals (n=7, 43.8%) had multiple episodes of thrombosis during the course of their disease. The most common sites of thrombosis were intra-abdominal veins. Three out of 26 patients developed thrombosis while on eculizumab. In none of the 16 patients, the thrombotic event was fatal. Our findings, despite the small number of patients, confirmed that thrombosis continues to be a significant complication of PNH affecting more than one third of the patients.
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Affiliation(s)
- S. Chatzileontiadou
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E. Hatjiharissi
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - M. Angelopoulou
- Department of Hematology, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - J. V. Asimakopoulos
- Department of Hematology, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - N. E. Loutsidi
- Hematology - Lymphomas Department and Bone Marrow Transplant Unit, Evangelismos General Hospital, Athens, Greece
| | - T. Chatzikonstantinou
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - P. Zikos
- Department of Hematology, General Hospital of Patras “Aghios Andreas”, Patras, Greece
| | - A. Bouchla
- Second Department of Internal Medicine and Research Unit, Hematology Unit, University General Hospital, “Attikon”, Athens, Greece
| | - Z. Bezirgiannidou
- Department of Hematology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - E. Kouvata
- Department of Hematology, University Hospital of Larissa, Larissa, Greece
| | - C. Frouzaki
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - P. Chaloudis
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - D. Sotiropoulos
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - V. Douka
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - A. Sirigou
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - E. Mandala
- Forth Department of Medicine, Aristotle University of Thessaloniki, “Hippokration” Hospital, Thessaloniki, Greece
| | - M. Psyllaki
- Department of Hematology, University of Crete School of Medicine, University Hospital of Heraklion, Heraklion, Greece
| | - H. A. Papadaki
- Department of Hematology, University of Crete School of Medicine, University Hospital of Heraklion, Heraklion, Greece
| | - T. Marinakis
- Department of Hematology, “G. Gennimatas” General Hospital, Athens, Greece
| | - N. A. Viniou
- Hematology Unit, First Department of Internal Medicine, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - S. Kokkori
- Hematology Laboratory, University General Hospital “Attikon”, Athens, Greece
| | - F. Kontopidou
- 2nd Department of Internal Medicine, Medical School, University of Athens, Hippokration General Hospital, Athens, Greece
| | - A. Skepetari
- 2nd Department of Internal Medicine, Medical School, University of Athens, Hippokration General Hospital, Athens, Greece
| | - G. Vassilopoulos
- Department of Hematology, University Hospital of Larissa, Larissa, Greece
| | - I. Kotsianidis
- Department of Hematology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - V. Pappa
- Second Department of Internal Medicine and Research Unit, Hematology Unit, University General Hospital, “Attikon”, Athens, Greece
| | - C. Lalayanni
- Department of Hematology, Bone Marrow Transplantation Unit, G. Papanicolaou Hospital, Thessaloniki, Greece
| | - I. Baltadakis
- Hematology - Lymphomas Department and Bone Marrow Transplant Unit, Evangelismos General Hospital, Athens, Greece
| | - S. Delimpassi
- Hematology - Lymphomas Department and Bone Marrow Transplant Unit, Evangelismos General Hospital, Athens, Greece
| | - M. Pagoni
- Hematology - Lymphomas Department and Bone Marrow Transplant Unit, Evangelismos General Hospital, Athens, Greece
| | - M. Papaioannou
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- *Correspondence: M. Papaioannou,
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Muacevic A, Adler JR, Hock RA, Nguyen B, Prakash S, Rojas Murguia A, Vahora I, Corral J, Padilla O, Dihowm F. Attack of the Clones: A Patient With Untreated Aplastic Anemia Presenting With Classical Paroxysmal Nocturnal Hemoglobinuria. Cureus 2023; 15:e34093. [PMID: 36843778 PMCID: PMC9946272 DOI: 10.7759/cureus.34093] [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] [Accepted: 01/23/2023] [Indexed: 01/24/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired X-linked, clonal hematopoietic stem cell disease. Patients with PNH may complain of vague symptomatology that contributes to the challenge of its diagnosis. This is especially true in the clinical context of a coinciding hematologic disorder. Aplastic anemia (AA) is an additional immune-mediated illness that results in the destruction of hematopoietic precursors and pancytopenia. The authors encourage screening for PNH clones in patients initially diagnosed with AA, treating underlying hematologic disease to prevent clonal expansion, and further research to investigate the effectiveness of eculizumab in an unusual "classical" PNH secondary to AA with hypercellular bone marrow.
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21
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Wang R, Guo X, Tang Y, Qi X. Portal vein thrombosis as the first presentation of paroxysmal nocturnal hemoglobinuria. Drug Discov Ther 2022; 16:200-203. [PMID: 35989282 DOI: 10.5582/ddt.2022.01033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired clonal hematopoietic stem cell disorder, characterized by hemolytic anemia, bone marrow failure and thrombosis. Portal vein thrombosis (PVT) is relatively rare in patients with PNH. In this paper, we reported PVT as the first clinical presentation of PNH in a female patient. PVT related symptoms resolved after anticoagulation therapy.
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Affiliation(s)
- Ran Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yufu Tang
- Department of Hepatobiliary Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Xingshun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang, China
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22
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Lee JW, Brodsky RA, Nishimura JI, Kulasekararaj AG. The role of the alternative pathway in paroxysmal nocturnal hemoglobinuria and emerging treatments. Expert Rev Clin Pharmacol 2022; 15:851-861. [PMID: 35980222 DOI: 10.1080/17512433.2022.2109462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by uncontrolled activation of the terminal complement pathway, leading to intravascular hemolysis (IVH) and a prothrombotic state. Treatment with terminal complement (C5) inhibitors, the current standard of care, suppresses IVH and reduces the risk of thrombosis and the associated morbidity and mortality. Opportunities exist to further improve care by alternative modes of administration and the reduction of clinically significant anemia and transfusion dependence caused by extravascular hemolysis in some patients. AREAS COVERED This review describes the pathophysiology of PNH, provides an overview of the current standard of care, and discusses potential avenues for enhancing patient care, with a focus on the literature describing new and emerging treatments that target the alternative pathway. Emerging treatments include biosimilars and novel C5 inhibitors as well as agents with novel mechanisms of action that target the proximal complement pathways (C3 inhibitors, factor B inhibitors, and factor D inhibitors). EXPERT OPINION Alternative complement pathway inhibitors may offer further benefit as long as terminal complement is completely inhibited to reduce IVH and disease activity. This may lead to improvements in adherence and health-related quality of life for patients with PNH.
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Affiliation(s)
- Jong Wook Lee
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Robert A Brodsky
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jun-Ichi Nishimura
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Austin G Kulasekararaj
- King's College Hospital-NHS Foundation Trust, NIHR/Wellcome King's Clinical Research Facility, UK & King's College London, London, UK
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23
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Hosokawa K, Nakao S. Somatic mutations and clonal expansions in paroxysmal nocturnal hemoglobinuria. Semin Hematol 2022; 59:143-149. [DOI: 10.1053/j.seminhematol.2022.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/17/2022] [Accepted: 08/17/2022] [Indexed: 01/02/2023]
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24
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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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25
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Al-Riyami AZ, Al-Kindi Y, Al-Qassabi J, Al-Mamari S, Fawaz N, Al-Khabori M, Al-Huneini M, Al Kindi S. Clinicopathological Profile of Paroxysmal Nocturnal Hemoglobinuria among Omani Patients: A Case Series. Oman Med J 2022; 37:e405. [PMID: 35949713 PMCID: PMC9357272 DOI: 10.5001/omj.2022.13] [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: 08/17/2020] [Accepted: 12/23/2020] [Indexed: 11/03/2022] Open
Abstract
We aimed to estimate the nature and prevalence of paroxysmal nocturnal hemoglobinuria (PNH) among Omani patients. We performed a retrospective review of all patients who were tested for PNH by flow cytometry at the Sultan Qaboos University Hospital, Muscat, between 2012 and 2019. Manifestations, treatment modalities, and outcomes were assessed. A total of 10 patients were diagnosed or were on follow-up for PNH (median age 22.5 years). Clinical manifestations included fatigue (80%) and anemia (70%). Six patients had classical PNH with hemolysis, three had PNH in the context of aplastic anemia, and one patient had subclinical PNH. The median total clone size (type II + III) for neutrophils was 95.5 (range: 1.5-97) (FLAER/CD24) and for monocytes was 91.6 (range = 0.04-99) (FLAER/CD14). Four patients had clone sizes > 50% at the time of diagnosis. The median follow-up period of the patients was 62 months (range = 8-204 months). One patient suffered thrombosis. Three patients were on immunosuppressant agents, five were initiated on eculizumab, and four had a bone marrow transplant. No deaths were reported in the cohort. The estimated average incidence of PNH among Omani patients was 1.5 per 5 000 000. PNH is rare in the Omani population. The predominant presentation is hemolytic anemia.
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Affiliation(s)
- Arwa Z. Al-Riyami
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Yahya Al-Kindi
- College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Jamal Al-Qassabi
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Sahimah Al-Mamari
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Naglaa Fawaz
- Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman
| | | | | | - Salam Al Kindi
- Department of Hematology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
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26
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Kulasekararaj AG, Brodsky RA, Nishimura JI, Patriquin CJ, Schrezenmeier H. The importance of terminal complement inhibition in paroxysmal nocturnal hemoglobinuria. Ther Adv Hematol 2022; 13:20406207221091046. [PMID: 35663504 PMCID: PMC9160915 DOI: 10.1177/20406207221091046] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/14/2022] [Indexed: 11/30/2022] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, chronic hematologic disorder associated with inappropriate terminal complement activity on blood cells that can result in intravascular hemolysis (IVH), thromboembolic events (TEs), and organ damage. Untreated individuals with PNH have an increased risk of morbidity and mortality. Patients with PNH experiencing IVH often present with an elevated lactate dehydrogenase (LDH; ⩾ 1.5 × the upper limit of normal) level which is associated with a significantly higher risk of TEs, one of the leading causes of death in PNH. LDH is therefore used as a biomarker for IVH in PNH. The main objective of PNH treatment should therefore be prevention of morbidity and mortality due to terminal complement activation, with the aim of improving patient outcomes. Approval of the first terminal complement inhibitor, eculizumab, greatly changed the treatment landscape of PNH by giving patients an effective therapy and demonstrated the critical role of terminal complement and the possibility of modulating it therapeutically. The current mainstays of treatment for PNH are the terminal complement component 5 (C5) inhibitors, eculizumab and ravulizumab, which have shown efficacy in controlling terminal complement-mediated IVH, reducing TEs and organ damage, and improving health-related quality of life in patients with PNH since their approval by the United States Food and Drug Administration in 2007 and 2018, respectively. Moreover, the use of eculizumab has been shown to reduce mortality due to PNH. More recently, interest has arisen in developing additional complement inhibitors with different modes of administration and therapeutics targeting other components of the complement cascade. This review focuses on the pathophysiology of clinical complications in PNH and explores why sustained inhibition of terminal complement activity through the use of complement inhibitors is essential for the management of patients with this chronic and debilitating disease.
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Affiliation(s)
- Austin G. Kulasekararaj
- Department of Haematological Medicine, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
- National Institute of Health Research/Wellcome King’s Clinical Research Facility and King’s College London, London, UK
| | | | - Jun-ichi Nishimura
- Department of Hematology and Oncology, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Christopher J. Patriquin
- Division of Medical Oncology & Hematology, University Health Network – Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Hubert Schrezenmeier
- Institute of Transfusion Medicine, University of Ulm, and Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, and University Hospital Ulm, Ulm, Germany
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27
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Arachchillage DJ, Mackillop L, Chandratheva A, Motawani J, MacCallum P, Laffan M. Guidelines for thrombophilia testing: A British Society for Haematology guideline. Br J Haematol 2022; 198:443-458. [PMID: 35645034 PMCID: PMC9542828 DOI: 10.1111/bjh.18239] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/24/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Deepa J Arachchillage
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK.,Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Lucy Mackillop
- Women's Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Jayashree Motawani
- Department of Haematology, Birmingham Children's Hospital, Birmingham, UK
| | - Peter MacCallum
- Department of Haematology, Barts Health NHS Trust, London, UK.,Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Mike Laffan
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK.,Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
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28
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Rehan ST, Hashmi MR, Asghar MS, Tahir MJ, Yousaf Z. Pegcetacoplan ‐ a novel
C3
inhibitor for paroxysmal nocturnal hemoglobinuria. Health Sci Rep 2022; 5:e512. [PMID: 35509414 PMCID: PMC9059189 DOI: 10.1002/hsr2.512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/19/2021] [Accepted: 01/16/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
| | | | | | | | - Zohaib Yousaf
- Internal Medicine Hamad Medical Corporation Doha Qatar
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29
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Ikezoe T, Noji H, Ueda Y, Kanda Y, Okamoto S, Usuki K, Matsuda T, Akiyama H, Shimono A, Yonemura Y, Kawaguchi T, Chiba S, Kanakura Y, Nishimura JI, Ninomiya H, Obara N. Long-term follow-up of patients with paroxysmal nocturnal hemoglobinuria treated with eculizumab: post-marketing surveillance in Japan. Int J Hematol 2022; 115:470-480. [PMID: 35146630 DOI: 10.1007/s12185-022-03287-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/13/2022] [Accepted: 01/13/2022] [Indexed: 11/29/2022]
Abstract
All Japanese patients with paroxysmal nocturnal hemoglobinuria (PNH) treated with eculizumab were enrolled in post-marketing surveillance (PMS) between June 2010 and August 2019 to assess the long-term effectiveness and safety of eculizumab. The reduction in intravascular hemolysis, the change in hemoglobin (Hb) level, and the change in renal function were assessed to determine the effectiveness of eculizumab. The types and frequencies of adverse events (AEs) were assessed to determine its safety. A total of 632 patients were enrolled and the median treatment duration was 3.6 years. Treatment with eculizumab significantly reduced lactate dehydrogenase (LDH) levels and significantly increased Hb levels. These changes were maintained for up to 5 years of treatment. An estimated glomerular filtration rate ≥ 60 ml/min/1.73 m2 and higher LDH level at baseline were associated with increases in Hb levels during eculizumab treatment. The overall incidence of any AE was 69.92/100 patient-years. Hemolysis was the most common AE (6.43/100 patient-years). The incidence of infection-related AEs was 20.57/100 patient-years, and included meningococcal infection in three patients (0.12/100 patient-years). This long-term follow-up of patients with PNH demonstrated the sustained effectiveness of eculizumab and supports its well-established safety profile.
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Affiliation(s)
- Takayuki Ikezoe
- Department of Hematology, Fukushima Medical University, Hikarigaoka-1, Fukushima, Fukushima, 960-1295, Japan.
| | - Hideyoshi Noji
- Department of Hematology, Fukushima Medical University, Hikarigaoka-1, Fukushima, Fukushima, 960-1295, Japan.,Minami Fukushima Cardiovascular Hospital, Fukushima, Japan
| | - Yasutaka Ueda
- Osaka University Graduate School of Medicine, Suita, Japan
| | | | | | | | | | | | | | | | - Tatsuya Kawaguchi
- Kumamoto University Hospital, Kumamoto, Japan.,Kumamoto Health Science University, Kumamoto, Japan
| | | | - Yuzuru Kanakura
- Osaka University Graduate School of Medicine, Suita, Japan.,Sumitomo Hospital, Osaka, Japan
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30
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Colden MA, Kumar S, Munkhbileg B, Babushok DV. Insights Into the Emergence of Paroxysmal Nocturnal Hemoglobinuria. Front Immunol 2022; 12:830172. [PMID: 35154088 PMCID: PMC8831232 DOI: 10.3389/fimmu.2021.830172] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
Paroxysmal Nocturnal Hemoglobinuria (PNH) is a disease as simple as it is complex. PNH patients develop somatic loss-of-function mutations in phosphatidylinositol N-acetylglucosaminyltransferase subunit A gene (PIGA), required for the biosynthesis of glycosylphosphatidylinositol (GPI) anchors. Ubiquitous in eukaryotes, GPI anchors are a group of conserved glycolipid molecules responsible for attaching nearly 150 distinct proteins to the surface of cell membranes. The loss of two GPI-anchored surface proteins, CD55 and CD59, from red blood cells causes unregulated complement activation and hemolysis in classical PNH disease. In PNH patients, PIGA-mutant, GPI (-) hematopoietic cells clonally expand to make up a large portion of patients’ blood production, yet mechanisms leading to clonal expansion of GPI (-) cells remain enigmatic. Historical models of PNH in mice and the more recent PNH model in rhesus macaques showed that GPI (-) cells reconstitute near-normal hematopoiesis but have no intrinsic growth advantage and do not clonally expand over time. Landmark studies identified several potential mechanisms which can promote PNH clonal expansion. However, to what extent these contribute to PNH cell selection in patients continues to be a matter of active debate. Recent advancements in disease models and immunologic technologies, together with the growing understanding of autoimmune marrow failure, offer new opportunities to evaluate the mechanisms of clonal expansion in PNH. Here, we critically review published data on PNH cell biology and clonal expansion and highlight limitations and opportunities to further our understanding of the emergence of PNH clones.
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Affiliation(s)
- Melissa A. Colden
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sushant Kumar
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Bolormaa Munkhbileg
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Daria V. Babushok
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- *Correspondence: Daria V. Babushok,
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31
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Risitano AM, Peffault de Latour R, Marano L, Frieri C. Discovering C3 targeting therapies for paroxysmal nocturnal hemoglobinuria: Achievements and pitfalls. Semin Immunol 2022; 59:101618. [PMID: 35764467 DOI: 10.1016/j.smim.2022.101618] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/26/2022] [Accepted: 06/08/2022] [Indexed: 01/15/2023]
Abstract
The treatment of paroxysmal nocturnal hemoglobinuria (PNH) was revolutionized by the introduction of the anti-C5 agent eculizumab, which resulted in sustained control of intravascular hemolysis, leading to transfusion avoidance and hemoglobin stabilization in at least half of all patients. Nevertheless, extravascular hemolysis mediated by C3 has emerged as inescapable phenomenon in PNH patients on anti-C5 treatment, frequently limiting its hematological benefit. More than 10 years ago we postulated that therapeutic interception of the complement cascade at the level of C3 should improve the clinical response in PNH. Compstatin is a 13-residue disulfide-bridged peptide binding to both human C3 and C3b, eventually disabling the formation of C3 convertases and thereby preventing complement activation via all three of its activating pathways. Several generations of compstatin analogs have been tested in vitro, and their clinical evaluation has begun in PNH and other complement-mediated diseases. Pegcetacoplan, a pegylated form of the compstatin analog POT-4, has been investigated in two phase I/II and one phase III study in PNH patients. In the phase III study, PNH patients with residual anemia already on eculizumab were randomized to receive either pegcetacoplan or eculizumab in a head-to-head comparison. At week 16, pegcetacoplan was superior to eculizumab in terms of hemoglobin change from baseline (the primary endpoint), as well as in other secondary endpoints tracking intravascular and extravascular hemolysis. Pegcetacoplan showed a good safety profile, even though breakthrough hemolysis emerged as a possible risk requiring additional attention. Here we review all the available data regarding this innovative treatment that has recently been approved for the treatment of PNH.
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Affiliation(s)
- Antonio M Risitano
- AORN San Giuseppe Moscati Avellino, Italy; Federico II University of Naples, Naples, Italy; Severe Aplastic Anemia Working Party of the European Society for Blood and Marrow Transplantation, Leiden, Netherlands
| | - Regis Peffault de Latour
- Severe Aplastic Anemia Working Party of the European Society for Blood and Marrow Transplantation, Leiden, Netherlands; French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint-Louis Hospital and Université de Paris, Paris, France
| | | | - Camilla Frieri
- AORN San Giuseppe Moscati Avellino, Italy; Federico II University of Naples, Naples, Italy; French Reference Center for Aplastic Anemia and Paroxysmal Nocturnal Hemoglobinuria, Saint-Louis Hospital and Université de Paris, Paris, France
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32
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Brodsky RA, Lee JW, Nishimura JI, Szer J. Lactate dehydrogenase versus haemoglobin: which one is the better marker in paroxysmal nocturnal haemoglobinuria? Br J Haematol 2021; 196:264-265. [PMID: 34923628 DOI: 10.1111/bjh.17860] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/09/2021] [Accepted: 09/12/2021] [Indexed: 12/31/2022]
Affiliation(s)
- Robert A Brodsky
- Division of Hematology, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Jong Wook Lee
- Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | | | - Jeff Szer
- Peter MacCallum Cancer Centre, The Royal Melbourne Hospital, Melbourne, Australia
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33
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Gurnari C, Nautiyal I, Pagliuca S. Current Opinions on the Clinical Utility of Ravulizumab for the Treatment of Paroxysmal Nocturnal Hemoglobinuria. Ther Clin Risk Manag 2021; 17:1343-1351. [PMID: 34934322 PMCID: PMC8684432 DOI: 10.2147/tcrm.s273360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 11/28/2021] [Indexed: 01/15/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare disorder of hematopoietic stem cells genetically defined by the acquisition of somatic mutations in the X-linked phosphatidylinositol glycan anchor biosynthesis, class A (PIGA) gene. PIGA is essential for the synthesis of glycosyl phosphatidylinositol (GPI) anchor proteins and its mutations result in a deficiency of such molecules on the membrane of blood cells derived from the mutant clone. In particular, the lack of the GPI-linked complement regulatory proteins CD55 and CD59 is responsible for the increased sensitivity of PNH erythrocytes to complement-mediated destruction. Indeed, the classical clinical picture of PNH includes signs and symptoms of intravascular hemolysis along with variable degrees of cytopenia and a strong tendency to thrombosis, hallmarks of the disease. Before the introduction of anti-complement inhibitors, PNH was characterized by a high mortality primarily due to thrombotic events. The approval of the terminal anti-complement inhibitor eculizumab in 2007 introduced a paradigm shift in the treatment of the disease with improvement of the chronic hemolytic process and dramatic reduction of the thrombotic rate. However, eculizumab has a relatively short half-life when considering a life-long treatment, with obvious consequences as to the quality of life of treated patients necessitating relatively frequent drug administrations. Moreover, up to 30% of PNH patients undergoing eculizumab therapy show a suboptimal response, continuing to require red cell transfusions because of extravascular hemolysis or breakthrough hemolytic episodes. In 2019, the FDA approved the second-generation C5 inhibitor ravulizumab, a long-lasting agent with a better control of disease manifestations. Herein, we discuss the use of ravulizumab in PNH, its differences with first-generation C5 inhibitors, the research evidence supporting the safety and efficacy of this drug and its impact on costs for health systems and quality of life of PNH patients.
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Affiliation(s)
- Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of Biomedicine and Prevention, PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Ishani Nautiyal
- Department of Translational Hematology and Oncology Research, Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Simona Pagliuca
- Department of Translational Hematology and Oncology Research, Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, OH, USA
- ED561 Hematology, Oncogenesis and Biotherapies, University of Paris, Paris, France
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34
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Hock H, Kelly HR, Meyerowitz EA, Frigault MJ, Massoth LR. Case 31-2021: A 21-Year-Old Man with Sore Throat, Epistaxis, and Oropharyngeal Petechiae. N Engl J Med 2021; 385:1511-1520. [PMID: 34644476 PMCID: PMC8531984 DOI: 10.1056/nejmcpc2027096] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Hanno Hock
- From the Departments of Medicine (H.H., M.J.F.), Radiology (H.R.K.), and Pathology (L.R.M.), Massachusetts General Hospital, the Departments of Medicine (H.H., M.J.F.), Radiology (H.R.K.), and Pathology (L.R.M.), Harvard Medical School, and the Department of Radiology, Massachusetts Eye and Ear (H.R.K.) - all in Boston; and the Department of Medicine, Montefiore Medical Center, New York (E.A.M.)
| | - Hillary R Kelly
- From the Departments of Medicine (H.H., M.J.F.), Radiology (H.R.K.), and Pathology (L.R.M.), Massachusetts General Hospital, the Departments of Medicine (H.H., M.J.F.), Radiology (H.R.K.), and Pathology (L.R.M.), Harvard Medical School, and the Department of Radiology, Massachusetts Eye and Ear (H.R.K.) - all in Boston; and the Department of Medicine, Montefiore Medical Center, New York (E.A.M.)
| | - Eric A Meyerowitz
- From the Departments of Medicine (H.H., M.J.F.), Radiology (H.R.K.), and Pathology (L.R.M.), Massachusetts General Hospital, the Departments of Medicine (H.H., M.J.F.), Radiology (H.R.K.), and Pathology (L.R.M.), Harvard Medical School, and the Department of Radiology, Massachusetts Eye and Ear (H.R.K.) - all in Boston; and the Department of Medicine, Montefiore Medical Center, New York (E.A.M.)
| | - Matthew J Frigault
- From the Departments of Medicine (H.H., M.J.F.), Radiology (H.R.K.), and Pathology (L.R.M.), Massachusetts General Hospital, the Departments of Medicine (H.H., M.J.F.), Radiology (H.R.K.), and Pathology (L.R.M.), Harvard Medical School, and the Department of Radiology, Massachusetts Eye and Ear (H.R.K.) - all in Boston; and the Department of Medicine, Montefiore Medical Center, New York (E.A.M.)
| | - Lucas R Massoth
- From the Departments of Medicine (H.H., M.J.F.), Radiology (H.R.K.), and Pathology (L.R.M.), Massachusetts General Hospital, the Departments of Medicine (H.H., M.J.F.), Radiology (H.R.K.), and Pathology (L.R.M.), Harvard Medical School, and the Department of Radiology, Massachusetts Eye and Ear (H.R.K.) - all in Boston; and the Department of Medicine, Montefiore Medical Center, New York (E.A.M.)
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Bhusal K, Kadel PB, Bhandari K, Aryal S, Gyawali N, Kushwaha A, Shrestha KR, Shrestha A. Popliteal artery thrombosis as a rare complication of paroxysmal nocturnal hemoglobinuria (PNH): A case report. Int J Surg Case Rep 2021; 87:106445. [PMID: 34607268 PMCID: PMC8497847 DOI: 10.1016/j.ijscr.2021.106445] [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: 08/06/2021] [Revised: 09/21/2021] [Accepted: 09/21/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction and importance Popliteal artery thrombosis a rare but life-threatening complication of Paroxysmal Nocturnal Hemoglobinuria caused due to hemolysis. Complications of further thrombotic event are common after initial management. Case presentation A 38 years old male, known case of PNH for 2 years, presented with the history of loss of pain sensation, coldness and loss of movement in left lower leg for 5 days and history of multiple blood transfusion. The patient underwent knee amputation because of possible complication of PNH. Clinical discussion Intermittent claudication along with paresthesia, lower extremity weakness, stiffness, and cool extremities are seen in patients of Peripheral Artery Disease. Ultrasound color duplex is a sensitive and specific examination for peripheral flow while gold standard techniques like MRI and CT angiogram to detect and diagnose arterial lesions. Conclusion The risk of thrombo-embolism in a patient of PNH should be considered by a treating doctor while early imaging and management should be done to reduce the complications and risk of amputation. Popliteal artery thrombosis is a rare life-threatening complication of Paroxysmal nocturnal hemoglobinuria (PNH) We report a known case of PNH patient diagnosed with acute occlusion of Popliteal artery due to thrombosis. Complications of further thrombotic event are common after initial management and subsequent above knee amputation was done.
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Affiliation(s)
- Kiran Bhusal
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal.
| | - Prashiddha B Kadel
- Manmohan Cardiothoracic Vascular and Transplant Center, Tribhuvan University, Kathmandu, Nepal
| | | | - Shova Aryal
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Nitin Gyawali
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Ashok Kushwaha
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Kajan Raj Shrestha
- Manmohan Cardiothoracic Vascular and Transplant Center, Tribhuvan University, Kathmandu, Nepal
| | - Anjan Shrestha
- Department of Hemato-Oncology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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Schwartz CE, Stark RB, Borowiec K, Myren KJ. No impact of Asian ethnicity on EORTC QLQ-C30 scores: Group differences and differential item functioning in paroxysmal nocturnal hemoglobinuria. Health Qual Life Outcomes 2021; 19:228. [PMID: 34583705 PMCID: PMC8477512 DOI: 10.1186/s12955-021-01860-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/13/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, life-threatening terminal-complement-mediated disease resulting in intravascular hemolysis and thrombosis with significant morbidity and premature mortality. There exists no disease-specific quality-of-life (QOL) measure for PNH. Its QOL effects resemble those of hematologic cancers, which supports the use of cancer-specific QOL measures in PNH clinical trials. The European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 has published norms for many European and North American countries, but not for Asian countries. We investigated differences by Asian ethnicity in scores and item function on the EORTC QLQ-C30. METHODS This secondary analysis focused on two non-inferiority PNH trials (301 and 302) comparing eculizumab and ravulizumab (n = 441). Analysis of covariance examined the main effect of Asian ethnicity on baseline EORTC QLQ-C30 scores, after adjusting for propensity scores encompassing trial, demographic and clinical factors. Mixed modeling of longitudinal data compared subscale scores in Asian vs. non-Asian patients, after propensity adjustment. Differential item function (DIF) was examined using ordinal regression models at baseline and longitudinally, to predict item score from total score, ethnicity, and their interaction to test for uniform DIF (significant main effect for Asian) and non-uniform DIF (significant Asian-by-total-score interaction). RESULTS Of the 15 baseline domains, Asian patients scored slightly better on role and emotional functioning and slightly worse on constipation and diarrhea (0.22 < Cohen's d < 0.36). In longitudinal models, Asians reported slightly higher appetite loss, diarrhea, and financial difficulties than non-Asians (R2 increment < 0.0005). There was negligible uniform and non-uniform DIF, i.e., R2 0 to 0.018, far below Zumbo's (1999) criterion of 0.13. On average there were larger differences from norms for Asians (mean = 0.05, sd = 0.44) than non-Asians (mean = -0.07, sd = 0.36), but the size and direction of the differences varied considerably by domain, age, and gender. CONCLUSION When compared to norms, Asian patients showed no systematic biases. DIF results supported this finding. We conclude that Asian ethnicity does not impact interpretation of EORTC QLQ-C30 scores.
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Affiliation(s)
- Carolyn E Schwartz
- DeltaQuest Foundation, Inc, 31 Mitchell Road, Concord, MA, 01742, USA.
- Departments of Medicine and Orthopaedic Surgery, Tufts University Medical School, Boston, MA, USA.
| | - Roland B Stark
- DeltaQuest Foundation, Inc, 31 Mitchell Road, Concord, MA, 01742, USA
| | - Katrina Borowiec
- DeltaQuest Foundation, Inc, 31 Mitchell Road, Concord, MA, 01742, USA
- Department of Measurement, Evaluation, Statistics, & Assessment, Boston College Lynch School of Education and Human Development, Chestnut Hill, MA, USA
| | - Karl-Johan Myren
- Health Economics and Outcome Research, Alexion Pharmaceuticals, Inc, Stockholm, Sweden
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Schwartz CE, Stark RB, Borowiec K, Nolte S, Myren KJ. Norm-based comparison of the quality-of-life impact of ravulizumab and eculizumab in paroxysmal nocturnal hemoglobinuria. Orphanet J Rare Dis 2021; 16:389. [PMID: 34526067 PMCID: PMC8442345 DOI: 10.1186/s13023-021-02016-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/24/2021] [Indexed: 11/25/2022] Open
Abstract
Aims Paroxysmal nocturnal hemoglobinuria (PNH) is a rare and life-threatening intravascular hematologic disorder with significant morbidity and premature mortality. Clinical trials (NCT02946463 and NCT03056040) comparing ravulizumab with eculizumab for PNH have supported the non-inferiority of the former and similar safety and tolerability. This secondary analysis compared PNH trial participants after 26 weeks on either treatment (n = 438) to a general-population sample (GenPop) (n = 15,386) and investigated response-shift effects. Methods Multivariate analysis of covariance (MANCOVA) investigated function and symptom scores on the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 of people with PNH as compared to GenPop, after covariate adjustment. Risk-factor groups were created based on clinical indicators known to be associated with worse PNH outcomes, and separate MANCOVAs were computed for lower- and higher-risk-factor groups. Differential item functioning (DIF) analyses examined whether item response varied systematically (1) by treatment, (2) compared to GenPop, and (3) over time, the latter two suggesting and reflecting response-shift effects, respectively. DIF analyses examined 24 items from scales with at least two items. Recalibration response shift was operationalized as uniform DIF over time, reflecting the idea that, for a given group, the difficulty of endorsing an item changes over time, after adjusting for the total subscale score. Reprioritization response shift was operationalized as non-uniform DIF over time, i.e., the relative difficulty of endorsing an item over time changes across the total domain score. Results Across PNH risk-factor levels, people who had been on either treatment for 26 weeks reported better-than-expected functioning and lower symptom burden compared to GenPop. Ravulizumab generally showed larger effect sizes. Results were similar for lower and higher PNH risk factors, with slightly stronger effects in the former. DIF analyses revealed no treatment DIF, but did uncover group DIF (9 items with uniform DIF, and 11 with non-uniform) and DIF over time (7 items with uniform DIF, and 3 with non-uniform). Conclusions This study revealed that people with PNH on ravulizumab or eculizumab for 26 weeks reported QOL levels better than those of the general population. Significant effects of DIF by group and DIF over time support recalibration and reprioritization response-shift effects. These findings suggest that the treatments enabled adaptive changes. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-02016-8.
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Affiliation(s)
- Carolyn E Schwartz
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA. .,Departments of Medicine and Orthopaedic Surgery, Tufts University Medical School, Boston, MA, USA.
| | - Roland B Stark
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA
| | - Katrina Borowiec
- DeltaQuest Foundation, Inc., 31 Mitchell Road, Concord, MA, 01742, USA.,Department of Measurement, Evaluation, Statistics, and Assessment, Boston College Lynch School of Education and Human Development, Chestnut Hill, MA, USA
| | - Sandra Nolte
- Division of Psychosomatic Medicine, Medical Department, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Karl-Johan Myren
- Health Economics and Outcome Research, Alexion Pharmaceuticals, Inc., Stockholm, Sweden
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Risitano AM, Peffault de Latour R. How we('ll) treat paroxysmal nocturnal haemoglobinuria: diving into the future. Br J Haematol 2021; 196:288-303. [PMID: 34355382 PMCID: PMC9291300 DOI: 10.1111/bjh.17753] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Paroxysmal nocturnal haemoglobinuria (PNH) is characterized by complement-mediated intravascular haemolysis, severe thrombophilia and bone marrow failure. While for patients with bone marrow failure the treatment follows that of immune-mediated aplastic anaemia, that of classic, haemolytic PNH is based on anti-complement medication. The anti-C5 monoclonal antibody eculizumab has revolutionized treatment, resulting in control of intravascular haemolysis and thromboembolic risk, with improved long-term survival. Novel strategies of complement inhibition are emerging. New anti-C5 agents reproduce the safety and efficacy of eculizumab, with improved patient convenience. Proximal complement inhibitors have been developed to address C3-mediated extra-vascular haemolysis and seem to improve haematological response.
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Affiliation(s)
- Antonio Maria Risitano
- Department of Onco-Hematology, AORN San Giuseppe Moscati Avellino, Avellino, Italy.,Department of Clinical Medicine and Surgery, Federico II University of Naples, Naples, Italy.,Severe Aplastic Anaemia Working Party (SAAWP) of the European Group for Bone Marrow Transplantation (EBMT), Leiden, the Netherlands
| | - Régis Peffault de Latour
- Severe Aplastic Anaemia Working Party (SAAWP) of the European Group for Bone Marrow Transplantation (EBMT), Leiden, the Netherlands.,French Reference Centre for Aplastic Anaemia and Paroxysmal Nocturnal Haemoglobinuria, Assistance Publique - Hôpitaux de Paris, Saint-Louis Hospital, Paris, France.,Bone Marrow Transplant Unit, Université de Paris, Denis Diderot, Paris, France
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Cruz DS, da Silva Santos M, Santos B. Cost-Utility Analysis of Eculizumab for the Treatment of Paroxysmal Nocturnal Hemoglobinuria from the Perspective of the Brazilian Public Health System. Value Health Reg Issues 2021; 26:113-125. [PMID: 34332185 DOI: 10.1016/j.vhri.2021.03.003] [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: 02/24/2020] [Revised: 01/12/2021] [Accepted: 03/22/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To perform a first cost-utility analysis of eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria from the perspective of the Brazilian Unified Health System. METHODS A Markov decision model was developed for 35-year-old patients with symptomatic paroxysmal nocturnal hemoglobinuria. We used a cycle length of one month and a time horizon of 20 years. The effectiveness measure was the quality-adjusted life year (QALY). Data were extracted from clinical trials, historical cohorts, and Unified Health System databases. Resource use and costs were estimated from the perspective of the Unified Health System. Deterministic and probabilistic sensitivity analyses were performed. RESULTS The estimated gain in effectiveness with the use of eculizumab was 1.08 QALY through the incremental cost of R$10,959,375.95. The incremental cost-effectiveness ratio was R$10,139,542.84 per QALY, being 331.92 times greater than the Brazilian gross domestic product per capita. In the deterministic sensitivity analysis, the parameters related to the utilities of health states were associated with greater impact in the model. The results of the probabilistic sensitivity analysis with 1000 simulations evidence that 100% of the simulations were not considered cost-effective with the arbitrated willingness to pay R$30,548.40 and R$91,645.20 per QALY. CONCLUSIONS The gain in effectiveness with the use of eculizumab was modest, associated with an unjustifiable incremental cost. Therefore, eculizumab is not a cost-effective drug compared with the current standard of care in the treatment of paroxysmal nocturnal hemoglobinuria from the Brazilian Unified Health System perspective.
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Affiliation(s)
- Daniela Souza Cruz
- Secretaria da Câmara de Regulação do Mercado de Medicamentos, Agência Nacional de Vigilância Sanitária, Brasília, Brasil.
| | | | - Braulio Santos
- Instituto Nacional de Cardiologia, Rio de Janeiro, Brasil
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Goren Sahin D, Akay OM, Keklik M, Okan V, Karakus A, Demir C, Erkurt MA, Ilkkilic K, Yildirim R, Akgun Cagliyan G, Aksu S, Dogu MH, Dal MS, Karakus V, Gemici AI, Terzi H, Kelkitli E, Sivgin S, Unal A, Yilmaz M, Ayyildiz O, Korkmaz S, Eser B, Altuntas F. Clinical characteristics and therapeutic outcomes of paroxysmal nocturnal hemoglobinuria patients in Turkey: a multicenter experience. Ann Hematol 2021; 100:1667-1675. [PMID: 33988739 DOI: 10.1007/s00277-021-04554-4] [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: 04/23/2020] [Accepted: 05/02/2021] [Indexed: 11/30/2022]
Abstract
The aim of this study is to collect paroxysmal nocturnal hemoglobinuria (PNH) patient data from hematology centers all over Turkey in order to identify clinical features and management of PNH patients. Patients with PNH were evaluated by a retrospective review of medical records from 19 different institutions around Turkey. Patient demographics, medical history, laboratory findings, and PNH-specific information, including symptoms at the diagnosis, complications, erythrocyte, and granulocyte clone size, treatment, and causes of death were recorded. Sixty patients (28 males, 32 females) were identified. The median age was 33 (range; 17-77) years. Forty-six patients were diagnosed as classic PNH and 14 as secondary PNH. Fatigue and abdominal pain were the most frequent presenting symptoms. After eculizumab became available in Turkey, most of the patients (n = 31/46, 67.4%) were switched to eculizumab. Three patients with classic PNH underwent stem cell transplantation. The median survival time was 42 (range; 7-183 months) months. This study is the first and most comprehensive review of PNH cases in Turkey. It provided us useful information to find out the differences between our patients and literature, which may help us understand the disease.
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Affiliation(s)
- Deniz Goren Sahin
- Department of Hematology, Demiroglu Bilim University, Istanbul, Turkey.
| | | | - Muzaffer Keklik
- Department of Hematology, Erciyes University, Kayseri, Turkey
| | - Vahap Okan
- Department of Hematology, Gaziantep University, Gaziantep, Turkey
| | | | - Cengiz Demir
- Gazi Yasargil Training and Research Hospital, University of Health Sciences, Diyarbakir, Turkey
| | | | - Kadir Ilkkilic
- Recep Tayyip Erdogan University Training and Research Hospital, Rize, Turkey
| | - Rahsan Yildirim
- Division of Hematology, Medical Park Antalya Hospital, Antalya, Turkey
| | | | - Salih Aksu
- Department of Hematology, Hacettepe University, Ankara, Turkey
| | - Mehmet Hilmi Dogu
- Istanbul Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Mehmet Sinan Dal
- Ankara Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Volkan Karakus
- Mugla Sitki Kocman University Training and Research Hospital, Mugla, Turkey
| | - Ali Ihsan Gemici
- Department of Hematology, Istanbul Medipol University, Istanbul, Turkey
| | - Hatice Terzi
- Department of Hematology, Cumhuriyet University, Sivas, Turkey
| | - Engin Kelkitli
- Department of Hematology, Ondokuz Mayis University, Samsun, Turkey
| | - Serdar Sivgin
- Division of Hematology, Acibadem Kayseri Hospital, Kayseri, Turkey
| | - Ali Unal
- Department of Hematology, Erciyes University, Kayseri, Turkey
| | - Mehmet Yilmaz
- Department of Hematology, Gaziantep University, Gaziantep, Turkey
| | - Orhan Ayyildiz
- Department of Hematology, Dicle University, Diyarbakir, Turkey
| | - Serdal Korkmaz
- Kayseri City Training and Research Hospital, University of Health Sciences, Kayseri, Turkey
| | - Bulent Eser
- Division of Hematology, Medical Park Antalya Hospital, Antalya, Turkey
| | - Fevzi Altuntas
- Ankara Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
- Department of Hematology, Yildirim Beyazit University, Ankara, Turkey
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Dhawan R, Ahluwalia J, Malhotra P, Mahapatra M, Varma N, Varma S. Markers of Thrombin Generation and Inflammation in Patients with Paroxysmal Nocturnal Hemoglobinuria. Indian J Hematol Blood Transfus 2021; 37:204-209. [PMID: 33867725 DOI: 10.1007/s12288-019-01239-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 11/23/2019] [Indexed: 02/02/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) presents with intravascular hemolysis, bone marrow failure and thrombosis. Various studies have reported geographic and ethnic variation in prevalence of thrombosis in PNH. There is limited data on thrombosis in PNH from the Indian subcontinent. In this study we describe disease burden and risk factors for thrombosis in 18 Indian PNH patients. We studied markers of thrombin generation (Thrombin-antithrombin complexes; TAT and D-Dimer), endothelium and platelet activation (soluble P-selectin) and inflammation (interleukin-6; IL-6) in PNH patients and compared their levels with healthy controls. Thrombosis was identified in 17% of PNH patients. TAT, sP-selectin and D-Dimer levels were significantly elevated in PNH patients (TAT: 5.06 ± 1.08 ng/ml; sP-selectin: 80.57 ± 19.5 ng/ml; D-Dimer mean: 936 ng/ml 95% CI 559, 1310) compared to control population (TAT: 3.39 ± 0.769 ng/ml P = 0.016; sP-selectin: 44.67 ± 5.17 ng/ml P = 0.002). Using Youden's J statistic, the cut-off values for TAT and sP-selectin in our cohort of PNH patients were 2.90 ng/ml and 58.41 ng/ml respectively. TAT, sP-selectin and D-Dimer levels were elevated beyond the cut-off values in PNH patients with thrombosis compared to those without thrombosis. A positive correlation was noted between TAT, sP-selectin and D-Dimer levels. Increased TAT, sP-selectin, and D-Dimer levels may indicate impending thrombosis in PNH.
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Affiliation(s)
- Rishi Dhawan
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, 110608 India.,Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jasmina Ahluwalia
- Department of Haematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manoranjan Mahapatra
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, 110608 India
| | - Neelam Varma
- Department of Haematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Subhash Varma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Brodsky RA. How I treat paroxysmal nocturnal hemoglobinuria. Blood 2021; 137:1304-1309. [PMID: 33512400 PMCID: PMC7955407 DOI: 10.1182/blood.2019003812] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/28/2020] [Indexed: 01/06/2023] Open
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, clonal, complement-mediated hemolytic anemia with protean manifestations. PNH can present as a hemolytic anemia, a form of bone marrow failure, a thrombophilia, or any combination of the above. Terminal complement inhibition is highly effective for treating intravascular hemolysis from PNH and virtually eliminates the risk of thrombosis, but is not effective for treating bone marrow failure. Here, I present a variety of clinical vignettes that highlight the clinical heterogeneity of PNH and the attributes and limitations of the 2 US Food and Drug Administration-approved C5 inhibitors (eculizumab and ravulizumab) to treat PNH. I review the concept of pharmacokinetic and pharmacodynamic breakthrough hemolysis and briefly discuss new complement inhibitors upstream of C5 that are in clinical development. Last, I discuss the rare indications for bone marrow transplantation in patients with PNH.
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43
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Wilson NR, Abbas HA, Kala J. Paroxysmal Nocturnal Hemoglobinuria Presenting with Hemorrhagic Esophageal Varices. Am J Med 2021; 134:e147-e149. [PMID: 33121958 DOI: 10.1016/j.amjmed.2020.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Nathaniel R Wilson
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston.
| | - Hussein A Abbas
- Department of Hematology and Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston
| | - Jaya Kala
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston
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Ueno M, Shimodate Y, Okada K, Takaya R, Yamamoto H, Mizuno M. Upper gastrointestinal ischemia as a rare complication of paroxysmal nocturnal hemoglobinuria. Clin Case Rep 2021; 9:506-510. [PMID: 33489204 PMCID: PMC7813057 DOI: 10.1002/ccr3.3567] [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: 08/18/2020] [Revised: 10/12/2020] [Accepted: 10/30/2020] [Indexed: 11/10/2022] Open
Abstract
When patients with PNH present with abdominal symptoms, thrombosis-induced gastrointestinal injury should be considered; computed tomography and esophagogastroduodenoscopy may help make the diagnosis of this potentially serious complication.
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Affiliation(s)
- Masayuki Ueno
- Department of Gastroenterology and HepatologyKurashiki Central HospitalKurashikiJapan
| | - Yuichi Shimodate
- Department of Gastroenterology and HepatologyKurashiki Central HospitalKurashikiJapan
| | - Kazuya Okada
- Department of Hematology/OncologyKurashiki Central HospitalKurashikiJapan
| | - Ryosuke Takaya
- Department of Hematology/OncologyKurashiki Central HospitalKurashikiJapan
| | - Hiroshi Yamamoto
- Department of Gastroenterology and HepatologyKurashiki Central HospitalKurashikiJapan
| | - Motowo Mizuno
- Department of Gastroenterology and HepatologyKurashiki Central HospitalKurashikiJapan
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Vyrides N, Douka V, Gavriilaki E, Papaioannou G, Athanasiadou A, Neofytou S, Vyrides Y, Lalayanni C, Anagnostopoulos A, Kokoris SI. Paroxysmal nocturnal hemoglobinuria and myelodysplastic syndrome: Disappearance of cytogenetic abnormalities. Cancer Genet 2020; 250-251:1-5. [PMID: 33188967 DOI: 10.1016/j.cancergen.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 09/18/2020] [Accepted: 11/02/2020] [Indexed: 11/16/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare life-threatening disease resulting from clonal hematopoietic stem cell evolution. There is a strong link between PNH and other acquired bone marrow failure syndromes, including myelodysplastic syndrome (MDS). Cytogenetic, morphological abnormalities or both are observed in the range of MDS/PNH diagnosis. Herein, we investigate cytogenetic abnormalities in PNH patients. We found two patients with PNH clones and MDS-associated abnormalities that later disappeared. The first patient, originally diagnosed with MDS and Trisomy 6, developed a large PNH clone. At the time of PNH diagnosis, the abnormal cytogenetic clone was no longer detectable despite persistent trilineage dysplasia. In the second patient, a large PNH clone and MDS-defining abnormality were detected at diagnosis, without evidence of dysplasia. No cytogenetic abnormalities were evident after complement inhibition. Our report adds significant information on the complex link between MDS and PNH, suggesting that distinction between these entities may be difficult in some cases. Especially in transplant eligible patients, the clinical phenotype may be the leading feature for treatment decisions in the era of complement inhibition. Lastly, the transient presence of cytogenetic abnormalities is a unique characteristic of our patients' course that needs to be further elucidated in larger studies.
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Affiliation(s)
- Niki Vyrides
- Haematology Department, Vyrides Clinic, Nicosia, Cyprus; University of Nicosia Medical School, Nicosia, Cyprus.
| | - Vassiliki Douka
- Hematology Department-BMT Unit, G. Papanicolaou Hospital, Thessaloniki; Greece
| | - Eleni Gavriilaki
- Hematology Department-BMT Unit, G. Papanicolaou Hospital, Thessaloniki; Greece
| | | | | | - Sofia Neofytou
- Cytogenetic Department, Archbishop Makarios III Hospital - Nicosia, Cyprus
| | - Yiannis Vyrides
- Great Western Hospitals NHS Foundation Trust, Swindon, United Kingdom
| | - Chrysavgi Lalayanni
- Hematology Department-BMT Unit, G. Papanicolaou Hospital, Thessaloniki; Greece
| | | | - Styliani I Kokoris
- Laboratory of Hematology and Hospital Blood Transfusion Department, University General Hospital "Attikon", National and Kapodistrian University of Athens, Medical School, Greece
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46
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The erythroblastic island niche: modeling in health, stress, and disease. Exp Hematol 2020; 91:10-21. [DOI: 10.1016/j.exphem.2020.09.185] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 12/19/2022]
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47
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Demir C, Ebinç S, Ekinci Ö. Presence of paroxysmal nocturnal hemoglobinuria in patients with idiopathic portal vein thrombosis: a single-center study. Turk J Med Sci 2020; 50:1344-1349. [PMID: 32490645 PMCID: PMC7491302 DOI: 10.3906/sag-1912-204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 05/23/2020] [Indexed: 01/04/2023] Open
Abstract
Background/aim Paroxysmal nocturnal hemoglobinuria (PNH) is a very rare clonal hematopoietic stem cell disease characterized by chronic hemolytic anemia and thrombosis. We report data from a study of the occurrence of PNH among patients with idiopathic portal vein thrombosis (PVT). Materials and methods Patients who were followed up with the diagnosis of idiopathic PVT were enrolled into this study. Those with laboratory and/or imaging evidence of any local or systemic factor that could lead to PVT were excluded. PNH clone was examined in all patients using established FLAER methodology. Results A total of 112 patients (42 males and 70 females), none of them had a markedly PNH clone, but 4 patients (3.6%) with confirmed tests two times had small PNH clones (size between 3.02% and 4.62%). The median ages of PNH clone (-) and PNH clone (+) patients were 42 (range; 24–59) vs 39 (range; 36–42) years, respectively. The median hemoglobin concentration, platelet count and leukocyte count were lower in the PNH clone (+) group than the PNH clone (-) group. Anemia, thrombocytopenia, and leukopenia were detected in all PNH clone (+) patients. In addition, the PNH clone positivity size in monocytes was higher than erythrocytes in all of 4 patients. Conclusions PNH should be considered during differential diagnosis among patients with idiopathic PVT. Small PNH clones can be detected in PVT patients that we cannot clearly determine its relationship with PVT. We need furthermore studies to explore the potential role of this finding.
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Affiliation(s)
- Cengiz Demir
- Department of Hematology, Faculty of Medicine, Yüzüncü Yıl University, Van, Turkey
| | - Senar Ebinç
- Department of Hematology, Faculty of Medicine, Yüzüncü Yıl University, Van, Turkey
| | - Ömer Ekinci
- Department of Hematology, Faculty of Medicine, Fırat University, Elazığ, Turkey
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48
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Macrae FL, Peacock‐Young B, Bowman P, Baker SR, Quested S, Linton E, Hillmen P, Griffin M, Munir T, Payne D, McKinley C, Clarke D, Newton DJ, Hill A, Ariëns RAS. Patients with paroxysmal nocturnal hemoglobinuria demonstrate a prothrombotic clotting phenotype which is improved by complement inhibition with eculizumab. Am J Hematol 2020; 95:944-952. [PMID: 32311169 DOI: 10.1002/ajh.25841] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/10/2020] [Accepted: 04/15/2020] [Indexed: 12/26/2022]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematological disorder, characterized by complement-mediated intravascular hemolysis and thrombosis. The increased incidence of PNH-driven thrombosis is still poorly understood, but unlike other thrombotic disorders, is thought to largely occur through complement-mediated mechanisms. Treatment with a C5 inhibitor, eculizumab, has been shown to significantly reduce the number of thromboembolic events in these patients. Based on previously described links between changes in fibrin clot structure and thrombosis in other disorders, our aim was to investigate clot structure as a possible mechanism of thrombosis in patients with PNH and the anti-thrombotic effects of eculizumab treatment on clot structure. Clot structure, fibrinogen levels and thrombin generation were examined in plasma samples from 82 patients from the National PNH Service in Leeds, UK. Untreated PNH patients were found to have increased levels of fibrinogen and thrombin generation, with subsequent prothrombotic changes in clot structure. No link was found between increasing disease severity and fibrinogen levels, thrombin generation, clot formation or structure. However, eculizumab treated patients showed decreased fibrinogen levels, thrombin generation and clot density, with increasing time spent on treatment augmenting these antithrombotic effects. These data suggest that PNH patients have a prothrombotic clot phenotype due to increased fibrinogen levels and thrombin generation, and that the antithrombotic effects of eculizumab are, in-part, due to reductions in fibrinogen and thrombin generation with downstream effects on clot structure.
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Affiliation(s)
- Fraser L. Macrae
- Discovery and Translational Science DepartmentLeeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds Leeds UK
| | - Barnaby Peacock‐Young
- Discovery and Translational Science DepartmentLeeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds Leeds UK
| | - Polly Bowman
- Discovery and Translational Science DepartmentLeeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds Leeds UK
| | - Stephen R. Baker
- Discovery and Translational Science DepartmentLeeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds Leeds UK
- Department of PhysicsWake Forest University Winston Salem North Carolina USA
| | - Sam Quested
- Discovery and Translational Science DepartmentLeeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds Leeds UK
| | - Emma Linton
- Discovery and Translational Science DepartmentLeeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds Leeds UK
| | - Peter Hillmen
- Department of HaematologyLeeds Teaching Hospitals NHS Trust Leeds UK
| | - Morag Griffin
- Department of HaematologyLeeds Teaching Hospitals NHS Trust Leeds UK
| | - Talha Munir
- Department of HaematologyLeeds Teaching Hospitals NHS Trust Leeds UK
| | - Daniel Payne
- Department of HaematologyLeeds Teaching Hospitals NHS Trust Leeds UK
| | - Claire McKinley
- Division of Haematology and ImmunologyLeeds Institute of Medical Research at St James's, University of Leeds Leeds UK
| | - Deborah Clarke
- Division of Haematology and ImmunologyLeeds Institute of Medical Research at St James's, University of Leeds Leeds UK
| | - Darren J Newton
- Division of Haematology and ImmunologyLeeds Institute of Medical Research at St James's, University of Leeds Leeds UK
| | - Anita Hill
- Department of HaematologyLeeds Teaching Hospitals NHS Trust Leeds UK
| | - Robert A. S. Ariëns
- Discovery and Translational Science DepartmentLeeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds Leeds UK
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49
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Röth A, Araten DJ, Larratt L, Kulasekararaj AG, Maciejewski JP, Wilson A, Gustovic P, Kanakura Y. Beneficial effects of eculizumab regardless of prior transfusions or bone marrow disease: Results of the International Paroxysmal Nocturnal Hemoglobinuria Registry. Eur J Haematol 2020; 105:561-570. [PMID: 32640047 DOI: 10.1111/ejh.13485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the effects of eculizumab on transfusions and thrombotic events (TEs) in patients with and without prior history of transfusion in the International Paroxysmal Nocturnal Hemoglobinuria (PNH) Registry. METHODS Registry patients enrolled on or before January 1, 2018, initiated on eculizumab no more than 12 months prior to enrollment, having known transfusion status for the 12 months before eculizumab initiation, and ≥12 months of Registry follow-up after eculizumab initiation, were included. RESULTS Eculizumab treatment was associated with a 50% reduction in transfusions in patients with a transfusion history (10.6 units/patient-year before eculizumab vs 5.4 after; P < .0001), with greater reduction observed in those with no history of bone marrow disease vs those with bone marrow disease. Mean lactate dehydrogenase levels decreased from a mean of 6.7 to 1.4 times the upper limit of normal (ULN) in patients with transfusion history and from 5.1 to 1.2 times ULN in those with no transfusion history. TE and major adverse vascular event rates also decreased by 70% in patients with and without history of transfusion. CONCLUSIONS The benefit of eculizumab therapy does not appear to be limited to any group defined by transfusion history or bone marrow disease history.
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Affiliation(s)
- Alexander Röth
- West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | | | | | | | | | | | - Yuzuru Kanakura
- Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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50
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Sun L, Babushok DV. Secondary myelodysplastic syndrome and leukemia in acquired aplastic anemia and paroxysmal nocturnal hemoglobinuria. Blood 2020; 136:36-49. [PMID: 32430502 PMCID: PMC7332901 DOI: 10.1182/blood.2019000940] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/09/2019] [Indexed: 02/06/2023] Open
Abstract
Acquired aplastic anemia (AA) and paroxysmal nocturnal hemoglobinuria (PNH) are pathogenically related nonmalignant bone marrow failure disorders linked to T-cell-mediated autoimmunity; they are associated with an increased risk of secondary myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). Approximately 15% to 20% of AA patients and 2% to 6% of PNH patients go on to develop secondary MDS/AML by 10 years of follow-up. Factors determining an individual patient's risk of malignant transformation remain poorly defined. Recent studies identified nearly ubiquitous clonal hematopoiesis (CH) in AA patients. Similarly, CH with additional, non-PIGA, somatic alterations occurs in the majority of patients with PNH. Factors associated with progression to secondary MDS/AML include longer duration of disease, increased telomere attrition, presence of adverse prognostic mutations, and multiple mutations, particularly when occurring early in the disease course and at a high allelic burden. Here, we will review the prevalence and characteristics of somatic alterations in AA and PNH and will explore their prognostic significance and mechanisms of clonal selection. We will then discuss the available data on post-AA and post-PNH progression to secondary MDS/AML and provide practical guidance for approaching patients with PNH and AA who have CH.
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MESH Headings
- Age of Onset
- Anemia, Aplastic/drug therapy
- Anemia, Aplastic/genetics
- Anemia, Aplastic/pathology
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Benzoates/adverse effects
- Benzoates/therapeutic use
- Bone Marrow/pathology
- Chromosome Aberrations
- Chromosomes, Human, Pair 7/genetics
- Clonal Evolution/drug effects
- Clone Cells/drug effects
- Clone Cells/pathology
- Disease Progression
- Granulocyte Colony-Stimulating Factor/adverse effects
- Granulocyte Colony-Stimulating Factor/therapeutic use
- Hemoglobinuria, Paroxysmal/drug therapy
- Hemoglobinuria, Paroxysmal/genetics
- Hemoglobinuria, Paroxysmal/pathology
- Humans
- Hydrazines/adverse effects
- Hydrazines/therapeutic use
- Leukemia, Myeloid, Acute/epidemiology
- Leukemia, Myeloid, Acute/etiology
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Models, Biological
- Monosomy
- Mutation
- Myelodysplastic Syndromes/epidemiology
- Myelodysplastic Syndromes/etiology
- Myelodysplastic Syndromes/genetics
- Myelodysplastic Syndromes/pathology
- Oncogene Proteins, Fusion/genetics
- Pyrazoles/adverse effects
- Pyrazoles/therapeutic use
- Selection, Genetic
- Telomere Shortening
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Affiliation(s)
- Lova Sun
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA; and
| | - Daria V Babushok
- Division of Hematology-Oncology, Department of Medicine, University of Pennsylvania, Philadelphia, PA; and
- Comprehensive Bone Marrow Failure Center, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
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